Wednesday, November 29, 2006

Nurses and Ventilators

How much do nurses need to know about ventilators?

This is another of those questions found in the "search engine keywords" section of our counter software.

The answer is, it depends where you work.

In the US, for example, many (but not all) critical care units use Respiratory Therapists to do much of their ventilator management. The position of RT does not exist where I work, so nurses do all of the ventilation, guided by the senior medical staff.

In our PICU, I would hope that the new nurses would know at minimum:

  • Which type of ventilator we use for which patients

  • Which circuit size and type to choose when setting up

  • How to set up and check each ventilator correctly (this is quite a lot more complicated than it sounds)

  • How to strip and clean each ventilator without throwing anything important away!

  • Standard settings for inspiratory time, PEEP, assist sensitivity and so on.

  • How to set sensible alarm limits.

  • How to manually ventilate safely and effectively using an anaesthetic bag.

  • How to wean a patient from ventilation.

This is a fair bit of learning in itself, especially when you take into account all the different age groups and conditions that a nurse here might be expected to encounter. There's also all the attendant skills like being able to suction, change ETT taping, good positioning, preventing ETT-related pressure areas and the list goes on. Fortunately we never work in isolation, and there is always someone to ask in case of uncertainty.

More senior nurses would need to be able to:

  • Set up, test and use our various transport ventilators.

  • Set up, test and use a High Frequency Oscillator.

  • Troubleshoot all ventilator types on the unit.

  • Be able to distinguish between a machine problem and a patient problem (this can be a particularly hard skill to learn.)

  • Have a sense of what their patient will tolerate in terms of weaning, level of activity, procedures, how much sedation is required, and so on. You can't teach this, it's experiential.

  • Be able to spot deterioration early, and do something about it.

There will be a subset of the nurses, maybe four or five in the unit, for whom ventilation is a particular area of interest. They're good resources on ventilation and provide a sounding board for the team. Ditto some of the docs.

The junior medical staff are often unfamiliar with the ventilators depending on what their background has been. I say "junior", really they've been at this awhile because we don't have beginner docs rotating through PICU. Still, it's unrealistic to expect some of them to have anything more than the fundamentals of ventilator theory. They can tell me about Bernoulli's law but are not used to standing and watching the rise and fall of a chest, listening to the subtle changes in sound from the machine and the circuit, reading blood gases and the monitor with the patient and not just the textbook in mind.

They might, for example, understand in a basic sense what SIMV mode implies, but not know the details of how SIMV is delivered on one particular ventilator. Since all manufacturers have their own interpretation on SIMV, this can be distinctly different from machine to machine. Often senior nurses fill in the gaps in this understanding, which requires that you know the common modes on your ventilators inside and out. Not just the manual's description, but what you've learned about patient response to the mode during thousands of hours of observation.

Oh, and just in case you weren't feeling like you had enough responsibility yet:

You are your patient's last defence against hospital-acquired respiratory infection.
You are your patient's last defence against apnoea.
You are your patient's last defence against baro/volutrauma.
You are your patient's last defence against a bad ventilation order.
You are your patient's first and last defence against accidental extubation and airway occlusion.

We take it seriously because, well, it's breathing. Breathing is good. Not breathing is bad. In randomised controlled trials, 100% of patients who breathe do better than patients who do not. Scientific fact.
Posted by PaedsRN at 6:03 PM

Blogger Kim, at 11:20 AM  

I have only one comment.

Thank god for respiratory therapists.

I have the patient skills and a functional knowledge of the ventilators.

The RTs know every little thing about the mechanical aspects and it frees me up to worry about the patient ramifications of mechanical ventilation.

Plus, I don't work in a PICU; I imagine I would need much more knowledge in that department.

Blogger PaedsRN, at 8:37 PM  

That's the thing, we don't have RT's here. I actually like it that way, I'd have to literally sit on my hands not to be making adjustments to my patient's ventilator otherwise!

Blogger Judy, at 6:52 AM  

Back in the dark ages, when we used modified adult ventilators for our preemies, I knew all the ins and outs of several types. As we acquired neonatal ventilators and an oscillator, I learned about them too (and we do have respiratory therapists here).

The current ventilator we're using is an amazing machine. You tell it the patient's approximate weight and it comes up with start-up settings based on its programming. I'm learning about that one, but it will be slow because the RT's are very territorial about it -- they've been using it in the adult ICU's for several years longer than we've been using it in the NICU and they're totally comfortable with it (unlike the neonatal ventilators which often frightened them).

