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The following should be included in your initial assessment and documentation of a ventilated patient:         ETT size, length at lip or teeth (teeth is frequently better in trauma patients due to swelling of lips), position in mouth, and date of insertion If a patient is trached, note the size of the trach, date of insertion, stoma condition, presence of oozing around site; dressing condition Cuff Pressure (< 25 mm Hg is optimal) Vent parameters - both set and measured Breathing: Spontaneous resps over ventilator? Tolerance (synchrony, work of breathing, comfort) Suctioning: Colour, amount, viscosity Alarms

Hourly assessments include all values:  Peak Pressures  Resp Rate – any spontaneous breaths?  Tidal Volumes  Minute Volumes  WOB Don’t accept CIS data from the ventilator unless you have reviewed it. It’s very important that you are aware of changing measurements so that you can intervene as appropriate. Look for changes up or down and relate these to the patient’s condition. Recognize how these changes may affect his ventilation or oxygenation – you may need to do an ABG. When you change the ETT position you need to document where you moved it to and whether it remains at the same marker level at the lip/teeth. Before retaping the tube you must listen for equal bilateral breath sounds to ensure you have not dislodged it. When you do your trach dressing you need to document how you cleaned it and what the site looks like, and if you took any additional measures (ie notified the MD if it appears infected). Additional items to note during your assessment:   How much dead space is there? Can the tube be trimmed? Can the catheter mount be shrunk? Is the patient trying to initiate his own breaths but unsuccessful? Have your RT look at the sensitivity level and adjust if necessary or, if the patient is not supposed to be breathing, consider increased sedation Graphics: Use this workbook and study your graphics daily to see if you can recognize issues with ventilation. I’ve placed a Ventilator Graphics Handout in your shared folder.


There are 3 parts to a recruitment manoeuvre: 1. delaying exhalation and thereby keeping the alveoli expanded for a bit longer c.Recruitment manoeuvres are done by creating a sustained increase in pressure as a means of recruiting the collapsed alveoli. However. This can be done a few ways: a. It’s done by increasing the pressures for a sustained period. Deflation: By looking at the graphs. Inspiratory Hold: While patient is inhaling you ‘hold’ the air in. Increase PEEP by 5 for several minutes 2. this helps you determine the pressure where most units re-collapse A= Point of collapse of alveoli during Exhalation B= Point of opening of alveoli during Inspiration 3. Sustained CPAP of 30-40 for about 40 seconds b. good ventilation therapy includes doing a recruitment manoeuvre every time PEEP is broken. Re-inflation: You can now choose your new PEEP settings based on the abovemeasured deflation value RM’s should be done at least once per shift. Recruitment manoeuvres are doctorordered and done by the doctor or the RT at this time. Caution: This increases intrathoracic pressure for up to 60 seconds so beware of barotrauma. Inflation: this step helps to open as much of the lung as possible. following suction. or following a leak in the system. Set the pressure to 20 above the PEEP for 10-12 breaths. . then increase PEEP so Peak Pressure is 40 for about 40-60 seconds d.

you are the only one who will know that because you are the only one at the beside for 12 hours. WEANING Weaning from ventilation should be done as soon as possible to avoid complications. study the ventilator daily. Some of these are directly related to ventilation measurements while others relate to a patient’s overall condition. Interpret your ABGs and decide how you would adjust the ventilator. weaning is not recommended. Reason for Intubation: Has the original reason for intubation resolved? Always consider why the patient was intubated in the first place. Ventilation affects all other systems and influences the speed of recovery. Look at the ventilator readings regularly and with each nursing intervention to see how your patient reacts. There are certain basic criteria for weaning: 1. By ensuring you are optimizing ventilation you can help your patient recover faster and avoid complications. and then see if it coincides with what the RT or the MD does. For instance: CLINICAL PARAMETERS: Acid-base balance Anemia Temp Cardiac issues Electrolyte balance Exercise tolerance (up in chair) Fluid balance Pain Psychological issues Sleep deprivation Infection Glycemic stability Level of Consciousness Ability to protect and clear airway VENTILATION PARAMETERS: . Measurable Criteria: There are certain measurable parameters one can look at to determine readiness for weaning. 2. Understanding ventilation is the difference between an average ICU nurse and an exceptional one. It these issues are still present.In summary. Does this change make sense based on the bigger picture? Remember.

