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Ventilator Trouble shooting Presented by Lily To & James Lindsey.

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1 Ventilator Trouble shooting Presented by Lily To & James Lindsey

2 Ventilator Troubleshooting Involves identification & resolution of a technical problem A problem is a situation in which one finds oneself in that can not be immediately corrected Solving Ventilator Problems Access situation Gather & analyze pertinent data This information should point to a number of potential solutions A solution should be tried – with making an observation of the patient’s response A positive response leads to correction of the problem A negative response – undo what was tried – find out why it didn’t work before attempting a new solution Determining cause of the problem – helps prevent the problem from reoccurring Protecting the Patient Always ensure patient safety When alarm is triggered – check patient first Look for LOC, increased WOB, use of accessory muscles, auscultation, SpO 2, heart rate, skin color, diaphoresis Distress - bag patient, if necessary Check alarm & alarm settings

3 Ventilator – Related Causes System leaks Disconnected circuit Low FiO 2 Patient – Ventilator asynchrony – Causes Artificial airway problems Bronchospasm Secretions Pulmonary edema Pulmonary embolism Dynamic hyperinflation Abnormal respiratory drive Body positioning Pneumothorax Anxiety Improper Settings Incorrect support mode Sensitivity Flow Time cycled PEEP Identifying Patient Distress Notice when patient is “fighting the vent” or asynchrony Signs include: tachypnea, nasal flaring, diaphoresis, use of accessory muscles, retractions, paradoxal chest abdomen movement, abnormal breath sounds, tachycardia, arrhythmia, hypertension Sudden Causes of Respiratory Distress

4 Common Patient – Related Problems Airway problems Kinked ET tube, biting Displacement of tube in right lobe or upward Rupture of an artery Fistula obstructed ET tube Pneumothorax Look for increased work of breathing, nasal flaring, use of accessory muscles, absence of breath sounds, uneven chest movement & cardiovascular assessment Bronchospasm Signs include: dyspnea, wheezing, increased work of breathing, paradoxical chest/abdomen movement, retractions and increased R AW Secretions Evaluation can lead to differentiate problems Dry secretions – insufficient humidification? Copious amounts – pulmonary edema? Detect infection? Pneumothorax

5 Common Patient – Related Problems Pulmonary Edema Cardiogenic pulmonary edema Sudden – thin, frothy, white to pink secretions. Follow through with additional testing – ECG, Bp, JVD and Hx of heart disease Treatment includes medications to reduce preload and afterload (lasix), increase contractility (Lanoxin) Non-cardiogenic pulmonary edema Not sudden – increase in pulmonary capillary permeability (treatment similar to above) Dynamic Hyperinflation Auto-PEEP causes dynamic hyperinflation – leads to difficulty triggering ventilator & increased work of breathing Causes hypertension and reduced cardiac output Suspected when flow does not return to baseline in flow-time curve. Treatment: reduce T I, V E and correct R AW Abnormalities in Respiratory Drive Decrease is result of heavy sedation, neurological disorders, neuromuscular blockage Increase is result of pain, anxiety, peripheral sensory stimulation, medications and improper ventilator settings

6 Common Patient – Related Problems Changes in Position Can cause accidental extubation Alter oxygenation by bending, twisting circuit Cause mucous plugging Drug Induced Distress Can cause respiratory distress & maybe failure Abdominal Distention Distention - can be associated with other disorders that introduce air into the stomach (ascites, GI bleed, liver & kidney problems) Pulmonary Embolism Emergency Leads to asynchrony Sudden onset – hypoxemia Patient presents with bilateral breath sounds, increased WOB, elevated HR, Bp and RR Increasing flow and FiO 2 does nothing to correct Treat with increased respiratory rate Capnography – helps us see – reduced V T & CO 2

7 Ventilator – Related Problems Leaks – cuff, circuit Alarm activates Low/high pressure Low minute ventilation Inadequate Oxygenation SpO 2 alarm Signs – hypoxemia Inadequate Ventilator Support Causes increased work of breathing, respiratory acidosis & hypoxemia Leads to asynchrony Sensitivity Causes auto-triggering –setting too low - high pressure, patient can not trigger Flow Setting Air starvation – correct by increasing flow or changing flow pattern Other Problems Auto-PEEP – makes vent more difficult for patient to trigger a breath – correct by increasing E-time PSV - may cause asynchrony with certain disorders and if it is set too low Drager V500 Puritan Bennet 840

8 Normal Alarm Settings: V T : high, 200ml above setting – low, 100ml below setting Pressure: high, 10cmH 2 O above PIP – low, 5cmH 2 O below PIP Rate: high, 10 bpm above setting – low, 5 bpm below setting Flow: high, 2L above setting – low, 2L below setting Apneic: 20 seconds FiO 2 : high, 5% above setting – low, 5% below setting Common Alarm Situations

