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CARE OF CLIENT IN MECHANICAL VENTILATOR

The mechanical ventilator device functions as a substitute for the bellows action of the thoracic cage and diaphragm. The mechanical ventilator can maintain ventilation automatically for prolonged periods. It is indicated when the patients is unable to maintain safe levels of oxygen or carbon dioxide by spontaneous breathing even with the assistance of other oxygen delivery devices. IndicationsA. Mechanical failure of Ventilation Neuromuscular disease Central nervous system disease Central nervous system depression(drug intoxication, respiratory depressants, cardiac arrest) Musculoskeletal disease Inefficiency of thoracic cage in generating pressure gradients necessary for ventilation (chest injury, thoracic malformation) B. Disorders of pulmonary gas exchange Acute respiratory failure Chronic respiratory failure Left ventricular failure Pulmonary disease resulting in diffusion abnormality Pulmonary disease resulting in ventilation / perfusion mismatch Underlying principles1. Variables that control ventilation and oxygenation includea. Ventilator rate- adjusted by rate setting b. Tidal volume (VT) adjusted by tidal volume settings measured as inhaled volume. c. Fraction inspired oxygen concentration(FiO2)- set on ventilator or with an O2 blender, measured with an oxygen analyzer. d. Ventilator dead space-circuitry (tubing) common to inhalation and exhalation, tubing is calibrated. e. PEEP- set within the ventilator or with the use of external PEEP (also by rate and tidal volume) 2. CO2 elimination is controlled by tidal volume ,rate and dead space. 3. Oxygen tension is controlled by oxygen concentration and PEEP (also by rate and tidal volume). 4. In most cases, the duration of inspiration should not exceed exhalation.

a. Rate , tidal volume, gas flow in liters per minute, and inspiratory pause all control inspiratory time. b. Inverse inspiration: exhalation (I:E) ratio results in stacking of breaths or build up of pressure within the airway. Barotraumas and decreased cardiac output can result when inverse I:E ration is used. 5. The inspired gas must be warmed humidified to prevent thickening of secretions and decrease in body temperature. Sterile water by way of a heated humidifier.

Types of ventilatorsA. Negative pressure ventilators1. Applies negative around the chest wall. This causes intra-airway pressure to become negative thus drawing air into the lungs through the patients nose and mouth. 2. No artificial airway is necessary , patient msut be able to control and protect own airway. 3. Indicated for selected patients with respiratory neuromuscular problems, or as adjunct to weaning from positive pressure ventilation. B. Positive pressure ventilators During mechanical ventilation, air is actively delivered to the patients lung under positive pressure. Exhalation is passive. Requires use of a cuffed artificial airway. 1. Pressure limited. a) Terminates the inspiratory phase when a preselected airway pressure is achieved. b) Volume delivered depends on lung compliance. c) Use of volume-based alarms is recommended because any obstruction between the machine and lungs that allows a build up of pressure in the ventilator circuitry will cause the ventilator to cycle , but the patient will receive no volume. 2. Volume limited a) Terminates the inspiratory phase when a designated volume of gas is delivered into the ventilator circuit. (10 to 15 ml/ kg body weight usual starting volume). b) Delivers the predetermined volume regardless of changing lung compliance ( although airway pressures will increase as compliance decreased). Airway pressures vary from patient to patient and from breath to breath. c) Pressure- limiting valves, which prevent excess pressure buildup within the patient-ventilator system are used. Without this valve pressure could increase indefinitely and pulmonary barotraumas could result . usually equipped with a system that alarms when selected pressure limit is exceeded and vents excess inspired air to the atmosphere.

