CCT Vent Mgt

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Anonymous
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8443
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CCT Vent Mgt
Updated:
2010-02-28 13:24:05
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Vent Management
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CCT Ventilator Management
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  1. What is the Goal of a ventilator
    To maintain alveolar Gas exchange appropriate for the patients metabolic needs and to correct hypoxia and/or hypercapnia.
  2. What is Tidal Volume (Vt) and how is it calculated?
    • – Volume of each delivered breath
    • – How is it calculated?
    • • 7-10 ml/kg of “ideal body weight”
    • • Overweight people do not have bigger lungs
  3. What is FiO2?
    • – Fraction of inspired concentration of
    • oxygen
    • • Ranges from 21% to 100%
    • • Initially set the FiO2 at 100% and titrate down based on blood gas values
    • • Once blood gases have been obtained it is possible to titrate the FiO2
  4. What determines the Respiratory Rate on a ventilated patient?
    • – Number of breaths per minute
    • – Depends on what is wrong with the patient
    • – Initially set at 12-14 (adult) breaths per minute but can be higher or lower
    • – Rate must be matched with the Vt to ensure adequate minute volume
  5. What is Minute Volume-Vm?
    • – Function of tidal volume and respiratory rate and is normally 6-10 liters in an adult
    • – Represented by the following formula:
    • • Vm (L/min) = Vt (ml) X respiratory rate (BPM).
  6. What are the four modes for Volume Control on a ventilator?
    • – Assist Control-AC
    • – Synchronized intermittent mandatory ventilation-SIMV
    • – Continuous Positive Airway Pressure- CPAP
    • – Bilevel Positive Airway Pressure- BiPAP
  7. How does Assist Control-AC work?
    • – Provides full Vt at a minimum preset rate
    • – Patient can initiate breaths in this mode, providing additional full Vt
    • – Provides near complete resting of the ventilatory muscles
    • – Patient can be awake, sedated or paralyzed
    • – Pressure support can not be initiated in this mode
    • • Since patients can initiate ventilation, they can hyperventilate and become alkalotic. They can also “stack” breaths which can result in air-trapping and the possibility of barotrauma. May want to consider sedation/paralysis to facilitate more effective ventilations
  8. How does SIMV work?
    • – Delivers a fixed Vt at a preset rate but allows patient to take their own breaths.
    • – When ventilator breath is delivered, ventilator will deliver set Vt.
    • – Patient initiated breaths are totally dependant on
    • patient.
    • – Advantages-patients are more comfortable since they have more control over ventilations
    • – Can result in respiratory fatigue if the rate is set too low causing a rise in pCO2 and air trapping i.e.: stacking breaths or auto PEEP.
  9. How does CPAP work?
    • • In this mode you can only have the components of:
    • – FiO2
    • – PEEP
    • – Pressure Support
    • • No set rate or Vt.
    • • Cannot give neuromuscular blockers to patients in CPAP
    • • Use sedation conservatively and with extreme caution
    • – Generally used for weaning and mode used prior to
    • extubation.
  10. What is PEEP and how does it work?
    • • Ventilators can be set to provide a fixed airway pressure at the end of expiration
    • • Opens closed alveolar units increasing lung area for gas exchange.
    • • PEEP can improve secretion drainage from closed alveoli
    • • Typical PEEP settings are from 5-10 but can go over 20
    • – PEEP can reduce venous return and lower left ventricular afterload; PEEP especially at high pressures can cause barotrauma
  11. How does Pressure Support work?
    • • “Turbo Boost” added to each Patient Initiated breath to help overcome the resistance of the Vent circuit and airway device
    • • Patient triggers the ventilator at a predetermined pressure during inspiration (sensitivity), ventilation is terminated when the patient ceases to inspire
    • • Patient has full control over his ventilatory pattern and minute volume
    • • Cannot be used in heavily sedated, paralyzed or comatose patients
  12. What is the Sensitivity setting on a Ventilator?
    • • Amount of inspiratory effort required to initiate an assisted breath – Ranges from 1-8 L/min.
    • – 1 L/min. is the most sensitive meaning it is the most sensitive to the patient initiation of a breath which decreases their work of breathing
    • – If the sensitivity is turned off that means the ventilator is in full control mode-The patient cannot initiate a breath on their own
    • • This is very uncomfortable and frightening for the patient unless they are sedated and paralyzed
  13. What is Flow Rate?
    • – Can be adjusted so that the inspiratory volume can be delivered in time to allow for adequate exhalation.
