ces mechanical ventilators[1]

8/7/2019 Ces Mechanical Ventilators[1]

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MECHANICALMECHANICAL

VENTILATORSVENTILATORS


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MECHANICALMECHANICAL

VENTILATORSVENTILATORS

Mechanical VentilationMechanical VentilationNeed to control patients respirationsNeed to control patients respirations

To oxygenate the blood when the patients ventilatory efforts areTo oxygenate the blood when the patients ventilatory efforts are

inadequateinadequate

To rest the respiratory musclesTo rest the respiratory muscles

Indications for mechanical ventilationIndications for mechanical ventilationPatient has continuous decrease in oxygenationPatient has continuous decrease in oxygenation

Increase in arterial carbon dioxide levelsIncrease in arterial carbon dioxide levels

Persistent acidosisPersistent acidosis

= Breathing device that can maintain ventilation and oxygen

delivery for a prolonged period.


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Thoracic or abdominal surgery

Drug overdoseNeuromuscular disorders

Inhalation injury

COPD

Multiple trauma

Shock

Multisystem failure

Coma

Positive-pressure ventilator

Classification

Negative-pressure ventilator

Conditions


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= exerts a negative pressure on the external chest by

decreasing the intrathoracic pressure duringinspiration allows air to flow into the lung, filling its

volume

= similar to spontaneous ventilation

= for chronic respiratory failure associated with

neuromuscular conditions:

=does not require intubation of airway

= for home use

= contraindicated for patients condition: unstable or

complex patient or whose condition requires frequent

ventilatory changes

poliomyelitismuscular dystrophy

amyotropic lateral sclerosis

myasthenia gravis

Negative-Pressure Ventilator


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A negative-pressure

chamber used for

ventilation, works by

exposing the surface

of the chest wall to

sub-atmospheric

pressure. This

reduces the work of

breathing and

therefore relieves

respiratory distressin children with

severe breathing

difficulties.

Iron Lung ( Drinker Respirator Tank)


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= Requires a rigid case or

shell to create a negative-

pressure chamber around thethorax and abdomen.

Body Wrap (Pneumowrap) and Chest Cuirass (Tortoise Shell)


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= inflate the lungs by exerting positive pressure on the airwaybellow mechanism forcing the alveoli to expand during

inspiration occurs passively

= endotracheal intubation or tracheostomy is necessary

Positive-Pressure Ventilator

Classification

pressured- cycled

- Ends inspiration when a

preset pressure has been

reached, delivers a flow of airuntil it reaches a

predetermined pressure then

cycles off.


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volume-cycled

- The

volume of air to be deliveredwith each inspiration is preset,

once the volume is delivered to

the patient, the ventilator cycles

off and exhalation occurs

passively.

No -i v ive o itive

re ure ve til tio

- Given via face mas s

that cover the nose and mouth,nasal mas s or other nasal

devices.

- liminates the need

for endotracheal intubation

time-cycled

- Terminate or control

inspiration after a preset time,

the volume of air the patient

receives is regulated by the

length of inspiration and the

flow of rate of the air.


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MODEMODE DEFINITIONDEFINITION INDICATIONSINDICATIONS

Control Mode (CM)Control Mode (CM) Preset tidal volume and preset ratePreset tidal volume and preset ratedelivered to the client regardless of thedelivered to the client regardless of the

clients respiratory effort. Client cannotclients respiratory effort. Client cannot

initiate breaths or change theinitiate breaths or change the

ventilatory pattern.ventilatory pattern.

--Neuromuscular diseaseNeuromuscular disease

--Drug overdoseDrug overdose

--Reduction of work ofReduction of work ofbreathingbreathing

ContinousContinous

MandatoryMandatory

Ventilation (CMV)Ventilation (CMV)

Preset tidal volume at preset rate isPreset tidal volume at preset rate is

delivered to the client. The client candelivered to the client. The client can

initiate breaths that are delivered at theinitiate breaths that are delivered at the

preset tidal volumepreset tidal volume

--Reduction of work ofReduction of work of

breathingbreathing

-- Respiratory muscleRespiratory muscle

fatiguefatigue

--COPDCOPD

--PostanesthesiaPostanesthesia

SynchronizedSynchronized

intermittentintermittentmandatorymandatory

ventilation (SIMV)ventilation (SIMV)

