when the ventilator alarm sounds santanilla

7/27/2019 When the Ventilator Alarm Sounds SANTANILLA

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When the Ventilator Alarm

Sounds: Troubleshooting theIntubated PatientJairo I. Santanilla, MD

Section of Critical Care MedicineOchsner Medical Center

&Clinical Assistant Professor of MedicineSection of Emergency Medicine

Section of Pulmonary/Critical Care Medicine LSUHSC New Orleans


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Disclosures

No Conflicts of Interest to Disclose


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Goals and Outline

Provide a framework for troubleshooting themechanically ventilated patient

Focus on the Cardiac Arrest/Near Arrestpatient and the Near Stable/Stable patient

Like ACLS and ATLS, this is a framework Bedside clinical judgment supersedes Often perform several steps in tandem, instead

of in sequence.


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Determine Hemodynamic

Stability

Evaluate US andCXR

Check Respiratory

Mechanics and Waveforms

Check Gas Exchange

Focused History and

Physical Exam

Hand Ventilate with 100% Oxygen

Look for unequal chest riseListen for air-leak and unequal breath soundsFeel for difficulty to ventilate and crepitus

Disconnect from

Ventilator)

Stable/Near StableCardiac Arrest/Near Arrest

Evaluate Sedation

Likely Auto-PEEP

Check Settings and

Ventilator

Check Settings

and Ventilator

Determine that the ETT is functioning and in

proper position

Direct Visualization orPass Suction Catheter or Pass Intubating Stylet

Rush of Air,

Improvement

Improvement,

Unclear if Auto-PEEP

No Improvement

No Improvement

Special Procedures:

Ultrasound, CXR,

Needle Decompression

Evaluate for ETT position

adjustment, exchange, or

re-intubation

Improvement

ETT NOT functioning or

NOT in proper position

ETT functioning & in

proper position


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When you hear the alarms

Look at the patient and the monitor Try not to focus on the vent


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Determine Hemodynamic Stability

All intubated patients are critically ill Some more than others

How stable is the patient?

How quickly is the patient deteriorating? How much time do I have to find cause and

address problems?

Cardiac Arrest/Near Arrest Near Stable/Stable

SBP > 90

Pox > 90%

SBP < 70

POx < 70%


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Troubleshooting

During your evaluation, pt may transitionfrom stable to unstable and back and

forth. If unsure start with Near Arrest Be flexible in your thoughts and actions Constantly add to your differential and

re-arrange most likely choice

Keep in mind condition that necessitatedintubation, pt may simply be worseningfrom this.


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Cardiac Arrest/Near Arrest

Time is of the essence Disconnect patient from vent This can be diagnostic and therapeutic A quick rush of air or prolonged

expiration of air can diagnose and treat

Auto-PEEP (within a few seconds)

Success = Return of hemodynamicstability


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Hand Ventilate with 100% O2

Look for unequal chest riseDDx: Pneumothorax, mucus plug, mainstem

intubation Listen for air escaping from around the

ETT or through the nose (air leak)

DDx: Extubation, Pilot balloon or cuff failure Listen over the epigastrium and both

axilla


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Hand Ventilate with 100% O2

Feel the ease of hand ventilationStiff lungs can be due to mucus plug,

bronchospasm, pneumothorax, auto-PEEP,decreased respiratory system compliance

Feel for subcutaneous crepitusSearch for pneumothorax

Keep respiratory rates 8-10 bpm


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Determine ETT is Functioning

and in Proper Position Direct Visualization

DL or visualize carina with fiberoptic scope Pass the suction catheter

Easy: may or may not be in proper positionDifficult: ETT is dislodged, obstructed, twisted, or

pt biting.

Gently pass GEB or Eschmann introducerResistance should be met at approx 30 cmPassage without any resistance implies esophagus


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Procedures

After disconnecting from vent, handventilating, and checking proper placement:

Consider Tension PTX and need for needledecompressionFocused Hx, Physical ExamBedside US, CXR if time permits14g, 5cm over-the-needle catheter preferredRequires subsequent chest tube placement


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Near Stable/Stable Patient

Focused History Focused Physical Exam Check Gas Exchange Check Respiratory Mechanics Observe Waveforms Evaluate CXR and Ultrasound Evaluate Sedation


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Focused History Indication for intubation Difficulty of intubation

Useful if you need to re-intubate Depth of ETT Vent Settings Recent Procedures or Moves

New central line, thoracentesis, chest tube orattempts. Chest tube removal or water seal.

