When the Ventilator Alarm Sounds SANTANILLA
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Transcript of When the Ventilator Alarm Sounds SANTANILLA
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When the Ventilator Alarm
Sounds: Troubleshooting theIntubated PatientJairo I. Santanilla, MD
Section of Critical Care MedicineOchsner Medical Center
&Clinical Assistant Professor of MedicineSection of Emergency Medicine
Section of Pulmonary/Critical Care Medicine LSUHSC New Orleans
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Disclosures
No Conflicts of Interest to Disclose
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Goals and Outline
Provide a framework for troubleshooting themechanically ventilated patient
Focus on the Cardiac Arrest/Near Arrestpatient and the Near Stable/Stable patient
Like ACLS and ATLS, this is a framework Bedside clinical judgment supersedes Often perform several steps in tandem, instead
of in sequence.
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Determine Hemodynamic
Stability
Evaluate US andCXR
Check Respiratory
Mechanics and Waveforms
Check Gas Exchange
Focused History and
Physical Exam
Hand Ventilate with 100% Oxygen
Look for unequal chest riseListen for air-leak and unequal breath soundsFeel for difficulty to ventilate and crepitus
Disconnect from
Ventilator)
Stable/Near StableCardiac Arrest/Near Arrest
Evaluate Sedation
Likely Auto-PEEP
Check Settings and
Ventilator
Check Settings
and Ventilator
Determine that the ETT is functioning and in
proper position
Direct Visualization orPass Suction Catheter or Pass Intubating Stylet
Rush of Air,
Improvement
Improvement,
Unclear if Auto-PEEP
No Improvement
No Improvement
Special Procedures:
Ultrasound, CXR,
Needle Decompression
Evaluate for ETT position
adjustment, exchange, or
re-intubation
Improvement
ETT NOT functioning or
NOT in proper position
ETT functioning & in
proper position
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When you hear the alarms
Look at the patient and the monitor Try not to focus on the vent
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Determine Hemodynamic Stability
All intubated patients are critically ill Some more than others
How stable is the patient?
How quickly is the patient deteriorating? How much time do I have to find cause and
address problems?
Cardiac Arrest/Near Arrest Near Stable/Stable
SBP > 90
Pox > 90%
SBP < 70
POx < 70%
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Troubleshooting
During your evaluation, pt may transitionfrom stable to unstable and back and
forth. If unsure start with Near Arrest Be flexible in your thoughts and actions Constantly add to your differential and
re-arrange most likely choice
Keep in mind condition that necessitatedintubation, pt may simply be worseningfrom this.
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Cardiac Arrest/Near Arrest
Time is of the essence Disconnect patient from vent This can be diagnostic and therapeutic A quick rush of air or prolonged
expiration of air can diagnose and treat
Auto-PEEP (within a few seconds)
Success = Return of hemodynamicstability
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Hand Ventilate with 100% O2
Look for unequal chest riseDDx: Pneumothorax, mucus plug, mainstem
intubation Listen for air escaping from around the
ETT or through the nose (air leak)
DDx: Extubation, Pilot balloon or cuff failure Listen over the epigastrium and both
axilla
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Hand Ventilate with 100% O2
Feel the ease of hand ventilationStiff lungs can be due to mucus plug,
bronchospasm, pneumothorax, auto-PEEP,decreased respiratory system compliance
Feel for subcutaneous crepitusSearch for pneumothorax
Keep respiratory rates 8-10 bpm
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Determine ETT is Functioning
and in Proper Position Direct Visualization
DL or visualize carina with fiberoptic scope Pass the suction catheter
Easy: may or may not be in proper positionDifficult: ETT is dislodged, obstructed, twisted, or
pt biting.
Gently pass GEB or Eschmann introducerResistance should be met at approx 30 cmPassage without any resistance implies esophagus
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Procedures
After disconnecting from vent, handventilating, and checking proper placement:
Consider Tension PTX and need for needledecompressionFocused Hx, Physical ExamBedside US, CXR if time permits14g, 5cm over-the-needle catheter preferredRequires subsequent chest tube placement
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Near Stable/Stable Patient
Focused History Focused Physical Exam Check Gas Exchange Check Respiratory Mechanics Observe Waveforms Evaluate CXR and Ultrasound Evaluate Sedation
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Focused History Indication for intubation Difficulty of intubation
Useful if you need to re-intubate Depth of ETT Vent Settings Recent Procedures or Moves
New central line, thoracentesis, chest tube orattempts. Chest tube removal or water seal.
