Out-of Hospital Ventilation : An Interdisciplinary Perspective on Landscape and Health

Safe handling of patient and device in home ventilation! This book offers all relevant contents of the further training "Basic qualification extra-clinical artificial respiration" and addresses itself to maintaining and responsible persons, who supply ventilated humans at home or in the nursing home. Learn comprehensive basics about anatomy, pathology and the different ventilation modes and benefit from the authors' wealth of experience. Here you can read in an easily understandable and concise manner how to provide your patients or residents with all-round competent care and how to handle the ventilation situation with confidence.Ideal for all employees and nursing services to train and qualify for the challenging care of ventilated patients! Preface Acknowledgments Contents Contributors I: Basics of Breathing and Respiratory Failure 1: Anatomy and Physiology of Respiration 1.1 Upper Airways 1.1.1 Tasks of the Upper Airways 1.1.2 Reference to Artificial Respiration 1.1.3 Nose 1.1.4 Larynx and Vocal Cords 1.2 Lower Airways 1.2.1 Trachea (Windpipe) 1.2.2 Carina 1.2.3 Bronchial tree (Bronchial System) 1.2.4 Mucociliary Clearance 1.2.5 The Position of the Lungs in the Body 1.2.6 The Lobes, Lobes and Segments of the Lungs 1.2.7 Alveoli and Surfactant 1.2.8 Pulmonary Vessels 1.3 Respiratory Support Musculature 1.3.1 Inspiration 1.3.2 Expiration 1.4 Physiology 1.4.1 Breathing Air 1.4.2 Diffusion Time: Diffusion Distance 1.4.3 Breathing Regulation 1.4.4 Physiological Shunt Volume 1.4.5 Breathing Mechanics 1.5 Central and Peripheral Nervous System 1.5.1 Anatomy of the Brain 1.5.2 Brain Structure 1.5.3 The Lobes and Regions of the Brain 1.5.4 Pyramidal and Extrapyramidal System 1.5.5 Blood Supply to the Brain 1.6 Spinal Cord 1.6.1 Structure of the Spinal Cord 1.6.2 The Internal Structure of the Spinal Cord 1.6.3 Structure of a Nerve Cell 1.7 Phrenic Nerve 1.8 Interconnection of the Nerve Tracts References 2: Indications and Goals of Ventilation 2.1 Respiratory Insufficiency 2.1.1 Failure of the Respiratory Pump 2.1.2 Failure of Pulmonary Gas Exchange 2.1.3 Disturbance of Pulmonary Gas Exchange 2.1.4 Interaction Between the Lungs and the Respiratory Pump 2.2 Ventilation Goals References 3: Diseaseology 3.1 Basics and Diagnostics of Respiratory Disorders 3.1.1 Types and Frequency of Home Ventilation 3.1.2 Central Respiratory Regulation 3.1.3 Airways 3.1.4 Breathing Mechanics 3.1.5 Lungs 3.1.6 Gas Exchange 3.2 Illnesses and Treatment 3.2.1 Hypoxic Brain Damage Anoxia or Asphyxia Persistent Vegetative State: Rehabilitation Phase Model Clinic Ventilation for Hypoxic Brain Damage 3.2.2 Stroke: Ischemic Insult Causes Clinic and Symptoms Ventilation for Stroke 3.2.3 Paraplegia Causes and Frequency Clinic and Symptoms Tetra- and Paraplegia Ventilation for Severe Paraplegia 3.2.4 Neuromuscular Diseases (NMD) Definition Overview Occurrence and Frequency General Symptoms Description of Different Diseases Therapy Ventilation 3.2.5 COPD Indicator of COPD Pathophysiology of COPD