Care of child requiring long

term ventilation

Moderator : Mrs. Kiran Kaur

Junior Lecturer, C.O.N
PGIMS, Rohtak
= | ad - Presenter :Aruna Shastri

-
M.Sc. 24 year student

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 OBJECTIVES
= Incidence of continuous ventilation
= Goals of mechanical ventilation.
= Classification of different modes of ventilation.
ljustment on the ventilator.
Guidelines recommended during mechanical ventilation
® Monitoring child with continuous ventilation
= \VWeaning from the ventilation.
= Monitoring child with non-invasive oxygen therapy.
= Complication of continuous ventilation.
=» Nursing management of ventilated patient.
 Introduction:

= Children who are long-term ventilated have been found to have a

Significantly health-related poor quality of life.

ildren and young people on long-term ventilation require the most

complex care that is given outside a hospital environment and there
are significant risks involved in looking after a child on long-term
ventilation in the community.

= Competencies and training needed is also a major concern for long

term ventilation.
 Incidence
gnificant rise in number of children on long term ventilation
- (Wallis et al 2010, Goodwin et al 2011)
>» The need for long term ventilation to discharge home is an average of /-9
months

> The number of tracheostomy ventilated children managed out of hospital is

approximately 250-275 per 10000

> 1000-1300 children with complex needs dependent upon non-invasive

entilation under specialist respiratory follow-up.
*\Currently the financial cost of the hospital for recent onset complex long term
xentilation is high
-Pediatric Critical Care Clinical Reference Group (CRG)
 Normal respiration :
Exchange of oxygen ( O2 ) and carbon dioxide (CO2) between the
lungs and the external environment

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Difference in pediatric and adult respiratory system

Anatomy PEDIATRIC ADULT

Tongue Large Normal

Eiglottis Shape Floppy, omega shaped Firm, flatter

Epiglottis Level Level of C3 - C4 Level of C5 - C6

Trachea Smaller, shorter Wider, longer

Larynx Shape Funnel shaped Column

Larynx Position Angles posteriorly away from glottis | Straight up and down
At level of Vocal
Narrowest Point Sub-glottic region cords

Lung Volume 250ml at birth 6000 ml as adult

 Respiratory Failure
eInability of the pulmonary system to meet the metabolic demands of the
body through adequate gas exchange.
Two types of respiratory failure:
Hypoxemic
Hypercarbic
ch can be acute and chronic.
Both can be present in the same patient.
‘Management of this condition required assisted mechanical ventilation
 Mechanical ventilation

_}] Mechanical ventilation can be defined as the technique

through which gas is moved toward and from the lungs
through an external device connected directly to the
patient. -

LL] Mechanical ventilation is the medical term for artificia!

ntilation where mechanical means is used to assist or
eplace spontaneous breathing
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 Indication for mechanical ventilation in children

= Apnoea with respiratory arrest

= Acute respiratory acidosis with paCO, > 50 mmHg & pH < 7.25
= Hypoxemia with PaO, <50 mm Hg with FiO, > 60%
= Vital capacity <2 times tidal volume
=® KR> 35/min
Acute lung injury (including ARDS, trauma)
= Obstructive diseases like Asthma
= Hypotension including sepsis, shock, CHF
= Neurological diseases such as GB syndrome.
 Functions
> Achieve and maintain adequate pulmonary gas exchange
> Minimize the risk of lung injury
> Reduce patient work of breathing
> Optimize patient comfort
» To normalize blood gases and provide comfortable
breathing
> To maintain sufficient oxygenation and ventilation.
> To provide safe environment for the patient while
protecting the lungs from damage due to oxygen toxicity,
pressure.
 Definitions
= Tidal Volume (TV): volume of each breath.

= Rate: Breaths per minute.

inute Ventilation (MV): total ventilation per minute. MV = TV x Rate.

= Flow: volume of gas per time.

= Compliance: the distensibility of asystem. The higher the

compliance, the easier it is to inflate the lungs.

= Resistance: impediment to airflow.

 Definitions
= PIP: Maximum pressure measured by the ventilator during inspiration.

= PEEP: Pressure present in the airways at the end of expiration.

= CPAP: Amount of pressure applied to the airway during all phases of the
respiratory cycle.

