#Ventilators

VENTILATORS
and Mechanical Ventilation
- Dr Nisar Ahmed Arain
- Assistant Professor
-Anesthetist/Critical Care/ER

-CONTENTS
-1-Anatomy and Physiology of Respiratory system
-2-Introduction about Mechanical Ventilation
-3-History
-4-Meaning of Mechanical Ventilation
-5-Indications for Use
-6-Types of Forms of Mechanical ventilation
-7-Settings of Mechanical Ventilation
-8-Modes of Mechanical Ventilation
-9-Complications associated with Mechanical Ventilation
-10-Nursing management of Ventilator Patients

-Anatomy and Physiology of Respiratory System

Introduction about
Mechanical Ventilation
--Mechanical Ventilation is typically used
after an invasive intubation, a procedure
wherein an endotracheal or tracheostomy
tube is inserted into the airway.
-- It is used in acute settings such as in the
ICU for a short period of time during a
serious illness.
--It may be used at home or in a Nursing or
re-habilitation institution, if patients have
chronic illnesses that require long term
Ventilation assistance.

-HISTORY
--The Roman Physician Galen may
have been the first to describe
Mechanical Ventilation.
--If you take a dead animal and blow air
through its Larynx [Through a reed],
you will fill its bronchi and watch its
lungs attain the greatest distension.
-- Vesalius too describes ventilation by
inserting a reed or Cane into the
trachea of the animals.
--In 1908 George Poe demonstrated
his Mechanical respirator by
asphyxiating Dogs and seemingly
bringing them back to life

-MEANING OF MECHANICAL VENTILATION
-In Medicine, Mechanical Ventilation is a method
to mechanically assist or replace of Spontaneous
breathing

-INDICATIONS FOR USE OF VENTILATOR
Common Medical indications for use include
--Acute Lung injury (Including ARDS, Trauma)
--Apnea with respiratory arrest, including cases from
Intoxication
--Chronic obstructive Pulmonary disease (COPD)
--Acute Respiratory acidosis with partial pressure of carbon
dioxide (pCO2) >50 mmHg and pH <7.25 which may be due
to paralysis of the Diaphragm due to “Guillain Barre”
syndrome, Myasthenia Gravis, Spinal Cord injury, or the effect
of Anesthetic drugs and Muscle relaxant drugs
--Increased work of breathing as evidenced by significant
Tachypnea retractions, and other physical signs of Respiratory
distress.
--Hypoxemia with arterial partial pressure of Oxygen (PaO2) with
supplemental fraction of inspired oxygen (FiO2) < 55 mmHg
--Hypotension including Sepsis, shock, Congestive heart Failure
--Neurological diseases such as Muscular Dystrophy Amyotrophic
lateral sclerosis

-TYPES OR FORMS OF MECHENICAL VENTILATION
--The two major types of Mechanical ventilation
are Negative pressure and positive pressure
ventilation
--The main form of Mechanical ventilation,
which works by increasing the pressure in
the patient’s airway and thus forcing air into
the lungs. Less common today are
Negative pressure ventilators
(For Example, the “Iron lung”) that create a
negative pressure environment around the
patient’s chest, thus sucking air into the lungs

--Types or Forms of Mechanical Ventilation
-Negative pressure ventilation
-Positive pressure ventilation

-Settings of Mechanical Ventilation
--Mechanical Ventilator Settings
Regulates the Rate, Depth and
other characteristic's of
ventilation Settings are based
on the patient’s Status
(ABG’s, Body weight, level
of Consciousness and Muscle
strength

-PARAMETERS OF
MECHANICAL VENTILATION
ARE FOLLOWING
--RESPIRATORY RATE (f) :- Normally 10 to 20 b/m
--TIDAL VOLUME (VT) :- 5 --- 15 ML / Kg
--OXYGEN CONCENTRATION (FIO2) :-b/w 21--90%
-- I : E Ratio :- 1: 2
--FLOW RATE :- 40– 100 L/ min
--SENSITIVITY / TRIGGER :- 0.5 1.5 cm H2O
--PRESSURE LIMIT :- 10---25 cm H2O
--PEEP :- Usually, 5---10 cm H2O

