INTRODUCTION: - Mechanical ventilation is machine-supported respiratory support which may completely replace or assist the patient's spontaneous efforts. Mechanical ventilation is typically provided through an artificial airway, although mechanical ventilators may be used as an adjunct to noninvasive positive pressure ventilation A mechanical ventilator is a positive- or negative-pressure breathing device that can maintain ventilation and oxygen delivery for a prolonged period. Caring for a patient on mechanical ventilation has become an integral part of nursing care in critical care or general medical-surgical units, extended care facilities, and the home. DEFINITION: - MECHANICAL VENTILATION ™ An appropriate design to quality the air that is breathed thought it or to either intermittently or continuously control pulmonary ventilation called also respirator. ANATOMY & PHYSIOLOGY OF RESPIRATORY SYSTEM: - DIVISIONS OF THE RESPIRATORY SYSTEM The respiratory system may be divided into the upper Respiratory tract and the lower respiratory tract. The upper respiratory tract consists of the parts outside the chest cavity: the air passages of the nose, nasal cavities, Pharynx, larynx, and upper trachea. The lower respiratory tract consists of the parts found within the chest cavity: the lower trachea and the lungs themselves, Which include the bronchial tubes and alveoli? Also part of the respiratory system are the pleural Membranes and the respiratory muscles that form the Chest cavity: the diaphragm and intercostal muscles. NOSE AND NASAL CAVITIES:- Air enters and leaves the respiratory system through the nose, which is made of bone and cartilage covered with skin, Just inside the nostrils are hairs, which help block the entty of dust. The two nasal cavities are within the skull, separated by the nasal septum, which is a bony plate made of the ethmoid bone and vorner. The nasal mucosa (lining) is ciliated epithelium, with goblet cells that produce mucus. Three shelf-like or scroll-like bones called conchae project from the lateral wall of each nasal cavity. You may also recall our earlier discussion of the paranasal sinuses, air cavities in the manillae, frontal, sphenoid, and ethmoid bones. These sinuses are lined with ciliated epithelium, and the mucus produced drains into the nasal cavities. The functions of the paranasal sinuses are to lighten the skull and provide resonance (more vibrating ait) for the voice. PHARYNX:- The pharynx is a muscular tube posterior to the nasal and oral cavities and anterior to the cervical vertebrae. For descriptive purposes, the pharynx may be divided into three parts: the nasopharynx, oropharynx, and laryngopharynx.— eS oe The uppermost portion is the nasopharynx, which is behind the nasal eras a palate is elevated during swallowing to block the nasopharynx and pre\ a from going up rather than down: The uvula is the part of the soft palate you can see at the back of the a (On iho nosiy wall of the nasopharynx is the adenoid or pharyngeal tonsil, a lymph nodule ains macrophages : , m= Opening into the nasopharynx are the two Eustachian tubes, which extend to the middle ear cavities. The purpose of the Eustachian tubes is to permit air to enter or leave the middle ears, allowing the eardrums to vibrate properly. The nasopharynx is a passageway for air only, but the remainder of the phar food passageway, although not for both at the same time. The oropharynx is behind the mouth; its mucosa is stratified squamous epithelium, continuous wit that of the oral cavity. On its lateral walls are the palatine tonsils, also lymph nodule The laryngopharynx is the most inferior portion of the pharynx. It opens anteriorly into the larynx and posteriorly into the oesophagus. im LARYNX:- The larynx is often called the voice box, a name that indicates one of its functions, which is speaking. The other function of the larynx is to be an air passageway between the pharynx and the trachea. Air The largest cartilage of the larynx is the thyroid cartilage (Fig. 15-2), which you can feel on the anterior surface of your neck. The epiglottis is the uppermost cartilage. During swallowing, the larynx is elevated, and the epiglottis closes over the top, rather like a trap door or hinged lid, to prevent the entry of saliva or food into the larynx. ™ TRACHEA AND BRONCHIAL TREE:- 1m The trachea is about 4 to 5 inches (10 to 13 cm) long and extends from the larynx to the primary bronchi, The wall of the trachea contains 16 to 20 C-shaped pieces of cartilage, which _ keep the trachea open. The right and left primary bronchi are the branches of the trachea that