ZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 03/21/2023
Downloaded from http://journals.lww.com/nursingmadeincrediblyeasy by BhDMf5ePHKav1zEoum1tQfN4a+kJLhE
Set the stage for
ventilator Are you puzzled by ventilator modes? We help you differentiate
between invasive and noninvasive ventilation and understand the
2.0 common settings for each.
ANCC
CONTACT HOURS
By Nichole Miller, BSN
Direct Care Nurse, ICU • Dwight D Eisenhower Army Medical Center • Fort Gordon, Ga.
Your patient in the ICU today is Mrs. J,
who was intubated for hypercapnic
respiratory failure yesterday after she
failed a trial on bilevel positive airway
pressure (BIPAP). Her ventilator settings
are assist control (AC), 12; tidal volume
(TV), 600; positive end-expiratory pres-
sure (PEEP), 5; and Fio2, 40%. You sud-
denly feel like you’re on another planet
and people are speaking a different
language. In this article, we’ll show you
how to identify the difference between
invasive and noninvasive ventilation,
understand the basic mechanisms of dif-
ferent ventilator modes, and interpret the
ventilator settings.
Indications for mechanical ventilation
• Partial pressure of oxygen in arterial blood (PaO2) < 50 mm Hg with FiO2 > 0.60
• PaO2 > 50 mm Hg with pH < 7.25
• Vital capacity < two times TV
• Negative inspiratory force < 25 cm H2O
• Respiratory rate > 35/minute
Source: Smeltzer SC, Bare BG, Hinkle JL, Cheever KH. Brunner and Suddarth’s Textbook of
Medical-Surgical Nursing. 11th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007.
44 Nursing made Incredibly Easy! May/June 2013
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Invasive ventilation
Invasive positive pressure ventilation
requires that the patient be intubated
by placing an endotracheal (ET) tube to
provide direct ventilation to the lungs.
It’s indicated for patients who aren’t
breathing (apneic) or breathing ineffec-
tively, causing ventilation problems.
Intubation is necessary for any patient
with impending or current respiratory
failure. There are no specific contraindi-
cations to mechanical ventilation when a
patient isn’t breathing, but facial, neck,
or tracheal trauma can make oral intu-
bation undesirable (see Indications for
mechanical ventilation).
Almost all ventilators have the capability
of being set to four basic modes: AC, syn-
chronized intermittent mandatory ventilation
(SIMV), airway pressure release ventilation
(APRV), and pressure support (PS). Most
newer ventilators can also be set to specialty
modes, such as high frequency oscillatory
ventilation (HFOV).
Let’s take a closer look at these standard
ventilator modes (see Picturing modes of
mechanical ventilation).
www.NursingMadeIncrediblyEasy.com
ZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 03/21/2023
Downloaded from http://journals.lww.com/nursingmadeincrediblyeasy by BhDMf5ePHKav1zEoum1tQfN4a+kJLhE

settings

www.NursingMadeIncrediblyEasy.com May/June 2013 Nursing made Incredibly Easy! 45

Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
ZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 03/21/2023
Downloaded from http://journals.lww.com/nursingmadeincrediblyeasy by BhDMf5ePHKav1zEoum1tQfN4a+kJLhE

