Professional Documents
Culture Documents
Ventilator The Basic Course
Ventilator The Basic Course
THE BASICCOURSE
HISTORY OF
VENTILATOR
MODERN VENTILATOR
INTRODUCTION
INDICATION FOR MECHANICAL VENTILATION
MECHANICAL VENTILATOR- WHAT IT IS ?
MECHANICAL VENTILATORS- CLASSIFICATION
VENTILATOR MODES
HOW TO INITIATE MECHANICAL VENTILATION?
VENTILATOR SETTINGS
NURSING CARE
SEDATION AND NEUROMUSCULAR BLOCKADE
ASSESMENT CRITERIA
WEANING AND EXTUBATION
FAILURE TO WEAN
METHODS OF WEANING
POST EXTUBATION CARE
P0ST-TEST EVALUATION
HANDS ON VENTILATOR
HANDS ON INTUBATING MANNIQUINE
VENTILATOR
THE BASIC
MECHANISM OF RESPIRATION
A mechanism for telling the body that it is time to breath:
This involves CO2 sensors in the brainstem, which signal diaphragmatic
movement via the cervical nerves.
Ventilation Failure
Oxygenation Failure
Failure to Ventilate
Is it
Central:
stroke
Spinal:
Failure to Oxygenate
Diffusion abnormality
Mechanical
Ventilator
What is it?
expiration is
passive
These arent
used
Mechanical
Ventilators
Classification
Either
Volume Controlled (volume limited, volume targeted) and Pressure Varia
or
Pressure Controlled (pressure limited, pressure targeted) and Volume Varia
or
Dual Controlled (volume targeted (guaranteed) pressure limited)
2) Cycling:
Time cycled - such in in pressure controlled ventilation
Flow cycled - such as in pressure support
Volume cycled - the ventilator cycles to expiration once a set tidal volu
has been delivered: this occurs in volume controlled vent
-If an inspiratory pause is added,
then the breath is both volume and time cycled
(contd)
3) Triggering:
what causes the ventilator to cycle to inspiration?
Ventilators may be
time triggered,
pressure triggered or
flow triggered.
Time: the ventilator cycles at a set frequency as determined by the
controlled rate.
Pressure: the ventilator senses the patient's inspiratory effort
Mandatory (controlled)
Assisted
5) Flow pattern:
Constant
Accelerating
a reservoir.
2. Loss of chest wall or lung compliance causes reduced FRC.
KEY-POINTS
3. Exhalation below FRC is active causing dynamic airway collapse,
trapping air in the alveoli (auto PEEP)
4. At residual volume it is not possible to empty alveoli of air further,
due to dynamic airway collapse (airway closure)
5. The closing volume (CV) is the point at which dynamic compression of the airways
begins.
6. Such airway closure occurs normally within FRC, and it is known as the closing
volume (CV).
With age and disease the CV moves into the tidal breathing range.
7. The CV increases with age, smoking, lung disease, and body position (supine >
erect).
8. Airway collapse increases the work of breathing and leads to ventilation-perfusion
mismatch
9. In mechanically ventilated patients airway collapse is prevented by applying
positive pressure
to the airway throughout the respiratory cycle CPAP/PEEP
10. PEEP/CPAP works by increasing FRC, maintaining alveolar recruitment facilitating
gas
exchange (and removal of CO2 and replenishment of O2), and
reducing the workload of breathing.
11. The patient requires sufficient PEEP to prevent alveolar de-recruitment, but not so
much PEEP
that alveolar over-distension, dead space ventilation and hypotension occurs.
12. The ideal level of PEEP is that which prevents de-recruitment of the majority of
alveoli,
while causing minimal over-distension.
13. Recruitment maneuvers are used to re-inflate collapsed alveoli, a sustained
pressure above
the tidal ventilation range is applied, and PEEP is used to prevent de-recruitment.
14. Auto-PEEP is gas trapped in alveoli at end expiration, due to inadequate time for
VENTILATOR
WAVE FORMS
Ventilator Waveforms
Airway pressure screen
Flow screen:
Flow
pattern
Ventilator
Modes
Ventilator Modes
Control Ventilation (CV)
Assist-Control Ventilation (A/C)
Synchronous Intermittent Mandatory Ventilation (SIMV)
Pressure Support Ventilation (PSV)
Positive End Expiratory Pressure (PEEP)
tidal
who
-HFV delivers a small amount of gas at a rapid rate (as much as 60breaths per minute.)
