A SEMINAR ON
MECHANICAL VENTILATION
PRESENTED PRESENTED BY Nirupama.K.S 1st YearM.ScNursing College of Nursing Thiruvananthapuram
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CENTRAL OBJECTIVE On comp comple leti tion on of semi semina nar, r, the the grou group p gets gets a thor thorou ough gh know nowledg ledgee reg regardi ardin ng mech mechan anic ical al venti entillatio ation, n, appr apprec ecia iate tess its impo import rtan ance ce and and appl apply y its its vari variou ouss aspect aspectss un clinical practice.
SPECIFIC OBJECTIVE On completion of seminar, the group Defines mechanical ventilation mechanical Explains historical evolution of ventilator List down indications of mechanical ventilation Describe the modes of mechanical ventilators Discuss the settings of mechanical ventilators Explor oree the the com complic plicat atio ions ns of mech echanic anical al Expl ventilators Analyse the nursing management of patient on mechanical ventilator Iden Identi tify fy the the nurs nursin ing g diag diagno nosi siss of pati patien entt on mechanical ventilator Explain weaning from mechanical ventilator List down the causes for failure to wean from mechanical ventilators
INTRODUCTION The respiratory system is both remarkable and complicated. Its overall function is to provide life sustaining oxygen to all the cells of the body and to remove remove the byproduct byproduct of cellula cellularr metab metaboli olism. sm. Therefo Therefore re the the effici efficient ent pulmon pulmonary ary system system,, along along with with the cardio cardio vascul vascular ar system system is intimately intimately related to the body’s metabolic metabolic processes. processes. This becomes even more evident with an understanding of humoral control of ventilation. Knowl Knowledg edgee of pulmo pulmonary nary anatomy anatomy provide providess a sound foundat foundation ion for understanding understanding the complex complex process process of respiratio respiration. n. Respiratory Respiratory support support forms a major part of an intensive care work load, and is rarely required in isolat isolation ion from from other other proble problems ms which which may may have have their their own own adverse adverse 2
effects on respiratory function. There is a wide diversity of conditions leading to acute respiratory failure requiring mechanical ventilation. The classic indications for ventilatory support is reversible acute respiratory failure. Guidelines for instituting ventilation may be based on respiratory mechanics, oxygenation and ventilation.
MECHANICAL MECHANICAL VENTILATION Mechanical ventilation is the process by which room air or oxygenenriched air is moved into and out of the lungs mechanically. It is a mean meanss of supp suppor orti ting ng pati patien ents ts unti untill they they reco recove verr the the abil abilit ity y to breathe independently or a decision is to make to withdraw ventilatory support.
EVOLUTION OF MECHANICAL VENTILATION AD 175 – Galen used a fire place bellows to inflate the lungs of a deceased animal. 1555 - Vasalius resurrected the technique to keep an experimental animal alive while he examined its thoracic contents. 1776 - John Hunter, an avid proponent of manual ventilation, constructed a double bellows device so that one could insufflate air and the other could evacuate air from the lungs through a tracheostomy tube 1826 - Leory developed a bellows ventilator with a graduated scale and a two way valve that permitted inhalation and exhalation 1882 - Dr.Joseph. O’Dweyer investigated translaryngeal intubation of trachea in cadavers. cadavers. He constructed plaster casts of the trachea to determine the appropriate size and configuration of the tubes and used his tubes for translaryngeal intubation of patients 1893 - Dr.George.E.Fell, described a ventilator that he used to maintain artificial breathing in several cases of optimum toxicity.The breathing device became known as the “Fell O’ Dweyer” apparatus. Later Meltzer and Auer introduced a method of artificial ventilation for experimental thoracic operations that they are called ‘respiration by continuous intra tracheal insufflation of air’ 1913 - Jane Way developed developed an automatic automatic intermittent intermittent positive pressure ventilator that could provide mandatory or patient initiated
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breaths during thoracic operations 1929- Drinker, Louis shaw, and Charles.E.Mckhann developed developed first “Iron Lung” for resuscitation after industrial asphyxial accidents. It was constructed using sheet metal cylinder that was sealed at one end. The tank accommodated the patient’s lower body and chest up to the neck leaving head out side. The neck opening provided an airtight seal enabling a suction suction device to generate negative pressure around chest and lower body within the tank. The use of the cabinet ventilator was associated with a variety of problems. Patients suffered from lack of nursing care, neck sores, venous engorgement of neck and face and adverse psychological effects effects of being partially enclosed in cabinet. A simpli simplifie fied d version version of Tank Tank ventil ventilato ator, r, Cuirass Cuirass venti ventilat lator or was was develo developed ped later. later. It consis consists ts of a rigid rigid cylind cylindrica ricall shell shell place placed d around around patient’s chest and abdomen. It was covered with a nylon or plastic coat that produces an airtight seal between ambient air and the space between the cylinder and chest wall. Intermittent negative pressure ventilation using Iron lung continued in wide wide spre spread ad use use thro throug ugh h the the mid 1950 1950s, s, duri during ng the the epid epidem emic icss of poliomyelitis. 1953 - Bang developed developed an an automati automaticc ventila ventilator tor that that could could be used used to to admini administe sterr a given given minut minutee volum volumee with with contro controll lled ed or patie patient nt limit limited ed pressure breaths. ( “The Clause Bang Ventilator” ) 1967 - HFV developed by Sjostrand 1977 - Hewlett discovered mandatory minute ventilation 1980 - Seimens- Elma introduced Pressure supported ventilation( Servo 900 series ) 1987 1987 Ventilator
Down Downss and and Stoc Stock k intr introd oduc uced ed Airw Airway ay Pres Pressur suree Rele Release ase
1983- Puritan Bennett Bennett 7200 was introduced introduced 1984- Puritan Bennett 7200 7200 AE was introduced introduced 1991- SensorMedics 3100A High Frequency Frequency Oscillatory Ventilator Ventilator 1994- SensorMedics 3100B High Frequency Oscillatory Ventilator Ventilator ,
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2010 2010 - Drä Dräg ger Babyl abylog og VN500 500 was was Intr Introd oduc uced ed Dräger Evita XL, 4
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Dräger Savina® 300, Dräger Carina, Dräger Babylog 8000 plus,
INDICATIONS FOR MECHANICAL VENTILATION •
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Lung or airway airway disorders disorders or trauma trauma e.g. Pneumonia, Pneumonia, ARDS, rib fractures, asthma, pulmonary edema, pneumothorax. Circulatory disorders e.g. MI, cardiogenic cardiogenic shock, heart heart failure, Acute exacerbation of COPD Neuromuscular disorders and trauma e.g. GBS, Myasthenia gravis, head injury. Airway Airway obstru obstructi ction on e.g. e.g. facial facial trauma, trauma, aspira aspiratio tion, n, head head / neck neck / chest burns, oral cavity burns. Intra-operatively & Post-operativel Respiratory acidosis / Respiratory rate > 30- 40 / minute Poor oxygenation Poisoning / certain drugs Unconsciousness
TYPES OF VENTILATORS 1.Invasive: Includes the use of an endotracheal tube or tracheostomy. 2.Non invasive: Non invasive techniques, that is, those that do not require the use of an ETT or tracheostomy.it provide ventilation via a nasal or oral mask, or mouth piece with a tight seal. It is used in conjunction with a portable ventilator. on invasive positive pressure ventilation is primarily used in home care setting to treat individuals with chronic respiratory failure , often only at night. Negative pressure pressure ventilat ventilators ors: Negative Negative pressure ventilation involves the use of chambers that enca encase se the ches chestt or bod body and surr surro ound und it with inte interm rmiitten ttentt sub sub atmospheric or negative pressure. Intermittent negative pressure around the chest wall causes the chest to be pulled outward. This reduces intra thorac thoracic ic pressur pressure. e. Air Air rushes rushes the upper airway airway , which which is outsid outsidee the sealed membrane. Expiration is passive. Eg: Iron lung, Cuirass ventilators 5
Positive Positive pressure pressure ventilat ventilators ors : Positive pressure ventilation is the most common method for providing ventilation in acute care setting. This method of mechanical vent ventil ilat atio ion n forc forces es air air into into the the lung lungss , usua usuall lly y thro throug ugh h an ETT ETT or tracheostomy tube, via positive pressure. Unlike spontaneous ventilation, intra thoracic pressure is raised during lung inflation rather than lowered. Expiration occurs passively as in normal expiration. Eg. CPAP, BiPAP, NIPPV Positive pressure ventilators are categorised into; Volume me cycl cycled ed vent ventil ilat ator ors: s: With volume ume ventilators , a Volu predetermined tidal volume ( VT ) is delivered with each inspiration, and the amount of pressure needed to deliver the breath vari varies es base based d on the the comp compli lian ance ce and and resi resist stan ance ce fact factor orss of the the patient- ventilator system. Time cycled ventilators : With a time cycled ventilator, inspiration and expiration is are terminated by a preset time duration. Many of the infant ventilators used are time cycled ventilators. Primary time cycled ventilators deliver a tidal volume in the time allotted for inspiration. These machines have a wide range of available flow rates, thus they can accommodate accommodate changes changes in lung complianc compliancee and airway resistance. Pressure cycled ventilators: With pressure ventilators, the peak inspiratory pressure is predetermined, and the VT delivered to the patient varies based on the selected pressure and the compliance and resistance factors of the patient-ventilator system.