Assist control for a small person and up to 800 mL for a

AC is one of the most common modes used larger person.
for ventilation in the ICU. It’s often used for Measured as a percentage, FiO2 is the
patients who require the most support from amount of oxygen the patient requires to
the ventilator. When looking at the ventila- maintain appropriate blood oxygen levels.
tor, you’ll see that there are several basic PEEP is the pressure that’s applied at the
settings within AC mode. These include the end of the expiratory phase that helps keep
respiratory rate, TV, Fio2, and PEEP (see the alveoli from snapping shut when the
Initial ventilator settings). Let’s look at each patient exhales. This can minimize the risk of
one of these terms. developing atelectasis and prevent shearing
The respiratory rate is the minimum force trauma to the alveoli. Shearing is
amount of breaths that the patient will caused when the alveoli are opening and
be allowed to take. This rate is pro- shutting too quickly. PEEP can also be used
grammed into the ventilator, often set to help open areas of collapsed alveoli, also
between 12 and 18. known as atelectasis. PEEP is measured in
TV is the amount of air that will go into centimeters of water and is often seen at
the patient’s lungs with each breath. This is levels between 5 and 10 cm H2O.
based on the ideal body weight of the In AC mode, the patient will have a set
patient, most often calculated at 10 mL/kg. respiratory rate, meaning that it’s a time-
Some patients may require a smaller TV triggered mode. If for some reason the
due to poor lung compliance (the amount patient doesn’t initiate a breath on his or her
of stretch the lungs can handle without own after so many seconds, the ventilator
damage). TV is usually set between 400 mL will sense that the patient hasn’t attempted a
breath and will deliver the TV. The time
between breaths is based on the set respira-
Initial ventilator settings tory rate. For example, if the respiratory rate
The following guide is an example of the steps involved in operating a is set to 12 and there’s no breath initiated
mechanical ventilator. The nurse, in collaboration with the respiratory within 5 seconds, the ventilator will give the
therapist, always reviews the manufacturer’s instructions, which vary patient a controlled, or ventilator-dependent,
according to the equipment, before beginning mechanical ventilation. breath. The ventilator will give this set num-
1. Set the machine to deliver the TV required (10 to 15 mL/kg). ber of breaths every minute as long as the
2. Adjust the machine to deliver the lowest concentration of oxygen to patient isn’t attempting to breathe. The venti-
maintain normal PaO2 (80 to 100 mm Hg). This setting may be high
lator won’t allow the patient to breathe less
initially but will gradually be reduced based on ABG results.
than the set amount.
3. Record peak inspiratory pressure.
4. Set mode (AC or SIMV) and rate according to the healthcare provider’s
If the patient is capable of taking breaths
order. Set PEEP and PS if ordered. on his or her own, the ventilator will sense
5. Adjust sensitivity so that the patient can trigger the ventilator with a that the patient is taking a breath by the neg-
minimal effort (usually 2 mm Hg negative inspiratory force). ative flow of air and will help facilitate the
6. Record minute volume and obtain ABGs to measure partial pressure of breath by delivering the set TV. The patient
carbon dioxide, pH, and PaO2 after 20 minutes of continuous mechanical can breathe as many times a minute as he or
ventilation. she wants but will get the same TV with
7. Adjust setting (FiO2 and rate) according to results of ABG analysis to pro- each breath.
vide normal values or those set by the healthcare provider. The benefit of AC mode is that it can be
8. If the patient suddenly becomes confused or agitated or begins bucking
used in both patients who are spontaneously
the ventilator for some unexplained reason, assess for hypoxia and
breathing and those who aren’t. It will pro-
manually ventilate on 100% oxygen with a resuscitation bag.
vide the set number of breaths every minute,
Source: Smeltzer SC, Bare BG, Hinkle JL, Cheever KH. Brunner and Suddarth’s Textbook of
Medical-Surgical Nursing. 11th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007. but also allow patients who want a higher
rate to initiate breaths on their own. This can

46 Nursing made Incredibly Easy! May/June 2013 www.NursingMadeIncrediblyEasy.com

Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
ZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 03/21/2023
Downloaded from http://journals.lww.com/nursingmadeincrediblyeasy by BhDMf5ePHKav1zEoum1tQfN4a+kJLhE

Picturing modes of mechanical

ventilation
decrease anxiety by allowing the patient to
set his or her own respiratory rate while still 
being supported by the full TV. 9ROXPH
For weak or critically ill patients, the FF

ventilator does most of the work, meaning
that the patient doesn’t have to do much of &RQWUROOHGYHQWLODWLRQ
the work of breathing. The downside of
using this mode is that every breath is the 

