mechanical ventilator

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INTRODUCTION TO VENTILATORS

A mechanical ventilator is simply a machine used to replace or supplement the natural function

of breathing.

Ventilation carries in oxygen and carries off carbon dioxide.

Mechanical ventilation is a method to mechanically assist or replace spontaneous

breathing when patients cannot do so on their own.

Negative Pressure Ventilation :-

� The iron lung, also known as the Drinker and Shaw tank, was developed in 1929 and was

one of the first negative-pressure machines used for long-term ventilation.

Positive pressure ventilation machines :-

The design of the modern positive-pressure ventilators were mainly based on technical

developments by the military during World War-II to supply oxygen to fighter pilots in

high altitude.

Positive pressure through manual supply of 50% oxygen through a tracheostomy tube led

to a reduced mortality rate among patients with polio and respiratory paralysis.

However, because of the sheer amount of man-power required for such manual

intervention, mechanical positive-pressure ventilators became increasingly popular.

Positive-pressure ventilators work by increasing the patient's airway pressure through an

endotracheal or tracheostomy tube.

The positive pressure allows air to flow into the airway until the ventilator breath is

terminated.

Subsequently, the airway pressure drops to zero, and the elastic recoil of the chest wall

and lungs push the tidal volume -- the breath -- out through passive exhalation.

MECHANICAL VENTILATION:-

WHY DO WE VENTILATE?

Inadequate Ventilation (C02 too high)

Inadequate Oxygenation (02 too low)

Patients intubated for Airway protection



HOW DO WE VENTILATE?

Invasively

Via Endotracheal

Tracheostomy tube

Non-invasively

Via mask

INDICATIONS FOR MECHANICAL VENTILATION:-

Elective :- To allow for sedation and paralysis during major surgery

Therapeutic

Inadequate Alveolar Ventilation

R efractory Hypoxemia

Airway protection (indication for intubation)

INADEQUATE ALVEOLAR VENTILATION :-

� Apnea

� R espiratory Failure

� Impending R espiratory Failure

� R esuscitation

� Neuromuscular Disorders

� C NS disorders

- Poliomyelitis

- Cerebral trauma

- Guillian-Barre syndrome

- Spinal cord injury

- Phrenic Nerve Paralysis

- Narcotic / barbiturate poisoning



� Chest Wall Diseases

� Excessive Work of Breathing

� Acute Airway Obstruction

� COPD exacerbation

� Severe Asthma

� Excessive Secretions

� Intra-thorax

� Pleural disease

REFRACTORY HYPOXEMIA: -

Pneumonia

Atelectasis

Pulmonary Edema

AR DS

AIRWAY PROTECTION:-

Inadequate cough / gag

Tracheal obstruction / trauma

Severe Allergic R eaction

SIGNS OF RESPIRATORY FAILURE:-

Subjective signs

Increasing breathlessness

Fatigue

Change in level of consciousness

Use of accessory muscles

Diaphoresis



COMMON MEDICAL INDICATION S:-

Acute lung injury (including AR DS, trauma)

Apnea with respiratory arrest, including cases from intoxication

Chronic obstructive pulmonary disease (COPD)

Acute respiratory acidosis with partial pressure of carbon dioxide (pCO2) > 50 mmHg

and pH < 7.25, which may be due to paralysis of the diaphragm due to:

-Guillain-Barré syndrome,

- Myasthenia Gravis,

- Spinal cord injury,

- The effect of anaesthetic and

- Muscle relaxant drugs.

Increased work of breathing as evidenced by significant tachypnea, retractions, and other

physical signs of respiratory distress

Hypoxemia with arterial partial pressure of oxygen (PaO2) with supplemental fraction of

inspired oxygen (FiO2) < 55 mm Hg

Hypotension including sepsis, shock, congestive heart failure.

TYPES OF VENTILATORS :-

1. N egative pressure ventilators

2. Positive pressure ventilators

A) ANESTHESIA VENTILATOR ± Controlled Ventilation only. Aim is to control

patient¶s oxygenation during surgery under General Anesthesia (GA).