SETTINGS OF MECHANICAL MECHANICAL VENTILATION PARAMETER
Respiratory rate ( f )
Tidal Volume ( VT ) Oxygen ( FIO2 )
DESCRIPTION
Number of breaths the ventilator delivers per minute ; usual setting is 4 – 20 breaths / minute. Volum Volumee of gas delive delivered red to patien patientt during during each each ventilator breath ; usual volume is 5 – 15 ml / kg
Fraction of inspired oxygen delivered to patient ; Concentration may be set between 21 % and 100 % ; usually adjusted to maintain PaO2 level > 60 mm Hg or SaO2 level > 90 %
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I : E ratio
Dura uration of inspi spiration ( I ) to duration of expiration ( E ) ; usual setting is 1 : 2 to
Flow rate
Spee Speed d with with which hich the the VT is deli delive vere red d ; usua usuall setting 40 – 100 L / min
Sensitivity / Trigger
Determines the amount of effort the patient must generate to initiate a ventilator breath ;
Pressure limit
Sigh
Humidification
Regulates the maximal pressure the ventilator can generate to deliver the VT ; when the pressure is reached , the ventilator terminates the breath and spills the undelivered volume into the atmosphere ; usua usuall set setting ting is 10 – 20 cm H2O abov abovee peak eak inspiratory pressure. The lungs are hyperinflated periodically to open collapsed alveoli. The sigh is given by a machine or manual hand bag ventilation. Sigh volume is 2 times tidal volume every 5-10 minutes. Helps to prevent atelectasis and secondary infection. Bubble diffusion humididifiers provide molecules of water and saturate the inspired gas to 100% humidity.
MODES OF MECHANICAL VENTILATION The variable methods by which the patient and the ventilator interact to deliver effective ventilation are called modes. The vent ventil ilat ator or mode mode sele select cted ed is base based d on how how much much ‘wor ‘work k of brea breath thin ing’ g’ (WOB) the patient ought to or can perform and is determined by the patient’s ventilatory status, respiratory drive and ABGs. Generally, ventilator modes are controlled or assisted. Control olle led d Manda Mandator tory y Vent Ventil ilat atio ion n (CMV (CMV ) : With ith CMV CMV , 1. Contr breaths are delivered at a set rate per minute and VT , which are independent of the patient’s ventilatory efforts. It is used when the patient has no drive to breathe ( eg. Anaesthetised patient ) or is unable unable to breath breathee sponta spontaneo neousl usly y ( e.g paraly paralyzed zed patie patient nt ). The The patient performs no WOB in this mode and cannot adjust respirations to changing demands. 2. Assist Control Mechanical Ventilation (ACV ) : With ACV.the ventilator delivers a preset frequency ,and when the patient initiates a spontaneous breath, a full VT is delivered.The ventilator senses a decrea decrease se in intrath intrathora oracic cic pressu pressure re and then then delive delivers rs the preset preset 7
VT.Th VT.This is mode has the advant advantage age of allowi allowing ng the patien patientt some some control over ventilation while providing assistance. ACV is used in patients with a variety of conditions, including neuromuscular disorders ( e.g. Guillain-Barre syndrome ), pulmonary oedema, and acute respiratory failure. Intermittent Mandatory Mandatory Ventilation Ventilation:: IMV IMV allo allows ws pati patien entt to 3. Intermittent breathe on his own, determining his own rate and tidal volume. A mandatory breath is supplied by the machine at a predetermined volume and frequency without regard to patient’s demand. In this mode, the patient patient is responsible responsible for regulating regulating his own ventilato ventilatory ry pattern, which may provide more normal ABG values and provide more more psyc psycho holo logi gicc sati satisfa sfact ctio ion. n. Also Also the the mean mean intr intraa thor thorac acic ic pressure is lower and venous return is less impeded than with contro controlle lled d ventil ventilati ation on .IMV .IMV is usuall usually y used used in weanin weaning g proces processs .The main disadvantages are: If the patient becomes apnoeic during IMV IMV mode mode,, adeq adequa uate te vent ventil ilat atio ion n may may not not be deli delive vere red d by the the ventilator .Also the patient’s own breath and the machine delivered breath may occur simultaneously. Thus the patient receives a larger breath than the normal. This is regarded as “sigh” and is usually not thought to be a problem. Intermittent Mandatory Ventilation 4. Synchronised ( SIMV );The SIMV deliver deliver a preset preset VT VT at a preset preset respiratory respiratory rate and permit the patient to breathe spontaneously at his or her own respiratory rate and depth between the ventilator breaths, the SIMV mode delivers preset breaths that are synchronised synchronised with with the patient’s spontaneous efforts .SIMV mode prevents the patient from from compet competing ing with with the venti ventilat lator or durin during g sponta spontaneo neous us effort efforts. s. This mode is commonly used in weaning patients from mechanical ventilation. SIMV has advantages over other modes with respect to card cardio iova vasc scul ular ar effe effect cts. s. Spon Sponta tane neou ouss insp inspir irat atio ion n decr decrea ease sess intrathoracic pressure and enhances venous blood return to heart. Thus a patient with an extra cellular fluid volume deficit is better to maintain cardiac output. Pressur suree Su Supp ppor ortt Vent Ventil ilat atio ion n ( PSV PSV ):With ith PSV PSV , posi positi tive ve 5. Pres pressure is applied to the airway only during inspiration and is used in conjunction with the patient’s spontaneous respirations. As the patient initiates a breath, the machine senses the spontaneous effort and supplies a rapid flow of gas at the initiation of the breath and variable flow throughout the breath. With PSV, patient determines inspiratory length, VT , and respiratory rate. Advantages of PSV includ includee increa increased sed patien patientt comfort comfort,, decrea decreased sed WOB, WOB, decrea decreased sed oxygen consumption , and increased endurance conditioning.
