Nursing Care of Clients on

Mechanical Ventilation
For BSN IV Students
LEARNING OUTCOMES
At the end of this lecture, the students will be able to:
• To define what is the mechanical ventilator (MV).
• Describe the goals of MV
• Understand the major indications for MV
• To determine modes of MV
• To know how to adjust MV
• To know how to deal with complications of MV
• To determine nursing management for ventilated client .
DEFINITION
• MECHANICAL VENTILATOR is a machine that generates a
controlled flow of gas into a client’s airways. O2 and air
are received from cylinders or wall outlets, the gas is
pressure reduced and blended according to the
prescribed inspired O2 tension (FiO2), accumulated in a
receptacle within the machine, and delivered to the
client using one of many available modes of ventilations.
INDICATIONS
- Need for sedation/ neuromuscular blockage.
- Need to ↓ systemic or myocardial oxygen consumption.
- Use of hyperventilation to reduce intracranial pressure
- Respiratory distress (RR > 30, use of accessory muscles)
- Respiratory Failure: 2 Types
• Hypoxemic Respiratory Failure: PaO2 < 60 mmHg
• Hypercapnic Respiratory Failure: PaCO2 > 50 mmHg
• “Ventilatory Failure”, caused by ↑ work of breathing, ↓
ventilatory drive, or muscle fatigue
- Need to Protect the Airway
• pt’s ability to sneeze, gag or cough à been dulled à possibility
of aspiration
Cont…
Ventilation abnormalities
ØRespiratory muscle dysfunction
ØRespiratory muscle fatigue
ØChest wall abnormalities
ØNeuromuscular diseases
Oxygenation Abnormalities
ØRefractory hypoxemia.
ØNeed for positive end expiratory pressure.
ØExcessive work of breathing (WOB).
CONTRAINDICATION: ARTIFICIAL
AIRWAY
• Pt’s desire to not be resuscitated has been expressed and
is documented in the patient’s chart
Establishing an
Artificial Airway
VIA AN ENDOTRACHEAL TUBE (ET)

Adult female 8.0

Adult male 9.0
Miller vs. MacIntosh Blades
 Intubation
Procedure
Check and Assemble Equipment:

üOxygen flowmeter and O2 tubing

üSuction apparatus and tubing
üSuction catheter or yankauer
üAmbu bag and mask
üLaryngoscope with assorted blades
ü3 sizes of ET tubes
üStylet
üStethoscope
üTape
üSyringe
üMagill forceps
üTowels for positioning
 Intubation
Procedure
Position your patient into the sniffing position
 Intubation
Procedure
Preoxygenate with 100% oxygen to provide apneic or distressed
patient with reserve while attempting to intubate.

Do not allow more than 30 seconds to any intubation

attempt.
If intubation is unsuccessful, ventilate with 100% oxygen for
3-5 minutes before a reattempt.
Intubation Procedure
Insert Laryngoscope
Intubation
Procedure
 Intubation
Procedure
After displacing the epiglottis insert the ETT.

The depth of the tube for a male

patient on average is 21-23 cm at teeth
The depth of the tube on average for a female patient is
19-21 at teeth.
Intubation
Procedure
Confirm tube position:

üBy auscultation of the chest

üBilateral chest rise
üTube location at teeth
üCO2 detector – (esophageal
detection device)
Intubation Procedure
Stabilize the ETT
 Intubation
Procedure
Video on Intubation:

http://youtube.com/watch?v=eRkleyIJi9U&fe
ature=related
DIFFERENT TYPES OF VENTILATORS
Cont…
HIGH FREQUENCY MECHANICAL VENTILATOR
 VENTILATOR SETTINGS
• A/C : Assist-Control
• IMV : Intermittent Mandatory Ventilation
• SIMV : Synchronized Intermittent Mandatory
Ventilation
• BILEVEL : Non-inversed Pressure Ventilation with
Pressure Support
• PRVC : Pressure Regulated Volume Control
• PEEP : Positive End Expiratory Pressure
• CPAP : Continuous Positive Airway Pressure
• PSV : Pressure Support Ventilation
• NIPPV : Non-Invasive Positive Pressure Ventilation
VOLUME VS. PRESSURE
VENTILATION
• Volume ventilation: Volume is constant and pressure will
vary with patient’s lung compliance.
• Pressure ventilation: Pressure is constant and volume will
vary with patient’s lung compliance.
MODES OF VENTILATOR
• Spontaneous
• The machine is not giving pressure breath.
• The client breath spontaneously.
• The client needs only specific FiO2 to maintain its
normal blood gases.
Cont…
• Control Mode:
• The machine controls the client ventilation according to
set tidal volume and respiratory rate.
• Spontaneous respiratory effort of client is locked out à
client with sedation and paralyzing drugs
 Cont…
• Assist/Control Mode
• The client triggers the machine with negative inspiratory
effort.
• If the client fails to breath à vent. will deliver a controlled
breath at a minimum rate and volume already set.
• The pt generated resp. effort over & above the set rate.
 Cont…
Sychronized Intermittent Mandatory Ventilation (SIMV):
• Machine allows the client to breath spontaneously while
providing preset FiO2, and a number of ventilator breaths to
ensure adequate ventilation without fatigue
• Delivers a pre-set no. of breaths at a set vol. & flow rate.
• Allows to generate spontaneous breaths, volumes, and flow rates
between the set breaths.
• Detects a spontaneous breath attempt & doesn’t initiate a
ventilatory breath.
 Cont…
Pressure Regulated Volume Control (PRVC)
• It is a vol. targeted, pressure limited mode. (available in SIMV or
AC)
• Each breath is delivered at a set volume with a variable flow rate
and an absolute pressure limit.
• The vent. delivers pre-set volume at the LOWEST required peak
pressure and adjust with each breath.
Cont…
Continuous Positive Airway Pressure (CPAP)
• A pre-set pressure is present in the circuit and lungs
throughout both the inspiratory and expiratory phases of
the breath.
• To keep alveoli from collapsing, resulting in better
oxygenation and less work of breathing.
• Commonly used as a mode to evaluate the patients
readiness for extubation.
HIGH FREQUENCY VENTILATION
Comparison of HFOV & Conventional Ventilation
Cont…
• Oxygenation: primarily controlled by the Mean Airway
Pressure (Paw) and the FiO2.
• Paw: a constant pressure used to inflate the lung and
hold the alveoli open.
• Since the Paw is constant à reduces the injury that
results from the lung open for each breath
INITIAL SETTINGS
• Select mode of ventilation
• Set sensitivity at Flow trigger mode
• Set Tidal Volume
• Set Rate
• Set Inspiratory Flow (if necessary)
• Set PEEP
• Set Pressure Limit
• Humidification
POST INITIAL SETTINGS
• Obtain an ABG (arterial blood gas) about 30 minutes after
set the patient up on the ventilator.
• ABG: will give information about any changes that may
need to be made to keep the patient’s oxygenation and
ventilation status within a physiological range.
Cont…
ABG
• Goal: keep patient’s acid/base balance within normal
range:
• pH 7.35 – 7.45
• PCO2 35-45 mmHg
• PO2 80-100 mmHg
TROUBLESHOOTING
• In mech. vent. pts, acute elevations in airways pressures can
be triggered by both benign & life-threatening causes.
• When the ventilator alarms, what is your approach in
troubleshooting the potential problems? The causes?
• Can be due to a malfunction of the ventilator
• Patient may need to be suctioned
• Frequently the patient needs medication for anxiety or
sedation to help them relax
• Responsibility:
• Attempt to fix the problem
• Call physician in charge
Cont…
• Low Pressure Alarm
• Usually due to a leak in the circuit.
• Attempt to quickly find the problem
• Bagging the patient and call the doctor.
• High Pressure Alarm
• Usually caused by:
• A blockage in the circuit (water condensation)
• Patient biting his ETT
• Mucus plug in the ETT
• Attempt to quickly fix the problem
• Bagging the patient and call the doctor.
Cont…
• Low Minute Volume Alarm
• Usually caused by:
• Apnea of the patient (CPAP)
• Disconnection of the patient from the ventilator
• Attempt to quickly fix the problem
• Bagging the patient and call the doctor
Cont…
• Accidental extubation
• Role of the Nurse:
• Ensure the BVM is attached to the oxygen flowmeter
and it is on à supply the patient with ventilation.
• When the nurse have concerns, hear alarms, notice the
changes in ventilator or faced with other problem with
ventilated patient à call for help à NEVER PUSH THE
SILENCE BUTTON
ADJUSTMENT OF MV
• Purpose of adjustment:
• So that the client is comfortable and "in sync " with the
ventilator
• Minimal alteration of the normal cardiovascular and
pulmonary dynamics is desired.
• If the volume of ventilator is adjusted appropriately ,
the client arterial blood level will be satisfactory and
there will be no or little cardiovascular compromise
