CARING OF CLIENT
ON VENTILATOR

SUBMITTED TO: SUBMITTED BY:

MRS.JAYASREE.V P.BALA JYOTHI

ASSOCIATE PROFESSOR M.Sc (N)2nd YEAR

DEPT . OF MEDICAL SURGICAL NURSING JMJ COLLEGE OF

NURSING

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INTRODUCTION:

Mechanical ventilation is the medical term for artificial ventilation where mechanical means

is used to assist or replace spontaneous breathing. This may involve a machine called
a ventilator or the breathing may be assisted by an anaesthesiologist, certified registered
nurse anaesthetist, physician, physician assistant, respiratory therapist, paramedic, or other
suitable person compressing a bag or set of bellows.

THE NURSE MUST BE ABLE TO DO THE FOLLOWING:

1. Identify the indications for mechanical ventilation.

2. List the steps in preparing a patient for intubation.

3. Determine the FIO2, tidal volume, rate and mode of ventilation on a given ventilator.

4. Describe the various modes of ventilation and their implications.

5. Describe at least two complications associated with patient’s response to mechanical

ventilation and their signs and symptoms.

6. Describe the causes and nursing measures taken when trouble-shooting ventilator
alarms.

7. Describe preventative measures aimed at preventing selected other complications

related to endotracheal intubation.

8. Give rationale for selected nursing interventions in the plan of care for the ventilated
patient.

9. Complete the care of the ventilated patient checklist.

10. Complete the suctioning checklist.

1. To review indications for and basic modes of mechanical ventilation, possible

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 complications that can occur, and nursing observations and procedures to
detect and/or prevent such complications.
2. To provide a systematic nursing assessment procedure to ensure early
detection of complications associated with mechanical ventilation.

INDICATION FOR INTUBATION

1. Acute respiratory failure evidenced by the lungs inability to maintain arterial oxygenation
or eliminate carbon dioxide leading to tissue hypoxia in spite of low-flow or high-flow oxygen
delivery devices. (Impaired gas exchange, airway obstruction or ventilation-perfusion
abnormalities).

2. In a patient with previously normal ABGs, the ABG results will be as follows:

PaO2 > 50 mm Hg with pH < 7.25

PaO2 < 50 mm Hg on 60% FIO2 : restlessness, dyspnea, confusion, anxiety, tachypnea,

tachycardia, and diaphoresis

PaCO2 > 50 mm Hg : hypertension, irritability, somnolence (late), cyanosis (late), and LOC
(late)

3. Neuromuscular or neurogenic loss of respiratory regulation. (Impaired ventilation)

4. Usual reasons for intubation: Airway maintenance, Secretion control, Oxygenation and
Ventilation.

TYPES OF INTUBATION: Orotracheal, Nasotracheal, Tracheostomy

PREPARING FOR INTUBATION:

1. Recognize the need for intubation.

2. Notify physician and respiratory therapist. Ensure consent obtained if not emergency.

3. Gather all necessary equipment:

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a. Suction canister with regulator and connecting tubing

b. Sterile 14 Fr. suction catheter or closed in-line suction catheter

c. Sterile gloves

d. Normal saline

e. Yankuer suction-tip catheter and nasogastric tube

f. Intubation equipment: Manual resuscitator bag (MRB), Laryngoscope and blade, Wire
guide, Water soluble lubricant, Cetacaine spray

g. Endotracheal attachment device (E-tad) or tape

h. Get order for initial ventilator settings

i. Sedation prn

j. Soft wrist restraints prn

k. Call for chest x-ray to confirm position of endotracheal tube

l. Provide emotional support as needed/ ensure family notified of change in condition.

Intubation

Types of Ventilators: There are two main types of Ventilators

(a) Positive pressure ventilator: where air (or another gas mix) is pushed into the
lungs through the airways
(b) Negative pressure ventilator: where air is in essence sucked into the lungs by
stimulating movement of the chest.
There are manual ventilators such as bag valve masks and anesthesia bags that
require the users to hold the ventilator to the face or to an artificial airway and
maintain breaths with their hands. Mechanical ventilators are ventilators not requiring
operator effort and are typically computer controlled or pneumatic controlled.

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Mechanical ventilators typically require power by a battery or a wall outlet (DC or AC )
though some ventilators work on a pneumatic system not requiring power.

Transport ventilators: These ventilators are small and more rugged,and can be powered
pneumatically or via AC or DC power sources.