B) CRITICAL CARE VENTILATOR- Both Controlled and Spontaneous ventilation

modes are available. Aim is to synchronize with the patient effort and helping patient to win

off from ventilator.



VENTILATOR SETTINGS/ PARAMETERS:-

� FiO2 (Fraction of inspired oxygen concentration)

� Tidal volume

� R espiratory rate

� Sensitivity

� Flow rate/ Peak Flow

� Inspiratory to expiratory ratio (I:E ratio)

� Positive end expiratory pressure (PEEP)

� Plateau or Inspiratory Pause

� Sigh

FRACTION OF INSPIRED OXYGEN (FIO2):-

� Use high FiO2 in the beginning (.7 ± 1.0)

� FiO2 may be reduced after achieving a clinically acceptable goal

� An FiO2 of .5 or less minimizes oxygen toxicity

� For infants, and especially in premature infants, avoiding high levels of FiO2 (>60%) is

important

� When using 100% FiO2, the degree of shunting is estimated by subtracting the measured

PaO2 (from an arterial blood gas) from 700 mmHg.

� For each difference of 100 mmHg, the shunt is 5%.

� A shunt of more than 25% should prompt a search for the cause of this hypoxemia, such

as mainstem intubation or pneumothorax, and should be treated accordingly.

If such complications are not present, other causes must be sought after, and PEEP should

be used to treat this intrapulmonary shunt. Other such causes of a shunt include:

Alveolar collapse from major atelectasis

Alveolar collection of material other than gas, such as pus from pneumonia, water and

protein from acute respiratory distress syndrome, water from congestive heart failure, or

blood from haemorrhage



TIDAL VOLUME:-

� Volume of the gases in each cycle of respiration

� Generally a tidal volume of 10-15 ml/kg is recommended during mechanical ventilation

� The exhaled tidal volume (EVt) is the most accurate measurement of the volume received

by the patient

� The difference between set & actual received tidal volume should not be more than 100

ml

� For adult patients and older children:

- Tidal volume is calculated in mls/kg.

- Traditionally 10mls/kg was used but has been shown to cause barotrauma, or injury to

the lung by overextension. 6-8 mls/kg is now common practice in ICU.

- H ence a patient weighing 70 kg would get a TV of 450- 500 ml. I n adults a rate of 12

is generally used.

With acute respiratory distress syndrome (AR DS) -- A tidal volume of 6-8 mL/kg is used with a

rate of 10-12/minute.

- This reduced tidal volume allows for minimal volutrauma but may result in an elevated

pCO2 (due to the relative decreased oxygen delivered) but this elevation does not need to be

corrected (termed permissive hy percapnia)

F or infants and younger children

Without existing lung disease -- a tidal volume of 4-8 ml/kg to be delivered at a rate of

30-35 breaths per minute

With R DS -- decrease tidal volume and increase respiratory rate sufficient to maintain

pCO2 between 45-55. Allowing higher pCO2 (sometimes called permissive hypercapnia)

may help prevent ventilator induced lung injury

As the amount of tidal volume increases, the pressure required to administer that volume

is increased.

This pressure is known as the peak airwa y pressure.

If the peak airway pressure is persistently above 45 cmH2O for adults, the risk of

barotrauma is increased and efforts should be made to try to reduce the peak airway

pressure.



In infants and children it is unclear what level of peak pressure may cause damage. In

general, keeping peak pressures below 30 is desirable.

Monitoring for barotrauma can also involve measuring the plateau pressure, which is the

pressure after the delivery of the tidal volume but before the patient is allowed to exhale.

Normal breathing pattern involves inspiration, then expiration.

The ventilator is programmed so that after delivery of the tidal volume (inspiration), the

patient is not allowed to exhale for a half a second.

Therefore, pressure must be maintained in order to prevent exhalation, and this pressure

is the plateau pressure.

Barotrauma is minimized when the plateau pressure is maintained < 30-35 cmH2O.

