Nursing Role in Preventing complications of MV

Outline

Airway complications

Hemodynamic disturbances

Ventilator associated lung injury: VILI

Oxygen toxicity

Ventilator associated pneumonia

Pulmonary emboli

Patient ventilator asynchrony

Sleep disturbance

Outline

Airway complications

Hemodynamic disturbances

Ventilator associated lung injury: VILI

Oxygen toxicity

Ventilator associated pneumonia

Pulmonary emboli

Patient ventilator asynchrony

Sleep disturbance

Injuries to mouth, lips and oropharynx

Trauma to the lips and cheeks from tube ties

Avulsion of skin due to adhesive tape

Injuries to the entrapped tongue

Pressure ulcers to the palate and oropharynx

Perioral herpes

Skin flap avulsion during extubation due to adhesive tape.

Endotracheal Tube Fixator

Slipped ETT

Chest X-Ray

3-4 cm

Correct ET Tube Placement

Correct ET Tube Placement

Secure ET tube in place, note the numberSedate patient with appropriate MAASAvoid accidental, or self extubation

Laryngeal Inguries

Laceration and hematoma in the left vocal fold during direct laryngoscopy. Exam performed with rigid telescope

Laryngeal Injuries

Bilateral intubation granulomas inserted in the vocal apophasis.

Exam performed with rigid telescope.

Ulcerated lesion in the posterior glottic commissure soon after extubation. Exam performed

with rigid telescope.

Laryngeal Injuries

diffuse posterior erythema, edema and piled-up mucosa of inter-arytenoid area

Cuff Related Injuries

Risk of aspirationRisk of mechanical complications

Prince J S et al. Radiographics 2002;22:S215-S230

Postintubation stenosis

Tracheal and Glottic Stenosis

Tracheal stenosis (exam performed with flexible nasofibroscope)

Glottic stenosis (exam performed with rigid telescope).

Ulceration of the mucosa and cartilage, granulation tissue, and fibrous tissue

Tracheomalacia

Tracheal collapse of more than 50% during expiration is diagnostic of tracheomalacia

AnapnoGuard

The AnapnoGuard system detects air leakage from the lungs by measuring the CO2 level above the cuff. Detection of high CO2 levels above the cuff represents leakage

Sphygmomanometers

Minimum Leak Volume Technique

Air inflation of the tube cuff until the airflow heard escaping around the cuff during positive pressure breath ceases.

Place a stethoscope over larynx. Indirectly assesses inflation of cuff.

Slowly withdraw air (in 0.1-mL increments) until a small leak is heard on inspiration.

Remove syringe tip, check inflation of pilot balloon

Outline

Airway complications

Hemodynamic disturbances

Ventilator associated lung injury: VILI

Oxygen toxicity

Ventilator associated pneumonia

Pulmonary emboli

Patient ventilator asynchrony

Sleep disturbance

Case Scenario

64 year old male with history of COPD who presented with severe respiratory distress and required to be intubated and placed on CMV, VT of 650 ml and a rate of 24/min.

Immediately post intubation, his systolic blood pressure dropped from 132 mm Hg to 73 mm Hg.

Hypotension following MV

PPV vs. Spontaneous Ventilation

0

5

3

-3

120

0

10

0

5

3

-3

110

0

8

PPV vs. Spontaneous Ventilation

Effect of Lung Volume on Venous Return

No effect in Normal individual with PEEP less than 10 cmH2O

Major effect in patients with Dynamic Hyperinflation such as asthma and COPD, and in pre-existing pulmonary hypertension

Small changes in PVR can cause considerable hemodynamic compromise secondary to acute increase in PVR

Avoid air trapping in these patients

Symptoms of hemodynamic effects

Decreased cardiac output, decreased venous return

Observe for:▪ Decreased BP▪ Restlessness, decreased LOC▪ Decreased urine output▪ Decreased peripheral pulses▪ Slow capillary refill▪ Increasing Tachycardia

Outline

Airway complications

Hemodynamic disturbances

Ventilator associated lung injury: VILI

Oxygen toxicity

Ventilator associated pneumonia

Pulmonary emboli

Patient ventilator asynchrony

Sleep disturbance

Ventilator-associated lung injury (VALI)

