NURSING MANAGEMENT OF

MECHANICALLY VENTILATED
PATIENTS

Presented By
Bibini Baby
2nd year MSc. Nsg
Govt. College of Nsg
Kottayam
1
 Spontaneous respiration vs.
Mechanical ventilation
• Natural Breathing
– Negative inspiratory force
– Air pulled into lungs
• Mechanical Ventilation
– Positive inspiratory pressure
– Air pushed into lungs

2
 Mechanical ventilation
• Negative pressure
• Positive pressure
 Invasive
 Noninvasive

3
 Negative-Pressure Ventilators

• Early negative-pressure ventilators were

known as “iron lungs.”

• The patient’s body was encased in an iron

cylinder and negative pressure was generated

• The iron lung are still occasionally used

today.

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• Intermittent short-term negative-pressure
ventilation is sometimes used in patients with
chronic diseases.

• The use of negative-pressure ventilators is

restricted in clinical practice, however, because they
limit positioning and movement and they lack
adaptability to large or small body torsos (chests) .

• Our focus will be on the positive-pressure

ventilators.

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POSITIVE PRESSURE VENTILATION
(INVASIVE)

7
Initiation of Mechanical Ventilation

• Indications
– Indications for Ventilatory Support
–Acute Respiratory Failure
–Prophylactic Ventilatory Support
–Hyperventilation Therapy

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 Initiation of Mechanical Ventilation

• Indications
– Acute Respiratory Failure (ARF)
• Hypoxic lung failure (Type I)
– Ventilation/perfusion mismatch
– Diffusion defect
– Right-to-left shunt
– Alveolar hypoventilation
– Decreased inspired oxygen
– Acute life-threatening or vital
organ-threatening tissue hypoxia 9
 Initiation of Mechanical Ventilation

• Indications
– Acute Respiratory Failure (ARF)
• Acute Hypercapnic Respiratory Failure (Type II)
– CNS Disorders
» Reduced Drive To Breathe: depressant
drugs, brain or brainstem lesions (stroke,
trauma, tumors), hypothyroidism
» Increased Drive to Breathe: increased
metabolic rate (CO2 production),
metabolic acidosis, anxiety associated with
dyspnea
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 Initiation of Mechanical Ventilation

• Indications
– Acute Respiratory Failure (ARF)
• Acute Hypercapnic Respiratory Failure (Type II)
– Neuromuscular Disorders
» Paralytic Disorders: Myasthenia Gravis, Guillain-
Barre´11, poliomyelitis, etc.
» Paralytic Drugs: Curare, nerve gas, succinylcholine,
insecticides
» Drugs that affect neuromuscular transmission;
calcium channel blockers, long-term
adenocorticosteroids, etc.
» Impaired Muscle Function: electrolyte imbalance,
malnutrition, chronic pulmonary disease, etc. 11
 Initiation of Mechanical Ventilation
• Indications
– Acute Respiratory Failure (ARF)
• Acute Hypercapnic Respiratory Failure
– Increased Work of Breathing
» Pleural Occupying Lesions: pleural effusions,
hemothorax, empyema, pneumothorax
» Chest Wall Deformities: flail chest, kyphoscoliosis,
obesity
» Increased Airway Resistance: secretions, mucosal
edema, bronchoconstriction, foreign body
» Lung Tissue Involvement: interstitial pulmonary
fibrotic diseases
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 Initiation of Mechanical Ventilation
• Indications
– Acute Respiratory Failure (ARF)
• Acute Hypercapnic Respiratory Failure
– Increased Work of Breathing (cont.)
» Lung Tissue Involvement: interstitial pulmonary
fibrotic diseases, aspiration, ARDS, cardiogenic PE,
drug induced PE
» Pulmonary Vascular Problems: pulmonary
thromboembolism, pulmonary vascular damage
» Dynamic Hyperinflation (air trapping)
» Postoperative Pulmonary Complications

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 Initiation of Mechanical Ventilation
• Prophylactic Ventilatory Support
– Clinical conditions in which there is a high risk of
future respiratory failure

• Examples: Brain injury, heart muscle injury, major

surgery, prolonged shock, smoke injury

• Ventilatory support is instituted to:

–Decrease the WOB
–Minimize O2 consumption and hypoxemia
–Reduce cardiopulmonary stress
–Control airway with sedation 14
 Initiation of Mechanical Ventilation
• Hyperventilation Therapy
– Ventilatory support is instituted to control and
manipulate PaCO2 to lower than normal levels
• Acute head injury

15
 Criteria for institution of ventilatory
support:
Parameters Ventilation Normal
indicated range
A- Pulmonary function
studies:
• Respiratory rate > 35 10-20
(breaths/min).
• Tidal volume (ml/kg <5 5-7
body wt)
• Vital capacity (ml/kg < 15 65-75
body wt)
• Maximum Inspiratory <-20 75-100
Force (cm HO2)
16
 Criteria for institution of ventilatory
support:

Parameters Ventilation Normal

indicated range
B- Arterial blood
Gases

• PH < 7.25 7.35-7.45

• PaO2 (mmHg) < 60 75-100
• PaCO2 (mmHg) > 50 35-45
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Initiation of Mechanical Ventilation

• Contraindications
– Untreated pneumothorax

• Relative Contraindications
– Patient’s informed consent
– Medical futility
– Reduction or termination of patient pain
and suffering

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 Essential components in mechanical
ventilation
• Patient
• Artificial airway
• Ventilator circuit
• Mechanical ventilator
• A/c or D/c power source
• O2 cylinder or central oxygen supply

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 Artificial airways
• Tracheal intubation
– Nasal
– Oral
• Supraglottic airway
• Cricothyrotomy
• Tracheostomy

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Laryngeal airway

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 Intubation Procedure
Check and Assemble Equipment:

Oxygen flowmeter and O2 tubing

Suction apparatus and tubing
Suction catheter
Ambu bag and mask
Laryngoscope with assorted blades
3 sizes of ET tubes
Stillet
Stethoscope
Tape
Syringe
Sterile gloves
 Intubation Procedure
Position your patient into the sniffing
position
 Intubation Procedure
Preoxygenate with 100% oxygen to
provide apneic or distressed patient
with reserve while attempting to
intubate.
Do not allow more than 30 seconds to any
intubation attempt.
If intubation is unsuccessful, ventilate
with 100% oxygen for 3-5 minutes before
a reattempt.
Intubation Procedure
Insert Laryngoscope
 Intubation Procedure

After displacing the epiglottis insert the ETT.