enter the lungs. Within the lungs, each primary bronchus branches into secondary bronchi leading to the lobes of each lung (three right, two left). The further branching of the bronchial tubes is often called the bronchial tree. Imagine the trachea as the trunk of an upside-down tree with extensive branches that become smaller and smaller; these smaller branches are the | bronchioles. No cartilage is present in the walls of the bronchioles; this becomes clinically | important in asthma The smallest bronchioles terminate in clusters of alveoli, the air sacs of the lungs. LUNGS AND PLEURAL MEMBRANES:- | The lungs are located on either side of the heart in the chest cavity and are encircled and protected by the rib cage. The base of each lung rests on the diaphragm below; the apex (superior tip) is at the level of the clavicle. ™ On the medial surface of each lung is an indentation called the hilum, where the primary bronchus and the pulmonary artery and veins enter the lung. The pleural membranes are the serous membranes of the thoracic cavity. The parietal pleura lines the chest wall, and the visceral pleura is on the surface of the lungs. Between the pleural membranes is serous fluid, which prevents friction and keeps the two membranes together during breathing. Alveoli The functional units of the lungs are the air sacs called alveoli. The flat alveolar type | cells that form most of the alveolar walls are simple squamous epithelium. In the spaces between clusters ofalveoli is elastic connective tissue, which is important for exhalation. Within the alveoli are | macrophages that phagocytize pathogens or other foreign material that may not have been swept out by the ciliated epithelium of the bronchial tree. There are millions of alveoli in each lung, and their total surface area is estimated to be 700 to 800 square feet Each alveolus is surrounded by a network of pulmonary capillaries Recall that capillaries are also made of simple squamous epithelium, so there are only two cells between the air in the alveoli and the blood in the pulmonary capillaries, which permits efficient diffusion of gases. FUNCTIONS OF RESPIRATORY SYSTEM:- > VENTILATION is the term for the movement of air to and from the alveoli. The two aspects of ventilation are inhalation and exhalation, which are brought about by the nervous system and the respiratory muscles. > INHALATION Inhalation, also called inspiration, is a precise sequence of events that may be described as follows: Motor impulses from the medulla travel along the phrenic nerves to the diaphragm and along the intercostal nerves to the external intercostal muscles. > EXHALATION Exhalation may also be called expiration and begins when motor impulses from the medulla decrease and the diaphragm and external intercostal muscles relax. As the chest cavity becomes smaller, the lungs are compressed, and their elastic connective tissue, which was stretched during inhalation, recoils and also com- presses the alveoli. As intrapulmonic pressure rises above atmospheric pressure, air is forced out of the lungs until the two pressures are again equal. > EXCHANGE OF GASES There are two sites of exchange of oxygen and carbon dioxide: the lungs and the tissues of the body. The exchange of gases between the air in the alveoli and the blood in the pulmonary capillaries is called external respiration. | exchange that involves air from the external environment, though the exchange takes place within the lungs. Internal respiration is the exchange of gases between the blood in the systemic capillaries and the tissue fluid (cells) of the body. > TRANSPORT OF GASES IN THE BLOOD Although some oxygen is dissolved in blood plasma and does create the PO2 values, it is only about 1.5% of the total oxygen transported, not enough to sustain life. As you already know, most. ‘oxygen is carried in the blood bonded to the haemoglobin in red blood cells (RBCs). The mineral iron is part of haemoglobin and gives this protein its oxygen-carrying ability. Goals ™ To provide alveolar ventilation, while avoiding respiratory acidosis or alkalosis ™ To provide mechanical ventilation in the absence of spontaneous ventilation = To maintain ventilation automatically for a prolonged period . To reverse respiratory failure by improving alveolar gas exchange without impending the circulation. DICATIONS FORMECHANICAL VENTILATION fa patient has a continuous decrease in oxygenation (Pa02), An increase in arterial carbon dioxide levels (PaCO2), and A persistent acidosis (decreased pH), mechanical ventilation may be necessary, Conditions such as thoracic or abdominal surgery, Drug