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OBJECTIVES

UNIT II (C) VENTILATOR

CARE
Acknowledgement:
Tanzeel Ul Rahman
Amna
Ayesha

Edition:
Akash Samuel
Nursing Instructor

Mechanical ventilator MECHANICAL VENTILATION

A medical ventilator (or simply ventilator in context) is a

mechanical ventilator, machine designed to move
breathable air into and out of the lungs, to provide
breathing for a patient who is physically unable to
breathe, or breathing insufficiently.
• Mechanical ventilation can be defined as the
technique through which gas is moved toward and
from the lungs through an external device connected
directly to the patient.

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VENTILATORY CARE
PURPOSE
Caring for a patient who ❖To establish and maintain effective
requires assisted ventilation by ventilation
means of a mechanical ❖To prevent complication associated with
artificial ventilation
ventilation.
❖To ensure position and patency of
endotracheal and tracheostomy tube
❖To clear and remove secretions from
airway

EQUIPMENTS
❖Bed locker with necessary articles,
ventilator
❖ Suction apparatus
❖ Continuous monitoring apparatus
❖ Resuscitation chart with defibrillators
❖ oxygen setup
❖ Manual ventilation bag (embu bag)
❖ Endotracheal intubations set
PURPOSE/
OUTCOMES
• Reversal of hypoxemia
• Reversal of acute respiratory acidosis
• Relief of respiratory distress
• Prevention or reversal of atelectasis
• Resting of ventilatory muscles

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INDICATIONS Cont….
❖ Respiratory Failure
❖ Cardiopulmonary arrest ❖ RR>25/min
❖ Trauma (especially head, neck, and chest) ❖ PCO2>50mmHg
❖ Cardiovascular impairment (strokes, ❖ PO2< 50mmHg
tumors, infection, emboli, trauma)
❖ SpO2<90%
❖ Neurological impairment (drugs, poisons,
myasthenia gravis, GBS)
❖ pH < 7.25
❖ Pulmonary impairment (infections, tumors,
pneumothorax, COPD, trauma, pneumonia, poisons)

Types of ventilation
Negative pressure ventilation
❖ Positive pressure ventilation
Encase the patient’s body and exert negative
pressure that pulls the thoracic cage outward to
❖ Negative pressure ventilation
initiate inspiration

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Positive pressure ventilation Types/Modes of positive

pressure ventilators
Much more commonly used, deliver air by pumping ❖ Volume-cycled ventilators
it into the patient’s lungs.
With positive pressure ventilation, the normal relationship ❖ Pressure-cycled ventilators
b/w intrapulmonary pressures during inspiration and
expiration is reversed (i.e pressure during inspiration are
positive and pressure during expiration are negative
❖ Time-cycled ventilators

❖ High-frequency ventilation.

Volume-cycled
ventilators
With volume ventilation, a
designated volume of air (tidal
volume) is delivered with each
breath.
This type is ideal for patients with
acute respiratory distress syndrome
or bronchospasm, since the same
tidal volume is delivered regardless of
airway resistance or compliance.
Pressure-cycled
ventilators
With pressure ventilation, a selected gas
pressure is delivered to the patient and
sustained throughout the phase of
ventilation
The benefit is a decreased risk of lung
damage from high inspiratory pressures. The
disadvantage is that the tidal volume
delivered can vary with changes in lung
resistance and compliance if the patient has
poor lung compliance and increased

