Using a Ventilator at Home Introduction

Only a few years ago, it seemed very uncommon for a person on a ventilator to be living at home. It was thought that knowing how to work this machine might be too hard for non-medical people. However, because people on ventilators with spinal cord injury are living long, healthy and full lives, it has now become important to teach families how to do this.

With a little training and practice, most people can learn how to take care of a person who is on a ventilator at home. This lesson will explain important issues about the ventilator. There are many other skills related to caring for the person on the ventilator such as suctioning, trach care, assist coughing and using an inexsufflator. All of the information about these areas can be found in the lessons of this Module. Please review them as well.

What is a ventilator?
A ventilator is a machine that moves air through a persons lungs. It is attached to a trach tube in the persons throat. It blows air or air with extra oxygen in to the lungs. It has many settings and alarms. Each person's ventilator has different settings that are determined by the doctor. Some people need a ventilator all of the time while others only use it part of the time. It depends on the persons needs and what the doctor orders. This is a common type of home ventilator. Yours may differ depending on your supplier. Always refer to your "Owner's Manual" and your home care company for operating instructions.

Why is a Ventilator Necessary?

People with a spinal cord injury in the neck area may require a ventilator. This is true because the spinal cord and its nerves help control breathing. It does so by helping the diaphragm, abdominal and rib muscles move to allow air in and out of the lungs. Helping these muscles also provides the body with the ability to cough and move mucous out of the lungs and throat. The amount of breathing problems a person has depends on the level of injury, the persons general physical condition or if the person was a heavy smoker. People with a C1 or C2 injury will require a ventilator all of the time because the injury is so high in the cord that it cannot send any messages to the diaphragm, rib or abdominal muscles. Some people with C3 injuries may need a ventilator all of the time or part of the time. People with C4 - C8 injuries may not need the ventilator at all but are still at high risk for breathing problems.

What do the Controls Do?

On/Off Switch: The switch is located at the bottom left row on this machine. The gray square box must be pressed to turn machine on or off.If you have 2 portable ventilators at home, keep the bedside ventilator plugged into an electrical outlet. The second portable ventilator should be hooked up to your power chair and attached to chair battery.

Mode of Ventilation: The doctor will determine which method of ventilation will best benefit the patients respiratory system. The doctor will order the Assist / Control or the SIMV / CPAP mode.

Breath Rate: controls how many breaths are given each minute. The amount of breaths will also be ordered by your doctor. It is important to always check the rate to make sure enough breaths are being given.

Tidal Volume: controls how much air is given in each breath. The setting is ordered by your doctor. It is important to know the tidal volume setting when doing routine ventilator checks.

Inspiratory Time: controls how fast to deliver the set tidal volume during inhalation. The respiratory therapist will set the time.

Pressure Support: Pressure Support control can only be used in the SIMV/CPAP mode, to help wean the patient off the ventilator. This control supports each spontaneous breath the patient takes by providing extra pressure which will reduce the patients work of breathing. This setting will be ordered by the doctor.

Oxygen control will read 21% oxygen, unless the patient is receiving extra oxygen in the hospital setting.

Sensitivity allows the ventilator to be set according to the person's breathing effort. The ventilator can provide 100% of the breathing work or it can be set to "assist" a person who has some breathing. This setting will be set by the respiratory therapist.

LOCK can be pressed to lock the settings. This control will prevent children from changing ventilator settings in the home.

What do the Alarms Do?

Alarms are indicators that will let you know if something is wrong with the ventilator. When an alarms sounds it is important that you respond to it immediately.

Here are some immediate actions you can take:

Check the person to make sure they are not in distress. If they are, take them off the ventilator and use the Ambu Bag to breathe for the person. Bag the person until you find the problem. If the ventilator tubing has popped off the trach tube, simply re-attach it. If it is not something obvious, continue bagging the person and begin checking the tubing starting where it connects to the person and search the tubing all the way back to the machine. If tubing has become disconnected, reconnect it. Check the trach cuff as you were taught. If

it is low, insert a little more air and see if this stops the alarm. If you still cannot find the problem, keep bagging and call 911 for help. You will also need to call your homecare company and respiratory therapist after the emergency situation is over.

High Pressure Limit: alarm tells you that there has been an increase in air pressure delivered to the lungs. It could mean that the person has too much mucous in the lungs and needs to be suctioned. It can also mean that the ventilator tubing has become kinked. Low Pressure: alarm tells you that there has been a drop in air pressure delivered to the lungs. It could mean that the ventilator tubing has popped off the trach tube or that there is a leak or a piece of tubing has disconnected. Sometimes there could even be a problem with the trach cuff. This is not a ventilator problem, but it will still sound the alarm because not enough air pressure is being given to the person. Low Min. Vol:This setting with be set by the respiratory therapist. When this alarm sounds it indicates that the lung volume has dropped. Check trach cuff pressure and ventilator tubing for leak Silence / Reset: this control performs two functions: When pressed to silence ringing alarm, it will do so for 60 seconds. Silence should only be pressed after the problem has been fixed. Reset: is pressed to return ventilator back to patients ventilator settings.

