NUR 3232

MANAGEMENT OF
CRITICALLY ILL
Suzilawati Mohamed Ariffin

Acknowledgement :

CLIENTS WITH
Masmunaa Hassan, Melissa Dearing & Curtis Shelley Hermann
Childrens Hospital
LEARNING OUTCOMES
At the end of this lecture, the students will be
able to:
To define what is the mechanical ventilator
(MV).
Describe the goals of MV
Understand the major indications for MV
To determine modes of MV
To know how to adjust MV
To know how to deal with complications of MV
To determine nursing management for
ventilated client .
DEFINITION
MECHANICAL VENTILATOR is a machine
that generates a controlled flow of gas into a
clients airways. O2 and air are received from
cylinders or wall outlets, the gas is pressure
reduced and blended according to the
prescribed inspired O2 tension (FiO2),
accumulated in a receptacle within the
machine, and delivered to the client using
one of many available modes of ventilations.
INDICATIONS
- Need for sedation/ neuromuscular blockage.
- Need to systemic or myocardial oxygen consumption.
- Use of hyperventilation to reduce intracranial pressure
- Respiratory distress (RR > 30, use of accessory
muscles)
- Respiratory Failure: 2 Types
Hypoxemic Respiratory Failure: PaO2 < 60 mmHg
Hypercapnic Respiratory Failure: PaCO2 > 50 mmHg
Ventilatory Failure, caused by work of
breathing, ventilatory drive, or muscle fatigue
- Need to Protect the Airway
pts ability to sneeze, gag or cough been dulled
possibility of aspiration
Cont
Ventilation abnormalities
Respiratory muscle dysfunction
Respiratory muscle fatigue
Chest wall abnormalities
Neuromuscular diseases
Oxygenation Abnormalities
Refractory hypoxemia.
Need for positive end expiratory pressure.
Excessive work of breathing (WOB).
CONTRAINDICATION:
ARTIFICIAL AIRWAY
Pts desire to not be resuscitated has been
expressed and is documented in the patients
chart
DIFFERENT TYPES OF VENTILATORS
Cont
HIGH FREQUENCY MECHANICAL VENTILATOR
 VENTILATOR SETTINGS
A/C : Assist-Control
IMV : Intermittent Mandatory Ventilation
SIMV : Synchronized Intermittent Mandatory
Ventilation
BILEVEL : Non-inversed Pressure Ventilation
with Pressure Support
PRVC : Pressure Regulated Volume Control
PEEP : Positive End Expiratory Pressure
CPAP : Continuous Positive Airway Pressure
PSV : Pressure Support Ventilation
NIPPV : Non-Invasive Positive Pressure
Ventilation
VOLUME VS. PRESSURE
VENTILATION
Volume ventilation: Volume is constant and
pressure will vary with patients lung
compliance.
Pressure ventilation: Pressure is constant and
volume will vary with patients lung
compliance.
MODES OF VENTILATOR
Spontaneous
The machine is not giving pressure breath.
The client breath spontaneously.
The client needs only specific FiO2 to
maintain its normal blood gases.
Cont
Control Mode:
The machine controls the client ventilation
according to set tidal volume and respiratory
rate.
Spontaneous respiratory effort of client is
locked out client with sedation and
paralyzing drugs
 Cont
Assist/Control Mode
The client triggers the machine with negative inspiratory
effort.
If the client fails to breath vent. will deliver a
controlled breath at a minimum rate and volume already
set.
The pt generated resp. effort over & above the set rate.
 Cont
Sychronized Intermittent Mandatory Ventilation (SIMV):
Machine allows the client to breath spontaneously
while providing preset FiO2, and a number of ventilator
breaths to ensure adequate ventilation without fatigue
Delivers a pre-set no. of breaths at a set vol. & flow
rate.
Allows to generate spontaneous breaths, volumes,
and flow rates between the set breaths.
Detects a spontaneous breath attempt & doesnt
initiate a ventilatory breath.
 Cont
Pressure Regulated Volume Control (PRVC)
It is a vol. targeted, pressure limited mode. (available
in SIMV or AC)
Each breath is delivered at a set volume with a
variable flow rate and an absolute pressure limit.
The vent. delivers pre-set volume at the LOWEST
required peak pressure and adjust with each breath.
Cont
Continuous Positive Airway Pressure (CPAP)
