Ventilator and Practical Review

1. Ventilator and Practical Review Kishore P. Critical Care Conference

2. Format • You will be assigned to a ventilator • The practical will last approximately 30 minutes per person, each day (total of 60 minutes) • You will be asked to setup the ventilators circuit, read the scenario and input your settings and alarms; also apnea alarms • After placing the patient on the vent you will be given a scenario, from this scenario you will make the appropriate adjustments Kishore P. Critical Care Conference

3. Format • Settings: Must be able to set appropiate VT per IBW, or PCV with an acceptable Pressure limit. Know what flow to set, sensitivity, rate and FIO2. • You will be expected to use appropiate VT ranges per the given scenario 8-12 ml/kg or 5-7 ml/kg • Know how to calculate CD, CS, RAW and understand what each means and when to change to a lung protective mode Kishore P. Critical Care Conference

4. Format • You must know how to correct acidosis and alkalosis, setup appropriate VT, rate and FIO2 • You will also be asked to perform a inspiratory hold, assess for auto-peep and over distention utilizing the graphics • You will be asked to adjust flow and I-time to get a specific I:E ratio • Be able to calculate spontaneous VT, Ve, flow, and I:E calculations Kishore P. Critical Care Conference

5. Format • Troubleshooting: You will be asked to trouble shoot, either a high pressure or low pressure. You must identify the cause as being a compliance issue or a mechanical problem • Be able to answer questions concerning weaning parameters and readiness to wean including: • VC, MIP, Blood pressure, CXR, compliance, O2 demand… Kishore P. Critical Care Conference

6. Format Know weaning strategies, including PSV, SBT, ATC… The practical is worth a exam grade. There will be remediation for those who fail. The remediation will be longer and harder than the original! Kishore P. Critical Care Conference

7. Ventilator Review • Trigger: What begins inspiration, either time, flow or pressure. The time applies to non patient triggered breaths. Control trigger by setting sensitivity • Set sensitivity 1-3. If the sensitivity is set >3 may lead to difficulty triggering breath on and induce WOB, if set to low may cause auto-triggering • Set in all modes (including CPAP, PSV still needs a trigger!) Kishore P. Critical Care Conference

8. Ventilator Review • Cycle: This is what cycles the breath off. Either flow, pressure or volume. Pressure and volume limits are the most common • Volume: Set appropriate per patients size. If patient has restrictive lungs or is air trapping severely, use 5-7 ml/kg range • Pressure Limit: Set 15-25, increase to increase VT, decrease to lower VT Kishore P. Critical Care Conference

9. Ventilator Review • MODES: • AC: start with this mode if patient is apneic or if patient’s spontaneous breaths are inadequate or erratic. Patient can trigger breaths but machine will complete the breath at preset limits • SIMV: May start with this mode on any patient who is apneic if you suspect he/she will regain spontaneous breathing. Otehrwise, use only if spontaneous breaths are adequate. Must set a PSV in this mode Kishore P. Critical Care Conference

10. Ventilator Review • CPAP/Spontaneous: May start for Type I failure, patient must have ability to breathe spontaneously without much need for ventilatory support. Must have a PSV or ATC or VS • PRVC: duel mode, set in either AC or SIMV mode. Set pressure limit, target VT…Does not work well with erratic breathing patterns Kishore P. Critical Care Conference

11. Ventilator Review • APRV: for restrictive lungs only, spontaneously breathing • HFOV: for restrictive lungs only, sedate/paralyze. • ASV: used as a single mode, from start to finish, not for ARDS or neurological breathing patterns Kishore P. Critical Care Conference

12. Ventilator Review • Flow: Set only in Volume control. When set use either constant or decelerating patterns. Increased flow= decreased I-time. Give patients with COPD increased flows to meet demands and give long E-time. Increase when you increase VT, or change flow pattern • I-time: Set in PRVC, PCV. Increase or decrease to achieve appropriate I:E, increased rates=decreased I-time. Inverse used for restrictive diseases to increase oxygenation Kishore P. Critical Care Conference

13. Ventilator Review • Non-compensated Respiratory Acidosis: • You need to increase Ve. On AC mode this is done by: • Increasing VT (8-12 range), watch PIP’s • Increasing PIP, watch total PIP • Increasing rate, unless patient is breathing over BUR • increase Ve target if on MMV or ASV modes • Remove any unnecessary mechanical deadspace On SIMV mode: you can increase rate even if patient is over BUR, or increase VT/PIP or increase PSV to increase Spontaneous VTe Kishore P. Critical Care Conference

