MECHANICAL

VENTILATION
OBJECTIVES:-
UPON COMPLETION OF THIS LAB, THE
STUDENTS WILL BE ABLE TO,
 Identify function of respiratory system.
 Define mechanical ventilation.
 Identify goals of mechanical ventilation.
 Enumerate indications of mechanical ventilation.
 Distinguish between types of Ventilators.
 List Indications for NIV.
 Identify common ventilator settings.
 List complications of mechanical ventilation.
 Explain Nursing care of patients on mechanical ventilation
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 FUNCTIONS OF THE RESPIRATORY SYSTEM

 Acid base regulation – Through the process of

ventilation, the lung removes CO2 and regulates the pH
of the body.
 Blood reservoir – The lung receives the venous blood
from the right ventricle.
 Filtering mechanism – The lung also constantly
filters the air we breathe and removes particles through
the mucocillary clearance mechanism and the lymphatic
system. The lung also acts as a filtering mechanism for
blood by removing particles such gas bubbles, small
fibrin or blood clots, fat cells.
 Metabolism –. Some chemicals passing through the
lungs are converted into their more active form, such as 3
angiotensin I, produced by the kidneys, which is
converted to angiotensin II, a potent vasoconstrictor.
MECHANICAL VENTILATION

 Mechanical ventilation or assisted

ventilation is the medical term
for artificial ventilation where mechanical
means is used to assist or replace
spontaneous breathing.
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 GOALS OF MECHANICAL VENTILATION

Two main goals of mechanical ventilation

 facilitate ventilation

 facilitate oxygenation through decrease the

work of breathing & improve patient’s

comfort. 5
 INDICATIONS
1- Acute respiratory failure due to:

Mechanical failure, includes neuromuscular diseases,

and Poliomyelitis (failure of the normal respiratory
neuromuscular system).
Musculoskeletal abnormalities, such as chest wall
trauma (flail chest).

Infectious diseases of the lung such as pneumonia,

tuberculosis.
2- Abnormalities of pulmonary gas exchange as
in:

 Obstructive lung disease in the form of chronic

bronchitis or emphysema.

 Conditions such as pulmonary edema,

atelectasis, pulmonary fibrosis.

 Patients who has received general anesthesia as

well as post cardiac arrest
 CRITERIA FOR INSTITUTION OF VENTILATOR
SUPPORT:
Parameters Ventilation indicated Normal range

A- Pulmonary function
studies:
• Respiratory rate > 35 10-20
(breaths/min).
• Tidal volume (ml/kg <5 5-7
body wt)
•Maximum Inspiratory
Force (cm HO2) <-20 75-100
CRITERIA FOR INSTITUTION OF VENTILATOR
SUPPORT:

Parameters Ventilation Normal

indicated range
B- Arterial blood
Gases

• PH < 7.25 7.35-7.45

• PaO2 (mmHg) < 60 75-100
• PaCO2 (mmHg) > 50 35-45
 CLASSIFICATION OF VENTILATORS
1- Non-invasive.

2- Invasive

 Ventilation therapy is provided by non-invasive

through Face or nasal masks are selected conscious

patients or invasive means trachea through the

mouth, such as an endotracheal tube or the skin, such as

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a tracheostomy tube and with positive pressure breaths.
 NON-INVASIVE VENTILATION

NIV delivers mechanical ventilatory support to the

spontaneously breathing patient, who is able to

protect their airway in the absence of endotracheal
intubation. A well-fitting mask over the face or nose is
used to provide either CPAP (Continuous Positive
Airway Pressure) or bi-level support (BiPAP) which
assists both the inspiratory and expiratory
phases of breathing. 11
NON-INVASIVE VENTILATION

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 TERMINOLOGY

 BiPAP (also referred to as BPAP) is short for Bi-level Positive Airway Pressure and this machine

has a very similar function to CPAP machine therapy.they are a non-invasive form of

therapy for those suffering from sleep apnea.

 But using a Bi PAP machine, patients can breathe easier as the machine reduces the pressure level

during exhalation, allowing the patient to exhale more easily and breathe more comfortably. But ,

CPAP constant singular pressure uncomfortable to breathe against

 Minute volume is the volume of air moved into or out of the lungs in one minute. Respiratory rate

multiply tidal volume (VT) = minute volume. Several symbols can be used to represent minute 13

volume. Several symbols can be used to represent minute volum as Q , V , MV, and VE.
 USES OF CPAP & PEEP