A pre-set pressure is present in the circuit and
lungs throughout both the inspiratory and
expiratory phases of the breath.
To keep alveoli from collapsing, resulting in
better oxygenation and less work of breathing.
Commonly used as a mode to evaluate the
patients readiness for extubation.
HIGH FREQUENCY VENTILATION
Comparison of HFOV & Conventional Ventilation
Cont
Oxygenation: primarily controlled by the
Mean Airway Pressure (Paw) and the FiO2.
Paw: a constant pressure used to inflate the
lung and hold the alveoli open.
Since the Paw is constant reduces the
injury that results from the lung open for
each breath
INITIAL SETTINGS
Select mode of ventilation
Set sensitivity at Flow trigger mode
Set Tidal Volume
Set Rate
Set Inspiratory Flow (if necessary)
Set PEEP
Set Pressure Limit
Humidification
POST INITIAL SETTINGS
Obtain an ABG (arterial blood gas) about 30
minutes after set the patient up on the
ventilator.
ABG: will give information about any changes
that may need to be made to keep the
patients oxygenation and ventilation status
within a physiological range.
Cont
ABG
Goal: keep patients acid/base balance within
normal range:
pH 7.35 7.45
PCO2 35-45 mmHg
PO2 80-100 mmHg
TROUBLESHOOTING
In mech. vent. pts, acute elevations in airways
pressures can be triggered by both benign & life-
threatening causes.
When the ventilator alarms, what is your approach in
troubleshooting the potential problems? The causes?
Can be due to a malfunction of the ventilator
Patient may need to be suctioned
Frequently the patient needs medication for
anxiety or sedation to help them relax
Responsibility:
Attempt to fix the problem
Call physician in charge
Cont
Low Pressure Alarm
Usually due to a leak in the circuit.
Attempt to quickly find the problem
Bagging the patient and call the doctor.
High Pressure Alarm
Usually caused by:
A blockage in the circuit (water condensation)
Patient biting his ETT
Mucus plug in the ETT
Attempt to quickly fix the problem
Bagging the patient and call the doctor.
Cont
Low Minute Volume Alarm
Usually caused by:
Apnea of the patient (CPAP)
Disconnection of the patient from the
ventilator
Attempt to quickly fix the problem
Bagging the patient and call the doctor
Cont
Accidental extubation
Role of the Nurse:
Ensure the BVM is attached to the oxygen
flowmeter and it is on supply the patient
with ventilation.
When the nurse have concerns, hear alarms,
notice the changes in ventilator or faced with
other problem with ventilated patient call
for help NEVER PUSH THE SILENCE
BUTTON
ADJUSTMENT OF MV
Purpose of adjustment:
So that the client is comfortable and "in
sync " with the ventilator
Minimal alteration of the normal
cardiovascular and pulmonary dynamics is
desired.
If the volume of ventilator is adjusted
appropriately , the client arterial blood level
will be satisfactory and there will be no or
little cardiovascular compromise
RECOMMENDED
GUIDELINES
1. Set the vent. to deliver the required tidal volume ( 6 -
8 ml/kg)
2. Adjust the vent. to deliver the lowest concentration
of the O2 to maintain normal PaO2 (80 - 100mmhg).
Early stage may be set high gradually reduced
based on ABGs result.
3. Record peak inspiratory pressure.
4. Select mode (assist/control or SIMV) and rate
accordingly
5. If using assist/control mode, adjust sensitivity so that
the patient can trigger the vent. with the minimum
effort (usually 2mmHg negative inspiratory force)
Cont
6. Record the setting
7. Take ABG after 20 - 30 minutes of mechanical
ventilation: measure carbon dioxide partial
pressure (PaCO2), Ph
8. Adjust FiO2 and rate according to results of ABG
9. In case of client suddenly having onset of
confusion, agitation, restless or unexplained
"bucking the ventilator" assess for hypoxemia
and manually ventilate on 100% oxygen with
resuscitation bag (AMBU bag/ Bag valve mask).
10.Clients who are on controlled ventilation & have
spontaneous respiration may "fight/buck" the
vent., because they cannot synchronize their own
