nursing care in mechanical ventilation

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Nursing Care of the Mechanically Ventilated Patient





• Nursing care of patients who are being mechanically ventilated requires some special considerations.

• Some special considerations relate specifically to the type of tube via which the patient is being ventilated (i.e. endotracheal or tracheostomy) and others related to the patient, and the ventilator itself.




Precaution & Care

• Tracheobronchial Hygiene:

• Placement of tube: Chest movementAuscultationPost intubation X-ray

• Cuff pressure: If insufficient- LeakDisplacement of the tubeAspiration

If high pressure - Tracheal stenosisDesired Pressure - 20-30cm water




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Care of the Ventilator Patient

• Observe and document– Airway type, size, and

position– Character of insertion

site– Date airway inserted– Pulmonary assessment

• Inspection• Palpation• Percussion• Auscultation

• Provide oral care prn• Reapply ETT tape

q24h and prn• Provide trach care

and replace inner cannula q12h and prn

• Monitor for complications

• Suction as needed• Wean and extubate





• Pulmonary assessment is perhaps never as important as it is in the mechanically ventilated patient.

• These patients require frequent reassessments on a schedule and on an “as needed” basis.

• Further assessments can be documented in Protouch under “Reassessments”.




Nursing Assessment Components: Breath Sounds

• Breath sounds should be assessed at least every four hours, and more frequently as needed.

• Both the anterior and the posterior chest need to be auscultated bilaterally.

• Clearly document any adventitious breath sounds that are heard, and report significant alterations to the Physician.




Nursing Assessment Components: Rate & Volume

• Make sure to assess and document the patient’s spontaneous respiratory rate and tidal volume. This information tells you a lot about the patient’s respiratory functioning.

• Note any changes in this area, and report significant findings to the patient’s Physician.




Anatomy




Nursing Assessment Components:Pulse Oximetry

• Pulse oximetry is a useful monitoring tool, but provides minimal indication of the patient’s ventilatory or acid-base status.

• Readings can be affected by abnormal hemoglobins, vascular dyes, and poor perfusion.

• Plus, the machine can’t distinguish between normal and abnormal hemoglobins, so a patient with carbon monoxide poisoning could have a pulse ox reading of 100%.




• 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 – p r n or twice daily




Remember that • PaO2 depends on FiO2 & PEEP• PaCO2 depends on Tidal volume & Rate

In ICU, our primary aim is • To get a PaO2 of 60-90 mmHg &• PaCO2 of 30-50mmHg.• Ensure that plateau inspiratory pressure

does not exceed 30cm of H2O ( risk of VALI –Ventilator Associated Lung Injury)




ABG - Setting

• pH = 7.16• PaCO2 = 81 mmHg• HCO3 = 28 mEq/L• PaO2 = 36 mmHg• SaO2 = 69%

• A VT = 500• B RR = 12• C O2 = 50• D PEEP = 5




PH=7.49PaCO2=30 میلی متر جیوهBE= +0.5 میلی اکی واالن در لیترHCO3 = 22.6 رمیلی اکی واالن درلیتPaO2= 72 میلی متر جیوهSao2=95.8%




PH=7.46PaCO2=56 میلی متر جیوهBE=+13 میلی اکی واالن در لیتر HCO3 =40میلی اکی واالن درلیترPaO2=58 میلی متر جیوه Sao2=90.7%

-




PH=7.25PaCO2=48 میلی متر جیوهBE=-6.5 میلی اکی واالن در لیترHCO3 =20.6میلی اکی واالن درلیترPaO2=56 میلی متر جیوه Sao2=83.4%

-




PH=7.٢٨PaCO2= ۶٩میلی متر جیوه BE=+ ٢.۵میلی اکی واالن در لیتر HCO3 = ٣٢میلی اکی واالن درلیتر PaO2= 49 میلی متر جیوهSao2=٧٨%




ABG - Setting

• pH = 7.4• PaCO2 = 50 mmHg• HCO3 = 30 mEq/L• PaO2 = 60 mmHg• SaO2 = 90%• Pplat = 33 cmH2O

• A VT = 400• B RR = 13• C O2 = 44• D PEEP = 11




Nebulisation

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

• Nebulise as per the doctor’s order




Pain related to Mechanical ventilation & ET tube placement

• Positioning of the tube, pulling of the circuits, in appropriate flow rates, sensitivity setting that requires patient’s greater efforts, etc.

