HOLY CROSS COLLEGE OF NURSING, KOTTIYAM

ADVANCED NURSING PRACTICE

CLINICAL TEACHING

ON

MECHANICAL VENTILATOR

SUBMITTED BY: SUBMITTED TO:

MR. GIREESH S PILLAI MS. JISHA K JOSEPH

FIRST YEAR MSc NURSING LECTURER

HOLY CROSS COLLEGE OF – HOLY CROSS COLLEGE OF-

NURSING, KOTTIYAM NURSING, KOTTIYAM

SUBMITTED ON: 26.12.2019

Name of student : Mr. Gireesh S Pillai Class : III Year BSc Nursing

Subject : Advanced Nursing Practice No. of Students :

Unit :XI Date &Time :

Topic of Lesson : Mechanical Ventilator Duration : 30 minute

Previous Knowledge of Students : Magazines, Books, Media Venue : Holy Cross Hospital, Kottiyam

Method of Teaching : Lecture Cum Discussion

AV Aids : LCD With Projector, Leaflets, Charts, Pamphlet

 GENERAL
OBJECTIVES

At the completion of the class the group will be gain adequate knowledge regarding the “Mechanical Ventilator” and will be
able to practice knowledge in future with a positive attitude.

SPECIFIC OBJECTIVES:

At the end of the class students will be able to

define Mechanical ventilator

outline the goals of mechanical ventilator

list down the indications of mechanical ventilator

Specific Objectives explain the types of mechanical ventilator

enumerate the modes of mechanical ventilator

illustrate the nursing assessment &intervention of mechanical ventilator

Sl Time Specific Contents Teaching Student AV Aids Evaluation
No Objectives Activities Activities

1 1Minute INTRODUCTION Teacher

The mechanical ventilator device functions as a Introduces
substitute for the bellows action of the thoracic cage the topic
and diaphragm. The mechanical ventilator can through
maintain ventilation automatically for prolonged narration.
periods. It is indicated when the patient is unable to
maintain safe levels of oxygen or CO2 by spontaneous
breathing even with the assistance of other oxygen
delivery devices.
Mechanical ventilation is a method to
mechanically assist or replace spontaneous breathing.
This may involve a machine called a ventilator or the
breathing may be assisted by a registered nurse,
physician, respiratory therapist, paramedic, or other
suitable person compressing a bag or set of bellows.
Mechanical ventilation is termed "invasive" if it
involves any instrument penetrating through the mouth
(such as an endotracheal tube) or the skin (such as a
tracheostomy tube). There are two main modes of
mechanical ventilation within the two divisions:
positive pressure ventilation, where air (or another gas
 mix) is pushed into the trachea, and negative pressure Teacher
ventilation, where air is, in essence, sucked into the Announce
lungs. the topic

At the end of
class student
will be able
to:

2 2 Minute define DEFINITION Teacher Actively LCD with

mechanical “A mechanical ventilator is a machine that helps a defines listen & Projector
ventilation patient breathe (ventilate) when they are having mechanical take down
surgery or cannot breathe on their own due to a critical ventilation notes
illness. The patient is connected to the ventilator with a
hollow tube (artificial airway) that goes in their mouth
and down into their main airway or trachea.”
(American Heart Association)

“Mechanical ventilation can be defined as the

technique through which gas is moved toward and
from the lungs through an external device connected
directly to the patient.” What is-
Mechanical
Ventilation?
3 2 Minute outline the GOALS OF MECHANICAL Teacher Reading LCD with
goals of VENTILATION outlines the AV aids Projector
mechanical  Relieve respiratory distress goals of &take
ventilator  Decrease work of breathing mechanical downs

 Improve pulmonary gas exchange ventilator notes What are

 Reverse respiratory muscle fatigue the goals of

 Permit lung healing mechanical

 Avoid complications ventilators?

3 5 Minute list down the CLINICAL INDICATIONS OF MECHANICAL Teacher list Asking LCD with
clinical VENTILATORS downs the doubts & Projector
indications of  Neuromuscular disease clinical take
mechanical  Central nervous system (CNS) disease indications downs
ventilation  CNS depression (drug intoxication, respiratory of notes
depressants, cardiac arrest) mechanical
 Musculoskeletal disease ventilation
 Inefficiency of thoracic cage in generating
pressure gradients necessary for ventilation
(chest injury, thoracic malformation)
Disorders of Pulmonary Gas Exchange
 Acute respiratory failure What are
 Chronic respiratory failure the clinical
 Left ventricular failure indications
 Pulmonary diseases resulting in diffusion of -
 abnormality mechanical
 Pulmonary diseases resulting in ventilation- ventilation?
perfusion mismatch.

