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no Time Specific Objective Content Teaching A/V aids Evaluation

learning
activities
1 2min Introduce of the Introduction:- Mechanical ventilation is the medical term Lecture cum slides What do you
topic for artificial ventilation where mechanical means is used to discussion mean by
assist or replace spontaneous breathing. This may involve a mechanical
machine called a ventilator or the breathing may be assisted by
ventilator?
an anesthesiologist, certified registered nurse
anesthetist, physician, physician assistant, respiratory
therapist, paramedic, or other suitable person compressing
a bag or set of bellows. Mechanical ventilation is termed
"invasive" if it involves any instrument penetrating
the trachea through the mouth, such as an endotracheal tube or
the skin , such as a tracheostomy tube.)

2 1min Define the topic Definition: Lecture cum Slides Define

Ventilator A ventilator is an automatic mechanical device discussion Mechanical
defined to provide part of the work the body must produce to ventilator.
move gas into and out of the lungs

Mechanical ventilation can be defined as the technique

through which gas is moved toward and from the lungs through
an external device connected directly to the patient.

.
3 5 min Discuss about the Mechanical ventilation is indicated when the patient's Lecture cum Slides What are the
indication of spontaneous ventilation is inadequate to maintain life. It is also discussion indication of
mechanical indicated as prophylaxis for imminent collapse of other mechanical
ventilator. physiologic functions, or ineffective gas exchange in the lungs.
ventilator?
 Bradypnea or apnea with respiratory arrest
  Acute lung injury and the acute respiratory distress
syndrome
 Tachypnea (respiratory rate >30 breaths per minute)
 Arterial partial pressure of oxygen (PaO 2) with a
supplemental fraction of inspired oxygen (FIO 2) of less
than 55 mm Hg
 Respiratory muscle fatigue
 coma
 Hypotension
 Acute partial pressure of carbon dioxide (PaCO 2) greater
than 50 mm Hg with an arterial pH less than 7.25

Neuromuscular disease

Enumerate the Classification

classification of
ventilator. A. Negative Pressure Ventilators (Extrathoracic) Lecture cum slide Enumerate the
Negative-pressure ventilators exert a negative pressure on discussion classification of
the external chest. Decreasing the intrathoracic pressure ventilator.
during inspiration allows air to flow into the lung, filling
its volume. Physiologically, this type of assisted
ventilation is similar to spontaneous ventilation. It is used
mainly in chronic respiratory failure associated with
neuromuscular conditions, such as poliomyelitis, muscular
dystrophy, amyotrophic lateral sclerosis, and myasthenia
gravis. It is inappropriate for the unstable or complex
patient or the patient whose condition requires frequent
ventilatory changes. Negative-pressure ventilators are
simple to use and do not require intubation of the airway;
consequently, they are especially adaptable for home use.
There are several types of negative-pressure ventilators:
iron lung, body wrap, and chest cuirass.
Iron lung (Drinker Respirator Tank) The iron lung is a
negative-pressure chamber used for ventilation. It was
used extensively during polio epidemics in the past and
currently is used by polio survivors and patients with other
neuromuscular disorders.
Body Wrap (Pneumowrap) 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.
B. Positive Pressure ventilators (intrapulmonary
Pressure)
C. Positive-pressure ventilators inflate the lungs by exerting
positive pressure on the airway, similar to a bellows
mechanism, forcing the alveoli to expand during
inspiration. Expiration occurs passively. Endotracheal
intubation or tracheostomy is necessary in most cases.
These ventilators are widely used in the hospital setting
and are increasingly used in the home for patients with
primary lung disease. Positive Pressure ventilators
(intrapulmonary Pressure)

Positive-pressure ventilators inflate the lungs by exerting

positive pressure on the airway, similar to a bellows
mechanism, forcing the alveoli to expand during
inspiration. Expiration occurs passively. Endotracheal
intubation or tracheostomy is necessary in most cases.
These ventilators are widely used in the hospital setting
and are increasingly used in the home for patients with
primary lung disease.
Types of Positive Pressure Ventilators: There are three
types of positive pressure ventilators.

