Mechanicalventilationppt

NURSING
MANAGEMENT OF
MECHANICALLY
VENTILATED
PATIENTS
Spontaneous
respiration vs.
Mechanical
Natural Breathing
ventilation
Negative inspiratory force
Air pulled into lungs
Mechanical Ventilation
Positive inspiratory pressure
Air pushed into lungs
Mechanical ventilation
Negative pressure
Positive pressure
Invasive
Noninvasive
Negative-Pressure
Ventilators
Early negative-pressure
ventilators were known as iron
lungs.
The patients body was encased
in an iron cylinder and negative
pressure was generated
The iron lung are still
occasionally used today.
Intermittent short-term negativepressure 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) .
Our focus will be on the positivepressure ventilators.
POSITIVE PRESSURE
VENTILATION (INVASIVE)
Initiation of Mechanical
Ventilation
Indications
Indications for Ventilatory
Support
Acute Respiratory
Failure
Prophylactic Ventilatory
Support
Hyperventilation
Therapy
8
Ventilation
Indications
Acute Respiratory Failure
(ARF)
Hypoxic lung failure (Type I)
Ventilation/perfusion
mismatch
Diffusion defect
Right-to-left shunt
Alveolar hypoventilation
Decreased inspired
9
oxygen
Ventilation
Indications
Acute Respiratory Failure (ARF)
Acute Hypercapnic Respiratory
Failure (Type II)
CNS Disorders
Reduced Drive To Breathe:
depressant drugs, brain or
brainstem lesions (stroke,
trauma, tumors),
hypothyroidism
Increased Drive to Breathe:
increased metabolic rate (CO2
10
production), metabolic
Ventilation
Indications
Acute Hypercapnic Respiratory Failure
(Type II)
Neuromuscular Disorders
Paralytic Disorders: Myasthenia
Gravis, Guillain-Barre11,
poliomyelitis, etc.
Paralytic Drugs: Curare, nerve gas,
succinylcholine, insecticides
Drugs that affect neuromuscular
transmission; calcium channel
11
blockers, long-term
Ventilation
Indications
Increased Work of Breathing
Pleural Occupying Lesions: pleural
effusions, hemothorax, empyema,
pneumothorax
Chest Wall Deformities: flail chest,
kyphoscoliosis, obesity
Increased Airway Resistance:
secretions, mucosal edema,
bronchoconstriction, foreign body
Lung Tissue Involvement: interstitial
12
pulmonary fibrotic diseases
Ventilation
Indications
Increased Work of Breathing (cont.)
Lung Tissue Involvement: interstitial
pulmonary fibrotic diseases, aspiration,
ARDS, cardiogenic PE, drug induced PE
Pulmonary Vascular Problems:
pulmonary thromboembolism,
pulmonary vascular damage
Dynamic Hyperinflation (air trapping)
Postoperative Pulmonary Complications
13
Ventilation
Prophylactic Ventilatory Support
Clinical conditions in which there is a high
risk of future respiratory failure
Examples: Brain injury, heart muscle injury,
major surgery, prolonged shock, smoke
injury
Ventilatory support is instituted to:
Decrease the WOB
Minimize O2 consumption and hypoxemia
Reduce cardiopulmonary stress
Control airway with sedation
14
Ventilation
Hyperventilation Therapy
Ventilatory support is instituted to
control and manipulate PaCO2 to lower
than normal levels
Acute head injury
15
Criteria for institution of

ventilatory support:
Normal
range
Ventilation
indicated
10-20
35 <
5-7
5>
65-75
15 >
75-100
20->
Parameters
A- Pulmonary function
:studies
Respiratory rate
(breaths/min).
Tidal volume (ml/kg
body wt)
Vital capacity (ml/kg
body wt)
Maximum Inspiratory
Force (cm HO2)
16
Criteria for institution of

ventilatory support:
Normal
range
Ventilation
indicated
Parameters
B- Arterial blood
Gases
7.35-7.45
75-100
35-45
7.25 >
60 >
50 <
PH
PaO2 (mmHg)
PaCO2 (mmHg)
17
Ventilation
Contraindications
Untreated pneumothorax
Relative Contraindications
Patients informed consent
Medical futility
Reduction or termination of
patient pain and suffering
18
Essential components in mechanical ventilation
Patient
Artificial airway
Ventilator circuit
Mechanical ventilator
A/c or D/c power source
O2 cylinder or central oxygen supply
19
Artificial airways
Tracheal intubation
Nasal
Oral
Supraglottic airway
Cricothyrotomy
Tracheostomy
20
Laryngeal airway
21
Intubation Procedure
Check and Assemble Equipment:
Oxygen flowmeter and O2 tubing
Suction apparatus and tubing
Suction catheter
Ambu bag and mask
Laryngoscope with assorted blades
3 sizes of ET tubes
Stillet
Stethoscope
Tape
Syringe
Sterile gloves
Intubation
Procedure
Position your patient into
the sniffing position
Intubation
Procedure
Preoxygenate with 100%
oxygen to provide apneic or
distressed patient with
reserve while attempting to
intubate.
Do not allow more than 30
seconds to any intubation
attempt.
If intubation is unsuccessful,
ventilate with 100% oxygen for
3-5 minutes before a
Insert Laryngoscope
After displacing the epiglottis insert the ETT.
The depth of the tube for a male patient
on average is 21-23 cm at teeth
The depth of the tube on average for a
female patient is 19-21 at teeth.
Confirm tube position:
By auscultation of the
chest
Bilateral chest rise
Tube location at teeth
CO2 detector
(esophageal
detection device or by
Stabilize the ETT
Ventilator circuit
Breathing System Plain
Breathing System with Single Water
Trap
Breathing System with Double Water
Trap.
Breathing Filters HME Filter
Flexible Catheter Mount
29
Ventilator
circuit
Breathing system plain

