Respiratory TherapyTraci Mask, RRT

January 20, 2018

Oxygenation VS Ventilation

Objectives

After the presentation, the attendee will be able to:

Describe the tools used to assess oxygenation.

Define limitations of pulse oximetry.

Better understand the importance of the S curve of the ODC

and how quickly desaturation occurs when the SpO2 falls

below 90% and the PaO2 < 60mmHg.

State the causes and symptoms of hypoxemia.

Objectives(Continued)

Describe the tools used to help assess adequate ventilation.

Describe the causes and symptoms of hypercarbia.

Comprehend the difference between oxygenation and

ventilation by using the tools of the trade and clinical

assessment skills to determine the best treatment plan.

“

”

Understanding ventilation

versus oxygenation is the key

in airway management.

-Samual M. Galvagno, Jr.

*Oxygenation and ventilation are 2 very distinct

processes of the breathing cycle.*

Terminology

Oxygenation-The process of adding oxygen to a

system

Hypoxemia-Low oxygenation levels in the blood

Hypoxia-Low levels of oxygen at the tissue level

*Note that sometimes these 2 terms are used interchangeably.*

How to Assess Oxygenation

Cyanosis- Unreliable

Pulse oximetry (P.O.)

oNormal 95-100%, < 92% is considered low

o Limitations to P.O.

1. Delay in desaturation

2. Affected by perfusion

3. Affected by nail polish and skin pigmentation

How to Assess Oxygenation

Arterial Blood Gases (ABG’s)

oNormal Partial Pressure of Oxygen (PaO2) 80-100

mmHg

o < 80 mmHg is considered low

Levels of Hypoxemia

Hemoglobin-O2 Binding Curve

0 20 40 60 80 1000

20

40

60

80

100

0

5

10

15

20

26

50

75

90

97.5

PaO2 (mm Hg)

% S

atu

rati

on

of

Hem

og

lob

in

Hb

-O2 co

nten

t

(ml O

2 /100 ml b

loo

d)

Oxyhemoglobin Disassociation Curve

(ODC)

ODC

The ODC represents a relationship between the

partial pressures of oxygen in the blood and the

percentage of saturation of hemoglobin with O2.

The PaO2 is measured by an ABG.

The SpO2 is measured by a pulse oximetry.

ODC

The plateau of the S curve indicates an

increase in PaO2 without much of an increase

in O2 saturation.

The curve of the S indicates how quickly

oxygenation drops once PaO2 falls below 60

mmHg and Spo2 below 90%.

Causes of Hypoxemia

Anemia

Pneumonia, pulmonary edema, pulmonary embolism

COPD, ARDS, interstitial lung disease

Sleep apnea

Pain medications

Cardiac dysfunction

Symptoms of Hypoxemia

Feeling short of breath

Frequent headaches

Severe sleepiness

Severe mood changes

What is wrong with this picture?

Terminology

Ventilation-The process of air moving into and out of the lungs .

Hypercarbia-High level of carbon dioxide (CO2) in the blood

Hypocarbia-Low levels of CO2 in blood

oNot as critical as hypercarbia

How to Assess for Effective

VentilationChest rise

Respiratory rate (RR)

Capnography

oYellow-Good

oPurple-Poor

Continuous capnography-Normal End Tidal CO2 (ETCO2) 35-37 mmHg

Causes of Hypercarbia

Chronic Obstructive Pulmonary Disease

(COPD)

Drug overdose

Brainstem stroke

Hypothermia

Symptoms of Hypercarbia

Paranoia

Depression

Confusion

Coma

Muscle twitches

Seizures

Summary

Capnography and pulse oximetry should be

used in the prehospital setting to help

determine patient’s oxygenation and

ventilation status.

These monitoring tools do not ‘treat’ the

patient.

The best monitor is the provider at the scene.

Summary

Using both the information from the monitors

and clinical assessment skills in making

decisions is important in treating patients.

Knowing the difference between oxygenation

and ventilation is crucial and must be fully

comprehended and is pertinent in successful

airway management.

Noninvasive Ventilation

(NIV)

Objectives

After the presentation, the attendee will be able to:

Describe what NIV is, when it is indicated, and when it is

contraindicated.

State the differences between CPAP & BiPAP and what each

mode is best used for.

Comprehend how to make adjustments in CPAP and BiPAP

modes to better treat patients in the field.

Noninvasive Ventilation

Ventilator support without the use of an invasive

artificial airway (endotracheal or tracheostomy tube).

Requires patient compliance and cooperation.

Requires proper fitting of the mask.

Can be used to prevent intubation or as a method of

weaning off of mechanical ventilation.

