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MECHANICAL VENTILATION
Mechanical ventilation is a form of life support. A mechanical ventilator is a machine
that takes over the work of breathing when a person is not able to breathe enough on
their own. The mechanical ventilator is also called a ventilator, respirator, or breathing
machine. There are many reasons why a patient may need a ventilator, but low oxygen
levels or severe shortness of breath from an infection such as pneumonia are the most
common reasons.

WHY ARE VENTILATORS USED?

■ To deliver high concentrations of oxygen into the lungs.
■ To help get rid of carbon dioxide.
■ To decrease the amount of energy a patient uses on breathing so their body can
concentrate on fighting
Infection or recovering.
■ To breathe for a person who is not breathing because of injury to the nervous system,
like the brain or spinal cord, or who has very weak muscles.
■ To breathe for a patient who is unconscious because of a severe infection, buildup of
toxins, or drug overdose.

HOW DOES A VENTILATOR WORK?

When a person needs to be on a ventilator, a healthcare provider will insert an
endotracheal tube (ET tube) through the patient’s nose or mouth and into their
windpipe (trachea). This tube is then connected to the ventilator. The endotracheal tube
and ventilator do a variety of jobs. The ventilator pushes a mixture of air and oxygen
into the patient’s lungs to get oxygen into the body. The ventilator can also hold a
constant amount of low pressure, called positive end-expiratory pressure (PEEP), in
order to keep the air sacs in the lung from collapsing. The endotracheal tube allows
doctors and nurses to remove mucous from the windpipe by suction. If a person has a
blockage in the trachea, such as from a tumor, or needs the ventilator for a long period
of time, then they may need a tracheostomy procedure. During a tracheostomy, a
surgeon makes a hole in the patient’s neck and trachea, then inserts a breathing tube
called a tracheostomy tube into the hole. The tracheostomy tube is then connected to
the ventilator. A tracheostomy tube can stay in as long as needed, but does not have to
be permanent and can be removed if a patient no longer needs it. It is possible for a
person to talk and eat with a tracheostomy tube. For more information about having a
tracheostomy tube, see ATS Patient Information.

HOW ARE PATIENTS ON VENTILATORS MONITORED?

Most patients on a ventilator are monitored in an ICU. Anyone on a ventilator in an ICU
setting will be hooked up to a monitor that measures heart rate, respiratory rate, blood
pressure, and oxygen saturation (“O2 sats”). Other Tests that may be done include
chest-x-rays and blood drawn to measure oxygen and carbon dioxide (“blood gases”).
Members of the health care team (including doctors, nurses, and respiratory therapists)
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will use this information to assess the patient’s status and make adjustments to the
ventilator if necessary.

MODES OF MECHANICAL VENTILATOR

01-Volume-Controlled Ventilation (VCV): Delivers a preset tidal volume to the

patient with each breath.

Tidal Volume Setting: In VCV, the healthcare provider sets the desired tidal volume on
the ventilator. This volume is typically based on the patient's size and respiratory needs.

Constant Volume Delivery: Regardless of the patient's lung compliance (the ease with
which the lungs can expand) or airway resistance (the force opposing airflow in the
airways), the ventilator ensures that the set tidal volume is delivered consistently with
each breath.

Ventilator-Controlled Breathing: VCV is mainly ventilator-controlled, meaning the

machine initiates and controls each breath. The patient's own respiratory efforts may
not influence the rate or volume of delivered breaths.

Use Cases: VCV is often used in patients with various respiratory conditions, such as
acute respiratory distress syndrome (ARDS) or in surgical settings where precise
control of ventilation is necessary. It can be adjusted to deliver different tidal volumes
based on the patient's needs.

Monitoring and Adaptation: Caregivers closely monitor the patient's response to VCV
and may make adjustments to the tidal volume or other ventilator settings as needed to
maintain proper oxygenation and ventilation.

2. Pressure-Controlled Ventilation (PCV): Maintains a constant airway pressure

during inspiration, useful in managing conditions with high airway resistance.
Constant Pressure: In PCV, the ventilator is set to maintain a constant airway pressure
during inspiration. This means that the pressure is the primary parameter controlled by
the ventilator, rather than the tidal volume as in Volume-Controlled Ventilation (VCV).

Pressure Limit: The clinician sets the desired inspiratory pressure (often referred to as
the "pressure limit" or "peak inspiratory pressure") on the ventilator. This pressure
limit is the maximum pressure allowed during inspiration.

Variable Tidal Volume: Unlike VCV, where the tidal volume is predetermined, the tidal
volume achieved in PCV is variable and depends on the patient's lung compliance and
airway resistance. This can be beneficial in patients with variable lung conditions.

