evidence & practice / critical care: 6

MECHANICAL VENTILATION

An overview of mechanical ventilation

in the intensive care unit
Elliot ZJ, Elliot SC (2018) An overview of mechanical ventilation in the intensive care unit. Nursing Standard. 32, 28, 41-49.
Date of submission: 5 October 2016; date of acceptance: 14 July 2017. doi: 10.7748/ns.2018.e10710

Zoe Joanne Elliot Abstract

Advanced critical care
practitioner, Leeds
Teaching Hospitals
NHS Trust, Leeds, West
Yorkshire, England
Stuart Charlton Elliot
Advanced critical care
practitioner trainee,
Leeds Teaching Hospitals
NHS Trust, Leeds, West
Yorkshire, England
This article discusses the history, types and essential components of mechanical
ventilation. It addresses the potential complications associated with mechanical
ventilation and outlines the nurse’s role in the recognition and prevention of such
complications. This article provides an overview of some of the advances in mechanical
ventilation and emphasises the importance of patient safety through an awareness of the
associated risks and limiting or avoiding mechanical ventilation where possible.
Keywords
critical care, intensive care, mechanical ventilation, negative pressure ventilation,
positive pressure ventilation, respiratory function, respiratory system

Correspondence MECHANICAL VENTILATION is volutrauma, barotrauma, tracheal injury,

Z.Elliot@nhs.net
Conflict of interest
None declared
Peer review
This article has been
subject to external
double-blind peer
review and checked
for plagiarism using
automated software
Online
For related articles visit
the archive and search
using the keywords.
Guidelines on writing for
publication are available
at: rcni.com/writeforus
a method used to artificially support
respiratory function by means of a
ventilator machine. It can be used to either
assist or replace normal spontaneous
breathing and can be undertaken invasively
or non-invasively. There are several reasons
why patients may require mechanical
ventilation, its main aim being to correct
hypoxia, hypercapnia, physiological stress
and/or respiratory failure. These conditions
are commonly caused by infection, trauma,
sepsis and cardiac failure, or occur in
patients who are unable to maintain
their airway, for example those with a
neurological injury or disease, or under
general anaesthetic (Tobin 2013).
Mechanical ventilation is performed
for relatively short periods in operating
theatres and for longer periods of time
in intensive care units (ICUs). It is also
performed in specialist ward areas and
in the patient’s home. The nurse’s role
in the management of a patient on
mechanical ventilation is complex and
multifactorial, and has been shown to
directly affect patient outcomes, including
patient-acquired complications such as
ventilator-associated pneumonia and
multiple organ failure (Alphonso et al
2004, Burns 2005, British Association of
Critical Care Nurses 2010).
Outside the operating theatre, the care
of patients on mechanical ventilation
is primarily undertaken by intensive
care nurses, in collaboration with the
multidisciplinary team. Therefore,
these nurses require a comprehensive
understanding of respiratory mechanics,
ventilation theory and the components
of mechanical ventilation. Continuous
monitoring, ongoing safety assessment and
knowledge of the variety of methods used
to manipulate physiological parameters are
also essential to prevent harm to patients
on mechanical ventilation.
Intensive care nurses are ideally placed
to promote safe and optimal ventilation
because of their role in monitoring the
patient’s condition and their continual
bedside presence. The knowledge and skills
of nurses caring for critically ill patients may
directly affect the patient outcomes outlined
previously (British Association of Critical
Care Nurses 2010). An understanding of

nursingstandard.com volume 32 number 28 / 7 March 2018 / 41

evidence & practice / critical care: 6
Acknowledgement mechanical ventilation may also be useful
Nursing Standard wishes in areas of healthcare such as emergency
to thank Nicola Credland, departments, high dependency units and
lecturer in critical care anywhere a patient is likely to experience
and advanced practice respiratory deterioration.
at the University of Hull, The simplest type of artificial ventilation
for coordinating and is used in emergencies when a patient
developing the critical is in cardiac or respiratory arrest. A
care series trained healthcare professional provides
respiration by compressing an ambulatory
bag attached to either a tight-fitting face
mask or via a supraglottic airway device
or endotracheal tube that maintains the
patient’s airway. In this case, the healthcare
professional compressing the bag regulates
breath delivery. While this type of
ventilation is adequate in an emergency,
ventilation for extended periods will have
to be accurately delivered by a ventilator.
There are two main types of mechanical
ventilation: negative pressure ventilation
and positive pressure ventilation.
Types of mechanical ventilation
Negative pressure ventilation
Negative pressure ventilation can be
delivered via a machine known as an
‘iron lung’, which was predominantly
used in the 1940s and 1950s for patients
with polio. The iron lung functioned
by augmenting respiratory function. In
normal physiological inspiration, negative
intrapleural pressure is generated as
the ribcage expands and the diaphragm
contracts. An expanding chest cavity
creates an inward pressure gradient
between the atmosphere and the alveoli.
