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Questions and Answers
What is the primary focus of early rehabilitation in critically ill patients?
What is the primary focus of early rehabilitation in critically ill patients?
Which of these is a key factor in predicting long-term impairments after critical illness?
Which of these is a key factor in predicting long-term impairments after critical illness?
What is one potential effect of post-intensive care syndrome?
What is one potential effect of post-intensive care syndrome?
Which publication discusses cardiopulmonary physiotherapy in trauma settings?
Which publication discusses cardiopulmonary physiotherapy in trauma settings?
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What aspect of intensive care unit (ICU) is addressed in the World Federation of Societies of Intensive and Critical Care Medicine's report?
What aspect of intensive care unit (ICU) is addressed in the World Federation of Societies of Intensive and Critical Care Medicine's report?
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Which of the following studies addresses early rehabilitation approaches?
Which of the following studies addresses early rehabilitation approaches?
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Which of the following is NOT a focus of post-intensive care syndrome?
Which of the following is NOT a focus of post-intensive care syndrome?
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What does the systematic review by Fuke et al. primarily focus on?
What does the systematic review by Fuke et al. primarily focus on?
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What is a significant risk associated with long ICU stays, according to the literature?
What is a significant risk associated with long ICU stays, according to the literature?
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What is one effect of post-suctioning on breath sounds as per the content?
What is one effect of post-suctioning on breath sounds as per the content?
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What therapeutic area is highlighted in the references by Main and Denehy?
What therapeutic area is highlighted in the references by Main and Denehy?
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What is the maximum catheter size allowed for adult suction according to the specifications?
What is the maximum catheter size allowed for adult suction according to the specifications?
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Which of the following is considered a relative contraindication for suctioning?
Which of the following is considered a relative contraindication for suctioning?
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When should the suction catheter be inserted to the end point and then withdrawn 1 cm?
When should the suction catheter be inserted to the end point and then withdrawn 1 cm?
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What size catheter should be used for a newborn weighing less than 1 kg?
What size catheter should be used for a newborn weighing less than 1 kg?
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What is the appropriate cuff pressure range for suctioning?
What is the appropriate cuff pressure range for suctioning?
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Which of the following is an indication for nasopharyngeal suction?
Which of the following is an indication for nasopharyngeal suction?
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What is the recommended action if a patient is experiencing frank hemoptysis?
What is the recommended action if a patient is experiencing frank hemoptysis?
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What is the primary goal of mechanical ventilation?
What is the primary goal of mechanical ventilation?
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For patients aged 6 to 16 years, what is the appropriate suction catheter size?
For patients aged 6 to 16 years, what is the appropriate suction catheter size?
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Which mode of ventilation allows the patient to trigger their own breaths while receiving support from the ventilator?
Which mode of ventilation allows the patient to trigger their own breaths while receiving support from the ventilator?
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What should be the duration of suctioning to ensure patient safety?
What should be the duration of suctioning to ensure patient safety?
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What is a common complication associated with prolonged mechanical ventilation?
What is a common complication associated with prolonged mechanical ventilation?
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Which of the following is NOT an indication for suctioning?
Which of the following is NOT an indication for suctioning?
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Which parameter indicates a successful weaning trial from mechanical ventilation?
Which parameter indicates a successful weaning trial from mechanical ventilation?
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What is the purpose of Positive End Expiratory Pressure (PEEP) in mechanical ventilation?
What is the purpose of Positive End Expiratory Pressure (PEEP) in mechanical ventilation?
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Which factor is NOT commonly assessed when monitoring for adverse reactions during suctioning?
Which factor is NOT commonly assessed when monitoring for adverse reactions during suctioning?
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When is non-invasive positive pressure ventilation (NIPPV) recommended?
When is non-invasive positive pressure ventilation (NIPPV) recommended?
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What does VIDD stand for in the context of mechanical ventilation?
What does VIDD stand for in the context of mechanical ventilation?
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Which of the following describes the primary focus during the extubation process?
Which of the following describes the primary focus during the extubation process?
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Study Notes
Ventilation & Suctioning - FTP 303
- Topics covered include Introduction to ICU, Ventilation, Suctioning, Evaluation of ICU patients, Haemodynamic monitoring, Different ICU settings, and Rehabilitation and CPR.
Objectives
- Describe various ventilation modes.
- Interpret ventilator settings.
- List and explain ventilation complications.
- Explain weaning and physiotherapy's role.
- Detail indications for suctioning.
- List adverse reactions for suctioning.