High Airway Resistance: PCV is particularly beneficial in patients with conditions that
cause high airway resistance, such as asthma, chronic obstructive pulmonary disease
(COPD), or bronchospasm. It helps in delivering adequate ventilation while preventing
barotrauma (lung injury due to high pressure) by limiting the maximum pressure.
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Lung Protective Strategy: PCV is often used as part of a lung-protective ventilation

strategy in patients with acute respiratory distress syndrome (ARDS). By maintaining a
controlled pressure, it helps reduce the risk of over inflation and potential lung injury.

Monitoring: Caregivers closely monitor the patient's response to PCV and adjust the
pressure settings as needed to ensure proper oxygenation and ventilation.

3. Synchronized Intermittent Mandatory Ventilation (SIMV): Combines mandatory

breaths with patient-triggered breaths, giving the patient some control.

Mandatory and Patient-Triggered Breaths: In SIMV, the ventilator delivers a set

number of mandatory breaths per minute at a predetermined rate. These mandatory
breaths provide the basic ventilatory support needed to maintain adequate oxygenation
and ventilation.

Patient Control: In addition to the mandatory breaths, patients have the option to
initiate their own breaths whenever they want. These patient-triggered breaths allow
the patient to take extra breaths beyond the mandatory ones, providing a degree of
control over their breathing.

Control Over Tidal Volume: For patient-triggered breaths, the tidal volume (the
amount of air moved in and out of the lungs with each breath) can be controlled by the
patient's own effort, but it is often assisted by the ventilator to ensure adequate
ventilation.

Use Cases: SIMV is commonly used in patients who are transitioning from full
ventilatory support to weaning. It allows patients to gradually regain control of their
breathing while still receiving assistance as needed.

Weaning Process: As the patient's respiratory function improves, the number of

mandatory breaths provided by the ventilator is reduced over time. The goal is to wean
the patient off the ventilator entirely and encourage them to breathe independently.

Reducing Ventilator Dependence: SIMV is an important mode for avoiding ventilator-

associated muscle weakness and promoting patient participation in the weaning
process, ultimately facilitating a smoother transition to spontaneous breathing.

Monitoring and Adjustment: Clinicians closely monitor the patient's progress and
adjust the ventilator settings, including the number of mandatory breaths, to match the
patient's changing needs as they recover.

4. Assist-Control Ventilation (AC): Provides a set number of breaths per minute, and
patients can initiate additional breaths. Each breath can be pressure-controlled or
volume-controlled.

Controlled and Assisted Breath: In AC mode, the ventilator provides a preset number
of breaths per minute (mandatory breaths). These mandatory breaths can be either
pressure-controlled or volume-controlled, depending on the settings chosen by the
healthcare provider.
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Patient-Initiated Breaths: Patients can also trigger additional breaths beyond the
mandatory ones. These additional breaths can be initiated by the patient when they feel
the need to breathe. The patient-triggered breaths are supported by the ventilator.

Protection and Support: AC mode ensures that the patient receives a minimum
number of breaths, which is particularly important in critical cases where the patient
may be unable to initiate breaths on their own. This mode offers a safety net by
guaranteeing a certain level of ventilation.

Choice of Ventilation Type: In AC mode, the ventilator can be configured to provide

either pressure-controlled or volume-controlled breaths for the mandatory component.
Pressure-controlled ventilation maintains a set airway pressure during inspiration,
while volume-controlled ventilation delivers a predetermined tidal volume with each
breath.

Adaptability: AC mode can be tailored to suit the specific needs of the patient, making it
versatile for a wide range of respiratory conditions. Clinicians can adjust the settings
based on the patient's lung mechanics and respiratory status.

Use Cases: AC is frequently used in various clinical situations, including patients with
respiratory failure, post-operative care, or those with reduced respiratory drive. It is
also utilized when transitioning patients from full ventilatory support to more
spontaneous breathing.

Monitoring and Adjustment: Healthcare professionals closely monitor the patient's

response to AC ventilation and may make adjustments to the ventilator settings as
needed to maintain optimal oxygenation and ventilation.

5. Pressure Support Ventilation (PSV): Supports spontaneous breaths initiated by the

patient by delivering a positive pressure during inspiration.

Spontaneous Breathing: PSV is used for patients who can initiate their own breaths
but may require assistance. It does not provide a set number of mandatory breaths like
other modes but supports the patient's efforts to breathe spontaneously.

Pressure Assistance: The ventilator in PSV delivers a positive pressure during

inspiration to make it easier for the patient to take a breath. This pressure helps
overcome the resistance of the airways and the elasticity of the lung tissue.

Variable Tidal Volume: The tidal volume in PSV is not fixed and depends on the
patient's own effort. The patient determines the depth of each breath, while the
ventilator ensures a consistent level of pressure support.

