respiratory failure and ards by laurie dickson with thanks to nancy jenkins

RESPIRATORY FAILURERESPIRATORY FAILUREand ARDSand ARDS

By Laurie DicksonBy Laurie Dickson

with thanks to Nancy Jenkinswith thanks to Nancy Jenkins

Exchange of O2 and CO2Exchange of O2 and CO2

gas exchange

www.le.ac.uk/pathology/teach/va/anatomy/case2/lunganim.gif

Respiratory FailureRespiratory Failure

the inability of the cardiac and the inability of the cardiac and pulmonary systems to maintain pulmonary systems to maintain

an adequate exchange of an adequate exchange of oxygen and CO2 in the lungsoxygen and CO2 in the lungs

Acute Respiratory FailureAcute Respiratory Failure

HypoxemiaHypoxemia• Inadequate O2 transferInadequate O2 transfer• PaO2 of 60 mmHg or less when patient PaO2 of 60 mmHg or less when patient

receiving 60% or greater O2receiving 60% or greater O2 HypercapniaHypercapnia

• Insufficient CO2 removalInsufficient CO2 removal• Increases PaCO2Increases PaCO2

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.

Classification of Respiratory Failure

Fig. 68-2

Hypoxemic Respiratory Failure-Hypoxemic Respiratory Failure-(Affects the pO2)(Affects the pO2)

V/Q MismatchV/Q Mismatch ShuntShunt Diffusion LimitationDiffusion Limitation Alveolar Hypoventilation- inc. CO2 and Alveolar Hypoventilation- inc. CO2 and

dec. PO2dec. PO2

VentilationPerfusion MismatchVentilationPerfusion Mismatch(V/Q)(V/Q)

Normal V/Q =1 (1ml air/ 1ml of blood)Normal V/Q =1 (1ml air/ 1ml of blood) Ventilation=lungsVentilation=lungs Perfusion or Q=perfusionPerfusion or Q=perfusion Pulmonary Embolus- (VQ scan)Pulmonary Embolus- (VQ scan)

Range of V/Q RelationshipsRange of V/Q Relationships

Fig. 68-4

Pulmonary EmbolusPulmonary Embolus

ShuntShunt

2 Types2 Types1.1. AnatomicAnatomic- blood passes through an anatomic - blood passes through an anatomic

channel of the heart and does not pass through channel of the heart and does not pass through the lungs ex: ventricular septal defectthe lungs ex: ventricular septal defect

ShuntShunt

2. Intrapulmonary 2. Intrapulmonary - blood flows through pulmonary - blood flows through pulmonary capillaries without participating in gas exchange capillaries without participating in gas exchange ex: alveoli filled with fluidex: alveoli filled with fluid

** Patients with Patients with shuntsshunts are are more hypoxemic more hypoxemic than than those with VQ mismatch and they may require those with VQ mismatch and they may require mechanical ventilatorsmechanical ventilators

Diffusion LimitationsDiffusion Limitations

Gas exchange is compromised by a Gas exchange is compromised by a process that thickens or destroys the process that thickens or destroys the membranemembrane• 1. Pulmonary fibrosis1. Pulmonary fibrosis• 2. ARDS2. ARDS

* A * A classic sign classic sign of diffusion limitation is of diffusion limitation is hypoxemia during exercise but not at resthypoxemia during exercise but not at rest

Diffusion LimitationDiffusion Limitation

Fig. 68-5

Alveolar HypoventilationAlveolar Hypoventilation

Mainly due to hypercapnic respiratory Mainly due to hypercapnic respiratory failure but can cause hypoxemiafailure but can cause hypoxemia

Increased pCO2 with decreased PO2Increased pCO2 with decreased PO2• Restrictive lung diseaseRestrictive lung disease• CNS diseasesCNS diseases• Chest wall dysfunctionChest wall dysfunction• Neuromuscular diseasesNeuromuscular diseases

HypercapnicHypercapnic Respiratory Failure Respiratory FailureFailure of Failure of VentilationVentilation

PaCO2>PaCO2>4545 mmHg in combination with mmHg in combination with acidemiaacidemia (arterial pH< (arterial pH< 7.357.35))

Hypercapnic Respiratory FailureHypercapnic Respiratory FailureVentilatory Failure- affects CO2Ventilatory Failure- affects CO2

1. Abnormalities of the 1. Abnormalities of the airways and alveoli-airways and alveoli- air flow obstruction and air trappingair flow obstruction and air trapping

• Asthma, COPD, and cystic fibrosisAsthma, COPD, and cystic fibrosis

2. Abnormalities of the 2. Abnormalities of the CNSCNS--

suppresses drive to breathesuppresses drive to breathedrug OD, narcotics, head injury, spinal cord injurydrug OD, narcotics, head injury, spinal cord injury

Hypercapnic Respiratory FailureHypercapnic Respiratory Failure

3. Abnormalities of the 3. Abnormalities of the chest wallchest wall Restrict chest movementRestrict chest movement

• Flail chest, morbid obesity, kyphoscoliosisFlail chest, morbid obesity, kyphoscoliosis

44. . NeuromuscularNeuromuscular Conditions- Conditions- respiratory muscles are weakened:respiratory muscles are weakened:

Guillain-Barre, muscular dystrophy, Guillain-Barre, muscular dystrophy, myasthenia gravis and multiple sclerosismyasthenia gravis and multiple sclerosis

Tissue Oxygen needsTissue Oxygen needs

Tissue O2 delivery is determined by:Tissue O2 delivery is determined by:

• Amount of O2 in hemoglobinAmount of O2 in hemoglobin• Cardiac outputCardiac output

• *Respiratory failure places patient at *Respiratory failure places patient at more risk more risk ifif cardiac problems cardiac problems or or anemiaanemia

Signs and Symptoms of Signs and Symptoms of Respiratory FailureRespiratory Failure

hypoxemia hypoxemia • pO2<50-60pO2<50-60

May be hypercapnia May be hypercapnia • pCO2>50pCO2>50• only one cause- hypoventilationonly one cause- hypoventilation

*In patients with *In patients with COPDCOPD watch for watch for acute drop acute drop in in pO2pO2 and and O2 sats O2 sats along with along with inc. C02inc. C02

Specific Clinical ManifestationsSpecific Clinical Manifestations Respirations- depth and rateRespirations- depth and rate Patient position- tripod positionPatient position- tripod position Pursed lip breathingPursed lip breathing OrthopneaOrthopnea Inspiratory to expiratory ratio (normal Inspiratory to expiratory ratio (normal

1:2)1:2) Retractions and use of accessory Retractions and use of accessory

musclesmuscles Breath soundsBreath sounds

HypoxemiaHypoxemia

Tachycardia and Hypertension to comp.Tachycardia and Hypertension to comp. Dyspnea and tachypnea to comp.Dyspnea and tachypnea to comp. CyanosisCyanosis Restlessness and apprehensionRestlessness and apprehension Confusion and impaired judgmentConfusion and impaired judgment Later dysrhythmias and metabolic Later dysrhythmias and metabolic

acidosis, decreased B/P and CO.acidosis, decreased B/P and CO.

