Types of Mechanical Ventilators Negative Pressure Ventilators -exerts a negative pressure on the external chest and the underlying

g lung to expand it during inspiration. Air then flows into the lung, filling its volume. Physiologically, the type of assisted ventilation is similar to spontaneous ventilation. It is used mainly in respiratory failure associated with neuromuscular conditions such as poliomyelitis, muscular dystrophy, multiple sclerosis, and myasthenia gravis. Negative pressure ventilators are simple to use and do not require intubation of the airway. Consequently, they are especially adaptable for home use. Drinker Respirator Tank (Iron Lung)

-is a negative pressure chamber used in ventilation. It is efficient and reliable and does not require intubation. It is cumbersome to use, not very portable, and not always effective in the presence of diseased lungs.

Body Wrap (Pneumo-wrap) and Chest Cuirass (Tortoise Shell)

- both of these portable devices require a rigid cage or shell to create a negative-pressure chamber around the thorax and abdomen.

Positive Pressure Ventilators

-inflate the lungs by exerting positive pressure on the airway, thus forcing the alveoli to expand during inspiration. Expiration occurs passively. -These ventilators are widely used in the hospital setting and are increasingly used in the home in patients with primary lung disease.

Pressure-Cycle Ventilators

-is a positive pressure ventilator in which the inspiratory pressure to be reached with each inspiration is controlled. The ventilator cycles on, delivers a flow of air until a certain predetermined pressure is reached, and then cycles off.

Time-Cycled Ventilators

- Time-cycled ventilators terminate or control inspiration after preset time. The volume of air the patient is regulated by the length of inspiration and the flow rate of the air.

Volume-Cycled Ventilators

- Volume- cycled ventilators are the most commonly used positive pressure ventilators. With this type of ventilator, the volume of air to be delivered with each inspiration is controlled. Once this preset volume is delivered to the patient, the ventilator cycles off and exhalation occurs passively. From breath to breath , the volume of air delivered by the ventilator is constant, assuring consistent, adequate breaths.

VENTILATION MODES CONTROL MODES - one of the mechanical ventilation modes where the ventilator delivers the breaths at a set rate to the patient on life support - It is typically only used when the patient is sedated and experiencing severe respiratory failure or paralysis ASSIST MODE - artificial respiration kicks in when the ventilator senses that the patient is trying to take a breath on his or her own - patients essentially control the amount of breathing assistance they receive from the ventilators. CONTINUOUS MECHANICAL VENTILATION MODE - combination of control modes and assist modes, and they involve setting the control rate to a minimum number of breaths per minute, which the ventilator will deliver - If the patient takes more on his or her own, the machine adjusts to coincide with the patients breathing pattern

INTERMITTENT MANDATORY VENTILATIONS - a combination of control mechanical ventilation modes and spontaneous breathing - a set number of breaths is delivered, but the patient may breathe spontaneously between mechanical breaths as he or she wishes. Humidified oxygen will be available in this case for the patient to breathe PRESSURE SUPPORT MODES - the ventilator monitors both the mechanical breaths and the spontaneous breaths, and inspiratory flow rates are delivered to the breathing circuit to maintain the airway pressure - When the patient's inspiration stops, the ventilator cuts off the breathing flow to the circuit, and the patient can exhale - holds the airway pressure constant while tidal volume varies, depending on the behavior of the lungs

PROBLEM Respiratory infection

Nursing Management Do not let patient exert any effort on self Check sensitivity screen Administer antibiotics as ordered Control temperature with antipyretics, TSB and hypothermia blankets Turn patient frequently Physical activity should be kept at a minimum for at least 24 hours

Cardiac failure

Monitor hemodynamic status

Decrease fluid volume, as ordered

Give diuretics as ordered

Decrease IV rate

Check intake and output hourly Barotrauma; possible tension pneumothorax This is an emergency; call a CODE BLUE