INTENSIVE CARE VENTILATORS: These ventilators are larger and usually run on AC
power (though virtually all contain a battery to facilitate intra transport and as a back up in
the event of a power failure).This style of ventilator often provides greater control of a wide
variety of ventilation parameters (such as inspiratory rise time).Many ICU ventilators also
incorporate graphics to provide visual feed back of each breath.

NEONATAL VENTILATORS: Designed with preterm neonate in mind, theses are a

specialized subset of ICU ventilators that are designed to deliver the smaller, more precise
volumes and pressures required to ventilate these patients.

POSITIVE AIRWAY PRESSURE VENTILATOR: These ventilators are specifically

designed for non invasive ventilation. This includes ventilation for use at home for treatment
of chronic condition such as sleep apnea or COPD.

Modes of Mechanical Ventilation:

(a) Volume -cycled

(b) Pressure – cycled
(c) Spontaneously cycled

Complications of Mechanical Ventilation

 Problem/challenge
 Identify the goal behaviour
 Describe the step by step approach/method to this problem
 Common pitfalls
 National standars,core indications and quality measures.

1. Associated with patient’s response to mechanical ventilation:

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A. Decreased Cardiac Output

1. Cause - venous return to the right atrium impeded by the dramatically increased
intrathoracic pressures during inspiration from positive pressure ventilation. Also reduced
sympatho-adrenal stimulation leading to a decrease in peripheral vascular resistance and
reduced blood pressure.

2. Symptoms – increased heart rate, decreased blood pressure and perfusion to vital
organs, decreased CVP, and cool clammy skin.

3. Treatment – aimed at increasing preload (e.g. fluid administration) and decreasing the
airway pressures exerted during mechanical ventilation by decreasing inspiratory flow rates
and TV, or using other methods to decrease airway pressures (e.g. different modes of
ventilation).

B. Barotrauma

1. Cause – damage to pulmonary system due to alveolar rupture from excessive airway
pressures and/or over distention of alveoli.

2. Symptoms – may result in pneumothorax, pneumomediastinum, pneumoperitoneum, or

subcutaneous emphysema.

3. Treatment - aimed at reducing TV, cautious use of PEEP, and avoidance of high airway
pressures resulting in development of auto-PEEP in high risk patients (patients with
obstructive lung diseases (asthma, bronchospasm), unevenly distributed lung diseases
(lobar pneumonia), or hyperinflated lungs (emphysema).

C. Nosocomial Pneumonia

1. Cause – invasive device in critically ill patients becomes colonized with pathological
bacteria within 24 hours in almost all patients. 20-60% of these, develop nosocomial
pneumonia.

2. Treatment – aimed at prevention by the following:

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Avoid cross-contamination by frequent hand washing

Decrease risk of aspiration (cuff occlusion of trachea, positioning, use of small-bore NG

tubes)

Suction only when clinically indicated, using sterile technique

Maintain closed system setup on ventilator circuitry and avoid pooling of condensation in
the tubing

Ensure adequate nutrition

Avoid neutralization of gastric contents with antacids and H2 blockers

D. Positive Water Balance

1. Syndrome of Inappropriate Antidiuretic Hormone (SIADH) – due to vagal stretch

receptors in right atrium sensing a decrease in venous return and see it as hypovolemia,
leading to a release of ADH from the posterior pituitary gland and retention of sodium and
water. Treatment is aimed at decreasing fluid intake.

2. Decrease of normal insensible water loss due to closed ventilator circuit preventing water
loss from lungs. This fluid overload evidenced by decreased urine specific gravity, dilutional
hyponatremia, increased heart rate and BP.

E. Decreased Renal Perfusion – can be treated with low dose dopamine therapy.

F. Increased Intracranial Pressure (ICP) – reduce PEEP

G. Hepatic congestion – reduce PEEP

H. Worsening of intracardiac shunts –reduce PEEP

2. Associated with ventilator malfunction:

A. Alarms turned off or nonfunctional – may lead to apnea and respiratory arrest

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Troubleshooting Ventilator Alarms

Low exhaled volume: Cuff leak, Tubing disconnect, Patient disconnected

Evaluate cuff; reinflate prn; if ruptured, tube will need to be replaced. Evaluate
connections; tighten or replace as needed; check ETT placement, Reconnect to ventilator

High pressure: Secretions in airway, Patient biting tubing, Tube kinked, Cuff herniation,
Increased airway resistance/decreased lung compliance (caused by bronchospasm, right
mainstem bronchus intubation, pneumothorax, pneumonia), Patient coughing and/or
fighting the ventilator; anxiety; fear; pain.

