SiROC Ventilation Presentaion Draft_Michele Adjustments .pptx

Management of Ventilation for Patients in the Community MICHELE ENGLISH, AINSLEY HOARE, MELISS A PASSMORE, DEBRA PATERSON, AND S ANJA PAVLOVIC RRT Normal Respiratory System Upper Respiratory Tract •Nose •Mouth •Larynx (voice box) Lower Respiratory Tract •Trachea (windpipe) •Right and Left lung...

Management of Ventilation for Patients in the Community MICHELE ENGLISH, AINSLEY HOARE, MELISS A PASSMORE, DEBRA PATERSON, AND S ANJA PAVLOVIC RRT Normal Respiratory System Upper Respiratory Tract •Nose •Mouth •Larynx (voice box) Lower Respiratory Tract •Trachea (windpipe) •Right and Left lung •Bronchi (airways) •Alveoli (air sacs) •Capillaries Respiratory Muscles •Diaphragm (largest muscle) •Intercostal (rib cage) •Abdominal muscles What happens when I breathe? Upper Airway Lower Airway Inhalation Exhalation • Diaphragm contracts (moves down), ribs expand and oxygen rich air moves into lungs • Upper airway filters, warms and humidifies air • Gas exchange • Capillaries and alveoli work to remove CO2 in the lower airway • Alveoli, then diaphragm and ribs relax • Ribs gently fall causing air to be pushed out of lungs Need for Mechanical Ventilation Pulmonary/Cardiovascular Disorders • • • • Severe chronic lung disease Hypoventilation syndromes Restrictive Lung disease (e.g. Skeletal Dysplasia, Fused Rib Cage) Congenital Heart Defects Neurological/Neuromuscular Disorders • Neuromuscular disorders (e.g. SMA, ALS, MD) • Congenital syndromes • Spinal cord injury; Diaphragm paralysis What you should know about your patient! You are responsible to know the following information regarding your patient’s ventilation • Diagnosis • Type (Non-Invasive vs. Invasive) • Reason for Mechanical Ventilation • Know what would happen to your patient without the ventilator or if ventilator is not used as prescribed •No patient/family/caregiver support •Ability and availability of patient/caregivers Education Challenges Family Life Home ventilation impacts every aspect of the lives of our patients and their families Despite this, they have taught us just how resilient they can be! Mechanical Ventilation – What is it? - A type of therapy to assist with moving air in and out of their lungs because they are unable to do this on their own - A ventilator can do all of the breathing (total support) or some of the breathing (partial support) depending on the persons needs - Some ventilators provide extra pressure (e.g. PEEP pressure) to prevent the alveoli (air sacks) from collapsing Types of Ventilation Support Partial Support • Person is able to breathe on their own between ventilator breaths • Person has some breathing effort of their own and the ventilator does not have to deliver the full breath Total Support • Person who needs the ventilator to do all their breathing • Tracheostomy often used to support the airway Different Types of Ventilation Non – Invasive Ventilation: •administration of ventilatory support without using an invasive artificial airway Invasive Ventilation: •positive pressure delivered to the patient's lungs via an artificial airway (endotracheal tube or a tracheostomy) Non-Invasive Ventilation •Breathing support that is given to your patient with via a mask or nasal prong interface •Is delivered by a non-invasive machine or a ventilator that can do non-invasive ventilation support •Your patient should be on their non-invasive support as prescribed by their medical team Non-Invasive Ventilation Components •Non-Invasive Ventilator •Heated Humidifier •Circuit (usually single-limb) •Interface (mask or prongs and headgear) Types of Interface Masks Nasal • Most commonly used • Fits over the nose Full face • Covers nose and mouth • Used if significant leak with nasal mask Total Face • Covers eyes, nose and mouth Nasal Pillows • Insert directly into nares • Good option for older patients as often too big for • younger children Modes of Non-Invasive Ventilation CPAP (Continuous Positive Airway Pressure) • A set pressure delivered through the system to the patient all the time BiLevel (BiLevel Positive Airway Pressure) • Two different set pressure levels delivered to the patient one set for inspiration and one set for expiration BiLevel Modes S (Spontaneous) • A breaths