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20

MONITORING VENTILATOR
FUNCTION
Richard D. Branson, RRT

CURRENTLY USED VENTILATORS

Considerable controversy exists over which mode of ventilation is

the most efficacious and which ventilator is the best. Single features of
ventilators frequently are compared, but these studies generally fail to
demonstrate important clinical differences between ventilators. Compar-
isons of ventilator modes are done infrequently, usually biased, and
typically fail to appreciate the role of physician experience with a given
technique as an important factor. In all likelihood, these controversies
will continue to exist and answers will continue to be elusive.
In 1992, the American Association for Respiratory Care (AARC)
convened a consensus conference on "The Essentials of Mechanical
Ventilators." The goals of this conference were:
To provide standard nomenclature for discussing and describing
mechanical ventilators.
To identify the essential support features of mechanical ventilators
to be used in the intensive care unit (ICU), at home, and during
transport.
To identify the heat and humidity requirements necessary to maintain
the integrity of the respiratory tract during mechanical ventilation.
To identify the essential monitoring and alarm features of mechani-
cal ventilators used in the ICU, the home, and during transport.
To identify what constitutes an order for mechanical ventilation.
The conference specifically avoided recommending any particular
types of equipment or identifying which modes and techniques were

From the Division of Trauma and Critical Care, Department of Surgery, University of
Cincinnati, Cincinnati, Ohio

CRITICAL CARE CLINICS

VOLUME 11 •NUMBER 1 •JANUARY 1995 127

128 BRAN SON

believed to be superior. The resulting document was intended as a

generic blueprint for choosing a ventilator that possesses the features
deemed essential in the document. A review of this document as it
pertains to critical care is provided here.

Support Features

Prior to a discussion of features, the conference participants decided

it was necessary to define the terms to be used in describing the role of
a specific device, component, or characteristic:
Essential-considered to be necessary for safe and effective opera-
tion in the majority (75%) of patients in the specified setting.
Recommended-considered to be necessary for optimal management
of virtually all patients in the specified setting.
Optional-considered to be possibly useful in limited situations but
not necessary for a majority of patients in a specified setting.
These terms are used throughout the document and understanding
their definitions is required to interpret the proceedings.
Table 1 describes the features for ventilators used in critical care,
during transport, and at home. Consensus was reached that all critical
care ventilators require the ability to deliver positive-pressure breaths
(volume or pressure controlled), allow control of set respiratory rate,
manipulation of inspiration:expiration (I:E) via inspiratory flow or inspi;-
ratory time controls, provide positive end-expiratory pressure (PEEP),
and have an adjustable inspired oxygen (Fro2 ) control with a range of
0.21 to 1.0.
It also was agreed that ICU ventilators should allow spontaneous
breathing with and without a set rate (continuous positive airway pres-
sure and intermittent mandatory ventilation), and allow the patient to
trigger the ventilator via pressure or flow sensing. The ability to provide
pressure support ventilation (PSV) was recommended, although a good
number of the participants were divided on this issue.
Some of the newer modes, such as mandatory minute ventilation,
pressure regulated volume control, and other similar feedback control
techniques were considered optional. Data concerning the efficacy of
these new modes were lacking and the participants were reluctant to
recommend techniques proved only to increase the cost of the ventilator.
At first glance, these guidelines seem quite broad. Because of the
paucity of data concerning the efficacy of modes and features, this was
a necessity. But this document helps the director of respiratory care and
the ICU physician decide which features are required to care adequately
for critically ill patients. Concentrated research on the role of ventilatory
techniques and ventilator capabilities certainly is in order.

Monitoring Features

Expanded monitoring capabilities are one of the most significant

changes in mechanical ventilators over the past decade. 10 Past genera-
 MONITORING VENTILATOR FUNCTION 129

Table 1. ESSENTIAL, RECOMMENDED, AND OPTIONAL FEATURES* OF A POSITIVE

PRESSURE VENTILATOR FOR MECHANICAL VENTILATORY SUPPORT VIA THE
CONTROLLED AIRWAY
Principal Ventilator Application

Critical Care Transport Home Care

Clinician-set features
Positive pressure tidal breaths Essential Essential Essential
Mandatory rate Essential Essential Essential
Flow or l:E or inspiratory time Essential Recommended Recommendedt
Expiratory pressure (PEEP) Essential Essential Optional
Foo2tto 1 Essential Essential Optional
Patient-interactive features
Patient spontaneous breath Essential Recommended Optional
(e.g., CPAP, IMV)
Breath-triggering mechanism Essential Recommended Recommendedt
(flow or pressure sensors to
initiate a ventilator breath)
Flow-timing interaction (e.g., Recommended Optional Optional
pressure support)
Feedback control
(e.g., mandatory minute Optional Optional Optional
ventilation)

*Essential = considered to be necessary for safe and effective operation in the majority of patients
in the specified setting; recommended = considered to be necessary for optimal management of
virtually all patients in the specified setting ; optional = considered to be possibly useful in limited
situations but not necessary for a majority of patients in the specified setting.
tF002 = oxygen concentration delivered by device; F002 = F102 when patient demand (inspiratory
flow rate) is met.
:j:Essential feature if patient has intact ventilatory drive and respiratory muscles or possibility of
partial or complete ventilator independence is anticipated.
From AARC-ARCF Consensus Conference: Consensus statement on mechanical ventilators. Respir
Care 37:1000-1008, 1992; with permission.

tions of ventilators relied on mechanical devices with poor accuracy.

Microprocessor technology allows the ventilator to rapidly measure,
process, and display pressure, flow, and volume signals. These can be
displayed numerically or graphically and trended over time.
Table 2 lists the monitoring variables and the value of each as
described in the consensus document. Critical care ventilators were
believed to require monitoring of peak, mean, plateau, and end-expir-
atory pressures and spontaneous and mandatory tidal volumes. Patient
and ventilator rate were considered essential variables to be monitored
and measurements of lung mechanics were considered to be optional.1
The lack of enthusiasm for measurements of lung mechanics cen-
tered around their questionable accuracy. Some ventilators used strict
criteria for reporting lung compliance, whereas others reported compli-
ance based on any positive-pressure breath (PSV included). Validation
of ventilator lung mechanics packages is necessary before any further
consideration is given to their efficacy.
130 BRANSON

Table 2. ESSENTIAL, RECOMMENDED, AND OPTIONAL VARIABLES* TO BE

MONITORED ON MECHANICAL VENTILATORSt
Principal Ventilator Application

Variable Critical Care Transport Home Care

Pressure
Ppeak Essential Essential Essential
P mean Essential Optional Optional
pplateau Essential Optional Optional
PEEP (set) Essential Essential Optional::f:
Intrinsic PEEP (auto-PEEP) Recommended Optional Optional
Volume
Vr expired machine Essential Recommended Optional
VE machine Essential Optional Optional
Vr expired spontaneous Essential Recommended Optional
VE spontaneous Essential Optional Optional
Vr inspired spontaneous Recommended Optional Optional
Timing
Flow mechanical Recommended Optional Optional
Flow spontaneous Optional Optional Optional
l:E ratio Essential Recommended Optional
Rate mechanical Essential Recommended Optional
Rate spontaneous Essential Recommended Optional
Gas Concentration
Foo2§ Essential Optional::f: Optional::f:
Lung Mechanics
Effective compliance Optional Optional Optional
lnspiratory airways resistance Optional Optional Optional
Expiratory airways resistance Optional Optional Optional
Maximal inspiratory pressure Optional Optional Optional
Circuit Characteristics
Tubing compliance Recommended Optional Optional

*Essential = considered to be necessary for safe and effective operation in the majority of patients
in the specified setting; recommended = considered to be necessary for optimal management of
virtually all patients in the specified setting; optional = considered to be possibly useful in limited
situations but not necessary for a majority of patients in the specified setting.
tMonitors need not be integral part of ventilator.
tEssential if feature is used on a specific patient.
§F 002 = oxygen concentration delivered by device; F002 = F102 when patient demand (inspiratory
flow rate) is met.
VT = tidal volume ; VE = set minute ventilation.
From AARC-ARCF Consensus Conference: Consensus statement on mechanical ventilators. Respir
Care 37:1000-1008, 1992; with permission.