1. Volume Cycled - Volume-cycled ventilators are by far

the most commonly used positive-pressure ventilators
today. With this type of ventilator, the volume of air to
be delivered with each inspiration is preset. 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 relatively constant, ensuring consistent,
adequate breaths despite varying airway pressures.
2. Pressure Cycled – The pressure-cycled ventilator ends
inspiration when a preset pressure has been reached. In
other words, the ventilator cycles on, delivers a flow of
air until it reaches a predetermined pressure, then
cycles off. Its major limitation is that the volume of air
or oxygen can vary as the patient’s airway resistance or
compliance changes. As a result, the tidal volume
delivered may be inconsistent,possibly compromising
ventilation. Consequently, in adults, pressure-cycled
ventilators are intended only for short-term use.
Time Cycled - Time-cycled ventilators terminate or control
inspiration after a preset time. The volume of air the patient
receives is regulated by the length of inspiration and the flow
rate of the air. Most ventilators have a rate control that
determines the respiratory rate, but pure time-cycling is rarely
used for adults. These ventilators are used in newborns and
infants

. Non-invasive Positive -Pressure Ventilation

Positive-pressure ventilation can be given via facemasks that

cover the nose and mouth, nasal masks, or other nasal devices.
This eliminates the need for endotracheal intubation or
tracheostomy and decreases the risk for nosocomial infections
such as pneumonia. The most comfortable mode for the patient
is pressure controlled ventilation with pressure support. This
eases the work of breathing and enhances gas exchange. The
ventilator can be set with a minimum backup rate for patients
with periods of apnea.
Indication of Non-invasive Positive -Pressure Ventilation
 Acute or chronic respiratory failure
 Acute pulmonary edema
 COPD
 Chronic heart failure with a sleep-related breathing
disorder
The device also may be used at home to improve tissue
oxygenation and to rest the respiratory muscles while the
patient sleeps at night.

Contraindication
 Respiratory arrest
 Serious dysrhythmias
 Cognitive impairment
 Head or facial trauma
Noninvasive ventilation may also be used for patients at the end
of life and those who do not want endotracheal intubation but
may need short- or long-term ventilatory support (Scanlan,
Wilkins & Stoller, 1999).

Bilevel positive airway pressure (bi-PAP) ventilation offers

independent control of inspiratory and expiratory pressures
while providing pressure support ventilation. It delivers two
levels of positive airway pressure provided via a nasal or oral
mask, nasal pillow, or mouthpiece with a tight seal and a
portable ventilator. Each inspiration can be initiated either by
the patient or by the machine if it is programmed with a backup
 rate. The backup rate ensures that the patient will receive a set
number of breaths per minute (Perkins & Shortall, 2000). Bi-
PAP is most often used for patients who require ventilatory
assistance at night, such as those with severe COPD or sleep
apnea. Tolerance is variable; bi-PAP is usually most successful
with highly motivated patients.
4 2 min Described the Ventilator settings Lecture cum Black What are the
settings of discussion board parameters you
ventilator. The clinician determines appropriate ventilator settings have to set in the
according to the condition and needs of the patient. The
ventilator?
settings include:
 FIO2 - The measure of oxygen the ventilator is
delivering during inspiration. When the patient is
attached to the ventilator, initially the FiO2 is set at 1.0
(100%) and once the patient is stabilized, it is gradually
reduced to below 0.6 generally believed to represent the
threshold value for the risk of oxygen toxicity.
 Rate - The number of breaths delivered by the
ventilator per minute.
 Tidal volume - The volume of air delivered with each
breath. Traditionally, the tidal volumes were set at 10-
15 ml/kg, but there is increasing evidence that
“Volutrauma” can cause lung injury. Therefore, lower
tidal volumes (8 to 10 ml/kg) are now recommended
especially in ARDS where tidal volumes of 5-7 ml/kg
have been shown to have better outcomes than higher
volumes. It is important to limit the plateau pressure to
30 cm H2O, even if it means accepting low tidal volume
and minute ventilation.
 Sensitivity - This alerts the ventilator when to
recognize the start of a patient’s spontaneous breath (or
breathing effort). When the ventilator recognizes the
 patient’s effort, it triggers a response, either to provide
a mechanical breath or to support a spontaneous one.
 Peak flow - The flow of air (flow rate) used to deliver
each mechanical breath to the patient.
 Inspiratory and expiratory times - The total time
required for one complete respiratory cycle. Typically,
patients are comfortable with an expiratory time two to
three times longer than the inspiratory time.
 Cycling - The manner in which the ventilator ends the
inspiratory phase of the breath and allows the patient to
exhale. Ventilator breaths can be volume cycled, time
cycled or flow cycled.
 Limit - This setting restricts the volume, pressure or
time air is delivered to the patient during the inspiratory
phase.
Parameter of mechanical ventilator