Minute Volume < 10-15 LPM Tidal Volume < 4-6 LPM Rate < 35 bpm PaO2 ≥ 60 PEEP ≤ 5-8 PaO2/FiO2 >200 Work of breathing Muscle strength .

using CPAP (PEEP 5 and PS 5-8). and his WOB is within normal limits. minimize the dead space (trim the ETT. SBTs can be done either while still attached to the ventilator. then weaning will begin. Other institutions get a bit more scientific and use pulmonary mechanics (listed below) as a measure of readiness to wean. close the bevels on the catheter mount (you should always do this anyway). such as Rapid Shallow Breathing Index (RSBI). There are a number of other parameters that can be measured. adjust the sensitivity on the ventilator so it’s easy to trigger breaths . 3. Negative Inspiratory Force (NIF). Spontaneous Breathing Trials (SBTs): Depending on the institution. or disconnected and via a T-piece. Each institution uses their own choice of measured parameters – the combination is frequently referred to as Pulmonary Mechanics.Many institutions use the above criteria alone to determine whether a patient is ready for weaning – if the initial problem has resolved and the patient’s strength is sufficient. Drive to Breathe. The results can tell a clinician if a patient is ready to wean. Before starting. The newer vents are now doing these calculations automatically and make adjustments in PS and CPAP as needed.

Next time you’re weaning a patient ask the doc if he knows about this feature!! SBTs usually last at least 30 minutes but no longer than 120 minutes. Decreasing the rate and volume too fast will not allow time for the kidneys to compensate for the new respiratory conditions – you can throw your patient into an acidosis which will make him increase his RR and WOB and likely result in weaning failure. these patients may require the ETT to be left in place until the airway is patent. edema). However. What       can cause SBT failures? Fluid in lungs (CHF) Acid-Base Disturbances Psychological factors such as anxiety Muscle Weakness (see why physio is so important???) Malnourishment (see why nutrition is so important???) Residual effects of drugs (see why Sedation Vacations are so important???)  Sleep deprivation (see why a quiet environment is so important???) It is important to point out here that even if many of the above criteria for weaning are not met.(yet ensuring the vent is not responding to external ‘noise’ such as heart beats). always reduce the rate and volume very slowly during weaning. meeting the above criteria also does not ensure success. and the criteria listed above are satisfied. A patient may be able to breathe entirely on his own but removing the ETT will put his airway at risk. For . As medicine is not an exact science. weaning can still be successful. The Evita XL ventilator has an automatic setting that will choose the optimal support for a patient being weaned. and ensure your flow is 60-100 LPM. By activating ATC and entering the details of the ETT. Another point to consider is that if your patient has a compensated ABG. some clinicians feel that if the ETT is large enough (8. throat inflammation (surgery. the patient’s own breathing mechanics can do the work alone. or obstructions. there is no way to 100% predict a patient’s abilities. particularly if the patient has been vented for awhile. If a patient is tolerating these conditions. the ventilator will then choose the correct amount of support to overcome tube resistance. he should be extubated immediately. The last thing to consider about weaning is the continued need for an airway. If comfortable breathing through the tube and there is no respiratory distress.0 or greater) these settings are not needed because tube resistance would be no greater than the resistance of a normal upper airway. Likewise. there is occasionally no need for the ventilator. Why do we keep any CPAP or PS during a wean? It helps the patient overcome the resistance of the ETT and makes it easier to draw in breaths. In the case of burns patients.

