For advanced education

1. Care of patient on Mechanical Ventilator
ANEETTA BABU
STAFF NURSE-CRITICAL CARE

2. Topic
Includes
Introduction
Definition
Purpose
Indication
Contraindication
Type
Mode
Nursing care
Complication

3. Introduction
What is ventilator?
Patient might present with respiratory failure,
thus requiring invasive mechanical ventilation
(MV) to help or replace spontaneous breathing.

4. Definition
Mechanical ventilation (MV) works by
applying a positive pressure breath and is
dependent on the compliance and
resistance of the airway system.
Mechanical ventilators are mainly used
in hospitals and transport system such as
ambulances .They can be used at home
incase of long-term illness.
(Tracheostomized)

5. Purpose
To maintain
gas exchange
and chronic
respiratory
failure .
To maintain
ventilator
support after
CPR.
To reduce
pulmonary
vascular
resistance.
To excrete
increased CO2
production.
To give
general
anesthesia
with muscle
relaxants.

6. Indications
 Respiratory failure.
 Major surgeries like CABG, HIP replacement, organ transplant .
 Upper and lower Airway Obstruction.
 Neuro muscular disease like myasthenia gravies ,Guillain barre
syndrome, Polio myelitis Cardiac arrest.
 Lung disease like Chest injury, Pneumothorax, COPD, ARDS/ NRDS.
 CNS disease like cerebrovascular accident , seizure, cerebral
aneurysm, Head injury.
 Other cases like poison, drowning, Inadequate reversal of anesthesia.

7. Types
Invasive
Non-invasive

8. Types(Continues)
 Invasive
 Positive pressure delivered to the patient’s lung via ET tube or tracheostomy tube .
 Invasive mechanical ventilation (IMV) is usually initiated in the operating room,
emergency room, or intensive care unit
 Insertion of the airway generally requires sedation, and the indications necessitate a
monitored setting for care.
eg.,The patient who have COPD with severe hypoxia and acidosis, who is unsuitable for
non-invasive needs mechanical ventilator.
 Non-invasive
 It's a ventilatory support that provided via a face mask to the patient's upper airway .
e.g., It's used for both acute and chronic respiratory failure, but need more close
monitoring.

9. Parameters of the ventilator
Fraction of inspired oxygen
(FiO2):
delivered in the inspiratory gas mixture,
expressed as a decimal fraction. FiO2 can
range from 21% (room air) to up to 100%
(pure oxygen).
Respiratory
Rate/Frequency (RR or F)
in respirations per minute; this may be
the patient’s intrinsic rate or set using the
ventilator.

10. Parameters of the ventilator
Tidal volume (Vt):
Is the amount of air that moves in or out of
the lungs with each respiratory cycle. It
measures around 500 mL in an average
healthy adult male and approximately 400
mL in a healthy female.
Positive End-Expiratory
Pressure
 Pressure given in expiratory phase to
prevent closure of the alveoli and allow
increased time for O2 exchange
 Used in pts who haven’t responded to
treatment and are requiring high
amount of FiO2
 PEEP will lower O2 requirements by
recruiting more surface area
 Normal PEEP is approximately 5cmH20.
Can be as high as 20cmH20

11. Parameters of
the ventilator
Inspiratory time (Ti)
 the inspiratory time is the amount
of time it takes to deliver the tidal
volume of air to the lung. The ratio
of inspiratory time to expiratory
time is a vital indication of
respiration quality and is directly
related to the respiration rate.

12. Modes of
ventilators
Controlled
modes
Supported
modes
Combined
modes
Spontaneous
breathing
VC PS VC – VS CPAP
PC VS PC – PS Nasal CPAP
PRVC NIV- PS PRVC – VS BiPAP
NIV – PC SIMV :
VC + PS
SIMV :
PC + PS
SIMV :
PRVC + PS

13. Modes of ventilator (Continue..)
 Volume control mode( VC )
Preset tidal volume is delivered at a set rate, primarily
used when the patient has no spontaneous breathing.
 Pressure control(PC)
 The ventilator delivers a breath to a set pressure and set
rate .
 This is primarily used when the patient has no
spontaneous breathing but will support the patient if they
are able to trigger a breath.
 Pressure regulated volume control (PRVC)
 It is a controlled mode of ventilation which combines
pressure and volume.
 A preset tidal volume is delivered at set rate like VC, but
it's delivered with the lowest possible pressure.