Prevent atelectasis or collapse of alveoli

Treat atelectasis or collapse of alveoli

Improve gas exchange & oxygenation

Treat hypoxemia refractory to oxygen

therapy.(prevent oxygen toxicity

Treat pulmonary edema ( pressure help expulsion of

fluids from alveoli
 PHYSIOLOGICAL BENEFITS OF NIV

 Improved oxygenation

 Decreased work of breathing

 Improved V/Q Matching

 Decreased fatigue

 Increased minute ventilation

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 INDICATIONS FOR NIV

 Severe (acute) exacerbation of COPD (pH<7.35 and relative

hypercarbia)
 Acute respiratory failure and acute pulmonary edema in the
absence of shock or acute coronary syndrome requiring acute
coronary revascularization
 Immunosuppressed patients with acute respiratory failure
 Post extubation ventilator support
 Acute respiratory failure post lung resection surgery or post
abdominal surgery
 Asthma
 Acute respiratory failure in selected ‘not for intubation’ patients
 Acute deterioration of disorders associated with sleep 16
hypoventilation such as neuromuscular and chest wall restrictive
disorders and obesity hypoventilation syndrome
 CONTRAINDICATIONS FOR NIV

1. Hemodynamic instability
2. Cardio pulmonary arrest
3. Fascial trauma and deformity
4. Severe upper gastrointestinal bleed
5. Severe encephalopathy
6. Inability to cooperate and protect airway
7. Inability to clear secretions
8. Upper airway obstructions
9. High risk for aspiration
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 NIV PARAMETER SETTING

 FiO2 (% O2) – Set between 21% to 100% depending on

patients clinical condition, oxygen requirements, PaO2 and

Sa O2.

 CPAP – Set in the CPAP mode. This can be set between

4cmH2O to 20cmH2O pressure. Usual start up setting is

5cm H2O.
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 NIV PARAMETER SETTING ( CONTINUE)

 IPAP – Inspiratory Positive Airway Pressure. This is the

positive pressure delivered on inspiration. IPAP cannot
be set lower than the EPAP. This can be set between
4cmH2O to 40cmH2O pressure. Usual start up is about
10cm H2O.
 EPAP – Expiratory Positive Airway Pressure. It
determines the amount of PEEP that will be delivered.
EPAP cannot be set higher than IPAP. This can be set
between 4cmH2O to 20cmH2O. Usual start up setting
is 5cm H2O.
 PS - Pressure Support. This is the difference between
IPAP and EPAP, e.g.: IPAP 10 – EPAP 5=PS 5. It helps
in reducing the work of breathing. 19
 INVASIVE VENTILATION PRINCIPLES
 modern ventilators are positive pressure ventilators, to
force air into the lungs during inspiration.
 Expiration occurs passively during positive pressure
ventilation
4 respiratory phases of ventilation:
 Trigger inspiration (initiation of inflation/triggering a
breath).

 Limit inspiration (how the lungs are inflated).

 Cycle (ends inspiration).

 Expiration (deflates lungs & prepares for next inflation).

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 3 WAYS IN WHICH A VENTILATOR CAN
DELIVER A CONTROLLED BREATH ARE:

 Volume controlled (volume limited) and pressure

variable

 Pressure Controlled (pressure limited,) and volume

variable.

 Dual controlled (volume targeted ( guaranteed)

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pressure limited)
 TYPES OF MECHANICAL VENTILATORS:

 Negative-pressure ventilators

Is a negative pressure ventilation-Pressure lower than atmospheric

pressures is applied to extra thoracic space during the inspiration

 Positive-pressure ventilators is a positive pressure

ventilation-pressure higher than atmospheric pressures is applied to

the intra alveolar space during inspiration

NEGATIVE-PRESSURE VENTILATORS

 Early negative-pressure ventilators were known

as “iron lungs.”

 The patient’s body was encased in an iron

cylinder and negative pressure was generated .

 The iron lung are still occasionally used today.

 Intermittent short-term negative-pressure
ventilation is sometimes used in patients
with chronic diseases.

 The use of negative-pressure ventilators is

restricted in clinical practice, however, because
they limit positioning and movement and
they lack adaptability to large or small
body torsos (chests) .
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 MODES OF VENTILATION CONTINUE

■ Controlled Mechanical Ventilation (CMV): Machine controls rate of

breathing. Delivery of preset volume (TV) and rate regardless of patient’s
breathing pattern. Sedation or paralyzing agent (e.g., Pavulon) usually
required.
 ■ Assist Controlled Ventilation (ACV): The ventilator provides the patient
with a pre-set tidal volume at a pre-set rate .The patient may initiate a breath
on his own, but the ventilator assists by delivering a specified tidal volume to
the patient.
 ■ Intermittent Mandatory Ventilation (IMV): Patient breathes
spontaneously (own tidal volume) between ventilator breaths of a preset volume
and rate.

