Ventilator Mekanik.pptx

Ventilator Mekanik

Peran dan fungsi perawat pada pasien dengan respirator mekanik

By MAS YOESZ’

Review System Pernafasan Airway management Mengenal Terminologi ventilasi Mekanik Tatalaksana Ventilasi Mekanik Mode Ventilasi Mekanik Trobleshoting Ventilasi Mekanik Weaning Peran Dan Fungsi Perawat Modalitas Perawatpada Pasien Dengan Respirator Mekanik

POKOK BAHASAN

MEMBUKA JALAN NAPASMEMBERIKAN TAMBAHAN OKSIGENMENUNJANG VENTILASIMENCEGAH ASPIRASI

TUJUAN PERLINDUNGAN AIRWAY

EndotrachealTube

1. INFANT ATERM, ID 3,5mm, PANJANG 12 cm

2. ANAK, ID : 4 + , PANJANG 14 +

3. DEWASA : ◦ ID WANITA 7 –7.5, PANJANG 20 -24◦ ID LAKI-LAKI 7.5 -9, PANJANG 20 -24

Ukuran ETT :

Umur4

Umur4

Masih ingat

Masih ingat?

Ingatkah……

PROSES MEKANIK, KELUAR MASUKNYA UDARA DARI LUAR KE DALAM PARU DAN SEBALIKNYA YAITU BERNAFAS

TERJADI ANTARA UDARA DALAM ALVEOLUS DENGAN DARAH DALAM KAPILER, PROSESNYA DISEBUT DIFUSI

PROSES RESPIRASI PROSES RESPIRASI

VENTILASI PARU

PERTUKARAN GAS

EKSTERNA EKSTERNA

INTERNA INTERNA

UTILISASI O2

PERTUKARAN GAS

PEMAKAIAN OKSIGEN DALAM SEL PADA REAKSI PELEPASAN ENERGI

PERTUKARAN GAS ANTARA DARAH DENGAN SEL JARINGAN/TISUE

MEKANISME INSPIRASI

KONTRAKSI DIAFRAGMA & INTERKOSTALIS EKST

VOLUME INTRATORAKS >>

INTRAPLEURAL PRESSURE >> NEGATIF

PARU EKSPANSI (MENGEMBANG)

INTRAPULMONAL PRESSURE >> NEGATIF

UDARA MENGALIR KE DALAM PARU

VENTILASI PARUVENTILASI PARU

HUKUM BOYLEHUKUM BOYLE PRESSURE DARI GAS BERBANDING TERBALIK DGN VOL CONTAINER

VOLUME

PRESSURE

VOLUME

PRESSURE

PERUBAHAN VOLUME MENYEBABKAN PERUBAHAN PRESSURE

TABRAKAN PARTIKEL2 GAS

KE DINDING KONTAINER

MENIMBULKAN PRESSURE


VENTILASI PARUVENTILASI PARUINSPIRASIINSPIRASI

KONTRAKSI OTOT INTERKOSTALIS EKSTERNA IGA TERANGKAT

KONTRAKSI DIAFRAGMA DIAFRAGMA BERGERAK INFERIOR

EKSPIRASIEKSPIRASI

RELAKSASI OTOT INTERKOSTALIS EKSTERNA IGA KE POSISI SEMULA

RELAKSASI DIAFRAGMA DIAFRAGMA BERGERAK KE POSISI SEMULA

INTRATORAK

VOLUME

PRESSURE

VOLUME

PRESSURE

Terminologi Ventilator Mechanic

AIRWAY RESISTANCE (RAW)

AIRWAY RESISTANCE (RAW)

COMPLIANCE (COMPL)

COMPLIANCE (COMPL)


CL

RAW

LUNG

AIRWAY

– Membatasi jumlah gas yg mengalir melewati jalan nafas (obstruksi jalan nafas)

– Flow = pressure/resistance

– Jika R Flow

– Ditentukan oleh besarnya diameter jalan nafas

– Pada nafas spontan, jika resistance me , secara normal respon tubuh adalah meningkatkan usaha nafas (WoB = RR >>, otot bantu nafas >>)

AIRWAY RESISTANCE (RAW)AIRWAY RESISTANCE (RAW)

