Transcript Section_3_Adequate_Resp_Support

Initiation and Modification of
Therapeutic Procedures
Achieve Adequate Respiratory Support
Instruct Patients in Deep
Breathing / Muscle Training
Used in Acute Care:
 Aid secretion clearance
 Prevent or treat post-op atelectasis
 Improve aerosol drug delivery
Used in rehabilitation to improve:
 Efficiency of ventilation
 Exercise tolerance
Instruct Patients in Deep
Breathing / Muscle Training
Deep Breathing Exercises:
 Inspiratory Breathing Exercises
 Diaphragmatic (abdominal) breathing
 Lateral costal breathing
 Promote effective use of diaphragm
 Improve efficiency of ventilation by increasing VT and
decreasing respiratory rate
 Expiratory Breathing Exercises
 Pursed-lip breathing
 Increases back pressure in the airways during exhalation
 Can help lessen air-trapping
Instruct Patients in Deep Breathing /
Muscle Training
Incentive Spirometry
 Used primarily in the acute care setting for patients at risk for or
diagnosed with atelectasis, (typically following thoracic or
abdominal surgery)
 If the patient cannot cooperate or cannot generate an inspiratory
capacity at least 33% of predicted, recommend IPPB as an
alternative
 Recommend discontinuation when clinical signs indicate resolution
of atelectasis
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Resolution of fever
Improvement of breath sounds
Normal chest X-ray
Improved arterial oxygenation
Inspiratory Muscle Training Techniques (IMT)have largely replaced
manual breathing exercises as the method of choice for COPD
patients.
 Flow and threshold resistors
Initiate and Adjust Mechanical
Ventilation
IPPB Therapy
Indicated to:
 Improve lung expansion in patients with atelectasis who cannot use
other methods, such as incentive spirometry.
 Aid in delivery of aerosolized drugs (usually when other methods
have failed)
 Provide short-term ventilatory support for patients with acute
hypercapnic respiratory failure or chronic muscle weakness
Only absolute contraindication:
 Untreated pneumothorax
IPPB initial settings:
Sensitivity of about -2 cm H2O
Cycle pressure between 10 and 20 cm H2O with a
moderate flow
Approximate the O2% during the IPPB to the patient’s O2
therapy prescription
 Attach to O2 blender with machine set to deliver pure
source gas to deliver precise FiO2
Goal
To achieve quick and near-effortless on-triggering, followed
by a relatively rapid pressure rise and ending in a short
plateau.
Initiate and Adjust Mechanical
Ventilation
Continuous Mechanical Ventilation Settings
Candidates who cannot properly select appropriate modes
and set and adjust ventilator parameters will not be able to
pass the CRT exam
The NBRC hospital expects you to be familiar with:
 All common modes, including control mode, assist/control
mode, SIMV, pressure support ventilation, CPAP, and bi-level
positive airway pressure (BiPAP)
 Dual breath modes such as pressure-regulated volume
control (PRVC) and airway pressure release ventilation
(APRV)
 MODES
 Mechanical ventilation should be tailored to each patient’s
needs
 In the early stages of acute respiratory failure, you should select
or recommend a mode that provides full ventilatory support
(A/C or normal-rate SIMV)
 As patient improves and is able to carry more of the ventilatory
load, you should begin using modes that allow or encourage
spontaneous breathing (partial ventilatory support)
NBRC hospital
 Expect the NBRC to emphasize selection of either volumeor pressure-oriented assist/control or SIMV (with or without
pressure support) for most patients needing ventilatory
support
 Also apply PEEP to patients if they require more than 50% O2
to maintain adequate arterial oxygenation
 CPAP (with backup ventilation) is the mode of choice for
critically ill patients who have adequate ventilation but who
due to shunting need extra support for oxygenation
Select volume-targeted ventilation if CO2
elimination is the primary goal and the patient
comfort and lung distention are secondary issues.
Select pressure-targeted ventilation if patientventilator synchrony is important and CO2
elimination is of lesser concern.
Primary goals for adjusting ventilator settings:
 Achieve acceptable arterial blood gases
 Minimize dyspnea, accessory muscle use, and
paradoxical breathing.
