1. CRITICAL NURSING CARE
UNIT II (C) VENTILATOR CARE
PRESENTED TO:
MAM ROHI
PRESENTED BY :
RUBI MUMTAZ
SHANZA BATOOL
ASIA SAIF
SHARIF COLLEGE OF NURSING
BSC Nursing 4th Year
2. MECHANICAL
VENTILATOR
A medical ventilator (or simply ventilator in
context) is a mechanical ventilator, machine
designed to move breathable air into and out of the
lungs, to provide breathing for a patient who is
physically unable to breathe, or breathing
insufficiently.
3. MECHANICAL VENTILATION
Mechanical ventilation can be
defined as the technique through
which gas is moved toward and
from the lungs through an
external device connected directly
to the patient.
4. PURPOSE
To establish and maintain effective ventilation
To prevent complication associated with artificial
ventilation
To ensure position and patency of endotracheal
and tracheostomy tube
To clear and remove secretions from airway
5. EQUIPMENTS
Bed locker with necessary articles,
ventilator
Suction apparatus
Continuous monitoring apparatus
Resuscitation chart with defibrillators
oxygen setup
Manual ventilation bag (embu bag)
Endotracheal intubations set
6. PURPOSE/
OUTCOMES
• Reversal of hypoxemia
• Reversal of acute respiratory acidosis
• Relief of respiratory distress
• Prevention or reversal of atelectasis
• Resting of ventilatory muscles
12. POSITIVE PRESSURE
VENTILATION
Much more commonly used, deliver air by pumping
it into the patient’s lungs.
With positive pressure ventilation, the normal
relationship b/w intrapulmonary pressures during
inspiration and expiration is reversed (i.e pressure
during inspiration are positive and pressure during
expiration are negative
14. VOLUME-
CYCLED
VENTILATORS
With volume ventilation, a
designated volume of air (tidal
volume) is delivered with each
breath.
This type is ideal for patients with
acute respiratory distress
syndrome or bronchospasm, since
the same tidal volume is delivered
regardless of airway resistance or
compliance.
15. PRESSURE-
CYCLED
VENTILATORS
With pressure ventilation, a selected gas
pressure is delivered to the patient and
sustained throughout the phase of
ventilation
The benefit is a decreased risk of lung
damage from high inspiratory pressures.
The disadvantage is that the tidal volume
delivered can vary with changes in lung
resistance and compliance if the patient
has poor lung compliance and increased
16. TIME-CYCLED
VENTILATORS
Terminate or control inspiration after a preset
time.
The volume of air the patient receives is
regulated by the length of inspiration and the
flow rate of the air.
Used very rarely
17. HIGH FREQUENCY
VENTILATORS
Accomplishes oxygenation by the diffusion of oxygen
and carbon dioxide from high to low gradients of
concentration. Diffusion is increased when the kinetic
energy of the gas molecules is increased
High frequency ventilation uses small tidal volumes (1-
3ml/kg) at frequencies greater than 100 breaths/minute
18. VARIOUS TYPES OF LUNG INJURY CAN
OCCUR WITH POSITIVE PRESSURE
VENTILATION:
• Barotrauma can result from high pressures. With barotrauma, air can leak from the
alveoli into the pleural space, resulting in pneumothorax or pneumomediastinum.
• Volutrauma is caused by the delivery of large tidal volumes. The alveoli develop
fractures that allow fluid and protein to seep into the lungs, resulting in a form of non
cardiogenic pulmonary edema.
• Atelectrauma is a shear-induced injury resulting from repeated opening and
closing of the alveoli.
• Biotrauma is damage to the alveoli caused by the release of cytokines and other
chemical mediators of the inflammatory response in response to positive-pressure
ventilation.
19. CONT…
• Ventilator-associated lung injury (VALI) and ventilator-induced lung injury
(VILI) are terms used to describe damage to the lungs resulting from prolonged
ventilation. Prolonged high levels of oxygen, high volumes, and pressures may lead
to loss of surfactant and increased inflammation of the lung parenchyma and
alveoli. The increase in inflammatory mediators damages the alveolar capillary
membrane, resulting in fluid leaking into the lungs and non cardiogenic pulmonary
edema.