RESPIRATORY RATE (RR):-

� The RR set on ventilator should be close to physiological RR : 10-20 breaths/min

� Frequent adjustments are often required to reduce work of breathing as well as

adjustment of pH & PaCO2

SENSITIVITY:-

� The sensitivity setting allows the triggering of ventilator to deliver the inspiratory flow

� This may be pressure triggered or flow triggered

� The normal setting: -2 cm H2O (2 cmH2O below the base line pressure)

FLOW RATES/ PEAK FLOW:-

� Speed with which the tidal volume is delivered

� The tidal volume should be delivered within an appropriate & comfortable time

� It is measured in liter/min

� Generally a flow rate of 40-60 L/min is adequate to achieve the patient¶s need

INSPIRATORY-TO-EXPIRATORY RATIO (I:E RATIO)

� Duration of inspiration in comparison to expiration

� Generally I:E ratio is set 1:2 (i.e. 33% of respiratory cycle is spent in inspiration)

� This IE ratio is similar to spontaneous respiration



� Inverse ratio ventilation (I:E of 1:1,2:1 or higher are used in AR DS patients

PEEP (POSITIVE END EXPIRATORY PRESSURE):-

PEEP is an adjuvant to the mode of ventilation used to help maintain functional residual

capacity (FR

C).

At the end of expiration, the PEEP exerts pressure to oppose passive emptying of the lung

and to keep the airway pressure above the atmospheric pressure.

The presence of PEEP opens up collapsed or unstable alveoli and increases the FR C and

surface area for gas exchange, thus reducing the size of the shunt.

For example, if a large shunt is found to exist based on the estimation from 100% FiO2

then PEEP can be considered and the FiO2 can be lowered (< 60%) in order to maintain

an adequate PaO2, thus reducing the risk of oxygen toxicity.

This prevents the atelectasis and thus improves the oxygenation

PEEP ranges from 5-20 cmH2O

Higher level of PEEP may lead to haemodynamic changes

It treats a shunt, reduses requirement of Fio2

PEEP may also be useful to decrease the work of breathing.

PEEP can cause significant haemodynamic consequences through decreasing venous

return to the right heart and decreasing right ventricular function.

As such, it should be judiciously used and is indicated for adults in two circumstances.

o If a PaO2 of 60 mmHg cannot be achieved with a FiO2 of 60%

o If the initial shunt estimation is greater than 25%

* If used, PEEP is usually set with the minimal positive pressure to maintain an adequate PaO2

with a safe FiO2.

AP

EEP

of less than 10 cmH

2O is usually safe in adults if intravascular volume depletionis absent.

Lower levels are used for pediatric patients.

When putting a patient of PEEP a close hemodynemic monitoring is required.



PEEP should be withdrawn from a patient until adequate PaO2 can be maintained with a

FiO2 < 40%.

When withdrawing, it is decreased through 1-2 cmH2O decrements while monitoring

haemoglobin-oxygen saturations.

Any unacceptable haemoglobin-oxygen saturation should prompt reinstitution of the last

PEEP level that maintained good saturation.

INSPIRATORY PAUSE OR PLATEAU:-

Measured in seconds, this parameter delays exhalation, therefore lengthening inspiration.

SIGHS:-

An adult patient breathing spontaneously will usually sigh about 6-8 times/hr to prevent

microatelectasis, And this has led some to propose that ventilators should deliver 1.5-2

times the amount of the preset tidal volume 6-8 times/hr to account for the sighs.

However, such high quantity of volume delivery requires very high peak pressure that

predisposes to barotrauma.

Currently, accounting for sighs is not recommended if the patient is receiving 10-12

mL/kg or is on PEEP.

If the tidal volume used is lower, the sigh adjustment can be used, as long as the peak and

plateau pressures are acceptable.

Sighs are not generally used with ventilation of infants and young children.

MODES OFMECHANICAL VENTILATION:-

� Controlled mechanical ventilation (CMV)

� Assist/control mode (A/C)

� Synchronized intermittent mandatory ventilation (SIMV)

� Continuous Positive Airway Pressure (CPAP)

� Pressure support ventilation (PSV)



CONTROLLEDMECHANICAL VENTILATION (CMV):-

� Patient receives preset number of breath/min

� Can be classified as volume control or pressure control

� Volume control ventilation delivers a fixed tidal volume at a preset number of respiratory

rate

� Pressure control ventilation delivers a tidal volume at a preset pressure depending on lung

condition.