= PS: Amount of pressure applied to the airway during spontaneous inspiration

by the patient.

= |-time: Amount of time delegated to inspiration.

= SIMV: Patient breathes spontaneously between ventilator breaths. Allows

patient-ventilator synchrony, making for a more comfortable experience.
 Types of ventilation

1. Positive pressure ventilation.

= Volume cycled
= Pressure cycled
= Time cycled

| 2. Negative pressure ventilation.

 MODES
Volume cycled
= Controlled Mandatory ventilation
= Assist-Control Ventilation
= Intermittent Mandatory Ventilation (IMV)
a synchronous Intermittent Mandatory Ventilation (SIMV)
ressure cycled
= Pressure Control Ventilation (PCV)
= Pressure Support Ventilation (PSV)
= PEEP (Positive End Expiratory Pressure)
= CPAP (Continuous Positive Airway Pressure)
= BiPAP (Bilevel Positive Airway Pressure)
 Ventilator mode

= Volume control

= Pressure Control

Pressure Support-CPAP

= Pressure-Regulated Volume Control

 Volume Control
= The patient is given a specific volume of air during inspiration.

= |The ventilator uses a set flow for a set period of time to deliver the
volume.

The PIP observed is a product of the lung compliance, airway

resistance and flow rate.

= The PIP tends to be higher than during pressure control ventilation to

deliver the same volume of air.
 Pressure Control
= Patient receives a breath at a fixed airway pressure.

= The ventilator adjusts the flow to maintain the pressure.

= Flow decreases throughout the inspiratory cycle.

The pressure is constant throughout inspiration.

= \VVolume delivered depends upon the inspiratory pressure, I-time, pulmonary

compliance and airway resistance.

> ns delivered volume can vary from breath-to-breath depending upon the
actors.
 Comparison of ‘volume-controlled’
and ‘pressure-controlled’ breaths

VCV PCV
Tidal volume Fixed Variable

Airway pressure Variable Fixed

Minute Volume Ss) Measured

Inspiratory Flow Constant/Square Decelerating

 CPAP-Pressure Support
= No mandatory breaths.

= Patient sets the rate, I-time, and respiratory effort.

= CPAP performs the same function as PEEP, except that it is constant

throughout the inspiratory and expiratory cycle.

Pressure Support (PS) helps to overcome airway resistance and

inadequate pulmonary effort and is added on top of the CPAP during
inspiration.
 Modes of Ventilation:

Controlled:
The machine controls the patient ventilation according to set tidal volume and
respiratory rate . spontaneous respiratory effort of Pt. is locked out, ( patient
who receives sedation and paralyzing drugs he will on controlled Mode).

ist/control:
e Pt. triggers the machine with negative inspiratory effort. If the Pt. fails to
reath the machine will deliver a controlled breath at a minimum rate and
volume already set.
 Modes of Ventilation:

SIMV:
= Machine allows the Pt to breath spontaneously while providing preset
FlO2, and a number of ventilator breaths to ensure adequate
ventilation without fatigue. SIMV can be volume or pressure
ontrolled.

Spontaneous:
= The machine is not giving pressure breath.
= The Pt. breath spontaneously.
= The Pt. needs only specific FlO2 to maintain its normal blood gases.
 Initial Ventilator Settings
= Rate: 20-24 for infants and preschoolers16-20 for grade school kids
12-16 for adolescents.

= TV: 10-15ml/kg

PEEP: 3-5cm H,O

= FiO,: 100%

= |-time: 0.7 sec for higher rates, 1sec for lower rates.

= PIP (for pressure control): about 24cm H,O.

