Mechanical Ventilation for PT Module 3

What are some reasons for mechanical ventilation?

Assist with work of breathing
Increase available oxygen
Decrease carbon dioxide
Protection of airway
Surgery

What are some patient populations that may require ventilation?

ARDS
Head injury or stroke
Trauma patients (>2 rib fractures, > 65)
Surgeries
Cardiac Arrest
Drug Overdose
Neonatal Respiratory Distress Syndrome
Pneumonia
Sepsis

What is a mechanical ventilator?

Machine that blows air, or air with increased O2, through tubes into the patient’s airways

What is an Endotracheal Tube (ETT)?

A tube that goes through the patient’s mouth and into the windpipe

What is a Nasogastric (NG) tube?

A tube that goes through the patient’s nose and into the stomach

What is a Tracheostomy?

Surgical opening (stoma) in the neck and trachea to provide an airway

What are some Tracheostomy Tube Types?

Metal
Plastic
Cuffed
Cuffless

What is the difference between cuffed vs cuffless tracheostomy tube?

Cuffed: secure, prevents air leaks, for mechanical ventilation
Cuffless: lower risk of suffocation, allows leak speech, higher aspiration risk

How does mechanical ventilation work?

Air flowing to the patient passes through a humidifier, which warms and moistens the air. Exhaled air flows away from the patient

What settings can ventilators be found?

Acute care
SNF
LTACH
Home
School systems

What are the two main types of mechanical ventilation

Invasive vs Non-Invasive

What are examples of Invasive Mechanical Ventilation?

Artificial Airway
ETT, trach

What are examples of Non-Invasive Mechanical Ventilation?

Nasal or facial mask
BiPAP or CPAP

What is a “trigger”

Mechanism that initiates the inspiratory phase, signaling/causing a breath to be delivered by vent

What is “flow rate”

Speed at which the vent breath is delivered (L/min)

What is “frequency”

Number of breaths over time (Ex. 10 breaths per minute)

What is “spontaneous breath”

Taking a breath without assistance from the vent

What is a Controlled Mechanical Ventilation (CMT) or “total support”

The vent delivers all the breaths at a preset frequency, volume/pressure or flow rate. patients do not take spontaneous breaths

Why might a Controlled Mechanical Ventilator (CMT) be used?

When patients are sedated or paralyzed

What is an Assist Control (AC) or “partial support of ventilation”

Vent has a preset pressure of volume, frequency, and flow rate and no spontaneous breathing can occur. The patient can trigger the machine to deliver another breath, but must be between machine-cycled breaths

What is a Synchronous Intermittent Mandatory Ventilation (SIMV)

Vent with a present number of minimum breaths that still provides volume or pressure support, and allows spontaneous breaths between mandatory breaths
(Ex. If set to 10 breaths per minute but patient has only taken 8, it will trigger 2 more)

What are some benefits to a Synchronous Intermittent Mandatory Ventilation (SIMV)?

If the patient is getting fatigued, the machine will help and take over for them where they lack

What is Pressure Support Ventilation (PSV)?

Spontaneous breaths only; trigger present amount of inspiratory support until flow rate reaches minimal level of preset pressure in the airway

In a Pressure Support Ventilation (PMV) what does the patient control?

Frequency, tidal volume and inspiratory time

True or False: PSV is often seen as the first step of weening

True

Which ventilator mode delivers breaths at set rates and pressures, with no spontaneous breaths allowed

Controlled Mechanical Ventilation

Which ventilation mode allows patients to trigger extra breaths but no spontaneous breathing, with the machine fully supporting the volume/pressure

Assist Control Ventilation

Which ventilation mode provides a set number of mandatory (minimum) breaths while still providing volume or pressure support, allowing spontaneous breaths between mandatory breaths

Synchronous Intermittent Mandatory Ventilation

What is the difference between SIMV and Assist Control?

In AC, all breaths fully supported (even spontaneous ones)
SIMV spontaneous breaths are not fully supported

What ventilation mode is spontaneous breaths only, patient triggered, and pressure-limited

Pressure Support Ventilation

What are the most common alarms we may hear?

High pressure**
Low pressure
Low FiO2
Apnea
Disconnection
Volume

True or False: The higher the PEEP, the more worried we are about tube disconnection and lungs being open to outside pressure

True

What does a “High Pressure” alarm mean?

More than preset pressure is needed to deliver the volume of ventilation

What are some possible reasons for a “High Pressure” alarm to go off?

Check for secretions
Check tubing for possible occlusions from compression or excessive water
Patient experiencing bronchospasm or holding their breath

What would a “Low Pressure” alarm mean?