14. Modes of ventilator (Continue..)
 Synchronized intermitted mandatory ventilation ( SIMV)
 It’s a type of volume control mode of ventilation .
 The ventilator will deliver a mandatory set numbers of breaths with a set volume ,while at
the same time allowing spontaneous breath .
e.g.; patient take a breath and the ventilator adds pressure to the breath to make it easier for
the patient to achieve a good tidal volume
 Pressure support (PS)
 Pressure support provide support for every patient triggered breath.
 It is used for patients who don’t have sufficient capacity or facilities weaning.
 The patient initiates a breath, and the ventilator delivers support with the preset
pressure level above peep.
 With the support of ventilator , the patient regulates the respiratory rate and tidal
volume.

15. Modes of ventilator (Continue..)
 Volume Support(VS)
 Its works in a very similar way to pressure
support but tidal volume and peep are set
rather than pressure.
 The patient initiates the breath, and the
ventilator delivers support in proportion to
the inspiratory effort and the target volume.
 The set tidal volume is delivered to the
patient with different support from the
ventilator depending on the patient’s activity.

17. Modes of ventilator (Continue..)
 Nasal CPAP
 Nasal CPAP can be delivered oxygen through nasopharyngeal tube,
nasal mask or nasal prongs on infants from 500g to 10kg .
 The CPAP level and oxygen concentration is set, and the ventilator will
deliver the flow necessary to maintain the desired pressure
compensating for the leak ( maximum flow is 33Lmin).
 Continue mandatory ventilation( CMV)
 The mode described were all the patient’s breath are being provided by
the ventilator .
e.g. ; The patient is sedated all breath are triggered ,limited and cycled by
the ventilator.

18. Modes of ventilator (Continue..)
 Non- invasive ventilation (NIV)
 The delivery of oxygen (ventilator support)via a face mask and there for
eliminating the need of an endotracheal airway .
 The patient must be conscious and breathing spontaneously .
 The patient must have an adequate gag and cough reflex .
 NIV–Pressure control
 In this controlled mode of ventilation ,ventilator deliverers a flow to
maintain the preset pressure at a set respiratory rate and inspiratory time
(like invasive pc).
 The patient can also trigger a controlled breath.

19. Modes of ventilator (Continue..)
 NIV–Pressure Support
 In this spontaneous mode of ventilation were the patient initiates the breath
and the ventilator delivered support with the preset pressure level.
 The patient regulates the respiratory rate and tidal volume so the alarm
parameters must be set appropriately.

20. The following guidelines are
recommended
Set the
machine to
deliver the
required tidal
volume6-
8ml/kg.
Adjust the
machine to
deliver the lowest
concentration of
the oxygen to
maintain normal
PaCO2(80-
100mmhg).The
setting may be set
high and
gradually reduced
based on ABGs
result.
Record peak
inspiratory
pressure.
Set
mode(assist/
control or
SIMV)and rate
according to
physician
order.
If patient is on
assist/control
mode, adjust
sensitivity so that
the patient can
trigger the
ventilator with
the minimum
effort (usually
2mmHg negative
inspiratory
force).
Record minute
volume and
measure carbon
dioxide partial
pressure
PaCO2,pHafter
20minutes of
mechanical
ventilation.

21. The following guidelines are
recommended(Continue..)
Adjust FIO2 and rate
according to results of ABG
to provide normal values or
those set by the physician.
In case of sudden onset of
confusion, agitation or
unexplained-bucking the
ventilator the patient should be
assessed for excess secretion
hypoxemia and manually
ventilated on 100%oxygen
with resuscitation
bag(AMBU).
Patient who are on controlled
ventilation and have
spontaneous respiration may
fight or buck the ventilator,
because they cannot
synchronize their own
respiration with the machine
cycle.

