Pandemic [H1N1] 2009 RT Education Module 2

1. Pandemic [H1N1] 2009RT EducationModule 2 Lung Protection

2. Outline • VAP Strategies • EVAC tubes • Cuff Pressure • Calculating Lung Mechanics • PEEP • PEEP Studies (to be added-worth while teaching?) • Recruitment Maneuvers • ARDSnet Protocol

3. What is Ventilator Associated Pneumonia [VAP]? • The VAP Bundle includes the following components: • HOB >30 degrees [prevention of gastric-esophageal reflux]. • Assessment of weaning/extubation. • Oral gastric [OG] versus nasal gastric tube [NG]. • Use of an EVAC tube.

4. EVACTM Tubes Purpose: • The EVACTM feature of an artificial airway is used to remove secretions proximal to the inflated cuff in order to reduce the risk of aspiration. Set Up: • A dedicated source of negative pressure is required for this application. • Negative pressure from the source may not be split between two applications • The negative pressure should be set between 20 and 30 mmHg.

5. EVACTM Tubes Care: • The Respiratory Therapist on duty will have the primary responsibility for assessment care and troubleshooting of the Evac™ function of the artificial airway. • The Evac™ function must be assessed with each monitoring and more frequently as necessary. • Lumen patency of the Evac™ line must be verified every four hours or more frequently as thought necessary. • EvacTM line patency is verified by successful injection of 10 mL of air through the line. • Listen at the mouth for sounds of air escaping. • If no sounds are observed manually aspirate 10 mL from the line. • “Milking” the line may be necessary to achieve satisfactory aspiration. • In the absence of a dedicated source of continuous negative pressure, aspiration of the Evac™ line must occur every two hours or more frequently if required.

6. Cuff Pressure Purpose: • To minimize the likelihood of aspiration of subglottic secretions and/or damage to the tracheal mucosa resulting from impaired mucosal blood flow in patients with an artificial endotracheal airway. Goal: • To maintain the intra cuff pressure in the range 20-30 cm H2O

7. Calculating Lung Mechanics Plateau Pressure: • The ‘real’ airway pressure! • Whereas the Peak airway pressure is a reflection of the pressure in the major airways, the plateau pressure is a reflection of the pressure at the alveolar level. • An Inspiratory hold of at least 0.5-1.0sec must be achieved. • Ensure the waveform has a adequate and visible ‘plateau’. • Control of the plateau pressure is believed to help prevent ventilator induced lung injury. • Plateau pressures approaching 35cm H2O may cause distention in the lungs above which volutrauma is thought to occur.

8. Calculating Lung Mechanics Auto Peep: • Occurs when small to medium airways collapse causing air trapping and hyperinflation. • An expiratory hold is placed on the breath [via the ventilator] causing the patient to exhale against a closed expiratory valve. • The expiratory hold should last at least 2-3seconds. • Once the pressure is held and measured it is considered the TOTAL PEEP. • TOTAL PEEP-PEEP SET=AUTOPEEP

9. PEEP [Positive End Expiratory Pressure] • Tool to increase FRC. • Improve oxygenation. • Recruit collapsed lungs in patients with low compliance. • Example: ARDS • PEEP Orders

10. PEEP Studies

11. Recruitment Maneuvers Purpose: • To maintain resting lung volume by opening closed airways and/or reinflating collapsed alveoli. Procedure: • CPAP using any critical care ventilator • BILEVEL PB 840 • EVITA

12. CPAP Method: • Obtain an order for the CPAP level (and inspiratory time?) to be used. • Suction the patient if required • Measure arterial blood gas tension • Set FIO2 to 1.0 • Select CPAP mode • Set the CPAP level to the prescribed setting • Change ventilation mode to CPAP • During the procedure monitor Blood Pressure, pulse and SpO2 • Upon conclusion of the prescribed time period revert to the pre-procedure settings • Fifteen minutes following the procedure obtain an ABG analysis

13. Recruitment Maneuvers Special Considerations: • Recruitment maneuvers must be used with extreme caution in the following conditions: • Head Trauma • Intracranial Hypertension • Thoracotomy • Pulmonary Barotrauma Documentation!

14. Acute Respiratory Distress Syndrome [ARDS] What? • ARDS is an acute lung syndrome associated with alveolar collapse. • Once the alveoli collapse gas exchange is impaired and low oxygen levels in the blood persist.

15. ARDS Net Protocol Ventialtory Approach: • Phasic opening and closing of the injured lung tissue can cause further damage to the lung tissue and worsen the injury. • By combining low Tidal Volumes [Vt] with higher than normal PEEP it may be possible to reduce the shear injuries.

16. ARDS Net Protocol Purpose: • To minimize the incidence of baro/volu trauma in patients receiving mechanical ventilation. • Calculate Predicted Body Weight [PBW] in Kg.

17. ARDS Net Protocol Goals: • Pplat< 30ch H2O • Lowest Vt possible while maintaining pH goals • pH7.20-7.45 • PEEP and FiO2 work together based on an established algorithm. • PaO2 55-80mmHg or SpO2 88-95% • Ensure goals are achieved via patient assessment And ABG’s.