Complications with Mechanical Ventilation (Nursing)

by Rhonda Lawes, PhD, RN

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    00:01 I want to group the complications into two main categories.

    00:04 One is immediate Those that you could see right away, and then others that would be chronic.

    00:09 Now remember, this is for patients that are on a ventilator.

    00:13 So let's say you walk into a room, let's deal with an immediate queue you should be looking for.

    00:18 You noticed that your patients O2 saturation is dropping.

    00:22 That's not a good sign.

    00:24 That's a cue telling you, "Hey, we're having a problem here." First, I want to make sure that the pulse ox was adequately on their finger.

    00:32 And that's an accurate reading. The next thing I'm going to do is make sure that I listened to their lungs.

    00:37 Both sides, front and back, to make sure that while they're being ventilated, air is reaching all of the lobes, front and back, top and bottom of the lungs.

    00:46 So when you see a dropping O2 saturation, those are some very basic things that you should do first, to see if you can figure out what is the cause of it.

    00:55 So what do you do when you cannot get their oxygen saturation up? Well, what you do is you bag them.

    01:01 We call this a Ambu bag.

    01:04 Now this is a manual ventilation with resuscitation mask is the very fancy way to say it.

    01:09 We use an Ambu bag.

    01:11 Now, resuscitation bag or an Ambu bag is at the head of everyone's bed in critical care.

    01:18 Because we know if something happens, we can't raise that O2 we're going to grab that bag and start bagging the patient until we can figure out what the underlying cause is.

    01:27 But if you're ever having an Ambu bag someone, you want to make sure that you call for help, because that is definitely not a good sign.

    01:34 And most places that would be calling a code or calling a writ.

    01:38 But you need more people there more heads together to figure out what is the underlying cause.

    01:43 So that's an immediate problem if you notice.

    01:46 Now, we're going to talk about a chronic problem that you can watch for.

    01:50 Well, actually, we're going to talk about more than one.

    01:52 The chronic problem is all grouped under ventilator induced injury.

    01:56 They call them VILI, V-I-L-I. Now there's lots of subtypes.

    02:01 And we'll talk about those next.

    02:02 But really important that we put this in here, so you and I can talk about it.

    02:07 Because these are the injuries that you are most likely to see.

    02:11 These are things that can happen and they become so common in the past that we came up with a plan to how to try to prevent these or to minimize them.

    02:19 The first one is ventilator associated pneumonia, or you hear it called VAP. This is really not acceptable, if this happens to a patient.

    02:30 This is why we have a whole lot of things that we go through to make sure that doesn't happen.

    02:34 Another chronic problem can be oxygen toxicity.

    02:38 Patient get into with auto-PEEP or like air stacking, Peptic ulcers can develop.

    02:44 We've grouped these four types of ventilator induced lung injuries together.

    02:48 So we're going to walk through and kind of compare them so you get to see what's the same. And what's different.

    02:53 Here's the major takeaway point, being on a ventilator can cause damage to the lungs you're trying to save.

    03:00 So whether it's barotrauma, or biotrauma, or volutrauma, atelectrauma, it's all trauma to the lungs.

    03:07 So let me give you the definitions. The first one is barotrauma.

    03:11 Now, this is because of high lung inflation pressures.

    03:14 Take a look at the picture. We try really hard here to do pictures that will help you remember.

    03:21 Now you see this smooth muscle, that dark pink band that's wrapped around the airway, and then it's ending in three alveoli.

    03:29 The one on the right, and the left look very different than the one in the middle.

    03:34 What's going on there? Well, doesn't it look like they kind of exploded? That's what barotrauma is, is because you have these high long inflation pressures, very different than a natural breath in and they cause damage to the alveoli, then you end up with a pneumothorax.

    03:51 That's a problem because you're not going to be able to adequately exchange CO2 for O2.

    03:58 So first one of the four? Barotrauma.

    04:01 Next one, we're going to talk about atelectrauma.

    04:04 And this one is kind of an unusual term, but it's going to make sense as we walk through it.

    04:09 This is because of high shearing forces.

    04:11 Now, in barotrauma, where we had high lung inflation pressures with this one of at atelectrauma, it's because of these high shear forces.

    04:21 Now, here's what happened. It's caused by the shearing forces as the alveoli that are right next to each other, right? We kind of spread them out in our drawing that alveoli are really right next to each other.

    04:32 Now, when they collapse and re expand during mechanical ventilation, there's a shearing force problem.

    04:38 So this is adelectrauma shearing force, because these alveoli that are very close to each other are inflating and then collapsing in between breasts.

    04:48 So to avoid or minimize atelectrauma, that's why we will sometimes use positive-end expiratory pressure or PEEP.

    04:57 So that will keep those alveoli open and minimize that shearing pressure, which is at adelectrauma.

    05:04 Now, the third one is volutrauma.

    05:06 And I've got several points for you here to kind of understand this one.

    05:09 But this is when the alveoli become over distended and the kind of a string that's placed on that tissue that epithelial tissue is strained.

    05:18 You also ended up with lipid mobilization, that would not normally happen, unless the lungs weren't experiencing this, over distension of the alveoli.

