VENTILATOR CARE

1. CAREOFCHILD
REQUIRING LONGTERM
VENTILATOR

2. OBJECTIVES
Incidence of continuous ventilation
Goals of mechanical ventilation.
Classification of different modes of ventilation.
 Adjustment on the ventilator.
 Guidelines recommended during mechanical ventilation
 Monitoring child with continuous ventilation
Weaning from the ventilation.
Monitoring child with non-invasive oxygen therapy.
 Complication of continuous ventilation.
 Nursing management of ventilated patient.

3. INTRODUCTION
Children who are long-term ventilated have been
found to have a significantly health-related poor
quality of life.
Children and young people on long-term ventilation
require the most complex care that is given outside
a hospital environment and there are significant risks
involved in looking after a child on long-term
ventilation in the community.
Competencies and training needed is also a major
concern for long term ventilation.

4. INCIDENCE
 Significant rise in number of children on long term
ventilation - (Wallis et al 2010, Goodwin et al 2011)
 The need for long term ventilation to discharge home is an
average of 7-9 months.
 The number of tracheostomy ventilated children managed
out of hospital is approximately 250-275 per 10000
 1000-1300 children with complex needs dependent upon
non-invasive ventilation under specialist respiratory follow-up.
 Currently the financial cost of the hospital for recent onset
complex long term ventilation is high.

6. Respiratory Failure
•Inability of the pulmonary system to meet the metabolic demands
of the body through adequate gas exchange. Two types of
respiratory failure:
 Hypoxemic
 Hypercarbic
 •Each can be acute and chronic.
 •Both can be present in the same patient.
 •Management of this condition required assisted mechanical
ventilation

7. Mechanical ventilation
Mechanical ventilation can be defined as the technique through
which gas is moved toward and from the lungs through an external
device connected directly to the patient.
Mechanical ventilation is the medical term for artificial ventilation
where mechanical means is used to assist or replace spontaneous
breathing

8. INDICATIONS
 Apnoea with respiratory arrest
 Acute respiratory acidosis with paCO2 > 50 mmHg & pH <
7.25
 Hypoxemia with PaO2 <50 mm Hg with FiO2 > 60%
 Vital capacity <2 times tidal volume
 RR> 35/min
 Acute lung injury (including ARDS, trauma)
 Obstructive diseases like Asthma
 Hypotension including sepsis, shock, CHF
 Neurological diseases such as GB syndrome.

9. FUNCTIONS
 Achieve and maintain adequate pulmonary gas exchange.
 Minimize the risk of lung injury
 Reduce patient work of breathing
 Optimize patient comfort
 To normalize blood gases and provide comfortable
breathing
 To maintain sufficient oxygenation and ventilation.
 To provide safe environment for the patient while
protecting the lungs from damage due to oxygen toxicity,
pressure.

10. DEFINITIONS
 Tidal Volume (TV): volume of each breath.
 Rate: Breaths per minute.
 Minute Ventilation (MV): total ventilation per minute. MV = TV x Rate.
 Flow: volume of gas per time.
 Compliance: the distensibility of a system. The higher the compliance,
the easier it is to inflate the lungs.
 Resistance: impediment to airflow.

11. CONTD……
 PIP: Maximum pressure measured by the ventilator during
inspiration.
 PEEP: Pressure present in the airways at the end of expiration.
CPAP: Amount of pressure applied to the airway during all phases of
the respiratory cycle.
 PS: Amount of pressure applied to the airway during spontaneous
inspiration by the patient.
 I-time: Amount of time delegated to inspiration.
 SIMV: Patient breathes spontaneously between ventilator breaths.
Allows patient-ventilator synchrony, making for a more comfortable
experience.

12. Ventilator Mode
 Volume control
 Pressure Control
 Pressure Support-CPAP
 Pressure-Regulated Volume Control

13. HOW ITWORKS

15. Volume Control
 The patient is given a specific volume of air during
inspiration.
 The ventilator uses a set flow for a set period of time to
deliver the volume.
 The PIP observed is a product of the lung compliance,
airway resistance and flow rate.
 The PIP tends to be higher than during pressure control
ventilation to deliver the same volume of air.

