Pratica di Shadowing: What is Mechanical Ventilation? - Ventilators EXPLAINED - Impara a parlare inglese con YouTube

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All right, you guys, welcome back to another lesson.

Here in this lesson today, we are going to be talking about invasive mechanical ventilation and what the heck that is.

My name is Eddie Watson, and I welcome you guys to ICU Advantage.

My goal here with ICU Advantage is to really take these complex critical care topics and break them down and really try to make them easy to understand for you guys.

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Now, in addition to that, I also want to send a special shout out to another YouTube channel here, a YouTuber who goes by the name of Respiratory Coach.

Once again, he's been very helpful in the review of the information here in this lesson.

And he's got a great channel with a lot of great topics relating to respiratory therapy.

So again, if you guys haven't watched him or subscribed, head on over there.

There's a link down in the description.

All right, so invasive mechanical ventilation.

Let's go ahead and get started here talking about it.

And so let's really start off and talk about what is mechanical ventilation.

So essentially, invasive mechanical ventilation, this refers to respiratory support for our patients that requires some sort of artificial airway.

So here, think of an endotracheal tube or a tracheostomy, and then from there, placing that patient on a machine that we call a ventilator, aka vent, in order to control their breathing.

And so let's actually talk through some of the indications for this invasive mechanical ventilation.

Essentially, mechanical ventilation is going to be indicated when other forms of non-invasive management and support have really failed to help improve either our patient's oxygenation or ventilation.

Now, our decision to mechanically ventilate someone is based on their own ability to either oxygenate or ventilate themselves effectively.

So essentially, they either have hypoxemic or hypercapnic respiratory failure or some combination of both.

Now I did talk about these types of respiratory failure in the previous lesson, talking about non-invasive ventilation.

So I'm going to link to that up above as well as down in the lesson description for you to check out there.

But when making the decision to mechanically ventilate our patients, there really are some basic physiological impairments that are really going to tell us this is probably something we need to do.

The first of these is going to be apnea.

So here, if they have some sort of neurologic or neuromuscular reason for the apnea, think of GCS of 8 or less, we want to intubate.

Also, if our patients are unconscious and really unable to protect their airway, again, we're going to want to consider intubation.

The next thing we really want to consider is our hemodynamic instability or cardiovascular collapse.

We want to be looking at intubation for patients who have acute ventilatory failure.

This is going to be that hypercapnic respiratory failure we talked about in the previous lesson.

Here if we have a PaCO2 that's greater than 50 or a respiratory acidosis with a pH less than 7.25,

or if we're just seeing an acute rise in our patient's CO2 from their baseline with the presence of that acidosis.

We also need to look to intubation if our patients have impending ventilatory failure.

And this is going to be for those patients who are continually declining with repeated ABGs and ultimately having symptoms and an increasing work of breathing.

We also need to look to intubation for patients that have refractory hypoxemic respiratory failure.

So again, these are going to be those patients who just aren't responding to other sorts of treatment.

And so if we still persist with PAO2 less than 60, or if we have a PF ratio that's less than 300, we really want to be considering intubation.

Now our PF ratio, if you guys aren't aware, is where we take our patient's PaO2 and divide it by the FiO2 that they're currently receiving.

And this is in that fraction form.

So as a quick example, if our patient's ABG showed a PaO2 of 100 and they were on 50% FiO2, we would take 100 divided by 0.5, which would give us a PF ratio of 200.

We also need to consider intubating patients who are having respiratory muscle fatigue.

Now this is going to be for patients who are not contracting effectively due to this fatigue, and we're going to see a rising PaCO2.

So here we want to be looking for things like a tidal volume that's less than 5 milliliters per kilogram.

Our normal is 5 to 7 here.

Also, if our patients have a respiratory rate that's less than 10 or greater than 35, these are going to be indications.

And finally, we may need to use intubation to relieve our patients from some sort of obstruction.

And this is where you can really think about things like swelling from anaphylaxis, edema, head and neck trauma, things like that.

Again, the big takeaway here is don't wait, don't delay.

If we see these signs or this impending sign that your patient is ultimately not going to do well, make the decision to intubate proactively instead of waiting until they tuck her out.

Now, we don't always have that luxury.

Sometimes these patients just crump and we don't have the time and we're going to be crashing into an intubation anyways.

But if we do have the time, we really should try to consider this stuff and attempt to intubate these patients on our terms.

All right, so let's move on and talk about some basic principles of mechanical ventilation.

So the first of these is we can either partially or fully take over a patient's ventilation.

Now also remember that mechanical ventilation is merely a means of support.

This is going to do absolutely nothing to solve the patient's underlying problem, and it's going to offer us no curative properties.