FLOW = PRESSURE

RESISTANCE

BRONKUS NORMAL


FLOW = PRESSURE

RESISTANCE

BRONKODILATASI: EPINEFRINAMINOFILINBETA 2 AGONIS


FLOW = PRESSURE

RESISTANCE

BRONKOKONSTRIKSI: HISTAMIN

OBSTRUKSI: MUKUS/SEKRET


FLOW = PRESSURE

RESISTANCE

BRONKOSPASME

TUMOR/SEKRET

ETT TERLALU KECIL

KOLAPS/ATELEKTASIS


Kaku Elastis

LOW COMPLIANCE

HIGH COMPLIANCE

BALON

COMPLIANCE (COMPL)COMPLIANCE (COMPL)

DefinisiRasio perubahan volume akibat terjadinya perubahan

pressure V/PTerbagi 2;

Compl paru (edema paru, fibrosis, surfactan <<) Compl dinding dada (obesitas, distensi abdomen)

Low compliance ◦ Edema paru, pneumonia berat, ARDS, efusi pleura,

hematopneumotoraks, abdominal pressure >>: u/ memasukkan volume yang diinginkan dibutuhkan pressure yg lebih besar.

High compliance◦ Muscle relaxant, COPD, open chest dgn pressure yg

kecil dapat tidal volume yg masuk besar

COMPLIANCE (COMPL)COMPLIANCE (COMPL)

P-V LOOP

15

30

250

500

0

P

Vol

500

500

250

250

15

30

15

30

LOW COMPLIANCE

HIGH COMPLIANCENORMAL

PEEP 5

INSPIRASI

EKSPIRASI

NAFAS SPONTAN

SHUNT DAN DEAD SPACE

ANATOMICAL DEAD SPACE

ALVEOLAR DEAD SPACE

PHYSIOLOGICAL DEAD SPACE

VENOUS ADMIXTURE (SHUNT)

V/Q =

V/Q > 1

V/Q = 1

V/Q < 1

V/Q = 0

Hubungan Ventilasi (V) dan Perfusi (Q)Hubungan Ventilasi (V) dan Perfusi (Q)

TRAKEA

KAPILER PARU MECHANICAL

DEAD SPACE:

TUBE

CONNECTOR

ET CO2

BREATHING CIRCUIT

NORMAL

FiO2 :

FRAKSI KONSENTRASI OKSIGEN INSPIRASI YG DIBERIKAN (21 – 100%)

TIDAL VOLUME (VT):

JUMLAH GAS/UDARA YG DIBERIKAN VENTILATOR SELAMA INSPIRASI DALAM SATUAN ml/cc ATAU liter. (5-10 cc/kgBB)

FREKUENSI / RATE (f) :

JUMLAH BERAPA KALI INSPIRASI DIBERIKAN VENTILATOR DALAM 1 MENIT (10-12 bpm)

FLOW RATE :

KECEPATAN ALIRAN GAS ATAU VOLUME GAS YG DIHANTARKAN PERMENIT (liter/menit)

- Menentukan siklus respirasi - Jika setting RR pd ventilator 10 x/menit

maka 60/10 = 6 dtk- Jadi T (Total) = T (Inspirasi) + T (Ekspirasi) = 6 dtk

- Berarti inspirasi + ekspirasi harus selesai dalam waktu 6 dtk.

6 dtk 6 dtk

Ins + Eksp

Ins + Eksp

T I M E = WAKTU frekuensiT I M E = WAKTU frekuensi

Sensitivity

Setelan sensitifitas akan menentukan variabel trigger Variabel trigger menentukan kapan ventilator mengenali adanya

upaya nafas pasien Ketika upaya nafas pasien dikenali, ventilator akan memberikan

nafas Variabel trigger dapat berupa pressure atau flow

Pressure Triggering

Upaya nafas pasien dimulai saat terjadi kontraksi otot diafragma

Upaya nafas ini akan menurunkan tekanan (pressure) di dalam sirkuit ventilator (tubing)

X X

Pressure Triggering

Ketika pressure turun mencapai batas yang diset oleh dokter, ventilator akan mentrigger nafas dari ventilator

Namun tetap ada keterlambatan waktu antara upaya nafas pasien dengan saat ventilator mengenali kemudian memberikan nafas.