•Overdistention Volutrauma

•Repeated recruitment and collapse

Atelectetrauma

•Inflammatory mediatorsBio trauma

•High-pressure induced lung damageBarotrauma

•FiO2Oxygen toxic effect

Ventilation-Induced Lung Injury (VILI)Atelectrauma:

Repetitive alveolar collapse and

reopening of the under-recruited

alveoli

Volutrauma:Over-distension of

normally aerated alveoli due to excessive volume

delivery

*Dreyfuss: J Appl Physiol 1992

Cytokines, complement, prostanoids, leukotrienes, O2

- Proteases

Biotrauma

Pinsp = 40 mbar

Recognized Mechanisms of Airspace Injury

“Stretch”

“Shear”

Airway Trauma

Gas Extravasation Barotrauma

Barotrauma

Barotrauma

Barotrauma

Volume

Pressure

Zone ofOverdistention

“Safe”Window

Zone ofDerecruitmentand Atelectasis

Injury

Injury

Optimized Lung Volume “Safe Window”

Overdistension Edema fluid accumulation Surfactant degradation High oxygen exposure Mechanical disruption

Derecruitment, Atelectasis Repeated closure / re-

expansion Stimulation inflammatory

response Inhibition surfactant Local hypoxemia Compensatory

overexpansion

Diseased Lungs Do Not Fully Collapse,Despite Tension Pneumothorax

And they cannot always be fully “opened”

Dimensions of a fully Collapsed Normal Lung

Outline

Airway complications

Hemodynamic disturbances

Ventilator associated lung injury: VILI

Oxygen toxicity

Ventilator associated pneumonia

Pulmonary emboli

Patient ventilator asynchrony

Sleep disturbance

Oxygen Toxicity : FIO2 > 60 % for > 24h

Absorptive atelectasis O2/N2 = 21/79

>>>>>> 50/50 Accentuation of

hypercapnia Chronic respiratory

failure: PCO2 with PO2

Damage to airways Bronchopulmonary

dysplasia Diffuse alveolar

damage

Carbon dioxide

Water vapour

Oxygen

Nitrogen

2A2A2A2A NPOHPCOPOPpressureAlveolar

Diffuse Alveolar Damage

Oxygen toxicity Reduce FiO2?

PEEP Alveolar recruitment maneuvers Alternative modes of ventilation

Inverse-ratio , APRV, HFV, ….. Inhaled nitric oxide (iNO) Extracorporeal membrane oxygenation (ECMO) Diuresis

if pulmonary edema is possible Bronchopulmonary hygiene

if secretions are prominent Augmentation of antioxidants??

Outline

Airway complications

Hemodynamic disturbances

Ventilator associated lung injury: VILI

Oxygen toxicity

Ventilator associated pneumonia

Pulmonary emboli

Patient ventilator asynchrony

Sleep disturbance

Path to VAP

Ventilator Associated Pneumonia: Definitions

VAP – ventilator associated pneumonia >48 hours on vent Combination of:

▪ CXR changes▪ Sputum changes▪ Fever, ↑ WBC▪ positive sputum culture

Occurs secondary to micro-aspiration of upper airway secretions

Risk Factors for VAP

No 1 risk factor is endotracheal intubation Factors that related to cross contamination:

Poor adherence to infection control standards Factors that enhance colonization of the oropharynx

&/or stomach: Poor oral hygiene

Conditions favoring aspiration into the respiratory tract or reflux from GI tract: Supine position NGT placement Re-Intubation and self-extubation Surgery of head/neck/thorax/upper abdomen GERD Coma/ depressed Glascow coma scale

Chest X-Ray: VAP

Prevent Contamination: Hand Wash

Prevent Contamination: Hand Wash

Prevent Contamination: Personal Protective Equipments

Prevent Contamination: Change gloves when changing from contaminated to clean area

Prevent Contamination: Environmental Cleaning

Prevent Contamination: Use closed inline system for MDIs

Prevent Contamination: Use condensate traps

Prevent Contamination: Chnage HME every 48 hrs

Reduce Colonization: Oral Hygien, frequent tooth brushing

Reduce Colonization: Oral Hygien mouth swabbing with chlorhexidine

Reduce Colonization: Oral Hygien suctioning of oral secretion

Prevent Colonization: Closed suction system

Prevent Colonized Circuits: Changed when visibly soiled

Prevent Colonization: Periodically drain the condensate

Prevent Aspiration: Head of Bed 40 degrees

Prevent Aspiration: HOB Elevation

HOB at 30-45º

CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004 ATS / IDSA Guidelines for VAP

