Learning Module For

Mechanical Ventilation – Maintenance and Weaning Post Entry Level Competency for RNs and LPNs in designated areas

Revised by:

Revision Date:

Mechanical Ventilation Initiation, Maintenance and Weaning Learning Module

Kim Thompson BSc RRT Louanna Bethune BSc RRT Debbie White CNE April 2013

CC 45-070

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Mechanical Ventilation – Initiation, Monitoring and Weaning Learning Module CC 45-070

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Table of Contents Purpose …………………………………………………………………………. Learning Objectives ……………………………………………………………. Definitions ………………………………………………………………………. Method …………………………………………………………………………... Theory …………………………………………………………………………… Clinical Indications ……………………………………………………………... Complications ………………………………………………………………….. Alarms …………………………………………………………………………… Weaning …………………………………………………………………………. References ……………………………………………………………………… Appendices Appendix A – Ventilators at Capital Health ………………………….. Appendix B – Definition – Modes of Ventilation …………………….. Test ………………………………………………………………………………. Proficiency Standard Skills Check List ……………………………………….

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PURPOSE This learning module provides the Registered Nurse and, in approved practice settings, the LPN with the theory necessary to care for the patient requiring mechanical ventilation and weaning. After completion of the learning objectives, the RN and LPN will demonstrate competency according to the proficiency standards.

LEARNING OBJECTIVES On completion of this learning package the RN / LPN will be able to: 1. Describe the indications for mechanical ventilation. 2. Explain how ventilators function. 3. Describe the modes of ventilation. 4. Explain the commonly monitored ventilator settings and alarms. 5. Specify complications of mechanical ventilation. 6. Discuss indications and basic approaches to the weaning process. 7. Complete the post-test 8. Complete the proficiency standards check list (maintenance / weaning)

DEFINITIONS Tidal Volume:

Amount of air inspired and expired with each breath

Respiratory Rate:

Number of breaths delivered each minute

Positive End Expiratory Pressure (PEEP):

Minimum level of pressure maintained in the patient circuit throughout expiration. Purpose is to maintain the functional residual capacity (FRC) in the lungs and to splint open the airways. Helps to improve oxygenation.

Continuous Positive Airway Pressure (CPAP):

Positive pressure applied during the whole breathing cycle of a spontaneously breathing patient. Similar to PEEP in the spontaneously breathing patient

Pressure Support:

The amount of additional support that is used to achieve Peak Airway Pressure (PAP). It is used to augment tidal volume.

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METHOD In order to complete the theory section of this learning package, the RN/LPN needs to review the following Capital Health documents: CC 45-070 Mechanical Ventilation: Initiation, Monitoring, and Weaning CC 45-025 Endotracheal Tube and Extubation - Care of the Patient CC 45-090 Tracheostomy, Care and Management of Patients with Tracheostomy CC 45-075 Prone Positioning/Proning MM 20-040 Nebulized Epoprostenol (Flolan®/ Prostacyclin/Prostaglandin 12)In addition the RN/LPN need to: Complete the post test Complete the proficiency standard check list on mechanical ventilation

THEORY Mechanical ventilation may be defined as the use of a mechanical device to provide ventilator support for patients. There are 2 types of mechanical ventilation: positive and negative pressure ventilation. Positive pressure ventilation delivers a positive pressure to inflate the lungs. Expiration is passive. Negative pressure ventilation is a noninvasive technique where the patient is fitted with a device over the thorax that is connected to a ventilator. It creates a negative pressure causing the patient to inhale, exhalation is passive. CAPITAL HEALTH ONLY USES POSITIVE PRESSURE VENTILATORS. All references to ventilation are referring to positive pressure ventilators. Ventilation can be divided into mandatory, spontaneous and combined ventilation. 1. Mandatory Methods Volume Controlled Modes Pressure Controlled Modes 2. Spontaneous Breathing Method Spontaneous/Assisted Modes 3. Combined Combination of both spontaneous and mandatory breathing (return to Table of Contents) This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and should be checked against the electronic file version prior to use.