 Adjusting The Ventilator
= pCO, too high

= pCO, too low

= pO, too high

= pO, too low

= PIP too high

The Following Guidelines are Recommended

1. Set the machine to deliver the required tidal volume ( 6 to 8 ml/kg)

2. Adjust the machine to deliver the lowest concentration of the oxygen
to maintain normal PaO2 (80 to 100mmhg). The setting may be set
igh and gradually reduced based on ABGs result.
3. Record peak inspiratory pressure.
4. Set mode (assist/control or SIMV)and rate according to physician
order.
o. If Pt. is on assist/control mode , adjust sensitivity so that the Pt. can
trigger the ventilator with the minimum effort( usually 2mmHg negative
inspiratory force)
 The Following Guidelines :are
Recommended
6. Record minute volume and measure carbon dioxide partial pressure
PaCO2, PH after 20 minutes of mechanical ventilation.
7. Adjust FlO2 and rate according to results of ABG to provide normal
lues or those set by the physician.
8. In case of sudden onset of confusion , agitation or unexplained "
bucking the ventilator " the Pt. should be assessed for hypoxemia and
manually ventilated on 100% oxygen with resuscitation bag (AMBU
bag) Bag — Valve — mask.
9. Patient who are on controlled ventilation and have spontaneous
respiration may " fight or buck " the ventilator, because they cannot
synchronize their own respiration with the machine cycle.
 Weaning Priorities
= Wean PIP to <35cm H,O

= \Wean FiO, to <40%

@\WVean PEEP to <8cm H,O

= \Wean PEEP, PIP, I-time, and rate towards extubating settings.

 SEDATION & MUSCLE RELAXANTS
Midazolam
m 50-150 mcg/kg IV qi-2hr PRN.
= 1-2 mcg/kg/min IV infusion
= <32 weeks gestation: 0.5
mcg/kg/min IV infusion
Vecuronium
= 1-10 years old 0.1 mg/kg IVP;
repeat qthour PRN, OR_
=® Continuous Infusion: 0.05-0.07
mg/kg/hour IV
succinyl choline
= Loading dose
= 1-2 mg/kg IV x1 dose.
m@ 3-4 mg/kg deep IM x1 dose (no
adequate IV)
= Maintenance dose
= Q.3-0.6 mg/kg IV q5-10min PRN
Fentanyl
@ 0.5-2 mcg/kg/dose IV q1-2hr
 SEDATION & MUSCLE RELAXANTS
Midazolam
m 50-150 mcg/kg IV qi-2hr PRN.
= 1-2 mcg/kg/min IV infusion
= <32 weeks gestation: 0.5
mcg/kg/min IV infusion
Vecuronium
= 1-10 years old 0.1 mg/kg IVP;
repeat qthour PRN, OR_
=® Continuous Infusion: 0.05-0.07
mg/kg/hour IV
succinyl choline
= Loading dose
= 1-2 mg/kg IV x1 dose.
m@ 3-4 mg/kg deep IM x1 dose (no
adequate IV)
= Maintenance dose
= Q.3-0.6 mg/kg IV q5-10min PRN
Fentanyl
@ 0.5-2 mcg/kg/dose IV q1-2hr
 Extubation Criteria

= Neurologic

= Cardiovascular

Pulmonary
 Neurologic
= Patient must be able to protect his airway, e.g, have cough, gag, and
swallow reflexes.

= Level of sedation should be low enough that the patient doesnt become
apneic once the ETT is removed.

= No apnea on the ventilator.

= \Viust be strong enough to generate a spontaneous IV

= Being able to follow commands is preferred.

 Cardiovascular

= Patient must be able to increase cardiac output to meet demands of

work of breathing.

= atient should have evidence of adequate cardiac output without

being on significant inotropic support.

= Patient must be hemodynamically stable.

 Pulmonary
= Patient should have a patent airway.

= Pulmonary compliance and resistance should be near normal.

= Patient should have normal blood gas and work-of-breathing on the

following settings:
=FiO. <40%

= PEEP 3-5cm H,O

= Rate: 6bpm for infants, 2b0m for toddlers, CPAP/PS for 1hr for
older children and adolescents
=m PS 5-8cm H,O0
= Spontaneous IV of 5-/ml/kg
 ABG
> ABG analysis is the gold standard for monitoring the adequacy of gas
exchange

° SpO2 targets of 85-93% is the most appropriate.

“In term and near term infants and older children who are mechanically
ventilated it is acceptable to target SoO2 between 92-95 % and in
children with cyanotic CHD SpO2 between 70 -75% are acceptable if
tissue oxygenation is good.
 Respiratory Disturbances

= Acute respiratory acidosis occurs when CO, Is retained acutely.

= Chronic respiratory acidosis occurs when the retained CO, gets

iifered by renal retention of HCO,.