18. CPAP Pressure
Support
 CPAP is a way of delivering PEEP but also maintains the set
pressure throughout the respiratory cycle, during both
inspiration and expiration. [1] It is measured in centimeters of
water pressure (cm H2O).

19. Modes of
Ventilation:
 Controlled: The machine controls the patient ventilation according to set
tidal volume and respiratory rate . spontaneous respiratory effort of Pt. is
locked out, ( patient who receives sedation and paralyzing drugs he will on
controlled Mode).
 Assist/control: The Pt. triggers the machine with negative inspiratory effort.
If the Pt. fails to breath the machine will deliver a controlled breath at a
minimum rate and volume already set.

22.  1. Set the machine to deliver the required tidal volume ( 6 to 8
ml/kg)
 2. Adjust the machine to deliver the lowest concentration of the
oxygen to maintain normal PaO2 (80 to 100mmhg).The setting
may be set high and gradually reduced based on ABGs result.
 3. Record peak inspiratory pressure.
 4. Set mode (assist/control or SIMV)and rate according to
physician order.
 5. If Pt. is on assist/control mode , adjust sensitivity so that the
Pt. can trigger the ventilator with the minimum effort( usually
2mmHg negative inspiratory force)

23.  6. Record minute volume and measure carbon dioxide partial pressure
PaCO2, PH after 20 minutes of mechanical ventilation.
 7. Adjust FIO2 and rate according to results of ABG to provide normal
values or those set by the physician.
 8. In case of sudden onset of confusion , agitation or unexplained "
bucking the ventilator " the Pt. should be assessed for hypoxemia and
manually ventilated on 100% oxygen with resuscitation bag ( AMBU bag)
Bag – Valve – mask.
 9. Patient who are on controlled ventilation and have spontaneous
respiration may " fight or buck " the ventilator, because they cannot
synchronize their own respiration with the machine cycle.

24. Weaning
Priorities
1. Wean PIP to <35cm H2O
2. Wean FiO2 to <40%
3. Wean PEEP to <8cm H2O
4. Wean PEEP, PIP, I-time, and rate towards
extubating settings.

34. BundleCare
 Bundle is a structured way of improving the processes
of care and patient outcomes.
 A small straightforward set of evidence –based
practices-generally 3-5 that performed collectively and
reliably, have been proven to improve patients
outcomes,

35. WHY
BUNDLE IS
SO SPECIAL:
 Science based.
 They were well established best practices, but they are
often not performed uniformly, making treatment
unreliable.
 A bundle ties the changes together into a package of
interventions that people know must be followed for every
patient, every single time.

36.  Bundle can be used to ensure the delivery of
minimum standard care.
 Used as a audit tool to assess the delivery of
interventions.
 Most utilized bundle is sepsis care bundle
worldwide.

40. 5.Apply vassopressure (for hypotension that does not respond to initial fluid resuscitation
) to maintain a mean arterial pressure(MAP ≥65 mmhg)
6. In the event of persistent hypotension after initial fluid administration (MAP < 65 mm
Hg) or if initial lactate was ≥4 mmol/L, re-assess volume status and tissue perfusion.
7. Re-measure lactate if initial lactate elevated

41. THE CVC
MAINTENANCE
BUNDLE
1. Check the clinical indication why the
CVC is in situ – is it still required?
2. Is the CVC dressing intact and
changed within the last 7 days?
3. Has CVC hub decontamination been
performed before each hub access?

42. 4. Has hand hygiene been
performed before and after all CVC
maintenance/access procedures?
5. Has Chlorhexidine gluconate 2%
in alcohol (if compatible with CVC)
been used for cleaning the insertion
site during dressing changes?

62. CONCLUSION
 Monitoring to optimize the respiratory support and limit the
potential complications of ventilator induced lung injury,
oxygen toxicity , air leaks and nosocomial infections.
 In acute intensive care units, more than one-fourth of patients
with invasive ventilation required prolonged ventilation. Babies
requiring mechanical ventilation require close observation