Modes Of Operation A. Controlled ventilation (CV) i. Cycles automatically at rate selected by operator. ii. Provides a fixed level of ventilation, but will not cycle or have gas available in circuitry to respond to patients own inspiratory efforts. This typically increases work of breathing for patients attempting to breathe spontaneously. iii. Possibly indicated for patients whose respiratory drive is absent. B. Assist/ Control (A/C) i. Inspiratory cycle of ventilator is activated by the patients voluntary inspiratory effort and delivers preset volume. ii. Ventilator also cycles at a rate predetermined by the operator . should the patient stop breathing, or breaths so weakly that the ventilator cannot function as an assistor, this mandatory baseline rate will prevent apnea. A minimum level of minute ventilation(VE) is provided. iii. Indicated for patients who are breathing spontaneously, but who have the potential to lose their respiratory drive or muscular control of ventilation . in this mode, the patients work of breathing is greatly reduced. C. Intermittent Mandatory Ventilation (IMV) i. Allows patient to breathe spontaneously through ventilator circuitry. ii. Periodically , at preselected rate and volume, cycles to give a mandated ventilator breath. A minimum level of ventilation is provided. iii. Gas provided for spontaneously breaths usually flows continuously through the ventilator. iv. Indicated for patients who are breathing spontaneously, but at a tidal volume and/or rate less than adequate for their needs. Allows the patients to do some of the work of breathing. v. Can cause stacked breaths when machine breath and patient-generated occurs concurrently. D. Synchronized Intermittent Mandatory Ventilation (SIMV) i. Allows patient to breathe spontaneously through the ventilator circuitry. ii. Periodically, at a preselected time, a mandatory breath is delivered. The patient may initiate the mandatory breath with own inspiratory effort, and the ventilator breath will be synchronized with the patients efforts, or will be assisted . if the patient does not provide inspiratory effort, the breath will still be delivered, or controlled. iii. Gas provided for spontaneous breathing is usually delivered through a demand regulator, which is activated by the patient. iv. Indicated for patients who are breathing spontaneously but at a tidal volume and/or rate less than adequate for their needs. Allows the patients to do some of the work of breathing.

E. Pressure Support i. A positive pressure is set. ii. During spontaneous respiration, ventilator circuitry is rapidly pressurized to the predetermined pressure and held at this pressure. iii. When the inspiratory flow rate decreases to a preset minimal level(20% to 25% or peak inspiratory flow), the positive pressure returns to baseline. The patient may exhale or complete inspiration without pressure support. iv. The patient ventilates spontaneously , establishing own rate, and inspiring the tidal volume that feels appropriate. v. Pressure support may be used, independently as a ventilator mode or used in conjunction with CPAP or SIMV. Special Positive Pressure Ventilation Techniques A. Positive end expiratory pressure (PEEP) 1. Maneuver by which pressure during mechanical ventilation is maintained above atmosphere at end of exhalation , resulting in an increased functional residual capacity. Airway pressure is therefore positive throughout the entire ventilator cycle. 2. Purpose is to increase functional residual capacity (or the amount of air left in the lungs at the end of expiration). This aids ina) Increasing the surface area of gas exchange. b) Preventing collapse of alveolar units and development of atelectasis. c) Decreasing intrapulmonary shunt. 3. Benefits a) Because a greater surface area for diffusion is available and shunting is reduced , it is often possible to use a lower fraction of inspired oxygen concentration(FiO2) than otherwise would be required to obtain adequate arterial oxygen levels. This reduces the risk of oxygen toxicity in conditions such as adult respiratory distress syndrome(ARDS) . b) Increased lung compliance resulting in decreased work of breathing. 4. Hazards a) Because the mean airway pressure is increased by PEEP venous return is impeded. This may result in a decrease in cardiac output. b) The decreased venous return may cause ant diuretic hormone formation to be stimulated, resulting in decreased urine output. B. Continuous positive airway pressure(CPAP) 1. Also provides for positive airway during all parts of a respiratory cycle, but refers to spontaneous ventilation rather than mechanical ventilation. 2. May be delivered through ventilator circuitry when ventilator rate is at 0 or may be delivered through a separate CPAP circuitry that does not require the ventilator.

3. Indicated for patients who are capable of maintaining an adequate tidal volume, but who have pathology preventing maintenance of adequate levels of tissue oxygenation. Newer Modes Of VentilationA. Inverse ratio ventilation (IRV) 1) I:E ratio is greater than 1 (normally inspiration is shorter than expiration) 2) Potentially used in patients who are in acute severe hypoxemic respiratory failure. Oxygenation is thought to be improved. 3) Used with heavily sedated patients. 4) Still under investigation- only used in rare cases B. Non- invasive positive pressure ventilation(NIPPV) 1) Uses a nasal mask, nasal pillow, oral mask, or mouthpiece attached to a standard ventilator. Delivers air through portable ventilator that is either volume-cycled or flow cycled. 2) Used primarily in the past for patients with chronic respiratory failure associated with neuromuscular disease. Now, is being used somewhat successfully during acute exacerbations. Some patients are able to avoid invasive intubation . Other indications include weaning and postextubation respiratory decompensation. 3) Used easily in home setting-equipment is portable and relatively easy to use. C. High- frequency ventilation (HFV) 1) Uses very small tidal volumes (less than dead space volume) and high frequency (ratios greater than 100). 2) Gas exchange occurs through various mechanisms, not the same as conventional ventilation (convection). 3) Types a) High- frequency oscillatory ventilation (HFOV) b) High- frequency jet ventilation (HFJV) 4) Theory is that there is decreased barotraumas by having small tidal volumes and that oxygenation is improved by constant flow of gases. 5) Has not yet proven to be significantly helpful, but is being tested in neonates (HFOV) , and in adults for the treatment of ARDS ( HFJV), as well as bronchopleural fistula (HFJV).