HypercapniaHypercapnia

Dyspnea to respiratory depression- if too high Dyspnea to respiratory depression- if too high CO2 narcosisCO2 narcosis

Headache-vasodilationHeadache-vasodilation PapilledemaPapilledema Tachycardia and inc. B/PTachycardia and inc. B/P Drowsiness and comaDrowsiness and coma Respiratory acidosisRespiratory acidosis

• ****Administering O2 may eliminate drive to breathe Administering O2 may eliminate drive to breathe especially with COPD patientsespecially with COPD patients

DiagnosisDiagnosis Physical AssessmentPhysical Assessment Pulse oximetryPulse oximetry ABGABG CXRCXR CBCCBC ElectrolytesElectrolytes EKGEKG Sputum and blood cultures, UASputum and blood cultures, UA V/Q scan if ?pulmonary embolusV/Q scan if ?pulmonary embolus Pulmonary function testsPulmonary function tests

Treatment GoalsTreatment Goals

O2 therapyO2 therapy Mobilization of secretionsMobilization of secretions Positive pressure ventilation(PPV)Positive pressure ventilation(PPV)

O2 TherapyO2 Therapy

If secondary to V/Q mismatch- 1-3Ln/c or 24%-32% If secondary to V/Q mismatch- 1-3Ln/c or 24%-32% by maskby mask

If secondary to intrapulmonary shunt- positive If secondary to intrapulmonary shunt- positive pressure ventilation-PPVpressure ventilation-PPV• May be via ET tubeMay be via ET tube• Tight fitting maskTight fitting mask

• Goal is PaO2 of 55-60 with SaO2 at 90% or more at Goal is PaO2 of 55-60 with SaO2 at 90% or more at lowest O2 concentration possiblelowest O2 concentration possible

• O2 at high concentrations for longer than 48 hours O2 at high concentrations for longer than 48 hours causes O2 toxicity causes O2 toxicity

Mobilization of secretionsMobilization of secretions

Effective coughing- quad cough, huff cough, staged Effective coughing- quad cough, huff cough, staged coughcough

Positioning- HOB 45 degrees or recliner chair or Positioning- HOB 45 degrees or recliner chair or bedbed• ““Good lung down”Good lung down”

Hydration - fluid intake 2-3 L/day Hydration - fluid intake 2-3 L/day Humidification- aerosol treatments- mucolytic Humidification- aerosol treatments- mucolytic

agentsagents Chest PT- postural drainage, prercussion and Chest PT- postural drainage, prercussion and

vibrationvibration Airway suctioningAirway suctioning

Positive Pressure VentilationPositive Pressure Ventilation

Invasively through oro or nasotracheal intubationInvasively through oro or nasotracheal intubation Noninvasively( NIPPV) through maskNoninvasively( NIPPV) through mask

• Used for acute and chronic resp failureUsed for acute and chronic resp failure• BiPAPBiPAP- different levels of pressure for inspiration and - different levels of pressure for inspiration and

expiration- (IPAP) higher for inspiration,(EPAP) lower expiration- (IPAP) higher for inspiration,(EPAP) lower for expiration for expiration

• CPAPCPAP- for sleep apnea- for sleep apnea

• Used best in chronic resp failure in patients with chest Used best in chronic resp failure in patients with chest wall and neuromuscular disease, also with HF and wall and neuromuscular disease, also with HF and COPD. COPD.

NPPVNPPV

NPPV

Endotracheal tube

endotrachael intubation

Endotracheal TubeEndotracheal Tube

Fig. 66-17

Surgical Intervention-Surgical Intervention-TracheostomyTracheostomy

TracheotomyTracheotomySurgical Surgical procedure procedure performed performed when need for when need for an artificial an artificial airway is airway is expected to be expected to be long termlong term

Exhaled C02 (ETC02) normal 35-45Exhaled C02 (ETC02) normal 35-45

Used when trying to wean Used when trying to wean patient from a ventilatorpatient from a ventilator

Drug TherapyDrug Therapy

Relief of bronchospasm- Relief of bronchospasm- • BronchodilatorsBronchodilators • metaproterenol (Alupent) and albuterol-(metaproterenol (Alupent) and albuterol-(Ventolin, Ventolin,

Proventil, Proventil-HFA, AccuNeb, Vospire, Proventil, Proventil-HFA, AccuNeb, Vospire, ProAirProAir ) )

• Watch for what side effect?Watch for what side effect?

Reduction of airway inflammationReduction of airway inflammation• corticosteroids by inhalation or IV or pocorticosteroids by inhalation or IV or po

Reduction of pulmonary congestion-Reduction of pulmonary congestion-• diuretics and nitroglycerine with heart failurediuretics and nitroglycerine with heart failure

Drug TherapyDrug Therapy

Treatment of pulmonary infections-Treatment of pulmonary infections-• IV antibiotics- vancomycin and ceftriaxone (Rocephin) IV antibiotics- vancomycin and ceftriaxone (Rocephin)

Reduction of anxiety, pain and agitationReduction of anxiety, pain and agitation• propofol (Diprivan), lorazepam (Ativan), midazolam (Versed), propofol (Diprivan), lorazepam (Ativan), midazolam (Versed),

opioids opioids

May need sedation or neuromuscular blocking May need sedation or neuromuscular blocking agent if on ventilatoragent if on ventilator• vecuronium (Norcuron), cisatracurium besylate (Nimbex )vecuronium (Norcuron), cisatracurium besylate (Nimbex )

• assess with peripheral nerve stimassess with peripheral nerve stim..

Medical Supportive TreatmentMedical Supportive Treatment

Treat underlying causeTreat underlying cause Maintain adequate cardiac output- monitor Maintain adequate cardiac output- monitor

B/P and MAP. B/P and MAP. Maintain adequate Hemoglobin Maintain adequate Hemoglobin

concentration- need 9g/dl or greaterconcentration- need 9g/dl or greater

**Need B/P of **Need B/P of 90 systolic 90 systolic and and MAP of 60MAP of 60 to to maintain perfusion to the vital organsmaintain perfusion to the vital organs

NutritionNutrition

During acute phase- enteral or During acute phase- enteral or parenteral nurtitionparenteral nurtition

In a hypermetabolic state- need more In a hypermetabolic state- need more caloriescalories

If retain CO2- avoid high carb dietIf retain CO2- avoid high carb diet

Acute Respiratory FailureAcute Respiratory FailureGerontologic ConsiderationsGerontologic Considerations

Physiologic aging results inPhysiologic aging results in• ↓ ↓ Ventilatory capacityVentilatory capacity• Alveolar dilationAlveolar dilation• Larger air spacesLarger air spaces• Loss of surface area Loss of surface area • Diminished elastic recoilDiminished elastic recoil• Decreased respiratory muscle strength Decreased respiratory muscle strength • ↓ ↓ Chest wall complianceChest wall compliance

ARDSARDSAlso known as DADAlso known as DAD

(diffuse alveolar disease)(diffuse alveolar disease)or ALI (acute lung injury)or ALI (acute lung injury)

a variety of acute and diffuse a variety of acute and diffuse infiltrative lesions which cause infiltrative lesions which cause

severe refractory arterial severe refractory arterial hypoxemia and life-threatening hypoxemia and life-threatening

arrhythmiasarrhythmias

Memory JoggerMemory Jogger

AAssault to the pulmonary systemssault to the pulmonary system

RRespiratory distressespiratory distress

DDecreased lung complianceecreased lung compliance

SSevere respiratory failureevere respiratory failure

150,000 adults dev. ARDS150,000 adults dev. ARDS

About 50% surviveAbout 50% survive

Patients with gram negative septic shock and Patients with gram negative septic shock and ARDS have mortality rate of 70-90%ARDS have mortality rate of 70-90%

Direct Causes (Inflammatory Direct Causes (Inflammatory process is involved)process is involved)

Pneumonia* Pneumonia* Aspiration of gastric contents* Aspiration of gastric contents* Pulmonary contusion Pulmonary contusion Near drowning Near drowning Inhalation injuryInhalation injury

Indirect Causes (Indirect Causes (Inflammatory Inflammatory process is involved)process is involved)

Sepsis* (most common) gm -Sepsis* (most common) gm - Severe trauma with shock state Severe trauma with shock state

that requires multiple blood that requires multiple blood transfusions* transfusions*

Drug overdose Drug overdose Acute pancreatitis Acute pancreatitis

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.

