RESPIRATOR AND VENTILATOR BASICS - albany.edu · Silvercrest – Respirator and Ventilator Basics...

Silvercrest – Respirator and Ventilator Basics UAlbany – 01/28/2011

NYS DOH Surveyor Training

RESPIRATOR AND VENTILATOR BASICSSTATE UNIVERSITY OF NEW YORK

UNIVERSITY OF ALBANY

NEW YORK STATE DEPARTMENT OF HEALTHSURVEYOR TRAINING – WEBINAR #1

Friday • January 28th, 2011 • 10:00AM

Agenda

Welcome

Who Needs Respiratory / Ventilator Care Respiratory Diseases

Neurological Diseases

Post-Cardiac Surgery & Other Indications

Indications for Mechanical Ventilation

What is Mechanical Ventilation

Life Expectancy / Outcomes

Common Comorbidities and Related Clinical Issues

Documentation and Care Planning

Webinar #1 – Respiratory and Ventilator Basics

Welcome

Format of Webinars

The Silvercrest Center

Speakers

Robert Fleming, MD FCCP

Mustafa Salehmohamed, DO

Daniel Russo, MD CMD

Denise Lawson, RN




Welcome

Webinars

Respiratory / Ventilator Basics 01/28/11

Ventilator / Tracheostomy Mechanics 02/25/11

Vent Weaning & Best Practices 03/25/11

Each webinar is 2 hours in length

10:00am to 12:00pm

1 ½ hour presentation & ½ hour for Q & A


Welcome

The Silvercrest Center 320 Skilled Nursing Facility in Queens, NY

Case Mix Index 1.23 Full House

1.64 Vents

Largest SNF Vent Program in NY State Ventilator Program Started in 1992

48 Certified Ventilator Dependent Beds in Discrete Unit

ADC 70 Vents (Private Pay and Commercial Insurance)

Member of the NewYork-Presbyterian Healthcare Systemand an Affiliate of Weill Medical Cornell College


Welcome

Speakers Robert Fleming, MD FCCP Director of the Ventilator Unit at The Silvercrest Center for Nursing

and Rehabilitation and Director for the Respiratory DiseaseManagement Unit at New York Hospital Queens

Mustafa Salehmohamed, DO Pulmonologist at The Silvercrest Center for Nursing and

Rehabilitation and New York Hospital Queens

Daniel Russo, MD CMD Vice President of Services and Medical Director at The Silvercrest

Center for Nursing and Rehabilitation

Denise Lawson, RN Director for Performance Improvement at The Silvercrest Center

for Nursing and Rehabilitation




Who Needs Respiratory / Ventilator Care

Respiratory Diseases


Post-Cardiac Surgery and Other Indications


What is Mechanical Ventilation?

Presenter: Dr. Robert Fleming

Director of the Ventilator Unit at The Silvercrest Center forNursing and Rehabilitation and Director for the RespiratoryDisease Management Unit at New York Hospital Queens




Chronic diseases of the airways & other structures ofthe lung. Most common examples:

Asthma

Chronic Obstructive Pulmonary Disease (COPD) Chronic Bronchitis

Emphysema

Respiratory Allergies

Occupational Lung Disease

Pulmonary Hypertension




Important Risk Factors for chronic respiratory disease:

Occupational Risks and Vulnerability

Indoor and Outdoor Air Pollution

Allergens

Smoking






2007 World Health Organization estimates:

300 million with asthma

210 million with COPD

2009 NYS Asthma Surveillance Report

1 in 11 children and adults in NYS has asthma

1.3 million New Yorkers had self reported currentdiagnosed asthma

17.2 per 100,000 mortality rate in 2007



Respiratory Diseases COPD 4th leading cause of death

in America, 120,970 in 20061

85%-90% of COPD deathscaused by smoking2

12.1 million U.S. adults wereestimated to have COPD3

672,000 hospital discharges in2006; a discharge rate of 22.5per 100,000 population. 4

Approximately 64% ofdischarges were in the 65 yearsand older population in 2006. 5