Review AARC Clinical Practice Guidelines for initial
adult ventilator settings and adjustments.
Initiate and Adjust Mechanical
Ventilation
Noninvasive Ventilation
The delivery of assisted mechanical ventilation without the
need for an artificial tracheal airway.
 Negative Pressure: iron lung or tank ventilator, chest
curiass, pneumosuit
 Positive Pressure: bi-level positive pressure support
Application of NPPV requires that the patient have control
over upper airway function, be able to manage secretions,
and be cooperative and motivated.
Initiate and Adjust Mechanical
Ventilation
Elevated Baseline Pressure (CPAP, PEEP)
CPAP
 Mode of ventilation
 Involves spontaneous breathing at an elevated baseline
pressuure
 Indicated to treat sleep apnea, acute cardiogenic pulmonary
edema, manage refractory hypoxemia in patients with
adequate ventilation
PEEP
 Add-on that can be applied to any mode
 Used in patients for whom additional “machine” breaths are
needed to assure adequate ventilation
 Helps lower FiO2 needs
 Helps improve patient-ventilator synchrony (by decreasing autoPEEP)
NBRC Hospital standard of care is the application of low
levels of PEEP (typically 5 cm H2O) to all adult patients
receiving ventilatory support.
Helps maintain FRC and prevent airway closure/auto-PEEP
Maximize benefits and minimize risks to patient by
determining “optimum” PEEP
Four methods to determine optimum PEEP
 Maximize O2 delivery to the tissues
 Highest static total compliance
 Maximum volume change for a given change in pressure
 Lowest pressure needed to exceed lower inflection point (LIP
or Pflex) on the pressure-volume curve
Select Ventilator Graphics
Select Ventilator Graphics
Scalar Graphics (time-based)
 Flow vs. Time
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Identify presence of auto-PEEP (expiratory)
Identify flow starvation (VCV)
Assess / adjust rise time (PCV, PSV)
Identify asynchrony
 Pressure vs. Time
 Confirm PIP and PEEP level
 Visually assess mechanics using PIP-Pplat (~ Raw) and Pplat-PEEP
(~Cstat)
 Assess sensitivity/trigger response
 Identify asynchrony
 Volume vs. Time
 Identify leaks
 Identify asynchrony
X-Y Loop Graphics (loops)
 Pressure (X-axis) vs. volume (Y-axis)
 Assess overall work of breathing
 Identify overdistension
 Assess trigger work
 Adjust PSV levels
 Volume (X-axis) vs. flow (Y-axis)
 Assess bronchodilator response
 Identify presence of auto-PEEP
 Identify leaks
Apply Disease-Specific Ventilator
Protocols
National Heart, Lung, and Blood Institute (NHLBI) ARDS
protocol
 Consider implementing this protocol for any patient who
exhibits an acute onset of respiratory distress not
associated with heart failure and has:
 A PaO2/FiO2 less than 300 (signifying acute lung injury)
 Bilateral diffuse infiltrates on X-ray consistent with pulmonary
edema
Initiate and Select Appropriate
Settings for High-Frequency
Ventilation
You need to be familiar with both infant/child and adult
applications
 Indicated for hypoxemic respiratory failure for
infants/children/adults who have not responded to more
conventional methods of improving oxygenation.
 Decreasing HFOV frequency tends to lower the PaCO2,
while increasing the HFOV frequency tends to raise the
PaCO2
Initiate and Modify Weaning
Parameters
Carefully monitoring the SBT provides the most valid
information for deciding whether or not a patient can stay
off the ventilator.
NBRC will assess your ability to independently implement a
SBT protocol:
 Straight T-tube breathing
 CPAP
 Pressure support
 Pressure support + CPAP
Administer Medications
Aerosolized Drugs:
 If the patient is receiving several inhaled medications, the
recommended order is bronchodilator first, followed by
mucolytic, then bronchial hygiene therapy, then steroids,
and then the aerosolized antibiotic.