Stages of Edema Formation in Stages of Edema Formation in ARDSARDS

AA, Normal alveolus and , Normal alveolus and pulmonary capillary pulmonary capillary

BB, Interstitial edema , Interstitial edema occurs with increased occurs with increased flow of fluid into the flow of fluid into the interstitial space interstitial space

CC, Alveolar edema , Alveolar edema occurs when the fluid occurs when the fluid crosses the bloodcrosses the blood--gas gas barrierbarrier

Fig. 68Fig. 68--88

*Causes (see notes)

DIFFUSE lung injury(SIRS or MODS)

Damage to alveolar capillary membrane

Pulmonary capillary leak

Interstitial & alveolar edema

Inactivation of surfactant

Alveolar atalectasis

↓COMetabolic acidosis

↑CO

Severe & refractory hypoxemia

HypoventilationHypercapneaRespiratory Acidosis

HyperventilationHypocapneaRespiratory Alkalosis

SHUNTINGStiff lungs

Pathophysiology of ARDSPathophysiology of ARDS

Damage to alveolar-capillary membraneDamage to alveolar-capillary membrane Increased capillary hydrostatic pressureIncreased capillary hydrostatic pressure Decreased colloidal osmotic pressureDecreased colloidal osmotic pressure Interstitial edemaInterstitial edema Alveolar edema or pulmonary edemaAlveolar edema or pulmonary edema Loss of surfactantLoss of surfactant

What does surfactant do?What does surfactant do?

Pathophysiologic Stages in Pathophysiologic Stages in ARDS ARDS

Injury or Exudative- Injury or Exudative- 1-7 days1-7 days• Interstitial and alveolar edema and atelectasisInterstitial and alveolar edema and atelectasis• Refractory hypoxemia and stiff lungsRefractory hypoxemia and stiff lungs

Reparative or ProliferativeReparative or Proliferative-1-2 weeks after-1-2 weeks after• Dense fibrous tissue, increased PVR and Dense fibrous tissue, increased PVR and

pulmonary hypertension occurspulmonary hypertension occurs FibroticFibrotic-2-3 week after-2-3 week after

• Diffuse scarring and fibrosis, decreased surface Diffuse scarring and fibrosis, decreased surface area, decreased compliance and pulmonary area, decreased compliance and pulmonary hypertension hypertension

The essential disturbances of The essential disturbances of ARDSARDS

interstitial and alveolar edema and interstitial and alveolar edema and atelectasisatelectasis

Progressive arterial hypoxemia Progressive arterial hypoxemia in spite of inc. O2 is hallmark of in spite of inc. O2 is hallmark of

ARDSARDS

Clinical Manifestations: EarlyClinical Manifestations: Early

Dyspnea-(almost always present), Dyspnea-(almost always present), tachypnea, cough, restlessnesstachypnea, cough, restlessness

Chest auscultation may be normal or Chest auscultation may be normal or reveal fine, scattered crackles reveal fine, scattered crackles

ABGs ABGs • Mild hypoxemia and respiratory alkalosis Mild hypoxemia and respiratory alkalosis

caused by hyperventilationcaused by hyperventilation

Clinical Manifestations: EarlyClinical Manifestations: Early

Chest x-ray may be normal or show Chest x-ray may be normal or show minimal scattered interstitial infiltratesminimal scattered interstitial infiltrates

Edema may not show until 30% Edema may not show until 30% increase in lung fluid contentincrease in lung fluid content

Clinical Manifestations: LateClinical Manifestations: Late

Symptoms worsen with progression of fluid Symptoms worsen with progression of fluid accumulation and accumulation and decreaseddecreased lung lung compliancecompliance

Pulmonary function tests reveal Pulmonary function tests reveal decreaseddecreased compliance and lung volumecompliance and lung volume

Evident discomfort and Evident discomfort and increasedincreased WOB WOB

Clinical Manifestations: LateClinical Manifestations: Late

Suprasternal retractions Suprasternal retractions

Tachycardia, diaphoresis, changes in Tachycardia, diaphoresis, changes in sensorium with decreased mentation, sensorium with decreased mentation, cyanosis, and pallor cyanosis, and pallor

Hypoxemia and a PaOHypoxemia and a PaO22/FIO/FIO22 ratio <200 ratio <200

despite increased FIOdespite increased FIO2 2 ( ex: 80/.8=100) ( ex: 80/.8=100)

Clinical ManifestationsClinical Manifestations

As ARDS progresses, profound As ARDS progresses, profound respiratory distress respiratory distress requires requires endotracheal intubation and positive endotracheal intubation and positive pressure ventilationpressure ventilation

Chest x-ray termed Chest x-ray termed whiteoutwhiteout or white or white lung because of consolidation and lung because of consolidation and widespread infiltrates throughout lungswidespread infiltrates throughout lungs

Clinical ManifestationsClinical Manifestations

If prompt therapy not initiated, severe If prompt therapy not initiated, severe hypoxemia, hypercapnia, and metabolic hypoxemia, hypercapnia, and metabolic acidosis may ensueacidosis may ensue

Nursing DiagnosesNursing Diagnoses

Ineffective airway clearanceIneffective airway clearance Ineffective breathing patternIneffective breathing pattern Risk for fluid volume imbalanceRisk for fluid volume imbalance AnxietyAnxiety Impaired gas exchangeImpaired gas exchange Imbalanced nutrition: Less than body Imbalanced nutrition: Less than body

requirementsrequirements

PlanningPlanning

Following recovery Following recovery • PaOPaO22 within normal limits or at within normal limits or at

baseline baseline

• SaOSaO22 > 90% > 90%

• Patent airwayPatent airway• Clear lungs or auscultationClear lungs or auscultation

ARDS DiagnosisARDS Diagnosis

Progressive hypoxemia due to shuntingProgressive hypoxemia due to shunting

Decreased lung compliance Decreased lung compliance

Bilateral diffuse lung infiltrate Bilateral diffuse lung infiltrate

Chest X-Ray of ARDS Chest X-Ray of ARDS

Fig. 68-10

The Auscultation Assistant - Breath Sounds

Dyspnea and TachypneaDyspnea and Tachypnea

CyanosisCyanosis

Nursing AssessmentNursing Assessment

Lung soundsLung sounds ABG’sABG’s CXRCXR Capillary refillCapillary refill Neuro assessmentNeuro assessment Vital signsVital signs O2 satsO2 sats Hemodynamic monitoring valuesHemodynamic monitoring values

Diagnostic TestsDiagnostic Tests

ABG-reviewABG-review CXRCXR Pulmonary Function Tests- decreased Pulmonary Function Tests- decreased

compliance and vital capacitycompliance and vital capacity Hemodynamic Monitoring- to rule out Hemodynamic Monitoring- to rule out

pulmonary edemapulmonary edema

ABG REVIEWABG REVIEW.