Alarm Features

Alarms are the features of ventilators that most frequently frustrate

the respiratory care staff. Alarms appear to be added with little rhyme
or reason and with little concern for the practitioner bombarded by
ICU sounds. 23 Yet alarms are necessary for patient safety and hospital
liability.
The consensus participants adopted a different approach to the
question of alarms, providing a classification denoting three levels of
alarms (Table 3). Alarms were differentiated based on the seriousness of
the event and the response required. Based on these criteria, it was
 MONITORING VENTILATOR FUNCTION 131

Table 3. PRIORITIES FOR MECHANICAL VENTILATOR ALARMS

Immediate
Life- Response
Priority Threatening Required Redundant Alarm Type

Level 1 Yes, immediately Yes Yes Loud audible & visual

Level2 Yes, potentially Yes No Soft audible & visual
Level 3 No No No Visual

From AARC-ARCF Consensus Conference: Consensus statement on mechanical ventilators. Respir

Care 37:1000-1008, 1992; with permission.

suggested that high-priority alarms (denoting life-threatening events)

should be visual, audible, and redundant.
Tables 4 and 5 describe the types of events monitored, the monitor-
ing sites necessary to detect the event, and the types of alarms required
by ventilators for a given clinical situation.

Heat and Humidity Requirements

The adverse effect of dry gases on respiratory function has been

appreciated for nearly half a century. 16• 19• 24• 39 Whenever the upper
airway is bypassed by tracheal intubation, inspired gases must be heated
and humidified. Heat and humidity typically are provided during me-
chanical ventilation by a heated water bath humidifier. In recent years,
passive devices collectively known as "artificial noses" have been intro-
duced. These devices collect the patient's expired heat and moisture and
return it on the subsequent inspiration. 11, 14, 1s, 20, 25, 27, 31, 34, 37, 4o, 44, 47
The American Society of Testing Materials has suggested that
heated humidifiers should deliver 30 mg H 20/L 5 Several studies have
attempted to define the minimum level of humidity required to prevent
mucosal injury, with values of 18 mg H 20/L to 35 mg H 20/L being
reported. 19 • 24 Recent studies have demonstrated that artificial noses with
moisture outputs of 25 mg H 20 /L have been used successfully for up
to 7 days. 13 The consensus conference recommended a moisture output
of 25 to 35 mg H 20 and monitoring of sputum consistency to assure
adequate humidification. 1
It should be remembered that the consensus document is not a
manufacturing standard; it is a recommendation to users as to what
features are necessary for care of critically ill patients.

MONITORING THE VENTILATOR

While considerable data and a wealth of opinions are available on

monitoring the patient during mechanical ventilation and weaning, little
of either is available concerning monitoring the ventilator. The following
is a review of published recommendations seasoned with a healthy dose
of common sense.
 132 BRANSON

Table 4. EVENTS AND MONITORING SITES FOR VENTILATOR ALARMS

Event Possible Monitoring Site

Level 1
Power failure (including when battery in Electrical control system*
use)
Absence of gas delivery (apnea) Circuit pressures,* circuit flows, timing
monitor, carbon dioxide analysis
Loss of gas source Pneumatic control system*
Excessive gas delivery Circuit pressures,* circuit flows , timing
monitor
Exhalation valve failure Circuit pressures, circuit flows , timing
monitor
Timing failure Circuit pressures, circuit flows , timing
monitor
Level 2
Battery power loss (not in use) Electrical control system*
Circuit leak* Circuit pressures,* circuit flows
Blender failure F102 sensor
Circuit partially occluded Circuit pressures, circuit flows
Heater/humidifier failure Temperature probe in circuit
Loss of/or excessive positive end- Circuit pressures
expiratory pressure
Autocycling Circuit pressures, circuit flows
Other electrical or preventive subsystem Electrical and pneumatic systems monitor
out of limits without immediate overt
gas delivery effects
... Level 3
Change in central nervous system drive Circuit pressures, circuit flows , timing
monitor
Change in impedances Circuit pressures, circuit flows, timing
monitor
Intrinsic positive end-expiratory pressure Circuit pressures, circuit flows
(auto) >5 cm H20

*Alarms currently defined in the International Standards Organization and ASTM 5 standards.
From AARC-ARCF Consensus Conference: Consensus statement on mechanical ventilators . Respir
Care 37 :1000-1008, 1992; with permission.

Patient-Ventilator System Checks

Most respiratory care practitioners (RCP) refer to the patient-

ventilator system check as "vent checks." Vent checks, for the most part,
are ill-defined and open to tremendous variations in practice. They
range from " kicking the tires" in a few minutes, to a complete evaluation
of the patient-ventilator system requiring 15 to 20 minutes.
By definition, a patient-ventilator system check is "the documented
evaluation of a mechanical ventilator and of the patient's response to
mechanical ventilatory support." 4 The title of this article may be mis-
leading in that the ventilator and patient should be considered as a unit.
Documenting ventilator settings and function of the ventilator without
observation of the patient invites disaster. The term patient-ventilator
system check was adopted by the AARC clinical practice guideline com-
mittee to emphasize the importance of the patient in this procedure.
 MONITORING VENTILATOR FUNCTION 133

Table 5. ESSENTIAL, RECOMMENDED, AND OPTIONAL ALARMS* FOR

MECHANICAL VENTILATORSt
Principal Ventilator Application

Home or Skilled
Level:j: Critical Care Transport Nursing Facility

Level 1 Essential Essential Essential§

Level 2 Essential Essential Recommended
Level 3 Recommended Optional Optional

*Essential = considered to be necessary for safe and effective operation in the majority of patients
in the specified setting; recommended = considered to be necessary for optimal management of
virtually all patients in the specified setting; optional = considered to be possibly useful in limited
situations but not necessary for a majority of patients in the specified setting.
tAlarms need not be integral components of the ventilator.
:j:Levels are defined in Table 4.
§Redundancy is required only if ventilator is providing total support.
From AARC-ARCF Consensus Conference: Consensus statement on mechanical ventilators. Respir
Care 37:1000-1008, 1992; with permission.