9 Low Pressure Alarm Causes: Patient disconnected Circuit leaks – inspiratory/expiratory circuits Ventilator related disconnections Humidifiers, filters, water traps, nebulizers, closed circuit catheter Temperature monitors Exhalation valve leak Cracked, unseated, improperly connected Airway leaks Improper cuff inflation Cut hole in pilot balloon/ cuff Migration of ET tube Chest tube leaks *Most often activated by leaks* High Pressure Alarm Causes: Coughing Biting, kinking, positioning of ET tube Herniation of ET tube/cuff Increased airway resistance (secretions, edema, bronchospasm) Decreased compliance (pneumothorax, pulmonary embolism) Patient – ventilator asynchrony Accumulation of water in circuit Kinking in inspiratory circuit Malfunction with inspiratory/expiratory valves

10 Additional Alarms Low PEEP/CPAP Activated when airway pressure falls below desired baseline during PEEP/CPAP Causes include: leaks or by active inspiration Apnea alarm 20 seconds Causes: patient apneic or disconnection, leaks, sensitivity setting Low-Source Gas Pressure/ Power Alarm If gas or power source fails I:E Ratio Alarm Most ventilators do not allow I:E ratio to be set less than 1:1 Causes: flow set too low for desired V T delivery I:E – may change with a change in waveform (constant to descending - lengthens T I in VC)

11 Additional Alarms High PEEP/CPAP alarms Causes are similar to those of high pressure flow-cycle modes, check for leaks Low V T, low V E or low flow alarms Causes are similar to low pressure alarms Determine if spontaneous ventilation has decreased Check all alarms Check flow sensors, disconnection/malfunction High V T, high V E or high flow alarms Check sensitivity setting, causes auto-triggering Check patient for possible cause of increased V E Check alarm settings If nebulizer in use, reset alarm until treatment is completed Check flow sensors, contamination/malfunction Low/high FiO2 alarms Check gas source Check built-in oxygen analyzer is functioning properly Flow Sensor Nebulizer

12 Use of Ventilator Graphics to Identify Ventilator Problems Ventilator graphics can alert of abnormalities before obvious signs appear Flow-time & Pressure-time graphs are used for accessing patient triggering, flow starvation, auto-PEEP, I:E time, flow pattern, plateau time, rise times and asynchrony Volume-time graph accesses auto-PEEP Pressure-Volume loop accesses leaks, overdistention, increased R AW, asynchrony and patient triggering Flow-Volume loops are used to access obstructive/restrictive lungs, the effects of bronchodilators and leaks Waveform ringing in Flow-time & Pressure-time Occurs when flow & pressure are very high at a beginning of a breath – a result of oscillation of air at beginning of a breath Flow-Volume

13 Use of Ventilator Graphics to ID Problems Leaks – low pressure, low volume, low minute ventilation or apnea will trigger alarm Pressure-Volume LoopFlow-Volume Loop Flow-time curve Volume-time curve Leak Auto-PEEP, air trapping

14 Overdistention Examples of additional graphic curves Pressure-Volume Loop Overdistention Correct: increase E-time Correct: reduce volume, pressure Obstruction: administer bronchodilator

15 Unexpected Ventilator Responses Unseated/Obstructed Expiratory Valve Blocked or unseated valve, unable to get expiratory pause – plateau pressure High Tidal Volume Delivery Occurs with small volume nebulizer (SVN) Flowmeters can add extra flow – can increase tidal volume Excessive CPAP/PEEP Eliminate leaks – causes application of high flow to maintain CPAP/PEEP Nebulizer Impairment of Patient’s Ability to Trigger PSV Nebulizer makes it more difficult for patient to trigger ventilator Usually occurs with external gas sourced nebulizer Use manufacturer’s nebulizer if provided Flowmeter 840

16 Is patient demand V E increased Is vent Auto-triggering Is a nebulizer In use Is flow sensor malfunctioning Is alarm set too low Check operators Manual/contact manufacturer Check cause of increased V E demand to determine if change is needed yes 1. Check sensitivity setting 2. Check the MMV setting yes Adjust vent settings until treatment is completed yes 1.Clean & calibrate sensor 2.Clear sensor line 3.Check its function and replace if needed yes Adjust alarm setting Increased V T, V E or rate alarm NoNo 1. Check machine for sensitivity level for auto-triggering 2. Check for cause of increased V E 3. Ensure alarms have been properly set 4. External nebulizer used; reset alarm until treatment is completed 5. Check flow sensors for calibrations, contamination or malfunction Please Note always start by checking patient’s stability and is adequately ventilated

