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Mechanical Ventilation Add in library

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Questions:

1. You are making the initial attempt to wean a patient from mechanical ventilation in the CMV mode using a T-piece. After 30 minutes on the T-piece you observe the following

• Pulse 90
• Stable blood pressure 125/80
• Respiratory rate 18/min
•Physical appearance-no signs of distress

Discuss what would your next action include?

2. List 4 things that would keep a patient from being able to wean on the ventilator.

3. Your patient has the following parameters collected to determine if the patient is ready to wean from mechanical ventilation. This patient’s IBW is 80 kg. The patient has been on the SIMV with pressure support of 10 with a rate of 4 and VT of 700 with an Fio2 of 40%. You put him on CPAP for 2 minutes and obtain the following data:
HR 110        RR 14   BP 130/90       VC 900 mL      MIP 40 cm H2O        VT 500 ml

4. A 44-year-old male with severe COPD is intubated and ventilated with pressure support ventilation. You note that he is making inspiratory efforts that do not trigger the ventilator. What is the most likely cause and what can you do to improve the patient-ventilator interaction?
 
 

Answers:

1. The patient who is continuous mandatory ventilation (CMV) is weaned for the ventilator. The vital parameters after 30 min are 90 per min, 125/80 mm of Hg and 18 per min respectively for pulse, blood pressure and breathing rate. The parameters are in the range of normal values for pulse, blood pressure and respiratory rate (George, Nicole & Andrew, 2013). In addition, there are no signs of distress. The results indicate that the patient is able to have normal respiration; therefore the mechanical ventilation may be not required. The mechanical ventilators support is required in the instances where the vital parameters are adversely affected.

2. The following are the few parameters to be considered to keep a patient from being able to wean on the ventilator (Laura, 2012)

  • Check ventilator settings and modes: Breathing rate, setting of ventilations etc
  • Educating the patient and attends about the implications
  • Managing the air passage (way)
  • Check the suction for appropriateness

3. The SIMV (Synchronized Intermittent Mandatory Ventilation) is mode of intermittent mandatory ventilation to provide partial ventilation in order to support the patient for mechanical ventilation. During SIMV, the patient can be provided with mandatory, synchronized and spontaneous breath. In the current case, the patient is supported of 10 with a rate of 4, VT of 700 with 40% FiO2. Then the patient was switchover to continuous positive airway pressure (CPAP) for 2 minutes. The observations as follows

  • Heart Rate : 110      
  • Respiratory Rate (RR) : 14  
  • Blood Pressure : 130/90 mm of Hg
  • Vital Capacity : 900 mL
  • Maximal inspiratory pressure: 40 cm H2O       
  • Tidal Volume (Vt): 500 ml

3.1. What is RSBI?

The term, Rapid Shallow Breathing Index (RSBI) is a ratio used as an indicator for the assessment of respiration and decides the patient for weaning of ventilator. It can be measured by calculating the ratio of respiratory rate (f) and tidal volume (Vt) and a value below 105 of RSBI is considered as the accepted value for weaning of extubation (Crawford, Otero, Donnino, Garcia, Khazal & Lenoir, 2007). In the current case, the value is 0.028.

3.2. Would we be able to wean this patient and why?

Yes the patient can be weaned off for the ventilation based on the RSBI. It is below 105 therefore can be weaned off using suitable method

3.3. Which method of weaning would you use and why?

The methods that are used for weaning of ventilation include T-piece trials, SIMV and pressure support ventilation. Among the methods, SIMV can be sued for weaning. The method comprises of gradual decreasing the mandatory rate by 2 to 4 bpm (Jeremy & Mark, 2005). The gradual reduction prevent sudden onset of side effects and facilitate the patient for normal respiration.

4. Pressure Support Ventilation (PSV) is operated at preset pressure and it supports the patient in initiation of breath and regulation of certain parameters (breathing rate and tidal volume). Ideally, the ventilator should respond to a patient’s inspiratory effort. The factors that influence the sensitivity trigger include pressure, flow, and/or time. In the current case, the set parameters are not helping to trigger the ventilation and lead to increase in load on the respiratory muscles. Else, the time for of trigger stint may be prolonged due to the pressure transducer from the ventilator (Mellott, Grap, Munro,  Sessler & Wetzel, 2009). Therefore the patient and ventilator interaction can be improved manipulating the pressure; flow and/or time E.g. Setting a shortest time for trigger will minimize the efforts of patient in terms of inspiration.

 

References

Crawford, J., Otero, R., Donnino, M., Garcia, J., Khazal, R & Lenoir, T (2007) Rapid shallow breathing index- a key predictor for noninvasive ventilation. Critical Care 11(Suppl 2) P169

George, Y., Nicole, AD & Andrew, MR (2013) Respiratory rate and breathing pattern MUMJ 10(1) 23-25

Jeremy, L & Mark, JG (2005) Weaning from mechanical ventilation Contin Educ Anaesth Crit Care Pain 5 (4): 113-117.

Laura, CPM (2012) Top 10 care essentials for ventilator patients American Nurse Today 7(3)13-16

Mellott, KG., Grap, MJ., Munro, CL., Sessler, CN & Wetzel, PA. (2009). Patient-ventilator dyssynchrony: Clinical significance and implications for practice. Critical Care Nurse, 29(6), 41–55.

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