Baseline

Trigger

Patient effort

Pressure

Pressure Triggering

1. Setelan sensitivity pada -2 cm H2O

2. Gambar dibawah menunjukkan pada 2 nafas pertama upaya nafas pasien mencapai sensitivitas yang diset; sedangkan gbr ketiga terlihat bahwa upaya nafas pasien tidak mencapai sensitivitas yg diset sehingga ventilator tidak mengenalinya

-2 cm H2O

Flow Triggering

Ventilator secara kontinyu memberikan flow rendah ke dalam sirkuit pasien (open system)

Delivered flowReturned flow

No patient effort

Flow Triggering

1. Upaya nafas dimulai saat kontraksi diafragma2. Saat pasien bernafas beberapa bagian flow didiversi ke

pasien

Delivered flowLess flow returned

Flow Triggering

1. Level flow yg rendah akan lebih nyaman untuk pasien (lebih sensitif)

2. Keterlambatan waktu lebih kecil dibanding pressure trigger3. Meningkatan respon waktu dari ventilator

All inspiratory efforts recognized

Time

Pressure

PEEP

DEFINISI◦POSITIVE END EXPIRATORY PRESSURE◦SEWAKTU AKHIR EXPIRATORY, AIRWAY

PRESSURE TIDAK KEMBALI KETITIK NOL DIGUNAKAN BERSAMA DENGAN MODE

LAIN SEPERTI; SIMV, ACV ATAU PS DISEBUT CPAP JIKA DIGUNAKAN PADA

MODE NAFAS SPONTAN

PEEP(Positive End Expiratory Pressure)PEEP(Positive End Expiratory Pressure)

PEEP 5

REDISTRIBUSI CAIRAN EKSTRAVASKULAR PARU

MENINGKATKAN VOLUME ALVEOLUS

MENGEMBANGKAN ALVEOLI YG KOLAPS (ALVEOLI RECRUITMENT)

REDISTRIBUSI CAIRAN EKSTRAVASKULAR PARU

+10

0

A B


MENINGKATKAN VOLUME ALVEOLUS

+20

+10

0

A B C


Indications for Mechanical ventilation

Goals

Patient comfort and rest Reversal of Hypoxemia Reversal of acute respiratory acidosis Reversal of respiratory muscle

fatigue Prevention/Reversal of atelectasis Decrease myocardial ischemic Allowance of neuromuscular blockade Improve lung compliance

Variables for Initial Settings

Fraction of Inspired O2 - FIO2 Tidal Volume - TV Respiratory Rate - RR(f) Flow Rate - Vi(L/m) PSV Mode (A/C, SIMV, PS) PEEP (cm of H2O)

Mechanical Ventilation

Non Invasive

Invasive

Non Invasive: Ventilatory support that is given without establishing endo- tracheal intubation or tracheostomy is called Non invasive mechanical ventilation

Invasive: Ventilatory support that is given through endo-tracheal intubation or tracheostomy is called as Invasive mechanical ventilation

Non invasive

Negative pressure

Producing Neg. pressure intermittently in the pleural space/ around the thoracic cage

Positive pressure

Delivering air/gas with positive pressure to the airway

e.g.: Iron Lung

BiPAP & CPAP

Non Invasive Mechanical ventilation

การใช้� non-invasive mechanical ventilation ในผู้�ป่�วยที่��เหมาะสม จะลดโอกาสการใส�ที่�อช้�วยหายใจได�

Non invasive mechanical ventilation

Head gear

Interface (mask)

ventilator

Positive Pressure

Pressure cycle Volume cycle Time cycle

Invasive

Modes of Ventilation


Mode◦ Description of a breath type and the timing

of breath delivery Basically there are three breath delivery

techniques used with invasive positive pressure ventilation CMV – controlled mode ventilation SIMV – synchronized Spontaneous modes


CMV◦ Continuous Mandatory Ventilation

All breaths are mandatory and can be volume or pressure targeted

Controlled Ventilation – when mandatory breaths are time triggered

Assist/Control Ventilation – when mandatory breaths are either time triggered or patient triggered


CMV◦ Continuous Mandatory Ventilation

Controlled Ventilation – when mandatory breaths are time triggered Mandatory breath – ventilator determines the start

time (time triggered) and/or the volume or pressure target


CMV◦ Controlled Ventilation

Appropriate when a patient can make no effort to breathe or when ventilation must be completely controlled Drugs Cerebral malfunctions Spinal cord injury Phrenic nerve injury Motor nerve paralysis



In other types of patients, controlled ventilation is difficult to use unless the patient is sedated or paralyzed with medications Seizure activity Tetanic contractions Inverses I:E ratio ventilation Patient is fighting (bucking) the ventilator Crushed chest injury – stabilizes the chest Complete rest for the patient



Adequate alarms must be set to safeguard the patient Ex. disconnection

Sensitivity should be set so that when the patient begins to respond, they can receive gas flow from the patient

Do not lock the patient out of the ventilator!