• Prevent all the above as much as possible.




Eye & Mouth care• For unconscious patients

eyes are kept closed by taping.

• Goggles can also be used.

• Regular & proper mouth care should be given.




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)




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.




Important :Skeletal muscle weakness Difficult weaning

Hypophosphatemia Poor contractility diaphragm that accompany with ARF & ARDS

Caloric in take (Hyper alimentation) CO2Production Necessitating VA

Nutritional support




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.




Positioning:

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




CDC Guideline for Prevention of Healthcare Associated Pneumonias, 2003Drakulovic et al, Lancet, 1999,354:1851

In the absence of medical contraindication(s).




Signs and Symptoms of Acute Hypoxia

• Tachycardia• Tachypnea• Dyspnea• Euphoria• Stupor• Tremors• Hyperreactive

reflexes

• Anxiety• Arrhythmias • Decreased PaO2• HTN • Impaired judgment • Blurred Vision • Coma/Death




Oxygen Delivery MethodsMechanical Ventilation

• Allows administration of 100% oxygen

• Controls breathing pattern for patients who are unable to maintain adequate ventilation

• Is a temporary support that “buys time” for correcting the primary pathologic process




Hazards of Oxygen Therapy• Oxygen induced hypoventilation with the

following risk criteria:– Pts baseline PaCO2 > 50 mmHg– Baseline O2 saturation < 90%– With supplemental O2, PaO2 doesn’t exceed 60

mmHg• Absorption atelectasis with the following risk

criteria:– FiO2 > 50%– Decreasing alveolar volumes– Airway obstruction




Signs of Oxygen Toxicity

• Substernal pain• Cough• Dyspnea• Anxiety• Paresthesia• Fatigue• Pulmonary

infiltrates• Decreased PaO2

• Decreased compliance

• Pulmonary edema• Atelectasis• Decreased vital

capacity• Increased shunting

(V/Q mismatching)




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 PaO2of 55 – 70 mmHg.




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




Nursing Care of the Patient with an Tracheostomy Tube

• Trach care should be performed at least every shift, and as needed as ordered by the patient’s Physician.

• The patient should always be pre-oxygenated with 100% oxygen prior to suctioning.

• Saline should not be routinely instilled into the airway. Saline installation has been shown to increase infection rates and to cause decreased oxygen levels for longer periods of time than suctioning without it.




Closed suction systems




Albert, NEJM 1981; Preston, AJM 1981; Tablan, 1994




Oral Cavity• Suction the oral cavity• Swab the oral cavity every 4 hours and

PRN to cleanse and maintain oral mucosal integrity

• Moisturize oral cavity every 4 hours




Oropharyngeal Suctioning

• Suction every 12 hours to remove secretions from the oropharyngeal area above the vocal cords.




Brush Teeth• Brush teeth 2 times per day to remove

dental plaque




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.




Nursing Care of the Ventilator• Record and document

the following settings per unit standards– Rate (mech and spont)– FiO2– Tidal volume (mech &

spont)– PS/PEEP/CPAP– Peak pressure (PIP)– SpO2

• NEVER use the top of the ventilator as a desk

• NEVER sit liquids on or near the ventilator

• NEVER make changes to ventilator settings

• Refer to RT, MD, or Charge Nurse as needed




47




Injury during Mechanical Ventilation

• Possibility of ventilator associated lung injury, baro-trauma, tracheal necrosis etc have to be detected in time and take appropriate action.

• Use soft restrainers whenever necessary.