are started (triggered) and controlled by the patient. If they do not breathe, the machine will not give any breaths T (Timed) • All breaths are controlled by the machine. The machine gives the amount of breaths each minute that are set into the machine S/T (Spontaneous/Timed) • Breaths are started (triggered) by the patient. If they do not breathe, there is a set rate that the machine will deliver to the patient known as “back-up ventilation” BiLevel Parameters IPAP – inspiratory positive airway pressure EPAP – expiratory positive airway pressure PEEP – positive end expiratory pressure PS – pressure support RR – respiratory rate Vt – tidal volume amount of air per breath - Remember IPAP does NOT equal pressure support IPAP = PEEP + PS Back up Rate – number of breaths the machine will deliver per minute if the patients breathing rate falls below the rate set on the vent Inspiratory Time (It) - time in seconds the patient will receive the IPAP Rise Time – time it takes for the pressure to reach IPAP from EPAP Ramp – time in minutes that the ventilator takes to reach the set pressure MV – minute volume or minute ventilation MV= RR x Vt (directly correlates to CO2 clearance Non- Invasive Operational Checks • Importance of an intentional leak (vented masks) • Application of a mask/nasal device on a patient • Necessity of routine checking of the BiLevel settings as prescribed • Draining water from the tubing “rain out” • Checking the alarms as prescribed • Check that equipment is plugged into electrical outlets • Importance of a whisper swivel/exhalation port • Circuit and accessories STELLAR 150 Stellar Control Panel Stellar 150 Non – Invasive Set Up Stellar 150 Air Filter Replacem ent Stellar 150 Key Symbols Unlocking! accessing the clinical mode Possible problems associated with BiLevel Ventilation •Gagging or vomiting in the morning •Headaches in the morning •Sore eyes in the morning •Skin on face where mask/interface touches is red in the morning •Nosebleeds and nasal congestions •Patient will not wear the mask/interface •The mask/interface is not comfortable Invasive Ventilation Invasive Ventilation •Breathing support delivered by the ventilator to your patient directly into their lungs •Delivered via tracheostomy tube (artificial airway) •Your patient should be on their ventilation support as prescribed by their medical team Types of Invasive Ventilation Determines how a breath is delivered Pressure Control Ventilation Volume Ventilation •A pressure (cmH2O) is set on the ventilator, air is delivered from the ventilator to the patient to inflate the lung • A set amount of volume of air is delivered to the patient from the ventilator to inflate the lung •Different patients need different pressures to inflate their lungs • Volume is decided by the weight of the patient (bigger lungs need bigger volumes) • The amount of air will change from breath to breath but the pressure from the ventilator stays the same • The ventilator will adjust the amount of pressure it needs to give the set volume within set safety limits Delivered Breath Types Mandatory • Completely controlled by the ventilator • Ventilator controls the beginning and end of the patients inhalation • Breaths are given depending on how the volume or pressure is set Delivered Breath Types continued Assisted • Controlled by both the patient and the ventilator • Breath is initiated by the patient’s effort and breath is assisted with set volume or pressure limits • Volume assisted breaths will give a set tidal volume within a set inspiratory time • Pressure assisted breaths will give set inspiratory pressure for the set inspiratory time • Inspiration stops when the set inspiratory time has elapsed Delivered Breath Types – continued Spontaneous • Breaths are triggered or initiated by the patient • Breaths delivered are determined by the set pressure or volume on the ventilator • Inhalation ends with the patients exhalation or by the ventilator depending on the mode Invasive Ventilation -Modes CPAP A mode is the way the ventilator gives different types of breathing support • Continuous positive airway pressure – One set pressure all the time that supports spontaneous breathing on inhalation and exhalation PC • Pressure Control – Delivers assisted and