overdose, Neuromuscular disorders, Inhalation injury, COPD, multiple trauma, shock, ‘multisystem failure, and coma all may lead to respiratory failure and the need for mechanical ventilation. Other Indications for mechanical ventilator support Progressive hypoxia Cardio respiratory failure , inadequate ventilation where Pao2 may drop below 80 mmHg Apnea Neuromuscular deficit Quadriplegia with spinal cord injuries Meningitis and encephalitis Septicaemia Chronic obstructive lung diseases Poison ,Snake bite , Scorpion sting Respiratory failure Central nervous system depression Chronic renal failure Burns Post operative children after major surgery Lower pao? level in children with ICP CLASSIFICATION OF VENTILATOR The two general categories are negative-pressure and positive-pressure ventilators. The most common category in use today is the positive pressure ventilator. Negative-Pressure Ventilators Negative-pressure ventilators exert a negative Pressure on the external chest. Decreasing the intrathoracic pressure during inspiration Allows air to flow into the lung, filling its volume. Physiologically, this type of assisted ventilation is similar to spontaneous ventilation. It is used mainly in chronic respiratory failure associated with neuromuscular conditions, such as poliomyelitis, muscular dystrophy, amyotrophic lateral sclerosis, and myasthenia gravis. It is inappropriate for the unstable or complex patient or the patient whose condition requires frequent ventilator changes. Negative-pressure ventilators are simple to use and do not require intubation of the airway; consequently, they are especially adaptable for home use. There are several types of negative-pressure ventilators: iron lung, body wrap, and chest cuirass- VVVVVVVVY IRON LUNG (DRINKER RESPIRATOR TANK) The iron lung is a negative-pressure chamber used for ventilation. It was used extensively during polio epidemics in the past and currently is used by polio survivors and patients with other neuromuscular disorders.BODY WRAP (PNEUMOWRAP) AND CHEST CUIRASS (TORTOISE SHELL) Both of these portable devices require a rigid cage or shell to create a negative-pressure chamber around the thorax and abdomen. Because of problems with proper fit and system leaks, these types of ventilators are used only with carefully selected patients. Positive-Pressure Ventilators Positive-pressure ventilators inflate the lungs by exerting positive pressure on the airway, similar to a bellows mechanism, forcing the alveoli to expand during inspiration. Expiration occurs passively. Endotracheal intubation or tracheostomy is necessary in most cases. These ventilators are widely used in the hospital setting and are increasingly used in the home for patients with primary lung disease. There are three types of positive-pressure ventilators, which are classified by the method of ending the inspiratory phase of respiration: pressure-cycled, time-cycled, and volume cycled. Pressure cycled ventilators 1 Itterminates the respiratory cycle when a present respiratory pressure is reached volume will differ greatly depending on the flow rate of the delivery of the gas . Volume cycled ventilator ™ It terminates respiration when a present volume is delivered. Time cycled ventilator It terminated inspiration when inspiration time is reached .Tidal volume is greatly affected by the compliance of the ventilator tubing. Modes of ventilation This may be broadly classified as :- ™ Controlled mechanical ventilation (CMV) ™ Assist mode — patient effort is assisted by the ventilator (ACV) ™ Spontaneous mode — patient is breathing on his or her own (SMV) Controlled Mechanical ventilation ( CMV) ™ All breaths are initiated and delivered by the ventilators with the patient taking no active role in the ventilator cycle = CMV may be volume controlled or volume limited time cycled where a present tidal volume is delivered during a set inspiratory time at a set frequency and constant flow irrespective of the peak pressure generates ™ In pressure — controlled or pressure limited time cycle , CMV the ventilator delivers a Positive pressure up to a pre determined pressure limit (PIP) above PEEP during a preset inspiratory time at a frequency . The ventilator is set to deliver all of the ventilation. sist control ventilati > The mode is used most often for unconscious person. > The A/C mode is a method of ventilation in which the ventilator delivers a preset number of breaths of a present VT ; between these machine — initiated breaths, the patient may trigger spontaneous breaths. > The only work the patient must perform is the negative inspiratory effort, the