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Mechanical Ventilation is ventilation of the lungs by artificial means usually by a ventilator. Once a patient’s PaO2 cannot be maintained by the basic methods of oxygen delivery systems, i.e. masks, cannula; endotracheal intubation and mechanical ventilation are instituted. A ventilator delivers gas to the lungs with either negative or positive pressure. It must be understood that no mode of mechanical ventilation can or will cure a disease process but merely supports the patient until resolution of his/ her symptoms is accomplished. Purposes: Mechanical ventilation is instituted to: 1- Maintain or improve ventilation, i.e. for adequate tissue oxygenation. 2- Decrease the work of breathing and improve patient’s comfort. Indications: Acute respiratory failure due to: • Mechanical failure, includes neuromuscular diseases as Myasthenia Gravis, Guillain-Barré Syndrome, and Poliomyelitis (failure of the normal respiratory neuromuscular system) • Musculoskeletal abnormalities, such as chest wall trauma (flail chest) • Infectious diseases of the lung such as pneumonia, tuberculosis. Abnormalities of pulmonary gas exchange as in: •Obstructive lung disease in the form of asthma, chronic bronchitis or emphysema. •Conditions such as pulmonary edema, atelectasis, pulmonary fibrosis.
Dr. Sahar Hossni El-Shenawi-
Assistant Professor Of Critical Care Nursing
Criteria for institution of ventilatory support: Parameters Pulmonary function studies: • Respiratory rate (breaths/min). Dr.45 75-100 35-45 NB. These parameters are used in making judgments about the adequacy of respiratory function. • Tidal volume (ml/kg body wt) • Vital capacity (ml/kg body wt) • Maximum Inspiratory Force (cm HO2) Arterial blood Gases • • • PH Pa2 (mmHg) PaCO2 (mmHg) > 35 <5 < 15 <-20 10-20 5-7 65-75 75-100 Ventilation indicated Normal range < 7.Critical Care Nursing Theory Mechanical ventilation **Patients who has received general anesthesia as well as post cardiac arrest patients often require ventilatory support until they have recovered from the effects of the anesthesia or the insult of an arrest.35-7.25 < 60 > 50 7. Types of Mechanical ventilators: 12- Negative-pressure ventilators Positive-pressure ventilators. Sahar Hossni El-Shenawi- Assistant Professor Of Critical Care Nursing 2 .
. amyotrophic lateral sclerosis [ALS]). Rarely. Dr.Critical Care Nursing Theory Mechanical ventilation Negative-Pressure Ventilators . The iron lung are still occasionally used today. forming a seal over the chest. Sahar Hossni El-Shenawi- Assistant Professor Of Critical Care Nursing 3 .Intermittent short-term negative-pressure ventilation is sometimes used in patients with chronic diseases. .Early negative-pressure ventilators were known as “iron lungs.Our focus will be on the positive-pressure ventilators.Positive-pressure ventilators deliver gas to the patient under positivepressure.The use of negative-pressure ventilators is restricted in clinical practice. . Positive-pressure ventilators . These patients suffer from a wide variety of conditions such as . during the inspiratory phase. To improve mobility and comfort. and a pressure gradient was formed so that air flowed into the lungs. this method of support is chosen for patients who are not candidates for aggressive mechanical ventilation as provided through an artificial airway. because they limit positioning and movement and they lack adaptability to large or small body torsos. A hose connects the shell to a negative-pressure generator. Most negative-pressure ventilators in use today are more portable. there is a device that fits like a tortoise shell.Neuromuscular diseases (Duchenne’s muscular dystrophy.” The patient’s body was encased in an iron cylinder and negative pressure was generated by a large piston to enlarge the thoracic cage.COPD.Diseases of the chest wall (kyphoscoliosis). . however. This caused alveolar pressures to fall. . The thoracic cage is literally pulled outward to initiate inspiration.The iron lung is cumbersome to use and very large. .
inspiratory time. . .The amount of pressure required to deliver the set volume depends on :. volume is not. Dr. A typical pressure mode delivers a selected gas pressure to the patient early in inspiration. . and with some mode options (i. With changes in resistance or compliance. and tidal volume are selected for the mechanical breaths. PIP must be monitored in volume modes because it varies from breath to breath. By meeting the patient’s inspiratory flow demand throughout inspiration. Sahar Hossni El-Shenawi- Assistant Professor Of Critical Care Nursing 4 . The basic principle of this ventilator is that a designated volume of air is delivered with each breath. . .The use of pressure ventilators is increasing in critical care units. and sustains the pressure throughout the inspiratory phase. exhaled tidal volume is the variable to monitor closely.Critical Care Nursing Theory Mechanical ventilation Positive-Pressure Ventilators Volume Ventilators.With pressure modes.Although pressure is consistent with these modes. described later). . patient effort is reduced and comfort increased..With this mode of ventilation.Patient’s lung compliance . volume will change.The volume ventilator is commonly used in critical care settings. . rate and inspiratory time are preset as well.Therefore.Patient–ventilator resistance factors. Pressure Ventilators.e. . pressure controlled [PC]. a respiratory rate.Therefore. the pressure level to be delivered is selected.