CMV◦ Assist/Control Ventilation

A time or patient triggered CMV mode in which the operator sets a minimum rate, sensitivity level, type of breath (volume or pressure)

The patient can trigger breaths at a faster rate than the set minimum, but only the set volume or pressure is delivered with each breath


CMV◦ Assist/Control Ventilation

Indications Patients requiring full ventilatory support Patients with stable respiratory drive

Advantages Decreases the work of breathing (WOB) Allows patients to regulate respiratory rate Helps maintain a normal PaCO2

Complications Alveolar hyperventilation


CMV◦ Volume Controlled –

CMV Time or patient

triggered, volume targeted, volume cycled ventilation

Graphic (VC-CMV) Time-triggered, constant

flow, volume-targeted ventilation


CMV◦ Volume Controlled – CMV

Time or patient triggered, volume targeted, volume cycled ventilation

Graphic (VC-CMV) Time-triggered,

descending-flow, volume-targeted ventilation


CMV◦ Pressure Controlled – CMV

PC – CMV (AKA – Pressure control ventilation - PCV)

Time or patient triggered, pressure targeted (limited), time cycled ventilation

The operator sets the length of inspiration (Ti), the pressure level, and the backup rate of ventilation

VT is based on the compliance and resistance of the patient’s lungs, patient effort, and the set pressure



Note inspiratory pause



Note shorter Ti



Airway pressure is limited, which may help guard against barotrauma or volume-associated lung injury Maximum inspiratory pressure set at 30 – 35 cm

H2O Especially helpful in patients with ALI and ARDS

Allows application of extended inspiratory time, which may benefit patients with severe oxygenation problems

Usually reserved for patient who have poor results with a conventional ventilation strategy of volume ventilation



Occasionally, Ti is set longer than TE during PC-CMV; known as Pressure Control Inverse Ratio Ventilation Longer Ti provides better oxygenation to some

patients by increasing mean airway pressure Requires sedation, and in some cases paralysis


IMV and SIMV◦ Intermittent Mandatory Ventilation – IMV

Periodic volume or pressure targeted breaths occur at set interval (time triggering)

Between mandatory breaths, the patient breathes spontaneously at any desired baseline pressure without receiving a mandatory breath Patient can breathe either from a continuous flow

or gas or from a demand valve



Indications Facilitate transition from full ventilatory support

to partial support

Advantages Maintains respiratory muscle strength by

avoiding muscle atrophy Decreases mean airway pressure Facilitates ventilator discontinuation – “weaning”



Complications When used for weaning, may be done too quickly

and cause muscle fatigue Mechanical rate and spontaneous rate may

asynchronous causing “stacking” May cause barotrauma or volutrauma


IMV and SIMV◦ Synchronized IMV

Operates in the same way as IMV except that mandatory breaths are normally patient triggered rather than time triggered (operator set the volume or pressure target)

As in IMV, the patient can breathe spontaneously through the ventilator circuit between mandatory breaths



At a predetermined interval (respiratory rate), which is set by the operator, the ventilator waits for the patient’s next inspiratory effort

When the ventilator senses the effort, the ventilator assists the patient by synchronously delivering a mandatory breath



If the patient fails to initiate ventilation within a predetermined interval, the ventilator provides a mandatory breath at the end of the time period



Indications Facilitate transition from full ventilatory support

to partial support

Advantages Maintains respiratory muscle strength by

avoiding muscle atrophy Decreases mean airway pressure Facilitates ventilator discontinuation – “weaning”



Complications When used for weaning, may be done too quickly

and cause muscle fatigue


Spontaneous Modes◦ Three basic means of providing support

for continuous spontaneous breathing during mechanical ventilation

Spontaneous breathing

CPAP

PSV – Pressure Support Ventilation


Spontaneous Modes◦ Spontaneous breathing

Patients can breathe spontaneously through a ventilator circuit; sometimes called T-Piece Method because it mimics having the patient ET tube connected to a Briggs adapter (T-piece)