14. Ventilator Review • On HFOV: To decrease PaCO2 • Increase AMP, then decrease Hz, Induce leak around ETT cuff. • To increase PaCO2 do the opposite • To improve PaO2, increase FIO2 and MAP • On APRV: • To decrease PaCO2 Increase HP or Increase LT or decrease low Pressure Kishore P. Critical Care Conference

15. Ventilator Review • Uncompensated Respiratory Alkalosis • On ACV mode: • Decrease rate first if patient is not breathing over BUR. • Decrease VT or PIP On SIMV decrease Rate, VT/PIP or PSV OR change to CPAP mode Kishore P. Critical Care Conference

16. Ventilator Review • Vent Check: • Check ventilator orders, check for new orders and assure old orders. Weaning orders? Pertinent procedures that would require transport or procedures that would require your presence like a bronch? • Assess patients chart first know patients Hx and why they are on the ventilator • CXR, CT scan and all other pertinent diagnostic tests • ABG, CBC, other pertinent labs • Sedation • Hemodynamics, BP, arrthymias and cardiac status Kishore P. Critical Care Conference

17. Ventilator Review • Vent Check • Note if patient is in isolation • Assess patient’s vital signs • Check BS, HR, Spo2, cardiac rhythm, BP and hemodynamics • Assess capnography if applicable • Note presence of Foley and its contents, chest tubes, NG tubes, PICC lines, IV’s, A-lines… • Note medications hanging in room • Note patients ETT tape or holder, does it need to be changed Kishore P. Critical Care Conference

18. Ventilator Review • Vent Check • Note ETT size and location at lip. • Note patient and their sensorium • Perform MLT/MOV or check cuff pressure directly • Ensure tubing is free from condensation, if patient is on a heater, drain circuit into water trap, ensure heater water is filled. If HME, ensure it is not occluded, if it is, change it • Note inline suction ballard, if heavily soiled, change it Kishore P. Critical Care Conference

19. Ventilator Review • Vent Check • Check patients settings, mode, VT/Pip, rate, rise time, sensitivity…also alarm settings and apnea settings • Assess ventilator graphics, note presence of over distension, air leaks, auto-peep, secretions… • Record monitored data including: PIP, VTE/VTI, Ve, Rate, Static Compliance, Dynamic compliance, MAP, total PEEP… • Check suction pressure, suction patients lungs as needed and also mouth with yonker • Document all pertinent information • If you do not document it wasn’t done! Kishore P. Critical Care Conference

20. Ventilator Review • Vent Check • Your first vent check should be the most time consuming. • Any changes that are made, make sure the patients RN is aware • As a student you will not be making any changes without approval from your preceptor • Typically a brief summary is written regarding the patient. Put any changes you made or ABG’s you drew here and maybe the plan for the day • Inline HHN or MDI’s should be given AFTER you have done your check and suctioned patient (if it was needed) Kishore P. Critical Care Conference

21. Ventilator Review • Vent Check • The patient should have a resusitation bag at bedside, plugged into oxygen. If the patient is on PEEP, ensure there is a peep valve. • The ventilator should be plugged into the red outlet incase of power outage • Note signs in room for Dialysis Shunts • A spare trach should be in the room for trach patients Kishore P. Critical Care Conference

22. Ventilator Review • Transporting patients: • The hospital will either make you attach the patient to a transport ventilator or you will bag the patient to their destination • You may have to bring along the ventilator and attach it once you reach the area you are transporting to, in this case, simply select same patient so that all the settings remain • Have a full E-tank available. Assist in the pushing of gurney and also the attachment of monitors Kishore P. Critical Care Conference

23. Ventilator Review • Do’s • Do participate as much as possible by volunteering to do all tasks including Bronch assisting, ventilator checks, Extubation, intubation assists… • Do your research, make sure you know the ventilator you are working on. Download the user guide online. • Make sure you know your patient. Keep a small notebook, and have all pertinent info handy. Only identify patient by room number. Be able to communicate with MD’s and other healthcare personnel effectively. • Give report if possible and also participate in rounds Kishore P. Critical Care Conference

24. Ventilator Review • Don’t do anything you are not comfortable with, make sure your preceptor is in close proximity • Don’t be meek, be aggressive and inquisitive but not a burden for your preceptor • Don’t lie on your charting. • Don’t short cut your patient care • Don’t use improper language • Don’t be afraid to be wrong • Don’t make changes to the vent by yourself. • Don’t take orders from the physician. • Don’t undermine or talk ill of licensed staff. YOU ARE A STUDENT, and your presence at the facility is a gracious act by the facility, they receive absolutely no monetary benefit from your presence, except perhaps a future employee. Kishore P. Critical Care Conference