same size. If the TV is set at 600 mL, then 9ROXPH

FF
every breath (both spontaneous and assisted) 
will be approximately 600 mL. After the
volume has been delivered, a valve closes $&
in the circuit and the patient is forced to 
exhale. However, a person’s normal breath- 9ROXPH
ing pattern doesn’t include identical FF
breaths. If a patient wants larger breaths 
than the set TV, it can cause anxiety and
6,09
interrupt the patient’s breathing pattern,
which may lead to resistance in ventilation. 
This can lead to tachypnea and hyperventi- 9ROXPH
lation, which, in turn, may result in respira- FF
%DVHOLQHIXQFWLRQDOUHVLGXDOFDSDFLW\HOHYDWHG
tory alkalosis. 
Another common issue seen with the use 3((3 6HUYR
of AC mode is often caused by the low work YHQWLODWLRQ69
 ZLWK
of breathing. When patients have been in
9ROXPH &3$3
this mode for a period of time, it can cause
FF
weakened respiratory muscles and increase 
in ventilator times. Sedation, appropriate
volumes, and weaning trials can often help &3$3 69
ZLWK
decrease these complications.  36
9ROXPH
Synchronized intermittent FF
mandatory ventilation 
SIMV is also a common mode of ventila- 36
tion used in the ICU. It works on the same
basic principles of AC mode—a set num- 
ber of breaths will be delivered each 9ROXPH
minute, but the patient can breathe as P/

many times a minute as he or she feels
the need to. These breaths can be patient- $359
or ventilator-initiated, but the difference ,QVSLUDWLRQDLUIORZ
is how TV is delivered. All ventilator- ([KDODWLRQ
initiated breaths will have the full TV 3DWLHQWWULJJHUHGEUHDWK
delivered, but for patient-initiated breaths, 6SRQWDQHRXVLQVSLUDWLRQRQORZSUHVVXUHOHYHO

the set respiratory rate will be an indepen- 6SRQWDQHRXVLQVSLUDWLRQRQKLJKSUHVVXUHOHYHO
dent breath and the TV won’t be deliv-
Source: Smeltzer SC, Bare BG, Hinkle JL, Cheever KH. Brunner and Suddarth’s Textbook of Medical-
ered. The patient will need to inhale the Surgical Nursing. 11th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007.
TV independently.

www.NursingMadeIncrediblyEasy.com May/June 2013 Nursing made Incredibly Easy! 47

Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
ZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 03/21/2023
Downloaded from http://journals.lww.com/nursingmadeincrediblyeasy by BhDMf5ePHKav1zEoum1tQfN4a+kJLhE

The rationale behind using SIMV instead
of AC is to help work the patient’s respiratory
muscles by providing periods of decreased
support. Remember, if the respiratory rate
is set high or the patient isn’t breathing
spontaneously, then this mode functions
identically to AC mode.
The benefit of using SIMV is seen most
often in surgical patients who require venti-
lator support for a short period of time post-
operatively. As the patient wakes up, he or
she is able to take an increasing number of
unassisted breaths. By using this mode, it
helps determine at what point the patient is
ready for extubation.
The downside of SIMV is often
seen when it’s used with weakened or
critically ill patients. The increased work
of breathing can actually cause a patient
to tire out and lead to longer intubation
times or failed weaning attempts. Other
issues include hypoventilation from the
inability to take adequate TV with inde-
pendent breaths and anxiety from not
knowing what breaths will be assisted
or unassisted.

Troubleshooting problems with mechanical ventilation

Problem Cause Considerations
Ventilator problems
Increase in peak airway Coughing or plugged airway tube Suction airway for secretions; empty
pressure condensation fluid from circuit.
Patient “bucking” ventilator Adjust sensitivity.
Decreasing lung compliance Manually ventilate patient.
Assess for hypoxia or bronchospasm.
Check ABG values.
Sedate only if necessary.
Tubing kinked Check tubing; reposition patient; insert oral
airway if necessary.
Pneumothorax Manually ventilate patient; notify healthcare
provider.
Atelectasis or bronchospasm Clear secretions.
Decrease in pressure or loss Increase in compliance None
of volume Leak in ventilator or tubing; cuff on tube/ Check entire ventilator circuit for patency.
humidifier not tight Correct leak.