Depending on which RT is on, I may or may not get my hand slapped for touching anything other than the Fi02, but the night I had to drag one out and set it up because the RT's were all occupied elsewhere in an emergency, they were pretty darn glad I'd learned to tinker with it.

If I worked on a medical floor where there are no intubated patients, I wouldn't know a solitary thing about the ventilators, but I'd know about a lot more high tech stuff that never gets into the NICU.

Blogger blessnfaith, at 6:32 AM  

pulmonetics 950 ltv
ltv=lap top vent

At 13 pounds it sure does come close to being a laptop. It's much easier to use though. I call it the vent for dummies. The fact that it's a life-sustaining piece of medical equipment is hard to get past. I guess you have to both lose and gain respect for it at the same time in order to take your kid home from the hospital on one. You have to lose respect in that if everything else looks good and the vent is putting up some scary shit you learn to go with everything looking good. Then of course you have to figure out why your numbers are screwy. There's often a reasonable explanation. It's hard though when you first come home not to get excited by all the flashing lights and alarms going off. It helps to have a good respiratory therapist from the start, you know, some one who can keep things simple for you and help to weed out real problems from mechanical glitches. You also have to gain respect for the vent and for your ability to take care of it properly.

Don't get me wrong, taking home a kid on a vent is no walk in the park. I've been an R.N. for over thirty years and I was scared shitless to bring Sonnyboy home. I had made Hubby PROMISE not to let them make us do it. In the end we did bring him home and while it has not been easy ( lots of crying and exhaustion at first) it has been worthwhile in a very personal way. For a time even after we came home we decided to try a respite facility. We found out there is no place like home. It is certainly worth it to try home care.

In order to gain respect for the vent there are some important things to know about the vent itself. Be sure they set you up in the hospital with the vent for at least a week before you go home. Get to know your home therapist. Have everyone in your family and all of your friends get to know the vent. Make sure you understand how to do a tubing (circuit) change and actually do it in the hospital before going home. Know how to set the vent up for home (wet) and for travel (dry). Find out how to clean the filters and have them give you extras. Get used to the alarms and learn how to turn them off and what they mean. Be aware that if the kid yawns or coughs or laughs the alarm is going to go off. Yes, kids on vents can and do laugh. Remember though to always check that your kid's airway is clear and that the tubing has not disconnected all the way from the kid's trach to the machine. This vent has a bad habit of popping apart at the point where the filter connects to the vent if you bump it , just be aware and push it back together. Another trouble spot is right at the trach but there are solutions using small pieces of extention tubing called omniflex and by using two different kinds of trach ties. Make sure you are comfortable with doing the trach care, changing the ties and doing the suctioning. Suctioning is scary because it looks uncomforable but if you ever talk to some one who has needed to be suctioned they will tell you it tickles and that it is a relief to have a clear airway. Be sure to be there when they do a trach change and then do at least two changes yourself before going home. One other silly thing the vent does is give out false readings if the tiny sensor tubings get water in them - there might be a better way to handle this problem but we have found that the best way to fix it is to just do a circuit change.

Taking someone home on mechanical ventilation is not easy, especially at first, but it does get easier. Like when you realize instead of fumbling for that extra breath button during suctioning you can just unlock the vent before you suction and dial up the rate by a few breaths per minute and then dial it down to the prescription rate after your finished and lock it again. Of course you would want to check that out with your doctor first. Every patient is different. Every family is different too. Not everyone can handle a vent patient at home. It can be done though. I didn't think we could do it but I am glad DH broke his PROMISE to me and let them make me take my son home. There truly is no place like home.

Blogger blessnfaith, at 6:41 AM  

Nurses need to learn alot about ventilators in order to safely and effectively care for their patient.
The standards of nursing care dictact the need for the knowledge and the home care patient needs a competant nurse to survive, maintain and sustain the best quality of life. Although I know some families who can manage their loved ones vents as good as a qualifed Nurse if not better than some. And I have met some PICU nurses who can't change a trach? Level of competancy vary, but the need for high quality vent management is
a priority for home care weather the family or the nurse or both are on the case.

Bayada nurses has a wonderful trach and vent learning packet for both peds and adult. Their standards of care are very high.

In home care the nurse is there and usually not the RT. Nurse need to learn the mechanics of the vent and trouble shoot.

Blessnfaith RN

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