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Mechanical Ventilation

Mechanical Ventilation. H. Arthur Sadhanandham Medical ICU CMC, Vellore. Primary Function. To facilitate the movement of gas into the lungs. Goals :. To maintain adequate Oxygenation To maintain optimum Co 2 elimination To reduce the load of work of breathing

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Mechanical Ventilation

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  1. Mechanical Ventilation H. Arthur Sadhanandham Medical ICU CMC, Vellore

  2. Primary Function To facilitate the movement of gas into the lungs.

  3. Goals: • To maintain adequate Oxygenation • To maintain optimum Co2 elimination • To reduce the load of work of breathing • To regulate the rate of alveolar Ventilation

  4. MechanicalVentilation Non Invasive Invasive Non Invasive: Ventilatory support that is given without establishing endo- tracheal intubation or tracheostomy is called Non invasive mechanical ventilation Invasive: Ventilatory support that is given through endo-tracheal intubation or tracheostomy is called as Invasive mechanical ventilation

  5. Non invasive Negative pressure Producing Neg. pressure intermittently in the pleural space/ around the thoracic cage Positive pressure Delivering air/gas with positive pressure to the airway e.g.: Iron Lung BiPAP & CPAP

  6. Invasive Positive Pressure Pressure cycle Volume cycle Time cycle Pressure Cycle: A pre determined and preset pressure terminates inspiration. Pressure is constant and volume is variable. Volume Cycle: A pre determined and preset volume -on completion of its delivery , terminates the inspiration. Pressure is variable and volume is constant. Time Cycle: Delivers air/gas over a set time (Insp. Time) after which the inspiration ends. Example: Pressure Controlled ventilation

  7. MODES PCV ACV CMV SIMV PSV CPAP Intermittent Mandatory Ventilation (IMV) Synchronised intermittant mandatory ventilation (SIMV) CPAP Assist control ventilation (ACV) Controlled (CMV) FiO2 PEEP Conventional Modes Psup Tp Vt Ti Pinsp Rate Te @ Controls

  8. Non Invasive Invasive

  9. Continuous Positive Airway Pressure (CPAP) • Given through air tight mask/ ET/ Tracheostomy tube • Applies continuous positive pressure to the air way. • Tidal volume and Resp. Rate are patient dependent. • FiO2 & PEEP are to be set in the equipment.

  10. Assist Controlled Ventilation (ACV): • Delivers a preset tidal volume for every breath initiated by the machine • Or triggered through the patient’s effort

  11. Controlled Mandatory Ventilation (CMV) • Delivers a preset tidal volume / pressure at a preset rate, ignoring the patients own ventilatory effort.

  12. Intermittent Mandatory Ventilation (IMV): • Delivers a preset tidal volume at a preset rate while allowing the patient to breathe at his own rate and tidal volume in between. • Can cause breath stacking – because preset frequency of the machine may not occur in the same phase as the patient’s own efforts.

  13. Synchronised intermittent Mandatory Ventilation (SIMV):- • Delivers a preset, mandatory tidal volume. • Synchronised to the patient’s respiratory effort.

  14. SETTINGS Power O2 Air Ventilator Patient

  15. Initial Settings • Mode : SIMV with Pressure support (if available) • FiO2 : 1.0 (100%) • PEEP : 5 • Tidal Volume : 6-7 ml / kg • Rate : 10-15 / minute • Pressure support : 15 cm H2O / If flow assist: 0.5 sec • Alarms : Max Pressure : 35 cm of H2O : Min. pressure: 10 cm of H2O Special consideration in the settings should be shown to COPD and ARDS patients. ABG – After one hour and adjust the settings

  16. Remember that • PaO2 depends on FiO2 & PEEP • PaCO2 depends on Tidal volume & Rate In ICU, our primary aim is • To get a PaO2 of 60-90 mmHg & • PaCO2 of 30-50mmHg. • Ensure that plateau inspiratory pressure does not exceed 30cm of H2O ( risk of VALI – Ventilator Associated Lung Injury)

  17. Precaution & Care • Tracheobronchial Hygiene: • Placement of tube: Chest movement Auscultation Post intubation X-ray • Cuff pressure: If insufficient- Leak Displacement of the tube Aspiration If high pressure - Tracheal stenosis Desired Pressure - 20-30cm water

  18. Humidification Filling water & adjusting temperature appropriately : • If inadequate: secretions would become thicker and lead to tube block Medication: • Besides specific therapautic drugs the following basic drugs are to be given. • Sedatives & paralysing agents if needed. • Analgesics • Diuretics to reduce circulating fluid and volume overload • Reduce Gastric Acid: H2 blockers