Clinical Symptoms of COPD Staging Ventilation for COPD 3.2.6 Obesity Hypoventilation Syndrome (OHS) Clinic and Symptoms Further Pathophysiological Mechanisms Ventilation with OHS Criteria 3.2.7 Thoracic Restrictive Disorders Problems of Thoracic Restrictive Diseases Indications for NIV Targets of Ventilation in Thoracic Restrictive Diseases Ventilation for Thoracic Restrictive Diseases Criteria for Ventilation References II: Ventilation Options 4: Tracheotomy 4.1 Terminology 4.1.1 Indication for Tracheotomy 4.1.2 Advantages and Disadvantages of Tracheotomy 4.1.3 Places of Tracheotomy 4.2 Tracheotomy Procedure 4.2.1 Implementation of PDT (According to Caglia) 4.2.2 Plastic Tracheostoma 4.2.3 Changes Caused by a Tracheostoma 4.3 Various Tracheal Cannulas 4.3.1 Tracheal Cannula with Cuff 4.3.2 Construction of a Tracheal Cannula Subglottic Suctioning 4.3.3 Speech Valve: Inhalation Valve 4.3.4 Tracheal Cannula Without Cuff 4.3.5 Core or Inner Cannula 4.3.6 Fenestrated Cannulas 4.4 Dressing Changes for Tracheal Cannulas 4.5 Changing the Tracheal Cannula 4.5.1 Preparation 4.5.2 Implementation 4.6 Closure of the Tracheotoma 4.6.1 Cuff Leak Test 4.6.2 Placeholders References 5: NIV (Non-invasive Ventilation) 5.1 Indications and Contraindications 5.1.1 Indications Possibilities of NIV Risks in the Application of NIV 5.1.2 Contraindications of NIV 5.2 Characteristics of the NIV 5.3 Different Mask Systems 5.3.1 Nasal Mask 5.3.2 Full-Face Mask (Oronasal Mask) 5.3.3 Total Face Mask 5.3.4 Special Models 5.4 Modern NIV Masks 5.5 Typical Applications 5.5.1 COPD 5.5.2 Thoracic Restrictive Disorders 5.5.3 Obesity Hypoventilation Syndrome 5.5.4 Neuromuscular Diseases (NME) 5.6 Assessment of an Adjusted Ventilation Setting 5.7 Ventilation Setting of the NIV References III: Ventilation Modes and Patterns 6: Respirator Models 6.1 Air or Piston Pump Model 6.2 Model Ambu Bag (Respiratory Bag) 6.3 Model of Open/Semi-Open Systems 6.4 Model of a Surge Tank 6.5 Respirator Model of an Intensive Care Ventilator 6.6 Intensive Care and Turbine-Controlled Ventilators 6.6.1 Intensive Care Ventilators 6.6.2 Turbine Controlled Ventilators 6.7 Ventilation Hose Systems 6.7.1 Leakage System 6.7.2 Single Hose System with Integrated Exhalation Valve 6.7.3 Two-Hose System 6.7.4 Grommet and Function Check 6.8 Breathing Gas Conditioning: Breathing Gas Humidification 6.8.1 Passive Humidifiers 6.8.2 Active Humidifiers Reference 7: Spontaneous and Positive Pressure Ventilation 7.1 Respiratory Pattern on the Respirator 7.1.1 Other Characteristics of Spontaneous Rest Breathing 7.2 Positive Pressure Ventilation References 8: Ventilation Modes 8.1 Distinguishing Features of Ventilation Modes 8.2 Ventilation Curves 8.2.1 Pressure Curve 8.2.2 Flow Curve 8.2.3 Volume Curve 8.2.4 CO2 Curve References 9: Pressure-Controlled Ventilation (PCV/A-PCV) 9.1 Nomenclature 9.2 Parameter Setting 9.2.1 Oxygen 9.2.2 PEEP and EPAP Advantages of PEEP Adverse Effects of PEEP 9.2.3 Inspiration Example Example Example 9.2.4 Frequency 9.2.5 Inspiration Time Example 9.2.6 Breathing Time Ratio I:E 9.2.7 Ramp or Rise