Complications of Mechanical Ventilators

Question 1

Range from benign and asymptomatic to lifethreatening - in lifethreatening - notify PCP and prepare for emergent treatment
Mechanical ventilation is often lifesaving; however, it is not without complications. Some complications are preventable, whereas others can be minimized but not eradicated.
Physiologic complications

Answer 1

Complications

Question 2

Ventilator-induced lung injury (chapter 19)
Cardiovascular compromise
Gastrointestinal disturbances
VAP

Answer 2

Physiologic complications

Question 3

Barotrauma
Air leaks

Answer 3

Ventilator-induced lung injury (chapter 19)

Question 4

Trauma to alveolar space
Leads to air leak disorders
Once alveolar space damaged to point ruptures - air leaks to space where not belongs or alveoli or vasculature attached to RBC
Affects alveoli

Answer 4

Barotrauma

Question 5

Air getting into space not meant to be

Answer 5

Air leaks

Question 6

Positive pressure ventilation decreases preload
Change pressure in lungs, change pressure in thoracic cavity; need to remember veins not have muscular wall so when increase pressure around vein in thoracic cavity can compress it and when compress vein, decrease amount preload that get to RV

Answer 6

Cardiovascular compromise

Question 7

If air gets into esophagus and not lungs

Answer 7

Gastrointestinal disturbances

Question 8

Ventilator associated pneumonia
Tube in trachea - highway for secretions to go into lungs

Answer 8

VAP

Question 9

Best way to treat is prevent
Positioning: Semirecumbant position; 30 degrees or > - prevent secretions from pooling inback of throat
Sedation Vacation
Suctioning
Use appropriate tidal volume and the lowest amount of PEEP for therapeutic response. - get pt to where need be; do calculation based on tidal volume - lower - body has work; PEEP - at lowest can tolerate, increased end expiratory pressure, can harm alveoli and if harm alveoli, O2 exchange not happen and cause serious injuries including pneumothorax and crepitus

Answer 9

Prevention of complications

Question 10

Per policy
Reduce amount IV sedation pt receiving - see if wake up and follow instructions and ready for weaning trial - not want on mechanical ventilator longer than need
A daily interruption of sedation to evaluate the pt.
Not appropriate for all patients - barbituate coma, lighten sedation and ICP through roof - causing harm; vast majority get this; small percent who won’t

Answer 10

Sedation Vacation

Question 11

Subglottic and regular suctioning
Subglottal - oral secretions pooling on top of the balloon that is helps secure ET tube in trachea; not 100 occlusive - if secretions sitting on balloon, over time will ooze around it and get into lungs and cause pneumonia
Regular suctioning through ET tube into bronchial tree and help manages secretions to prevent pneumonia

Answer 11

Suctioning

Question 12

Result excessive pressure in alveoli; usually due to high PEEP (positive end expiratory pressure)
Volume trauma - excessive volume in alveoli - tidal volume on ventilator too high for too long
Atelectrauma - repeat open and closing of alveoli
End result of trauma: air enters interstitial space and travels where not belong; goes in various parts of body and where goes diff name
Air enters the interstitial space (from alveolar rupture) then travels through the pulmonary interstitium (pulmonary interstitial emphysema) and lands in various places in the body.
Usually benign, except for pneumothorax & tension pneumothorax - may drop O2 sat; may become acidotic - manage O2 and ventilation

Answer 12

Air leak: barotrauma

Question 13

Mediastinum (pneumomediastinum)
Pleural space (pneumothorax [can escape] & tension pneumothorax [in interstitial space and cannot escape])
Subcutaneous tissues (subcutaneous emphysema)
Pericardium (pneumopericardium)
Peritoneum (pneumoperitoneum)
Retroperitoneum (pneumoretroperitoneum).

Answer 13

Air enters the interstitial space (from alveolar rupture) then travels through the pulmonary interstitium (pulmonary interstitial emphysema) and lands in various places in the body.

Question 14

Aka creptius
Air in interstitial space unterneah dermis
Symmetry on chest - want this - palpate chest - feels like packing bubbles where give and feel air underneath - feel give on skin
The result of excessive pressure in the alveoli that lead to extreme alveolar wall stress and damage to the alveolar-capillary membrane, causing air to escape into the surrounding spaces
Assessment: Crepitus, usually around the face, neck, and upper chest - up in face - eyes look edematus - gives way
Pt annoyed and some SOA and low SpO2 because not ventilating appropriately if air escaping from lung
Treatment: Optimize oxygenation and ventilation: on ventilator - Increase FIO2, decrease PEEP - can deteriorate if not noticed early; sometimes ride out - do not pull out air - body reabsorbs air slowly

