BACHELOR OF SCIENCE IN NURSING:

CRITICAL CARE NURSING
COURSE MODULE COURSE UNIT WEEK
2 2 10

BASIC VENTILATORY MANAGEMENT

ü Read course and unit objectives

ü Read study guide prior to class attendance
ü Read required learning resources; refer to unit
terminologies for jargons
ü Proactively participate in classroom discussions
ü Participate in weekly discussion board (Canvas)
ü Answer and submit course unit tasks

At the end of this unit, the students are expected to:

Cognitive:
1. Define objectively when a patient needs to be intubated.
2. Understand the basic principles of ventilator mechanics.
3. Understand basic modes of mechanical ventilation.
4. Understand and discuss initial settings on the ventilator.

 
Affective:
1. Listen attentively to the discussions and opinions in the class
2. Initiate asking questions that challenge class thinking
3. Express freely the personal opinion with respect to others opinion

Psychomotor:
1. Participate actively during class discussions
2. Confidently express personal opinion and thoughts in front of the class

 
Chulay, Marianne, Burns Suzanne (2011) . AACN Essentials of Critical Care
Nursing (2nd edition). International: McGraw-Hill Medical

BASIC VENTILATORY MANAGEMENT

DEFINITION

Mechanical ventilation, or assisted ventilation is the medical term for artificial ventilation where
mechanical means are used to assist or replace spontaneous breathing. This may involve a
machine called a ventilator. Mechanical ventilation is termed "invasive" if it involves any instrument
inside the trachea through the mouth, such as an endotracheal tube or the skin, such as
a tracheostomy tube.

Indication
1. Respiratory failure
2, hypoxemia
3. Inadequate lung expansion
4. Inadequate respiratory muscle strength
5. Unstable ventilatory drive

Types of ventilator
1. Negative-pressure ventilator
2. Positive-pressure ventilator

 
Negative-pressure ventilator
The iron lung or tank ventilator is the most common type of negative-pressure ventilator used in the
past. These ventilators work by creating sub-atmospheric pressure around the chest, thereby
lowering pleural and alveolar pressure and facilitating flow of air into the patient’s lungs.

Indication:
They are effective for various conditions, especially neuromuscular and skeletal disorders, particularly for
long-term night time ventilation and weak respiratory muscle.
Use for Long-term non-invasive ventilatory support
v decreases intrathoracic pressure by applying neg (-) pressure to the chest.The gas
is drawn from the lungs.

Positive-pressure ventilaton
The provision of air under pressure by a mechanical respirator, a machine designed to improve the
exchange of air between the lungs and the atmosphere. The device is basically designed for
administering artificial respiration, especially for a prolonged period, in the event of inadequate
spontaneous ventilation or respiratory paralysis.

TYPES
1. Invasive ventilation with a tube inserted into the patient’s airway, performed in the intensive
care unit in the hospital.
2. Noninvasive ventilation that can be used at home by people with respiratory difficulties.

Patient-ventilator system
Components:

1.Endotracheal tube is placed when a patient is unable to breathe on her own; when it is necessary to
sedate and "rest" someone who is very ill; or to protect the airway. The tube maintains the airway so that
air can pass into and out of the lungs.

Tracheostomy is a medical procedure, either temporary or permanent that involves creating an

opening in the neck in order to place a tube into a person’s windpipe. The tube is inserted through
a cut in the neck below the vocal cords. This allows air to enter the lungs. Breathing is then done
through the tube, bypassing the mouth, nose, and throat.

2.Tubing circuit
The ventilator circuit refers to the tubing that connects the ventilator to the patient, as well as
any devices that might be connected to the circuit. Ventilator tubing circuit, the circuit is
scientific term is called breathing system.

3. Ventilator control panel include, control settings, alarm settings and visual display.

A. Control settings – mode of ventilation that refers to the method of ventilation.

 
 • Volume
Ø Tidal volume (Vt) - amount of air inspired/expired per breath
Ø Minute volume (Mv) - the amount of air inspired/expired per min.
• Pressure
PFR (peak flow rate) - amount of force the ventilator delivers per breath
• Respiratory rate (BPM) Back up Rate (BUR) – number of breaths per minute (4-20)
• FIO2 (fraction of inspired oxygen) - percentage of oxygen delivered (21 – 100%)
• PEEP – positive end-expiratory pressure , increase the volume of gas remaining in
the lungs at the end of expiration to improve gas exchange.

Modes of ventilator

1. Control ventilation- the respirator delivers the preset tidal volume or pressure regardless
of the patient own inspiratory efforts.

2. Assist Control Ventilation – there is a specific number of breaths a patient is receiving

from the ventilator. The ventilator will work for the breathing of the patient while allowing
the patient to control the rate of breathing

3. SIMV – the ventilator attempt to synchronized the patients respiratory effort with the
mandatory machine breaths.

4. Spontaneous breathing (SPONT)- the preset number and volume of breaths is delivered
per minute but allows the patient to breath spontaneously

5. CPAP/flow-by/SPONT – continuous positive airway pressure. It is the gold standard

treatment for obstructive sleep apnea, a constant flow of pressurized air that helps to
maintain an open airway by preventing its collapse.
This air is delivered via a fitted mask.