difference between A/C and CMV is that with A/C mode the ventilator is sensitive and responses to Patients effort , in many ventilators these two are mentioned together.ents every pati > The ventilator has asset minimum number of breaths and augm' Ty patient respiratory effort with a preset TV. sation (SIM - Synchronized Intermittent mandatory ventilation 7 ; _ Spontaneous breathing is permissible between mechanical breaihs, 1 Tote is most often used during the weaning process lf the cao a riggs within, il li ic eath. bs allotted time , the ventilator delivers a conventional Df e mt The ventilator supports a preset number of breaths with a preset TV, and the patient; generate additional spontaneous TV. Time cycle — pressure — limited ventilation : 4 mt In this mode , the rate and inspiratory time (Ti) (or LE ratio ) are present, The present is determined such that excessive pressure is not produced , Preset pressure is deliveres throughout inspiration ,cycling being determined by time, ahaa (VT) is depend on respiratory compliance and airway pressure can be avol led . Pressure support ventilation (PSV) 1 Itis a mode of ventilation in which the augmented by the delivery of a preset amount ™ During PSV, the patient determined the respiral 1 The breathing support combines the advantages 0 spontaneous breathing , because the chosen press! more the lungs are filled m Every patient effort is supported with positive pressu from supported breath to supported breath. ive End expiratory pressure (PEEP] PEEP is the application of a constant , positive pressure in the airways so that , at end expiration the pressure is never allow to return to atmospheric pressure PEEP is meas in centimeters of water and ranges from 5 to 20 cm The usual level of PEEP applied vari between 5-15 cm H2 Setting of the Mechanical ventilator Fraction of Inspired oxygen concentration ( FiO2) m= When one is initiating mechanical ventilation for a patient in respiratory failure, its bestto start with high Fio2 (0.7 - 1.0) to ensure adequate oxygenation. m Oxygen toxicity is minimized at Fio2 of 0.5 or less, if higher Fio2 is required to maintain oxygenation then addition of PEEP should be considered. Tidal volume IH Itis generally accepted that VT should be in range of 10m- 12 ml / kg body weight for mos of the patients, as small tidal volume (5 - 7 ml / kg) promotes the development of mict® atelectasis while very large tidal volume can cause barotraumas and cardio vascular decompensation . . fee ee to determining adequate tidal volume is to evaluate desired degre chest expansion during manual ventilation a ned ee ind reproduced when connected tothe = . . f See al voluro is eee 5~8./Ka; in mechanical ventilation conventional 10 mmended to prevent progressing alveolar collapse. rf patients spontaneous respiratory activity is of inspiratory positive pressure tory rate , inspiratory time and tidal vo} f pressure controlled ventilation with ure is constant , the flow decreases re at a preset level— TVs may vary Peak inspiratory _ pressure (PIP } im Peak pressure in volume cycled ventilation i vores i d ventilation is the end — result of factors such as J2mNr tidal volume and flow rate PIP is increased to maintain proper oxygenation and ventilation ea Ahigh PIP increases the risk of pulmonary barotraumas and May also impaired pulmonary and systemic circulation.PIP is set as follows Normal lungs : 15 — 19 cm ™ Mild lung diseases : 20-24 cm ™ Moderate lung diseases: 25- 30cm ™ Sever lung disease : > 30 cm Respiratory Rate The respiratory rate set on the ventilator should generally be as near as physiological for that age group , for eg 25 — 30 for infant & 20 — 25 for children Frequent changes in the RR are often required and are bases on observation of the Patients work of breathing and comfort and on assessment of Pao2 and PH Majority of the patients , initially required full ventilatory support. he respiratory rate at this time is selected on the basis of tidal volume , so that minute on the sis of tidal volume , so that minute ventilation (RR X VT + MV) is sufficient to maintain a normal id base status .As the patient begins to participate in the ventilatory work , the ventilatory RR ay be decreased, low Rate ™ Itis speed with which the tidal volume is delivered , which is measured in liters per minute >the flow is usually 3 — 4times the minute ventilation In volume targeted ventilation flow is kept at 1- 3 Likg. /. Min to provide tidal volume of 15 - 15 ml/kg. The inspiratory flow is the chief determinant of inspiratory time and thus have the I:E ratio , so the flow rate must be adjusted for each