� These modes are used to in patients with minimal or no respiratory efforts, AR DS or flail

chest

� Patient needs adequate sedation & muscle relaxant

ASSIST/CONTROLMODE (A/CMODE):-

� In this mode the ventilator provides a mechanical breath with either a pre-set tidal volume

or peak pressure every time the patient initiates a breath.

� Traditional assist-control used only a pre-set tidal volume--when a preset peak pressure is

used this is also sometimes termed Intermittent Positive Pressure Ventilation or IPPV.

Synchronized intermittent mandatory ventilation (SIMV):-

� Patient is guaranteed a preset number of breaths of a preset tidal volume

� Between these mandatory breath patient may initiate spontaneous breath

� This mode allows a synchronization between patient & ventilator

CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP):-

� Positive pressure is applied throughout the respiratory cycle

� The patient should have respiratory drive and an adequate tidal volume

� This prevent the alveolar collapse & thus improves the oxygenation

� This also improves the respiratory muscle strength

PRESSURE SUPPORT VENTILATION (PSV):-

� This mode is for spontaneously breathing patients

� The inspiratory pressure augments the tidal volume during each breath



� PSV may be used alone or in conjunction with SIMV

� The pressure support level should be adjusted to minimize the work of breathing &

provide maximum comfort

NON-INVASIVE VENTILATION (NIPPV):-

This refers to all modalities that assist ventilation without the use of an endotracheal tube.

Non-invasive ventilation is primarily aimed at minimizing patient discomfort and the

complications associated with invasive ventilation.

It is often used in cardiac disease, exacerbations of chronic pulmonary disease, sleep

apnea, and neuromuscular diseases.

Non-invasive ventilation refers only to the patient interface and not the mode of

ventilation used; modes may include spontaneous or control modes and may be either

pressure or volume modes.

Some commonly used modes of NI PP V include:

- Continuous positive airway pressure (CPAP).

- Bi-level Positive Airway Pressure (BIPAP).

- Intermittent positive pressure ventilation (IPPV) via mouthpiece or mask

BI-LEVEL POSITIVE AIRWAY PRESSURE (BIPAP):

Pressures alternate between Inspiratory Positive Airway Pressure (IPAP) and a lower

Expiratory Positive Airway Pressure (EPAP), triggered by patient effort. On many such

devices, backup rates may be set, which deliver IPAP pressures even if patients fail to initiate

a breath.(Wheatley 2000 et all).

NEURALLY ADJUSTED VENTILATORY ASSIST (NAVA):-

NAVA is a new positive pressure mode of mechanical ventilation, where the ventilator is

controlled directly by the patient's own neural control of breathing.

The neural control signal of respiration originates in the respiratory center, and aretransmitted through the phrenic nerve to excite the diaphragm.

These signals are monitored by means of electrodes mounted on a nasogastric feeding

tube and positioned in the esophagus at the level of the diaphragm.

As respiration increases and the respiratory center requires the diaphragm for more effort,

the degree of ventilatory support needed is immediately provided.



This means that the patient's respiratory center is in direct control of the mechanical

support required on a breath-by-breath basis, and any variation in the neural respiratory

demand is responded to by the appropriate corresponding change in ventilatory

assistance.

WEANING FROM VENTILATOR:-

Withdrawal from mechanical ventilation²also known as weaning²should not be

delayed unnecessarily, nor should it be done prematurely.

Patients should have their ventilation considered for withdrawal if they are able to

support their own ventilation and oxygenation, and this should be assessed continuously.

There are several objective parameters to look for when considering withdrawal, but

there is no specific criteria that generalizes to all patients.

The best measure of when a patient may be extubated is the R apid Shallow Breathing

Index(Tobin Index).

This is calculated by dividing the respiratory rate by the tidal volume in liters(RR /TV).

A rapid shallow breathing index of less than 100 is considered ideal for extubation.

Certainly, other measures such as patient's mental status such be considered.

