Respiratory TherapyBiPAP is used for either ventilation issues or both oxygenation and ventilation...
Transcript of Respiratory TherapyBiPAP is used for either ventilation issues or both oxygenation and ventilation...
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.