Transcript INTUBATED PATIENT

INTUBATED PATIENT
Step by Step
4-16-07
Dora M Alvarez MD
INITIAL PROCES
1. Call from ED requesting bed for and
intubated patient
2. Resident / Supervisor (if applicable)
obtains information on patients condition
on the phone, gets Sign out Sheets and
Ventilator Order Flow sheets and goes to
see patient in the ED
3. Information needed:
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Reason for intubation (*)
Clinical Diagnosis and patient’s condition
* Reason for Intubation
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Airway protection ?
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Alter Mental Status
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Seizures
Drug overdose
Angioedema
Facial Trauma
Severe Respiratory Distress / Impending resp Failure ?
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Airway disease
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Parenchyma disease
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Upper airway (Trauma with edema, angiodema, FB, Croup, Epiglotittis)
Lower airway (Asthma. brochiolitis, CF, BPD )
Pneumonia, Pulmonary edema, Pulmonary hemorrhage, Aspiration episode,
ACS /Pneumonia)
Broncho-parenchymal problem; (Mechonial aspiration, Aspiration,
BPD
Trauma chest (Flair, pulmonary contusion, pneumothorax,
hemothorax.)
Muscular Diseases.(SMA, Botulism, Guillen Barre)
Information needed
• Intubation process,
– ET tube Size, cuff or not cuff,
– Intubated by: anesthesiologist?, ED attending?,
resident?
– Medications given
– Complication
• Difficult intubation
• Vomited ? Aspiration
• CxR ray, position of tubes, (ET and NG); lungs findings
• Ventilatory settings (write settings in the “Ventilator
order flow sheet)
• ABG
Ventilator setting
Example: 8 yo with status asthmaticus (45 kg)
• Type Ventilator: …..PB 840, PB (720)
• Mode:
– Volume Control: CMV, A/C - SIMV
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Rate: (15)
TV: (320 mL (8 ml/kg) …..read the PIP is ??)
I:time… (read the I:time or I:E rate show)
Flow:… (30 L/min)
PEEP: …(0 - 4)
FIO2: …. (100%)
PICU Admission.
• Be and Stay in the room when patient arrives &
Check …
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ET tube in place, well taped
C-R monitor, VS, O2 Sat, ETCO2
Suction: observe and describe type of secretions.
Check Ventilator setting and order according to guidelines:
• Usually patient’s are place on CMVor A/C in ED because they are
paralyzed and/or heavily sedated. Changed to SIMV with PS mode
according to patient’s condition, with this mode patient may be
allow to breath spontaneously, supporting his/her respirations.
• Wean FiO2 according to O2 Sat. Usually patient came with 100%
O2 and an ABG showing high PaO2 > 300.
– Continue brochodilator if indicated, back to back, MDI 6
puffs Q 30-60 min.
– Sedation order (Verbal) Midazolan / Fentanil. Code sheet
at bedside.
Monitoring Intubated patient
Check:
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O2 Sats
ETC02, monitoring
Lung auscultation
Assessment of A&B. Ventilation and
oxygenation
– ABG
– Temp
– CV: HR, PB, perfusion.
PICU Admission continue
Review /Check X Ray if not done before and document
ET tube position
Order:
- Ventilator order as per guidelines, considering patient’s
condition / lung pathology.
- Sedation (Midazolan PRN and/Or drip, Fentanyl Or
Ketamine drip for asthma)
- If indicated order Bronchodilator. MDI 6 puffs Alb/
Atrovent alternated - IV solumedrol
- IV Fluids requirements, considering metabolic
demands, fluid deficit and ongoing loses as indicated.
Reevaluate the need for continuation of
Respiratory support considering the
Indication for intubation
1. If intubated because Alter mental status
2nd to post-ictal and /or medications >>
patient may be allowed to wake up (No
sedation), wean respiratory support
quickly, assessing if oxygenating and
ventilating with no increase work of
breathing on minimal respiratory support,
patient may be extubated soon. (See
criterion for extubation **)
Reevaluate the need for continuation of Respiratory
support considering the Indication for intubation
2. If patient is intubated because:
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Hypoxic/Mix respiratory failure 2nd to parenchyma
pathology: I.e: Pneumonia, Asthma, bronchiolitis;
patient will need sedation and mechanical ventilarory
support till the diseases processes improves/resolves.
3. If patient was intubated because cardiovascular
instability: Shock (Cardiac, septic )
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Patient should remained, deeply sedated /paralyzed
and given full respiratory support till
hemodynamically stable
4. Facial trauma, protective airway > Patient should
remained, deeply sedated /paralyzed? and given full
respiratory support till airway is consider maintainable.
**Extubation Criteria
1.
Resolution of condition / reasons for intubation:
examples
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If patient was intubated for alter mental status 2nd to drug
overdose or post-ictal >>Pt is ready for extubation when patient
is waking up and responsive and breathing spontaneously. (NO
NEED TO KEEP SEDATING PATIENT TO KEEP
INTUBATED)
If patient is intubated for respiratory failure 2nd to lower airway
obstruction (asthma / bronchiolitis) >> Pt is ready for extubation
when airway obstruction is much improved / resolving and
patient will be able to breath without significant respiratory
effort / work of breathing.
