Respiratory Distress, Failure, Mechanical Ventilation

Respiratory Distress, Failure, Mechanical Ventilation

Respiratory Distress begins with

Ventilation and diffusion problems.

The respiratory compromise continuum

Distress --> Failure --> Arrest.

Signs of Respiratory Distress

DYSPNEA, tachypnea, Unable to speak, forward lean, Increased effort (nasal flaring, retractions, accessory muscle use, abdominal muscles) Inadequate effort (bradypnea, hypoventilation, Abnormal airway sounds (stridor, wheezing, grunting

Assessing respiratory distress may reveal etiology

Hemoptysis (pe/pulmonary edema), soot around mouth (smoke), chest pain (MI or PE) DVT (PE), tracheal deviations (tension pneumothorax)

Signs of Hypoxia

Skin color changes (cyanosis), Increased BP and tachycardia. (early SNS) Decreased BP and bradycardia. (late/fatigue) Cardiac arrythmias, Anxiety, confusion, restlessness, LOC change, Headache

Hypoxia Headache

compensation causes cerebral vasodilation

Hypoxia Patient Care

Elevate the head of the bed (HOB) Place oxygen. Assess the patient

Hypoxia Assess

Respiratory rate and effort, Breath sounds, Pulse oximetry and ABGs. Chest x-ray (CXR) labs? (CBC for infec, HgB o2 deivery, D dimer clotting) Etiology known? Tx available? (asthma nebulizer, Pul edema diuretic)

Simple mask

NEVER put less that 5 L (hypercapnic) 5-10 L/min

High Flow NC (vapotherm)

Heated, humified, up to 60L/min flow, 21-100% FiO2, proves PEEP

PEEP

Positive End-Expiratory Pressure (keep avioli open)

Pulse Oximetry accuracy

Waveform and Heart rate (needs to match EKG or pulse)

Pulse Oximetry Limitations

Perfusion(low BP or vasopressors), temperature, CO poisoning, Smoker, Elevated Hgb A1c (non o2 saturation) Reduced Hgb

Arterial blood gases (ABGs)

Resp Alkalosis (dyspnea short) Resp Acidosis (Co2 retained) , Metabolic Acidosis (poor perfusion lactic) Mixed Acidosis

PaO2

80-100 (dissolved in plasma)

SaO2

95-100 (attached to cells)

Respiratory distress Get help if needed!

Nursing staff, Respiratory therapy, Rapid response team, Call a code for respiratory arrest and begin rescue breathing, Possibly assist with intubation

Call a code for respiratory arrest and begin rescue breathing

Agonal breathing (is reflective) Bag-valve-mask (BVM) Ambu bag, Respiratory adjuncts (nasopharyngeal or oropharyngeal airway, nasal trumpet) DON’T over inflate , Can transport with an ambu bag and oxygen tank if needed

Rescue breathing

1 breath Q 5-6 seconds (10-12 BPM), ½ bag squeeze over 1 second,

Rescue breathing Consequences of over inflation?

hypotension(thorastic pressure decrease preload to heart), Aspiration(gastric inflation), hypoxia to brain

Respiratory Failure Criteria

Hypoxemia failure or hypercapnic failure

Hypoxemia failure

PaO2 less than 60 despite O2 delivery

hypercapnic failure

PaCO2 greater than 50, Ph leass than 7.35

Acute Respiratory Distress Syndrome (ARDS)

Multiple direct and indirect causes SEPSIS is the leading cause of ARDS.

ARDS pathophysiologic changes

Activation and release of inflammatory mediators, Compromise of the alveolar-capillary membrane, Fluid, protein, WBCs into the alveoli and interstitial spaces, Fibrotic changes, stiff/noncompliant lungs, Pulmonary htn and right sided heart failure, Reduction in Lt heart preload, reduced C.O. and BP, Tissue hypoxia and lactic acidosis

ARDS potential etiologies

Sepsis, pneumonia, Trauma and burns, Smoke inhalation, Pancreatitis, Shock, TRALI

TRALI (Transfusion-Related Acute Lung Injury)

Serious respiratory complication with specific ARDS criteria

Acute onset (less than 7 days) Refractory hypoxemia. PF ratio < 300 mm Hg, Diffuse bilateral infiltrates on CXR (“white out” or “ground glass”) Cardiac etiology for pulmonary edema ruled out. With Lt heart failure

ARDS criteria Cardiac etiology for pulmonary edema ruled out. With Lt heart failure

BNP and ECO to rule out CHF

PF ratio

PaO2 /FIO2 (decimal form)

ARDS Manifestations

Dyspnea (rapid onset, severe), tachypnea & other signs of distress. Chest pain possible. Fever and hypotension, Adventitious lung sounds, Cyanosis and other signs of hypoxia, Acidosis and elyte changes (K), Signs of Rt heart failure (edema, JVD)

ARDS hypotension

pressure ahead of R ventricle fatigue comprised preload low bp goes back into venous circulation leading to R HF

ARDS Patient Care Features

Ventilation management (Ventilator strategies, ECMO potential), Fluid volume maintenance (CVP < 4, PCWP < 8), PRBCs, Sputum Cx, possible Abx, Prone positioning , BP Support

ARDS Care Medications

Diuretics, Bronchodilators, Steroids, Inhaled Nitric Oxide (NO), Possible Neuromuscular blockade (NMB), Epoprosternol (veletri), PRBCs

ARDS BP Support

Inotropic drugs (dobutamine e.g.), vasopressors

ARDS Prone positioning

Maximal expansion of the diaphragm, increased blood flow and oxygenation via gravity to the anterior lungs, Labor intensive, risk for accidents, Contraindications (unstable spinal fractures), Don’t forget basics (nutrition, skin care, DVT prevention, GI protection)

Epoprosternol (veletri)

nubelized med reduces PVR, side effects – low BP and platelets

Mechanical Ventilation Basics

Oral endotracheal tube (OETT) or nasally inserted endotracheal tube (NETT) to ventilator for airway maintenance and support of ventilation.

