Department of Critical Care Medicine
Kovai Medical Center and Hospital
Supportive Care of Patients on
Mechanical Ventilation
Dr.M.N.Sivakumar DA.,DNB.,IDCCM.,EDIC.,
Senior Consultant in Critical care
Head - Dept. of Critical Care Medicine
Kovai medical Center and Hospital
ACKNOWLEDGEMENT
Dr Ram E Rajagopalan, AB (Int Med), AB (Crit Care)
Dr Mahendran, MD
Dr N Selvarajan, MD
Department of Critical Care Medicine
Kovai Medical Center and Hospital
NOSOCOMIAL PNEUMONIA
Intubation for
mechanical
ventilation
increases the
risk for
pneumonia
3x to 21x !
AJRCCM 2002; 165:867-903
Department of Critical Care Medicine
Kovai Medical Center and Hospital
Colonization
Aspiration
MRSA*
VAP
Department of Critical Care Medicine
Kovai Medical Center and Hospital
GOAL
• Suctioning
• Humidification
• Aerosol delivery
Department of Critical Care Medicine
Kovai Medical Center and Hospital
SUCTIONING
SUCTIONING
Introduction
• Commonly done procedure in a patient on Mechanical Ventilation.
• Includes preparation, Suctioning event and follow up care.
• Closed or Open
Department of Critical Care Medicine
Kovai Medical Center and Hospital
SUCTIONING
NEED FOR SUCTION
• Saw tooth pattern on FV loop
Inspiration
Flow
(L/min)
• Increase PIP in VCV
• Decrease SPo2
Volume
(ml)
• Visible secretions in airway
• Patients inability to generate effective cough.
• Acute Respiratory distress
• Suspecting aspiration of gastric secretion or upper
airway secretions
Department of Critical Care Medicine
Kovai Medical Center and Hospital
Expiration
Normal
Abnormal
SUCTIONING
SUCTIONING - PREPARATION
Suction Catheter
• More influence on lung volume loss than suction
pressure.
• Diameter of the catheter should not exceed > half ID of
ET Tube.
Department of Critical Care Medicine
Kovai Medical Center and Hospital
SUCTIONING
SUCTIONING - PREPARATION
•
Pre oxygenation
•
100%
:
Setting the Fio2
O2 Enrichment programme
Manual Breath not recommended
• Suction
:
Checked
• Negative Hg
:
150mm.hg for adults.
80-100mm.hg for neonates
Department of Critical Care Medicine
Kovai Medical Center and Hospital
SUCTIONING
SUCTIONING
Department of Critical Care Medicine
Kovai Medical Center and Hospital
SUCTIONING
SUCTIONING
Department of Critical Care Medicine
Kovai Medical Center and Hospital
SUCTIONING
SUCTIONING
Department of Critical Care Medicine
Kovai Medical Center and Hospital
SUCTIONING
SUCTIONING
Department of Critical Care Medicine
Kovai Medical Center and Hospital
SUCTIONING
SUCTIONING
Department of Critical Care Medicine
Kovai Medical Center and Hospital
SUCTIONING
SUCTIONING
Department of Critical Care Medicine
Kovai Medical Center and Hospital
SUCTIONING
SUCTIONING
Department of Critical Care Medicine
Kovai Medical Center and Hospital
SUCTIONING
• Don’t apply suction as you go in
• Don’t disconnect for suction > 15 sec
• Don’t use soda bicarbonate or saline
• On need basis
• Pre-oxygenation must
• Should be done with sterile precautions
Department of Critical Care Medicine
Kovai Medical Center and Hospital
SUCTIONING
SUCTIONING
CLOSED SUCTION
• In hypoxic pts on high PEEP
• MDR infections - Open TB, Viral Infections
(HCW protection)
• Does not reduce VAP
• OPEN SUCTION OK IN MOST PATIENTS
Department of Critical Care Medicine
Kovai Medical Center and Hospital
SUCTIONING
COMPLICATIONS OF SUCTION
• Decreases FRC
• Atelectasis
• Hypoxemia
• Tissue trauma
• Bronchospasm
• Colonization of lower airways
• Increases BP & Arrhythmia
• Increases ICP
Department of Critical Care Medicine
Kovai Medical Center and Hospital
SUCTIONING
HUMIDIFICATION
Definition:
• Absolute Humidity :
Density of moisture (water vapour) per unit volume of air,
expressed usually as kilogram per cubic meter (kg/m3).
• Relative Humidity :
Absolute Humidity
Maximum capacity
Department of Critical Care Medicine
Kovai Medical Center and Hospital
100
SUCTIONING
HUMIDIFICATION
Introduction
•
Normal breathing upper airway does the function of warm, humidification,
and filtered inspired gases.
•
Lower airway also contribute but less effective.