They focus on muscle strength and psychological preparation. Additionally. FACTORS CONTRIBUTING TO WEANING FAILURE       Advanced age Repeated/traumatic intubations Female Hemoglobin < 10 Past failed attempts Poorly designed weaning protocols Failed attempts at weaning play a psychological role and can negatively affect the success of further attempts. If NPPV is used for post-extubation difficulties it results in less reintubations. Weaning. therefore. should not be attempted unless patient is ready. a reliable communication system and occasional distraction techniques all contribute to a successful wean.patients with suspected airway difficulties. Nebulization/MDI’s Obstruction/Swelling Racemic Epinephrine nebulizer Laryngospasm Nebulization/MDI’s Consider early application of Non-Invasive Ventilation (BiPAP). It is important to continuously monitor a patient post-extubation for at least 30 minutes to ensure he can not only maintain his airway but also support his ventilation. patients should be placed on 50% facemask. Studies show that the role of the nurse during weaning is of utmost importance – providing reassurance. Post-Extubation: Once extubated. which all translates to decreased costs and decreased long-term complications for the patient. patients need to frequently cough post-extubation to clear secretions and the added oxygen prevents them from becoming short of breath during coughing. decreased infection rates and decreased mortality. increased FiO2 Secretions Encourage lots of deep breathing and coughing. For those proving difficult to wean. Almost always they will be placed on steroids to reduce swelling. Weaning Programs which specialize in individual care plans prove quite successful. a shorter ICU stay. WEANING PROTOCOLS . comfort measures. The additional oxygen helps to lower the WOB and the stress related to the removal of supportive ventilation. The following problems can frequently be seen post-extubation:      Aspiration Keep patient’s HOB elevated 30o Increased WOB Consider positioning. pain relief and splinting. anxiety. they are assessed regularly for cuff leaks.

ARDS . get ABGs. or oro-nasal) and patients initiate all breaths. they are. as a clinician your expertise and monitoring can help determine when a patient is ready for weaning and you can get the ball rolling. but without the need for invasive access to the trachea. The positive pressure is maintained either in a BiPAP or CPAP mode – in BiPAP there are both Inspiratory and expiratory pressures (IPAP [or PS] and EPAP [or PEEP]). proactive nursing team that generates successful results. Our work can show the MDs that the patient is ready for extubation. NON-INVASIVE VENTILATION Non-invasive ventilation still works on the principle of positive pressure. observe. ABGs will help you decide which IPAP/EPAP is required. Focus on comfort measures and anxiety reduction in order for treatment to be more successful. Nurses and RTs and always present in the units and can more effectively monitor the patient and his abilities. The “Let’s leave them for one more day” mentality can be eliminated by an observant. and in CPAP there is inspiratory pressure only. The ‘pros’ of protocols:       Clinician-driven (RTs and/or RNs) Improves success Decreases rates of re-intubation Offers a shorter weaning time Reduces length of stay Reduces costs to patient Studies show that MDs are too conservative when it comes to weaning from ventilation. therefore. adjust. perfect choices for managing weaning protocols.The purpose of weaning protocols is to provide a standardized method for the general patient population which aims for the earliest weaning possible. adjust. This is possibly because they are not at the bedside on a continual basis and don’t want to risk the patient’s condition. Even if weaning protocols are not in place. Observe. get ABGs. When do we use Non-Invasive Ventilation (NIV)?   For patients with sleep apnea For patients who need intermittent ventilator support (a C-6 fracture patient who can breathe most of the day but needs support when supine) As a bridge post-extubation for those patients not fully able to breathe without the added support As a last-ditch effort to prevent the need for invasive ventilation   Non invasive ventilation is not always tolerated well. Ventilation is delivered via a mask (nasal.