-CONNECTION TO VENTILATORS
--FACE MASK
--AIR WAY
--LARYNGEAL MASK
--TRACHEAL INTUBATION
--TRACHEOSTOMY

--MODES OF MECHANICAL VENTILATION
--Controlled Mandatory Ventilation (CMV)
--Assist—Control Mandatory Ventilation (ACV)
--Synchronized Intermittent Mandatory
Ventilation (SIMV)
--Positive Expiratory End Pressure (PEEP)
--Continuous Positive Airway Pressure (CPAP)
--Pressure Support Ventilation (PSV)

-MODES OF
MECHENICAL VENTILATION

--CONTROLLED MADATORY
VENTILATION (CMV)
-CONTROLLED MECHANICAL VENTILATION(CMV)
--In this mode the ventilator provides a
mechanical breath on a present timing
Patients respiratory efforts are ignored.
--This is generally uncomfortable for
children and adults who are conscious
and is usually only used in an
unconscious patient.
--It may also be used in infants who often
quickly adapt their breathing pattern to
the ventilator timing

-ASSIST – CONTROL MANDATORY VENTILATION (ACV)
-Assist control (AC):-In this mode the Ventilator provides
a mechanical breath with either a Pre-set tidal volume
or Peak pressure, every time a patient initiates a breath.
--Traditional control used only a Pre-set tidal volume.
--When a Pre-set Peak pressure is used, this is also
sometimes termed Intermittent Positive pressure
Ventilation or IPPV.
--However the initiation timing is the same-both provides
a ventilator breath with patients every effort.
--In most ventilators a back up minimum breath rate can
be set in the event that the patient becomes apnoeic.
--Although a maximum rate is not usually set, an alarm can
be set if the ventilator cycles too frequently.
--This can alert that the patient is Tachypneic or that the
ventilator may be auto-cycling (A problem that results
when the ventilator interprets fluctuations in the circuit
due to the last breath termination as a new breath
initiation attempt.

-SYNCHRONIZED INTERMITENT MANDATORY VENTILATION (SIMV)
--In this mode the ventilator provides a pre-set Mechanical breath
(Pressure or volume limited every specified number of seconds
( determined by dividing the respiratory rate into 60 – thus a
respiratory rate of 12 results in a 5 second cycle time).
-- Within that cycle time the ventilator waits for the patient to initiate
a breath using either a pressure or flow sensor.
-- When the ventilator senses the first patients breathing attempt
within the cycle, it delivers the Pre-set ventilator breath.
-- If the patient fails to initiate a breath , The ventilator delivers a
Mechanical breath at the end of the breath cycle.
--Additional spontaneous breaths after the first one within the breath
cycle do not trigger another SIMV breath. However SIMV may be
combined with pressure support.
-- SIMV is frequently employed as a method of decreasing ventilatory
support. (weaning) by turning down the rate, which requires the
patient to take additional breaths beyond the SIMV triggered breath.
--SYNCHRONIZED INTERMITENT MANDATORY VENTILATION (SIMV):-

-POSETIVE END EXPIRATORY PRESSURE
--PEEP:- is functionally the same as CPAP, but refers to the
use of an elevated pressure during the Expiratory Phase of
the ventilatory cycle. After delivery of the set amount of
breath by the ventilator, the patient then Exhales passively.
-- The volume of gas remaining in the lung after a normal
Expiration is termed “Functional Residual Capacity” (FRC).
--The FRC is Primarily determined by the elastic qualities of
the lung and chest wall.
--In many lung diseases, leading to a decreased surface area
for gas exchange and Intrapulmonary shunting with wasted
oxygen inspired.
-- Adding PEEP can reduce the work of breathing
(at low levels) and help pressure FRC.

-CONTINUOUS POSETIVE
AIRWAY PRESSURE (CPAP)
--(CPAP)-=A continuous level of elevated
pressure is provided through the patient
circuit to maintain adequate oxygenation,
decrease the work of breathing, and
decrease the work of heart (such as in
Left-sided heart failure --- CHF)
--Note that no cycling of ventilator pressure
occurs and the patient must initiate all
breaths
--In addition, no additional pressure above the
CPAP pressure is provided during those
breaths
--CPAP may be used invasively through an
endotracheal tube or tracheostomy or
non-invasively with a face mask or nasal
prongs

