Mechanical Ventilation Nurse Icu

8/8/2019 Mechanical Ventilation Nurse Icu

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Mechanical Ventilation:Principle & Practice

.


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Phramongkutklao college of Medicine

Topics to cover

Mechanic of breathing

Mode of mechanical breath

Initial ventilator setting Ventilator in specific diseases

Monitoring of mechanic ventilated pt.

Weaning from ventilator Common problem for the ventilated pt.

New mode/old mode


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Hypoxemia

Hypoventilation

work of breathing unstable

hemodynamic


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Oxygenation oxygenation failure

o ( O2)oET-tube FiO2 ~ 1.0o alveoli collapse Tidalvolume PEEPo gas mean alveoli pressure (mean airwaypressure) PEEP, pattern

IRV


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Ventilation o minute ventilation 40%

o o Rapid shallow breathing

o Respiratory-abdominal paradox

o Neuromuscular disorder


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Mechanic of ventilation


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Negative pressureventilation Positive pressure

ventilation


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Positive pressure ventilation

Noninvasive

Invasive

Volume

preset

Pressure

preset


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Mode of ventilation

spontaneous

CPAP

Mandatory

Pressuretarget

Volumetarget

SIMV

PSV CMVAMV


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Terminology

A/C: Assist-Control

IMV: Intermittent Mandatory

Ventilation SIMV: Synchronized Intermittent

Mandatory Ventilation

Bi-level/Biphasic: Non-inversedPressure Ventilation with PressureSupport (consists of 2 levels ofpressure)


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Terminology(cont)

PRVC: Pressure Regulated VolumeControl

PEEP: Positive End ExpiratoryPressure

CPAP: Continuous Positive Airway

Pressure PSV: Pressure Support Ventilation

NIPPV: Non-Invasive Positive

Pressure Ventilation


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Terminology

Respiratory Rate (RR) Number of breaths delivered by the ventilatorper minute

Tidal Volume (VT) Volume of gas delivered during each ventilatorbreath

FiO2 Amount of oxygen delivered by ventilator topatient


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Basic ventilator setting

1 2 3 4 5 6

3

0

Sec

PawcmH2O

-

1

0

Slope/Rise= flowVCV= =flow

pattern+ peak flow rate

PCV/PSV==pressure level risetime

Pressure-time wave form

Inspiratory Termination =cycling

VCV==volumePCV= = inspiratorytime (Ti)PSV== none

Esense

Onset of Trigger

Time= = RRPatient = = sense

Pressure

Flow


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tidal volume minimum minute ventilation

compliance/resistance

flow volume ventilator support

ventilate

Volume control


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pressure controlled ventilator supply flow pressure system

(pressure control level) maintain pressure (Ti) flow

tidal volume airwayresistance + lung compliance pressure control level + Ti

Pressure Control


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pressure barotrauma flow limitation Control I-Time

ventilation distribute tidal volume

Pressure Control


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Volume control Pressure control


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Initial setting

Objective

Work of breathing

Hypoxemia

Hypercapnia/resp

iratory acidosis

Avoidance

Ventilator inducedlung injury

O2 toxicity

Compromisehemodynamic


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Phramongkutklao college of MedicineVentilator setting

sense

Flow Vt

RR

Paw FiO2

12 x 5 = 60


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Spontaneous breath:

CPAP Settings

RR

CPAP~PEEP


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Initial setting :

HypoxemiaHypoxemia

Aim : keep SaO2 > 90%

How: FiO2PEEP

Prone position

Avoid: FiO2 > 0.60


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Initial setting:CO2

Hypercapnia + acute respiratoryacidosis

Aim: pH ~7.40 or PaCO2

~40

How: minute ventilation

= RR x Vt

Avoid: Pplateau > 30 cmH2O

Or accept for permissive hypercapnia


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Initial setting : WOB

Work of breathing

Aim: to rest respiratory muscle

How: trigger (sense)inspiratory flow

I:E

PEEP (autoPEEP)