ETT manipulation, bed transfer, rotation,movement
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Focused Physical Exam
General survey Is patient agitated, gasping for breaths (air
hunger), tearing?Hand ventilate, talk to pt, consider sedation/
analgesia
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Focused Physical Exam
Airway Look, Listen and Feel to Evaluate ETT
position and function
Look if ETT is deeper or shallower thandocumented
Listen and Feel if there is an air-leakFeel the pilot balloon
If flat, add air at 1-2 ml aliquotsPass the suction catheter, direct visualization,
or GEB/Eschmann
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Endotracheal Tube
Pilot Balloon
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Focused Physical Exam
BreathingLook for unequal chest rise
Look for disconnected circuit, oscillatingwater
Listen for air-leakListen over the epigastrum and axillaFeel for ease of ventilation and crepitus
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Focused Physical Exam
CirculationCheck pulses, cycle BP cuff, check a-line
waveform and transducer levelBradycardia may be due to hypoxia,
propofol, precedex
Fluid bolus +/- vasopressor
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Asses Gas Exchange
Pulse oximeter is adequate to determineoxygenation
Waveform should correlate with HRPulse Ox may have 20-30 second lag time
Hypercapnia will be missed by POx If in doubt, place on 100% FiO2 andobtain ABG
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Check Respiratory Mechanics
Check Peak and Plateau PressuresObtain in Volume-Targeted modes
Peak Pressures are a function of tidal volume,resistance to airflow and respiratory systemcompliance
Plateau Pressures are obtained during aninspiratory pause, thus no airflow.
Plateau Pressures are a function of tidalvolume and respiratory system compliance
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Time (sec)
Paw
(cm
H2O)
PEEP
Inspiratory Hold
Pplat
Pressures
Ppeak
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Pearls
Plateau Pressure can never be higherthan peak pressure
If the Plateau Pressure increases, so willthe Peak pressure
Measurements are not reliable in thebucking patient
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Time (sec)
Paw
(cmH
2O)
Same Pplat
Increased Ppeak
Increased Peak Pressure
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Increased Peak Pressures
(increased resistance to airflow)
Biting on ETT
Obstruction of ETT by secretions,mucus, blood
Twisted/kinked ETT Bronchospasm/Reactive Airway Disease Partial bronchial mucus plugging Increased Plateau Pressures
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Time (sec)
Paw
(cmH
2O) Increased Pplat
Increased Ppeak
Increased Plateau Pressure
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Observe Ventilator Waveforms
Notching in the pressure-time or flow-time waveforms
Double or triple stacking Inadequate exhilation of tidal volume
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Time (sec)P
aw
(cm
H2O
)
Negative pressuredeflection showing air
hunger
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Time (sec)Flow
(L/min)
Time (sec)
Flow
(L/min)
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Normal
PatientInspiration
Expiration
Time (sec)Flow(L/min)
Air Trapping
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Evaluate CXR and US
ETT Position Mainstem intubation Atelectasis Pneumothorax Worsening parynchemal or pleural process
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Aspiration Major Trauma
Abdominal Sepsis Pneumonia
ARDS
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Ultrasound
Seashore Sign Barcode Sign
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Evaluate Sedation
SedativesPropofol, Precedex, Ketamine, BenzodiazepinesSometimes less is moreGoal is not a comatose patient
AnalgesicsFentanyl, Hydromorphone, Morphine
Treat underlying conditionPain is under appreciated
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Five Most Common Vent Alarms
High Pressure Low Pressure Apnea Circuit Disconnect High Exhaled Tidal Volume
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High Pressure Alarm
CoughingSuction, ensure ETT is above carina, nebulized
lidocaine, opiates
Biting on the ETT Decreased Lung Compliance Increased Secretions Alarm set too low
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Apnea Alarm
No inspiratory trigger by patient ormachine in a set time (usually 20 sec)
Flow greater than patient effort Alarm time interval set too short
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Circuit Disconnect