- Describe and perform suctioning procedures.
Pressure Relationships
- Atmospheric pressure is balanced by transpulmonary and intrapleural pressures.
- Transpulmonary pressure is 4 mmHg.
- Intrapleural pressure is -4 mmHg.
- Intrapulmonary/Alveolar pressure is 0 mmHg.
Respiratory Cycle
- Tidal volume (VT) is the amount of air moved in and out of the lungs during a respiratory cycle.
- Intrapulmonary pressure equals atmospheric pressure during the respiratory cycle.
- Volume increases in the thoracic cavity during inhalation.
- Intrapleural pressure decreases during inhalation.
- Intrapulmonary pressure decreases to -1 mmHg, then rises as air flows into the lungs.
- Transpulmonary pressure is 4 mmHg.
- Intrapleural pressure is -4 mmHg.
- Intrapulmonary/Alveolar pressure is 0 mmHg.
Mechanical Ventilation
- Temporarily replaces or supports spontaneous breathing.
- Goals include maintaining alveolar ventilation, optimizing O2 delivery, optimizing work of breathing, minimizing toxicity, and ensuring favorable cardio-respiratory interaction.
Indications for Intubation
- Problems with breathing (e.g., rib fractures, muscle paralysis, during/after surgery, airway obstruction).
- Oxygenation defects (e.g., ARDS, pulmonary edema, lung contusion).
- Cardiac failure.
- Respiratory failure.
- Neuromuscular disease or head injury.
- Decrease ICP due to hyperventilation – vasoconstriction.
- Postoperatively.
Methods of Intubation
- Endotracheal tube: Most common, inserted through the mouth or nose into the airway.
- Oropharyngeal: From mouth to airway.
- Nasopharyngeal: From nose to airway.
- Tracheostomy: Opening in the trachea for long-term ventilation.
Ventilator Settings (Graphical examples shown)
- Various modes of ventilation (e.g., CPAP, PSV, SIMV, AC) and their corresponding ventilator parameters (e.g., FiO2, Rate, PEEP, PSV) are discussed.
Modes of Ventilation
- Various modes of ventilation are identified and defined (example: Pressure Support Ventilation, Continuous Positive Airway Pressure, Synchronized Intermittent Mandatory Ventilation, Assist Control)
PEEP (Positive End Expiratory Pressure)
- Alveolar pressure at the end of expiration is above atmospheric pressure.
- Open collapsed alveoli, increase surface area for oxygenation.
- Too much PEEP can injure capillaries.
Pressure Support Ventilation (PSV)
- Patient triggers breaths, ventilator supports with positive pressure.
- Airway pressure held at a pre-set level throughout inspiration.
- Pre-set pressure level selected to maintain tidal volume of 6–8 ml/kg.
- Often used with SIMV.
- Decreases work of breathing.
- Decreases respiratory failure.
- Increases patient comfort.
Continuous Positive Airway Pressure (CPAP)
- Positive pressure maintained throughout respiratory cycle.
- Patient is not generating negative airway pressure to receive oxygen.
- Maintains functional residual capacity and good oxygenation in spontaneously breathing patients.
Synchronized Intermittent Mandatory Ventilation (SIMV)
- Ventilator delivers gas at a pre-set rate.
- Volume controlled (6-8 ml/kg) / Pressure conttrolled.
- Allows spontaneous breaths from the patient.
- Used often after surgery.
- Maintains breathing during surgery/sedation.
- Can be used as a weaning mode.
Assist Control (AC)
- Patient sedated and paralysed.
- No spontaneous breaths.
- Ventilated at a pre-set rate.
- Pre-set Peak inspiratory airway pressure cannot be exceeded.
- Tidal volume uncontrolled – depends primarily on lung compliance.
- Recruit collapsed alveoli.
- Limiting PIP may decrease barotrauma.
- As compliance improves, tidal volume increases.
Other Ventilation Methods
- High-frequency oscillatory ventilation (HFOV)
- Extracorporeal membrane oxygenation (ECMO)
- Extracorporeal carbon dioxide removal (ECCO2R)
Criteria for Weaning Trial
- Reversal of intubation reason.
- Cardiovascular stability (HR, SBP).
- Minimal inotropic support.
- Stable metabolic status.
- Adequate cough.
- Absence of excessive secretions.
- FiO2, PEEP, RR, PaO2, PaO2/FiO2 ratio, and RSBI values within specific ranges.
Predictors of Successful Extubation
- Spontaneous breathing trial (SBT).