WEANING CRITERIA & ASSESMENT

� Oygenation & Ventilation

� R espiratory mechanics eg. tidal volume, vital capacity

� R espiratory rate

� Haemodynamic stability

� Neurological status

� Nutritional status

� Infection, fever or other hypermetabolic state

� Psychological readiness



METHODS OF WEANING:-

� SIMV with PSV

� SIMV

� PSV

� CPAP

� T-Piece trial

COMPLICATIONS OFMECHANICAL VENTILATION

1. Associated with patient¶s response to mechanical ventilation:

A. Decreased Cardiac Output

Cause - venous return to the right atrium impeded by the dramatically increased intrathoracic pressures during inspiration from positive pressure ventilation. Also reduced sympatho-adrenal

stimulation leading to a decrease in peripheral vascular resistance and reduced blood pressure.

Symptoms ± increased heart rate, decreased blood pressure and perfusion to vital organs,

decreased CVP, and cool clammy skin.

Treatment ± aimed at increasing preload (e.g. fluid administration) and decreasing the airway

pressures exerted during mechanical ventilation by decreasing inspiratory flow rates and TV, or using other methods to decrease airway pressures (e.g. different modes of ventilation).

B. Barotrauma

Cause ± damage to pulmonary system due to alveolar rupture from excessive airway pressures

and/or overdistention of alveoli.

Symptoms ± may result in pneumothorax, pneumomediastinum, pneumoperitoneum, or subcutaneous emphysema.

Treatment - aimed at reducing TV, cautious use of PEEP, and avoidance of high airway pressures resulting in development of auto-PEEP in high risk patients (patients with obstructivelung diseases (asthma, bronchospasm), unevenly distributed lung diseases (lobar pneumonia), or

hyperinflated lungs (emphysema).



Nosocomial Pneumonia

Cause ± invasive device in critically ill patients becomes colonized with pathological bacteriawithin 24 hours in almost all patients. 20-60% of these, develop nosocomial pneumonia.

Treatment ± aimed at prevention by the following:

Avoid cross-contamination by frequent handwashing Decrease risk of aspiration (cuff occlusion of trachea, positioning, use of small-bore NG

tubes) Suction only when clinically indicated, using sterile technique

Maintain closed system setup on ventilator circuitry and avoid pooling of condensation inthe tubing

Ensure adequate nutrition Avoid neutralization of gastric contents with antacids and H2 blockers

D. Positive WaterB

alance

1. Syndrome of Inappropriate Antidiuretic Hormone (SIADH) ± due to vagal stretch receptors in

right atrium sensing a decrease in venous return and see it as hypovolemia, leading to a release of ADH from the posterior pituitary gland and retention of sodium and water. Treatment is aimed at

decreasing fluid intake.

2. Decrease of normal insensible water loss due to closed ventilator circuit preventing water loss

from lungs. This fluid overload evidenced by decreased urine specific gravity, dilutionalhyponatremia, increased heart rate and BP.

E. Decreased Renal Perfusion ± can be treated with low dose dopamine therapy.

F. Increased Intracranial Pressure (ICP) ± reduce PEEP

G. Hepatic congestion ± reduce PEEP

H. Worsening of intracardiac shunts ±reduce PEEP

2. ASSOCIATED WITH VENTILATOR MALFUNCTION:

A. Alarms turned off or nonfunctional ± may lead to apnea and respiratory arrest

Troubleshooting Ventilator Alarms

Low exhaled volume: Cuff leak, Tubing disconnect, Patient disconnected



Evaluate cuff; if ruptured, tube will need to be replaced. Evaluate connections; tighten or replace as needed; check ETT placement, R econnect to ventilator

High pressure: Secretions in airway, Patient biting tubing, Tube kinked, Cuff herniation,

Increased airway resistance/decreased lung compliance (caused by bronchospasm, right

mainstem bronchus intubation, pneumothorax, pneumonia),P

atient coughing and/or fighting theventilator; anxiety; fear; pain.

Suction patient, Insert bite block, R eposition patient¶s head/neck; check all tubing lengths,Deflate and reinflate cuff, Auscultate breath sounds, Evaluate compliance and tube position;

stabilize tube, Explain all procedures to patient in calm, reassuring manner, Sedate/medicate asnecessar

Low oxygen pressure: Oxygen malfunction

Disconnect patient from ventilator; manually bag with AMBU.

