Transcript Trouble shooting-Case scenarios

Ventilator and Practical Review
Format
• You will be assigned to a ventilator
• The practical will last approximately 30 minutes
per person, each day (total of 60 minutes)
• You will be asked to setup the ventilators circuit,
read the scenario and input your settings and
alarms; also apnea alarms
• After placing the patient on the vent you will be
given a scenario, from this scenario you will make
the appropriate adjustments
Format
• Settings: Must be able to set appropiate VT per
IBW, or PCV with an acceptable Pressure limit.
Know what flow to set, sensitivity, rate and FIO2.
• You will be expected to use appropiate VT ranges
per the given scenario 8-12 ml/kg or 5-7 ml/kg
• Know how to calculate CD, CS, RAW and
understand what each means and when to
change to a lung protective mode
Format
• You must know how to correct acidosis and
alkalosis, setup appropriate VT, rate and FIO2
• You will also be asked to perform a inspiratory
hold, assess for auto-peep and over distention
utilizing the graphics
• You will be asked to adjust flow and I-time to
get a specific I:E ratio
• Be able to calculate spontaneous VT, Ve, flow,
and I:E calculations
Format
• Troubleshooting: You will be asked to trouble
shoot, either a high pressure or low pressure.
You must identify the cause as being a
compliance issue or a mechanical problem
• Be able to answer questions concerning
weaning parameters and readiness to wean
including:
– VC, MIP, Blood pressure, CXR, compliance, O2
demand…
Format
Know weaning strategies, including PSV, SBT, ATC…
The practical is worth a exam grade. There will be
remediation for those who fail. The remediation
will be longer and harder than the original!
Ventilator Review
• Trigger: What begins inspiration, either time, flow
or pressure. The time applies to non patient
triggered breaths. Control trigger by setting
sensitivity
• Set sensitivity 1-3. If the sensitivity is set >3 may
lead to difficulty triggering breath on and induce
WOB, if set to low may cause auto-triggering
• Set in all modes (including CPAP, PSV still needs a
trigger!)
Ventilator Review
• Cycle: This is what cycles the breath off. Either
flow, pressure or volume. Pressure and volume
limits are the most common
• Volume: Set appropriate per patients size. If
patient has restrictive lungs or is air trapping
severely, use 3-5 ml/kg range, otherwise 6-8
• Pressure Limit: Set 15-25, increase to increase VT,
decrease to lower VT
• Rate: The smaller the VT the higher the rate. Use
10-20 for VT 6-8, and 15-25 for 3-5, keep Ve >5L
Ventilator Review
• MODES:
• AC: start with this mode if patient is apneic or if
patient’s spontaneous breaths are inadequate or
erratic. Patient can trigger breaths but machine
will complete the breath at preset limits
• SIMV: May start with this mode on any patient
who is apneic if you suspect he/she will regain
spontaneous breathing. Otehrwise, use only if
spontaneous breaths are adequate. Must set a
PSV in this mode
Ventilator Review
• CPAP/Spontaneous: May start for Type I
failure, patient must have ability to breathe
spontaneously without much need for
ventilatory support. Must have a PSV or ATC or
VS
• PRVC: duel mode, set in either AC or SIMV
mode. Set pressure limit, target VT…Does not
work well with erratic breathing patterns
Ventilator Review
• APRV: for restrictive lungs only, spontaneously
breathing
• HFOV: for restrictive lungs only,
sedate/paralyze.
• ASV: used as a single mode, from start to
finish, not for ARDS or neurological breathing
patterns
Ventilator Review
• Flow: Set only in Volume control. When set use
either constant or decelerating patterns.
Increased flow= decreased I-time. Give patients
with COPD increased flows to meet demands and
give long E-time. Increase when you increase VT,
or change flow pattern
• I-time: Set in PRVC, PCV. Increase or decrease to
achieve appropriate I:E, increased
rates=decreased I-time. Inverse used for
restrictive diseases to increase oxygenation
Ventilator Review
• Non-compensated Respiratory Acidosis:
• You need to increase Ve. On AC mode this is done
by:
– Increasing VT (8-12 range), watch PIP’s
– Increasing PIP, watch total PIP
– Increasing rate, unless patient is breathing over BUR
– increase Ve target if on MMV or ASV modes
– Remove any unnecessary mechanical deadspace
On SIMV mode: you can increase rate even if patient is
over BUR, or increase VT/PIP or increase PSV to
increase Spontaneous VTe
Ventilator Review
• On HFOV: To decrease PaCO2
– Increase AMP, then decrease Hz, Induce leak
around ETT cuff.
