Sub: Critical Care Nursing

Unit: II Tools of Critical Care Nursing

Topic: Ventilator Care
Lect: 16
Faculty: Ms. Almas Ghaffar (Asso.Professor)
MSN
PNS, LUMHS, Jamshoro
Date: 29 /07/2021

What is Ventilator?
A ventilator is a device that supports or takes over the breathing process, pumping air into the lungs. People
who stay in intensive care units (ICU) may need the support of a ventilator.

What Do Ventilators Do?

 A ventilator trusted source is a device that supports or recreates the process of breathing by pumping
air into the lungs.
 Sometimes people refer to it as a vent or breathing machine.
 Ventilators are used if a person cannot breathe adequately on their own. This may be because they are
undergoing general anesthesia or have an illness that affects their breathing.
 Ventilators play an important role in saving lives, both in hospitals and ambulances.
 People who require long-term ventilation can also use them at home.

Types of Ventilators
 There are different types of ventilator, and each provides varying levels of support.
 The type a doctor uses will depend on the person’s condition.
 There are several ways a person can receive ventilator support.
These include:
1. Face mask ventilators
2. Manual resuscitator bags
3. Tracheostomy ventilators
4. Mechanical ventilators

1. Face mask ventilator

 A face mask ventilator is a noninvasive method of supporting a person’s breathing and oxygen
levels.
 To use one, a person wears a mask that fits over the nose and mouth while air blows into their
airways and lungs.

2. Manual resuscitator bags

 Manual resuscitator bags are pieces of equipment that allow people to control the airflow of their
ventilator with their hands.
 These devices consist of an empty bag, or “bladder,” that a person squeezes to pump air into the
lungs.
 This can be useful as a temporary solution if a person on a mechanical ventilator needs to stop using
it. For example, if there is a power outage, a person can use a manual resuscitator bag while waiting
for the power to come back on.
 3. Tracheostomy ventilator
 People who have undergone a tracheostomy require a different type of ventilator.
 A tracheostomy is a procedure where a doctor creates an opening in the windpipe and inserts a tube,
which allows air to flow in and out.
 This enables a person to breathe without using their nose or mouth.
 People who have undergone tracheostomies can also receive ventilator support through this opening.
 Instead of inserting a ventilator through the mouth, doctors insert it directly into the windpipe.

4. Mechanical Ventilator (MV)

 Mechanical ventilator is a machine that provides mechanical ventilation by moving breathable air into
and out of the lungs, to deliver breaths to a patient who is physically unable to breathe, or breathing
insufficiently.
 It is computerized microprocessor-controlled machines, but patients can also be ventilated with a
simple, hand-operated bag valve mask.
 Ventilators are sometimes called "respirators", a term commonly used for them in the 1950s
(particularly the “Bird respirator”.
 However, contemporary hospital and medical terminology uses the word "respirator" to refer instead
to a face-mask that protects wearers against hazardous airborne substances.
https://en.wikipedia.org/wiki/Ventilator
 It 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 the fraction of inspired oxygen is the concentration of oxygen in the gas mixture), accumulated
in a receptacle within the machine, and delivered to the patient using one of many available modes of
ventilations.
Purposes
1. To maintain gas exchange in case of acute and chronic respiratory failure.
2. To maintain ventilatory support after CPR.
3. To reduce pulmonary vascular resistance.
4. To excrete increased CO2 production.
5. To give general anesthesia with muscle relaxants.

Classification/Types of Mechanical Ventilators

1. Positive pressure
2. Negative pressure

Positive Pressure Ventilator

 Positive pressure ventilators inflate the lungs by exerting positive pressure on the airway forcing the
alveoli to expand during inspiration pushes the air into the lungs.
 Expiration occurs passively.
 Positive-pressure ventilators require an artificial airway (Endotracheal or tracheostomy tube) and use
positive pressure to force gas into a patient's lungs.
 Inspiration can be triggered either by the patient or the machine.
 Positive-pressure ventilators, which are much more commonly used, deliver air by pumping it into
the patient’s lungs.
 With positive-pressure ventilation, the normal relationship between intrapulmonary pressures during
inspiration and expiration is reversed (i.e. pressures during inspiration are positive and pressures
during expiration are negative).