Avoid: ventilator asynchrony


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Mode

CMV AMV SIMV PSV

Targetvolume Pressure

Trigger

Time Pressure or Flow

Rx

Hypoxemia: FiO2/PEEP

Hypercapnia: RR x Vt


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Inspiratory sensitivity

-1 cmH2O =

1cmH2O

sensitivity

auto-trigger


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Respiratory Rate

10-20/ minute

ventilation

WOB

respiratoryalkalosis dynamichyperinflationairway diseases


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TidalVolume

8-10 cc/kg ideal body weight

respiratory rate minute ventilation

6-8 cc/kg

Normal minute ventilation ~ 110 ml/Kg IBW


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PEEP Positive end expiratory

pressure

residual volumes and total

lung volumes, venousreturn

3-5 cm H2O = physiologic

PEEP Therapeutic PEEP> 5 cm H2O

Hypoxemia

autoPEEP


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PEEP Contraindications/ precautions

Increased ICP

Bronchopleural fistulaunilateral lung disease

Hypotension (esp. hypovolemia)


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FiO2 hypoxemic

respiratory failure FiO2 1.0 titrate pulse oximetry

FiO2 0.60 >24 Lunginjury

FiO2 1.0 absorptiveatelectasis


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Peak Flow

40-60 L/min 80-120 L/min

airways disease Peak flow peak airwaypressure plateau pressures barotrauma

peak inspiratory flow flow wave form


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Flow waveform

Volume preset 2 ramp square waveform

Ramp Square

Ti Paw (peak) Paw (mean) Gas distribution Gas distribution Short Ti, Te


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ModeVCV/PCVA/CMV, SIMV, PSV

CPAP

Vt: 6-10 ml/kg

RRBackup rate~ 8-12/min

Supporting rate~ pt rate-4/min

PF 40-60L/min4 x Ve

Sense~1-2 cmH2O

FiO2~0.40-1.0


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High Pressure +5-10 cmH2O Paw Low Pressure -10 cmH2O Paw High RR +10 average rate Low Vt -100-200 ml < setting Low Ve 2-4 L < mean level Loss of PEEP 3-5 cmH2O < PEEP


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Monitoring

+ Hemodynamic


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artificial airway


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Lung Mechanics

Gas exchange

Waveform analysis

CXR/ cuff pressure


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Vital signs (BP, P, RR, T )+ SpO2


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( 12-20 /)

accessory muscle of Respiration

=


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chest

2 (one lung intubation,

pneumothorax )

Wheezing

(air trapping )


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Gas Exchanges

Invasive

ABG : pH

, PaO2

,PaCO2 , SaO2

Noninvasive

Pulse Oximetry : SpO2

Capnography : PetCO2

Aim to keep SpO2 90%


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Ventilator setting in specificconditions

Severe hypoxemia (ARDS)

Severe airflow limitation (COPD)


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Management of severe

hypoxemiaPathophysiology of hypoxemia

V/Q mismatch Shunt

Diffusion defect


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Phramongkutklao college of MedicinePRAY

hypoxemia

Position(Good lung down)Partial liquid ventilationProlong inspiratory time

Tracheal gas insufflationIndependent lung ventilation

Recruitment

Maneuver


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Severehypoxemia

Acute

Ratio

PO2/FiO2


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Normal alveoli

Partial collapse alveoli

Atelectatic lung

effusion effusion

V/Q missmatch

V/Q ~n ,Vd

shunt


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Alveolar Recruitment Strategies

Prevent atelectatic trauma

Prevent volume trauma


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PEEP5

PEEP20


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ARDS

small tidal volume ( 6-8 cc/KgIBW)