**Extubation Criteria
2. Off sedation, awake, able to follow up
commands, (open eyes spontaneously)
3. Positive gag reflex, good cough effort
4. Able to maintain open airway.
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If intubation was because primary upper airway
obstruction (Croup, epiglotittis, stenosis ?), need to
check for leak around the tube or by documenting
normal anatomy by inspection.
5. Able to lift Head and grip
**Extubation Criteria
6. Tolerating weaning down Ventilator support to
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CPAP or T-Piece
Pressure support down < 4 (at least consideration to be wean to
nasal/mask CPAP or BIPAP which should be available at bedside)
PEEP < 4
FiO2 < 40 %, O2 Sat > 95 %, with out desaturaion when
succioning.
7. Patient is breathing on his own, without significant effort or
increase work of breathing (retractions) and has been able to
maintain an normal Pa CO2 by ABG and /Or ETCO2
8. Patient is hemodynamically stable
9. For patient who can cooperate and able to follow directions, ask
respiratory therapy to check NIF (Negative Inspiratory Flow)
which assess respiratory muscle strength.
10. “If Patient is trying to take the tube out” > and fits above criteria,
wean quickly to prevent accidental extubations.
Things to do prior to Extubation:
• NPO (Stop NG/GT feeding for 4-6 hrs before
planned intubation.
• Have the following ready.
– Oral airway, proper size.
– Working suctioning equipment (younker)
– Proper side ET tube, laryngoscopy for possible need for
reintubation.
– Ambu-Bag connected to oxygen
– Aerosolized oxygen delivery system
– Nebulizer treatments (Vaponefrin and Albuterol)
Extubation Procedure
• Suction ET tube and pharynx thoroughly
• Pre-oxygenate Lungs manually inflated with 100% O2 to
keep Sat 100% to provide a
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Reservoir oxygen buffer.
• Cuff deflated (if applicable
• Provide Humidify oxygen with aerosolize mask 40-50%
• Remove restrains and sit patient up
• Auscultate to check air-entry and if any adventitious signs.
Post – Extubation
• Observe for presence of stridor, if significant and/or persistent stridor
give racemic epinephrine nebulizer treatment. If prolonged, consider
the use of Decadron (0.3 -0.5 mg/kg ..Max 10 mg 1 dose)
• Observe for increase work of breathing and wheezing. Can try
Nebulizer albuterol, “gentle Chest PT, and deep pharyngeal suction to
stimulate cough, especially in younger patients.
• Assess Oxygen requirement by decreasing FIO2 gradually if O2 Sat
are > 98%
• ABG, (or capillary, VENOUS IS NOT ACCEPTABLE), if patient is
having signs of respiratory distress / increase work of breathing and is
still requiring > 35 % FiO2.
• CxR is not routinely indicated. Post intubation atelectasis is common
and demonstrating this in CxR may not change patient management.
• Incentive spirometry and CPT may be indicated in patients who are not
having and effective cough.
Examples
1 mo old frequent apnea episodes
in between 100 % RA
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Check patient
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Nasal and/or oropharingeal secretion, suction
RR in between 30 .min
Mental status/ activity ..Stimulated response temporaly, cry
vigorous and has good color
Lungs auscultation clear, no murmurs
HR normal 140 good perfusion
Observation of apnea, increasing frequency Q 15-20 min sat 88
%
Chest studies: CxR, EKG ABG normal, CBC, SMA,
Blood cultures. U/A
Intervention: CPAP >> CPAP SIMV
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FiO2 30 %
PEEP 5
Flow.
1 mo old frequent apnea episodes
in between 100 % RA
Interventions/ Options:
1. Stimulator (using Bear Cub respirator)•
Order:Mechanical Ventilation-Neonatal (Patient is not
intubated >the breath are going to be deliver into a
globe which is place under the back of the babe)
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Mode: SIMV
Rate: 25-30
Flow (Check guide lines)
I:time 0.5
PEEP 0
FiO2: RA
1 mo old frequent apnea episodes
in between 100 % RA
Interventions/ Options:
2. Nasal CPAP
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Flow (Check guide lines)
PEEP 4-5
FiO2: 28 –30 % ( as needed to keep O2 Sats > 95 %
3. CPAP / SIMV
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Rate: 25-30
Flow (Check guide lines)
I:time 0.5
PEEP 4-5
FiO2: 28 –30 % ( as needed to keep O2 Sats > 95 %
Intubation if continue with apneas
and bradycardias
• Ventilator: Bear Cub
– Mode: CMV / SIMV
– Rate: 25-30
– PIP 12-14 (low as pat. Has no lung pathology >see
chest raise and check exhale tidal volume)
– I:Time 0.5
– Flow 12
– PEEP 4
– FiO2: 25-30 %