25. Troubleshooting • If the ventilator is alarming and the immediate fix is not apparent, you must take the patient off and bag them until the problem can be solved • For high pressure alarms: assess patient for asynchrony, fighting ventilator, mucus, change in compliance, increase RAW, bronchospasm, biting tube…. Inform your preceptor if you can not resolve the issue yourself. For example patient is biting tube, inserting an oral airway, don’t do it alone Kishore P. Critical Care Conference

26. Consider the following • Secretions in airway • Tube block • Kinking of tube • Biting the tube • Water in the tube • Cuff herniation • Rt. bronchial intubation • Fighting the ventilator • Cough • Increased airway resistance • Bronchospasm • Decreased compliance • Atelectasis • Fluid overload • Pneumothorax Kishore P. Critical Care Conference

27. Troubleshooting • If the low pressure, or low Vte alarm is sounding. • Check for obvious leaks, if a leak if found plug it • Check cuff pressure, if blown, let your preceptor know, the ETT may have to be changed • If patient self extubated, and it is plainly obvious (tube is seen hanging from patients mouth), finish the extubation, bag as needed and call for help Kishore P. Critical Care Conference

28. Troubleshooting • 18 yr old man intubated for organophosphorus poisoning and intermediate syndrome was on the following settings: AC 12, VT 550, FIO2 30% • He suddenly desaturates. You notice that his resp rate is 35/min, heart rate is 120/min, BP is 90/70mmHg. • Auscultation reveals equal vesicular breath sounds. What would you do? Kishore P. Critical Care Conference

29. Troubleshooting • A 35 yr old man with status epilepticus following organochloride ingestion is being ventilated in the ICU. You are called because of desaturation and persistent low pressure alarms. How would you tackle the situation? Kishore P. Critical Care Conference

30. Consider the following • Cuff leak. • Leak in the circuit • Loose connections • ET tube displacement • Disconnection • Inadequate flow • Low supply gas pressures Kishore P. Critical Care Conference

31. Low pressure alarm • FiO2 to 100% • Check all connections for leaks. Start from ventilator inspiratory outlet—humidifier—inspiratory limb—nebulizer—Y junction—dead space—et tube cuff—expiratory limb—expiratory valve. • If inspiratory effort excessive-inadequate flow—increase inspiratory flow, decrease Ti, increase TV • Check gas pressures • If all normal and problem persists, change ventilator Kishore P. Critical Care Conference

32. High pressure alarm • FiO2 to 100% • Look at chest movement, auscultate air entry. Kishore P. Critical Care Conference

33. Weaning • If the patient is to be weaned… • Perform weaning parameters. This may be done through the ventilator on most modern vents. If you are to do a VC or MIP, the patient is typically on CPAP mode without PEEP and minimal PSV if any. Assess VC, MIP, MEP several times for reproducibility • While weaning note vital signs, RSBI, Vte, RR, SpO2… • If patient fatigues to the point that their vitals decline, you should place them back on previous mode/settings • You may get a ABG after a short time frame while weaning to assess effectiveness • Weaning can be done numerous ways…SBT, CPAP trials, to Bipap… Kishore P. Critical Care Conference

34. Practical Review • The practical is 15 minutes long (it is a timed test) • You will be given the questions and are expected to setup the ventilator, input settings, including alarms, change modes and answer questions in this time frame • You should know the material well enough to get through it as quickly as possible • If you fail to answer any questions and time has expired, you will receive a 0 for those questions. • This means you should know it well enough not to have to lament on each question Kishore P. Critical Care Conference

35. Practical Review • You will be read the question one time, it may be repeated if needed. You are expected to set up the vent without any help of the instructor. The instructor will observe you but will not assist you in your decisions. • You WILL NOT do a short self test, the machine should be initiated with the test lung OFF Kishore P. Critical Care Conference

36. Practical Review • You will be expected to setup the ventilator appropriately. This includes: • Placing the inspiratory and expiratory filters on appropriately • Placing the HME on • Ensuring the vent is plugged in to a red outlet and that the compressor is on Kishore P. Critical Care Conference

37. Practical Review • Once the circuit is on you will be given a scenario. From the scenario you will input appropriate settings. • Remember IBW for VT settings. You may use any mode you like • If the patient is described as a restrictive patient or someone with severe air trapping, be sure to keep this in mind when setting up the vent Kishore P. Critical Care Conference

