Mechanical

Ventilation
Critical Care
Two Kinds of Mechanical Ventilator
● Positive
pressure
ventilator

● Negative
pressure
ventilator

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Negative pressure ventilators
Example of iron lung:
https://www.youtube.com/watch?v=4ClRT0Poag8

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Negative pressure ventilators

https://www.youtube.com/watch?v=AANRR0ybR4Q
NEW Life Saving technology saves child, Lubbock,
Texas - Biphasic Cuirass Ventilation Machine
https://www.youtube.com/watch?v=xMwE8qpW-Bg
Advantages of biphasic cuirass ventilation.

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Negative pressure ventilators
● Used for chronic respiratory
failure associated with
neuromuscular conditions

● Not for unstable conditions

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Noninvasive Positive-Pressure
Ventilation

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 Noninvasive Positive-Pressure
Ventilation
● Deliver positive
pressure via masks
● Eliminates the need
for endotracheal
intubation or
tracheostomy
● Decreases the risk of
nosocomial infections
such as pneumonia
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Noninvasive Positive-Pressure
Ventilation (NPPV)
● Contraindications:
○ Respiratory arrest
○ Serious
dysrhythmias
○ Cognitive impairment
○ Head or facial
trauma

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Noninvasive Positive-Pressure
Ventilation (NPPV)
CPAP
● Oxygenation
● Obstructive
sleep apnea
BIPAP:
● Ventilation
● Central sleep
apnea

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Intubation

● When to intubate the patient:

○ Worsening ABGs
○ Worsening encephalopathy or agitation
○ Inability to tolerate the mask
○ Hemodynamically unstable
● Steps involved in intubation.
https://www.youtube.com/watch?v=FtJr7i7ENMY
● Sedative induction agent: e.g. propofol: onset 15-45 seconds,
duration 5-10 minutes, adverse effect: hypotension.
● Paralytic induction agent: e.g. succinylcholine: onset 45
seconds; duration 6-10 minutes; adverse effect: hyperkalemia

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endotracheal intubation

● http
://www.youtube.com/watch?v=V8
VIw0fk4X0
(review of resp system and
intubation process) (5:39)
● Right after the intubation:
○ Assess for placement:
■ Check symmetry of chest
expansion, auscultate
breath sounds or anterior
and lateral chest bilaterally
■ Obtain order for chest x-
ray to verify proper tube
placement
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Intubation-nursing documentation
● Depth of the tube
● Size of the tube
● Chest x-ray taken

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endotracheal intubation
Normal cuff pressure: 20-
25mmHg
Unwanted conditions
caused by high cuff
pressure
● Tracheal bleeding Unwanted conditions
● Ischemia caused by low
● Pressure necrosis pressure:
● Air leak
● Aspiration
pneumonia 13
endotracheal intubation
● If a patient needs permanent ventilation or
long term ventilation through a mechanical
ventilator, a patient should receive a
tracheostomy.
● Reflexes depressed by the endotracheal and
tracheostomy tubes:
○ Cough
○ Swallowing
● Life threatening complication of endotracheal
intubation:
○ Unintentional or premature removal of the tube
■ Laryngeal swelling
■ Hypoxemia
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Self-extubation

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Extubation process: ICU
● h
ttps://www.youtube.com/watch?v=1hN7yRfm
a_s
● Give heated humidified oxygen and maintain
the pt in a sitting or high Fowler’s position
● Monitor vital signs
● Keep NPO for next few hours
● Teach pt to perform coughing and deep-
breathing exercises

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 Endotracheal tube v.s. Tracheostomy tube

● Endotracheal tube can

only be left in place for
up to 2 weeks
● Tracheostomy:
○ increase patient comfort
and oral hygiene
○ Lower hospital mortality
○ Higher successful weaning
rates in ICU patients
receiving prolonged MV