Stay with the patient and assist respirations

Prepare equipment for oxygenation and thoracentesis

Assist with chest tube insertion

Monitor ABG results

Monitor vital signs closely

Administer bicarbonate as indicated Gastointestinal distention Take daily measurements of abdominal girth at the umbilicus

Assess for distention, tympany and bowel sounds

Assess the clients complaints of pain, fullness, bloated feeling or need of laxative

Maintain adequate bowel evacuation

Monitor hematocrit count

Bleeding or Stress Ulcers

Administer antacids and anticholinergics to relieve pain as ordered

Provide rest periods

Surgery for recurrent ulcers Inability to wean the patient from the venitilator Medical decision necessary to determine longterm goals

Reassure the patient that he is progressively doing more of the work breathing

Stay with the patient during removal from the machine and after extubation

Provide diversional therapy

Extubate in the morning when the patient is rested

Do not give respiratoy depressants such as morphine sulfate or diazepam

Guidelines 1. Steps in Operating Mechanical Ventilation 1.1 set the machine to deliver tidal volume required (10-15 mmHg) 1.2 Adjust machine to deliver 100% inspired O2 or whatever is necessary to maintain normal PaCo2 (70-100 mmHg) 1.3 Record peak inspiratory pressure 1.4 Adjust inspiratory expiratory ratio. 1.5 Adjust sensitivity so that patient can trigger the machine with a minimum effort 1.6 Record minute volume and measure PCO2, pH, and PO2 after 20 mins of continuous ventilation on 100% inspired concentration. 1.7 Adjust fraction of inspired O2 (FiO2) according to results of ABG on 100% (1.00) inspired O2-FiO2 should be frequently monitored. 1.8 Add mechanical dead space if required to maintain normal PaCO2 when large tidal volumes are used. 1.9 Use 100% FiO2 setting to follow progress of pulmonary status 1.10 Rule out the possibility of an impending catastrophe whenever patient is out of phase with the ventilator. 2. Nursing Care to Patient with Mechanical Ventilator - Give a brief explanation to the patient. - Establish the airway by means of a cuffed endotracheal or tracheostomy tube. - Prepare the ventilator - Couple the patients airway to the ventilator - Assess the patient for adequate chest movement and rate. Do not depend on digital rate readout of ventilator. Note peak airway pressure and PEEP. - Set airway alarms according to patients baseline (High pressure/ Low pressure alarm)

- Assess frequently for change in respiratory status via arterial blood gas, spontaneous rate, use of accessory muscles, color, and vital signs. - Monitor and trouble-shoot alarm conditions. Ensure appropriate ventilation at all times - Turn patient from side to side every 2 hours, or more frequently if possible. - Asses for need of suctioning. - Assess breath sounds every 2hrs - Check the water levels in the humidification reservoir. - Assess airway pressures at frequent intervals. - Measure delivered tidal volume and analyze oxygen every 4 hrs or more frequently if indicated. - Monitor cardiovascular function. Assess for depression. - Monitor for pulmonary infection. - Evaluate need for sedation or muscle relaxants. - Report intake and output precisely and attain an accurate daily weight to monitor fluid balance. - Monitor nutritional status. - Monitor GI function. - Provide for care and communication needs of patient with an artificial airway. - Provide psychological support.

BIBLIOGRAPHY
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Lippincott Manual of Nursing Practice 4th edition and 5th edition Asheervath and Blevins. Handbook of Clinical Nursing Practice Smith and Germain. Care of the Adult Patient: Medical Surgical Nursing 4th edition Lippincott Williams and Wilkins. Nursing Know-How Interpreting ECGS Lippincott Williams and Wilkins. Critical Care Nursing Brunner and Suddarth. Textbook of Medical- Surgical Nursing 11th edition volume 1. www.ceufast.com/courses/viewcourse.asp?id=239 Joyce M. Black. Medical Surgical Nursing 6th edition volume 2