Mechanical Ventilation Introduction & Application for Physical Therapists

Transcription

1 Mechanical Ventilation Introduction & Application for Physical Therapists Lindsey Montana Fan, PT, DPT, CCS NYPTA Greater District of New York September 10th,

2 Objectives Understand the premise & main indications for mechanical ventilation Obtain/interpret information on settings & patient performance from ventilator screen Become familiar with basic ventilator terminology & modes Identify PT treatment indications for mechanically ventilated & weaning patients 2

3 Why not wait until the patient is extubated? Muscle Strength decreases 1.3-3% for each day the healthy individual spends on bedrest (Topp, et al. 2002) Effects are even more profound in older individuals & those with critical illness (Yende, et al. 2006) 3

4 Ventilation Ventilation is the process by which gases are moved in & out of the lungs Spontaneous Ventilation is a result of negative intrathoracic pressure being created by the inspiratory muscles Muscles contract & pull on pleura Pressure in the intrapleural space decreases Negative pressure gradient pulls air from the atmosphere into the lungs 4

5 Mechanical Ventilation Mechanical Ventilation is the use of artificial means to support or replace spontaneous ventilation Mechanical Ventilation must satisfy a patient s respiratory needs without Damaging the lungs Impairing circulation Causing patient discomfort 5

6 Indications Mechanical Ventilation Hypoxemic Respiratory Failure Inadequate Gas Exchange Decrease in PaO2 Inability to maintain % oxygen saturation Hypoventilation V/Q mis-match Diffusion Impairment Hypercapnic Respiratory Failure Increase in PaCO2 Inability to ventilate Respiratory muscle fatigue Neuromuscular disorders CNS depression Musculoskeletal disorders 6

7 Indications Mechanical Ventilation Airway Protection Preventative Measure Cardiac Arrest Life-saving measure Management of ICP Creation of alkalosis --> vasoconstriction --> decreased cerebral blood flow/reduction of ICP Airway Obstruction Maintenance of patent airway Surgery or Trauma General Anesthesia 7

8 Delivery Endotracheal Tube Nasal Endotracheal Tube Tracheostomy 8 8

9 Key Units of Measurement Volume ml Pressure cmh2o Rate Breaths/min FiO2 % Flow L/min 9

10 Types of Mechanical Ventilation Pressure Ventilation Negative pressure ventilation Iron Lung Chest Cuirass Positive pressure ventilation The application of positive pressure to the lungs to improve gas exchange The opposite of natural spontaneous breathing Volume Ventilation The application of supplemental volume to the lungs to improve gas exchange 10

11 Screen Organization Patient Performance Data Clinician Entered Settings 11

12 Modes: Assist-Control Full Ventilatory Support Mandatory breaths delivered at set parameters Rate Inspiratory Pressure or Volume FiO2 PEEP Ventilator will also support any patienttriggered breaths at these set parameters 12

13 Assist-Control Settings View Mode Pressure Control (PC) Rate (f) Inspiratory Pressure (PI) FiO2 (O2 %) PEEP 13

14 Assist-Control Performance Data View Type of Breath Delivered (A or C) Respiratory Rate (ftot) Tidal Volume (VTE) 14

15 Modes: Spontaneous All breaths are initiated & terminated by the patient. Ventilator assists the patient s inspiratory efforts to Over-come airway resistance Augment tidal volumes Decrease work of breathing Mode Settings Pressure Support FiO2 PEEP 15

16 Spontaneous Settings View Mode Spontaneous (SPONT) Pressure Support (PS) FiO2 (O2 %) PEEP 16

17 Spontaneous Performance Data View Type of Breath Delivered (S) Respiratory Rate (ftot) Tidal Volume (VTE) 17

18 PEEP Positive End Expiratory Pressure Elevates baseline pressure at which inspiration is delivered Increases alveolar recruitment & surface area available for gas exchange Prevents alveolar collapse at end-expiration 18

19 Alarms Red Alarms Circuit Disconnect Apnea Yellow Alarms Low Tidal Volume High Respiratory Rate High Pressure 19

20 Adverse Side-Effects Prolonged Exposure to Mechanical Ventilation Impaired Circulation Decreased Cardiac Out-put Ventilator-Induced Lung Injury Respiratory Muscle Atrophy Barotrauma Ventilator-Associated Pneumonia 20

21 Application for Physical Therapists 21 21

22 PT Considerations Call Respiratory Therapy For status update, notification, & assistance Understand hospital policy Schedule Assistant Time Monitor Patient Performance Top of ventilator screen Vital signs Suctioning Competency Ballard/Closed In-Line Suction 22