30
Ventilator Breathing
System (1.6m)
31
Ventilator Breathing System

(1.6m)
32
heat & moisture exchanger HME

filter
33
34
MECHANICAL
VENTILATOR
A mechanical ventilator is a machine
that generates a controlled flow of
gas into a patients airways. Oxygen
and air are received from cylinders or
wall outlets, the gas is pressure
reduced and blended according to
the prescribed inspired oxygen
tension (FiO2), accumulated in a
receptacle within the machine, and
delivered to the patient using one of
35
Types of Mechanical
ventilators
Transport ventilators
Intensive-care ventilators
Neonatal ventilators
Positive airway pressure
ventilators for NIV
36
Classification of positivepressure ventilators

Ventilators are classified according to
how the inspiratory phase ends. The
factor which terminates the
inspiratory cycle reflects the machine
type.
They are classified as:
ventilator
ventilator
1- Pressure cycled
2- Volume cycled
37
1- Volume-cycled
ventilator
Inspiration is terminated after a
preset tidal volume has been
delivered by the ventilator.
The ventilator delivers a preset
tidal volume (VT), and
inspiration stops when the
preset tidal volume is achieved.
38
2- Pressure-cycled
ventilator
In which inspiration is
terminated when a specific
airway pressure has been
reached.
The ventilator delivers a preset
pressure; once this pressure is
achieved, end inspiration occurs.
39
3- Time-cycled ventilator
In which inspiration is
terminated when a preset
inspiratory time, has elapsed.
Time cycled machines are not
used in adult critical care
settings. They are used in
pediatric intensive care areas.
40
Mechanical Ventilators
Different Types of Ventilators Available:
Will depend on your place of
employment
Ventilators in use in MCH
Servo S by Maquet
Savina by Drager
42
43
44
MODES OF
VENTILATION
Ventilator mode
The way the machine ventilates
the patient
How much the patient will
participate in his own ventilatory
pattern.
Each mode is different in
determining how much work of
breathing the patient has to do.
46
A- Volume Modes
1.
2.
3.
4.
CMV or CV
AMV or AV
IMV
SIMV
47
B- Pressure Modes
1- Pressure-controlled ventilation (PCV)
2- Pressure-support ventilation (PSV)
3- Continuous positive airway pressure
(CPAP)
4- Positive end expiratory pressure
(PEEP)
5- Noninvasive bilevel positive airway
pressure ventilation (BiPAP)
48
Control Mode
Delivers pre-set volumes at a preset rate and a pre-set flow rate.

The patient CANNOT generate
spontaneous breaths, volumes, or
flow rates in this mode.
Control Mode
Assist/Control Mode
Delivers pre-set volumes at a
pre-set rate and a pre-set flow
rate.
The patient CANNOT generate
spontaneous volumes, or flow
rates in this mode.
Each patient generated
respiratory effort over and
above the set rate are
delivered at the set volume
and flow rate.
Assist Control
Volume or Pressure control mode
Parameters to set:
Volume or pressure
Rate
I time
FiO2
52
Assist Control
Machine breaths:
Delivers the set volume or pressure
Patients spontaneous breath:

Ventilator delivers full set volume or
pressure & I-time
Mode of ventilation provides the

most support
53
Assist Control
Negative
deflection,
triggering
assisted breath
SYCHRONIZED
INTERMITTENT
MANDATORY
VENTILATION (SIMV):
Delivers a pre-set number of

breaths at a
set volume and flow rate.
Allows the patient to generate
spontaneous breaths, volumes, and
flow
rates between the set breaths.
Detects a patients spontaneous
SIMV
Synchronized intermittent mandatory ventilation
Machine breaths:
Delivers the set volume or pressure
Patients spontaneous breath:

Set pressure support delivered
Mode of ventilation provides moderate

amount of support
Works well as weaning mode
56
SIMV cont.
Machine Breaths
Spontaneous Breaths
57
IMV
Ingento EP & Drazen J: Mechanical Ventilators, in Hall JB, Scmidt

GA, & Wood LDH(eds.): Principles of Critical Care
58
Volume Modes
59
PRESSURE REGULATED VOLUME CONTROL (PRVC):
This is a volume targeted,

pressure limited mode.
(available in SIMV or AC)
Each breath is delivered at a set
volume with a variable flow rate
and an absolute pressure limit.
The vent delivers this pre-set
volume at the LOWEST required
peak pressure and adjust with
each breath.
60
PRVC (Pressure regulated volume control)