Suction patient, Insert bite block, Reposition patient’s head/neck; check all tubing lengths,
Deflate and reinflate cuff, Auscultate breath sounds, Evaluate compliance and tube position;
stabilize tube, Explain all procedures to patient in calm, reassuring manner,
Sedate/medicate as necessary

Low oxygen pressure: Oxygen malfunction

Disconnect patient from ventilator; manually bag with ambu; call R.T

3. Other complications related to endotracheal intubation.

A. Sinusitis and nasal injury – obstruction of paranasal sinus drainage; pressure necrosis
of nares

1. Prevention: avoid nasal intubations; cushion nares from tube and tape/ties.

2. Treatment: remove all tubes from nasal passages; administer antibiotics.

B. Tracheoesophageal fistula – pressure necrosis of posterior tracheal wall resulting from

overinflated cuff and rigid nasogastric tube

1. Prevention: inflate cuff with minimal amount of air necessary; monitor cuff pressures q. 8

2. Treatment: position cuff of tube distal to fistula; place gastrostomy tube for enteral

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feedings; place esophageal tube for secretion clearance proximal to fistula.

C. Mucosal lesions – pressure at tube and mucosal interface

1. Prevention: Inflate cuff with minimal amount of air necessary; monitor cuff pressure q. 8
h.; use appropriate size tube.

2. Treatment: may resolve spontaneously; perform surgical interventions.

D. Laryngeal or tracheal stenosis – injury to area from end of tube or cuff, resulting in
scar tissue formation and narrowing of airway

1. Prevention: inflate cuff with minimal amount of air necessary; monitor cuff pressure q.
8.h.; suction area above cuff frequently.

2. Treatment: perform tracheotomy; place laryngeal stint; perform surgical repair.

E. Cricoid abcess – mucosal injury with bacterial invasion

1. Prevention: inflate cuff with minimal amount of air necessary; monitor cuff pressure q. 8
h.; suction area above cuff frequently.

2. Treatment: perform incision and drainage of area; administer antibiotics.

4. Other common potential problems related to mechanical ventilation:

Aspiration, GI bleeding, Inappropriate ventilation (respiratory acidosis or alkalosis, Thick

secretions, Patient discomfort due to pulling or jarring of ETT or tracheotomy, High PaO2,
Low PaO2, Anxiety and fear, Dysrhythmias or vagal reactions during or after suctioning,
Incorrect PEEP setting, Inability to tolerate ventilator mode.

PLAN OF CARE FOR THE VENTILATED PATIENT

Patient Goals:

1. Patient will have effective breathing pattern.

2. Patient will have adequate gas exchange.

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 3. Patient’s nutritional status will be maintained to meet body needs.
4. Patient will not develop a pulmonary infection.
5. Patient will not develop problems related to immobility.

CONCLUSION:

A medical ventilator (or simply ventilator in context) is a mechanical ventilator, a machine

designed to move breathable air into and out of the lungs, to provide breathing for a patient
who is physically unable to breathe, or breathing insufficiently. While modern ventilators are
computerized machines, patients can be ventilated with a simple, hand-operated bag valve
mask. Ventilators are chiefly used in intensive care medicine, home care, and emergency
medicine (as standalone units) and in anaesthesia (as a component of an anaesthesia
machine).Medical ventilators are sometimes colloquially called "respirators", a term
stemming from commonly used devices in the 1950s (particularly the "Bird Respirator").
However, in modern hospital and medical terminology, these machines are never referred
to as respirators, and use of "respirator" in this context is now a deprecated anachronism
signaling technical unfamiliarity. In the present-day medical field, the word "respirator"
refers to a protective face mask.

REFERENCE

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2.Jump up to:a b Geddes LA (2007). "The history of artificial respiration". IEEE Engineering

in Medicine and Biology Magazine : the Quarterly Magazine of the Engineering in Medicine
& Biology Society. 26(6): 38–41. doi:10.1109/EMB.2007.907081. PMID 18189086.

3.Jump up^ Russell WR, Schuster E, Smith AC, Spalding JM (April 1956). "Radcliffe
respiration pumps". The Lancet. 270 (6922): 539–41. doi:. PMID 13320798.

4.Jump up Bellis, Mary. "Forrest Bird invented a fluid control device, respirator & pediatric
ventilator". About.com. Retrieved 2009-06-04.

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5.Jump up Skinner, M (1998). "Ventilator function under hyperbaric conditions". South
Pacific Underwater Medicine Society Journal. 28 (2). Retrieved 2009-06-04.

6.Jump up Weaver LK, Greenway L, Elliot CG (1988). "Performance of the Seachrist 500A

Hyperbaric Ventilator in a Monoplace Hyperbaric Chamber". Journal of Hyperbaric
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