The depth of the tube for a male patient on

average is 21-23 cm at teeth
The depth of the tube on average for a female
patient is 19-21 at teeth.
 Intubation Procedure

Confirm tube position:

By auscultation of the chest

Bilateral chest rise
Tube location at teeth
CO2 detector – (esophageal
detection device or by
capnography)
Intubation Procedure
Stabilize the ETT
 Ventilator circuit

• Breathing System Plain

• Breathing System with Single Water Trap
• Breathing System with Double Water Trap.
• Breathing Filters HME Filter
• Flexible Catheter Mount

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Ventilator circuit

Breathing system plain

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Ventilator Breathing System (1.6m)

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Ventilator Breathing System (1.6m)

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heat & moisture exchanger HME filter

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34
 MECHANICAL VENTILATOR
• A mechanical ventilator is a machine that
generates a controlled flow of gas into a
patient’s airways. Oxygen and air are received
from cylinders or wall outlets, the gas is
pressure reduced and blended according to
the prescribed inspired oxygen tension (FiO2),
accumulated in a receptacle within the
machine, and delivered to the patient using
one of many available modes of ventilation.
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 Types of Mechanical ventilators
• Transport ventilators
• Intensive-care ventilators
• Neonatal ventilators
• Positive airway pressure ventilators for NIV

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 Classification of positive-pressure ventilators

• Ventilators are classified according to how the

inspiratory phase ends. The factor which terminates
the inspiratory cycle reflects the machine type.
• They are classified as:
1- Pressure cycled ventilator

2- Volume cycled ventilator

3- Time cycled ventilator

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 1- Volume-cycled ventilator
• Inspiration is terminated after a preset tidal
volume has been delivered by the ventilator.

• The ventilator delivers a preset tidal volume

(VT), and inspiration stops when the preset
tidal volume is achieved.

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 2- Pressure-cycled ventilator
• In which inspiration is terminated when a
specific airway pressure has been reached.

• The ventilator delivers a preset pressure;

once this pressure is achieved, end
inspiration occurs.

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 3- Time-cycled ventilator
• In which inspiration is terminated when a
preset inspiratory time, has elapsed.

• Time cycled machines are not used in adult

critical care settings. They are used in
pediatric intensive care areas.

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 Mechanical Ventilators
Different Types of Ventilators Available:
Will depend on your place of employment
Ventilators in use in MCH
Servo S by Maquet
Savina by Drager
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MODES OF VENTILATION
 Ventilator mode
• The way the machine ventilates the patient

• How much the patient will participate in his

own ventilatory pattern.

• Each mode is different in determining how

much work of breathing the patient has to
do.

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 A- Volume Modes
• 1. CMV or CV
• 2. AMV or AV
• 3. IMV
• 4. SIMV

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 B- Pressure Modes
1- Pressure-controlled ventilation (PCV)

2- Pressure-support ventilation (PSV)

3- Continuous positive airway pressure

(CPAP)

4- Positive end expiratory pressure (PEEP)

5- Noninvasive bilevel positive airway pressure

ventilation (BiPAP)
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 Control Mode

Delivers pre-set volumes at a pre-set rate and

a pre-set flow rate.
The patient CANNOT generate spontaneous
breaths, volumes, or flow rates in this mode.
Control Mode
 Assist/Control Mode

•Delivers pre-set volumes at a pre-set

rate and a pre-set flow rate.
•The patient CANNOT generate
spontaneous volumes, or flow rates in
this mode.
•Each patient generated respiratory effort
over and above the set rate are delivered
at the set volume and flow rate.
 Assist Control
• Volume or Pressure control mode
• Parameters to set:
– Volume or pressure
– Rate
– I – time
– FiO2

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 Assist Control
• Machine breaths:
– Delivers the set volume or pressure
• Patient’s spontaneous breath:
– Ventilator delivers full set volume or pressure &
I-time
• Mode of ventilation provides the most
support

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Assist Control

Negative deflection,
triggering assisted
breath
 SYCHRONIZED INTERMITTENT
MANDATORY VENTILATION
(SIMV):
Delivers a pre-set number of breaths at a
set volume and flow rate.
Allows the patient to generate
spontaneous breaths, volumes, and flow
rates between the set breaths.
Detects a patient’s spontaneous breath
attempt and doesn’t initiate a ventilatory
breath – prevents breath stacking
 SIMV
Synchronized intermittent mandatory ventilation

• Machine breaths:
– Delivers the set volume or pressure
• Patient’s spontaneous breath:
– Set pressure support delivered
• Mode of ventilation provides moderate amount of
support
• Works well as weaning mode

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 SIMV cont.

Machine Breaths
Spontaneous Breaths

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 IMV

Ingento EP & Drazen J: Mechanical Ventilators, in Hall JB, Scmidt GA, & Wood
LDH(eds.): Principles of Critical Care 57
Volume Modes

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 PRESSURE REGULATED VOLUME
CONTROL (PRVC):
• This is a volume targeted, pressure limited
mode. (available in SIMV or AC)
• Each breath is delivered at a set volume with
a variable flow rate and an absolute pressure
limit.
• The vent delivers this pre-set volume at the
LOWEST required peak pressure and adjust
with each breath.