■ Synchronized Intermittent Mandatory Ventilation (SIMV): This mode

allow the patient to breath on their own between the set rate of breaths given by
the machine 33
 Modes of Ventilation continue
■ Positive End-Expiratory Pressure (PEEP): Keeps alveoli inflated
after expiration. Can use lower O2 concentrations with PEEP;
decreases risk of O2 toxicity. Ordered as 5–10 cm H2O.
conditions require a higher PEEP to be applied in recruiting
collapsed alveoli is Bronchiectasis
■ Continuous Positive Airway Pressure (CPAP): Maintains
positive pressure throughout the respiratory cycle of a spontaneously
breathing patient. Increases the amount of air remaining in the lungs
at the end of expiration. Less complications than PEEP. Ordered as 5–
10 cm H2O.
■ pressure support ventilation (PSV) One of the following modes of
ventilation reduces the work of breathing. is a spontaneous mode of
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ventilation. The patient initiates every breath and the ventilator
delivers support with the preset pressure value.
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 COMMON VENTILATOR SETTINGS
PARAMETERS/ CONTROLS

 Fraction of inspired oxygen (FIO2)

 Tidal Volume (VT)

 Peak Flow/ Flow Rate

 Respiratory Rate/ Breath Rate / Frequency ( F)

 Minute Volume (VE)

 I:E Ratio (Inspiration to Expiration Ratio)

 Sigh
 COMMON VENTILATOR SETTINGS
PARAMETERS/ CONTROLS

 Fraction of inspired oxygen (FIO2)

The percent of oxygen concentration that the patient is

receiving from the ventilator. (Between 21% & 100%)

(room air has 21% oxygen content).

Initially a patient is placed on a high level of FIO2 (60%

or higher).

Subsequent changes in FIO2 are based on ABGs and the

SaO2.
In adult patients the initial FiO2 may be set at
100% until arterial blood gases can document
adequate oxygenation.
An FiO2 of 100% for an extended period of time can
be dangerous ( oxygen toxicity) but it can protect
against hypoxemia
For infants, and especially in premature infants,
high levels of FiO2 (>60%) should be avoided.
Oxygen toxicity is a concern when an FIO2 of
greater than 60% is required for more than 25
hours
Signs and symptoms of oxygen toxicity :-

1- Flushed face

2- Dry cough

3- Dyspnea

4- Chest pain

5- Tightness of chest

6- Sore throat
● TIDAL VOLUME (VT)

 The volume of air delivered to a patient

during a ventilator breath.

 Another definition VT is the volume of air

inspired/expired with each breath

.
 In the volume ventilator, Tidal volumes of
10 to 15 mL/kg of body weight were
traditionally used.

 the large tidal volumes may lead to

(volutrauma) aggravate the damage
inflicted on the lungs

 For this reason, lower tidal volume targets

(5 to 7 mL/kg) are now recommended.
For adult patients and older children:-
With COPD

 A reduced tidal volume

 A reduced respiratory rate

For infants and younger children:-

 A small tidal volume

 Higher respiratory rate
● PEAK FLOW/ FLOW RATE
 The speed of delivering air per unit of time, and
is expressed in liters per minute.

 The higher the flow rate, the faster peak airway

pressure is reached and the shorter the
inspiration;

 The lower the flow rate, the longer the

inspiration.
● RESPIRATORY RATE/ BREATH
RATE / FREQUENCY ( F)

 The number of breaths the ventilator will deliver/minute

(10-16 b/m).

 Total respiratory rate equals patient rate plus ventilator

rate.

 The nurse double-checks the functioning of the ventilator

by observing the patient’s respiratory rate.
 I:E Ratio (Inspiration to
Expiration Ratio):- The ratio of inspiratory time to
expiratory time during a breath
(Usually = 1:2)
● SIGH
 A deep breath.

 A breath that has a greater volume than the

tidal volume.

 It provides hyperinflation and prevents

atelectasis.

 Sigh volume :------------------Usual volume is 1.5 –2

times tidal volume.

 Sigh rate/ frequency :---------Usual rate is 4 to 8

times an hour.
 ● PEAK AIRWAY PRESSURE:-

 In adults if the peak airway pressure is

persistently above 45 cmH2O, the risk of

barotrauma is increased.

 In infants and children it is unclear what level of

peak pressure may cause damage. In general,

keeping peak pressures below 30 is desirable.

ENSURING HUMIDIFICATION AND
THERMOREGULATION

 All air delivered by the ventilator passes

through the water in the humidifier, where it is
warmed .

 Humidifier temperatures should be kept close to

body temperature 35 ºC- 37ºC.

 In some rare instances (severe hypothermia), the

air temperatures can be increased.

