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By: Ms. Shanta Peter

Caring patient on Mechanical

Ventilator

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Indications for Mech. Vent

    

• PaO2 <50 mm Hg with FiO2 > 0.60• PaO2<50mmHg with pH <7.25• Vital Capacity <2 times TV• Negative inspiratory force < 25 cm, H2O• Respiratory >35/min  

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• Pt has continuous ↓in oxygenation (PaO2 )

• Increase in PaCO2• Persistent acidosis ( Decreased pH)• Abdominal/ Thorasic Surgery• Drug overdose• Neuromuscular disease• Inhalation injury• COPD• Pt with apnea –not readily reversible • Multiple trauma• Multi system failure• Coma All these will lead to Resp Failure

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Mechanical ventilator … Nursing Interventions

Unique technical and interpersonal skill

Assess patient first then ventilator

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GOAL• Patient will be supported on mechanical

ventilation without complication- then weaned , extubated . The complications will be detected, treated timely C/O patient on ventilator 

• Detection• Treatment• Prevention

Complications of Intubation &  Mech. 

Ventilation

Actual Patient Problems Eg .Infection

Ventilator Problems 

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Two important Nsg interventions while caring a patent on ventilator are :

Interpretation of ABG

& Pulmonary Auscultation

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General Nursing Interventions

• Assess for decreased cardiac output and administer appropriate Nursing Care

• Monitor for positive water balance – Pressure breathing may cause increase in ADH- Anti Diuretic Hormone and retention of water

• Auscultate chest for altered breath sounds-Take CVP /PCWP reading as ordered -Observe /assess for peripheral edema -Maintain accurate I & O-Assess Daily weights

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Nsg Intervention .… 

• Monitor for barotrauma – tension pneumothorax• Assess ventilator checking every 4 hrs• Auscultate breath sounds every 2 hrs • Monitor ABGs• Perform complete pulmonary-physical assessment

every shift• Monitor for GI problems- stress ulcer• Administer muscle relaxants . tranquilizers,

analgesics or paralyzing agents as ordered , to increase client machine synchronized by relaxing the client

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Gas Exchange

• Judicious administration of analgesics without suppressing the respiratory drive

• Frequent re-positioning – to diminish pulm. effects of immobility

• Monitor adequate Fluid balance – observe peripheral edema, I& O chart, weight

• Pot. side effects of medications

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Promoting Effective Airway Clearance

Positive pressure increase secretion • Auscultate lungs Q2-4 hrs• Suctioning – physiotherapy, position changes,

- not as scheduled – but clinically related Observe for barotrauma/ pneumothorax• Humidification – • Bronchodilators, mucolytic agents – dilate

bronchioles and liquefy secretions

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Preventing trauma and infection

• Maintain ET /tracheostomy tube – position ventilator --- no pulling on tube

• Monitor cuff pressure Q8hrly – 25cm H2O• Tracheostomy/tube care Q6hrs • More care to immuno compromised patients • Replace Vent Circuits/ inline suction tubing – as peer

policy• Oral hygiene • NGT and use of antacids—cause nosocomial

pneumonia from aspiration of tube feeding and gastric contents

• Semi-fowlers position

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Promote optimal level of mobility

• When stable -after weaning -- assist him to sit up in chair

• Mobility of muscle activity – stimulate respiration and improve morale

• Active /passive ROM exercise if bed bound – prevent muscle atrophy , contractures and venous stasis

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Promote optimal Communication

• Evaluate his abilities—Conscious?- can communicate ? he node or move hand ?