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PRVC (Pressure regulated volume control)

A control mode, which delivers a set tidal volume

with each breath at the lowest possible peak
pressure.

Delivers the breath with a decelerating flow

pattern that is thought to be less injurious to the
lung…… “the guided hand”.

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PRCV: Advantages

Decelerating inspiratory flow pattern

Pressure automatically adjusted for changes in

compliance and resistance within a set range
Tidal volume guaranteed
Limits volutrauma
Prevents hypoventilation

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 PRVC: Disadvantages
Pressure delivered is dependent on tidal volume achieved on
last breath
Intermittent patient effort  variable tidal volumes
Pressure
Flow
Volume

Set tidal volume

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© Charles Gomersall 2003
 PRVC: Disadvantages
Pressure delivered is dependent on tidal volume achieved on
last breath
Intermittent patient effort  variable tidal volumes
Pressure
Flow
Volume

Set tidal volume

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© Charles Gomersall 2003
PRVC

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 POSITIVE END EXPIRATORY PRESSURE
(PEEP):
• This is NOT a specific mode, but is rather an
adjunct to any of the vent modes.
• PEEP is the amount of pressure remaining in
the lung at the END of the expiratory phase.
• Utilized to keep otherwise collapsing lung
units open while hopefully also improving
oxygenation.
• Usually, 5-10 cmH2O

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 Pplat
• Measured by occluding the ventilator 3-5 sec at
the end of inspiration
• Should not exceed 30 cmH2O

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 Peak Pressure (Ppeak)
• Ppeak = Pplat + Pres

Where Pres reflects the resistive element of

the respiratory system (ET tube and airway)

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 Ppeak
• Pressure measured at the end of inspiration

• Should not exceed 50cmH2O?

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 Auto-PEEP or Intrinsic PEEP

– Normally, at end expiration, the lung volume is

equal to the FRC

– When PEEPi occurs, the lung volume at end

expiration is greater than the FRC

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 Auto-PEEP or Intrinsic PEEP
• Why does hyperinflation occur?

– Airflow limitation because of dynamic collapse

– No time to expire all the lung volume (high RR or
Vt)
– Decreased Expiratory muscle activity
– Lesions that increase expiratory resistance

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 Auto-PEEP or Intrinsic PEEP
• Adverse effects:

– Predisposes to barotrauma
– Predisposes hemodynamic compromises
– Diminishes the efficiency of the force generated by
respiratory muscles
– Augments the work of breathing
– Augments the effort to trigger the ventilator

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 Continuous Positive Airway Pressure
(CPAP):
• This is a mode and simply means that a pre-
set pressure is present in the circuit and lungs
throughout both the inspiratory and
expiratory phases of the breath.
• CPAP serves to keep alveoli from collapsing,
resulting in better oxygenation and less WOB.
• The CPAP mode is very commonly used as a
mode to evaluate the patients readiness for
extubation.

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Combination “Dual Control” Modes

Combination or “dual control” modes combine features

of pressure and volume targeting to accomplish
ventilatory objectives which might remain unmet by
either used independently.

Combination modes are pressure targeted

Partial support is generally provided by pressure support
Full support is provided by Pressure Control

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Combination “Dual Control” Modes
Volume Assured Pressure Support
(Pressure Augmentation)

Volume Support
(Variable Pressure Support)

Pressure Regulated Volume Control

(Variable Pressure Control, or Autoflow)

Airway Pressure Release

(Bi-Level, Bi-PAP)
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• Inverse ratio ventilation (IRV) mode reverses this
ratio so that inspiratory time is equal to, or longer
than, expiratory time (1:1 to 4:1).

• Inverse I:E ratios are used in conjunction with

pressure control to improve oxygenation by
expanding stiff alveoli by using longer distending
times, thereby providing more opportunity for gas
exchange and preventing alveolar collapse.

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• As expiratory time is decreased, one must monitor
for the development of hyperinflation or auto-PEEP.
Regional alveolar overdistension and
barotrauma may occur owing to excessive total
PEEP.

• When the PCV mode is used, the mean airway and

intrathoracic pressures rise, potentially resulting in
a decrease in cardiac output and oxygen delivery.
Therefore, the patient’s hemodynamic status must
be monitored closely.

• Used to limit plateau pressures that can cause

barotrauma & Severe ARDS

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HIGH FREQUENCY OSCILLATORY
VENTILATION
 HIFI - Theory
• Resonant frequency phenomena:
– Lungs have a natural resonant frequency
– Outside force used to overcome airway resistance
• Use of high velocity inspiratory gas flow:
reduction of effective dead space
• Increased bulk flow: secondary to active
expiration

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 HIFI - Advantages
• Advantages:
– Decreased barotrauma / volutrauma: reduced swings
in pressure and volume
– Improve V/Q matching: secondary to different flow
delivery characteristics
• Disadvantages:
– Greater potential of air trapping
– Hemodynamic compromise
– Physical airway damage: necrotizing tracheobronchitis
– Difficult to suction
– Often require paralysis

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 HIFI – Clinical Application
• Adjustable Parameters
– Mean Airway Pressure: usually set 2-4 higher
than MAP on conventional ventilator
– Amplitude: monitor chest rise
– Hertz: number of cycles per second
– FiO2
– I-time: usually set at 33%

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 Comparison of HFOV
& Conventional Ventilation

Differences CMV HFOV

Rates 0 - 150 180 - 900

Tidal Volume 4 - 20 ml/kg 0.1 - 3 ml/kg
Alveolar Press 0 - > 50 cmH2O 0.1 - 5 cmH2O
End Exp Volume Low Normalized
Gas Flow Low High