Time Example 9.2.8 Trigger Flow Trigger Pressure Trigger Purpose of the Trigger Functions 9.2.9 Maximum Air Pressure Limit 9.3 Procedure for Pressure-Controlled Ventilation 9.4 Application of PCV Ventilation 9.5 Case Study: PB 560 (Covidien) References 10: Volume Controlled Ventilation (VCV) 10.1 Nomenclature 10.2 Parameter Setting 10.2.1 Breathing Volume 10.2.2 Flow Example 10.3 Procedure for Volume-Controlled Ventilation 10.3.1 Why Does the Air Pressure Drop Again? 10.3.2 Plateau Phase 10.3.3 Expiration 10.4 Problems of Volume-Controlled Ventilation 10.4.1 Risk of Unknown Air Pressures 10.4.2 Pendulum Air 10.4.3 Shearing Forces 10.4.4 Atelectasis and Emphysema 10.5 Application of VCV Ventilation 10.6 Case Study: Astral 150 (ResMed Company) References 11: Pressure-Regulated- Volume-Controlled Ventilation 11.1 Nomenclature 11.2 Parameter Setting 11.3 Independent Ventilation Pressure Level Adjustment 11.3.1 Lung Extensibility (Compliance) 11.3.2 Resistance 11.4 Application of Pressure-Regulated-Volume-Controlled Ventilation 11.5 Case Study: PB 560 (Covidien Company) Reference 12: Pressure Support Ventilation (PSV) 12.1 Nomenclature 12.2 Parameter Setting 12.3 Pressure Support for Breathing 12.3.1 Optimum Level of Pressure Support 12.3.2 Trigger Flow Trigger Pressure Trigger Example 12.3.3 Back-Up 12.4 Case Study: PSV Breathing 12.5 Exhalation Trigger 12.6 Advantages and Disadvantages 12.6.1 Benefits of PSV Breathing 12.6.2 Disadvantages of PSV: 12.7 ST Mode 12.7.1 Description of the ST Ventilation Mode References 13: SIMV (Synchronized Intermittent Mechanical Ventilation) 13.1 Volume-Controlled SIMV (VC-SIMV) 13.1.1 Parameter Setting 13.2 Pressure Controlled SIMV (PC SIMV) 13.2.1 Parameter Setting 13.3 Advantages and Disadvantages of SIMV 13.3.1 Advantages of SIMV 13.3.2 Disadvantages of SIMV 13.4 Application in Out-of-Hospital Ventilation References 14: AVAPS (Average Volume Assured Pressure Support) 14.1 Pressure Controlled Ventilation and AVAPS 14.2 Parameter Setting 14.3 Case Study: Trilogy 100 (Phillips Respironics) 14.4 Using AVAPS References 15: Emergency Management 15.1 What Is an Emergency? 15.2 Who Is Responsible and When? 15.2.1 If the Family Doctor Is Not Available ... 15.2.2 Weaning Centre 15.2.3 Rescue Service 15.2.4 Qualification of Rescue Service Personnel 15.2.5 Making an Emergency Call 15.2.6 Transport Management 15.3 Patient Assessment 15.4 Red Thread of Emergency Care 15.5 Ventilation Problems 15.5.1 Tracheal Cannula Relocation 15.5.2 Accidental Decannulation 15.5.3 Torn Cuff Tube 15.6 Cerebral Seizure 15.6.1 Symptoms 15.6.2 Hazards 15.6.3 First aid 15.6.4 Extended Measures 15.6.5 Causes 15.6.6 Epidemiology 15.7 Resuscitation 15.7.1 Procedure 15.7.2 Advanced Resuscitation Measures 15.7.3 The Resuscitation Result (Outcome) 15.8 Child Resuscitation 15.8.1 Procedure References IV: Further Treatment Measures 16: Pharmacology 16.1 Introduction to Pharmacology 16.1.1 The Action of a Medicinal Product in the Body 16.1.2 Application Types 16.1.3 Pharmaceutical Forms Oral Use Bronchopulmonary Use 16.2 Groups of Medicines 16.2.1 