Adjuncts To Mechanical
Ventilation
Tantani Sugiman
Dept. Anesthesiology & Intensive Care
Faculty of Medicine, University of Indonesia
Jakarta
Objectives
Humidification
Suctioning
Positioning
Aerosol therapy
HUMIDIFICATION
Humidification
Normal temperature, relative humidity, and absolute
humidity levels at three sites in the respiratory tract
Humidification
Problems with inadequate humidity
Inadequate humidity due to
Heat loss + moisture loss
Epithelial damage of trachea & bronchi
Drying secretion
Atelectasis
hypoxemia
Humidification
Problems with excessive humidity
Over-humidification : temperature > 37oC
absolute humidity > 44 mg/L
Aerosol therapy
Humidification
Techniques of humidification of
inspired gases
Heated humidifiers
Artificial noses
Humidification
A. Properly set humidifier with heated wire circuit that
delivers 100% body humidity to the patients. B. heated wire
circuit with setting too low, delivering inadequate humidity to
the patients
SECRETION CLEARANCE
Mucociliary activity is impaired due to
the presence of the artificial airway
airway trauma due to suctioning
inadequate humidification
high FiO2
drugs
underlying pulmonary disease
Methods
Suction
Positioning
Postural drainage
Inhaled beta-agonist
Bronchoscopy
SUCTIONING
Abnormal breath sounds
No routine suctioning orders
Faced to complications
Can be performed in open or closed suction
Fig. A Closed Suction Sytem
Complications of Suctioning
Hypoxemia
Atelectasis
Cardiac arrhytmia
Airway trauma
Contamination
Selective secretion clearance from R/bronchus
Increased intracranial pressure
Coughing and bronchospasm
Techniques to avoid suctioning-related complications
Hyperoxygenation with FiO2=1
Used closed suction catheter
Use proper catheter size
Use least amount of vacuum
pressured(<150mmHg)
Limit the time of each suction attempt to <15s
Only suction during withdrawal of the catheter
Use a gentle technique
Saline installation
To remove thick secretions
Installing 1-3ml of sterile NaCl into the airway
More saline is installed than is removed:
Worsen airway obstruction
Airway irritation
Bronchospasm
Nosocomial pneumonia is increased
SHOULD NOT BE A ROUTINE PROCEDURE
Postural Drainage Therapy
Indication: sputum production >25-30mls/d
To improve the mobilization of bronchial
secretion
Using the effects of
gravity;positioning,percusion,vibration,and
coughing
Only effective in atelectasis & acute lobar
collaps
No evidence as prophylactic procedure
Complications of Postural Drainage
Therapy
Hypoxemia
Hypercapnia
Increased intracranial pressure
Acute hypotension
Pulmonary hemorrhage
Pain
Vomiting, aspiration
Bronchospasm
dysrithmias
POSITIONING
Position with the head of the bed >30 degrees reduces
the risk of aspiration and VAP
POSITIONING
Upright positioning improves lung volume, gas
exchange and WOB
POSITIONING
Lateral positioning with the
good lung down:
A higher PaO2
Improved V/Q
Lateral Position
POSITIONING
Prone position
Prone position
The improvement in oxygenation due to
An increase in FRC
Changes in diaphragm position / movement
Postural drainage of secretion
Gravity-directed blood flow to less injured
lung regions
Reduction in the compressive effects of the
heart & mediastinum on the lung
Changes in chest compliance
Indications of fiberoptic bronchoscopy
Clearing of secretions that aren’t adequately cleared
by conservative methods
Obtain lower respiratory tract secretions for dx
pneumonia
Persistent atelectasis
Assess upper airway patency
Perform difficult intubation
Remove aspirated foreign body
Complications of fiberoptic
bronchoscopy
Hypoxemia
Hypercarbia
Air-trapping with bronchoscope in airway
Bronchospasm
Contamination of lower respiratory tract
Dysrhythmias
Pneumothorax
Hemoptysis
AEROSOL THERAPY
Aerosol therapy
Pulmonary deposition of aerosol
during mv is less than 5% due to
Impaction of aerosol on the walls of the
ventilator tubing
Humidity in the circuit
Breathing patterns
Nebulizer brand
Endotracheal tube size
Severity of disease
Aerosol therapy
Techniques
Small volume nebulizer
Meter dose inhaler
Aerosol therapy
Technique for Nebulizer Use During
Mechanical Ventilation
Step Description
1 Place drug and diluent in nebulizer, noting that nebulizer
efficiency varies with brand
2 Place the nebulizer in-line approximately 18 in. from the
circuit Y
3 Ensure a 6-8 L/min. gas flow to the nebulizer, continuously or
intermittently
4 Adjust tidal volume to ³ 0.5 L; inspiratory flow to achieve
Ti/Ttot > 0.3
5 Adjust minute volume if an external nebulizer gas flow is used
6 Disable any continuous flow through the ventilator
7 Assure nebulizer function throughout the treatment
8 Remove the nebulizer from the circuit when the medication is
spent
9 Assure restitution of ventilator settings
Aerosol therapy
Disadvantages using SVN
Increased tidal volume or pressure
Triggering more difficult
Increases resistance of expiratory filtero
Contamination of the lower respiratory tract
Aerosol therapy
MDI adapters for use in ventilator circuits
Aerosol therapy
Technique for MDI Use During Mechanical
Ventilation
Step Description
1 Adjust tidal volume to ³ 0.5 L; inspiratory flow to achieve Ti/Ttot
> 0.3
2 Assure that the ventilator breath is synchronized with the patient’s
inspiratory effort
3 Shake the MDI cannister vigorously
4 Insert the MDI into a cylindrical chamber-spacer located in the
inspiratory limb proximal to the Y adapter
5 Actuate the MDI to correspond with the onset of inspiration by the
ventilator
6 Allow a passive exhalation
7 Repeat actuations in 20-30 second intervals until the dose is
delivered
Fig. Flow-volume loops on mechanical breaths, before & after bronchodilator
Aerosol therapy
Evaluation of response
Decrease airway resistance
Decrease active expiratory time
Decrease auto PEEP
Increased peak expiratory flow
Improved break sounds
THANK YOU
