MECHANICAL VENTILATION

Patient On Mechanical Ventilator

MECHANICAL VENTILATION

Ventilation of the lungs by artificial means usually by a ventilator. Mechanical ventilation is

used when a patient is unable to breathe adequately on his or her own.

PURPOSES OF MECHANICAL VENTILATION

 Maintain or improve ventilation.

 Decrease the work of breathing and improve patient's comfort.

 Decreases myocardial and systemic oxygen consumption.

 Reduce intracranial pressure ICP through controlled hyperventilation, thus mechanical

ventilation is often used in patients with brain injuries.

INDICATIONS FOR MECHANICAL VENTILATION

 Acute respiratory failure due to:

 Mechanical failure includes neuromuscular diseases as Myasthenia Gravis,

Guillain-Barre syndrome, and Poliomyelitis.

 Musculoskeletal abnormalities, as chest wall trauma (flail chest).

 Infectious diseases of the lung as pneumonia, tuberculosis.

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 Abnormalities of pulmonary gas exchange as in:

 Obstructive lung disease.

 Pulmonary edema, atelactasis, pulmonary fibrosis.

 Patients that receive general anesthesia as well as post cardiac arrest patients.

CRITERIA FOR INSTITUTION OF VENTILATORY SUPPORT

 Pulmonary Function Studies:

 Respiratory rate (breath/min) >35 or < 6 (n=12-20)

 Tidal volume (ml/ kg body wt) <5 (normal5-8)

 Vital Capacity (ml/ kg body wt) <10-15 (n=65-75)

 Maximum Inspiratory Force (cm H2O) <20 (n=75-100)

 Arterial Blood Gases:

 PH <7.25 (n=7.35-7.45)

 Pao2 (mmHg)<50 (n=75-100) (on room air)

 Paco2 (mmHg)>50 (n=35-45)

MECHANICAL VENTILATOR

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 VENTILATOR TYPES

1. Negative Pressure Ventilator - periodically applies negative air pressure to the body to
contract and expand the chest cavity

2. Positive Pressure ventilators - air is pushed in to the lungs through the airways

3. High Frequency Ventilators - high frequency ventilators use small tidal volume at high
frequencies

TYPES OF POSITIVE PRESSURE VENTILATORS

a) Volume cycled ventilators: delivering a constant volume with each breath (pressure may
vary)

b) Pressure cycled ventilators: delivering a constant volume with each breath (volume
delivered may vary)

c) A combination of volume and Pressure cycled ventilators

d) Time cycled ventilators: inspiration is terminated when a preset inspiratory time has
elapsed. Time cycled ventilators are not used in adult critical care setting. They are used
in pediatric ICU.

VENTILATOR MODES

Mode refers to how the machine will ventilate the patient in relation to the patient’s own
respiratory efforts.

1. Control Mandatory Ventilation (CMV)

Ventilation is completely provided by the ventilator, and the ventilator totally controls the
patient's ventilation.

2. Assist-Control Ventilation (A/C)

 The ventilator provides the patient with a preset tidal volume at a preset rate and the
patient may initiate a breath on his own, but the ventilator assists by delivering a specified
tidal volume to the patient.

 The patient can breathe at a higher rate than the minimum number of breaths/minute that
has been set.

 The patient may need to be sedated to limit the number of breaths since hyperventilation
can occur.

 This mode is used for patients who can initiate a breath but who have weakened
respiratory muscles.

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 Disadvantages

 Dys-synchrony

 Respiratory alkalosis

3. Intermittent Mandatory Ventilation (IMV)

 The ventilator provides the patient with a preset number of breath/min at a specified tidal
volume and fio2. In between the ventilator-delivered breaths, the patient is able to breathe
spontaneously.

 The ventilator does not assist the spontaneous breaths.

 The mandatory breathing (ventilator) breaths are not synchronized with the patient's
spontaneous breathing.