Cardiacs Antihypertensives (High Blood Pressure, Hypertension) Heart Failure Antiarrhythmics (Cardiac Arrhythmia) 16.2.2 Bronchodilatatives/Bonchospasmolytics Beta-2 Receptor Agonists Theophylline Anticholinergics/Beta-2 Sympathomimetics PDE-4 Inhibitors 16.2.3 Secretolytics/Expectorants Ambroxol Acetylcysteine (ACC) Saline Solutions 16.2.4 Sedatives Benzodiazepines Zolpidem and Zopiclon Neuroleptics 16.2.5 Antidepressants SSRI (Selective Serotonin Reuptake Inhibitors) SSNRI (Selective Serotonin/Noradrenaline Reuptake Inhibitor) NaSSA (Norepinephrine and Specifically Serotonergic Antidepressants) MAO inhibitors (Tranylcypromine, Moclobemide) 16.2.6 Anticoagulants Antiplatelet Aggregation Inhibitor Direct and Indirect Anticoagulants Further Reading 17: Oxygen Therapy 17.1 Respiratory Tasks 17.1.1 Absorption of Oxygen and Release of Carbon Dioxide 17.1.2 Oxygen and Carbon Dioxide Oxygen (O2) Carbon Dioxide (CO2) 17.2 Symptoms of Oxygen Deficiency 17.3 Measuring Methods for Oxygen Measurement 17.3.1 Transcutaneous Oxygen Saturation 17.3.2 Pulse Oximetry 17.4 Indications for Oxygen Administration 17.4.1 Long-Term Oxygen Therapy (LTOT) 17.4.2 Intermittent Oxygen Administration 17.4.3 Basic Diagnostics 17.5 Devices for Oxygen Supply 17.5.1 Oxygen Concentrator 17.5.2 Oxygen Cylinders Bottle Sizes Humidification Filling Quantities and Consumption Demand Systems or Trigger Systems 17.5.3 Liquid Oxygen 17.5.4 Selection of an Appropriate Mobile System 17.6 Application Systems 17.7 Safety Against Fire References 18: Dysphagia 18.1 Physiological Swallowing 18.2 Impaired Swallowing 18.2.1 Symptoms of Dysphagia 18.3 Causes of Dysphagia 18.4 Diagnosis of Dysphagia 18.4.1 Medical History 18.4.2 Own/Foreign Anamnesis 18.4.3 Clinical Diagnostics General Assessment Examination of Motor and Sensitive Functions Screenings to Assess the Risk of Aspiration Severity Classification Instrumental Diagnostics Video Copy of Swallowing (FEES) Videofluoroscopy of Swallowing Further Instrumental Diagnostic Procedures 18.5 Therapy of Dysphagia 18.5.1 Therapy Preparation 18.5.2 Restitutive Therapy Procedures 18.5.3 Compensatory Therapy Procedures 18.5.4 Adaptive Therapy Methods 18.6 Tracheal Cannula Management 18.6.1 Cooperation 18.6.2 Patient Examples References 19: Communication in Care Relationships 19.1 Communication Partners 19.2 Theory of Cognitive Control Conclusion 19.3 Transmitter–Receiver Model 19.3.1 Iceberg Model Conclusion 19.3.2 Distorted Perceptions 19.4 Theories of Communication Science 19.4.1 5 Axioms by Paul Watzlawick 19.4.2 Four-Sided Model 19.4.3 Small Talk, High Talk, Move Talk 19.5 Communication Model of Transaction Analysis 19.5.1 Communication as a Transaction 19.5.2 Other Concepts of Transactional Analysis O.K. Position Covert Transactions Healthy and Unhealthy Symbiosis Discount Stamp Model Contracts Conclusion References V: Monitoring and Nursing Care of the Patient and Ventilation 20: Hygiene 20.1 Introduction to Hygiene 20.2 Service Life 20.2.1 General 20.2.2 Aqua 20.2.3 Hose Systems 20.2.4 Disinfection 20.3 Dry Breathing Systems 20.3.1 Reusable