Terminology
Volume of air set to be delivered with each breath
Tidal Volume (Vt - weight based)
provided settings: IPAP or driving pressure
hint: utilized for weaning
Pressure Support
Oral care should be completed on all ventilated patients or patients receiving Respiratory Support at this interval
Every 4 hours
These setting changes are likely to be ordered with the following ABG results:
Current Settings: Current ABG:
FiO2: 100% pH:7.42
Peep:8 PaO2:132
RR: 16 PCo2:43
Decreased FiO2
What does SAT/SBT stand for?
Spontaneous Awakening Trial and Spontaneous Breathing Trial
This is the highest pressure recorded during inspiration
Peak Inspiratory Pressure (PIP- less than 35)
Settings given: Vt, RR, Fio2
This is often used as a lung protective mode
Volume Control
The appropriate care actions included in the VAP bundle are (6)
1)Compliance with oral care (2) HOB greater than 30 degrees (3) Early mobility (4) early parenteral nutrition (5) minimize sedation/regular sedation vacations (6) proper care and maintenance of the ventilator circuit and machine
In weaning patients from the ventilator, a set of values referred to as "breathing mechanics" is obtained to ensure muscular and respiratory capacity and readiness to separate from the ventilator. These mechanics include what values? (2)
Tidal volume ( Vt)
Negative Inspiratory Force (NIF)
Name 3 exclusion criteria for SAT
1. Receiving sedation for RASS goal of -3 to -4
2. Heart rate greater than 140
3. Respiratory rate greater than 35 breaths/minutes
4. Evidence of increased intracranial pressure
5. Evidence of active myocardial ischemia in the prior 24 hours
6. Receiving neuromuscular blockers
7. Receiving escalating doses of sedative for RASS greater than +2
8. Receiving a sedative infusion for active seizures/burst suppression or alcohol withdrawal
This constant amount of pressure is applied throughout expiration with the goal of keeping the alveoli open contributing to alveolar recruitment and improved gas exchange
PEEP Positive End Expiratory Pressure (5-20 cm H2O)
Settings Given: Vt, RR, FiO2, PEEP
In this setting the patient will receive the full set tidal volume with every breathe, even with spontaneous breaths.
Assist Control (AC,VC)
Can create issues if the patient is breathing over the vent frequently or tachypneic
" in assist control we assist each breath"
This two-part process is utilized to gauge readiness for ventilator liberation by assessing responsiveness, basic neurological status and respiratory capability.
SAT/ SBT
Scenario: Your patient has been off sedation for around 30 mins. RT places them on PS for a SBT. A few mins later, a series of apnea alarms is heard. The appropriate action is:
Place the patient back on original ventilator setting. Document a failed SBT and plan for a repeat SBT with provider and RT
Name 3 exclusion criteria for SBT
1. Inadequate oxygenation (SpO2 less than 88%)
2. FiO2 of greater than 50%
3. End-expiratory pressure (PEEP greater than 8 cm H2O)
4. No spontaneous inspiratory effort in a 5-minute period (consideration of the set respiratory rate is recommended)
5. Agitation/RASS greater than +2
6. More than 1 vasopressor in use or with escalating doses
7. Evidence of increased intracranial pressure
This static pressure is measured at the end of a full breath during mechanical ventilation. This value is an indicator of lung compliance.
Plateau Pressure (Pplat- less than 30)
settings given: Vt, RR, FiO2, PEEP
When patient takes a spontaneous breath, they will pull just the volume they are breathing in without extra support from the ventilator
SIMV
- asynchronous respiratory patterns possible
- used in weaning or often in the OR
Often noted in patients with persistent or thick secretions, a high-pressure alarm with a low volume alarm and elevated Plateau Pressure can be indicators of this complication.
A Mucus Plug, Kink or blockage in the circuit
Current Vent Settings: Most Recent ABG:
FiO2: 65% pH:7.48
PEEP:8 PaO2:92
RR:24 Co2:35
Decrease Respiratory rate
Decrease FiO2
Your patient is on propofol and precedex for RASS of 0 to -2, and fentanyl for CPOT goal less than 3. All are continuous drips. You need to initiate a SAT. What are your next steps?
This setting is utilized during the weaning process and with other respiratory support devices giving the patient an extra push of air to support spontaneous respiration. Often this is described as helping the patient to overcome the work required to take spontaneous breaths through the circuit tubing.
Pressure Support (5-20 mmHg)
These supportive modes are often utilized in hypoxic or hypercarbic respiratory scenarios in an effort to provide positive pressure ventilatory support while preventing or prolonging the need for intubation.
Positive Pressure Ventilation via BiPap or CPAP
Per Policy, a ventilator order must include these listed parameters and details(7)
1) Time of order 2)Ordered Mode 3)Ordered Rate
4) Ordered Tidal Volume 5)Order Pressure Support
6)Ordered Peep 7)Ordered FIo2
A nurse is caring for a patient on SIMV with the following settings: FiO2 70% RR 18 PEEP 8 Vt 450. On assessment, the nurse notes that the patient is breathing 28BPM with low tidal volumes with spontaneous breaths and increased work of breathing. The nurse also notes increasing PIPs but no indications of a mucus plug or blockage. The patient is adequately sedated. The nurse should anticipate an order for this type of medication.
An order for paralytics
Your patient has been on SBT for 15 minutes. Upon assessment, you note HR increase from 88 to 120, RR increase from 16 to 30 and breathing labored, SPO2 dropped from 96% to 89%, and patient coughing with accessory muscle use. What are your next steps?
Fail SBT, put patient back on rate and reinitiate sedation at half previous dose.