Negative Pressure Ventilator

  Negative pressure ventilation sucks the air into the lungs by making the chest expand and contract.
 It encase (cover) the patient’s body and exert negative pressure that pulls the thoracic cage outward
to initiate inspiration.
 In current clinical practice, use of negative-pressure ventilators is limited.
 Elongated tank, which encases the patient up to the neck. The neck is sealed with a rubber gasket, the
patient's face are exposed to the room air.
 These exert negative pressure on the external chest decreasing the intra-thoracic pressure during
inspiration, allows air to flow into the lungs, filling its volume.
 The cessation of the negative pressure causes the chest wall to fall and exhalation to occur.
 These are simple to use and do not require intubations of the airway; consequently, they are
especially adaptable for home use.
 It is used mainly in chronic respiratory failure associated with neuromuscular conditions such as
poliomyelitis, muscular dystrophy and myasthenia gravis.
 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).

Indications
 Need for sedation/ neuromuscular blockage.
 Need to decrease systemic or myocardial oxygen consumption.
 Use of hyperventilation to reduce intracranial pressure.

Ventilation Abnormalities
 Respiratory muscle dysfunction
 Respiratory muscle fatigue
 Chest wall abnormalities
 Neuromuscular diseases

Oxygenation Abnormalities
 Refractory hypoxemia.
 Need for positive end expiratory pressure.
 Excessive work of breathing
 Bradypnea or apnea with respiratory arrest.
 Acute lung injury and the acute respiratory distress syndrome.
 Tachypnea (respiratory rate >30 breaths per minute)
 Vital capacity less than 15 mL/kg.
 Minute ventilation greater than 10 L/min.
Modes of Ventilation

Spontaneous
 The machine is not giving pressure breath.
 The patient breath spontaneously.
 The patient needs only specific FIO2 to maintain its normal blood gases.

Controlled
 The machine controls the patient ventilation according to set tidal volume and respiratory rate.
 Spontaneous respiratory effort of patient is locked out, (patient who receives sedation and paralyzing
drugs he will on controlled Mode).

SIMV (Synchronized intermittent mandatory ventilation mode)

 Machine allows the patient to breath spontaneously while providing preset FIO2, and a number of
ventilator breaths to ensure adequate ventilation without fatigue.
Assist/Control (A/C) Mode
 The patient triggers the machine with negative inspiratory effort.
 If the patient fails to breath the machine will deliver a controlled breath at a minimum rate and
volume already set.

Adjustment on the Ventilator

 The ventilator is adjusted so that the patient is comfortable and "in sync " with the machine.
 Minimal alteration of the normal cardiovascular and pulmonary dynamics is desired.
 If the volume of ventilator is adjusted appropriately, the patient arterial blood level will be
satisfactory and there will be no or little cardiovascular compromise.

The Following Guidelines are recommended

1. Set the machine to deliver the required tidal volume (6 to 8 ml/kg)
2. Adjust the machine to deliver the lowest concentration of the oxygen to maintain normal (PaO2)
partial pressure of oxygen (80 to 100mmhg).
3. The setting may be set high and gradually reduced based on ABGs result.
4. Record peak inspiratory pressure.
5. Set mode (Assist/Control or SIMV) and rate according to physician order.
6. If patient is on assist/control mode, adjust sensitivity so that the patient can trigger the ventilator with
the minimum effort (usually 2mmHg negative inspiratory force)
7. Record minute volume and measure carbon dioxide partial pressure PaCO2, PH after 20 minutes of
mechanical ventilation.
8. Adjust FIO2 and rate according to results of ABG to provide normal values or those set by the
physician.
9. In case of sudden onset of confusion, agitation or unexplained “bucking the ventilator " the patient
should be assessed for hypoxemia and manually ventilated on 100% oxygen with resuscitation bag
(AMBU bag) Bag – Valve – mask.
10. Patient who are on controlled ventilation and have spontaneous respiration may “fight or buck” the
ventilator, because they cannot synchronize their own respiration with the machine cycle.