– To increase PaCO2 do the opposite
– To improve PaO2, increase FIO2 and MAP
• On APRV:
– To decrease PaCO2 Increase HP or Increase LT or
decrease low Pressure
Ventilator Review
• Uncompensated Respiratory Alkalosis
• On ACV mode:
– Decrease rate first if patient is not breathing over
BUR.
– Decrease VT or PIP
On SIMV decrease Rate, VT/PIP or PSV OR
change to CPAP mode
Ventilator Review
• Vent Check:
– Check ventilator orders, check for new orders and
assure old orders. Weaning orders? Pertinent
procedures that would require transport or
procedures that would require your presence like a
bronch?
– Assess patients chart first know patients Hx and why
they are on the ventilator
– CXR, CT scan and all other pertinent diagnostic tests
– ABG, CBC, other pertinent labs
– Sedation
– Hemodynamics, BP, arrthymias and cardiac status
Ventilator Review
• Vent Check
– Note if patient is in isolation
– Assess patient’s vital signs
– Check BS, HR, Spo2, cardiac rhythm, BP and
hemodynamics
– Assess capnography if applicable
– Note presence of Foley and its contents, chest tubes,
NG tubes, PICC lines, IV’s, A-lines…
– Note medications hanging in room
– Note patients ETT tape or holder, does it need to be
changed
Ventilator Review
• Vent Check
– Note ETT size and location at lip.
– Note patient and their sensorium
– Perform MLT/MOV or check cuff pressure directly
– Ensure tubing is free from condensation, if patient
is on a heater, drain circuit into water trap, ensure
heater water is filled. If HME, ensure it is not
occluded, if it is, change it
– Note inline suction ballard, if heavily soiled,
change it
Ventilator Review
• Vent Check
– Check patients settings, mode, VT/Pip, rate, rise time,
sensitivity…also alarm settings and apnea settings
– Assess ventilator graphics, note presence of over
distension, air leaks, auto-peep, secretions…
– Record monitored data including: PIP, VTE/VTI, Ve,
Rate, Static Compliance, Dynamic compliance, MAP,
total PEEP…
– Check suction pressure, suction patients lungs as
needed and also mouth with yonker
– Document all pertinent information
– If you do not document it wasn’t done!
Ventilator Review
• Vent Check
– Your first vent check should be the most time consuming.
– Any changes that are made, make sure the patients RN is
aware
– As a student you will not be making any changes without
approval from your preceptor
– Typically a brief summary is written regarding the patient.
Put any changes you made or ABG’s you drew here and
maybe the plan for the day
– Inline HHN or MDI’s should be given AFTER you have done
your check and suctioned patient (if it was needed)
Ventilator Review
• Vent Check
– The patient should have a resusitation bag at
bedside, plugged into oxygen. If the patient is on
PEEP, ensure there is a peep valve.
– The ventilator should be plugged into the red
outlet incase of power outage
– Note signs in room for Dialysis Shunts
– A spare trach should be in the room for trach
patients
Ventilator Review
• Transporting patients:
– The hospital will either make you attach the
patient to a transport ventilator or you will bag
the patient to their destination
– You may have to bring along the ventilator and
attach it once you reach the area you are
transporting to, in this case, simply select same
patient so that all the settings remain
– Have a full E-tank available. Assist in the pushing
of gurney and also the attachment of monitors
Ventilator Review
• Do’s
– Do participate as much as possible by volunteering to
do all tasks including Bronch assisting, ventilator
checks, Extubation, intubation assists…
– Do your research, make sure you know the ventilator
you are working on. Download the user guide online.
– Make sure you know your patient. Keep a small
notebook, and have all pertinent info handy. Only
identify patient by room number. Be able to
communicate with MD’s and other healthcare
personnel effectively.
– Give report if possible and also participate in rounds
Ventilator Review
• Don’t do anything you are not comfortable with, make sure your
preceptor is in close proximity
• Don’t be meek, be aggressive and inquisitive but not a burden for
your preceptor
• Don’t lie on your charting.
• Don’t short cut your patient care
• Don’t use improper language
• Don’t be afraid to be wrong
• Don’t make changes to the vent by yourself.
• Don’t take orders from the physician.
• Don’t undermine or talk ill of licensed staff. YOU ARE A STUDENT,
and your presence at the facility is a gracious act by the facility,
they receive absolutely no monetary benefit from your presence,
except perhaps a future employee.