 Respiratory rate – normally 10-20 breath/min.

 Tidal volume – 5-10ml/kg
 Oxygen concentration – 21-90% (Fio2)
 I : E – 1:2
 Inspiratory flow rate and time – 40-100 l/min. And time
is 0.8 – 1.2 sec.
 Sensitivity/trigger – 0.5-1.5 cm H2O
 Pressure limit – 10-25 cm H2O
 PEEP – 5-10 cm H2O
5 5min Enlist the different Ventilator modes Lecture cum Slides Explain the
modes of ventilator discussion different modes
Ventilator manufacturers offer combinations of modes and of ventilator?
breath types that characterize how and when a breath is
delivered to the patient.

Assist/control (A/C)

All breaths delivered by the ventilator will control either

volume or pressure. The ventilator delivers the same measured
breath every time, whether the breath is patient initiated or
ventilator initiated, based on the rate setting.

Continuous positive airway pressure ventilation (CPAP)

All breathing is initiated and sustained by the patient. The

ventilator delivers no machine (mandatory) breaths. The
ventilator controls the delivered oxygen concentration and
delivers as much flow and volume as necessary to meet the
patient’s inspiratory demands. The patient decides the tidal
volume and number of spontaneous breaths.

This mode also allows the patient to breathe at a continuous,

elevated airway pressure that can improve oxygenation.

The ventilator can also apply positive pressure during

spontaneous inspirations taken during CPAP mode to reduce
the patient’s work to breathe.
Synchronized intermittent mandatory ventilation (SIMV)

The ventilator synchronizes machine breath delivery with the

patient’s spontaneous breath efforts. This mode is a
combination of set mandatory machine breaths synchronized
with the patient’s own spontaneous breaths.

Pressure control ventilation (PCV or PC)

This is a type of mandatory breath that can be used in either

A/C or SIMV modes and targets a specific pressure during
inspiration. The delivered flow rate varies according to the
patient’s demand and own lung characteristics, such as lung
compliance and airway resistance. The delivered tidal volume
also varies with changes in compliance and resistance. In PC
mode, the clinician also sets a specific time for inspiration or
inspiratory time.

Pressure support ventilation (PSV or PS)

This is a type of spontaneous breath that can be used in either

CPAP or SIMV modes and targets a set inspiratory pressure,
much like PC. But the PS inspiration ends as the lung gets full
and the delivered flow decreases to a specific valve set by the
clinician. The patient decides the respiratory rate and
inspiratory time as well as the flow rate and tidal volume.

Positive end expiratory pressure (PEEP)

Mechanical positive pressure is applied at the end of exhalation
to prevent the lungs from emptying completely and returning
to a “zero” reading. The benefit of positive pressure at the end
of exhalation is increased lung volume for improved
oxygenation.

Controlled Mechanical Ventilation

The ventilator delivers a present number of breathes/min of a

preset volume. Additional breathes cannot be triggered by the
patient, as in the case of ACV. It is used in patients who are
paralyzed.

Intermittent Mandatory Ventilation

It delivers a preset volume at a preset rate. It Permits

spontaneous breathing (unlike AC). Although it produces a
statistically significant decrease in the degree of respiratory
alkalosis, the change is unlikely to be clinically significant. It
Considerable respiratory work may result from demand valve.
As SIMV rate is decreased, the work of breathing and pressure-
time product (a superior index of energy expenditure) increase
for both the spontaneous and assisted breathes. At any SIMV
rate, there is no difference in pressure-time product between
spontaneous and assisted breathes. This indicates that patients
display little breath-to-breath adaptation to machine assistance
during SIMV.
6 3min Why it is important Adjusting the ventilator Lecture cum Slides Explain the
to adjust the discussion importance of
ventilator? The ventilator is adjusted so that the patient is comfortable and adjusting the
breathes “in sync” with the machine. Minimal alteration of the
ventilator.
normal cardiovascular and pulmonary dynamics is desired. If
the volume ventilator is adjusted appropriately, the patient’s
arterial blood gas values will be satisfactory and there will be
little or no cardiovascular compromise.