•
During exhalation, upper airway reclaim most of the heat and moisture added
during inspiration.
•
Normal daily respiratory tract loss 1470J of heat and 250ml of H20.
•
Normal upper airway remarkably effective at extremes of temperature.
Department of Critical Care Medicine
Kovai Medical Center and Hospital
SUCTIONING
HUMIDIFICATION
Introduction
•
Moisture output for HH – 33mg H20 / L
•
AARC - Required moisture output to be determined relative to application
and duration of use.
•
Moisture output based – Insp Time
RR
TV
Temperature
Rebreathing
Department of Critical Care Medicine
Kovai Medical Center and Hospital
SUCTIONING
HUMIDIFICATION
Isothermic Saturation boundary
• Point of which gases reaches alveolar condition is
known as Isothermic Saturation boundary.
• Under normal condition - 4th or 5th subsegmental
bronchi.
• Post Intubation – shifted down, less effective.
Department of Critical Care Medicine
Kovai Medical Center and Hospital
SUCTIONING
HUMIDIFICATION
Types
• High flow Humidifier - Bubble through
- Flow over
• HME
Department of Critical Care Medicine
Kovai Medical Center and Hospital
SUCTIONING
HUMIDIFICATION
High flow Humidifier
Consist of
• Heating elements
• Water reservoir
• Temperature control unit
• Gas - liquid interface
Capable of providing wide range of temperature and humidification.
Department of Critical Care Medicine
Kovai Medical Center and Hospital
SUCTIONING
HUMIDIFICATION
High flow Humidifier
• Water level maintained
- Manual fill
- Auto fill ( float)
• Servo controlled
• Alarms
• Heated wire circuit available
• Circuits with water trap
Department of Critical Care Medicine
Kovai Medical Center and Hospital
HEATED HUMIDIFIER
• Gold standard
• Raining is a problem
• Cannot be maintained as a closed system
• Condensate should be drained away from
pts to water trap
• Newer generation less raining & can be
maintained as a closed system
(AUTOFILL)
• VAP rate > HME
Department of Critical Care Medicine
Kovai Medical Center and Hospital
HEATED HUMIDIFIER
• Gold standard
• Raining is a problem
• Cannot be maintained as a closed system
• Condensate should be drained away from
pts to water trap
• Newer generation less raining & can be
maintained as a closed system
(AUTOFILL)
• VAP rate > HME
Department of Critical Care Medicine
Kovai Medical Center and Hospital
SUCTIONING
HUMIDIFICATION
HME
•
Hygroscopically treated Devices (HHME)
•
HHME & Bacterial Filter - HHMEF
•
Aluminium insert with fibrous element
•
Polypropylene insert with hygroscopic channel usually ca or lithium
chloride for moisture conservation.
•
Filter material - spun Polypropylene, is electrostatically charged attracts
and traps airborne particles.
Department of Critical Care Medicine
Kovai Medical Center and Hospital
SUCTIONING
HUMIDIFICATION - HME
Department of Critical Care Medicine
Kovai Medical Center and Hospital
SUCTIONING
HUMIDIFICATION
HME
•
Increases Resistance - <3.5cm.H2O
•
Increases Resistance when occluded with blood or secretions
•
Disconnect during Aerosol devices
•
Visual inspection - Manufacturing defect
•
Dead space - Minimal
Department of Critical Care Medicine
Kovai Medical Center and Hospital
SUCTIONING
HUMIDIFICATION
HME
Desirable Qualities
•
Moisture output - 28 mg H2O/L
•
Dead space - 50ml
•
Resistance <2.5cm. H2O
•
Always involves net loss of heat and temperature.
Department of Critical Care Medicine
Kovai Medical Center and Hospital
HME
DON’T USE
1.
Hypothermia
2.
Thick secretions
3.
Bloody secretions
Department of Critical Care Medicine
Kovai Medical Center and Hospital
SUCTIONING
HUMIDIFICATION - ALGORITHM
Department of Critical Care Medicine
Kovai Medical Center and Hospital
SUCTIONING
HME Vs HUMIDIFIER
No difference in terms of
• ICU Mortality
• Length of ICU stay
• Duration of Mechanical Ventilation
• Episodes of airway occlusion
Department of Critical Care Medicine
Kovai Medical Center and Hospital
FACTORS AFFECTING DRUG DELIVERY
DURING MV
• Position of patient
• Aerosol generator & Configuration in ventilator circuit
• Aerosol particle size
• Ventilatory parameters
Department of Critical Care Medicine
Kovai Medical Center and Hospital
INHALED MEDICATIONS EMPLOYED IN PATIENTS
RECEIVING MECHANICAL VENTILATION
• Bronchodilator
• Beta-agonist (albuterol, metaproteronol, fenoterol)
• Anticholinergic (ipratropium bromide)
• Prostaglandin (alprostadil, prostacyclin, iloprost,
treprostonil)
• Mucolytics (acetylcysteine)
• Proteins (Pulmozyme)
Department of Critical Care Medicine
Kovai Medical Center and Hospital
INHALED MEDICATIONS EMPLOYED IN PATIENTS
RECEIVING MECHANICAL VENTILATION
• Surfactant (Exosurf)
• Antibiotics
• Antibacterial (aminoglycosides)
• Antiviral (Ribavirin)
• Antifungal (amphotericin)
• Corticosteroids (beclomethasone; budesonide)
• Miscellaneous
Department of Critical Care Medicine
Kovai Medical Center and Hospital
OPTIMAL TECHNIQUE FOR DRUG DELIVERY
BY PMDI IN VENTILATED PATIENTS
• Review order, identify patient, and assess need for bronchodilator.