Set Value Dial: large gray dial below the alarm section. When any of the settings in the control panel need to be changed, the gray square box under the setting must be press, and the Set Value dial is turned to lower or increase the number setting. You will notice that the setting number will be highlighted and the rest of the numbers on the panel will be dimmed down. Once the desired number is set, press the gray square box again. To prevent anyone from making any changes to the settings, the CONTROL LOCK can be pressed to lock the settings. This control will prevent children from changing ventilator settings in the home.

The low pressure number and low minute volume numbers will blink when there is a disconnection or leak. Check connection at trach and all tubing connections. Check the cuff pressure of the trach tube. It might need more air. Move the vent tubing to make sure it is lying on the patient's chest. The high pressure alarm will beep when a patient needs to be suctioned.

When the PIP level incrases from it's normal level, it also means that the patient needs to be suctioned. Airway Pressure Display this is the long, rectangle window, that when Select is pressed you will be able to read several pieces of information, for example , the three most important homecare readings are: PIP is for airway pressure, exhaled tidal volume, and breath rate. An increase or decrease in airway pressure (PIP) can indicate that the patient needs suctioning or has an airway leak.The exhale tidal volume might need to be monitored if the patient is weaning off the ventilator.

Power Indicator (upper right hand corner in front of the ventilator ) During the day time hours while the converter box is on the EXTERNAL POWER LIGHT should be ON AND GREEN. During the night time hours while ventilator is being charged, the CHARGE STATUS light will blink iuntil it is fully charged, then it becomes a STEADY AMBER LIGHT.

Important Things to Remember

Alert the power company, fire & police departments and other emergency personnel (911) that you have a person at home on a ventilator prior to discharge from the rehabilitation facility. Have the home care company check the power in your home before the person comes home from rehabilitation. Consider having alternative electrical equipment such as a generator and batteries in case of power failure. Place the ventilator on a sturdy utility cart. You can buy this at your local discount store. Make sure it is sturdy and that it has wheels. If you use a wood burning stove in your home, never stay in the same room as the stove Always give extra breaths (bag) with the Ambu Bag if the person has trouble breathing or there is equipment failure Always call 911 & the home care company for help if there is equipment failure. If the person is unresponsive, call 911, open the front door, get back to the person and begin CPR.

If the person is using oxygen, please note the following:

never smoke while oxygen is in use never place oxygen equipment near heat, electrical appliances (battery shavers are ok) or the furnace never use petroleum jelly (like vaseline) products on oxygen equipment or the person

Mechanical Ventilation: What Is It?

Mechanical ventilation is a method for using machines to help patients breathe when they are unable to breathe sufficiently on their own. Most often, mechanical ventilation is used for a few days to help a patient breathe during a serious illness. This type of breathing support is usually done in an intensive care unitan ICU for short. Sometimes patients still can't breathe on their own after the acute illness is over, despite efforts to restore spontaneous breathing. Patients may no longer need to be in the ICU but still require mechanical ventilation because of an extended need for the breathing assistance of the ventilator. Other patients may have stable, longer-term (chronic) conditions that make them unable to breathe on their own. Due to a variety of reasons, including the cost of hospital care and the patient's quality of life, for the patient who is dependent on a ventilator for breathing assistance, it may be better to receive mechanical ventilation at home or at a nonhospital institution offering specialized nursing or rehabilitation services. Over time, with the professional support of physicians and respiratory therapists, some ventilator-assisted individuals are able to become less dependent on the ventilator and breathe on their own for substantial portions of every day. Other patients have medical conditions that require

24-h mechanical ventilation for many months or years, or even for a lifetime. The method of long-term mechanical ventilation that is best for the patient will be determined by the physician, respiratory therapist, and the patient. A patient capable of some independent activities and several hours a day off the ventilator will have different requirements than the patient who needs ventilator assistance 24 h a day. Invasive methods use a tracheostomya surgical hole in the windpipe through which a tube is channeled to assist breathing. Noninvasive methods use masks, nasal tubes, and other techniques that do not require surgical entry into the respiratory tract. Some apply positive pressure to the mouth and/or nose. Others apply negative pressure to the chest or body by lowering the pressure outside the body. All methods of ventilation require an initial assessment of comfort and efficacy and follow-up monitoring of daytime and nighttime breathing. The patient and caregivers should be educated in use and maintenance of the equipment needed to provide the support. Noninvasive Methods Positive Pressure Ventilation: Mouth and/or Nose Positive pressure ventilation delivers air (and sometimes extra oxygen when medically necessary) to the patient through a face mask, mouthpiece, or nasal mask. Patients who can be independent of the ventilator for portions of the day may use noninvasive positive-pressure ventilation to assist nighttime breathing.

Negative Pressure Ventilation

Entry of air into the lungs is assisted by applying intermittent negative pressure (like a vacuum) to the chest and abdomen by means of a body tank (iron lung), a chest shell, or a body jacket.