The result is that air flows into the lungs
(Thomson 1997).
In patients with polio, normal
ventilation becomes impaired as a result
of respiratory muscle weakness and
shrinkage, and paralysis. By enclosing the
patient’s body in a cylindrical steel drum
with only their head and neck protruding
from an airtight seal at one end, chamber
pressure switches between positive and
negative pressure to mimic conventional
respiration. When the chamber is
vacuumed (negative pressure), inhalation
is facilitated. When this process is reversed
with positive pressure, exhalation occurs
(Corrado and Gorini 2002).
42 / 7 March 2018 / volume 32 number 28
One advantage of negative pressure
ventilation is that it is physiologically
complementary to normal breathing, and,
because it is delivered from outside the
body, it is ‘non-invasive’. However, there
are practical challenges for healthcare
professionals in providing care and
treatment for a patient who is enclosed in
an iron casing. The only negative pressure
ventilator currently marketed in the UK is
the relatively light, portable biphasic cuirass
ventilator, which only envelops the patient’s
upper torso. Although the biphasic cuirass
ventilator may potentially be used in all
instances of respiratory failure, in practice it
is rarely used (Yamashita et al 2012).
Positive pressure ventilation
Negative pressure iron lungs have been
superseded by positive pressure ventilation,
which is the direct delivery of forced
air and oxygen into the lungs. Positive
pressure ventilation can be delivered in
two ways: non-invasively via a tight-fitting
face or nasal mask; or, more commonly,
invasively, via a tube placed in the larynx
or trachea. In positive pressure ventilation,
normal physiological breathing is bypassed,
and oxygen and air is forced into the
lungs using a positive pressure generated
externally by the ventilator. This enables
easier access to the patient compared
with an iron lung but has the potential to
cause more damage to the delicate lung
tissue (Soni and Williams 2008). Figure 1
shows a mechanical ventilator for positive
pressure ventilation.
There are several essential components
of positive pressure ventilation, including:
oxygen and air delivery, respiratory rate,
volume and pressure-controlled ventilation,
pressure support, positive end-expiratory
pressure (PEEP) and continuous positive
airway, breath trigger, monitoring and
alarms, and humidification.
Components of positive pressure
ventilation
Oxygen and air delivery
All ventilators have the ability to deliver
a blended percentage of oxygen and air,
known as the fraction of inspired oxygen
(FiO2). In extreme cases and emergencies, it
nursingstandard.com
might be necessary to deliver 100% oxygen
to the patient, but this should be avoided
where possible, because high oxygen levels
can become toxic to the body (O’Brien
2013). The general rule is to reduce oxygen
delivery to the minimum requirement.
Awareness of the patient’s normal lung
function is essential when instigating
mechanical ventilation, with parameters
set to deliver appropriate and realistic
targets for arterial blood gas analysis
and oxygen saturation (SaO2). The nurse
caring for the patient should be able to
recognise unacceptable partial pressure of
oxygen (PO2) levels or partial pressure of
carbon dioxide (PCO2) levels and respond
by manipulating the ventilator directly or
reporting the inadvertent readings to senior
colleagues (Higginson 2011).
Respiratory rate
Initial mechanical ventilation rates are
typically set at between 12-20 breaths
per minute – physiologically normal
parameters – however, protective
ventilation guidance suggests rates of
20-35 breaths per minute (Kilickaya and
Gajic 2013). The set respiratory rate
may be increased or decreased to enable
elimination or retention of arterial carbon
dioxide (CO2). Increasing the mechanical
ventilation delivery rate acts to ‘blow off’
or remove CO2 from the lungs. This is
preferred to increasing volume delivery,
which will also facilitate removal of CO2,
but has the potential to cause lung injury
(Soni and Williams 2008).
Modern intensive care ventilators have
the ability to synchronise the ventilator-
delivered breaths with the spontaneous
breaths of the patient. If the patient
initiates a breath, the ventilator will act to
support the breath rather than attempt to
override it with one of its own. Ventilators
have a variety of settings to deliver
either mandatory breaths, synchronised
breaths or supported spontaneous patient-
initiated breaths. In relation to supported
spontaneous patient-initiated breaths,
the ventilator has the ability to deliver
mandatory ventilation in the event that the
patient stops initiating breathing on their
own (Open Anesthesia 2018).
nursingstandard.com
Volume and pressure-controlled
ventilation
Positive pressure can be delivered into
the lungs using one of two modes. The
ventilator can either be set to deliver a pre-
set tidal volume with each breath (volume-
controlled ventilation) or to deliver
positive pressure up to a set maximum
pressure with each breath (pressure-
controlled ventilation) (Courey and Hyzy
2017). Initially, these modes may appear
synonymous with one another, because
delivering a set tidal volume will generate
a pressure, and conversely, generating a
pressure will deliver a certain tidal volume.