  19. Suction • Should be done on PRN basis • Ascultate and assess • View the chest X-ray • Determine the need and for effective suctioning • Hyperoxygenation & ventilation – ambu/normal • Keep strict vigil on the cardiac monitor pulse oximeter during and soon after suctioning • If necessary carry out effective chest physio

  20. Monitoring: Continuous and Periodic monitoring of • Vital parameters such as temperature,SpO2, Pulse, BP,ECG pattern, breath rate etc. • Ventilator settings: All settings should be recorded – as per the doctors order • Sensorium • Intake and output • Level of comfort • Arterial blood gases – p r n or twice daily

  21. Nebulisation • It is advisable to put all the patients on bronchodilators on regular basis. • Nebulise as per the doctor’s order

  22. Injury during Mechanical Ventilation • Possibility of ventilator associated lung injury, baro-trauma, tracheal necrosis etc have to be detected in time and take appropriate action. • Use soft restrainers whenever necessary.

  23. Pain related to Mechanical ventilation & ET tube placement • Positioning of the tube, pulling of the circuits, in appropriate flow rates, sensitivity setting that requires patient’s greater efforts, etc. • Prevent all the above as much as possible.

  24. Eye & Mouth care • For unconscious patients eyes are kept closed by taping. • Goggles can also be used. • Regular & proper mouth care should be given.

  25. Monitoring for infection • Colour, consistency, and amount of the sputum / secretions with each suctioning should be observed. • Fever and other parameters have to closely observed for any other infection. (central line, etc)

  26. Oxygen toxicity • Try and maintain a SpO2 of > 90% and PaO2 of 60 – 90 mmHg with minimum possible FiO2 to prevent O2 toxicity. • Especially for COPD patients : Maintain SpO2 of 85 – 90% and PaO2 of 55 – 70 mmHg.

  27. Nutrition: • Enteral nutrition to support the patient’s metabolic needs and defend against infection. • Avoid high carbohydrate diet during weaning. NG tube if necessary – relieves gastric distension and prevents aspiration.

  28. Stress gastric ulcer • Very common in critically ill patients • Send stools for occult blood and gastric juice for pH estimation • Auscultate bowel movements • Sedation and antacids adequately.

  29. Alarms & Positioning: • Never keep alarm system muted • Never ignore even when you know the cause for the alarm and may not be fatal • Place the patient in low or semi Fowler’s position to improve comfort and facilitate respiration.

  30. Communication: • If conscious, explain the environment, procedures, co-operation expected etc. • Use verbal & non verbal methods • Use paper & pen if necessary • Provide calling bell if necessary • Reassurance and support the patient during the period of anxiety, frustration and hopelessness • Document patient’s emotional response and any signs of psychosis • Include family in the care

  31. Co-operation with medical and nursing interventions Certain breathing techniques The patient to recognize the importance of breathing techniques. Frequent assessment of consciousness level, adequate rest etc. are necessary. Teach……

  32. Weaning • Assess for readiness to wean. • Follow a clear cut protocol • Provide emotional support and decrease the patient’s fear and anxiety • Never try weaning at night • If weaning once failed ( fatigue, sweating, dyspneic etc..) do not attempt for the next 24-48 hours. • Once weaning is successful, switch over to T piece • Before extubation, do a leak test and cough test . • if the above tests are positive -extubate by following proper protocol

  33. Minimum expectations from a Ventilator • Ability to accurately deliver a tidal volume from 20 ml to 1000 ml • Ability to deliver the set volume or the set pressure against high resistance and / or low compliance • Ability to deliver low flow rates • Ability to deliver at the rate ranging from 2 – 60 /mt. • Ability to deliver set FiO2 accurately • Ensure it has a NIV mode

  34. Contd… • Ability to deliver with variable inspiratory and expiratory ratio. • Ability to maintain good humidification • Ability to apply effective PEEP & Pressure support. • Ease of sterilization • Quietness of Ventilator • Effective Battery back up

  35. Sterilisation and decontamination • After use, the patient circuit should be detached from the ventilator and disassembled to expose all surfaces prior to cleaning. • Thoroughly clean to remove all blood, secretions, thick mucus and other residue. • You may use multi enzyme cleaner. • Medical detergent solution can also be used to thoroughly to flush the tubings.

  36. Contd… • 2% Glutaraldehyde is used for routine sterilisation of tubings and other accessories. • Please follow manufacturer’s directions and recommendations. • Ethylene Oxide – gas sterilisation is also used. Ethylene oxide may cause superficial crazing of plastic components and will accelerate the aging of rubber components.

  37. Contd… • Ensure complete dryness of the tubes before sending for gas sterilisation as ethylene glycol may be formed which is poisonous. • After sterilisation, the tubings must be properly aerated to dissipate residual gas absorbed by the materials.

  38. Thank you

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