Nursing Assessment And Interventions 1. Monitor for complications.

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a) Airway obstruction (thickened secretions, mechanical problem with artificial airway or ventilator circuitry. b) Tracheal damage. c) Pulmonary infection. d) Barotrauma e) Decreased cardiac output f) Atelectasis g) Alteration in GI function (dilution , bleeding) h) Alteration in renal function Suction the patient as indicated. a) When secretions can be seen or sounds resulting from secretions are heard with or without the use of a stethoscope. b) After chest physiotherapy . c) After bronchodilator treatments. d) After a sudden rise or the popping off of the peak airway pressure in mechanically ventilated patients that is not due to the artificial airway or ventilator tube kinking, the patient biting the tube, the patient coughing or struggling against the ventilator , or a pneumothorax. e) Routine suction is not indicated, but should be based on assessment, patients underlying condition, and chest X-ray finding. Provide routing care for patient on mechanical ventilator. Assist with the weaning process, when indicated. a) Patient must have acceptable ABGs, no evidence of acute pulmonary pathology, and be hemodynamically stable. b) Obtain serial ABGs and/or oximetry readings, as indicated. c) Monitor very closely for change in pulse and blood pressure, anxiety and increased rate of respiration. Once weaning is successful extubate and provide alternate means of oxygen. a) Extubation will be considered when the pulmonary function parameters of tidal volume (VT), vital capacity (VC) , an negative inspiratory force (NIF) are adequate , indicating strong respiratory muscle function.

Managing the patient requiring mechanical ventilationEquipment Artificial airway Mechanical ventilator Ventilation circuitry Humidifier

Procedure NURSING ACTION Preparatory Phase 1. Obtain baseline samples for blood Baseline measurements serve as a guide in gas determinations (PH, PaCO2, determining progress of therapy HCO3) and chest x-ray. Emphasize that mechanical ventilation is a Performance Phase 1. Give a brief explanation to the temporary measure. The patient should be prepared patient. psychological for weaning at the time the ventilator is first used. 2. Establish the airway by means of a A closed system between the ventilator and patients cuffed endotracheal or lower airway is necessary for positive pressure tracheostomy tube. ventilation. 3. Prepare the ventilator. a) Set up desired circuitry. b) Connect oxygen and compressed air source. c) Turn on power. d) Set tidal volume (usually 10 to 15 ml/kg body weight) e) Set oxygen concentration f) Set ventilator sensitivity g) Set rate at 12 to 14 breaths per minute. RATIONALE

Adjusted according to PH and paCO2 Adjusted according to paO2 This setting approximates normal ventilation. These machines settings are subject to change according to the patients condition and response, and the ventilator type being used.

h) Adjust flow rate (velocity of gas The slower the flow, the lower will be the peak flow during inspiration). airway pressure resulting from set volume delivery. Usually set at 40 to 60 L/ min This result in lower intrathoracic pressure and less impendence of venous return. However, a flow that is too low for the rate selected may result in inverse inspiratory: expiratory ratios. i) Select mode of ventilation j) Check machine function- Ensures safe functions. measure tidal volume , rate, I: E ratio, analyze oxygen , check oxygen, check all alarms.

4. Couple the patients airway to the Be sure all connections are secure. Prevent ventilator ventilator. tubing from pulling on artificial airway, possibly resulting in tube dislodgement or tracheal damage. 5. Assess patient for adequate chest Ensures proper function of equipment. movement and rate. Do not depend on digital rate readout of ventilator.