Now, the mechanical ventilation is not going to really help our patient in the sense of what their underlying problem is, but rather it allows them time to survive until they can recover from that problem.

Now, again, we can provide ventilation to our patients either invasively or non-invasive, and we really want to attempt non-invasive whenever possible.

Again, I'm going to link to that previous lesson up above on our non-invasive ventilation.

But in order for us to have invasive ventilation, that this is going to require either intubation with an ET tube or a tracheostomy.

Now, when we talk about ventilation, there's really two primary categories in which we can ventilate our patients.

We have either negative pressure or positive pressure.

To really help to explain the difference between these better for you, Let me go ahead and bring up a picture of a patient here.

Now first, let's talk about negative pressure.

This is rarely something that's used to manage acute respiratory failure in the hospital.

But to give you an understanding of how this principle works is we'd have a shell around the chest of our patient.

And this shell actually creates negative pressure outside our patient's body.

This actually decreases the extrathoracic pressure and causes the chest and the lungs to expand, which causes air to be drawn into our patient's lungs.

Now on the other hand with our positive pressure ventilation that this is going to deliver pressure into the patient's lungs during inspiration and this air coming in is going to cause the lungs to expand.

There are risks though that are associated with this method and really all forms of mechanical ventilation that we use today are going to be some sort of variant of positive pressure ventilation.

Now when we talk about therapeutic benefits of ventilation, there's really only three benefits.

The first one is a guaranteed delivery of high oxygen levels.

Another is that by providing positive pressure that we can reduce intrapulmonary shunt.

And really what I mean here is to think of things like atelectasis, ARDS, pneumonia, pulmonary edema,

things like that in which having that positive pressure both to keep alveoli open, as well as put pressure on fluid and other things that may be inside those alveoli to try and open those up as well, that those are going to be beneficial.

And finally, we can provide the work of breathing for our patient until they're able to do it themselves.

And really, for the last part of our basic principles, I want to talk about a real basic overview of how the ventilator circuit works.

So first and foremost is that we have a closed circuit that's attached to our patient's artificial airway.

We maintain this closed circuit, one, to ensure that we're getting the gas delivery that we want, as well as to prevent complications such as ventilator-acquired pneumonia.

So essentially, the basics of the vent is, so on inspiration, we're going to have gas that comes from our vent and goes down into what we call an HME, which is a heat and moisture exchanger.

And here, this is going to be humidifying and warming the air prior to entering our patient's lungs.

Again, if you think about here, we're bypassing the upper airway of our patient with this endotracheal tube or tracheostomy tube, and so they're not going to get that natural humidification and warming of the air, and so that's the point of this HME.

Now again, this is accomplished with positive pressure to the patient, and these pressures are going to be continually monitored on the display of the vent.

We also can nebulize medications and give those into the circuit here just prior to reaching the patient.

Now on exhalation, gas is going to be passively exhaled out through the expiratory circuit of our vent tubing.

Now remember here that this is just a quick overview, and unless you work in a facility where nurses are really operating the vent, that your respiratory therapist is going to be the keeper of the vent.

They're a fantastic resource and they're great to troubleshoot problems with, so make sure you guys are relying on their expertise.

Alright, so let's go ahead and move on and talk about some of the complications that we can see with mechanical ventilation.

Now again, this is just going to cover a couple of the main big problems that we see.

There certainly are other complications in addition to these ones here, so don't think that this is just a completely exhaustive list.

All right, so the first complication that I want to talk about here is our hemodynamic compromise.

And so what's happening here is we actually have a change in our normal intrathoracic pressure when compared to spontaneously breathing patients.

Now, normally our intrapleural pressure range from about negative 8 centimeters of water on inspiration and plus 5 on exhalation.

And it's this decrease on inspiration that really facilitates lung expansion and venous blood return.

And so if you think about this decrease in pressure is going to reduce pressure on the veins returning to the heart, allowing that blood to return more easily.

But in positive pressure ventilation, all of this is reversed.

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So now we're going to have this positive pressure, these higher pressures that we're going to see on inspiration.

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And this can really impede the venous return and ultimately decrease our cardiac output.

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If you want to understand this better, I'm going to link to a lesson up above on a previous series that I did on hemodynamics and talking about cardiac output.

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Now, in some patients, this decrease in cardiac output can really be significant, leading to things like increased heart rate, decreased blood pressure, and ultimately decreased perfusion.

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So it's going to be really important that you guys are assessing your patient's cardiovascular response, especially after you make changes to the vent.

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Now, your sicker patients are going to require higher PEEP or higher pressures, which again can cause a further decline in our patient's cardiovascular status.