Preset tidal volume at preset rate isPreset tidal volume at preset rate is

synchronized with the clientssynchronized with the clientsspontaneous breathing to reducespontaneous breathing to reduce

competition between machinecompetition between machine--

delivered and clientdelivered and client-- spontaneousspontaneous

breathsbreaths

--Primary ventilatory modePrimary ventilatory mode

--Used to wean clientsUsed to wean clientsfrom mechanicalfrom mechanical

ventilationventilation

Pressure supportPressure support

ventilation (PSV)ventilation (PSV)

Provides positive pressure during theProvides positive pressure during the

inspiratory cycle of a spontaneousinspiratory cycle of a spontaneous

inspiratory effort.inspiratory effort.

--Weaning clients in COPDWeaning clients in COPD

--Primary ventilatory modePrimary ventilatory mode

in higher pressuresin higher pressures


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MODEMODE DEFINITIONDEFINITION INDICATIONSINDICATIONS

airway pressureairway pressure

release ventilationrelease ventilation

(APRV)(APRV)

-- ventilator supplies a low level ofventilator supplies a low level of

CPAP alternating with a relatively highCPAP alternating with a relatively high

level ofCPAP; it can be coupled withlevel ofCPAP; it can be coupled with

pressure support. When used in apressure support. When used in apatient who is not spontaneouslypatient who is not spontaneously

breathing, this mode is no differentbreathing, this mode is no different

than pressure control ventilationthan pressure control ventilation

--potential for barotraumapotential for barotrauma

and overdistension isand overdistension is

reducedreduced

--venous return isvenous return ispreservedpreserved

--permits spontaneouspermits spontaneous

breathsbreaths

--better for postbetter for post--op andop and

mildly diseased lungs andmildly diseased lungs and

role in severe respiratoryrole in severe respiratory

failure is unclearfailure is unclear

Continuous PositiveContinuous Positive

Airway PressureAirway Pressure

(CPAP).(CPAP).

--A continuous level of elevatedA continuous level of elevated

pressure is provided through thepressure is provided through the

patient circuit to maintain adequatepatient circuit to maintain adequate

oxygenation, decrease the work ofoxygenation, decrease the work of

breathing, and decrease the work ofbreathing, and decrease the work of

the heartthe heart-- used with spontaneous breathingused with spontaneous breathing

CHF (LeftCHF (Left--sided heartsided heart

failure)failure)

positive endpositive end--

expiratory pressureexpiratory pressure

(PEEP)(PEEP)

-- functionally the same as CPAP, butfunctionally the same as CPAP, but

refers to the use of an elevatedrefers to the use of an elevated

pressure during the expiratory phasepressure during the expiratory phase

of the ventilatory cycleof the ventilatory cycle

-- when used with assistwhen used with assist--controlcontrolventilation, the term PEEP is usedventilation, the term PEEP is used

used in cases where theused in cases where the

FRC is reducedFRC is reduced

Adding PEEP can reduceAdding PEEP can reduce

the work of breathing (atthe work of breathing (at

low levels) and helplow levels) and helppreserve FRC.preserve FRC.


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VentilatorParametersVentilatorParameters

PARAMETERPARAMETER DEFINITIONDEFINITION VENTILATOR SETTINGVENTILATOR SETTING

Tidal VolumeTidal Volume

(V(VTT))

Amount of air inspired and expiredAmount of air inspired and expired

with each breathwith each breath

1010--15 ml/kg of body weight15 ml/kg of body weight

RespiratoryRespiratory

rate (RR)rate (RR)

Number of breaths delivered perNumber of breaths delivered per

minuteminute

1010--16 bpm16 bpm

Fraction ofFraction of

inspiredinspired

oxygen (FiOoxygen (FiO22))

Amount of oxygen the clientAmount of oxygen the client

receivesreceives

21 %21 % -- 100% to maintain PaO100% to maintain PaO22 6060--

80 torr80 torr

PEEPPEEP Positive pressure applied at endPositive pressure applied at end

expiration to improve oxygenationexpiration to improve oxygenation

+3 to 5 cm H+3 to 5 cm H22O may be used toO may be used to

approximate physiologicalapproximate physiological

PEEPPEEP

SighSigh Larger than normal breath toLarger than normal breath to

provide hyperinflation; helpsprovide hyperinflation; helps

prevent atelectasisprevent atelectasis

Usually twice the tidal volumeUsually twice the tidal volume

breath; about 10breath; about 10 --15 ml/kg15 ml/kg

Rate is usually set at 10Rate is usually set at 10--15 times15 times

per hourper hour

SensitivitySensitivity Determines the inspiratory effortDetermines the inspiratory effort

required to trigger the ventilatorrequired to trigger the ventilator

Set to respond to an inspiredSet to respond to an inspired

volume of less than 1% of thevolume of less than 1% of the

clients tidal volumeclients tidal volume


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PARAMETERPARAMETER DEFINITIONDEFINITION VENTILATOR SETTINGVENTILATOR SETTING

