Invasive Procedure For Respiratory Disorder Patients: Abg, Ippv, Nippv DR Arkers Wong

Download as pdf or txt
Download as pdf or txt
You are on page 1of 54

Invasive procedure for

respiratory disorder patients


ABG, IPPV, NIPPV
Dr Arkers Wong
Learning objectives
• Describe the usage and the interpretation of ABG
• Discuss different types of mechanical ventilator and
their usage
• Discuss the potential complications for patients with
mechanical ventilator
• Discuss the nursing management caring for a patient
with NIPPV
Interpretation of ABG
Indication
• Unexplained changes in mental state
• Acute onset of dyspnea
• Respiratory failure
• Circulatory failure
• On mechanical ventilation
• Pre-op assessment of respiratory function
ABG gives information on…
• Oxygenation status—PaO2, SaO2
• Alveolar ventilation status—PaCO2
• Acid base status—pH, PaCO2, HCO3, BE
Definition
PH
• Determined by the ratio of HCO3 to PaCO2
PaCO2
• Amount of CO2 dissolved in blood
• Regulated by lung
• Hyperventilation--- PaCO2
• Hypoventilation--- PaCO2
PaO2
• Amount of O2 dissolved in blood
• Reflect oxygenation status
Definition
HCO3
• Concentration of bicarbonate in blood
• Regulated by kidneys (reabsorb or excrete)
BE
• Indicate the difference between the normal serum
bicarbonate level and the client’s bicarbonate level (positive
indicates excess bicarbonate relative to normal values)
• Serves to estimate the severity of acid base disorder
• 0+-5 respiratory acid base disorder
• >+5 metabolic alkalosis
• <-5 metabolic acidosis
Acid base disorder
• Metabolic acidosis
• Metabolic alkalosis
• Respiratory Acidosis
• Respiratory Alkalosis
Metabolic acidosis
• Gain of acid—
• Loss of base—

Treatment
• Treat the cause
• Administer NaHCO3 if pH <7.2
Metabolic alkalosis
• Loss of acid—
• Gain in base—

Treatment
• Treat the cause
Respiratory acidosis
• Causes—

Treatment
• Treat the cause
• Increased ventilation
Respiratory Alkalosis
• Causes—

Treatment
• Treat the cause
• Decreased ventilation to build up CO2 level
States of compensation
• Non compensation
• Partial compensation
• Complete compensation
Sample
• F/47, Hx of asthma. On 30% O2 mask. RR
30/min

• pH: 7.5 (7.35-7.45)


• HCO3: 20 mmol/L (22-26)
• PaCo2: 4 Kpa (4.7-6)
• PaO2: 10 Kpa (10-13)
Principle of mechanical ventilation
Mechanical ventilation
Definition:
• The movement of gas into and out of the
lungs by artificial means
• Invasive positive pressure ventilator (IPPV)
• Non-invasive positive pressure ventilator
(NIPPV)
Indications
• Central control failure e.g. head injury
• Drug overdose
• Mechanical derangement e.g. fracture ribs
• Pulmonary pathology e.g. severe pneumonia
• Post anesthetic support
Goals
• To improve oxygenation
• To ventilate the lungs adequately
• To reduce the work of breathing
Criteria for administering
mechanical ventilation
parameter normal Need mechanical
ventilation
Respiratory rate (bpm) 10-20 >35

