How We Deal With Bad Baby's In A Small Town Hospital

It was 1997. A senior RT introduced me to OB for the first time. She showed me the Sechrist ventilator. It seemed stressful enough. But, then she introduced me to an older ventilator. I think it was called a Baby Bird. Now, that was a stressful baby ventilator.

The Sechrist was a great ventilator for its time. You plugged it in. And then you dialed in some settings. My preceptor taught me that all you have to do is remember numbers, such as 5 and 20. You set the PEEP at 5 and Pressure Control at 20. You set the rate at 30 or whatever the value was back then. And there were a few others to remember. Then you adjusted to meet the needs of the newborn.

But, they were all simple to remember. And then you set it up on the baby and didn't have to do much more.

This was nice, because it's stressful enough when you have a bad baby. When you work in a small hospital like I do, you might get only one bad baby in a five year period who requires a ventilator. So, it's good that you have something that is easy to set up if you do need it. But when I was introduced to that Baby Bird or whatever it was, that was stress. It was so confusing that you even had to take out a calculator to determine what your ventilator settings would be. It was stress just thinking about it.

Then we advanced to the Servo 300. It just sat back in the closet collecting dust. Well, not really, because we took it out monthly to play with it. We had fake scenarios that we would do. We needed to practice because we use this machine so seldom. And the few times we did have to set it up we were applauded by the nursing staff. They were so often impressed at how we therapists set it up with such aplomb. It was, as a nurse once said, as though you guys set these things up every day."

Then we advanced to the Servo i. By this time we also had another new machine. It was called the Neopuff. When this machine was first bought by the OB supervisor we RTs were annoyed. We weren't even checked off on it. We had no idea what it was. And we refused to use it. Instead, we resorted to the old method of bagging babies. Carefully squeeze, but not enough to pop a hole in the baby's lungs. Not easy to do, especially when you had to bag for 4 hours until the baby buggy arrived from larger hospital down south.

Then we started taking Neonatal Resuscitation. And here we learned of the value of the Neopuff. We learned how dangerous bagging was. That even minute changes in the pressures when we squeezed the bag could damage those baby lungs. And the Neopuff guarantees that each breath will be the same depth. Using it greatly reduced the incidence of conditions like hyaline membrane disease and bronchopulmonary dysplasia. Yep! Remember learning about those diseases?

Today we are told intubations can cause trauma to newborns too. Well, that makes sense. But, when a baby can't breathe, a tube is still needed. But, our protocol no longer calls for intubation on infants that are breathing. Even if they are retracting. And Lord knows infants born too early to make their own surfactant do need assistance. But, today the Neopuff can provide CPAP. So, we are encouraged to use it rather than intubate.

It's to the point now that we no longer even have a neonatal ventilator. Well, we have one, but it's no longer stored in OB. Basically, modern evidence shows CPAP and ship to larger children's hospital. Today I applied that CPAP to infants faces for four straight hours. Silly that we can't use our ventilator to apply that CPAP to the infant. But, this is how it is when you work at a small hospital. The experts at the children's hospital where we transfer infants to said it's best that we just use the Neopuff and leave everything else to the experts.

The baby buggy arrives eventually. Usually, it's 3-4 hours. And then we ship the baby. And our stress is gone. But, still, with the Neopuff and no ventilator, there's really not much to remember anymore other than the basic Neonatal Resuscitation stuff. A far cry from just 2 years ago.

Ventilator bundle to prevent Ventilator Associated Pneumonia

By the late 1990s it was known that about 15% of patients intubated and placed on a ventilator acquired what was then termed ventilator associated pneumonia (VAP), and that about 30% of those with VAP would ultimately die.  A major effort was then begun to try to reduce these numbers.

Solid data was now available that allowed the Centers for Disease Control and Prevention (CDC) to compile guidelines for combating VAT.  Considering the limited options for treating pneumonia, the main effort was aimed at prevention.

The initial guidelines included many of the following.  These are often referred to as the essential parts of a "Ventilator Bundle."