-PRESSURE SUPPORT VENTILATION
-Pressure support ventilation (PSV).
--When a patient attempts to breath spontaneously
through an endotracheal tube, the narrowed
diameter of the airway results in higher
resistance to airflow, and thus a higher work
of breathing.
--PSV was developed as a method to decrease the
work of breathing in-between ventilator
mandated Breaths by providing an elevated
pressure triggered by spontaneous breathing
that “supports” ventilation during Inspiration

--COMPLICATIONS
--HYPOTENSION
--PNEUMOTHORAX
--DECREASED CARDIAC OUTPUT
--NOSOCOMIAL PNEUMONIA
--POSETIVE WATER BALANCE
--INCREASED INTRACRANIAL PRESSURE (ICP)
--ALARMS TERNED OFF OR NON-FUNCTIONAL
--SINUSITIS AND NASAL INJURY
--MUCOSAL LESIONS
--ASPIRATION
ASPIRATION
-G.I Bleeding
-In appropriate Ventilation
-Respiratory Acidosis OR Alkalosis
-Thick Secretions
-Patients discomfort due to
Pulling OR Jarring of ETT or
tracheostomy
-High PaO2
-Low PaO2
-Anxiety and Fear
-Dysrhythmia's or vagal reactions during
or after Suctioning
-Incorrect PEEP setting
-Inability to tolerate Ventilator Mode

-TERMINOLOGIES USED IN MECHANICAL VENTILATION
--APRV---airway-pressure-release-ventilation
--ASB---assisted-spontaneous-breathing
--ASV—assisted-spontaneous breathing
--ASV---adaptive support ventilation
---a patented technology
---closed-loop-mechanical-respiration
---a further development of MMV
---can also stand for assisted spontaneous
ventilation
--ATC---automatic-tube-compensation
--BIPAP---biphasic positive airway pressure
--CMV---continuous mandatory ventilation
--CPAP---continuous-positive-airway-pressure
--CPPV---continuous-positive-pressure-ventilation
--EPAP---expiratory-positive-airway-pressure

-TERMINOLOGIES USED IN MECHANICAL VENTILATION cont.
--HVF---high-frequency-ventilation
a-HFFI—high-frequency-flow-interruption
b-HFJV---high frequency-jet-ventilation
--HFOV---high-frequency-oscillatory-ventilation
--HFPPV---high-frequency-positive-pressure-ventilation
--ILV---independent-lung-ventilation
also called separate sides positive pressure ventilation
--IPAP---inspiratory positive airway pressure
--IPPV---intermittent-positive-pressure-ventilation
--IRV---inversed-ratio-ventilation (mechanical ventilation
with switched respiration phases / time rate.
--LEPPV—low-frequency-positive-pressure-ventilation
—MMV---mandatory-minute-volume
--NAVA---neutrally-adjusted-ventilatory-assistant

-NURSING MANAGEMENT
--CHECK THE AIR AND OXYGEN CONNECTIONS
--CONNECT THE VENTILATOR TUBES TO VENTILATOR
-HOW TO KEEP THE VENTILATOR
READY TO RECEIVE THE CASE

--CONNECT THE CHEST LUNG
TO THE VENTILATOR TUBINGS
--MAKE SURE THAT YOU CORRECTLY
CONNECTED THE TUBING’S AND
CHECK FOR ANY LOOSENESS
-HOW TO KEEP VENTILATOR READY TO RECEIVE THE CASE

--CONNECT THE SERVO GUARD
FROM THE PATIENT
--CONNECT THE FILTER
TO THE PATIENT

--HOW TO KEEP VENTILATOR READY TO RECEIVE THE CASE
--CHECK THE TUBING’S
FOR ANY LEAKAGE
--CHANGE THE BACTERIA FILTER

--CHANGE THE BACTERIAL FILTER

-PLAN OF THE CARE FOR THE
VENTILATED PATIENT
-PATIENTS GOALS
--Patients will have effective breathing pattern
--Patients will have adequate gas exchange.
--Patient’s Nutritional status will be maintained
to meet body needs
--Patient will not develop a pulmonary infection
--patient will not develop problems related to immobility.
--Patient and / or family will indicate understanding
of the purpose for Mechanical ventilation

--NURSING INTERVENTIONS--1
--Observe changes in respiratory rate and
depth Observe for the use of necessary
muscles
--Observe for tube misplacement – note
and post cm. marking at lip / teeth after
x ray confirmation
--prevent accidental extubation by taping
tube securely, by checking q.2h
restarting / sedating as needed