*PATIENT MUST BE SPONTANEOUSLY

BREATHING*

Indications of NIV

Obstructive sleep apnea (OSA)

COPD exacerbation

Pneumonia

CHF/Pulmonary edema

Neuromuscular disorders

Acute lung injury (ALI)

Weaning from vent

Contraindications of NIV

Respiratory arrest or unstable cardiopulmonary status

Uncooperative patients

Inability to protect airway

Trauma or burns to the face

Facial, esophageal, or gastric surgery

Apnea

Pneumothorax

Reduced consciousness

Complications of NIV

Drying of the upper airway

Drying of secretions/inability to mobilize

secretions

Skin break down

Modes of NIV

CPAP- (Continuous Positive Airway

Pressure) One set pressure

BiPAP- 2 set pressures

AVAPS (average volume-assured pressure

support). Set tidal volume and rate.

Pressure Control- ventilates using a set max

pressure.

CPAP

One pressure (EPAP- end positive airway

pressure) similar to PEEP (Positive end

expiratory pressure)

Helps with oxygenation

Used for OSA and hypoxia with sleep

Patient may feel claustrophobic

Must have minimal leaks

BiPAP

2 pressures (IPAP- inspiratory positive airway

pressure) + EPAP

Aids ventilation and oxygenation

IPAP – EPAP= Pressure support (how big the

breath is)

Needs a tight sealed mask

OSA (obstructive sleep apnea)- COPD & Obesity

hypoventilation population

Patient may be claustrophobic- antianxiety meds

Appropriate Adjustments

Use CPAP on patients that are having a difficult time

oxygenating.

O2 sat’s not improving:

Readjust mask

Increase EPAP

Increase FIO2

Antianxiety meds

Appropriate Adjustments

BiPAP is used for either ventilation issues or both oxygenation

and ventilation issues.

Minimal settings 10/4.

Max IPAP 20-24 cmH2O- consider NG tube

Set pressures to achieve tidal volumes 6-8ml/kg of ideal body

weight (IBW).

Goal: reduce CO2- Bigger gap between IPAP & EPAP.

Goal: increase oxygenation-increase IPAP & EPAP together

Example

You arrive to the scene to find a known COPD patient who is

unresponsive. P.O. upon arrival is 88% on the patient’s home

O2 at 3LPM. You place the patient on Bipap 10/5. 10

minutes later, the patient is still unresponsive with a P.O. of

93% with 4LPM bled into the Bipap. The Bipap was

increased to 15/5. 5 minutes later the patient started to wake

up.

Mechanical Ventilation

Objectives

After the presentation, the attendee will be able to:

Explain indications for mechanical ventilation.

Explain vent settings and various modes of ventilation.

Describe ventilator weaning.

Describe ventilator alarms.

State indications for suctioning.

Demonstrate appropriate placement and indications for a PEEP valve on an ambu bag.

Mechanical Ventilation

Used to support or assist patient’s breathing who are

unable to do so on their own.

Can completely control a patient’s breathing pattern

or help support/assist their breathing.

It is invasive ventilation because it requires an

endotracheal tube or a tracheostomy tube.

Indications for Mechanical

VentilationSurgery (cardiac, crani, etc.)

Respiratory failure (increased PCO2)

Decreased oxygenation (decreased PaO2/SaO2)

Neuro (decreased LOC, head bleed, OD, airway

protection

Transport

Vent Settings

Volume-The amount of air delivered per breath.

Pressure- The upper limit of how much pressure the ventilator will deliver. Striving for the lowest pressure possible to deliver the tidal volume.

BMP, f, or rate-The number of breaths delivered per minute.

Vent Settings

FIO2-Oxygen percentage

Positive End Expiratory Pressure (PEEP)- The

pressure used to keep airways open.

Increases airway pressure at the end of expiration to

force alveoli open.

Improves oxygenation.

Too much PEEP may reduce cardiac output.

Mechanical Ventilation

• Tidal volume (vt)- The amount of air exhaled with

each breath.

• Minute volume (MV)- The amount of air exhaled in

one minute. (RR x vt)

• Peak Pressure- The maximum pressure generated

to inflate the lungs.

Assist-Control (AC)

Provides full support for the patient.

Delivers a set number of breaths at a set volume.

The patient may trigger spontaneous breaths. The

spontaneous breaths are all delivered at the pre-set

or fixed volume.

Unable to control inspiratory pressures.

Pressure Regulated Volume

Control (PRVC)

Full support mode

Aims to deliver a set volume at the lowest

pressure possible to decrease the risk of

barotrauma.

Synchronized Intermittent

Mechanical Ventilation (SIMV)Often used as a weaning mode.

Delivers breaths at a set rate and volume that is

synchronized to the patient’s efforts.

Allows the patient to breathe spontaneously. These

breaths are unassisted. Pressure support is usually

added to this mode to support spontaneous breaths.