1. Mandatory Education:  Everyone involved in the care of the patient should be aware of VAP and how to prevent and treat it.
2. Mandatory Infection Control:  Everyone taking care of the patient, including visitors, should be aware of the hospitals infection policy.  The best method of spreading infections is by frequent and vigorous hand washing. This may also include wearing masks and gowns when necessary. Sterile technique should be followed when inserting lines or drawing blood.
3. Routine Oral Hygiene:  Since bacteria from the upper airway may pool over the cuff, it is essential to keep the upper airway clean.  Many guidelines recommend oral suctioning and cleaning at least every two hours. 
4. Regular Change-out policy:  Closed suction systems and suction canisters and tubing should be changed every 24 hours.  Ventilator circuits should remain closed at all times, and changed at least once a week.  
5. Maintain Closed circuit:  The ventilator circuit should remain closed at all times.  Special adapters can be added to the circuit to introduce breathing treatment and metered dose inhalers.  Closed suction systems such as a ballard can be introduced between the ETT and the "Y" to prevent the need to break the circuit in order to suction.  Heated circuits prevent condensation inside the circuit and reduce the need to open the circuit for water removal. Changing ventilator circuits weekly instead of daily may also help reduce the introduction of bacteria to the patient. 
6. Limit normal saline introduction:  The introduction of normal saline into the ETT to assist with the removal of thick secretions should not be routinely performed by nurses, and should only be done by respiratory therapists on an as needed basis. 
7. Stress ulcer prophylaxis:  Since gastric contents may work their way to the upper airway and into the lungs, efforts must be made to prevent this.  Since all patients on a ventilator are at increased risk for stress fracture, they should all be treated for this. 
8. Ventilator extubation protocols:  Creation of weaning protocols are shown to speed up time from intubation to extubation. This forces clinicians to start thinking about weaning the moment a patient is intubated. 
9. Maintain cuff pressure:  Studies show that a cuff pressure of 30 or greater prevents the micro-aspiration of secretions that pool over the cuff.  To read further about this read the post "What tracheal cuff pressure measurement is ideal?" Cuff pressure should be measured and recorded each shift. While the ETT should be rotated each shift, unnecessary maneuvering of the tube should be avoided.  Also, the cuff pressure should never be less than 20 in adults as this significantly increases the risk of aspiration.  Vigorous suctioning should be performed before rotating the cuff and prior to deflating the cuff.  (1, page 8)
10. Elevate head 30-45 degrees:  This should prevent the aspiration of stomach contents.  This should be required in all ventialtor care policies. 
11. Prevent early extubation:  ETT should be adequately secured, and the patient adequately sedated or watched in order to prevent inadvertent or purposeful early patient extubation.  Ventilator protocols should help guide clinicians as to the best extubation time.  
12. Consider tracheotomy:  If a patient should need to be on a ventilator more than a week, the patient should be trached. Trachs also allow for normal physiologic swallow mechanisms which prevent secretions and stomach contents from being inhaled.  They also make it easier to wean patients, make it so less sedation is required, reduced airway resistance, and enhances secretion removal. It allows application of speaking valves to allow patient to speak, even while on ventilator.  Studies show they also improve overall patient morale.  
13. Avoid heated moisture exchangers (HME):  Do not use HMEs unless absolutely necessary, such as when you need to transfer the patient. Studies have linked them with an increased risk for VAP. 
14. Limit sedatives:  This topic continues to be controversial and debated.  Some experts recommend limiting the use of sedatives in the early mornings to make sure the patient awake enough for weaning trials.  Ideally, sedatives should be stopped at least four hours prior to doing weaning parameters or weaning attempts.  However, some experts suggest that some sedatives allow patient to be alert enough to follow commands.  
15. Daily Chest X-Ray:  Since it is very difficult to know when a patient is developing pneumonia, it is important to have a chest x-ray every morning in order to monitor patient's lungs for signs of pneumonia.  
16. Prophylactic antibiotic therapy:  Some experts recommend automatically starting patients on a broad spectrum antibiotic to prevent the development of infection.  This is also recommended as the top line treatment for VAP.  
17. Obtain sputum ASAP after intubation:  Obtaining a sputum sample immediately after intubation will help determine if the patient already has pneumonia, or confirm that the patient did not have pneumonia.  This will help determine if a pneumonia is pre-existing or caused by the ventilator. 
18. Cleaning equipment: Equipment must be efficiently cleaned between patients in order to prevent contamination from one patient to the next. 
19. Lower tidal volumes:  These may reduce the inflammatory response seen by higher tidal volumes.  
20. Serial Lab tests:  Daily laboratory testing can help determine if white blood cell counts are increasing, or other markers, which will show that a patient has an infection. 

This post will be updated as new wisdom is obtained.  The following graphic from the CDC pretty much sums it up.

