CARE OF PATIENT ON VENTILATORDr. Jayesh Patidar (PhD, M.Sc. Nursing)
MECHANICAL VENTILATORFunctions 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 ventilation1. Neuromuscular disease2. Central nervous system disease3. CNS depression4. Musculoskeletal disease5. Thoracic malformation/ trauma• Disorders of pulmonary gas exchange1. Acute respiratory failure2. Chronic respiratory failure3. Left ventricular failure4. Pulmonary disease resulting in difusion or perfusion abmornality
Volume- Cycled Modes of Ventilation Mode DefinitionControl Rate and volume of breaths are controlled by the ventilatorAssist-Control All breaths are ventilator assisted and deliver a preset tidal volume, including spontaneous breaths.Intermittent Mandatory Ventilations are delivered at a preset rate and tidal volume. Spontaneous breathsVentilation (IMV) can occur at the patients rate and tidal volume. SIMV is synchronized with the patientsSynchronized spontaneous breathing to reduce competitionIntermittent between spontaneous efforts and machine.MandatoryVentilation (SIMV).
Cont………Pressure Support Augments the patients inspiratory effort with aVentilation (PSV 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- PEEP is the addition of positive End-ExpiratoryExpiratory Pressure pressure to the airway at the end of Pressure(PEEP) (PEEP) expiration;Continuous CPAP is spontaneous breathing with a fixed amountPositive Airway of pressure applied to the airway throughout thePressure (CPAP). 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 Patients who have spontaneous ventilations andVentilation (IMV) need ventilator support. Patients who can initiateSynchronized Spontaneous ventilations with adequate tidalIntermittent MandatoryVentilation (SIMV) Volume but need a backup rate. Useful as a weaning mode with some patients.Pressure Support Those who have a stable ventilator drive andVentilation (PSV) can generate enough negative airway pressure (-20 to -25) to trigger the pressure support. Used as weaning mode, to augment patients spontaneous efforts, and decrease the work of breathing.
Cont………Positive End-Expiratory Increases FRC to decrease or preventPressure (PEEP) alveolar collapse.ContinuousPositive AirwayPressure (CPAP)
Trouble shoting alarams of ventilationDisplay Possible Cause RemedymessageHIGH Airway is higher than set Check client, Check circuitCONTINOU PEEP plus 15 cm H2O for Check ventilator setting andS more than 15 sec. alarm limit.PRESSURE Disconnected pressure Check ventilator internalCHECK transducer block pressure replace filter, remove waterTUBING transducer Water in from tubing Check heater expiratory limb. Wet bacterial wire. Refer to service. filter clogged bacterial filter. Kinked/blocked tubing. Check client, Check Mucus or secretion plug in ventilator setting and alarmAIRWAYS ETT or airways clientPRESSURE limit. coughing or fighting.TOO HIGH
Display Possible Cause RemedymessageLIMITED Kinked/blocked Mucus in Check client, CheckPRESSURE tubing coughing / fighting ventilator setting and alarm patient. limit. Increased client activityEXPRIED Check client Check trigger ventilator auto cycling. sencesitivity and alarmMINUTE Improver alarm setting lowVOLUME TOO setting. Dry the flow flow transducer. transducer.HIGH Low spontaneous client Check client cuff pressureEXPRIED breathing activity. LeakageMINUTE circuit pause time and in cuff. Improver alarmVOLUME TOO graphics. setting.LOW
Display Possible Cause RemedymessageEXPRIED MINUTE Flow transducer faulty Replace flow transducerVOLUME DISPLAY Circuit disconnected from connect Y piece toREADS client client.APNEA ALARM Time between two Check client and consecutive insperatory ventilator setting effort exceeds. Adult : 20 sec. Pead : 15 sec. Neonate : 10 sec Leakage in cuff and client Check cuff pressurePEEP/CPAP & OR circuit Improper alarm limit Check client circuitPLATEAV setting. check pause time andPRESSURE FAILSTO BE MAINTAIN graphics to verify consider more ventilatory support .
Care at patient on ventilator :-Endotracheal tube careFeedingHygieneAvoid bed sores byMaintain patients safetyRecords 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 activedisease 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.
ii) Ventilator related :-• Disconnection• Malfunctioniii) Suctioning related :- Hypoxemia Arrhythmiasiv) Ventilation related :- Nosocomial Infection Homodynamic effect Pneumothorax Oxygen toxicity Respiratory Alkalosis Increased I.C.P.
NURSING MANAGEMENTInability to sustain spontaneous ventilation related to imbalancebetween ventilatory capacity ventilator demand.Impaired gas exchange and ineffective breathing pattern related tounderlying disease process and artificial airways and ventilatorsystem.Ineffective airways clearance related to cough and increasedsecretions 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 respiratorytactAltered nutrition : Less than body requirements related to lack abilityto eat while on ventilator and increased metabolic needs.Impaired verbal communication related to mute sate when ET tube isin place.Altered oral mucous membranes related to nothing by mouth (NPO)status.