A control mode, which delivers a set tidal volume
with each breath at the lowest possible peak
pressure.
Delivers the breath with a decelerating flow pattern
that is thought to be less injurious to the lung
the guided hand.
61
PRCV: Advantages
Decelerating inspiratory flow pattern
Pressure automatically adjusted for
changes in compliance and resistance
within a set range
Tidal volume guaranteed
Limits volutrauma
Prevents hypoventilation
62
PRVC: Disadvantages
Pressure delivered is dependent on tidal volume
achieved on last breath
Volume
Flow
Pressure
Intermittent patient effort variable tidal volumes
Set tidal volume
63
Charles Gomersall 2003
PRVC: Disadvantages
Pressure delivered is dependent on tidal volume
achieved on last breath
Volume
Flow
Pressure
Intermittent patient effort variable tidal volumes
Set tidal volume
64
Charles Gomersall 2003
PRVC
65
POSITIVE END EXPIRATORY PRESSURE (PEEP):
This is NOT a specific mode, but

is rather an adjunct to any of the
vent modes.
PEEP is the amount of pressure
remaining in the lung at the END
of the expiratory phase.
Utilized to keep otherwise
collapsing lung units open while
hopefully also improving
oxygenation.
Usually, 5-10 cmH2O
66
67
Pplat
Measured by occluding the ventilator 35 sec at the end of inspiration
Should not exceed 30 cmH2O
68
Peak Pressure (Ppeak)

Ppeak = Pplat + Pres
Where Pres reflects the resistive
element of the respiratory system
(ET tube and airway)
69
Ppeak
Pressure measured at the end of
inspiration
Should not exceed 50cmH2O?
70
Auto-PEEP or Intrinsic PEEP

Normally, at end expiration, the lung
volume is equal to the FRC
When PEEPi occurs, the lung volume at
end expiration is greater than the FRC
71

Why does hyperinflation occur?
Airflow limitation because of dynamic
collapse
No time to expire all the lung volume
(high RR or Vt)
Decreased Expiratory muscle activity
Lesions that increase expiratory
resistance
72

Adverse effects:
Predisposes to barotrauma
Predisposes hemodynamic compromises
Diminishes the efficiency of the force
generated by respiratory muscles
Augments the work of breathing
Augments the effort to trigger the
ventilator
73
Continuous Positive Airway

Pressure (CPAP):
This is a mode and simply means
that a pre-set pressure is
present in the circuit and lungs
throughout both the inspiratory
and expiratory phases of the
breath.
CPAP serves to keep alveoli from
collapsing, resulting in better
oxygenation and less WOB.
The CPAP mode is very
commonly used as a mode to
74
Combination Dual Control Modes

Combination or dual control modes combine features of
pressure and volume targeting to accomplish ventilatory
objectives which might remain unmet by either used
independently.
Combination modes are pressure targeted
Partial support is generally provided by pressure support
Full support is provided by Pressure Control
75
Combination Dual Control Modes

Volume Assured Pressure Support
(Pressure Augmentation)
Volume Support
(Variable Pressure Support)
Pressure Regulated Volume Control
(Variable Pressure Control, or Autoflow)
Airway Pressure Release
(Bi-Level, Bi-PAP)
76
Inverse ratio ventilation (IRV) mode

reverses this ratio so that inspiratory
time is equal to, or longer than,
expiratory time (1:1 to 4:1).
Inverse I:E ratios are used in
conjunction with pressure control to
improve oxygenation by expanding
stiff alveoli by using longer
distending times, thereby providing
more opportunity for gas exchange
and preventing alveolar collapse.
77
As expiratory time is decreased, one

must monitor for the development of
hyperinflation or auto-PEEP. Regional
alveolar overdistension and
barotrauma may occur owing to
excessive total PEEP.
When the PCV mode is used, the
mean airway and intrathoracic
pressures rise, potentially resulting in
a decrease in cardiac output and
oxygen delivery. Therefore, the
patients hemodynamic status must
be monitored closely.
Used to limit plateau pressures that
can cause barotrauma & Severe ARDS78
HIGH FREQUENCY
OSCILLATORY
VENTILATION
HIFI - Theory
Resonant frequency phenomena:
Lungs have a natural resonant
frequency
Outside force used to overcome airway
resistance
Use of high velocity inspiratory gas

flow: reduction of effective dead
space
Increased bulk flow: secondary to
active expiration
80
HIFI - Advantages
Advantages:
Decreased barotrauma / volutrauma:
reduced swings in pressure and volume
Improve V/Q matching: secondary to
different flow delivery characteristics
Disadvantages:
Greater potential of air trapping
Hemodynamic compromise
Physical airway damage: necrotizing
tracheobronchitis
Difficult to suction
Often require paralysis
81
HIFI Clinical Application

Adjustable Parameters
Mean Airway Pressure: usually set 2-4
higher than MAP on conventional
ventilator
Amplitude: monitor chest rise
Hertz: number of cycles per second
FiO2
I-time: usually set at 33%
82
Comparison of HFOV
& Conventional
Ventilation
Differences
Rates
CMV
0 - 150
Tidal Volume
HFOV
180 - 900
4 - 20 ml/kg
0.1 - 3 ml/kg
Alveolar Press 0 - > 50 cmH2O 0.1 - 5 cmH2O