May signify a leak or disconnection, so the patient is not being ventilated

Before mobilizing a patient, what are some things we should take note of?

When was patient intubated?
Check for trends of ventilation
Check for water collection in tubing
Check of adequate slack in tubes
Oral intubation requires more sedation than trach

For mobilizing patients, what values should the PEEP and FiO2 be?

PEEP <12 and FiO2 <60

What are some signs that a patient is NOT tolerating the ventilator?

Desaturation
Requiring change in vent settings, pressure support settings, or FiO2
CO2 retention

True or False: Endotracheal tubes are fine for in-bed and out-of-bed exercises

True

True or False: Tracheostomy tubes are fine for in-bed and out-of-bed exercises

True

True or False: An FiO2 level greater than 0.60 is fine for in-bed and out-of-bed exercises

False; caution

What should the oxygen saturation be for in-bed or out-of-bed exercises?

Greater than or equal to 90%

What should the respiratory rate for a patient to be fine with in-bed and out-of-bed exercises?

Less than or equal to 30 bpm

For a patient to participate in in-bed and out-of-bed exercises, what should the PEEP value be?

Less than or equal to 10

Mobilizing patients _____ hours after mechanical ventilation may be optimal for improving clinical outcomes for mechanically ventilated patients

48-72

Why is mobilizing our patients on mechanical ventilation important?

Decreases ICU-acquired weakness
Reduce duration of ventilation
Move secretions
More likely to discharge home

What are some potential barriers to mobilizing patients?

Time
Family Members
Space in the ICU
Not enough hands to help you
Nurse/RT buy in
Not enough chairs/equipment

When preparing to suction a patient, what three phases should be considered?

Preparation before Suctioning
Actual Suctioning Procedure
Post Suctioning

What is an Open Suctioning System?

Disconnecting the ventilator tubing and suctioning

What is a Closed Suctioning System?

Done directly in-line with the ventilator tubing

Difference between left mainstream and right mainstream aspiration?

Left: use Coude tip catheter
Right: straight catheter usually sufficient

What positioning should be done for suctioning in patients with a Nasotracheal and/or Pharyngeal tube? Tracheostomy and/or Endotracheal?

Naso/Pharyng- Fowler or Semi-Fowler
Trach/Endo - Supine

How long should the suctioning duration be? Why?

No longer than 5-10 seconds to avoid hypoxia. Prolonged suctioning can precipitate dysrhythmia or cardiac arrest

What vacuum settings should be put for suctioning?

The lowest possible setting because higher settings are at greater risk for trauma to the tracheal mucosa

True or False: The catheter should be moistened in sterile saline or gel

True

What are some complications for suctioning?

Hypoxia
Cardiac Dysrhythmia
Bronchospasm
Infection

How can Hypoxia occur from suctioning?

Oxygen is removed from the airways which could lead to tissue hypoxia.

Why should we pre-oxygenate the patient before suctioning?

To prevent hypoxia

How can we prevent Cardiac Dysrhythmia from occurring during suctioning?

Hyper-oxygenate the patient prior and discontinue if it occurs to allow for patient stabilization

How can we prevent Bronchospasms from occurring during suctioning?

Administer bronchodilators before suctioning

How can we prevent Infections from occurring during suctioning?

Maintain sterile techniques with gloves and a sterile catheter

For Nasopharyngeal airways, why is aggressive suctioning sometimes indicated?

If a patient is in comatose, it lessens trauma of frequent passage of a catheter

Why is suctioning so important?

Removes secretions that would obstruct airways

How big should the suction be?

No larger than half the diameter of the tube opening (or it could occlude airway fully)

If a patient has excessive mucus, what sounds might we hear?

Coarse, rattling sound

If a patient has peripherally located fluid, what sounds might we hear?

Fine, bubbling sound

What are the steps of a general suctioning procedure for an artificial airway?

1. Hyperoxygenate with 100% oxygen for 3-5 breaths with bag

2. Place patients neck in extension

3. Place catheter without suction upward and backward until the obstruction (carina) is reached

4. When obstruction is reached, the patient will generally cough

5. Pull catheter back slightly from the carina (1cm), and apply suction no more than 120 mm Hg as catheter is withdrawn in rotating motion

6. Aspiration time should be within 10-15 seconds total

7. Allow patient to rest for several seconds and preoxygenate again

8. Check breath sounds and repeat if necessary

9. Suction the pharynx

10. Observe the patient and monitor of any dysrhythmias

11. Use pulse oximetry to monitor desaturation