4/2/2017. Sophisticated Modes of Mechanical Ventilation - When and How to Use Them. Case Study 1. Case Study 1. ph 7.17 PCO 2 55 PO 2 62 HCO 3

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1 Sophisticated Modes of Mechanical entilation - When and How to Use Them Dr. Leanna R. Miller DNP, RN, CCRN-CMC, PCCN-CSC, CEN, CNRN, CMSRN, NP LRM Consulting Nashville, TN Case Study 1 A 55 year-old man with a history of COPD presents to the ED with a two day history of worsening shortness of breath which came on following a recent viral infection. In the ED, his oxygen saturation is 88% on room air. He is working hard to breathe and is only speaking in short sentences. On exam, he has diffuse wheezes and a prolonged expiratory phase. His chest x-ray reveals changes consistent with COPD but no new focal infiltrates. Case Study 1 An arterial blood gas (ABG) is done and shows: ph 7.17 PCO 2 55 PO 2 62 HCO

2 Case Study 1 What are some indications for starting a patient on mechanical ventilation? Case Study 1 hypercapnic respiratory failure hypoxemic respiratory failure prevent or reverse atelectasis prevent or reverse muscle fatigue permit sedation and/or neuromuscular blockade stabilize the chest wall ensure airway protection Case Study 1 Do you think non-invasive positive pressure ventilation (bi-level positive airway pressure) could be used in this patient? 2

3 Case Study 1 What is the difference between bi-level positive airway pressure (BiPAP) and continuous positive airway pressure (CPAP)? What are the indications for using these different modes of noninvasive mechanical ventilation? A 45 year-old 6-foot tall man presented to the ED with a two day history of fever and cough productive of brown sputum He was hemodynamically stable at the time with a blood pressure of 130/87 His chest x-ray showed a right middle lobe infiltrate ABG on room air ABG showed ph 7.32 PCO 2 32 PO2 78 HCO 3-18 he was started on antibiotics and admitted to the floor 3

4 4 hours later, the patient begins to deteriorate ital signs are as follows: BP 85/60 HR 120 beats/minute SaO2 97% on 2L N/C; 78% on patient is obviously laboring to breathe with use of accessory muscles and is less responsive than he was on admission he is diaphoretic and cannot talk in full sentences on lung exam, he has crackles throughout the bilateral lung fields chest x-ray shows increasing bilateral, diffuse lung opacities ABG on a non-rebreather mask shows ph 7.17 PCO 2 45 PO 2 58 HCO 3 14 What should you do now? Is there a role for CPAP or bi-level positive airway pressure in managing his hypoxemia? 4

5 A decision is made to intubate the patient and initiate mechanical ventilation for worsening respiratory failure. The intubation proceeds without difficulty. The tube position is confirmed and the anesthesiologist leaves the room. The respiratory therapist has secured the endotracheal tube. What settings are most likely to be ordered for the ventilator? the mode of mechanical ventilation the tidal volume respiratory rate inspired oxygen concentration (FIO 2 ) level of positive end-expiratory pressure (PEEP) The use the volume-targeted Assist Control (AC) mode of mechanical ventilation is suggested. How does this work? How does it differ from Synchronized Intermittent Mandatory entilation (SIM) or Pressure Control (PC)? Which mode is better for your patient? 5

6 If the patient is placed on a volume-targeted Assist Control mode of mechanical ventilation. How do you choose the tidal volume? rather than using the patient s actual weight to determine the tidal volume, you should, instead, use the patient s ideal body weight (IBW), the value of which is derived from the patient s height. To calculate the ideal body weight in kilograms, you can use the following formulas: Men: [(height in inches 60) X 2.2] + 50 Women: [(height in inches 60) X 2.2] + 45 What respiratory rate should you choose for the patient? 6

7 What should the FIO 2 and PEEP be set at? Case Study 3 patient is admitted to the ICU with severe necrotizing pancreatitis. a few hours after admission, he developed increasing oxygen requirements and was intubated for hypoxemic respiratory failure initially, his oxygen saturation improved to the mid-90% range on an FIO 2 of 0.5, but in the past 2 hours, the nurse has had to increase the FIO 2 back to 0.7 and his SaO 2 is still in the lower 90% range. patient remains on a PEEP of 5 cm H 2 O Case Study 3 ABG on FIO 2 of 0.7 shows: ph 7.35 pco 2 38 PO 2 60 HCO 3-22 patient s repeat chest x-ray is shown 7

8 Case Study 3 echocardiogram performed earlier in the day revealed normal left ventricular function. patient is admitted to the ICU w ith severe necrotizing pancreatitis a few hours after admission, he developed increasing oxygen requirements and was intubated for hypoxemic respiratory failure initially, his oxygen saturation improved to the mid- 90% range on an FIO 2 of 0.5, but in the past 2 hours, the nurse has had to increase the FIO 2 back to 0.7 and his SaO 2 is still in the low er 90% range Case Study 3 patient remains on a PEEP of 5 cm H 2 O ABG on 0.8 shows: ph 7.35 pco 2 38 PO 2 60 HCO Case Study 3 How do you explain his worsening oxygenation status? 8