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6. Pressure Control Inverse Ratio Ventilator( PC-IRV): PC-IRV
combin combines es pressur pressuree limite limited d ventil ventilati ation on with with an inverse inverse ratio ratio of inspiratio inspiration n ( I ) to expiration expiration ( E ).This value is normally < 1.With IRV , the I/ E ratio ratio approaches 1. With IRV , a prolonged prolonged positive positive pressure is applied , increasing inspiratory time. IRV progressively expands collapsed alveoli. IRV is indicated for patients with ARDS who continue to have refractory hypoxemia despite high levels of PEEP. Positive ve End End-Ex -Expir pirator atory y Pressu Pressure( re( PEEP PEEP ):It is a ventil ventilato atory ry 7. Positi mane maneuve uverr in whic which h posi positi tive ve pres pressur suree is appl applie ied d to the the airw airway ay during exhalation. Normally during exhalation , airway pressure drops to zero. And exhalation occurs passively. With PEEP, airway pressure remains higher than the atmospheric pressure during both inspiration and expiration( often 3-20 cm H2O ).PEEP keeps the patient’s airway open at the end of expiration and increases the functi functiona onall residu residual al capaci capacity. ty. The The mecha mechanis nisms ms by which which PEEP PEEP increa increases ses FRC FRC and oxygen oxygenati ation on includ includee , increa increased sed aerati aeration on of patent alveoli, aeration of previously collapsed alveoli, and prevention of alveolar collapse throughout the respiratory cycle. Often 5 cm of H2O PEEP PEEP is used prophylacti prophylactically cally to replace replace the glott glottic ic mechani mechanism, sm, help mainta maintain in a normal normal FRC, FRC, and prevent prevent alveolar collapse.PEEP is indicated in lungs with diffuse disease , seve severe re hypo hypoxe xemi miaa unre unresp spon onsi sive ve to FIO2 FIO2 > 50% 50% , and and loss loss of compliance or stiffness.It is contraindicated in patients with highly compliant lungs ( COPD ), hypovolemia, unilateral diseases, and low cardiac output. 8. Continuous Positive Airway Pressure( CPAP ): Whereas PEEP is used to increase the FRC during mechanically assisted breaths, CPAP is used to augment FRC during spontaneous ventilation and in combination with the spontaneous breaths of IMV and SIMV. CPAP CPAP is also lso used used as a metho ethod d for weani eaning ng pat patients ents from rom mechanical ventilators. CPAP can be administered via face mask or mechanical ventilators.It is also used at night by some patients who suffer from sleep apnoea. 9. High Frequency Ventilation( HFV ): HFV involves delivery of small tidal volumes ( usually 1-5 ml/kg body weight ) at rapid resp respir irat atory ory rate rate ( 100-3 100-300 00 brea breath thss per per minu minute te ) in an effo effort rt to recr recrui uitt and and main mainta tain in lung lung volu volume me and and redu reduce ce intr intraa pulm pulmon onar ary y shunting. One benefit of HFV may be the ability to support gas exch exchan ange ge whil whilee mini minimi mizi zing ng the the risk risk of baro barotr trau auma ma.. Pati Patien ents ts rece receiv ivin ing g HFV HFV must ust be para parallysed ysed to supp suppre ress ss spon sponta tane neou ouss respiration. There are 3 types of HFV.
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High Frequency Jet ventilation ventilation : Delivers Delivers humidifie humidified d gas from a high pressure source through a small-bore cannula positioned in the airway. With HFJV , precise VT is difficult to predict and is a function of numerous variable. High Frequency Frequency Percussive Percussive ventilation ventilation : attempts to combine the posit sitive effects of both HFV and conventional mechanical ventilation. A piston mechanism positioned at the end of the ET tube is driven by a high-pressure gas supply at a rate of 200 to900 beats/ minute. These highfrequency beats are superimposed on a conventional pressure controlled ventilator mode. High Frequency Frequency Oscillator Oscillatoryy ventilation: ventilation: Uses a diaphragm or piston in the ventilator to generate vibrations of sub physiologic volumes of gas. It can produce respiratory frequencies in excess of 3000 breaths per minute.
10.Airway Pressure Release Ventilation : It is described as two levels of CPAP that are applied for a set period of time time and combines the the features of CPAP and PCV. APRV differs conceptually from all other ventilatory modali modalitie tiess becaus becausee it effect effectss movem movement ent of gas by decrea decreasing sing airway airway pressure below some constant baseline inflation pressure which maintains rest restin ing g lung lung volu volume me abov abovee FRC. FRC. The The insp inspir irat ator ory y flow flow valv valvee is open open throughout the ventilatory cycle such that the patient is able to breathe spontaneously in a manner similar to CPAP. However at preset intervals, vent ventil ilat ator or supp suppor ortt is supe superi rimp mpos osed ed on spon sponta tane neou ouss resp respir irat atio ions ns by releasing the positive pressure at the airway opening and allowing the lungs to deflate to some volume above FRC determined by a preset end expiratory expiratory pressure. pressure. Augmentat Augmentation ion of alveolar alveolar ventilation ventilation with with low peak airway pressure and without over distension of lung parenchyma appears to be a majo majorr adva advant ntag agee of APRV APRV.. Othe Otherr adva advant ntag ages es incl includ udee low low intr intrat atho hora raci cicc pres pressu sure re and and impr improv oved ed match atchin ing g of vent ventil ilat atio ion n and and perfusion. 11 . Partial Liquid Ventilation : Currently clinical trials are investigating the the use of perf perflu lubr bron on ( Liqu Liquii Vent Vent ) in part partia iall liqu liquid id vent ventil ilat atio ion n for for patients with ARDS. Perflubron is an inert, biocompatible, clear, odourless liquid derived from organic compounds that has an affinity for both oxygen and carbon dioxide and surfactant like quality. Perflubron is trickled down a specially designed ET tube through a side port into the lungs of a mechanically ventilated patients. The amount used is usually equiva equivalen lentt to patien patient’s t’s FRC. FRC. PLV PLV has demonst demonstrate rated d few detrim detriment ental al effects on hemodynamics and may evolve as an important adjunct in the management of ARDS.
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12. Independent Lung Ventilation : It is achieved by using a double lume lumen n endo endo bron bronch chia iall tube tube to vent ventil ilat atee each each lung lung sepa separa rate tely ly.. Two Two ventilators are usually required and settings and ventilatory modes can be selectively applied without need for synchronisation. ILV is an acceptable form form of ventil ventilato atory ry suppor supportt in respir respirato atory ry failur failuree with with a unilat unilatera erall or differe different nt lung lung pathol pathology ogy such such as unila unilatera terall edema, edema, aspira aspiratio tion n or chest chest trauma.