Rocking Bed

A bed with rocking motion assists ventilation by intermittently causing the diaphragm to move up and down, creating a "pumping" motion in the chest, and thus, helping air to go in and out of the lungs.

Pneumobelt

An inflatable band around the abdomen presses on the abdomen and forces air in and out of the lungs. The pneumobelt may be used in combination with other noninvasive methods of ventilation. It may not be

suitable for some patientsfor example, patients who are excessively underweight or overweight. The patient must be sitting up for this device to work. It is often used by patients in a wheelchair.

Diaphragm Pacing

An electronic pacer stimulates the diaphragm to contract, thus assisting breathing by "bellows" motion of the diaphragm. This method is used by patients who have high (C1-C2) spinal cord injury, and with tracheostomy in some children who cannot breathe spontaneously because of a problem with central control of breathing.

Glossopharyngeal Breathing

Sometimes called "frog" breathinga technique in which the patient learns to "gulp" air into the lungs. Some patients use this technique in order to spend more time off the ventilator and to have "free" time in case of ventilator failure.

Manually Assisted Coughing

A caregiver helps the patient to exhale and clear mucus from the lungs by delivering a thrust similar to a Heimlich maneuver. Thorough training of the patient and caregivers is required to make this technique effective and to avoid injury to the patient. Invasive Methods Invasive methods may be needed for patients who are unable to use noninvasive methods. Invasive mechanical ventilation requires a tracheostomy for placement of a tracheostomy tube into the windpipe to deliver air directly into the lungs. The patient and caregivers are trained in care of the tracheostomy and tube to prevent complications such as infection around the tracheostomy tube or clogging of the tube.

Caring for the Patient on a Ventilator 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 patients 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 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 lowflow 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: 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 Ventilator Settings Modes of Mechanical Ventilation Complications of Mechanical Ventilation 1. Associated with patients response to mechanical ventilation: 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 overdistention 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: Avoid cross-contamination by frequent handwashing Decrease risk of aspiration (cuff occlusion of trachea, positioning, use of smallbore 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 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 patients 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 necessar 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 h. 2. Treatment: position cuff of tube distal to fistula; place gastrostomy tube for enteral 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 tracheostomy; 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 tracheostomy, 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. 2. 3. 4. 5. 6. Patient will have effective breathing pattern. Patient will have adequate gas exchange. Patients nutritional status will be maintained to meet body needs. Patient will not develop a pulmonary infection. Patient will not develop problems related to immobility. Patient and/or family will indicate understanding of the purpose for mechanical ventilation.

Nursing Diagnosis

Nursing Interventions

Rationale

Ineffective breathing pattern r/t ____________________________.

Observe changes in respiratory rate and depth; observe for SOB and use of accessory muscles. Observe for tube misplacement- note and post cm. Marking at lip/teeth/nares after xray confirmation and q. 2 h. Prevent accidental extubation by taping tube securely, checking q.2h.; restraining/sedating as needed.

An increase in the work of breathing will add to fatigue; may indicate patient fighting ventilator.

Indicates correct position to provide adequate ventilation.

Avoid trauma from accidental extubation, prevent inadequate ventilation and potential respiratory arrest. Determines adequacy of breathing pattern; asymmetry may indicate hemothorax or pneumothorax. Indicates volume of air moving in and out of lungs. Pain may prevent patient from coughing and deep breathing. Shows extent and location of fluid or infiltrates in lungs. Ventilator provides adequate ventilator pattern for the patient. This position moves the abdominal contents away from the diaphragm, which facilitates its contraction.

Inspect thorax for symmetry of movement.

Measure tidal volume and vital capacity.

Asses for pain

Monitor chest x-rays

Maintain ventilator settings as ordered.

Elevate head of bed 6090 degrees.

Impaired gas exchange r/t alveolarcapillary membrane changes

Monitor ABGs.

Determines acid-base balance and need for oxygen. These signs may indicate hypoxia. Determine adequacy of blood flow needed to carry oxygen to tissues. Indicates the oxygen carrying capacity available. Decreases work of breathing and supplies supplemental oxygen. May result in inadequate ventilation or mucous plug. Repositioning helps all lobes of the lung to be adequately perfused and ventilated. Indicates adequate visceral protein. Calories, minerals, vitamins, and protein are needed for energy and tissue repair. Provides guidance and continued surveillance. Prevent mucosal

Assess LOC, listlessness, and irritability. Observe skin color and capillary refill.

Monitor CBC.

Administer oxygen as ordered. Observe for tube obstruction; suction prn; ensure adequate humidification.

Reposition patient q. 12 h.

Potential altered nutritional status: less than body requirements r/t NPO status

Monitor lymphocytes and albumin. Provide nutrition as ordered, e.g. TPN, lipids or enteral feedings. Obtain nutrition consult.