38. Practical Review • If you are given a ABG before setup and have an idea about the patients ventialtion and oxygenation you may setup the vent accordingly. • Example: A 56 year old man, 5’8 with severe COPD is in respiratory failure, an ABG is drawn while bagging with 100% O2 and shows: • 7.18, 106 paCO2, 56 paO2, HCO3 36 Kishore P. Critical Care Conference

39. Practical Review • You can start more aggressive, but realize that this patient has air trapping, so instead of giving excessive volumes, you may want to instead increase the rate. • Example settings: VT 500, AC 22, FIO2 65%, PEEP 5 • The patient is a COPD patient, so 65% is suffice. • If you set a rate of 22, make sure the patient gets sufficient flow. Your goal is a I:E ratio of 1:3 to 1:4 with COPD patients and 1:2 to 1:3 with most other patients Kishore P. Critical Care Conference

40. Practical Review • If no prior ABG is given in regards to your patient then use generic starting settings. Still take into consideration the scenario, if patient is air trapping or has a restrictive disease use smaller volumes. • Rate 8-12 • FIO2 50-100% (you will be inputting this, I will hit the silence button) • VT 5-7 ml/kg or 8-12 ml/kg • Flow 40-60, I-tme 0.8-1 second • Sensitivity 1-3 Kishore P. Critical Care Conference

41. Practical Review • Typically start with AC mode. Only use SIMV mode if the patient is apneic and you suspect he will wake up and start breathing. • Do not use SIMV if patient’s spontaneous breaths are erratic. • Example: A patient with a RR 46, is awake/anxious and developing respiratory failure. You will use AC mode. Kishore P. Critical Care Conference

42. Practical Review • If you use SIMV as your starting mode, make sure to include PSV • You may use either PCV, VC or VC+ as your starting breath type. Kishore P. Critical Care Conference

43. Practical Review • After you input your initial settings • including: Mode, Breath type, VT or Pressure limit, flow or I-time, FIO2, sensitivity, rate and PEEP You will then set your alarms and apnea settings This of course can be adjusted once you place the machine on the patient, however you should place your settings here first. This should be automatic. If you have to be prompted to set your alarms and apnea you will be marked off Kishore P. Critical Care Conference

44. Practical Review • Once your alarms are set and your alarms are set, you may attach the vent to the test lung. • All of this should be done in approximately 5-6 minutes. Kishore P. Critical Care Conference

45. Practical Review • After the vent has been initiated, you will be given a follow up ABG. • From this ABG you will need to make appropriate ventilator changes. • Remember the guidelines. You will be told if the patient has spontaneous respirations or not Kishore P. Critical Care Conference

46. Practical Review • You will also have to demonstrate the ability to do a static pressure (by pressing the inspiratory hold button) • Know what the normal value should be • Know how to quickly scan the graphics for auto-peep. To assess auto-peep you should check the FLOW-TIME graphic • You should know how to adjust I-time or flow to achieve certain I:E’s Kishore P. Critical Care Conference

47. Practical Review • You will be expected to change modes, example: AC to Spontaneous mode. • In doing so, a PSV should be added automatically without prompt from the instructor. Start with 6-10 for PSV • Know how to assess patient for weaning. You would note: Vitals, CXR, underlying condition change, spontaneous breathing, RSBI, weaning parameters • Know what strategies you might try to initiate weaning Kishore P. Critical Care Conference

48. Practical Review • You may also be asked to troubleshoot. • This may include scanning for leaks or noting high pressure from kinked tubings Kishore P. Critical Care Conference

49. Case 1 • A 25 year old with suspected statitucusasthmaticus is intubated after bronchodilators have failed. The patient is 65 KG IBW, Set the ventilator for this patient, no previous ABG is drawn and the patient is anxious, in respiratory failure with the following vitals while being bagged: • HR 156, RR 45, BS decreased bilaterally, BP elevated. Kishore P. Critical Care Conference

50. Case 2 • A 40 yr old man with malaria developed progressive breathlessness and hypoxia requiring intubation in the ward. X-ray done is suggestive of ARDS. He is being shifted into the ICU. Body weight 60kg. Set the ventilator for this patient, SpO2 while being bagged on 100% was 87%. • One hr later ABG done-pH 7.20, PCO2 65, PaO2 55, HCO3 25, BE 1.0, SaO2 86%. What changes would you make. Kishore P. Critical Care Conference