Breathing Tube 20.3.2 Disposable Hose Systems 20.3.3 Standing Times 20.3.4 System Change 20.3.5 Reusable Systems 20.4 Tubes with Humidifier 20.4.1 Hose Systems 20.4.2 Changing the Heatable Hose Systems 20.4.3 Humidifying Liquids 20.5 HME Filters and Goose Gargle 20.6 Ventilation Masks 20.7 Tracheal Cannula Management 20.7.1 Lay Days 20.7.2 Cleaning of Cannulae 20.8 Equipment Maintenance 20.8.1 Ventilators 20.8.2 Cough Assist 20.8.3 Oxygen Equipment 20.8.4 Suction Devices 20.9 Washing Hands Conclusion References 21: Resistance and Compliance 21.1 Resistance 21.1.1 Standard Values 21.1.2 Effect of the Resistance Pressure Controlled Ventilation Volume-controlled Ventilation Pressure-supported Ventilation Volume-controlled-pressure-regulated Ventilation PEEP Conclusion 21.2 Compliance 21.2.1 Standard Values 21.2.2 Impact of Compliance Pressure Controlled Ventilation Volume-controlled Ventilation Pressure-supported Ventilation Volume-controlled-pressure-regulated Ventilation PEEP Conclusion 21.3 Resistance and Compliance References 22: Control Mechanisms and Types of Control 22.1 Ventilation Control Mechanisms 22.2 Ventilation Control Modes 22.3 Ventilation Modes of Practical Relevance Reference 23: Flow and Flow Curves 23.1 Sinus Flow, Constant Flow, Decelerating Flow 23.1.1 Statements of Flow Curves 23.1.2 Advantages of the Decelerating Flow 23.2 Flow During Volume-controlled Ventilation 23.3 Flow During Pressure-controlled Ventilation 23.3.1 Flow Behaviour with Different Steep Ramps 23.3.2 Flow Behaviour at Different Pinsp 23.3.3 Flow Curve for Too Short Expiratory Time 23.3.4 Flow Curve with Too Short Inspiration Time 23.3.5 Flow Trigger 23.3.6 Pressure Trigger 23.3.7 Flow Trigger Versus Pressure Trigger Conclusion 23.4 Flow Curve in PSV 23.4.1 Flow Trigger 23.4.2 Rise or Ramp 23.4.3 Expiratory Trigger Reference 24: Alarms and Alarm Settings 24.1 Alarm Message Levels 24.2 Special Alarms 24.2.1 Airway Pressure/Pmax 24.2.2 Minute Volume 24.2.3 Breathing Volume 24.2.4 Respiratory Rate 24.2.5 Apnea Time/Apnea Ventilation/Back-up Setting Reference 25: Ventilation Measured Values 25.1 Measured Values 25.1.1 Pressure Values 25.1.2 Volumes 25.1.3 Frequency Values 25.1.4 Further Measurement Parameters 25.2 Ventilation Protocol Conclusion References 26: Monitoring 26.1 Clinical View/Clinical Monitoring 26.2 Pulse Oximetry 26.3 Capnometry 26.4 Circulation, Pulse and Blood Pressure References 27: Blood Gas Analysis (BGA) 27.1 Assessment of a BGA 27.2 Oxygen and Carbon Dioxide 27.2.1 Oxygen (O2) 27.2.2 Carbon Dioxide (CO2) 27.2.3 Partial Pressure of Oxygen and Carbon Dioxide (pO2 and pCO2) 27.2.4 Oxygen Saturation 27.2.5 Oxygen Fixation Curve Right Shift Left Shift 27.2.6 Central Venous Oxygen Saturation (ScvO2) 27.2.7 Horowitz Quotient 27.3 Acid–Base Balance 27.3.1 pH Value 27.3.2 Buffers and Buffer Systems 27.3.3 Regulation of the Acid–Base Balance Carbon Dioxide Bicarbonate Buffer System Regulation Via the Kidney Regulation via the Lungs and Respiration 27.3.4 Disturbances of the Acid–Base Balance 27.3.5 Base Excess (BE) Respiratory Acidosis Respiratory