Ventilation & Suctioning PDF, FTP 303, 2024

Ventilation & Suctioning FTP 303 13 May 2024 Dr. R Brandon Themes Theme 1: Introduction to ICU Theme 2: Ventilation Theme 3: Suctioning Theme 4: Evaluation of an ICU patient Theme 5: Haemodynamic monitoring Theme 6: Different ICU settings Theme 7: Rehabilitation and CPR O...

Ventilation & Suctioning FTP 303 13 May 2024 Dr. R Brandon Themes Theme 1: Introduction to ICU Theme 2: Ventilation Theme 3: Suctioning Theme 4: Evaluation of an ICU patient Theme 5: Haemodynamic monitoring Theme 6: Different ICU settings Theme 7: Rehabilitation and CPR Objectives Describe different modes of ventilation Interpret the ventilator settings List and explain complications of ventilation Explain the process of weaning and the role of physiotherapy List the indications for suctioning Loading… List the adverse reactions for suctioning Describe the procedure and perform suctioning Pressure Relationships Transpulmonary pressure 4 mmHg Intrapleural pressure -4 mmHg Intrapulmonary / Alveolar pressure 0 mmHg Respiratory Cycle Single cycle of inhalation and exhalation Tidal volume (VT)= amount of air you move into or out of your lungs during a single respiratory cycle. Intrapulmonary Volume Increase, Decrease in pressure = Expansion intrapleural atmospheric pressure Loading… thoracic cavity pressure Transpulmonary pressure 4 mmHg Intrapleural and Intrapulmonary pressure intrapulmonary pressures decrease to -1 mmHg, begin rise rapidly – forcing air out to rise as air flows into the Intrapleural pressure of the lung lungs -4 mmHg Intrapulmonary / Alveolar pressure 0 mmHg  Mechanical Ventilation Temporarily replace or support spontaneous breathing Goal of MV Maintain sufficient alveolar ventilation Optimise O2 delivery and ventilation Optimise work of breathing Minimize toxicity Ensure favourable cardio-respiratory interaction  Indication for Intubation Ventilation defect “Problem with breathing” Rib fractures – pain Paralysis of breathing muscles eg GBS / SCI Anaesthetics - during / after surgery To maintain open airway in case of obstruction Oxygenation defect “Problem / disease of the lung” Eg ARDS / Pulmonary oedema / BrPn Lung contusion Cardiac failure Respiratory failure Neuromuscular disease / head injury Decrease ICP due to hyperventilation - Vasoconstriction Post operatively  Methods of Intubation Endotracheal tube Oropharyngeal Most common method From mouth to airway Nasopharyngeal From nose to airway Tracheostomy Opening in the trachea Long term ventilation Ventilator Ventilation Pressure Volume FiO2 Rate AC PEEP SIMV FiO2 Rate PEEP CPAP PSV FiO2 PEEP FM PSV https://www.googleimages/emojicrying https://www.googleimages/emojihappy  Modes of Ventilation Pressure Support Ventilation (PSV) Continuous Positive Airway Pressure (CPAP) Synchronised Intermittent Mandatory Ventilation (SIMV) Loading… Assist Control (AC)  PEEP Positive End Expiratory Pressure Alveolar pressure at end of expiration is above atmospheric pressure Open collapsed alveoli Increase surface area of alveoli Increase surface for oxygenation Too much PEEP – capillaries injured  PSV Pressure support ventilation Patient triggers breath – supported by ventilator by positive pressure Throughout inspiration airway pressure is held at pre-set level Pre-set pressure level selected to maintain Tidal Volume of 6 – 8ml/kg Often used in conjunction with SIMV Decrease work of breathing Decrease respiratory failure Increase patient comfort  CPAP Spontaneous breathing Positive pressure maintained throughout respiratory cycle Patient not generating negative airway pressure to receive oxygen ET tube or Mask Maintain Functional residual capacity and good oxygenation in spontaneously breathing patients  SIMV Ventilator deliver gas at pre-set rate Volume controlled (6-8ml/kg) Pressure controlled Allow patient to breath spontaneously Often used with PSV Most common mode after surgery Maintain breathing during surgery / sedation Used as weaning mode  AC Patient sedated and paralysed No spontaneous breaths Ventilated at pre-set rate Pressure controlled Pre-set Peak inspiratory airway pressure can not be exceeded Tidal volume uncontrolled – depend on lung compliancy Recruit collapsed alveoli Limiting PIP may decrease barotrauma As compliance improves, tidal volume will increase Volume controlled Pre-set