Classification of positive-pressure ventilators: .Lowering the risk of barotrauma . volume or time cycled machines. that is to say according to how the inspiratory phase ends.High-frequency ventilators use small tidal volumes (1 to 3 mL/kg) at frequencies greater than 100 breaths/minute. . . Sahar Hossni El-Shenawi- Assistant Professor Of Critical Care Nursing 5 . . when used in the absence of adequate humidification.Critical Care Nursing Theory Mechanical ventilation High-Frequency Ventilators. panting entails moving small volumes of air at a very fast rate.They are classified as: pressure. Dr.Potential adverse effects associated with high-frequency ventilators include: .The high-frequency ventilator accomplishes oxygenation by the diffusion of oxygen and carbon dioxide from high to low gradients of concentration. thereby . This diffusion movement is increased if the kinetic energy of the gas molecules is increased.Necrotizing tracheobronchitis.A high-frequency ventilator would be used to achieve lower peak ventilatory pressures.Improving ventilation– perfusion matching because . .Ventilators are classified by their method of cycling from the inspiratory phase to the expiratory phase (changeover from inspiratory to expiratory phase).Gas trapping . The factor which terminates the inspiratory cycle reflects the machine type. The breathing pattern of a person on a high-frequency ventilator is somewhat analogous to the breathing pattern of a panting dog. .
In which inspiration is terminated after a preset volume has been delivered by the ventilator.Critical Care Nursing Theory Mechanical ventilation • Volume-cycled ventilator. and inspiration stops when the preset tidal volume is achieved. .e. i. i. the ventilator delivers a preset pressure.e. . Dr. . the ventilator delivers a preset tidal volume (VT). Time-cycled ventilator. end inspiration occurs. • Pressure-cycled ventilator. Sahar Hossni El-Shenawi- Assistant Professor Of Critical Care Nursing 6 .In which inspiration is terminated when a preset inspiratory time. Time cycled machines are not used in adult critical care settings.In which inspiration is terminated when a specific airway pressure has been reached. once this pressure is achieved. They are used in pediatric intensive care areas. has elapsed.
Critical Care Nursing Theory Mechanical ventilation Ventilator Modes . .Synchronized intermittent mandatory ventilation (SIMV) mode. he or she can trigger the ventilator and receive a full-volume breath.Client can breathe at a higher rate than the minimum number of breaths/minute that has been set. 1.e.Assist-control (A/C) mode 2.i.Often used as initial mode of ventilation -This mode of ventilation is often used fully to support a patient. a mandatory (or “control”) rate is selected. .The total respiratory rate is determined by the number of spontaneous inspiration initiated by the patient plus the number of breaths set on the ventilator. . but the ventilator assists by delivering a specified tidal volume to the patient. Each mode is different in determining how much work of breathing the patient has to do.The ventilator provides the patient with a pre-set tidal volume at a pre-set rate and the patient may initiate a breath on his own.Assist Control Mode A/C . although each mode has its advantages and disadvantages.There is no one best mode for managing patients in respiratory failure.If the patient wishes to breathe faster.In A/C mode. such as Dr. . .The term “ventilator mode” refers to the way the machine ventilates the patient . Sahar Hossni El-ShenawiAssistant Professor Of Critical Care Nursing 7 . Modes of mechanical ventilation . A. .Several different modes of ventilatory control are available on ventilators. how much the patient will participate in his own ventilatory pattern.Client can initiate breaths that are delivered at the preset tidal volume.Volume Modes 1. .
the patient determines the respiratory rate and tidal volume. Sahar Hossni El-ShenawiAssistant Professor Of Critical Care Nursing 8 . Advantages: .Ensures ventilator support during every breath . .Each breath has the same tidal volume Disadvantages: .Synchronized Intermittent Mandatory Ventilation SIMV . .When the patient is too weak to perform the work of breathing (e.e. . Dr.Adding pressure support during spontaneous breaths can minimize the risk of increased work of breathing.When the patient is first intubated . when emerging from anesthesia). any breaths taken above the set rate are spontaneous breaths taken through the ventilator circuit. ventilators breaths are synchronized with the patient spontaneous breathe. .The ventilator provides the patient with a pre-set number of breaths/minute at a specified tidal volume and fio2. unlike the A/C mode. 2. In between the ventilator-delivered breaths.The tidal volume of these breaths can vary drastically from the tidal volume set on the ventilator. SIMV has been used as a popular weaning mode. In the past.Hyperventilation.In SIMV mode.Same as intermittent mandatory ventilation except stacking is avoided i. .. because the tidal volume is determined solely by the patient’s spontaneous effort.g.However.Between machine breaths.Work of breathing may be increased if sensitivity or flow rate is too low. . the client can breathe spontaneously at his own tidal volume and rate with no assistance from the ventilator.Air trapping . . The ventilator does not assist the spontaneous breaths i. .Critical Care Nursing Theory Mechanical ventilation . the patient is able to breathe spontaneously.If the patient wants to breathe above this rate. the rate and tidal volume are preset. he or she may.e.