These is the example , CPAP/flow-by/SPONT

 
Support modes:

1. Pressure support ventilation (PSV), also known as pressure support, is a spontaneous

mode of ventilation. The patient initiates every breath and the ventilator
delivers support with the preset pressurevalue. With support from the ventilator, the patient
also regulates his own respiratory rate and tidal volume.

2. PEEP – positive end-expiratory pressure – used in conjunction of any ventilator modes

PEEP is a mode of therapy used in conjunction with mechanical ventilation. At the end of
mechanical or spontaneous exhalation, PEEP maintains the patient's airway pressure above
the atmospheric level by exerting pressure that opposes passive emptying of the lung.

3. BiPAP (also referred to as BPAP) stands for Bilevel Positive Airway Pressure, and is very
similar in function and design to a CPAP machine (continuous positive airway pressure).
Similar to a CPAP machine, A BiPAPmachine is a non-invasive form of therapy for patients
suffering from sleep apnea.

Alarm settings
• Disconnect alarm
• Pressure alarm
• Low pressure alarm
• High pressure alarm

Ventilator complications

1. Hemodynamic compromise - High intrathoracic pressure à impede venous return à low

cardiac output.
2. Barotrauma refers to injuries caused by increased air or water pressure, such as during
airplane flights or scuba diving. Barotrauma of the ear is common. Generalized barotraumas,
also called decompression sickness, affects the entire body.

 
3. Volutrauma refers to the local overdistention of normal alveoli. Volutrauma has gained
recognition over the last 2 decades and is the impetus for the lung protection ventilation with
lower tidal volumes of 6–8 mL/kg.

4. Auto (intrinsic) PEEP – incomplete expiration prior to the initiation of the next breath
causes progressive air trapping (hyperinflation). This accumulation of air increases alveolar
pressure at the end of expiration, which is referred to as auto-PEEP.
Auto-positive end expiratory pressure (auto-PEEP) is a physiologic event that is
common to mechanically ventilated patients. Auto-PEEP is commonly found in acute
severe asthma, chronic obstructive pulmonary disease, or patients receiving inverse
ratio ventilation.

5. Ventilator associated pneumonia

6. Hyponatremia is a low sodium concentration in the blood. It is generally defined as a sodium

concentration of less than 135 mmol/L (135 mEq/L), with severe hyponatremia being below 120
mEq/L. Symptoms can be absent, mild or severe.

7. Upper Gastro Intyestinal hemorrhage

8. Ventilator malfunctioning

Extubation refers to removal of the endotracheal tube (ETT). It is the final step in liberating a
patient from mechanical ventilation. Assessing the safety of extubation, the technique
of extubation, and post extubation management are described in this topic.

Assess for readiness

Ability to maintain spontaneous breathing
Adequate ABG values
With minimal FIO2 (<50%)
Ability to protect the airway
Ability to clear pulmonary secretions

Extubation
Explain the procedure
What to expect
The need to cough

Extubation
Set up O2 delivery method to be used
Position patient (30-45*)
Suction ET prior to removal
Obtain baseline cardiopulmonary assessment
Hyperoxygenation before extubation
Deflate balloon prior
Post extubation:
Apply O2 at once
Encourage deep breathing and coughing
Monitor response, VS, lung field

 
Post extubation:
Apply O2 at once
Encourage deep breathing and coughing
Monitor response, VS, lung field
Set up O2 delivery method to be used
Position patient (30-45*)
Suction ET prior to removal
Obtain baseline cardiopulmonary assessment
Hyperoxygenation before extubation
Deflate balloon prior
Post extubation:
Apply O2 at once
Encourage deep breathing and coughing
Monitor response, VS, lung field

Complications after extubation

Aspiration
Bronchospasm
Tracheal damage

Bronchospasm or a bronchial spasm is a sudden constriction of the muscles in the walls of the
bronchioles.

Mechanical ventilators are machines that act as bellows to move air in and out of your lungs.
Your doctor can set the ventilator to control how often it puts air into your lungs and how much air
you get.

Pulmonary aspiration is the entry of material such as pharyngeal secretions, food or drink, or
stomach contents from the oropharynx or gastrointestinal tract, into the larynx (voice box) and
lower respiratory tract, the portions of the respiratory system from the trachea (windpipe) to the
lungs.

Reading assignment Basic electrophysiology Chapters 3. 2nd edition AACN Essentials of Critical
Care Nursing by Marianne Chulay and Suzanne M. Burns
https://en.wikipedia.org/wiki/Mechanical_ventilation
https://en.wikipedia.org/wiki/Negative_pressure_ventilator

 
Study Questions

• Make a scenario wherein a patient need to put on mechanical ventilation, discuss the
situation.

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