4 10 Minute explain the TYPES OF VENTILATORS Teacher Observing LCD with

types of  Negative Pressure Ventilators explains the AV aids Projector
mechanical  Applies negative pressure around the chest types of and take
ventilators wall. This causes intra-airway pressure to mechanical downs -
become negative, thus drawing air into the ventilators notes
lungs through the patient's nose and mouth.
 No artificial airway is necessary; patient
must be able to control and protect own
airway.
 Indicated for selected patients with
respiratory neuromuscular problems, or as
adjunct to weaning from positive pressure
ventilation.
 Examples are the iron lung and cuirass
ventilator.
 Positive Pressure Ventilators
During mechanical inspiration, air is actively delivered
to the patient's lungs under positive pressure.
Exhalation is passive. Requires use of a cuffed
artificial airway
 Pressure limited
 Terminates the inspiratory phase when a
preselected airway pressure is achieved.
 Volume delivered depends on lung
compliance.
 Use of volume-based alarms is recommended
because any obstruction between the
machine and lungs that allows a build-up of
pressure in the ventilator circuitry will cause
the ventilator to cycle, but the patient will
receive no volume.
Volume limited
 Terminates the inspiratory phase when a
designated volume of gas is delivered into
the ventilator circuit (5 to 7 mL/kg body
weight (usual starting volume).
 Delivers the predetermined volume
regardless of changing lung compliance
(although airway pressures will increase as
compliance decreases). Airway pressures
vary from patient to patient and from breath
to breath.
 Pressure-limiting valves, which prevent
excessive pressure build-up within the
 patient-ventilator system, are used. Without
this valve, pressure could increase
indefinitely and pulmonary barotrauma could What are
result. Usually equipped with a system that the types of
alarms when selected pressure limit is mechanical
exceeded. Pressure-limited settings terminate ventilator?
inspiration when reached.

5 6 Minute enumerate the MODES OF OPERATION Teacher Asking LCD with

modes of Controlled Ventilation enumerates doubts Projector
mechanical  Cycles automatically at rate selected by the modes
ventilators operator. of