Tidal volume (ml/kg) 5-7 <3

Vital capacity (ml/kg) 65-75 <10

Maximum inspiratory force 75-100 <20


(cmH2O)
PaO2 (Kpa) 10-13 <8
Ventilator

Puritan bennett 840


Monitored Data
Delivered O2%
Positive end expiratory pressure (PEEP)-- maintains the
patient's airway pressure above the atmospheric level by
exerting pressure that opposes passive emptying of the
lung
Spontaneous minute volume (VE SPONT)– total volume
that a patient inhales spontaneously in a minute
Exhaled minute volume (VE TOT)– the volume of gas
exhaled from a person’s lungs per minute
Exhaled tidal volume (VTE)
Inspired tidal volume (VTI)
Mandatory inspired tidal volume (VT MAND) (with VC+
only)
I:E ratio
Total respiratory rate (fTOT)
Rapid shallow breathing index (f/VT)– respiratory
frequency/ tidal volume. People on a ventilator who cannot
tolerate independent breathing tend to breathe rapidly
(high frequency) and shallowly (low tidal volume)
Spontaneous inspiratory time (TI SPONT)
Inspired spont tidal volume (VTI SPONT)
Vital Capacity (VC)
Types of ventilator
• Volume cycled ventilator
• Pressure cycled ventilator
• Time cycle ventilator
Volume cycled vs pressure cycled
Volume cycled Pressure cycled

Definition Need to set a preset tidal Need to set a preset


volume e.g. 500 ml inspiratory pressure e.g. 30
cmH2O

Pros Adequate and constant A low mean airway


tidal volume can ensure an pressure can result in a
optimal ventilation effect better distribution of gas
within the lungs
Cons Complication like Unstable and inadequate
pneumothorax tidal volume results in
hypoventilation
Ventilation mode
Major mode

Total control mode CMV


PCV

Semi-control mode SIMV

Spontaneous mode CPAP


CMV-controlled mandatory
ventilation
The client automatically receives breaths with
controlled tidal volume and frequency
PCV-pressure controlled ventilation
The client automatically receives breaths with
controlled pre-set pressure
SIMV-synchronized intermittent
mandatory ventilation
The client breaths spontaneously through the
ventilator between mandatory breaths with
controlled tidal volume and frequency
CPAP-continuous positive airway
pressure ventilation
• Positive pressure applied during spontaneous
breaths
BiPAP Vision
NIPPV
• NIPPV used to maintain adequate oxygenation
in patients who cannot maintain these
functions independently
• Delivery of mechanically assisted breaths
without placement of artificial airway
• BiPAP or CPAP
• BiPAP can provide both short term acute
respiratory support and long term home
ventilatory support
Principles of BiPAP
• Supply pressurized air through a mask
• Deliver two level of positive pressure:
--Higher pressure at inspiration (IPAP)
--Lower pressure at expiration (EPAP)
Principles of BiPAP
Inspiratory Positive Airway Pressure (IPAP)
• Amount of pressure that applies to the
airways during inspiration
• Enhance patient’s breathing effort during
inspiration
• IPAP must be set higher than EPAP
• Increase IPAP affects the cardiovascular
system
Principles of BiPAP
Expiratory Positive Airway Pressure (EPAP)
• Amount of pressure applied during expiration,
and during the pause between expiration and
inspiration
• Keep the patient’s alveoli open during
expiration
• Prevent the oropharynx from collapsing before
the onset of inspiration
• Always lower than IPAP
Indication for BiPAP therapy
• Unacceptable or worsening hypoventilation
with a respiratory acidosis
• Ventilatory muscle dysfunction or fatigue e.g.
use of accessory muscle
• Unacceptable hypoxaemia despite
administration of supplementary oxygen
• Ventilatory difficulty after extubation
Contraindication to BiPAP therapy
Cardiac or respiratory arrest without a spontaneous respiratory
drive:
• It must not be used as a life support ventilator

Unable to maintain a patent airway or adequately clear


secretions:
• Fixed obstruction of the upper airway
• Epistaxis or excessive secretions

High risk for aspiration of gastric contents:


• Severe upper gastrointestinal bleeding
• Absence of gag reflexes
Contraindication to BiPAP therapy
• Cardiac problem or unstable cardiac
arrhythmia
• Uncooperative, intolerant or agitated patient
• Pneumothorax without chest drain
• Facial burns, deformity and recent oral surgery
• History of allergy or hypersensitivity to the
mask materials
Advantages of BiPAP therapy
• Do not require endotracheal intubation
• Lessen the need for sedative or paralytic drugs
• Reduce risk of infection
• Decrease in work of breathing
• During the period of BiPAP is off, patient can
eat and drink
• Patient can speak during BiPAP therapy
Disadvantages of BiPAP therapy
• Facial skin abrasion
• Eye irritation
• Risk for aspiration
• Dry mouth
Accessories of BiPAP Vision
Circuit tubing:
• 72 inches smooth inner lumen tubing for
standard noninvasive circuit