SIMV (PRVC) +PS, SIMV (PC)+PS, SIMV (VOL)

+PS are other synchronous modes available.

Pressure Support (PS) or CPAP

Weaning modes

No set rate

PS sets bi-level pressures-a high pressure and a low

pressure (PEEP)

CPAP sets one level (PEEP). Everyone has some natural

PEEP that is bypassed by the use of an artificial airway.

Pressures are set and weaned by monitoring the patients

work of breathing and exhaled tidal volumes.

Weaning

Can vary by institution, intensive care unit, and physician.

Work with the RN to find a middle ground with the sedation. Don’t want an anxious patient too awake, but has to have a spontaneous drive to breathe.

Underlying problem should be resolved or improved.

Weaning

FIO2 should be at an appropriate level.

Once patient is in a ventilator weaning mode,

monitor vital signs, resp. rate, SpO2, NICO, ABG’s,

WOB.

Always look at the patient.

Common Vent Alarms

Peak inspiratory pressure (PIP)- Coughing, gagging,

‘fighting’ the ventilator

Apnea- Patient not triggering breaths or possible patient

disconnect.

High minute volume- Patient is over breathing the set limit.

Low minute volume- Patient is under breathing the set limit

or possible patient disconnect.

Indications for Suctioning

High Peak Inspiratory Pressures

Coughing/gagging

Secretions visible in the tube

Coarse or rhonchi breath sounds

Ambu Bags

If patient on > 5 cmH2O of PEEP, consider using a

PEEP valve.

PEEP Valve

PEEP Valve on Ambu Bag

Tracheostomy Tubes

Objectives

After the presentation, the attendee will be able to:

Explain the indications, advantages, risks, and disadvantages

of a tracheostomy tube.

Understand the parts of the trach tube.

Understand that trach tubes come in many different sizes and

brands and each have different purposes.

Successfully transport a trach patient requiring oxygen.

Successfully ambu bag a patient with a cuffless trach.

Objectives(Continued)

Better understand the trach weaning process.

Better understand the use of one-way speaking valves.

Better understand the purpose of hard cap trials on trach

patients.

Better understand the decannulation process

Tracheostomy Tubes

Tube is inserted through a cut in the neck below the

vocal cords.

Breathing now bypasses the mouth, nose, and throat

and occurs through the trach tube.

Emergent or Non-emergent

Indications for Tracheostomies

Anaphylaxis

Burns

Cancer of the neck/tumors

Chronic lung disease

Diaphragm dysfunction

Inability to protect the airway due to:

Impaired mental status

Inability to manage excessive secretions

Indications

Injury to larynx

Infection

For prolonged respiratory or vent support

OSA

Vocal cord paralysis

Severe neck or throat injuries

Advantages

Decreased deadspace

Decreased airway resistance

Overall patient comfort

Increased patient mobility

Shorter duration of mechanical ventilation

Ease of tube replacement

Increased ability for patient to communicate

Risks & Disadvantages

Erosion of trachea

Scarring

Stenosis

Fistulas-Esophageal or innominate artery

Requires specialized skills, equipment, environment, and personnel for insertion and maintenance

Stoma bleeding/infection

Trach Parts

Types of Trach Tubes

Cuffed/Uncuffed

XLT-D/XLT-P

Foam cuffs/Air filled/Water filled

Shiley/Bivona/Portex/Jackson

ID/OD

Inner cannulas

Cuffless Trachs

Transporting with a Trach & O2

*Difficult to transfer

with humidification*

Venturi 24-50%

Liter flow varies

by manufacturer

Ambu Bagging with an Uncuffed

Trach

If the patient has an uncuffed trach, you will not be able to

ventilate appropriately by bagging through the trach.

Option for better ventilation:

Change to a cuffed trach if available OR:

Plug trach with gloved finger

Ambu bag with mask, covering nose and mouth

Getting Ready for Decannulation

Weaning and decannulation strategies are institution

dependent

Decannulation is the process of removing the trach

tube.

Getting Ready for Decannulation

Normal speech occurs by air passing through the vocal cords,

causing them to vibrate, creating sounds and speech.

Trach tube-

Cuff inflated- blocks most air from passing through the

vocal cords which is why sound or speech is unlikely. The

patient is breathing in and out through the trach tube.

Cuff deflated- some air is able to move around the trach

and through the vocal cords allowing for some noise.

Speaking with a Trach

Once the patient tolerates the trach mask, important

to establish that the upper airway is patent.

This is important because the trach tube can cause

upper airway obstruction.

Speaking with a Trach

The upper airway can be assessed by DEFLATING THE

CUFF and placing a gloved finger over the trach tube opening

to detect air through the upper airway and vocal cords,

allowing phonation.