ABG review

ABG Review and PracticeABG Review and Practice

RealNurseEd (Education for Real Nurses by a Real Nurse)

ARDS X-RayARDS X-Ray

Severe ARDSSevere ARDS

ARDS Lungs on AutopsyARDS Lungs on Autopsy

Goal of Treatment for ARDSGoal of Treatment for ARDS

Maintain adequate ventilation and Maintain adequate ventilation and respirations.respirations.

Prevent injuryPrevent injury

Manage anxietyManage anxiety

TreatmentTreatment

Mechanical Ventilation- Mechanical Ventilation- • goal PO2>60 and 02 sat 90% with FIO2 < 50goal PO2>60 and 02 sat 90% with FIO2 < 50

PEEPPEEP- - • can cause dec. CO, B/P and barotraumacan cause dec. CO, B/P and barotrauma

PositioningPositioning- - • prone, continuous lateral rotation therapy and prone, continuous lateral rotation therapy and

kinetic therapykinetic therapy Hemodynamic Monitoring- Hemodynamic Monitoring-

• fluid replacement or diureticsfluid replacement or diuretics

TreatmentTreatment

Enteral or Parenteral Feeding- Enteral or Parenteral Feeding- • high calorie, high fat. Research shows that high calorie, high fat. Research shows that

formulas enriched with omega -3 fatty formulas enriched with omega -3 fatty acids may improve the outcomes of those acids may improve the outcomes of those with ARDSwith ARDS

Crystalloids versus colloidsCrystalloids versus colloids Mild fluid restriction and diureticsMild fluid restriction and diuretics

PEEPPEEP

pt. can not expire completely. Causes pt. can not expire completely. Causes alveoli to remain inflatedalveoli to remain inflated

Complications can include Complications can include decreased cardiac output, decreased cardiac output,

pneumothorax, and increased pneumothorax, and increased intracranial pressure intracranial pressure

PEEP ( Positive end-expiratory pressure)PEEP ( Positive end-expiratory pressure)

Vent settings to improve <oxygenation>Vent settings to improve <oxygenation>

•PEEP • Increases FRC

• Prevents progressive atelectasis and intrapulmonary shunting

• Prevents repetitive opening/closing (injury)•Recruits collapsed alveoli and improves

V/ Q matching• Resolves intrapulmonary shunting• Improves compliance

•Enables maintenance of adequate PaO2at a safe FiO2 level

•Disadvantages• Increases intrathoracic pressure (may

require pulmonary a. catheter)• May lead to ARDS• Rupture: PTX, pulmonary edema

PEEP and FiO2 are adjusted in tandem

Oxygen delivery (DO2), not PaO2, should be used to assess optimal PEEP.

ProningProning

Proning typically reserved for Proning typically reserved for refractory hypoxemia not refractory hypoxemia not responding to other therapiesresponding to other therapies

Plan for immediate repositioning Plan for immediate repositioning for cardiopulmonary for cardiopulmonary resuscitation ***resuscitation ***

ProningProning

Positioning strategiesPositioning strategies• Mediastinal and heart contents place Mediastinal and heart contents place

more pressure on lungs when in supine more pressure on lungs when in supine position than when in proneposition than when in prone– Predisposes to atelectasisPredisposes to atelectasis

• Turn from supine to prone positionTurn from supine to prone position– May be sufficient to reduce inspired OMay be sufficient to reduce inspired O22 or or

PEEPPEEP

• Fluid pools in dependent regions of lungFluid pools in dependent regions of lung

Prone DeviceProne Device

•Prone positioning With position change to

prone, previously nondependent air-filled alveoli become dependent, perfusion becomes greater to air-filled alveoli opposed to previously fluid-filled dependent alveoli, thereby improving ventilation-perfusion matching.

No benefit in mortalityNo benefit in mortality

clinical trial

Benefits to ProningBenefits to Proning

Before proning ABG on Before proning ABG on 100%O2 7.28/70/70100%O2 7.28/70/70

After proning ABG on After proning ABG on 100% 7.37/56/227100% 7.37/56/227

PositioningPositioning

Other positioning strategiesOther positioning strategies• Kinetic therapy Kinetic therapy • Continuous lateral rotation therapyContinuous lateral rotation therapy

Continuous Lateral Rotation Continuous Lateral Rotation

Fig. 68-12

Oxygen TherapyOxygen Therapy

High flow systems used to High flow systems used to maximize Omaximize O22 delivery delivery

SaOSaO22 continuously monitored continuously monitored

Give lowest concentration that Give lowest concentration that results in PaOresults in PaO22 60 mm Hg or 60 mm Hg or

greatergreater

Respiratory TherapyRespiratory Therapy

Risk for Risk for OO2 2 toxicity toxicity increases when increases when

FIOFIO22 exceeds exceeds 60% 60% for more than for more than

48 hours 48 hours

Patients will commonly need Patients will commonly need intubation with mechanical intubation with mechanical ventilation because PaOventilation because PaO22 cannot cannot

be maintained at acceptable levelsbe maintained at acceptable levels

Oxygen TherapyOxygen Therapy

Mechanical ventilationMechanical ventilation

PEEP at 5 cm HPEEP at 5 cm H22O compensates for O compensates for

loss of glottic formationloss of glottic formation

Opens collapsed alveoliOpens collapsed alveoli

Mechanical ventilationMechanical ventilation

Higher levels of PEEP are often needed Higher levels of PEEP are often needed to maintain PaOto maintain PaO2 2 at 60 mm Hg or greaterat 60 mm Hg or greater

High levels of PEEP can compromise High levels of PEEP can compromise venous returnvenous return

–↓ ↓ Preload, CO, and BPPreload, CO, and BP

Medical Supportive TherapyMedical Supportive Therapy

Maintenance of cardiac output Maintenance of cardiac output and tissue perfusionand tissue perfusion• Continuous hemodynamic Continuous hemodynamic

monitoringmonitoring• Continuous BP measurement via Continuous BP measurement via

arterial catheterarterial catheter


Pulmonary artery catheter to Pulmonary artery catheter to monitor pulmonary artery monitor pulmonary artery pressure, pulmonary artery pressure, pulmonary artery wedge pressures, and COwedge pressures, and CO• Administration of crystalloid fluids or Administration of crystalloid fluids or

colloid fluids, or lower PEEP if CO colloid fluids, or lower PEEP if CO fallsfalls


Use of inotropic drugs may be Use of inotropic drugs may be necessarynecessary

Hemoglobin usually kept at levels Hemoglobin usually kept at levels greater than 9 or 10 with greater than 9 or 10 with SaOSaO22 ≥90%≥90%

Packed RBCsPacked RBCs Maintenance of fluid balanceMaintenance of fluid balance


May be volume depleted and May be volume depleted and prone to hypotension and prone to hypotension and decreased CO from mechanical decreased CO from mechanical ventilation and PEEPventilation and PEEP