ETT manipulation, bed transfer, rotation,movement


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Focused Physical Exam

General survey Is patient agitated, gasping for breaths (air

hunger), tearing?Hand ventilate, talk to pt, consider sedation/

analgesia


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Airway Look, Listen and Feel to Evaluate ETT

position and function

Look if ETT is deeper or shallower thandocumented

Listen and Feel if there is an air-leakFeel the pilot balloon

If flat, add air at 1-2 ml aliquotsPass the suction catheter, direct visualization,

or GEB/Eschmann


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Endotracheal Tube

Pilot Balloon


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BreathingLook for unequal chest rise

Look for disconnected circuit, oscillatingwater

Listen for air-leakListen over the epigastrum and axillaFeel for ease of ventilation and crepitus


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CirculationCheck pulses, cycle BP cuff, check a-line

waveform and transducer levelBradycardia may be due to hypoxia,

propofol, precedex

Fluid bolus +/- vasopressor


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Asses Gas Exchange

Pulse oximeter is adequate to determineoxygenation

Waveform should correlate with HRPulse Ox may have 20-30 second lag time

Hypercapnia will be missed by POx If in doubt, place on 100% FiO2 andobtain ABG


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Check Respiratory Mechanics

Check Peak and Plateau PressuresObtain in Volume-Targeted modes

Peak Pressures are a function of tidal volume,resistance to airflow and respiratory systemcompliance

Plateau Pressures are obtained during aninspiratory pause, thus no airflow.

Plateau Pressures are a function of tidalvolume and respiratory system compliance


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Time (sec)

Paw

(cm

H2O)

PEEP

Inspiratory Hold

Pplat

Pressures

Ppeak


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Pearls

Plateau Pressure can never be higherthan peak pressure

If the Plateau Pressure increases, so willthe Peak pressure

Measurements are not reliable in thebucking patient


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Time (sec)

Paw

(cmH

2O)

Same Pplat

Increased Ppeak

Increased Peak Pressure


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Increased Peak Pressures

(increased resistance to airflow)

Biting on ETT

Obstruction of ETT by secretions,mucus, blood

Twisted/kinked ETT Bronchospasm/Reactive Airway Disease Partial bronchial mucus plugging Increased Plateau Pressures


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Time (sec)

Paw

(cmH

2O) Increased Pplat

Increased Ppeak

Increased Plateau Pressure


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Observe Ventilator Waveforms

Notching in the pressure-time or flow-time waveforms

Double or triple stacking Inadequate exhilation of tidal volume


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Time (sec)P

aw

(cm

H2O

)

Negative pressuredeflection showing air

hunger


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Time (sec)Flow

(L/min)

Time (sec)

Flow

(L/min)


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Normal

PatientInspiration

Expiration

Time (sec)Flow(L/min)

Air Trapping


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Evaluate CXR and US

ETT Position Mainstem intubation Atelectasis Pneumothorax Worsening parynchemal or pleural process


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Aspiration Major Trauma

Abdominal Sepsis Pneumonia

ARDS


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Ultrasound

Seashore Sign Barcode Sign


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Evaluate Sedation

SedativesPropofol, Precedex, Ketamine, BenzodiazepinesSometimes less is moreGoal is not a comatose patient

AnalgesicsFentanyl, Hydromorphone, Morphine

Treat underlying conditionPain is under appreciated


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Five Most Common Vent Alarms

High Pressure Low Pressure Apnea Circuit Disconnect High Exhaled Tidal Volume


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High Pressure Alarm

CoughingSuction, ensure ETT is above carina, nebulized

lidocaine, opiates

Biting on the ETT Decreased Lung Compliance Increased Secretions Alarm set too low


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Apnea Alarm

No inspiratory trigger by patient ormachine in a set time (usually 20 sec)

