CARE OF PATIENT ON VENTILATOR

Dr. Jayesh Patidar

(PhD, M.Sc. Nursing)

MECHANICAL VENTILATOR

Functions for below thorasic cage & diaphragm. It can maintain ventillation automatically for prolonged time. It is indicated in patient who unable to maintain safe level of oxygen or CO2 by sopntanous brathing even with assistantance.

INDICATIONS• Mechanical failure of ventilation 1. Neuromuscular disease

2. Central nervous system disease

3. CNS depression

4. Musculoskeletal disease

5. Thoracic malformation/ trauma

• Disorders of pulmonary gas exchange1. Acute respiratory failure

2. Chronic respiratory failure

3. Left ventricular failure

4. Pulmonary disease resulting in difusion or

perfusion abmornality

Mode DefinitionControl

Assist-Control

Intermittent Mandatory

Ventilation (IMV)

Synchronized Intermittent

Mandatory

Ventilation (SIMV).

Rate and volume of breaths are controlled

by the ventilator

All breaths are ventilator assisted and

deliver a preset tidal volume, including

spontaneous breaths.

Ventilations are delivered at a preset rate

and tidal volume. Spontaneous breaths

can occur at the patient's rate and tidal volume.

SIMV is synchronized with the patient's spontaneous breathing to reduce competition between spontaneous efforts and machine.

Volume- Cycled Modes of Ventilation

Cont………

Pressure Support Ventilation (PSV

Augments the patient's inspiratory effort with a

selected amount of inspiratory pressure. This

pressure is maintained throughout the inspiratory

cycle, allowing the patient to select rate, tidal volume,

And timing. May be used in conjunction with SIMV

and CPAP.

Positive End-Expiratory Pressure (PEEP)

PEEP is the addition of positive End-Expiratory

pressure to the airway at the end of Pressure (PEEP)

expiration;

Continuous

Positive Airway

Pressure (CPAP).

CPAP is spontaneous breathing with a fixed amount

of pressure applied to the airway throughout the

respiratory cycle

Mode Recommended UseControl Anesthetized or paralyzed patients with no

spontaneous respiratory efforts.

Assist - control Patient who are able to initiate spontaneous ventilations, but require greater tidal volume than they can generate.

Intermittent Mandatory Ventilation (IMV) Synchronized Intermittent Mandatory Ventilation (SIMV)

Patients who have spontaneous ventilations and

need ventilator support. Patients who can initiate

Spontaneous ventilations with adequate tidal

Volume but need a backup rate. Useful as a

weaning mode with some patients.

Pressure Support Ventilation (PSV)

Those who have a stable ventilator drive and

can generate enough negative airway pressure

(-20 to -25) to trigger the pressure support. Used

as weaning mode, to augment patient's

spontaneous efforts, and decrease the work of

breathing.

Cont………

Positive End-Expiratory

Pressure (PEEP)

Continuous

Positive Airway

Pressure (CPAP)

Increases FRC to decrease or prevent

alveolar collapse.

Trouble shoting alarams of ventilation

Display message

Possible Cause Remedy

HIGH CONTINOUS PRESSURE

CHECK TUBING

AIRWAYS PRESSURE TOO HIGH

Airway is higher than set PEEP plus 15 cm H2O for more than 15 sec.

Disconnected pressure transducer block pressure transducer Water in expiratory limb. Wet bacterial filter clogged bacterial filter.

Kinked/blocked tubing. Mucus or secretion plug in ETT or airways client coughing or fighting.

Check client, Check circuit Check ventilator setting and alarm limit.

Check ventilator internal replace filter, remove water from tubing Check heater wire. Refer to service.

Check client, Check ventilator setting and alarm limit.

Display message

Possible Cause Remedy

LIMITED PRESSURE

EXPRIED MINUTE VOLUME TOO HIGH

EXPRIED MINUTE VOLUME TOO LOW

Kinked/blocked Mucus in tubing coughing / fighting patient. Increased client activity ventilator auto cycling. Improver alarm setting low flow transducer.

Low spontaneous client breathing activity. Leakage in cuff. Improver alarm setting.

Check client, Check ventilator setting and alarm limit.

Check client Check trigger sencesitivity and alarm setting. Dry the flow transducer.

Check client cuff pressure circuit pause time and graphics.

Display message

Possible Cause Remedy

EXPRIED MINUTE VOLUME DISPLAY READS

APNEA ALARM

PEEP/CPAP & OR PLATEAV PRESSURE FAILS TO BE MAINTAIN

Flow transducer faulty Circuit disconnected from client

Time between two consecutive insperatory effort exceeds.

Adult : 20 sec.

Pead : 15 sec.

Neonate : 10 sec

Leakage in cuff and client circuit Improper alarm limit setting.

Replace flow transducer connect Y piece to client.

Check client and ventilator setting

Check cuff pressure Check client circuit check pause time and graphics to verify consider more ventilatory support .

Care at patient on ventilator :-

Endotracheal tube care

Feeding

Hygiene

Avoid bed sores by

Maintain patients safety

Records and reports

WEANING :- Weaning is the word used

to describe the process of gradually removing the patient from ventilator and restoring spontaneous breathing after a period of mechanical ventilator.

Criteria For Weaning Trial :-- Respiratory criteria :-

Minute ventilation < 15/Lmin

Respiratory rate < 38 breaths / min

Tidal volume > 325 ml

Max inspiratory pressure < -15 cm H2O

FiO2 < 50%

Other Criteria :-

Improvement, correction or stabilization of the active

disease process.

Nutritional and fluid balance maintained

Adequate physical strength & mental alertness.

Stable cardiovascular, renal & cerebral status.

Optimal level of alertness blood gases electrolytes, hemoglobin & other laboratory tests.

Steps of weaning :-

A B G Evaluation

CPAP mode

T- piece

Extubation :- Do suctioning Give chest physiotherapy & nebulization keep crash cart & Intubations tray ready Remove ETT, do suctioning & nebulization & oxygenation.

Non invasive ventilator if required.

Oxygen by mask.

Continue monitoring in each step.

COMPLICATIONS OF VENTILATION :-

i) Intubetion Realated :-Early :-

HypoxiaRight mainstem intubationOesophagal intubation Upper airway trauma Hypo-tension Aspiration

Late :-Cuff leak, sinusitisUpper airway stenosisSelf extubation

ii) Ventilator related :-• Disconnection• Malfunction

iii) Suctioning related :-HypoxemiaArrhythmias

iv) Ventilation related :-Nosocomial InfectionHomodynamic effectPneumothoraxOxygen toxicityRespiratory AlkalosisIncreased I.C.P.

NURSING MANAGEMENTInability to sustain spontaneous ventilation related to imbalance between ventilatory capacity ventilator demand. Impaired gas exchange and ineffective breathing pattern related to underlying disease process and artificial airways and ventilator system.Ineffective airways clearance related to cough and increased secretions formation in the lower tracheobronchial tree from ET tube.Anxiety related to dependence on CMV for breathing.High risk for complication of CMV and positive pressure ventilation (PPV). Risk for infection related to impaired primary defenses in respiratory tactAltered nutrition : Less than body requirements related to lack ability to eat while on ventilator and increased metabolic needs. Impaired verbal communication related to mute sate when ET tube is in place.Altered oral mucous membranes related to nothing by mouth (NPO) status.