End Exp Volume Low
Gas Flow
Low
Normalized
High
83
Video on HFOV
http://youtube.com/watch?v=jLroOPoPl
ig
84
INITIAL SETTINGS
Select your mode of ventilation
Set sensitivity at Flow trigger
mode
Set Tidal Volume
Set Rate
Set Inspiratory Flow (if necessary)
Set PEEP
Set Pressure Limit
Inspiratory time
Fraction of inspired oxygen
85
Trigger
There are two ways to initiate a ventilatordelivered breath: pressure triggering or flow-by
triggering
When pressure triggering is used, a ventilatordelivered breath is initiated if the demand valve
senses a negative airway pressure deflection
(generated by the patient trying to initiate a breath)
greater than the trigger sensitivity.
When flow-by triggering is used, a continuous flow of
gas through the ventilator circuit is monitored. A
ventilator-delivered breath is initiated when the return
flow is less than the delivered flow, a consequence of
the patient's effort to initiate a breath
86
Post Initial Settings

Obtain an ABG (arterial blood gas)
about 30 minutes after you set
your patient up on the ventilator.
An ABG will give you information
about any changes that may need
to be made to keep the patients
oxygenation and ventilation status
within a physiological range.
87
ABG
Goal:
Keep patients acid/base balance
within normal range:
pH
7.35 7.45
PCO2 35-45 mmHg
PO2
80-100 mmHg
88
Ventilation
Initial Ventilator Settings
Tidal Volume
Spontaneous VT for an adult is 5 7 ml/kg of
IBW
Determining VT for Ventilated Patients
A range of 6 12 ml/kg IBW is used for adults
10 12 ml/kg IBW (normal lung function)
8 10 ml/kg IBW (obstructive lung
disease)
6 8 ml/kg IBW (ARDS) can be as low as
4 ml/kg
A range of 5 10 ml/kg IBW is used for
infants and children
89
Ventilation
Respiratory Rate
Normal respiratory rate is 12-18
breaths/min.
A range of 8 12 breaths per
minute (BPM)
Rates should be adjusted to try and
minimize auto-PEEP
90
Ventilation
Minute Ventilation
Respiratory rate is chosen in conjunction with tidal
volume to provide an acceptable minute
ventilation
= VT x f
Normal minute ventilation is 5-10 L/min
Estimated by using 100 mL/kg IBW
ABG needed to assess effectiveness of initial
settings
If PaCO2 >45 ( minute ventilation via f or VT)
If PaCO2 <35 ( minute ventilation via f or VT)
91
Ventilation

Inspiratory Flow
Rate of Gas Flow
As a beginning point, flow is normal set to
deliver inspiration in about 1 second (range 0.8
to 1.2 sec.), producing an I:E ratio of
approximately 1:2 or less (usually about 1:4)
This can be achieved with an initial peak flow of
about 60 L/min (range of 40 to 80 L/min)
Most importantly, flows are set to meet a
patients inspiratory demand
92
Expiratory Flow Pattern

Beginning of expiration
exhalation valve opens
Inspiration
Flow (L/min)
Expiratory
time
TE
Time (sec)
Duration of
expiratory flow
Expiration
Peak Expiratory Flow Rate

PEFR
93
Initiation of Mechanical Ventilation

Flow Patterns
Selection of flow pattern and flow rate may
depend on the patients lung condition, e.g.,
Post operative patient recovering from
anesthesia may have very modest flow
demands
Young adult with pneumonia and a strong
hypoxemic drive would have very strong
flow demands
Normal lungs: Not of key importance
94

Flow Pattern
Constant Flow (rectangular or square waveform)
Generally provides the shortest TI
Some clinician choose to use a constant
(square) flow pattern initially because it
enables them to obtain baseline measurements
of lung compliance and airway resistance
95

Flow Pattern
Sine Flow
May contribute to a more even distribution of
gas in the lungs
Peak pressures and mean airway pressure
are about the same for sine and square wave
patterns
96

Flow Pattern
Descending (decelerating) Ramp
Improves distribution of ventilation, results in a
longer TI, decreased peak pressure, and
increased mean airway pressure (which
increases oxygenation)
97

Positive End Expiratory Pressure (PEEP)
Initially set at 3 5 cm H2O
Restores FRC and physiological PEEP that
existed prior to intubation
Subsequent changes are based on ABG
results
Useful to treat refractory hypoxemia
Contraindications for therapeutic PEEP (>5 cm
H2O)
Hypotension
Elevated ICP
98

FiO2
Initially 100%
Severe hypoxemia
Abnormal cardiopulmonary functions
Post-resuscitation
Smoke inhalation
ARDS
After stabilization, attempt to keep FiO2 <50%
Avoids oxygen-induced lung injuries
Absorption atelectasis
Oxygen toxicity
99
Ventilation
FiO2 of 40% or Same FiO2 prior to
mechanical ventilation
Patients with mild hypoxemia or normal
cardiopulmonary function
Drug overdose
Uncomplicated postoperative recovery
100
Ventilation
Initial Ventilator Settings For PCV
Rate, TI, and I:E ratio are set in PCV
as they are in Volume mode
The pressure gradient (PIP-PEEP) is
adjusted to establish volume delivery
Remember: Volume delivery
changes as lung characteristics
change and can vary breath to
breath
101
Ventilation
Initial Ventilator Settings For

PCV
Flow Pattern
PCV provides a
descending ramp
waveform
Note: The patient can
vary the inspiratory flow
on demand
102
Ventilation
Initial Ventilator Settings For PCV

