Chapter 12: Methods to Improve Ventilation in Patient-Ventilator Management

correcting respiratory alkalosis/acidosis

-adjust tidal volume or respiratory frequency (f) -keep frequency constant, change tidal volume -keep tidal volume constant, change frequency

MDIs

-Fewer problems than SVNs -MDI with a spacer shown more efficient than a nebulizer -Place in the inspiratory limb of circuit -HME consideration

factors affecting aerosol administration

-Type of aerosol-generating device -Ventilator mode and settings -Severity of the patient's condition -Nature and type of medication and gas being used

permissive hypercapnia (PHY)

-a lung technique to avoid lung over-distention and injury of the lung -*allow PaCO2 to rise above normal* (e.g., ≥50 and ≤150 mm Hg), and pH values are allowed to fall below normal (e.g., ≥*7.10-7.30*) -sedate the patient, avoid high-ventilating procedures, and maintain oxygenation

pink-tinged sputum

*May indicate fresh blood or can occur after treatment with aerosol*ized epinephrine, isoproterenol, racemic epinephrine, or isoetharine

how do you correct respiratory acidosis?

-Adjusting the set tidal volume or frequency to achieve the desired minute ventilation -Regardless if VC or PC ventilation, *increasing minute ventilation (VE) will decrease PaCO2* -increase inspiratory time (Ti) or increase pressure

suctioning: monitoring

-Breath sounds -Oxygen saturation (SpO2) -FIO2 -Respiratory rate and pattern -Pulse rate, blood pressure (BP), electrocardiogram (ECG), if indicated and available -Sputum (color, volume, consistency, odor) -Ventilator parameters -ABGs -Cough effort -ICP, if indicated and available

once pt gets off vent, they may experience

-Combativeness -Restlessness -Anxiousness -Depression -Frustration -Anger -Hallucinations

suctioning hazards/complications

-Decrease in dynamic lung compliance and functional residual capacity (FRC) -Pulmonary atelectasis: reduction of lung volume -Hypoxia or hypoxemia -Hypoxia or hypoxemia: ventilator disconnection and loss of positive end-expiratory pressure (PEEP) -Tracheal or bronchial mucosal trauma: suction pressures -Cardiac dysrhythmias -Hypertension -Hypotension -Possible association of the routine use of normal saline instillation before ET suctioning with excessive coughing, decreased oxygen saturation, bronchospasm, and dislodgment of bacterial biofilm that colonizes the ET into the lower airways

increased metabolism and carbon dioxide production

-Elevated in patients who have fever, burns, multiple trauma, sepsis, hyperthyroidism, muscle tremors or seizures, agitation, and in those patients who have undergone multiple surgical procedures Correction -*Increase ventilator rate, switch to PC-CMV, using sedation*

patient safety

-Emergency equipment should be readily accessible -Never leave the system unattended -Monitor at regular intervals -Anticipate problems -Trust assessments

hazards and complications of in-hospital transport

-Hyperventilation during manual ventilation, which may result in respiratory alkalosis, cardiac arrhythmias, and hypotension -Loss of PEEP/CPAP leading to hypoxemia or shock -Position changes leading to hypotension, hypercarbia, and hypoxemia -Tachycardia and other arrhythmias -Equipment failure resulting in inaccurate data, loss of data, and loss of monitoring capabilities -Accidental disconnection of intravenous access for drug administration resulting in hemodynamic instability -Disconnection from ventilatory support and respiratory compromise resulting from movement -Accidental extubation -Accidental removal of vascular access -Loss of O2 supply leading to hypoxemia -Ventilator-associated pneumonia resulting from transport

respiratory alkalosis is associated with

-Hypoxia with compensatory -Parenchymal lung disease -Medications -Mechanical ventilation -CNS disorders -Anxiety -Metabolic problems

correcting metabolic alkalosis

-Identifying the underlying cause -A respiratory component may also be involved -*administer albuterol*

how do you correct metabolic acidosis?