Endotracheal Instillation
 Lidocaine, epinephrine, atropine, or naloxone (LEAN)
 Mucolytics
 Surfactant
Treating and Preventing
Hypoxemia
Administer Oxygen
In otherwise normal patients, adjust the flow/FiO2 to the lowest level
needed to maintain normal oxygenation (PaO2 of 80 – 100 torr with a
saturation ≥ 95%)
If you cannot maintain normal oxygenation on less than 50% oxygen,
accept a PaO2 ≥ 55-60 torr with a SaO2 (SpO2) ≥ 88%
When treating patients with carbon monoxide poisoning, cyanide
poisoning, acute pulmonary edema, shock, trauma, or acute
myocardial infarction in emergency settings, provide the highest
possible FiO2
For patients with chronic hypoxemia, aim to keep the PaO2 in the 5560 torr range to prevent depression of ventilation
In low birth weight or preterm infants at risk for ROP, your goal should
be a PaO2 in the 50-70 torr range.
Position Patient to Minimize Hypoxemia
Semi-Fowler’s position (head of bed elevated 30 degrees)
 To minimize ventilator-associated pneumonia in patients
receiving mechanical ventilation
Lateral rotation therapy
 To prevent or minimize respiratory complications associated with
immobility in bedridden patients
“Keeping the good lung down”
 To improve the oxygenation in patients with unilateral lung
disease
Prone positioning
 To improve oxygenation in patients with ARDS and refractory
hypoxemia
Prevent Procedure-Associated Hypoxemia
Always monitor the patient’s SpO2 with a pulse oximeter prior
to, during, and after any procedure that can cause
hypoxemia.
Common Errors to Avoid on the Exam
 Never use or recommend incentive spirometry for patients
who cannot cooperate
 Never administer IPPB to a patient with an untreated tension
pneumothorax
 Never use or recommend noninvasive positive pressure
ventilation (NPPV) for patients who do not have control over
upper airway function or cannot manage their secretions
 Whenever possible, avoid plateau pressures above 30 cmH2O
during mechanical ventilation
 Do not use or recommend high-frequency oscillation
ventilation for patients with obstructive lung disease
More Common Errors to Avoid on the
Exam
 Never administer a mucokinetic agent without also providing
appropriate bronchial hygiene measures to facilitate secretion
removal
 Do not use or recommend mast cell stabilizers (cromolyn
sodium, nedrocromil) for acute bronchospasm
 Never mix Tobramycin (Tobi) with other drugs for inhalation
 Avoid suctioning (if possible) for 6 hours following surfactant
instillation
 Never withhold supplemental oxygen from a patient who
needs it
Exam Sure Bets
 To confirm patient understanding of muscle training,
incentive spirometry, or IPPB, always require a “return
demonstration” of the procedure by the patient
 To prevent hyperventilation during IPPB, always instruct
the patient to avoid forceful exhalation and to breathe
slowly.
 When initiating mechanical ventilation, always use a
high FiO2 (0.60 - 0.90) until an ABG can be obtained.
 Except with ARDS patients, when initiating mechanical
ventilation, set the initial VT to 8 – 10 ml/kg IBW when
targeting volume or set the pressure limit to 20 - 30 cm
H2O when targeting pressure
More Exam Sure Bets
 To adjust a patient’s PaCO2 / pH during
mechanical ventilation, always change the rate
first; change the VT / pressure limit only if rate
changes exceed the recommended adult limits (8
– 24 breaths/min) or if you do not achieve the
desired results.
 Unless contraindicated, always use an oronasal /
“full” face mask when initiating NPPV on patients
with acute respiratory failure
 To avoid esophageal opening / gastric distention,
always keep IPAP levels during NPPV below 20 – 25
cm H2O
 Whenever a patient’s cardiac output or blood
pressure falls when raising the PEEP level, decrease
PEEP back to its prior setting
More Exam Sure Bets
 Always give the bronchodilator first when ordered in
combination with a mucokinetic or anti-infective
agent
 To prevent pharyngitis and oral candidiasis with
inhaled steroids, always have patients rinse their
mouth out after administration
 When treating patients with carbon monoxide
poisoning, cyanide poisoning, acute pulmonary
edema, shock, trauma, or acute myocardial
infraction in emergency settings, always provide the
highest possible FiO2
Reference:
Certified Respiratory Therapist Exam Review Guide, Craig Scanlon,
Albert Heuer, and Louis Sinopoli
Jones and Bartlett Publishers