In fact, a patient-ventilator system check should include verification

that ventilator settings coincide with the most recent physician orders,
ventilator function is appropriate, alarm settings are appropriate, patient
assessment is satisfactory (breath sounds, adequacy of tracheal tube
position and function, need for suctioning, and patient comfort), inspired
gases are conditioned properly, and the ventilator circuit is functioning
properly. All of this should be followed by documenting set and moni-
tored variables, as well as patient response, in the bedside chart.
Patient-ventilator systems checks are performed to assure appro-
priate continued operation of the ventilator following the initial set-up.
Early ventilators were prone to variations in function because of their
design. Today's microprocessor-managed ventilators provide greater
control and more sophisticated monitoring. In essence, the change in the
reliability of ventilator function has changed the rationale for performing
patient-ventilator system checks and the role of the RCP.
Greater reliability, more sophisticated monitoring, and expanded
alarm packages allow the RCP to spend more time assessing the patient's
response to ventilatory support. A trained RCP is invaluable in re-
sponding to alarm situations and trouble-shooting problems, however.
This includes assessment of the patient and ventilator to determine the
source of leaks (circuit versus cuff or chest tube leak), excessive pressure
(kinked tubing versus tension pneumothorax), or patient-ventilator dys-
synchrony (inappropriate flow or sensitivity versus auto-PEEP).

Components of the Patient-Ventilator System Check

Operational Verification Procedures

During initial set-up of the ventilator, an operational verification
procedure (OVP) should be accomplished and documented. An OVP
134 BRANSON

can be as simple as assuring that electric and pneumatic power sources

are activated, followed by occluding the patient outlet of the circuit to
verify the ventilator's ability to pressurize the circuit. This typically is
done with neonatal and pediatric ventilators, in which microprocessor
control is still the exception rather than the rule.
Microprocessor ventilators usually have self-initiated or operator-
initiated OVPs, which test the internal electronics and provide feedback
for proper ventilator operation. A good example of ventilator-initiated
OVPs is those offered by the Puritan-Bennett 7200 (Puritan-Bennett,
Carlsbad, CA) ventilators. 41 These include the power on self-test (POST),
the quick extended self-test (QUEST), and the total extended self-test
(TEST).
A POST is performed automatically by the ventilator when the
power is turned on. A POST requires about 5 seconds and consists of a
check of the microprocessor's electronics. If an error is detected, the
ventilator operates in a back-up mode of ventilation and signals the
operator with visual and audible alarms. A message is displayed (RUN
EST-DO NOT USE), prompting the operator to perform a more thor-
ough evaluation of ventilator operation. If the POST fails to detect an
error, the ventilator can begin operating immediately.
A QUEST should be performed prior to initiating ventilatory sup-
port and following a ventilator circuit change. The QUEST requires 90
seconds to complete and runs through 26 test sequences. These include
memory tests; cross-checks of the differential, absolute, and PEEP pres-
sure transducers; a leak test of the patient's circuit; calculation of the
compliance of the ventilator circuit for volume monitoring compensa-
tion; and calculation of the area ratio of the exhalation valve.
The QUEST procedure allows the ventilator to set pressure trans-
ducers to zero to allow accurate pressure measurements regardless of
local barometric pressure, assures the circuit is patent and leak-free
to prevent nuisance alarms, allows the ventilator to compensate for
compressible volume lost in the circuit such that delivered and measured
tidal volume are accurate, and provides data to the microprocessor for
precise control of end-expiratory pressure. QUEST is a quick version
of TEST.
A TEST should be performed between patients, following error
messages, and any time the function of the ventilator is in question. The
TEST procedure performs 60 test sequences of ventilator components
and requires approximately 5 minutes to complete. TEST includes a
thorough evaluation of the microprocessor, the electronics, and the
pneumatic system. Testing the pneumatic system involves evaluation of
the proportional solenoid valves, the air compressor, and the nebulizer
circuit. The TEST procedure includes all parts described in the QUEST
procedure.
Other ventilators perform similar test protocols, including calibra-
tion of flow measurement devices, leak testing, and pressure transducer
calibration. Regardless of the ventilator used, the operator should per-
form the OVP according to the manufacturer's specifications, prior to
connecting the patient to the ventilator.
 MONITORING VENTILATOR FUNCTION 135

Parameters to Monitor During a Patient-Ventilator

System Check

Initial evaluation of the patient and ventilator should consist of

observation. Patient respiratory pattern, color, chest excursion, level of
consciousness, and position of the airway all can be assessed without
technical aids. Patient comfort and patient-ventilator synchrony are
important observations that provide the RCP with a clue as to what
more sophisticated evaluations should be done.17

Airway Pressure
With every patient-ventilator system check, airway pressures
should be observed and recorded. This includes peak inspiratory pres-
sure (PIP), PEEP, mean airway pressure (Paw), plateau pressure (Ppiat),
and auto-PEEP. If a combination of modes is used, such as intermittent
mandatory ventilation (IMV) and PSV, the PIP of mandatory and sup-
ported breaths should be measured and recorded.
During volume control ventilation (VCV), PIP provides a rough
estimate of lung compliance. 51 At a given inspiratory flow (V1), tidal
volume (VT), and PEEP, PIP increases as compliance and resistance
increase. Elevated PIP may be the result of a kink in the endotracheal
tube or ventilator circuit, secretions in the airway, bronchospasm, the
patient fighting the ventilator (dys-synchrony), or a true reduction in
lung compliance.
Because elevated PIP often is associated with barotrauma and may
cause further lung injury, mimicking adult respiratory distress syndrome
(ARDS), a change in PIP of greater than 8 to 10 cm H 2 0 or 15% of a
previously reported value should be investigated actively.42 If a mechani-
cal problem (e.g., secretions, kinked tube) cannot be found, the physician
should be notified. Trending of values is important, but any single value
should be assessed in light of a group of values obtained over the
preceding 6 to 8 hours.
Reductions in PIP may be caused by technical problems, including
leaks in the circuit, leaks in the humidifier, or an improper tracheal tube
cuff seal. The RCP should begin evaluation of a low PIP at the patient,
working back toward the ventilator, looking for sources of a leak. Low
gas inlet pressures or disconnection of source gases also can lead to low
PIP. If the delivery system is secure, a reduction in PIP may be the result
of improved compliance or reduced airway resistance.
Ppiat is measured by adding an inspiratory pause of 1 to 2 seconds
such that a static pressure can be measured at zero flow. 51 Most ventila-
tors are capable of making P plat measurements if the RCP sets the appro-
priate pause time. In addition, P plat should be measured on an unassisted
breath using a constant inspiratory flow. Patient effort during a Pplat
measurement can cause the true pressure to be underestimated.
P plat is thought to provide the closest approximation of peak alveolar
pressure. Recent evidence from laboratory studies suggests that a peak
136 BRAN SON