References:

1. Van Hooser, Theron, "Ventilator Associated Pneumonia: Best Practice Strategies for Caregivers," 2002, http://en.haiwatch.com/data/upload/tools/VAP_CEU_Booklet_Z0406.pdf, Kimberly Clark Co., accessed 4/21/14
2. "Protocols and Definitions Device-associated Models: Ventilator Associated Pneumonia," Centers for Disease Control, http://www.cdc.gov/nhsn/PDFs/slides/VAP-DA_gcm.pdf, accessed 4/21/14
3. "Intubation And VAP: A Complex Condition Requires Bundled Solution," rtmagazine.com, http://www.rtmagazine.com/2014/04/intubation-vap-complex-condition-bundled-solutions/, accessed 4/23/14

What's the best way to do weaning parameters

When I was in RT School back in 1995 the Bennet 7200 was the most popular ventilator and some of the newer ones provided the ability to do weaning parameters on the machine without even disconnecting the patient from the ventilator.  Our teacher said doing parameters on the ventilator was a bad idea.

He said it was a bad idea because the parameters would be not as good as if the patient were taken off the ventilator.  For example, if you would get a 500 tidal volume by doing the parameters off the vent, you'd get a 450 on the vent.  For NIF it would be the same:  the value while on the vent will be less than if you did it by hand with the patient off the ventilator.

Fifteen years later we are fifteen years wiser.  And I have to say I agree with my teacher that weaning parameters on the vent are a litte less.  However, I don't agree that it's less effective.  Now that we have the Servo i's we are able to do all parameters (VT, NIF and FVC) without even disconnecting the patient from the vent.

As a rule, as long as everyone does it the same way, that's all that matters.  If my coworker does parameters one morning and gets a 400 tidal volume off the vent, and the next day I use the vent and get a 350, my 350 doesn't look so good.  It looks like the patient is going in the wrong direction.

However, if we both would have done it the same way, then we would have known  the patient was consistently getting the same tidal volumes.  So consistency is the key.

At our hospital we have a protocol that if the ETT is 7.5 or greater we put the patient on a PEEP of 5 and a PS of zero, and if the ETT is smaller than 7.5 we use a PEEP of 5 and a PS of 5 to make up for the resistance of the ETT.  We all use the Servo i (if the patient is on that ventilator).  All parameters this way are consistent because we're all doing them the same way.

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guidelines to adjusting ventilator settings

So you're tired of doctors just making up ventilator changes. Here are the recommended AARC guidelines for adjusting ventilator settings. Study these, and impress a doctor or a nurse with your wisdom:

1. PaCo2 greater than 45 (or EtCo2 greater than 50)

• Increase RR
• Increase VT

2. PaCo2 less than 35 (or EtCO2 less than 30)

• Decrease Rate
• Decrease VT

3. PO2 less than 60 (or SpO2 less than 90%)

• Increase FiO2 to 60%
• Increase PEEP
  
• Increase FiO2 to 100%

4. SpO2 greater than 95% (or appropriate oxygenation for patient)

• Reduce FiO2 to 60%
• Reduce PEEP to 5
  

This is to act as a guideline only to assist you in making the appropriate ventilator changes based on invasive ABG results and/ noninvasive EtCO2 and SpO2 monitoring. Of course you'll need to know your patient.

For a great review of EtCO2 monitoring check out this post.

For a printable cheat sheet with this information and more, click here.

For a printable cheat sheet for EtCO2 monitoring click here.

Why paralyze when you could just extubate?

Sometimes I'm glad I'm not a doctor. They have a responsibility on their shoulders that I would never want to have. There are a lot of times I opine that this should be done or that, but it's the doctor who has to bolster the brunt of the responsibility for that person's life.

So when this 47-year-old male came in after overdosing for the second time, he was placed on a ventilator to support his breathing and to protect his airway. But this came a little too late, as he had already aspirated. So, when he started waking up the next day, and went ballistic, the doctor decided to paralyze (and sedate) him instead of taking him off the vent.

Do you see the problem my co-worker and I have with this. We had already sucked a ton of brown shit from this guys lungs, so there isn't a lot of it left. He was breathing fine on his own even with a load of sedatives in his system, and when they let those wear off, he went ballistic again. But, instead of yanking the tube and letting him fly on his own, the doctor decided to paralyze him again.

Yesterday my co-worker told me he went ballistic himself because, "there is no f#%%ing reason not to extubate that patient."

How inhumane is it to keep paralyzing someone because they are "TICKED" that they have a tube up every orifice.

To be fair, however, we have to look at the doctor's end of this. The patient did aspirate. He did OD before and ended up on a vent that time too, and he did develop ARDS that time. But still, there are no signs the patient is in ARDS now.

Due to the drug he overdosed on ( I can't remember what it was), there were some complications to watch out for, but the patient, according to the nurse, "is fine other than the fact he's paralyzed."

Are we missing something here? Are we right that this patient is inhumanely paralyzed, or is the doctor right? We may never know. And that is why doctors make the big bucks and we don't.

To be honest, it's easy taking care of a paralyzed vent patient. But is that what's in the best interest of the patient? It's not our decision to make.