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And so for these patients, we may need to look at either increasing their preload or decreasing or adjusting the ventilator settings or the mode that they're in, which I am going to talk about in a future lesson.

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Now the next major complication that I want to talk about is going to be our barotrauma and our volutrauma.

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And so we can really look at these two things a little bit differently here.

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Barotrauma is going to be damage to our lungs from alveolar rupture that is a result of excessive pressure or over-distention of those alveoli.

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Now this can lead to things like pneumothorax, pneumomediastinum, pneumoperitoneum, or subcutaneous emphysema.

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And consequentially, a pneumo can progress to tension and ultimately lead to cardiovascular collapse in our patient.

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So in order to really prevent this, we want to avoid large tidal volumes, we want to have cautious use of PEEP, and we really want to avoid high airway pressure.

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So now if we look at volutrauma, this is where we're going to have alveolar damage that results from high pressure due to a large volume ventilation in these patients who have ARDS.

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So here, the alveolar damage is going to be fractures and flooding, unlike the complete rupture that you're going to see in barotrauma.

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And really our way to avoid this is to use smaller tidal volumes in these patients.

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All right, the next major complication I want to talk about is our ventilator-associated pneumonia.

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It's also what you'll hear referred to as VAP.

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So this here is a complication that our patients can develop while they're in the hospital in our care.

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And this does have an increased risk for morbidity and mortality associated with patients who get this.

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Here real quickly are some tips that we have for preventing this.

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First is have the head of the bed 30 to 45 degrees.

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This is going to help prevent aspiration.

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Next, you want to be using some sort of subglottic suctioning, especially prior to deflating the cuff of an ET tube.

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We also want to make sure and be maintaining the cuff pressure of that ET tube.

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We want to make sure that we have oral care protocols in place every two to four hours.

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And we also want to be using daily CHG with that.

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We want to be doing daily sedation vacations and assessing our patient's readiness to extubate.

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Also, we want to ensure that we have the proper nutrition for our patients, as well as frequently assessing the placement of that feeding tube.

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And finally, and probably most basic, is have good hand hygiene and minimize the circuit disconnects.

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Alright, and finally, the last major complication I want to talk about here is our ventilator malfunction.

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Now, while these certainly are rare, there are times that we do have equipment malfunction, and obviously this can cause complication for our patients when this happens.

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Now, typically these malfunctions are the result of inappropriate setup or use.

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But you always want to make sure that you have your alarm set and enabled to be able to provide you warning with quick intervention if needed.

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Make sure that you're maintaining a high level of vigilance and that you're checking the equipment and really paying attention to those alarms.

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If a problem does come up, switch over from the vent and manually oxygenate and ventilate your patient with a bag valve mask until that problem is corrected.

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All right, and so moving on from here, the last thing that I want to talk about is the goals of care for patients who are being mechanically ventilated.

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So one thing that's really important to know is that most patients who do have respiratory failure are going to improve once the underlying illness or the problem is resolved.

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This is really good news.

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We just have to provide the support that they need and give them time and figure out whatever we need to do to fix this other problem, and ultimately their respiratory failure should resolve itself.

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Therefore, as a result, we have certain goals of care that we really want to strive for.

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First is we want to protect the lung from iatrogenic injury, so we don't want to be causing any more damage to the lungs.

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We also want to quickly and aggressively be treating the underlying illness or injury.

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We want to ensure that we're providing these patients with appropriate nutrition.

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We want to try to early mobilize these patients whenever possible.

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Once our patient's recovering, we want to be assessing their readiness to extubate every single day.

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Important thing to remember here is to be patient as it might take some time.

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Also, once it's evident that they're going to require prolonged support, we really want to consider moving to a tracheostomy.

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And finally, the last piece of advice I really have for you is, most importantly, remember that your patient is another human being, just like yourself.

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They have wants, needs, cares, and concerns just like you do.

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Make sure that you're speaking to them even if they can't speak back.

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Make sure you guys are being respectful to them even if they're not being respectful to you.

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Remember the basics of human kindness and that they truly have placed their lives in your hands.

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Don't ever forget that.

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All right, and so with that said, I want to thank you guys so much for watching.

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If you found this lesson helpful, leave us a like on the video down below.

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Don't forget to subscribe in order to continue to get the latest in critical care education.

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Don't forget to check out ICU Advantage on social media, as well as I just recently started a Patreon page, so if you'd like to show support beyond YouTube, head on over there.

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I do have additional content that you won't find just on YouTube.

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Finally, make sure and check out this awesome video we have linked right here.

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And as always, you guys have a great day, and I'll see you in the next video.

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