ARDS is the greatest respiratory challenge for adult critical care teams and therefore deserves a section of its own. . leading to the leaking of protein-rich plasma out of the capillary into the interstitium and the alveolar space. the capillary osmotic pressure pulls the fluids out of the alveoli. but this function is lost in ARDS. and consolidation in the dependent lobes. a ‘ground glass’ appearance in the midregions. Normally. A typical ARDS CXR shows normal lung fields in the non-dependent areas. This fluid and debris increase alveolar dead space and interfere with oxygen exchange into the bloodstream. This leads to a greater V/Q mismatch and pulmonary shunt. inflammatory debris and edema. The fluid also makes the lungs heavy and stiff decreasing the lungs’ ability to expand (compliance) and therefore decreasing lung volumes. The inflammation is not equal across the lung fields – some areas function normally and are still able to participate in gas exchange and these are usually in the non-dependent areas . collapsing the alveoli. ARDS is a serious condition that prevents enough oxygen from getting into the blood due to damaged alveoli. resulting in severe hypoxemia. the dependent areas of the lung receive the best blood flow but they also have the greatest amount of collapsed and/or fluid-filled alveoli. The inflammation results in abnormal thickening of the alveolar wall and partial filling of the alveolar space with cell debris. A further complication of ARDS that contributes to the hypoxemia is the fact that due to gravity. Inflammation of the capillary and alveolar walls result in increased permeability of these tissues. The alveolar structures (including terminal bronchioles) become airless.

Exudative phase/stage: Characterized by accumulation of excessive fluid in the lungs due to exudation (leaking of fluids) and acute injury to the endothelium (lining membrane) and epithelium (surface layer of cells). The second phase/stage typically lasts 3-10 weeks. Treatment is predominantly the same although secondary ARDS will respond better to Recruitment Manoeuvres. and to treat the underlying cause. abnormally enlarged air spaces and fibrotic tissue (scarring) are increasingly apparent. Fibrosis phase . such as aspiration. sometimes up to 100%. alveolar collapse is predominant. On a CXR lungs appear mostly consolidated. certain criteria must be present:  A precipitating condition (listed above)  Refractory Hypoxemia (PaO2/FiO2 ≤ 200)  Severe pulmonary shunting (> 20%)  Reduced compliance (< 30 ml/cm)  Diffuse bilateral infiltrates VENTILATING AN ARDS PATIENT . It is at this stage that steroids can be added to the treatment. Regardless of the cause. many others progress after about a week into the second phase/stage. This is the phase where many people die. STAGES OF ARDS 1. sepsis. Fibroproliferative phase/stage: Connective tissue and other structural elements in the lungs proliferate in response to the initial injury. Two to four weeks after the onset of lung injury. The goal of therapy is supportive ventilation while the patient heals. sepsis and multi-organ failure. There is usually a need for high pressures or volumes at this stage in order to adequately ventilate someone. 3. There is resolution of inflammation and fibrosis begins to settle. In this type. Some practitioners divide ARDS into direct or indirect categories. pneumonia. or trauma. Indirect ARDS (or nonpulmonary ARDS) is when the cause is not lung-related. 2.Repair and recovery: The lung reorganizes and recovers during this phase. There is also danger of pneumonia. Some individuals quickly recover from this first phase. SIRS (Systemic Inflammatory Response Syndrome). inhaled or ingested toxins.ARDS is caused by a number of health conditions. Direct ARDS is when the primary injury is caused by actual lung-related disorders. Oxygention is usually most severe during this phase. in both cases the hypoxemia is severe enough that the patient requires increased FiO 2. Lung repair may take as long as 6 to 12 months depending on the precipitating condition and severity of the initial injury. The term “stiff lungs" characterize this phase. To diagnose ARDS. Oxygenation improves and discontinuation of mechanical ventilation is possible.

