Mechanical Ventilation

• Mechanical Ventilation is ventilation of the lungs by artificial means usually by a

ventilator.
• A ventilator delivers gas to the lungs with either negative or positive pressure.
Purposes:
• To maintain or improve ventilation, & tissue oxygenation.
• To decrease the work of breathing & improve patient’s comfort.
Indications:
Acute respiratory failure due to:
 Mechanical failure, includes neuromuscular diseases as Myasthenia Gravis,
Guillain-Barré Syndrome, 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.
Abnormalities of pulmonary gas exchange:
 Obstructive lung disease in the form of asthma, chronic bronchitis or emphysema.
 Conditions such as pulmonary edema, atelectasis, pulmonary fibrosis.
 Patients who has received general anesthesia as well as post cardiac arrest patients
often require ventilatory support until they have recovered from the effects of the
anesthesia or the insult of an arrest.
Modes of Mechanical Ventilation

Assist Control Mode A/C

 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. Client can initiate breaths that
are delivered at the preset tidal volume.
 Client can breathe at a higher rate than the preset number of breaths/minute
 The total respiratory rate is determined by the number of spontaneous inspiration
initiated by the patient plus the number of breaths set on the ventilator.
 In A/C mode, a mandatory (or “control”) rate is selected.
 If the patient wishes to breathe faster, he or she can trigger the ventilator and
receive a full-volume breath.
 Often used as initial mode of ventilation
 When the patient is too weak to perform the work of breathing (e.g., when
emerging from anesthesia).

Synchronized Intermittent Mandatory Ventilation (SIMV)

  The ventilator provides the patient with a pre-set number of breaths/minute at a
specified tidal volume and FiO2.
 In between the ventilator-delivered breaths, the patient is able to breathe
spontaneously at his own tidal volume and rate with no assistance from the
ventilator.
 However, unlike the A/C mode, any breaths taken above the set rate are
spontaneous breaths taken through the ventilator circuit.
 The tidal volume of these breaths can vary drastically from the tidal volume set on
the ventilator, because the tidal volume is determined by the patient’s spontaneous
effort.
 Adding pressure support during spontaneous breaths can minimize the risk of
increased work of breathing.
Continuous Positive Airway Pressure (CPAP)
 Constant positive airway pressure during spontaneous breathing
 CPAP allows the nurse to observe the ability of the patient to breathe
spontaneously while still on the ventilator.
 CPAP can be used for intubated and non-intubated patients.
 It may be used as a weaning mode and for nocturnal ventilation (nasal or mask
CPAP)

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%)
 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.
 Usually the FIO2 is adjusted to maintain an SaO2 of greater than 90% (roughly
equivalent to a PaO2 >60 mm Hg).
 Oxygen toxicity is a concern when an FIO2 of greater than 60% is required for more
than 25 hours
Tidal Volume (TV)
 The volume of air delivered to a patient during a ventilator breath.
 The amount of air inspired and expired with each breath.
 Usual volume selected is between 5 to 15 ml/ kg body weight)
  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 (6 to 8 mL/kg) are now recommended.
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.
Ensuring humidification and thermoregulation
 All air delivered by the ventilator passes through the water in the humidifier, where it is
warmed and saturated.
 Humidifier temperatures should be kept close to body temperature 35 ºC- 37ºC.
 The humidifier should be checked for adequate water levels
 An empty humidifier contributes to drying the airway, often with resultant dried
secretions, mucus plugging and less ability to suction out secretions.
 Humidifier should not be overfilled as this may increase circuit resistance and interfere
with spontaneous breathing.
 As air passes through the ventilator to the patient, water condenses in the corrugated
tubing. This moisture is considered contaminated and must be drained into a receptacle
and not back into the sterile humidifier.
 If the water is allowed to build up, resistance is developed in the circuit and PEEP is
generated. In addition, if moisture accumulates near the endotracheal tube, the patient can
aspirate the water.
 The nurse and respiratory therapist jointly are responsible for preventing this
condensation buildup. The humidifier is an ideal medium for bacterial growth.
Nursing care of patients on mechanical ventilation
Assess the patient.
Assess the artificial airway (tracheostomy or endotracheal tube).
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.
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
Weaning
 Weaning is accomplished by gradually lowering the set rate and allowing the patient to
assume more work

1. 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
2. Continuous Positive Airway Pressure ( CPAP) Weaning
 When placed on CPAP, the patient does all the work of breathing without
the aid of a backup rate or tidal volume.
 No mandatory (ventilator-initiated) breaths are delivered in this mode i.e.
all ventilation is spontaneously initiated by the patient.

3. T-Piece trial
 It consists of removing the patient from the ventilator and having him / her
breathe spontaneously on a T-tube 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.

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%
 Chest x-ray reviewed for correctable factors; treated as indicated.
 Major electrolytes within normal range.
 Core temperature >36°C and <39°C.
 Adequate management of pain/anxiety/agitation.
  Adequate analgesia/ sedation (record scores on flow sheet).
 No residual neuromuscular blockade.
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
- Protein
- Sleep deprivation
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.
9. Provide for rest period on ventilator for 15 – 20 minutes after suctioning.
10. Ensure patient’s comfort & administer pharmacological agents for comfort, such as
bronchodilators or sedatives as indicated.
11. Help the patient through some of the discomfort and apprehension.
12. Support and reassurance help the patient through the discomfort and apprehension as
remains with the patient after initiation of the weaning process.
13. Evaluate and document the patient’s response to weaning.

Role of nurse during weaning:

 Wean only during the day.
 Remain with the patient during initiation of weaning.
 Instruct the patient to relax and breathe normally.
 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.
Signs of Weaning Intolerance Criteria
 Diaphoresis refers to excessive sweating for no apparent reason
  Dyspnea & Labored respiratory pattern an abnormal respiration characterized by
evidence of increased effort to breathe, including the use of accessory muscles of
respiration, stridor, grunting, or nasal flaring
 Increased anxiety
 Restlessness the inability to rest or relax as a result of anxiety or boredom
 Decrease in level of consciousness
 Dysrhythmia a problem with the rate or rhythm of your heartbeat caused by changes in
your heart's normal sequence of electrical impulses
 Increase or decrease in heart rate
 Increase or decrease
 Increase in respiratory rate
 SaO2 < 90%
 Increase in PaCO2

Role of nurse after weaning

 Ensure that extubation criteria are met .
 Decanulate or extubate.
 Documentation