Mechanical Ventilator - PTY262 - Physiotherapy Management

PHYSIOTHERAPY MANAGEMENT IN CARDIORESPIRATORY DYSFUNCTION II PTY262 MECHANICAL VENTILATOR RABIATUL ADAWIAH ABDUL RAHMAN Lecturer Physiotherapy Programme UiTMCPP Kampus Bertam...

PHYSIOTHERAPY MANAGEMENT IN CARDIORESPIRATORY DYSFUNCTION II PTY262 MECHANICAL VENTILATOR RABIATUL ADAWIAH ABDUL RAHMAN Lecturer Physiotherapy Programme UiTMCPP Kampus Bertam 1  Course Learning Outcomes At the end of the course, students should be able to: CLO1 Determine the various modalities and monitoring system used in surgical and critical care unit. (PLO2, C4) CLO2 Explain the different types of surgery in thoracic wall, lung, heart, and abdominal wall surgery in surgical and critical care unit. (PLO5, A3) CLO3 Demonstrate the pre and post-operative physiotherapy assessment and management in surgical and critical care units. (PLO3, P3)  Topic Learning Outcomes At the end of the session, students should be able to: 1. Outline the indications and rationale for using MV 2. Differentiate the different modes of MV 3. Describe physiological effect of ventilator on respiratory and cardiovascular system  Lecture Content Invasive. Noninvasive Principles of mechanical ventilation and weaning Physiological effect of ventilator on respiratory and cardiovascular system.  Definition: Mechanical Ventilator A mechanical ventilator is a machine that takes over the work of breathing when a person is not able to breathe enough on their own. The mechanical ventilator is also called a ventilator, respirator, or breathing machine. (American Thoracic Society, 2020)  Definition: Mechanical Ventilation Mechanical ventilation is a form of life support which mechanically assist or replace spontaneous breathing. It is utilized in intensive care and long-term care settings to assist patients who require additional respiratory support. (American Thoracic Society, 2020)  Introduction Ventilators are used in patients undergoing general anaesthesia & in most patients requiring intensive care Modern ventilators provide a wealth of different modalities to cater for patients from the most critically ill through the weaning process to extubation. Mechanical ventilation Non - invasive (if patient can protect airway and is hemodynamically stable) Mask: usually orofacial to start Invasive Endotracheal tube (ETT) Tracheostomy – if upper airway is obstructed long term  tak culmp On GCS 18 ? ↑ - > Indication for Mechanical Ventilation Cardiac or respiratory arrest too high Tachypnea or bradypnea with respiratory fatigue or impending arrest Acute respiratory acidosis Retention (U2 Refractory hypoxemia (when the PaO2 could not be maintained above 60 mm Hg with inspired O2 fraction) well-balanced not Inability to protect the airway associated with depressed levels of consciousness. n use invansive  Indication for Mechanical Ventilation Shock associated with excessive respiratory work Inability to clear secretions with impaired gas exchange or excessive respiratory work Newly diagnosed neuromuscular disease with a vital capacity atmospheric pressure 1. Negative pressure ventilators (iron lung) vacuum like 2. Positive pressure ventilators  Principles of ventilation Inspiration may be generated by application of either a constant pressure or a constant flow of gas to the lungs. Expiration is allowed when either a set pressure has been reached, a set volume has been delivered, or a set time has passed p = Veovaries  TERMS norm-12-16 kita tentukan http://www.nursingcenter.com (2020) http://www.nursingcenter.com (2020) http://www.nursingcenter.com (2020) http://www.nursingcenter.com (2020) Airway Management Endotracheal Tube (ETT) Can be placed orally (most common) or nasally Passes through the vocal cords Airway Management Tracheostomy tube Cuff or cuff less Inserted below the vocal cords Used in more long-term airway management Ventilator Settings Tidal Volume PEEP Mode (type of assist given by vent) Rate (Breaths per minute.Adjusted based on patient’s own respiratory rate) FiO2 (amount of O2 being delivered)  Actual respiratory rate Type of respiration Mode Set respiratory rate FiO2 PEEP PEEP Prevent collapse Positive End-Expiratory Pressure ↑ Pressure given in expiratory phase to prevent closure of the alveoli and allow increased time for O2 exchange Used in pts who haven’t responded to treatment and are requiring high amount of FiO2 PEEP will lower O2 requirements by recruiting more surface