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tracheostomy
● http://www.youtube.com/watch?v=d
_5eKkwnIRs
(animation)
● https://www.youtube.com/watch?v=
thjhhByzlwo
(life surgery)
● Indication:
○ by pass an upper airway obstruction
○ Removal of secretion s
○ Long-term use of mechanical ventilation

monitor every 6-8 hours 18

tracheostomy
● Early complications of tracheostomy tube
○ Bleeding
○ Pneumothorax
○ Air embolism
○ Aspiration
○ Subcutaneous or mediastinal emphysema
○ Recurrent laryngeal nerve damage
○ Posterior tracheal wall penetration

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tracheostomy
● Long term complications of tracheostomy
tube
○ airway obstruction from accumulation of
secretions of protrusion of the cuff over the
opening of the tube
○ infection
○ rupture of the innominate artery
○ dysphagia
○ tracheoesophageal fistula
○ tracheal dilation
○ tracheal ischemia
○ necrosis
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tracheostomy
● Complications prevention:
● administer adequate warmed humidity
● maintain cuff pressure at appropriate level
● suctions as needed per assessment findings
● maintain skin integrity. Change tape and dressing
as needed or per protocol.
● auscultate lung sounds
● monitor for signs and symptoms of infection,
including temperature and white blood cell count
Cont.

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tracheostomy
● Complications prevention:
● administer prescribed oxygen and monitor oxygen
saturation
● monitor for cyanosis
● maintain adequate hydration of the patient
● use sterile technique when suctioning and performing
tracheostomy care.

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Closed suctioning
● Allow rapid suction when
needed and to minimize
cross-contamination by
airborne pathogens
● Decreases hypoxemia,
sustain PEEP, decrease
patient anxiety
● Protects staff from
patient secretions

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Mechanical Ventilator

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Indications for Mechanical Ventilation

FEV1: Forced expiratory volume of the 1st second.

Vital capacity: the total amount of air exhaled after maximal inhalation.

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mechanical
ventilation:
indications

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mechanical ventilation
ventilator modes:
● how breaths are delivered to the patient
● most commonly used mode:
○ assist-control (AC)
○ synchronized intermittent mandatory ventilation
(SIMV)
○ pressure support ventilation

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mechanical ventilation
● Volume-cycled: delivers a preset volume of
air with each inspiration
● Pressure-cycled: delivers a flow of air
(inspiration) until it reaches a preset
pressure
● Three different modes.
● https://www.youtube.com/watch?v=IUZ3Plmz_YQ
(ventilator type and modes 1)
● https://www.youtube.com/watch?v=nGJIePPGQn0
● (ventilator type and modes 2)

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mechanical ventilation: A/C
assist-control (A/C)
ventilation:
MODE: A/C
Rate: 12
Tidal volume: 600 ml
FiO2: 0.4
PEEP: 3 cmH2O

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mechanical ventilation: SIMV
synchronized intermittent mandatory
ventilation (SIMV):
● between ventilator-delivered breaths,
the patient can breathe spontaneously
with NO assistance from the ventilator
on those extra breaths
● bucking (patient-ventilator dyssynchrony) is
reduced

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mechanical ventilation: SIMV
● preset number of ventilator breaths is
decreased
● patient does more of the work of breathing
● in what condition does SIMV=AC?
● Sample order:
○ Mode: SIMV
○ Rate: 8
○ Tidal volume: 600mL
○ FiO2: 30%
○ PEEP: 5 cmH2O

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mechanical ventilation: PSV
pressure support ventilation (PSV):
● applies a pressure plateau to the airway to
decrease resistance within the tracheal tube
and ventilator tubing (this is similar to
which mode that we discussed previous?)
● no mandatory breath
● pressure support is reduced gradually as the
patient's strength increases
● A SIMV backup rate may be added for extra
support
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Initial ventilator settings

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initial ventilator settings
● if the patient suddenly becomes confused or
agitated or begins bucking the ventilator for
some unexplained reason, assess for
hypoxia and manually ventilate on 100% oxygen with a
resuscitation bag

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Monitoring a patient on ventilator
● Ventilator settings
● Water in the tubing, disconnection or kinking
of the tubing
● Humidification and temperature
● Alarms (turned on and functioning properly)
● Two important nursing interventions:
○ Pulmonary auscultation
○ Interpretation of ABGs.