mandatory breaths with a set pressure CV • Control Ventilation – Mandatory breath with a set volume is delivered to patient AC or C- Assist/Control or Control • Assisted and mandatory breaths – assisted breaths are given when the patient initiates a breath and ends when the It setting has been reached – a mandatory breath is given if the patient does not spontaneously breathe within the set breath per minute (BPM) Invasive Ventilation Modes – continued SIMV • Synchronized Intermittent Mandatory Ventilation – senses patients effort to inhale and allows for spontaneous breaths between mandatory breaths – ventilator will deliver a mandatory (set) number of breaths with a set volume while at the same time allowing spontaneous breaths, giving a boost of pressure • PC-SIMV Pressure Controlled SIMV - – senses patients effort to inhale and allows for spontaneous breaths between mandatory breaths - ventilator will deliver mandatory (set) number of breaths with a set pressure while at the same time allowing spontaneous breaths, giving a boost of pressure • PS Pressure support – A pressure boost for each breath given above PEEP Invasive Ventilator Parameters PIP –positive inspiratory pressure; the amount of pressure it takes to fill the lungs with inspiration PEEP – positive end expiratory pressure; pressure ventilator holds at the end of each breath to prevent alveoli from collapsing RR – respiratory rate; set number of breaths to be delivered per minute Vt – tidal volume; amount of air being inhaled and exhaled per breath Sensitivity - determines how easy it is for the patient to trigger the initiation of a breath Inspiratory Flow Rate – maximum flow at which a set tidal volume breath is delivered by the ventilator Alarms – prescribed per patient for parameters Invasive Ventilator Parameters – cont’d I:E ratio – proportion between the inspiratory time and expiratory time of each breath cycle Oxygen – percentage of oxygen delivered above room air (21%) Inspiratory Time (It) - length of time the breath is held in the inspiratory phase during machine controlled breaths Rise Time – time it takes for the pressure to reach PIP from PEEP MV – minute volume or minute ventilation; amount of ventilation delivered over the past minute MV= RR x Vt (directly correlates to CO2 clearance) Alarm indicator and audio pause button Trilog y 200 Front Panel Display Screen Up/Down Toggle Power Button Left and Right Toggle Side Panels and Features Exhalation Porting Block Depends on the type of exhalation device being used Breathing Circuit Secure Digital (SD) Card Slot Records patient usage and therapy information from the device Connection Connect the circuit tubing system hereInlet AC Power Power cord plugs in here Left Side Panel Right Side Panel Rear Panel and Features Detachable Battery Pack Slot Lithium-Ion detachable battery – allows additional usage time when device is unplugged from AC power Cord Retainer Prevents accidentally disconnecting the power cord Air Inlet and Filter Insert the supplied filter Filters the air going into the ventilator from dust and debris Oxygen Inlet Connector Connects oxygen to the ventilator External Battery Connector (DC Power inlet) Connects an external, stand-alone lead acid battery here Oxygen Inlet Port • Oxygen is delivered through the O2 inlet port via a flowmeter on the patient concentrator or portable tanks • Apply Oxygen as per your patient’s prescription Oxygen • Indications • How oxygen is applied to the ventilator • Types of home oxygen Ventilator Power Supply The ventilator operates on electricity from either A/C (alternating current) or D/C (direct current) power. Sources of electricity: • A/C Power – Plugged into the wall outlet - light on front of Trilogy is green • D/C Power • External Battery • Detachable Battery Pack • Internal Battery Battery times: • External 12-24 hrs • Detachable battery approx. 3 hrs • Internal battery approx. 