PEEP hypoxemiaHigh PEEP approach

respiratory rateAccept permissive hypercapnea

PEEP effect suction Lung expansion/ recruitment

FiO2-PEEP


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Recruitment maneuver

( atelectaticalveoli )ARDS shunt protective lung strategies

Pressure PEEP


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Localized lung diseases

Increased intracranial pressure recruitmentmaneuver

RM

ARDS RM/


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volume control ventilation monitor Paw Ppl (derecruitment ) Ppl

= reatelectasis Pressure control : monitor Vt

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Maximum recruitment


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Severe airflow limitation

Asthma

COPD

PathophysiologyAir trapping

Hyperinflation/ barotrauma

autoPEEP/Dynamic hyperinflation( work of breathing)


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Adequate expiratory time(Te)

Short inspiratory time(Ti)

Increased inspiratory flow

Smaller tidal volume Decreased respiratory rate

Reverse bronchospasm/inflammation

Bronchodilator

Corticosteroid

Clear secretion


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Adequate expire time?Adequate expire time?

Assessment of adequate

Clinically: wheezing

Graphic monitoring: flow-time curve


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Initial setting for COPD

setting SuggestionMode A/C(CMV)

Rate 8-12/min

VCV/PCV Pressure or volumeVt 8-10 ml/kg (Ppl 60)

PEEP


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Condition Perioperative

ARDS COPD Neuromuscular

CHF

Setting

hemodyn

amic

mode A/CMV SIMV

A/CMV A/CMVSIMV ,PSV

A/CMV A/CMVPSV SIMV

FiO2

0.4-0.6PaO2 >80

PaO2

> 60

FiO2 60

VT ml/kg 10-12 6-8 8-10 10-12 8-12

RR 8-12 12-20 6-10 8-12 8-12

FlowL/min

40 60 >60 < 60 > 60

PEEP < 5 8-16 80%

(PEEP i )

0-3 5-10


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Vt~10ml/kg, RR~ 12/min,

Peak flow 60 L/min, FiO2 1.0,PEEP 3 cmH2O, sense 1cmH2O ( Flow sense 3/10L/min),

Initial ventilator setting

MonitorOxygenation&O2 toxcity = SpO2Barotrauma=Pplateau ( Ppl)

Work of breathing(WOB)=

SpO2 >90%SpO2 >95%(acute MI ,acute brain syndrome)

Ppl >30 cmH2O( Paw >45 cmH2O) trigger pressure-time


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SpO2 >90%SpO2 >95%(acute MI ,

acute brain syndrome)

minimal

FiO2 (FiO2


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Ppl >30 cmH2O( Paw >45 cmH2O)

Vt, RR, PF,sense

Vt (6-10 ml/kg)

trigger pressure-time

flow sense flow triggerPEEP (autoPEEP) respiratory drive


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62 CABG

on high dose Dopamine O.R. FiO2 0.60 PEEP 5

cmH2O, A/CMV mode, Vt 500 RR 12( rate 18/min) SpO2 96% Dopamine 10 ug/kg/min

BP 90/60 mmHg , HR 120/min

wean


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Drive

CVS

StrengthLoad


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Criteria for weaning

PaO2/FiO2

>200

PaO2> 60 mmHgFiO2< 0.35 PEEP< 5 cmH2O

Hemodynamic stable (Dopamine


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Criteria for weaning

weaning index

Ve 10-15 L/min RR < 30-38 /min

NIF -30 cmH2O

Vt >4-6 ml/kg T-piece RVR < 105


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Wean?


