Mechanical Ventilation of the Adult

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15 Mechanical Ventilation of the Adult

Note 1: This book is written to cover every item listed as testable on the Entry Level Examination (ELE), Written Registry Examination (WRE), and Clinical Simulation Examination (CSE).

The listed code for each item is taken from the National Board for Respiratory Care (NBRC) Summary Content Outline for CRT (Certified Respiratory Therapist) and Written RRT (Registered Respiratory Therapist) Examinations (http://evolve.elsevier.com/Sills/resptherapist/). For example, if an item is testable on both the ELE and the WRE, it will be shown simply as: (Code: …). If an item is testable only on the ELE, it will be shown as: (ELE code: …). If an item is testable only on the WRE, it will be shown as: (WRE code: …).

Following each item’s code will be the difficulty level of the questions on that item on the ELE and the WRE. (See the Introduction for a full explanation of the three question difficulty levels.) Recall [R] level questions typically expect the exam taker to recall factual information. Application [Ap] level questions are harder because the exam taker may have to apply factual information to a clinical situation. Analysis [An] level questions are the most challenging because the exam taker may have to use critical thinking to evaluate patient data to make a clinical decision.

Note 2: A review of the most recent ELEs has shown that an average of 43 questions (out of 140), or 31% of the exam, cover mechanical ventilation of the adult. A review of the most recent WRE has shown that an average of 23 questions (out of 100), or 23% of the exam, cover mechanical ventilation of the adult. The CSE is comprehensive and may include everything that should be known by an advanced level respiratory therapist.

MODULE A

1. Ventilator flow, volume, and pressure waveforms

a. Review the patient’s chart for information on airway graphics (Code: IA7c) [Difficulty: ELE: R; WRE: Ap]

A patient who has been intubated and placed on a modern mechanical ventilator with a microprocessor and graphics software can have ventilator flow, volume, and pressure waveforms visualized on the monitor, stored in memory, or printed out. Look for this information and compare it with the patient’s current situation. See Figure 15-1 for examples of pressure, volume, and flow tracings. See Figure 15-2 for key points of information available from a flow vs. time graph.

c. Select ventilator graphics (Code: IIID3) [Difficulty: ELE: R, Ap; WRE: An]

The operator typically can select any two of the following for display on the monitor: time, flow, pressure, and/or volume. Certain combinations are selected to best present the needed information. For example, air trapping is best shown by comparing flow vs. time (Figure 15-3) peak and plateau pressures are best shown by comparing pressure vs. time (Figure 15-4), and lung inflection points are best shown by comparing volume vs. pressure (discussed later). Note examples of ventilator graphics throughout this chapter.

2. Review the patient’s chart for information on the work of breathing (Code: IA7d) [Difficulty: ELE: R; WRE: Ap]

Work of breathing (WOB) normally refers to how much energy the patient has to expend to inhale. Patients with stiff lungs or high airway resistance or both have an increased WOB. Exhalation normally is passive and requires no work. However, some patients with high airway resistance have to work to exhale. Look in the patient’s chart for information on patient complaints of shortness of breath and easy tiring as signs of increased WOB.

A patient who has been intubated and placed on a modern mechanical ventilator with a microprocessor and graphics software can have WOB measured. See Figure 15-5 for a pressure/volume loop tracing that shows a patient’s WOB. WOB is minimized when the ventilator is set to minimize the negative pressure and inspiratory flow the patient has to generate.

If the breathing of an intubated and ventilated patient appears to be unsynchronized with the ventilator, his or her WOB should be evaluated. Ask the conscious patient simple questions to try to determine what the problem is. Observe the patient for use of accessory muscles as a sign of increased WOB. If the ventilator is capable, program it to perform a pressure/volume loop of the patient’s WOB. Be prepared to adjust parameters such as the machine’s sensitivity and inspiratory flow to minimize the patient’s workload.

3. Airway resistance

c. Determine the patient’s airway resistance (Code: IB9n) [Difficulty: ELE: R, Ap; WRE: An]

Most of the microprocessor ventilators offer software for calculating all of these values. However, in other situations, they must be calculated manually.