alveolar pressure greater than 35 cm H 20 above PEEP is associated with

ventilator-induced lung injury. P plat also is necessary to measure static
lung compliance and airway resistance. Because a peak alveolar pressure
greater than 35 cm H 2 0 above PEEP is associated with alveolar overdis-
tention and barotrauma, PP 1. , should be measured and recorded rou-
tinely. If it changes by more than 5 cm H 20 or 15% of the previous
value, the cause should be found and the physician notified.
Paw is the average pressure during a single respiratory cycle. Inves-
tigators have shown Paw to correlate with oxygenation as well as hemo-
dynamic compromise. 9· 22 • 30• 36 The ability of Paw to predict mean alveolar
pressure changes with the relationship between inspiratory and expir-
atory resistance. Changes in ventilator frequency, inspiratory time, PIP,
PEEP, auto-PEEP, and inspiratory flow waveform all alter Paw. 3• 36 Be-
cause of its effect on oxygenation, Paw should be measured and re-
corded with each patient-ventilator system check.
PEEP is set by the operator and controlled by the ventilator, yet
errors in calibration or set-up, or pressure-sensing problems can cause
actual PEEP to deviate from set PEEP. Ventilators measure airway
pressure at the proximal airway or in the inspiratory or expiratory limb
of the ventilator. Each of these locations is acceptable, but each also is
prone to errors related to ancillary equipment, including the humidifier,
the expiratory filter, and the circuit. The measured PEEP level should
be recorded with each check.
Maintenance of a stable PEEP level also is important to triggering
ventilator function. Most ventilators trigger on using the set PEEP as a
reference value. This means if PEEP is set at 5 cm H 20 and sensitivity
at -1 cm H 20, the ventilator will trigger on when pressure falls below
4 cm H 20 . If actual PEEP is 3.5 cm H 20, the ventilator will auto-trigger.
If actual PEEP is 6.5 cm H 20, the patient will need to generate - 2.5 cm
H20 to trigger the ventilator on. 12
Auto-PEEP or intrinsic PEEP is a common complication of mechani-
cal ventilation. 8• 15• 38• 46 Auto-PEEP can cause barotrauma, increase the
work of breathing, lead to patient-ventilator dys-synchrony, contribute
to hemodynamic compromise, and cause miscalculation of lung compli-
ance.49 Patient-predisposing factors for the development of auto-PEEP
include pre-existing lung disease, minute ventilation greater than 10
L/ minute, small endotracheal tubes (< 7-mm internal diameter), and
advanced age (>60 years old).
In their original description of auto-PEEP, Pepe and Marini 43 re-
ferred to it as occult PEEP, which may be the most appropriate term
because auto-PEEP is not seen on the ventilator's airway pressure dis-
play. The only way to find auto-PEEP is to look for it. Auto-PEEP
usually is measured using the expiratory port occlusion technique. In
this instance, the expiratory port of the ventilator is occluded just prior
to delivery of the next mandatory breath. During the occlusion, static
pressure is created between the ventilator's pressure transducer and the
respiratory system.
Graphic monitoring of pressure, volume, and flow allows the ready
 MONITORING VENTILATOR FUNCTION 137

detection of auto-PEEP. When auto-PEEP is caused by insufficient expir-

atory time, expiratory flow fails to return to baseline prior to delivery
of the next mandatory breath. This scalloping of the expiratory flow
pattern suggests the presence of auto-PEEP, but does not quantify the
pressure. When auto-PEEP is caused by premature airway collapse as a
consequence of obstructive lung disease, however, the expiratory flow
pattern may appear normal. In this instance, use of the expiratory port
occlusion technique is required to measure auto-PEEP.
Figure 1 shows pressure, volume, and flow graphically displayed
using a Hamilton Veolar ventilator (Hamilton Medical, Reno, NV) and
the graphic monitoring program known as Leonardo. The patient was a
62-year-old ventilator-dependent man with end-stage bullous emphy-
sema. He was brought to the hospital for r pair of a perforated bowel.
Presenting in the ICU, the patient was able to trigger the ventilator
despite obvious use of the accessory uscles of respiration and was
"fighting" the ventilator. The graphic display demonstrated a prolonged
expiratory phase, but expiratory flow appeared to return to zero before
the next mandatory breath was delivered. Using the "hold" control in

,--~-- _. ·-·_._._. ·- · ...__.._..._

· -.:..~·J..: ...:-:...;...;.-
·

r Exp.

PIP

Expiratory
l
Hold
Figure 1. Volume , flow , and pressure waveforms during an expiratory hold maneuver to
measure auto-PEEP. PEEPE = set PEEP; PEEP, = intrinsic or auto-PEEP ; PEEPT =
total PEEP.
138 BRANSON

the special functions drawer of the Veolar, an expiratory port occlusion

was performed. By depressing the hold button, the operator causes the
Veolar to close both the inspiratory and expiratory valves, creating a
static pressure column within the patient-ventilator system.
Activation of the expiratory hold (see arrow) shows the rise in
pressure as alveolar pressure equilibrates with circuit pressure. In this
instance, the patient had a set PEEP of 5 cm H 20 and a total PEEP of 18
cm H 20. The auto-PEEP is the difference. The patient had been unable
to trigger the ventilator because, with a set PEEP of 5 cm H 20, auto-
PEEP of 13 cm H 20, and sensitivity of - 2 cm H 20, he would have had
to create a negative pressure -15 cm H 20 to reach the trigger threshold.
This further demonstrates the errors introduced in the measurement of
compliance if auto-PEEP is not considered. Auto-PEEP is a common
complication of mechanical ventilation. If the clinical situation suggests
auto-PEEP may be present, measurements should be taken with each
patient-ventilator system check. If auto-PEEP is present, measures to
reduce or eliminate it should be undertaken. 35

Inspired Oxygen Concentration

Current ICU ventilators provide a stable Fro2 under most conditions.
In an adult ICU, Fro2 typically is measured once per nursing shift to
verify the set Fro2 • In the neonatal ICU, where the effects of high Fro 2
can have devastating results, Fro 2 is monitored continuously. 28 • 45
Fluctuating Fro 2 usually is caused by problems in the gas delivery
system. In the event of a gas source failure, the RCP should know the
proper maintenance personnel to contact and how to access reserve gas
supplies, and be familiar with the use and location of gas supply zone
valves and alarms. Several reports have identified a cross-connection
between air and oxygen sources occurring via a ventilator connected to
air and oxygen station outlets with the ventilator's electrical power
turned off.7· 33• 53 In each of these instances, oxygen flowed through the
air-oxygen mixing system of the ventilator, into the air supply. This
caused all other ventilators in use to deliver an Fro 2 greater than their
set Fro2 • When any gas-mixing equipment is not being used, it should
be disconnected from the gas supply.

Volume, Flow, and Timing

Recording set variables is part of the documentation process that
allows the RCP to verify that settings conform with the most recent
physician orders and that they have not been changed inadvertently.
With each patient-ventilator system check, the relevant volumes and
flows should be measured and recorded. These include set frequency
(f), set VT, set minute ventilation (VE), set Yr and/or inspiratory time
(Tr). Flow waveform (square, decelerating, sine) also should be included.
Monitored variables that should be measured and recorded are delivered
VT, spontaneous VT, total measured VE, spontaneous VE, total f, spontane-
ous f, and the I:E ratio.
 MONITORING VENTILATOR FUNCTION 139