Monitor PAWP, daily weights, Monitor PAWP, daily weights, and I and Os to assess fluid and I and Os to assess fluid statusstatus

MedicationsMedications

Inhaled Nitric OxideInhaled Nitric Oxide Surfactant therapySurfactant therapy NSAIDS and NSAIDS and corticosteroidscorticosteroids

Nitric OxideNitric Oxide

Dilates pulmonary blood Dilates pulmonary blood vessels and helps vessels and helps reduce shuntingreduce shunting

ARDS Prioritization and Critical ARDS Prioritization and Critical Thinking Questions #28Thinking Questions #28

When assessing a 22 Y/o client admitted 3 days ago with When assessing a 22 Y/o client admitted 3 days ago with pulmonary contusions after an MVA, the nurse finds shallow pulmonary contusions after an MVA, the nurse finds shallow respirations at a rate of 38. The client states he feels dizzy and respirations at a rate of 38. The client states he feels dizzy and scared. O2 sat is 80% on 6 Ln/c. which action is most scared. O2 sat is 80% on 6 Ln/c. which action is most appropriate?appropriate?

A.Inc. flow rate of O2 to 10 L/min and reassess in 10 min.A.Inc. flow rate of O2 to 10 L/min and reassess in 10 min. B.Assist client to use IS and splint chest using a pillow as he B.Assist client to use IS and splint chest using a pillow as he

coughs.coughs. C.Adminster ordered MSO4 to client to dec. anxiety and reduce C.Adminster ordered MSO4 to client to dec. anxiety and reduce

hyperventilation.hyperventilation. D.Place client on non-rebreather mask at 95-100% FiO2 and D.Place client on non-rebreather mask at 95-100% FiO2 and

call the Dr.call the Dr.

#25.The nursing assistant is taking VS #25.The nursing assistant is taking VS for an intubated client after being for an intubated client after being suctioned by RT. Which VS should be suctioned by RT. Which VS should be immediately reported to the RN?immediately reported to the RN?

A. HR 98A. HR 98 B.RR 24B.RR 24 C.B/P 168/90C.B/P 168/90 D.Temp 101.4D.Temp 101.4

#15. After change of shift report, you are assigned to #15. After change of shift report, you are assigned to care of the following clients.care of the following clients.

Which should be assessed first?Which should be assessed first?68 y/o on ventilator who needs a sterile sputum 68 y/o on ventilator who needs a sterile sputum

specimen sent to the lab.specimen sent to the lab.59y/o with COPD and has a pulse ox on previous shift 59y/o with COPD and has a pulse ox on previous shift

of 90%.of 90%.72y/o with pneumonia who needs to be started on IV 72y/o with pneumonia who needs to be started on IV

antibiotics.antibiotics.51y/o with asthma c/o shortness of breath after using 51y/o with asthma c/o shortness of breath after using

his bronchodilator inhaler. his bronchodilator inhaler.

VentilatorsVentilators

song Ventilate me

VentilatorVentilator

a machine that moves air in and a machine that moves air in and out of the lungsout of the lungs

Mechanical VentilationMechanical Ventilation

IndicationsIndications• Apnea or impending inability to breatheApnea or impending inability to breathe• Acute respiratory failureAcute respiratory failure• Severe hypoxiaSevere hypoxia• Respiratory muscle fatigue Respiratory muscle fatigue

Mechanical VentilatorMechanical Ventilator

What is a ventilator tutorialWhat is a ventilator tutorial

VentWorld - What is a Ventilator?

Mechanical Vent ObjectiveMechanical Vent Objective

support circulation and maintain support circulation and maintain pt. respirations until can breathe pt. respirations until can breathe

on ownon own

Goal of Mechanical VentilationGoal of Mechanical Ventilation

adequate controlled ventilationadequate controlled ventilation relief of hypoxia without hypercapniarelief of hypoxia without hypercapnia relief of work of breathingrelief of work of breathing access to airwaysaccess to airways

Criteria to put on ventCriteria to put on vent

Apnea or impending inability to breatheApnea or impending inability to breathe Acute respiratory failureAcute respiratory failure

• pH<7.25pH<7.25• pCO2>50pCO2>50

Severe hypoxia - pO2<50Severe hypoxia - pO2<50 Respiratory muscle fatigueRespiratory muscle fatigue


Types of mechanical ventilationTypes of mechanical ventilation• Negative pressure ventilationNegative pressure ventilation

– Uses chambers that encase chest or body and Uses chambers that encase chest or body and surround it with intermittent subatmospheric or surround it with intermittent subatmospheric or negative pressurenegative pressure

– NoninvasiveNoninvasive ventilation that ventilation that does not require does not require an artificial airway an artificial airway

– NotNot used extensively for used extensively for acutely ill acutely ill patients patients – Mostly used for neuromuscular diseases, CNS Mostly used for neuromuscular diseases, CNS

and injuries of the spinal cordand injuries of the spinal cord

Negative Pressure VentilatorNegative Pressure Ventilator

Fig. 66-21


Types of mechanical ventilation Types of mechanical ventilation • Positive pressure ventilation (PPV)Positive pressure ventilation (PPV)

– Used primarily in acutely ill patientsUsed primarily in acutely ill patients

– Pushes air into lungs under positive pressure Pushes air into lungs under positive pressure during during inspirationinspiration

– Expiration occurs passivelyExpiration occurs passively

Patient Receiving PPV Patient Receiving PPV

Fig. 66-22

Mechanical VentilatorMechanical Ventilator

Settings to MonitorSettings to Monitor

FIO2 -% of O2FIO2 -% of O2 Vt-<5ml/kg for ARDS (normal 10-12)Vt-<5ml/kg for ARDS (normal 10-12) raterate

• Control (CMV) Continuous Mandatory VentilationControl (CMV) Continuous Mandatory Ventilation• assist controlassist control• IMVIMV• SIMVSIMV

inspiratory pressureinspiratory pressure Pressure support- only in spontaneous Pressure support- only in spontaneous

breaths (gets the balloon started) Pt. controls breaths (gets the balloon started) Pt. controls all but pressure limitall but pressure limit

SETTING FUNCTION USUAL PARAMETERS

Respiratory Rate (RR) Number of breaths delivered by the

ventilator per minute

Usually 4-20 breaths per minute

Tidal Volume (VT) Volume of gas delivered during each

ventilator breath

Usually 5-15 cc/kg

Fractional Inspired Oxygen (FIO2) Amount of oxygen delivered by ventilator

to patient

21% to 100%; usually set to keep PaO2 > 60

mmHg or SaO2 > 90%

Inspiratory:Expiratory (I:E) Ratio Length of inspiration compared to length of

expiration

Usually 1:2 or 1:1.5 unless inverse ratio

ventilation is required

Pressure Limit Maximum amount of pressure the ventilator

can use to deliver breath 10-20 cm H2O above peak inspiratory

pressure; maximum is 35 cm H2O

Ventilator ModesVentilator Modes

Mode refers to how the machine Mode refers to how the machine will ventilate the patient in will ventilate the patient in relation to the patient’s own relation to the patient’s own respiratory efforts.respiratory efforts.