= The pH is higher than in acute respiratory acidosis, but it is still <7.4.

 Chest radiograph:
The findings to look for:
> Position of the ET, central lines and umbilical catheters.
> Optimal positioning for ETT is approximately 1 -1.5 cm above the
carina.
> MDisplacement of the tube into the oesophagus Is indicated by a low
ETT position.
> Poor aeration of the lungs and gaseous distension of the Gl tract
> Look for the atelectasis, flattening of the diaphragm and lung
expansion reaching the tenth rib suggests over expansion and
increased risk of pulmonary air leaks and lung injury.
Tube securing/ fixation of ET tube
 ET SUCTIONING

Indications for ET suctioning

= Presence of visible secretions in the tube
Drop in oxygen saturation
= High pressure ventilator alarm
™ Increase in respiratory rate and decrease in tidal volume.
= Suctioning is a PRN procedure
 Post extubation management
= Close monitoring

= Every patient should be oxygenated post-extubation.

ygenation and airway clearance

® This may include suctioning, bronchodilator therapy, diuresis, or

Noninvasive positive pressure ventilation (NPPV)

= Devices that provide adequate oxygenation and comfort for the patient
are preferred — low flow devices
 Complications

Pulmonary Gastrointestinal
= Barotrauma =» |lleus
= Ventilator-induced lung injury = Hemorrhage
Nosocomial pneumonia
= Pneumoperiteneum
= Tracheal stenosis
Renal
= Tracheomalacia
= Fluid retention
= Pneumothorax
Nutritional
Cardiac
® (Vialnutrition
=» Vyocardial ischemia
= Reduced cardiac output = Overfeeding
Troubleshooting mechanical ventilation

DOPE
= D— DISPLACEMENT OF TUBE.

= O —- OBSTRUCTION OF TUBE.

= P —-PNEUMOTHORAX

= E —- EQUIPMENT FAILURE
Care of child on ventilator is a

© Team approach include

> Physician
> Nursing staff
> Physiotherapist
> Respiratory physiotherapist(available in some
selected tertiary centre )
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 Nursing Management of Ventilated Patient

1) Promote respiratory function.

2) Monitor for complications

3) Prevent infections.

4) Provide adequate nutrition.

9) Monitor GI bleeding.
1. Promote respiratory function

= Auscultate lungs frequently to assess for abnormal sounds.

= Suction as needed.

= Turn and reposition every 2 hours.

= Secure ETT properly.

= Monitor ABG value and pulse oximetry.

Mobilize
the
secretions

Prevent
pneumonia
Reduce
hospital
stay
 Suction of an Artificial Airway
1. To maintain a patent airway.

2. IO improve gas exchange.

3. To obtain tracheal aspirate specimen.

4. To prevent effect of retained secretions.

( Its important to OXYGENATE before and after suctioning)
 2. Monitor for complications

1. Assess for possible early complications Rapid electrolyte changes.

® Severe alkalosis.
> ypotension secondary to change in Cardiac output.

2. Monitor for signs of respiratory distress:

= Resitlessness
= Apprehension
® Irritability and
™ increase HR.
 Monitor for complications
3. assess for signs and symptoms of barotrauma(rupture of the lungs)
increasing dyspnea.
= Agitation.

= “Decrease or absent breath sounds.

= Tracheal deviation away from affected side.

= Decreasing paoz2 level .

4. Assess for cardiovascular depression: hypotension tachycardia and

bradycardia dysrhythmias.
 3. Prevent infection

1. Maintain sterile technique when suctioning.

2. Monitor color, amount and consistency of sputum.
4. PROVIDE ADEQUATE NUTRITION
1. Begin tube feeding as soon as it is evident the patient will remain on the
ntilator for a long time.
‘ Weigh daily.
3. 3. Monitor I&O .
5. MONITOR FOR GI BLEEDING
1. Monitor bowel sounds.
2. Monitor gastric PH and hematest gastric secretions every shift.
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© ORAL CARE:
a) Tooth brushing twice a day
b) Chlorhexidine rinse twice a day
fo