What we need to do. Protective Lung Strategies and Permissive Hypercapnia: Because it’s frequently not possible to achieve normal ABGs without risking further injury to the lungs. yet despite high FiO 2 . PaO2 can still be low (<60). normal ABGs are not always possible to achieve. then. for those critical enough to require ventilation. However. then. is allow a little bit of ‘wiggle room’ on our ABGs. do we proceed? Typically. it is not advisable to leave patients on oxygen higher than 55% for more than 24 hours. Ventilation. Lung compliance is reducing and if we continue to target normal ABGs we will require higher and higher pressures to get the same volumes into the lungs. How. Because high oxygen concentrations can lead to further damage of alveoli and further shunting. How do we do this?   Aim for plateau pressures < 30 to avoid overdistention of the healthy lung units Aim for FiO2 < 55% . we allow the PCO2 to remain higher than normal. some patients cope with highflow oxygen or NIV. but studies show that an ABG slightly outside the normal range is a less harmful alternative. Recall that the primary goal is to correct hypoxemia. then.Full ventilatory support is not always required. is suboptimal. The idea behind protective lung strategies is to keep a MV on the lower side of normal while keeping the pressures in the lungs low enough to avoid injury. This causes further damage and results in an even greater hypoxemia. the patient will become harder and harder to ventilate to normal ABGs.

       Use the lowest PEEP possible (but don’t be afraid to use PEEP up to 15 if needed) Aim for lower VT (4-6 ml/kg) Allow PCO2 to climb as high as 80 (permissive hypercapnia. Continue to increase PEEP in order to be able to decrease FiO2 to less than 55%. 2. max of 90) Accept Sats ≥ 88% PaO2/FiO2 > 250 (this is a ratio used to predict the amount of shunt. though. which leads to reduced oxygenation. resulting in Auto-PEEP and further increased pressures in the lungs. how do we choose ventilator settings? 1. Additionally.40) Aim for a lower PaO2 (as low as 60. “Why don’t we just lower the required tidal volume and increase the rate?” This is a good question. To improve oxygenation start with a high FiO2 and decrease it as you increase PEEP. however.25-7. ratios less than 250 indicate severe shunt and severe hypoxemia. pressure control is better at decreasing the WOB and controlling pressures. but remember from the notes above that rates > 35 typically limit the I-time. Any ratio < 300 indicates Acute Lung Injury) GUIDELINES FOR CHOOSING FiO2 and PEEP: FiO2 PEEP You are probably asking. With a PEEP of ≤ 15 you should be able to reach the minimum threshold of PaO 2 of 60. . keep in mind that an increase in PCO 2 increases the respiratory drive so the patient will need sedation) Allow for the pH to gradually become slightly acidotic (between 7. Anything less indicates shunt. Once your PEEP reaches 15 there is very little point in going higher – at this stage you have recruited most of the alveoli that you can recruit and are at risk of compromising the patient’s hemodynamics and compressing the alveolar capillaries. in some cases higher FiO 2 and PEEP is required (see table above). the higher the rate the less time for exhalation. which would require a greater flow in a shorter time – once again increasing the pressures. it’s time to consider high frequency oscillation – more on that later. Ideally you want to keep the RR < 25 bpm if possible. If this is the case. So. As mentioned previously. as the patient deteriorates. You can ventilate ARDS patients on either volume control or pressure control.

