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Nursing Role in Preventing complications of MV. Outline. Outline. Injuries to mouth, lips and oropharynx. Avulsion of skin due to adhesive tape. Pressure ulcers to the palate and oropharynx . Trauma to the lips and cheeks from tube ties. Injuries to the entrapped tongue. Perioral herpes.
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Injuries to mouth, lips and oropharynx Avulsion of skin due to adhesive tape Pressure ulcers to the palate and oropharynx Trauma to the lips and cheeks from tube ties Injuries to the entrapped tongue Perioral herpes
Chest X-Ray 3-4 cm
Correct ET Tube Placement • Secure ET tube in place, note the number • Sedate patient with appropriate MAAS • Avoid accidental, or self extubation
Laryngeal Inguries Laceration and hematoma in the left vocal fold during direct laryngoscopy. Exam performed with rigid telescope
Laryngeal Injuries Ulcerated lesion in the posterior glottic commissure soon after extubation. Exam performed with rigid telescope. Bilateral intubation granulomas inserted in the vocal apophasis. Exam performed with rigid telescope.
Laryngeal Injuries diffuse posterior erythema, edema and piled-up mucosa of inter-arytenoid area
Cuff Related Injuries Risk of mechanical complications Risk of aspiration
Postintubation stenosis Prince J S et al. Radiographics 2002;22:S215-S230
Tracheal and Glottic Stenosis Tracheal stenosis (exam performed with flexible nasofibroscope) Glottic stenosis (exam performed with rigid telescope).
Ulceration of the mucosa and cartilage, granulation tissue, and fibrous tissue
Tracheomalacia Tracheal collapse of more than 50% during expiration is diagnostic of tracheomalacia
AnapnoGuard The AnapnoGuard system detects air leakage from the lungs by measuring the CO2 level above the cuff. Detection of high CO2 levels above the cuff represents leakage
Minimum Leak Volume Technique • Air inflation of the tube cuff until the airflow heard escaping around the cuff during positive pressure breath ceases. • Place a stethoscope over larynx. Indirectly assesses inflation of cuff. • Slowly withdraw air (in 0.1-mL increments) until a small leak is heard on inspiration. • Remove syringe tip, check inflation of pilot balloon
Case Scenario • 64 year old male with history of COPD who presented with severe respiratory distress and required to be intubated and placed on CMV, VT of 650 ml and a rate of 24/min. • Immediately post intubation, his systolic blood pressure dropped from 132 mm Hg to 73 mm Hg.
PPV vs. Spontaneous Ventilation 120 5 3 0 -3 10 0
PPV vs. Spontaneous Ventilation 110 5 3 0 -3 8 0
Effect of Lung Volume on Venous Return • No effect in Normal individual with PEEP less than 10 cmH2O • Major effect in patients with Dynamic Hyperinflation such as asthma and COPD, and in pre-existing pulmonary hypertension • Small changes in PVR can cause considerable hemodynamic compromise secondary to acute increase in PVR • Avoid air trapping in these patients
Symptoms of hemodynamic effects • Decreased cardiac output, decreased venous return • Observe for: • Decreased BP • Restlessness, decreased LOC • Decreased urine output • Decreased peripheral pulses • Slow capillary refill • Increasing Tachycardia
Atelectrauma: Repetitive alveolar collapse and reopening of the under-recruited alveoli Volutrauma: Over-distension of normally aerated alveoli due to excessive volume delivery Cytokines, complement, prostanoids, leukotrienes, O2- Proteases Ventilation-Induced Lung Injury (VILI) Biotrauma *Dreyfuss: J ApplPhysiol 1992
Recognized Mechanisms of Airspace Injury Airway Trauma “Stretch” “Shear”
Optimized Lung Volume “Safe Window” • Overdistension • Edema fluid accumulation • Surfactant degradation • High oxygen exposure • Mechanical disruption • Derecruitment, Atelectasis • Repeated closure / re-expansion • Stimulation inflammatory response • Inhibition surfactant • Local hypoxemia • Compensatory overexpansion Zoneof Overdistention Injury “Safe” Window Zone of Derecruitment and Atelectasis Volume Injury Pressure
Diseased Lungs Do Not Fully Collapse, Despite Tension Pneumothorax And they cannot always be fully “opened” Dimensions of a fully Collapsed Normal Lung
Oxygen Toxicity : FIO2 > 60 % for > 24h Oxygen Carbon dioxide Water vapour Nitrogen • Absorptive atelectasis • O2/N2 = 21/79>>>>>> 50/50 • Accentuation of hypercapnia • Chronic respiratory failure: PCO2 with PO2 • Damage to airways • Bronchopulmonary dysplasia • Diffuse alveolar damage
Oxygen toxicity Reduce FiO2? • PEEP • Alveolar recruitment maneuvers • Alternative modes of ventilation • Inverse-ratio , APRV, HFV, ….. • Inhaled nitric oxide (iNO) • Extracorporeal membrane oxygenation (ECMO) • Diuresis • if pulmonary edema is possible • Bronchopulmonary hygiene • if secretions are prominent • Augmentation of antioxidants??
Ventilator Associated Pneumonia: Definitions • VAP – ventilator associated pneumonia • >48 hours on vent • Combination of: • CXR changes • Sputum changes • Fever, ↑ WBC • positive sputum culture • Occurs secondary to micro-aspiration of upper airway secretions
Risk Factors for VAP • No 1 risk factor is endotracheal intubation • Factors that related to cross contamination: • Poor adherence to infection control standards • Factors that enhance colonization of the oropharynx &/or stomach: • Poor oral hygiene • Conditions favoring aspiration into the respiratory tract or reflux from GI tract: • Supine position • NGT placement • Re-Intubation and self-extubation • Surgery of head/neck/thorax/upper abdomen • GERD • Coma/ depressed Glascow coma scale