Initial ventilator setting

The following guide is an example of the steps involved in

operating a mechanical ventilator. The nurse, in collaboration
with the respiratory therapist, always reviews the
manufacturer’s instructions, which vary according to the
equipment, before beginning mechanical ventilation.

1. Set the machine to deliver the tidal volume (10 to 12 mL/kg).

6-8ml /kg in acute chest injury.

2. Adjust the machine to deliver the lowest concentration of

oxygen to maintain normal PaO2 (80 to 100 mm Hg). This
setting may be high initially but will gradually be reduced
based on arterial blood gas results.

3. Record peak inspiratory pressure.

4. Set mode (assist–control or synchronized intermittent

mandatory ventilation) and rate according to physician order.
Set PEEP and pressure support if ordered.
 5. Adjust sensitivity so that the patient can trigger the ventilator
with a minimal effort (usually 2 mm Hg negative inspiratory
force).

6. Record minute volume and measure carbon dioxide partial

pressure (PCO2), pH, and PO2 after 20 minutes of continuous
mechanical ventilation.

7. Adjust setting (FiO2 and rate) according to results of arterial

blood gas analysis to provide normal values or those set by the
physician.

8. If the patient suddenly becomes confused or agitated or

begins bucking the ventilator for some unexplained reason,
assess for hypoxia and manually ventilate on 100% oxygen
with a resuscitation bag.

7 1 min Enlist the Complication Lecture cum Slides List the

complication of discussion complication of
ventilator  Hypotension ventilator.
 Pneumothorax
 Decreased cardiac output
 Nosocomial pneumonia
 Increased intracranial pressure
 Sinusitis and nasal injury
 Mucosal lesion
 Aspiration, GI bleeding, thick secretion, anxiety and fear,
dysrhythmia or vagal reaction after, during or after
suctioning, incorrect PEEP setting, inability to tolerate
ventilate mode.
8 2minutes Define weaning. Weaning from positive pressure ventilation and extubation Lecture cum Slides Explain the steps
discussion of weaning.
Weaning is the process of reducing ventilator support and
resuming spontaneous ventilation, the weaning process differ
for patients requiring short term ventilation. Weaning generally
consist of three phase.

Pre-weaning phase – assessment phase determine the patient

ability to breath spontaneously. The patients lung should be
clear on auscultation and chest x ray.

Spontaneous breathing trial – It is recommended in patients

who demonstrate weaning readiness. A spontaneous breathing
trial should be at least 30 minutes but no more than 120
minutes. Tolerance of trial may lead to extubation.

Outcome phase – it is the period when the patient is extubated

or weaning is stopped. The patient who is ready for extubation
should receive hyper oxygenation and suctioning (e.g.
Orophaynx, ET tube). Instruct the patient to take a deep breath
and at the peak of inspiration, deflate the cuff and remove the
tube in one motion. Administer oxygen and provide naso oral
care.

Write the nursing Nursing Diagnosis Lecture cum Slides Explain the
diagnosis of discussion nursing
ventilator patient? • Impaired gas exchange related to underlying illness, or management of
ventilator setting adjustment during stabilization or weaning. ventilator patient.
• Ineffective airway clearance related to increased mucus
production associated with continuous positive-pressure
mechanical ventilation