MODE
USE
FUNCTION
CLINICAL
Usually used for patients who
inspiratory efforts
breathing patient
with weakened
do so within preset amount of time
respiratory
muscles
mechanica
ventilation
with patients respiratory effort
Ventilation (SIMV)
weaning
patients inspiratory effort and
decreases the work of breathing
Positive End Expiratory Pressure
(PEEP)
opening collapsed
alveoli
MODE
Independent Lung Ventilation (ILV)
lung
FUNCTION
Ventilates each lung separately;
CLINICAL USE
Used for patients with unilateral
disease or different disease
process
In each lung
requires two ventilators and
sedation/paralysis
High Frequency Ventilation (HFV)
instability,
procedures, or if
pneumothorax
rapid rate (60-100 breaths/minute);
requires sedation/paralysis
Inverse Ratio Ventilation (IRV)
patients
Improves oxygenation in
who are still hypoxic even
with PEEP;
collapsing
inspiration; requires sedation/
paralysis
These are bag in bottle mechanical bellows which are controlled by three f
1) tidal volume, 2) respiratory rate, 3) I:E ratio.
Conventional anesthesia ventilator: the patient is delivered mandatory breaths from a bag in bottle ve
He can also draw unsupported spontaneous breaths from an in-line reservoir bag:
Pressure-assist ventilation
Pressure assist ventilation is pressure control without a set rate.
Patients take pressure controlled breaths at the rate of their choosin
and the volumes derived are determined by the pressure preset lev
the Ti and the flow demanded.
This is a very comfortable mode,
and is used in weaning from pressure control (the pressure limit is w
assist-controlled
If the flow rate is too high, the volume is rapidly delivered to only the
most compliant lung tissues (and not to the inelastic diseased ti
If the peak flow is too low, the patient will demand more gas than the
ventilator is set up to supply and dysynchrony with the machine oc
The inspiratory flow rate is measured in liters per minute, and it determines
how quickly the breath is delivered.
The time required to complete inspiration is determined by the tidal volume
delivered and the flow rate:
Ti = VT/Flow Rate.
controlled breaths
decelerating flow
pattern
assisted
breaths
Ventilation How
to Initiate
Mechanical
Ventilation
or
Monitoring:
blood pressure, ECG, pulse oximetry, end tidal CO2 (if available)
Options:
Ventilator
Settings
Ventilator Settings
Respiratory Rate (RR)
-The respiratory rate is the number of breaths the ventilator delivers
to the
patient each minute.
-The rate chosen depends on the
tidal volume
the type of pulmonary pathology
the patients target PaCO2.
-Obstructive lung disease, the rate should be set at 6-8
breaths/minute to avoid
the development of auto-PEEP
and hyperventilation
-Restrictive lung disease usually tolerate a range of 12-20
breaths/minute.
- Patients with normal pulmonary mechanics can tolerate a rate of 812Tidal Volume (VT)
breaths/minute.
-The tidal volume is the volume of gas the ventilator delivers to the
patient with
each breath.
-The usual setting is 5-15 cc/kg, based on compliance, resistance, and
type of
pathology.
-Patients with normal lungs can tolerate a tidal volume of 12-15 cc/kg,
-Patients with restrictive lung disease may need a tidal volume of 5-8
cc/kg.
Flow rate
-The flow rate is the speed with which the tidal volume is delivered. The
usual setting is 40-100 liters per minute.
Sensitivity/Trigger
-The sensitivity determines the amount of effort required by the patient to
initiate inspiration.
-It can be set to be triggered by pressure or flow
-Sigh
-The ventilator can be programmed to deliver an occasional sigh with a
larger tidal volume.
-it prevents collapse of the alveoli (atelectasis)
-Minute volume (VE)
Minute volume is the total volume of air inhaled and exhaled in one
minute. The patients minute volume should be less than 10 liters per
minute.
Ventilator Settings
The following is a summary of the settings that nurses deal with the
most.