Normal Damage+Cholinergic tone

Bronchi and COPD


Respiratory Diseases COPD Age-Adjusted Death Rates Based on the 1940

and 2000 Standard Populations, 1979-2006





First-Listed Hospital Discharge Rates per 10,000 Population by Age, 1979-2006




Amyotrophic Lateral Sclerosis (ALS or Lou Gehrig’s Disease)

Motor neurons in lungs affected affecting strength of respiratorymuscles

Maybe gradual or sudden

Spinal Cord Injuries (SCI)

Pulmonary failure and related complications are the most commoncauses of death in SCI patients

At 5 years after injury, 33% of ventilator dependent SCI patientsremain alive

Guillian-Barre (GB)



Post-Cardiac Surgery and Other Indications

Post Operatively

Over sedation

Paralytics

Pain control






Impending Respiratory Failure

Acute Respiratory Failure / Arrest

Airway Establishment and Control




Impending Respiratory Failure

Progressively worsening clinical appearance

Worsening chest x-ray (CXR)

Hypoxemic respiratory failure Too little oxygen (O2) in the blood

Examples: CHF and Pneumonia

Hypercapnic respiratory failure

Too much carbon dioxide (CO2) in the blood

Examples: ALS and COPD




Acute Respiratory Failure / Arrest

Acute change in arterial blood gas (ABG) / pulse oximeterresults

Respiratory arrest / Status post CPR

Acute epiglottitis / anaphylaxis Swelling of the epiglottis, a flap of tissue that covers the

windpipe during swallowing to protect against choking. Swellingof the epiglottis is a potentially life-threatening breathingobstruction






Airway Establishment and Control

Clearing the upper airway

Maintaining an open air passage with amechanical device

Assisting with respirations


Endotracheal - Acute

Tracheostomy – Post Acute

Situations Requiring Airway ControlEmergencies Urgencies

• Cardiac arrest• Respiratory arrest or

apnea (eg, due to CNSdisease, drugs, or hypoxia)

• Deep coma, when thetongue relaxes to occludethe glottis

• Acute laryngeal edema• Laryngospasm• Foreign body at the larynx

(eg, “cafe coronary”)• Drowning• Upper airway trauma• Head or high spinal cord

injuries

• Respiratory failure• Need for ventilatory support (eg, in acute respiratory distress

syndrome, smoke or toxic inhalation, respiratory burns,gastric aspiration, exacerbations of COPD or asthma, diffuseinfectious or other parenchymal lung problems,neuromuscular diseases, respiratory center depression, orextreme respiratory muscle fatigue)

• Need to relieve the work of breathing in patients in shock orwith low cardiac output or myocardial stress that must bedecreased

• Before gastric lavage in patients with an oral drug overdoseand altered consciousness

• Before esophagogastroscopy in patients with upper GI bleeding• Before bronchoscopy in patients with marginal respiratory status• Before radiologic procedures in patients with altered sensorium,

particularly if sedation is required



The simplest way to look at mechanical ventilation is as a way tokeep the blood gases normal.

Mechanical ventilation is a life support treatment.

A mechanical ventilator is a machine that helps people breathewhen they are not able to breathe enough on their own.

The mechanical ventilator is also called a ventilator, respirator, orbreathing machine.

Most patients who need support from a ventilator because of asevere illness are cared for in a hospital’s intensive care unit (ICU).

People who need a ventilator for a longer time may be in a regularunit of a hospital, a rehabilitation facility, or cared for at home.





Why are ventilators used? To get oxygen into the lungs and body

To help the lungs get rid of carbon dioxide

To ease the work of breathing—Some people can breathebut it is very hard. They feel short of breath anduncomfortable.

To breathe for a patient who is not breathing because ofbrain damage or injury (like a coma) or high spinal cordinjury or very weak muscles. If a person has had a seriousinjury or illness that causes breathing effort to stop, aventilator can be used to help the lungs breathe until theperson recovers.