Respiratory frequency is measured easily by the ventilator's micro-

processor or by the caregiver with a watch. The importance of f often is
underestimated because of the simplicity of measurement, but f has
been shown to be the variable most predictive of weaning success. 52
Normal, spontaneous VT is 4 to 6 mL/kg and mandatory VT may
be set anywhere from 7 to 15 mL/kg. Monitoring VT during spontaneous
breathing or PSV can be helpful in determining the patient's response
to therapy. Measurement of mandatory VT is complicated by loss of
compressible volume in the ventilator circuit. A typical circuit has a
compressible volume factor of 2 to 3 mL/ cm H 20. This means, at a set
VT of 1000 mL and a PIP of 50 cm H 20, the delivered VT is 850 to 900
mL. This problem is clinically important when small VTs are used in
patients with stiff lungs. 6• 29• 32
Different ventilators deal with the issue of compressible volume
using a variety of methods, depending on their site of volume measure-
ment. Ventilators that measure volume on the expiratory side of the
circuit typically report VT and compressible volume, and the RCP must
make the calculation manually. The Puritan-Bennett 7200 determines
circuit compressible volume during the extended self test (EST) and
adds volume to ensure the set VT is delivered and subtracts the com-
pressible volume from measurements made on the expiratory side. If set
VT is 1000 mL, compressible volume is 3 mL/cm H 20, and PIP is 40 cm
H 20, for instance, the 7200 will deliver 1120 mL so the patient receives
1000 mL, as set. The expired VT display will show a VT of 1000 mL
because the ventilator compensates for compressible volume. The Hamil-
ton Veolar unit measures VT at the proximal airway, therefore displaying
only expired VT. In the same situation described for the 7200 machine
above, the Veolar would simply display a measured VT of 880 mL. If a
VT of 1000 mL was desired, the RCP would increase set VT to 1120 mL
or until 1000 mL was measured. The RCP responsible for care of the
ventilator should be familiar with how the ventilator handles the issue
of compressible volume.
Minute ventilation can be affected by patient respiratory drive,
respiratory muscle function, carbon dioxide production, dead space, and
patient comfort. 35 As a single parameter, VE has not been shown as a
reliable predictor of weaning success, but trending VE over time can
give the clinician clues as to changes in the patient's respiratory function.

Alarms
Proper alarm settings are important for patient safety and to reduce
false alarms. Frequently, the alarm section of the patient-ventilator sys-
tem check is relegated to a cursory position; the only entry concerning
alarms is a check mark or the designation that alarms are "on."
Current microprocessor-run ventilators have a never-ending array
of alarms. When appropriate, these alarms should be set and the settings
recorded. Of particular importance are low- and high-pressure alarms
during VCV and low- and high-volume alarms during pressure control
ventilation.
140 BRANSON

During VCV, the low-pressure alarm should be set at a value

20% of the normal PIP. With lower settings, meant only to determine
disconnection, the circuit can fall into the bed linen and produce enough
back pressure to prevent activation of the alarm. 2 Resistance from an
artificial nose on the end of the circuit also has been reported to prevent
activation of an improperly set low-pressure alarm. 48 During PCV, vol-
ume is variable and the RCP should set high- and low-VT alarms to
warn of potential hypoventilation or excessive VT, which may lead to
barotrauma.

Miscellaneous
Other variables that should be recorded include the mode of ventila-
tory support, breath sounds, quality and quantity of respiratory secre-
tions, endotracheal tube cuff pressure, position of the endotracheal tube,
and a brief narrative of pertinent observations. All entries should be
signed by the responsible RCP.

Ancillary Equipment

Ventilators require a humidifier and ventilator circuit to provide

gas to the patient. As is the case with many mechanical ventilation
topics, controversy exists as to the type of humidification, the tempera-
ture, and the frequency of ventilator circuit changes required.
The ill effects of dry gases on the respiratory mucosa have been
appreciated for half a century, 16, 19, 24 , 39 yet the ideal temperature of gases
delivered to the airway is still unknown. The suggestion by Chatbum
and Primiano to mimic normal temperatures appears a sound one.21
During nose breathing, gas entering the trachea has a temperature of
30° to 32°C and a relative humidity of approximately 90%. This means
that delivery of gas to the proximal airway at 33 ± 1°C should meet
humidity requirements.
This can be accomplished by a heated humidifier or artificial nose.
We recently reported the results of a protocol for humidification in the
ICU using both heated humidifiers and artificial noses. 13 As part of the
patient-ventilator system check, the RCP should record the proximal
airway temperature, observe and maintain the volume of water in the
humidifier, and evaluate the adequacy of humidification by examining
secretions. If secretions become thick and tenacious, the amount of
delivered humidity should be increased by changing devices or increas-
ing temperature, to a maximum of 37°C.
Ventilator circuits typically are changed every 48 hours, but recent
evidence has shown the incidence of nosocomial pneumonia is less
when circuits are never changed compared with every 48 hours.26 This
may be related to the less frequent need to handle the circuit. As
part of the patient-ventilator system check, the RCP should remove
condensate from the circuit, assure the circuit is leak free and patent,
 MONITORING VENTILATOR FUNCTION 141

inspect the circuit for soiling, and change the circuit as required by
hospital policy. At the University of Cincinnati, we have successfully
gone to every-7-day ventilator circuit changes without a significant
change in the incidence of nosocomial pneumonia.

When and How Often Patient-Ventilator System

Checks Should Be Done

There is considerable controversy over the best frequency of ventila-

tor checks. It seems practical, however, that the frequency of checks be
dictated by the severity of the patient's illness. The AARC clinical
practice guideline suggests a patient-ventilator system check be per-
formed:
Prior to obtaining blood samples for analysis of blood gases and pH;
Prior to obtaining hemodynamic or bedside pulmonary function
data;
Following any change in ventilator settings;
As soon as possible following an acute deterioration of the patient's
condition;
Any time ventilator performance is in question.
This scheme allows the sickest patients to receive the majority of
the RCP's time and attention. In the ICU, I believe the minimum time
between documented ventilator checks should be 6 hours; the Society of
Critical Care Medicine has suggested a minimum of every 4 hours. 50 In
step-down units, in which patients are expected to be on ventilators
long term, this time might be extended to once per shift.

Best Personnel to Perform Patient-Ventilator

System Checks

As a RCP familiar with the intricacies of the current generation of

mechanical ventilators, I believe only a RCP is capable of performing a
patient-ventilator system check. Although nurses are well versed in
patient assessment and physiology, their training does not include suffi-
cient time in learning the operation of these complex devices or on
trouble-shooting problems. The role of the RCP, however, should not be
limited to "kicking the tires" on the ventilator, but should include
assessment and evaluation of the patient and the patient's response to
therapy.
A copy of the AARC clinical practice guideline is provided in the
Appendix as a reference.