PROBLEMS PROBLEMS WITH MECHANICAL VENTILATORS
Ventilator problems:
CAUSE
SOLUTION
Incre ncreas asee in peak peak air - coughing or -suction air way way pressure plugged air way - Adjust sensitivity tube -Man -Manua uall lly y vent ventil ilat atee - patient bucking patient ventilator -asse -assess for for hypo hypoxi xiaa or lung bronchospasm - decreased compliance -check ABGs -sedate if necessary
-tubing kinked
-atelectasis bronchospasm
-check tubing -reposition the patient -insert oral air way if necessary , -clear secretions
-dec -decre rease ase in pres pressur suree -lea -leak k in vent ventil ilat ator or or -check entire or loss of volume tubing vent ventil ilat ator or circ circui uitt for for patency.
COMPLICATIONS VENTILATION
OF
1.Pulmonary System:
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MECHANICAL
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Barotrauma Barotrauma: Barotrauma is the presence of extra-alveolar air. This air may escape into the pleura, mediastinum, pericardium, or under the skin . Barotrauma may occur when the alveoli are over distended, such as with positive pressure ventilation, high VT (>15 ml/kg), and PEEP. Signs and symptoms include high peak inspiratory pressure, pressu re, decreased breath sounds, high mean airway airway pressure, pressure, tracheal tracheal shifts shifts and symptoms associated associated with with hypo hypoxe xemi mia. a. A life life thre threat aten enin ing g com complic plicat atio ion n is tens tensio ion n pneumothorax.When tension pneumothorax occurs, pressurised air enters the pleural space. Air is unable to exit from the pleural space and continues to accumulate. Collapse of cardiopulmonary system occurs rapidly. Treatment consists of immediate insertion of a chest tube. Volu-pressure trauma: It relates to the lung injury that occurs when large tidal volumes are used to ventilate non-compliant lungs.( lungs.( eg. ARDS ARDS ).Volupressure ).Volupressure trauma trauma results results in alveolar alveolar fractures and movement of fluids and proteins into the alveolar spaces spaces.. To limit limit this this compli complicat cation ion , it is recomm recommend ended ed that that smal smalle lerr tida tidall volu volume mess or pres pressu sure re vent ventil ilat atio ion n be used used in patients with stiff lung. Alveolar Alveolar hypo ventilation ventilation: Hypoventilation can be caused by inap inappro propr pria iate te vent ventil ilat ator or sett settin ings gs,, leak leakag agee of air air from from the the ventilator tubing or around the ET tube or trSIMV rate in a patient who is unable to produce adequate spontaneous respiration respirationss causes hypoventil hypoventilation, ation, respiratory respiratory acidosis, acidosis, and addi additi tion onal al prob proble lems ms rel related ated to acid acidos osis is such such as card cardia iacc arrhythmias. Alveolar Alveolar hyperventil hyperventilation ation: Respiratory alkalosis can occur if the respiratory rate or VT is set too high or if the patient receiving receiving assisted assisted ventilatio ventilation n is hyper ventilatin ventilating. g. Alkalosi Alkalosis, s, espe especi cial ally ly if onse onsett is abrup abrupt, t, can can have have addi additi tion onal al seri seriou ouss cons conseq eque uenc nces es incl includ udin ing g hypo hypoka kale lemi mia, a, hypo hypoca calc lcem emia ia and and arrhythmia. Ventil Ven tilator ator associ associate ated d Pneumo Pneumonia nia: Pati Patien ents ts with ith arti artifi fici cial al airw airway ayss are are at an incr increa eased sed risk risk for for pulm pulmon onary ary infe infect ctio ion n because normal defense mechanisms in the nose are bypassed. Additiona Additionally, lly, procedures procedures such as endotracheal endotracheal suctioning suctioning also predispose the patient to an increased risk of infection. infection. Intubation Intubation of right main stem bronchus bronchus: The right main stem bronchus is straighter than the left. If the ETT is manipulated, such as occurring during changing of the tapes or repositioning of the tube in the mouth, it may move into the right main stem bronchus. Symptoms include absent or diminished breath 12
sounds in the left lung. Whwnever the ETT is manipulated , the nurse must auscultate the chest for bilateral breath sounds after the procedure is completed. Unplanned extubation: The ETT can become dislodged dislodged if it is not not secu secure red d prop properl erly, y, if the the pati patien entt move movess or duri during ng tape tape changes on ETT.The ETT may end up in the back of throat, in the esophagus, or completely removed.Auscultation of bilateral breath sounds can be used to verify that the ETT is in the airway. Tracheal damage: Damage to the trachea can occur because of pressure from the cuff. However, the risk of tracheal damage has decreased since all ETTs and tracheostomy tubes have low pressure cuffs. An intervention for preventing tracheal damage is monitoring of cuff pressure on a routine basis; pressures should not exceed 30 cm H2O . Associated Associated with oxygen administrat administration: ion: If 100 % oxygen is administe administered red , there is lack of nitrogen nitrogen in the distal air spaces. spaces. Nitrogen is needed in order to prevent collapse of the airway. Therefore Therefore the patient is prone for absorption absorption atelectasis. atelectasis. Other complications associated with oxygen administration include tracheo-br -bronchitis,ARDS, and chronic pulmonary dysplasia.As a rule, an FiO2 up to 1.0 can be tolerated up to 48 hours.After that period, the goal is to lower the FiO2 less than 0.60 to prevent further lung damage. Aspiration: Aspiration: Most Most pati patien ents ts requ requir iree tube tube feed feedin ings gs.G .Gas astr tric ic distention, impaired gastric emptying with large amounts of gastric residua, and esophageal reflux predispose patients to aspiration. Vent Ve ntil ilat ator or Depe Depend ndan ance/ ce/ Inabi Inabili lity ty to we wean an: Pati atient ents who requir requiree long-t long-term erm mecha mechanic nical al ventil ventilati ation on are usuall usually y very very chal challe leng nging ing to wean wean from from vent ventil ilat ator ors. s. E.g. E.g.:: pati patien ents ts with with COPD and neuromuscular disease. 2. Cardio Cardiovasc vascula ularr system system:: PPV PPV can can affe affect ct circ circul ulat atio ion n beca becaus usee of transmission of increased mean airway pressure to the thoracic cavity. With increased intra thoracic pressure, thoracic vessels are compressed. This results in decreased venous return to heart, decreased left ventricular end end dias diasttolic olic volum olumee ( prel preloa oad d ), decr decrea ease sed d card cardia iacc outpu utputt and and hypotension. 3. Sodium and Water Imbalance : Progressive fluid retention often occurs after 48-72 hours of PPV. Fluid balance changes may be due to decr decrea ease sed d CO, CO, whic which h in turn turn resul results ts in dimi dimini nishe shed d rena renall perf perfusi usion on.. Consequently rennin release is stimulated with subsequent production of angiotensin angiotensin and aldosteron aldosterone. e. This results in sodium sodium water water retention retention.. It is •