9 Case Study 3 What can you do to improve his oxygenation? Case Study3 What other changes should you consider making in the ventilator settings? Case Study 3 If his oxygen saturation fails to improve despite being on high levels of support, what other options do you have for improving his oxygenation? 9

10 46 year old unrestrained female MC fractures right radial, ulnar, fibula left ankle pelvis contusion RML CT head & spine negative patient c/o left chest pain vital signs unstable Case Study4 Admission Film Patient transported to OR for fracture repair ital signs stable 24 hours later patient develops respiratory distress X-ray reveals diffuse pulmonary infiltrates 10

11 Date 9/17 Time FiO Mode NRB Rate olume MAP AMP PEEP ph 7.38 PCO2 36 PO2 68 HCO3 21 SaO2 92 ETCO2 Date 9/17 9/19 Time 0233 FiO Mode NRB NRB Rate olume MAP AMP PEEP ph PCO PO HCO SaO ETCO2 patient placed on 100% mask with CPAP 10 cmh 2 O patient increasingly agitated, SOA, use of accessory muscles patient intubated 1.0/AC/650/14 (No PEEP) SaO 2 78% patient sedated & paralyzed PEEP 10 cmh 2 O added 11

12 Date 9/17 9/19 9/19 Time FiO Mode NRB NRB A/C Rate 14 olume 650 MAP AMP PEEP 10 ph PCO PO HCO SaO ETCO2 Date 9/17 9/19 9/19 9/21 Time FiO Mode NRB NRB A/C A/C Rate olum e MAP AMP PEEP 10 8 ph PCO PO HCO SaO ETCO2 although slightly improved, patient became more agitated RR > 30 HR & BP increased high pressure alarmed triggered SaO 2 < 40 12

13 Pre- 9/ Patient transitioned to, initial settings MAP 28, Hz 5, AMP 70, I Time 33%, FiO patient paralyzed & sedated, ETCO ABG 7.19/87/159 AMP 86, dopamine & sedation w eaned ABG 7.21/65/116 FiO 2 0.7, AMP 98 ABG 7.33/50/101 Date 9/17 9/19 9/19 9/21 9/21 Time FiO Mode NRB NRB A/C A/C Rate Hz olume MAP 28 AMP 70 PEEP 10 8 ph PCO PO HCO SaO ETCO

14 Date 9/17 9/19 9/19 9/21 9/21 9/21 Time FiO Mode NRB NRB A/C A/C Rate Hz 5 Hz olume MAP AMP PEEP 10 8 ph PCO PO HCO SaO ETCO2 77 Date 9/17 9/19 9/19 9/21 9/21 9/21 9/21 Time FiO Mode NRB NRB A/C A/C Rate Hz 5 Hz 5 Hz olume MAP AMP PEEP 10 8 ph PCO PO HCO SaO ETCO2 77 Date 9/17 9/19 9/19 9/21 9/21 9/21 9/21 9/22 Time FiO Mode NRB NRB A/C A/C Rate Hz 5 Hz 5 Hz 5 Hz olume MAP AMP PEEP 10 8 ph PCO PO HCO SaO ETCO

15 Date 9/17 9/19 9/19 9/21 9/21 9/21 9/21 9/22 9/23 Time FiO Mode NRB NRB A/C A/C Rate Hz 5 Hz 5 Hz 5 Hz 4 Hz olume MAP AMP PEEP 10 8 ph PCO PO HCO SaO ETCO2 77 9/ Transition to CM PC = 30 cmh 20 T = 680 (78.0 kg) FiO 2 = 0.6 PEEP = 5 cmh 20 ABG 7.47/44/62 PC: 20 cmh 2 O, PEEP 8 cmh

16 Date 9/17 9/19 9/19 9/21 9/21 9/21 9/21 9/22 9/23 9/24 Time FiO Mode NRB NRB A/C A/C Rate Hz 5 Hz 5 Hz 5 Hz 4 Hz 18 PC olume MAP AMP PEEP ph PCO PO HCO SaO ETCO2 77 PC 9/ Date 9/19 9/19 9/21 9/21 9/21 9/21 9/22 9/23 9/ Time FiO Mode NRB A/C A/C PC Rate Hz 5 Hz 5 Hz 5 Hz 4 Hz olume MAP AMP PEEP PC ph PCO PO HCO SaO ETCO

17 Date 9/19 9/21 9/21 9/21 9/21 9/22 9/23 9/24 9/24 9/29 Time FiO Mode A/C A/C PC PC PS Rate Hz 5 Hz 5 Hz 5 Hz 4 Hz olume MAP AMP PEEP ph PCO PO HCO SaO ETCO2 77 patient extubated on 4/29 and placed on high humidity bronchodilator therapy and incentive spirometry discharged to rehabilitative facility on 5/2 17

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