stephanie wild, b.s., rrt lead respiratory therapist ... therapy... · support or manipulate...
TRANSCRIPT
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Stephanie Wild, B.S., RRT
Lead Respiratory Therapist
Cardiac/Medical Intensive Care Unit
Clinical Adjunct, Respiratory Care Program,
Seminole State College
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Describe different types of respiratory support, from low flow oxygen devices to ventilator management and weaning.
Explain the process of spontaneous breathing trials.
Explain respiratory therapists role in mobility of the clinically fragile patient.
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The overall goal of oxygen therapy is to maintain adequate tissue oxygenation while minimizing cardiopulmonary work.◦ correct documented or suspected acute hypoxemia
◦ decrease the symptoms associated with chronic hypoxemia
◦ decrease the workload hypoxemia imposes on the cardiopulmonary system
Egan’s Fundamentals of Respiratory Care 8th Edition
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Nasal Cannula
High Flow Nasal Cannula
Heated High Flow Nasal Cannula
Trach Collar/T-tube
Face Mask
Face Tent
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Adjust and titrate flow and FiO2 for desired O2 Sats
Indications:◦ Airway reactivity from cool
aerosol devices
◦ Patients requiring Fio2>40% or flow demand >15lpm in which other devices will not meet their demands or comfort
◦ Patients requiring high oxygen demands that have poor mask compliance
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http://www.medline.com/product/Aerosol-and-Oxygen-Masks-by-Westmed-Inc/Masks/
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Venturi Mask
Partial Rebreather Mask
Non-Rebreather Mask
Oxygenator
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http://www.medline.com/product/Aerosol-and-Oxygen-Masks-by-Westmed-Inc
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Mechanical Ventilation Physiological and Clinical Applications 4th Ed.
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Support or manipulate pulmonary gas exchange
Increased lung volume
Reduce the work of breathing
Reverse acute respiratory failure
Reverse respiratory distress
Reverse hypoxemia
Prevent or reverse atelectasis and maintain FRC
Reverse respiratory muscle fatigue
Reduce systemic or myocardial oxygen consumption
Minimize associated complications and reduce mortality
Mechanical Ventilation Physiological and Clinical Applications 4th Ed.
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Defined as “ the application of positive of pressure via the upper airway tract for the purpose of augmenting the alveolar ventilation.”
CPAP vs BiPAP◦ Continuous Positive Airway Pressure
Settings: PAP & FiO2
◦ Bi-level Positive Airway Pressure
Settings: IPAP, EPAP & FiO2
Interfaces◦ Full Face Mask
◦ Face Mask
◦ Nasal Mask
◦ Nasal Prongs
Mechanical Ventilation Physiological and Clinical Applications 4th Ed.
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Chronic Care: ◦ Alleviates symptoms of chronic hypoventilation
◦ Improves duration and quality of sleep
◦ Improves functional capacity
◦ Prolongs survival
◦ Improves mobility
Acute Care: ◦ Reduces need for intubation
◦ Reduces incidence of nosocomial pneumonia
◦ Shortens stay in intensive care unit (decreases hospital length of stay)
◦ Reduces mortality
◦ Preserves airway defenses
◦ Improves patient comfort
◦ Reduces need for sedation
Mechanical Ventilation Physiological and Clinical Applications 4th Ed.
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Chronic Care:◦ Restrictive thoracic disease
◦ Chronic obstructive pulmonary disease (COPD)
◦ Nocturnal hypoventilation
Acute Care: ◦ COPD exacerbation
◦ Asthma
◦ Cardiogenic pulmonary edema
◦ Hypoxemic respiratory failure
◦ Community-acquired pneumonia
◦ Immunocompromised patients
◦ Postoperative patient
◦ “Do not intubate” status Mechanical Ventilation Physiological and Clinical Applications 4th Ed.
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Absolute:◦ Respiratory arrest
◦ Cardiac arrest
◦ Upper airway obstruction
◦ Inability to protect the airway or high risk of aspiration
◦ Inability to clear secretions
◦ Facial or head surgery or trauma
Relative: ◦ Cardiovascular instability
◦ Uncooperative patient
◦ Copious or viscous secretions
◦ Fixed nasopharyngeal abnormalities
◦ Extreme obesity
Mechanical Ventilation Physiological and Clinical Applications 4th Ed.
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Respiratory Arrest
Cardiac Arrest
Failure of NPPV
Upper airway obstruction
Respiratory failure (hypoxemic vs. hypercapnic)
Inability to protect the airway or high risk of aspiration
Non-respiratory organ failure
Life threatening hypoxemia
Severe acidosis
Facial or head surgery or trauma
Severe dyspnea with use of accessory muscles and possible paradoxical breathing
Cardiovascular complications
Mechanical Ventilation Physiological and Clinical Applications 4th Ed.