4. Synchronized Intermittent Mandatory Ventilation (SIMV)

 SIMV delivers the preset volume and rate while allowing the patient to breathe
spontaneously in between ventilator breaths.

 Each ventilator breath is delivered in synchrony with the patient’s breaths. The ventilator
attempts to synchronize the set number of mandatory breaths with the patient’s
respiratory efforts

 SIMV is used as a primary mode of ventilation, as well as a weaning mode.

5. Pressure Support Ventilation (PSV)

 The patient initiates a breath. The ventilator delivers a predetermined level of positive
pressure each time

 Patient must initiate all pressure support breaths and completely controls the respiratory
rate and tidal volume.

 It is a mode used primarily for weaning from mechanical ventilation

Advantages

 The flow rate, inspiratory time, and frequency are variable and determined by the
patient

 Decreased inspiratory work of breathing

 Enhanced muscle reconditioning

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 Disadvantages

 Requires spontaneous respiratory effort

 Delivered volumes affected by changes in lung compliance (variable tidal volume,

RR)

ADJUNCTS TO VENTILATOR MODES

1. Positive End Expiratory Pressure (PEEP)

Advantages

 One method of improving the patient’s oxygenation without increasing the FiO2 is
the use of PEEP.

 Decreases physiological shunting

 Increased lung compliance

Disadvantages

 Increased incidence of pulmonary barotrauma

 Potential decrease in venous return

 Increased intracranial pressure

2. Constant Positive Airway Pressure (CPAP)

 CPAP is similar to PEEP except that it works only for patients who are breathing
spontaneously.

 CPAP allows the nurse to observe the ability of the patient to breathe spontaneously while
still on the ventilator.

 CPAP can also be administered using a mask and CPAP machine for patients who do not
require mechanical ventilation, but who need respiratory support, for example, patients
with sleep apnea.

VENTILATOR SETTINGS

1. Respiratory Rate (RR)

The respiratory rate is the number of breaths that the ventilator delivers to the patient each
minute.

2. Tidal Volume (Vt)

The tidal volume is the volume of gas the ventilator delivers to the patient with each breath.
The usual setting is 6-8 cc/kg.

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3. Fractional Inspired Oxygen (FIO2)

The percent of oxygen delivered to the patient. It can range from 0.21 (room air) to 1.
The100% oxygen should not be used continuously for long periods of time because of the
risk of oxygen toxicity.

4. Inspiratory: Expiratory (I: E) Ratio

It is the ratio of inspiratory time to expiratory time. The I: E ratio is usually set at 1:2 or 1:1.5
to approximate the normal physiology of inspiration and expiration.

5. Pressure Limit

The pressure limit regulates the amount of pressure delivered. Because high pressures can
cause lung injury, it’s recommended that the pressure not exceed 35 mmHG

6. Flow Rate

The flow rate is the speed with which the tidal volume is delivered. The usual setting is 40-
100 liters per minute.

7. Sensitivity/Trigger

The sensitivity determines the amount of effort required by the patient to initiate inspiration.

8. Sigh

Is a deep breathing that has greater volume than the tidal volume. It provides hyperinflation
and prevents collapse of the alveoli (atelectasis). The usual volume is 1.5-2 times tidal
volume, and usual rate is 4-5 times/ hour.

VENTILATOR ALARMS (ALARM TYPE)

1. Ventilator Inoperative

 Causes: Ventilator Failure

 Nursing Intervention: Manually ventilate patient and have someone else troubleshoot
the ventilator

2. Low Pressure

 Causes: Disconnected tubing

Leak in the system from a cuff leak, hole in the ventilator tubes,
a leak in the humidifier

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 Nursing Intervention: Secure all connections

Deflate, and then reinflate the cuff

Recheck cuff pressure

Change the tube

Tighten the humidifier

3. Apnea

 Causes: No spontaneous breath taken

 Nursing Intervention: Encourage patient to breathe or give him a single breath

Notify physician

4. High Pressure

 Causes: Increased secretions

Kinked ventilator tubing or ETT

Patient biting the ETT

Water in the ventilator tubing

ETT advanced into right main stem bronchus

Bronchospasm.