However, in practice, there are different
advantages to using each mode in relation
to ventilator and lung compliance.
Pressure-controlled ventilation is
preferred for most patients in the ICU
(Rittayamai et al 2015). In this mode,
pressure delivered to the lungs will be set
at a constant maximum level, while the
actual tidal volume delivered may alter
according to the compliance within the
lungs. In patients with diseased, infected,
obstructed or traumatised lungs, delivering
a set pressure will ensure further injury to
the lungs can be controlled and limited,
whereas delivering a set tidal volume
can cause deleterious peaks of pressure,
Figure 1. Mechanical ventilator for positive pressure ventilation
Settings interface and
PETER LAMB
patient monitoring
Nasogastric tube goes Mechanical ventilator
through the patient’s nose blows air, or air with
increased oxygen, through
and into the stomach
tubes into the patient’s
airways
Filter
Humidifier,
which warms
and moistens
the air
Exhaled air flowing
Endotracheal tube goes
through the patient’s away from the patient
mouth and into the Air flowing to the
trachea patient
volume 32 number 28 / 7 March 2018 / 43
evidence & practice / critical care: 6
KEY POINT leading to further lung injury. However,
Breathing through the volume-controlled ventilation may be
ventilator mechanics, useful in neurosurgical intensive care,
tubing and endotracheal because delivering a set ventilator volume
tube has been likened enables tighter control of arterial CO2
to breathing through a levels (Schirmer-Mikalsen et al 2016). This
long thin straw. Therefore, is important when attempting to control
a degree of positive raised intracranial pressure, because
pressure or high-flow fluctuations in arterial CO2 directly affect
oxygen is required to the vasomotor response of blood vessels in
support spontaneous the brain.
breathing through a
mechanical ventilator and Pressure support
compensate for circuit Pressure support is another form of
resistance pressure-controlled ventilation, but this
mode is used to support spontaneous
breaths made by the patient. Breathing
spontaneously through a mechanical
ventilator unaided is difficult for the
patient, especially when their normal
lung mechanics are weakened by lack
of muscle use, their underlying illness
and the ‘hangover’ effects of sedation
(Soni and Williams 2008). This difficulty
is compounded by the fact that the
ventilator incorporates a series of valves,
has long lengths of circuit tubing and
culminates at the endotracheal tube,
which is a fraction of the size of the
patient’s normal airway. Breathing
through the ventilator mechanics, tubing
and endotracheal tube has been likened
to breathing through a long thin straw.
Therefore, a degree of positive pressure
or high-flow oxygen is required to
support spontaneous breathing through a
mechanical ventilator and compensate for
circuit resistance.
The pressure support mode is used to
wean patients off mechanical ventilation.
Initially, when patients are waking
from sedation and beginning to initiate
spontaneous breaths, pressure support will
be delivered at a relatively high-pressure
level to support their breathing. This
can be reduced according to the patient’s
requirements until it is deemed appropriate
and safe to discontinue and remove them
from mechanical ventilation altogether
(Hagberg 2017). The aim, in this case, is to
synchronise mechanical ventilation support
to normal physiological breathing without
a ventilator and an endotracheal tube.
44 / 7 March 2018 / volume 32 number 28
Positive end-expiratory pressure and
continuous positive airway pressure
Normal physiological breathing prevents the
lungs from completely collapsing at the end
of expiration, since the epiglottis closes the
airway, leaving a residual volume of air in
the lungs. This is not possible if the larynx is
permanently open because of the presence of
an endotracheal tube. The term ‘open lung’
is used to refer to the lungs being directly
open to the atmosphere by a tube. PEEP
ensures that a certain amount of pressure
remains in the lungs throughout the entire
ventilatory cycle. Usually, the PEEP will
be at least 5cmH2O, increasing depending
on the patient’s physiology, for example
stiffer lungs may require an increase in
PEEP (Kilickaya and Gajic 2013). However,
in prolonged ventilation, alveoli may
continue to collapse as a result of several
physiological and mechanical processes, such
as lack of surfactant, sputum retention and
endotracheal suctioning. In this case, PEEP
should be intermittently increased to higher
levels to enable alveoli to re-open. This is
known as a lung recruitment manoeuvre.
The non-invasive equivalent of PEEP
is continuous positive airway pressure
(CPAP). Delivering CPAP requires an
inward flow of air against exhalation,
which can be uncomfortable for patients
(Tobin 2013). Patients tiring on CPAP will
require non-invasive pressure support or
invasive mechanical ventilation.
