Nursing Management of

patient with Mechanical

Ventilation

S U L EK H A S H R E S T H A
L E C T U R E R, K U S M S
 Introduction
Mechanical ventilation may be required for a variety of reasons,

including the need to control the patient’s respirations, to

oxygenate the blood when the patient’s ventilatory efforts are
inadequate, and to rest the respiratory muscles.
Many patients placed on a ventilator can breathe spontaneously,

but the effort needed to do so may be exhausting.

Caring for a patient on mechanical ventilation has become an

integral part of nursing care in critical care units.

 Introduction
Nurses, physicians, and respiratory therapists must

understand each patient’s specific pulmonary needs and

work together to set realistic goals.
Positive patient outcomes depend on;

 an understanding of the principles of mechanical ventilation

 the patient’s care needs
 open communication among members of the health care team about
the goals of therapy, weaning plans,
 the patient’s tolerance of changes in ventilator settings.
 Indications for M. Ventilation
 If a patient has a continuous decrease in oxygenation (PaO2), an

increase in arterial carbon dioxide levels (PaCO2), and a

persistent acidosis (decreased pH)

 Conditions such as thoracic or abdominal surgery, drug

overdose, neuromuscular disorders, inhalation injury, COPD,

multiple trauma, shock, multisystem failure, and coma all may

lead to respiratory .

 A patient with apnea that is not readily reversible also is a

candidate for mechanical ventilation.

 Criteria

PaO2 < 50 mm Hg with FiO2 > 0.60

PaO2 > 50 mm Hg with pH < 7.25

Vital capacity < 2 times tidal volume

Negative inspiratory force < 25 cm H2O

Respiratory rate > 35/min

 Assessment

The nurse has a vital role in assessing the patient’s

status and the functioning of the ventilator.

In assessing the patient, the nurse evaluates the

patient’s physiologic status and how he or she is

coping with mechanical ventilation.
Physical assessment includes systematic assessment

of all body systems, with an in-depth focus on the

respiratory system.
 Respiratory Assessment

The nurse is often the first to note changes

in physical assessment findings or

significant trends in blood gases that signal
the development of a serious problem (e.g.,
pneumothorax, tube displacement,
pulmonary embolus).
 Respiratory Assessment

It includes vital signs, respiratory rate and pattern,

breath sounds, evaluation of spontaneous ventilatory

effort, and potential evidence of hypoxia.
Assess respiratory status every 4 hr;

 Breath sounds
 patient’s diaphragmatic excursions and use of accessory
muscles of respiration.
 Patient’s ability to initiate a spontaneous breath
 Assess for signs and symptoms of hypoxemia
Listen with stethescope to the chest in all lobes

bilaterally. It confirms the proper placement of the

ET or tracheostomy tube.
Assess for the presence of secretions by lung

auscultation at least every 2 to 4 hours.

Determine whether breath sounds are present or

absent, normal or abnormal and whether a change

has occurred.
Monitor cuff pressures of ETT.

 Inflate cuff to prevent leak of air around the cuff

 Use commercial devices to monitor cuff pressures

 Notify the physician if pressures exceed 30 cm H2O

 Monitor oxygenation and ventilation

 Pulse oximetry and ETCO2 measurements

 ABGs

 Monitor serial chest x-ray studies for ETT placement

and improvement or worsening.

Increased adventitious breath sounds may indicate

a need for suctioning.

The nurse also evaluates the settings and
functioning of the mechanical ventilator.
 VT, FiO2, respiratory rate
 Mode of ventilation
 Use of PEEP, CPAP or pressure support
 Peak inspiratory pressure
 Alarms on
Assess for need of suctioning at least every 2

hours because patients with artificial airways

on mechanical ventilation are unable to clear
secretions on their own. Suctioning may help to
clear secretions and stimulate the cough reflex.
Check the water level in the humidification

reservoir to ensure that the patient is never

ventilated with dry gas.
 Cardiovascular Assessment

Monitor cardiovascular function. Assess for

abnormalities.
Monitor pulse rate and arterial BP; intra-arterial

pressure monitoring may be carried out.

Measure central venous pressure. Use pulmonary

artery catheter to monitor pulmonary capillary

wedge pressure (PCWP) and cardiac output (CO).
 Neurological Assessment

Assess the patient’s neurologic status and

effectiveness of coping with the need for assisted
ventilation and the changes that accompany it.
Evaluate need for sedation or muscle relaxants.

