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Dec.28.2021
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Mechanical Ventilation: Troubleshooting (Respiratory Therapy)

ALERT

If the cause of an alarm cannot be identified and corrected quickly, remove the patient from the ventilator and begin manual ventilation with a manual resuscitation bag (MRB).

To maintain patient safety, never disable alarms.

OVERVIEW

Mechanical ventilator alarms are used to warn of changes in patient or ventilator status. All alarms should be set according to the patient’s condition and per the organization’s practice. For patient safety, alarms should never be disabled.

Some essential alarms on the ventilator include ventilator inoperative (vent INOP), power failure, no gas delivery to the patient, low peak inspiratory pressure (PIP), low tidal volume (VT), low or high minute volume (MV), low positive end-expiratory pressure and continuous positive airway pressure (PEEP–CPAP), apnea, inspiratory:expiratory (I:E) ratio, high-pressure limit, high respiratory rate, and low or high fraction of inspired oxygen (FIO2). The brand-specific mechanical ventilator manual should be consulted for all available alarms and troubleshooting options.

SUPPLIES

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EDUCATION

  • Provide developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, and overall neurologic and psychosocial state.
  • Explain the need for routine ventilator checks to verify the proper function of the system and alarms.
  • Explain the meaning of the audible and visual alarms to the patient and family.
  • Explain the corrective measures needed or taken to address alarms as soon as possible.
  • Assure the patient and family that staff members will respond appropriately to all alarms.
  • Encourage questions and answer them as they arise.

ASSESSMENT AND PREPARATION

Assessment

  1. Perform hand hygiene before patient contact. Don appropriate personal protective equipment (PPE) based on the patient’s need for isolation precautions or the risk of exposure to bodily fluids.
  2. Introduce yourself to the patient.
  3. Verify the correct patient using two identifiers.
  4. When an alarm sounds, quickly assess the patient’s vital signs, including heart rate, respiratory rate, breath sounds, and peripheral oxygen saturation (SpO2).

Preparation

  1. Before initiating mechanical ventilation, check the system microprocessor or ventilation system. Perform a short self-test as appropriate before patient connection.1
  2. Ensure that an MRB with an appropriate-size face mask is readily available, functional, and attached to a supplemental oxygen source. Attach a PEEP valve, if necessary.

PROCEDURE

  1. Perform hand hygiene and don gloves. Don additional PPE based on the patient’s need for isolation precautions or the risk of exposure to bodily fluids.
  2. If time permits, verify the correct patient using two identifiers.
  3. If the reason for the alarm(s) cannot be immediately identified, begin manual ventilation with an MRB until alarm(s) can be corrected.2
  4. Explain the procedure to the patient.

Ventilator Inoperative (Vent INOP)

  1. Turn the ventilator off and restart it.2
  2. Follow the message instructions on the ventilator, if available.
  3. If the ventilator fails to operate properly, tag it for a maintenance check and replace it with another ventilator.
  4. Ensure that the ventilator settings and alarms are set properly.
  5. Verify that the alarm has been corrected and the patient is stable.
  6. Remove PPE and perform hand hygiene.
  7. Document the procedure in the patient's record.

Power Failure

  1. Assess the ventilator to ensure that the power cord is plugged into an electric outlet that is connected to an emergency backup power source.2
  2. If the external or internal battery is low, reconnect the ventilator’s power cord to an electric outlet.
  3. If applicable, check the fuse or circuit breaker by replacing the fuse or pressing the reset button next to the circuit breaker.
  4. Ensure that the ventilator settings and alarms are set properly.
  5. Verify that the alarm has been corrected and the patient is stable.
  6. Remove PPE and perform hand hygiene.
  7. Document the procedure in the patient’s record.

No Gas Delivery to the Patient

  1. Ensure that all high-pressure gas hoses are tightly connected to the appropriate gas sources.
  2. Check the oxygen and air pressure. The gas pressure gauge is located at the gas shut-off valve for the unit.
  3. Check the cylinder tank gauges if using gas cylinders.
  4. Ensure that the ventilator settings and alarms are set properly.
  5. Verify that the alarm has been corrected and the patient is stable.
  6. Remove PPE and perform hand hygiene.
  7. Document the procedure in the patient’s record.

Low PIP2

  1. Check the circuit for leaks or disconnections. Tighten or reconnect the connections.
  2. Check the patient's artificial airway cuff for leaks or deflation.
  3. Check the humidifier for leaks or disconnections and tighten or reconnect the connections.
  4. Check the inline suction system for leaks or disconnections. Tighten or reconnect the connections. Replace the inline suction system if a leak persists.
  5. Check inline adapters for a metered-dose inhaler (MDI) or a small volume nebulizer (SVN). Check them for leaks or disconnections and tighten or reconnect the adapter connections.
  6. Check for chest tube leaks. If one is found, consult the practitioner for further interventions.
  7. Ensure that the proximal pressure line is connected and unobstructed.
  8. Ensure that ventilator settings and alarms are set properly.
  9. Verify that the alarm has been corrected and the patient is stable.
  10. Remove PPE and perform hand hygiene.
  11. Document the procedure in the patient’s record.