• Can he write? – right – left hand • Understand patient

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Promoting coping ability

• Encourage family to communicate – and verbalize fears

• Explain procedures every time to patient • Restore sense of control- encourage to

participate in his care • Inform his progress – if long time on vent • Stress reduction techniques – rubbing back ,

relaxation techniques ……………

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Nurse should assess /monitor the ventilator

• Check type of ventilator—Volume cycled, Pres Cycled, -ve pres

• Controlling mode- ( Controlled vent, A/C , SIMV)• TV and rate settings- ( TV is usually 10-15 ml/Kg , rate

12-16;lmt• FiO2 – (Fraction of inspired O2) – setting• Inspiratory pressure reached and pressure limit ( normal 15- 20 cm of H2O (This increase in conditions where there is increased Airway resistance or decreased compliance)• Sensitivity:( 2cm H2O Inspiratory force should trigger

the ventilator

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Ventilator…….• Insp to Exp Ratio(IE) usually 1:3 ( 1 second of insp to 3

sec of expiration) or 1:2• Minute Volume ( TV X RR ) usually 6-8 L/min• SIGH setting – usually 1.5 times the TV ..and range

from 1-3 /hr… if applicable • Tubing. Water in the tubing – disconnection or kinking

of the tubing • Humidification( Humidifier filled with water) and

temperature• Alarms ( Functioning properly) • PEEP and/or Pressure support level, if applicable PEEP

is usually 5-15 cm of H2O Observe for Complications

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BUCKING the Ventilator

Patient struggles out of phase of ventilator • Patient try to breathe out during the

ventilators inspiratory phase , or when there is a jerky and abd. muscle effort

Causes:• Anxiety, hypoxia, increased secretions

hypercarbia, inadequate minute volume , pulm edema…………….

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Bucking the ventilator …contd

Correct these problems before giving paralyzing agents …..otherwise the underlying problem will mask the condition and condition become worse• Muscle relaxants, tranquilizers, analgesics

and paralyzing agents are administered – to increase  Patient – machine synchrony

• Obtain Baseline ABG – To monitor progress of therapy

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ALARMS……Causes

High pressure alarms• Increased secretions in airway• Decreased A Way size due to wheezing or

bronchospasm• Displacement of ET tube• Obstructed ET tube – water/kink in tubing• Pt coughs gags, or bites the ET tube• Anxious pts – fights(Bucking) on VentLOW Pressure alarm• Disconnection /leak in the ventilator or airway cuff• Pt stops spontaneous breathing

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COMPLICATIONS

• Hypotension caused by +ve pressure – which increase intra thoracic pressure and inhibit blood return to heart

• Air leak • Airway obstruction • Respiratory complications…. pneumothorax, subcutaneous

emphysema due to +ve pressure (Barotrauma ), resp failure

• G.I alterations – stress ulcers bleeding • Malnutrition – if not supported • Infections• Muscular deconditioning• Ventilator dependence or inability to wean

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WEANING …………….The process of going OFF from ventilator dependence to spontaneous breathing 3 stages………pt gradually weaned from ------------• Ventilator• Tube• Oxygen

• Decision is made on the physiologic view point by the physician considering his clinical status.

• It’s a joined effort of Physician – Resp Therapist & Nurse

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Criteria for weaningThe ventilator capacities include—Ability to generate Vital Capacity of 10-15 ml/kg (The minimum required volume is usually range of 1000ml in adult)• A spontaneous resp. force at least 20 cmH20• PaO2 > 60mmHg with an FiO2 of < 40%• Stable vital signs ..When the• above ventilator capacity is adequate

CHECK →

Baseline Measurements • Vital Capacity• Insp . Force• Resp Rate • Resting TV• Minute Ventilation• ABG levels• FiO2

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Patient Preparation must consider patient as a wholeConsider factors that--• impair the deliver the O2 • impair elimination of CO2 • increase O2 demand ( sepsis, seizures, thyroid imbalance) • Decrease in pts over all strength ( Nutrition, Neuro- muscular

disease) Adequate psychological preparations • Pt need to know what is expected of them during procedure

Explain properly.. • Assure the availability of Nurses near him at all time to answer

his questions… • Often frightened --- reassure that they are improving and well

enough to handle his own spontaneous breathingProper preparation will reduce the weaning time

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Methods of WEANING

• There is NO BEST method – success depends on – • Adequate patient preparation ,• Available equipment, and• Interdisciplinary approach to solve problems