Breath trigger
When oxygenation and CO2 removal are
critically impaired or require tight control,
the patient’s own respiratory trigger (central
and peripheral chemoreceptors) can be
supressed with the use of anaesthetics.
However, when improvement and signs
of recovery are evident, sedation will be
reduced and the patient will be encouraged
to take supported spontaneous breaths
through the ventilator. For this to occur, the
ventilator needs to sense that the patient is
going to take a breath. This function is not
required for patients undergoing surgery
because the period of mechanical ventilation
is usually short and the anaesthetic is
usually easily reversed; however, it is a vital
component for more sophisticated intensive
nursingstandard.com
care ventilators, where patients will
require gradual weaning from mechanical
ventilation (Higginson 2011).
The first type of mechanical ventilation
trigger was based on pressure sensitivity,
in which the ventilator detects a negative
pressure at the inspiratory limb of the
mechanical ventilator and delivers a
pressure-supported breath. One issue
with this is that there is an inherent
time lag between ventilator sensing and
actual support delivery. To combat this,
flow triggering is used in preference to
pressure sensitivity. All modern ventilators
maintain a flow of air and oxygen around
the ventilator circuit (flow rate). The
ventilator detects this flow via sensors
at the inspiratory and expiratory limbs.
When the patient attempts a breath, the
negative pressure generated enables flow
from the ventilator circuit into the lungs.
The subsequent deficit in flow is detected
by the ventilator and a positive pressure is
released to support the breath (Singer and
Corbridge 2009). Although this mechanism
is more responsive than pressure sensitivity
triggering, there remains a miniscule time
lag between sensing and delivery. This time
lag is sufficient to cause distress for some
patients who are on mechanical ventilation.
One innovation in relation to ventilator
triggering is neurally adjusted ventilatory
assist (NAVA), which is able to sense the
electrical activity of the diaphragm before
inspiration. As a result, the ventilator is
able to synchronise support precisely with
each spontaneous, patient-initiated breath
and also vary the level of pressure support
according to the amplitude of the signal.
Theoretically, this mode enables seamless,
supported, spontaneous breathing
(Verbrugghe and Jorens 2011, Ducharme-
Crevier et al 2015). However, NAVA
requires additional expertise to set up and
adjust settings, it requires placement of an
enteral catheter to detect the diaphragmatic
electrical activity, and it has ongoing
disposable costs, which are an additional
expense.
Monitoring and alarms
All modern ventilators have the ability to
display general settings on a visible screen,
nursingstandard.com
including ventilation mode, respiratory KEY POINT
rate, tidal volume, minute volume (breaths One innovation in relation
per minute multiplied by tidal volume), to ventilator triggering
inspiratory pressures, and whether is neurally adjusted
mandatory breaths, synchronised breaths ventilatory assist (NAVA),
or supported spontaneous patient-initiated which is able to sense
breaths are being delivered. They also the electrical activity of
incorporate a series of alarms, which can the diaphragm before
be set at the default settings or may be inspiration. As a result,
adjusted to incorporate individually-set the ventilator is able to
patient parameters. The alarms will trigger synchronise support
when the set parameters are breached, precisely with each
for example in: apnoeic episodes; high or spontaneous, patient-
low inspiratory pressures, respiratory rate initiated breath and also
or minute volumes; or if a disconnection vary the level of pressure
occurs in the circuit. support according to the
Electrocardiogram, SaO2 and end- amplitude of the signal
tidal CO2 monitoring are mandatory for
patients who are on mechanical ventilation
in hospital. Additionally, patients on
prolonged mechanical ventilation will
require arterial blood pressure monitoring,
arterial blood gas analysis and central
venous access. Therefore, nurses have
a central role in monitoring, analysing
and interpreting a range of inter-related
information, and should be able to
recognise and action abnormal parameters
and identify when the patient requires
additional support (Higginson 2011).
Humidification
In normal breathing, 75% of respiratory
gas conditioning (warming, humidification
and cleaning) takes place in the upper
respiratory tract (nasopharynx), and
the remaining 25% via the trachea
(American Association for Respiratory
Care et al 2012). However, in patients
with an endotracheal tube, these processes
are unable to occur. Therefore, it is vital
that the gas is clean, warm and humidified
when delivering mechanical ventilation
invasively or non-invasively.