Rise Time (slope, flow acceleration)
Rise time is the amount of TI it takes for
the ventilator to reach the set pressure at
the beginning of inspiration
Inspiratory flow delivery during PCV can
be adjusted with an inspiratory rise time
control
103 to set the
Ventilator graphics can be used
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 per hour.
104
Ensuring humidification and

thermoregulation
All air delivered by the ventilator passes
through the water in the humidifier, where
it is warmed and saturated or through an
HME filter
Humidifier temperatures should be kept
close to body temperature 35 C- 37C.
In some rare instances (severe
hypothermia), the air temperatures can be
increased.
The humidifier should be checked for
105
Ventilation
Ventilator Alarm Settings
High Minute Ventilation
Set at 2 L/min or 10%-15% above
baseline minute ventilation
Patient is becoming tachypneic
(respiratory distress)
High Respiratory Rate Alarm
Set 10 15 BPM over observed
respiratory rate
Patient is becoming tachypneic
(respiratory distress)
106
Ventilation
Low Exhaled Tidal Volume Alarm
Set 100 ml or 10%-15% lower than expired
mechanical tidal volume
Causes
System leak
Circuit disconnection
ET Tube cuff leak
107

High Inspiratory Pressure Alarm
Set 10 15 cm H2O above PIP
Common causes:
Water in circuit
Kinking or biting of ET Tube
Secretions in the airway
Bronchospasm
Tension pneumothorax
Decrease in lung compliance
Increase in airway resistance
Coughing
108

Low Inspiratory Pressure Alarm
Set 10 15 cm H2O below observed PIP
Causes
System leak
Circuit disconnection
ET Tube cuff leak
High/Low PEEP/CPAP Alarm (baseline alarm)
High: Set 3-5 cm H2O above PEEP
Circuit or exhalation manifold obstruction
Auto PEEP
Low: Set 2-5 cm H2O below PEEP
Circuit disconnect
109

High/Low FiO2 Alarm
High: 5% over the analyzed FiO2
Low: 5% below the analyzed FiO2
High/Low Temperature Alarm
Heated humidification
High: No higher than 37 C
Low: No lower than 30 C
110

Apnea Alarm
Set with a 15 20 second time delay
In some ventilators, this triggers an apnea
ventilation mode
Apnea Ventilation Settings
Provide full ventilatory support if the
patient become apneic
VT 8 12 mL/kg ideal body weight
Rate 10 12 breaths/min
FiO2 100%
111
TROUBLESHOOTING
112
Trouble Shooting the Vent

Common problems
High peak pressures
Patient with COPD
Ventilator asynchrony
ARDS
113

If peak pressures are increasing:
Check plateau pressures by allowing for
an inspiratory pause (this gives you the
pressure in the lung itself without the
addition of resistance)
If peak pressures are high and plateau
pressures are low then you have an
obstruction
If both peak pressures and plateau
pressures are high then you have a lung
compliance issue
114

High peak pressure differential:
High Peak Pressures
Low Plateau Pressures
High Peak Pressures

High Plateau Pressures
Mucus Plug
ARDS
Bronchospasm
Pulmonary Edema
ET tube blockage
Pneumothorax
Biting
ET tube migration to a single

bronchus
Effusion
115
COPD
If you have a patient with history of COPD/asthma with
worsening oxygen saturation and increasing
hypercapnia differential includes:
Must be concern with breath stacking or auto- PEEP
Low VT with increased exhalation time is advisable
Baseline ABGs reflect an elevated PaCO 2 should not
hyperventilated. Instead, the goal should be restoration
of the baseline PaCO2.
These patients usually have a large carbonic acid load,
and lowering their carbon dioxide levels rapidly may
result in seizures.
116
COPD and Asthma

Goals:
Diminish dynamic hyperinflation
Diminish work of breathing
Controlled hypoventilation
(permissive hypercapnia)
117

Increase in patient agitation and dissynchrony on the ventilator:
Could be secondary to overall
discomfort
Increase sedation
Could be secondary to feelings of air

hunger
Options include increasing tidal volume,
increasing flow rate, adjusting I:E ratio,
increasing sedation
118
Trouble shooting the vent

If you are concern for acute respiratory
distress syndrome (ARDS)
Correlate clinically with radiologic findings of
diffuse patchy infiltrate on CXR
Obtain a PaO2/FiO2 ratio (if < 200 likely ARDS)
Begin ARDSnet protocol:
Low tidal volumes
Increase PEEP rather than FiO2
Consider increasing sedation to promote synchrony
with ventilator
119
Accidental Extubation
Role of the Nurse:
Ensure the Ambu bag is attached to
the oxygen flowmeter and it is on!
Attach the face mask to the Ambu
bag and after ensuring a good seal
on the patients face; supply the
patient with ventilation.
120
Pulmonary Disease:
Obstructive
Airway obstruction causing increase resistance to
airflow: e.g. asthma
Optimize expiratory time by minimizing minute
ventilation
Bag slowly after intubation
Dont increase ventilator rate for increased CO2
121
Pulmonary Disease:
Restrictive
Compromised lung volume:
Intrinsic lung disease
External compression of lung
Recruit alveolia, optimize V/Q

matching
Lung protective strategies
High PEEP
Pressure limiting PIP: 30-35 cmH2O
Low tidal volume: 4-8 ml/kg
FiO2 <60%
Permissive hypercarbia
122
In a patient with head injury,