Patient Control: Patients can control both the timing and depth of their breaths, giving
them a greater sense of control over their own respiration.

Weaning and Reducing Work of Breathing: PSV is often used during the weaning
process when a patient is transitioning from full ventilatory support to spontaneous
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breathing. It helps reduce the work of breathing for patients who are regaining their
respiratory function.

Monitoring and Adjustment: Clinicians closely monitor the patient's response to PSV
and adjust the level of pressure support to match the patient's respiratory needs. This
adjustment can be based on factors like respiratory rate and oxygenation.

Use Cases: PSV is commonly used in weaning protocols and for patients recovering
from respiratory conditions or surgeries. It allows patients to regain their ability to
breathe independently while providing support as needed.

Comfort and Interaction: PSV is well-regarded for its ability to provide a more natural
and comfortable breathing experience for patients. It also allows for better patient-
ventilator interaction.

TYPES OF MECHANICAL VENTILATOR

1. Critical Care Ventilators: These are versatile ventilators designed for use in
intensive care units (ICUs) and other critical care settings. They offer a wide range of
ventilation modes and settings to provide advanced respiratory support for critically ill
patients.

2. Transport Ventilators: Transport ventilators are portable and compact, designed

for use during patient transportation within a healthcare facility or even during
ambulance transport. They are built to withstand movement and maintain reliable
ventilation.

3. Neonatal Ventilators: These specialized ventilators are designed for premature

infants and neonates. They provide precise control of very small tidal volumes and
gentle pressure to protect delicate neonatal lungs.

4. Pediatric Ventilators: Pediatric ventilators are designed for children and

adolescents. They offer settings and features tailored to the smaller lung capacities and
unique needs of pediatric patients.

5. Home Ventilators: These ventilators are designed for use in a home setting. They are
often more user-friendly and compact, allowing patients with chronic respiratory
conditions to receive ventilatory support while remaining at home.

6. Non-Invasive Ventilators: Non-invasive ventilators provide respiratory support

without intubation. They are used in conditions like sleep apnea, chronic obstructive
pulmonary disease (COPD), and other cases where invasive ventilation is not required.

7. High-Frequency Ventilators: High-frequency ventilators deliver very rapid, small-

volume breaths at high frequencies. They are used in neonatal and pediatric patients
with acute respiratory distress.
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8. Volume-Controlled Ventilators: These ventilators deliver a preset tidal volume

with each breath, ensuring a consistent volume of air is moved in and out of the lungs.

9. Pressure-Controlled Ventilators: Pressure-controlled ventilators maintain a

constant airway pressure during inspiration, making them suitable for conditions with
high airway resistance.

10. Bi-level Positive Airway Pressure (BiPAP) Ventilators: BiPAP devices are
primarily used for non-invasive ventilation, providing two pressure levels for inhalation
and exhalation to assist patients with conditions like sleep apnea or acute respiratory
failure.

11. Continuous Positive Airway Pressure (CPAP) Ventilators: CPAP devices

maintain a constant positive pressure throughout the respiratory cycle, commonly used
to treat obstructive sleep apnea and provide oxygenation support.

12. Pressure Support Ventilators: These devices support spontaneous breaths

initiated by the patient by delivering a positive pressure during inspiration. They are
useful in weaning patients from full mechanical ventilation.

HOW LONG IS A VENTILATOR USED?

A ventilator can be lifesaving, but its use has risks. It doesn’t fix the problem that led to
the person needing the ventilator in the first place; it just helps support a person until
other treatments become effective, or the person gets better on their own. The health
care team always tries to help a person get off the ventilator at the earliest possible
time. “Weaning” refers to the process of getting the patient off the ventilator. Some
patients may be on a ventilator for only a few hours or days, while others may require
the ventilator for longer. How long a patient needs to be on a ventilator depends on
many factors. These can include overall strength, how well their lungs were before
going on the ventilator, and how many other organs are affected (like the brain, heart
and kidneys). Some people never improve enough to be taken off the ventilator.

HOW DOES A PATIENT FEEL WHILE ON A VENTILATOR?

The ventilator itself does not cause pain, but the tube may cause discomfort because it
can cause coughing or gagging. A person cannot talk when an ET tube passes between
the vocal cords into the windpipe. He or she also cannot eat by mouth when this tube is
in place. A person may feel uncomfortable as air is pushed into the lungs. Sometimes a
person will try to breathe out when the ventilator is trying to push air in. This is
working (or fighting) against the ventilator and makes it harder for the ventilator to
help.

WHAT ARE RISKS OF MECHANICAL VENTILATION?