Once PIP ≤ 30 is reached. making it less likely for Shunt to occur and therefore making it easier to exchange gases. continuing to press down on and collapse alveoli in the dependent areas. Increase PIP. Prone positioning also helps because the great vessels are no longer pressing down on the lungs. But as a general guideline. if you need to). an ARDS lung can weigh triple the amount of a normal lung. if patient is not hemodynamically unstable. Protective Lung Strategies are evidence-based yet tragically. Meanwhile. 4. Although the use of steroids is still controversial. both physiological and psychological. Gravity increases pressures on the lung units from surrounding tissues but gravity also directs more blood to these areas. the alveolar-to-capillary tension decreases. and should be 3-4 cm H2O above the Inflection Point (review this section above. Steroids should be added if fibrotic changes appear on the CXR – this usually happens between Weeks 23. PEEP should be decreased if patient is non-septic. Increasing the airway pressures helps with alveolar recruitment as well. . 5. do not go higher. ARDS has a 40-90% mortality rate and for those that do survive. PRONE POSITIONING: Why do we prone in ARDS patients? In non-ARDS lungs V/Q Matching is higher in the upper lung areas (but optimal V/Q matching is still found in the bases). studies have shown that the administration of glucocorticoids before Day 14 showed reduced inflammation and improved patient outcomes. thereby creating Auto-PEEP and increasing lung pressures. To complicate matters further. With the best blood flow going to this area this results in a greater V/Q mismatch and shunting. many have long-term residual effects. if lung injury has improved or if the PaO 2/FiO2 ≥ 250. PEEP increases should be applied early in order to be effective . This decreases hypoxemia. blood flow is now sent to the uninjured areas of the lungs because these are now the lowest part of the patient. As PEEP increases. In ARDS lungs the injury is primarily to the dependent areas due to the intrapleural water. despite the evidence in their favour. The optimal PEEP needed can be determined from reading the pressure graphics. PEEP counteracts this weight. keeping PPL ≤ 30 in an effort to improve MV.3. start to allow permissive hypercapnia and a gradual decrease in pH as an alternative to increasing PIP and causing further injury. By proning a patient these dependent alveoli are now ‘on top’ so they have a chance to lose some of their water and re-open. Try to avoid RR >35 because rates this high may lead to a reduction in E-time. PEEP of 5-15 is the normal range but frequently PEEP > 15 is required (although you must weigh this against any potential hemodynamic compromise). How long is PEEP needed? This is unknown. thereby allowing higher amounts of oxygen pick-up. up to 25% of Critical Care Physicians do not use them. At this stage.

helping to prevent derecruitment. The primary difference in HFOV is that both inspiration and expiration are active – gas is pushed into the lungs and actively pulled out. Review the first half of this handout again so the following section makes sense. An oscillator will likely be in the unit before you have your Respiratory classes. This is the . What.Additionally. The settings on an oscillator are very different to those of conventional ventilation. though. right? But recall earlier when I said that if you increase the respiratory rate too high it can interfere with the ability to fully exhale.. The concept of high frequency ventilation originated when a physician was watching his dog panting and he started to wonder how gas exchange occurred at such high rates of ventilation. HFO uses very low tidal volumes (approximately equal to the volume of anatomical dead space) at very high rates (up to 360 cycles per minute). in spite of the above strategies.. doesn’t it? Not so. P AW is increased when the PaO2 is < 60. Sometimes. HIGH FREQUENCY OSCILLATION This is just a quick introduction to High Frequency Oscillation Ventilation (HFOV). It is imperative that you understand the physiology of ventilation in order to understand how HFOV works. and decreased if PaO 2 is > 60 or if sats are ≥ 88%. this is usually about 5 cm H 2O higher than the last setting on the conventional ventilator. causing air trapping and thereby increasing pressure in the lungs? Sounds like a no-win situation. this is Mean Airway Pressure. HFOV was developed as an alternative mode of ventilation for those instances when conventional ventilation is insufficient. P AW is set to maintain adequate lung inflation as seen on a CXR. One has to wonder how any gas exchange can occur at all under these conditions. then? If we can’t go up on volumes and pressures then in order to maintain an adequate MV we have to increase our rates. and indirectly reflects minute ventilation – a higher ∆P indicates a larger tidal volume. the release of inflammatory mediators in ARDS can affect other organs and lead to multi-system organ failure. This helps keep the lung inflated at pressures greater than the closing pressures of alveoli. it’s still difficult to oxygenate/ventilate an ARDS patient. It determines lung expansion and is.. usually between 24-35. Clinicians set the following parameters: PAW: Also known as MAP. essential to oxygenation. therefore. We can’t exchange gas as optimally as we need to. but they still correlate and follow basic ventilation principles. It is usually set at 60-90 cm H 2O. ∆P: Is the amplitude or measure of the pressure the ventilator uses to push air into the circuit.