Respiratory alkalosis may be required
to promote cerebral vasoconstriction,
with a resultant decrease in ICP.
In this case, the tidal volume and
respiratory rate are increased
( hyperventilation) to achieve the
desired alkalotic pH by manipulating
the PaCO2.
123
Complications
of Mechanical Ventilation:I- Airway Complications,
II- Mechanical complications,
III- Physiological Complications,
IV- Artificial Airway Complications.
124
I- Airway Complications
1- Aspiration
2- Decreased clearance of
secretions
3- Nosocomial or ventilatoracquired
pneumonia
125
126
WHAT IS SUCTIONING?.....
The patient with an
artificial airway is not
capable of effectively
coughing, the
mobilization of secretions
from the trachea must be
facilitated by aspiration.
Indications
Coarse breath sounds
Noisy breathing
Visible secretions in the airway
Decreased SpO2 in the pulse oximeter &
Deterioration of arterial blood gas values
Clinically increased work of breathing
Changes in monitored flow/pressure
graphics
Increased PIP; decreased Vt during
ventilation
NECESSARY EQUIPMENT
Vaccum source with adjustable

regulator suction jar
stethoscope
Sterile gloves for open
suctioning method
Clean gloves for closed
suctioning method
Sterile catheter
Clear protective goggles,
apron & mask
Sterile normal saline
Bains circuit or ambu bag for
preoxygenate the patient
Suction tray with hot water for
TYPES OF SUCTIONING
OPEN
SUCTION
CLOSED
SUCTION
OPEN SUCTION SYSTEM:

Regularly using system in
the intubated patients.
CLOSED SUCTION SYSTEM:
This is used to facilitate

continuous mechanical ventilation
and oxygenation during the
suctioning.
Closed suctioning is also

indicated when PEEP level above
Patient Preparation
Explain the procedure to the
patient (If patient is
concious).
The patient should receive
hyper oxygenation by the
delivery of 100% oxygen for
>30 seconds prior to the
suctioning (by increasing the
FiO2 by mechanical ventilator).
Position the patient in supine
position.
PROCEDURE
Perform hand hygiene,
wash hands. It reduces
transmission of
microorganisms.
Turn on suction
apparatus and set
vacuum regulator to
appropriate negative
pressure. For adult a
pressure of 100-120
mmHg, 80-100mmhg
Continue..
Goggles, mask & apron
should be worn to prevent
splash from secretions
Preoxygenate with 100% O2
Open the end of the suction
catheter package & connect it
to suction tubing (If you are
alone)
Wear sterile gloves with
sterile technique
With a help of an assistant
Continue..
With a help of an assistant
disconnect the ventilator
Kink the suction tube & insert
the catheter in to the ETtube
until resistance is felt
Resistance is felt when the
catheter impacts the carina or
bronchial mucosa, the suction
catheter should be withdrawn
1cm out before applying
suction
Continue.....
Apply continuous suction
while rotating the suction
catheter during removal
The duration of each
suctioning should be less the
15sec.
Instill 3 to 5ml of sterile
normal saline in to the
artificial airway, if required
Assistant resumes the
ventilator
Continue..
Continue making suction passes, bagging
patient between passes, until clear of
secretions, but no more than four passes
Return patient to ventilator
Flush the catheter with hot water in the
suction tray
Suction nares & oropharynx above the
artificial airway
Discard used equipments
Flush the suction tube with hot water
Auscultate chest
Wash hands
Document including indications for
Closed suctioning
procedure
Wash hands
Wear clean gloves
Connect tubing to closed
suction port
Pre-oxygenate the patient
with 100% O2
Gently insert catheter tip
into artificial airway
without applying suction,
stop if you met resistance
or when patient starts
Closed suction
139
Continue..
Place the dominant
thumb over the control
vent of the suction port,
applying continuous or
intermittent suction for
no more than 10 sec as
you withdraw the
catheter into the sterile
sleeve of the closed
suction device
Repeat steps above if
needed
Clean suction catheter
with sterile saline until
clear; being careful not
to instill solution into the
ASSESSMENT OF OUTCOME
Improvement in breath sounds.
Decreased peak inspiratory
pressure; Increased tidal
volume delivery during
ventilation.
Improvement in arterial blood
gas values or saturation as
reflected by pulse oximetry.
(SpO2)
Removal of pulmonary
secretions.
CONTRAINDICATIONS
Most contraindications are relative to
the patient's risk of developing
adverse reactions or worsening
clinical condition as result of the
procedure.
Suctioning is contraindicated when
there is fresh bleeding.
When indicated, there is no absolute
contraindication to endotracheal
suctioning because the decision to
abstain from suctioning in order to
avoid a possible adverse reaction
LIMITATIONS OF METHOD
Suctioning is potentially an
harmful procedure if carriedout
improperly.
Suctioning should be done when
clinically necessary (not
routinely).
The need for suctioning should be
assessed at least every 2hrs or
more frequently as need arises.
http://www.youtube.com/watch?v=
bXXWNCYZ_N0
144
LIMITATIONS OF METHOD
Suctioning is potentially an
harmful procedure if carriedout
improperly.
Suctioning should be done when
clinically necessary (not
routinely).
The need for suctioning should be
assessed at least every 2hrs or
more frequently as need arises.
II- Mechanical
complications
1- Hypoventilation with atelectasis with
respiratory
acidosis or hypoxemia.
2- Hyperventilation with hypocapnia and
respiratory alkalosis
3- Barotrauma
a- Closed pneumothorax,
b- Tension pneumothorax,
c- Pneumomediastinum,
d- Subcutaneous
emphysema.
4- Alarm turned off
5- Failure of alarms or ventilator
6- Inadequate nebulization or humidification
146
7- Overheated inspired air, resulting in
III- Physiological
Complications
1- Fluid overload with humidified air
and
sodium chloride (NaCl) retention
2- Depressed cardiac function and
hypotension
3- Stress ulcers
4- Paralytic ileus
5- Gastric distension
6- Starvation
7- Dyssynchronous breathing pattern
147
IV- Artificial Airway Complications