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 Video on HFOV

http://youtube.com/watch?v=jLroOPoPlig

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 INITIAL SETTINGS
• Select your mode of ventilation
• Set sensitivity at Flow trigger mode
• Set Tidal Volume
• Set Rate
• Set Inspiratory Flow (if necessary)
• Set PEEP
• Set Pressure Limit
• Inspiratory time
• Fraction of inspired oxygen
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 Trigger
 There are two ways to initiate a ventilator-delivered
breath: pressure triggering or flow-by triggering
 When pressure triggering is used, a ventilator-delivered
breath is initiated if the demand valve senses a negative
airway pressure deflection (generated by the patient
trying to initiate a breath) greater than the trigger
sensitivity.
 When flow-by triggering is used, a continuous flow of gas
through the ventilator circuit is monitored. A ventilator-
delivered breath is initiated when the return flow is less
than the delivered flow, a consequence of the patient's
effort to initiate a breath 85
 Post Initial Settings
• Obtain an ABG (arterial blood gas) about 30
minutes after you set your patient up on
the ventilator.
• An ABG will give you information about any
changes that may need to be made to keep
the patient’s oxygenation and ventilation
status within a physiological range.

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 ABG
• Goal:
• Keep patient’s acid/base balance within
normal range:

• pH 7.35 – 7.45
• PCO2 35-45 mmHg
• PO2 80-100 mmHg

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 Initiation of Mechanical Ventilation
• Initial Ventilator Settings
– Tidal Volume
• Spontaneous VT for an adult is 5 – 7 ml/kg of IBW
Determining VT for Ventilated Patients
• A range of 6 – 12 ml/kg IBW is used for adults
– 10 – 12 ml/kg IBW (normal lung function)
– 8 – 10 ml/kg IBW (obstructive lung disease)
– 6 – 8 ml/kg IBW (ARDS) – can be as low as 4 ml/kg
• A range of 5 – 10 ml/kg IBW is used for infants and
children

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 Initiation of Mechanical Ventilation

• Initial Ventilator Settings

– Respiratory Rate
• Normal respiratory rate is 12-18
breaths/min.
• A range of 8 – 12 breaths per minute (BPM)
Rates should be adjusted to try and minimize auto-
PEEP

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 Initiation of Mechanical Ventilation

• Initial Ventilator Settings

– Minute Ventilation
• Respiratory rate is chosen in conjunction with tidal
volume to provide an acceptable minute ventilation
= VT x f

• Normal minute ventilation is 5-10 L/min

• Estimated by using 100 mL/kg IBW
• ABG needed to assess effectiveness of initial settings
– If PaCO2 >45 ( minute ventilation via f or VT)
– If PaCO2 <35 ( minute ventilation via f or VT)

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 Initiation of Mechanical Ventilation
• Initial Ventilator Settings
– Inspiratory Flow
• Rate of Gas Flow
– As a beginning point, flow is normal set to deliver
inspiration in about 1 second (range 0.8 to 1.2 sec.),
producing an I:E ratio of approximately 1:2 or less (usually
about 1:4)

– This can be achieved with an initial peak flow of about 60

L/min (range of 40 to 80 L/min)
Most importantly, flows are set to meet a patient’s inspiratory
demand

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 Expiratory Flow Pattern
Beginning of expiration
exhalation valve opens

Inspiration
Expiratory time
TE

Time (sec)
Flow (L/min)

Duration of
expiratory flow
Expiration

Peak Expiratory Flow Rate 92

PEFR
 Initiation of Mechanical Ventilation

– Flow Patterns
• Selection of flow pattern and flow rate may depend on
the patient’s lung condition, e.g.,
– Post – operative patient recovering from anesthesia
may have very modest flow demands
– Young adult with pneumonia and a strong
hypoxemic drive would have very strong flow
demands
– Normal lungs: Not of key importance

93
 Initiation of Mechanical Ventilation
• Initial Ventilator Settings
– Flow Pattern
• Constant Flow (rectangular or square waveform)
– Generally provides the shortest TI
– Some clinician choose to use a constant (square) flow
pattern initially because it enables them to obtain baseline
measurements of lung compliance and airway resistance

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 Initiation of Mechanical Ventilation

– Flow Pattern
• Sine Flow
– May contribute to a more even distribution of gas in the
lungs
– Peak pressures and mean airway pressure are about the
same for sine and square wave patterns

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 Initiation of Mechanical Ventilation
• Initial Ventilator Settings
– Flow Pattern
• Descending (decelerating) Ramp
– Improves distribution of ventilation, results in a longer TI,
decreased peak pressure, and increased mean airway
pressure (which increases oxygenation)

96
 Initiation of Mechanical Ventilation
• Initial Ventilator Settings
– Positive End Expiratory Pressure (PEEP)
• Initially set at 3 – 5 cm H2O
– Restores FRC and physiological PEEP that existed prior
to intubation
– Subsequent changes are based on ABG results

• Useful to treat refractory hypoxemia

• Contraindications for therapeutic PEEP (>5 cm H2O)
– Hypotension
– Elevated ICP
– Uncontrolled pneumothorax
97
 Initiation of Mechanical Ventilation
• Initial Ventilator Settings
– FiO2
• Initially 100%
– Severe hypoxemia
– Abnormal cardiopulmonary functions
» Post-resuscitation
» Smoke inhalation
» ARDS

• After stabilization, attempt to keep FiO2 <50%

– Avoids oxygen-induced lung injuries
» Absorption atelectasis
» Oxygen toxicity 98
 Initiation of Mechanical Ventilation