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also possible that that pressure changes within within the thorax are associated associated with decr decrea ease sed d rele release ase of atri atrial al natr natriu iure reti ticc pept peptid ide, e, also also causi causing ng sodi sodium um retention. In addition, as a part of stress response, release of antidiuretic hormone and cortisol may be increases, contributing to sodium water retention. 4. Gastrointestinal system: Patients receiving PPV are often stressed because of serious illness, immobility, and discomforts associated with the ventilator. Thus the ventilator patient is at risk for developing stress ulcers and GI bleeding. Any kind of circulatory compromise, including reduction of CO caused by PPV, may contribute to ischemia of gastric and intestinal mucosa and possibly increase the risk of translocation of GI bacteria. Gastric and bowel dilation may occur as a result of gas accumulation in the GI tract from swallowed air.This may put pressure on the vena cava, decr decrea ease se CO and and proh prohib ibit it adeq adequa uate te diap diaphr hrag agma mati ticc excu excursi rsion on duri during ng spontaneous breathing. Elevation of the diaphragm as a result of paralytic ileus or bowel dilation leads to compression of the lower lobes of the lungs, which may cause atelectasis and compromise respiratory function Immobility, sedation, circulatory impairment, decreased oral intake, use of opioid pain medications and stress contribute to decreased peristalsis, and and as a resu result lt,, the the vent ventil ilat ator ory y pati patien entt coul could d be pred predis ispo pose sed d to constipation. 5. Neurologic System: In patients with head injury, PPV, especially with PEEP, can impair cerebral blood flow. This is related to increased intra thoracic positive pressure impeding venous drainage from the head, as evid eviden ence ced d by jugu jugula larr veno venous us dist disten ensi sion on.A .Ass a resul resultt of the the impa impair ired ed venous return and increase in cerebral volume, the patient may exhibit increa increases ses in intra intra crania craniall pressur pressure. e. Eleva Elevatin ting g the the head head of the bed and keepin keeping g the patien patient’s t’s head head in alignm alignment ent may may decrea decrease se the the delete deleterio rious us effects of PPV on intra cranial pressure. 6. Psychos Psychosoci ocial al compli complicat cation ions: s: The The pati patien ents ts rece receiv iving ing mech mechan anic ical al ventilation may experience physical and emotional stress. Usually the critical care milieu is one of continuous, excessive sensory s ensory stimulation for the patient. An attitude by the practitioner of confidence and knowledge of the equipment will help allay the patient’s fears of safety. Communication becomes an almost intolerable problem for the patient rece receiv ivin ing g vent ventil ilat ator or ther therap apy. y. The The pati patien entt must must have have some some mean meanss of commun communica icatio tion n to relay relay his needs and feelings feelings to his his famil family y and the health care team.Continuity of the care givers who are compatable and accu accust stom omed ed to the the pati patien entt is also also impo importa rtant nt in fost fosteri ering ng the the sens sensee of independence and control . A trusting relationship is needed if behaviour modifi modificat cation ion techni technique quess are used used with with the the patien patient, t, most most impor imporata atantl ntly y when the ventilator weaning process is begun. 14
NURSING MANAGEMENT MAIN MA INTA TAIN ININ ING G A PATE PA TENT NT AIRW AI RWAY AY o
o
o
o o o
o
Assess the need for suctioning e.g. noisy respirations, restlessness, increased pulse. Ausculate the chest for equal air entry, presence of abnormal breath sounds, observe for asymmetrical chest expansion. Provi Provide de chest chest physio physiothe therapy rapy in the form form of nebuli nebulisat sation ion,, humidification, adequate hydration, positioning, percussion, vibrations and tapotment, postural drainage.(to prevent RTI). Suction the patient :Maintain sterility at all times. Check the ET / TT is well secured and inflated, prior to suctioning. 100% oxygenation prior to suctioning (ambu / ventilator).
PREVE PR EVENT NTION ION OF INFEC IN FECTIO TION N
o o
o
o o o o o
o
Practice proper hand washing. Any health personnel having RTI should avoid caring for these patients or remember to use a mask while providing care. Use of aseptic technique while suctioning, while changing trache tracheost ostomy omy dressi dressings ngs,, perfor performin ming g invasi invasive ve proced procedure uress / inserting any device, etc. Maintain adequate oral and personal hygiene. Avoid entry of water / foreign body into the trachea. Change tubing's, bacterial / ventilator filters as per protocol. Provide adequate nutrition (HPD, HCD). Obser Observe ve for for S/S S/S of infe infect ctio ion n (loc (local al / syst system emic ic), ), devi device ce related. Good Good respira respiratory tory hygien hygiene. e. (sucti (suction, on, chest chest physio physiothe therapy rapy,, etc).
PREVENTION OF ASPIRATION o
A cuffed endotracheal or tracheostomy tube should be used in a patient
15
o o
o
o
o
o
o
o
who requires mechanical ventilation. The cuff inflation pressure should be adjusted until there is no audible air leak leak whil hile usi using norm ormal insp inspir irat ator ory y airway rway press ressur ures es.. An endo endotr trac ache heal al cuff cuff pres pressu sure re of at leas leastt 20cm 20cm H2O H2O shou shoulld be maintained. In patients requiring prolonged ventilatory support, cuff deflation shou should ld be cons consiidere dered d when when the pati patien entt is aler alert, t, has has norm normal al swallowing and is tolerating trials of spontaneous breathing. Aspiration of subglottic secretions should be considered in patients who are expected to be mechanically ventilated for more than 48 hours. Mechanically ventilated patients should be nursed in the semirecumbent position (elevation of the head of the bed to 30-45°), unless contraindicated. The The use use of rota rotati ting ng beds beds may may be cons consid idere ered d in mecha mechani nica call lly y vent ventil ilat ated ed pati patien ents ts who cann cannot ot tole tolera rate te the the sem semi-re i-recu cumb mben entt position. Gastric distension should be avoided in mechanically ventilated patients who are being fed enterally.
NUTRITI NUTR ITIONAL ONAL NEEDS o
o o o o o
o o o o o
HPD and high carbohydrate / fiber diet through Ryle’s tube. Points to be remembered while giving giving RT feeds feeds :Check for presence of gastric motility by auscultation. Confirm placement of RT. Assess amount of residual feed. Administer feeds in PUP. Maintain this position for half an hour after feeds. Prevent air entry into the RT. Aspirate after 1 hour to confirm digestion of feeds. Perform suctioning prior to feeds. Provide nasal care / oral care. Prepa Prepare re a diet diet plan plan base based d on pati patien ent’ t’ss need needs. s.(p (prot rotei eins ns / calories/ fluids).
POSITIONING o
Provide change of poistion every two hours along with back massage and limb physiotherapy.
16
o
Use comfort comfort device devicess to preven preventt bed-sor bed-sores, es, contrac contractur tures& es& footdrop (> in unconscious patients )
PREVENTION OF COLONISATION OF THE AERODIGESTIVE TRACT o
o
o
Hista Histamin minee recept receptor or 2 antago antagonis nists ts and proton proton pump pump inhib inhibito itors rs should be used in mechanically ventilated patients at high risk of develo developin ping g upper upper gastro gastroint intest estina inall bleedi bleeding. ng. Sulcra Sulcralfa lfate te may may be considered in patients at low to moderate risk of bleeding. Regula Regularr oral oral hygien hygienee should should be carrie carried d out in all mecha mechanic nicall ally y ventilated patients. A soft toothbrush should be used to clean the oral mucosa, except where contraindicated (e.g., increased risk of bleeding, thrombocytopenia) at least 12-hourly. The topical application of chlorhexidine gluconate (0.12%- 2%) should be considered in such an oral care programme. Povidoneiodine (10%) should be considered for use in patients with severe head head inju injury ry.. No rec recomm ommenda endati tion on is made ade for sele select ctiive decontamination of the digestive tract .
ACTIVITY o o
o
Provide active & passive ROM excercises. Plan care to provide periods of activity & rest. Encourge early ambulation
.