1. Procedure for calculating airway resistance

4. Auto-PEEP detection

a. Perform the procedure to detect auto-PEEP (WRE code: IB9w) [Difficulty: WRE: R, Ap, An]

Auto-PEEP is positive end-expiratory pressure in the lungs that cannot be seen on the ventilator’s pressure manometer. (The terms inadvertent PEEP and intrinsic PEEP also are used.) Auto-PEEP is caused by air trapping resulting from an inadequate expiratory time. It becomes more likely when the inspiratory time is increased or the expiratory time is decreased, or in patients with long time constants of ventilation. Simply put, the next breath is delivered before the patient has exhaled completely (see Figure 15-3). This problem is seen frequently in patients with status asthmaticus or COPD because of early small airway closure. In patients with acute respiratory distress syndrome (ARDS) who are receiving pressure-controlled inverse ratio ventilation (PCIRV), the long inspiratory times used increase the risk of expiratory air trapping. Auto-PEEP is more likely to be found when the inspiratory/expiratory (I : E) ratio becomes 2 : 1 or greater.

The level of auto-PEEP can be determined in different ways, depending on the type of ventilator that is being used. It can be measured on the pressure manometer of most ventilators. The trapped expiratory gas also can be seen on the graphic display of all current generation microprocessor-type ventilators. The following procedure can be followed for determining the presence or level of auto-PEEP:

It is important to add any auto-PEEP to the amount of therapeutic PEEP the patient has. This should be recorded as the total PEEP. For example, the patient has 5 cm of therapeutic PEEP and 2 cm of auto-PEEP for 7 cm of total PEEP. It may be thought that the total PEEP level places the patient at risk for volutrauma or decreased venous return and lowered cardiac output. The amount of auto-PEEP can be reduced by decreasing the inspiratory time, increasing the expiratory time, or decreasing the tidal volume. Lack of auto-PEEP can be confirmed by this procedure. If the auto-PEEP cannot be eliminated, therapeutic PEEP can be added to match it. By increasing the baseline pressure, the patient can more easily trigger an assisted or synchronous intermittent mandatory ventilation (SIMV) breath. It is especially important to decrease auto-PEEP and therapeutic PEEP levels as the patient’s lung compliance improves and airway resistance returns to normal.

b. Interpret ventilator graphics to detect auto-PEEP (WRE code: IB10w) [Difficulty: WRE: R, Ap, An]

Figure 15-3 demonstrates two ways that air trapping on exhalation can be identified as auto-PEEP (unintended positive end-expiratory pressure). Note in Figure 15-3 (bottom) that the patient’s expiratory flow does not reach baseline pressure before another breath is delivered. This proves that air trapping has occurred. The larger the gap between the pressure at the end of expiration and at baseline, the greater is the air trapping.

6. Lung compliance

c. Determine the patient’s plateau pressure and lung compliance (Code: IB9n) [Difficulty: ELE: R, Ap; WRE: An]

Most microprocessor ventilators offer software that can be used for calculating all of these values. However, in other situations, they must be calculated manually, as follows.

1. Procedure for calculating the tubing compliance factor

Before the actual calculation of the patient’s static and dynamic compliance can be performed, the compliance of the breathing circuit should be determined. During positive-pressure ventilation, some of the set tidal volume never reaches the patient because it is “lost” in the circuit. Remember that when a positive-pressure breath is delivered, the ventilator circuit will be expanded and the gas within the tubing will be compressed. The term compressed volume is commonly used to describe this lost volume. Subtract the compressed volume from the exhaled volume coming from the ventilator to determine the patient’s actual tidal volume. (Some of the current generation of microprocessor ventilators will calculate the compressed volume. The therapist can have the ventilator compensate for the lost volume and deliver a tidal volume that meets the set volume on the ventilator.)

For greatest accuracy in the calculation of static and dynamic compliance and the calculation of actual tidal and sigh volumes, any lost volume must be subtracted from the exhaled tidal volume to find the actual tidal volume. The tubing compliance factor is used in the calculation to determine the compressed volume, through the following procedure:

3. Procedure for calculating dynamic compliance

5. Calculate the dynamic compliance (Cdyn) by using this formula:

image

in which compressed volume is Compliance factor × Peak pressure.