Used to wean the patient from the mechanical ventilator. the ventilator initiates and controls both the volume delivered and the frequency of breath.Client does not breathe spontaneously. the mandatory breaths were gradually decreased.Pressure-support ventilation (PSV) mode.Pressure modes include :1.Control Mode CM Continuous Mandatory Ventilation( CMV) .To wean the patient. 1. respiratory rate and oxygen concentration prescribed by the physician. 3. . . 5.Continuous positive airway pressure (CPAP)/PEEP mode.Pressure-controlled ventilation (PCV) mode. .Allows spontaneous breaths (tidal volume determined by patient) between ventilator breaths.Weaning is accomplished by gradually lowering the set rate and allowing the patient to assume more work Disadvantages: Patient–ventilator asynchrony possible B. Sahar Hossni El-Shenawi- Assistant Professor Of Critical Care Nursing 9 . .Noninvasive bilevel positive airway pressure ventilation (BiPAP) mode.e.Often used as initial mode of ventilation and for weaning Advantages: . -Ventilator totally controls the patient’s ventilation i. .Ventilation is completely provided by the mechanical ventilator with a preset tidal volume.Critical Care Nursing Theory Mechanical ventilation .Pressure Modes .Client can not initiate breathe Dr. thereby allowing the patient to assume more and more of the work of breathing. 2.
The “unnatural” feeling of this mode often requires muscle relaxants to ensure patient– ventilator synchrony. one must monitor for the development of hyperinflation or auto-PEEP. the patient’s hemodynamic status must be monitored closely. the mean airway and intrathoracic pressures rise. expiratory time (1:1 to 4:1).As expiratory time is decreased. respiratory rate. Regional alveolar overdistension and barotrauma may occur owing to excessive total PEEP. . . Dr.The inspiratory pressure level. or longer than. . potentially resulting in a decrease in cardiac output and oxygen delivery. .Inverse I:E ratios are used in conjunction with pressure control to improve oxygenation in patients with ARDS by expanding stiff alveoli by using longer distending times.When the PCV mode is used.Sedation and the use of neuromuscular blocking agents are frequently indicated. This promotes venous return and allows time for air to exit the lungs passively.Inverse ratio ventilation (IRV) mode reverses this ratio so that inspiratory time is equal to. because any patient–ventilator asynchrony usually results in profound drops in the SaO2.This is especially true when inverse ratios are used. thereby providing more opportunity for gas exchange and preventing alveolar collapse. . - . Therefore.Most ventilators operate with a short inspiratory time and a long expiratory time (1:2 or 1:3 ratio). .Tidal volume varies with compliance and airway resistance and must be closely monitored. . . Sahar Hossni El-ShenawiAssistant Professor Of Critical Care Nursing 10 . and inspiratory–expiratory (I:E) ratio must be selected.Pressure-Controlled Ventilation Mode( PCV) The PCV mode is used to control plateau pressures in conditions such as ARDS where compliance is decreased and the risk of barotrauma is high. It is used when the patient has persistent oxygenation problems despite a high FIO2 and high levels of PEEP.Critical Care Nursing Theory Mechanical ventilation 1.
The patient breathes spontaneously while the ventialtor applies a predetermined amount of positive pressure to the airways upon inspiration.Pressure support ventilation may be combined with other modes such as Dr.Used to limit plateau pressures that can cause barotrauma Severe ARDS Disadvantages: Patient–ventilator asynchrony possible. Barotrauma. Sahar Hossni El-ShenawiAssistant Professor Of Critical Care Nursing 11 . necessitating sedation/paralysis Monitor abcTidal volume at least hourly. Barotraumas Hemodynamic instability Inverse ratio ventilation (IRV) Usually used in conjunction with PCV Increases ratio I:E to aAllow for recruitment of alveoli bImprove oxygenation Disadvantages: . assisting each spontaneous inspiration. .Critical Care Nursing Theory Mechanical ventilation . 2.Pressure Support Ventilation ( PSV) .e. . Hemodynamic instability.Almost always requires paralysis Monitor for abcAuto-PEEP. .Helps to overcome airway resistance and reducing the work of breathing.Patient must initiate all pressure support breaths.Pressure support ventilation augments patient’s spontaneous breaths with positive pressure boost during inspiration i. .