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Mandatory Ventilation 1. Volume Control Ventilation During volume-controlled ventilation, the set tidal volume is supplied by the ventilator at a constant flow. The inspiratory pressure is variable and changes depending on the changes lung mechanics. The tidal volume and the number of mandatory breaths per minute (RR) can be adjusted. This results in the minute volume (MV). The velocity at which the breathing volume (VT) is delivered is adjusted by changing the inspiratory flow. Volume Controlled Modes: 1. Assist Control (VC- A/C) 2. Continuous Mandatory Ventilation (VC- CMV) 2. Pressure Control Ventilation During pressure-controlled ventilation, two pressure levels are kept constant: the lower pressure level PEEP and the upper pressure level Pinsp. The tidal volume supplied to the patient varies depending on the pressure difference between PEEP and Pinsp, the lung mechanics and the breathing effort of the patient. The number of mandatory breaths is defined by the set breathing frequency (RR). Pressure Control Modes 1. Assist Control (PC- A/C) 2. Continuous Mandatory Ventilation (PC- CMV)

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Spontaneous Ventilation Spontaneous / Assisted During the spontaneous ventilation modes, the patient must initiate each breath. The pressure level PEEP (CPAP) at which spontaneous breathing takes place can be adjusted. In all spontaneous ventilation modes, the spontaneous breaths are supported mechanically by using Pressure Support. Spontaneous Modes 1. CPAP / PS Combined Ventilation The patient can breathe spontaneously at any time. If no independent breathing attempt is detected during the trigger window or preset minute ventilation is not obtained, a machinetriggered mandatory breath is applied. Combined Modes 1. Synchronized Intermittent Mandatory Ventilation (VC- SIMV) 2. Mandatory Minute Volume (VC-MMV) 3. Synchronized Intermittent Mandatory Ventilation (PC- SIMV) 4. Mandatory Minute Volume (PC-MMV) Refer to Appendix B for the definitions for the different modes of ventilation , Clinical Indications for Mechanical Ventilation Include: 1. Exacerbation of COPD 2. Respiratory Arrest 3. Respiratory Failure 4. Permitting sedation and / or neuromuscular blockade 5. Decreasing myocardial oxygen consumption 6. Reducing intracranial pressure 7. Stabilizing the chest wall 8. Severe hypoxemia 9. Respiratory muscle fatigue (return to Table of Contents) This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and should be checked against the electronic file version prior to use.

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10. 11. 12.

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Spinal Cord Trauma Severe pneumonia / atelectasis Neuromuscular compromise

OBJECTIVES OF MECHANICAL VENTILATION: 1. To maintain alveolar ventilation and arterial oxygenation. 2. To deliver appropriate concentrations of oxygen more reliably 3. To increase lung volume and functional residual capacity 4. To maintain effective PEEP 5. To reduce the work of breathing COMPLICATIONS OF MECHANICAL VENTILATION Although mechanical ventilation may be viewed as a life saving medical treatment it also has serious complications. These include volume pressure trauma, hemodynamic changes and barotrauma as well as (AACN Manual,2011): Ventilator Associated Pneumonia (VAP): Refers to the development of pneumonia while the patient is being mechanically ventilated. Capital Health has implemented a ventilator associated pneumonia bundle of care interventions-(as per Safer Healthcare Canada 2005) - including raising the head of the bed 30 degrees or more, the use of oral versus nasogastric tubes, a daily sedation vacation in order to assess the readiness to wean well as the use of inline suction on all patients ventilated for longer than 24 hours. {Refer to CC 45-076 Ventilator Associated Pneumonia (VAP)} Anxiety and Fear : The patient may experience loss of control, feeling of suffocation or fear. The patient’s anxiety and fear may be exacerbated by a lack of sleep, discomfort, noise, impaired communication and sensory overload. There are various interventions that the nurse can utilize with patients who are anxious and fearful. However, when reassurance and explanations are not effective and the patient continues to be inadequately ventilated, pharmacological intervention may be necessary. Patients should have a delirium assessment scale completed at least once per shift (CAMICU) Acid Base Imbalance: Respiratory acidosis is caused by under ventilation due to inadequate tidal volume, rate or increased CO2. Over ventilation results from ventilating the patient at respiratory rates or tidal volumes higher than the patient requires, leading to respiratory alkalosis. Respiratory alkalosis is caused by hyperventilation which may be due to anxiety, restlessness, pain, hypoxemia or CNS malfunction. The patient’s rate, mode or tidal volume may need to be adjusted.