• Suction endotracheal tube and airway secretions.
• Shake pMDI and warm to hand temperature.
• Place pMDI in space chamber adapter in ventilator circuit.
• Remove HME. Do not disconnect humidifier.
• Coordinate pMDI actuation with beginning of inspiration.
• Wait at least 15 seconds between actuations; administer total dose.
• Monitor for adverse response.
• Reconnect HME.
• Document clinical outcome.
Department of Critical Care Medicine
Kovai Medical Center and Hospital
OPTIMAL TECHNIQUE FOR DRUG DELIVERY BY JET
NEBULIZER IN VENTILATED PATIENTS
• Review order, identify patient, and assess need for bronchodilator.
• Suction endotracheal and airway secretions.
• Place drug in nebulizer to fill volume of 4 ml to 6ml.
• Place nebulizer in the inspiratory line 18 inches (46 cm) from the patient y-piece.
• Turn off flow-by or continuous flow during nebulizer operation.
• Remove HME from circuit (do not disconnect humidifier).
• Set gas flow to nebulizer at 6 L to 8 L per minute.
• Use a ventilator if it meets the nebulizer flow requirements and cycles on
inspiration, or
• Use continuous flow from external source.
Department of Critical Care Medicine
Kovai Medical Center and Hospital
OPTIMAL TECHNIQUE FOR DRUG DELIVERY BY JET
NEBULIZER IN VENTILATED PATIENTS
• Adjust ventilator volume or pressure limit to compensate for added flow.
• Tap nebulizer periodically until nebulizer begins to sputter.
• Remove nebulizer from circuit, rinse with sterile water and run dry, store
in safe place.
• Reconnect humidifier or HME, return ventilator settings and alarms to
previous values.
• Monitor patient for adverse response.
• Assess outcome and document findings.
Department of Critical Care Medicine
Kovai Medical Center and Hospital
AEROSOL DELIVERY
• MDI preferred
• MDI adaptor placed 18cm from ‘Y’ of inspiratory
limb
• May use collapsible chambers
• Actuation timed to end of expiration
• Remove HME in place
Department of Critical Care Medicine
Kovai Medical Center and Hospital
HAND HYGIENE
Department of Critical Care Medicine
Kovai Medical Center and Hospital
HAND HYGIENE
•
Intubation: If elective standard hand wash + sterile gloves
If emergent hand rub + sterile gloves
•
Suctioning : Alcohol hand rub before and after procedure Clean gloves
•
Bronch’: Surgical hand / forearm scrub
Full sterile field, gown and gloves
•
Always consider masks, splash guards and eyewear.
•
Full chlorhexidine hand wash if accidental exposure to secretions
Department of Critical Care Medicine
Kovai Medical Center and Hospital
FAST HUG
F ………….
Feeding
A …………. Analgesia
S ………….
Sedation
T …………. Thrombo prophylaxis
H ……….... Head-of-bed elevation
U …………. Ulcer prophylaxis
G …………. Glucose control
Department of Critical Care Medicine
Kovai Medical Center and Hospital
DON’TS
• Paralyze endlessly to calm down
• Daily CXR in stable pts
• Don’t put soda bicarb to loosen the secretions
• Change ET tube or ventilator circuits routinely
• Don’t make them starve
• Don’t sent ET or suction catheter tip – c/s
• No prophylactic antibiotics
Department of Critical Care Medicine
Kovai Medical Center and Hospital
TRAINING COURSES OFFERED AT KMCH ICU
 Indian Diploma in Critical Care Medicine
Conducted by Indian Society of Critical Care Medicine
 Indian Fellowship in Critical Care Medicine
Conducted by Dr MGR Medical University,
 BSc Respiratory Therapy
Conducted by Dr MGR Medical University
 Post Graduate Dip. In Critical Care Nursing
Conducted by Christian Medical Association & INC
Department of Critical Care Medicine
Kovai Medical Center and Hospital
ICU TEAM
TEAM - Together Everyone Achieves More
Thank You