Specific uses of PSV are . Sahar Hossni El-ShenawiAssistant Professor Of Critical Care Nursing 12 .When PSV mode is used as a stand-alone mode of ventilation. endurance conditioning is enhanced. . . .In PSV mode.PSV mode augments or assists spontaneous breathing efforts by delivering a high flow of air to a selected pressure level early in inspiration. .The patient’s effort determines the rate. . tidal volume decreases and respiratory rate increases.PSV mode should be used with caution in patients with - Bronchospasm other reactive airway conditions. and maintaining that level throughout the inspiratory phase.Critical Care Nursing Theory Mechanical ventilation SIMV or used alone for a spontaneously breathing patient.At high pressure levels.In general. Intact respiratory drive in patient necessary Dr. As a weaning tool.It is a mode used primarily for weaning from mechanical ventilation. the pressure support level is adjusted to achieve the approximate targeted tidal volume and respiratory rate. . the inspired tidal volume and respiratory rate must be monitored closely to detect changes in lung compliance. if compliance decreases or resistance increases. .For weaning.Because the level of pressure support can be gradually decreased. . . . PSV mode provides nearly total ventilatory support. inspiratory flow. .To decrease the work of breathing necessary to overcome the resistance of the endotracheal tube.PSV is thought to increase the endurance of the respiratory muscles by Decreasing the physical work Decreasing oxygen demands during spontaneous breathing.To promote synchrony with the ventilator. .To promote patient comfort . and tidal volume. . .Indicated for patients with small spontaneous tidal volume and difficult to wean patients.
PEEP is the term used to describe positive end-expiratory pressure with positive-pressure (machine) breaths. and in some cases of dyssynchrony 2.All ventilation is spontaneously initiated by the patient.Critical Care Nursing Theory Mechanical ventilation Used as a weaning mode. They improve oxygenation by opening collapsed alveoli & preventing them from collapsing at the end of expiration.No mandatory breaths (ventilator-initiated are delivered in this mode) . . CPAP assists spontaneously breathing patients to improve their oxygenation by elevating the end-expiratory pressure in the lungs throughout the respiratory cycle. preventing upper airway obstruction in patients with obstructive sleep apnea. . . for patients breathing spontaneously.CPAP is supplied during spontaneous breathing.Constant positive airway pressure for patients who breathe spontaneously Advantages: . . .Positive pressure applied at the end of expiration during spontaneous breaths i. .Continuous Positive Airway Pressure CPAP (a variation of PEEP) . Sahar Hossni El-Shenawi- Assistant Professor Of Critical Care Nursing 13 .CPAP allows the nurse to observe the ability of the patient to breathe spontaneously while still on the ventilator.PEEP & CPAP are used in patients with hypoxemia refractory to oxygen therapy. .CPAP can be used for intubated and nonintubated patients.e.Used in intubated or nonintubated patients Disadvantages: Dr.It may be used as a weaning mode and for nocturnal ventilation (nasal or mask CPAP) to splint open the upper airway.
or a full-face mask.Ventilation with a full-face mask should be used cautiously because it may increase the risk of aspiration and of rebreathing carbon dioxide. 4.To avoid intubation in patients with respiratory failure & hypercarbia . Dr.Noninvasive Bilateral Positive Airway Pressure Ventilation (BiPAP) .BiPAP is beneficial in worsening nocturnal hypoventilation in patients with . . Sahar Hossni El-Shenawi- Assistant Professor Of Critical Care Nursing 14 . . . .Obstructive sleep apnea.On some systems.To avoid reintubation after extubation in borderline cases.Critical Care Nursing Theory Mechanical ventilation . a- .It is used in the treatment of :Patients with chronic respiratory insufficiency to manage acute or chronic respiratory failure without intubations and conventional mechanical ventilation. . . no alarm if respiratory rate falls .COPD.BiPAP is a noninvasive form of mechanical ventilation provided by means of a nasal mask or nasal prongs. cAs an alternative to conventional mechanical ventilation in patients who are ventilated in their homes.Chest wall deformity.Neuromuscular disease. . bUsed as a bridge to weaning patients from mechanical ventilation.The system allows the clinician to select two levels of positive-pressure support: ab- An inspiratory pressure support level (referred to as IPAP) An expiratory pressure called EPAP (PEEP/CPAP level).Monitor for increased work of breathing.
Advantages: abDecreased cost when patients can be cared for at home.Patient discomfort or claustrophobia .The patient should be monitored for :ab- Gastric distension. Air leaks from mouth Dr.Thick or copious secretions and poor cough may be relative contraindications to BiPAP. Sahar Hossni El-Shenawi- Assistant Professor Of Critical Care Nursing 15 . No need for artificial airway Disadvantages: .Critical Care Nursing Theory Mechanical ventilation .
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