Problems that can develop from using a ventilator include:
■ Infections—Patients who are on the ventilator are more likely to get pneumonia,
which can be a serious problem.
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A patient may need to remain on the ventilator for longer while the pneumonia is
treated with antibiotics.
■ Collapsed lung (pneumothorax)—sometimes, a part of the lung can become weak
and develop a hole, letting air leak out and causing a collapsed lung. If the lung collapse
is severe enough, it can cause death. In order to re-expand the lung, a tube needs to be
placed into the chest (chest tube) to drain the air that is leaking out. Once the lung has
healed, then the tube can be removed. For additional information on chest tubes.
■ Lung damage—the pressure of putting air into the lungs with a ventilator can
damage the lungs. Doctors try to keep this risk at a minimum by using the lowest
amount of pressure that is needed. Very high levels of oxygen may be harmful to the
lungs as well. Doctors only give as much oxygen as it takes to make sure the body is
getting enough to supply vital organs. Sometimes it is hard to reduce this risk when the
lungs are damaged. However, this damage may heal if a person is able to recover from
the serious illness.
■ Side effects of medications—Sedatives and pain medications can cause a person to
seem confused or delirious, and these side effects may continue to affect a person even
after the medications are stopped. The healthcare team tries to adjust the right amount
of medication for a person. Different people will react to each medicine differently. If a
medication to prevent muscle movement is needed, the muscles may be weak for a
period of time after the medication is stopped. This may get better over time.
Unfortunately, in some cases, the weakness remains for weeks to months.
■ Inability to discontinue ventilator support—Sometimes, the illness which led a
person to need a ventilator does not improve despite treatment. When this happens, the
healthcare team will discuss your treatment preferences regarding continuing support
on the ventilator. Often the healthcare team will have these discussions with family
members or the patient, if the person is able to participate. In situations where a person
is not recovering or is getting worse, a decision may be made to discontinue ventilator
support and allow death to occur.

HOW CAN I MAKE MY WISHES ABOUT USING A VENTILATOR KNOWN?

Mechanical ventilation is a “life-sustaining treatment”. It is a treatment that can prolong

life. It may be needed for only a short time. However, some people cannot be weaned off
the ventilator and do not want to stay on the machine. Other people who know they
have a very severe lung or health problem may not even want to use a ventilator at all
because the ventilator cannot fix their underlying disease. Some people have very
specific thoughts about if and when they should be placed on a ventilator. Although the
healthcare team helps people and their families make tough decisions about the end of
life, it is the person him or herself who has the final say. If a person cannot talk or
communicate decisions, the healthcare team will talk with his or her legally authorized
representative (usually a parent, wife or husband, adult child, or next of kin). It is
important that you talk with your family members and your healthcare provider about
using a ventilator and what you would like to happen in different situations. The more
clearly you explain your values and choices to friends, loved ones and the healthcare
team, the easier it makes it for them to follow your wishes if and when you are unable to
make decisions yourself. Advance directives are ways to also put your wishes in writing
to share with others. In the hospital, nurses, doctors and social workers can provide
information about an advance directive form.
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DISADVANTAGES OF MECHANICAL VENTILATOR

1. Infection Risk: Ventilators can introduce pathogens into the lungs, increasing the
risk of pneumonia and other respiratory infections.

2. Ventilator-Associated Lung Injury: Mechanical ventilation can potentially cause

lung damage, such as ventilator-induced lung injury (VILI), if not managed properly.

3. Barotrauma: High-pressure settings on a ventilator can lead to barotrauma, causing

damage to the lung tissue.

4. Oxygen Toxicity: Prolonged exposure to high levels of oxygen from a ventilator can
lead to oxygen toxicity and lung damage.

5. Ventilator-Associated Pneumonia (VAP): Patients on ventilators are at an

increased risk of developing VAP due to the presence of the breathing tube.

6. Dependency: Prolonged use of a ventilator can lead to patient dependency on

mechanical ventilation, making it challenging to wean them off the device.

7. Discomfort: Being on a ventilator can be uncomfortable for patients, as it often

involves sedation and immobilization.

8. Cost: Ventilators and their associated care can be expensive, and long-term use can
lead to high healthcare costs.

9. Mechanical Issues: Ventilators can experience technical problems or malfunction,

which can be life-threatening if not promptly addressed.

10. Difficulty in Communication: Patients on ventilators may have difficulty

communicating, which can lead to frustration and emotional distress.

CONCLUSION

Mechanical ventilation is an indispensable tool in modern medicine, but its application

necessitates a thorough understanding of its advantages and disadvantages. The
benefits of ventilatory support in saving lives and improving patient outcomes are
undeniable. However, the potential risks and complications require healthcare
providers to exercise caution, adhere to best practices, and continually monitor and
adjust treatment to ensure the safety and well-being of patients. With proper
management and vigilance, mechanical ventilation continues to be a cornerstone of
critical care and respiratory medicine, contributing significantly to the advancement of
healthcare worldwide.