 Provides a fixed level of ventilation, but mechanical

will not cycle or have gas available in ventilators
circuitry to respond to patient's own
inspiratory efforts. This typically
increases work of breathing for patients
attempting to breathe spontaneously.
 Possibly indicated for patients whose
respiratory drive is absent
Assist/Control Ventilation
 Inspiratory cycle of ventilator is activated
by the patient's voluntary inspiratory
effort and delivers preset volume or
 pressure.
 Ventilator also cycles at a rate
predetermined by the operator. Should the
patient stop breathing, or breathe so
weakly that the ventilator cannot function
as an assistor, this mandatory baseline rate
will prevent apnoea. A minimum
respiratory rate is provided.
 Indicated for patients who are breathing
spontaneously, but who have the potential
to lose their respiratory drive or muscular
control of ventilation. In this mode, the
patient's work of breathing is greatly
reduced.
Intermittent Mandatory Ventilation
 Allows patient to breathe spontaneously
through ventilator circuitry.
 Periodically, at preselected rate and
volume or pressure, cycles to give a
mandated ventilator breathe. A minimum
level of ventilation is provided.
 Gas provided for spontaneous breaths
usually flows continuously through the
ventilator.
  Indicated for patients who are breathing
spontaneously, but at a tidal volume
and/or rate less than adequate for their
needs. Allows the patient to do some of
the work of breathing.
Synchronized Intermittent Mandatory
Ventilation
 Allows patient to breathe spontaneously
through the ventilator circuitry.
 Periodically, at a preselected time, a
mandatory breath is delivered. The patient
may initiate the mandatory breath with
own inspiratory effort, and the ventilator
breath will be synchronized with the
patient's efforts, or will be assisted. If the
patient does not provide inspiratory effort,
the breath will still be delivered, or
controlled.
 Gas provided for spontaneous breathing is
usually delivered through a demand
regulator, which is activated by the
patient.
 Indicated for patients who are breathing
spontaneously, but at a VT and/or rate less
 than adequate for their needs. Allows the
patient to do some of the work of
breathing.
Pressure Support Ventilator
 A positive pressure is set.
 During spontaneous inspiration, ventilator
circuitry is rapidly pressurized to the
predetermined pressure and held at this
pressure.
 When the inspiratory flow rate decreases to a
preset minimal level (20% to 25% of peak
inspiratory flow), the positive pressure returns
to baseline and the patient may exhale.
 The patient ventilates spontaneously,
establishing own rate, and inspiring the VT that
feels appropriate.
 Pressure support may be used independently as
a ventilator mode or used in conjunction with
CPAP or synchronized intermittent mandatory
ventilation (SIMV).
Special Positive Pressure Ventilation
Techniques
 Positive End-Expiratory Pressure:
 Maneuver by which pressure during
 mechanical ventilation is maintained above
atmospheric at end of exhalation, resulting in
an increased functional residual capacity.
Airway pressure is therefore positive
throughout the entire ventilator cycle.
 Purpose is to increase functional residual
capacity (or the amount of air left in the
lungs at the end of expiration). This aids in:
o Increasing the surface area of gas exchange.
o Preventing collapse of alveolar units and
development of atelectasis.
o Decreasing intrapulmonary shunt.
 Benefits:
o Because a greater surface area for diffusion
is available and shunting is reduced, it is
often possible to use a lower FIO2 than
otherwise would be required to obtain
adequate arterial oxygen levels. This
reduces the risk of oxygen toxicity in
conditions such as acute respiratory distress
syndrome (ARDS).
o Positive intra-airway pressure may be
helpful in reducing the transudation of fluid
from the pulmonary capillaries in situations
 where capillary pressure is increased (i.e.,
left-sided heart failure).
o Increased lung compliance resulting in
decreased work of breathing.
 Hazards:
o Because the mean airway pressure is
increased by PEEP, venous return is
impeded. This may result in a decrease in
cardiac output (especially noted in
hypovolemic patients).
o There is disagreement that the increased
airway pressure may possibly result in
alveolar rupture. The likelihood of damage
is greater from peak airway pressure during
mechanical ventilation than end-expiratory
pressure. The likelihood is greater in
patients with noncompliant lungs. This
barotrauma may result in pneumothorax,
tension pneumothorax, or development of
subcutaneous emphysema.
o The decreased venous return may cause
antidiuretic hormone formation to be
stimulated, resulting in decreased urine
output.
 Precautions:
 Monitor frequently for signs and symptoms
of pneumothorax (increased pulmonary
artery pressure, increased size of
hemothorax, decreased lung movement,
hyper resonant percussion, diminished
breath sounds).
 Monitor for signs of decreased venous
return (decreased blood pressure, decreased
cardiac output, decreased urine output,
peripheral edema).
 Abrupt discontinuance of PEEP is not
recommended. The patient should not be
without PEEP for longer than 15 seconds.
The manual resuscitation bag used for
ventilation during suction procedure or
patient transport should be equipped with a
PEEP device. In-line suctioning may also
be used so PEEP can be maintained. Some
clinicians believe that loss of PEEP for
short periods is not detrimental in the lower
ranges (less than 10 cm H2O). An
exception might be patients with increased
ICP.
  Intrapulmonary blood vessel pressure may
increase with compression of the vessels by
increased intra-airway pressure. Therefore,
central venous pressure (CVP), pulmonary
artery pressure (PAP), and pulmonary
capillary wedge pressure (PCWP) may be
increased. The clinician must bear this in
mind when determining the clinical
significance of these pressures.
 Continuous Positive Airway Pressure:
 Also provides for positive airway pressure
during all parts of a respiratory cycle, but
refers to spontaneous ventilation rather than
mechanical ventilation.
 May be delivered through ventilator circuitry
when ventilator rate is at or may be delivered
through a separate continuous positive
airway pressure (CPAP) circuitry that does
not require the ventilator.
 Indicated for patients who are capable of
maintaining an adequate tidal volume, but
who have pathology preventing maintenance
of adequate levels of tissue oxygenation or
for sleep apnoea.
  CPAP has the same benefits, hazards, and What are
precautions noted with PEEP. Mean airway the modes
pressures may be lower because of lack of of
mechanical ventilation breaths. This results mechanical
in less risk of barotrauma and impedance of ventilator?
venous return.