Key Terms in Mechanical Ventilation:

Inspiration = Act of breathing in; inhalation

Expiration = Process of expelling air from the lungs;exhalation

Ventilation = Breathing, or more specifically, the act ofmoving air into and out of the lungs

Respiration = Transport and exchange of gasesbetween the atmosphere and the cells via the lungs andblood vessels




Physiology of Breathing




Origins of MechanicalVentilation

Negative-pressureventilators (“iron lungs”)

Air is sucked into the lungs

Non-invasive ventilationfirst used in BostonChildren’s Hospital in 1928

Used extensively duringpolio outbreaks in 1940s –1950s


The iron lung created negative pressure in abdomen aswell as the chest, decreasing cardiac output.

Iron lung polio ward at Rancho Los Amigos Hospital in 1953.


Origins of MechanicalVentilation

Positive-pressureventilators

Air is forced into the lungs

Invasive ventilation firstused at MassachusettsGeneral Hospital in 1955

Now the modern standardof mechanical ventilation


Massachusetts General 1955

Portable ventilators in various settings


Future of Mechanical Ventilation

Portable, negative and positive pressure ventilator with infinite powerand oxygen sources








Figure 2. Survival among low-risk patients (.70%probability of surviving 2 months), medium-riskpatients (51% to 70%), high-risk patients(≤50%), and patients in whom ventilator supportwas withheld in anticipation of death.

Agenda

Common Comorbidities and Related ClinicalIssues Presenter: Mustafa Salehmohamed, DO

Pulmonologist at The Silvercrest Center for Nursing andRehabilitation and New York Hospital Queens




Common Comorbidities and Related Clinical IssuesLife Expectancy / Outcomes


Infections

Ventilator Associated Pneumonia (VAP)

MRSA

C Diff

Sepsis

Pressure Ulcers and Other Skin Conditions



Decannulation and Trach Tube Dislodgements Restraints

Feeding and Hydration Incontinence

PEG Tubes

Speech Disorders and Dysphasia Communication

Paralysis and Quadriplegia

Quality of Life



Tracheostomy vs. Oral Intubation

Dysphagia requiring PEG tube

SNFs in general do not accept nasogastric tubes

Ventilator associated pneumonia (VAP)

Multidrug Resistant Organisms (MDRO)

MRSA, VRE, C Diff, etc





Infections Ventilator Associated Pneumonia (VAP)

MRSA

C Diff

Sepsis

Pressure Ulcers and Other Skin Conditions

Decannulation and Trach Tube Dislodgements Restraints

Feeding and Hydration Incontinence

PEG Tubes

Speech Disorders and Dysphasia

Paralysis and Quadriplegia

Quality of Life

Communication

Common Comorbidities and Related Clinical IssuesCase Study


PHYSICIAN'S MONTHLY ASSESSMENT

PROGRESS NOTE: 71 y.o. man with Resp. failure on vent support, s/p hospitalization at NYHQ12/23/10 – 12/30/10 for Hematemesis, GI bleed, Anemia, s/p Blood trabsfusion, VAP, s/pEGD on EGD on 12/27/10, found with Hiatus hernia, GERD with esophagitis, deformedgastric antrum, scarring of duodenal bulb; suggested PPI`s & Reglan. S/p PICC line placementon 12/30/10. . Since re-admission:- completed ABT for Pneumonia (IV Zosyn & Flagyl) on 1/5/10;- s/p GI cons done on 1/6/10, sug to r/o Celiac disease, w/u done, neg;-Dx with Vitamin D deficiency, started vit D 1000 IU via GT daily;-observed with diarrhea, Leukocytosis, elevated ESR thought due to C.Diff Colitis; orderedStool for C.Diff x 3, started Flagyl 500 mg via GT q 8 h on 1/12/11; Stool C.Diff neg x 3,completed Flagyl course today;-D/C-ed foley cath on 1/12/11, no SxS of urinary retention noted;- decrease FSBG monitoring to BIW (Mo & Thu);-s/p Pulmonary f/u on 1/10/11, pt was entered into the weaning protocol;-Today – no fever, mild lethargy, still with diarrhea.