A- Complications related to
Endotracheal Tube:-
1- Tube kinked or plugged

2- Tracheal stenosis or tracheomalacia
3- Mainstem intubation with contralateral
(located on or affecting the opposite side of
the
Lung) lung atelectasis
5- Cuff failure
6- Sinusitis
7- Otitis media
8- Laryngeal edema
148
B- Complications related to
Tracheostomy tube:1- Acute hemorrhage at the site
2- Air embolism
3- Aspiration
4- Tracheal stenosis
5- Failure of the tracheostomy cuff
6- Laryngeal nerve damage
7- Obstruction of tracheostomy tube
8- Pneumothorax
9- Subcutaneous and mediastinal emphysema
10- Swallowing dysfunction
11- Tracheoesophageal fistula
12- Infection
14- Accidental decannulation with loss of airway
149
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
150
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:-
151
Nursing Interventions
8- 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
152
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 must153
Alarms must never be

ignored or disarmed.
Ventilator malfunction is a
potentially serious problem.
Nursing or respiratory
therapists perform ventilator
checks every 2 to 4 hours,
and recurrent alarms may
alert the clinician to the
possibility of an equipmentrelated issue.
154
When device malfunction is

suspected, a second person
manually
ventilates
the
patient while the nurse or
therapist looks for the cause.
If a problem cannot be
promptly
corrected
by
ventilator
adjustment,
a
different machine is procured
so the ventilator in question
can be taken out of service
for analysis and repair by
technical staff.
155
WEANING
156
Weaning readiness Criteria

Awake and alert
Hemodynamically stable, adequately
resuscitated, and not requiring
vasoactive support
Arterial blood gases (ABGs)
normalized or at patients baseline
- PaCO2
acceptable
- PH of 7.35
7.45
- PaO2 > 60 mm
157
Hg ,
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
158
Chest x-ray reviewed for

correctable factors; treated as
indicated,
Major electrolytes within normal
range,
Hematocrit >25%,
Core temperature >36C and
<39C,
Adequate management of
pain/anxiety/agitation,
Adequate analgesia/ sedation
(record scores on flow sheet),
No residual neuromuscular
159
Methods of Weaning
1- T-piece trial,
2- Continuous Positive Airway Pressure
(CPAP) weaning,
3- Synchronized Intermittent
Mandatory Ventilation (SIMV)
weaning,
4- Pressure Support Ventilation (PSV)
weaning.
160
1- T-Piece trial
It consists of removing the patient
from the ventilator and having him /
her breathe spontaneously on a Ttube connected to oxygen source.
During T-piece weaning, periods of
ventilator support are alternated with
spontaneous breathing.
The goal is to progressively increase
the time spent off the ventilator.
161
2-Synchronized Intermittent
Mandatory Ventilation ( SIMV)
Weaning
SIMV is the most common method of
weaning.
It consists of gradually decreasing
the number of breaths delivered by
the ventilator to allow the patient to
increase number of spontaneous
breaths
162
3-Continuous Positive Airway

Pressure ( CPAP) Weaning
When placed on CPAP, the patient
does all the work of breathing
without the aid of a back up rate or
tidal volume.
No mandatory (ventilator-initiated)
breaths are delivered in this mode i.e.
all ventilation is spontaneously
initiated by the patient.
Weaning by gradual decrease in
pressure value
163
4- Pressure Support Ventilation

(PSV) Weaning
The patient must initiate all pressure
support breaths.
During weaning using the PSV mode the
level of pressure support is gradually
decreased based on the patient maintaining
an adequate tidal volume (8 to 12 mL/kg)
and a respiratory rate of less than 25
breaths/minute.
PSV weaning is indicated for :- Difficult to wean patients
- Small spontaneous tidal volume.
164
Role of nurse before

weaning:1- Ensure that indications for the
implementation of Mechanical ventilation
have improved
2- Ensure that all factors that may interfere
with successful weaning are corrected:- Acid-base abnormalities
- Fluid imbalance
- Electrolyte abnormalities
- Infection
- Fever
- Anemia
- Hyperglycemia
- Sleep deprivation
165
Role of nurse before

weaning:3- Assess readiness for weaning
4- Ensure that the weaning criteria /
parameters are met.
5- Explain the process of weaning to the
patient and offer reassurance to the
patient.
6- Initiate weaning in the morning when
the patient is rested.
7- Elevate the head of the bed & Place
the patient upright
8- Ensure a patent airway and suction if
necessary before a weaning trial,
166
Role of nurse before weaning:9 - Provide for rest period on ventilator

for 15 20 minutes after suctioning.
10- Ensure patients comfort &
administer
pharmacological agents for
comfort, such as
bronchodilators or sedatives as
indicated.
11- Help the patient through some of
the
discomfort and apprehension.
13- Evaluate and document the
patients
167
Role of nurse during

weaning:1- Wean only during the day.
2- Remain with the patient during
initiation of weaning.
3- Instruct the patient to relax and breathe
normally.
4- Monitor the respiratory rate, vital signs,
ABGs, diaphoresis and use of accessory
muscles frequently.
If signs of fatigue or respiratory distress
develop.
Discontinue weaning trials.
168
Signs of Weaning Intolerance