Potential for pulmonary infection

Secure airway and

r/t compromised tissue integrity.

support ventialtor tubing. Provide good oral care q. 4 h.; suction when need indicated using sterile technique; handwashing with antimicrobial for 30 seconds before and after patient contact; do not empty condensation in tubing back into cascade. Use disposable saline irrigation units to rinse in-line suction; ensure ventilator tubing changed q. 7 days, inline suction changed q. 24 h.; ambu bags changes between patients and whenever become soiled.

damage.

Measures aimed at prevention of nosocomial infections.

IAW Infection Control Policy and Respiratory Therapy Standards of Care for CCNS.

Potential for complications r/t immobility.

Assess for psychosocial alterations.

Dependency on ventilator with increased anxiety when weaning; decreased ability to communicate; social isolation/alteration in family dynamics.

Assess for GI problems. Preventative measures include relieving anxiety, antacids or H2 receptor antagonist therapy, adequate sleep cycles, adequate communication system.

Most serious is stress ulcer. May develop constipation.

Observe skin integrity for pressure ulcers; preventative measures include turning patient at least q. 2 h.; keep HOB < 30 degrees with a 30 degree side-lying position; use pressure relief mattress or turning bed if indicated; follow prevention of pressure ulcers plan of care; maintain nutritional needs. Maintain muscle strength with active/activeassistive/passive ROM and prevent contractures with use of span-aids or splints. Explain purpose/mode/and all treatments; encourage patient to relax and breath with the ventilator; explain alarms; teach importance of deep breathing; provide alternate method of communication; keep call bell within reach; keep informed of results of studies/progress; demonstrate confidence.

Patient is at high risk for developing pressure ulcers due to immobility and decreased tissue perfusion.

Patient is at risk for developing contractures due to immobility, use of paralytics and ventilator related deficiencies.

Knowledge deficit r/t intubation and mechanical ventilation

Reduce anxiety, gain cooperation and participation in plan of care.

Mechanical ventilation
From Wikipedia, the free encyclopedia
In architecture and climate control, mechanical or forced ventilation is the use of powered equipment, e.g. fans and blowers, to move air see ventilation (architecture).

Mechanical ventilation
Intervention ICD-9: MeSH OPS-301 code: 93.90 96.7 D012121 8-71

In medicine, 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 physician, respiratory therapist or other suitable person compressing a bag or set of bellows. Traditionally divided into negativepressure ventilation, where air is essentially sucked into the lungs, or positive pressure ventilation, where air (or another gas mix) is pushed into the trachea. There are two main divisions of mechanical ventilation: invasive ventilation and non-invasive ventilation.[1] There are two main modes of mechanical ventilation within the two divisions: positive pressure ventilation and negative pressure ventilation.

Contents
[hide]

1 History 2 Complications 3 Application and duration o 3.1 Negative pressure machines o 3.2 Positive pressure machines 4 Indications for use 5 Associated risk 6 Types of ventilators o 6.1 Mechanical ventilators 7 Breath delivery o 7.1 Trigger o 7.2 Cycle o 7.3 Limit 8 Breath exhalation 9 Modes of mechanical ventilation o 9.1 Volume controlled continuous mandatory ventilation o 9.2 Volume controlled intermittent mandatory ventilation o 9.3 Pressure controlled continuous mandatory ventilation o 9.4 Pressure controlled intermittent mandatory ventilation o 9.5 High frequency ventilation o 9.6 Continuous spontaneous ventilation 9.6.1 Pressure Support Ventilation 9.6.2 Continuous positive airway pressure 10 Choosing amongst ventilator modes 11 Modification of settings o 11.1 Weaning from mechanical ventilation 12 Respiratory monitoring 13 Artificial airways as a connection to the ventilator 14 References 15 External links [edit]History

The Roman physician Galen may have been the first to describe mechanical ventilation: "If you take a dead animal and blow air through its larynx [through a reed], you will fill its bronchi and watch its lungs attain the greatest distention."[2] Vesalius too describes ventilation by inserting a reed or cane into the trachea of animals.[3] In 1908 George Poedemonstrated his mechanical respirator by asphyxiating dogs and seemingly bringing them back to life.[4]

[edit]Complications
Mechanical ventilation is often a life-saving intervention, but carries many potential complications including pneumothorax, airway injury, alveolar damage, and ventilator-associated pneumonia.[5] In many healthcare systems prolonged ventilation as part of intensive care is a limited resource (in that there are only so many patients that can receive care at any given moment). It is used to support a single failing organ system (the lungs) and cannot reverse any underlying disease process (such as terminal cancer). For this reason there can be (occasionally difficult) decisions to be made about whether it is suitable to commence someone on mechanical ventilation. Equally many ethical issues surround the decision to discontinue mechanical ventilation.[6]

[edit]Application

and duration

It can be used as a short term measure, for example during an operation or critical illness (often in the setting of an intensive care unit). It may be used at home or in a nursing or rehabilitation institution if patients have chronic illnesses that require long-term ventilatory assistance. Owing[clarification needed] to the anatomy of the human pharynx, larynx, andesophagus and the circumstances for which ventilation is required then additional measures are often required to secure the airway during positive pressure ventilation to allow unimpeded passage of air into the trachea and avoid air passing into the esophagus and stomach. Commonly this is by insertion of a tube into the trachea which provides a clear route for the air. This can be either an endotracheal tube, inserted through the natural openings of mouth or nose or a tracheostomy inserted through an artificial opening in the neck. In other circumstances simple airway maneuvres, an oropharyngeal airway or laryngeal mask airway may be employed. If the patient is able to protect their own airway and non-invasive ventilation or negative-pressure ventilation is used then a airway adjunct may not be needed.