Advantage Ventilator can monitor the patient’s breathing

and activate an alarm if something undesirable occurs

Disadvantage May increase patient’s WOB with older

ventilators


Spontaneous Modes◦ CPAP

Ventilators can provide CPAP for spontaneously breathing patients Helpful for improving

oxygenation in patients with refractory hypoxemia and a low FRC

CPAP setting is adjusted to provide the best oxygenation with the lowest positive pressure and the lowest FiO2

Continuous Positive Airway Pressure (CPAP) Positive airway pressure maintained

throughout respiratory cycle: during inspiratory and expiratory phases

Can be administered via ETT or nasal prongs


Spontaneous Modes◦ CPAP

Advantages Ventilator can

monitor the patient’s breathing and activate an alarm if something undesirable occurs


Spontaneous Modes◦ PEEP (Positive End Expiratory Pressure)

“According to its purest definition, the term PEEP is defined as positive pressure at the end of exhalation during either spontaneous breathing or mechanical ventilation. However, use of the term commonly implies that the patient is also receiving mandatory breaths from a ventilator.” (Pilbeam)

PEEP becomes the baseline variable during mechanical ventilation


Spontaneous Modes◦ PEEP

Helps prevent early airway closure and alveolar collapse and the end of expiration by increasing (and normalizing) the functional residual capacity (FRC) of the lungs

Facilitates better oxygenation

NOTE: PEEP is intended to improve oxygenation, not to provide ventilation, which is the movement of air into the lungs followed by exhalation


Spontaneous Modes◦ Pressure Support Ventilation – PSV

Patient triggered, pressure targeted, flow cycled mode of ventilation

Requires a patient with a consistent spontaneous respiratory pattern

The ventilator provides a constant pressure during inspiration once it senses that the patient has made an inspiratory effort


Spontaneous Modes◦ PSV



Indications Spontaneously breathing patients who require

additional ventilatory support to help overcome WOB, CL, Raw Respiratory muscle weakness

Weaning (either by itself or in combination with SIMV)



Advantages Full to partial ventilatory support Augments the patients spontaneous VT

Decreases the patient’s spontaneous respiratory rate

Decreases patient WOB by overcoming the resistance of the artificial airway, vent circuit and demand valves

Allows patient control of TI, I, f and VT



Advantages Set peak pressure Prevents respiratory muscle atrophy Facilitates weaning Improves patient comfort and reduces need for

sedation May be applied in any mode that allows

spontaneous breathing, e.g., VC-SIMV, PC-SIMV



Disadvantages Requires consistent spontaneous ventilation Patients in stand-alone mode should have back-

up ventilation VT variable and dependant on lung

characteristics and synchrony Low exhaled E Fatigue and tachypnea if PS level is set too low


Spontaneous Modes◦ Flow Cycling During PSV

Flow cycling occurs when the ventilator detects a decreasing flow, which represents the end of inspiration

This point is a percentage of peak flow measured during inspiration PB 7200 – 5 L/min Bear 1000 – 25% of peak flow Servo 300 – 5% of peak flow

No single flow-cycle percent is right for all patients


Spontaneous Modes◦ Flow Cycling During

PSV Effect of changes in

termination flow

A: Low percentage (17%)

B: High percentage (57%)

Newer ventilators have an adjustable flow cycle criterion, which can range from 1% - 80%, depending on the ventilator


Spontaneous Modes◦ PSV during SIMV

Spontaneous breaths during SIMV can be supported with PSV (reduces the WOB)

PCV – SIMV with PSV


Spontaneous Modes◦ PSV during SIMV

Spontaneous breaths during SIMV can be supported with PSV

VC – SIMV with PSV



NOTE: During pressure support ventilation (PSV), inspiration ends if the inspiratory time (TI) exceeds a certain value. This most often occurs with a leak in the circuit. For example, a deflated cuff causes a large leak. The flow through the circuit might never drop to the flow cycle criterion required by the ventilator. Therefore, inspiratory flow, if not stopped would continue indefinitely. For this reason, all ventilators that provide pressure support also have a maximum inspiratory time.