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Cardiac Dysrhythmias: Vagal reactions, during or after suctioning, can lead to cardiac Dysrhythmias. These may also result from hypoxia, acidosis, alkalosis or a decreased cardiac output. Volume Pressure Trauma: Large tidal volumes may result in high pressures and acute lung injury. This may result in tears in the alveoli followed by inflammation and leaking of fluid. Volutrauma can occur with low ventilating pressures as well. All patients are at risk of volutrauma. Lower tidal volumes are recommended to prevent stretch receptors from being activated. Tidal volumes of 6mLs per kg are recommended. Pulmonary barotraumas: Defined as damage to the lung from extra pulmonary air that may result from changes in intrathoracic pressures during PPV. Barotrauma is manifested by pneumothorax, pneumomediastinum, pneumopericardium, pneumoperitoneum and subcutaneous emphysema Hemodynamic changes: Depend on the level of positive pressure, the duration, the amount of pressure transmitted, patients’ blood volume, and the adequacy of hemodynamic compensatory mechanisms. Positive pressure ventilation (PPV) can reduce venous return, shift the intraventricular septum to the right and increase right ventricular afterload. Auto Peep: Caused by inadequate expiratory time relative to the patients’ lung condition. Auto Peep is associated with prolonged inspiratoty times, short expiratory times, high minute ventilation requirements, bronchospasm, mucous hypersecretion, increased wall thickness, airway closure or collapse Ventilator Parameters and Alarms {AACN (2011)page 266} The respiratory therapist is responsible for adjusting ventilator settings and alarms The nurse’s role is to monitor the ventilator settings and alarms to ensure that the patient’s ventilator needs are met The alarms provide visible and/or an audible warning of either technical or patient events which require attention. They provide protection for ventilated patients These alarms do not replace monitoring of the patient. Alarms common to all ventilators include apnea alarm, high and low pressure alarms, exhaled tidal volume and minute ventilation alarms. The nurse must know how to respond to the alarms and what action must be carried out to preserve the patient’s respiratory status. Always check the patient first. 1. Disconnect Alarms-low pressure or low volume. This alarm is meant to immediately notify the clinician that a disconnect has occurred. This alarm may also occur with a circuit leak even though the patient may be receiving a portion of the breath. 2. Pressure alarms: (return to Table of Contents) This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and should be checked against the electronic file version prior to use.

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2.1. High pressure-these are set with all ventilation modes to ensure the clinician is aware of pressure that exceeds the set threshold.These are usually set 10-15 cm.H2o above the peak inspiratory pressure. These alarms may be initiated by secretions, condensation, biting on the ET tube, bronchospasm, pulmonary edema, pneumothorax, and tubing compression. 2.2. Low pressure alarms-used to sense disconnection, circuit leaks, changing compliance and resistance. 3. Minute ventilation alarms---used to sense disconnection, changes in breathing pattern. Both high and low minute ventilation alarms are usually set. Alarm Silence/Pause The ventilator’s alarm can be bypassed by pressing a “silence” button located on the machine. It is important to immediately reset the alarms once the procedures (such as suctioning or turning) are complete. When a patient is on a mechanical ventilator, the alarms must always be turned on. Most ventilators have a time delay of 2 minutes after which the alarm will automatically reset. The nurse/RRT should always ensure that the alarms are reset before leaving the patient’s bedside. When the ventilated patient appears to be in respiratory distress and the RN/LPN cannot immediately solve the problem, the patient should be manually ventilated until the problem can be solved and the respiratory therapist should be paged. NOTE: Patients on mechanical ventilators should always have a manual resuscitation bag at the bedside. Manual resuscitators with a reservoir bag connected to oxygen are capable of delivering 100% Fi02. The tidal volume that the resuscitator bag will deliver depends on the force used to squeeze the bag. When the bag is completely deflated, the delivered volume approximates 800 mLs. The respiratory rate is determined by the number of times the bag is squeezed per minute. When the bag is used, the nurse/respiratory therapist should synchronize the manually delivered breaths with the patient’s inspiratory effort. WEANING FROM THE MECHANICAL VENTILATOR (AACN 2010)(Cochrane review 2011 Determining readiness to wean is a requirement of the VAP bundle of Care interventions. Weaning is the gradual withdrawal of mechanical ventilation until the patient is totally independent of the ventilator. Weaning begins after the original process that necessitated ventilator support is corrected and the patient is stable. Mechanical ventilation and immobilization contribute to delirium and weakness and can affect weaning. (return to Table of Contents) This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and should be checked against the electronic file version prior to use.