[edit]

Negative pressure machines

An iron lung
Main article: Iron Lung The iron lung, also known as the Drinker and Shaw tank, was developed in 1929 and was one of the first negative-pressure machines used for long-term ventilation. It was refined and used in the 20th century largely as a result of the polio epidemic that struck the world in the 1940s. The machine is effectively a large elongated tank, which encases the patient up to the neck. The neck is sealed with a rubbergasket so that the patient's face (and airway) are exposed to the room air. While the exchange of oxygen and carbon dioxide between the bloodstream and the pulmonary airspace works by diffusion and requires no external work, air must be moved into and out of the lungs to make it available to the gas exchange process. In spontaneous breathing, a negative pressure is created in the pleural cavity by the muscles of respiration, and the resulting gradient between theatmospheric pressure and the pressure inside the thorax generates a flow of air. In the iron lung by means of a pump, the air is withdrawn mechanically to produce a vacuum inside the tank, thus creating negative pressure. This negative pressure leads to expansion of the chest, which causes a decrease in intrapulmonary pressure, and increases flow of ambient air into the lungs. As the vacuum is released, the pressure inside the tank equalizes to that of the ambient pressure, and the elastic coil of the chest and lungs leads to passive exhalation. However, when the vacuum is created, the abdomen also expands along with the lung, cutting off venous flow back to the heart, leading to pooling of venous blood in the lower extremities. There are large portholes for nurse or home assistant access. The patients can talk and eat normally, and can see the world through a well-placed series of mirrors. Some could remain in these iron lungs for years at a time quite successfully. Today, negative pressure mechanical ventilators are still in use, notably with the polio wing hospitals in England such as St Thomas' Hospital in London and the John Radcliffe inOxford. The prominent device used is a smaller device known as the cuirass. The cuirass is a shell-like unit, creating negative pressure only to the chest using a combination of a fitting shell and a soft bladder. Its main use is in patients with neuromuscular disorders who have some residual muscular function. However, it was prone to falling off and caused severe chafing and skin damage and was not used as a long term device. In recent years this device has re-surfaced as a modern polycarbonate shell with multiple seals and a high pressure oscillation pump in order to carry out biphasic cuirass ventilation.

[edit]

Positive pressure machines

Neonatal mechanical ventilator

The design of the modern positive-pressure ventilators were mainly based on technical developments by the military during World War II to supply oxygen to fighter pilots in high altitude. Such ventilators replaced the iron lungs as safe endotracheal tubes with high volume/low pressure cuffs were developed. The popularity of positive-pressure ventilators rose during the polio epidemic in the 1950s in Scandinavia and the United States and was the beginning of modern ventilation therapy. Positive pressure through manual supply of 50% oxygen through a tracheostomy tube led to a reduced mortality rate among patients with polio and respiratory paralysis. However, because of the sheer amount of man-power required for such manual intervention, mechanical positive-pressure ventilators became increasingly popular. Positive-pressure ventilators work by increasing the patient's airway pressure through an endotracheal or tracheostomy tube. The positive pressure allows air to flow into the airway until the ventilator breath is terminated. Subsequently, the airway pressure drops to zero, and the elastic recoil of the chest wall and lungs push the tidal volume the breathout through passive exhalation.

[edit]Indications

for use

Mechanical ventilation is indicated when the patient's spontaneous ventilation is inadequate to maintain life. It is also indicated as prophylaxis for imminent collapse of other physiologic functions, or ineffective gas exchange in the lungs. Because mechanical ventilation only serves to provide assistance for breathing and does not cure a disease, the patient's underlying condition should be correctable and should resolve over time. In addition, other factors must be taken into consideration because mechanical ventilation is not without its complications (see below) Common medical indications for use include:

Acute lung injury (including ARDS, trauma)

Apnea with respiratory arrest, including cases from intoxication Chronic obstructive pulmonary disease (COPD) Acute respiratory acidosis with partial pressure of carbon dioxide (pCO2) > 50 mmHg and pH < 7.25, which may be due to paralysis of the diaphragm due to Guillain-Barr syndrome, Myasthenia Gravis, spinal cord injury, or the effect of anaesthetic and muscle relaxant drugs

Increased work of breathing as evidenced by significant tachypnea, retractions, and other physical signs of respiratory distress