Flow greater than patient effort Alarm time interval set too short


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Circuit Disconnect

ETT disconnected from ventilator circuit Circuit disconnected from ventilator


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High Exhaled Tidal Volume

Increased compliance Decreased resistance In-line aerosol treatment increasing

volume


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Special Considerations

ChildrenETT migrate in/out with flexion/extension

Place C-collar to stabilize head positionMost intubating stylets and fiberoptic scopes are

too large for pedi tubes


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Tracheostomy

If trach dislodged, quickly decide if you willorally intubate or replace through stoma

Determine reason for trachLaryngectormy (imposible); Difficult AirwayMost are for chronic respiratory failure

Determine Age of TrachLess than 1 week, immature, high risk for creating false

tract Gently place 6.0 ETT through stoma

Stop if resistanceConfirm with fiberoptic


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Case 1

POx improves slightly and BP remains steady You quickly determine that you have timePlaced back on vent (same alarm)

Focused Hx: pt had been intubated forpneumonia, no recent moves or procedures, easyairway, ETT secured at 22cm

Focused Exam: ETT same position, pilot balloondeflated. Volume added but remains deflated.Suction catheter passes easily. ETCO2 has goodwaveform, VTE is 200 ml, set at 500


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Determine that the endotracheal

tube is in the tracheaIntubating styletDirect visualizationFiberoptic scope (if time allows)Be prepared to re-intubate

Re-intubation is

required

Feel the pilot balloon.

Note if it is deflated

Add air (2-5ml) to the pilot balloon. If this stops

the air-leak, document that air was added to the

balloon

Determine the ability to repair the pilot balloonmechanism with commercially available kit

If air leak persists, the pilot balloon does not inflate or the

pilot balloon deflates with time and the air leak returns with

time, there is a defect in the pilot balloon-cuff apparatus or

endotracheal tube has migrated out of the trachea

If air leak persists after repair or repair

not possible, the endotracheal tube will

need to be replaced

Determine Hemodynamic

Stability

Stable/Near StableCardiac Arrest/Near Arrest

Not in the trachea

Dealing withAir Leak


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Case 2

Called to bedside because change is status Pox 82% (95%), BP 90/45 (110/65), HR 130s

(110), Vent Alarming High Pressure

Disconnect from ventNo rush of air and no quick improvement

Hand Ventilate with 100% O2Mild resistance to Bag, Equal Chest Rise and

decreased BS on Left , no audible air-leak, no crepitus

DDx: : Pneumothorax, mucus plug, mainstemintubation


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Case 2

POx and BP improve You quickly determine that you have timePlaced back on vent (same alarm)

Focused Hx: pt had been intubated for COPD,no recent moves or procedures, easy airway,ETT secured at 21cm

Focused Exam: ETT same position, pilotballoon inflated. Suction catheter passes easily.ETCO2 has good waveform


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Whole Lung Atelactasis

Recruitment ManeauversHand Ventilate, Provide PEEP

Suctioning Rotate Patient Chest Percussion Bronchodilators Bronchoscopy


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Case 3

Called to bedside, pt is Crashing POx 85,80,70poor waveform HR 120s140s; BP 70s/palp No Time. Disconnect no improvement Hand Ventilate, Look, Listen, Feel. No

leak, equal distant BS bilaterally, nocrepitus. Difficult to bag. (decreasedcomplaince). Pilot ballon inflated.


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Case 3

GEB meets resistance at 28cm (ETT inplace)

Continues to decline, about to arrest

Fluid bolus by pressure bag Decision time is current issue due to

ventilator or not? Such a rapid declineimplies auto-PEEP, tension PTX, ETT notfunctioning or dislodged, atelectasis, PE,or bleed


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Case 4

Called to bedside because pt worsening Pox 80% , BP 80s systolic and HR 130s Disconnected from vent and prolonged

expiration with air rush from ETT.

POx and BP improveAuto-PEEP(breath-stacking, dynamic hyperinflation,intrinsic PEEP)


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Auto-PEEP

Look for causes: high set respiratory rate,high intrinsic rate (AC), obstructive airwaydisease

Monitor flow-time waveform Consider bronchodilators Consider decreasing tidal volume and

respiratory rate in patients with RADDecreasing set RR, ineffective in patients with highintrinsic rate while on volume-targeted AC

Optimize sedation, esp opiates

when the ventilator alarm sounds santanilla

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