Peak Airway pressurePeak Airway pressure The maximal pressureThe maximal pressure

level required to deliverlevel required to deliverthe desired tidal volumethe desired tidal volume

< 40cm H< 40cm H22OO

I:E ratioI:E ratio Comparison ofComparison of

inspiratory (I) toinspiratory (I) to

expiratory (E) timeexpiratory (E) time

Normally set 1:1, 1:2, orNormally set 1:1, 1:2, or

1:3 (seconds)1:3 (seconds)

Exhaled minuteExhaled minute

ventilation (Vventilation (VEE))

Measures the exhaledMeasures the exhaled

minute ventilators inminute ventilators inlitersliters

Alarm set at 15% greaterAlarm set at 15% greater

than clients average Vthan clients average VEE(RR x Tidal Volume)(RR x Tidal Volume)


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INTUBATION


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Implementation

Verify physicians order for ventilator support. If the patient isnt already

intubated, prepare him for intubation

When possible, explain the procedure to the patient and his family to help

reduce anxiety and fear. Assure the patient and his family that staff members

are nearby to provide care.

Perform a complete physical assessment, and draw blood forABG analysis

to establish a baseline.

Suction the patient, if necessary.

Plug the ventilator into the electrical outlet and turn it on. Adjust settings

on the ventilator as ordered. Make sure the ventilators alarms are set as

ordered that the humidifier is filled with sterile distilled water.

Put on gloves and personal protective equipment.

Connect the endotracheal tube to the ventilator. Observe for chest

expansion and auscultate for bilateral breath sounds to verify the patient is

being ventilated.

Monitor the patients ABG values after the initial ventilator setup (usually

20-30 minute), after changes in ventilator settings and as patients clinical

condition indicates to determine whether the patient is being adequately

ventilated and to avoid oxygen toxicity.


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Check the ventilator tubing frequently for condensation, which can be

cause resistance to airflow and which may also be aspirated by the patient.

Drain the consedate as needed, but dont drain the condensate into the

humidifierbecause condensate may be contaminated with the patients

secretions.

Check the in line thermometer to make sure the temperature of the air

delivered is close to body temperature.

When monitoring the patients vital signs, count spontaneous breaths as

well as ventilator-delivered breaths.

Change, clean, or dispose of the ventilator tubing and equipmentaccordingly. (48-72 hours)


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Special Considerations

Provide emotional support to the patient during all phases of mechanical

ventilation to reduce anxiety and promote successful treatment.

Make sure the ventilator alarms are on at all times. These alarms alert the

nursing staff to potentially hazardous conditions and changes.

If an alarm sounds and the problem cant be identified easily, disconnect

the patient from the ventilator and use a handheld resuscitation bag to

ventilate him.

Unless contraindicated, turn patient from side to side every 1 to 2 hours to

facilitate lung expansion and removal of secretions.

Perform active or passive range of motion exercise for all extremities to

reduce the hazards of immobility.

If the patient conditions permits, position him upright at regular intervals

to increase lung expansion.When moving the patient or the ventilator tubing, be careful to prevent

condensation in the tubing from flowing into the lungs because aspiration of

this contaminated moisture can cause infection.


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Assess the patients peripheral circulation, and monitor his urine output for

signs of decreased cardiac output. Watch out for signs and symptoms of fluid

volume excess or dehydration.

Place the call light within the patients reach and establish a method ofcommunication board because intubation and mechanical ventilation impair

patients ability to speak.

Administer a sedative or neuromuscular blocking agent as ordered to relax the

patient or eliminate spontaneous breathing efforts that can interfere with the

ventilators action.

Patient receiving a neuromuscular blocking drug requires close observationbecause of his inability to breathe or communicate.