Low VT2

  1. Check the circuit for leaks or disconnections. Tighten or reconnect the connections.
  2. Check the artificial airway cuff for leaks or deflation.
    1. Check cuff pressure and listen for an air leak in the patient's trachea.
    2. Identify and correct the cause of the leak.
  3. Check the humidifier for leaks or disconnections and tighten or reconnect the connections.
  4. Check the inline suction system for leaks or disconnections. Tighten or reconnect the connections. Replace the inline suction system if a leak persists.
  5. Check inline adapters for an MDI or an SVN. Check them for leaks or disconnections and tighten or reconnect the adapter connections.
  6. Check for chest tube leaks. If one is found, consult the practitioner for further interventions.
  7. Ensure that the ventilator settings and alarms are set properly.
  8. Verify that the alarm has been corrected and the patient is stable.
  9. Remove PPE and perform hand hygiene.
  10. Document the procedure in the patient's record.

Low MV2

  1. Assess the patient's respiratory rate and clinical condition for apnea, low respiratory rate, or low exhaled VT.
    1. If necessary, contact the practitioner and correct the clinical problem.
    2. Begin manual ventilation with an MRB if the patient is apneic.
  2. Check the circuit for leaks or disconnections. Tighten or reconnect the connections.
  3. Check the patient's artificial airway cuff for leaks or deflation.
    1. Check cuff pressure and listen for an air leak in the patient's trachea.
    2. Identify and correct the cause of the leak.
  4. Check the humidifier for leaks or disconnections and tighten or reconnect the connections.
  5. Check the inline suction system for leaks or disconnections. Tighten or reconnect the connections. Replace the inline suction system if a leak persists.
  6. Check inline adapters for an MDI or an SVN. Check them for leaks or disconnections and tighten or reconnect the adapter connections.
  7. Check for chest tube leaks. If one is found, consult the practitioner for further interventions.
  8. Ensure that ventilator settings and alarms are set properly.
  9. Verify that the alarm has been corrected and the patient is stable.
  10. Remove PPE and perform hand hygiene.
  11. Document the procedure in the patient's record.

Low Positive End-Expiratory Pressure and Continuous Positive Airway Pressure (PEEP–CPAP)2

  1. Check the circuit for leaks or disconnections. Tighten or reconnect the connections.
  2. Check the patient's artificial airway cuff for leaks or deflation.
    1. Check cuff pressure and listen for an air leak in the patient's trachea.
    2. Identify and correct the cause of the leak.
  3. Check the humidifier for leaks or disconnections and tighten or reconnect the connections.
  4. Check the inline suction system for leaks or disconnections. Tighten or reconnect the connections. Replace the inline suction system if a leak persists.
  5. Check inline adapters for an MDI or an SVN. Check them for leaks or disconnections and tighten or reconnect the adapter connections.
  6. Check for chest tube leaks. If one is found, consult the practitioner for further interventions.
  7. Ensure that the proximal pressure line is connected and unobstructed.
  8. Check the exhalation valve for leaks. If a leak is found and an external exhalation valve is in place, replace the circuit and the ventilator.
  9. Ensure that ventilator settings and alarms are set properly.
  10. Verify that the alarm has been corrected and the patient is stable.
  11. Remove PPE and perform hand hygiene.
  12. Document the procedure in the patient's record.

Apnea2

  1. Assess the patient's breathing.
    1. If the patient is apneic, begin manual ventilation with an MRB.
    2. Assess the patient's clinical condition for causes of apnea and contact the patient's practitioner, if necessary, to correct the clinical problem.
  2. Check the ventilator's sensitivity setting to ensure that it detects the patient's inspiratory efforts.
  3. Check the circuit for leaks or disconnections. Tighten or reconnect the connections.
  4. Ensure that ventilator settings and alarms are set properly.
  5. Verify that the alarm has been corrected and the patient is stable.
  6. Remove PPE and perform hand hygiene.
  7. Document the procedure in the patient's record.

I:E Ratio

  1. Ensure that the inspiratory time is set appropriately. An I:E alarm usually indicates an inverse I:E ratio.2
  2. Ensure that the flow rate is set appropriately.
  3. Check the patient's respiratory rate.
  4. Ensure that ventilator settings and alarms are set properly.
  5. Verify that the alarm has been corrected and the patient is stable.
  6. Remove PPE and perform hand hygiene.
  7. Document the procedure in the patient's record.