Sedatives may be prescribed to decrease anxiety or to

relax the patient to prevent “competing” with the
ventilator.
 Neurological Assessment

Monitor and maintain a flow sheet to record

ventilation patterns, neurological assessment

findings, ABGs, biochemical lab values, hemoglobin
and hematocrit, status of fluid balance and
assessment of the patient’s condition.
This establishes means of assessing effectiveness and

progress of treatment.
 Skin Integrity

Assess the patient’s comfort level and ability to

communicate as well.
Assess for the condition of the skin. Breakage in the

skin integrity on the pressure areas brings a huge

complication to the patients on mechanical
ventilation.
 GI Assessment

Monitor nutritional status and GI function:

Weaning from mechanical ventilation requires
adequate nutrition. Therefore, it is important to
assess the function of the gastrointestinal system
and nutritional status.
The abdomen is assessed for distention by
listening bowel sounds and measuring the girth of
abdomen.
 Nursing Diagnosis

Impaired gas exchange related to underlying illness,

or ventilator setting adjustment during stabilization

or weaning.
Ineffective airway clearance related to increased

mucus production associated with continuous

positive-pressure mechanical ventilation
Risk for trauma and infection related to endotracheal

intubation or tracheostomy
 Nursing Diagnosis

Impaired physical mobility related to ventilator

dependency
Impaired verbal communication related to

endotracheal tube and attachment to ventilator

Defensive coping and powerlessness related to

ventilator dependency
 NURSING INTERVENTIONS

Nursing care of the mechanically ventilated patient

requires expert technical and interpersonal skills.

specific interventions are determined by the underlying

disease process and the patient’s response.

Two general nursing interventions important in the

care of the mechanically ventilated patient are

pulmonary auscultation and interpretation of arterial
blood gas measurements.
ENHANCING GAS EXCHANGE
The purpose of mechanical ventilation is to optimize

gas exchange by maintaining alveolar ventilation and

oxygen delivery.
The health care team, including the nurse, physician

and respiratory therapist, continually assesses the

patient for adequate gas exchange, signs and
symptoms of hypoxia, and response to treatment.
Thus, the nursing diagnosis impaired gas exchange
is, by its complex nature, multidisciplinary and
collaborative.
Monitor ventilator settings:

 VT, FiO2, RR
 Use of PEEP, CPAP or pressure support
 Peak inspiratory pressure
 Alarms on

Monitor cuff pressures of ETT or tracheostomy:

 Inflate cuff to prevent leak of air around the cuff

 Use commercial devices to monitor cuff pressures.
 Notify physician if pressures exceed 30 cm H2O.
Provide judicious administration of analgesic agents

to relieve pain without suppressing the respiratory

drive and frequent repositioning to diminish the
pulmonary effects of immobility.
Monitor for adequate fluid balance by assessing for

the presence of peripheral edema, calculating daily

intake and output, and monitoring daily weights.
Administer medications prescribed to control the

primary disease and monitor for their side effects.

Keep tubings free of moisture; to avoid aspiration

of moisture, empty tubings before repositioning

patient.
Empty tubings as needed.

Avoid draining water backward through the

ventilator circuit where the tubing connects to the
patient.
Use devices (e.g., water traps) to facilitate drainage

of moisture.
PROMOTING EFFECTIVE AIRWAY
CLEARANCE
Patients with artificial airways on mechanical

ventilation are unable to clear secretions on their

own.
Continuous positive-pressure ventilation increases

the production of secretions.

Measures to clear the airway of secretions include

suctioning, chest physiotherapy, frequent position

changes, and increased mobility as soon as possible.

Frequency of suctioning should be determined

by patient assessment; pressure alarm on

ventilator. Audible secretions, harsh breath
sounds on auscultation.
Assess breath sounds after suctioning.

If tracheal secretions are thick, assess

hydration of patient and humidification of
ventilator.
Reposition the patient frequently to mobilize

secretions. This may improve secretion

clearance and reduce atelectasis.
Turn patient from side to side every 2 hours, or

more frequently if possible. This may result in

sleep deprivation for patients on long-term
ventilation. Follow a turning schedule best
suited to a particular patient’s condition.
Lateral turns are desirable; from right semiprone

to left semiprone.
Sit the patient upright at regular intervals if

possible which increases lung compliance.