Patients requiring mechanical ventilation for longer than 7-14 days will

have a tracheostomy placed (increased patient comfort and other benefits).

Ventilator Settings

Rate, Fraction of inspired oxygen (FIO2), Tidal volume, Continuous positive airway pressure (CPAP) or positive end expiratory pressure (PEEP), Pressure Support

Ventilator Rate

Number of ventilator breaths per minute. If no set rate, patient initiates every breath spontaneously.

Ventilator Tidal volume (vT or TV)

Volume of air the patient receives with each breath.

Ventilator Continuous positive airway pressure (CPAP) positive end expiratory pressure (PEEP)

first without a set vent rate, 2nd with a set vent rate, Increased intra-thoracic pressure (risk for pneumothorax, barotrauma, reduced cardiac output and BP) 5-15 cm H2O pressure

Ventilator Pressure Support (PS)

Pressure provided during inspiration. 5-30 cm H2O pressure

Ventilator Change in settings or mode?

Increase or decrease support as needed—based on patient assessment., Work with respiratory therapist and HCP., Changes made on ventilator per RT or RN (per hospital protocol), Document changes per protocol., Assess and monitor patients for response to changes., Possible ABG guidance

Ventilator Changes for respiratory acidosis?

Increase RR, TV, and pressure

Ventilator Changes for respiratory alkalosis?

Reduce RR, TV, and pressure

Patient Care for Ventilated Patients

HOB 30-45 degree per protocol, NPO, TPN or tube feeding. Hydration, GI protection, DVT prevention, Trach care and suction, Mouth care per protocol, Nebulized meds often per RT, Respond to ventilator alarms.

Patient Care for Ventilated Patients Sedation and Pain management

Pt has “Air Hunger” feeling, Pain/comfort assessment, possible Restraints

Patient Care for Ventilated Patients assess

Respiratory assessment Q 2 hrs and PRN Check ETT placement and vent setting per protocol. Clear oral secretions, ETT suction PRN , Monitor for ventilator acquired pneumonia (VAP) signs.

Ventilated Patients VAP Prevention

Oral care! (Q 2 hr swab, Q 12 hrs brush teeth!) HOB elevated., Subglottic secretion drainage., Turn patient as tolerated, DO NOT routinely instill saline into the ETT.

Be aware of “ALARM FATIGUE.” When responding,

assess the patient first, then problem solve ventilator issues. (Safety Alert)

ALARM when you’re just not sure

Rescue breath with ambu bag if necessary

Ventilated Low pressure Alarm

Disconnect, Apnea (may need to request a set RR), Cuff leak (if talking audible coughing)

Ventilated High pressure Alarm

Obstruction, Mucous plug, Biting (use bite block—oral airway), Coughing, Kink, Water collection, pneumothorax, breathing against vent

Mucous plug

suction if possible, if complete blocked, take out and put a new on or saline and push air (bronchoscopy later)

Ventilated PT always have at bed

An ambu bag and O2 source

Unplanned extubation prevention

Sedation and analgesia, Soft wrist restraints if necessary, Patient education and support, Family education

Unplanned extubation management

Rapid patient assessment. Re-intubation essential? Stay with the patient and call for assistance. Supplemental oxygen, Airway support--Rescue breath if necessary!

Assess readiness for extubation

Individualized, Patient capable of spontaneous breathing , Able to maintain “work of breathing?”, RT evaluates “weaning criteria.”, Sedation vacation

Prepare for extubation

DC sedation per protocol, Have suction available. Deflate cuff. RT or HCP extubates.

Post-extubation care

HOB elevated, Respiratory assessment, Limit speaking, teach ICS use Monitor Vital signs, Ability to clear secretions, Development of respiratory distress, Avoid patient transfer out of ICU too soon

Ventilator Modes CPAP

Patient initiates all breaths, Minimal vent support, often used during weaning process

SIMV (synchronized intermittent mandatory ventilation)

Set number of ventilator delivered breaths, Patient can breathe spontaneously above set rate, Pressure support for vent delivered breaths, Goal to wean vent breaths and pressure support

Assist-Control ventilation

Similar to SIMV mode, Pressure support for vent and patient initiated breaths, Helpful for respiratory muscle recovery

CMV (controlled mechanical ventilation)

ALL ventilator breaths are per ventilator, Patient requires chemical paralytic with sedation and analgesia

APRV (airway pressure release ventilation)

Spontaneous or vent delivered rate, High level of associated pressure, Inspiration is longer than expiration, “alveolar recruitment” is the goal