-Identifying the underlying cause -A respiratory component may also be involved -*body compensates by hyperventilating.* -must be *treated by administering HCO3* not adjusting the ventilator.

suction: assessment of outcome

-Improvement in the appearance of ventilator graphics and breath sounds -Decreased PIP with narrowing of PIP-Pplateau; decreased airway resistance or increased dynamic compliance; increased VT delivery during pressure-limited ventilation -Improvement in ABG values or saturation as reflected by oxygen saturation measured by pulse oximetry (SpO2) -Removal of pulmonary secretions

Postural Drainage and Chest Percussion

-In ventilated patients, involves placing the patient in a number of prescribed positions to drain the affected lung segment -Commonly accompanied by percussion of the chest wall Recommend the follow -positioning: -->45-degree rotation prone with left side up -->45-degree rotation prone with right side up -->Return to supine

transporting pts while providing ventilation

-Manual ventilation with a self-inflating bag -Transport ventilator that is specifically designed for this purpose -Most current generation of intensive care unit (ICU) ventilators for transport

suctioning: contraindications

-Most contraindications are relative to the patient's risk of developing adverse reactions -No absolute contraindication exists -Abstaining could have an adverse reaction

respiratory acidosis is associated with

-Parenchymal lung problems -Airway disease -Pleural abnormalities -Chest wall abnormalities -CNS problems

suctioning: indications

-Patient's inability to generate an effective spontaneous cough -Changes in monitored flow-volume graphics -Deterioration of oxygen saturation or ABG values -Increased peak inspiratory pressure (PIP) with volume ventilation -Decrease in VT with pressure ventilation -Visible secretions in the airway -Acute respiratory distress -Suspected aspiration of gastric or upper-airway secretions

airway clearance

-Performed only when necessary *Shallow suctioning* -->The catheter is inserted to a depth that approximates the length of the artificial airway *Deep suctioning* -->Involves inserting the catheter into the artificial airway until a resistance is met -->Withdrawn approximately 1 cm before negative pressure is applied *Open suctioning (circuit) technique* -->Requires disconnecting the patient from the ventilator *Closed suctioning (circuit) technique* -->Without removing the patient from the ventilator

SVNs

-Place proximal to the humidifier -Ventilator function can be affected -Use the ventilator nebulizer system when appropriate

fluid balance

-Positive pressure ventilation increases the plasma antidiuretic hormone (ADH) level Urine output -Normal: 50 to 60 mL/h -Oliguria: <20 mL/h -Polyuria: >100 mL/h

aerosols: hazards and complications

-Prolonged inspiratory or expiratory pause -Inappropriate selection or use of a device or technique -Device malfunction -Pharmacologic complications -->High doses of β-agonists -->Potential for hypokalemia and atrial or ventricular dysrhythmias with high doses in the patient who is critically ill -Aerosol medications, propellants, or cold, dry gases that bypass the natural upper respiratory tract, causing bronchospasm or irritation of the airway -Aerosol device or adapter used and the technique of its use, affecting ventilator performance -Addition of gas to circuit -Addition of gas from flowmeter

aerosols: contraindications

-Prolonged inspiratory pause for patients with high auto-PEEP -Use of certain medications

contraindications of in-hospital transport

-Provide adequate oxygenation and ventilation during transport either by manual resuscitation bag, portable ventilator, or standard ICU ventilator -Maintain acceptable hemodynamic stability during transport -Monitor the patient's cardiopulmonary status during transport -Maintain a patent airway during transport

bronchodilator therapy

-Reduced PIP -Reduced transairway pressure (PTA) -Increased peak expiratory flow rate (PEFR) -Reduced auto-PEEP levels

normal saline instillation

-The intent of saline lavage is to loosen secretions and stimulate the patient to cough -Insufficient evidence to support this practice -In fact, a number of recent studies indicate that this practice actually may be harmful -->Less fluid is suctioned compared with the amount instilled into the airway -->Saline instillation can increase the volume of secretions in the airways and potentially add to airway obstruction