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62 CABG

on high dose Dopamine O.R. FiO2 0.60 PEEP 5

cmH2O, A/CMV mode, Vt 500 RR 12( rate 18/min) SpO2 96% Dopamine 10 ug/kg/min

BP 90/60 mmHg , HR 120/min wean


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FiO2 0.35 PEEP 5

cmH2O

SpO2 96% Dopamine 3 ug/Kg/min BP110/70 mmHg

sense -20 cmH2O trigger

RVRspontaneous breath Vt 500 ml, RR 16 /min wean


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Clinical + Parameters

wean FiO2 - 20

RVR < 105Hemodynamic stable

wean


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1. T-piece trial

2. Intermittent T-piece

3. PSV4. PSV + CPAP

5. SIMV

6. SIMV + CPAP7. SIMV + PSV

8. SIMV + CPAP + PSV

Your choice


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wean21

(spontaneous breathing trial) T-

piece continuous positive airwaypressure (CPAP)2

(weaning)

pressure support ventilation (PSV)synchronized intermittent mandatoryventilation (SIMV)

W i


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Weaning

techniqueStudy 1Techniqe

T-piece 3PSV 4

SIMV 5

1=Esteban A, Tobin MJ, et al. NEJM 1995; 332:345-350

2= Brochard LJ, et.al AJRCCM 1994;150:896


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Anxiety , agitation , diaphoresis ,cyanosis

> 35/ ( 5) 10/

HR >110 / >20/


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SBP > 180 ,< 90 . SBP > 20 mmHg, > 30 mmHg

DBP > 10 mmHg EKG PVC >4-6 /min oxygen saturation < 90 %

10 20 30


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76y/o COPD 4acute MI Vt 0.5 L, SIMV 8/min,FiO2 0.4 PEEP/CPAP 5 cmH2O ABG: pH7.37, PCO2 36,PO2 78, SpO2 93%

weaning parameter T-piece

wean 30 ,tachycardia, rapid shallow breathing,

SpO2 90% CVP 8 12 chest pain dysrhythmias wean


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Drive_Load_Strength


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wean Respiratory load

mechanical loads pulmonary congestion

metabolic loads CO2 , severemetabolic acidosis)

respiratory drive ( sedative metabolic causes hypothyroid)

respiratory strength :malnutrition, electrolyte imbalance

Mg PO4


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wean

cardiovascular

CHF positive negative pressure ventilation ( T-piece )

venous return


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fully ventilatory support 24

SB

T

Cuff leak test cuff leakvolume

Cough peak flow > 60 L/min


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ET-T/

Oxygenation Hemodynamic stable

Weaning index

SBT

no

yes

-+

Need ET-T no Cuff-leak test

-

ok EX


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New Mode

Dual mode

Proportional assist ventilation

Airway pressure-release ventilation

Mandatory minute ventilation

Adaptive support ventilation

etc

Close loop techniqueLess setting, more intelligence


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Pressure Control+Volume Control

Dual Control (mode)

Pressure Control+Volume Control

Dual Control (mode)

Pressure regulated volume


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Pressure-regulated volumecontrol

pressure preset(PCV ) volume

Inspiratory pressure PEEP 5 cmH2O high pressure limit

inspiratory pressure

lung mechanic inspiratory pressure 3cmH2O volume

PCVAdjusted3cmH2O

Untilreach

Target Vt

High

PressureLimit 5

PEEP


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1. R ,C

2. exponential curve

3.

4.

time cycling

PRVC

Adaptive Support Ventilation


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Adaptive Support Ventilation


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% support mintute ventilation

RR Vt WOB Vt PCV PSV

PCV time triggered PSV triggered

lung mechanic minuteventilation pressure 2 cmH2O target Vt


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APRV


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Role of the Nurse

Monitoring the patients respiratory status.

Keep an eye on any equipment required bythe patient, including ventilators andmonitoring equipment, and to respond tomonitor alarms.


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Operation and Maintenance

There should be a manual resuscitationbag at the bedside of every patientreceiving mechanical ventilation, so they

can be manually ventilated if needed. When mechanical ventilation is initiated,

the ventilator goes through a self-test toensure that its working properly.


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Operation and Maintenance

The ventilator tubing should bechanged every 24 hours and

another self-test run afterwards.