Common Comorbidities and Related Clinical IssuesCase Study – Continued


PAST MEDICAL HISTORY: DM, CAD, HTN, s/p CABG, s/p PPM (ventricular), Hyperlipidemia, PVD,s/p R 1st & 2nd toes amputation, GERD, Cataracts, s/p CVA w L HP, Seizure d/o, Resp.Failure, s/p Trach(8/30/10), s/p PEG (9/2/10), s/p Pneumonia (8/10), UTIECHO (8/15/10): EF 50-55%. Mild LVH.ECHO (11/3/10): normal LVEF 65-70%, hypokinesis basal anteroseptal wall, mild AI.Carotid Doppler (8/16/10): moderate stenosis RECA & RICA; L ECA&ICA wnl.Hospitalizations:-8/14/10 – 9/10/10 – Flushing Medical Center for CVA w L HP, Seizure d/o, RESP. FAILURE,s/p TRACH (8/30/10), s/p PEG (9/2/10), s/p Pneumonia (8/10), UTI.-10/30/10 – 11/05/10 – NYHQ, for Hematemesis, H/H remained stable, stool guaiac pos,s/p GI eval., no endoscopic procedure done; Dx with VRE UTI, Candiduria, started ABT; PPMinterrogated (11/4/10).-12/23/10 – 12/30/10 – NYHQ for Hematemesis, GI bleed, Anemia, s/p Blood trabsfusion,VAP, s/p EGD on EGD on 12/27/10, found with Hiatus hernia, GERD with esophagitis,deformed gastric antrum, scarring of duodenal bulb; suggested PPI`s & Reglan. S/p PICC lineplacement on 12/30/10.

CONSULTATIONS (this month): Pulmonary (1/10/11), Wound care specialist, Wound NP

REVIEW OF SYSTEMS: no fever, no cough, no SOB, no edema, no abdominal distension, +diarrhea, no constipation, no vomiting, no melena, no bruising, no dysuria, no hematuria, noagitation.





PHYSICAL EXAMINATIONVS T 97.6 Pulse 79 R 14 BP 124/67WEIGHT: 154.6 lbs [ ]Stable [x]Weight change – -2.8 lbs (Re-adm. Wt 151.8 lbs)O: MENTAL STATUS: Drowsy, arousable, in NAD.HEENT: PEERL, no eye discharge, no ear discharge.ORAL CAVITY: moist, no ulcers.NECK: supple, no JVD, trach in place, no carotid murmur.CHEST: no local tenderness, no deformityBREASTS: normal maleLUNGS: b/l AE, b/l scat rhonchi, no rales, no wheezing.C.V.: S1S2 RRR, no S3.ABDOMEN: soft, non tender, BS +. PEG site with min sero-sanguineous oozing.RECTAL: loose brown stool, no BRBPRGU: normal male.EXTREMITIES: no leg edema, no clubbing, diminished peripheral pulses, LUE contacted in elbow & swollen.Amputated R 1st & 2nd toes.CONTRACTURES: LUENEURO: MS as above, L HPHEMIPLEGIA/HEMIPARESIS: L HPPSYCH/BEHAVIOR: no agitationSKIN: Full thickness arterial wound dorsal bordering lateral and medial aspects right 3rd toe



SPECIAL PROBLEMSFeeding Tube: [ ]Not Applicable [ x ]Yes Reason: DysphagiaIf YES, type: [ ]NG [ x ]GT [ ]JT[ x ]Continue [ ]Discontinue

Catheter[x ]Not Applicable [ ]YesReason: [ ]Indwelling [ ]Cystostomy [ ]Texas[ ]Continue [ ]Discontinue

Tracheostomy[ ]Not Applicable [ x ]YesIndication: Respiratory failure

Oxygen:[ ]Not Applicable [ x ]Yes[ ]PRN for:[ x ]Continuously For: Respiratory failure



Antipsychotic Meds[ ]Not Applicable[x ]YesDrugs: Seroquel 25 mg via GT BID, Clonazepam 0.25 mg via GT q 12 hReason - Target behavior(s): anxiety, agitationis it effective?: YesSide Effects: [ ]T.D. [ ]Other: none