23 ET Tube Placement Placement indicator at level of teeth or lip Confirm placement with RT or RN before & after mobilization 23 23

24 Documentation Assist-Control Spontaneous Mode Inspiratory Pressure or Volume Set Rate FiO2 PEEP Mode Pressure Support FiO2 PEEP 24

25 Ventilator Weaning Ventilatory discontinuance. The process of reducing ventilator support Goal: Restoration of pt. s ability to independently & adequately ventilate without the mechanical ventilator Changing the mode Changing the settings Trach collar trial/t-piece trial 25

26 Weaning Considerations VO2 increases with all forms of exercise Increase in cardiac out-put Increase O2 extraction across capillary beds Spontaneous breathing trials Reduction of Ventilator support Pressure Support/Trach Collar Can increase cardiovascular work-load Tailor treatments accordingly Monitor patient tolerance Provide adequate rest periods MORE vent support is BETTER For PT/OT during preliminary weaning trials Exercise clinical judgement 26

27 Exercise Intolerance In the setting of increasing workload... Increasing respiratory rate Decreasing tidal volumes Increasing accessory muscle use Looks for the signs, know when to take a break! 27

28 Safety & Feasibility---The Evidence Mobilization with Patients Receiving Mechanical Ventilation One study conducted 1,449 activity events in 103 mechanically ventilated patients. Adverse activity-related events occurred in <1% No patients were extubated during activity (Bailey, et al. 2007) Another study conducted PT & OT in 49 mechanically ventilated patients on a median of 1.5 days s/p intubation Therapy was provided on 90% of MICU days 89% of patients encountered had at least 1 potential barrier to mobilization in addition to mechanical ventilation Therapy was interrupted prematurely in only 4% of all sessions (Pohlman, et al. 2010) 28

29 Evidence Continued Prospective, observational study 179 mobilization therapies with 63 critically ill patients Patient level of mobilization achieved by Physical Therapists was significantly higher than that achieved by Registered Nurses (Garzon-Serrano, et. al 2011) 29 29

30 Early Mobilization A strategy for whole-body rehabilitation--- consisting of interruption of sedation & physical & occupational therapy in the earliest days of critical illness Safe & effective Better functional outcomes at hospital discharge Shorter duration of delirium More ventilator-free days compared with standard of care Decreased length of hospital stay (Schweickert, et al. 2009) 30

31 References Bailey P, Thomsen G, Spuhler V, et al. Early activity is feasible and safe in respiratory failure patients. Crit Care Med. 2007(35): Frownfelter D, Dean E. Cardiovascular and Pulmonary Physical Therapy: Evidence and Practice. Missouri: Mosby Elsevier; Garzon-Serrano J, Ryan C, Waak K, et al. Early mobilization in critically ill patients: patients mobilization level depends on healthcare provider s profession. PM&R. 2011(3): Hillegass E, Fick A, Pawlik A, et al. Supplemental oxygen utilization during physical therapy interventions. Cardiopulmonary Physical Therapy Journal. 2014(25): Korupolu R, Gifford J, Needham D. Early mobilization of critically ill patients: reducing neuromuscular complications after intensive care. Contemporary Critical Care. 2009(6): Kress J. Clinical trials of early mobilization of critically ill patients. Crit Care Med. 2009(37):s442-s447. Martin K. Mechanical ventilation: an overview. RC Educational Consulting Services, Inc. Apr Patman S, Dennis D, Hill K. Exploring the capacity to ambulate after a period of prolonged mechanical ventilation. Journal of Critical Care Med. 2012(27): Pinsky M. Breathing as exercise: the cardiovascular response to weaning from mechanical ventilation. Intensive Care Med. 2000(26): Pohlman M, Schweickert W, Pohlman A, et al. Feasibility of physical and occupational therapy beginning from initiation of mechanical ventilation. Crit Care Med. 2010(38): Schweickert W, Pohlman M, Pohlman A, et al. Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomised controlled trial. Lancet. 2009(373): Topp R, Ditmyer M, King K, et al. The effect of bedrest and potential of prehabilitation on patients in the intensive care unit. AACN Clin Issues. 2002(13): Wilkins R, Stoller J, Scanlan C. Egan s Fundamentals of Respiratory Care. Missouri: Mosby; Yende S, Waterer G, Tolley E, et al. Inflammatory markers are associated with ventilatory limitation and muscle dysfunction in obstructive lung disease in well functioning elderly subjects. Thorax. 2006(61):