SETTING
PARAMETERS
Respiratory Rate (RR)
breaths/mt
FUNCTION
Number of breaths delivered
USUAL
usually 4-20
usually 5-
21%-100% to
PaO2>60mmHg
SaO2>90%
Inspiratory:Expiratory
1:1.5
usually 1:2 or
High Pressure
Exhaled Volume
Low Pressure
Secretions in
tubing not
ETT/airway or
connected
condensation in
cuff or
tubing
seal
Kink in vent
Tubing
of
Patient biting on
alarm
ETT
Patient coughing,
breath
gagging, or trying
Low
-vent
pain
-secreations in ETT/
airway
- Hypoxia
- Hypercapnia
-Leak in
inadequate cuff
-Occurrence
another
preventing full
delivery of
Noninvasive
Forms
of
Mechanical
Ventilation
IPPB
for a
Bite block -If the patient has a bite block to prevent them from biting on
the tube, it must be removed and cleaned or replaced every
eight hours.
-If the tube is taped to the patients face, the tape must be
removed and replaced on the opposite side of the face at least
once per day .
-The amount of air in the cuff should be checked every eight
hours to ensure that the cuff is not exerting too much pressure
on the
trachea walls.
-ETT should be confirmed to be the same as prior to the
procedure
Sterile suctioning
- Suctioning should be performed only when the patient needs
it; the need should be assessed at least every two hours.
- Pre-oxygenation with 100% O2
- two separate suction catheters for oral and ETT
- size of suction catheter should be 1/3rd of ETT diameter
- Duration of each suction pass should be limited to ten seconds
-The number of passes should be limited to three or less
- saline installation should not be used routinely
Eyes
Eyes
This
is to avoid dryness of
cornea & subsequent
development of any ulceration.
Care of Bladder
Continuous bladder drainage
GIT Care
Oral
cavity examination
Abdominal Examination
Per Rectal Examination
Care to avoid
development of bed sore
Constant
changing position
of patient
Avoid pressure points
Alpha bed or Water bed
Psychological care
Good
communication
Alleviate anxiety and
promote emotional well
being
Orientation of patient to
surrounding, Time and
Persons
Sedation &
Neuromuscular
Blockade
Midazolam
Onset of action
Immediately
5-15 minutes
1-3 minutes
Half-life
hours
6-15 hours
1 hour
Loading Dose
mcg/kg
0.05 mg/kg
0.03 mg/kg
Propofol
1 minute
< 30 minutes
0.5 mg/kg
1.5-3
1
NEUROLEPTICS
-Given to patients who are experiencing delirium or
ICU psychosis.
Symptoms -disorganized thinking,
- audio and visual hallucinations, and
- disorientation.
Haloperidol - intravenously in 2-10 mg doses every 2 to 4 hours
ANALGESICS
Intravenous narcotics Morphine,fentanyl or hydromorphone
PARALYTICS AGENTS or neuromuscular blocking agents (NMBs)
- must always be administered with other sedatives and
narcotics
Two classes of NMBs:
intubation)
- Depolarizing
( Atracurium,Pancuranium,Vecuranium)
Assessment
Criteria
Assessment Criteria
Breath Sounds
- Breath sounds should be assessed at least every four hours
Crackles (rales)
Rhonchi
Wheeze
Pleural friction rub
Spontaneous Respiratory Rate and Tidal Volume
-If the spontaneous tidal volume is low
-the patient may not do well with weaning attempts.
-If the respiratory rate is high, particularly with weaning modes
indicate
-the patient isnt tolerating the mode,
-needs suctioning,
-or he or she is anxious or trying to communicate.
Pulse Oximetry
-The machine detects the percent of hemoglobin that is fully
saturated.
-pulse oximetry can be a helpful guide when titrating FIO2
-In general, a SpO2 of 92% in white patients, and 95% in black
patients
indicates adequate oxygenation (PaO2 > 60 mmHg).
CO2
Considered a measure of bicarbonate concentration; includes
total of
bicarbonate and carbonic acid.
Normal = 23-27 mEq/L
Base Excess/Deficit
Measures excess amount of acid or base present in blood. This is
independent of changes in PaCO2; therefore, its a measure of
metabolic
acid-base balance.
Increased HCO3 = base excess (alkalosis)
Decreased HCO3 = base deficit (acidosis)
PaO2
The amount of oxygen dissolved in plasma (about 3% of total; the
other 97% is bound to hemoglobin).