Hypoxemia with arterial partial pressure of oxygen (PaO2) < 55 mm Hg with supplemental fraction of inspired oxygen (FiO2) = 1.0

Hypotension including sepsis, shock, congestive heart failure Neurological diseases such as Muscular Dystrophy and Amyotrophic Lateral Sclerosis

[edit]Associated

risk

Barotrauma Pulmonary barotrauma is a well-known complication of positive pressure mechanical ventilation.[7] This includes pneumothorax, subcutaneous emphysema,pneumomediastinum, and pneumoperitoneum.[7] Ventilator-associated lung injury Ventilator-associated lung injury (VALI) refers to acute lung injury that occurs during mechanical ventilation. It is clinically indistinguishable from acute lung injury or acute respiratory distress syndrome (ALI/ARDS).[8] Diaphragm Controlled mechanical ventilation may lead to a rapid type of disuse atrophy involving the diaphragmatic muscle fibers, which can develop within the first day of mechanical ventilation. [9] This cause of atrophy in the diaphragm is also a cause of atrophy in all respiratory related muscles during controlled mechanical ventilation.[10] Motility of mucocilia in the airways Positive pressure ventilation appears to impair mucociliary motility in the airways. Bronchial mucus transport was frequently impaired and associated with retention of secretions and pneumonia.[11]

[edit]Types

of ventilators

SMART BAG MO Bag-Valve-Mask Resuscitator

Ventilators come in many different styles and method of giving a breath to sustain life. There are manual ventilators such as Bag valve masks and anesthesia bags require the user 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.

[edit]

Mechanical ventilators

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, 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-facility 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 feedback of each breath.

Neonatal ventilators Designed with the preterm neonate in mind, these are a specialized subset of ICU ventilators which are designed to deliver the smaller, more precise volumes and pressures required to ventilate these patients.

Positive airway pressure ventilators (PAP) These ventilators are specifically designed for noninvasive ventilation. This includes ventilators for use at home for treatment of chronic conditions such as sleep apnea or COPD.

[edit]Breath
[edit]

delivery

Trigger

The trigger is what causes a breath to be delivered by a mechanical ventilator. Breaths may be triggered by a patient taking their own breath, a ventilator operator pressing a manual breath button, or by the ventilator based on the set breath rate and mode of ventilation.

[edit]

Cycle

The cycle is what causes the breath to transition from the inspiratory phase to the exhalation phase. Breaths may be cycled by a mechanical ventilator when a set time has been reached, or when a preset flow or percentage of the maximum flow delivered during a breath is reached depending on the breath type and the settings. Breaths can also be cycled when an alarm condition such as a high pressure limit has been reached, which is a primary strategy in pressure regulated volume control.

[edit]

Limit

Limit is how the breath is controlled. Breaths may be limited to a set maximum circuit pressure or a set maximum flow.

[edit]Breath

exhalation

Exhalation in mechanical ventilation is almost always completely passive. The ventilator's expiratory valve is opened, and expiratory flow is allowed until the baseline pressure (PEEP) is reached. Expiratory flow is determined by patient factors such as compliance and resistance.

[edit]Modes

of mechanical ventilation

Main article: Modes of mechanical ventilation Mechanical ventilation utilizes several separate systems for ventilation referred to as the "mode". Modes come in many different delivery concepts but all modes generally fall into one of the few main flagship categories such as volume controlled continuous mandatory ventilation, volume controlled intermittent mandatory ventilation, pressure controlled continuous mandatory ventilation, pressure controlled intermittent mandatory ventilation, continuous spontaneous ventilation and the high frequency ventilation systems.

Volume controlled continuous mandatory ventilation

[edit]
Controlled mechanical ventilation (CMV) In this mode the ventilator provides a mechanical breath on a preset timing. Patient respiratory efforts are ignored. This is generally uncomfortable for children and adults who are conscious and is usually only used in an unconscious patient. It may also be used in infants who often quickly adapt their breathing pattern to the ventilator timing. Since CMV is no longer contained in its original form the term volume controlled continuous mandatory ventilation has consumed it into its definition and overall has combined any CMV mode for mechanical ventilation into the more accepted term in nomenclature for mechanical ventilation. Volume controlled continuous mandatory ventilation In this mode the ventilator provides a mechanical breath with either a pre-set tidal volume or peak pressure every time the patient initiates a breath. Traditional assist-control used only a pre-set tidal volumewhen a preset peak pressure is used this is also sometimes termed intermittent positive pressure ventilation (IPPV). However, the initiation timing is the sameboth provide a ventilator breath with every patient effort. In most ventilators a back-up minimum breath rate can be set in the event that the patient becomes apnoeic. Although a maximum rate is not usually set, an alarm can be set if the ventilator cycles too frequently. This can alert that the patient is tachypneic or that the ventilator may be auto-cycling (a problem that results when the ventilator interprets fluctuations in the circuit due to the last breath termination as a new breath initiation attempt).