High MV2

  1. Assess the patient for signs of respiratory distress.
    1. If distress is found, take appropriate action to correct the cause.
    2. If necessary, contact the practitioner.
  2. Ensure that ventilator settings and alarms are set properly.
  3. Verify that the alarm has been corrected and the patient is stable.
  4. Remove PPE and perform hand hygiene.
  5. Document the procedure in the patient's record.

High-Pressure Limit2

  1. Assess the patient for signs of respiratory distress.
  2. Attempt to pass a suction catheter through the patient's artificial airway to check for an obstruction.
    1. If the tube is kinked, reposition it to straighten it.
    2. If the patient bites the tube, consider placing an oral airway or bite block.
    3. If the tip of the artificial airway has impinged on the tracheal wall, reposition the tube to free the obstruction.
    4. For all other obstructions, attempt to clear the tube with a suction catheter.
    5. If unable to clear the tube with a suction catheter, attempt these steps:
      1. Remove and replace the inner cannula of the tracheostomy tube.
      2. Remove the artificial airway and begin manual ventilation.
      3. Contact the practitioner for further interventions.
  3. Check the ventilator circuit for water. Drain condensation away from the patient and toward the expiratory limb.
  4. Check the ventilator circuit for kinking or obstructions.
  5. Check breath sounds to determine if bronchospasm, secretions, or pneumothorax is present:
    1. Bronchospasm: Consult the practitioner and consider bronchodilator therapy.
    2. Secretions: Suction the secretions to clear the patient’s airway.
    3. Pneumothorax: Immediately contact the practitioner for further interventions.
  6. Check the exhalation valve and filter for failure; if it has failed, immediately remove the patient from the ventilator and begin manual ventilation with an MRB. Replace the filter.
  7. Ensure that ventilator settings and alarms are set properly.
  8. Verify that the alarm has been corrected and the patient is stable.
  9. Remove PPE and perform hand hygiene.
  10. Document the procedure in the patient's record.

High Respiratory Rate

  1. Assess the patient for signs of respiratory distress.
    1. If distress is found, take appropriate action to correct the cause.
    2. If necessary, contact the practitioner.
  2. Ensure that ventilator settings and alarms are set properly.
  3. Verify that the alarm has been corrected and the patient is stable.
  4. Remove PPE and perform hand hygiene.
  5. Document the procedure in the patient's record.

Low or High FIO22

  1. Check the gas source to ensure that the ventilator is connected to a high-pressure oxygen source.
  2. Ensure that the FIO2 is set properly.
  3. Recalibrate the internal oxygen analyzer, if able.
  4. Check the FIO2 with the calibrated external oxygen analyzer. If the correct FIO2 is not being delivered, replace the ventilator.
  5. Ensure that ventilator settings and alarms are set properly.
  6. Verify that the alarm has been corrected and the patient is stable.
  7. Remove PPE and perform hand hygiene.
  8. Document the procedure in the patient's record.

MONITORING AND CARE

  1. Ensure that the patient’s artificial airway is patent and secure.
  2. Ensure that ventilator settings and alarms are on and set appropriately.
  3. Keep the ventilator tubing free from condensation. Drain tubing away from the patient and toward the expiratory limb or water trap.
  4. Check the alarm settings at regular intervals during a ventilator system check.
  5. Observe the patient for signs and symptoms of pain. If pain is suspected, report it to the authorized practitioner.

EXPECTED OUTCOMES

  • Resolution of alarms
  • Return of heart rate, respiratory rate, breath sounds, and SpO2 to baseline
  • Properly functioning ventilator

UNEXPECTED OUTCOMES

  • Patient death or harm
  • Pulmonary barotrauma or volutrauma
  • Discrepancy between set and measured values

DOCUMENTATION

  • Education
  • Alarm parameters
  • Adverse patient response
  • Patient's vital signs
  • Hemodynamic values
  • SpO2 readings
  • Respiratory interventions in response to alarms
  • Unexpected outcomes and related interventions

HOME CARE CONSIDERATIONS

  • Alarms must be set loud enough to be heard in other rooms.
  • Alarms should never be disabled.

REFERENCES

  1. Cairo, J.M. (2020). Chapter 7: Final considerations in ventilator setup. In Pilbeam's mechanical ventilation: Physiological and clinical applications (7th ed., pp. 97-116). St. Louis: Elsevier.
  2. Cairo, J.M. (2020). Chapter 18: Troubleshooting and problem solving. In Pilbeam's mechanical ventilation: Physiological and clinical applications (7th ed., pp. 334-354). St. Louis: Elsevier.
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