Troubleshooting
• If the ventilator is alarming and the immediate fix
is not apparent, you must take the patient off and
bag them until the problem can be solved
• For high pressure alarms: assess patient for
asynchrony, fighting ventilator, mucus, change in
compliance, increase RAW, bronchospasm, biting
tube…. Inform your preceptor if you can not
resolve the issue yourself. For example patient is
biting tube, inserting an oral airway, don’t do it
alone
Consider the following
• Secretions in airway
• Tube block
• Kinking of tube
• Biting the tube
• Water in the tube
• Cuff herniation
• Rt. bronchial intubation
• Fighting the ventilator
•Cough
•Increased airway
resistance
•Bronchospasm
•Decreased compliance
•Atelectasis
•Fluid overload
•Pneumothorax
Troubleshooting
• If the low pressure, or low Vte alarm is
sounding.
– Check for obvious leaks, if a leak if found plug it
– Check cuff pressure, if blown, let your preceptor
know, the ETT may have to be changed
– If patient self extubated, and it is plainly obvious
(tube is seen hanging from patients mouth), finish
the extubation, bag as needed and call for help
Troubleshooting
• 18 yr old man intubated for
organophosphorus poisoning and
intermediate syndrome was on the following
settings: AC 12, VT 550, FIO2 30%
• He suddenly desaturates. You notice that his
resp rate is 35/min, heart rate is 120/min, BP
is 90/70mmHg.
• Auscultation reveals equal vesicular breath
sounds. What would you do?
Troubleshooting
• A 35 yr old man with status epilepticus
following organochloride ingestion is being
ventilated in the ICU. You are called because
of desaturation and persistent low pressure
alarms. How would you tackle the situation?
Consider the following
•
•
•
•
•
•
•
Cuff leak.
Leak in the circuit
Loose connections
ET tube displacement
Disconnection
Inadequate flow
Low supply gas pressures
Low pressure alarm
• FiO2 to 100%
• Check all connections for leaks. Start from ventilator
inspiratory outlet—humidifier—inspiratory limb—
nebulizer—Y junction—dead space—et tube cuff—
expiratory limb—expiratory valve.
• If inspiratory effort excessive-inadequate flow—
increase inspiratory flow, decrease Ti, increase TV
• Check gas pressures
• If all normal and problem persists, change ventilator
High pressure alarm
•FiO2 to 100%
•Look at chest movement, auscultate air entry.
AUSCULTATION
UNEQUAL AIR ENTRY
•Collapse,
•tube malposition
•pneumothorax
DECREASED AIR
ENTRY BILATERALLY
Tube/tracheal block
WHEEZES
Bronchospasm
Weaning
• If the patient is to be weaned…
– Perform weaning parameters. This may be done through
the ventilator on most modern vents. If you are to do a VC
or MIP, the patient is typically on CPAP mode without PEEP
and minimal PSV if any. Assess VC, MIP, MEP several times
for reproducibility
– While weaning note vital signs, RSBI, Vte, RR, SpO2…
– If patient fatigues to the point that their vitals decline, you
should place them back on previous mode/settings
– You may get a ABG after a short time frame while weaning
to assess effectiveness
– Weaning can be done numerous ways…SBT, CPAP trials, to
Bipap…
Practical Review
• The practical is 15 minutes long (it is a timed test)
• You will be given the questions and are expected
to setup the ventilator, input settings, including
alarms, change modes and answer questions in
this time frame
• You should know the material well enough to get
through it as quickly as possible
• If you fail to answer any questions and time has
expired, you will receive a 0 for those questions.
• This means you should know it well enough not
to have to lament on each question
Practical Review
• You will be read the question one time, it may
be repeated if needed. You are expected to set
up the vent without any help of the instructor.
The instructor will observe you but will not
assist you in your decisions.
• You WILL NOT do a short self test, the
machine should be initiated with the test lung
OFF
Practical Review
• You will be expected to setup the ventilator
appropriately. This includes:
– Placing the inspiratory and expiratory filters on
appropriately
– Placing the HME on
– Ensuring the vent is plugged in to a red outlet and
that the compressor is on
Practical Review
• Once the circuit is on you will be given a
scenario. From the scenario you will input
appropriate settings.
• Remember IBW for VT settings. You may use
any mode you like
• If the patient is described as a restrictive
patient or someone with severe air trapping,
be sure to keep this in mind when setting up
the vent
Practical Review
• If you are given a ABG before setup and have
an idea about the patients ventialtion and
oxygenation you may setup the vent
accordingly.