3 hours • Charging timesdetachable battery & internal battery ~ 8 hrs Power Source Indicators On the status panel, a drawing power from will be around the battery that the ventilator is Invasive Operational checks •Check that settings and alarms are as prescribed •Necessity of routine checking of the ventilator settings as prescribed •Draining water from the tubing “rain out” •Check humidity for function •Check water levels •Check that equipment is plugged into electrical outlets •Circuit and accessories Circuits-Dry •Used for portability •Reusable •Cleaned weekly or when soiled •Uses HME for humidity Heat and Moisture Exchanger for Humidity •Purpose •Indications for use •Uses patients own heat and humidity to moisturizer secretions •Different sizes depending on patient •Contraindications of use •Types of “HME”s Circuits-Wet •Change weekly •Disposable •Uses heated humidity •On a stand with humidifier Ventilator Circuit Passive White filter, green elbow and 15 mm connector (White) Short tube to humidifier Long tube from humidifier Attach exhalation port to long tube and white extension tube to exhalation port Exhalation Ports-Passive Circuit Trilogy 200-Active Circuits ACTIVE CIRCUIT •Used for patients who may need additional help with breathing •Has a different exhalation port then passive •Has extra lines that go back into the ventilator ACTIVE CIRCUIT EXHALATION PORT Humidifier Components • Importance of humidification Temperature Display in Celsius Alarm Silence • Indications of improper/inadequate humidification Invasive/Non-invasive setting Heater Wire Power Button Temperature Probe Humidifier Water Chambers Refillable/ Reusable Auto-feed with water bag Disposable system Fisher and Paykel Heated Humidifier •The air from the ventilator travels across the heated water in the chamber pot and is now heated and humidified for inhalation •Delivers 100% relative humidity •Always use sterile distilled water for the humidifier •The humidifier should always be in the invasive setting (if the setting is incorrect, press and hold the setting button until it changes to invasive) •Display shows the temperature of the air at the temperature probe – set to maintain temperature of 37C (body temperature) Humidifier Alarm Indicators Indicates a problem with the temperature probe reading Indicates a problem with the heater wire or heated circuit Indicates a problem with the temperature probe Indicates a problem with the temperature probe reading Indicates no reading from the heater wire or temperature probe Temperature Indicator Alarm Manufacturer Alarm Indicator Humidifier Wires There are 2 cables that plug into the ventilator circuit Heater Wire • Plugs into the humidifier and the circuit • Controls the temperature of the heated wire inside the circuit to keep the air going to your patient warm Temperature Probe • Plugs into the humidifier and to ports in the ventilator circuit • Measures the temperature of the air and gives feedback to the humidifier telling it how much to heat up or cool down Humidifier Wires Insertion Locations Remove cap and insert the head of the temperature probe (Blue) Plug in heater wire (yellow) here Remove the cap and insert the triangular shaped temperature probe (Blue) into the circuit at the humidifier chamber Circuit AdditionsSheathed “In-Line” Catheter Suction •Attaches to the ventilator circuit and stays in-line with the circuit • 5cm is added to the measurement for suction to include the attachments length • Depth is looked at the hub of the suction catheter If the in-line catheter malfunctions, your patient can be disconnected from the ventilator and a standard suction catheter may be used. Manual Resuscitator •Purpose and function of a manual resuscitator •Operational check •Oxygen application Why Does the Ventilator have Alarms? •Alarms on the ventilator will alert you to a change in your patient’s breathing •Alarms on the ventilator will alert you to a possible malfunction of the ventilator •Alarms on the ventilator will you alert you to a power loss Automatically set alarms (machine control) Trilogy 200 Alarms •High/low expiratory pressure •High internal oxygen •Check circuit •Low circuit leak •Power alarms (low battery, replace detachable battery, AC power disconnect, battery discharging stopped due to extreme temperatures, check external battery, battery depleted, battery not charging, external battery disconnected, detachable battery disconnected, ventilator is running on battery) •Card error •High temperature alarm •Keypad stuck •Ventilator inoperative •Ventilator service required •Loss of power User-set alarms •Circuit