MEET ME ETIN ING G THE HYGI HY GIEN ENIC IC NEED NE EDS S o o
Provide oral care every 2 - 4 hourly. Also provide sponge bath, back care, eye care, nasal care, etc.
MEET ME ETIN ING G TH THE E EL ELIM IMIN INAT ATIO ION N NEED NE EDS S o o o o o
Catheter care. Hydration of the patient. Provide bedpan and clean patient, as required. Provide privacy. Observe for constipation / diarrhea (modify diet).
MEET ME ETIN ING G TH THE E SPIR SP IRIU IUAL AL & PSYC PS YCHO HOSO SOCI CIAL AL NEEDS NEE DSss ss
17
Make provisions for meeting spiritual leaders and for prayers. Plan for visiting hours without unnecessary disturbances.
Facilitate communication between patient, family,healthpersonnel
.
CUFF CU FF CARE CA RE o
o
o
o
Deflate the cuff every 1 hour for 5 mins. Be with the patient at this time. (varies (varies with hospital policy). Inflate cuff at all other times. Especially when suctioning, giving trach. care, positioning, positioning, mouth care, change of tapes, feeding. Assess for cuff leak – by ascultating, checking TV, excessive movement of tube.(hazards - reduced TV, aspiration, accidental extubation) Check cuff pressures – 20 – 24 mmHg (hazards of high/ prolonged pressures - necrosis, bleeds, fistula)
ENDO EN DOTR TRAC ACHE HEAL AL / TRAC TR ACHE HEOS OSTO TOMY MY TUBE TU BE CARE CA RE o
o
o o
Check the ET level intermittently and after suctioning and positioning. Secure the tube well with tape / tie. Alternate sides every 24 hours. Use the appropriate size to prevent injury. injury. Assess for bilaterally bilaterally equal air entry entry at all all times.
HAND HA NDLI LING NG AN ALAR AL ARM M o
o o
o
o o
NEVER PUT OFF AN ALARM ALARM WITHOUT DETERMINING IT’S CAUSE After silencing the alarm, attend to it IMMEDIATELY Find the problem and solve it before re-setting the alarm again. If alarm sounds again, DO DO NOT ASSUME it is is for the same reson. Investigate it. Set limits appropriately. Suspend alarms only when required e.g. suctioning. At these times, obeserve patie nt and monitor monitor readings readings closely.
18
WEANING FROM MECHANICAL VENTILATOR Weaning is the gradual withdrawal of mechanical ventilation. The client’s abil abilit ity y to brea breath thee inde indepe pend nden entl tly y is the the most most impo import rtan antt crit criter erio ion n for for successful weaning. The length of time required for successful weaning generally relates to the underlying disease process and to the client’s state of health, before the ventilator was used. Weaning should be instituted after after paraly paralytic ticss are discon discontin tinued, ued, and sedat sedation ion is tapere tapered d off. off. During During weaning process, the client should be observed for increased respiratory rate, shallow breathing and decreased tidal volume , which may indicate muscle fatigue. CRITERIA FOR A VENTILATOR WEANING TRIAL • •
•
• • •
• • •
• •
Reversal of underlying cause of respiratory failure Adequate oxygenation, indicated by, - PaO2 ≥ 60 mm Hg on FiO2 < 40-50 % requirement ≤5-8 cm of H2O H2O - PEEP requirement - pH ≥ 7.25 Heart rate ≤ 140 beats/min Stable BP with no or minimal vasopressive medication No myocardial ischemia Temperature ≤100.4 ◦ F Hb ≥ 8-10 g/dL Acceptable electrolyte values Adequate cough Capability to initiate respiration Adequate mentation without continuous IV sedation
METHODS OF WEANING
There are two methods of weaning. 1. The convention conventional al method method is the episodi episodicc ventilator ventilator with with T-piece T-piece or CPAP. Briggs T-piece is used. The patient is disconnected from the vent ventil ilat ator or for for a spec specif ific ic peri period od of time time and and allo allowe wed d to brea breath th spontaneously using the Briggs T-piece or CPAP. Weaning starts with shorter intervals such as 5-10 minutes every hour or more. The patient requires rest period. period. Weaning Weaning should not be attempted attempted during during night night until until the patient can maintain maintain spontaneous spontaneous breathing. breathing. The vital capacity and signs of fatigue are monitored closely during the weaning period. 19
2. Intermittent Mandatory Ventilation weaning: IMV is a technique
by which patient can breathe spontaneously and in addition receive mechanically ventilated breaths at specific pre selected rate. Set rate, interval and keep sensitivity at maximum setting. Record at each weaning interval heart rate, blood pressure and respiratory rate and ABG and pulse oxygenation while IMV is used. The sponta spontaneo neous us rate rate should should not exceed exceed 30 breath breaths/ s/ minut minutes es as this this result resultss in fatig fatigue, ue, CO2 CO2 retent retention ion and respir respirato atory ry acidos acidosis. is. Rates Rates greater greater than 30 indicate indicate a need to reduce weaning weaning time. Weaning Weaning can continue as long as patient’s condition is stable and arterial pH is 7.32 – 7.35. Patient is positioned in sitting or fowlers position during weaning. All respiratory and other parameters are monitored. Patient is supported emotionally during weaning process. CAUSES OF FAILURE TO WEAN
1. Pati Patien entt Fact Factor ors: s: Inadequate spontaneous breathing Intrinsic pulmonary disease resulting in atelectasis Consolidation Edema Bronchospasm which can be managed with PEEP and chest physiotherapy Chest wall trauma Muscle weakness Abnormal cardiac functioning Starvation (protein loss cause break down of muscle mass result resulting ing in decrea decreased sed respir respirato atory ry muscle muscle functi function on which which may affect weaning process ) 2. Ventil Ventilato atorr Syste System m Facto Factors: rs: Ventil Ventilato atory ry design design and PEEP PEEP devices devices are a major major source source of of weanin weaning g proble problems. ms. Metic Meticulo ulous us attent attention ion should should be paid paid to the appr approp opri riat atee sett settin ing g of flow flow and and sens sensit itiv ivit ity y when when IMV IMV is used used.. Continuous Positive Pressure should be produced with a system that provides a minimum of external work for patient. 3. Airw Airway ay Fac Facto tors rs:: The artificial airway also may produce weaning problems. It is notice noticed d that that endotr endotrach acheal eal tube tube of small small inter inter diamet diameter er requir requires es increased patient effort during spontaneous ventilation obstruction of tube can be a cause of sudden and marked change in weaning ability.