mixed acid-base disturbances

-The pH may actually be near normal -Combined respiratory alkalosis with metabolic acidosis -Combined respiratory acidosis with metabolic alkalosis

aerosols: indication

-The treatment of *bronchoconstriction* or *increased airway resistance * -Should be based on the patient's history and physical assessment findings

physical discomfort due to vent can be caused by

-Trauma and/or disease -Awkward body position -Distended organs -Inadequate ventilation -Heavy tubing -Bad connections -Restraints -Limb boards -Loss of speech -Inability to talk, swallow, cough, yawn -Inability to maintain oral hygiene -Overcooling or overheating

increased physiological dead space

-if respiratory acidosis persists after alveolar ventilation has been increased, the pt may have a problem that is the result of increase alveolar dead space -can be caused by pulmonary embolism and low cardiac output resulting in low pulmonary perfusion -normal ratio of dead space to tidal volume (VD/VT) is 0.2 to 0.4 in critically ill patients, this value can be greater

managing permissive hypercapnia

-remove sources of mechanical dead space -increase the frequency of mandatory breaths -*reduce CO2 production by using paralytic agents, cool the patient, and restricting glucose intake* -*administer sodium bicarbonate, tris-hydroxymethyl aminomethane (THAM), and Carbicarb to keep pH >7.25*

green sputum, thick

Suggests that *sputum has been in the airway for a while, because the breakdown of mucopolysaccharides* (a component of sputum) results in a green color

correcting ventilation abnormalities via ABG sample

1: acid base status -*pH* 2: ventilation -*PaCO2* -*HCO3-* 3: oxygenation status -*DO2* -*PaO2* -*SaO2* -*CaO2*

yellow sputum

Suggests the presence of pus (white blood cells) and possible infection

aerosol devices used during mechanical ventilation

MDIs and SVNs

metabolic acidosis is associated with

MUDPILES *M*ethanol intoxication *U*remia *D*iabetic ketoacidosis *P*araldehyde ingestion *I*nfection *L*actic acid *E*thylene glycol ingestion *S*alicylate overdose

rust colored sputum

Might indicate a Klebsiella infection

use of nebulizers during noninvasive positive pressure ventilation

To achieve the greatest aerosol deposition when using an MDI or SVN, the device should be placed: -Close to the patient -Between the leak port and the face mask

can you administer a DPI (spiriva) through a SVN or MDI?

NO

green, foul smelling

Occurs with *Pseudomonas infection*

fresh blood present in sputum

Suggests airway trauma, pneumonia, pulmonary infarction, or emboli

What are some indications for using a closed system suction catheter?

Unstable patients who are ventilated (acute lung injury or ARDS) and have high ventilator requirements -High PEEP ≥ 10 cm H2O -Patients who become hemodynamically unstable during suctioning with an open system and ventilator disconnection -Patients who desaturate significantly during suctioning with an open system and ventilatory disconnection -Patients with contagious infections, such as active tuberculosis, where open suctioning and ventilatory disconnect may contaminate healthcare workers -Ventilated patients who require frequent suctioning (more than 6 times a day) -Patients receiving inhaled gas mixtures that cannot be interrupted by ventilator disconnection

how do you correct respiratory alkalosis?

Volume controlled ventilation -*Decrease frequency* and if necessary decrease tidal volume Pressure controlled ventilation -*Decrease frequency* and if necessary decrease set pressure -decrease minute ventilation by decreasing RR and/or tidal volume OR -decrease RR then decrease pressure

Intentional iatrogenic hyperventilation

hyperventilation could be useful, but it is very controversial.

pink, copious, and frothy

indicates pulmonary edema

metabolic alkalosis is associated with

loss of fixed acids (vomitting) -*Loss of gastric fluid and stomach acids* -Acid loss in the urine -Acid shift into the cells -Lactate, acetate, or citrate administration -*Excessive HCO3-* loads

brown sputum

old blood