Consider prone positioning to improve
oxygenation. Proning has been shown to have
some beneficial effects or the improvement of
oxygenation in some cases, such as in ARDS
patients.
 Enhancing Communication

It is important to develop alternative methods of

communication for the patient on a ventilator.

The patient may have pain or discomfort but cannot

communicate these sensations so the nurse must

anticipate the patient's needs regarding pain and
comfort.
 Enhancing Communication

Check the patient's position to ensure it is

comfortable and in normal alignment and talks to

and not about the patient while in the patient's
presence.
The nurse assesses the patient’s communication

abilities to evaluate for limitations.

 Enhancing Communication

Establish method for communication.

 Yes/no questions
 Clipboard with paper and pencil
 Picture communication boards
 Computerized systems
 Attempt lip reading if patient has nasotracheal tube or tracheostomy

Speak slowly and clearly to patient; do not shout

Explain procedures

Expect frustrations
Preventing risk for trauma and
infection
 PREVENTING ACCIDENTAL OR
UNPLANNED EXTUBATION
Provide adequate patient sedation and comfort

Apply protective devices (e.g. soft wrist

restraints) according to hospital protocol
Adequately secure the ET tube

Cut the end of the ET tube 2 inch beyond the

fixation point
 PREVENTING ACCIDENTAL OR
UNPLANNED EXTUBATION
Mark the lip line on ET tube with an indelible marker;

assess tube position routinely.

Provide support for the ventilator tubing and closed

suction systems; keep these items away from

patient’s reach.
Use two staff members when repositioning ET tube;

one to secure ETT and one for taping the tube

Educate the patient and family.
 Preventing risk for trauma and infection
 Some patients who are unconscious have their eyes

open and have inadequate or absent corneal reflexes.

 The cornea may become irritated, dry or scratched,

leading to ulcerations.
 The eyes may be cleansed cotton balls moistened

with sterile normal saline to remove debris and

discharge.
Preventing risk for trauma and infection

 If artificial tears are prescribed, they may be instilled every

2 hourly.
 Eye patches should be used cautiously because of the

potential for corneal abrasion from contact with the patch.

Monitor temperature every 4 hours.

Use good hand washing techniques.

Wear gloves for procedures.

Use aseptic technique for suctioning.

Preventing risk for trauma and infection

Assess oral mucous membranes for ulcers and

lesions.
Provide good mouth care at least once per shift.

 Use oral swabs specifically designed for mouth care.

 Brush teeth; use syringe to rinse mouth and tonsil
 Suction to remove secretions
 Lubricate lips with water-soluble emollients
 Avoid agents that contain alcohol such as some
mouthwashes.
 Preventing Urinary Retention

 Patient with altered LOC is often incontinent or has

urinary retention.

 The bladder is palpated or scanned at intervals to

determine whether urinary retention is present.

 Catheterization should be done in order to reduce risk of

UTI and to monitor urinary output. However, catheters are

major cause of UTI, the patient is observed for fever and

cloudy urine.
 Preventing Urinary Retention

 Urethral orifice is inspected for drainage and

cleansed routinely.
 An external catheter (condom catheter) for male

and absorbent pads for female patients can be

used.
 Incontinent patient is monitored frequently for

skin irritation and breakdown.

 Promoting Bowel Function
 There is a risk of diarrhea from infection and

antibiotic agents.
 Immobility and lack of fibre rich diet can cause

constipation.
 Nurse should observe and monitor the number and

consistency of bowel movements.

Assess gastric contents and stools for presence of

occult blood.
 Promoting Bowel Function

 Rectal examination for signs of fecal impaction

may be needed. Stool softeners should be

administered according to the prescription.
 To facilitate bowel empting a glycerin suppository

or an enema to empty the lower colon may be

indicated.
 General measures

Skin Care: Immobilization as well as drugs

predispose the patient to deep vein thrombosis,
muscle atrophy and skin breakdown.
Shearing of the sacrum may develop therefore the

client’s skin should be completely assessed twice

daily.
Provide skin care, passive exercises, chest
physiotherapy as well as position change frequently.
 Nutritional Support
It is required for all patients who require mechanical

ventilation for more than 3 days.