20. VENTILATOR
SETTINGS
Fraction of inspired oxygen(FIO2)
Tidal volume
Respiratory rate
Positive end-expiratory pressure(PEEP)
Peak flow
Peak inspiratory pressure limit (high pressure
alarm)
Sensitivity
Inspiratory:expiratoray ratio
Humidification and temperature
sighs
21. POSITIVE END-EXPIRATORY PRESSURE(PEEP)
Control and adjust the pressure that is
maintained in the lungs at the end of
expiration
PEEP increases the functional residual
capacity by re inflating collapsed alveoli
Maintaining the alveoli in an open
position
Improve lung compliance
22. Peak flow
Is the velocity of gas flow per unit
of time and is expressed as liters
per minute
23. HUMIDIFICATION AND
TEMPERATURE
Inspiratory gas must be filtered, warmed and
humidified before delivery to the patient
Humidifier humidifies the inspired gas by passing it
over or bubbling it through a head water.
Condensation should be seen in the inspiratory
ventilator circuit or the proximal ETT or both which
indicates that the inspired gas is fully saturated with
water vapors.
25. VENTILATORS
MODES
1 Volumes Modes
With volume modes of ventilation, a
respiratory rate , inspiratory time and
tidal volume are selected for the
mechanical breaths
Nurse Must Monitor PIP
26. 1. CONTROLLED
The client receives a set tidal volumes at a set
rate.
Used for clients who cannot initiates respiratory
efforts.
Least used mode; if the client attempts to initiate a
breath, the ventilator blocks the efforts,
27. 2.ASSIST – CONTROL
MODE
A respiratory rate and tidal volumes are
preset if the patient attempts to initiate a
breath, the ventilator is triggered and
delivered the full preset tidal volumes with
every breath.
29. 2 PRESSURE
MODES
A typical pressure mode of ventilation sets a
maximum PIP, not a tidal volumes. When the
ventilator delivers a breath it continues delivering
the volumes until the preset pressure limit is
reached, then it stops delivering the breath
Risk of hypoventilation and respiratory acidosis
30. 1 PRESSURE CONTROLLED
VENTILATION(PCV) MODE
Delivers breaths at a preset pressure limit
The “unnatural”feeling of this mode
often requires sedation and the use of
NMB agents to ensure patient–ventilator
synchrony
When the PCV mode is in use, the
mean airway and intrathoracic pressures rise,
potentially resulting in a decrease in cardiac output.
Therefore, it is necessary to monitor the patient’s
hemodynamic status closely.
31. 2 PRESSURE SUPPORT
VENTILATION PSV
Assist spontaneous breathing efforts by
delivering a high flow of gas to a selected
pressure level early in inspiration maintain
that level throughout the inspiratory phase
Patient effort reduced and comfort level is
increased
PSV mode is also used with SIMV mode
and as weaning technique.
32. INVERSE RATIO VENTILATION
(IRV).
• This type of ventilation inverses the I:E ratio so that
inspiratory time is equal to, or longer than, expiratory
time (eg, 1:1 to 4:1; see Fig. 10-8C). Because the
expiratory time is decreased, the nurse must monitor
for the development of auto- PEEP
33. AIRWAY PRESSURE RELEASE VENTILATION
(APRV) MODE.
• A high-pressure and a low pressure are set. Alveolar recruitment and
oxygenation occur during the high-pressure setting
35. CONTINUOUS
POSITIVE AIRWAY
PRESSURE (CPAP)
Similar to PEEP
Supplies pressure throughout the respiratory cycle, help to
improve oxygenation in spontaneously breathing patients.
Used for intubated or nonintubated patients.
Weaning mode from mechanical ventilation and for nocturnal
ventilation to splint open the upper airway
Preventing upper airway obstruction in patients with obstructive sleep
apnea
36.
37. BI-LEVEL
POSITIVE
PRESSURE (BIPAP)
Provided by means of nasal mask, nasal
prongs, or full facemask
Two levels of positive pressure support
An inspiratory pressure referred to IPAP
An expiratory pressure referred to as EPAP
Used in patient with acute, short term
respiratory problems to avoid intubation and
mechanical ventilation
41. CARE OF ETT/
TRACHEOSTOMY
Secure positioning of ETT/ tracheostomy tube with
adhesive plaster
Inflate cuff once correct positioning has been
confirmed
Cuff is inflated with air using syringe
42.