– FiO2 of 40% or Same FiO2 prior to mechanical

ventilation

• Patients with mild hypoxemia or normal

cardiopulmonary function
–Drug overdose
–Uncomplicated postoperative recovery

99
 Initiation of Mechanical Ventilation

• Initial Ventilator Settings For PCV

– Rate, TI, and I:E ratio are set in PCV as they are
in Volume mode
– The pressure gradient (PIP-PEEP) is adjusted to
establish volume delivery
Remember: Volume delivery changes as lung
characteristics change and can vary breath to
breath

100
 Initiation of Mechanical Ventilation
• Initial Ventilator Settings For PCV
– Flow Pattern
• PCV provides a descending ramp
waveform

Note: The patient can vary the

inspiratory flow on demand

101
 Initiation of Mechanical Ventilation
• Initial Ventilator Settings For PCV
– Rise Time (slope, flow acceleration)
• Rise time is the amount of TI it takes for the
ventilator to reach the set pressure at the beginning
of inspiration

• Inspiratory flow delivery during PCV can be adjusted

with an inspiratory rise time control

• Ventilator graphics can be used to set the rise time

102
 ● Sigh
• A deep breath.

• A breath that has a greater volume than the tidal volume.

• It provides hyperinflation and prevents atelectasis.

• Sigh volume :------------------Usual volume is 1.5 –2 times tidal

volume.

• Sigh rate/ frequency :---------Usual rate is 4 to 8 times per

hour.

103
 Ensuring humidification and
thermoregulation

• All air delivered by the ventilator passes through the water

in the humidifier, where it is warmed and saturated or
through an HME filter

• Humidifier temperatures should be kept close to body

temperature 35 ºC- 37ºC.

• In some rare instances (severe hypothermia), the air

temperatures can be increased.

• The humidifier should be checked for adequate water levels

104
 Initiation of Mechanical Ventilation
• Ventilator Alarm Settings
– High Minute Ventilation
• Set at 2 L/min or 10%-15% above baseline minute
ventilation
– Patient is becoming tachypneic (respiratory distress)

– High Respiratory Rate Alarm

• Set 10 – 15 BPM over observed respiratory rate
– Patient is becoming tachypneic (respiratory distress)

105
 Initiation of Mechanical Ventilation
• Ventilator Alarm Settings
– Low Exhaled Tidal Volume Alarm
• Set 100 ml or 10%-15% lower than expired mechanical tidal
volume
• Causes
– System leak
– Circuit disconnection
– ET Tube cuff leak

106
 Initiation of Mechanical Ventilation
• Ventilator Alarm Settings
– High Inspiratory Pressure Alarm
• Set 10 – 15 cm H2O above PIP
• Common causes:
– Water in circuit
– Kinking or biting of ET Tube
– Secretions in the airway
– Bronchospasm
– Tension pneumothorax
– Decrease in lung compliance
– Increase in airway resistance
– Coughing
107
 Initiation of Mechanical Ventilation
• Ventilator Alarm Settings
– Low Inspiratory Pressure Alarm
• Set 10 – 15 cm H2O below observed PIP
• Causes
– System leak
– Circuit disconnection
– ET Tube cuff leak
– High/Low PEEP/CPAP Alarm (baseline alarm)
• High: Set 3-5 cm H2O above PEEP
– Circuit or exhalation manifold obstruction
– Auto – PEEP
• Low: Set 2-5 cm H2O below PEEP
– Circuit disconnect 108
 Initiation of Mechanical Ventilation
• Ventilator Alarm Settings
– High/Low FiO2 Alarm
• High: 5% over the analyzed FiO2
• Low: 5% below the analyzed FiO2

– High/Low Temperature Alarm

• Heated humidification
– High: No higher than 37 C
– Low: No lower than 30 C

109
 Initiation of Mechanical Ventilation
• Ventilator Alarm Settings
– Apnea Alarm
• Set with a 15 – 20 second time delay
• In some ventilators, this triggers an apnea
ventilation mode
– Apnea Ventilation Settings
• Provide full ventilatory support if the patient
become apneic
• VT 8 – 12 mL/kg ideal body weight
• Rate 10 – 12 breaths/min
• FiO2 100%
110
TROUBLESHOOTING

111
 Trouble Shooting the Vent
• Common problems
– High peak pressures
– Patient with COPD
– Ventilator asynchrony
– ARDS

112
 Trouble Shooting the Vent
• If peak pressures are increasing:
– Check plateau pressures by allowing for an
inspiratory pause (this gives you the pressure in
the lung itself without the addition of resistance)
– If peak pressures are high and plateau pressures
are low then you have an obstruction
– If both peak pressures and plateau pressures are
high then you have a lung compliance issue

113
 Trouble Shooting the Vent
• High peak pressure differential:
High Peak Pressures High Peak Pressures
Low Plateau Pressures High Plateau Pressures

Mucus Plug ARDS

Bronchospasm Pulmonary Edema

ET tube blockage Pneumothorax

Biting ET tube migration to a single bronchus

Effusion

114
 COPD
• If you have a patient with history of COPD/asthma with worsening
oxygen saturation and increasing hypercapnia differential includes:

– Must be concern with breath stacking or auto- PEEP

– Low VT with increased exhalation time is advisable
• Baseline ABGs reflect an elevated PaCO2 should not hyperventilated.
Instead, the goal should be restoration of the baseline PaCO2.

• These patients usually have a large carbonic acid load, and lowering
their carbon dioxide levels rapidly may result in seizures.