tidal volume Minute volume guaranteed (VT x RR) No control of PIP May cause barotrauma  Other Methods of Ventilation High Frequency Oscillatory Ventilation HFOV Oscillation of continuous distending pressure Rate of 3 – 15 Hz Stable CPAP with control of ventilation at high rate and small tidal volume Sedated / paralysed Extracorporeal membrane oxygenation ECMO Blood continuously pumped from patient through membrane oxygenator Imitates gas exchange to add O2 Extracorporeal carbon dioxide removal ECCO2R Imitates gas exchange to remove CO2 Ventilation Pressure Volume FiO2 Rate AC PEEP SIMV FiO2 Rate PEEP CPAP PSV FiO2 PEEP FM PSV https://www.googleimages/emojicrying https://www.googleimages/emojihappy Ventilator Ventilator Ventilator  Complications of Ventilation Infection Sinusitis Barotrauma Alveolar rupture Mean airway pressure more than 30 cmH2O Atelectasis Tracheal injury Ventilator dependency Sputum retention Ineffective cough Peripheral and respiratory muscle weakness Increase FiO2 can cause broncho-pulmonary dysplasia  Weaning from Mechanical Ventilation Process of decreasing & withdrawing the ventilator support Time consuming – 40% of ICU stay Multidisciplinary team approach Classification: Simple weaning Passes initial SBT, successfully extubated with 1st attempt Difficult weaning Up to 3 SBT or 7 days after 1st SBT extubated Prolonged weaning > 3 SBT’s or > 7 days after 1st SBT extubated  Factors Influencing Weaning Respiratory load Increase WOB – inappropriate ventilator settings Bronchoconstriction Phrenic nerve injury Reduced compliancy (pneumonia, pulmonary fibrosis, pulmonary haemorrhage) Increase airway resistance (ETT, glottis oedema, increase secretions Cardiac load Cardiac dysfunction prior to critical illness Unresolved sepsis Dynamic hyperinflation of lungs (COPD) Myocardial dysfunction due to increased cardiac workload  Factors Influencing Weaning Neuromuscular Depressed central drive (sedatives) Brainstem strokes Peripheral dysfunction (CIM, CIP) Psychological Delirium Anxiety, depression Metabolic Electrolyte disturbances Corticosteroids Low albumin Anaemia and low haematocrit VIDD  Pathophysiology of Difficult Weaning Multifactorial Success depends on the ability of respiratory muscle pump to cope with load Decrease force generating capacity of the respiratory muscles VIDD: Ventilator induced diaphragmatic dysfunction 18-69 hours of mechanical ventilation Critical Illness Polyneuropathy / myopathy = ICUAW 25% of patients ventilated > week  Criteria for Weaning Trial Reason for intubation reversed Cardiovascular stability HR < 140 b/min SBP 90-160 mmHg Minimal inotropic support Stable metabolic status Respiratory system Adequate cough Absence of excessive secretions FiO2 60 PaO2/FiO2 ratio > 150 RSBI < 105 b/min/L  Predictors of Successful Extubation Spontaneous Breathing Trial (SBT) Golden standard T-piece or ventilator with pressure support 30 min – 120 min Maximum Inspiratory Pressure (MIP < 20-25 cmH2O) Represents maximum pressure during inhalation against an obstructed airway Assess inspiratory muscle strength Greater sensitivity and specificity than RSBI Rapid Shallow Breathing Index (RSBI) Ratio of respiratory rate and spontaneous tidal volume f/VT < 105 Cough strength, handgrip strength, heart rate variability All used in combination Signs of Failed Weaning Respiratory rate > 35 b/min SpO2 < 90% Heart rate > 130 b/min Clinical signs of respiratory distress Sweating Agitation Loading… Depressed mental status  Failed Extubation Need of re-intubation within 48-72 hours post planned extubation Statistically 10% - 20% of successful SBT fail extubation Increase mortality rate – 25% - 50% Reasons: CCF Ineffective cough with airway secretions Upper airway obstruction New onset of sepsis Consequences: Damage to vocal cords with repeated intubation Increase need for tracheostomy Increase risk of nosocomial pneumonia, ICU stay, Mortality Non-invasive positive pressure ventilation (NIPPV) High flow nasal cannula (HFNC)  Prolonged Mechanical Ventilation Ventilation > 48 hours Detrimental to human body Increase risk of developing nosocomial infections, Increase ICU length of stay Increase hospital length of stay Increase financial expenditures Increase development of critical illness myopathy / polyneuropathy Decrease functional ability and quality of life 