All mechanical ventilation circuits will
contain a respiratory filter to prevent
pathogens or foreign material entering the
patient’s body, and usually an external
warming and humidification system will
be added to the ventilator circuit. For
prolonged mechanical ventilation, this
is achieved by passing the ventilator gas
through an external, heated water bath
volume 32 number 28 / 7 March 2018 / 45
evidence & practice / critical care: 6
KEY POINT
While mechanical
ventilation technology has
improved significantly
over the past two decades,
it could be suggested
that the most significant
benefits in relation to
mechanical ventilation over
this period have resulted
from the realisation that it
is harmful, and therefore
best avoided, or at least
limited to the shortest time
possible
46 / 7 March 2018 / volume 32 number 28
chamber (wet circuit). To prevent water
vapour accumulating in the ventilator
tubing, known as ‘rain out’, inspiratory
circuit tubing usually incorporates a heater
wire over its entire length.
For shorter-term ventilation, for instance
for operative and post-operative patients, a
simple heat and moisture exchange filter can
be incorporated into the ventilator circuit
at a point close to the endotracheal tube. A
heat and moisture exchange filter relies on
the moisture and warmth of the air from the
lungs being recycled through a filter system
that also prevents the entrance of invasive
pathogens. This type of circuit is referred to
as a ‘dry circuit’ (Life in the Fast Lane 2015).
Complications
While mechanical ventilation is necessary
to provide critically ill patients with
potentially life-saving respiratory support, it
is not a benign intervention. The common
complications of mechanical ventilation
relate, in part, to patients being incapacitated
with sedatives, analgesics, muscle relaxants
and paralytic agents. However, paralytic
agents are only warranted in the ICU
in extreme situations because of their
associated risks, particularly in relation to
muscle weakness (Esteban et al 2002).
Incapacity can lead to nutrition deficits,
muscle weakness, deep vein thrombosis
and susceptibility to infection, particularly
in the lungs, where an inability to
clear secretions and bypassing normal
respiratory defence mechanisms – such
as the oropharynx and cilia – with an
endotracheal tube increases the risk of
nosocomial infection (Klompas 2013,
Courey and Hyzy 2017).
The presence of an endotracheal tube is
associated with the risk of inflammation,
infection, vocal cord paralysis,
laryngotracheal stenosis and fistula
formation, and can be uncomfortable and
irritating for patients (Courey and Hyzy
2017). In addition, sedatives and analgesics
commonly cause cardiac compromise and
induce hypotension, often resulting in the
need for vasopressor drug infusion, which is
itself potentially noxious and administered
via a central venous catheter, increasing the
risk of bacteraemia (Band and Gaynes 2015).
Prolonged use of sedatives can also cause
delirium when the patient wakes and the
cumulative effects of ventilator drug therapy
can lead to polyneuropathy, rendering the
patient further incapacitated (Jackson et al
2010). The continuous intensive and invasive
monitoring required in mechanical
ventilation restricts patient mobility and
accessibility, and invasive monitoring is
associated with additional risks of harm.
Nurses caring for patients on mechanical
ventilation can minimise potential harm
and complications. Knowledge of adequate
sedation practice is essential in achieving
the required level of sedation, as assessed
using the Richmond Agitation-Sedation
Scale (Barr et al 2013). For instance,
deep sedation may be required in patients
who require paralytic agents, whereas
minimal sedation may be required to
enable endotracheal tube tolerance while
maintaining spontaneous breathing and
reaction to stimulation. Effective oral care
and endotracheal suctioning technique
are also crucial in preventing ventilator-
associated pneumonia and trauma to the
lung tissue. Regular repositioning and
scrupulous pressure area care can also
reduce harm to patients on mechanical
ventilation (Higginson 2011).
Advances in practice
While mechanical ventilation technology
has improved significantly over the past two
decades, it could be suggested that the most
significant benefits in relation to mechanical
ventilation over this period have resulted
from the realisation that it is harmful, and
therefore best avoided, or at least limited
to the shortest time possible. Aside from
the risks and complications associated
with mechanical ventilation, prolonged
use has been shown to directly negatively
affect patient morbidity and mortality
(Esteban et al 2002, Loss et al 2015).
Mechanical ventilation can cause
overdistension of alveoli, which in turn
compromises gaseous exchange, leading to
alveolar capillary leakage and atelectasis.
If unchecked, this injury to the lungs can
progress to multiple organ failure. This
was demonstrated in a seminal trial by
the Acute Respiratory Distress Syndrome
nursingstandard.com
Network et al (2000), which found that
mechanical ventilation delivery of larger
gas volumes – with subsequent higher
pressures – caused greater lung damage
than delivery of smaller gas volumes and
lower pressures (tidal volumes of 6mL/kg).