22. Ventilator
alarms and
causes
Alarm Definition Potential Causes
High Pressure Pressure required to ventilate
exceeds present pressure.
Pneumothorax , excessive
secretions, decreased lung
compliance.
Low pressure Resistance to inspiratory flow
is less than preset pressure.
Disconnected from
ventilator, break in circuit.
Low exhaled
volume
Exhaled tidal volume drops
below preset amount.
Leak in system, increased
airway resistance decreased
lung compliance.
Rate/apnea Respiratory rate drops below
present level. Apnea period
exceeds set time.
Client fatigue, decreased RR
due to medication.
FIO2 Indicates FIO2 drift from
present range.
Change in level of
consciousness, disconnected
from O2 source, break in
circuit.

23. Ventilator alarms and causes
 General principles…
 Look at the patient first!!! Then follow tubing to the vent to search for any
disconnections.
 If can’t find the problem and the patient is in distress, disconnect the patient
from the vent and bag with 100% O2 (and call for help).

24. Essential
care for
ventilator
patients
 Assess the patient condition
 Manage airway
 Suction appropriately
 Check the ventilator setting and modes
 Meet the patient's physiological needs
 Provide psychological support to patient's
and family
 Abide with VAP bundle.
 Review communication
 Prevent hemodynamic instability
 Monitor GI bleeding
 Prevent complication of ventilator

25. Essential care for ventilator
patients(Continue..)
 Assess the patient condition
 Assess patient's level of pain ,anxiety level and sedation needs.
 Monitor vital signs.
 Monitor for airway obstruction ,ineffective breathing pattern, ET tube
Kinking etc.
 Check oxygen saturation ,listen to breath sounds and note changes from
previous findings.

26. Essential care for ventilator
patients(Continue..)
 Manage Airway
 Assess respiratory rate and depth.
 Assess patient for oxygenation and signs and symptoms of
hypoxia.
 Elevate the head of bed.
 Proper cuff inflation ensure the patient receives proper ventilator
parameters ,such as proper oxygenation and tidal volume.
 Never add air to the cuff without using proper techniques.
 Performing suction and oral care ,ensure the patient got cleared the
airway.
 Provide chest physiotherapy and breathing exercises for secretion
mobilization.

27. Essential care for
ventilator
patients(Continue..)
Suction Appropriately
• General suctioning recommendations includes:
Assess the tube insertion site, breath sounds, vital signs to
identify complication.
Suction only as needed, Notify physician if any change.
Hyper oxygenate the patient before and after suctioning to
help prevent O2 desaturation .
Don’t instill normal saline solution into the endotracheal tube
to promote secretion removal.
Limit suctioning pressure to the lowest level needed to
remove secretions.
Suction for the shortest duration possible (Time 10-15sec).

28. Essential care for ventilator
patients(Continue..)
 Check ventilator setting and modes
 Read the patients order and obtain information about the
ventilator. compare current ventilator settings with the
settings prescribed in the order.
 Check type of ventilator, controlling mode, tidal volume and
rate settings, FiO2 setting, inspiratory to expiratory ratio,
inspiratory pressure, PEEP, humidifier etc.
 Familiarize yourself with ventilator alarms and the action to
take when an alarm sounds.

29. Care of essential for ventilator
patients (continue..)
 Meet the patient's physiological needs
 Provide eye, oral care and moisten the lips with lubricant.
 Maintain hygiene of the patient.
 Administer Naso-gastric tube feeding as ordered.
 If NG tube feeding is not possible, administer parenteral
nutrition.
 Address the patient's elimination needs.
 Provide catheter care.
 Keep quiet and calm environment to promote rest and sleep.
 Keep monitor alarm down if possible.
 Provide dim light at night.
 Provide patients eye with eye patch.

30. Essential care for ventilator
patients(Continue..)
 Provide psychological support to patient's and family
 To ease distress patient and family , teach them why mechanical ventilation is needed and
emphasize the positive outcome it can provide .
 Encourage family members to verbalize their feelings about the ventilators, patient condition.
 Explain the procedures to the patient and family each time.
 Reinforce the need and reason for multiple assessment and procedures, such as laboratory test
and x-rays.
 Communicate desired outcomes and progression toward outcomes so the patient and family
can actively participate in the plan of care.
 The nurse must be knowledgeable and confident while dealing with patient and his family
members.