115
 COPD and Asthma
• Goals:

– Diminish dynamic hyperinflation

– Diminish work of breathing
– Controlled hypoventilation (permissive
hypercapnia)

116
 Trouble Shooting the Vent
• Increase in patient agitation and dis-synchrony
on the ventilator:
– Could be secondary to overall discomfort
• Increase sedation
– Could be secondary to feelings of air hunger
• Options include increasing tidal volume, increasing flow
rate, adjusting I:E ratio, increasing sedation

117
 Trouble shooting the vent
• If you are concern for acute respiratory
distress syndrome (ARDS)
– Correlate clinically with radiologic findings of
diffuse patchy infiltrate on CXR
– Obtain a PaO2/FiO2 ratio (if < 200 likely ARDS)
– Begin ARDSnet protocol:
• Low tidal volumes
• Increase PEEP rather than FiO2
• Consider increasing sedation to promote synchrony
with ventilator

118
 Accidental Extubation
• Role of the Nurse:

– Ensure the Ambu bag is attached to the

oxygen flowmeter and it is on!
– Attach the face mask to the Ambu bag and
after ensuring a good seal on the patient’s
face; supply the patient with ventilation.

119
 Pulmonary Disease: Obstructive
Airway obstruction causing increase resistance to airflow: e.g.
asthma
• Optimize expiratory time by minimizing minute ventilation
• Bag slowly after intubation
• Don’t increase ventilator rate for increased CO2

120
 Pulmonary Disease: Restrictive
Compromised lung volume:
– Intrinsic lung disease
– External compression of lung
• Recruit alveolia, optimize V/Q matching
• Lung protective strategies
– High PEEP
– Pressure limiting PIP: 30-35 cmH2O
– Low tidal volume: 4-8 ml/kg
– FiO2 <60%
– Permissive hypercarbia
– Permissive hypoxia 121
In a patient with head injury,

• Respiratory alkalosis may be required to promote

cerebral vasoconstriction, with a resultant decrease
in ICP.
• In this case, the tidal volume and respiratory rate
are increased
( hyperventilation) to achieve the desired alkalotic
pH by manipulating the PaCO2.

122
 Complications
of Mechanical Ventilation:-

I- Airway Complications,

II- Mechanical complications,

III- Physiological Complications,

IV- Artificial Airway Complications.

123
 I- Airway Complications

1- Aspiration

2- Decreased clearance of secretions

3- Nosocomial or ventilator-acquired
pneumonia

124
125
WHAT IS SUCTIONING?.....
The patient with an artificial
airway is not capable of effectively
coughing, the mobilization of
secretions from the trachea must be
facilitated by aspiration. This is
called as suctioning.
 Indications
 Coarse breath sounds
 Noisy breathing
 Visible secretions in the airway
 Decreased SpO2 in the pulse oximeter & Deterioration of
arterial blood gas values
 Clinically increased work of breathing
 Changes in monitored flow/pressure graphics
 Increased PIP; decreased Vt during ventilation
 NECESSARY EQUIPMENT
 Vaccum source with adjustable regulator
suction jar
 stethoscope
 Sterile gloves for open suctioning method
 Clean gloves for closed suctioning method
 Sterile catheter
 Clear protective goggles, apron & mask
 Sterile normal saline
 Bain’s circuit or ambu bag for
preoxygenate the patient
 Suction tray with hot water for flushing
 TYPES OF SUCTIONING

OPEN SUCTION CLOSED SUCTION

OPEN SUCTION SYSTEM:
Regularly using system in the intubated
patients.

CLOSED SUCTION SYSTEM:

 This is used to facilitate continuous
mechanical ventilation and oxygenation during
the suctioning.
 Closed suctioning is also indicated when PEEP
level above 10cmH2O.
 Patient Preparation
 Explain the procedure to the patient (If
patient is concious).
 The patient should receive hyper
oxygenation by the delivery of 100%
oxygen for >30 seconds prior to the
suctioning (by increasing the FiO2 by
mechanical ventilator).
 Position the patient in supine position.
 Auscultate the breath sounds.
 PROCEDURE
Perform hand hygiene, wash
hands. It reduces transmission
of microorganisms.

Turn on suction apparatus and

set vacuum regulator to
appropriate negative pressure.
For adult a pressure of 100-120
mmHg, 80-100mmhg for
children & 60-80mmhg for
infants.
Continue…..
Goggles, mask & apron should be worn
to prevent splash from secretions
Preoxygenate with 100% O2
Open the end of the suction catheter
package & connect it to suction tubing
(If you are alone)
Wear sterile gloves with sterile
technique
With a help of an assistant open suction
catheter package & connect it to suction
tubing
Continue…..
With a help of an assistant disconnect
the ventilator
Kink the suction tube & insert the
catheter in to the ETtube until resistance
is felt
Resistance is felt when the catheter
impacts the carina or bronchial mucosa,
the suction catheter should be
withdrawn 1cm out before applying
suction
 Continue.....
Apply continuous suction while rotating
the suction catheter during removal
The duration of each suctioning should
be less the 15sec.
Instill 3 to 5ml of sterile normal saline in
to the artificial airway, if required
Assistant resumes the ventilator
Give four to five manual breaths with
bag or ventilator
 Continue…..
 Continue making suction passes, bagging patient between
passes, until clear of secretions, but no more than four
passes
 Return patient to ventilator
 Flush the catheter with hot water in the suction tray
 Suction nares & oropharynx above the artificial airway
 Discard used equipments
 Flush the suction tube with hot water
 Auscultate chest
 Wash hands
 Document including indications for suctioning & any
changes in vitals & patient’s tolerance
 Closed suctioning procedure
Wash hands
Wear clean gloves
Connect tubing to closed suction
port
Pre-oxygenate the patient with
100% O2
Gently insert catheter tip into
artificial airway without applying
suction, stop if you met resistance
or when patient starts coughing and
pull back 1cm out
Closed suction