6 6 Minute illustrate the Teacher Actively LCD with

NURSING ASSESSMENT AND
nursing illustrate the listening Projector
INTERVENTIONS
assessment nursing and
 Monitor for complications.
And assessment reading
 Airway obstruction (thickened secretions,
intervention of And AV aids
mechanical problem with artificial airway
mechanical intervention
or ventilator circuitry)
ventilator of
 Tracheal damage
mechanical
 Pulmonary infection
ventilator
 Barotrauma (pneumothorax or tension
pneumothorax)
 Decreased cardiac output
 Atelectasis
 Alteration in GI function (dilation,
bleeding)
 Alteration in renal function
 Alteration in cognitive-perceptual status
  Respiratory acidosis or alkalosis
 Suction the patient as indicated.
 When secretions can be seen or sounds
resulting from secretions are heard with or
without the use of a stethoscope
 After chest physiotherapy
 After bronchodilator treatments
 After a sudden rise or the popping off of the
peak airway pressure in mechanically
ventilated patients that is not due to the
artificial airway or ventilator tube kinking,
the patient biting the tube, the patient
coughing or struggling against the
ventilator, or a pneumothorax.
 Provide routine care for patient on
mechanical ventilator. Provide regular oral
care to prevent ventilator-associated
pneumonia. Provide humidity and
repositioning to mobilize secretions.
 Assist with the weaning process, when
indicated (patient gradually assumes
responsibility for regulating and performing
own ventilations.
 Patient must have acceptable ABG values,
 no evidence of acute pulmonary pathology,
and must be hemodynamically stable.
 Obtain serial ABGs and/or oximetry
readings, as indicated.
 Monitor very closely for change in pulse
and blood pressure, anxiety, and increased
rate of respirations. The use of anxiolytics
to assist with weaning the anxious patient is
controversial; they may or may not be
beneficial.
 Once weaning is successful, extubate and
provide alternate means of oxygen. What are
 Extubation will be considered when the the nursing
pulmonary function parameters of VT, vital role of
capacity (VC), and negative inspiratory force client with
(NIF) are adequate, indicating strong mechanical
respiratory muscle function. ventilator?
7 3 Minute enlist the COMPLICATIONS OF MECHANICAL Teacher Actively LCD with
complications enlists the listening Projector
VENTILATOR
of mechanical complicatio and asking
 Pneumothorax
ventilators ns of doubts
 Airway injury
mechanical
 Alveolar damage
ventilators
 Ventilator associated pneumonia
 Diaphragm atrophy
  Decrease cardiac output What are
 Oxygen toxicity the compli-
 Acute respiratory distress syndrome cation of
 Acute lung injury mechanical
ventilator?
8 1 Minute SUMMARY Teacher
Now learning regarding the topic we came to know summarizes
the introduction, definition, goals, types, modes and the topic
nursing assessment and intervention of mechanical
ventilator.

9 1 Minute RECAPITULATION Actively

1. What is mechanical ventilator? answering
2. What are the types of mechanical ventilator?
3. What are the complication of mechanical
ventilator?

10 1 Minute ASSIGNMENT
“Nursing Responsibility client with mechanical
ventilator” on…………(Date) in First year MSc
Nursing Classroom at 10:00 am...
11 1 Minute CONCLUSION Teacher

Mechanical ventilation is also called positive concludes

pressure ventilation. Following an inspiratory trigger, a the topic
predetermined mixture of air (i.e. oxygen and other
gases) is forced into the central airways and then flows
into the alveoli. As the lungs inflate, the intra alveolar
pressure increases. A termination signal eventually
causes the ventilator to stop forcing air into the central
airways and the central airway pressure decreases.
Expiration follows passively, with air flowing from the
higher pressure alveoli to the lower pressure central
airways.

12 BIBLIOGRAPHY
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Philadelphia.
 American Heart Association (2010). ACLS
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(2009). Egan’s fundamentals of respiratory
care (9th ed.). St.Louis, MO: Mosby.
 Slutsky, A.S. (1993). Mechanical ventilation:
American College of Chest Physicians’
 Consensus Conference.Chest, 104, 1833.
 Datta Parul:(2007); Paediatric Nursing. 1st
edition. Mosby publication New Delhi, Pp-298.
 Hockenberry J. Marylin, Wilson David (2009)
Wongs Essentials of Paediatric Nursing,
Eighth edition. Mosby publication. U.P.
Pp.148, 850-853.
 Marlow R. Dorothy, Redding A. Barbara
(2006). Textbook of Paediatric Nursing
Reprinted 2006. Elsevier publication. New
Delhi. Pp-439-440
 Parthasarathy A., (2006).Textbook of
Paediatrics.3rd edition. Jaypee Brothers
Medical publishers New Delhi. Pp-1000-1006.

 Woodruff, D (2005). A quick guide to vent

essentials. Retrieved from
http://www.modernmedicine.com/modern-
medicine/news/quick-guide-vent-essentials