disconnect •Apnea •Apnea rate •High/low respiratory pressure •High/low respiratory rate •High/low minute ventilation •High Vte/low Vte •High Vti/low Vti Non- Invasive User Alarms ALARM Steps to take Possible cause Low Respiratory Rate Reassess patient and alarm value RR is below the set alarm level High Respiratory Rate Reassess Patient and alarm value RR is above the set alarm level Low Pressure Check for leaks/damage in circuit/interface Vent does not reach the pressure needed to give a full breath High Pressure ? blocked airway = suction, kink in tubing or blocked exhalation port Ventilator reaches a high pressure Low Minute Ventilation Reassess patient Minute ventilation has dropped below set level High Leak Reposition mask to reduce leak Mask leak exceeds 20 seconds Non-Vented Mask Alarm Ensure mask vents are not blocked and mask is vented Non-vented mask may be connected or mas Internal Battery Low Plug in to power source Internal battery capacity is below threshold High Priority Manufactur er Alarms •Loss of Power •Ventilator Inoperative •Ventilator Service Required •Audible and visual alarm •Ventilator will stop functioning or function improperly Action •Take patient off malfunctioning ventilator •Place onto resuscitator bag and give breaths •Put onto 2nd ventilator if able •Call for help (other care providers/911) •Contact family and/or VEP Low Battery •Escalates from medium to high priority (yellow/red) •Visual and Audible alarm indicators •Medium priority alarm with 20 minutes left of battery power •High priority alarm when there is 10 minutes left of battery power Troubleshooting Action: • Switch to new power source • Provide manual resuscitation and change to other ventilator High Temperature •Escalates from medium to high priority as condition worsens (Yellow-Red) Troubleshooting Action: • Check if air inlet filter is dirty or blocked • Ensure ventilator is not to close to heat source • External temperature maybe too high. Take ventilator to cooler place • Change ventilator or provide manual resuscitation Low Circuit Leak Troubleshooting Action: • Ensure exhalation valve is not occluded/covered • Check tracheostomy for dislodgement or blockage • Check for kink or pinching of the circuit • Check for excess water in circuit, exhalation valve • Change exhalation port and test-provide manual resuscitation or change to other ventilator while changing port Circuit Disconnect Troubleshooting Action: • Check for disconnection of circuit. Ensure it is properly attached • Check tracheostomy tube for dislodgement or blockage • If unable to fix the alarm, provide manual resuscitation or change to other ventilator and check/change ventilator circuit Alarm troubleshooting 101 • Check patient first for signs of distress • Check tracheostomy tube for dislodgment or blockage (Look/Suction) • Check for disconnections in ventilator circuit • Check for excess water in ventilator circuit • Check for any pinches or kinks or obstructions in the circuit • If you can’t find the problem-take patient off and use the patient’s resuscitator bag Respiratory Distress What is it? How will I know? Where do I assess? Why does it happen? What do I do about it? •Increased coughing Signs of Trouble Breathing •Restlessness •Large eyes, looking frightened •Feeling rattling on the chest •Trouble breathing •Bubbling of secretions out of the tube •Sucking in of the rib cage •Flaring of the nostrils •Pale, bluish colour of the lips •VENTILATOR ALARMS Infection Prevention **PREVENTION OF THE SPREAD OF GERMS THAT CAUSE INFECTION IS KEY** Clea n han ds Clean equipme nt Infectio n Prevent ion Clea n trac h Clean air Ventilator Equipment Pool - VEP Ontario Ventilator Equipment Pool http://www.ontvep.ca/ Link to equipment resources from VEP https://ontvep.ca/products-2/ Link to circuits used for trilogy and humidifier sent to patients https://ontvep.ca/wp-content/uploads/2022/03/Fisher-and-Paykel-circuits-pedi atric-references-removed.pdf References: http://www.crto.on.ca/pdf/ProfPractice/HFO_Training_Manual.pdf http://www.rcjournal.com/contents/04.05/04.05.0519.pdf http://www.tracheostomy.com/ http://www.passy-muir.com/ A special thanks to the Hamilton Health Science's Registered Respiratory Therapist’s for working in collaboration with SiROC.