Acalosis Metabolic Acidosis Metabolic Alkalosis 27.4 Effects of Acidosis and Alkalosis 27.5 Reading a BGA References 28: Breathing Gas Conditioning 28.1 Tasks of the Airways 28.2 Absolute and Relative Humidity 28.3 Active Respiratory Gas Humidification 28.3.1 Pass-over Evaporator 28.3.2 Countercurrent Method 28.4 Ventilation Filter 28.4.1 Mechanical Filters 28.4.2 Electrostatic Filters 28.5 Passive respiratory Gas Humidification 28.5.1 General Operation 28.5.2 Physical and Chemical HME Elements 28.5.3 HMEF 28.6 Active Versus Passive Humidification Further Reading 29: Secretary Management 29.1 Ability to Cough 29.1.1 Coughing Procedure 29.1.2 Problems with Reduced Cough 29.2 Support for Coughing 29.2.1 Measures to Increase the Intrathoracic Volume Mechanical Support Measures 29.2.2 Measures for Intensified Expiratory Air Flow Manual Cough Support Mechanical Cough Support 29.3 Endobronchial/Endotracheal Suction 29.3.1 Closed Versus Open Suction 29.3.2 Subglottic Suction 29.4 Inhalation Therapy 29.4.1 Deposition 29.4.2 Types of Deposition 29.4.3 Metered Dose Inhalers 29.4.4 Nebuliser Systems References 30: Weaning 30.1 Weaning Process 30.2 Weaning Classification 30.3 Conditions for Successful Weaning 30.4 Nursing Measures to Strengthen the Respiratory Musculature 30.5 Weaning Strategies 30.5.1 Discontinuous Weaning 30.5.2 Continuous Weaning 30.6 Weaning Index (RSB Index) 30.7 Weaning of Long-Term Ventilated Patients 30.7.1 Conditions 30.7.2 Weaning Process 30.7.3 Carrying Out the Spontaneous Breathing Test 30.7.4 Weaning 30.7.5 Closure of the Tracheotomy Further Reading VI: Legal Bases for Out-of-Hospital Ventilation 31: Discharge Management in Nursing 31.1 Legal Requirements 31.1.1 Supply Contract According to Sections 132, 132a Para. 2 SGB V 31.1.2 Care Contract for Outpatient Care According to Section 72 SGB XI 31.1.3 Requirement of the Medical Service of the Health Insurance Fund (MDK) 31.1.4 Recommendations of the Robert Koch Institute (RKI) 31.1.5 Staff Requirements 31.2 Discharge Management 31.2.1 Request for Patient Admission 31.2.2 Initial Interview 31.2.3 Contacting the Cost Unit 31.2.4 Regulation of Home Care 31.2.5 Maintenance Contract 31.2.6 Domestic visit 31.2.7 Contacting the Providers 31.2.8 Contact with the Family Doctor and Management of Medicines 31.2.9 Documentation 31.2.10 Personnel Planning 31.3 Outlook References 32: Criminal and Liability Aspects 32.1 The Sources of Law 32.2 Verification Scheme for Liability 32.3 Justification for the Exclusion of Fault 32.3.1 Legal Relationships 32.3.2 Contract Liability 32.4 Intent and Negligence 32.5 Personal Injury 32.6 Injunctive Relief References 33: Implementation of MPG/Operator Regulation 33.1 Reasons for a Medical Devices Act (Medizinproduktegesetz, MPG) 33.2 Sense and Purpose of the Medical Devices Act 33.3 Application of Medical Devices 33.4 Medical Devices Operator Ordinance References 34: Care, Power of Attorney and Living Will 34.1 General Information on Care 34.2 Provisional and General Power of Attorney 34.3 General Information on the Patient Decree References Appendix