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Factors to consider when weaning include how long the patient was on the ventilator, sleep deprivation and nutritional status. Major factors that influence the patient’s ability to wean include the ability of the lungs to participate in ventilation and respiration, cardiovascular performance and psychological readiness. Weaning is different between short term and long term ventilation. Weaning from short term ventilation is usually predictable. Long term weaning has its ups and downs. 1. Determine readiness for weaning by assessing : 1.1. daily assessment for Spontaneous Breathing Trail (SBT) 1.2. respiratory status 1.3. amount of secretions and the ability to expectorate secretions 1.4. ability to cough/strength 1.5. lab data (ABG’s, electrolytes, CBC) 1.6. vital signs (SpO2, blood pressure, pulse, temperature, respiratory rate) 1.7. nutritional status 1.8. level of consciousness (RASS score) as well as CAMICU 1.9. amount of sedation 1.10. pain, fatigue, weakness and other medical conditions that could affect weaning 2. Obtain a physician’s order to begin the weaning process. 3. Explain the procedure to the patient/family. 4. Obtain baseline vital signs. 5. Initiate weaning according to the desired mode 6. Provide support to the patient as required. 7. Monitor and document the following: 7.1. SpO2 , ETCO2 7.2. heart rate and rhythm 7.3. blood pressure 7.4. respiratory pattern (including RR, tidal volume, use of accessory muscles, increased intercostals retractions, increased flaring of nostrils, asynchronous breathing pattern, cyanosis, diaphoresis) 7.5. Mental status including anxiety level, confusion, agitation or somnolence 7.6. ABG’s as ordered (return to Table of Contents) This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and should be checked against the electronic file version prior to use.

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Weaning should be terminated if the following occurs: Heart Rate greater than 140/min or 20% change of the usual rate for greater than 5 minutes SpO2 less than 88% Respiration Rate (RR) greater than or equal to 35 breaths per minute (bpm) for 5 minutes or longer Blood Pressure (BP) greater than 180 mmHg or less than 90 mmHg or 20% change of the usual BP for greater than 5 minutes Marked use of accessory muscles Abdominal paradox Anxiety Chest pain Marked complaints of dyspnea

REFERENCES Blackwood,B.,Alder,F., Burns,K., Cardwell,C., et al (2011) use of weaning protocols for reducing duration of mechanical ventilation in critically ill adult patients: cochrane systematic review and meta-analysis, British Medical Journal. 1-14. Retrieved from BMJ.com August 16,2012. Burns, S.M).(2011) Invasive Mechanical Ventilation (Through an artificial airway):– Volume and Pressure Modes. In D.J. Lynn-Mc Hale Wiegand (6thEds) AACN Procedure Manual for Critical Care (pp.262-302). St. Louis: Elsevier Inc. Burns,S.M.,Fisher,C., Tribble,S.S., Lewis,R.,(2012) the relationship of 26 clinial factors to weaning outcome. American Journal of Critical Care.52-59. Crimlisk,J.T., Gustafson,A., and Silvia,J., (2012) Translating guidelines into practice, Dimensions of Critical Care Nursing. 31(2):118-123. Grap,M.J. Munro,C.L. Wetzel.P., best,A,M., (2012) Sedation in adults receiving mechanical ventilation: physiological and comfort outcomes, American Journal of Critical Care . 21(3) e53-e63. Instructions for Use Infinity Acute Care System- Evita Infinity V500. Drager. Mclean,S.E., Jensen,L.A., Schroeder,D.G., Gibnet,N.R., et al (2006) Improving adherence to a mechanical ventilation weaning protocol for critically ill adults: outcomes after an implementation program. American Journal of Critical Care. 15:299-309.