Make sure patient receives a sedative. Neuromuscular blocking agents cause

paralysis without altering the patient level of consciousness.

Reassure the patient and his family that paralysis is temporary

Ensure that the patient gets adequate rest and sleep because fatigue can delay

weaning from the ventilator.


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1) Patient in sync causing bucking the ventilator

Due to:

Anxiety

Hypoxia

Increased secretions

Hypercapnia

Inadequate minute volumePulmonary edema

Management:

Muscle relaxants

Tranquilizers

Analgesics

Paralyzing agentsProblems Regarding the Ventilator

Problems with Mechanical Ventilation

**Trouble shooting (_MS Word)


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Nursing Interventions1) Pulmonary auscultation

2) Interpretation of arterial blood gas measurements

3) Enhance gas exchange

=Assessment of patient for adequate gas exchange=Administration of analgesic agents

=Frequent repositioning

= Monitor adequate fluid balance

4) Promote effective airway clearance= Suctioning

=Chest physiotherapy

= Frequent position changes=Increased mobility

5) Prevent Trauma and Infection= Oral hygiene

= Position patient with the head elevated above the stomach as much as

possible6) Promote optimal level of mobility

=Active-range-of motion= Passive-range-of motion

7) Promote optimal communication

8) Promote coping ability

9) Monitor and manage potential complications

=Alternations in Cardiac Function

= Barotrauma and pneumothorax= Pulmonary Infection


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Respiratory weaning

-process of withdrawing the patient from dependence on the ventilator, takes

place in

three stages:

1. Patient is gradually removed from the ventilator

2. Patient is gradually removed from the tube

3. Patient is gradually removed from the oxygen

- started when the patient is recovering from the acute-stage of medical and

surgical problems

Weaning the Patient from the Ventilator


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Weaning from Tube-done when patient can breathe spontaneously, maintain an adequate

airway

Methods

First Method: Changing to a smaller size to increase the resistance to airflow and

simultaneously plugging the tracheostomy tube

Second method: Changing to a fenestrated tube (tube with opening or window in

its bend) that permits air to flow around and through the tube to the

upper airway and enables talking

Third Method: Switching to a smaller tracheostomy button

Weaning from the Oxygen

-patient who has been successfully weaned from the ventilator, cuff, and tube

has adequate respiratory function is then weaned from oxygen.

NutritionHigh fat diet

Adequate protein intake

Do not overfeed patient


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Complications of intubation:

1. early:

a) hypoxemia due to prolonged attempts

b) right mainstem intubation

c) intubation of esophagus

d) upper airway trauma

e) aspiration

f) hypotension immediately following intubation

2. late:

a) cuff leak

b) sinusitis

c) upper airway injury/stenosis

d) unplanned (self) extubation

Ventilator-related complications:1. disconnection

2. malfunction

Suctioning-related complications:

1. hypoxemia

a) patients should always be pre-oxygenated with 100% oxygen prior to suctioning

b) suction time should be limited2. arrhythmias

Complications of mechanical ventilation


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1. nosocomial infections

early removal ofNG tubes

hand washing

Semi-recumbant positioning of patient

adequate nutrition

avoid gastric overdistension

avoid nasal intubation (as opposed to oral intubation)

continuous subglottic suctioning

stress ulcer prophylaxis

2. hemodynamic effects:a) decreased cardiac output due to impaired venous return to the right heart and

increased pulmonary venous resistance due to positive pressure alveolar distension

b) autoPEEP

3. barotrauma

4. pneumothorax

5. oxygen toxicity

a) can occur as early as 24 hours after high oxygen exposureb) more frequent if the FiO2 is > 0.5

c) clinically resembles adult respiratory distress syndrome

d) very important to avoid since this often results in an inescapable vicious cycle of

high oxygen requirements ultimately resulting in fatal respiratory failure

6. respiratory alkalosis

7. increased intracranial pressure

8. atelectasis (especially the left lower lobe)

Ventilation-related complications:


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Just always rememberto:

M Make it a point

E Every time you give

C CareH Have the

A AMBU bag just next to you

N Note any deviations

I Implement what is needed

C Call the doctorA as soon asL Levels make tracks of up

and down because

V Ventilation

E entails a

N need

T toI inhale and exhale

L Like any other beingA absence of

O oxygen may

R result to DeathS SAYONARA in

short!

T this vital


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THANKS!!!

ces mechanical ventilators[1]

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