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Ventilation: Basic Principles

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Presentation to participants of the 'Resuscitation Workshop' in the Emergency Department - Canberra Hospital, 2006

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Ventilation: Basic Principles

  1. 1. Ventilation: Basic Principles Jamie Ranse Registered Nurse Emergency Department The Canberra Hospital
  2. 2. <ul><li>Introduction to Ventilation Principles </li></ul><ul><li>Respiratory Anatomy and Physiology </li></ul><ul><li>Indications for Ventilation </li></ul><ul><li>Modes of Ventilation </li></ul><ul><li>Patient Management </li></ul><ul><li>Complications </li></ul><ul><li>Questions </li></ul>Overview
  3. 3. <ul><li>Ventilation is the movement of air into and out of the alveoli. </li></ul>Introduction Hudak, et al, 1997, Critical Care Nursing: A Holistic Approach (7th Edn) , Lippincott, Philadelphia, USA
  4. 4. <ul><li>Mechanics of Ventilation: </li></ul><ul><li>Elasticity </li></ul><ul><li>Compliance </li></ul><ul><li>Resistance </li></ul><ul><li>Pressure </li></ul><ul><li>Gravity </li></ul>Introduction Hudak, et al, 1997, Critical Care Nursing: A Holistic Approach (7th Edn) , Lippincott, Philadelphia, USA
  5. 5. <ul><li>Respiratory Structures </li></ul><ul><li>Respiratory Zones </li></ul><ul><li>Partitioning of Respiratory Pressures </li></ul><ul><li>Boyles Law </li></ul><ul><li>Respiratory Volumes and Capacity </li></ul><ul><li>Ventilation and Perfusion </li></ul>Anatomy and Physiology
  6. 6. Anatomy and Physiology Porth CM, 1998, Pathophysiology (5 th Edn) , Lippincott, Philadelphia, USA Respiratory Structures
  7. 7. Anatomy and Physiology Porth CM, 1998, Pathophysiology (5 th Edn) , Lippincott, Philadelphia, USA Respiratory Zones
  8. 8. Anatomy and Physiology Porth CM, 1998, Pathophysiology (5 th Edn) , Lippincott, Philadelphia, USA Partitioning of Respiratory Pressures
  9. 9. Anatomy and Physiology Porth CM, 1998, Pathophysiology (5 th Edn) , Lippincott, Philadelphia, USA Boyles Law Increase V = Decreased P Decreased V = Increased P
  10. 10. Anatomy and Physiology Porth CM, 1998, Pathophysiology (5 th Edn) , Lippincott, Philadelphia, USA <ul><li>Boyles Law </li></ul><ul><li>Air flows from a region of higher pressure to a region of lower pressure. </li></ul><ul><li>To initiate a breath, airflow into the lungs must be precipitated by a drop in alveolar pressures. </li></ul>
  11. 11. Anatomy and Physiology Porth CM, 1998, Pathophysiology (5 th Edn) , Lippincott, Philadelphia, USA Respiratory Volumes and Capacity
  12. 12. Anatomy and Physiology perfusion without ventilation = shunt normal ventilation and perfusion ventilation without perfusion = dead space airway venous blood arterial blood Porth CM, 1998, Pathophysiology (5 th Edn) , Lippincott, Philadelphia, USA Ventilation and Perfusion
  13. 13. <ul><li>Airway Compromise (potential) </li></ul><ul><li>Respiratory Failure </li></ul><ul><ul><li>pH: <7.25 </li></ul></ul><ul><ul><li>PaCO 2 : >50 mmHg </li></ul></ul><ul><ul><li>PaO 2 : <50 mmHg </li></ul></ul><ul><li>Increased Work of Breathing </li></ul><ul><li>Head Injury Management </li></ul>Indications for Ventilation Hudak, et al, 1997, Critical Care Nursing: A Holistic Approach (7 th Edn) , Lippincott, Philadelphia, USA
  14. 14. <ul><li>Support though illness </li></ul><ul><li>Reversal of hypoxemia </li></ul><ul><li>Reversal of acute respiratory acidosis </li></ul><ul><li>Relief of respiratory distress </li></ul><ul><li>Resting of the ventilatory muscles </li></ul><ul><li>Decrease in oxygen consumption </li></ul><ul><li>Reduction in intracranial pressures </li></ul><ul><li>Stabilisation of the chest wall </li></ul>Objective of Ventilation Hudak, et al, 1997, Critical Care Nursing: A Holistic Approach (7 th Edn) , Lippincott, Philadelphia, USA
  15. 15. <ul><li>freq </li></ul><ul><li>Vt </li></ul><ul><li>MV </li></ul><ul><li>I:E ratio </li></ul><ul><li>Trigger </li></ul><ul><li>Ramp </li></ul>Modes of Ventilation Diepenbrock NH, 1999, Quick Reference to Critical Care, Lippincott, Philadelphia, USA: P166. <ul><li>Pmax </li></ul><ul><li>Paw </li></ul><ul><li>fspn </li></ul><ul><li>MVspn </li></ul><ul><li> </li></ul><ul><li>PEEP </li></ul>