    05:27 Now we have a lipid mobilization that causes cellular detachment of the vascular endothelial cells.

    05:35 Yeah, that's as bad as it sounds.

    05:37 When the lipids become mobilized, and you've got the cells detaching the vascular cells and the endothelial cells, we've got a problem.

    05:45 Then the alveolar epithelium begins to break down.

    05:49 Yeah, again, something else that's as bad as it sounds.

    05:53 You end up with alveolar and interstitial edema.

    05:57 Remember, a demon just messes everything up.

    05:59 When you've got inappropriate amounts of fluid and spaces.

    06:02 You can't function, whatever that organ is.

    06:05 And in here, we're talking about the alveoli, and the exchange of CO2 and O2.

    06:11 Remember, this is caused by the ventilator that we placed the patient on.

    06:15 Next, biotrauma. Now, bio meaning body.

    06:20 You have an inflammatory response going on in your body.

    06:23 You had some type of mechanical injury or something that's happened.

    06:26 You have this inflammatory response.

    06:28 And the cytokines are wreaking havoc.

    06:31 So you got the cytokines and the inflammatory mediators and all kinds of things are happening in the alveoli because of biotrauma.

    06:39 Now, let's break down some of the risks we discussed earlier.

    06:43 Ventilator associated pneumonia, or VAP.

    06:46 I wanted you to be sure that you recognize that it Doesn't just happen overnight.

    06:50 Usually requires a minimum about three days for the patient to be on mechanical ventilation.

    06:56 Let's look at the risk factors.

    06:58 So who is at highest risk to develop ventilator associated pneumonia? First of all, advanced age.

    07:05 That puts patients at increased risk for many things, but because they don't have the strong immune system they had when they were younger, they're at an increased risk for VAP.

    07:16 If a patient has a high degree of co-morbidities, that means things together co-morbidities. Multiple illnesses.

    07:25 So if a patient is on top of their lung problem, they're diabetic, they have some problems with pressure sores, they have all kinds of other medical health diagnoses, those are considered comorbidities.

    07:39 And it's just going to complicate their recovery and put them in an increased risk for VAP.

    07:45 They've been in the hospital a really long time, that can obviously, wear the patient's systems and responses down.

    07:53 So that puts them in increased risk because they're in a weakened state.

    07:57 It's also a risk factor.

    07:58 The longer the patient is actually on the ventilator, the longer they're on an invasive, mechanical ventilation within ET Tube isn't more of a risk for VAP.

    08:10 If they've been exposed to invasive procedure.

    08:12 So they've had procedures where there might have been suturing involved or surgery or any other type of invasive procedure, it's been noted that these patients are at an increased risk to develop VAP.

    08:24 Now, how do you diagnose this? Well, you're going to look based on the imaging and you see some increased respiratory secretions.

    08:31 So you've got the X ray.

    08:34 And you also notice that they're having increased respiratory secretions.

    08:38 Different than what the patient had been having.

    08:40 That's why trends of patient assessment data is so important.

    08:45 And you're going to culture it and that's going to what's going to confirming.

    08:48 You do like a bronchial alveolar lavage, or maybe a tracheal aspirate, but you do some type of culture.

    08:54 And that's going to help you diagnose along obviously with the physician who does the final medical diagnosis, and that patient is suffering from V-A-P.

    09:04 So we know that if they have increased respiratory secretions, we see some changes on their x ray, that really makes us think about there having VAP, then we draw a culture.

    09:16 But another issue is we're worried about the patient developing sepsis.

    09:21 Okay, so if we know they have sepsis, one of the sources we're going to look for, these are the things you're going to think about when the patient is being diagnosed.

    09:28 Oxygen toxicity sounds like kind of a weird concept.

    09:32 When you have a patient on a ventilator.

    09:33 I mean, isn't oxygen good? Well, it is good and the patient needs it if they're on a ventilator, but excessive oxygen exposure causes inflammation and cellular damage.

    09:46 So the higher the FIO to the patient has to be on for the longer period of time it does damage to their lungs.

    09:54 That's why we try to use the minimum FiO2 that we can and still keep the patients safe.

    10:00 We just want to make sure we hit whatever that target is for the patient's oxygenation.

    10:05 This problem is called Auto-PEEP or air stacking.

    10:10 Let me explain what it is. So the formal definition is results have persistent end-expiratory airflow, that compounds after each breath contributing to increasing pulmonary hyperinflation.

    10:24 Now, that sounds trickier than it really is, What I want you to do is look over at this weird drawing we have there for you.

    10:31 We're not expecting you to be able to interpret this.

    10:33 Here's what I want you to see.

    10:34 There are three waveforms on top of each other.

    10:38 You see that line that we have labeled F, R, C, but as functional residual capacity.

    10:45 Now above that line that represents three breaths in or out.

    10:50 It's going up and down, up and down.

    10:53 Now look at that green line in between the breaths up and down, up and down, and the functional residual capacity line.

    11:00 See it? What's happening from the left side of the strip to the right side of the strip? Do you notice a change in the height of that line? Well, sure, of course you do. That's what air stacking is.