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Time-cycled ventilators
Terminate or control inspiration after a preset time.
The volume of air the patient receives is regulated by
the length of inspiration and the flow rate of the air.
Used very rarely
VARIOUS TYPES OF LUNG INJURY CAN OCCUR
WITH POSITIVE PRESSURE VENTILATION:
• Barotrauma can result from high pressures. With barotrauma, air can leak from
the alveoli into the pleural space, resulting in pneumothorax or
pneumomediastinum.
• Volutrauma is caused by the delivery of large tidal volumes. The alveoli develop
fractures that allow fluid and protein to seep into the lungs, resulting in a form
of non cardiogenic pulmonary edema.
• Atelectrauma is a shear-induced injury resulting from repeated opening and
closing of the alveoli.
• Biotrauma is damage to the alveoli caused by the release of cytokines and other
chemical mediators of the inflammatory response in response to positive-
pressure ventilation.
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High frequency ventilators
Accomplishes oxygenation by the diffusion of oxygen and
carbon dioxide from high to low gradients of concentration.
Diffusion is increased when the kinetic energy of the gas
molecules is increased
High frequency ventilation uses small tidal volumes (1-
3ml/kg) at frequencies greater than 100 breaths/minute
CONT…
• Ventilator-associated lung injury (VALI) and ventilator-induced lung injury
(VILI) are terms used to describe damage to the lungs resulting from
prolonged ventilation. Prolonged high levels of oxygen, high volumes, and
pressures may lead to loss of surfactant and increased inflammation of the
lung parenchyma and alveoli. The increase in inflammatory mediators
damages the alveolar capillary membrane, resulting in fluid leaking into the
lungs and non cardiogenic pulmonary edema.
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Ventilator settings
❖ Fraction of inspired oxygen(FIO2)
❖ Tidal volume
Fraction of inspired oxygen(FIO2)
❖ Respiratory rate
❖ Positive end-expiratory pressure(PEEP) ❖Percentage of O2 in the air delivered to patient
❖ Peak flow
❖ Usually adjusted to maintain SaO2 of greater than
❖Peak inspiratory pressure limit (high pressure
alarm) 90%
❖ Sensitivity ❖ In start it is settled to be more than 60% but later
❖ Inspiratory:expiratoray ratio less then 60% to prevent oxygen toxicity
❖ Humidification and temperature
❖ sighs

Respiratory rate
Tidal volume
❖ Amount of air to be delivered with each breath ❖ No of breaths/min delivered to patient.
❖ 5 to 8 ml/kg of body weight ❖Determines alveolar ventilation or minute
❖ 500 ml ventilation, is equal to the respiratory rate
multiplied bye the tidal volume.
❖Adjustments in either of these parameters affect
the PaCO2.

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Positive end-expiratory pressure(PEEP)
❖Control and adjust the pressure that is
maintained in the lungs at the end of
expiration
❖PEEP increases the functional residual capacity
by re inflating collapsed alveoli
❖Maintaining the alveoli in an open
position
❖ Improve lung compliance
Peak flow
Is the velocity of gas flow per unit of
time and is expressed as liters per
minute
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AUTO-PEEP
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• Spontaneous development of PEEP
• Caused by gas trapping
• Insufficient expiratory time
• Incomplete exhalation
• Rapid RR
• Airflow obstruction
• Inverse I:E ventilation
• Assess by 2-sec pause (hold) maneuver
• Auto-PEEP = Total PEEP – Set PEEP
Peak inspiratory pressure limit (PIP) (high
pressure alarm)
❖ Highest pressure allowed in the ventilator circuit.
❖With volume ventilators, once the high pressure limit is reached, the
high-pressure alarm sounds and the inspiration is terminated.
❖ Steps must be taken to identified and address the underlying
cause (eg, coughing, accumulation of secretions, kinked
ventilator tubing, pneumothorax, decreasing compliance, or a
high pressure alarm that is set too low).
❖ Should be less than 40 mm Hg
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Sensitivity
❖Controls the amount of patient effort needed to initiate an
inspiration, as measured by negative inspiratory effort.
❖Increasing sensitivity (requiring less negative force)
deceases the amount of work the patient must do to initiate
a ventilators breath.
❖Decreasing the sensitivity increases the amount of negative
pressure that the patient needs to initiate inspiration and
increase the work of breathing.
Inspiratory:expiratoray ratio
❖Operate with a short inspiratory time and a long
expiratory time (1:2 or 1:3 ratio)
❖ Allows time for air to passively exit the lungs
❖ Lowering pressures in the thoracic cavity
❖ Allow increased venous return

Humidification and
temperature Sigh
❖Inspiratory gas must be filtered, warmed and humidified
before delivery to the patient The volumes of air that are 1.5 to 2 times the
❖Humidifier humidifies the inspired gas by passing it over set tidal volumes , delivered 6 to 10 times per
or bubbling it through a head water. hour
❖Condensation should be seen in the inspiratory ventilator
circuit or the proximal ETT or both which indicates that the
inspired gas is fully saturated with water vapors.

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Ventilators Modes
1 Volumes Modes
With volume modes of ventilation, a
respiratory rate , inspiratory time and tidal
volume are selected for the mechanical
breaths
Nurse Must Monitor PIP

2.Assist – control mode

1. controlled
❖A respiratory rate and tidal volumes are preset
❖The client receives a set tidal volumes at a set rate. if the patient attempts to initiate a breath, the
❖Used for clients who cannot initiates respiratory ventilator is triggered and delivered the full
efforts.
❖Least used mode; if the client attempts to initiate a
preset tidal volumes with every breath.
breath, the ventilator blocks the efforts,

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3. Synchronized intermittent 2 Pressure Modes

mandatory ventilation
❖A typical pressure mode of ventilation sets a
maximum PIP, not a tidal volumes. When the ventilator
❖Allows clients to breath spontaneously at own delivers a breath it continues delivering the volumes
rate and tidal volume between the ventilator until the preset pressure limit is reached, then it stops
breaths. delivering the breath
❖Can be used as a primary ventilator mode or as a ❖Risk of hypoventilation and respiratory acidosis
weaning mode.

