1. Trouble Shooting (Mechanical Ventilation) Arthur Sadhanandham Medical ICU, CMC.

2. ‘ WHEN NOAH BUILT THE ARK IT WAS NOT RAINING’

3. Precautions that would reduce troubles I. Power:  Plug into a grounded AC power with correct voltage receptacle.  Secure the power cord properly. Battery Back up:  Check the battery level before connecting.  Charging should be carried out regularly.  Remember it is for short term use.

4. II. Gas Source  Preferable to have centralised supply.  If cylinders used, should be full  Spare cylinders should be available.  Gas hoses should be in good condition.  Hoses – not contaminated with grease or oil (combustible)  Availability of compressors should be ensured.  Gases should remain dry and clean.

5. III. Personnel  Properly trained personnel should only use.  Familiarising staff with operator’s manuel before using on a patient. (One manufacturer’s manual may not exactly match with other brands).  Appropriate monitoring the functioning state of the ventilator while in use.

6. Contd… Contd…  Familiarizing staff with alarm system.  Do not place ventilators in a combustible or explosive environment.  Do not use with flammable anaesthetic agents such as nitrous oxide and ether.

7. IV Servicing and Testing  Qualified personnel should undertake servicing.  Ventilator housing should not be opened while it is still connected with power.  Follow the specifications mentioned in the service manual.  Use replacement parts supplied by the manufacturer only.

8. Contd….  General servicing at regular intervals should be done.  Run the prescribed tests and calibrations before using the ventilator on a patient.  Ensure that the ventilators pass all the tests before putting them in to clinical use.

9. ALARMS  All ventilators are equipped with visual and audible alarms which notify the user problems.

10. Points to remember  Never ignore an alarm.  Never mute the alarm on regular basis.  Find out for yourself what alarm is on.  Check the patient.  Silence the alarm.

11. Act Swiftly  Depending upon the patient’s status and nature of the alarm, act appropriately.  This includes disconnecting the ventilator and connecting another means of ventilation to patient – Bain’s/ Ambu.

12. Do not forget  The use of an alarm monitoring system does not give absolute assurance of warning for every form of trouble that may occur with the ventilator.  Ensure Alarm knobs / switches are turned on and functional.

13. Do not be like this ! But hear the alarm and respond See the problem and Ask if you do not know what to do

14. ALARMS High pressure alarm. The measured peak inspiratory pressure is great than set level. CAUSE CAUSE Cough Cough Increased airway Increased airway resistance or resistance or decreased decreased compliance compliance because of because of Bronchospasm Bronchospasm Atelectasis Atelectasis Fluid overload Fluid overload Pneumothorax Pneumothorax TROUBLE SHOOTING Medication & sedation Medication & sedation Adjust the settings Adjust the settings  V T &  Rate Adjust the settings Adjust the settings V T  Rate,  PEEP V T  Rate,  PEEP (Peak pressure to be monitored) Bronchodilators Bronchodilators Immediate intervention Immediate intervention

15. High Pressure Alarm  Secretions in airway  Secretions in airway Partial tube block Partial tube block Biting the tube Biting the tube Kinking and Kinking and Water in the Water in the circuit circuit Cuff herniation Cuff herniation Deep Rt. sided Deep Rt. sided intubation intubation Fighting the Fighting the ventilator ventilator Suctioning, Irrigation Suctioning, Irrigation Bite block insertion Bite block insertion Release tubings Release tubings Empty the tubings and Empty the tubings and water traps water traps Deflate & reinflate cuff Deflate & reinflate cuff 3-4 times 3-4 times Reposition the ET tube Reposition the ET tube Reposition the patient Reposition the patient Re assurance Re assurance Sedation & pain killers Sedation & pain killers

16. Low pressure or Low min.Vent Or Low exhaled volume or Disconnection The measured PIP is lesser than the set minimum level because of cuff leak. cuff leak. Leak in the Leak in the circuit circuit Connections Connections may be loose may be loose ET tube ET tube displacement displacement Disconnection Disconnection Inadequate Inadequate flow flow Evaluate cuff pressure Evaluate cuff pressure at regular intervals. at regular intervals. Reinflate if leak / Reinflate if leak / ruptured is noticed – ruptured is noticed – change ET tube. change ET tube. Check circuits, junctions- Check circuits, junctions- tighten or replace. tighten or replace. Check water traps Check water traps Check ET tube Check ET tube placement. Position it placement. Position it properly. properly. Reconnect ventilator. Reconnect ventilator. Patient may require Patient may require higher flow. higher flow.

17. Apnoea No breath was No breath was delivered for the operator delivered for the operator set apnoea time in spont, set apnoea time in spont, SIMV, AC, CMV & NIV. SIMV, AC, CMV & NIV. If spont. Ventilation is If spont. Ventilation is too is too high or patient too is too high or patient effort is very minimal effort is very minimal If improperTrigger level If improperTrigger level setting is done. setting is done. Check the patient- Check the patient- Arouse if needed Arouse if needed Activate back up facility Activate back up facility if it was not done if it was not done already. already. Consider switching Consider switching over to any mandatory over to any mandatory mode mode Or go up on rate Or go up on rate Set trigger level Set trigger level appropriately appropriately

18. Low SpO 2 Air / O 2 Blender continuous Alarm Delivery of O 2 - FiO 2 and PEEP and PEEP High resistance High resistance due to various due to various clinical reasons clinical reasons Supply pressures Supply pressures are inadequate. are inadequate. Disconnect patient Disconnect patient from ventilator from ventilator Manually bag with Manually bag with Bain’s and Ambu. Bain’s and Ambu. Insert the gas hose Insert the gas hose fittings (air & O 2 ) fittings (air & O 2 ) correctly into the wall correctly into the wall outlets. outlets. Ensure wall outlets Ensure wall outlets has adequate has adequate pressure pressure

19. Auto Cycling High Tidal Volume Leak Leak Improper trigger Improper trigger setting setting Patient trying to take Patient trying to take more volume of air more volume of air Secure all Secure all tubing tight tubing tight Set proper Set proper trigger level trigger level Increase flow Increase flow rate or rate or Increase tidal Increase tidal volume volume

20. Trouble shooting! THANK YOU FOR YOUR PATIENT HEARING... i KNOW THAT YOU ALL WOULD SAY “ WE KNEW ALL THESE”..