3. OTHER COMPLICATIONS RELATED TO ENDOTRACHEAL INTUBATION.

A. Sinusitis and nasal injury ± obstruction of paranasal sinus drainage; pressure necrosis of

nares

1. Prevention: avoid nasal intubations; cushion nares from tube and tape/ties.

2. Treatment: remove all tubes from nasal passages; administer antibiotics.

B. Tracheoesophageal fistula ± pressure necrosis of posterior tracheal wall resulting from

overinflated cuff and rigid nasogastric tube

1. Prevention: inflate cuff with minimal amount of air necessary; monitor cuff pressures q. 8 h.

2. Treatment: position cuff of tube distal to fistula; place gastrostomy tube for enteral feedings; place esophageal tube for secretion clearance proximal to fistula.

C.Mucosal lesions ± pressure at tube and mucosal interface

1. Prevention: Inflate cuff with minimal amount of air necessary; monitor cuff pressure q. 8 h.;use appropriate size tube.

2. Treatment: may resolve spontaneously; perform surgical interventions.

D. Laryngeal or tracheal stenosis ± injury to area from end of tube or cuff, resulting in scar tissue formation and narrowing of airway

1. Prevention: inflate cuff with minimal amount of air necessary; monitor cuff pressure q. 8.h.;

suction area above cuff frequently.



2. Treatment: perform tracheostomy; place laryngeal stint; perform surgical repair.

E. Cricoid abcess ± mucosal injury with bacterial invasion

1. Prevention: inflate cuff with minimal amount of air necessary; monitor cuff pressure q. 8 h.;

suction area above cuff frequently.

2. Treatment: perform incision and drainage of area; administer antibiotics.

4. OTHER COMMON POTENTIAL PROBLEMS RELATED TOMECHANICAL

VENTILATION:

Aspiration,

GI bleeding, Inappropriate ventilation (respiratory acidosis or alkalosis, Thick secretions ),

Patient discomfort due to pulling or jarring of ETT or tracheostomy,

High PaO2,

Low PaO2, Anxiety and fear,

Dysrhythmias or vagal reactions during or after suctioning, Incorrect PEEP setting,

Inability to tolerate ventilator mode.

CARE OF PATIENTS ON VENTILATOR:-

Goals of care:-

Effective breathing pattern

Adequate gas exchange

Maintain adequate nutritional status

Prevention of pulmonary or other infection

Prevention of respiratory muscle weakness & problems related with immobility

Psychological support to patient & relatives

COMPONENTS OF CARE:-

Monitoring

ET/ TT suctioning

Oral hygiene



Positioning

Eye care

Back care/ pressure sore prevention

Physiotherapy

Psychological support & communication

Infection preventive measures

DVT prophylaxis

R ecord maintenance

Nutrition

Sedation

Medications

MONITORING OF PATIENT ON VENTILATOR:-

Ventilatory parameters

Exipiratory tidal volume

Breath type

R espiratory rate

Minute ventilation

Peak & mean inspiratory pressure

Patient comfort

Haemodynamic monitiring

ECG/ Heart rate

Oxygen saturation

Blood pressure

CVP/PAP

Intake/output



ET/TT SUCTIONING :-

Use sterile gloves

Use new suction catheter

The diameter of suction catheter should be less than 2/3 of the ET tube diameter

The suction pressure should not be more than 150 mm Hg in adults.

Suction should be done within 10-15 second

Use normal saline for thick secretion

Few breath of 100% oxygen should be given before and after suctioning.

ORAL HYGIENE:-

Oral suction should be done regularly

The oral care should be done thrice daily

The chlorhexidine solution may be used for oral care

The colonization of bacteria in oral cavity may cause ventilator associated pneumonia

POSITIONING:-

The head should be kept at 30 degree elevated position to prevent ventilator-associated

pneumonia.

The patients should be kept in lateral position

The position should be changed 2 hourly

All the joints should be kept in neutral or slightly flexed position

The ET tube & other invasive lines should be supported during change of posture

Prone positioning has been used in patients with AR DS and severe hypoxemia.