Enteral feedings are preferred in individuals with an intact

gastrointestinal system. NG tubes are commonly used.

Monitor gastric residual volumes to assess absorption in

every 4 hours, and keeping the head of bed elevated (30

degrees) to reduce the risk of aspiration.
Monitor CO2 levels if high carbohydrate formulas are

given; formula may need to be changed.

 Patient and family support

It is also important to describe the purpose and

effects of the paralytic agent to the patient's family.

If they are unaware about it, they may become

distressed by the change in the patient's status.

Clear communications and frequent condition
updates are essential to keep the family adequately
informed.
Troubleshooting
the Ventilator
 Troubleshooting the ventilator

Individuals who care for patients receiving mechanical

ventilation must be knowledgeable about the equipment

and component of troubleshooting.
For the prevention of errors, two important rules must be

followed;
1. Never shut off alarms. It is acceptable to silence alarms for
a preset delay while working with a patient, such as during
suctioning. However alarms should never be shut off.
 Troubleshooting Contd…

2. Manually ventilate the patient with a bag-valve

device if you are unable to troubleshoot alarms
quickly or if you suspect equipment failure.
A bag-valve device must be readily available at the

bedside of every patient who is mechanically

ventilated.
 TROUBLESHOOTING

Anxious Patient

 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

 Attempt to fix the problem

 Call doctor
 High Pressure Alarms
If the amount of pressure needed for ventilating a

patient exceeds the preset pressure limit.

Usually caused by:

 Excess secretions; mucus

 Patient coughing, gagging or attempting to talk
 Patient’s biting of the ETT
 Kinks in the ventilator circuit
 Pulmonary edema; bronchospasm; pneumothorax
 Volume Alarms
 Low exhaled volume alarm sounds if the patient does not

receive the preset VT.

 Usually caused by:

 Disconnection of ventilator circuit from the artificial airway

 Leak from ETT /tracheostomy cuff.
 Displacement of the ETT or tracheostomy tube.
 Disconection of any part of the ventilator circuit.

Attempt to quickly fix the problem

Bag the patient and call for doctor.

 Apnea Alarms
An apnea alarm occurs if the ventilator does not

detect spontaneous respiration within a present

interval.
This alarm is very important when the patient is

receiving breaths at a very low rate.

The ventilator setting may need to be adjusted. The

nurse can manually ventilate the patient with bag-

valve device while the settings are adjusted.
 Accidental Extubation

Role of the Nurse:

 Ensure the Ambu bag is attached to the

oxygen flowmeter and it is on!
 Attach the face mask to the Ambu bag and
after ensuring a good seal on the patient’s
face; supply the patient with ventilation.

Bag the patient and call doctor

 Medications

Many patients will need medications to facilitate

ventilatory support.
Commonly used medications include analgesics,
sedatives and neuromuscular blocking agents.
Medications are chosen based on the desired patient

outcomes and often need a combination of drugs.

Medications are tapered or discontinued when the

patient is ready to wean from ventilator.

 Medications Contd…

Analgesics: Opiods analgesics are used for providing

pain relief and sedation in patients who are

hemodynamically stable.
Agents include morphine sulfate and fentanyl.
Fentanyl is preferred in patients who are
hemodynamically unstable, because hypotension is
less likely to occur.
 Medications Contd…

Sedatives: commonly used; benzodiazepines, neuroleptics and

propofol.
Benzodiazepines includes diazepam, lorazepam and midazolam.

They provide efficient sedation with few side effects.

Neuroleptics such as haloperidol provide efficient sedation with

minimal respiratory depression.

Propofol is short acting anesthetic agent given by constant

infusion. Onset is less than 1 minute and patients rapidly

awaken when the drug is discontinued.
 Medications Contd…
 Neuromuscular blocking agents: used when paralysis is

desired, such as for patients who have acute lung injury,

those who require advanced mechanical ventilation modes
and in the management of increased intracranial pressure.
 They have no anxiolytic, sedative or analgesic properties.

 Commonly used; pancuronium, atracurium and

vecuronium.
 In addition patient require administration of sedative

agents and meticulous skin and eye care.