43. MAINTAINING
VENTILATION
Effects of ventilation are assess by
observing pt color, chest movements, BP,
pulse rate, oxygen saturation
Ventilator make characteristics sound
during inspiration and expiration which
nurse must be capable of identifying
45. SUCTIONING
Explain procedure to patient
and family
Frequency of suction to be
carried out depending on pt’s
pulmonary state
Tracheal suction is an aseptic
procedure
46. STERILE CATHETER AND ONE
STERILE GLOVE TO BE USED
FOR EACH SUCTIONING
SESSION SUCTION IS
APPLIED WHILE CATHETER IS
BEING WITHDRAWN USING
INTERMITTENT TECHNIQUE
NOT MORE THAN 10 TO 15
SECONDS
47.
48. Measure blood, IV infusions
and fluid intake every hour
Measure blood loss, urine,
chest drainage bottles,
Maintain intake and output
every shift
Assess bowel action every
third day
8 hourly wound dressing
should be done
49. Change IV administration sets and
dressing of puncture sites everyday
Change suction bottle and
connecting tubing everyday
Record pt’s conditions and events that
have occurred during each shift in
nurse progress sheet
Give detailed hand over to nurse
on following shift
50. PSYCHOLOGICAL ASPECTS OF
PATIENT CARE
promote good relationship
with patient and family
Encourage them to express
fear, stress factors and feelings
Motivate patient and relatives
t0 participate in daily care
activities
53. READINESS TO
WEAN
• Underlying cause for mechanical ventilation resolved
• Hemodynamic stability; adequate cardiac output
• Adequate respiratory muscle strength
• Adequate oxygenation without a high FiO2 and/or highPEEP
• Absence of factors that impair weaning
• Mental readiness
• Minimal need for medicines that cause respiratory depression
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54. GUIDELINES FOR
WEANING
• weaning is generally initiated in the morning when the patient is rested
• The use of sedatives and narcotics during weaning is limited
• The nurse raises the head of the bed, ensures a patent airway, and provides
suction if necessary.
• The nurse remains with the patient throughout the weaning trial to provide
support and reassurance
• At the conclusion of the trial, the nurse also evaluates and documents the
patient’s response to weaning
58. AIRWAY MANAGEMENT
• Positioning
Devices
• Oral airway: An oropharyngeal airway is a hard plastic device
that is inserted through the mouth and extends to the
pharynx to prevent the tongue from occluding the airway
when muscle tone is decreased. Never insert in conscious
patient
• Nasopharyngeal airway: A nasopharyngeal airway (nasal
trumpet) is a flexible tube that is inserted nasally past the
base of the tongue to maintain airway patency.
• Endotracheal intubation: An endotracheal tube is a semi-rigid
tube that is inserted through the nose or mouth and extends
into the trachea
• Tracheostomy: A tracheostomy tube is inserted directly into the
trachea through a stoma made in the neck
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59. ENDOTRACHEAL
INTUBATION
• Insertion of an endotracheal tube (ETT) through the mouth or nose
• Orotracheal route preferred to reduce infections
• Used to:
• Maintain an airway
• Remove secretions
• Prevent aspiration
• Provide mechanical ventilation
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60. ENDOTRACHEAL TUBE
72
Figure 9-17. A. Endotracheal tube. B. Hi-Lo Evac endotracheal tube. Note suction port above the cuff for removal of pooled
secretions. (From Shilling A, Durbin CG. Airway management. In: Cairo JM, ed. Mosby’s Respiratory Care Equipment. 9th ed.
St. Louis: Mosby; 2013.)
62. ENDOTRACHEAL
INTUBATION
• Right size tube
• 7.5 to 8.0 mm female; 8.0 to 9.0 mm
male
• Check balloon on tube for leak
• Stylet
• Lubricate tube
• Laryngoscope and blade
• Sniffing position
• Premedicate prn
• Topical anesthetic/ paralytic
medication
• Ventilate patient
• Suction oropharynx
• Intubate within 30 sec
• Inflate balloon
• Verify placement
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63. VERIFY
PLACEMENT
• Auscultate epigastric area
• Auscultate bilateral breath sounds
• ETCO2 detector
• Esophageal detector device
• Chest x-ray—3 to 4 cm above carina
• Secure tube when placement is verified
• Record cm at the lip line for reference
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64. ENDOTRACHEAL
SUCTIONING
• Suction as indicated by assessment
• Visible secretions
• Coughing
• Rhonchi
• High PIP on ventilator
• Ventilator alarm
• Conventional versus closed suction
• Procedures
• Hyperoxygenate throughout procedure
• Avoid normal saline instillation
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