Setting the Level of Pressure Support Goal: To provide ventilatory support

Spontaneous tidal volume is 10 – 12 mL/Kg of ideal body weight

Maintain spontaneous respiratory rate <25/min

Goal: To overcome system resistance (ET Tube, circuit, etc.) in the spontaneous or IMV/SIMV mode Set pressure at (PIP – Pplateau) achieved in a

volume breath or at 5 – 10 cm H2O



Exercise: Using the PIP and the PPlateau from the pressure waveform below, recommend a pressure support setting for this patient (patient is in VC-SIMV mode)

35

25

Answer: 10 cm H2O


Spontaneous Modes◦ PSV - The results of your work

35 cm H2O

10 cm H2O


Spontaneous Modes◦ Bilevel Positive Airway Pressure (BiPAP)

An offshoot of PEEP/CPAP therapy Most often used in NPPV AKA

Bilevel CPAP Bilevel PEEP Bilevel Pressure Support Bilevel Pressure Assist Bilevel Positive Pressure Bilevel Airway Pressure



Commonly patient triggered but can be time triggered, pressure targeted, flow or time cycled

The operator sets two pressure levels IPAP (Inspiratory Positive Airway Pressure)

IPAP is always set higher than EPAP Augments VT and improves ventilation

EPAP (Expiratory Positive Airway Pressure) Prevents early airway closure and alveolar collapse

at the end of expiration by increasing (and normalizing) the functional residual capacity (FRC) of the lungs

Facilitates better oxygenation



The operator sets two pressure levels IPAP EPAP

NOTE: The pressure difference between IPAP and EPAP is pressure support

Trouble Shooting (Mechanical Ventilation)

Precautions that would reduce troubles

I. Power: Plug into a grounded AC power with

correct voltage receptacle.

Secure the power cord properly.

Battery Back up:

Check the battery level before connecting. Charging should be carried out

regularly. Remember it is for short term use.

II. Gas Source

Preferable to have centralised supply. If cylinders used, should be full Spare cylinders should be available. Gas hoses should be in good condition. Hoses – not contaminated with grease or

oil (combustible) Availability of compressors should be

ensured. Gases should remain dry and clean.

III. Personnel

Properly trained personnel should only use.

Familiarising staff with operator’s manuel before using on a patient.

(One manufacturer’s manual may not exactly match with other brands).

Appropriate monitoring the functioning state of the ventilator while in use.

Contd…

Familiarizing staff with alarm system. Do not place ventilators in a combustible or

explosive environment. Do not use with flammable anaesthetic

agents such as nitrous oxide and ether.

IV Servicing and Testing

Qualified personnel should undertake servicing.

Ventilator housing should not be opened while it is still connected with power.

Follow the specifications mentioned in the service manual.

Use replacement parts supplied by the manufacturer only.

Contd….

General servicing at regular intervals should be done.

Run the prescribed tests and calibrations before using the ventilator on a patient.

Ensure that the ventilators pass all the tests before putting them in to clinical use.

ALARMS

All ventilators are equipped with visual and audible alarms which notify the user problems.

Points to remember

Never ignore an alarm. Never mute the alarm on regular

basis. Find out for yourself what alarm is

on. Check the patient. Silence the alarm.

Act Swiftly Depending upon the patient’s status

and nature of the alarm, act appropriately.

This includes disconnecting the ventilator and connecting another means of ventilation to patient – Bain’s/ Ambu.

Do not forget

The use of an alarm monitoring system does not give absolute assurance of warning for every form of trouble that may occur with the ventilator.

Do not be like this !

But hear the alarm and respond

See the problem and Ask if you do not know what to

do

Common Troubles and Shooting

Ensure Alarm knobs / switches are turned on and functional.

Alarm Cause ShootingApnoea •No breath was

delivered for the operator set apnoea time in spont, SIMV, AC, CMV & NIV modes•Because spontaneous Ventilation is too high or patient effort is too minimal•Trigger level set improperly.

•Check the patient- Arouse if needed•Activate back up facility if it was not done already.•Consider switching over to any mandatory mode•Or go up on rate•Set trigger level appropriately

Low SpO2

Air / O2 Blender continuousalarm

Delivery of O2 : FiO2, PEEP

• High resistance due to various clinical reasons

Supply pressures are inadequate.

• Disconnect patient from ventilator• Manually bag with Bain’s and Ambu.