Restraints[ ] Not applicable [x] YesIf YES, type: Right hand "peek-a boo" mittensMedical Symptom(s)/Reason: to prevent self decanulationAlternatives tried: [ ] Yes [ ] No NAIf YES, Type:Reduction attempted: [ ] Yes [ ] NoIf YES, Successful? [ ] Yes [ ] No[ x ] Continue Restraint [ ] Discontinue Restraint

Pain Evaluation:[ ] No Pain [ X ] Pain presentPlan (if applicable): Tylenol 650 mg via GT 1 h prior to dressing change





DIAGNOSIS/PROBLEMS / PLAN OF CARE:

- RESPIRATORY FAILURE – in the weaning protocol, tolerating CPAP well. P: continuebronchodilators, weaning as per Pulmonary.

-S/p VAP – resolved clinically. P: observe off ABx.

-Diarrhea – no evidence of C.Diff colitis; completed 2 week course of Flagyl today. P: repeatstool for C.Diff, Stool for O&P, no more ABx for now, hydration via GT, labs next week.

-CAD, HTN, s/p CABG, s/p PPM – continue Plavix 75 mg via GT daily, Metoprolol 25 mg viaGT q 12 h, Isosorbide 20 mg via GT TID, monitor P&BP q shift, monitor SxS of CHF, off ASA inview of recurrent hematemesis. Pacemaker check q month. Last Pacemaker interrogation duringhospitalization (11/4/10 - see copy of report in chart).




-DM – HgbA1C 6% on 12/14/10. FSBG 96 - 109. P: off meds, FSBG BIW TID AC, f/uHgbA1C in 3/10.

-Anemia – prob. ACD + Iron deficiency, s/p blood transfusion during hospitalization on12/27/10. P: continue Iron supplement, monitor CBC prn.

-GERD/ Recurrent vomiting/ Hematemesis / GI PROPHYLAXIS – Omeprazole 20 mg via GTdaily, Reglan 10 mg via GT TID AC.

-S/P CVA w L HP, Dysphagia, s/p PEG – continue Plavix 75 mg via GT daily for CVAprophylaxis, off ASA in view of recurrent hematemesis, supportive care, GT feeds.

-Seizure d/o – Trileptal 300 mg via GT BID, seizure precautions.




-Vascular Dementia with delusions/psychosis – s/p Psych cons 9/30/10. Plan: continue Clonazepam 0.25mg via GT q 12 h, Seroquel 25 mg BID. Monitor for behavioral disturbances and behavior modificationmanagement. Psych f/u.

-BPH – s/p D/C foley cath on 1/12/11, no SxS of urinary retention. P: off foley cath, Flomax 0.8 mg viaGT qhs.

-DVT PROPHYLAXIS – Heparin 5000 units SQ q 12 h.

-Ulcer R 3rd toe – continue local Tx as per order, vit C to promote wound healing.

-Dermatitis scrotum – Zn oxide oint top q shift

-Vitamin D deficiency – vit D 1000 IU via GT daily, f/u level in 1-2 mo.

-Multiple full thickness wounds b/LE – top Tx as per order, pressure relief as much as possible, nutrition asper dietary), Wound NP f/u.

DNR Conditions Met? [ ]Not Applicable [ x ]YesDNR Ordered? [ ]Not Applicable [ x ]YesResident Plan of Care Discussed? [ ]Yes [ x ]No Reason: Patient unable to comprehend due to Dementia.




Assessments

Orders

Plans of Care

Evaluation of Progress

Presenter: Denise Lawson, RN

Director for Performance Improvement at TheSilvercrest Center for Nursing and Rehabilitation



Assessments Basic

Enhanced

Medical/Pulmonary

Nursing

Respiratory

Dietary

Rehabilitation

Social Services

Therapeutic Recreation / Activities



Documentation for ventilator dependent residents must meet thestandard for all residents in a Skilled Nursing Facility however thefollowing F Tags are the most significant to this population: F221

F248 F278

F279

F280

F281

F309

F314

F328

F329





Assessments

Medical/Pulmonary

Co-morbidities acute or chronic such as COPD, CHF, Post Cardiac surgery,

Diabetes, pressure ulcers, neurological (ALS, Guillian-Barre, etc.)