6. Set airway pressure alarms according to patients baselinea) High pressure alarm High airway pressure or pop off pressure is set at about 20cm H2O above peak airway pressure. An alarm sounds if airway pressure selected is exceeded. Alarm activation indicates- decreased lung compliance, decrease lung volume, increased airway resistance. b) Low pressure alarm Low airway pressure alarm set at 5 to 10cm H2O below peak airway pressure because of disconnection or leak, or inability to build up airway pressure because of insufficient gas flow to meet patients inspiratory needs. 7. Assess frequently for change in respiratory status via ABGs, pulse oximetry, spontaneous rate, use of accessory muscles breath sounds, and vital signs. 8. Monitor and troubleshoot alarm Priority is ventilation and oxygenation of the patient. conditions. Ensure appropriate In alarm conditions that cannot be immediately ventilation at all times. corrected, disconnected the patient from mechanical ventilation and manually ventilate with resuscitation bag. 9. Positioning a) Turn patient from side to side For patients on long-term ventilation, this may result every 2 hours , or more in sleep deprivation. Evolve a turning schedule best frequently if possible. suited to a particular patients condition. b) Lateral turns of 120 degrees are desirable, from right semiprone

to left semiprone. c) Sit the patient upright at regular Upright posture increases lung compliance. intervals if possible. 10. Carry out passive range-of motion exercises of all extremities for patients unable to do so. 11. Assess for need of suctioning at Patients with artificial airways on mechanical least every 2 hours. ventilation are unable to clear secretions on their own. Suctioning may help to clear secretions and stimulate the cough reflex. 12. Assess breath sounds every 2 hoursa) Listen with stethoscope to the Auscultation of the chest is a means of assessing chest from bottom to top on airway patency and ventilatory distribution. It also both sides. confirms the proper placement of the endotracheal or tracheostomy tube. b) Determine whether breath sounds are present or absent normal or abnormal, and whether a change has occurred. c) Observe the patients diaphragmatic excursions and use of accessory muscles of respiration. 13. Humidification. a) Check the water level in the humidification on reservoir to ensure that the patient is never ventilated with dry gas. Empty the water that condenses in the delivery and exhalation tubing into a separate receptacle, note into the humidifier. Always wash hands after emptying fluid from ventilator circuitry. Humidifier must be changed every 24 hours.

Water condensing in the inspiratory tubing may cause increased resistance to gas flow. This may result in increased peak airway pressures. Warm moist tubing is a perfect breeding area for bacteria. If this water is allowed to enter the humidifier , bacteria may be aerosolized into the lungs. Emptying the tubing also prevents introduction of water into the patients airways.

14. Assess airway pressures at frequent Monitor for changes in compliance, or onset of intervals. conditions that may cause airway pressure to increase or decrease. 15. Measure cardiovascular function.

Assess for depression. a) Monitor pulse rate and artierial blood pressure, intra-arterial monitoring may be carried out. b) Use swan-Ganz catheter to monitor pulmonary capillary and sensitivity testing. Thisis done immediately after endotracheal intubation and ins some instances on an every other day basis. 16. Monitor for pulmonary infection. a) Aspirate tracheal secretions into a sterile container and send to laboratory for culture and sensitivity testing. This is done immediately after endotracheal intubation and in some instances on an every-other day basis. b) Daily Grams staining of secretions may also be done in some institution.

Arterial catheterization for intra arterial pressure monitoring also . Intermittent and continuous positive pressure ventilation may increase the pulmonary artery pressures and decrease cardiac output.

This technique allows for the earliest detection of infection or change in infecting organisms in the tracheobronchial tree.

17. Measure delivered tidal volume and analyze oxygen concentration every 4 hours or more frequently if indicated. 18. Evaluate need for sedation or muscle relaxants. Sedatives may be prescribed to decrease anxiety or to relax the patient to prevent competing with the ventilators. 19. Report intake and output precisely and obtain an accurate daily weight Positive fluid balance resulting in increase in body to monitor fluid balance. weight and interstitial pulmonary edema is a frequent problem in patients requiring mechanical ventilation. 20. Monitor nutritional status. Patients with endotracheal tubes are to be NPO and must be entirely tube fed or parentarally nourished. 21. Monitor GI function Mechanically ventilated patient are at risk for a) Test all stools and gastric drainage development of stress ulcers. for occult blood. Stress may cause patients requiring mechanical ventilation to develop GI bleeding. b) Measure abdominal girth daily Abdominal distention occurs frequently with

respiratory failure and further hinders respiration by elevation of the diaphragm . measurement of abdominal girth provides objective assessment of the degree of distention. 22. Provide for care and communication needs of patient with an artificial airway. 23. Provide psychological support. a) Assist with communication . Mechanical ventilation may result in sleep b) Orient to environment and deprivation and loss of touch with surroundings and function of mechanical reality. ventilator. c) Ensure that the patient has adequate rest and sleep. Follow Up Phase Maintain a flow sheet to record ventilation patterns ,ABGs , venous chemical determination , Hb and hematocrit , status of fluid balance, weight.