1 Pressure controlled
ventilation(PCV) mode 2 Pressure support ventilation PSV
Delivers breaths at a preset pressure limit The “unnatural”
❖Assist spontaneous breathing efforts by delivering a high flow of
feeling of this mode often requires gas to a selected pressure level early in inspiration maintain that
sedation and the use of NMB agents to level throughout the inspiratory phase
ensure patient–ventilator synchrony ❖Patient effort reduced and comfort level is increased
When the PCV mode is in use, the ❖PSV mode is also used with SIMV mode and as weaning
mean airway and intrathoracic pressures rise, potentially resulting in a technique.
decrease in cardiac output. Therefore, it is necessary to monitor the
patient’s hemodynamic status closely.

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INVERSE RATIO VENTILATION (IRV). AIRWAY PRESSURE RELEASE VENTILATION

(APRV) MODE.
• A high-pressure and a low pressure are set. Alveolar recruitment and
oxygenation occur during the high-pressure setting
• This type of ventilation inverses the I:E ratio so that
inspiratory time is equal to, or longer than, expiratory
time (eg, 1:1 to 4:1; see Fig. 10-8C). Because the
expiratory time is decreased, the nurse must monitor
for the development of auto- PEEP

Non invasive ventilator modes Continuous positive

❖Continuous positive airway pressure
(CPAP)
❖ Bi-level positive pressure (BiPAP)
airway pressure
(CPAP)
❖ Similar to PEEP
❖Supplies pressure throughout the respiratory cycle, help to
improve oxygenation in spontaneously breathing patients.
❖ Used for intubated or nonintubated patients.
❖Weaning mode from mechanical ventilation and for nocturnal
ventilation to splint open the upper airway
❖Preventing upper airway obstruction in patients with obstructive sleep apnea

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Bi-level positive pressure

(BiPAP)
❖Provided by means of nasal mask, nasal
prongs, or full facemask
❖ Two levels of positive pressure support
❖ An inspiratory pressure referred to IPAP
❖ An expiratory pressure referred to as EPAP
❖Used in patient with acute, short term respiratory
problems to avoid intubation and mechanical
ventilation

TA B L E 1 0 - 2 MODES OF
VENTILATION
• Please review the table

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51
TYPES OF ALARMS 52

TROUBLESHOOTING

• Never shut alarms off; silence only • High peak pressure

• Manually ventilate if uncertain of problem • Low pressure; low

PEEP/CPAP
• Low exhaled tidal volume
• Low minute ventilation
• Apnea
• Heater alarm
• Table 10.4

CARE OF ETT/
TRACHEOSTOMY
❖Secure positioning of ETT/ tracheostomy tube with
adhesive plaster
❖Inflate cuff once correct positioning has been
confirmed
❖ Cuff is inflated with air using syringe

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Cont…
MAINTAINING ❖Administer sedation as prescribed to ensure
adequate artificial ventilation and promotion
VENTILATION of rest
❖Effects of ventilation are assess by observing pt color,
chest movements, BP, pulse rate, oxygen saturation
❖Ventilator make characteristics sound during inspiration
and expiration which nurse must be capable of
identifying

SUCTIONING ❖STERILE CATHETER AND ONE

STERILE GLOVE TO BE USED FOR
❖Explain procedure to patient and family EACH SUCTIONINGSESSION SUCTION
❖Frequency of suction to be carried out IS APPLIED WHILE CATHETER IS
depending on pt’s pulmonary state BEING WITHDRAWN USING
INTERMITTENT TECHNIQUE NOT
❖Tracheal suction is an aseptic procedure
MORE THAN 10 TO 15 SECONDS

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❖Measure blood, IV infusions

and fluid intake every hour
❖Measure blood loss, urine,
chest drainage bottles,
❖Maintain intake and output
every shift
❖Assess bowel action every
third day
❖8 hourly wound dressing
should be done

PSYCHOLOGICAL ASPECTS OF PATIENT

❖ Change IV administration sets and
dressing of puncture sites everyday
CARE
❖Change suction bottle and ❖promote good relationship
connecting tubing everyday
with patient and family
❖Record pt’s conditions and events that
have occurred during each shift in nurse ❖Encourage them to express fear,
progress sheet stress factors and feelings
❖ Give detailed hand over to nurse ❖Motivate patient and relatives t0
on following shift participate in daily care activities

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•Review pages 127 to 130 for WEANING

comprehensive ventilator patient care
the term "weaning" is used to describe the
gradual process of decreasing ventilator support.