  16. 16. <ul><li>Controlled </li></ul><ul><ul><li>Pressure Control (PC) </li></ul></ul><ul><ul><li>Volume Control (VC) </li></ul></ul><ul><li>Supported </li></ul><ul><ul><li>Continuous Positive Airway Pressure (CPAP) </li></ul></ul><ul><ul><li>Pressure Support (PS) </li></ul></ul><ul><li>Combined </li></ul><ul><ul><li>SIMV (PC) + PS </li></ul></ul><ul><ul><li>SIMV (VC) + PS </li></ul></ul>Modes of Ventilation Diepenbrock NH, 1999, Quick Reference to Critical Care, Lippincott, Philadelphia, USA: P166.
  17. 17. Modes of Ventilation: Control <ul><li>C ontrolled M echanical V entilation: </li></ul><ul><li>The Minute Volume is determined by the ventilator </li></ul><ul><li>The patient has no option to override the ventilator </li></ul>
  18. 19. Modes of Ventilation: Control <ul><li>P ressure C ontrol: </li></ul><ul><li>A preset peak inspiratory pressure is delivered to the patient at a preset respiratory rate </li></ul><ul><li>Volume is not preset and is determined by the mechanics of ventilation. </li></ul><ul><li>(elasticity, compliance, resistance, pressure, gravity) </li></ul>
  19. 20. Modes of Ventilation: Control <ul><li>V olume C ontrol: </li></ul><ul><li>A preset tidal volume is delivered at a present respiratory rate </li></ul><ul><li>7 – 10 mls/kg </li></ul><ul><ul><ul><li>50kg = 350 – 500mls </li></ul></ul></ul><ul><ul><ul><li>70kg = 490 – 700mls </li></ul></ul></ul><ul><ul><ul><li>90kg = 630 – 900mls </li></ul></ul></ul>
  20. 21. Modes of Ventilation: Support <ul><li>C ontinuous P ositive A irway P ressure: </li></ul><ul><li>A spontaneous breathing mode, where the patient generates their own breath </li></ul><ul><li>The ventilator maintains a constant positive pressure on expiration (PEEP) </li></ul><ul><li>Aims to increase Functional Residual Capacity </li></ul>
  21. 22. Modes of Ventilation: Support <ul><li>P ressure S upport: </li></ul><ul><li>A spontaneous breathing mode </li></ul><ul><li>Need for additional support to achieve optimal tidal volumes </li></ul><ul><li>Ventilator delivers a constant preset pressure on inspiration </li></ul><ul><li>CPAP + PS = BiPAP </li></ul>
  22. 23. Modes of Ventilation: Combined <ul><li>S ynchronised I ntermitted M andatory V entilation: </li></ul><ul><li>Similar to IMV </li></ul><ul><li>If the patient initiates a breath and the ventilator synchronises so the ventilator doesn’t deliver a breath at the same time </li></ul>
  23. 24. Modes of Ventilation: Combined <ul><li>SIMV (PC) + PS : </li></ul><ul><li>Pressure controlled ventilation with pressure support on spontaneous breaths </li></ul><ul><li>SIMV (VC) + PS : </li></ul><ul><li>Volume controlled ventilation with pressure support on spontaneous breaths </li></ul>
  24. 25. SIMV (VC) + PS Freq: 10 Vt: 500 (MV = 5.0) PEEP: 5 PS: 10
  25. 26. <ul><li>Monitoring </li></ul><ul><li>Suctioning </li></ul><ul><li>Other </li></ul><ul><ul><li>Sedation </li></ul></ul><ul><ul><li>Positioning </li></ul></ul><ul><ul><li>Oral and Eye Care </li></ul></ul>Patient Management
  26. 27. <ul><li>ECG </li></ul><ul><li>SpO 2 </li></ul><ul><li>ETCO 2 </li></ul><ul><li>Alarm limits </li></ul><ul><li>Air Entry / Work of Breathing </li></ul><ul><li>Ventilator observations and alarm limits </li></ul><ul><li>Full assessment </li></ul>Patient Management: Monitoring
  27. 28. <ul><li>PRN </li></ul><ul><ul><li>Increasing airway pressures </li></ul></ul><ul><ul><li>Decreasing SpO 2 </li></ul></ul><ul><ul><li>Increased work of breathing </li></ul></ul><ul><li>Pre-oxygenate (100% oxygen) </li></ul><ul><li>Less than 15 Seconds </li></ul>Patient Management: Suctioning
  28. 29. Patient Management: Other <ul><li>Sedation </li></ul><ul><ul><li>Propofol, Morphine and Midazolam </li></ul></ul><ul><li>Positioning </li></ul><ul><ul><li>2/24 </li></ul></ul><ul><li>Oral and eye care </li></ul><ul><ul><li>2/24 </li></ul></ul>
  29. 30. <ul><li>Airway </li></ul><ul><ul><li>Aspiration, decreased clearance of secretions, predisposition to infection </li></ul></ul><ul><li>Endotracheal Tube </li></ul><ul><ul><li>Tube kinking, sputum plug, right main bronchus intubation, tube migration, cuff failure, laryngeal oedema </li></ul></ul><ul><li>Mechanical </li></ul><ul><ul><li>Ventilator malfunction, hypoventilation, hyperventilation, barotrauma, pneumothorax </li></ul></ul>Complications
  30. 31. Questions
  31. 32. Ventilation: Basic Principles Jamie Ranse Registered Nurse Emergency Department The Canberra Hospital

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