References

1. AARC-ARCF Consensus Conference: Consensus Statement on Mechanical Ventilators.

Respir Care 37:1000-1008, 1992
142 BRANSON

2. Accidental breathing circuit disconnections in the critical care setting. HHS publication
no. FDA 90-4233. Rockville, MD, FDA, 1990
3. Al-Saady N, Bennett ED: Decelerating inspiratory flow waveform improves lung
mechanics and gas exchange in patients on intermittent positive-pressure ventilation.
Intensive Care Med 11:68-75, 1985
4. American Association for Respiratory Care: Clinical Practice Guideline: Patient-
ventilator system checks. Respir Care 37:882-886, 1992
5. American Na tional Standards Institute. Standard for humidifiers and nebulizers for
medical use. ANSI Z79:9, 1979
6. Bartel LP, Bazik JR, Pawner DJ: Compression volume during mechanical ventilation:
Comparison of ventilators and tubing circuits. Crit Care Med 13:851-854, 1985
7. Bedsole SC, Kempf J: More faulty Bear check valves. Respir Care 29:1159, 1984
8. Benson MS, Pierson DJ: Auto-PEEP during mechanical ventilation of adults. Respir
Care 33:557-568, 1988
9. Berman LS, Downs JB, Van Eeden J: Inspiration :expiration ratio: Is mean airway
pressure the difference? Crit Care Med 9:775-777, 1981
10. Branson RD: Enhanced capabilities of current ICU ventilators: Do they really benefit
patients? Respir Care 36:362-376, 1991
11. Branson RD: Humidification of inspired gases during mechanical ventilation. RT
3:55-66, 1991
12. Branson RD: Flow triggering systems. Respir Care 39:138-144, 1994
13. Branson RD, Davis K Jr, Campbell RS, et al: Humidification in the intensive care unit; a
prospective study of a new protocol utilizing heated humidification and a hygroscopic
condenser humidifier. Chest 104:1800-1805, 1993
14. Branson RD, Hurst JM: Laboratory evaluation of moisture output of seven airway heat
and moisture exchangers. Respir Care 32:741-747, 1987
15. Brown DG, Pierson DJ: Auto-PEEP is common in mechanically ventilated patients: A
study of incidence, severity, and detection. Respir Care 31:1069-1074, 1986
16. Burton JDK: Effects of dry anaesthetic gases on the respiratory mucous membrane.
Lancet 1:235, 1962
17. Campbell RS: Managing the patient- ventilator system: System checks and circuit
changes. Respir Care 39:227- 236, 1994
18. Chalan J, Markham JP, Ali MM, et al: The Pall Ultipor breathing circuit filter: An
efficient heat and moisture exchanger. Anaesth Analg 63:566-570, 1984
19. Chamney AR: Humidification requirements and techniques. Anaesthesia 24:602, 1969
20. Chatburn RL: Physiologic and methodologic issues regarding humidity therapy. J
Pediatr 114:416-420, 1989
21. Chatburn RL, Primiano FP Jr: A rational basis for humidity therapy. Respir Care
32:249-253, 1987
22. Ciszek TA, Modanlou HD, Owings D: Mean airway pressure-significance during
mechanical ventilation in neonates. J Pediatr 99:121-126, 1981
23. Cropp AJ, Woods LA, Raney D, et al: Name that tone. The proliferation of alarms in
the intensive care unit. Chest 105:1217-1220, 1994
24. Dahlby RW, Hogg JC: Effect of breathing dry air on structure and function of airways.
J Appl Physiol 61 :312-317, 1980
25. Department of Health and Social Security: Evaluation of heated humidifiers. Health
Equipment Information 177, 1987
26. Dreyfuss D, Djedaini K, Weber P: Prospective study of nosocomial pneumonia and of
patient and circuit colonization during mechanical ventilation with circuit changes
every 48 hours versus no change. Arn Rev Respir Dis 143:738-743, 1991
27. Emergency Care Research Institute: Heated humidifiers. Health Devices 16:741-747,
1987
28. Flynn JT, Bancalari E, Snyder ES: A cohort study of transcutaneous oxygen tension
and the incidence and severity of retinopathy of prematurity. N Engl J Med 326:1050-
1054, 1992
29. Forbat AF, Her C: Correction for gas compression in mechanical ventilators. Anesth
Analg 59:488-493, 1980
30. Gallagher TJ, Banner MJ: Mean airway pressure as a determinant of oxygenat.on
(abstract). Crit Care Med 8:A244, 1980
 MONITORING VENTILATOR FUNCTION 143

31. Gedeon A, Mebius C: The hygroscopic condenser humidifier: A new device for general
use in anaesthesia and intensive care. Anaesthesia 34:1043-1047, 1979
32. Hess D, McCurdy S, Simmons M: Compression volume in adult ventilator circuits:
A comparison of five disposable circuits and a nondisposable circuit. Respir Care
36:1113-1118, 1991
33. Jenner W, George BG: Oxygen-air shunt syndrome strikes again. Respir Care 27:604,
1982
34. Leigh JM, White MG: A new condenser humidifier (letter). Anaesthesia 39:492-493,
1984
35. Marini JJ: Monitoring during mechanical ventilation. Clin Chest Med 9:73-100, 1988
36. Marini JJ, Ravenscraft SA: Mean airway pressure: Physiologic determinants and clinical
importance. Part 2: Clinical implications. Crit Care Med 20:1604-1616, 1992
37. Mebius CL: A comparative evaluation of disposable humidifiers. Acta Anaesthesiol
Scand 27:403-409, 1983
38. Moore FA, Haenel JB, Moore EE: Auto-PEEP in the multisystem injured patient: An
elusive complication. J Trauma 30:1316- 1323, 1990
39. Moritz AR, Weisiger JR: Effects of cold air on the air passages and lungs. Arch Intern
Med 75:233-240, 1945
40. Ogino M, Kopotic R, Mannino FL: Moisture-conserving efficiency of condenser humidi-
fiers. Anaesthesia 40:990-995, 1985
41. Operators Manual, Puritan-Bennett 7200a. Carlsbad, CA, Puritan-Bennett Corpora-
tion, 1992
42. Parker JC, Hernandez LA, Peevy KJ: Mechanisms of ventilator-induced lung injury.
Crit Care Med 21:131-143, 1993
43. Pepe PE, Marini JJ: Occult positive end-expiratory pressure in mechanically ventilated
patients with airflow obstruction: The auto-PEEP effect. Am Rev Respir Dis 126:166--
170, 1982
44. Revenas B, Lindholm CE: The foam nose-new disposable heat and moisture ex-
changer: A comparison with other similar devices. Acta Anaesthesiol Scand 23:34-39,
1979
45. Salyer JW, Chatburn RL: Patterns of practice in neonatal and pediatric respiratory
care. Respir Care 35:879-888, 1990
46. Scott LR, Benson MS, Bishop MJ: Relationship of endotracheal tube size to auto-PEEP
at high minute ventilation. Respir Care 31:1080-1082, 1986
47. Shelly MP, Bethune OW, Latimer RD: A comparison of fr.re heat and moisture ex-
changers. Anaesthesia 41:527-532, 1986
48. Slee TA, Paulin EG: Failure of low pressure alarm associated with the use of a
humidifier. Anesthesiology 69:791-793, 1988
49. Smith TC, Marini JJ: Impact of PEEP on lung mechanics and work of breathing in
severe airflow obstruction. J Appl Physiol 65:1488-1499, 1988
50. Society of Critical Care Medicine, Task Force on Guidelines: Guidelines for standards
of care for patients with acute respiratory failure on mechanical ventilatory support.
Crit Care Med 19:275--278, 1991
51. Tobin MJ: Monitoring of pressure, flow, and volume during mechanical ventilation.
Respir Care 37:1081-1096, 1992
52. Yang KL, Tobin MJ: A prospective study of indexes predicting the outcomes of trials
of weaning from mechanical ventilation. N Engl J Med 324:1445-1450, 1991
53. Ziecheck HD: Faulty ventilator check valves cause pipeline gas contamination. Respir
Care 26:1009-1010, 1981