Patient problems
Cardiovascular compromise Decrease in venous return due to application of Assess for adequate volume status by
positive pressure to lungs measuring heart rate, BP, central venous
pressure, pulmonary capillary wedge pressure,
and urine output. Notify healthcare provider if
values are abnormal.
Barotrauma/pneumothorax Application of positive pressure to lungs; high Notify healthcare provider.
mean airway pressures lead to Prepare patient for chest tube insertion.
alveolar rupture Avoid high pressure settings for patients with
chronic obstructive pulmonary diease, ARDS,
or history of pneumothorax.
Pulmonary infection Bypass of normal defense mechanisms; Use meticulous aseptic technique.
frequent breaks in ventilator circuit; Provide frequent mouth care.
decreased mobility; impaired cough reflex Optimize nutritional status.

Source: Smeltzer SC, Bare BG, Hinkle JL, Cheever KH. Brunner and Suddarth’s Textbook of Medical-Surgical Nursing. 11th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007.

48 Nursing made Incredibly Easy! May/June 2013 www.NursingMadeIncrediblyEasy.com

Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
ZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 03/21/2023
Downloaded from http://journals.lww.com/nursingmadeincrediblyeasy by BhDMf5ePHKav1zEoum1tQfN4a+kJLhE
Airway pressure release ventilation
APRV is considered a rescue method of
ventilation and is often used for patients
who are having problems with lung com-
pliance or difficulty with oxygenation. This
is a fairly advanced and complicated mode
of ventilation, most commonly used in pa-
tients who have acute respiratory distress
syndrome (ARDS). APRV uses an inverse
ratio to achieve higher levels of pressure,
meaning that the expiratory phase is
longer than the inspiratory phase. This
allows higher levels of pressure to be held
throughout the respiratory cycle, although
this isn’t how we normally breathe. How-
ever, compared with older modes that used
an inverse ratio, APRV is much more com-
fortable for patients and allows for sponta-
neous breathing. The patient can take a
breath at any point in the ventilator cycle,
making the high pressures more tolerable.
These high pressures combined with
PEEP help improve and prevent areas
of atelectasis. This is one way that APRV
helps improve oxygenation when other
modes can’t.
Improved oxygenation is the biggest bene-
fit to using this mode. It has often been
shown to significantly improve oxygenation
in patients who are very difficult to oxygenate
otherwise. This is commonly seen in patients
with ARDS because of the decrease in lung
compliance and dense areas of atelectasis.
Another benefit seen over the use of other
inverse ratio modes is that paralysis and
heavy sedation aren’t required because
patients can breathe anywhere in the pressure
cycle.
There are more risks with the use of
APRV than with the other modes, including
a higher incidence of pneumothorax and
other ventilator trauma injuries because of
the higher levels of pressure combined with
the decrease in patient lung compliance.
High frequency oscillatory ventilation
Used when all other modes fail to improve
oxygenation, HFOV isn’t usually found on
www.NursingMadeIncrediblyEasy.com
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
a traditional ventilator. This mode, along
with APRV, is considered a rescue mode of Invasive
ventilation and is most commonly used in ventilation
adult patients with ARDS or for neonates usually requires
with neonate respiratory distress syndrome weaning.
or meconium aspiration. The benefit of
using this type of ventilation is that it has
been shown to significantly improve oxy-
genation when conventional methods have
been unsuccessful by sustaining very high
levels of PEEP almost continuously. This
high level of PEEP helps provide enough
pressure to reopen areas of collapsed
alveoli (atelectasis), often referred to
as recruitment.
The downside of HFOV is the potential
for the development of pneumothorax or
other barotrauma. There’s also a potential for
complications from the use of paralytics,
sedation, and pain medication. All three are
required for patients to tolerate HFOV. This
can lead to difficulty in assessing neurologic
function or when transitioning the patient to
a conventional mode. These patients are
often critically ill and require frequent close
monitoring of arterial blood gases (ABGs)
and one-to-one nursing care.
Pressure support
PS is considered a weaning mode used to
assess the patient’s readiness for extubation.
It doesn’t use a set respiratory rate and is a
pressure-driven mode rather than a time-
triggered one. PS requires the patient to
