Mechanical Ventilation

Essentials for Registered Nurses

Ventilatory assistance
Policy Patient Safety Patient Comfort Outcome Equipment Procedure

Policy
Nursing management of each patient receiving ventilatory assistance, should be provided by a responsible" registered nurse
Who has been orientated to the ICU Who has been assessed as competent in the management of the patient receiving ventilatory assistance by the Nursing Unit Manager (ICU/CCU) or their delegate.

Responsibility
constantly present at the patients bedside, so they are the primary healthcare professionals responsible for monitoring the patients respiratory status.
Nurses are

eye on any equipment required by the patient, including ventilators and monitoring equipment, and to respond to monitor alarms and notifying the physician.
They are expected to keep an The nurse is responsible for

documenting frequent respiratory assessments.

suctioning and provides oral and site care around the artificial airway.
The nurse also performs

Outcome
While receiving ventilatory assistance, the patient will experience An adequate supply of oxygen Adequate elimination of carbon dioxide All at the cellular level

Aim of ventilatory care

Physiology

Gas Exchange

Equipment
AMBU bag (with mask and oxygen flow tubing) Suction equipment Stethoscope

Preparation for intubation

Oxygen air source Bag and mask for ventilation Suction apparatus Stethoscope Gloves and mask Laryngoscope with appropriate blade ET tube and adaptor Stylette Adhesive tape for fixation

Endotracheal intubation

Easy intubation

Difficult Intubation
prolonged BVM another provider a smaller tube better lighting additional suctioning additional help

Oropharyngeal airway

Insertion of oropharyngeal airway

Additional help

Endotracheal tube position

The correct position / length of the endotracheal tube, as verified by Chest X-Ray, should be documented in the patient's progress notes and upon the daily flow chart. The "responsible" nurse should verify, at the beginning and end of their shift, that the endotracheal tube position is at the documented level.

Endotracheal /tracheostomy cuff care

At all times, the "responsible" nurse should listen for an air leak in the tube cuff, as evidenced by a gurgling sound. The cuff pressure should be maintained from 15 to 25 cm H2O.
at least every four hours; upon hearing an air leak after repositioning the endotracheal tube.

Suctioning
At least second-hourly, unless stipulated by the Director of ICU or his delegate Attend tracheal aspiration maintaining strict asepsis. Note the amount and nature of secretions on the daily flowchart.

Beware of the complications

Humidification
At the beginning of the shift: verify that the temperature of the inspiratory tubing is warm to touch. Hourly: check and document the temperature of humidified air it should be functioning at 37o C. (that is: 39o C. at humidifier base and -2o C. at distal end of temperature probe). Hourly: check and verify that the level of sterile water in the humidifier is around indicated level. Replenish volume as required, ensuring minimal interruption to ventilation.

Indications of ventilation

Working principle

Components of ventilator

What is mechanical ventilation

CO2

O2

Scientifically speaking

Avoid Lung Injury

Respiration vs ventilation

Initial ventilator setting

Minute volume calculations

Ventilators

Different ventilators

Patient safety
At the beginning of the shift, the nurse should perform the six-point safety check, as detailed in the "Nursing Alert". At no time, should the ventilated patient be left without the direct supervision of a "responsible" nurse. The principles of "Universal Precautions" are to be adhered to at all times. In particular, no piece of equipment is to be shared between patients, without having been first been cleaned

Patient safety
Involve the patient and their family in the planning and implementation of nursing care Orientate the patient to their environment and events carefully explain all procedures to the patient, prior to their commencement facilitate a proper day/night rhythm for the patient provide a suitable means of communication for the patient.

Ways of communication

Sedation on ventilator
To tolerate mechanical ventilation To tolerate endotracheal tube To remain calm To follow commands Benzodiazepines Barbiturates Propofol

Muscle relaxation on ventilator

Paralytic agents, or neuromuscular blocking agents Allow controlled mechanical ventilation. Do not have any sedative or analgesic effects Must always be administered with other sedatives There are : non-depolarizing and depolarizing The non-depolarizing agents are used for controlled mechanical ventilation.

Nursing Alert
The tube is adequately secured and is patent. There is a functioning suction source Suction equipment in close proximity to the patient. There is a functioning oxygen cylinder under the bed. All alarms on the ventilator are correctly functioning. The ventilator is attached to an uninterrupted power source.

Weaning from ventilator

Criteria Objective measurement Description Gas exchange acceptability Hemodynamic stability Stable ventilatory pattern Subjective clinical assessment indicating intolerance/failure Change in mental status Onset or worsening of discomfort Diaphoresis Signs of increased work of breathing

Nursing asessment during weaning

Vital signs and hemodynamics (PAS, PAD, PCWP, CO, CI) Dysrhythmias or ECG changes Oxygenation/Efficiency of gas exchange CO2 production and elimination pH level Bedside pulmonary function tests Work of breathing including use of accessory muscles Level of fatigue Patient discomfort Adequate nutrition

Common causes of ventilator alarm

Patient causes: Biting down on endotracheal tube Patient needs suctioning Coughing Gagging on endotracheal tube Patient bucking or not synchronous with the ventilator Patient attempting to talk Patient experiences period of apnea

Common causes of ventilatory alarm

Mechanical causes: Kinking of ventilator tubing Endotracheal tube cuff may need more air Leak in endotracheal tube cuff Excess water in ventilator tubing Leak or disconnect in the system Air leak from chest tube if present Malfunctioning of oxygen system Loss of power to ventilator

Nursing interventions for alarm

Check ventilator disconnects and tubing. Assess breath sounds, suction as needed. Remove excess water from ventilator tubing. Check endotracheal cuff pressure. Insert bite block or oral airway.

Man or Machine

Hypotention
Hypovolaemia Drugs Dynamic hyperinflation Tension pneumothorax

High airway pressure

Dyschrony
Agitation
Look for and treat cause Spontaneous vs SIMV vs Assist control BIPAP

Mode of ventilation I:E ratio Triggering

Flow Pressure Auto-PEEP

Desaturation
Endobronchial intubation Accidental extubation / disconnection Ventilator failure Oxygen failure All causes of hypoxic respiratory failure
Pulmonary embolus Pneumothorax

Post extubation Care

Humidified Oxygen Respiratory Exercise Assessment and Monitoring

Tracheostomy

Why?
Spares further laryngeal injury Facilitates nursing care and airway suctioning Increases patient mobility by providing a secure tube Facilitates transfer from the ICU Improves comfort Permits early return of speech Facilitates oral feeding Decreases airway resistance