-NURSING INTERVENTIONS--2
--Inspect thorax for symmetry of movement
determines adequacy of breathing pattern;
asymmetry may indicate “Hemothorax or
Pneumothorax”. Measure Tidal volume and
vital capacity
--Asses for Pain
--Monitor Chest X Rays
--Maintain ventilator settings as ordered

--Elevate head of bed from 60 to 90 degrees. This
condition moves the abdominal contents away
from the diaphragm, which facilitates its
contraction
--Monitor ABG’s. Determines acid base balance
and need for oxygen.
--Observe skin colour and capillary refill. Determine
adequacy of blood flow needed to carry oxygen
to the tissues

--Observe for tube obstruction; suction;
and ensure adequate humidification
--Provide nutrition as ordered, e.g TPN
lipids or parental feedings.
--Use disposable saline irrigation units
to rinse in-line suction; ensure
ventilator tubing changed q. 7 days,
in-line suction changed q. 24 h.;
Ambu bags changes between patients
and whenever become soiled

- NURSING INTERVENTIONS--5
--Asses for G.I problems. Preventative
measures include relieving anxiety,
antacids or H2 receptor antagonist therapy,
adequate sleep cycles, adequate
communication system.
--Maintain muscle strength with active
/active-assistive / passive ROM and
prevent contractures with use of span-acid
splints

--Explain purpose / Mode / and all treatments.
--Encourage patient to relax and breath with
the ventilator.
-- Explain Alarms; teach importance of deep
breathing
--Provide alternate method of communication
--Keep call bell within reach of patient
--Keep informed of results of studies / progress
--Demonstrate confidence

--THINGS WHICH WE SHOULD
NOT FORGET
-SUCTIONING
-MOUTH CARE
-NEBULIZATION

-DEFINATION
--A Medical ventilator is a
machine designed to provide
mechanical ventilation by
moving breathable air into
and out of the lungs, to deliver
breaths to a patient who is
physically unable to breath,
or breathing in-sufficiently

-BAG IN A BOTTLE
VENTILATORS
--Most Anesthesia ventilators have
a bellows in a box (Bag in a bottle,
double circuit) design
--The bellows is housed in a
pressure chamber, and the
inside of the bellows Is connected
to the breathing system

-OXYLOG VENTILATORS
WHAT IS HFOV
--This is not to be confused with the high
frequency jet ventilation (HFJV) which
is rarely used
--Its First established used is in neonatal
ARDS
--HFOV’s claim to fame is reduced of
ventilator-induced Lung injury (VILI)

--DRAGER OXYLOG 3000 PLUS
VENTILATOR

-DRAGER OXYLOG 3000 PLUS
VENTILATOR IN USE

-OXYLOG VENTILATORS
ANOTHER SHAPE

-BLEASE MEDICAL MANLEY MP3 VENTILATOR

-MANUAL JET VENTILATION FIXING

-FEATURES OF Manual Jet Ventilation
--The manual jet ventilator consists of five
permanently assembled parts
1-Hose to connect to high pressure
(50 psi) oxygen supply with DISS
connector (we keep an additional
adapter for an Ohio-Quick-Connect
outlet attached to the device
2-Flow Regulator
3-Valve with lever
4-Manometer
5-Hose to connect to patient side with
Luer-Lock-Adapter

-HIGH FREQUENCY VENTILATION
-High frequency ventilation is a type of
Mechanical ventilation which utilizes a
respiratory rate greater than four (4) times
the normal value, and very small Tidal
Volumes.
-High frequency ventilation is thought to
reduce ventilator-associated lung injury,
especially in the context of ARDS and
acute lung injury.

-HIGH FREQUENCY JET VENTILATOR

-THE BIRD VIP INFANT VENTILATOR

-TRANSPORT VENTILATORS:-
-These are small and more rugged, and can be powered
pneumatically or via AC or DC power sources

-INTENSIVE CARE VENTILATORS
NEGATIVE PRESSURE VENTILATORS

-INTENSIVE CARE VENTILATORS
NEGATIVE PRESSURE VENTILATORS
--IRON LUNG VENTILATORS

-THANK YOU
-SAVE THE LIFE SAFELY

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