2005

45o head-up tilt is the goal in all patients unless contraindicated

No benefit of semi-recumbency ~30o over standard care ~10o

Supine position is harmful

Prevent Aspiration: Measure cuff pressure 20-25 mm Hg

Prevent Aspiration: Subglottic suctioning

VAP prevention :VAP Bundle

Elevation of the head of the bed 30-45o Use 15-30o for neonates and small

infants, otherwise 30-45o Daily sedation vacations (minimize

duration of intubation) Daily assessment of readiness to

extubate Peptic ulcer disease (PUD)

prophylaxis Oral care protocol (chlorhexidine) DVT prophylaxis option

HOB Elevation Leads to Significant reduction in VAP

0

5

10

15

20

25

% V

AP

Supine HOB Elevation

Dravulovic et al. Lancet 1999;354:1851-1858

Does the VAP bundle work in real life

CCU VAP Bundle Compliance Vs Infection Rate

0

5

10

15

20

25

30

35

40

Oct

-06

No

v-06

Dec

-06

Jan

-07

Feb

-07

Mar

-07

Ap

r-07

May

-07

Jun

-07

Jul-

07

Au

g-0

7

Sep

-07

Oct

-07

No

v-07

Dec

-07

Jan

-08

Feb

-08

0%

20%

40%

60%

80%

100%

VAP Infection Rate VAP Bundle Compliance%

Linear (VAP Infection Rate) Linear (VAP Bundle Compliance%)

NHSN 50th Percentile 4.1NHSN 50th

Percentile 4.1

Outline

Airway complications

Hemodynamic disturbances

Ventilator associated lung injury: VILI

Oxygen toxicity

Ventilator associated pneumonia

Pulmonary emboli

Patient ventilator asynchrony

Sleep disturbance

Pulmonary Embolism

Bilateral pulmonary embolism

VAP prevention :VAP Bundle

Elevation of the head of the bed 30-45o Use 15-30o for neonates and small

infants, otherwise 30-45o Daily sedation vacations (minimize

duration of intubation) Daily assessment of readiness to

extubate Peptic ulcer disease (PUD)

prophylaxis Oral care protocol (chlorhexidine) DVT prophylaxis option

Outline

Airway complications

Hemodynamic disturbances

Ventilator associated lung injury: VILI

Oxygen toxicity

Ventilator associated pneumonia

Pulmonary emboli

Patient ventilator asynchrony

Sleep disturbance

Asynchrony with the ventiaitor

Fighting the ventilators Inconsistent tidal volume Increase work of breathing Barotraumas and thoracic air leak Insufficient gas exchange Disturbances in the cerebral blood

flow

Outline

Airway complications

Hemodynamic disturbances

Ventilator associated lung injury: VILI

Oxygen toxicity

Ventilator associated pneumonia

Pulmonary emboli

Patient ventilator asynchrony

Sleep disturbance

0

100

200

300

100

Stage 1

Stage 2

Stage 3

Stage 4

REM

Non R

EM

Age 40

Age 40

MV

Sle

ep T

ime (

min

ute

s)

8 10

12

14

16

18

20

22

0 2 4 6 8

Stage 1

Stage 2

Stage 3

Stage 4

REM

Normal Sleep Pattern

8 10

12

14

16

18

20

22

0 2 4 6 8

Stage 1

Stage 2

Stage 3

Stage 4

REM

Hyponogram for a Patient on Mechanical Ventilation

Mechanisms by which mechanical Ventilation Disrupt Sleep

Noise disruption Ventilator alarm:

▪ inappropriate threshold▪ Delayed alarm inactivation

Humidifier alarms Disruption by nursing interventions

Airway suction Nebulizer delivery

Ventilation-related pharmacological disruption Benzodiazepines (↓REM, ↓deep NREM) Opioids (↓REM, ↓deep NREM) Neuromuscular blocking drugs

والوضعياتاإلنذارات

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. P مهمًا P شيئًا ليس

وضعية في المريض لوضعية ضع فولر مشًابهةأخفض وتسهيل منهًاأو المريض راحة لزيًادة

التنفس.

Thank you