Address reprint requests to

Richard D. Branson, RRT
Division of Trauma and Critical Care
Department of Surgery
University of Cincinnati Medical Center
231 Bethesda Avenue, ML 558
Cincinnati, OH 45267--0558
 APPENDIX
AARC Clinical Practice Guideline*
PATIENT-VENTILATOR SYSTEM CHECKS
MV-SC 1.0 PROCEDURE:
Patient-Ventilator System Check
MV-SC 2.0 DESCRIPTION:
2.1 A patient-ventilator system
check is a documented evalua-
tion of a mechanical ventilator
and of the patient's response to
2.3 All data relevant to the patient-
mechanical ventilatory support.
This procedure is often referred
to simply as a ventilator check.
2.2 Objectives:
2.2.1 To evaluate and document
the patient's response to me-
chanical ventilation at the
time that the check is per-
formed
2.2.2 To assure and document
the proper operation of the
mechanical ventilator
2.2.3 To verify and document
that the ventilator is func-
tioning and is properly con-
nected to the patient
2.2.4 To verify and document
that appropriate alarms are
activated'
2.2.5 To verify and document
that inspired gas is properly
heated and humidified'
2.2.6 To verify and document
that inspired oxygen concen-
tration is measured with ev-
ery change in F102 or, at
least, every 24 hours.' (Al-
though retinopathy of pre-
maturity, or ROP, is
thought to be of multifacto-
rial etiology,2-4 the associa-
tion between ROP and dura-
*Reprinted from Respiratory Care 37:882-886, 1992, © American Association fo r
Respiratory Care; with permission.
"
tion of exposure to high
arterial oxygen levels sug-
gests that continuous mea-
surement of F10 2 for infants
at risk is waranted. 5)
2.2.7 To verify and document
that ventilator settings com-
ply with physician orders'' 6, 7
ventilator system check must be
recorded on the appropriate
hospital form(s) at the time of
performance, must be included
as an official part of the
patient's medical record,,, 6 7 and
include observations indicative
of the ventilator's operation at
the time of the check (except
where " should" is used). Observa-
tions should include but are not
limited to
2.3.1 observation that the ventila-
tor is turned on and that
the patient circuit is se-
curely attached; 8
2.3.2 documentation that an oper-
ational verification proce-
dure (OVP, as described in
the appropriate
department's policy and
procedure manual) was per-
formed prior to or at the
time that the ventilator was
first applied to the patient;'
2.3.2.1 An OVP may be accom-
plished manually by oc-
cluding the patient con-
nection and observing
airway pressure rise on
a pressure monitor or
145
146 BRANSON
may be a self-test per-
formed by the ventilator
to assure proper inter-
nal function.
2.3.2.2 OVP should be per-
formed at the bedside
just prior to connection
to the patient after the
patient circuit has been
changed or disassem-
bled for any reason.
2.3.3 documentation that an
alarm for airway discon-
nection is functional and is
properly set;
2.3.4 documentation of measured
Foo2 (fractional concentra-
tion of oxygen delivered)
with an appropriately cali-
brated analyzer;
2.3.5 documentation of measured
inspired gas temperature, if
applicable;
2.4 Patient-ventilator system checks
must include patient informa-
tion and observations indicative
of the ventilator's settings at the
time of the check. Observations
should include but are not limited
to
2.4.1 Patient name
2.4.2 Patient hospital number
2.4.3 Diagnosis
2.4.4 Endotracheal or tracheos-
tomy tube size and position
2.4.5 Documentation of time of
last patient circuit change
2.4.6 Date of patient-ventilator
system check
2.4.7 Time of patient-ventilator
system check
2.4.8 Current ventilator settings
2.4.8.1 Foo2 set and humidifier
temperature setting
(when applicable)
2.4.8.2 Mode of ventilation
2.4.8.3 Set ventilator frequency
2.4.8.4 Peak, mean, and base-
line airway pressures
and presence of auto-
PEEP (if applicable)
2.4.8.5 Set peak inspiratory
pressure limit and pres-
sure support level, if ap-
plicable
2.4.8.6 Set tidal volume (if ap-
plicable)
2.4.8.7 Delivered tidal volume
(measured or calcu-
lated)
2.4.8.8 Set sigh variables (if ap-
plicable)
2.4.8.9 Set minute ventilation
(if applicable)
2.4.8.10 Set minimum manda-
tory minute ventilation
(if applicable)
2.4.8.11 Set inspiratory flow-
rate and waveform (if
applicable)
2.4.8.12 Set continuous flow-
rate (for IMV mode, if
applicable)
2.4.8.13 Set I-E ratio, percent in-
spiration, or inspira-
tory and expiratory
times
2.4.8.14 Set sensitivity thresh-
old (if applicable)
2.4.9 Documentation of alarm set-
tings and activation of ap-
propriate alarms
2.4.10 A description of any in-
stance of equipment failure
2.4.11 Signature of person per-
forming patient-ventilator
system check (including
credentials) or initials (de-
pending on state law and/
or hospital policy)
2.5 Documentation of order from
physician (or other authorized
person) for mechanical ventila-
tor settings-orders should in-
clude at least one and preferably
both of the following:
2.5.1 Desired range for Paco2,
Ptcco2, and/ or desired
range for Pao2, Spo2, Ptc02,
or Sao2;
2.5.2 Ventilator variables to initi-
ate or manipulate in order
to achieve desired blood
gas results (eg, mode, tidal
volume, airway pressures,
ventilatory frequency, or
Foo2).
 MONITORING VENTILATOR FUNCTION
2.6 Patient-ventilator system
checks must include, in brief
narrative form, clinical obser-
vations indicative of the
patient's response to mechani-
cal ventilation at the time of
the check. Clinical observations
should include but are not lim-
ited to an evaluation of
2.6.1 breath sounds;
2.6.2 spontaneous respiratory
rate, volume, and pattern;
2.6.3 chest motion;
2.6.4 pallor, skin color;
2.6.5 patient's level of conscious-
ness or remarks;
2.6.6 endotracheal-tube cuff pres-
sure and apparent stability
and position of the tube;
2.6.7 secretions;
2.6.8 condition of ancillary equip-
ment (eg, chest tube appara-
tus and manual resuscita-
tor);
2.6.9 results of bedside pulmo-
nary function evaluations;
2.6.10 untoward effects of discon-
nection from ventilator
during bedside proce-
dures;
2.6.11 documentation of oxygen-
ation and ventilation status
(eg, arterial blood gas re-
sults, exhaled Pco2 mea-
surements, and transcuta-
neous saturation or
transcutaneous blood gas
measurements);
2.6.12 documentation of patient-
ventilator synchrony dur-
ing assisted or supported
breaths.
MV-SC 3.0 SETTINGS:
This guideline pertains to the in-hospi-
tal critical care setting.
MV-SC 4.0 INDICATIONS:
A patient-ventilator system check
must be performed on a scheduled ba-
147
sis (which is institution-specific) for
any patient requiring mechanical ven-
tilation for life support. In addition, a
check should be performed
4.1 prior to obtaining blood sam-
ples for analysis of blood gases
and pH;
4.2 prior to obtaining hemody-
namic or bedside pulmonary
function data;
4.3 following any change in ventila-