    • – Dependant on Vt, and Rate.
    • – Most commonly used rates are 40-80 lpm
    • • How quickly the breath is delivered
    • – If rate is set at 20 lpm the breath will be delivered slowly
    • – If the rate is set at 100 the breath will be delivered quickly
  14. What is the I/E Ratio?
    • Inspiration/Expiration Ratio
    • – Normal starting I/E ratio is 1:2
    • • It generally takes the average person to inspire in 1 second and expire in 2 seconds
    • – If the patient has an obstructive airway disease (COPD) then consider reducing to 1:3 or 1:4 to prevent air trapping
    • – Use Peak Flow to obtain adequate I:E.
  15. What is the DOPE method?
    • • Displacement
    • • Obstruction
    • • Pneumothorax
    • • Equipment Failure
    • – If equipment failure is suspected the patient should be removed from the ventilator and manually bagged
  16. What affects ETCO2 levels?
    • • Two things can change CO2
    • – Respiratory rate
    • – Vt
    • • Change only 1 setting at a time
    • • If you have calculated the Vt correctly, adjust the rate
    • • If rate changes seem inappropriate, change Vt first
  17. What can change the FiO2?
    • • Two things can change oxygenation levels
    • FiO2
    • PEEP
  18. How do we correct High ETCO2 levels?
    • • Consider increasing their respiratory rate
    • • Consider increasing Vt.
    • • Can result in respiratory acidosis
    • •We want to Increase Minute Volume
  19. How do we correct Low ETCO2 levels?
    • • Consider decreasing their respiratory rate
    • • Consider decreasing Vt
    • • Can result in respiratory alkalosis
    • • Decrease Minute Volume
  20. How will adjusting the rate effect the patient?
    • • Adult 12-14 BPM
    • • Increase will increase Vm, and Decrease ETCO2
    • • Decrease will Decrease Vm, and Increase ETCO2
  21. How will adjusting the Tidal Volume effect the patient?
    • 7-10 ml/Kg
    • Increase will increase Vm, and Decrease ETCO2
    • Decrease will decrease Vm, and Increase ETCO2
    • (Vm=Minute Volume)
  22. What are the differences between CPAP and BiPAP?
    • • CPAP-Continuous Positive Airway Pressure
    • – CPAP = PEEP
    • • BiPAP-Bilevel Positive Airway Pressure
    • – BiPAP = Two levels of (PS) PEEP + PS
    • • IPAP = Inspiratory PAP (PS)
    • • EPAP = Expiratory PAP (PEEP)
  23. What is Normal ETCO2
    • • “Normal” ETCO2 is 35 – 45
    • • “If V/Q are on equal terms, ETCO2 and PACO2 should be close to equal”
  24. What do you look for in ETCO2 Waveform?
    • • There are 4 Questions to use every time you monitor Waveforms.
    • – Is there rise and fall of the waveform?
    • –What is the number Value and is it “Normal”?
    • –What is the shape of the Waveform?
    • – Does it return to baseline?
  25. Analysis of ETCO2 waveform
    • – Frequency
    • A waveform should be present for every exhalation
    • Presence of a waveform = presence of carbon dioxide
    • – Height
    • Hypermetabolic states will increase the height of the capnogram as will prolonged hypoventilation
    • Decreases in cardiac output will decrease the height of the capnogram as will hyperventilation
    • – Baseline
    • Gradual elevations in Phase 0 or Phase I indicate re-breathing
    • A sudden rise in EtCO2 AND the baseline is likely indicative of sample contamination
    • – Shape
    • Deviations from the normal curve of the waveform have specific meanings
    • All humans with healthy lungs have the same shaped waveform
    • • Any variation warrants an evaluation of the cause
    • – Things to assess
    • • Expiratory upstroke
    • – Steep, sloping, prolonged
    • • Alveolar plateau
    • – Flat, prolonged, deflection, slope
    • • Inspiratory downstroke
    • – Steep, sloping or prolonged
    • –Whenever possible, compare the EtCO2 with the measured PaCO2on the ABG.
  26. Five Reasons for a “Flat Line” ETCO2 Wave
    • – ET Tube becomes Displaced
    • – ET Tube is Plugged or Kinked
    • – Cardiac Arrest
    • – Apnea or Mechanical Ventilator Failure
    • – Equipment Malfunction

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