- Maximum inspiratory pressure (MIP).
- Rapid shallow breathing index (RSBI).
- Ratio of respiratory rate and spontaneous tidal volume.
- Cough strength, hand-grip strength, heart rate variability.
- All used in combination
Signs of Failed Weaning
- Respiratory rate > 35 breaths/min.
- SpO2 <90%.
- Heart rate > 130 beats/min.
- Clinical signs of respiratory distress.
- Sweating.
- Agitation.
- Depressed mental status.
Failed Extubation
- Need for re-intubation within 48-72 hours.
- Increased mortality rate (25–50%).
- Reasons include:
- Ineffective cough.
- Airway secretions.
- Obstruction.
- New onset sepsis.
- Results in increased need for tracheostomy, risk of nosocomial pneumonia, ICU stay, and mortality.
- High-flow nasal cannula (HFNC) or non-invasive positive pressure ventilation (NIPPV).
Prolonged Mechanical Ventilation
- Ventilation for more than 48 hours is detrimental.
- Increased risk of nosocomial infections, ICU length of stay, hospital length of stay, financial expenditures, critical illness myopathy/neuropathy, reduced functional ability, and quality of life are observed.
Extubation
- Original reason for intubation is resolved.
- Weaning criteria are met.
- Effects of anaesthesia and other respiratory depressants are no longer present.
- Patient can maintain the airway independently.
- Patient can cough and is awake.
Suctioning
-
Indications:
- Remove retained secretions.
- Crepitations on auscultation.
- Visible secretions in airway.
- Inability to cough effectively.
- Suspected aspiration of gastric/upper airway secretions.
- Deterioration in ABG's.
- X-ray changes.
- Increase WOB (work of breathing).
- Obtain sputum specimen & Luki.
- Prevention is better than cure, - routine suctioning is discouraged.
Suction Parameters to Monitor
- SpO2 (pulse oximetry).
- Respiratory rate and pattern.
- Pulse.
- Blood pressure.
- Sputum characteristics.
- Cough effort.
- Intracranial Pressure (if indicated).
- Ventilator parameters (RR, PIP, VT).
Suction Adverse Reactions
- Hypoxaemia: Principle complication, reduced by pre-oxygenation.
- Mucosal damage/atelectasis/bleeding: From excessive negative pressure.
- Cardiac arrhythmias: Stimulation of vagus nerve can cause cardiac arrest.
- Increased ICP: Possible complication.
- Loss of PIP/PEEP: Reduced pressure support and positive end-expiratory pressure.
Relative Contraindications
- Hypoxaemia/Hypoxia.
- Mucosal trauma.
- Cardiac/Respiratory arrest.
- Uncontrolled cardiac arrhythmias.
- Bronchospasm not relieved with nebulization.
- Frank haemoptysis.
- Increased ICP.
- Interruption of high PEEP levels.
- Increased blood pressure greater than 20% of baseline.
Effect Post Suctioning
- Improved breath sounds during auscultation.
- Decreased PIP (positive inspiratory pressure).
- Increased tidal volume.
- Elevated SpO2 (oxygen saturation).
- Improved oxygenation seen in ABG (artery blood gas values) results.
- Removal of secretions.
Suction: Catheter Size
- Children: No more than 1½ times the diameter of the endotracheal tube (ETT).
- Adults: No more than ⅔ times the diameter of the ETT.
- Specific sizes for different age groups are given.
Nasopharyngeal Suction
- Indications: Weakness, semi-consciousness, similar to those for intubated patients.
- Precautions: Stridor, CSF leak/skull fracture (increased ICP and infection), clotting disorders, pulmonary edema, and bronchospasm.
- Other considerations: Recent pneumonectomy and oesophagectomy.
Suction Equipment
- Correct-sized catheter.
- Saline (10 ml in syringe).
- Sterile water for rinsing the suction catheter.
- Sterile gauze for cleaning the catheter.
- Goggles and mask for protection.
- Sterile alcohol swabs.
- Clean gloves.
- Suction device.
- Yankauer.
Suction Procedure
- Explain the procedure to the patient.
- Sterilize the equipment.
- Use protective sheath for the catheter.
- Oxygenation before and after suction.
- Catheter insertion depth adjustments based on eliciting cough reflex.
- Suctioning duration (10-15 seconds).
- Removal of catheter by rolling between fingers.
- Technique variations for ET/trach, nose, or mouth procedures.
Questions
- Questions remain outstanding.
References
- Citations of relevant articles, books, and websites are listed.
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