initiate each breath and then that breath is
assisted through the ET tube with a set
amount of pressure. This support helps
overcome the resistance of the ET tube.
When this mode is used, the pressure is
often started at a high rate, such as 20 cm
H2O, and titrated to usually 8 cm H2O
before extubation. The lower the pressure,
the more work the patient needs to do to
pull adequate TV through the ET tube. After
the patient has been weaned to the lowest
amount of PS and is able to achieve ade-
quate TV while maintaining oxygenation, it
suggests that he or she will be able to be
May/June 2013 Nursing made Incredibly Easy! 49
ZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 03/21/2023
Downloaded from http://journals.lww.com/nursingmadeincrediblyeasy by BhDMf5ePHKav1zEoum1tQfN4a+kJLhE
successfully extubated. PS can also be used
in conjunction with SIMV as additional
assistance for independent breaths.
When assessing a patient in this mode, it’s
important to ensure that he or she is getting
adequate TV. Remember that the patient
should be achieving volumes between 400
and 800 mL based on body weight. The
amount of time that a patient remains in PS
mode will depend on how ready he or she is
for extubation. Weaning often starts with
short periods of high pressures; as the
patient tolerates the trial, the periods can be
extended and the pressure decreased. Strong
patients may do a PS trial for less than an
hour and then be extubated. Patients who
are weak, who suffer from chronic lung
disease, or who’ve been intubated for
long periods of time may take several days
or even weeks with daily trials to be ready
for extubation.
The biggest benefit of using the PS mode
is that it acts as a stepping stone between a
dependent ventilator mode and extubation.
This helps decrease the risk of reintubation
by allowing adequate assessment of the
patient’s ability to breathe independently.
It also helps work the respiratory muscles to
get them ready for independent breathing.
The downside of PS is that the increased
work of breathing can leave the patient tired
did you know?
The use of ventilators has been recorded since the early 1800s, but
modern ventilation was first used in the 1940s. The early mechanism was
based on keeping the chest in a negative-pressure environment that was
contained in a closed system such as the “iron lung.” As technology
advanced, so did the benefits. Healthcare providers were able to perform
surgeries that weren’t possible without mechanical ventilation, and many
patients who previously wouldn’t have survived recovered from infections
such as pneumonia. However, there were also drawbacks. The equipment
was large and difficult to use, most ICUs weren’t able to handle more than
four or five ventilated patients, and there was difficulty maintaining
adequate ventilation. Today’s advanced ventilators are portable and use
positive pressure—the forcing of gases into the chest—instead of
negative pressure. Patients are no longer placed inside the ventilator; an
ET tube is all that’s required.
50 Nursing made Incredibly Easy! May/June 2013
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
and unable to pull enough TV to maintain
adequate ventilation. Poor ventilation can
lead to hypercapnia and respiratory acidosis.
Alarm limits should be set to detect patterns
of low volumes to help decrease this risk.
Tachycardia and tachypnea can also be signs
that a patient may need a higher level of
pressure or require rest in AC mode. Often,
patients who’ve been on mechanical ventila-
tion for an extended period of time have a
weak diaphragm due to the decreased work-
load of breathing while on the ventilator.
These patients may require higher levels of
support and many days of weaning trials
before extubation.
Noninvasive ventilation
Sometime patients don’t need to be intu-
bated but need breathing support. When
respiratory failure is pending, the health-
care team will often take the least aggres-
sive method of providing appropriate
ventilation. Noninvasive ventilation can
be an effective alternative to intubation.
There are two different methods of non-
invasive ventilation that can be used in
this situation: BIPAP and continuous
positive airway pressure (CPAP). Both
use a mask that’s placed over the nose
or face delivering positive airway pres-
sure and oxygen to help assist breathing.
These methods are to be used only for a
patient who’s breathing spontaneously.
Let’s take a closer look.
Bilevel positive airway pressure
BIPAP provides positive airway pressure
during both inspiration and exhalation.
This helps assist patients who are spontane-
ously breathing with ventilation and gas