Criteria
Diaphoresis
Dyspnea & Labored respiratory

pattern
Increased anxiety ,Restlessness,
Decrease in level of consciousness
Dysrhythmia,Increase or decrease in
heart rate of > 20 beats /min. or heart
rate > 110b/m,Sustained heart rate
>20% higher or lower than baseline
169
Signs of Weaning Intolerance Criteria

Increase or decrease in blood pressure
of > 20 mm Hg
Systolic blood pressure >180 mm Hg
or <90 mm Hg
Increase in respiratory rate of > 10
above baseline or > 30
Sustained respiratory rate greater
than 35 breaths/minute
Tidal volume 5 mL/kg, Sustained
minute ventilation <200
mL/kg/minute
SaO2 < 90%, PaO2 < 60 mmHg,
decrease in PH of < 7.35.
170
Role of nurse after

weaning
1- Ensure that extubation criteria
are
met .
2- Decanulate or extubate
2- Documentation
171
Noninvasive Bilateral Positive

Airway Pressure Ventilation
(BiPAP)
BiPAP is a noninvasive form of
mechanical ventilation provided by
means of a nasal mask or nasal
prongs, or a full-face mask.
The system allows the clinician to
select two levels of positive-pressure
support:
An inspiratory pressure support level
(referred to as IPAP)
An expiratory pressure called EPAP
172
NON INVASIVE VENTILATION
173
Absolute contraindications
Coma
Cardiac arrest
Respiratory arrest
Any condition requiring immediate
intubation
174
Suitable clinical conditions

Chronic obstructive pulmonary
disease
Cardiogenic pulmonary edema
After discontinuation of
mechanical ventilation(COPD)
OSP
175
Patient interfaces
full face masks,

nasal pillows,
Nasal masks
and orofacial masks
176
Ventilators
Usual ventilators for invasive
ventilation
Special noninvasive ventilators
Modes of ventilation
CPAP
BiPAP
177
Top 10 care essentials for

ventilator patients
Review communications.
Check ventilator settings and
modes.
Suction appropriately.
Assess pain and sedation needs.
Prevent infection.
178
Top 10 care essentials for

ventilator patients
Prevent hemodynamic
instability.
Manage the airway.
Meet the patients nutritional
needs.
Wean the patient from the
ventilator appropriately.
Educate the patient and family.
179
K
N
A
TH
U
O
Y
180

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NURSING

Intermittent short-term negativepressure ventilation is sometimes

Criteria for institution of

Criteria for institution of

Essential components in mechanical ventilation

Breathing system plain

Ventilator Breathing System

heat & moisture exchanger HME

Classification of positivepressure ventilators

Delivers pre-set volumes at a preset rate and a pre-set flow rate.

Patients spontaneous breath:

Mode of ventilation provides the

Delivers a pre-set number of

Patients spontaneous breath:

Mode of ventilation provides moderate

Ingento EP & Drazen J: Mechanical Ventilators, in Hall JB, Scmidt

PRESSURE REGULATED VOLUME CONTROL (PRVC):

This is a volume targeted,

PRVC (Pressure regulated volume control)

Intermittent patient effort variable tidal volumes

Set tidal volume

Intermittent patient effort variable tidal volumes

Set tidal volume

POSITIVE END EXPIRATORY PRESSURE (PEEP):

This is NOT a specific mode, but

Peak Pressure (Ppeak)

Auto-PEEP or Intrinsic PEEP

Auto-PEEP or Intrinsic PEEP

Auto-PEEP or Intrinsic PEEP

Continuous Positive Airway

Combination Dual Control Modes

Combination Dual Control Modes

Inverse ratio ventilation (IRV) mode

As expiratory time is decreased, one

Use of high velocity inspiratory gas

HIFI Clinical Application

Alveolar Press 0 - > 50 cmH2O 0.1 - 5 cmH2O

Post Initial Settings

Initial Ventilator Settings

Expiratory Flow Pattern

Peak Expiratory Flow Rate

Initiation of Mechanical Ventilation

Initiation of Mechanical Ventilation

Initiation of Mechanical Ventilation

Initiation of Mechanical Ventilation

Initiation of Mechanical Ventilation

Initiation of Mechanical Ventilation

Initial Ventilator Settings For

Initial Ventilator Settings For PCV

Ensuring humidification and

Initiation of Mechanical Ventilation

Initiation of Mechanical Ventilation

Initiation of Mechanical Ventilation

Initiation of Mechanical Ventilation

Trouble Shooting the Vent

Trouble Shooting the Vent

Trouble Shooting the Vent

High Peak Pressures

ET tube migration to a single

COPD and Asthma

Trouble Shooting the Vent

Could be secondary to feelings of air

Trouble shooting the vent

Recruit alveolia, optimize V/Q