138
 Continue…..
 Place the dominant thumb over
the control vent of the suction
port, applying continuous or
intermittent suction for no more
than 10 sec as you withdraw the
catheter into the sterile sleeve of
the closed suction device
 Repeat steps above if needed
 Clean suction catheter with sterile
saline until clear; being careful not
to instill solution into the ETtube
 Suction oropharynx above the
artificial airway
 Wash hands
 ASSESSMENT OF OUTCOME
Improvement in breath sounds.
Decreased peak inspiratory pressure;
Increased tidal volume delivery during
ventilation.
Improvement in arterial blood gas values or
saturation as reflected by pulse oximetry.
(SpO2)
Removal of pulmonary secretions.
 CONTRAINDICATIONS

 Most contraindications are relative to the patient's

risk of developing adverse reactions or worsening
clinical condition as result of the procedure.
 Suctioning is contraindicated when there is fresh
bleeding.
 When indicated, there is no absolute
contraindication to endotracheal suctioning
because the decision to abstain from suctioning in
order to avoid a possible adverse reaction may, in
fact, be lethal.
 LIMITATIONS OF METHOD

Suctioning is potentially an harmful procedure

if carriedout improperly.
Suctioning should be done when clinically
necessary (not routinely).
The need for suctioning should be assessed at
least every 2hrs or more frequently as need
arises.
• http://www.youtube.com/watch?v=bXXWNCY
Z_N0

143
 LIMITATIONS OF METHOD

Suctioning is potentially an harmful procedure

if carriedout improperly.
Suctioning should be done when clinically
necessary (not routinely).
The need for suctioning should be assessed at
least every 2hrs or more frequently as need
arises.
 II- Mechanical complications
1- Hypoventilation with atelectasis with respiratory
acidosis or hypoxemia.
2- Hyperventilation with hypocapnia and respiratory alkalosis
3- Barotrauma
a- Closed pneumothorax,
b- Tension pneumothorax,
c- Pneumomediastinum,
d- Subcutaneous emphysema.
4- Alarm “turned off”
5- Failure of alarms or ventilator
6- Inadequate nebulization or humidification
7- Overheated inspired air, resulting in hyperthermia

145
 III- Physiological Complications

1- Fluid overload with humidified air and

sodium chloride (NaCl) retention
2- Depressed cardiac function and
hypotension
3- Stress ulcers
4- Paralytic ileus
5- Gastric distension
6- Starvation
7- Dyssynchronous breathing pattern

146
 IV- Artificial Airway Complications
A- Complications related to
Endotracheal Tube:-

1- Tube kinked or plugged

2- Tracheal stenosis or tracheomalacia
3- Mainstem intubation with contralateral (located on
or affecting the opposite side of the
• Lung) lung atelectasis
5- Cuff failure
6- Sinusitis
7- Otitis media
8- Laryngeal edema
147
 B- Complications related to
Tracheostomy tube:-
1- Acute hemorrhage at the site
2- Air embolism
3- Aspiration
4- Tracheal stenosis
5- Failure of the tracheostomy cuff
6- Laryngeal nerve damage
7- Obstruction of tracheostomy tube
8- Pneumothorax
9- Subcutaneous and mediastinal emphysema
10- Swallowing dysfunction
11- Tracheoesophageal fistula
12- Infection
14- Accidental decannulation with loss of airway

148
 Nursing care of patients on mechanical
ventilation

Assessment:

1- Assess the patient

2- Assess the artificial airway (tracheostomy

or endotracheal tube)

3- Assess the ventilator

149
 Nursing Interventions
1-Maintain airway patency & oxygenation
2- Promote comfort
3- Maintain fluid & electrolytes balance
4- Maintain nutritional state
5- Maintain urinary & bowel elimination
6- Maintain eye , mouth and cleanliness and
integrity:-
7- Maintain mobility/ musculoskeletal
function:-

150
 Nursing Interventions
8- Maintain safety:-
9- Provide psychological support
10- Facilitate communication
11- Provide psychological support &
information to family
12- Responding to ventilator alarms
/Troublshooting ventilator alarms
13- Prevent nosocomial infection
14- Documentation

151
 Responding To Alarms
• If an alarm sounds, respond immediately because
the problem could be serious.
• Assess the patient first, while you silence the alarm.
• If you can not quickly identify the problem, take the
patient off the ventilator and ventilate him with a
resuscitation bag connected to oxygen source until
the physician arrives.
• A nurse or respiratory therapist must respond to
every ventilator alarm.

152
• Alarms must never be ignored or
disarmed.

• Ventilator malfunction is a potentially

serious problem. Nursing or respiratory
therapists perform ventilator checks
every 2 to 4 hours, and recurrent alarms
may alert the clinician to the possibility
of an equipment-related issue.

153
• When device malfunction is suspected,
a second person manually ventilates the
patient while the nurse or therapist
looks for the cause.
• If a problem cannot be promptly
corrected by ventilator adjustment, a
different machine is procured so the
ventilator in question can be taken out
of service for analysis and repair by
technical staff.

154
WEANING

155
 Weaning readiness Criteria
• Awake and alert

• Hemodynamically stable, adequately resuscitated,

and not requiring vasoactive support

• Arterial blood gases (ABGs) normalized or at

patient’s baseline
- PaCO2 acceptable
- PH of 7.35 – 7.45
- PaO2 > 60 mm Hg ,
- SaO2 >92%
- FIO2 ≤40%
156
• Positive end-expiratory pressure (PEEP) ≤5
cm H2O
• F < 25 / minute
• Vt 5 ml / kg
• VE 5- 10 L/m (f x Vt)
• VC > 10- 15 ml / kg

157
• Chest x-ray reviewed for correctable factors;
treated as indicated,
• Major electrolytes within normal range,
• Hematocrit >25%,
• Core temperature >36°C and <39°C,
• Adequate management of
pain/anxiety/agitation,
• Adequate analgesia/ sedation (record scores
on flow sheet),
• No residual neuromuscular blockade.