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Perry, A.G., & Potter, P.A. (2011). Care of the client on a mechanical ventilator. In Perry & Potter (eds). Clinical Nursing Skills and Techniques pp. St. Louis: Mosby. Rice,T., Morris,S., Bartholomew,J.T., Wheeler,A.R., et al (2012) Devaitions from evidence based clinical management guidelines increase mortality in critically injured trauma patients, Critical Care Medicine. 40(3)778-786. Parke, M., (2012) The ventilator management of a metabolic acidosis: a case study, Canadian Journal of Respiratory Therapy Vol 48(1)6-12. Postma,D., Sankatsing,S., Thijsen,S., & Endeman,H.,(2012) Effects of chlorhexidine oral decontamination on respiratory colonization during mechanical ventilation in intensive care unit patients, Infection Control Hospital Epidemiology. 33(95)527-530. Stawicki,S.P. (2007) ICU Corner mechanical ventilation: weaning and extubation. Opus 12 Scientist.1(2)13-16. Urden, L.D., Stacy, K.M., & Lough, M.E.) Thelan’s Critical Care Nursing Diagnosis and Management Edition) St. Louis: Mosby. Warr,J.,Thiboutot,Z.,Rose, L.,Mehta,S.,et al (20111) Current therapeutic uses, pharmacology, and clinical considerations of neuromuscular blocking agents for critically ill adults, The Annals of Pharmacotherapy. Vol 45,1116-1126. Vazquez,M., Pardavila,M-I., Lucia,M., Aguado,Y.et al,(2011) Pain assessment in turning procedures for patients with invasive mechanical ventilation. British Association of Critical Care Nurses.Vol 16(4)178-185.

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Appendix A Ventilators at Capital Health: Pritan Bennett 840

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Drager Evita

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Drager V500

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Maquet Servo I

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Appendix B

Definitions - Modes of Ventilation Continuous Mandatory Ventilation/Volume Control (VC- CMV): In the assist CMV mode, the tidal volume and flow rate for each mechanical breath are set by the clinician. A minimum mechanical breath rate is also set. In this mode, the patient may actually demand mechanical breaths in excess of the mandatory back-up rate provided the preset assist sensitivity threshold is met. Assist Control/Volume Control (VC- A/C): A ventilatory mode in which the ventilator delivers only mandatory breaths (patient, ventilator, or operator initiated) according to the current settings. Tidal Volume and frequency are set; pressure varies depending on lung characteristics. Note: same as CMV Synchronized Intermittent Mandatory Ventilation/Volume Control (VC-SIMV): SIMV is a mode in which there are both mechanical breaths (with clinician set volume and flow) and spontaneous breaths. The number of mechanical breaths is also preset by the clinician. The mechanical breaths may be either patient cycled (i.e. assisted) or time cycled if the patient is apneic or bradypneic. The number of spontaneous breaths is determined by the patient and may vary from minute to minute. Mandatory Minute Ventilation/Volume Control (VC-MMV): The applied time-cycled, machine-triggered mandatory breaths are synchronized with the breathing effort of the patient. The patient can always breathe spontaneously at PEEP level. If the spontaneous breathing of the patient is insufficient to achieve the set (MV), machine-triggered time cycled mandatory breaths are applied. These mandatory breaths are synchronized with the patient’s own breathing attempts. The set breathing frequency (RR) is therefore the maximum number of mandatory breaths. During spontaneous breathing at PEEP level, the patient can be pressure-supported using PS. Assist Control/Pressure Control (PC-A/C): The tidal volume supplied to the patient depends on the pressure difference between PEEP and Pinsp, the lung mechanics and the breathing effort of the patient. The number of mandatory breaths is defined by the set frequency (RR). In PC-AC, every detected breathing attempt at PEEP level triggers a mandatory breath. The patient thus determines the number of additional mandatory breaths. In order to give the patient sufficient time for expiration, it is not possible to trigger another mandatory breath immediately after a completed breath. Continuous Mandatory Ventilation/Pressure Control (CMV-PC): See PC-AC above