17 Is patient disconnected Is there a leak in the circuit Is there a cuff leak Is there a chest tube leak Is proximal airway pressure line obstructed Is the flow sensor malfunctioning Alarm set inappropriately Check manual/contact trained specialist yes Reconnect Repair/replace circuit Reinflate cuff/check it’s pressure –replace tube if necessary NoNo Contact physician/monitor pt Clear the line 1.Clear sensor & recalibrate it 2.Clear sensor line & recheck 3.Check sensor function & replace sensor if necessary yes Reset yes Low pressure. Low PEEP, low V T, low V E 1. Check for disconnection 2. Check for leaks in ventilator, circuits, airway & chest tubes 3. Check proximal pressure line is connected & unobstructed 4. Low-pressure maybe accompanied by a low minute volume or low tidal volume alarm

18 Is artificial airway completely obstructed Can it be cleared Is pt coughing Are there secretions in the airway Is the circuit obstructed Is ET tube being bitten Is the position of artificial airway altered Is the Raw increased or compliance increased High pressure, High PEEP alarms Change artificial airway Suction or relieve irritation 1.Drain condensation3. kinks in ventilator circuit 2.Check water traps Insert a bite block Reposition artificial airway Suction pt Assess & Correct 1.Secretions5. Pulmonary edema 2.Bronchospasm6. Pneumothorax 3.Mucosal edema7. Pleural effusion 4.Pneumonia8. Other NoNo yes Continued

19 Continued - High pressure, High PEEP Is pt breathing asynchronously Auto-PEEP present Is exhalation valve malfunctioning Is the venting pressure too high Is alarm set too low Check for possible causes ET cuff blocking the end of the artificial airway 1.Check inspiratory gas flow4. Check mode of ventilation 2.Check sensitivity5. Consider sedation 3.Check vent parameters 1.Check & treat for increased Raw (suction, bronchodilator) 2.Increase flow to shorten Ti and increase T E 3.Decrease V E Fix or replace valve Reduce pressure Increase alarm setting NoNo yes 1. Pt coughing; determine if secretions have built up in airway or pt is biting ET tube 2. Check for kinks or displacement of ET tube and circuit 3. Check to see if R AW has increased or CL has decreased 4. Check is patient is breathing synchronously with vent 5. Determine if there is auto-PEEP has developed 6. Make sure the expiratory filter & expiratory valve are functioning properly.

20 Is an adverse ratio desired Is vent time cycled Is volume being used with set flow too low Is volume being used with a set volume too high Is the rate too high Is vent flow reduced due to mechanical problem, increased Raw, or decreased compliance Change mode or V E parameters I:E Indicator NoNo Activate inverse ratio Decrease inspiratory time Increase flow Decrease volume Decrease rate Eval patient & vent’s performance and correct problem yes 1. Usually indicates I:E ratio greater than 1:1 2. If inverse is goal: disable I:E ratio limit or ignore alarm 3. If normal I:E desired: check alarm If increased R AW /decreased CL has resulted in lower flow, tx cause If flow is too low for desired V T, increase flow or change waveform

21 Is an actual apneic episode occurring Is the alarm setting appropriate Is vent insensitive to patient effort Is there a leak Is flow or pressure sensor faulty Check operator’s manual/contact trained technician Apneic Alarm Readjust vent support Reset alarm Reset the sensitivity See low pressure alarms Clean recalibrate, check & replace sensor if necessary yes NoNo 1. Is patient apneic 2. Check for leaks 3. Check sensitivity to make sure vent can detect patient effort 4. Check alarm time interval and volume setting

22 References :  AARC Clinical Practice Guidelines  Basic Clinical Lab Competencies for Respiratory Care, 5 th Ed., White  Cardiopulmonary Anatomy & Physiology, Essentials of Respiratory Care, 6 th Ed, Des Jardins  Egan’s Fundamentals of Respiratory Care, 10 th Ed, Kacmarek, Stoller, Heuer   Equipment Theory for Respiratory Care, 4 th Ed., White  John Hopkins Medical Health Library,   Mechanical Ventilation Physiological and Clinical Applications, 5 th Ed 2014, Pilbeam  Medline Plus, 2013  Medscape  NCBI, National Center for Biotechnology Information, U.S. National Library of Medicine, 2013  NDNR, Naturopathic Doctor News & Review, 2013  RC Journal  Respiratory Care, Principles & Practice, 2 nd Ed, Hess  The Essentials of Respiratory Care, 4 th Ed, Kacmarek

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