    11:15 At the end of every breath, it doesn't get completely exhaled, then the next breath you take still doesn't get completely exhaled.

    11:22 So that stacks on top of the previous volume with the next breath even more left over.

    11:28 So look at what's happening. That's why it's called stalking.

    11:31 Start with the first waveform, put your finger on it, then see how after the second waveform, it's a little bit higher that green line, and then by the third one, it's even higher.

    11:42 So this means the patient isn't able to really exhale as much as would be normal.

    11:47 They have extra air left in the lungs after each breath.

    11:52 With this extra air in there and the patient being on a ventilator, then you're going to have pulmonary hyperinflation or an over inflation of the lungs.

    12:01 And you know what happens when you have too much of an inflammation in the lungs, the alveoli start to take a hit, and the patient will not be able to exchange CO or O2 in an adequate manner.

    12:12 So you most commonly will see this in people with asthma, COPD, and ARDS.

    12:17 So air stackings, people that can't get the air all out of their lungs, you're going to see things this phenomenon called Auto-PEEP.

    12:25 Now, we talked about what the end result is.

    12:28 But I wanted to remind you here with this point again.

    12:31 But we've asking you a question, why does auto-PEEP or air stacking result in alveolar over distension? Can you remember why? Because it just keeps stacking those extra volumes that weren't meant to be in there on top of each other puts more barotrauma, right? Those high pressures on the alveoli, and they tend to pull, break or collapse.

    12:55 So that is what happens in air stacking or auto-PEEP.

    13:00 I always ask nursing students to say so what? So why does it matter if a patient is air stacking or auto peeping when they're on a ventilator? Well, it increases the intrathoracic pressure.

    13:13 Now on top of the barotrauma that happens to alveoli.

    13:17 You also have four issues and wants you to think about.

    13:20 Our bodies are amazing, but they are set to be at certain pressures.

    13:25 Since this patient isn't breathing in and out on their own.

    13:28 We've hooked them to a mechanical ventilator.

    13:31 They're getting this positive pressure pushed into their bodies.

    13:35 Now, that's going to raise the intrathoracic pressures above normal.

    13:39 So here's some of the things it does.

    13:41 First, it decreases venous return.

    13:44 Remember, all that comes through your thoracic cavity dumps into your heart to the superior vena cava and the inferior vena cava.

    13:52 But when you mess with the pressures and you have higher than normal pressures, you're going to have relatively less venous return to the heart Now when you have less venous return to the heart, you also have reduced cardiac preload, because that's the definition of preload.

    14:07 The amount of blood that returns to the heart.

    14:10 Now, in addition, it's not just the right side of the heart that has a problem, it's the left side of the heart.

    14:16 Because of those increased intrathoracic pressures, that left ventricle... is going to have to work much harder.

    14:24 The definition of afterload.

    14:26 How hard the heart has to work to push blood out of the heart, after the heart.

    14:33 Now, finally, what do you think is going to happen to your cardiac output? We've got less coming back to the heart, you're working harder to push blood out of the heart, what's going to happen to the cardiac output the amount of blood your heart is pumping out? Yeah, it's also going to be reduced.

    14:52 So what would be the impact? What cues would you be looking for? What happens to your vital signs? Well, your blood pressure is going to drop.

    14:59 Because you have less volume and it's harder to do it.

    15:03 You're going to notice a decrease in a patient's blood pressure.

    15:07 Another possible problem is peptic ulcers that can develop.

    15:11 Now, this might be associated with gastrointestinal bleeding if it becomes too advanced.

    15:16 But peptic ulcers were something that were noted to happen a lot in ventilator patients.

    About the Lecture

    The lecture Complications with Mechanical Ventilation (Nursing) by Rhonda Lawes, PhD, RN is from the course Mechanical Ventilation (Nursing).

    Included Quiz Questions

    1. Using the lowest fraction of inspired oxygen (FiO2) the client can tolerate.
    2. Using the lowest tidal volume the client can tolerate.
    3. Decreasing the client’s respiratory rate to increase CO2 levels.
    4. Limiting the amount of positive pressure ventilation the client receives.
    1. The 75-year-old with diabetes who has been on a ventilator for five weeks.
    2. The 30-year-old C4 quadriplegic recovering from an appendectomy.
    3. The 50-year-old who has been in the hospital for two weeks and has been on the ventilator for three days.
    4. The 60-year-old with hypertension who has been in hospital for two months.
    1. Atelectrauma
    2. Barotrauma
    3. Volutrauma
    4. Biotrauma
    1. Biotrauma
    2. Barotrauma
    3. Volutrauma
    4. Atelectrauma
    1. Auscultate the client’s lungs.
    2. Call the client’s provider.
    3. Lower the head of the bed.
    4. Increase the ventilator flow rate.
    1. The client with asthma.
    2. The client with hypertension.
    3. The client who is paralyzed.
    4. The client with lupus.

    Author of lecture Complications with Mechanical Ventilation (Nursing)

     Rhonda Lawes, PhD, RN

    Rhonda Lawes, PhD, RN

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