patient on the basis of the desired I: E ratio , the tidal volume , and the respiratory rate . Inspiratory Time and Expiratory time : - The component of respiration may be divided I to ventilation and oxygenation .This measure of time required for an alvelolar unit to reach equilibrium ie the time to fill up and get emptied , one time constant fills in 63 % of an alveolar , two fills 87 % and three 95% ™ Anormal infant has a time constant of 0.15 second .Normal inspiratory of time of 0.5 — 1.0 seconds is kept , with an appropriate I: E ration = The :E ratio is the duration of inspiration in comparison with expiration Generally the I: E ratio is set at 1:2 , that is 33% of the respiratory cycle is spent in inspiration and 66% in the expiration phase .In case of bronchospasm an: E ratio 1: 3 or 4: 4. Positive End Expiratory pressure PEEP is generally started at a level of 3- 5 cm water and increased gradually with the aim to achieve a SPO2 > 90 % with the lowest level of PEEP that allows FiO2 to be reduced to nontoxic levels (0.5) Avery high PEEP (> 15 cm water ) can lead to air leaks , depressed cardiac output and | barotraumas . lean Airway Pressure = MAP is the average airway pressure over the entire respiratory cycle and is a key determinant .In general , the same changes of MAP result in a similar changes of Pao2 regardless of ventilatory mode . ™ MAP is pressure the end result of many variable including inspiratory pressure , PEEP , | flow , inspiratory rime nitiation of mechanical ventilation 1) Before starting ventilation it is standards ventilation , it is standard practice to ensure that the ventilator is clean and patient circuit sterilized The humidifier should always be useddesired level .The patients baseline date is recorded . ; 3) Ventilation should be started in the control mode with 100% oxygen to correct hypoxia and bring blood gas value towards normal . The initial setting primarily depend on the nature of the lung are:- Monitoring of the patient ™ Clinical data — vital signs , RR , Hr, BP , temp , Spo2 ™ Lab data — Chest x- ray, ECG , blood counts , biochemistry , Blood sugar , electrolytes , urea , creatinine , ABG Intake and out put should be monitored closely : ™ Regular physiotherapy and suction ( Negative pressure limited to 50 — 100 mmHg ) is recommended Sedatives and muscle relaxants are often needed to enable effective ventilation. Nursing care of the mechanically ventilated p: Patient comfort Patient positioning Hygiene Eye care Mouth care Management of stressors ™ Communication stressors Patient comfort The promotion of patient comfort through focused nursing interventions is an integral component expert nursing care in the ICU. ™ Positioning: Hygiene intervention such as eye care, mouth care and washing. Patient Positioning : Positioning the intensive care ventilated patient comfort and also address the physiological aims of optimizing oxygen transport ™ Specific positioning used | ICU are , supine semi — recumbent , prone and side lyin ™ Head of the bed elevated from 35 to 45 degree, to reduce the incidence of ventilat acquired pneumonia. Hygiene : = Effective nursing measures to meet the mechanically ventilated patients basic hygiene needs. Eye care : = Mechanically ventilated patient who are sedated and or un conscious are a high risk group who are dependent on eye care to maintain eye integrity These patient are susceptible to control dehydration , abrasions and infection as a result of impairment of basic eye protective measure such as the blink reflex | Eye care is performed methods of eye care such as normal saline irrigation. Eye drops, taping, paraffin gauze, ointment, gels and polyethylene. |) Mouth care ™ There appears to be considered variation in ventilated patient . frequency of oral care has been reported at 2,3, 4 and 12 hrly intervals . use of oral hygiene and comfort in theWashing 1. Maintaining patients , personal hygiene is a fundamental aspect on nursing care.A range of benefits, such as 2. patient assessment and communication , can be gained when experienced nurses bathe or wash patients 3. Urinary catheter are a leading sources of nosocomial infections in the critically ill patient 4, Common practice is cleansing of the perineum and meatus twice daily with soap and water | Sleep disturbances ™ Sleep disturbances is a significant problems and a noted stressor for mechanically ventilated patient in the ICU .Critically ill patients have reported high levels of fragmented sleep . The common causes sleep disturbance have been reported as environmental noise including alarms , equipment , telephone and talking ) , lighting , discomfort , stress and pain . Discontinuation of mechanic ventilation (weaning ) Weaning has been defined as the process where by mechanical ventilation ids gradually withdrawn and the patients resumes spontaneous breathing = Mechanically ventilated patients that require a gradual weaning. Sometimes requiring weeks or months before discontinuation which is more problematic. Approaches to weaning ™ In general , the majority techniques of discontinued ventilator support van be grouped in to three categories ™ Pressure support ventilation = SIMV mT —Piece /CPAP trails Cor jous monitoring 1. Increasing tachypnea , associated with patient distress .A raise in the respiratory rate increases by more than 10 breaths per minute 2. Agitation , panic , diaphoresis or tachycardia 3. Acidemic : acute drop in PH to < 7.25 to 7.30 associated with increasing pao2 . Complications:- ™ Barotraumas Pneumo pericardium Pneumo mediastinum Pulmonary infection Nosocomial infection Atelectasis Decreased cardiac output Alteration in renal function .| | NURSING PRocEss: THE PATIENT ON A VENTILATOR || Assessment The nurse has a vital role in assessing the patient's status and the fun assessing the patient, the nurse evaluates the patient's physiologic sta! coping with mechanical ventilation. oo. Physical assessment includes systematic assessment of all body on ‘he respiratory system.Respiratory assessment includes vital signs, eee aa _ ; pattern, breath sounds, evaluation of spontaneous ventilatory effort,and potential evidence of hypoxia. Increased adventitious breath sounds may indicate a need for suctioning. J The nurse also evaluates the settings and functioning of the mechanical ventilator, as described previously. Assessment also addresses the patient's neurologic status and effectiveness of coping with the need for assisted ventilation and the changes that accompany it. The nurse should asses, the patient's comfort level and ability to communicate as well. Finally, weaning from mechanical ventilation requires adequate nutrition. Therefore, itis important to assess the function of the gastrointestinal system and nutritional status. NURSING DIAGNOSES Based on the assessment data, the patient's major nursing diagnoses may include: }} * !mpaired gas exchange related to underlying illness, or ventilator setting adjustment during stabilization or weaning. * Ineffective airway clearance related to increased mucus production associated with continuous |] Positive-pressure mechanical ventilation. * Risk for trauma and infection related to endotracheal intubation or tracheostomy. + Impaired physical mobility related to ventilator dependency Impaired verbal communication related to endotracheal tube and attachment to ventilator. || * Defensive coping and powerlessness related to ventilator dependency. tioning of the ventilator.In tus and how he or she is tems, with an in-depth focus COLLABORATIVE PROBLEMS/ POTENTIAL COMPLICATIONS Based on assessment data, potential complications may include: + Alterations in cardiac function }} Barotrauma (trauma to the alveoli) and pneumothorax + Pulmonary infection + Sepsis Planning and Goals The major goals for the patient may include achievement of optimal gas exchange, maintenance of a patent airway, absence | of trauma or infection, attainment of optimal mobility, adjustment to nonverbal methods of Communication, acquisition of successful coping measures, and absence of complications. ENHANCING GAS EXCHANGE The purpose of mechanical ventilation is to optimize gas exchange by maintaining alveolar ventilation and oxygen delivery. The alteration in gas exchange may be due to the underlying illness or to mechanical factors related to the adjustment of the machine to the patient. The health care team, including the nurse, physician, and respiratory therapist, continually assesses the patient for adequate gas exchange, signs and symptoms of hypoxia, and response to treatment. Thus, the nursing diagnosis impaired gasexchange is, by its complex nature, multidisciplinary and collaborative. The team members must share goals and information freely. All other goals directly or indirectly relate to this primary goal. Nursing interventions to promote optimal gas exchange include judicious administration of analgesic agents to relieve pain without suppressing the respiratory drive and frequent repositioning to diminish the pulmonary effects of immobility. The nurse also monitors for adequate fluid balance by assessing for the presence of peripheral edema, calculating daily intake and output, and monitoring daily weights. The nurse administers medications