• Insert the gas hose fittings (air & O2)

correctly into the wall outlets.• Ensure wall outlets has adequate pressure

High Pressure Alarm

The measured peak inspiratory pressure is great than set level because of•Secretions in airway • Partial block – (ETt)• Kinking of tube• Biting the tube• Water in the tube• Cuff herniation• Deep Rt. sided intubation • Fighting the ventilator

•Suctioning, Irrigation• Release tubings• Bite block insertion• Empty the tubings and water traps• Deflate & reinflate cuff 3-4 times• Reposition the ET tube• Reposition the patient• Re assurance• Sedation &

medication (pain)

Low pressure or Low min.VentOrLow exhaled volume or Disconnection

The measured PIP is lesser than the set minimum level because of • cuff leak.• Leak in the circuit • Connections may be loose• ET tube displacement• Disconnection• Inadequate flow

•Evaluate cuff pressure at regular intervals.• Reinflate if leak / ruptured is noticed – change ET tube.• Check circuits, junctions- tighten or replace.• Check water traps • Check ET tube placement. Position it properly.• Reconnect ventilator.• Patient may require higher flow.

High pressure alarm

• Cough• Increased airway resistance or decreased compliance because of• Bronchospasm• Atelectasis• Fluid overload

• Pneumothorax

• Medication• Bronchodilators• Adjust the settings ¯VT & Rate• Adjust the settings VT Rate, PEEP

(Peak pressure to be monitored)

• Immediate intervention

Auto Cycling

High Tidal Volume

Leak & Improper trigger setting

Patient trying to take more volume of air

• Secure all tubings tight• Set proper trigger level

• Increase flow rate or Increase tidal volume

Weaning from Mechanical Ventilation

Definition of Weaning

The transition process from total ventilatory support

to spontaneous breathing.

This period may take many forms ranging from abrupt withdrawal to gradual withdrawal from

ventilatory support.

Weaning

* Discontinuation of IPPV is achieved in most patients without difficulty

* up to 20% of patients experience difficulty

* requires more gradual process so that they can progressively assume spont. respiration

* the cost of care, discontinue IPPV should proceed as soon as possible

Reversible reasons for prolonged mechanical ventilation

Inadequate respiratory drive Inability of the lungs to carry

out gas exchange effectively Psychological dependency Inspiratory fatigue

WeaningPatients who fail attempts at weaning

constitute a unique problem in critical care

It is necessary to understand the mechanisms of ventilatory failure in order to address weaning in this population

Why patients are unable to sustain spontaneous breathing

Concept of Load exceeding Capacity to breathe

Load on respiratory systemCapacity of respiratory system

Balance Load vs Capacity

Most patients fail the transition from ventilator support to sustain spont. breathing because of failure of the respiratory muscle pump

They typically have a resp muscle load the exceeds the resp neuromuscular capacity

Load on Respiratory System

Need for increase ventilation increased carbon dioxide

production increased dead space ventilation increased respiratory driveIncreased work of breathing

Causes of Inspiratory respiratory muscle fatigue

Nutrition and metabolic deficiencies: K, Mg, Ca, Phosphate and thyroid hormone

Corticosteroids Chronic renal failure Systemic disceases; protein synthesis, degradation, glycogen stores Hypoxemia and hypercapnia

Capacity of respiratory system

Central drive to breatheTransmission of CNS signal via Phrenic

nerve Impairment of resp muscles to generate

effective pressure gradients Impairment of normal muscle force

generation

Definitions

Tolerated – observations to monitorLook at patient, do they look unsettled/tired/stressed?

Is respiratory rate below 35bpm & above 8bpm?

Are O2 saturations above 90%? (or as appropriate for patient)

Are ABGs acceptable for the patient?

Is PaO2 / FiO2 ratio >27.5kpc?

Is TV 5ml/kg?

Is patient cardiovasculary stable?

Is patient settled and showing no signs of fatigue?

Is respiratory rate/TV ratio <105 breaths/min (spontaneous rate for 1 min divided by the TV in Litres)

Signs of fatigue are: Decreasing TV Increasing respiratory rate Changes in blood gases Decreases in O2 saturations Tachycardic ECG changes Hypertension Breathlessness Use of accessory muscles Changes in conscious levels Sweating

Inform Anaesthetist and discontinue weaning if any changes noted.

Document: All changes on ventilator and check ventilator changes with another nurse.