READINESS TO WEAN
65
GUIDELINES FOR WEANING

• weaning is generally initiated in the morning when the patient is rested

• Underlying cause for mechanical ventilation resolved
• Hemodynamic stability; adequate cardiac output
• Adequate respiratory muscle strength
• Adequate oxygenation without a high FiO2 and/or highPEEP
• Absence of factors that impair weaning
• Mental readiness
• Minimal need for medicines that cause respiratory depression
• The use of sedatives and narcotics during weaning is limited
• The nurse raises the head of the bed, ensures a patent airway, and provides
suction if necessary.
• The nurse remains with the patient throughout the weaning trial to provide
support and reassurance
• At the conclusion of the trial, the nurse also evaluates and documents the
patient’s response to weaning

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67
STOP THE WEANING PROCESS 68

WEANING METHODS Respiratory Cardiovascular

• Respiratory rate > 35 or < 8
breaths/min
• Synchronized intermittent mechanical • Low spontaneous VT < 5 mL/kg
ventilation
• Labored respirations
• Pressure support
• Use of accessory muscles
• T-piece trials
• Abnormal breathing pattern
• CPAP
• Low oxygen saturation < 90%
• HR or BP changes > 20% from baseline
• Dysrhythmias (e.g., PVCs)
• ST-segment elevation
• Blood pressure changes more than 20% from
baseline
• Diaphoresis
Neurologic
• Decreased level of consciousness
• Anxiety/agitation
• Subjective discomfort

AIRWAY MANAGEMENT
• Positioning
• Devices
• Oral airway: An oropharyngeal airway is a hard plastic device that isinserted
through the mouth and extends to the pharynx to prevent the tongue from
occluding the airway when muscle tone is decreased. Never insert in conscious
patient
AIRWAY MANAGEMENT • Nasopharyngeal airway: A nasopharyngeal airway (nasal trumpet) is a
flexible tube that is inserted nasally past the base of the tongue to maintain
airway patency.
• Endotracheal intubation: An endotracheal tube is a semi-rigid tube that
is inserted through the nose or mouth and extends into the trachea
• Tracheostomy: A
tracheostomy tube is inserted directly into the
trachea through a stoma made in the neck

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71

ENDOTRACHEAL INTUBATION ENDOTRACHEAL TUBE 72

• Insertion of an endotracheal tube (ETT) through the mouth or nose

• Orotracheal route preferred to reduce infections
• Used to:
• Maintain an airway
• Remove secretions
• Prevent aspiration
• Provide mechanical ventilation

Figure 9-17. A. Endotracheal tube. B. Hi-Lo Evac endotracheal tube. Note suction port above the cuff for removal of pooled
secretions. (From Shilling A, Durbin CG. Airway management. In: Cairo JM, ed. Mosby’s Respiratory Care Equipment. 9th ed.
St. Louis: Mosby; 2013.)

ENDOTRACHEAL INTUBATION
INTUBATION EQUIPMENT 73

• Right size tube • Premedicate prn

• 7.5 to 8.0 mm female; 8.0 to 9.0 • Topical anesthetic/ paralytic
mm male medication
• Check balloon on tube for leak • Ventilate patient
• Stylet • Suction oropharynx
• Lubricate tube • Intubate within 30 sec
• Laryngoscope and blade • Inflate balloon
• Sniffing position • Verify placement

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VERIFY PLACEMENT 75
ENDOTRACHEAL SUCTIONING 76

• Auscultate epigastric area • Suction as indicated by assessment

• Visible secretions
• Auscultate bilateral breath sounds
• Coughing
• ETCO2 detector
• Rhonchi
• Esophageal detector device • High PIP on ventilator
• Chest x-ray—3 to 4 cm above carina • Ventilator alarm
• Secure tube when placement is verified • Conventional versus closed suction
• Record cm at the lip line for reference • Procedures
• Hyperoxygenate throughout procedure
• Avoid normal saline instillation

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NASOTRACHEAL INTUBATION 79

TRACHEOSTOMY
80

• Pass through the patient’s naris

• Performed in the operating room or bedside (percutaneous)

Thank you

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