The bacteria filters should bechecked for occlusions or tears

and the water traps


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TROUBLESHOOTING


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TROUBLESHOOTING

Anxious Patient

Can be due to a malfunction of the ventilator Patient may need to be suctioned Frequently the patient needs medication for

anxiety or sedation to help them relax

Attempt to fix the problem Call your Doctor


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Low Pressure Alarm

Usually due to a leak in the circuit.

Attempt to quickly find the problem

Bag the patient and call yourDoctor.


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High Pressure Alarm

Usually caused by:

A blockage in the circuit (watercondensation)

Patient biting his ETT

Mucus plug in the ETT

You can attempt to quickly fix theproblem

Bag the patient and call for yourDoctor.

Low Minute Volume


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Low Minute VolumeAlarm

Usually caused by:

Apnea of your patient

(CPAP)Disconnection of the

patient from the ventilator

You can attempt to quicklyfix the problem

Bag the patient and call for

your Doctor.

id l b i


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Accidental Extubation

Role of the Nurse:

Ensure the Ambu bag is attached tothe oxygen flowmeter and it is on!

Attach the face mask to the Ambubag and after ensuring a good sealon the patients face; supply thepatient with ventilation.

Bag the patient and call foryour Doctor.

O


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OTHER

Anytime you have concerns,alarms, ventilator changes or

any other problem with yourventilated patient.

Call for your RT

NEVER hit the silencebutton!

Alarms and Common Causes


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Alarms and Common Causes

High PressureLimit

Low Pressure High RespiratoryRate

Low ExhaledVolume

Secretionsin ETT/airway orcondensation intubing

Kink in venttubing

Patient biting onETT

Patientcoughing, gagging,or trying to talk

Increased

airway pressurefrombronchospasm or

pneumothorax

Ventilatortubing notconnected

Displaced ETTor tracheostomytube

Patient anxietyor pain

Secretions inETT/airway

Hypoxia

Hypercabnia

Ventilatortubing notconnected

Leak in cuff orinadequate cuffseal

Occurrence ofanother alarmpreventing fulldelivery of breath

Extubation


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Extubation

The nurse should explain theprocedure to the patient andprepare suction. The patientshould be sitting up at least 45degrees.

Prior to extubating, the patientshould be suctioned both via the

ETT and orally. All fasteners holding the ETT

should be loosened.


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Extubation

A sterile suction catheter shouldbe inserted into the ETT and

withdrawn as the tube is removed. The ETT should be removed in a

steady, quick motion as thepatient will likely cough and gag.

P t E t b ti C


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Post-Extubation Care

Humidified oxygen

Respiratory exercises

Assessment and monitoring

Prepare for intubation

VAP P ti IHI B dl


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VAP Prevention: IHI Bundle

* Head of Bed (HOB) Elevation > 30

* Hand Hygiene* Nursing Sensitive Quality Indicator

Daily Sedation Vacations

Assess readiness to extubate

Peptic Ulcer Disease Prophylaxis

Deep Vein Thrombosis Prophylaxis(www.ihi.org/IHI/Programs/Campaign/VAP.htm )

VAP Prevention


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VAP Prevention

* Oral Hygiene:Inspection of oral cavity

Timed oral care

Toothbrushing

* Early Mobilization

* Nursing Sensitive Quality Indicator

Decontamination of Devices

Double Lumen Endotracheal Tubes(Fields, 2008)


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Acid-Base Imbalance


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Acid Base ImbalanceRespiratory Acidosis

Hypoventilation from primary lung problem Atelectasis

Pneumonia

Respiratory failure

Airway obstruction

Chest wall injury

Cystic fibrosis

Hypoventilation from other factors

Drug overdose Head injury

Paralysis of respiratory muscles

Obesity

Acid-Base Imbalance


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Acid Base ImbalanceRespiratory Alkalosis

Hyperventilation from primary lungproblem

Asthma

PneumoniaInappropriate ventilator settings

Hyperventilation from other factors

AnxietyDisorders of the central nervous

system

Documents

Mechanical Ventilation Nurse Icu