Peran Dan Fungsi Perawat

SETTINGS

O2 Air Power

Ventilator

Patient

ม�น��าใน circuit มากจนต้�องเที่ที่"�งบ่�อยๆ

suction ETT

Stabilize the ETT

VAP: Preventive strategies

Nebulisation

Precaution & Care

Tracheobronchial Hygiene:

Placement of tube: Chest movementAuscultationPost intubation X-ray

Cuff pressure: If insufficient Leak - Displacement of the tube, Aspiration high pressure - Tracheal stenosis

Desired Pressure - 20-30cm water

Humidification Filling water & adjusting temperature appropriately :

If inadequate: secretions would become thicker and lead to tube block

Medication: Besides specific therapautic drugs the

following basic drugs are to be given. Sedatives & paralysing agents if needed. Analgesics Diuretics to reduce circulating fluid and

volume overload Reduce Gastric Acid: H2 blockers

Suction Should be done on PRN basis Ascultate and assess View the chest X-ray Determine the need and for effective

suctioning Hyperoxygenation & ventilation –

ambu/normal Keep strict vigil on the cardiac monitor

pulse oximeter during and soon after suctioning

If necessary carry out effective chest physio

Monitoring:

Continuous and Periodic monitoring of Vital parameters such as temperature,SpO2,

Pulse, BP,ECG pattern, breath rate etc.

Ventilator settings: All settings should be recorded as per the doctors order

Sensorium Intake and output Level of comfort Arterial blood gases twice daily

Nebulisation

It is advisable to put all the patients on bronchodilators on regular basis.

Nebulise as per the doctor’s order

Monitoring for infection

Colour, consistency, and amount of the sputum / secretions with each suctioning should be observed.

Fever and other parameters have to closely observed for any other infection. (central line, etc)

Oxygen toxicity

Try and maintain a SpO2 of > 90% and PaO2 of 60 – 90 mmHg with minimum possible FiO2 to prevent O2 toxicity.

Especially for COPD patients : Maintain SpO2 of 85 – 90% and PaO2

of 55 – 70 mmHg.

Nutrition: Enteral nutrition to support the

patient’s metabolic needs and defend against infection.

Avoid high carbohydrate diet during weaning.

NG tube if necessary – relieves gastric distension and prevents aspiration.

Stress gastric ulcer Very common in critically ill patients Send stools for occult blood and

gastric juice for pH estimation Auscultate bowel movements Sedation and antacids adequately.

Alarms & Positioning: Never keep alarm system muted Never ignore even when you know the

cause for the alarm and may not be fatal

Place the patient in low or semi Fowler’s position to improve comfort and facilitate respiration.

Communication:

If conscious, explain the environment, procedures, co-operation expected etc.

Use verbal & non verbal methods Use paper & pen if necessary Provide calling bell if necessary Reassurance and support the patient

during the period of anxiety, frustration and hopelessness

Document patient’s emotional response and any signs of psychosis

Include family in the care

Teach…… Co-operation with medical and nursing

interventions Certain breathing techniques The patient to recognize the importance

of breathing techniques. Frequent assessment of consciousness

level, adequate rest etc. are necessary.

• Multiply the tracheal tubes inner diameter by 2.

Then use the next smallest size catheter.

Example: 6mm ETT: 6 x 2 = 12; nextsmallest catheter is 10 French

Example: 8mm ETT: 6 x 2 = 16; nextsmallest catheter is 14 French

Choosing the right catheter

Hypoxemia - #1 complication– give oxygen before and after– catheter size• if the catheter is too big, there will be little or no airentrained– Time – suction no more that 15 secs.Tissue trauma– May be able to prevent it . . .– catheter selection?– intermittent vs. continuous– a “delicate touch”– vacuum adjustment

Complications and Hazards of Suctioning

Complications and Hazards of SuctioningCardiac arrhythmias– Vagal stimulation will cause

• bradycardia

– Hypoxemia can cause• PVCs• tachycardia

– If these occur…STOP procedure and give oxygen

Extubation

The nurse should explain the procedure to the patient and prepare suction. The patient should be sitting up at least 45 degrees.

Prior to extubating, the patient should be suctioned both via the ETT and orally.

All fasteners holding the ETT should be loosened.

Extubation

A sterile suction catheter should be inserted into the ETT and withdrawn as the tube is removed.

The ETT should be removed in a steady, quick motion as the patient will likely cough and gag.

Extubation

The patient should be asked to cough and speak. Quite often, the patient’s first request is for water because of a dry, sore throat. Generally, you can immediately swab the patient’s mouth with an oral swab dipped in water.

Post-Extubation Care

Humidified oxygen Respiratory exercises Assessment and monitoring Prepare for intubation

Ventilator Mekanik.pptx

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Transcript of Ventilator Mekanik.pptx