Alarms

• Never keep alarm system muted• Never ignore even when you know the

cause for the alarm and may not be fatal




Weaning• Assess for readiness to wean.• Follow a clear cut protocol• Provide emotional support and decrease the

patient’s fear and anxiety• Never try weaning at night• If weaning once failed ( fatigue, sweating,

dyspneic etc..) do not attempt for the next 24-48 hours.

• Once weaning is successful, switch over to T piece

• Before extubation, do a leak test and cough test .

• if the above tests are positive -extubate by following proper protocol




Methods of Weaning

1- T-piece trial,

2- Continuous Positive Airway Pressure (CPAP) weaning,

3- Synchronized Intermittent Mandatory Ventilation (SIMV) weaning,

4- Pressure Support Ventilation (PSV) weaning.




1- T-Piece trial

• It consists of removing the patient from the ventilator and having him / her breathe spontaneously on a T-tube connected to oxygen source.

• During T-piece weaning, periods of ventilator support are alternated with spontaneous breathing.

• The goal is to progressively increase the time spent off the ventilator.




2-Synchronized Intermittent Mandatory Ventilation ( SIMV) Weaning

• SIMV is the most common method of weaning.

• It consists of gradually decreasing the number of breaths delivered by the ventilatorto allow the patient to increase number of spontaneous breaths




3-Continuous Positive Airway Pressure ( CPAP) Weaning

• When placed on CPAP, the patient does all the work of breathing without the aid of a back up rate or tidal volume.

• No mandatory (ventilator-initiated) breaths are delivered in this mode i.e. all ventilation is spontaneously initiated by the patient.

• Weaning by gradual decrease in pressure value




4- Pressure Support Ventilation (PSV) Weaning

• The patient must initiate all pressure support breaths.

• During weaning using the PSV mode the level of pressure support is gradually decreased based on the patient maintaining an adequate tidal volume (8 to 12 mL/kg) and a respiratory rate of less than 25 breaths/minute.

• PSV weaning is indicated for :-

- Difficult to wean patients- Small spontaneous tidal volume.




Ventilator Weaning• Vital Capacity at least 10 – 15 ml/kg• Tidal Volume > 5 ml/kg• Resting minute volume <10 L per minute• ABG’s adequate on < 40% FiO2• Stable vital signs• Intact airway protective reflexes (strong cough)• Absence of dyspnea, neuromuscular fatigue,

pain, diaphoresis, restlessness, use of accessory muscles




Predictions of the outcome of weaning

Variables used to predict weaning success: Gas exchange

• PaO2 of > 60 mmHg with FiO2 of < 0.35• PaO2/FiO2 ratio of > 200




Weaning success prediction

• Tidal volume > 325 ml• Tidal volume/BW > 4 ml/kg• Dynamic Compliance > 22 ml/cmH2O• Static compliance > 33 ml/cmH2O• Rapid shallow breathing index < 105

breaths/min/L




Rapid Shallow Breathing Index(RSBI)

RSBI<105

In spontaneous breathing or CPAP mod PSV=5-7cmH2o

Respiratory(f)/Tidal volume(VT)




Extubation Procedure• Explain procedure to patient• RT must be at bedside• Wash your hands• Suction airway and oropharynx for pooled

secretions (prevents aspiration of secretions atop balloon)

• Place a towel on patient’s chest• Assure new oxygen setup is ready to use• Deflate cuff and remove tube instructing

patient to cough as tube is removed• Apply supplemental oxygen• Monitor pt for distress (stridor, coughing,

anxiety)




Complications of Mechanical Ventilation

• One of the reasons for such a frequent and thorough assessment of the pulmonary system while patients are being mechanically ventilated is due to the many complications that can occur with the use of mechanical ventilation.

• Thorough assessments can lead to the early discovery of potential complications, heading off more serious complications later.




Complications of Mechanical Ventilation

• Positive Pressure Ventilation: can cause:

hypotensiondecreased venous returndecreased cardiac output

Other complications:pneumothoraxsubcutaneous emphysemaair emboluslocalized pulmonary hyperinflationnosocomial infectionsincreased intracranial pressure (cerebral edema)




nursing care in mechanical ventilation

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