20
SIGNS AND SYMPTOMS OF WEANING INTOLERANCE •
•
•
•
•
•
•
•
•
•
•
•
•
Presence of dysrrhythmias Increase or decrease in the heart rate > 20 bpm Increase or decrease in BP of > 20 mm Hg Increase in respiratory rate of > 10 above baseline Tidal volume < 250 ml Increase in minute ventilation of > 5 litre / minute Sp O2 < 90 % Pa O2 < 60 mm Hg Increase in the PaCO2 with a decrease in pH of < 7.35. Sweating Shortness of breath Restlessness Decrease in the LOC
•
NURSING MANAGEMENT Nursing Diagnosis 1.Ineffective airway clearance related to presence of artificial airway, accumulati accumulation on of secretions and immobili immobility ty as manifested manifested by presence presence of abnormal breath sounds and presence of thick copious secretions - chan chang ge pati patien ent’ t’ss posi osition ion 2 hour hourlly and perfo erform rm postu ostura rall drai draina nage ge,, vibra vibrati tion on and and perc percuss ussio ion n mane maneuv uver er to prev preven entt pooling of secretions - have have pati patient ent coug cough h and, and, if feasi feasibl ble, e, deep deep breat breathe he 2 hourl hourly y to remove secretions and to prevent hypoventilation. - suction or oropharyn rynx - perf perfor orm m trac trache heo o bron bronch chia iall suct suctio ioni ning ng to remo remove ve reta retain ined ed secretions and improve oxygenation - asse ssess br breath so sound unds - asse ssess for adequate systemic hydrat ration and provide supple supplemen mental tal humidi humidific ficati ation on of ventil ventilato atorr deliv delivered ered gas because these will assist with thinning thinning of sputum. 2. Impa Impair ired ed gas gas exch exchan ange ge rela relate ted d to insu insuff ffic icie ient nt oxyg oxygen en leve levels ls or inadequate PEEP level. Monitor ABG’s. - Assess Assess LOC, LOC, listl listless essnes ness, s, and and irrit irritabi abilit lity. y. - Observ Observee skin skin color color and capi capilla llary ry refill refill.. (Determ (Determine ine adequ adequacy acy of blood flow needed to carry oxygen to tissues.) - Adm Adminis iniste terr oxyg oxygen en as orde ordere red d
21
-
Observ servee for for tube ube obstr bstruc ucttion; on; suc suction tion ; ensu ensure re adeq adequa uate te humidification. - Reposi Repositio tion n patie patient nt q. 1-2 1-2 h.( h.( Reposi Repositio tionin ning g helps helps all all lobes lobes of the lung to be adequately perfused and ventilated.) 3. Decreased cardiac output related to impeded venous return by PPV as manifested by decreased BP, decreased urine output, increased heart rate - monit monitor or vita vitall sign signss and and leve levell of of consc consciou iousne sness ss - observ observee and moni monitor tor for for clini clinical cal mani manifest festati ations ons of of decrea decreased sed cardiac output - moni monito torr hemody hemodyna nami micc para parame mete ters rs espec especia iall lly y when when > 10 cm of H2O of PEEP is used 4. Imbalanced nutrition less than body requirement related to NPO status - Prov Proviide nutri utrittion ion as orde ordere red, d, e.g. .g. TPN, PN, lipids pids or ente entera rall feedings. - Obtai Obtain n nutrit nutrition ion cons consult ult.. ( Provid Provides es guida guidance nce and and contin continued ued surveillance.) - Admi Admini nist ster er ente entera ra sol solutio utions ns at cont contin inua uall rate ratess by infu infusi sion on pump as warranted - Obse Observ rvee for for muscl usclee was wasti ting ng - Obse Observ rvee for for naus nausea ea,, vomit omitin ing, g, abdo abdomi mina nall dist disten ensi sion on,, and and palpability and stool characteristics - Inse Insert rt nasog nasogas astr tric ic tube tubess if if nee neede ded d 6.Impa 6.Impaire ired d verbal verbal commun communica icatio tion n relate related d to intub intubati ation on and artifi artificia ciall airway - evalua evaluate te patie patient nt’s ’s abilit ability y to com commun munica icate te by othe otherr means means - ensu ensure re that that call call bell bell is plac placed ed with within in easy easy reach reach of patie patient nt at all times - make eye contact with patient at all times - inst instru ruct ct famil family y memb member erss in talk talkin ing g with with patie patient nt to provid providee information about issues of concern to patient. 7. Risk Risk for infec infectio tion n relate related d to intuba intubati tion on and comprom compromise ised d defens defensee mechanism - evaluat uate risk factors ors that would pred redispo spose patient to infection - prov proviide oral oral hyg hygiene iene Q4H - moni monito torr sput sputum um for for chan change gess in char charac acte teri rist stic icss and and colo colour ur,, culture sputum - moni monito torr trac trache heost ostom omy y site site for for inf infec ecti tion on - maintain good hand washi shing technique and isolation precautions when warranted - mainta intaiin ster steril ilee tech techni niqu quees for all all dress ressiing chang hanges es and and suctioning - -Adm -Admin inis iste terr ant antib ibio ioti tics cs as orde ordered red 22
8. Risk for injury related to patient deterioration, mechanical break down, increased intrathoracic pressure, or bypassed defence mechanism. - keep keep ven venti tila lato torr alarm alarmss keep keep on at at all all time timess - cont contin inua uall lly y obser bserv ve whet hether her the pat patient ient is breat reathi hing ng in synchrony with the ventilator - monitor the patient on PEEP closel sely for barot rotraumas, decreased cardiac output, water retension and if the patient has an ICP monitor, increased ICP - obtain AB ABG va values - monitor patient for signs and symptoms for decreased sed cardiac cardiac output output such as hypotension, hypotension, tachycardia, tachycardia, arrhythmia arrhythmia and deteriorating mental status - drain drain cond condense ensed d flui fluid d from from the ventil ventilato atorr tubi tubing ng mainta tain in ster steril ilee tech techni nique que,, good good oral oral care care,, and and caref careful ul - main positioning and observe for signs and symptoms for pulmonary infections 9. Risk for dysfunctional ventilatory weaning response related to lack of physiologic and psychological readiness. - - antic anticip ipat atee wean weanin ing g when when the pati patien entt meets meets all the the criter criteria ia for weaning - - make make sure the the pati patient ent is is reste rested d , well well nour nouris ishe hed, d, orie orient nted ed and able to follow command - - expl explai ain n wean weanin ing g to the the pat patie ient nt and and fam famil ily y - - Obtai btain n base baseli line ne vital vital signs signs,, ABG ABG valu values es and and pulm pulmon onar ary y function measurements.