• Example: A 56 year old man, 5’8 with severe
COPD is in respiratory failure, an ABG is drawn
while bagging with 100% O2 and shows:
• 7.18, 106 paCO2, 56 paO2, HCO3 36
Practical Review
• You can start more aggressive, but realize that
this patient has air trapping, so instead of
giving excessive volumes, you may want to
instead increase the rate.
– Example settings: VT 500, AC 22, FIO2 65%, PEEP 5
– The patient is a COPD patient, so 65% is suffice.
– If you set a rate of 22, make sure the patient gets
sufficient flow. Your goal is a I:E ratio of 1:3 to 1:4
with COPD patients and 1:2 to 1:3 with most other
patients
Practical Review
• If no prior ABG is given in regards to your patient then
use generic starting settings. Still take into
consideration the scenario, if patient is air trapping or
has a restrictive disease use smaller volumes.
• Rate 8-12
• FIO2 50-100% (you will be inputting this, I will hit the
silence button)
• VT 5-7 ml/kg or 8-12 ml/kg
• Flow 40-60, I-tme 0.8-1 second
• Sensitivity 1-3
Practical Review
• Typically start with AC mode. Only use SIMV
mode if the patient is apneic and you suspect
he will wake up and start breathing.
• Do not use SIMV if patient’s spontaneous
breaths are erratic.
• Example: A patient with a RR 46, is
awake/anxious and developing respiratory
failure. You will use AC mode.
Practical Review
• If you use SIMV as your starting mode, make
sure to include PSV
• You may use either PCV, VC or VC+ as your
starting breath type.
Practical Review
• After you input your initial settings
– including: Mode, Breath type, VT or Pressure limit,
flow or I-time, FIO2, sensitivity, rate and PEEP
You will then set your alarms and apnea settings
This of course can be adjusted once you place the
machine on the patient, however you should
place your settings here first. This should be
automatic. If you have to be prompted to set
your alarms and apnea you will be marked off
Practical Review
• Once your alarms are set and your alarms are
set, you may attach the vent to the test lung.
• All of this should be done in approximately 5-6
minutes.
Practical Review
• After the vent has been initiated, you will be
given a follow up ABG.
• From this ABG you will need to make
appropriate ventilator changes.
• Remember the guidelines. You will be told if
the patient has spontaneous respirations or
not
Practical Review
• You will also have to demonstrate the ability
to do a static pressure (by pressing the
inspiratory hold button)
• Know what the normal value should be
• Know how to quickly scan the graphics for
auto-peep. To assess auto-peep you should
check the FLOW-TIME graphic
• You should know how to adjust I-time or flow
to achieve certain I:E’s
Practical Review
• You will be expected to change modes, example:
AC to Spontaneous mode.
• In doing so, a PSV should be added automatically
without prompt from the instructor. Start with 610 for PSV
• Know how to assess patient for weaning. You
would note: Vitals, CXR, underlying condition
change, spontaneous breathing, RSBI, weaning
parameters
• Know what strategies you might try to initiate
weaning
Practical Review
• You may also be asked to troubleshoot.
• This may include scanning for leaks or noting
high pressure from kinked tubings
Case 1
• A 25 year old with suspected status
asthmaticus is intubated after bronchodilators
have failed. The patient is 65 KG IBW, Set the
ventilator for this patient, no previous ABG is
drawn and the patient is anxious, in
respiratory failure with the following vitals
while being bagged:
• HR 156, RR 45, BS decreased bilaterally, BP
elevated.
Case 2
• A 40 yr old man with malaria developed
progressive breathlessness and hypoxia requiring
intubation in the ward. X-ray done is suggestive
of ARDS. He is being shifted into the ICU. Body
weight 60kg. Set the ventilator for this patient,
SpO2 while being bagged on 100% was 87%.
• One hr later ABG done-pH 7.20, PCO2 65, PaO2
55, HCO3 25, BE 1.0, SaO2 86%. What changes
would you make.
Case 3
• A 68 year old man, 55 Kg with known COPD
arrives in the ER with COPD exacerbation
requiring intubation. The patient has been
sedated. The following ABG was obtained
during bagging with 100% O2:
– 7.20, 98, 58, 35
Initiate the ventilator
Practice Practicals (given in class)
•
•
•
•
•
•
•
•
•
•
Listen to scenario
Attach ventilator circuit
Input settings, including alarms
Attach to test lung
Listen to ABG and make appropriate setting changes
Perform a static compliance
Change I:E to 1:3
Assess for auto-peep
Change to spontaneous mode
Answer questions