There is a mode for nearly There is a mode for nearly every patient situation, plus every patient situation, plus many can be used in conjunction many can be used in conjunction with each other. with each other.


Modes of volume ventilationModes of volume ventilation• Based on how much work of breathing Based on how much work of breathing

(WOB) patient should or can perform(WOB) patient should or can perform

• Determined by patient’s ventilatory status, Determined by patient’s ventilatory status, respiratory drive, and ABGsrespiratory drive, and ABGs

Control Mode or CMVControl Mode or CMV

1.1. Vt and RR areVt and RR are fixed fixed..

2.2. Used for Used for patients who are unable patients who are unable to initiate a breath to initiate a breath (anesthetized (anesthetized or paralyzed). or paralyzed).

CMV delivers the CMV delivers the preset volume preset volume or or pressure at pressure at pre-set rate pre-set rate regardless of regardless of the patient’s own inspiratory effort the patient’s own inspiratory effort

Spontaneously breathing patients must be Spontaneously breathing patients must be sedated and/or pharmacologically paralyzed sedated and/or pharmacologically paralyzed so they don’t breathe out of synchrony with so they don’t breathe out of synchrony with the ventilatorthe ventilator. .

**Ventilator does all the workVentilator does all the work

Assist ContolAssist Contol

1.1. A/C delivers the A/C delivers the preset volume preset volume or or pressure in pressure in response to the patient’s response to the patient’s own inspiratory effort, but will initiate the own inspiratory effort, but will initiate the breath if the patient does not do so within breath if the patient does not do so within the set amount of time.the set amount of time.

Patient Assists or triggers the vent –can breathe faster Patient Assists or triggers the vent –can breathe faster but not slowerbut not slower

Vent has back-up rateVent has back-up rate

May need to be sedated to limit the number of May need to be sedated to limit the number of spontaneous breaths since hyperventilation can spontaneous breaths since hyperventilation can occur.occur.

This mode is used for patients who This mode is used for patients who can can initiate initiate a breath but who have a breath but who have weakenedweakened respiratory muscles. respiratory muscles.

Synchronous Intermittent Synchronous Intermittent Mandatory Ventilation-SIMVMandatory Ventilation-SIMV

1.1. SIMV delivers the SIMV delivers the preset volume preset volume or pressure or pressure and and raterate while allowing the patient to breathe while allowing the patient to breathe spontaneously in between spontaneously in between ventilator ventilator breaths. breaths.

Each ventilator breath is delivered in synchrony Each ventilator breath is delivered in synchrony with the patient’s breaths, yet the with the patient’s breaths, yet the patientpatient is is allowed to completely allowed to completely control control the spontaneous the spontaneous breaths at own Vt. breaths at own Vt.

SIMV is used as a primary mode of SIMV is used as a primary mode of ventilation, as well as a weaning ventilation, as well as a weaning mode. mode.

• During weaning, the preset rate is During weaning, the preset rate is gradually reduced, allowing the patient gradually reduced, allowing the patient to slowly regain breathing on their own. to slowly regain breathing on their own.

• The disadvantage of this mode is that it The disadvantage of this mode is that it may increase the work of breathing and may increase the work of breathing and respiratory muscle fatigue respiratory muscle fatigue

Pressure Support VentilationPressure Support Ventilation

1.1. PSV is PSV is preset pressurepreset pressure that that augmentsaugments the patient’s spontaneous inspiratory effort the patient’s spontaneous inspiratory effort and decreases the work of breathing. and decreases the work of breathing.

2.2. The The patient completely controls patient completely controls the the respiratory respiratory rate and tidal volumerate and tidal volume. .

3.3. PSV is used for patients with a PSV is used for patients with a stablestable respiratory status respiratory status and is often used with and is often used with SIMV to overcome the resistance of SIMV to overcome the resistance of breathing through ventilator circuits and breathing through ventilator circuits and tubing. tubing.

Pressure supportPressure support

High Frequency VentilationHigh Frequency Ventilation

1.1. HFV delivers a small amount of gas at a HFV delivers a small amount of gas at a rapid rate (as much as 60-100 breaths per rapid rate (as much as 60-100 breaths per minute.) minute.)

2.2. This is used when conventional mechanical This is used when conventional mechanical ventilation would compromise ventilation would compromise hemodynamic stability, during short-term hemodynamic stability, during short-term procedures, or for patients who are at high procedures, or for patients who are at high risk for pneumothorax. risk for pneumothorax.

3.3. Sedation and pharmacological paralysis Sedation and pharmacological paralysis are required. are required.

Inverse Ratio VentilationInverse Ratio VentilationThe normal inspiratory:expiratory ratio is 1:2 but The normal inspiratory:expiratory ratio is 1:2 but

this is reversed during IRV to 2:1 or greater this is reversed during IRV to 2:1 or greater (the maximum is 4:1). (the maximum is 4:1).

This mode is used for patients who are still This mode is used for patients who are still hypoxic even with the use of PEEP. hypoxic even with the use of PEEP.

The The longer inspiratory longer inspiratory time increases the time increases the amount of air in the lungs at the end of amount of air in the lungs at the end of expiration (the functional residual capacity) and expiration (the functional residual capacity) and improves oxygenation by re-expanding improves oxygenation by re-expanding collapsed alveoli- collapsed alveoli- acts like PEEPacts like PEEP. .

Inverse Ratio VentilationInverse Ratio Ventilation

The shorter expiratory time prevents The shorter expiratory time prevents the alveoli from collapsing again. the alveoli from collapsing again.

Sedation and pharmacological paralysis Sedation and pharmacological paralysis are required since it’s very are required since it’s very uncomfortable for the patient. uncomfortable for the patient.

For patients with ARDS continuing For patients with ARDS continuing refractory hypoxemia despite refractory hypoxemia despite high levels of PEEPhigh levels of PEEP

Case StudyCase Study

Mr. Hill has been on the ventilator for 24 Mr. Hill has been on the ventilator for 24 hours. You volunteered to care for him today, hours. You volunteered to care for him today, since you know him from the intubation since you know him from the intubation yesterday. The settings ordered by the yesterday. The settings ordered by the pulmonologist after intubation were as pulmonologist after intubation were as follows: A/C, rate 14, VT 700, FIO2 60%. follows: A/C, rate 14, VT 700, FIO2 60%. Since 0700, Mr. Hill has been assisting the Since 0700, Mr. Hill has been assisting the ventilator with a respiratory rate of 24 (It’s ventilator with a respiratory rate of 24 (It’s now 1100). now 1100).

Describe the ventilator settings. Describe the ventilator settings.

AnswerAnswer

The ventilator delivers 14 breaths per minute, The ventilator delivers 14 breaths per minute, each with a tidal volume of 700 ml. The A/C each with a tidal volume of 700 ml. The A/C mode delivers the breaths in response to Mr. mode delivers the breaths in response to Mr. Hill’s own respiratory effort, but will initiate the Hill’s own respiratory effort, but will initiate the breath if he doesn’t within the set amount of breath if he doesn’t within the set amount of time. (He’s currently breathing above the vent time. (He’s currently breathing above the vent setting.) The oxygen concentration is 60%. setting.) The oxygen concentration is 60%.