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Pressure Regulated Volume Control (PRVC) This is a combination mode in which the tidal volume (Vt) is set (or targeted) but the breath delivery is pressure controlled. The first breath will be a volume controlled breath with a plateau. The plateau pressure is used to set the starting pressure. Using information from the previous breath, the Servo-i will regulate the pressure up or down in steps to try to deliver the target Vt on the subsequent breath. The change in pressure is never more than 3 cmH2O per step. The available pressure is limited to 5 cmH2O below the set high pressure limit alarm. If this pressure is reached, the ventilator will deliver as much Vt as possible with this pressure. The alarm Regulation Pressure Limited will be activated if this pressure is reached for 3 consecutive breaths. Synchronized Intermittent Mandatory Ventilation/Pressure Control (SIMV-PC): In PCSIMV the patient can breathe spontaneously at any time, but the number of mandatory breaths is specified. The mandatory breaths are synchronized with the patient’s own breathing attempts. If no independent breathing attempt is detected during the trigger window, the machine-triggered mandatory breath is applied. The mandatory tidal volume (VT) results from the pressure difference between PEEP and Pinsp, the lung mechanics and the breathing effort of the patient. Airway Pressure Release Ventilation (PC-APRV): Pressure-controlled, time cycled, machine-triggered, spontaneous breathing under continuous positive breathing pressure with brief pressure relief times. In PC-APRV, the patient’s spontaneous breathing takes place at an upper pressure level, Phigh. The Phigh is maintained for the duration of a set time, Thigh. To execute an active expiration, the pressure is reduced for the brief a period, Tlow to a set low pressure, Plow. To support CO2 elimination, the pressure is reduced to Plow for the brief period Tow. The alternation between the two pressure levels is machinetriggered and time cycled. The breathing volume (VT) expired during the relief times, results from the pressure difference between Plow and Phigh and the lung mechanics. Volume Support (VS): A spontaneous mode that functions in a similar manner to PRVC. The patient receives support in proportion to their effort and the target Vt. Automode: Combines a control mode with a support mode. If the patient begins to trigger, the ventilator will switch to a support mode. A Trigger Timeout period is set with the other parameters and is also available under “Additional Settings”. If the patient does not trigger a breath for a period of time equaling the trigger timeout setting, the ventilator switches back to the controlled mode. There are no alarms when this switch occurs. This mode is useful for the patient expected to wean easily (e.g. post-op) or for the person with periods of spontaneous breathing interspersed with apnea periods (e.g. drug OD)

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The coupling of modes is as follows: PRVC or VC PC

Volume Support Pressure Support

Automode is activated by pressing the Automode box either on the top screen border or within the “Set Ventilation Mode” menu. To exit Automode, press the Automode box again. Confirmation is required when activating or deactivating Automode from the main screen border. The Automode box on the top screen border turns white when this mode is active. Spontaneous breaths are indicated by a green bar within the Automode box. By reviewing the total and spontaneous respiratory rate in the Trends graph, the user can determine how long the patient was spontaneously breathing. Bilevel: A mixed mode that combines mandatory and spontaneous breathing. Mandatory breaths are always pressure controlled and spontaneous breaths can be pressure supported. In absence of spontaneous breathing, Bilevel establishes two levels of positive airway pressure, similar to having two levels of PEEP. Cycling between the two levels can be triggered by time or patient effort. Two pressure levels are called high PEEP (PEEP H) and low PEEP (PEEP L). Patients can breathe spontaneously at either pressure level and can be assisted with pressure support. Bivent: A pressure controlled breathing that allows the patient the opportunity of unrestricted spontaneous breathing. Two pressure levels are set together for a specific time at each. Spontaneous efforts can be pressure supported. Positive End Expiratory Pressure (PEEP): Minimum level of pressure maintained in the patient circuit throughout ventilation. PEEP is set and monitored. Continuous Positive Airway Pressure (CPAP): PEEP in a spontaneously breathing patient. Pressure Support (PS): a spontaneous breath type in which the ventilator delivers an operator set pressure in addition to PEEP during the inspiration phase. Neurally Adjusted Ventilatory Assist (NAVA): A new mode of ventilation that uses the electrical signal of the diaphragm to operate the ventilator. A functioning gastric tube (oral or nasal) containing an array of electrodes sits at the level of the hemi-diaphragms and picks up the electrical signal sent to the diaphragm by the brain (via the phrenic nerves) just (return to Table of Contents) This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and should be checked against the electronic file version prior to use.

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before the muscle fibers contract. The electrical signal tells the Servo-i when to begin inspiration and when to cycle into expiration. The user chooses how much pressure (in cmH20) the ventilator will deliver per microvolt (µV) of electrical signal throughout the inspiratory cycle. The pressure delivered is proportional to the signal throughout the entire inspiration

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SELF-TEST 1.