Proximal pressure line:


• A transparent smooth inner lumen line

Bacterial viral filter:


• Must use a high flow and low resistant filter
Nursing care
• Explain the procedure to patient
• Keep call bell within easy reach
• Prop up patient if no contraindication
• Set up the BiPAP machine and attach pulse
oximeter
• Adjust the mask if necessary
• Check ABG after 1-2 hours
• Ensure that the necessary equipment is ready
for emergency intubation
Nursing care
Minimize patient’s stress:
• Adequate explanation should be given to allay fear
and gain cooperation
• Anticipate patient’s needs by close and continuous
monitoring
• Provide communication means, e.g. call bell
• Advise patient to report any discomfort immediately
• Restraint is not recommended for the compliance
Nursing care
Take NIV off temporarily if…..
• Patient has stable haemodynamic and
improved arterial blood gas when weaning
BiPAP, inhaling or ingesting medications, and
performing light daily activities
Reapply NIV if…..
• Patient has signs of distress, unstable
haemodynamic, desaturation, altered mental
state or decreased consciousness
Nursing care
Maintain adequate oxygenation and ventilation:
• Ensure no air leakage through the mask and
the BiPAP system
• Close monitoring on patient’s response

Ensure adequate cardiac output and tissue


perfusion:
• Close monitoring on patient’s BP, P
Nursing care
Maintain adequate hydration and nutrition:
• Assist oral feeding if necessary
• Strict intake and output record
• Aware of side effect, e.g. dry mouth

Maintain an optimal physical functioning:


• Give appropriate assistance in ADL
Nursing management in avoiding
complications
Aspiration
• Stop operation of the BiPAP machine during
feeding
• Remove the mask if patient want to
expectorant or vomit
• Patient should avoid to eat or drink 1-2 hours
prior to bed time
Nursing management in avoiding
complications
Skin abrasion
• Placing a patch of dressing on pressure point

Eye irritation
• Appropriate size and fitting of mask will
reduce air leaking to eyes
Nursing management in avoiding
complications
Gastric distension
• Adequate explanation and education will
prevent the patient breathing by mouth
• Avoid soft drink during BiPAP therapy

Decrease in cardiac output


• Closely monitoring of blood pressure is
important to detect the decrease of cardiac
output
References:
• Chlan, L., Tracy, M.F., & Grossbach, I. (2011). Pulmonary care. Achieving
quality patient-ventilator management: advancing evidence-based nursing
care. Critical Care Nurse, 31(6), 46-50.
• Koutsoukou et al. (2019). Expiratory flow limitation and intrinsic positive
end-expiratory pressure. American Journal of Respiratory Critical Care
Medicine, 161(5), 1590-96.
• Proehl, J.A. (2009). Emergency nursing procedures ( 4th edition). Saunders:
Elsevier.
• Soh, K.L., Soh, K.G., Japar, S., Raman, R.A., & Davidson, P.M. (2011). A
cross-sectional study on nurses’ oral care practice for mechanically
ventilated patients in Malaysia. Journal of Clinical Nursing, 20(5/6), 733-
742.
• Specialty Advisory Group (Respiratory) (2014). Guidelines for Specialty
Nursing Services : Non-invasive ventilation (NIV) for adult patients with
acute respiratory failure. Hong Kong: Hospital Authority Head Office.
• Tracy, M.F., & Chlan, L. (2011). Nonpharmacological interventions to
manage common symptoms in patients receiving mechanical ventilation.
Critical Care Nurse, 31(3), 19-29.

You might also like