Complications of M.V
A- Decreased Cardiac Output

 Cause: Venous return to the right atrium impeded by the dramatically increased intra-thoracic
pressures during inspiration from positive pressure ventilation.
 Also reduced sympatho-adrenal stimulation leading to a decrease in peripheral vascular resistance and
reduced blood pressure.
 Symptoms: Increased heart rate, decreased blood pressure and perfusion to vital organs, decreased
CVP, and cool clammy skin.
 Treatment – aimed at increasing preload (e.g. Fluid administration) and decreasing the airway
pressures exerted during mechanical ventilation by decreasing inspiratory flow rates and Tidal
Volume, or using other methods to decrease airway pressures (e.g. Different modes of ventilation).

B. Barotrauma
 Cause: damage to pulmonary system due to alveolar rupture from excessive airway pressures and/or
over distention of alveoli.
 Symptoms: may result in pneumothorax, pneumomediastinum (mediastinal emphysema, is a
condition in which air is present in the mediastinum) and subcutaneous emphysema.
 Treatment: aimed at reducing Tidal Volume, cautious use of PEEP (positive end expiratory
pressure), 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 hyper-inflated lungs (emphysema).

C. Nosocomial Pneumonia

 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.
 Treatment: aimed at prevention by the following:
 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

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 intra-cardiac shunts: reduce PEEP
Other Common Potential Problems Related To Mechanical Ventilation

 Aspiration,  Patient discomfort due to pulling or jarring of ETT or

tracheostomy,
 GI bleeding,
 Dysrhythmias
 Inappropriate ventilation
 or vagal reactions during or after suctioning,
 (respiratory acidosis or alkalosis,
 Incorrect PEEP setting,
 Thick secretions,
 Inability to tolerate ventilator mode.
 High PaO2, Low PaO2,
 Anxiety and fear,

Nursing Management of Ventilated Patient

1. Promote respiratory function.
2. Monitor for complications
3. Prevent infections.
4. Provide adequate nutrition.
5. Monitor GI bleeding.

1. Promote Respiratory Function

 Auscultate lungs frequently to assess for abnormal sounds.
 Suction as needed.
 Turn and reposition every 2 hours.
 Secure ETT properly.
 Monitor ABG value and pulse oximetry.
Suction of an Artificial Airway
1. To maintain a patent airway
2. To improve gas exchange.
3. To obtain tracheal aspirate specimen.
4. To prevent effect of retained secretions.
(It is important to OXYGENATE before and after suctioning)
2. Monitor For Complications
i. Assess for possible early complications
 Rapid electrolyte changes.
 Severe alkalosis.
 Hypotension secondary to change in Cardiac output.

ii. Monitor for signs of respiratory distress:

 Restlessness Apprehension
 Irritability and increase HR.

iii. Assess for signs and symptoms of barotrauma(rupture of the lungs)

 Increasing dyspnea
 Agitation
 Decrease or absent breath sounds.
 Tracheal deviation away from affected side.
 Decreasing PaO2 level.

iv. Assess for cardiovascular depression: Hypotension

 Tachycardia. and Bradycardia
 Dysrhythmias.

2. Prevent Infection
 Maintain sterile technique when suctioning.
 Monitor color, amount and consistency of sputum.

3. Provide Adequate Nutrition

 Begin tube feeding as soon as it is evident the patient will remain on the ventilator for a long time.
 Weigh daily.
 Monitor I & O

4. Monitor For GI Bleeding

 Monitor bowel sounds.
 Monitor gastric PH and hematest gastric secretions every shift.

References
 Morton. G.P & Fontain. K.D., (2013)., Essentials of Critical Care Nursing. A Holistic Approach.
Lippincott Williams & Wilkins. Tokyo
 Chulay. M & Burns. S.M., (2006). AACN Essentials of Critical Care Nursing. Mc Graw
Hill.Toronto.
 https://en.wikipedia.org/wiki/Ventilator