It improves functional residual capacity (FR C), drainage of secretions, and ventilation-

perfusion matching (efficiency of gas exchange). It may improve oxygenation in > 50%

of patients, but no survival benefit has been documented.



EYE CARE:-

Eyes should be protected from exposure keratitis is sedated patients

Eye care should be done three times a day

An eye ointment may be used to prevent dryness & exposure keratitis

PRESSURE SORE PREVENTION:-

All the pressure point should be carefully examined frequently

R egular back care and back cleaning

Air mattresses should be used for all ventilated patients

Frequent change of posture

PHYSIOTHERAPY:-

Limbs physiotherapy :- due to disuse & nutritional deficiency there may be muscle wasting &

contracture formation

C hest physiotherapy :- This is required to maintain the respiratory muscle tone. This also

prevents atelectasis and helps in secretion mobilization.The chest physiotherapy includes

percussion, vibration or postural drainage

PSYCHOLOGICAL SUPPORT & COMMUNICATION:-

Be sympathetic with patient & relatives

Explain & console before any procedure

Always try to communicate with the patient depending on his condition

INFECTION PREVENTIVEMEASURE:-

Infection preventive measure

Hand hygiene



Aseptic technique for any invasive procedure

Appropriate care for invasive lines

Disinfection of patient equipment

VAP preventive maneuvers

Terminal disinfections on patient¶s discharge

R egular disinfections of ICUs

DVT PROPHYLAXIS:-

Trauma, sepsis surgery & immobility predisposes the lower limb for venous thrombosis

The prophylaxis is needed to prevent potentially life threatening pulmonary embolism

Heparin (low molecular weight)

Pneumatic compression device with garment

Stockings

NUTRITION IN PATIENTS ON VENTILATOR:-

The maintenance of appropriate nutrition in patients on ventilator is a fundamental part of

intensive care nursing.

TYPE OF NUTRITION

� E nteral :- Usually through Nasogastric tube

� Parenteral :- Central/Peripheral venous route

HOWMUCH NUTRITION IS REQUIRED?

� Daily energy requirement (Kcal)

Basal energy expenditure (BEE)=25xBody weight (kg)

The energy requirement increases in hypermetabolic state, such as fever

� Daily protein requirement :- 0.8-1.5 gm/kg body weight

� The nutrition should be supplemented with vitamins, electrolytes and

immunomodulators.



How to give nutrition enterally?

� It can be given as bolus or continuous infusion

� Check & confirm the position of NG tube before every feed

� Clean your hands

� Aspirate the gastric content before giving feed

� Do not hold the feed if aspiration is less than 150cc

� Flush the NG tube after every feed with plain water

� Give right lateral position for 2 hours if there is high aspiration

How to give nutrition parenterally?

� Use a dedicated line (Peripheral or central) for TPN

� TPN central should never be given through peripheral line

� Check peripheral line for thrombophlebitis

� Should not be given fast

SEDATION & ANALGESICS:-

Adequate sedation & analgesia should be given to all patients on ventilator

The sedation is required to relieve anxiety and the discomfort related with ventilator

Some time muscle relaxants are also required

The dose of sedation should be adjusted on individual patient basis

During day time the sedatives should be reduced/stopped which is helpful in reorientation

and appropriate weaning of patient.

Sedation

� Midazolam, diazepam, lorazepam

� Propofol

Analgesia



� Opiods eg fentanyl, morphine etc

� Non opiods eg ketorolac, diclofenac etc

M uscle relaxant

� Atracurium, rocuronium, pancuronium etc

Medication

F ollowing medicines should be administered as per order/ instruction :

Antibiotics,

S tress ulcer prophylaxis (H2 receptor antagonists or proton pump inhibitors) and

Ot her medication specificall y related wit h disease

RECORDMAINTENANCE

EVALUATION OF THE PROGRESS

ALTERATION OFMANAGEMENT STRATEGY

ANY CRITICAL EVENT SHOULD BE NOTED

MEDICO LEGAL ISSUES

mechanical ventilator

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