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Hypoxemia◦ ARDS
◦ Pulmonary embolism
◦ Pulmonary edema
◦ Septic shock
◦ Pulmonary infection (viral, bacterial, fungal)
◦ Inhalation (smoke, chemical, water)
◦ Pleural effusion
◦ Interstitial lung disease
◦ Obstructive lung disease
◦ Aspiration
◦ Primary pulmonary hypertension
Egan’s Fundamentals of Respiratory Care 8th Ed.
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Hypercapnic◦ Decreased Ventilatory Drive
Drug overdose, central sleep apnea, metabolic alkalosis, brainstem lesions, hypothyroidisim, infection (encephalitis)
◦ Increased Work of Breathing
COPD, asthma, obesity, pneumothorax, severe burns, kyposcoliosis, upper airway obstruction, pleural effusion, airway edema, infection
◦ Respiratory Muscle Fatigue
Guillain-Barre Syndrome, ALS, Myasthenia gravis, Muscular dystrophy, SLE, phrenic nerve injury, botulism, spinal cord injury, muscular weakness, hypokalemia, hypophosphatemia, hypomagnesemia, hypocalcemia
Egan’s Fundamentals of Respiratory Care 8th Ed.
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Interfaces◦ Endotracheal Tube
Oral pharynx
Nasal pharynx
◦ Tracheostomy Tube
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f – Frequency/Rate of breaths per minute
VT – Tidal Volume delivered
PC – Pressure Control
PEEP – Positive End Expiratory Pressure
PS – Pressure Support
FiO2 – Fractionated Inspired Oxygen
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Spontaneous (Spont or CPAP/PS)
Controlled Mandatory Ventilation (CMV)
Assist/Control (A/C)
Synchronized Intermittent Mandatory Ventilation (SIMV)
Adaptive Pressure Ventilation (APV)◦ APV-CMV
◦ APV-SIMV
Pressure Controlled Ventilation (PCV)◦ PC-CMV
◦ PC-SIMV
Adaptive Support Ventilation (ASV)
Airway Pressure Release Ventilation (APRV)
High Frequency Oscillatory Ventilation (HFOV)
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f VT TARGETVT
PC PEEP PS FiO2
SPONT X X X
A/C orCMV
X X X X
SIMV X X X X X
APV-CMV X X X X
APV-SIMV X X X X X
PC-CMV X X X X
PC-SIMV X X X X X
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Traditional ◦ Mode
◦ FiO2
◦ Peep
◦ Frequency
Provider Order Work Sessions ◦ Spontaneous/CPAP/PS trials
◦ Trach Collar/T-piece trials
◦ Other Physician specific orders
Spontaneous Breathing Trials ◦ Peep = 5
◦ PS = 5
◦ FiO2 50% or less
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Every day, every ventilator patient is assessed for SBT participation.
Inclusion vs Exclusion◦ Exclusion: continue with traditional weaning of parameters
◦ Inclusion: perform SBT
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Initial Assessment◦ Inclusion vs Exclusion determined by RT & RN
◦ Begins approx 0200-0400, sedation to be lightened
Trial of Spontaneous breathing ◦ Coordinated by RT & RN with the SAT
◦ Pre-SBT vital signs assessment completed
◦ SBT begins: Peep=5 PS=5 FiO2= < or = 50%
◦ 2 min vital signs assessment completed
Outcome ◦ Patient fails at 2min mark: requires increased ventilator
support, continue with traditional weaning
◦ Patient passes at 2min mark: continue SBT for >30 mins <2hours, contact MD for extubation or liberation orders
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Resolve issue requiring mechanical ventilation
Extubate intubated patient
Liberate trached patient
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Communication of Care Plans◦ Sedation, Delirium and Sleep
◦ Early Mobility and Physical Therapy
◦ Early Occupational Therapy
◦ Communication and Swallowing
Coordination of Care◦ Interdisciplinary Approach
MD, RN, RT, PT, OT, SLP, etc.
Continuity of Care ◦ Improved patient care and assessments
◦ Trust bond formed with patient
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Assess patients respiratory status, provide patients with adequate and appropriate oxygen therapy and respiratory support devices
Coordinate care plan of patient with interdisciplinary team members
Stabilize and liberate mechanically ventilated patients
Coordinate SAT & SBT with RN
Assist with mobility and therapy of mechanically ventilated patients in coordination with PT & OT
Assist with communication and swallowing of trached patients in coordination with SLP