Transcript Ventilator Check

Ventilator Check
It’s a thorough process that should
take longer than 2 minutes!
Step 1-Chart Review
• Verify Current ventilator settings with
physicians orders
• Insure correspondence between the MD
orders and actual values given in report and
that are on the ventilator
• Contact MD for discrepant values
• Check orders for ventilator changes, ABGs….
• Check current medications (sedation, blood
presser medications, antiobiotics…)
Step 1- Chart Review
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Look at patients CXR, note tube placement
Look at patients CBC and C/S results
Look at last ABG result
Read H & P, read pulmonary consult
Know what the general plan is for the patient
– Ex: weaning? Continue vent as is?...
Step 2-entering room
• You should have a good idea about why your
patient is on the vent from report and chart
review before actually seeing your patient
• Wash hands/gloves
• Enter room, assess the patient and ventilator by
inspection first
– Note medications hanging by IV
– Note presence of a feeding tube
– Note the monitor for HR, SpO2, BP, hemodynamics
parameters
– Look at the patient, note if they are awake/sedated
Step 2- entering the room
• Note if family is in the room, explain who you
are and what you are doing
• Only comment on matters regarding the
ventilator or respiratory, no lab tests…
• Now assess patient. First look at the vent
circuit, if patient is on a humidifier you may
have to drain the tubing, note water level on
huidifier and refill as needed
Step 3- Pt. Assessment
• Note patients chest movement, tape on ETT and
tube marking at lip or gum
• Re-tape as needed
• Change HME as needed
• Check MOV/MLT
• http://www.youtube.com/watch?v=NBKV3zuzlJE
• Check patient’s breath sounds, general
appearance, chest movement
Step 4- Ventilator Check
• Note Heart Rate, SpO2, ECG tracing, BP on
monitor, PETCO2, record where appropriate
• Check circuit for leaks, integrity
• On Ventilator monitor/record:
– Ventilator settings (ensure they are what was
ordered). Mode, FIO2, VT/PC, breath type, PEEP, Itime/flow, Alarms (adjust alarms as needed)
Step 4 Ventilator check
• Ventilator monitored data:
– PIP (if high note increases in RAW/fix)
– Total rate (if high note presence of fever, hypoxemia,
anxiety/aggtation, low Vt)
– Total PEEP (if higher than set= auto peep)
– MAP (normal 10-12, increased = decreased
compliance, higher distending pressures, set PEEP is
high)
– VTE / VTI (look for difference, if greater than +/- 50
may be a leak)
– FIO2 (if analyzer is way off, take vent out of service for
repair)
Step 4 Ventilator check
• Note graphics:
– FLOW/TIME: assess for aitrapping
– PRESSURE/TIME: assess for over distension, time
it takes to reach pressure
– VOLUME/TIME: Note if patient is receiving
adequate flow on inspiration
– PRESS/VOLUME LOOP: note compliance
– FLOW/VOLUME LOOP: Note obstructive patterns
Step 4 Ventilator check
• Perform lung mechanics:
– Inspiratory hold to get Static Compliance
– Expiratory hold to get Auto-PEEP
– RAW calculation
Step 4-Ventilator Check
• Suction patient as needed (noted by breath
sounds, PIP and airway graphics)
• Give breathing treatment after all checks are
done (adjust alarms as needed for treatment
delivery)
Communication
• When you make a change to the ventilator,
share your change with the RN
• The doctor should have been the one giving
you the order to change the vent, however if
not, share change with the MD as well
• During rounds (if they are present at the
hospital you go to) communicate your
ventilator settings and YOUR plan or
recomendation
Troubleshooting
• High PIP (safety valve opens)
– Agitation (sedation? Pain meds? Change in
mode?)
– Increase in airway secretions, suction/bronch
– Bronchospasm- broncho dilator
– Biting ETT (bite block)
– Patient talking/coughing/holding breath
Troubleshooting
• Low VTE/low PIP:
– Look for obvious leaks
– Does the patient have a chest tube
– Note cuff integrity
– Did the patient self extubate
– Is the patient on spontaneous mode without
proper PSV or support
Troubleshooting
• High Rate/high Ve:
– Pain, agitation, fear/anxiety?
– Fever?
– Low volumes?
– Compensation for Metabolic acidosis?
– Do they need sedation, change in mode, increased
flow?
Troubleshooting
• Low rate:
– Over sedated?
– Compensating for a metabolic alkalosis?
– Over ventilated with high Vte
– Atrophy of diaphragm?
– Neuromuscular impairment?
Weaning
• Weaning is done when parameters of interest
improve. For example oxygenation improves
as demonstrated by ABG and SpO2. Wean
FIO2 down in increments tolerable by patient.
– Wean to 60% first, then begin weaning PEEP
– Wean to a minimum of about 40% before
extubation is considered
Weaning
• Patients underlying condition must be
improved or improving
• Look at CXR, labs and physician notes
• Note if patient is on sedation
• Note hemodynamic stability, should be off
pressers
• Patient obviously should have drive and ability
to breathe, and ability to cough
Weaning
• Note weaning parameters:
– MIP
– MEP
– VC
– RSBI
– Vital signs within acceptable parameters
– ABG within patient’s normal limit
– Cuff pressure is normal
Weaning
• Strategies:
– SBT (spontaneous breathing trials)
– Taper down support (wean rate, change to less
controlled modes- SIMV then Spontaneous
modes)
– Give minimum PSV or use ATC/VS
– Extubate to BiPAP