However, delivery of smaller gas volumes
causes retention of CO2 in the circulation,
and the only way to mitigate a low volume
strategy was to increase the respiratory
rate (≤35 breaths per minute). As a result,
many ICUs advocated higher levels of CO2
to avoid trauma to the lungs, provided that
arterial pH ≥7.2 and SaO2 levels were in the
range of 88-95% (Slutsky and Ranieri 2000,
PulmCCM 2012). Allowing arterial CO2
to rise as a result is known as permissive
hypercapnia, while the onus on preventing
direct ventilator-associated harm is known
as a ‘protective ventilation strategy’.
Several procedures or adjuncts are
recommended in cases where standard
mechanical ventilation is not achieving
correction of respiratory failure. For
instance, placing a patient in the prone
position has been found to improve the
ability to achieve adequate ventilation
(Gattinoni et al 2001, Guérin et al 2013).
Prone positioning works by using gravity
to move fluid or secretions to different
areas of the lungs, enabling the expansion
of the posterior lung sections and
improving gaseous exchange as a result
(Guérin et al 2014). Prone positioning
requires no additional machinery or costs
and has therefore become increasingly
popular in ICU practice.
Extracorporeal membrane oxygenation
(ECMO) is used to completely rest the
lungs and is useful in patients with severe
lung injury or disease where standard
methods of ventilation are failing (Cho et al
2016). ECMO is achieved via a machine,
similar to a haemodialysis circuit.
Deoxygenated blood is taken directly
from the patient’s circulation via large
bore catheters placed in large veins such
as the internal jugular or femoral vein,
passed through an oxygenating membrane
and returned into the patient. As well
as increasing blood oxygenation, CO2 is
also removed (Rodriguez-Cruz 2017).
ECMO is generally used in the ICU when
nursingstandard.com
mechanical ventilation fails, and in effect KEY POINT
it temporarily isolates the lungs and makes Several procedures
them redundant for ventilation. Following or adjuncts are
the ‘swine flu’ (H1N1) pandemic, a network recommended in
of specific ECMO centres was set up in the cases where standard
UK. ECMO technology and equipment is mechanical ventilation is
becoming increasingly sophisticated and not achieving correction
user-friendly, and it may be that this is of respiratory failure. For
readily available in all UK hospitals in the instance, placing a patient
future. in the prone position has
There has also been increased focus on been found to improve the
extracorporeal carbon dioxide removal ability to achieve adequate
(ECCO2R) as an adjunct to protective ventilation (Gattinoni et al
ventilation strategies, which involves 2001, Guérin et al 2013)
removing CO2 from the circulation
thereby providing partial respiratory
support. ECCO2R requires lower blood
flow rates than ECMO and is simpler
to perform. Partially separating CO2
removal from lung function has several
clinical applications. In type II respiratory
failure, in which there is an excessive
accumulation of CO2, ECCO2R can aid
mechanical ventilation. In fact, it has been
used pre-emptively to delay or potentially
avoid ventilation in patients who are
non-sedated and awake. ECCO2R can
also potentially be used in conjunction
with mechanical ventilation to deliver
an ultra-protective lung strategy using
small ventilator volumes, without the
deleterious side effects of circulatory CO2
accumulation. This is being investigated
as part of a UK-wide multicentre trial
(McNamee et al 2017).
Improvements in anaesthetic and surgical
techniques have meant that many patients
previously admitted to the ICU post-
operatively are released from mechanical
ventilation immediately after surgery.
There have also been improvements in the
recognition of critically ill patients who
may progress to requiring mechanical
ventilation, particularly with the
introduction of the National Early Warning
Scoring (NEWS) system (Royal College of
Physicians 2012) and outreach services. It
is important these patients are identified
early, because delays in mechanical
ventilation for those who will ultimately
require it can negatively affect their
morbidity and mortality (Kang et al 2015).
Mechanical ventilation may not always
volume 32 number 28 / 7 March 2018 / 47
evidence & practice / critical care: 6
be an appropriate option, particularly
in the absence of a definitive reversible
cause of the patient’s underlying breathing
difficulties. There are also certain patient
groups for whom instigating mechanical
ventilation will be futile and should be
avoided, for example those who are
severely immunocompromised (Wilkinson
and Savulescu 2011).
There is a concerted effort in ICUs to
limit the deleterious effects of mechanical
ventilation. Protocolised sedation, sedation
scoring using the Richmond Agitation-
Sedation Scale (Barr et al 2013), daily
sedation holds and spontaneous breathing
trials all attempt to wean patients from
mechanical ventilation in a timely manner
(Jackson et al 2010). A percutaneous
tracheostomy is a valuable adjunct to
weaning from mechanical ventilation.
A tracheostomy makes the work of
breathing easier by reducing dead space
in the airway, and is often better tolerated
than an endotracheal tube. Therefore,
a tracheostomy should enable earlier
cessation of sedation and progression of
weaning from mechanical ventilation for
patients (Lim et al 2015).