Volume controlled intermittent mandatory ventilation

[edit]
Volume controlled intermittent mandatory ventilation (VC-IMV). Formerly known as synchronized intermittent mandatory ventilation (SIMV). In this mode the ventilator provides a pre-set mechanical breath (volume limited) every specified number of seconds (determined by dividing the respiratory rate into 60 seconds thus a respiratory rate of 12 results in a 5 second cycle time). Within that cycle time the ventilator waits for the patient to initiate a breath using either a pressure or flow sensor. When the ventilator senses the first patient breathing attempt within the cycle, it delivers the preset ventilator breath. If the patient fails to initiate a breath, the ventilator delivers a mechanical breath at the end of the breath cycle. Additional spontaneous breaths after the first one within the breath cycle do not trigger another SIMV breath. However, SIMV may be combined with pressure support (see below). SIMV is frequently employed as a method of decreasing ventilatory support (weaning) by turning down the rate, which requires the patient to take additional breaths beyond the SIMV triggered breath.

Pressure controlled continuous mandatory ventilation

[edit]
Pressure controlled continuous mandatory ventilation (PC-CMV) mechanical ventilation with preset inspiratory pressure (PIP) and inspiratory time (Ti). Every breath is machine initiated and mandatory.its right way

Pressure controlled intermittent mandatory ventilation

[edit]
Pressure controlled intermittent mandatory ventilation (formerly known as SIMV) In this mode the ventilator provides a pre-set pressure limited mechanical breath every specified number of seconds SIMV is frequently employed as a method of decreasing ventilatory support (weaning) by turning down the rate, which requires the patient to take additional breaths beyond the SIMV triggered breath. PC-IMV is fundamentally the same as VC-IMV with an emphasis on pressure support and control instead of volume. An example of PC-IMV is in the mode pressure regulated volume control.

[edit]

High frequency ventilation

High frequency ventilation refers to ventilation that occurs at rates significantly above that found in natural breathing. High frequency ventilation is further defined as any ventilation with a respiratory rate (V f) greater than 150 respirations per minute. Within the category of high-frequency ventilation, the two principal types are high-frequency ventilation (passive)(i.e. high-frequency jet ventilation) and high-frequency ventilation (active) (i.e. high-frequency oscillatory ventilation).

[edit]

Continuous spontaneous ventilation

Support Ventilation

[edit]Pressure

Pressure support ventilation (PSV). When a patient attempts to breathe spontaneously through an endotracheal tube, the narrowed diameter of the airway results in higher resistance to airflow, and thus a higher work of breathing. PSV was developed as a method to decrease the work of breathing in-between ventilator mandated breaths by providing an elevated pressure triggered by spontaneous breathing that "supports" ventilation during inspiration. Thus, for example, SIMV might be combined with PSV so that additional breaths beyond the SIMV programmed breaths are supported. However, while the SIMV mandated breaths have a preset volume or peak pressure, the PSV breaths are designed to cut short when the inspiratory flow reaches a percentage of the peak inspiratory flow (e.g. 1025%). New generation of ventilators provides user-adjustable inspiration cycling off threshold, and some even are equipped with automatic inspiration cycling off threshold function. This helps the patient ventilator synchrony. [12] The peak pressure set for the PSV breaths is usually a lower pressure than that set for the full ventilator mandated breath. PSV can be also be used as an independent mode.

[edit]Continuous

positive airway pressure

Continuous positive airway pressure (CPAP). A continuous level of elevated pressure is provided through the patient circuit to maintain adequate oxygenation, decrease the work of breathing, and decrease the work of the heart (such as in left-sided heart failure CHF). Note that no cycling of ventilator pressures occurs and the patient must initiate all breaths. In addition, no additional pressure above the CPAP pressure is provided during those breaths. CPAP may be used invasively through an endotracheal tube or tracheostomy or non-invasively with a face mask or nasal prongs. Non-invasive ventilation has become more common for treatment of acute respiratory failure.[1]

[edit]Choosing

amongst ventilator modes

Assist-control mode minimizes patient effort by providing full mechanical support with every breath. This is often the initial mode chosen for adults because it provides the greatest degree of support. In patients with less severe respiratory failure, other modes such as SIMV may be appropriate. Assist-control mode should not be used in those patients with a potential for respiratory alkalosis, in which the patient has an increased respiratory drive. Such hyperventilation and hypocapnia (decreased systemic carbon dioxide due to hyperventilation) usually occurs in patients with end-stage liver disease, hyperventilatory sepsis, and head trauma. Respiratory alkalosis will be evident from the initial arterial blood gas obtained, and the mode of ventilation can then be changed if so desired. Positive End Expiratory Pressure may or may not be employed to prevent atelectasis in adult patients. It is almost always used for pediatric and neonatal patients due to their increased tendency for atelectasis. High frequency oscillation is used most frequently in neonates, but is also used as an always alternative mode in adults with severe ARDS. Pressure regulated volume control is another option.