 Complications of
Mechanical Ventilation
Numerous complications are associated with
intubation and mechanical ventilation.
Many complications can be prevented and/or treated

rapidly.
 Pulmonary System

1. Barotrauma: Presence of extra-alveolar air. This air

may escape into the pleura (pneumothorax), the
mediastinum (pneumomediastinum), pericardium
(pneumopericardium) or under the skin
(subcutaneous crepitus).
It may occur when the alveoli are over distended,

such as with positive-pressure ventilation, high VT

(>15ml/kg) and PEEP.
 2. Intubation of right mainstem bronchus

The right mainstem bronchus is straighter than the left. If

the ETT is manipulated, such as occurs during changing of

the tape, it may move into the right mainstem bronchus.
Symptoms include absent or diminished breath sounds in

the left lung.

Whenever the ETT is manipulated, the nurse must assess

for bilateral breath sounds and reassess tube position at

the tip.
 3. Unexplained Extubation

The ETT can become dislodged if it is not secured

properly, during procedures such as changing the

tape on the ETT of if the patient is anxious or
agitated and attempts to pull the tube out.
The tube may end up in the back of the throat, in the

esophagus, or completely removed.

 4. Tracheal damage

Damage to trachea can occur because of pressure

from the cuff. However this risk is decreased

because all ETT and TTs have low-pressure cuffs.
Intervention for preventing this is monitoring cuff

pressures on a routine basis; pressures should not

exceed 30cm H20.
Monitor cuff pressures on a routine
basis
5. Damage to the oral or nasal mucosa

Tape and commercial devices used to secure to ETT

can cause breakdown of the lip and oral mucosa.

If the tube is inserted nasally, skin breakdown may

occur on the nares and the pt is at higher risk for

sinusitis.
Ongoing assessment and skin care can assist in

preventing damage to the mouth and nose.

 6. Acid-base disturbances
(hypocarbia/hypercardia)

If the ventilator is not adjusted properly, acid-base

disturbances result. If RR in ventilation is high,

respiratory alkalosis usually occurs but if low rate of
assisted ventilation (e.g. 2-6 breaths per minute) and
does not have additional spontaneous breathing
effort, respiratory acidosis may occur.
 7. Aspiration

Most patients who require mechanical ventilation

also require tube feedings. Gastric distention,

impaired gastric emptying with large amounts of
gastric residual and esophageal reflux predispose
patients to aspiration.
Keeping the head of bed elevated to 30 degrees may

help to prevent aspiration.

 8. Infection

Patients with artificial airways are at an increased risk

for pulmonary infection because normal defense

mechanisms in the nose are bypassed.
Procedures such as ETT suctioning also predispose

infection.
Bacteria that frequently cause infection include
streptococcus species, staphylococcus species,
Pseudomonas species, Escherichia coli.
 8. Infection

Hand-washing, sterile technique for suctioning and

adherence to protocols such as ventilator tubing

changes are essential in prevention of infection.
Sputum characteristics are monitored and cultures

are obtained when infection is suspected.

 9. Ventilator dependence/inability to wean

Patients who require long-term mechanical

ventilation are usually very challenging to wean
from the ventilator.
Examples; patients with underlying COPD and

neuromuscular disease.
 Cardiovascular System

A decreased cardiac output may be associated,

especially if PEEP therapy is used, secondary to

increased intra-thoracic pressure and decreased
venous return.
Patient who are hemodynamically unstable may

need a pulmonary artery catheter inserted to

monitor the hemodynamic effects of mechanical
ventilation.
 Gastrointestinal system

Stress ulcers and GI bleeding may occur in patients

who undergo mechanical ventilation.

Another possible complication is paralytic ileus.

Inadequate nutrition may occur if the patient is not

started on early nutritional support.
 Endocrine system

Fluid retention may be associated with increased

humidification provided by the ventilator.

Increased pressure on the baroreceptors in the
thoracic aorta from positive-pressure ventilation
stimulates the release of antidiuretic hormone (ADH).
This hormone causes water retention and stimulates
the renin-angiotensin-aldosterone mechanism which
further causes fluid retention.
 Psychosocial complications

Stress and anxiety may result as a result of

mechanical ventilation.
If the ventilator is not set properly or if the patient

resist breaths, patient-ventilator dysynchrony may

occur.
The noise of ventilator and the need for frequent

procedures such as suctioning may result in alteration

in sleep and wake patterns.
Thank you!