ETT disconnected from ventilator circuit Circuit disconnected from ventilator
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High Exhaled Tidal Volume
Increased compliance Decreased resistance In-line aerosol treatment increasing
volume
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Special Considerations
ChildrenETT migrate in/out with flexion/extension
Place C-collar to stabilize head positionMost intubating stylets and fiberoptic scopes are
too large for pedi tubes
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Tracheostomy
If trach dislodged, quickly decide if you willorally intubate or replace through stoma
Determine reason for trachLaryngectormy (imposible); Difficult AirwayMost are for chronic respiratory failure
Determine Age of TrachLess than 1 week, immature, high risk for creating false
tract Gently place 6.0 ETT through stoma
Stop if resistanceConfirm with fiberoptic
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Case 1
POx improves slightly and BP remains steady You quickly determine that you have timePlaced back on vent (same alarm)
Focused Hx: pt had been intubated forpneumonia, no recent moves or procedures, easyairway, ETT secured at 22cm
Focused Exam: ETT same position, pilot balloondeflated. Volume added but remains deflated.Suction catheter passes easily. ETCO2 has goodwaveform, VTE is 200 ml, set at 500
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Determine that the endotracheal
tube is in the tracheaIntubating styletDirect visualizationFiberoptic scope (if time allows)Be prepared to re-intubate
Re-intubation is
required
Feel the pilot balloon.
Note if it is deflated
Add air (2-5ml) to the pilot balloon. If this stops
the air-leak, document that air was added to the
balloon
Determine the ability to repair the pilot balloonmechanism with commercially available kit
If air leak persists, the pilot balloon does not inflate or the
pilot balloon deflates with time and the air leak returns with
time, there is a defect in the pilot balloon-cuff apparatus or
endotracheal tube has migrated out of the trachea
If air leak persists after repair or repair
not possible, the endotracheal tube will
need to be replaced
Determine Hemodynamic
Stability
Stable/Near StableCardiac Arrest/Near Arrest
Not in the trachea
Dealing withAir Leak
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Case 2
Called to bedside because change is status Pox 82% (95%), BP 90/45 (110/65), HR 130s
(110), Vent Alarming High Pressure
Disconnect from ventNo rush of air and no quick improvement
Hand Ventilate with 100% O2Mild resistance to Bag, Equal Chest Rise and
decreased BS on Left , no audible air-leak, no crepitus
DDx: : Pneumothorax, mucus plug, mainstemintubation
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Case 2
POx and BP improve You quickly determine that you have timePlaced back on vent (same alarm)
Focused Hx: pt had been intubated for COPD,no recent moves or procedures, easy airway,ETT secured at 21cm
Focused Exam: ETT same position, pilotballoon inflated. Suction catheter passes easily.ETCO2 has good waveform
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Whole Lung Atelactasis
Recruitment ManeauversHand Ventilate, Provide PEEP
Suctioning Rotate Patient Chest Percussion Bronchodilators Bronchoscopy
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Case 3
Called to bedside, pt is Crashing POx 85,80,70poor waveform HR 120s140s; BP 70s/palp No Time. Disconnect no improvement Hand Ventilate, Look, Listen, Feel. No
leak, equal distant BS bilaterally, nocrepitus. Difficult to bag. (decreasedcomplaince). Pilot ballon inflated.
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Case 3
GEB meets resistance at 28cm (ETT inplace)
Continues to decline, about to arrest
Fluid bolus by pressure bag Decision time is current issue due to
ventilator or not? Such a rapid declineimplies auto-PEEP, tension PTX, ETT notfunctioning or dislodged, atelectasis, PE,or bleed
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Case 4
Called to bedside because pt worsening Pox 80% , BP 80s systolic and HR 130s Disconnected from vent and prolonged
expiration with air rush from ETT.
POx and BP improveAuto-PEEP(breath-stacking, dynamic hyperinflation,intrinsic PEEP)
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Auto-PEEP
Look for causes: high set respiratory rate,high intrinsic rate (AC), obstructive airwaydisease
Monitor flow-time waveform Consider bronchodilators Consider decreasing tidal volume and
respiratory rate in patients with RADDecreasing set RR, ineffective in patients with highintrinsic rate while on volume-targeted AC
Optimize sedation, esp opiates