area Normal PEEP is approximately 5cmH20. Can be as high as 20cmH20 OxygenTherapy Prolonged exposure to high levels of oxygen can be toxic to the lungs High FiO2 (>.5) can lead to atelactasis Balancing act between FiO2 and PEEP  side h Adverse Effects of Positive MV Hemodynamic effects ✓Reduced venous return ✓Reduced Co ✓Reduced renal perfusion ✓Reduced B/P  Pulmonary effects ✓Increased V/Q ratio & dead space /tidal volume ratio ✓Air trapping ✓Barotrauma ✓Increased WOB Bila machine tolon jadi muscle relat lama ✓Respiratory muscle weakness - > ✓Infection – aspiration & suctioning  Others effects ✓ increased used of sedatives agents ✓Invasive measures – feeding tubes , arterial line ✓Increased ICP ✓Decreased mobility Modes ofVentilation coma/paralysed Controlled Mandatory Ventilation (CMV) Vent initiates all breaths at a pre-set rate and tidal volume Patient has no control over ventilation Vent will block any spontaneous breaths Used mainly in the OR for paralyzed and sedated patients. control mainly by machine Modes ofVentilation Assist Control (A/C) Vent will allow a patient to initiate a breath and then vent will deliver a pre-set tidal volume Machine set at a minimum rate so apnea will not occur if the patient does not initiate a breath Disadvantages: Hyperventilation if patient has increased respiratory rate (can lead to respiratory alkalosis) Vent dysynchrony, breath-stacking Assist Control (A/C) “Breath-Stacking” Modes ofVentilation Synchronized Intermittent Ventilation (SIMV) Similar to A/C, but patients can take own breaths with their own TV between mechanically assisted breaths Can be used as a primary mode or a weaning mode May lead to a low respiratory rate in a patient who does not initiate breaths if set rate is low SIMV Modes ofVentilation Pressure Support Ventilation (PSV) Also called “spontaneous mode” Pt initiates breath & vent delivers a pre-set inspiratory pressure to help overcome airway resistance and keeps airways open Patient controls the rate, tidal volume, and minute ventilation Tidal volume is variable Can be used in conjunction with SIMV or CPAP settings Pressure Support (PS) Modes ofVentilation Continuous Positive Airway Pressure (CPAP) Positive airway pressure provided during both inspiration and expiration Vent provides O2 and alarms, but no respirations Improves gas exchange and oxygenation in patients able to breathe on their own Can also be used non-invasively via a face or nasal mask for patients with sleep apnea  Non-Invasive Ventilation Ventilation with out an endotracheal tube or tracheostomy tube can be termed as non-invasive ventilation. 1. CPAP 2. BIPAP 3. IPPV /IPPB  Continuous positive airway pressure (CPAP) Oxygen delivered by a ventilator mode or through a separate system. In this positive pressure maintained through out inspiration & expiration Useful in cases where lung volumes are reduced, in particular the functional residual capacity (subsegmental collapse,pneumonia & acute respiratory distress syndrome)  Bi-Level Airway pressure (BiPAP) Delivered by mask, not through an airway Similar to CPAP, but can be set at one pressure for inhalation and another for exhalation. Used in sleep apnea, but also has been found to be useful in patients with CHF and respiratory failure to avoid intubation  Intermittent positive pressure breathing (IPPV/IPPV) Intermittent positive pressure breathing or ventilation is a pressure-cycled ventilator that when triggered by a patients inhalation, delivers ambient air or oxygen to the patient until a preset pressure is reached It is basically a lung expansion device that helps deliver an increased tidal volume  Purpose To increase alveolar ventilation Improve ventilation-perfusion ratio Mobilise & facilitate expectoration of thick secretion Decrease the work of breathing Deliver aerosolised medications  Contraindications Pneumothorax Large bullae Lung abscess as the size of air space may increase Severe haemoptysis Bronchial tumor in the proximal airways ALARM MANAGEMENT & PRECAUTION Alarm are important indicators of change in patient condition or a machine malfunction Most common alarms are those that monitors high & low pressure, Fio2, apnea, disconnection. Precaution in physiotherapy treatment ????? WEANING weaning is the process of reducing or removing ventilatory support. Most optimal time for weaning is early morning. Conventional weaning criteria involve 1. Clinical, 2. Mechanical 3. Biochemical parameters  Clinical The clinical condition of the patient is improving The patient is cooperative & alert and able to clear the secretions There is no abdominal distension, cardiovascular instability or likelihood of prolonged ventilation  Mechanical Vital capacity more than 15ml/kg Maximal inspiratory mouth pressure is more than 20cm of water Minute volume is less than 10 l/min  Biochemical Normal PH & Paco2 Pao2 more than 60mm Hg on no more than 40 % oxygen & 5 cm PEEP. Once the above criteria are satisfied, weaning may be started.  