This technique helps identify if the patient will be able to

tolerate the speaking valve or if the trach will need to be

downsized or changed to a cuffless trach.

Speaking Valves

One way speaking valves allow patient to breathe in

through the trach tube and out through the

mouth/nose.

CUFF MUST BE DEFLATED

Humidified oxygen source will be at the trach.

Increase time during the day on the speaking valve.

Hard Cap Trials

The step after speaking valve trials to get ready for

decannulation.

May need further downsize the trach.

If downsized as far as the team feels comfortable with,

consider a scope to visualize the airway.

Looking for:

Stenosis

Granulation of tissue

Vocal cord dysfunction

Hard Capping Trials

Cuffless trach is recommended due to increased bulk

and added resistance.

Increase time of hard cap trials until patient is hard

capped x 24 hrs.

Consider decannulation after 24-48 hrs. of hard cap

tolerance.

Criteria to Stop the Trials

Increase in hr > 20 bmp

RR > 35

Spo2 < 90%

FIO2 >/ 60%

Contraindications of Speaking Valve &

Hard Cap Trials

Severe aspiration risk

Severe upper airway obstruction

Medical instability

Foam filled trach tube

Thick, excessive, unmanageable secretions

Ensure Readiness for Decannulation

Level of consciousness (LOC)

Cough effectiveness

Volume of secretions

O2 requirements

Swallowing functions

Ability to tolerate tracheostomy occlusion

Advantages of Decannulation

Improve vocal cord and swallow function.

Easier process for discharging patients home and to

a lower level of care.

Improves patient comfort and physical appearance.

Post Decannulation

Place sterile gauze over stoma

5-7 days for complete closure

Varies from patient to patient

Decreased voice quality

Gently place 2 fingers over gauze covered stoma

24 hour monitoring of:

Telemetry

P.O.

References

Bradley JM, O'Neill B. Short-term ambulatory oxygen for chronic

obstructive pulmonary disease. Cochrane Database Syst Rev.

2005(4):CD004356.

Continuous or nocturnal oxygen therapy in hypoxemic chronic obstructive

lung disease: a clinical trial. Nocturnal Oxygen Therapy Trial Group. Ann.

Intern. Med. 1980;93(3):391-398.

Engels, P. T., Bagshaw, S. M., Meier, M., & Brindley, P. G. (2009, October).

Tracheostomy: from insertion to decannulation. Retrieved from

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2769112/

Galvagno, S. M. (2012, November 19). Understanding Ventilation and

Oxygenation is Key in Airway Management. Retrieved from

http://www.jems.com/articles/print/volume-37/issue-11/patient-

care/understanding-ventilation-vs-oxygenation.html

References

Hooley, J. (2017, July 20). Decoding the oxyhemoglobin dissociation curve. Retrieved from https://www.americannursetoday.com/decoding-oxyhemoglobin-dissociation-curve/

Hypoxemia. (2015, December 25). Retrieved December 03, 2017, from https://www.mayoclinic.org/symptoms/hypoxemia/basics/definition/SYM-20050930

Hypoxemia - What You Need to Know. (n.d.). Retrieved from https://www.drugs.com/cg/hypoxemia.html

Kovach, T., 2014. Oxygen hemoglobin dissociation curve. Youtube.

References

Leader, R. D. (2017, October 25). What Are the Causes and Symptoms of Hypercapnia in Blood? Retrieved from https://www.verywell.com/hypercapnia-symptoms-treatment-914862

Medical Definition of Hypoxia. (n.d.). Retrieved from https://www.medicinenet.com/script/main/art.asp?articlekey=3873

O'Conner, H. H., & White, A. C. (2010, August). Tracheostomy Decannulation. Retrieved from http://www.rcjournal.com/contents/08.10/08.10.1076.pdf

Pioboni, S., Markowitz, J., Windle, M., Filbin, M., Boothe D., Mosenifar, Z., 2015. Noninvasive procedures. Medscape.

References

Ries AL, Bauldoff GS, Carlin BW, et al. Pulmonary Rehabilitation: Joint ACCP/AACVPR Evidence-Based Clinical Practice Guidelines. Chest. 2007;131(5 Suppl):4S-42S.

Seheult, R., 2015. Oxygen hemoglobin dissociation curve explained clearly. Youtube.

Seidu, L., 2014. Hypoxia and hypoxemia: Symptoms, treatment, causes. WebMD.

Tracheostomy: Purpose, Procedure, and Risks. (n.d.). Retrieved January 13, 2018, from https://www.healthline.com/health/tracheostomy

References

Tracheostomy tube - speaking. (n.d.). Retrieved from

https://medlineplus.gov/ency/patientinstructions/000465.htm

Vogiatzis I. Strategies of muscle training in very severe COPD patients.

Eur. Respir. J. 2011;38(4):971-975.