 Nursing Intervention: Suction the patient.

Unkink tubing

Check for adequacy lung sound bilaterally.

Place an oral airway in patient's mouth.

Empty water from tubing.

Notify the doctor.

Administer prescribed medication (bronchodilator)

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5. Oxygen

 Causes: The oxygen supply is insufficient or is not properly connected

O2 source failure

 Nursing Intervention: Notify staff

Manually ventilate the patient with oxygen source.

Monitor oxygen saturation

6. High Respiratory Rate

 Causes: Patient anxiety

Pain

Hypoxia

Fever

 Nursing Intervention: Assure the patient and try to relieve patient's anxiety

Notify physician and assess the patient

COMPLICATIONS OF MECHANICAL VENTILATION

 Ventilation and perfusion abnormalities

 Stretch injuries

 Oxygen toxicity Fio2 of 100% can cause pulmonary change within 6 hours Fio2 > 60%
for more than 48 hours

 Hemodynamic abnormalities

 Pulmonary infections

 Ventilator muscle atrophy

 Renal abnormalities

 Gastrointestinal complications

 Patient-ventilator desynchronize

 Communication difficulties

 Aspiration and dental trauma

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 Mucosal damage to oral, nasal, tracheal, or laryngeal tissue

 Venous thromboembolism

 Pain from multiple tubes,

 Stress and anxiety, and Psychological trauma

WEANING FROM MECHANICAL VENTILATION

Methods of weaning:

1. SIMV

2. T-piece trial

3. Spontaneous Breathing Trial without removing the patient from the ventilator; It can be
performed with (CPAP), with low level of PSV (5-8 cmH2O)

WHEN TO START WEANING FROM MECHANICAL VENTILATION

Ask yourself the following questions:

 Is the process responsible for the patient's respiratory failure resolving or improving?

 Is the patient hemodynamically stable?

 Are mental and neuromuscular statuses appropriate with the patient on minimal or no
sedation?

 Does the patient have adequate strength of the respiratory muscles?

 Are the acid-base status and electrolyte status optimized?

 Is the patient afebrile?

WEANING CRITERIA

 PEEP ≤ 5 - 8 cmH2O

 FiO2 ≤ to 40- 50%

 PH 7.25 or greater

 PaO2-FiO2 ratio >150 -200

 Hemodynamic stability as" the absence of active myocardial ischemia and the absence of
clinically important hypotension.

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 WHEN TO STOP WEANING TRIAL

Objective indices of failure:

 Tachypnea (respiratory rate > 35 breaths/ min for ≥ 5 min);

 Hypoxemia (oxygen saturation by pulse oximeter, <90%);

 Tachycardia (heart rate >140 beats/min; sustained rate increase >20%);

 Bradycardia (sustained heart rate decrease >20%);

 hypertension (systolic BP >180 mmHg); hypotension (systolic BP < 90 mmHg);

Subjective indices of failure

 Agitation,

 Diaphoresis,

 Anxiety

 Signs of increased work of breathing (accessory muscle use, paradoxical movements,

intercostal retractions nasal flaring

NURSING CARE FOR MECHANICALLY VENTILATED PATIENT

1. Assessment and monitoring the mechanically ventilated patient

2. Assess ventilator settings

3. Assess the ETT or tracheostomy tube

Assessment and Monitoring the Mechanically Ventilated Patient

 Respiratory Status

A Breath Sounds should be assessed at least every four hours while patients are
mechanically ventilated. Both the anterior and posterior chest should be auscultated
bilaterally.

