Nursing Role in Preventing complications of MV

1. Nursing Role in Preventing complications of MV

2. Outline

3. Outline

4. Injuries to mouth, lips and oropharynx Avulsion of skin due to adhesive tape Pressure ulcers to the palate and oropharynx Trauma to the lips and cheeks from tube ties Injuries to the entrapped tongue Perioral herpes

5. Skin flap avulsion during extubation due to adhesive tape.

7. Endotracheal Tube Fixator

8. Slipped ETT

9. Chest X-Ray 3-4 cm

10. Correct ET Tube Placement

11. Correct ET Tube Placement • Secure ET tube in place, note the number • Sedate patient with appropriate MAAS • Avoid accidental, or self extubation

12. Laryngeal Inguries Laceration and hematoma in the left vocal fold during direct laryngoscopy. Exam performed with rigid telescope

13. Laryngeal Injuries Ulcerated lesion in the posterior glottic commissure soon after extubation. Exam performed with rigid telescope. Bilateral intubation granulomas inserted in the vocal apophasis. Exam performed with rigid telescope.

14. Laryngeal Injuries diffuse posterior erythema, edema and piled-up mucosa of inter-arytenoid area

15. Cuff Related Injuries Risk of mechanical complications Risk of aspiration

16. Postintubation stenosis Prince J S et al. Radiographics 2002;22:S215-S230

17. Tracheal and Glottic Stenosis Tracheal stenosis (exam performed with flexible nasofibroscope) Glottic stenosis (exam performed with rigid telescope).

18. Ulceration of the mucosa and cartilage, granulation tissue, and fibrous tissue

19. Tracheomalacia Tracheal collapse of more than 50% during expiration is diagnostic of tracheomalacia

20. AnapnoGuard The AnapnoGuard system detects air leakage from the lungs by measuring the CO2 level above the cuff. Detection of high CO2 levels above the cuff represents leakage

21. Sphygmomanometers

22. Minimum Leak Volume Technique • Air inflation of the tube cuff until the airflow heard escaping around the cuff during positive pressure breath ceases. • Place a stethoscope over larynx. Indirectly assesses inflation of cuff. • Slowly withdraw air (in 0.1-mL increments) until a small leak is heard on inspiration. • Remove syringe tip, check inflation of pilot balloon

23. Outline

24. Case Scenario • 64 year old male with history of COPD who presented with severe respiratory distress and required to be intubated and placed on CMV, VT of 650 ml and a rate of 24/min. • Immediately post intubation, his systolic blood pressure dropped from 132 mm Hg to 73 mm Hg.

25. Hypotension following MV

26. PPV vs. Spontaneous Ventilation 120 5 3 0 -3 10 0

27. PPV vs. Spontaneous Ventilation 110 5 3 0 -3 8 0

28. Effect of Lung Volume on Venous Return • No effect in Normal individual with PEEP less than 10 cmH2O • Major effect in patients with Dynamic Hyperinflation such as asthma and COPD, and in pre-existing pulmonary hypertension • Small changes in PVR can cause considerable hemodynamic compromise secondary to acute increase in PVR • Avoid air trapping in these patients

29. Symptoms of hemodynamic effects • Decreased cardiac output, decreased venous return • Observe for: • Decreased BP • Restlessness, decreased LOC • Decreased urine output • Decreased peripheral pulses • Slow capillary refill • Increasing Tachycardia

30. Outline

31. Ventilator-associated lung injury (VALI)

32. Atelectrauma: Repetitive alveolar collapse and reopening of the under-recruited alveoli Volutrauma: Over-distension of normally aerated alveoli due to excessive volume delivery Cytokines, complement, prostanoids, leukotrienes, O2- Proteases Ventilation-Induced Lung Injury (VILI) Biotrauma *Dreyfuss: J ApplPhysiol 1992

33. Pinsp = 40 mbar

34. Recognized Mechanisms of Airspace Injury Airway Trauma “Stretch” “Shear”

35. Gas ExtravasationBarotrauma

36. Barotrauma

37. Barotrauma

38. Barotrauma

40. Optimized Lung Volume “Safe Window” • Overdistension • Edema fluid accumulation • Surfactant degradation • High oxygen exposure • Mechanical disruption • Derecruitment, Atelectasis • Repeated closure / re-expansion • Stimulation inflammatory response • Inhibition surfactant • Local hypoxemia • Compensatory overexpansion Zoneof Overdistention Injury “Safe” Window Zone of Derecruitment and Atelectasis Volume Injury Pressure

41. Diseased Lungs Do Not Fully Collapse, Despite Tension Pneumothorax And they cannot always be fully “opened” Dimensions of a fully Collapsed Normal Lung

42. Outline

43. Oxygen Toxicity : FIO2 > 60 % for > 24h Oxygen Carbon dioxide Water vapour Nitrogen • Absorptive atelectasis • O2/N2 = 21/79>>>>>> 50/50 • Accentuation of hypercapnia • Chronic respiratory failure: PCO2 with PO2 • Damage to airways • Bronchopulmonary dysplasia • Diffuse alveolar damage

44. Diffuse Alveolar Damage

45. Oxygen toxicity Reduce FiO2? • PEEP • Alveolar recruitment maneuvers • Alternative modes of ventilation • Inverse-ratio , APRV, HFV, ….. • Inhaled nitric oxide (iNO) • Extracorporeal membrane oxygenation (ECMO) • Diuresis • if pulmonary edema is possible • Bronchopulmonary hygiene • if secretions are prominent • Augmentation of antioxidants??

46. Outline

47. Path to VAP

48. Ventilator Associated Pneumonia: Definitions • VAP – ventilator associated pneumonia • >48 hours on vent • Combination of: • CXR changes • Sputum changes • Fever, ↑ WBC • positive sputum culture • Occurs secondary to micro-aspiration of upper airway secretions

49. Risk Factors for VAP • No 1 risk factor is endotracheal intubation • Factors that related to cross contamination: • Poor adherence to infection control standards • Factors that enhance colonization of the oropharynx &/or stomach: • Poor oral hygiene • Conditions favoring aspiration into the respiratory tract or reflux from GI tract: • Supine position • NGT placement • Re-Intubation and self-extubation • Surgery of head/neck/thorax/upper abdomen • GERD • Coma/ depressed Glascow coma scale

50. Chest X-Ray: VAP