Backwards to conventional ventilation. Usually 4-6 Hz are the norm for an adult. Additional CXRs may be required in an effort to determine adequate lung inflation and optimal settings. Overinflation is a serious risk on HFOV. NURSING CONSIDERATIONS FOR PATIENTS ON HFOV   Documentation should include the above set parameters Assessment: Auscultation cannot be done on these patients so it is important to monitor patient shake. I-time: In HFOV. 1 Hz = 60 breaths per minute.primary parameter that controls ventilation. Frequency is adjusted as a secondary response to ventilation once the maximum ∆P has been reached. If the amount of shake changes. Frequency: This is the number of breaths delivered per second and is recorded in Hertz (Hz). patients need to be fully sedated and preferably paralyzed (although chemical paralysis is not well-studied in this population) Sedation vacations are not applicable    . down to groin. Always document and make note of the level of shake as part of your initial assessment (ie down to mid-thigh. and vice versa. Recruitment manoeuvres should be done on these patients regularly. Choosing the setting is a matter of experience and guesswork – a good measure of whether you’ve got an adequate setting is if the patient is shaking from the chest wall down to the groin. if the PCO2 is high the frequency is decreased. The following table illustrates adjustments based on clinical picture: Poor Oxygenation Increase FiO2 Over Oxygenation Decrease FiO2 Increase MAP* Decrease MAP (1-2cmH2O) (1-2cmH2O) Under Ventilation Increase Amplitude Decrease Frequency** (1-2Hz) if Amplitude Maximal Over Ventilation Decrease Amplitude Increase Frequency** (1-2Hz) if Amplitude Minimal Patients who go on oscillators are the most critically ill patients. your ventilation is going to change – immediately draw ABGs. changing this has little effect on outcomes.). the I-time is usually 1:2 and because breaths are so fast. It is increased when PaCO 2 is elevated and vice versa. with very poor alveolar function. etc. always monitor your patient and get a CXR if you suspect overinflation Patient comfort: this is a seriously abnormal method of breathing.

clamp your ETT so as not to lose your PEEP. Jaypee Brothers: New Delhi. S. 2nd edition. S. 37(1).. A Pocket Guide to Mechanical Ventilation and Other Measures of Respiratory Support for Pediatric and Adult Patients.. or if the ABG results reflect a decrease in gas exchange. Mechanical Ventilation. S & Cairo. R & Kaynar. Louis Marieb. Critical Care Medicine. 3rd edition. suction as little as possible as this can lead to de-recruitment of alveoli as well No transportation off the unit is allowed for patients on HFOV Patients can be repositioned. MacIntyre. P. Ruiz. N & Branson. S (2009). (2009). The ICU Book. 21(5).      If you must break the circuit. Hasan: USA Hynes-Gay. Human anatomy and physiology. Hasan. 2nd edition. E (1992). Lippincott Williams & Wilkins: Baltimore Pilbeam. M (2005). India Society of Critical Care Medicine (2000). Demarzo. physiological changes such as drops in saturation or an increase in heart rate. California Marino. MosbyElsevier: St. (2001). In general.. Critical Care Nurse. Using high frequency oscillatory ventilation to treat adults with acute respiratory distress syndrome. REFERENCES Caruso. Benjamin/Cummings: Redwood City. review patient shake after any position changes Watch for changes in bowel patterns or absorption of feeds – it is thought that the constant shaking can alter normal GI functions.S. 32-38. Denari. D (1998). Fundamental Critical Care Support. 2 nd edition. SCCM: Anaheim Unknown Author (2006). P. Louis Pillai. Mechanical Ventilation Made Easy.. J (2006). R (2009). Mechanical Ventilation: Physiological and Clinical Applications. SaudersElsevier: St. D. 38-46. a change in this can indicate a buildup of secretions or a pneumothorax Suctioning needs are determined by the same sort of parameters as with conventional ventilation: visible secretions. Deheinzelin. 2nd edition. Always look for equal chest wall movement. VAP Guidelin . Saline instillation before tracheal suctioning decreases the incidence of ventilator-associated pneumonia .