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Potential complications of MV
● Alterations in cardiac
function (hypotension)
● Barotrauma and
pneumothorax
● Pulmonary infection
● Abdominal distension

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Minute volume

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problems with mechanical
ventilation
Ventilator problems:
● increase in peak airway
pressure (high pressure
alarms)
● low pressure alarms
Patient problems
(complications)?

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weaning the patient from the
ventilator
Assess readiness
● How do you know?

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weaning the patient from the
ventilator
https://www.youtube
.com/watch?v=8IjA
DnVbBz4
(nurse initiated
weaning protocol)

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Weaning criteria
● Emphasize the importance of checking ABGs.
● improvement of respiratory failure
● absence of major organ failure
● intact ventilatory drive: ability to control their own level of ventilation
● respiratory rate <30
● minute ventilation of <12 L to maintain PaCO2 >60 mmHg
(fio2<40%)
● PEEP < 5cmH2O
● functional respiratory muscles
● appropriate level of consciousness
● cooperation
● intact cough reflex
● intact gag reflex
● able to expectorate secretions
● functional respiratory muscles with ability to support a strong and
effective cough

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weaning the patient from the
ventilator
weaning to exhaustion:
● RR>35/min
● SpO2<90%
● HR>140/min
● Sustained 20% increase in HR
● SBP>180mmHg, DBP>90mmHg
● anxiety
● diaphoresis

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weaning the patient from the
ventilator
● methods of weaning:
○ A/C:
■ control rate is decreased
○ SIMV:
■ decrease rate until the patient is breathing
spontaneously
○ PSV:
○ CPAP:

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weaning the patient from the
ventilator
methods of weaning:
● weaning trials:
○ using a T-piece or
tracheostomy mask
○ disconnected from the
ventilator, receiving humidified
oxygen only and performing all
work of breathing
○ ABG after 20 minutes
○ watch for distress

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weaning the patient from the
ventilator
methods of weaning:
● weaning trials:
○ if clinically stable, the patient can be extubated
within 2-3 hours after weaning and allowed
spontaneous ventilation by means of a mask with
humidified oxygen
○ closely monitor their vital signs and ABGs

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weaning the patient from the
ventilator
methods of weaning:
● weaning from the tube
○ if frequent suctioning is needed to clear secretions,
tube weaning may be unsuccessful
○ secretion clearance and aspiration risks are
assessed to determine whether active pharyngeal
and laryngeal reflexes are intact
○ once the patient can clear secretions adequately, a
trial period of mouth breathing or nose breathing is
conducted

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weaning the patient from the
ventilator
methods of weaning:
● weaning from the tube
○ downsize the tubing
○ replaced by a cuffless
tracheostomy tube
○ change to a fenestrated
tube

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weaning the patient from the
ventilator
methods of weaning:
● Passy-Muir valve:
● contraindications:
○ inflated cuff
○ excessive secretions
○ severely ill patients
● http://www.youtube.com/watch?v=7KTZzvF-Jfc

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Conclusion:

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Pharmacology
Sedatives used to decrease the anxiety of
patients receiving mechanical ventilation:
● lorazepam
● midazolam (versed)
● dexmedetomidine (Precedex)
● propofol (Diprivan)
● short acting barbiturates
○ Pentobarbital
○ Methohexital
○ Thiopental
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Pharmacology
Neuromuscular blocking agents can be used to
further paralyze the patient, if the patient is
“fighting” with the ventilator
● pancuronium (Pavulon)
● vecuronium (Norcuron)
● atracurium (Tracrium)
● rocuronium (Zemuron)

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Pharmacology
Unwanted side effects of neuromuscular
blocking agents:
● make sure always connect to the vent
● more chance for skin breakdown
● eye care (corneal abrasions)
● venous thromboembolism

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Pharmacology
Other often used drugs:
● Mucolytics (may trigger bronchospasm)
○ Hypertonic saline (3%)
○ Acetylcysteine (Mucomyst): sulfur content, rotten
eggs smell
● Ipratropium
● Albuterol

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