[edit]Modification

of settings

In adults when 100% FiO2 is used initially, it is easy to calculate the next FiO2 to be used and easy to estimate the shunt fraction. The estimated shunt fraction refers to the amount of oxygen not being absorbed into the circulation. In normal physiology, gas exchange (oxygen/carbon dioxide) occurs at the level of the alveoli in the lungs. The existence of a shunt refers to any process that hinders this gas exchange, leading to wasted oxygen inspired and the flow of un-oxygenated blood back to the left heart (which ultimately supplies the rest of the body with unoxygenated blood). When using 100% FiO2, the degree of shunting is estimated by subtracting the measured PaO2 (from an arterial blood gas) from 700 mmHg. For each difference of 100 mmHg, the shunt is 5%. A shunt of more than 25% should prompt a search for the cause of this hypoxemia, such as mainstem intubation or pneumothorax, and should be treated accordingly. If such complications are not present, other causes must be sought after, and PEEP should be used to treat this intrapulmonary shunt. Other such causes of a shunt include:

Alveolar collapse from major atelectasis Alveolar collection of material other than gas, such as pus from pneumonia, water and protein from acute respiratory distress syndrome, water from congestive heart failure, or blood from haemorrhage

[edit]

Weaning from mechanical ventilation

Withdrawal from mechanical ventilationalso known as weaningshould not be delayed unnecessarily, nor should it be done prematurely. Patients should have their ventilation considered for withdrawal if they are able to support their own ventilation and oxygenation, and this should be assessed continuously. There are several objective parameters to look for when considering withdrawal, but there is no specific criteria that generalizes to all patients. Trials of spontaneous breathing have been shown to accurately predict the success of spontaneous breathing.[13]

[edit]Respiratory

monitoring

Respiratory mechanics monitor

One of the main reasons why a patient is admitted to an ICU is for delivery of mechanical ventilation. Monitoring a patient in mechanical ventilation has many clinical applications: Enhance understanding of pathophysiology, aid with diagnosis, guide patient management, avoid complications and assessment of trends.[14] Most of modern ventilators have basic monitoring tools. There are also monitors that work independently of the ventilator, which allow to measure patients after the ventilator has been removed, such as a T tube test.

[edit]Artificial

airways as a connection to the

ventilator
Main article: Artificial airway There are various procedures and mechanical devices that provide protection against airway collapse, air leakage, and aspiration:

Face mask In resuscitation and for minor procedures under anaesthesia, a face mask is often sufficient to achieve a seal against air leakage. Airway patency of the unconscious patient is maintained either by manipulation of the jaw or by the use of nasopharyngeal or oropharyngeal airway. These are designed to provide a passage of air to the pharynx through the nose or mouth, respectively. Poorly fitted masks often cause nasal bridge ulcers, a problem for some patients. Face masks are also used for non-invasive ventilation in conscious patients. A full face mask does not, however, provide protection against aspiration.

Laryngeal mask airway The laryngeal mask airway (LMA) causes less pain and coughing than a tracheal tube. However, unlike tracheal tubes it does not seal against aspiration, making careful individualised evaluation and patient selection mandatory.

Tracheal intubation is often performed for mechanical ventilation of hours to weeks duration. A tube is inserted through the nose (nasotracheal intubation) or mouth (orotracheal intubation) and advanced into the trachea. In most cases tubes with inflatable cuffs are used for protection against leakage and aspiration. Intubation with a cuffed tube is thought to provide the best protection against aspiration. Tracheal tubes inevitably cause pain and coughing. Therefore, unless a patient is unconscious or anaesthetized for other reasons, sedative drugs are usually given to provide tolerance of the tube. Other disadvantages of tracheal intubation include damage to the mucosal lining of the nasopharynx ororopharynx and subglottic stenosis.

Esophageal obturator airway sometimes used by emergency medical technicians and basic EMS providers not trained to intubate. It is a tube which is inserted into theesophagus, past the epiglottis. Once it is inserted, a bladder at the tip of the airway is inflated, to block ("obturate") the esophagus,

and oxygen is delivered through a series of holes in the side of the tube which is then forced into the lungs.

Cricothyrotomy Patients who require emergency airway management, in whom tracheal intubation has been unsuccessful, may require an airway inserted through a surgical opening in the cricothyroid membrane. This is similar to a tracheostomy but a cricothyrotomy is reserved for emergency access.[15]

Tracheostomy When patients require mechanical ventilation for several weeks, a tracheostomy may provide the most suitable access to the trachea. A tracheostomy is a surgically created passage into the trachea. Tracheostomy tubes are well tolerated and often do not necessitate any use of sedative drugs. Tracheostomy tubes may be inserted early during treatment in patients with pre-existing severe respiratory disease, or in any patient who is expected to be difficult to wean from mechanical ventilation, i.e., patients who have little muscular reserve.

Mouthpiece Less common interface, does not provide protection against aspiration. There are lipseal mouthpieces with flanges to help hold them in place if patient is unable.