 The humidifier should be checked for adequate

water levels
 CAUSES OF VENTILATOR ALARMS
High pressure alarm

 Increased secretions

 Kinked ventilator tubing or endotracheal tube

(ETT)

 Patient biting the ETT

 Water in the ventilator tubing.

 ETT advanced into right main stem bronchus.

Low pressure alarm

 Disconnected tubing
 A cuff leak
 A hole in the tubing (ETT or ventilator tubing)
 A leak in the humidifier
Oxygen alarm
 The oxygen supply is insufficient or is not properly connected.
High respiratory rate alarm
 Episodes of tachypnea
 Anxiety
 Pain
 Hypoxia
 Fever
Temperature alarm
 Overheating due to too low or no gas flow.
 Improper water levels

The low tidal volume alarm on a client's ventilator keeps sounding. The nurse
must Check ventilator connections.
WEANING READINESS CRITERIA

Awake and alert

Hemodynamically stable, adequately resuscitated, and
not requiring vasoactive support
Arterial blood gases (ABGs) normalized or at patient’s
baseline
- PaCO2 acceptable
- PH of 7.35 – 7.45
- PaO2 > 60 mm Hg ,
- SaO2 >92%
- FIO2 ≤40%
 Positive end-expiratory pressure (PEEP) ≤5 cm
H2O

 F < 25 / minute

 Vt 5 ml / kg

 VE 5- 10 L/m (f x Vt)

 VC > 10- 15 ml / kg
 COMPLICATIONS
OF MECHANICAL VENTILATION:-

I- Airway Complications,

II- Mechanical complications,

III- Physiological Complications,

IV- Artificial Airway Complications.

I- AIRWAY COMPLICATIONS

1- Aspiration

2- Decreased clearance of secretions

3- Nosocomial or ventilator-acquired
pneumonia
 II- MECHANICAL COMPLICATIONS
1- Hypoventilation with atelectasis with respiratory acidosis or

hypoxemia.

2- Hyperventilation with hypocapnia and respiratory alkalosis

3- Barotrauma

4- Alarm “turned off”

5- Failure of alarms or ventilator

6- Inadequate nebulization or humidification

7- Overheated inspired air, resulting in hyperthermia

III- PHYSIOLOGICAL COMPLICATIONS

Depressed cardiac function and hypotension

Stress ulcers

Paralytic ileus

Gastric distension

Starvation
IV- ARTIFICIAL AIRWAY COMPLICATIONS
A- ENDOTRACHEAL TUBE:-

- Tube kinked or plugged

- Tracheal stenosis

- Cuff failure

- Sinusitis

- Otitis media

- Laryngeal edema
 B-COMPLICATIONS RELATED TO
TRACHEOSTOMY TUBE:-
Acute hemorrhage at the site
Air embolism
Aspiration
Tracheal stenosis
Failure of the tracheostomy cuff
Laryngeal nerve damage
Obstruction of tracheostomy tube
Pneumothorax
Swallowing dysfunction
Tracheoesophageal fistula
Infection
Accidental decannulation with loss of airway
NURSING CARE OF PATIENTS ON
MECHANICAL VENTILATION

Assessment:

1- Assess the patient

2- Assess the artificial airway

(tracheostomy or endotracheal tube)

3- Assess the ventilator

 NURSING INTERVENTIONS
1-Maintain airway patency & oxygenation
2- Promote comfort
3- Maintain fluid & electrolytes balance
4- Maintain nutritional state
5- Maintain urinary & bowel elimination
6- Maintain eye , mouth and cleanliness and integrity:-
7- Maintain mobility/ musculoskeletal function:- Maintain
safety
9- Provide psychological support
10-Facilitate communication
11-Provide psychological support & information to family
12-Responding to ventilator alarms /Troublshooting
ventilator alarms
13-Prevent nosocomial infection
14-Documentation
 NURSING INTERVENTIONS
 A client has been intubated and placed on a volume-cycled
mechanical ventilator. The nurse carefully assesses the client
for findings associated with a risk associated with this type of
ventilator. Barotrauma
 A client who has been on a mechanical ventilator for three
days develops a fever, green sputum, and right lower lobe
crackles. The nurse contacts the physician regarding possible
development of which complication. may be have Ventilator-
associated pneumonia.
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 Check tidal volume.
 RESPONDING TO ALARMS
If an alarm sounds, respond immediately because the problem could be

serious.

Assess the patient first, while you silence the alarm.

If you can not quickly identify the problem, take the patient off the ventilator

and ventilate him with a resuscitation bag connected to oxygen source until

the physician arrives.

A nurse or respiratory therapist must respond to every ventilator alarm.

 One of the following is a risk of keeping high PEEP is hypotension so that must check