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8/8/2019 Mechanical Ventilation Nurse Icu
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Mechanical Ventilation:Principle & Practice
.
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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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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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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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Recruitment maneuver
Localized lung diseases
Increased intracranial pressure recruitmentmaneuver
RM
ARDS RM/
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Recruitment maneuver
volume control ventilation monitor Paw Ppl (derecruitment ) Ppl
= reatelectasis Pressure control : monitor Vt
40/40
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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Phramongkutklao college of Medicine
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)
8/8/2019 Mechanical Ventilation Nurse Icu
109/111
Phramongkutklao college of Medicine
Acid-Base Imbalance
8/8/2019 Mechanical Ventilation Nurse Icu
110/111
Phramongkutklao college of Medicine
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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111/111
Acid Base ImbalanceRespiratory Alkalosis
Hyperventilation from primary lungproblem
Asthma
PneumoniaInappropriate ventilator settings
Hyperventilation from other factors
AnxietyDisorders of the central nervous
system