References
Acute Respiratory Distress Syndrome www.uptodate.com/contents/prevention-
Network, Brower RG, Matthay MA et al (2000) of-intravascular-catheter-related-infections
Ventilation with lower tidal volumes as (Last accessed: 26 February 2018.)
compared with traditional tidal volumes for
acute lung injury and the acute respiratory Barr J, Fraser GL, Puntillo K et al (2013) Clinical
distress syndrome. New England Journal of practice guidelines for the management of
Medicine. 342, 18, 1301-1308. pain, agitation, and delirium in adult patients
in the intensive care unit. Critical Care
Alphonso A, Quinones M, Mishra A et al (2004) Medicine. 41, 1, 263-306.
A Study to Evaluate the Competency of ICU
Personnel in Mechanical Ventilation. www. British Association of Critical Care Nurses
thefreelibrary.com/A+study+to+ (2010) Standards for Nurse Staffing in
Critical Care. icmwk.com/wp-content/
evaluate+the+competency +of+ICU+
personnel+in+mechanical...-a0139951647 uploads/2014/02/nurse_staffing_in_critical
_care_2009.pdf (Last accessed: 26 February
(Last accessed: 26 February 2018.)
2018.)
American Association for Respiratory Care,
Restrepo RD, Walsh BK (2012) Humidification Burns SM (2005) Mechanical ventilation
during invasive and noninvasive mechanical of patients with acute respiratory distress
syndrome and patients requiring weaning.
ventilation: 2012. Respiratory Care. 57, 5,
782-788. Critical Care Nurse. 25, 4, 14-24.
Band JD, Gaynes R (2015) Prevention of Cho YJ, Moon JY, Shin ES et al (2016) Clinical
Intravascular Catheter-Related Infections. practice guideline of acute respiratory
48 / 7 March 2018 / volume 32 number 28
Conclusion
Positive pressure ventilation using a mode
of pressure control is the most widely
used form of mechanical ventilation.
Nurses caring for patients on mechanical
ventilation require specialist knowledge
and skills to monitor, identify and prevent
the potential deleterious effects associated
with it. While novel interventions such
as ECMO, ECCO2R and NAVA may
enable patients to survive mechanical
ventilation and aid ventilator weaning,
it could be suggested that the most
significant development in relation to
mechanical ventilation has been the
increasing awareness of the potential
harm it can cause. This, combined with
early recognition of patients who would
benefit from mechanical ventilation,
alongside strategies to wean patients from
mechanical ventilation at the earliest
opportunity, should improve patient
mortality and morbidity. Therefore,
it is important for nurses to have an
understanding of the essential components
of mechanical ventilation and its associated
risks and complications, to enable them to
provide safe and effective patient care.
distress syndrome. Tuberculosis and Gattinoni L, Tognoni G, Pesenti A et al (2001)
Respiratory Diseases. 79, 4, 214-233. Effect of prone positioning on the survival of
patients with acute respiratory failure. New
Corrado A, Gorini M (2002) Negative-pressure England Journal of Medicine. 345, 8, 568-573.
ventilation: is there still a role? European
Respiratory Journal. 20, 1, 187-197. Guérin C, Baboi L, Richard JC (2014)
Mechanisms of the effects of prone
Courey AJ, Hyzy RC (2017) Overview of positioning in acute respiratory distress
Mechanical Ventilation. www.uptodate.com/ syndrome. Intensive Care Medicine. 40, 11,
contents/overview-of-mechanical-ventilation 1634-1642.
(Last accessed: 26 February 2018.)
Guérin C, Reignier J, Richard JC et al (2013)
Ducharme-Crevier L, Beck J, Essouri S et al Prone positioning in severe acute respiratory
(2015) Neurally adjusted ventilatory assist
distress syndrome. New England Journal of
(NAVA) allows patient-ventilator synchrony Medicine. 368, 23, 2159-2168.
during pediatric noninvasive ventilation: a
crossover physiological study. Critical Care. Hagberg CA (2017) Benumof and Hagberg’s
19, 44. doi: 10.1186/s13054-015-0770-7. Airway Management. Third edition. Elsevier
Health, Philadelphia PA.
Esteban A, Anzueto A, Frutos F et al (2002)
Characteristics and outcomes in adult Higginson R (2011) The role of the nurse in
patients receiving mechanical ventilation: mechanical ventilation. British Journal of
a 28-day international study. JAMA. 287, 3, Nursing. 20, 21, 1341.
345-355.
nursingstandard.com
Jackson DL, Proudfoot CW, Cann KF et al
(2010) A systematic review of the impact of
sedation practice in the ICU on resource use,
costs and patient safety. Critical Care. 14, 2,
R59. doi: 10.1186/cc8956.