158
 Methods of Weaning
1- T-piece trial,

2- Continuous Positive Airway Pressure (CPAP)

weaning,

3- Synchronized Intermittent Mandatory Ventilation

(SIMV) weaning,

4- Pressure Support Ventilation (PSV) weaning.

159
 1- T-Piece trial
• It consists of removing the patient from the
ventilator and having him / her breathe
spontaneously on a T-tube connected to oxygen
source.

• During T-piece weaning, periods of ventilator

support are alternated with spontaneous breathing.

• The goal is to progressively increase the time spent

off the ventilator.

160
 2-Synchronized Intermittent Mandatory
Ventilation ( SIMV) Weaning

• SIMV is the most common method of weaning.

• It consists of gradually decreasing the number of

breaths delivered by the ventilator to allow the
patient to increase number of spontaneous breaths

161
3-Continuous Positive Airway Pressure ( CPAP)
Weaning

• When placed on CPAP, the patient does all the work

of breathing without the aid of a back up rate or
tidal volume.

• No mandatory (ventilator-initiated) breaths are

delivered in this mode i.e. all ventilation is
spontaneously initiated by the patient.

• Weaning by gradual decrease in pressure value

162
4- Pressure Support Ventilation (PSV) Weaning

• The patient must initiate all pressure support breaths.

• During weaning using the PSV mode the level of pressure

support is gradually decreased based on the patient
maintaining an adequate tidal volume (8 to 12 mL/kg) and a
respiratory rate of less than 25 breaths/minute.

• PSV weaning is indicated for :-

- Difficult to wean patients

- Small spontaneous tidal volume.

163
 Role of nurse before weaning:-
1- Ensure that indications for the implementation of
Mechanical ventilation have improved
2- Ensure that all factors that may interfere with successful
weaning are corrected:-
- Acid-base abnormalities
- Fluid imbalance
- Electrolyte abnormalities
- Infection
- Fever
- Anemia
- Hyperglycemia
- Sleep deprivation

164
 Role of nurse before weaning:-
3- Assess readiness for weaning
4- Ensure that the weaning criteria / parameters are
met.
5- Explain the process of weaning to the patient and
offer reassurance to the patient.
6- Initiate weaning in the morning when the patient is
rested.
7- Elevate the head of the bed & Place the patient
upright
8- Ensure a patent airway and suction if necessary
before a weaning trial,
165
Role of nurse before weaning:-
9 - Provide for rest period on ventilator for 15 – 20
minutes after suctioning.
10- Ensure patient’s comfort & administer
pharmacological agents for comfort, such as
bronchodilators or sedatives as indicated.

11- Help the patient through some of the

discomfort and apprehension.

13- Evaluate and document the patient’s

response to weaning.

166
 Role of nurse during weaning:-
1- Wean only during the day.
2- Remain with the patient during
initiation of weaning.
3- Instruct the patient to relax and breathe
normally.
4- Monitor the respiratory rate, vital signs,
ABGs, diaphoresis and use of accessory
muscles frequently.

If signs of fatigue or respiratory distress develop.

• Discontinue weaning trials.

167
 Signs of Weaning Intolerance Criteria
• Diaphoresis

• Dyspnea & Labored respiratory pattern

• Increased anxiety ,Restlessness, Decrease in level of

consciousness

• Dysrhythmia,Increase or decrease in heart rate of >

20 beats /min. or heart rate > 110b/m,Sustained
heart rate >20% higher or lower than baseline

168
Signs of Weaning Intolerance Criteria
Increase or decrease in blood pressure of > 20 mm Hg
Systolic blood pressure >180 mm Hg or <90 mm Hg

• Increase in respiratory rate of > 10 above baseline

or > 30
Sustained respiratory rate greater than 35
breaths/minute

• Tidal volume ≤5 mL/kg, Sustained minute

ventilation <200 mL/kg/minute

• SaO2 < 90%, PaO2 < 60 mmHg, decrease in PH of <

7.35.
Increase in PaCO2
169
 Role of nurse after weaning
1- Ensure that extubation criteria are
met .

2- Decanulate or extubate

2- Documentation

170
 Noninvasive Bilateral Positive
Airway Pressure Ventilation (BiPAP)

• BiPAP is a noninvasive form of mechanical

ventilation provided by means of a nasal mask or
nasal prongs, or a full-face mask.

• The system allows the clinician to select two levels

of positive-pressure support:

• An inspiratory pressure support level (referred to as

IPAP)

• An expiratory pressure called EPAP (PEEP/CPAP

level).
171
NON INVASIVE
VENTILATION

172
 Absolute contraindications

• Coma
• Cardiac arrest
• Respiratory arrest
• Any condition requiring immediate intubation

173
 Suitable clinical conditions
• Chronic obstructive pulmonary disease
• Cardiogenic pulmonary edema
• After discontinuation of mechanical
ventilation (COPD)
• OSP

174
 Patient interfaces

• full face masks,

• nasal pillows,
• Nasal masks
• and orofacial masks

175
 Ventilators
• Usual ventilators for invasive ventilation
• Special noninvasive ventilators
• Modes of ventilation
• CPAP
• BiPAP

176
 Top 10 care essentials for ventilator
patients
• Review communications.
• Check ventilator settings and modes.
• Suction appropriately.
• Assess pain and sedation needs.
• Prevent infection.

177
 Top 10 care essentials for ventilator
patients
• Prevent hemodynamic instability.
• Manage the airway.
• Meet the patient’s nutritional needs.
• Wean the patient from the ventilator
appropriately.
• Educate the patient and family.

178
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