 A good time to do this is when repositioning the patient every two hours;

 The following is a review of abnormal breath sounds:

 Crackles (rales) Fluid in small airways/alveoli

 Rhonchi; Airflow over secretions or narrowing of large airways

 Wheeze; Airflow through narrowed small airways

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 B Respiratory Rate and Tidal Volume

C Chest inspection

D Pulse Oximetry

E (Capnography)

 Cardiovascular Status

Continuous cardiac monitoring

CVP measurement

 Renal Status

Monitor fluid and electrolyte balance

Daily weight

Intake & output measurement

 Neurological Status

Assess level of consciousness

 Gastro-Intestinal Status

Gastric secretions should be closely monitored for bleeding (because these patients at
risk of developing stress ulceration).

Listen for bowel sound.

Perform a nutritional assessment

Assess Ventilator Settings

 Modes of ventilation

 Fio2

 Tidal volume VT

 Minute ventilation VE

 Respiratory rate

 PEEP or CPAP

 I: E ratio

 Sigh

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Check for:

Alarm setting.

Level of water in the humidifying unit.

Temperature of the humidifier.

Tubing and connections

Assess The ETT or Tracheostomy Tube

 Assess the tissue around the ETT.

 Check the tape regularly to make sure it is not soiled or loosened.

 Check ETT position.

 Check cuff inflation pressure.

NURSING INTERVENTIONS FOR MECHANICALLY VENTILATED PATIENT

 Discomfort

Due to uncomfortable body position, infrequent position changes, physical restraints,

ABG sticks, ETT suctioning, dry mouth & throat.

Nursing Intervention

 Performance of arterial puncture by skilled personal.

 Skilled and gentle suctioning technique.
 Frequent oral hygiene.
 Frequent changing position.
 Range of motion exercises to reduce the effect of immobility.
 Assisting the patient to a chair as often as possible when he is stable.

 Ineffective Airway Clearance

Nursing Interventions

 Providing adequate humidification and warming

 Performing measures to mobilize secretions through physiotherapy and proper
suctioning technique to clear the airway
 Tube care through:
 Assure ETT securely to prevent tube movement.
 Check ETT position.
 Check tube patency.
 Checking the cuff pressure.
 Placing an oral bite block to prevent the patient from biting on the tube.

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 Fear and Anxiety

The following factors have been reported as causing fear and anxiety in mechanically
ventilated patient:

 Alarm noises
 Dyspnea associated with suctioning
 Suction- induced coughing
 Constant bright lighting
 Inability to differentiate between night and day
 Fear of not able to return to normal activities
 Fear of dying

Nursing Interventions

 Provide adequate information and explanation of all procedures.

 Answer alarms promptly.
 Oxygenate the patient before and after suctioning and remain with the patient until
his respiratory pattern and vital signs return to normal.
 Keep noise level to a minimum especially during bed rest period.
 Diminished lights during the night to stimulate night and day cycles.
 Place clocks & calendars within the patient's view & verbally confirm time & date
with the patient.
 Communicate with the patient by suitable way

 Alteration in Nutritional Status

All critically ill patients, and especially who require MV are at risk of developing stress
ulceration and malnutrition.

Nursing Interventions

 Testing PH of the patient's gastric secretion.

 Administering the prescribed prophylactic medications that maintain gastric acidity.
 Providing the correct portions of fats, CHO, and proteins as well as water through
the parental or enteral routes.
 Monitoring urea, creatinine, albumin, and total protein regularly to assess patient's
nutritional status.

 Eye, Mouth and Skin Problems

Nursing Interventions

 Performing regular oral hygiene (every 2 hours) to prevent infection.

 Skin care should be focus on the frequent relief of pressure through:
 Turning the patient every 2 hours
 Using special mattress.
 Bathing the patient daily.
 Keeping patient's clothes clean and dry.
 Keeping the linen clean, dry and unwrinkled.
 Massaging & lubricating the back and over the bony prominences.

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  Eye care includes:
 Use of artificial tears.
 Application of antibiotic drops or ointments as order.
 Closing the eyelids with tape to prevent corneal ulceration.

