MECHANICAL VENTILATOR

A mechanical ventilator is a positive or negative breathing device that can maintain ventilation and oxygen delivery for a prolonged period.

Indications:
continuous decrease in oxygenation an increase in arterial carbon dioxide levels persistent acidosis thoracic or abdominal surgery, drug overdose, neuromuscular disorders, inhalation injury, COPD, multiple trauma, shock, multisystem failure

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. o o Iron-lung ± used extensively during polio epidemics in the past Body-wrap and Chest Cuirass ± devices that require a rigid cage or shell to create a negativepressure chamber around the thorax and the abdomen.

Positive-pressure Ventilators
-inflate the lungs by exerting positive pressure on the airway, pushing air in, forcing the alveoli to expand during inspiration. Expiration occurs passively. Endot acheal intubation or tracheostomy is r usually necessary.

Means and Modes of Mechanical Ventilation
Mechanical ventilators are typically volume or pressure cycled; some newer models combine features of both. Because pressures and volumes are directly linked by the pressure -volume curve, any given volume will

the ventilator delivers a set tidal volume. This mode remains popular. In pressure support ventilation. pressure support ventilation (PSV). and vice versa. the ventilator initiates a breath. each inspiratory effort beyond the set sensitivity threshold triggers delivery of the fixed tidal volume. and several noninvasive modalities applied via a tight-fitting face mask. the ventilator delivers a set inspiratory pressure. patient efforts above the set respiratory rate are unassisted. this mode can theoretically benefit patients with acute lung injury/acute respiratory distress syndrome (ALI/ARDS). Because of its use in spontaneously breathing patients. In this mode. which includes assist-control (A/C) and synchronized intermittent mandatory ventilation (SIMV). aspiration is possible. with respirations triggered by the patient. each inspiratory effort beyond the set sensitivity threshold delivers full pressure support maintained for a fixed inspiratory time. constant pressure is maintained throughout the respiratory cycle with no additional inspiratory support. waveform. ensuring the desired minimum respiratory rate. In CPAP. changes in respiratory system mechanics can result in unrecognized changes in minute ventilation. Pressure-cycled ventilation: This form of mechanical ventilation includes pressure control ventilation (PCV). despite the fact that it neither provides full ventilator support as does A/C nor facilitates liberating the patient from mechanical ventilation. Hence. a longer or deeper inspiratory effort by the patient results in a larger tidal volume. Pressure is typically cut off when back-pressure causes flow to drop below a certain point. In all of these. NIPPV can be given in the form of continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BIPAP). Adjustable ventilator settings differ with mode but include respiratory rate. Because it limits the distending pressure of the lung. Pressure control ventilation is similar to A/C. The resultant airway pressure is not fixed but varies with the resistance and elastance of the respiratory system and with the flow rate selected. tidal volume. However. Noninvasive positive pressure ventilation (NIPPV): NIPPV is the delivery of positive pressure ventilation via a tight-fitting mask that covers the nose or both the nose and mouth. A minimum respiratory rate is maintained. Volume-cycled ventilation: In this mode.correspond to a specific pressure. the physician sets both the expiratory positive airway pressure (EPAP) and the inspiratory positive airway pressure (IPAP). tidal volume varies depending on the resistance and elastance of the respiratory system. it is primarily applied as a form of PSV. In this mode. although volume control can be used. SIMV also delivers breaths at a set rate and volume that is synchronized to the patient's efforts. Because the airway is unprotected. however. no clear clinical advantage over A/C has been shown. If the patient does not trigger the ventilator frequently enough. however. This mode is commonly used to liberate patients from mechanical ventilation by letting them assume more of the work of breathing. so patients must have adequate mentation and airway protective reflexes and no imminent indication for surgery or transport off the floor for prolonged . regardless of whether the ventilator is pressure or volume cycled. With BIPAP. A/C ventilation is the simplest and most effective means of providing full mechanical ventilation. although the intake valve opens to allow the breath. trigger sensitivity. no studies indicate that this approach is more successful. a minimum rate is not set. Thus. all breaths are triggered by the patient. In contrast to A/C. flow rate. and inspiratory/expiratory (I/E) ratio.

Indications for conversion to endotracheal intubation and conventional mechanical ventilation include the development of shock or frequent arrhythmias. Weaning the Patient from the Ventilator Respiratory weaning. In such circumstances. Also. the process of withdrawing the patient from dependence on the ventilator. usually 6-8 L/min) Water in the tubing. then from the tube. such as occurs with ileus. . myocardial ischemia. and transport to a cardiac catheterization laboratory or surgical suite where control of the airway and full ventilatory support are desired. NIPPV should be avoided in patients who are hemodynamically unstable or those with evide nce of impaired gastric emptying. Assessing the Equipment When monitoring the ventilator. Obtunded patients and those with copious secretions are not good candidates. Weaning from mechanical ventilation is performed at the earliest possible time consistent with patient safety. Weaning is started when the patient is recovering from the acute stage of medical and surgical problems and when the cause of respiratory failure is sufficiently reversed. the nurse notes the following: y y y y y y y y y y y y Type of ventilator Controlling mode Tidal volume and rate settings (tidal volume is usually set at 6-12mL/kg[ideal body weight]. and finally from oxygen. or pregnancy.procedures. the swallowing of large quantities of air may result in vomiting and life-threatening aspiration. disconnection or kinking of the tubing Humidification and temperature Alarms (turned on and functioning properly) PEEP and pressure support level (usually set at 5-15 cm H2O) Problems with Mechanical Ventilation Bucking the ventilator The patient is said to fight or buck the ventilator when he or she is out of phase with the machine. IPAP must be set below esophageal opening pressure (20 cm H2O) to avoid gastric insufflation. bowel obstruction. This is manifested when the patients attempts to breathe out during the ventilator¶s mechanical inspiratory phase or when there is jerky and increased abdominal muscle effort. rate is usually set at 12-16 breaths/min FiO2 (fraction of inspired oxygen) Inspiratory pressure reached and pressure limit (normal is 15 to 20 cm H2 O. this increase if there is increased airway resistance or decreased compliance) Sensitivity (a 2-am H2 O inspiratory force should trigger the ventilator) Inspiratory-to-expiratory ratio (usually 1:3 or 1:2) Minute volume (tidal volume x respiratory rate.

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