Current respiratory status, history including underlyingcardio-pulmonary conditions/diagnoses

Overall stability of conditions and wean potential



Assessments

Nursing

System, symptom and diagnosis specific for example;FLACC tool for non-verbal pain assessment

Skilled needs for example IV hydration

Safety issues for example preventing unplanneddecannulation

Education; importance adhering to aspirationprecautions



Assessments

Respiratory

Respiratory pattern for example normal or labored

Breath sounds

Secretions, i.e., amount, viscosity and color

Ventilator settings, including tidal volume, rate andoxygen

Equipment, including tracheostomy tube type(specialty versus standard) and size





Assessments Dietary Nutritional needs, for example caloric requirement, protein,

supplements, hydration Modified diet based on swallowing ability Therapeutic diet based on diagnosis for example diabetic and renal Preferences and culturally sensitive choices

Rehabilitation Restorative or maintenance PT/OT/SLP or unit based program

(PROM) Need for splints, adaptive or other devices Swallowing ability and secretion management Communication needs, vocal or non-vocal



Assessments Social Services Psychosocial needs

Advance Directives

End of life care

Family support

Expressions of sadness or hopelessness

Discharge potential

Therapeutic Recreation Spiritual needs

Leisure interests/recreational needs

Potential for isolation



Orders

Basic

Enhanced

Respiratory

Dietary

Advanced Directives





Orders Enhanced

Respiratory Ventilator settings for example ventilator mode (ventilator gives all breaths or

resident participates in taking/triggering a breath) Weaning protocol or modified weaning protocol (gradual decrease in ventilator

support and oxygen percentage based on specific parameters and individualtolerance)

Tracheostomy tube type and size Tracheostomy care

Tracheostomy tube change/frequency Inner cannula tube change/frequency

Ventilator tubing change/frequency Suctioning frequency Respiratory treatments/medications Other specialty areas

Speaking valve use Cuff deflation



Orders Enhanced Diet

Regular/Modified

Tube Feeding

Pleasurable

Adaptive device

Advance Directives DNR

DNI

Hospice

Palliative Care



Plan of Care

Basic

Enhanced

Medical/Pulmonary

Nursing

Respiratory

Dietary

Rehabilitation

Social Services

Therapeutic Recreation / Activities





Plan of Care

Enhanced

Medical/Pulmonary

Co-morbidities

Respiratory medications and treatments

Respiratory care including suctioning, tracheostomy tubecare, maintaining ventilator settings

Weaning



Plan of Care Enhanced

Nursing Diagnosis specific for example diabetes High-Risk/Population specific

Pressure ulcer prevention and management Infections for example UTI, Sepsis and Ventilator Associated Pneumonia Tube feeding; gastrostomy and jejunostomy Hydration including IV fluids PICC line management Urinary catheters Restraints Polypharmacy Pain Safety for example unplanned decannulation Resident/family education for example Weaning Protocol



Plan of Care Enhanced Respiratory

Ventilator support

Weaning

Capping and Decannulation

Treatments

Equipment, including specialty equipment

Dietary Nutritional status

Diet type and supplements

Weight loss/gain





Plan of Care Enhanced Rehabilitation

Restorative or maintenance PT/OT/SLP or unit based program

Swallowing and/or secretion management

Communication, vocal or non-vocal

Social Services Psychosocial/isolation/depression

Advance Directives

Therapeutic Recreation Spiritual

Leisure/recreational activities



Evaluation of Progress

Care plan meetings

Ventilator Rounds

Respiratory/Ventilator checks

As indicated


RESPIRATOR AND VENTILATOR BASICS

ANY QUESTIONS?

FOR ADDITIONAL INFO VISIT US AT:WWW.SILVERCREST.ORGOR CALL 718-480-4026

Friday • January 28th, 2011 • 10:00AM

RESPIRATOR AND VENTILATOR BASICS - albany.edu · Silvercrest – Respirator and Ventilator Basics...

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Transcript of RESPIRATOR AND VENTILATOR BASICS - albany.edu · Silvercrest – Respirator and Ventilator Basics...