You notice that Mr. Hill’s pulse oximetry has You notice that Mr. Hill’s pulse oximetry has been consistently documented as 100% since been consistently documented as 100% since intubation. You also notice that his intubation. You also notice that his respiratory rate is quite high and that he’s respiratory rate is quite high and that he’s fidgety, doesn’t follow commands, and fidgety, doesn’t follow commands, and doesn’t maintain eye contact when you talk doesn’t maintain eye contact when you talk to him. He hasn’t had any sedation since he to him. He hasn’t had any sedation since he was intubated. was intubated.

Which lab test should you check to find out Which lab test should you check to find out what what his true ventilatory status is? his true ventilatory status is?

AnswerAnswer

Arterial blood gas (ABG) - which he should Arterial blood gas (ABG) - which he should have had done with his morning labs. If not, have had done with his morning labs. If not, check with the pulmonologist about getting check with the pulmonologist about getting one. one.


Which two parameters on the ABG will give you a Which two parameters on the ABG will give you a quick overview of Mr. Hill’s status? quick overview of Mr. Hill’s status?

AnswerAnswer

PaCO2 (which affects the pH) and PaO2. PaCO2 (which affects the pH) and PaO2. With his high respiratory rate, Mr. Hill is at With his high respiratory rate, Mr. Hill is at risk for hypocapnia from “blowing off risk for hypocapnia from “blowing off CO2.” If the PaO2 is adequate, the FIO2 CO2.” If the PaO2 is adequate, the FIO2 could be decreased, since his oxygen could be decreased, since his oxygen saturation has been consistently 100%. saturation has been consistently 100%.


What are some possible causes of Mr. What are some possible causes of Mr. Hill’s increased respiratory rate? (Give Hill’s increased respiratory rate? (Give the corresponding nursing the corresponding nursing interventions as well.) interventions as well.)

AnswerAnswer

1. Secretions - suction through the ETT, as 1. Secretions - suction through the ETT, as well as his mouth. well as his mouth.

2. 2. Anxiety or pain - Mr. Hill hasn’t received Anxiety or pain - Mr. Hill hasn’t received any sedation since he was intubated. At any sedation since he was intubated. At this point, he should at least have a prn this point, he should at least have a prn order for sedation, if not a continuous IV order for sedation, if not a continuous IV infusion. infusion.

3. 3. The vent settings may not be The vent settings may not be appropriate – check the ABG’s and notify appropriate – check the ABG’s and notify the pulmonologistthe pulmonologist


Mr. Hill didn’t have an ABG done this Mr. Hill didn’t have an ABG done this morning, so you get an order from the morning, so you get an order from the pulmonologist to get one now (1130). When it pulmonologist to get one now (1130). When it comes back, the PaCO2 is 28, the pH is 7.48, comes back, the PaCO2 is 28, the pH is 7.48, and the PaO2 is 120 (normals: PaCO2 35-45 and the PaO2 is 120 (normals: PaCO2 35-45 mm Hg, pH 7.35-7.45 mm Hg, PaO2 80-100 mm Hg, pH 7.35-7.45 mm Hg, PaO2 80-100 mm Hg). mm Hg).

Based on the ABG, the pulmonologist Based on the ABG, the pulmonologist changes the vent settings to SIMV, rate 10, changes the vent settings to SIMV, rate 10, PS 10, FIO2 40%. The VT remains 700. How PS 10, FIO2 40%. The VT remains 700. How will these new settings help Mr. Hill? will these new settings help Mr. Hill?

AnswerAnswer

SIMV will deliver 10 breaths with the full tidal SIMV will deliver 10 breaths with the full tidal volume each minute, but in synchrony with Mr. volume each minute, but in synchrony with Mr. Hill’s spontaneous breaths. This mode is not Hill’s spontaneous breaths. This mode is not triggered to deliver a breath each time Mr. Hill triggered to deliver a breath each time Mr. Hill inhales, and the tidal volume of his spontaneous inhales, and the tidal volume of his spontaneous breaths is under his control. Pressure support breaths is under his control. Pressure support decreases the work of breathing that results decreases the work of breathing that results from breathing through the ventilator circuits from breathing through the ventilator circuits and tubing. The PaO2 was higher than desired, and tubing. The PaO2 was higher than desired, indicating that the FIO2 could be decreased. We indicating that the FIO2 could be decreased. We need to be careful to prevent oxygen toxicity. need to be careful to prevent oxygen toxicity.

The pulmonologist also orders midazolam The pulmonologist also orders midazolam (Versed) 1-2 mg every hour prn for sedation. (Versed) 1-2 mg every hour prn for sedation.

AlarmsAlarms

high pressurehigh pressure low pressure low pressure

Low Pressure Alarms

•Circuit leaks •Airway leaks •Chest tube leaks •Patient disconnection

High Pressure Alarms

•Patient coughing •Secretions or mucus in the airway •Patient biting tube •Airway problems •Reduced lung compliance (eg. pneumothorax) •Patient fighting the ventilator •Accumulation of water in the circuit •Kinking in the circuit

NEVER TURN NEVER TURN ALARMS OFF!ALARMS OFF!

Assess your patient Assess your patient

not the alarmsnot the alarms


Complications of PPV Complications of PPV • Cardiovascular system Cardiovascular system

– ↑↑ Intrathoracic pressure compresses thoracic Intrathoracic pressure compresses thoracic vessels vessels

• ↓↓ Venous return to heart, Venous return to heart, ↓↓ left ventricular end- left ventricular end- diastolic volume (preload), diastolic volume (preload), ↓↓ cardiac output cardiac output

• HypotensionHypotension• Mean airway pressure is further Mean airway pressure is further ↑↑ if PEEP if PEEP

>5 cm H>5 cm H22OO


Complications of PPV Complications of PPV • Pulmonary systemPulmonary system

– Barotrauma Barotrauma • Air can escape into pleural space from alveoli or Air can escape into pleural space from alveoli or

interstitium, accumulate, and become trapped interstitium, accumulate, and become trapped pneumothorax , subcutaneous emphysemapneumothorax , subcutaneous emphysema

• Patients with compliant lungs are at Patients with compliant lungs are at ↑↑ risk risk• Chest tubes may be placed prophylacticallyChest tubes may be placed prophylactically

Subcutaneous EmphysemaSubcutaneous Emphysema


Complications of PPV Complications of PPV • Ventilator-associated pneumonia (VAP)Ventilator-associated pneumonia (VAP)

– Pneumonia that occurs 48 hours or more after Pneumonia that occurs 48 hours or more after ET intubation ET intubation

– Clinical evidenceClinical evidence• Fever and/or elevated white blood cell countFever and/or elevated white blood cell count• Purulent or odorous sputumPurulent or odorous sputum• Crackles or rhonchi on auscultation Crackles or rhonchi on auscultation • Pulmonary infiltrates on chest x-ray Pulmonary infiltrates on chest x-ray


Complications of PPV Complications of PPV • Guidelines to prevent VAPGuidelines to prevent VAP

– HOB elevation at least 30 to 45 degrees unless HOB elevation at least 30 to 45 degrees unless medically contraindicated medically contraindicated

– No routine changes of ventilator circuit tubingNo routine changes of ventilator circuit tubing


Complications of PPVComplications of PPV• Guidelines to prevent VAP Guidelines to prevent VAP

– Use of an ET that allows continuous suctioning Use of an ET that allows continuous suctioning of secretions in subglottic areaof secretions in subglottic area

