MODES OF VENTILATION

Abbreviation Term

Explanation
Delivers gas @ preset TV & rate. Breaths can be synchronised to: 1. Pts inspiratory effort 2. Mandatory if no effort censored 3. Spontaneous if respiratory effort made by pt outside the set window period. Pre-set positive pressure used to ASSIST pts inspiratory efforts. Pt triggers onset of inspiration. Positive pressure is delivered & held constant during inspiration. Used in combination with other ventilation modes that permit spontaneous breathing Delivers pre-set number of breaths per minute, with a pre-set TV. Completely controlled by the Ventilator. No spontaneous breaths are allowed. Pressure or volumed controlled, machine triggered & machine cycled Pre-set constant pressure. Duration of Inspiratory & base line RR determined by ventilator settings. TV will vary with pt effort & respiratory mechanics. Delivers set volume @ set rate. Airway pressure determined by volume, flow & pts mechanics. Delivers set TV of gas in spite of higher than normal airway pressures. Pts can trigger extra spontaneous breaths depending on trigger sensitivity Constant positive airway pressure to pts who breath spontaneously. All work of breathing is performed by pt. No set rate. CPAP aids in promotion of 02 in same way as PEEP

Use & positive aspects

More comfortable for pt. Good for weaning ventilation Less sedation required

Negative aspects
Good acceptable airway pressures Stable, high O2 levels Pts have to be able to breath by self Volume of PS varies in proportion to pts inspiratory effort Can not trigger own breaths Require sedation & paralysing Airway pressures fixed by ventilator Unable to maintain specific TV High airway pressures Cause injury & discomfort

SIMV

PS

Synchronised Intermittent Mandatory Ventilation Pressure Support

CMV

Continuous Mandatory Ventilation Pressure Controlled Ventilation Volume Control

PCV

Good for weaning pts From ventilation More comfortable for the pt. Less sedation required Ranges 5 - 30cm H20 Good for complete mechanical ventilator support Good for fail chest Good for head injury pts ARDS (acute respiratory distress syndrome) Avoid high airway pressures Mucous plugs/secretions ARDS Bronchospasm Pulmonary oedema Alveolar collapse atelectasis & improves oxygenation Non invasive Asthma Obstructive sleep apnoea CAL Chest wall deformity

VC

CPAP

Continuous Positive Airway Pressure Bilevel Positive Airway Pressure

Has no influence on ventilation

BIPAP

Independent control of inspiratory & expiratory pressures. Flow triggered system

Requires humidification Pt has to be alert & able to take own breath

COMMON TERMS USED IN VENTILATION

Abbreviation
Term Settings Explanation & Use Trouble shooting tips

Kelly Eyre - 2007

Raper Ray 2006 ICU Ventilation guide Mosby Critical care pocket guide 2004 Adult invasive mechanical ventilation self learning package 2004 orlando regional health care education and development

PEEP

Positive End Expiratory Pressure Tidal Volume Minute Volume Respiratory Rate Peak airway Pressure Pressure support Inspiration expiration Ratios Plateau Trigger Variables

5 to 10cm H2o Natural Peep of 2 to 3cm H2o

Peep 5cm H20 in acute head injuries & cardiac output status. End expiration props open alveoli avoiding collapse. Good for VQ mismatch The volume of gas delivered to pt with each breath. Only set for volume controlled modes of ventilation The volume of gas moved in 1 minute Minimum N.O.B delivered per min to pt Highest pressure recorded in ventilatory cycle. Reflects alveolar pressure

PEEP if in 02 levels Therapeutic PEEP 10-35cm H20

TV MV

6 to 8mls per kg OR alter to lung size

TV may be too high - pneumothorax

TV multiplied by RR 10 to 16 OR according to PaCo2 Maximum of 30cmH2o Normal peak pressure 20cmH2o 5 to 40cm H2o normal1:1.5 1:2 Asthmatics 1:3 1:4 CAL 2:1 Normal 20%

Reset alarm limits or depending on Co2 reading Pt may require suctioning Pt may be fighting ventilator

RR or rate
PAP/PIP (peak inspiratory press) PS I:E Ratio

Titrate to give adequate TV on spontaneous breathing Ratio of inspire to expire. ratios to improve 02 allowing t ime for 02 mixing

T Plat Trigger HUMIDIFICATION (HME) Green filters ET & LIPS NORMAL Co2

0 to 10cm H2o OR 0 10L per min

Retains heat & moisture in exhaled air & returns it with next inspiration 19-24cm 35 to 45mmHg

CRICOID PRESSURE

Effective way to ventilate the plateau ensures that the ventilator cycle is held at peak inspiratory pressure longer and allows maximum gas exchange therefore ventilation requiring 2 less concentrations of 0 Determines how a breath is started. Either by pt or ventilator. Pt triggered breaths can be spontaneous, assisted or supported breaths Posterior compression of cricoid cartilage which compressors oesophagus. Prevents aspiration. Locate cricoid cartilage just below adams apple. Use thumb & forefinger, apply gentle pressure in downward & backwards direction

ET ON CXR 2 5cm above carina or inline with aortic arch NORMAL CUFF PRESSURE 20-25 mmHg

DRUGS AND INTUBATION (ADULT)

DRUG DURATION EFFECT DOSAGE ADVERSE

Kelly Eyre - 2007

Raper Ray 2006 ICU Ventilation guide Mosby Critical care pocket guide 2004 Adult invasive mechanical ventilation self learning package 2004 orlando regional health care education and development

Thiopentone

Short acting barbiturate & CNS depressant.