Before & during the weaning period, meticulous attention needs to be paid to nutrition, electrolyte status, control of infection, bronchospasm & mobilization of the patient Mobilization of the patient is the important factor to be considered by physiotherapist. Physiotherapist will be involved in making the pt sitting, standing & walking with extreme care taken for the line, tubes & catheters Weaning can be performed in 2 ways 1. Proportion of the breathing performed by the ventilator can be gradually reduced, letting the patient perform a greater & greater breathing until he is independent of the ventilator (with the help of IMV). 2. The patient can be allowed to breathe spontaneously for progressively longer periods with full ventilation between them Weaning parameters Adequate Oxygenation PaO2 >60-70 on FiO2.4 to.5,PEEP 5-8cmH20 PaO2/FiO2 ratio >150-200 AdequateVentilation PaCO2 35-45mmHg pH 7.3 to 7.45 Weaning parameters Adequate Respiratory Mechanics TidalVolume Respiratory Capacity MinuteVentilation Hemodynamic Stability Spontaneous Breathing Trials (SBT) Spontaneous breathing trials (whether single or multiple trials) lead to extubation more quickly than those receiving Pressure Support and IMV for weaning purposes in patients who are mechanically ventilated for > 1 week Weaning parameters Signs of distress during weaning… Increased tachypnea (>30) Increased heart rate Irregular breathing pattern or use of accessory muscles Agitation or panic unrelieved by assurance Decrease pH to less than 7.25-7.3 with increasing PCO2 Problems encountered while weaning Impaired ventilatory drive Upper & lower airway incompetence, obstruction or secretions Lung parenchymal fluid or infection Pleural effusion or pneumothorax Chest wall abnormality, instability or respiratory muscle weakness Electrolyte or nutritional problems Cardiovascular insufficiency Mobilizing the Patient requiring Mechanical Ventilation Patients weaning from mechanical ventilation Consider each patient’s case and determine their ability to tolerate both spontaneous breathing trials (SBTs) and rehab sessions May be optimal to treat prior to SBT or after they are rested Consider mobility and strengthening first, then weaning Ambulating a Patient on Mech Vent Requires teamwork with the entire medical team Most standard ventilators do not run on battery. Will likely need to use a portable ventilator or an ambu-bag to ventilate the patient while mobilizing Ambulating a Patient on Mech Vent ETT placement Make sure tape is secure prior to moving patient!!! Look at cm mark at lip before and after treatment to assure no movement had occurred May want to talk with team if patient has an FiO2 of.60 or greater and/or if PEEP is -10cm H2O or greater to ensure medical stability Steps to Mobilization… Look at BaselineVitals… Steps to Mobilization… Look at Baseline Vent Settings… Steps to Mobilization… Locate all, wires, tubes, etc. Steps to Mobilization… Move IV pole and lines to the side you are getting up on (usually towards the vent) Steps to Mobilization… Assist patient to sitting at the side of the bed towards the vent, making sure that all lines are accounted for and have enough slack Steps to Mobilization… Transfer to the chair while managing lines to ensure clearance Steps to Mobilization… Try to consolidate equipment together as best as you can Steps to Mobilization… Coordinate with medical team to place on portable vent (if necessary) Steps to Mobilization… Organize as much as you can to have all lines in front of the patient. Make sure no lines are on the floor or can get caught in the equipment. Steps to Mobilization… Supports lines, vent/IV pole and vent tubing along with assisting the patient Steps to Mobilization… Have a tech or nurse follow with a wheelchair for safety Steps to Mobilization… Always ensure that you have control of all lines and vent tubing/ETT with all transfers and movement of the patient