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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, SpO2, heart rate, skin color, diaphoresis Distress - bag patient, if necessary Check alarm & alarm settings

3 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 Patient – Ventilator asynchrony – Causes Artificial airway problems Bronchospasm Secretions Pulmonary edema Pulmonary embolism Dynamic hyperinflation Abnormal respiratory drive Body positioning Pneumothorax Anxiety Ventilator – Related Causes System leaks Disconnected circuit Low FiO2 Improper Settings Incorrect support mode Sensitivity Flow Time cycled PEEP

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 RAW 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 TI, VE and correct RAW 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 FiO2 does nothing to correct Treat with increased respiratory rate Capnography – helps us see – reduced VT & CO2

7 Ventilator – Related Problems
Leaks – cuff, circuit Alarm activates Low/high pressure Low minute ventilation Inadequate Oxygenation SpO2 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 Puritan Bennet 840 Drager V500

8 Normal Alarm Settings:
Common Alarm Situations Normal Alarm Settings: VT: high, 200ml above setting – low, 100ml below setting Pressure: high, 10cmH2O above PIP – low, 5cmH2O 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 FiO2: high, 5% above setting – low, 5% below setting

9 Common Alarm Situations
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 VT delivery I:E – may change with a change in waveform (constant to descending - lengthens TI in VC)

11 Additional Alarms High PEEP/CPAP alarms
Causes are similar to those of high pressure flow-cycle modes , check for leaks Low VT, low VE 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 VT, high VE or high flow alarms Check sensitivity setting, causes auto-triggering Check patient for possible cause of increased VE 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
Flow-Volume 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 RAW, 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

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

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

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 Increased VT, VE or rate alarm
Please Note always start by checking patient’s stability and is adequately ventilated N o Is patient demand VE increased yes Check cause of increased VE demand to determine if change is needed Is vent Auto-triggering yes 1. Check sensitivity setting 2. Check the MMV setting Is a nebulizer In use yes Adjust vent settings until treatment is completed Is flow sensor malfunctioning yes Clean & calibrate sensor Clear sensor line Check its function and replace if needed Is alarm set too low yes Adjust alarm setting 1. Check machine for sensitivity level for auto-triggering 2. Check for cause of increased VE 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 Check operators Manual/contact manufacturer

17 Low pressure. Low PEEP, low VT, low VE
Is patient disconnected yes Reconnect N o Is there a leak in the circuit yes Repair/replace circuit yes Is there a cuff leak Reinflate cuff/check it’s pressure –replace tube if necessary Is there a chest tube leak yes Contact physician/monitor pt Is proximal airway pressure line obstructed yes Clear the line Is the flow sensor malfunctioning yes Clear sensor & recalibrate it Clear sensor line & recheck Check sensor function & replace sensor if necessary Alarm set inappropriately yes Reset Check manual/contact trained specialist 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 High pressure, High PEEP alarms
No Is artificial airway completely obstructed Can it be cleared Change artificial airway yes Is pt coughing yes Suction or relieve irritation Suction pt Are there secretions in the airway yes Is the circuit obstructed yes Drain condensation 3. kinks in ventilator circuit Check water traps Is ET tube being bitten yes Insert a bite block Is the position of artificial airway altered yes Reposition artificial airway Is the Raw increased or compliance increased Assess & Correct Secretions 5. Pulmonary edema Bronchospasm 6. Pneumothorax Mucosal edema 7. Pleural effusion Pneumonia 8. Other yes Continued

19 Continued - High pressure, High PEEP
Is pt breathing asynchronously Check inspiratory gas flow 4. Check mode of ventilation Check sensitivity Consider sedation Check vent parameters yes No Auto-PEEP present yes Check & treat for increased Raw (suction, bronchodilator) Increase flow to shorten Ti and increase TE Decrease VE Is exhalation valve malfunctioning yes Fix or replace valve yes Reduce pressure Is the venting pressure too high Is alarm set too low yes Increase alarm setting 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 RAW 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. Check for possible causes ET cuff blocking the end of the artificial airway

20 I:E Indicator Is an adverse ratio desired yes Activate inverse ratio
No Is vent time cycled yes Decrease inspiratory time Is volume being used with set flow too low yes Increase flow Is volume being used with a set volume too high yes Decrease volume Is the rate too high yes Decrease rate Is vent flow reduced due to mechanical problem, increased Raw, or decreased compliance yes Eval patient & vent’s performance and correct problem 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 RAW/decreased CL has resulted in lower flow, tx cause If flow is too low for desired VT, increase flow or change waveform Change mode or VE parameters

21 Apneic Alarm No Is an actual apneic episode occurring yes
Readjust vent support Is the alarm setting appropriate yes Reset alarm Is vent insensitive to patient effort yes Reset the sensitivity Is there a leak yes See low pressure alarms Is flow or pressure sensor faulty yes Clean recalibrate, check & replace sensor if necessary Check operator’s manual/contact trained technician 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, 5th Ed., White Cardiopulmonary Anatomy & Physiology, Essentials of Respiratory Care, 6th Ed, Des Jardins Egan’s Fundamentals of Respiratory Care, 10th Ed, Kacmarek, Stoller, Heuer Equipment Theory for Respiratory Care, 4th Ed., White John Hopkins Medical Health Library, Mechanical Ventilation Physiological and Clinical Applications, 5th 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, 2nd Ed, Hess The Essentials of Respiratory Care, 4th Ed, Kacmarek

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