 Electrolyte Imbalance

In mechanically ventilated patients, sodium and water retention may occur. These
changes may be manifested by electrolyte imbalance.

Nursing Interventions

 Monitoring fluid balance.

 Monitoring urinary output & should be maintained at 20-60 ml/ hr.
 Accurate recording of intake & output
 Constipation is a problem that is often overlooked in the critically ill patient.

 High Risk for Infection

When upper airway defense mechanisms are bypassed with the use of ETT, patients are
more at risk of developing a pulmonary infection, also may be related destruction during
intubation or suctioning. Sinusitis is also a problem to patients with nasal intubation.

Nursing Interventions

 Frequent hand washing

 Meticulous sterile technique should be used when:
 Suctioning suction on "as needed bases"
 Changing tracheostomy dressings, skin around tracheostomy stoma should be kept
free of secretions, dry, and clear at all time.
 Perform stoma care Ventilator equipment and tubing should be changed regularly
and sterilized. Changes the ventilator circuit every 24-72 hrs.
 Only sterile water should be used in the humidifier and nebulizer.
 Condensation in the ventilator tubing should be drained & discarded regularly.
 If oral airway is present, it should be removed and cleaned every 8-12 hrs.
 Monitor the following for early detection of infection:
 Vital signs (increase temperature above 38º C, heart rate above 100 b/m.
 Erythema of tracheostomy.
 Change in secretion's color, amount, consistency & odor, should be evaluated
with each suctioning.
 Blood culture
 Chest X-ray

 Difficulty in Communication

Ventilated person cannot vocalized because of the presence of artificial airway,

furthermore the intubated patients experience fear and helplessness, so communication is
necessary.

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 Nursing Interventions

 Touch and hand gesturing.

 Provide paper and pencil.
 Use word or letter boards/ picture boards.
 Use erasable marker board.

 Family Needs

It is essential for the critical care nurse to consider the family needs of the mechanically
ventilated patient through:

 Familiarizing the family with the physical surroundings of the critical care unit.
 Informing the family of the visiting hours.
 Providing family with progress reports about their patient's condition.
 Encouraging family participation in patient care whenever the patient's condition
allows.
 Allow the family members to be involved in weaning plan.

 Documentation

The nurse should document the following:

 Ventilator settings.
 Patient's vital signs
 I&O
 CVP
 ABG
 Nursing care provided.
 Weaning plan
 Time of starting weaning.
 Any abnormal findings or patient's manifestations.

NURSING ROLE IN WEANING

 Before Weaning:

Assess patient readiness for weaning through checking the following: Indications for the
implementation of mechanical ventilation have improved.

The following are corrected:

 Acid base abnormalities

 Fever
 Infection
 Anemia
 Fluid & electrolytes imbalance
 Hyperglycemia
 Sleep deprivation
 Weaning criteria are met
 Patient should be positioned upright to facilitate breathing

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  Patient should be suctioned before weaning and provide for rest period on ventilator
for 15-20 min.
 The process of weaning should be explained to the patient

 During Weaning:

 Wean only during the day.

 Remain with the patient during initiation of weaning.
 Instruct the patient to relax and breath normally
 Frequent monitor the respiratory rate, vital signs, ABG, and S&S of weaning

 Outcome of Weaning:

The patient should be continuously monitored during weaning for signs of weaning
Intolerance:

 RR > 35 breaths/ min for ≥ 5 min

 Spo2 <90%
 HR >140 beats/min
 Systolic BP >180 or < 90 mmHg);
 Agitation & anxiety
 Diaphoresis
 Paradoxical movements
 Decreased level of consciousness

 Record:

 Date & time of starting weaning

 Method of weaning used.
 ABGs & oxygen saturation
 Use of accessory muscle.
 Spontaneous RR
 Patient's response.
 Time spent in the weaning process.

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