VENTILATOR EMERGENCIES

VENTILATOR EMERGENCIES

By: ENY LISTIOWATI
POST BASIC CARDIOVASCULAR COURSE XV
NATIONAL CARDIAC CENTRE ”HARAPAN KITA” JAKARTA
2007/2008

I.INTRODUCTION

Mechanical ventilation is a procedure accomplished to solve a ventilation problem/disturbance,in order to maintain the adequate oxygenation.However this procedure is not physiological, so problems or side effects may occur.

As a nurse, We must monitor and intervene quickly and exactly in case a problem occurs to a patient attached with a ventilator or there is a asynchrony between the patients and the ventilator marked by patient fighting the ventilator. This asynchrony may originate from ventilator or the patient.One of the common causes of this asynchrony comes from endotracheal tube connecting the patient to the ventilator.

In this paper titled “Ventilator Emergencies”,I will discuss about the definition,sign and symptoms,causes,and management of sudden distress respiratory to the patient attached to the ventilator.

The target of this study is for the nurse to understand the way to treat patients attached to a ventilator and to be able to handle problems which happened as a consequence of the procedure.Thus,to decrease mortality rate by maintaining ventilation and adequate oxygenization, keeping the synchronization between the ventilator and the person, and lessen the side effects.


II. DEFINITION

Fighting the ventilator is phrase often used to indicate that the patient is having acut respiratory distress and the patient and ventilator are breathing out of synchrony with one another(Lynelle N.B.Pierce,1995).

III.CAUSES/ETIOLOGI
A. Patient based causes:
a.Artificial airway problems
1. Cuff herniation
→ Cuff herniation caused by asymmetric inflation or hard cuff.
→ Herniation of the cuff over the lumen of the tube may happen if
the cuff of an old,perished tube is over-inflated.Its will cause
respiratory obstruction

(picture: )

Source : (1)Laurel D kersten,Comprehensive respiratory nursing,1989
(2)Dr.Guy Watney,Anesthesia equipment resource,2003

2. Upward migration
→ Migration is endotracheal tube interested upwards
→ There is sign of air leakage from nose or mouth.
This is occurs by moving the head become extension,
So, tube upward 1,9-5,2 cm out from trachea.
3. Main-stem intubation
→ Endobronchial intubation occurs if too long a tube is used and
inserted into one of the main stem bronchi
→ Usually the ETT insert into the right mainstem of bronchus,
because there is more sloping
→ there is occur by moving position of the head becomes flexion.
So, tube insert 1,9cm into carina/endobronchial.
Source: Anesthesia equipment resource,2003


b. Sudden increase in airway resistance
1. Bronchospasm
→ Bronchospasm is a sudden constriction of the muscles in the walls of
the bronchioles
2. Secretions
→ Secretion is very jell or it’s very much, and may be there is blood clot

c. Acute change in lung compliance:
1. Tension pneumothorax
→ Tension pneumothorax is the accumulation of air under pressure
in the pleural space.
. Source:ADAM-Benjamin/Cummings
2. Pulmonary oedema
→ Pulmonary oedema is swelling or fluid accumulation in the lungs.
It leads to impaired gas exchange and may cause respiratory failure.

d. Acut agitation and anxiety, possibly because of inadequate sedation,emergence from street drugs,alcohol withdrawal,or pain

e. Change in respiratory drive:Central neurogenic hyperventilation, Fatique

f. Unknown development of auto PEEP, which creates need for increased inspiratory effort,and thus work of breathing to trigger ventilator.

g. Acut change in ventilation/perfusion matching:
1. Pulmonary embolus
2. Change in body position that leads to hypoxemia
(e.g lung with greatest abnormality placed in dependent position).

B. Ventilator based causes:

a. Sensitivity set too high or too low.
b. Inadequate peak inspiratory flow rate setting.
c. Inadequate ventilatory support or inadequate delivery of oxygen.
d. Large air leak in circuity or patient-ventilator disconnection.