7. Interpret the patient’s lung mechanics results: plateau pressure, airway resistance, dynamic lung compliance, and static lung compliance values on the ventilator (Code: IB10n) [Difficulty: ELE: R, Ap; WRE: An]

Any increase in airway resistance or decrease in lung compliance or both creates an increase in the patient’s WOB. Examples of conditions or situations in which an increased airway resistance is found include bronchospasm, secretions, mucosal edema, airway tumor, placement of a small endotracheal tube, and biting or kinking of the endotracheal tube. Lung compliance is decreased by pneumonia, pulmonary edema, ARDS, pulmonary fibrosis, atelectasis, consolidation, hemothorax, pleural effusion, air trapping, pneumomediastinum, and pneumothorax. Examples of chest wall and abdominal conditions that reduce compliance include various chest wall deformities, circumferential chest or abdominal burns, enlarged liver, pneumoperitoneum, peritonitis, abdominal bleeding, herniation, and advanced pregnancy. Correction of the problem should return the patient’s ventilator pressure(s) to baseline and normalize the patient’s WOB.

Six possible combinations of increasing or decreasing static and dynamic lung compliance exist. Each has its own possible causes and is discussed in turn. The patient must be passive on the ventilator for the measured values to be accurate. Check two or three breaths for increased accuracy. Let the patient have a normal breath or two between each of the peak and plateau pressure measurement breaths.

e. False increased dynamic compliance with true increased static compliance

False increased dynamic compliance with true increased static compliance is noticed as a decrease in both peak and plateau pressures (Figure 15-10). This is seen when the patient’s lung/thoracic compliance improves. The plateau pressure decreases, and, as an artifact, the peak pressure also decreases. Notice that the difference between peak and plateau pressures remains the same. This indicates that the patient’s airway resistance is unchanged.

f. True increased dynamic compliance with true increased static compliance

True increased dynamic compliance with true increased static compliance also is noticed as a decrease in both peak and plateau pressures (Figure 15-11). This is seen when the patient’s airway resistance and his or her lung/thoracic compliance improve. Notice that the plateau pressure has decreased, thus indicating more compliant lungs. Also notice that the difference between peak and plateau pressures has decreased. This demonstrates that the airway resistance also has decreased.

All six examples of increasing or decreasing static or dynamic lung compliance or both make use of a single tidal volume that is analyzed for peak and plateau pressures. Some practitioners advocate using several different tidal volumes (e.g., 8, 10, and 12 mL/kg of ideal body weight) when measuring dynamic and static pressures. The measured values are plotted on a graph to find the patient’s optimal tidal volume that results in the highest static compliance value. Figure 15-12 shows a series of these graphs. The curves for diseased lungs and airways are quite different from those of a normal person or a patient with a pulmonary embolism. Because of this, a pulmonary embolism should be considered if the patient’s condition deteriorates rapidly and no change in dynamic or static compliance values is observed.

MODULE B

Conventional mechanical ventilation is defined here as the use of a single ventilator that can provide the customary modes and options needed by the large majority of patients. This ventilatory support is provided through an endotracheal tube or a tracheostomy tube. Several physiologic criteria have been compiled to help the clinician determine when a patient is in respiratory or ventilatory failure (Box 15-1) and needs ventilatory support. Remember that the patient may not fail each and every criterion; however, the patient often will fail one or more criteria in each category.

1. Perform the following procedures to make sure that the patient is adequately oxygenated

b. Administer oxygen, as needed, to prevent hypoxemia (ELE code: IIID6) [Difficulty: ELE: R, Ap, An]

Oxygen administration and adjustment were discussed in Chapter 6. In brief, the goal of oxygen administration is to keep the Pao2 level of most patients between 60 and 90 torr and the Spo2 level greater than 90%. Exceptions are the patient with COPD who is breathing on hypoxic drive and the patient who is in a cardiac arrest situation. The following formula can be used to help guide the use of supplemental oxygen in most stable patients:

image

Those patients who have refractory hypoxemia (e.g., ARDS) will not respond with a normal increase in Pao2 level as the oxygen percentage is increased. In the short term, use whatever oxygen percentage is needed to achieve the clinical goal. The risk of oxygen toxicity increases when the Fio2 is greater than 0.5 for periods of longer than 48 hours. Always recheck the patient’s arterial oxygen level after a change in the Fio2 has been made.