tor settings;
4.4 as soon as possible following an
acute deterioration of the
patient's condition (this may or
may not be heralded by a viola-
tion of ventilator-alarm thresh-
olds);
4.5 any time that ventilator perfor-
mance is questionable. 9
MV-SC 5.0 CONTRAINDICA-
TIONS:
There are no absolute contraindica-
tions to performance of a patient-ven-
tilator system check. If disruption of
PEEP or Foo2 results in hypoxemia,
bradycardia, or hypotension, portions
of the check requiring disconnection
of the patient from the ventilator may
be contraindicated. 10· 11
MV-SC 6.0 HAZARDS/COMPLI-
CATIONS:
6.1 Disconnecting the patient from
the ventilator during a patient-
ventilator system check may re-
sult in hypoventilation, hypox-
emia, bradycardia, and/ or hy-
potension.10· 11
6.2 Prior to disconnection, pre-
oxygenation and hyperventila-
tion may minimize these
complications. 12- 19
6.3 When disconnected from the pa-
tient, some ventilators generate
a high flow through the patient
circuit that may aerosolize con-
taminated condensate, putting
both the patient and clinician at
risk for nosocomial infection. 20
148 BRANSON
MV-SC 7.0 LIMITATIONS OF
PROCEDURENALIDATION OF RE-
SULTS:
Measurements of volumes and in-
spired oxygen concentration are af-
fected by the accuracy and reproduc-
ibility of the monitoring instruments.
7.1 Volume monitoring devices
should be calibrated at regular
intervals. Volume monitoring
accuracy should be ± 10% of
the measured volume.21
7.2 Oxygen analyzers should be cal-
ibrated at regular intervals. Oxy-
gen analyzer accuracy should
be ± 3% of actual concentration.
MV-SC 8.0 ASSESSMENT OF
NEED:
Because of the complexity of mechani-
cal ventilators and the large number
of factors that can adversely affect pa-
tient-ventilator interaction, routine
checks of patient-ventilator system
performance are mandatory.
MV-SC 9.0 ASSESSMENT OF
OUTCOME:
Routine patient-ventilator system
checks should prevent untoward inci-
dents, warn of impending events, and
assure that proper ventilator settings,
according to physician's order, are
maintained.
MV-SC 10.0 RESOURCES:
10.1 Equipment: Appropriate
equipment should be available
to perform the patient-ventila-
tor system check. Such equip-
ment should include but is not
limited to
10.1.1 stethoscope;
10.1.2 oxygen analyzer;
10.1.3 volume monitor (if applica-
ble);
10.1.4 pressure monitor (if appli-
cable);
10.1.5 supplies necessary for ob-
serving Universal Precau-
tions.21
10.2 Personnel: Mechanical ventila-
tion is a complex task that re-
quires the caregiver to under-
stand the technical
components of the ventilator,
the pathophysiology of the res-
piratory system, and patient-
ventilator interaction. Persons
performing checks should hold
a recognized and relevant cre-
dential (eg, CRTI, RRT, RN),
should be trained in and have
demonstrated ability in
10.2.1 the technical setup and op-
eration of the mechanical
ventilator;
10.2.2 cardiopulmonary physiol-
ogy and pathophysiology;
10.2.3 interpretation of the results
of arterial blood gas analy-
sis;
10.2.4 assessment of patient need
for and adverse reaction to
the procedure;
10.2.5 appropriate response to ad-
verse reactions;
10.2.6 application of Universal
Precautions.
MV-SC 11.0 MONITORING:
In order to assure that patient-ventila-
tor system checks are being per-
formed according to these guidelines,
an indicator should be created to mon-
itor this activity as part of the appro-
priate department's quality improve-
ment program. Specific criteria for the
indicator should include at least items 2.4
and 12.0 of this guideline.
MV-SC 12.0 FREQUENCY:
A patient-ventilator system check
should be performed at regularly
scheduled intervals and
12.1 following any change in venti-
lator settings;
12.2 prior to obtaining blood gas
samples;
12.3 prior to obtaining hemody-
namic or pulmonary function
data;
12.4 as soon as possible follow-
 MONITORING VENTILATOR FUNCTION
ing an acute deterioration of
the patient's condition, particu-
larly when this occurs after vi-
olation of a ventilator alarm
threshold.
MV-SC 13.0 INFECTION CON-
TROL ISSUES:
13.l Condensation from the patient
circuit should be considered in-
fectious waste and disposed of
according to hospital policy.
13.2 The patient circuit should be
changed at regular scheduled
intervals according to hospital
policy.
13.3 Universal Precautions should
be observed during the pa-
tient-ventilator system check. 22
Mechanical Ventilation Guidelines
Committee:
Richard D Branson RRT, Chairman,
Cincinnati OH
Robert S Campbell RRT, Cincinnati OH
Robert L Chatburn RRT, Cleveland OH
Jack Covington RRT, San Francisco CA
References
1. Joint Commission for Accreditation of
Health Care Organizations. Standard
RP.4 and RP.5. In: Accreditation man-
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2. Flyrm JT, Bancalari E, Bawol R, Gold-
berg R, Cassady J, Schiffman J, et al.
Retinopathy of prematurity: a random-
ized, prospective trial of transcutane-
ous oxygen monitoring. Ophthalmol-
ogy 1987;94:630-638.
3. Bancalari E, Flynn J, Goldberg TN, Ba-
wol R, Cassady J, Schiffman J, et al.
Influence of transcutaneous oxygen
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79:663-669.
4. Phelps DL. Retinopathy of prematurity
(editorial) . N Engl J Med 1992;326:
1078-1080.
5. Flyrm JT, Bancalari E, Snyder ES, Gold-
berg RN, Feuer W, Cassady J, et al. A
cohort study of transcutaneous oxygen
tension and the incidence and severity
149
of retinopathy of prematurity. N Engl J
Med 1992;326:1050-1054.
6. Pierson DJ. What constitutes an order
for mechanical ventilation, and who
should give it? Respir Care (in press).
7. AARC-ARCF Consensus Conference.
Consensus Statement on Mechanical
Ventilators. Respir Care (in press).
8. Accidental breathing circuit discon-
nections in the critical care setting. HHS
publication No. FDA 90-4233. From:
FDA, HFZ-240, Rockville MD 20857.
9. Center for Devices and Radiological
Health. A summary of the device user
facility reporting requirements of the
Safe Medical Devices Act of 1990 (pub-
lic law 101-629). Rockville MD: Center
for Devices and Radiological Health,
1990.
10. DeCampo T, Civetta JM. The effect of
short term discontinuation of high-level
PEEP in patients with acute respiratory
failure. Crit Care Med 1979;7:47--49.
11. Kirby RR, Downs JB, Civetta JM, Mod-
ell JH, Dannemiller FJ, Klein EF, et al.
High level positive end expiratory pres-
sure (PEEP) in acute respiratory insuf-
ficiency. Chest 1975;67:156-163.
12. Craig KC, Benson MS, Pierson DJ. Pre-
vention of arterial oxygen desaturation
during closed-airway endotracheal tube
suctioning: effect of ventilator mode.
Respir Care 1984;29:1013-1018.
13. Kelly RE, Yao FSF, Artusio JF Jr. Pre-
vention of suction-induced hypoxemia
by simultaneous oxygen insufflation.
Crit Care Med 1987;15:874-875.
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