Munro CL, et al.(2006) found CHX significantly reduced VAP

(24.4% vs. 52.4%, p=0.0093) compared with tooth
brushing alone
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© EYE CARE:
a) Ventilated patient is often sedated & Increase the risk
of (muscle relaxed)
1. Exposure keratitis
2,/. Corneal ulceration
3. Infection
TT. Passive closure of eyelid, use lubricants, (artificial tear.
Prevention: eye packing, lubricating ointments and artificial
tears, antibiotics eye drops)
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® SKIN CARE:
- Apply lotion to skin
- Prevent from decubitus ulcer formation
- Change position frequently
-“ Skin care to be given, massaging to be done to increase
circulation
© Moisturizers
® Skin disinfectants(cause skin necrosis, blistering, burns)
® Povidone-iodine proved better than 70% isopropyl alcohol
in pediatric patient.
. Ineffective airway clearance R/T ET obstruction
* Suctioning sos

+ Watch for Resp. Distress, agitation or alteration in LOC .

* Auscultate chest

“ Monitor Pao, & saturation

“ Ensure that inspired air is adequately humidified

2. Breathing pattern — ineffective R/T ventilator malfunction,
inappropriate ventilator support.
- Monitor patients color, responsiveness (LOC), Clinical
appearance.
- Asses patency & position of ET
- Ensure the chest expands equally & bilaterally
- Verify ventilator variables hourly.
- Check connections of all tubing's hourly
- Alarms should be active all times
- Monitor PIP (? PIP + Pneumothorax)
= 3. Altered cardiac output R/T hypoxia
“ Monitor for adequate perfusion
” Assess tube position & patency
“ Support CV function with fluids or with inotropic.
* Monitor fluid balance daily (+ve or —ve balance)
= 4. Alteration in nutrition less than body requirements R/T
chronic Immobility.
I.V,TPN, Plan calories & protein.
 NUROLIN JIAGNU =

5. a) Restlessness R/T hypoxia

* Watch for pink lips & mucous membranes
“ Watch for bilateral chest expansion.
* Watch for signs of hypoxia - TPR, TRR, alteration in systemic
perfusion deterioration in LOC, /Sao,, \Pao,
- Nasal flaring, 7 Pul. Congestion, /breath sounds.
- Check ventilator settings every hour.
b) Restlessness due to constant stimulation
- Provide comfortable bed & position
- Allow for undisturbed sleep times
- Reduce overhead lighting.
- Minimize Environmental Noise.
= 6. Potential for impaired gas exchange R/T Atelectasis.
“ Auscultate breath sounds hrly
“ Check adequate PEEP is provided
“ Monitor for resp. distress
Give 100% O, before suctioning
* Change position every 2"2 hrly.
“ Monitor regularly with chest x-ray & arterial blood gas.
“ Chest Physio hrly — cuffing, vibration
 NURSING DIAGNOSIS:-

7. Potential for hypoxia R/T pul edema or damage to alveolar

surface caused by barotraumas.
“ Fluid restriction
“ Monitor Sao.,, capillary refill, Pao,
“ Auscultate lung every hour.

8. Potential for fluid vol excess R/T 7T levels of ADH secretion

during ventilation at high peak or end exp. Pressure
“ Monitor I/O Chart
“See + ve or—ve balance
“ Calculate Fluid requirement daily & administer.
“ Auscultate breath sounds for evidence of pul edema.
* Aminister diuretics as ordered.
“ Monitor electrolyte balance
 NUROIN JIAGNU =
9. Potential for infection R/T
a. bypass of normal body defense mechanism (upper airway)
b. Break in aseptic technique during intubation & suctioning
c. Repeated traumatic suctioning
d. Compromise in nutritional status
iderlying pulmonary disease

* Assess for fever, leukocytosis ((WBC) TRespiration distress TQuantity or

ange In
consistency of secretions, Tpulmonary congestion by auscultation, & on chest
X-ray.
“ Follow meticulous hand washing.
“ Aseptic technique during suctioning, intubation & change in ventilator
ircuit.
* Monitor for WBC, platelet count for infection.
10. Potential for difficulty in weaning R/T failure of resolution of pul
disease or due to nutritional Compromise.

” Monitor clinical appearance throughout.

“ Change only one parameter at a time.

“ Assisted ventilation should be ready during resp. distress