Either of the following formulas can be used in the special situation of determining the flows of air and oxygen into a “bleed-in” type of intermittent mandatory ventilation (IMV) or continuous positive airway pressure (CPAP) system to obtain an ordered Fio2. Either version can be used for determining gas flows, total flow, and oxygen/air ratio through an air entrainment (Venturi) mask.

The first formula follows:

image

The second formula follows:

image

in which F1 is the flow of first gas (oxygen), C1 is the concentration of oxygen in the first gas (1.0 for pure oxygen), F2 is the flow of second gas (air), C2 is the concentration of oxygen in the second gas (0.21 for air), FT is the total flow of both gases, and CT is the concentration of oxygen in the mix of both gases. Use algebraic manipulation to solve for the unknown.

2. Initiate and adjust continuous mechanical ventilation settings (Code: IIID2b) [Difficulty: ELE: R, Ap; WRE: An]

b. Flow

Flow is adjusted to set the inspiratory time and the I : E ratio. In addition, flow is set to meet the patient’s needs. Inspiratory flow should be great enough to minimize the WOB. Increase flow if the patient has signs of greater demand, such as using accessory muscles of inspiration or lack of synchrony with the ventilator, or if the pressure manometer deflects greatly below the baseline pressure or shows a low initial increase in inspiratory pressure.

In addition, most current generation ventilators offer more than one inspiratory flow pattern (see Figure 15-1). The sine wave is most physiologically like a normal, spontaneous inspiration. The other waveforms can be compared with the sine wave to determine which one best meets the patient’s needs. Ideally, the best flow pattern is one in which the patient’s peak and mean airway pressures are lowest, exhalation is complete, breath sounds are improved bilaterally, heart rate and blood pressure are stable, and the patient feels most comfortable.

f. Modes of ventilation

The following modes of ventilation are delivered through most types of electrically powered and microprocessor-type volume-cycled ventilators.

1. Control

Control (C) is the simplest method of providing ventilatory support and is used on an apneic patient. The ventilator is set with a mandatory respiratory rate and tidal volume. The machine is incapable of allowing any patient interaction. For example, the ventilator might be set to deliver a tidal volume of 700 mL at a rate of 14 times/min. Because of this limitation, it is rarely, if ever, used in modern medicine except when the patient must be kept sedated or pharmacologically paralyzed (Figure 15-13 shows the pressure/time curve).

image

Figure 15-13 Pressure vs. time waveforms for various modes of mechanical ventilation. A, Control (C) mode shows no patient effort and consistent inspiration/expiration ratios. B, Assist/control (A/C) mode shows that patient’s initial effort triggers machine tidal volume breath. C, Intermittent mandatory ventilation (IMV) mode shows spontaneous tidal volume breaths occurring between predetermined machine tidal volume breaths. Note “stacked” breaths that happen when patient takes in a breath that then is supplemented by a machine breath. D, Synchronous intermittent mandatory ventilation (SIMV) mode shows that a patient effort within a time window results in delivery of machine tidal volume. Any other patient efforts within the time window result in a spontaneous tidal volume. If no patient efforts occur within the time window, machine tidal volume will be delivered automatically. E, Pressure support ventilation (PSV) mode shows how patient must initiate all breaths that then are supported to the predetermined airway pressure. Stable tidal volumes are seen if the patient inhales passively. Variably larger tidal volumes result if the patient inhales more actively. F, Positive end-expiratory pressure (PEEP) therapy can be added to A/C mode (as shown) or any other mode. The elevated baseline pressure prevents alveolar collapse. The sensitivity control must be set at −1 to −2 cm water so that the patient is able to trigger a breath without undue effort. G, Continuous positive airway pressure (CPAP) shows that the patient takes spontaneous tidal volumes while exhaling against an elevated baseline pressure.

4. Synchronous intermittent mandatory ventilation

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