Normal is 80-100 mmHg in healthy young people breathing room
air at sea
level; this decreases with age and altitude.
PaO2 > 60 mmHg is considered acceptable in critically ill,
mechanically ventilated adults
Weaning and
Extubation
Objective measurements
Subjective clinical
assessments
Description
Adequate oxygenation (eg, PO2 >60 mm Hg on FIO2 > 0.4; PEEP <510 cm H2O;
PO2/FIO2 >150300);
Stable cardiovascular system (eg, HR <140; stable BP; no (or minimal) pressors)
INTOLERENCE TO WEANING
Increased HR
Increasrd RR (>30/mt)
Sweating (Hypercapnia)
Hypertension
Hypoxia
patient is tolerant
How do I know if the
intolerant of the trial?
Weaning / Discontinuation of
Mechanical Ventilation
Weaning / Discontinuation of
Mechanical Ventilation
No
Yes
FailuretoVentilate
Sit the patient up in the bed, suction out the
endotracheal tube, explain what you are
going to do and extubate the patient.
Failure to Oxygenate
Other Factors
Recurrent Failure
Consider Tracheostomy:
requiring excessive sedation to
tolerate
ETT
marginal mechanics
psychological dependence on
ventilator
mobility
airway trauma.
Normalization of inspiratory
times
Failure to Wean
Failure to Wean:
Is the patient able to ventilate?
Is the patient able to oxygenate?
What other factors influence weaning?
Neurological
Anatomical Problems
Diffusion abnormalities,
ventilation-perfusion mismatch,
dead space and shunt.
Certain factors may limit successful weaning
- persistent lower respiratory tract infection,
-alveolar edema,
-airway/lobar collapse,
-lung fibrosis.
-the nerves that supply the diaphragm (including the neuromuscular junct
-the muscles themselves.
-Moreover the patient must be willing to breath and maintain their own
functional residual capacity (not if there is diaphragmatic splinting due t
-There must be room in the abdomen for the diaphragm and lungs to mov
-There must be adequate hemoglobin to deliver oxygen to the tissues.
Methods of
weaning
Methods of weaning
There are three primary methods
T piece/CPAP trials,
T-piece/CPAP trials
-T-piece trials consist of alternating intervals of time on the
ventilator with
intervals of spontaneous breathing.
-T-shaped tube is attached
- endotracheal or tracheostomy tube.
- tubing is attached to an oxygen flowmeter
-the other end is open
-watch for signs of hypercapnia
Tachycardia
Tachypnoea
Sweating
Hypertension
CPAP
- With CPAP, the patient breathes spontaneously, but has the benefit
of the
ventilator alarms if he or she has difficulty.
- CPAP maintains constant positive pressure in the airways, which
facilitates gas
exchange in the alveoli.
SIMV
-SIMV is a ventilator mode that delivers a preset number of breaths
to the
patient but coordinates them with the patients
spontaneous breaths.
-The ventilator may be set to deliver 12 breaths per minute, but the
patients
respiratory rate may be 16 (12 ventilator breaths plus 4
patient-initiated
breaths).
-The ventilator rate is usually decreased by one to three breaths at a
time and
an arterial blood gas (ABG) is obtained 30 minutes after
the change
Pressure support
- Placing the patient on the pressure support mode at a level that
allows the
patient to achieve a spontaneous tidal volume of 10-12
ml/kg.
- During weaning, the level of PS is decreased by 3-5 cm H2O as
long as the
Weaning criteria
Simple bedside pulmonary function tests
Vital capacity (VC)
exhaled
minute.
Respiratory rate (RR)
-The respiratory rate is the number of breaths per minute.
The
patients RR should be less than 25
breaths/minute.
Arterial blood gas (ABG)
The PaO2
50% oxygen
Post Extubation
Care
Post-Extubation Care
Humidified oxygen
-Supplemental oxygen requires humidification to prevent drying
and
irritation of the respiratory tract and to facilitate
removal of secretions.
-oxygen delivered through a mask for a few hours after
extubation.
Respiratory exercises
-coughing and deep breathing.
-incentive spirometry exercises.
IPPB
-is used in some institutions to assist patients to take deeper
breaths,
especially after surgery.
-The IPPB machine is a pressure-cycled ventilator that delivers
compressed
gas under positive pressure into the
patients airway.