exchange.
BIPAP is useful in assisting patients with
achieving full TV, leading to improved ven-
tilation in patients with impending respira-
tory failure. It can also provide supplemental
oxygen along with inspiratory pressure.
BIPAP is often used with patients who are
hypercapnic or who have elevated levels of
www.NursingMadeIncrediblyEasy.com
ZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 03/21/2023
Downloaded from http://journals.lww.com/nursingmadeincrediblyeasy by BhDMf5ePHKav1zEoum1tQfN4a+kJLhE
carbon dioxide (CO2). It helps improve ven-
tilation and decrease high CO2 levels, but
can only be used in patients who are able to
breathe independently. BIPAP isn’t appro-
priate for a patient who’s apneic or who has
a low respiratory rate.
Continuous positive airway pressure
CPAP is a noninvasive form of PEEP. It can
be provided through a ventilator as a sepa-
rate mode, but can also be delivered via
an independent machine. CPAP is most
commonly delivered through a small mask
that’s worn over the nose, but can also be
provided through a full-face mask.
CPAP provides a constant end-expiratory
pressure that helps keep the airway open;
some machines also provide supplemental
oxygen if required by the patient. Because this
type of noninvasive ventilation provides con-
stant airway pressure, it’s most often used for
patients with obstructive sleep apnea (OSA).
The biggest benefit of CPAP is decreasing
or even eliminating the adverse reactions of
OSA. The positive pressure helps prevent
obstruction while the patient is sleeping and
allows for effective ventilation and oxygen-
ation. Patients most often complain about
wearing the mask but, for most, the improved
quality of sleep outweighs the discomfort.
Nursing considerations
As the nurse caring for an intubated patient,
it’s important to be aware of the different
alarms you may encounter. One of the most
common alarms is a high pressure alarm,
which may mean that there are secretions
present and the patient requires suctioning
or that the patient is biting on the ET tube
and may require more sedation. Most
intubated patients will require some seda-
tion and analgesia to make tolerating the
ET tube more comfortable. The other com-
mon alarm is a low pressure alarm, which
may indicate that there’s an air leak in the
ventilator circuit or the cuff on the end of the
ET tube and air is leaking past the cuff and
out of the patient’s mouth. Adding some air
www.NursingMadeIncrediblyEasy.com
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
to the cuff or finding the leak in the circuit
will resolve this type of alarm (see Trouble- If you need help
shooting problems with mechanical ventilation). breathing,
Caring for an intubated patient also noninvasive
requires a basic care routine and assessment ventilation may
skills. Each ET tube is marked in centimeters,
be used.
and the position should be checked every
4 hours. When checking the tube’s position,
it’s also a good time to assess for skin integ-
rity, the stability of the securement device,
and lung sounds. Mouth care
should also be provided
every 4 hours, and the
patient’s teeth should be
brushed twice a day to
decrease the incidence
of ventilator-acquired
pneumonia.
You also need to be
aware of the complications of mechanical
ventilation. Two of the most dangerous are
volutrauma and barotrauma. Volutrauma is
often caused by a TV that’s too high, causing
overdistension of the alveoli and leading to
edema at the level of the alveoli where oxy-
genation takes place. Barotrauma is caused
by elevated pressure in the lungs from high
levels of PEEP. Most often seen in patients
who have decreased lung compliance, such
as in ARDS or pulmonary fibrosis, the first
signs of barotrauma are low oxygen levels,
tachypnea, agitation, and high airway pres-
sures.
For patients receiving BIPAP or CPAP,
you must assess the quality and rate of respi-
rations. If respirations change or decrease, it
may be a sign of worsening respiratory fail-
ure. Lung sounds should also be assessed at
regular intervals to evaluate adequate air
movement.
Like invasive ventilation, there are also
alarms associated with noninvasive ventila-
tion. The most common cause of alarms is
low volume due to a leak in the seal between
the mask and the patient’s face. Readjustment
of the mask to a tighter seal will usually
resolve this problem. Other alarms may be
for low or high respiratory rates or low TV,
May/June 2013 Nursing made Incredibly Easy! 51
ZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 03/21/2023
Downloaded from http://journals.lww.com/nursingmadeincrediblyeasy by BhDMf5ePHKav1zEoum1tQfN4a+kJLhE