prescribed to control the primary disease and monitors for their side effects. PROMOTING EFFECTIVE AIRWAY CLEARANCE Continuous positive-pressure ventilation increases the production of secretions regardless of the patient's underlying condition. The nurse assesses for the presence of secretions by lung auscultation at least every 2 to 4 hours. Measures to clear the airway of secretions include suctioning, chest physiotherapy, frequent position changes, and increased mobility as soon as possible. Frequency of suctioning should be determined by patient assessment. If excessive secretions are identified by inspection or auscultation techniques, suctioning should be performed. Sputum is not produced continuously or every 1 to 2 hours but as a response to a pathologic condition. Therefore, there is no rationale for routine suctioning of all patients every 1 to 2 hours. Although suctioning is used to aid in the clearance of secretions, it can damage the airway | mucosa . The sigh mechanism on the ventilator may be adjusted to deliver at least one to three sighs per hour at 1.5 times the tidal volume if the patient is on assist-control. Because of the risk of hyperventilation and trauma to pulmonary tissue from excess ventilator pressure (barotrauma, pneumothorax), this feature is not being used as frequently today. PREVENTING TRAUMA AND INFECTION Airway management must involve maintaining the endotracheal or tracheostomy tube. The nurse positions the ventilator tubing so that there is minimal pulling or distortion of the tube in the trachea; this reduces the risk of trauma to the trachea. Cuff pressure is monitored every 8 hours to maintain the pressure at less than 25 cm H20. The nurse evaluates for the presence of a cuff leak at the same time. Patients with endotracheal intubation or a tracheostomy tube do not have the inormal defenses of the upper airway. In addition,these patients frequently have multiple additional lbody system disturbances that lead to immunocompromise. Tracheostomy care is performed at least every 8 hours, and more frequently if needed, because of the increased risk of infection. The ventilator circuit and in-line suction tubing is replaced periodically. The nurse administers oral hygiene frequently because the oral cavity is a primary source of contamination of the lungs in the intubated and compromised patient. PROMOTING OPTIMAL LEVEL OF MOBILITY fe patient's mobility is limited because he or she is connected to the ventilator. The nurse should assist a patient whose condition has become stable to get out of bed and to a chair as soon as Possible. Mobility and muscle activity are beneficial because they stimulate respirations and prove morale. If the patient cannot get out of bed, the nurse encourages the patient to perform active range-of-motion exercises every 6 to 8 hours. If the patient cannot perform these exercises, the nurse performs passive range-of motion exercises every 8 hours to prevent contractures and Venous stasis. PROMOTING OPTIMAL COMMUNICATION tis important to develop alternative methods of communication for the patient on a ventilator. The nurse assesses the patient's communication abilities to evaluate for limitations.PROMOTING COPING ABILITY Dependence on a ventilator is frightening to both the patient and family and disrupts even the most stable families. Encouraging the family to verbalize their feelings about the ventilator, the patient's condition, and the environment in general is beneficial. Explaining procedures every time they are performed helps to reduce anxiety and familiarizes the patient with ventilator procedures. SUMMARY:- Today | dealt about definition of Mechanical ventilation, anatomy & physiology of respiratory system, goals, indications, classification, modes, settings, complications, management of mechanical ventilation. CONCLUSION:- ‘A mechanical ventilator is a positive- or negative-pressure breathing device that can maintain ventilation and oxygen delivery for a prolonged period. Caring for a patient on mechanical ventilation has become an integral part of nursing care in critical care or general medical-surgical units, extended care facilities, and the home. Nurses, physicians, and respiratory therapists must understand each patient's specific pulmonary needs and work together to set realistic goals. Positive patient outcomes depend on an understanding of the principles of mechanical ventilation an the patient’s care needs as well as open communication among members of the health care team about the goals of therapy, weaning plans, and the patient's tolerance of changes in ventilator settings.