When PEEP is applied to the ventilator, the nurse must monitor the patient for: a) decreased water retention due to stimulation of the renin-angiotensinaldosterone system b) decreased preload leading to a decreased cardiac output c) decreased after load leading to a decreased cardiac output d) increased preload leading to an increased cardiac output

2.

Interventions which could be used to manage overventilation of the mechanically ventilated patient could include: a) b) c) d)

3.

The assist / control mode of ventilation allows the patient to: a) b) c) d)

4.

increase tidal volume or increase rate decrease tidal volume or decrease rate decrease tidal volume or increase rate increase tidal volume or decrease rate

exercise the diaphragm take his/her own volume of air initiate the inspiratory cycle control the frequency of all breaths

The SIMV mode: a) delivers a mandatory breath that is synchronized with the patient’s spontaneous breath b) can only be used in a sedated patient c) does not require monitoring of the patient when used for the weaning process d) does not allow the patient to breath spontaneously

5.

Objectives of mechanical ventilation are:

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a) b) c) d) 6.

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To increase patients work of breathing (WOB) To maintain alveolar ventilation and arterial oxygenation. To decrease lung volumes To keep the patient sedated

Optimal weaning occurs when: a) the patient is lying flat in the bed b) analgesics are held regardless of the patient’s pain c) after the original process that necessitated ventilator support is corrected and the patient is stable d) when the patient is on 10cm H2O PEEP

7.

PEEP : a) decreases FRC b) improves Oxygenation c) increases the chance of atelectasis d) guarantees minute ventilation

8.

When the low exhaled volume alarm keeps sounding and the nurse cannot immediately solve the problem, the nurse should: a) b) c) d)

9.

The high pressure alarm sounds when: a) b) c) d)

10.

call the physician manually ventilate the patient recheck the ventilator settings suction the patient

air leaks from the ventilator connections when the patient is not receiving the prescribed amount of Fi0 2 when the patient does not initiate a breath within a preset time period when the patient is biting the tube, is anxious or has a decreased compliance

The low exhaled volume alarm indicates that:

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Mechanical Ventilation – Initiation, Monitoring and Weaning Learning Module CC 45-070

a) b) c) d) 11.

provide sedation for the patient insert an oral airway determine the cause of the agitation suction the patient

There are_____ negative pressure ventilators at CDHA: a) b) c) d)

15.

manually ventilate the patient turn off the ventilator assess/check the patient secure ventilator connections

The high pressure alarm is sounding and it is noted that the patient is noticeably distressed and agitated. The nurse should a) b) c) d)

14.

suction and / or bronchodilators add dead space tubing increase tidal volume and decrease respiratory rate decrease tidal volume and increase respiratory rate

The apnea alarm is sounding. The first thing he nurse should do is: a) b) c) d)

13.

the patient is not receiving the prescribed amount of Fi02 the patient is not initiating a breath within a prescribed time period air could be leaking from the ventilator connections and tubing the patient’s PEEP is greater then set

The interventions which could be performed to manage under-ventilation due to increased airway resistance are: a) b) c) d)

12.

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0 10 5 30

Weaning should be discontinued when the patient experiences:

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Mechanical Ventilation – Initiation, Monitoring and Weaning Learning Module CC 45-070

a) b) c) d) 16.

a drop in BP from 100/80 to 90/70 a respiratory rate of 25/ minute a rise in pulse from 95 / minute to 100 / minute a rise in pCO2 from 45 to 60

Which of the following groups of criteria is most reflective of those assessed in order to determine if a patient is ready to wean? a) b) c) d)

17.

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Respiratory rate, tidal volume, minute ventilation, level of consciousness electrolytes, right ventricular functioning and JVP anxiety level, JVP and FeV1 respiratory rate, tidal volume, minute ventilation and right ventricular functioning

Which respiratory parameters would be indicative of a decreased ability to wean? a) b) c) d)

Respiratory rate 35/min, SaO2 83 Respiratory rate 12/min, SaO2 92 Respiratory rate 24/min, Pa O2 65 Respiratory rate 30/min, PaO2 70

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Mechanical Ventilation – Initiation, Monitoring and Weaning Learning Module CC 45-070

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ANSWER KEY 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17.