Produces hypnosis & anaesthesia

3 5mls per kg 1ml per kg if hypotensive & or hypovolaemic 1.5mg per kg give over 10 to 30 secs ONCE ONLY

Hypotension Circulation collapse Apnoea Larynogospasm bronchospasm Severe hepatic disorders Malignant hyperthermia Hyperkalaemia - Caution with spinal injuries & crush injuries (releases to much K+) No cardiovascular or pulmonary side effects. Can cause histamine release

Suxamethonium

4 6mins duration

Depolarising neuromuscular blocking agent. Temporary result in muscle fibers being incapable of stimulation. Causes fasciculation

Vecuronim

30 40mins duration

Non-depolarising neuromuscular blocking agent. Blocks action of acetylcholine. Muscle fibres do not respond to acetylcholine; therefore paralyses temporarily

Initial = 0.08 0.1mg per kg Additional = 0.01 0.05mg per kg

Kelly Eyre - 2007

Raper Ray 2006 ICU Ventilation guide Mosby Critical care pocket guide 2004 Adult invasive mechanical ventilation self learning package 2004 orlando regional health care education and development

Ventilator Alarms
VENTILATOR ALARMS CAUSE Ventilator inoperative Ventilator Failure Pt is loosing all or some of Low pressure alarm their TV Low PEEP/CPAP alarm Low exhaled volume Apnea alarm
No spontaneous breath taken in preset number of seconds Pts PIP preset limit reached TV abandoned when limit reached Pt has obstruction in airway

ACTION TO TAKE Manually ventilate pt with bag

Check if pt or tubing is disconnected Check if airflow is adequate Check if ETT or cuff leak Manually ventilate until cause is found Commonly seen as low IMVs Encourage pt to breath or give mechanical breath rate of ventilations Is there secretions Does the pt require suctioning Is the pt biting on the ETT Does the pt require more sedation Is there H20 in the ventilator circuits or filter Pts compliance ARDS or Bronchospasm Tx the problem dont just pressure limit alarms (think barotrauma) Check all connections for leaks Assess & check RR Assess & evaluate pt Suction oropharynx & airway Check pt ventilator system Change sensor Assess & check RR Check pt ventilator system Evaluate pt ETCO2, SaPO2 ABG Pt improvement lung compliance Change sensor Check pt & ventilator system Evaluate ETCO2, SaPO2 ABG

Pressure limit alarm

Decreased Minute or TV

Increased Minute or TV

Change in RR

Sudden increase in maximal inspiratory pressure

Tube leak via ETT, through System or chest tube pt triggered RR lung compliance Airway secretions Altered settings Sensor malfunctions pt triggered RR Altered ventilator settings Hypoxia lung compliance Sensor malfunctions Altered setting metabolic demand Hypoxia Hypercarbia Coughing Airway secretions or plugs Kinked ventilator tubing H20 in ventilator tubing Kinked ETT Position of pt changed ETT in R main bronchus Bronchospasam/pneumothorax

improve coughing sedation/suction clear airway secretions check & or remove kinks or H20 in tubing reposition ETT & or pt verify ETT position find cause & treat decompress chest

VENTILATOR ALARMS

CAUSE

ACTION TO TAKE

Kelly Eyre - 2007

Raper Ray 2006 ICU Ventilation guide Mosby Critical care pocket guide 2004 Adult invasive mechanical ventilation se education and development

Gradual increase in maximal pressure

lung stiffness Diffuse obstructive process

Sudden decrease in maxima inspiratory pressure FIO2 Drift

Volume loss form leaks in ventilation system Clearing of secretions Relief of bronchospasm in compliance O2 analyzer error Blender piping failure 02 source failure 02 reservoir leak

Evaluate for reversible/treatable problems Atelectasis Bronchospasm in H20 in lungs Check ventilator settings & pt for leaks

I:E Ratio 1:3 or 1:1.5

Inspired gas temperature inappropriate Changes in delivered PEEP

Altered inspiratory flow rate Change in other settings that control I:E ratio Alteration in sensitivity settings Airway secretions Subtle leak Altered settings Thermostat failure Change in compliance Change in TV

Correct failure Change oxygen saturation probe Ensure a good oxygen saturation trace Check ventilator connected to blender Oxylog 2000 Check ventilator not connected to blender Oxylog 3000 Check setting are correct Clear airway of secretions Measure minute ventilation

Correct temperature control setting Replace ventilator Correct problem if possible PEEP setting to deliver desired level of PEEP Evaluate pt & correct if possible Check to determine if current settings are the ones intended

Lung compliance changes Changes in static pressure Changes in Inspiratory flow Changes in any of these settings can result from rate, sigh volume, assist or deliberate or accidental control mode, alarm status, adjustment of dials or knobs dead-space volume

Kelly Eyre - 2007

Raper Ray 2006 ICU Ventilation guide Mosby Critical care pocket guide 2004 Adult invasive mechanical ventilation se education and development