RECENT STUDIES
Meticulous mouth care is crucial for preventing VAP. Rincon-Ferrari and colleagues (2004) found that in head-injured patients, 40%-60% of the gramnegative bacilli found were due to endogenous lung colonization after after aspira aspiratio tion n of oropha oropharyn ryngea geall secret secretion ions. s. Twenty Twenty percen percentt to forty forty percent of these bacteria were Staphylococcus aureus, and more than half of the Staphylococcus Staphylococcus aureus were were methi methicil cillin lin-res -resist istant ant.. This This type type of
23
staphylococcus is exogenous, usually originating from the hands (Mori ( Mori et al., 2006). 2006). Studies Studies have shown that patients patients can become colonized colonized with pathogeni pathogenicc bacteria within 24 hours of admission to a critical care unit ( Garcia, Jendresky, & Colbert, 2004; 2004; Sole, Poalillo, Byers, & Ludy, 2002). 2002 ). The oral cavity and its components-especially dental plaque-are the perfect media in which bacteria can colonize (Garcia et al.). The Am Ameri erica can n As Asso soci ciat atio ion n of Cr Crit itic ical al-Ca -Care re Nu Nurs rses es publ publis ishe hed d an evidence-based practice alert in 2006 that offered guidelines for oral care of the mechan mechanica ically lly ventil ventilate ated d patien patient. t. In additi addition, on, Gr Grap ap an and d Mun unro ro (2004) and Collard and Saint (2004) recommended raising the head of the bed to an elevation of 30[degrees] to 40[degrees], using endotracheal tube tubess that that have have a dors dorsal al lum lumen abov abovee the the endo endottrach rachea eall cuff cuff,, and and sporadically changing ventilator circuits. Grap and Munro (2004) presented supporting evidence indicating that critically ill patients who are intubated for more than 24 hours are at higher higher risk for VAP, and therefore, mouth mouth care and oral health should be an important important part of nursing nursing care. Current literature literature identifie identified d a problem problem with with adeq adequa uate te oral oral care care in the the intu intuba bate ted d pati patien entt that that incl includ uded ed the the definition and quantification of oral care (Fourrier ( Fourrier et al., 2000). 2000 ). Bergmans and col collea league guess (20 (2001) 01) provid provided ed eviden evidence ce that that preven preventio tion n of bacter bacterial ial colonization of the oropharynx is the key to preventing VAP. The Centers for Disease Control and Prevention guidelines (Tablan, (Tablan, Anderson, Besser, Bridges, & Hajjeh, 2004) 2004 ) determined that the primary route of bacterial entr entry y into into the the lung lungss is throu hrough gh the the orop oropha hary rynx nx duri during ng epis episod odes es of microaspiration. Several studies (El-Solh (El-Solh et al., 2004; 2004 ; Schleder et al., 2002; 2002 ; Shinn, 2004) 2004) have verified that removing bacteria from the oropharynx requires the removal of dental plaque, and the only way to remove the plaque is with toothbrushing. Pea Pearson rson and Hut Hutton ton (20 (2002) 02) and and othe others rs foun found d that that the the majority of nurses use a soft Toothette(R) instead of toothbrushing and that the Toothettes do not remove plaque as effectively as toothbrushes; consequently, oral bacteria can proliferate (Baker, (Baker, 2007; 2007; Binkley, Furr, Carrico, & McCurren, 2004). 2004). Pearson and Hutton (2002) completed a controlled trial that compared the ability of foam swabs and toothbrushes to remove dental plaque and to quantify any differences. They concluded that toothbrushing skills must be taught to nurses and clinical support staff. Schleder (2003) reviewed the the pat pathog hogenes enesiis of bact acteria eria;; iden identi tifi fied ed risk risk facto actors rs,, incl ncludi uding 24
colo coloni niza zati tion on of the the orop oropha hary rynx nx;; and and reco recom mmend mended ed the the foll follow owin ing g approaches: 1. Use good oral hygiene, including toothbrushing, on all patients. 2. Implement oral-hygiene assessments and intervention strategies for all patients at risk for developing VAP. VAP. 3. Decont Decontami aminat natee device devicess that that come come into into contac contactt with with the the respir respirato atory ry tract. 4. Implement Implement the hand-hygiene hand-hygiene guideline guideliness released released by the CDC in 2003. The guidel guideline iness includ includee decont decontami aminat nating ing hands hands by washi washing ng them them with with antimi antimicrob crobial ial soap soap and water water or by using using an alcoho alcohol-ba l-based sed,, water waterles lesss antiseptic agent if hands are not visibly contaminated. In addition, gloves shou shoulld be worn orn when when hand handli ling ng resp respir irat ator ory y secr secret etio ions ns or obje object ctss contaminated with the respiratory secretions of any patient ( Schleder, 2003;; Tablan et al., 2004). 2003 2004 ). Grap, Munro, Ashtiani, and Bryant (2003) have substantiated the need to standardize oral care for a variety of reasons, the most compelling of whic which h is to prev preven entt or lowe lowerr VAP VAP rate ratess in mech mechan anic ical ally ly vent ventil ilat ated ed patients. Oral care is not only part of a standard of care that lowers infection rates by removing plaque-harboring organisms, but is also a comfort care issue (Fourrier (Fourrier et al., 2000; 2000 ; Munro & Grap, 2004). 2004). Using evid eviden ence ce-ba -base sed d outc outcom omes es and and rese researc arch, h, the the CDC CDC and and its its Hosp Hospit ital al Infection Control Practices Advisory Committee have developed a set of guidelines for VAP prevention that are beneficial for any institution. The guidelines include preferential use of orotracheal tubes over nasotracheal tubes, use of endotracheal tubes with a dorsal lumen to allow drainage, elevating the head of the bed to 30[degrees] or 40[degrees], routinely verify verifying ing placem placement ent of feedin feeding g tubes, tubes, and preven preventin ting g or modul modulati ating ng oropharyngeal colonization with implementation of a comprehensive oral hygiene program (Dodek (Dodek et al., 2004; 2004 ; Tablan et al., 2004). 2004 ).
CONCLUSION Care of critically ill patients requires knowledge of normal anatomy and physiology and excellent assessment skills. Skills in establishing and maintaining an open airway and initiating mechanical ventilation are also esse essent ntia ial. l. Care Care of the the pati patien entt requ requir irin ing g mecha mechani nica call vent ventil ilat atio ion n is an 25
everyday assignment in critical care unit. Therefore it is essential that the nurse must apply knowledge and skills in order to effectively care for these patients.
BIBLIOGRAPHY 1. Linda Linda.D. .D.Urd Urden, en, Priori Prioritie tiess in Criti Critical cal Care Care Nursin Nursing, g, 4 th Edition,
Mosby publishers, Missouri,2004, Pp 260-264 2. Lyne Lynell lle. e.N. N.B. B.Pi Pier erce ce,, Mangem angemen entt of Mech Mechan anic ical ally ly vent ventil ilat ated ed Patient, 2nd Edition, Saunders Publishers, Missouri, 2007 3. Lewis, Lewis, Heitkempe Heitkemper, r, Medical Medical Surgical Surgical Nursing, Nursing, 6th Edition, Mosby Publishers, Missuori, 2006, Pp 1780-1792 4. P.K.Verma, Mechanical Ventilation and Nutrition in Critically ill patients, 1st Edition, Elsevier publishers, NewDelhi, 2005 5. Jaya Kuruvilla, Essentials of Critical Care nursing, 1 st Edition, JayPee publishers, Newdelhi,2007 6. T.E.Oh T.E.Oh,, Intens Intensive ive care care Manua Manual, l, 3rd Edition, Edition, Sydney Sydney Butterwort Butterworth h publishers, London, 1990 7. Ake Greenvik, John Downs, Mechanical Ventilation and Assisted Respi Respira rati tion on,, 1st Edit Editio ion, n, Churc Churchi hill ll Livi Living ngsto stone ne publ publis ishe hers, rs, NewYork,1991 nd 8. Paul.L.Marine, The ICU Book, 2 Edition, Williams and Wilkins company, Pennsylvania, 2000, Pp 420-470 Edition, Saunders Saunders 9. C.T.Hinds & C.D.Watson, Intensive Care, 2 nd Edition, Publishers, London, 1996 10. Heartshorn and Sole , Introduction to Critical care Nursing, 3 rd Edition, Saunders Publishers, 1997, Philadephia. JOURNALS 1. .American Journal of Nursing, August 2007, Vol.107
2. Nighting Nightingale ale Nursing Nursing Times, Times, July July 2010, 2010, Vol.6 Vol.6 3. Nighting Nightingale ale Nursing Nursing Times, Times, December December 2010, 2010, Vol.6 Vol.6 4. Journa Journall of Nursing Nursing Researc Research h Societ Society y of India, India, Vol.1, Vol.1, October October 2008 INTERNET REFERENCES 1.www.wikepedia.com
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