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Traditional method:• T-Piece trials( one or more)Used with short vent assistance ( <2 days) and pt is awake, alert and breathing without difficulty , good gag reflex, and hemo-dynamically stable • Pt breathes spontaneously with humidified O2• During the process pt is maintained on same or higher O2

Conc than when on vent

T- Tube (Brigg’s Adaptor) --15 mm connection – Connects O2 source to an artificial airway. ET, tracheostomy. • Recommended rate is 10L/min • Inspired O2 Conc 24-100%Caution: Clear secretions occlude T-Tube lead to suffocate

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When on T-piece – observe for signs & Symptoms of Hypoxia, increasing fatigue, manifested as:• Tachy cardia- PVCs, Ischemic ECC changes• Restlessness• RR > 35/mt • Use of accessory muscles for breathing• Paradoxical chest movement

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If tolerating T –piece trial……….ABG – 20mts after spont. breathing at a constant FiO2 ( Alveolar-Arterial equalization occur15-20mins)• If ABG↓—exhaustion--- hypoxia---→ hook

back to vent• Wean on and off(Pt who had prolonged vent support need gradual weaning process – even weeks) • Primarily weaned during day time and placed

back on Vent during night

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SIMV – Method In pts who – satisfies all criteria for weaning but cannot have spontaneous breathing for long time SIMV for weaning--- observe the following • Respiratory Rate • Minute Volume• Spont /Machine Breaths & TV• FiO2• ABG levels No deterioration on parameters--- adequate TV , vent resp gradually decreased-- then weaning is completePressure support is used as an adjunct to SIMV weaning – to support insp. pressure ,and boost the spontaneous breaths. PS is reduced gradually as pts strength increases

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Successful weaning is supplemented by intensive pulm care like---• O2 therapy• ABG evaluation• Pulse oxymetry• Bronchodilator therapy• Chest physio• Adequate Nutrition, hydration,

humidification, • Incentive spirometry

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Weaning from TubeET/TT removed only if following criterion met• Spontaneous ventilation is adequate• Pharyngeal and laryngeal reflexes are active• Pt maintain adequate airway and can

swallow, move the jaw clench teeth , voluntary cough is effective to bring out secretion

Before the tube is removed—a trail with nose/mouth breathing is done – Deflating cuff, using fenestrated tube etc  

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Weaning from O2• Pt successfully weaned---- and has adequate

respiratory function – weaned from O2FIO2 is gradually reduced until PO2 is in range of 80-100 mmHg while breathing in Room air • If R air PO2 less than 70 supplementary O2

recommended

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 • Long tern ventilated pt need aggressive-

judicious NUTRITIONAL support as Resp. musculature( Diaphragm & intercostal

muscles) quickly become weak or atrophied after a few days of Mech. Ventilation – especially if nutrition is inadequate, • High CHO diet increase CO2—thus

increase the work of breathing –

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What you know about OXYGEN supplies & accessories ?

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Central O2  supply Through bulk liquid O2 system which store O2 @-

34C (-29F) and deliver it as gas through wall outlets

Gas Cylinders

Compressed O2 : Non-liquefied gas @ 1800-2400 lbs /Sq inch @ 21C (70 F)

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40% -- @5-6 L/min

45—50% @ 6-7 L/min

55 –60% @ 7-10L/min

Flow rate must be set at least

5L/min to flush the mask.

21--24 % @ 1L/min

24--28 % @ 2L/min

28--32 % @ 3L/ min

32-- 36% @ 4L/min

36 – 40% @ 5L/min

40 – 44% @ 6L/min

FiO2 through Nasal Cannula

Simple FACE MASK

VENTI MASK : Delivers exact O2 Conc. between

20-40% --despite patient’s respiratory pattern

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Partial Re-Breather Mask 70-90% FiO2 is delivered at 6-15L/min• A flow rate high enough to maintain the bag

2/3rd full during inspiration is needed.• Make sure the reservoir bag do not twist or

kink – which result in a deflated bag

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GOAL:• Patient will be supported on mechanical

ventilation without complication- then weaned , extubated .

• The complications will be detected , treated timely

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Thank you All