5 years post ICU discharge Extubation Original reason for intubation resolved Weaning criteria met Effects of anaesthesia & other respiratory depressant no longer exists Patient able to maintain airway Awake Cough Suctioning Should NEVER be routine – when indicated Indications Remove retained secretions Crepitations on auscultation Visible secretions in airway Inability to cough effectively Suspected aspiration of gastric / upper airway secretions Deterioration ABG’s X-ray changes Increased WOB - plugging Obtain sputum specimen Luki Mucous extractor Maintain patency of tube Stimulate patient’s cough Suction: Parameters to Monitor SpO2 – pulse oximeter Respiratory rate / pattern Pulse Blood pressure Sputum characteristics Cough effort Intracranial pressure (if indicated) Ventilator parameters ↑RR ↑PIP ↓VT Suction: Adverse Reactions Hypoxaemia Principle complication Reduce through pre-oxygenation Mucosal damage / atelectasis / bleeding Excessive negative pressure Excessive duration of procedure Adults: -80 - -120mmHg Paeds: -80 - -100mmHg Neonatal: -60 - -80mmHg Cardiac Arrythmias Stimulation of n. Vagus → cardiac arrest, dysrhythmia, BP changes & ↓RR Infection Increase ICP Loss of PIP / PEEP Relative Contraindications Hypoxaemia / hypoxia Mucosal trauma Cardiac / respiratory arrest Uncontrolled cardiac arrhythmias Bronchospasm not relieved with nebulisation Frank haemoptysis Increase ICP Interruption of high levels of PEEP ↑ / ↓ BP (more than 20% of base) Effect Post Suctioning Increase breath sounds on auscultation Decrease PIP Increase Tidal volume Increase SpO2 Increase oxygenation on ABG Removal of secretions Suction: Catheter Size Children Not more than ½ diameter of ET-tube Adults Not more then 2/3 diameter of ET-tube Size New born < 1kg → 5 New born 1 - 3kg → 6 New born > 3kg → 7 6 months → 6 - 8 18 months → 8 2-5 years → 8 - 10 6-16 years → 10 Adults → 10, 12, 14 Nasopharyngeal Suction Indications same as intubated Weakness Semi consciousness Precautions: Stridor CSF leak / post skull fracture – increase ICP & infection Clotting disorder Pulmonary oedema Bronchospasm Recent pneumonectomy – not further than larynx – damage bronchial stump Recent oesophagectomy – miss trachea – damage oesophageal anastomosis Suction Equipment Correct size catheter Saline (10 ml in syringe) Sterile water to rinse open suction catheter Sterile gauze to clean open suction catheter Goggles and mask Sterile alcohol swab Clean gloves Suction device Yankauer Suction Procedure Cuff pressure 18,5 – 25 cmH2O Always explain procedure to patient Intubated Sterile Close (catheter in protective sheath – remains attached to ET-tube / tracheostomy) Extubated Lavage (Saline) Adults 10ml Clean Infants 1-3ml Pre and post oxygenation Depths of insertion Elicit cough reflex No cough reflex – insert catheter to end point and withdraw 1cm before suction Duration of suction 10 – 15 seconds Apply suction while removing catheter – rolling between fingers ET / Trachy → Nose → Mouth  Questions?? https://www.googleimages/questionmark/clipart.com  References Main E, Denehy L. Cardiorespiratory physiotherapy; adults and Paedistrics. 5th ed. Elsevier; 2016. Van Aswegen H & Morrow B. Cardiopulmonary physiotherapy in Trauma. An evidence-based approach. 1st ed. Imperial College Press; 2015. Van Aswegen lecture notes Physiotherapy in ICU course 2011. www.googleimages.com Creative studios Prinshof – M. Booyens for images Mikkelsen M, Still M, Anderson B, Bienvenu O, Brodsky M, Brummel N et al. Society of Critical Care Medicine’s International consensus conference on prediction and identification of long-term impairments after critical illness. Crit Care Med. 2020;48:1670-1679. Fuke R, Hifumi T, Kondo Y, Hatakeyama J, Takei T, Yamakawa K et al. Early rehabilitation to prevent postintensive care syndrome in patients with critical illness: a systematic review and meta-analysis. BMJ Open. 2018;8:e019998. Inoue S, Hatakeyama J, Kondo Y, Hifumi T, Sakuramoto H, Kawasaki T et al. Post-intensive care syndrome: its pathophysiology, prevention and future directions. Acute Medicine & Surgery. 2019;6:233-246. Marcshall JC, Bosco L, Adhikari NK, Connolly B, Diaz JV, Dorman TD et al. What is an intensive care unit? A report of the task force of the World Federation of Societies of Intensive and Critical Care Medicine. J Crit Care.