31. Essential care for ventilator
patients(Continue..)
 Review communication
 Assess the ability of the ventilator-dependent patients to
communicate.
 Be alert to non-verbal clues of the patient and use non-
verbal methods of communication.
 Provide writing tools, communication board or call bell so
patient can express their needs.
 Ask simple yes/no questions to which patient can nod or
shake his/her head.

32. Essential care for ventilator
patients(Continue..)
 Prevent hemodynamic instability
 Monitor the patient’s blood pressure every hour, especially after
ventilator settings are changed or adjusted .
 To maintain hemodynamic stability , maintain iv fluids or
administer a drug such as dopamine or norepinephrine , if doctor
ordered.
 High levels of inspiratory pressure with PSV(Pressure support
ventilation) and PEEP(Positive end-expiratory pressure) increase
the risk of barotrauma and pneumothorax .To assess these
complication oftenly check breath sounds and oxygenation status.

33. Essential care for ventilator
patients(Continue..)
 Prevent complication of ventilator
 Wash hands and use appropriate personal protective equipment such
as gloves, when touching patient's intubation tubes or ventilation.
 Keep the head of the bed elevated 30-45 degree at all time ,if patient
condition allows.
 Provide oral care at least twice a day and provide oral moisturizes
every 2 to 4 hours.
 Observe skin for pressure sores, provide back care, use pressure
relief matters and change the position of the patient frequently.

34. Essential care for ventilator
patients(Continue..)
 Prevent complication of ventilator
 Provide deep vein thrombosis prophylaxis, as with an intermittent
compression device.
 Provide range of motion exercise and patient turning and
positioning to prevent the effects of muscle disuse.
 Monitor GI bleeding
 Monitor bowel sound.
 Monitor gastric PH and hematemesis gastric secretions every
shift.

35. Essential care for ventilator
patients(Continue..)
 Wean the patient from the ventilator appropriately
 As your patient’s indication for mechanical ventilator resolve and she or
he can take more breath by itself ,the healthcare team will consider
remove the patient's ventilator.
 Some patients may need weak of gradually reduce ventilator assistance
before extubated ,but some can’t be weaned at all .
 Main factors that affect of weaning include underlying disease process,
such as COPD or peripheral vascular disease .

36. Complication
 Intubation related
 Hypoxia
 Esophageal intubation
 Upper airway trauma
 Hypotension
 Aspiration
 Cuff leak, sinusitis
 Upper airway stenosis
 Self extubation
 Ventilator related
 Disconnection, malfunction
 Suction related
 Hypoxemia
 Arrhythmia
 Ventilation related
 Nosocomial infection
 Hemodynamic effect
 Pneumothorax
 Respiratory alkalosis
 Increased ICP

37. Weaning Process
1. Adequate Oxygenation:
 PaO2 >60-70 on FiO2 40%
to 50%, PEEP 5-8cmH20
 PaO2/FiO2 ratio >150-200
2. Adequate Ventilation:
 PaCO2 35-45mmHg
 PH 7.3 to 7.45
1. Adequate Respiratory
Mechanics:
 Tidal Volume
 Respiratory Capacity
 Minute Ventilation
2. Hemodynamic Stability.
3. Spontaneous Breathing
Trials (SBT).

38. References
 Invasive mechanical ventilation. (n.d.).
https://empendium.com/mcmtextbook/chapter/B31.IV.24.67.1.
 Ccaa, M. B. B. R. (n.d.). I:E Ratio. Pressbooks.
https://ecampusontario.pressbooks.pub/mechanicalventilators/chapter/ie-ratio/
 Clini, E & Ambrosino, N. (2005, Sep). Early physiotherapy in the respiratory intensive care
unit. Respiratory Medicine, (9):1096-104.
 ScienceDirect.com | Science, health and medical journals, full text articles and books.
(n.d.-b).
 John Hopkins