Answer 14

Air leak disorders: subQ emphysema

Question 15

Caused from barotrauma
Air escaping from damaged alveoli into pleural space
If smaller - air pocket in pleural space, compresses lung; as grows - goes from compression then causes all or part of lung to collapse
Alveoli in compressed lung/collapsed lung are underventilated - alveoli smushed closed - not active CO2 getting offloaded and O2 loaded onto RBC
The accumulation of air or other gas in the pleural space that, if large enough, compresses the lung. The affected area of the lung will collapse, and the alveoli become under-ventilated.
Air flows from the lung in the pleural space
Assessment:
Treatment:
Not always emergency - assess pt; cyanotic - emergency; little anxious and sats dropped to 90% - bump FiO2 up and call PCP to see what can do with ventilator settings or with pt to ensure getting enough O2 and able ventilate appropriately
Pneumothorax - subQ emphysema - push towards chest tube; sx on continuum; air occupying pleural space determines how profound sx are

Answer 15

Air leak: pneumothorax

Question 16

Small pneumothorax found on X-ray by accident
Small Subcutaneous emphysema - little blips underneath skin
A large pneumothorax: increased respiratory rate, increased heart rate, anxiety, and possibly cyanosis (bluish then to pale - no O2 circulating), breath sounds decreased or absent when lung compressed/collapsed, when big: unequal chest expansion - one side up higher and back to baseline; bulging interstitial spaces

Answer 16

Assessment: - Air leak: pneumothorax

Question 17

If the patient is not in distress, optimize oxygenation and ventilation.

Answer 17

Treatment: - Air leak: pneumothorax

Question 18

Beginning same as pneumothorax but as air enters the pleural space on inhalation and cannot exit on exhalation causing the pressure in the pleural space to increase (stays in pleural space - air bubble gets bigger in pleural space). The lung will collapse when the pressure is high enough.
EMERGENCY
NEVER STABLE
Resp distress more profound; SpO2 cont fall - acute resp acidosis quickly; full resp resp arrest and full cardiopulm arrest quickly
Assessment: Shifting of the mediastinum and trachea to the unaffected side, diminished breath sounds, hyperresonance to percussion, tachycardia, and hypotension - more pressure in innerthoracic space, getting into affecting whole pressure dynamic in thorax - affect venous return and without venous return, no preload and no BP so hypotension; Once start seeing - sim to pneumothorax - increase HR, increase RR, anxiety, cyanosis; no breath sides on affected side; check expansion unequal
Treatment: Supplemental oxygen (or increase FIO2 ALOT), Prepare for insertion of a chest tube so can place as soon as in room; notify PCP immediately
Complication of mechanical ventilator - presentation subtle and accidental finding on CXR because can be asymptomatic - more sick are less tolerate small insults
Barotrauma: EX PEEP high and alveoli leak air into pleural space - occupies space - lung gives readily; area that is squished - not participating in oxygenation or ventilation; PCP - watch it and CXR not bigger - go up on O2 level (FiO2); adjust settings to help with oxygenation - eval need - if (PEEP) positive end expiratory pressure high - eval need to keep high and consider lower it; more air escapes in pleural space - normal pneumothorax - air in and out - takes awhile for it to accumulate for regular pneumothorax - tension - air one way get complete collapse quickly

Answer 18

Tension Pneumothorax:

Question 19

More pleural space and lung smaller
More sx; SOB; less alveoli able participate in ventilation and oxygenation; ABG: respiratory acidosis; tachypneic; increased intrathoracic pressure - affecting venous return - hypotension
may/not chest tube - depends on sx and how much lung collapsed

Answer 19

Small pneumothorax

Question 20

Severely symptomatic
Resp distress
Low SpO2, SaO2; acidosis
Most lung not participating in oxygenation/ventilation
Get chest tube

Answer 20

Large pneumthorax

Question 21

Occurs when air escapes from the lung

Answer 21

Collapsed lung:

Question 22

Adv care provider
Issue with pt on ventilator - PCP, physician level
Management depends on the severity
Creptius underneath skin and not resp distress leave alone - supplemental O2 esp for crepitus and small pneumothorax, supp O2 or increase FiO2; larger pneumo - prepare for major intervention - primarily chest tube
Assess the pt.
X-ray
Small pneumothorax: Supplemental Oxygen, increase FIO2
A large pneumothorax (<15%) and tension pneumothorax requires intervention to evacuate air from the pleural space.
Needle decompression
Chest Tube

Answer 22

Medical - General management - air leak disorders

Question 23

Optimize oxygenation and ventilation - see creptius; s&s of pneumothorax - resp distress; on mechanical ventilator - increase FiO2 to give best chance to give best chance to oxygenate with open alveoli and hopefully optimatizes ventilation; Suction - optimizes oxygenation
Maintain chest tube drainage system
Assess for complications - assess q8hours; see if distress/cyanosis present/subQ emphysema - then lead to full on assessment

Answer 23

Nursing - General management - air leak disorders