IV.SIGN AND SYMPTOMS



(Source:Troubleshooting in ventilator management,Chonbuk National University)

SIGN AND SYMPTOM OF THE PATIENT WHO IS FIGHTING ON VENTILATOR
1. Tachypnea
2. Diaphoresis and nasal flaring or swide open mouth inspiratory effort
3. Recession of suprasterna supraclavicular space
4. Recession of intercostal space
5. Heightened sternomastoid activity
6. Tachycardia (indicates severe cardiopulmonary distress)
7 .Paradoxical motion of abdomen
8. Cyanosis (it is not a reliable physical sign)
9. Use of accessory ventilatory muscles
10. Hypoxemia patient
11. Hypertension
12. Expression of fear
13. Multiple ventilator alarm:High pressure limit, Low VT
14. Agitation

V. MANAGEMENT
The primary goal of management of the patient in distress is to ensure
adequate ventilation and oxygenIzation

Steps in management of sudden distress for a patient attached with ventilator
1. Remove (Disconnect) the patient from the ventilator
2. Manualy ventilate with ambubag at 100%FiO2
Is the patient difficult to ventilate?
* If the patient is not difficult to ventilate, the problem is a problem with the
ventilator or the circuit.
* If the patient is difficult to ventilate ,it is a problem with the endotracheal
tube or the respiratory system.
If the patient is unstable, remember “ABC” :
· If the bag fells heavy,may be there is many secretion.
Treatment: agresive suction or bronchoscopy.
· If the suction catheter can not insert to ETT, may be ETT kinking or biting treatment: change position of the head or tube
· If the Patient biting tubing or fighting ventilator : sedate as needed.
· If looking asymmetric expantion of the lung, breath sound only at right or left lung ,may be:
o Mainstem intubation.
Treatment : pull back the endotracheal tube, check CXR.
o Tension pneumothorax
Treatment: insert 14 gauge angiocath into 2nd intercostal space,
midclavicular line.
· If the ETT upward migration, rapid reintubation.
· Cuff herniation usually occured when move a neck.
Treatment: deflation of cuff and reintubation.
· Air leaked, may be it’s from cuff deflation.
Treatment : reinflate cuff and confirm positioning.
· Bronchospame (wheezing,increased work of breathing,retraction suprasternal,intercostals,increased peak airway pressure)Treatment : give nebulizer/bronchodilator,corticosteroid,theophylin

If, the patient is stable in manually ventilate:
Thinking about ventilator and circuit problems :
§ loss of electrical power : check electrical power cord for proper connection to working electrical outlet.
Treatment: provide manual ventilation until problem is corrected.
§ Loss of air oxygen pressure : check air and oxygen hose assemblies for proper connection and proper pressure.
Treatment: provide manual ventilation until problem is corrected.
§ Internal hardware or microprocessor dysfungtion :
Provide manually ventilation , remove and get a new ventilator.
§ Check circuit/tubing for obstruction or kinking.
Treatment: provide manual ventilation until tubing/circuit is corrected.
§ Disrupted tubing or ventilator malfunction :
Treatment: fix the problem or get a new ventilator.
§ Auto-PEEP : decrease set rate, decrease set amount of PEEP, decrease I:E ratio (increase flow rate), check for expiratory circuit obstruction.
§ Low exhaled volume
Treatment: check for cuff leak, bronchopleural fistula, low flow rate.
§ Increased respiratory rate :
Treatment: check for change in the patient's clinical status; draw ABG to assess for need to increase set rate or set tidal volume.
§ High minute ventilation
Treatment: check for hyperventilation (neurogenic, agitation, incorrect vent settings), hypermetabolic state (sepsis, fever, acidosis), or inefficient ventilation (increased dead space).
§ Massive atelectasis ?
Treatment: increase tidal volume and/or PEEP

VI. CONCLUTION

Mechanical Ventilation becomes the main choice of intervention for the patient who is unsuccessful to maintain adequat ventilation,so oxygenization is not enough for body needed.

Howefer, the problem is not finishes, because the ventilator is only breath tool and this is not physiologic. So this can be causes a new problem.
The Problem come from the patient and the ventilator,

Sudden distress respiratory marked a patient fighting the ventilator