meaning that the patient isn’t breathing deep
enough. These alarms may indicate that the
patient isn’t tolerating the therapy and may
require intubation. ABG monitoring may be
needed to determine if a patient is tolerating
noninvasive ventilation.
Ready, set, go!
allow you to assess what the next step for
your patient will be. ■
Learn more about it
Adams AB. Too many ventilator modes! Respir Care.
2012;57(4):653-654.
Daoud EG, Farag HL, Chatburn RL. Airway pressure
release ventilation: what do we know? Respir Care.
2012;57(2):282-292.

Invasive and noninvasive ventilator modes
aren’t as daunting as you may think. Venti-
lators have come a long way over the years
and are often seen in the ICU, ED, and OR
settings. When working in these areas, or
Want more
in other areas that commonly use ventila-
CE? You tors, it’s important to know how to inter-
got it! pret the settings. Knowing the ventilator
mode that your patient is on will help you
identify what settings will be present and
Kacmarek RM. The mechanical ventilator: past, present,
and future. Respir Care. 2011;56(8):1170-1180.
Siau C, Stewart TE. Current role of high frequency
oscillatory ventilation and APRV in acute lung injury
and acute respiratory distress syndrome. Clin Chest Med.
200;29(2):265-275.
Singer BD, Corbridge TC. Basic invasive mechanical
ventilation. South Med J. 2009;102(12):1238-1245.
The author and planners have disclosed that they have no financial
relationships related to this article.
DOI-10.1097/01.NME.0000428429.60123.f7

For more than 36 additional continuing education

articles related to respiratory topics,
go to Nursingcenter.com/CE.

Earn CE credit online:

Go to http://www.nursingcenter.com/CE/nmie
and receive a certificate within minutes.

Set the stage for ventilator settings
TEST INSTRUCTIONS
• To take the test online, go to our secure
Web site at http://www.nursingcenter.com/
CE/nmie.
• On the print form, record your answers in the
test answer section of the CE enrollment form on
page 56. Each question has only one correct
answer. You may make copies of these forms.
• Complete the registration information and
course evaluation. Mail the completed form and
registration fee of $21.95 to: Lippincott Williams &
Wilkins, CE Group, 74 Brick Blvd., Bldg. 4, Suite
206, Brick, NJ 08723. We will mail your certificate
in 4 to 6 weeks. For faster service, include a fax
number and we will fax your certificate within 2
business days of receiving your enrollment form.
• You will receive your CE certificate of earned
contact hours and an answer key to review your
results.There is no minimum passing grade.
• Registration deadline is June 30, 2015.
INSTRUCTIONS
DISCOUNTS and CUSTOMER SERVICE
• Send two or more tests in any nursing journal published by Lippincott Williams &
Wilkins together by mail and deduct $0.95 from the price of each test.
• We also offer CE accounts for hospitals and other health care facilities on nursingcenter.
com. Call 1-800-787-8985 for details.
PROVIDER ACCREDITATION
Lippincott Williams & Wilkins, publisher of Nursing made Incredibly Easy!, will award
2.0 contact hours for this continuing nursing education activity.
Lippincott Williams & Wilkins is accredited as a provider of continuing nursing edu-
cation by the American Nurses Credentialing Center’s Commission on Accreditation.
This activity is also provider approved by the California Board of Registered
Nursing, Provider Number CEP 11749 for 2.0 contact hours. Lippincott Williams &
Wilkins is also an approved provider of continuing nursing education by the District of
Columbia and Florida #FBN2454.
Your certificate is valid in all states.
The ANCC’s accreditation status of Lippincott Williams & Wilkins Department
of Continuing Education refers only to its continuing nursing educational activities
and does not imply Commission on Accreditation approval or endorsement of any
commercial product.

52 Nursing made Incredibly Easy! May/June 2013 www.NursingMadeIncrediblyEasy.com

Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.