B B C A B C B B D C A C C A D A A

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Mechanical Ventilation – Initiation, Monitoring and Weaning Learning Module CC 45-070

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Capital Health NURSING DIVISION PROFICIENCY STANDARD SKILLS CHECKLIST TITLE: Mechanical Ventilation - Maintenance NURSING UNIT SKILL

YES

NO

Explains the need for mechanical ventilation to the patient. Ensures that a method of communication is established so that the patient can alert the nurse. Checks size of tube and its placement (e.g. ETT cm at lips), proper placement of ties/commercial attachment device, minimal occlusive volume at time of insertion, and suctions as required. Evaluates respiratory status (ventilation and oxygenation) by using inspection, palpation, percussion and auscultation as well as laboratory data and 02 saturation and Co2 if available). Checks the following information to ensure it corresponds with the physician's orders: Mode{e.g. A/C(CMV), SIMV, Pressure Support} and parameters {FI02, tidal volumes(VT), PEEP/CPAP (if applicable)} If the ventilator settings do not correspond with the physician's orders, notifies the respiratory therapist. Monitors the patient's: tidal volumes (VT) - ventilator volumes and patient's volumes (if applicable), respiratory rate - the preset ventilator breaths and the patient’s breaths. Counts the rise and fall of the chest wall to verify the rate provided by the machine, peak inspiratory, plateau, mean, and end expiratory pressures such as PEEP, CPAP (as appropriate) Locates the following alarms: high pressure alarm, low pressure alarm, temperature alarm, oxygen alarm, apnea alarm, low exhaled volume alarm, When alarms sound, examines the patient and determines the cause and corrects it. (return to Table of Contents) This is a CONTROLLED document for internal use only. Any documents appearing in paper form are not controlled and should be checked against the electronic file version prior to use.

Mechanical Ventilation – Initiation, Monitoring and Weaning Learning Module CC 45-070

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SKILL

YES

NO

If unable to determine the reason for an alarm sounding, removes the patient from the ventilator, manually resuscitates ---and asks someone to page respiratory therapy. Locates and describes the following: alarm bypass / silence, alarm reset. Empties water that condenses in the ventilator tubing into a disposable cup. If applicable. Evaluates the patient's response to mechanical ventilation. This includes assessment of body systems, monitoring of blood gases, Sp02, laboratory tests, chest x-rays and psychological response. Monitors for complications (e.g. pneumothorax, decreased cardiac output, and dysrhythmias). Documents type of airway type of ventilator and it's settings peak, plateau, mean and end expiratory pressures such as PEEP, CPAP (according to unit guidelines), respiratory rate and tidal volume assessment findings patient's physical and psychosocial response

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Mechanical Ventilation – Initiation, Monitoring and Weaning Learning Module CC 45-070

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CDHA NURSING DIVISION PROFICIENCY STANDARD SKILLS CHECKLIST

TITLE: Mechanical Ventilation - Weaning NURSING UNIT: _________________________________________________ SKILL YES 1. Determine readiness for weaning by assessing the following: - respiratory status - ability to cough and expectorate secretions - laboratory data - vital signs - nutritional status - level of consciousness and motivation to wean - Optimize patient's condition in relation to pain, fatigue and other medical conditions which could affect weaning. 2) Obtain weaning parameters from respiratory therapist. 3) 4)

Discuss the assessment findings and weaning parameters with the physician and respiratory therapist. Develop a weaning plan. Explain procedure to the patient.

5)

Plan to initiate early in the day.

6)

Use semi-Fowler's position unless contraindicated.

7)

Obtain baseline vital signs

8)

Initiate weaning according to desired mode (T-piece or PSV). (If using T-piece, remove ventilator tubing and connect to T-piece. Consult with physician to determine if the FI02 is to be increased 510% higher on the weaning mode than on the ventilator.) Suction when necessary and administer bronchodilators as ordered.

9) 10)

Provide support to the patient and encourage the patient to breathe normally. 11) Monitor and documents objective and subjective findings. 12) Terminates weaning when the patient exhibits signs of respiratory distress. If safety allows, obtain a blood gas, place the patient back on the previous ventilator settings; notify the physician and document. 13) Lists indicators of respiratory distress. 14) Document the patient's response

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NO