• Risk for trauma and infection related to endotracheal

intubation or tracheostomy

• Impaired physical mobility related to ventilator dependency

Plan of care for the ventilated patient

Patient goal
 Patient will have effective breathing pattern.
 Patient will have adequate gas exchange.
 Patient nutritional status will be maintained to meet
body needs.
 Patient will not develop pulmonary infection.
Nursing intervention
 Observe change in respiratory rate, depth, observe for
use of accessory muscle.
 Observe for tube misplacement
 Prevent accidental extubation by taping tube securely,
sedating as needed.
 Inspect thorax for symmetry for movement.
 Determine adequacy of breathing pattern, asymmetry
may indicate hemothorax or Pneumothorax, measure
tidal volume and vital capacity.
 Assess for pain
 Monitor chest x ray
 Maintain ventilator setting as ordered.
 Elevate head of bed 60-90 degree. This position
moves the abdominal content away from the
diaphragm which facilitates its contraction.
 Monitor ABG, determine acid base balance and
need for oxygen.
 Observe skin colour and capillary refill time
determine adequacy of blood flow needed to carry
oxygen to tissue.
 Observe for tube obstruction, suction ensure
adequate humidification.
 Provide nutrition as ordered e.g. TPN, lipids or
parenteral feeding.
 Use disposable saline irrigation units to rinse in line
suction, ensure ventilator tubing changed in 7 days
and suction catheter change in 24 days.
 Assess for GI problems, preventive measures
include relieving anxiety, antacid or H2 receptor
antagonist therapy, adequate sleep cycles etc.
 Maintain muscle strength with active assistive
passive ROM and prevent contracture with use of
span aids or splints.
 Encourage patients to relax and breath with the
ventilator, explain alarms, teach importance of
deep breathing. Provide alternative method of
communication, keep call bell within reach.
 More emphasis for suctioning, mouth care and
nebulisation as ordered.
Bibliography

 Suddarth’s and Brunner. “A Text book of Medical

Surgical Nursing”. 12th edition. Wolters Kluwer
Publisher, New Delhi;2010, page no. 651-664
 lewis’s Medical surgical nursing , assessment and
management of clinical problems, published by Reed
elsevier india pvt. Ltd.page no.1707-1719.
 Lippincott “a text book of manual nursing practice” 8th
edition. Jaypee brothers medical publishers (P) Ltd,
Noida;2006, page no. 954-962
 “Joyce M. Black Jane Hokanson” medical surgical
nursing,7th edition, Elsevier publication, volume 1,page
no. 652-665
 “Saunders” comprehensive review for the NCLEX RN
examination, fifth edition, Elsevier publication, page
no. 527-530
 Alex Charles G, mechanical ventilation,
[Internet].India:[cited2017 november,24].Available
form- http://www.meddean.luc.edu/lumen/
meded/MEDICINE/PULMONAR/lecture/vent_f.htm
 Society of emergency medicine India ,www.semi.org
 Indian society of critical care medicine,www.isccm.org
 CLINICAL TEACHING
ON
VENTILATORS -MODES AND SETTING

SUBMITTED TO: SUBMITTED BY:

DR. BHARTENDRA SHARMA Ms RUMA CHOUDHURY

ASSOCIATED PROFESSOR M.Sc 2nd YEAR

AMITY COLLEGE OF NURSING AMITY COLLEGE OF NURSING

IDENTIFICATION DATA

NAME OF STUDENT TEACHER – MS .RUMA CHOUDHURY

CLASS –M.SC 2ND YEAR

SUBJECT –MEDICAL SURGICAL NSG

TOPIC VENTILATORS MODES AND SETTING

GROUP OF STUDENTS –M.SC 1ST YEAR AND 2ND YEAR B.SC. NURSING

SIZE OF GROUP –10

DURATION OF TEACHING – 30 MINUTES

VENUE OF TEACHING -ICU 1(ARTEMIS HOSPITAL)

SUPERVISOR DR.BHARTENDRA SHARMA

METHOD OF TEACHING –DEMOSTRATION

DATE AND TIME OF TEACHING – 21 -08-19

GENERAL OBJECTIVES –

To help the students acquiring knowledge and understanding about the ventilator modes and setting .

SPECIFIC OBJECTIVES –

At the end of the class the students will be able to:

 Define mechanical ventilator.

 Enlist the modes of mechanical ventilator
 Explain the purpose ventilator
 Enlist the equipments required for the care
 Describe the general instructions
 Classify the types of mechanical ventilator
 Enumerate the complications of mechanical ventilator
 Explain different nursing management for patients in mechanical ventilator