respiration with the machine cycle.
Cont
Sedative and neuromuscular blocking agents
may be given such as:
Pancuornium bromide (Pavulon)
Midazolam
Neuromuscular blocking agents block the
transmission of nerve impulses and result in
muscle paralysis.
 COMPLICATIONS
1. DECREASED CARDIAC OUTPUT
Cause: venous return to the Rt atrium impeded by
the dramatically intrathoracic pressures during
inspiration from +ve pressure ventilation. Also
reduced sympathoadrenal stimulation leading to a
inperipheral vascular resistance& BP
Symptoms: heart rate, BP and perfusion to vital
organs, CVP, cool clammy skin.
Tx:
aim to increase preload (e.g.
fluidchallenge/resus)
airwaypressures exerted duringMVby
decreasing inspiratory flow rates and TV
or using other methods to airwaypressures
(e.g. different modes of ventilation).
 Cont
2. BAROTRAUMA
Cause: damage to pulmonary system due to alveolar
rupture from excessive airwaypressures and/or over
distention of alveoli.
Symptoms: may result in pneumothorax,
pneumomediastinum, subcutaneous emphysema.
Treatment
aimed at reducing TV, cautious use of PEEP
avoidance of high airwaypressures resulting in
development of auto-PEEP in high risk clients:
(obstructivelung diseases: asthma,
bronchospasm)(unevenly distributedlung
diseases: lobarpneumonia)(hyperinflated lungs:
emphysema).
 Cont
3. NOSOCOMIAL PNEUMONIA
Cause: invasive device in critically ill clients becomes
colonized with pathological bacteria within 24 hours in
almost all patients.
Treatment: aiming for prevention action:
Avoid cross-contamination: frequent handwashing
risk of aspiration (cuff occlusion of trachea,
positioning, use of small-bore NG tubes)
Suction PRN: sterile technique, close method
Maintain closed system setup
onventilatorcircuitry and avoid pooling of
condensation in the tubing
Ensure adequate nutrition
Avoid neutralization of gastric contents with
antacids & H2 blockers
Cont
4. Decreased Renal Perfusion
can be treated with low dose
dopaminetherapy.
5. Increased Intracranial Pressure (ICP)
reduce PEEP
6. Hepatic congestion
reduce PEEP
7. Worsening of intracardiac shunts
reduce PEEP
OTHER COMMON
PROBLEM RELATED TO
Aspiration
MV
Gastrointestinal (GI) bleeding
Inappropriate ventilation (resp. acidosis or alkalosis)
Thick secretions
Discomfort: pulling or jarring of ETT or tracheostomy
High PaO2, Low PaO2
Anxiety and fear
Dysrhythmias/ vagal reactions during/ after
suctioning
Incorrect PEEP setting
Inability to toleratewith ventilatormode
NURSING MANAGEMENT
Promote respiratory
function.
Suctioning
Monitor for
complications
Prevent infections.
Provide adequate
nutrition.
Monitor GI bleeding.
Cont
Promote respiratory
function
Auscultate lungs frequently to
assess for abnormal sounds.
Suction PRN
Clock turning schedule every 2
hours.
Secure ETT properly.
Check ventilatory close system
Monitor ABG value and pulse
oximetry.
 Cont
Suctioning: purpose
maintain a patent airway
improve gas exchange.
obtain tracheal aspirate
specimen.
prevent effect of retained
secretions.

OXYGENATE before and after

suctioning!!!!
 Cont
Monitor for complications
Assess for possible early complications:
Rapid electrolyte changes, Severe alkalosis, Hypotension
secondary to change in cardiac output.
Monitor for signs of respiratory distress:
Restlessness, Apprehension, Irritability and increase HR.
Assess for S&S of barotrauma (rupture of the lungs)
Increasing dyspnea, Agitation, Decrease or absent
breath sounds, Tracheal deviation away from affected
side, Decreasing PaO2 level .
Assess for cardiovascular depression:
Hypotension, Tachycardia & Bradycardia, Dysrhythmias.
 Cont
Prevent infection
Frequent handwashing
Maintain sterile technique when suctioning.
Monitor color, amount and consistency of sputum.
Provide adequate nutrition
Begin tube feeding as soon as it is evident the client
will remain on the ventilator for a long time.
Weigh daily.
Monitor intake and output .
Monitor for gi bleeding
Assess bowel sounds.
Monitor gastric Ph & gastric secretions every shift.
THANK YOU