Kang BJ, Koh Y, Lim CM et al (2015) Failure of
high-flow nasal cannula therapy may delay
intubation and increase mortality. Intensive
Care Medicine. 41, 4, 623-632.
Kilickaya O, Gajic O (2013) Initial ventilator
settings for critically ill patients. Critical Care.
17, 2, 123.
Klompas M (2013) Complications of
mechanical ventilation: the CDC’s new
surveillance paradigm. New England Journal
of Medicine. 368, 16, 1472-1475.
Life in the Fast Lane (2015) Heat and Moisture
Exchanger. lifeinthefastlane.com/ccc/heat-
and-moisture-exchanger (Last accessed: 26
February 2018.)
Lim CK, Ruan SY, Lin FC et al (2015) Effect of
tracheostomy on weaning parameters in
difficult-to-wean mechanically ventilated
patients: a prospective observational study.
PLoS One. 10, 9. e0138294. doi: 10.1371/journal.
pone.0138294.
Call for papers
Nursing Standard is seeking CPD article submissions from
experienced or new authors on a variety of subjects, including:
Š Continence
Š Communication
Š Infection control
Contact Evidence & Practice editor Tanya Fernandes
at tanya.fernandes@rcni.com
nursingstandard.com
Loss SH, Pinheiro de Oliveira R, Maccari
JG (2015) The reality of patients requiring
prolonged mechanical ventilation: a
multicenter study. Revista Brasileira de
Terapia Intensiva. 27, 1, 26-35.
McNamee JJ, Gillies MA, Barrett NA et al (2017)
pRotective vEntilation with veno-venouS
lung assisT in respiratory failure: a protocol
for a multicentre randomised controlled trial
of extracorporeal carbon dioxide removal in
patients with acute hypoxaemic respiratory
failure. Journal of the Intensive Care Society.
18, 2, 159-169.
O’Brien J (2013) Absorption atelectasis:
incidence and clinical implications. American
Association of Nurse Anesthetists Journal.
81, 3, 205-208.
Open Anesthesia (2018) Modes of Mechanical
Ventilation: The Modern Approach to
Modes of Mechanical Ventilation. www.
openanesthesia.org/modes_of_
mechanical_ventilation (Last accessed: 26
February 2018.)
PulmCCM (2012) Mechanical Ventilation
in ARDS: Research Update. pulmccm.org/
review-articles/mechanical-ventilation-
in-ards-2012-update (Last accessed: 26
February 2018.)
Š IV therapy
Š Surgical complications
Š Wound care
Rittayamai N, Katsios CM, Beloncle
F et al (2015) Pressure-controlled vs volume-
controlled ventilation in acute respiratory
failure: a physiology-based narrative and
systematic review. Chest. 148, 2, 340-355.
Rodriguez-Cruz E (2017) Pediatric
Extracorporeal Membrane Oxygenation.
emedicine.medscape.com/article/1818617-
overview (Last accessed: 26 February 2018.)
Royal College of Physicians (2012) National
Early Warning Score (NEWS): Standardising
the Assessment of Acute-Illness Severity
in the NHS. Report of a Working Party. RCP,
London.
Schirmer-Mikalsen K, Vik A, Skogvoll E et al
(2016) Intracranial pressure during pressure
control and pressure-regulated volume
control ventilation in patients with traumatic
brain injury: a randomized crossover trial.
Neurocritical Care. 24, 3, 332-341.
Singer BD, Corbridge TC (2009) Basic invasive
mechanical ventilation. Southern Medical
Journal. 102, 12, 1238-1245.
Slutsky AS, Ranieri VM (2000) Mechanical
ventilation: lessons from the ARDSNet trial.
Respiratory Research. 1, 2, 73-77.
volume 32 number 28 / 7 March 2018 / 49
Soni N, Williams P (2008) Positive pressure
ventilation: what is the real cost? British
Journal of Anaesthesia. 101, 4, 446-457.
Thomson A (1997) The role of negative
pressure ventilation. Archives of Disease in
Childhood. 77, 5, 454-458.
Tobin MJ (2013) Principles and Practice
of Mechanical Ventilation. Third edition.
McGraw-Hill, London.
Verbrugghe W, Jorens PG (2011) Neurally
adjusted ventilatory assist: a ventilation tool
or a ventilation toy? Respiratory Care. 56,
3, 327-335.
Wilkinson DJC, Savulescu J (2011) Knowing
when to stop: futility in the intensive care
unit. Current Opinion in Anaesthesiology. 24,
2, 160-165.
Yamashita T, Taniwaki Y, Takayama H et al
(2012) Efficacy of biphasic cuirass ventilation
in the critical care department. Critical Care.
16, Suppl 1, P132.