RECOMMENDED GUIDELINES
1. Set the vent. to deliver the required tidal volume ( 6 - 8
ml/kg)
2. Adjust the vent. to deliver the lowest concentration of the
O2 to maintain normal PaO2 (80 - 100mmhg). Early stage à
may be set high à gradually reduced based on ABGs result.
3. Record peak inspiratory pressure.
4. Select mode (assist/control or SIMV) and rate accordingly
5. If using assist/control mode, adjust sensitivity so that the
patient can trigger the vent. with the minimum effort
(usually 2mmHg negative inspiratory force)
Cont…
6. Record the setting
7. Take ABG after 20 - 30 minutes of mechanical ventilation:
measure carbon dioxide partial pressure (PaCO2), Ph
8. Adjust FiO2 and rate à according to results of ABG
9. In case of client suddenly having onset of confusion,
agitation, restless or unexplained "bucking the ventilator" à
assess for hypoxemia and manually ventilate on 100%
oxygen with resuscitation bag (AMBU bag/ Bag valve
mask).
10. Clients who are on controlled ventilation & have
spontaneous respiration may "fight/buck" the vent.,
because they cannot synchronize their own respiration with
the machine cycle.
Cont…
• Sedative and neuromuscular blocking agents may be
given such as:
• Pancuornium bromide (Pavulon)
• Midazolam
• Neuromuscular blocking agents à block the
transmission of nerve impulses and result in muscle
paralysis.
 COMPLICATIONS
1. DECREASED CARDIAC OUTPUT
• Cause: venous return to the Rt atrium impeded by the
dramatically ↑ intrathoracic pressures during inspiration
from +ve pressure ventilation. Also reduced
sympathoadrenal stimulation leading to a ↓ in peripheral
vascular resistance & ↓ BP
• Symptoms: ↑ heart rate, ↓ BP and perfusion to vital
organs, ↓ CVP, cool clammy skin.
• Tx:
• aim to increase preload (e.g. fluid challenge/resus)
• ↓ airway pressures exerted during MV by decreasing
inspiratory flow rates and TV
• or using other methods to ↓ airway pressures (e.g.
different modes of ventilation).
 Cont…
2. BAROTRAUMA
• Cause: damage to pulmonary system due to alveolar rupture
from excessive airway pressures and/or over distention of
alveoli.
• Symptoms: may result in pneumothorax,
pneumomediastinum, subcutaneous emphysema.
Treatment
• aimed at reducing TV, cautious use of PEEP
• avoidance of high airway pressures resulting in
development of auto-PEEP in high risk clients:
(obstructive lung diseases: asthma,
bronchospasm)(unevenly distributed lung diseases:
lobar pneumonia)(hyperinflated lungs: emphysema).
 Cont…
3. NOSOCOMIAL PNEUMONIA
• Cause: invasive device in critically ill clients becomes
colonized with pathological bacteria within 24 hours in
almost all patients.
• Treatment: aiming for prevention action:
• Avoid cross-contamination: frequent handwashing
• ↓ risk of aspiration (cuff occlusion of trachea, positioning,
use of small-bore NG tubes)
• Suction PRN: sterile technique, close method
• Maintain closed system setup on ventilator circuitry and
avoid pooling of condensation in the tubing
• Ensure adequate nutrition
• Avoid neutralization of gastric contents with antacids & H2
blockers
Cont…
4. Decreased Renal Perfusion
• can be treated with low dose dopamine therapy.
5. Increased Intracranial Pressure (ICP)
• reduce PEEP
6. Hepatic congestion
• reduce PEEP
7. Worsening of intracardiac shunts
• reduce PEEP
OTHER COMMON PROBLEM
RELATED TO MV
• Aspiration
• Gastrointestinal (GI) bleeding
• Inappropriate ventilation (resp. acidosis or alkalosis)
• Thick secretions
• Discomfort: pulling or jarring of ETT or tracheostomy
• High PaO2, Low PaO2
• Anxiety and fear
• Dysrhythmias/ vagal reactions during/ after suctioning
• Incorrect PEEP setting
• Inability to tolerate with ventilator mode
NURSING MANAGEMENT
• Promote respiratory
function.
• Suctioning
• Monitor for
complications
• Prevent infections.
• Provide adequate
nutrition.
• Monitor GI bleeding.
Cont…
Promote respiratory function
• Auscultate lungs frequently to
assess for abnormal sounds.
• Suction PRN
• Clock turning schedule every 2
hours.
• Secure ETT properly.
• Check ventilatory close system
• Monitor ABG value and pulse
oximetry.
 Cont…
Suctioning: purpose
• maintain a patent airway
• improve gas exchange.
• obtain tracheal aspirate specimen.
• prevent effect of retained
secretions.

OXYGENATE before and after

suctioning!!!!
 Cont…
Monitor for complications
• Assess for possible early complications:
• Rapid electrolyte changes, Severe alkalosis, Hypotension
secondary to change in cardiac output.
• Monitor for signs of respiratory distress:
• Restlessness, Apprehension, Irritability and increase HR.
• Assess for S&S of barotrauma (rupture of the lungs)
• Increasing dyspnea, Agitation, Decrease or absent breath
sounds, Tracheal deviation away from affected side,
Decreasing PaO2 level .
• Assess for cardiovascular depression:
• Hypotension, Tachycardia & Bradycardia, Dysrhythmias.
 Cont…
Prevent infection
• Frequent handwashing
• Maintain sterile technique when suctioning.
• Monitor color, amount and consistency of sputum.
Provide adequate nutrition
• Begin tube feeding as soon as it is evident the client will remain
on the ventilator for a long time.
• Weigh daily.
• Monitor intake and output .
Monitor for gi bleeding
• Assess bowel sounds.
• Monitor gastric Ph & gastric secretions every shift.
THANK YOU