– Drain condensation that collects in ventilator Drain condensation that collects in ventilator tubingtubing

Continuous Subglottal Suctioning Continuous Subglottal Suctioning

Fig. 66-20


Complications of PPV Complications of PPV • Fluid retentionFluid retention

– Occurs after 48 to 72 hours of PPV, especially Occurs after 48 to 72 hours of PPV, especially PPV with PEEPPPV with PEEP

– May be due to May be due to ↓↓ cardiac output cardiac output– ResultsResults

• Diminished renal perfusionDiminished renal perfusion• Release of renin-angiotensin-aldosterone Release of renin-angiotensin-aldosterone

– Leads to sodium and water retention Leads to sodium and water retention


Complications of PPV Complications of PPV • Fluid retention Fluid retention

– Pressure changes within thorax are associated Pressure changes within thorax are associated with with ↓↓ release of atrial natriuretic peptide, also release of atrial natriuretic peptide, also causing sodium retentioncausing sodium retention

– As part of the stress response, antidiuretic As part of the stress response, antidiuretic hormone and cortisol may be hormone and cortisol may be ↑↑

• Contributes to sodium and water retentionContributes to sodium and water retention


Complications of PPV Complications of PPV • Gastrointestinal systemGastrointestinal system

– Risk for stress ulcers and GI bleedingRisk for stress ulcers and GI bleeding– ↑↑ Risk of translocation of GI bacteriaRisk of translocation of GI bacteria

• ↓↓ Cardiac output may contribute to gut ischemiaCardiac output may contribute to gut ischemia

– Peptic ulcer prophylaxis Peptic ulcer prophylaxis • Histamine (HHistamine (H22)-receptor blockers, proton pump )-receptor blockers, proton pump

inhibitors, tube feedings inhibitors, tube feedings – ↓↓ Gastric acidity, Gastric acidity, ↓↓ risk of stress risk of stress

ulcer/hemorrhageulcer/hemorrhage


Complications of PPV Complications of PPV • Musculoskeletal systemMusculoskeletal system

– Maintain muscle strength and prevent problems Maintain muscle strength and prevent problems associated with immobility associated with immobility

– Progressive ambulation of patients receiving Progressive ambulation of patients receiving long-term PPV can be attained without long-term PPV can be attained without interruption of mechanical ventilation interruption of mechanical ventilation


Psychosocial needsPsychosocial needs• Physical and emotional stress due to Physical and emotional stress due to

inability to speak, eat, move, or breathe inability to speak, eat, move, or breathe normallynormally

• Pain, fear, and anxiety related to tubes/ Pain, fear, and anxiety related to tubes/ machinesmachines

• Ordinary ADLs are complicated or Ordinary ADLs are complicated or impossibleimpossible


Psychosocial needs Psychosocial needs • Involve patients in decision makingInvolve patients in decision making• Encourage hope and build trusting Encourage hope and build trusting

relationships with patient and familyrelationships with patient and family• Provide sedation and/or analgesia to Provide sedation and/or analgesia to

facilitate optimal ventilationfacilitate optimal ventilation


Psychosocial needs Psychosocial needs • If necessary, provide paralysis to achieve If necessary, provide paralysis to achieve

more effective synchrony with ventilator more effective synchrony with ventilator and increase oxygenationand increase oxygenation

• Paralyzed patient can hear, see, think, feelParalyzed patient can hear, see, think, feel– Sedation and analgesia must always be Sedation and analgesia must always be

administered concurrentlyadministered concurrently

Respiratory TherapyRespiratory Therapy Alternative modes of mechanical Alternative modes of mechanical

ventilation if hypoxemia persistsventilation if hypoxemia persists• Pressure support ventilationPressure support ventilation• Pressure release ventilationPressure release ventilation• Pressure control ventilationPressure control ventilation• Inverse ratio ventilationInverse ratio ventilation• High-frequency ventilationHigh-frequency ventilation• Permissive hypercapniaPermissive hypercapnia• Independent Lung VentilationIndependent Lung Ventilation

Independent Lung VentilationIndependent Lung Ventilation

ResearchResearch

LiquiVent is an oxygen-carrying liquid LiquiVent is an oxygen-carrying liquid drug (perflubron) used for respiratory drug (perflubron) used for respiratory distress syndrome.distress syndrome.

The goal of "liquid ventilation" therapy is to The goal of "liquid ventilation" therapy is to open up collapsed alveoli (air sacs) and open up collapsed alveoli (air sacs) and facilitate the exchange of respiratory gases facilitate the exchange of respiratory gases while protecting the lungs from the harmful while protecting the lungs from the harmful effects of conventional mechanical effects of conventional mechanical ventilation. ventilation.


Partial liquid ventilation with perflubronPartial liquid ventilation with perflubron• Perflubron is an inert, biocompatible, clear, Perflubron is an inert, biocompatible, clear,

odorless liquid that has affinity for Oodorless liquid that has affinity for O22 and and

COCO22 and surfactant-like qualities and surfactant-like qualities

• Trickled down ET tube into lungs Trickled down ET tube into lungs


Extracorporeal membrane oxygenationExtracorporeal membrane oxygenation• Alternative form of pulmonary support for Alternative form of pulmonary support for

patient with severe respiratory failurepatient with severe respiratory failure• Modification of cardiopulmonary bypassModification of cardiopulmonary bypass• Involves partially removing blood through Involves partially removing blood through

use of large-bore catheters, infusing use of large-bore catheters, infusing oxygen, removing COoxygen, removing CO22, and returning blood , and returning blood

back to patient back to patient

Research and NewResearch and New

YouTube - Superman breather - USA

Prioritization and Delegation Prioritization and Delegation Questions on VentQuestions on Vent

The nurse is assigned to provide nursing care for a The nurse is assigned to provide nursing care for a client receiving mechanical ventilation. Which action client receiving mechanical ventilation. Which action should be delegated to the experienced nursing should be delegated to the experienced nursing assistant?assistant?

A. Assess respiratory status q 4 hours.A. Assess respiratory status q 4 hours. B. Take VS and pulse ox reading q4 hours.B. Take VS and pulse ox reading q4 hours. C. Check ventilator settings to make sure they are as C. Check ventilator settings to make sure they are as

prescribed.prescribed. D.Observe client’s need for suctioning q 2 hours. D.Observe client’s need for suctioning q 2 hours.

#27 The high pressure alarm on the vent goes off #27 The high pressure alarm on the vent goes off and when you enter the room to assess a client with and when you enter the room to assess a client with ARDS, her O2 sat is 87% and she is struggling to sit ARDS, her O2 sat is 87% and she is struggling to sit up. What action should be taken next?up. What action should be taken next?

A. Reassure client that the vent will do the work of A. Reassure client that the vent will do the work of breathing for her.breathing for her.

B. Manually ventilate the client while assessing B. Manually ventilate the client while assessing possible reasons for the alarm.possible reasons for the alarm.

C. Inc. the FiO2 to 100% in preparation for C. Inc. the FiO2 to 100% in preparation for endotracheal suction.endotracheal suction.

D. Insert an oral airway to prevent client from biting D. Insert an oral airway to prevent client from biting the endotracheal tube.the endotracheal tube.

respiratory failure and ards by laurie dickson with thanks to nancy jenkins

Documents

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