Caring for the mechanically ventilated patient

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CARING FOR THE
MECHANICALLY
VENTILATED PATIENT
Harishkumar S
Chief Coordinator
CNEU, GMCH Kollam
haricool18@yahoo.com

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Spontaneous respiration vs.
Mechanical ventilation
 • Natural Breathing
 – Negative inspiratory force
 – Air pulled into lungs
 • Mechanical Ventilation
 – Positive inspiratory pressure
 – Air pushed into lungs

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Mechanical ventilation
 Negative pressure
 Positive pressure
 Invasive
 Non invasive

z POLIO OUTBREAKS OF THE 1940S
AND 1950S

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Indications for Ventilatory Support
 Acute Respiratory Failure
 Prophylactic Ventilatory Support
 Hyperventilation Therapy

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Criteria for institution of ventilatory support
A- Pulmonary function studies: • Ventilation indicated Normal range
Respiratory rate (breaths/min). > 35 10-20
Tidal volume (ml/kg body wt) < 5 5-7
Vital capacity (ml/kg body wt) < 15 65-75
Maximum Inspiratory Force (cm H2O) < 20 75-100
B- Arterial blood Gases
PH < 7.25
7.35-7.45
PaO2(mmHg) < 60
75-100
PaCO2(mmHg) > 50
35-45

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Intubation Procedure
 Check and Assemble Equipment:
 Oxygen flowmeter and O2 tubing
 Suction apparatus and tubing
 Suction catheter
 Ambu bag and mask
 Laryngoscope with assorted blades
 3 sizes of ET tubes
 Stillet / bougie
 Stethoscope
 Tape
 Syringe
 Sterile gloves
 Check and Assemble Drugs:
 Sedatives
 Paralysing agents
 Emergency life saving
medicines

z Parts of ventilator circuit

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Parts of ventilator circuit
 Ventilator tubing with water trap
 HME filter
 Humidifier
 Nebulizer
 Catheter mount
 Heating circuit
 Test lung

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Classification of positive-pressure ventilators
 Ventilators are classified according to how the inspiratory phase ends. The
factor which terminates the inspiratory cycle reflects the machine type.
 They are classified as:
 1- Pressure cycled ventilator
 2- Volume cycled ventilator
 3- Time cycled ventilator

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Modes of ventillation
 Assist-Control Ventilation (ACV)/volume Controlled
Ventilation
 Synchronized Intermittent-Mandatory Ventilation (SIMV)
 Pressure-Controlled Ventilation (PCV)
 Pressure Support Ventilation (PSV)
 Inverse Ratio Ventilation(Normal I:E is 1:3)
 Continuous Positive Airway Pressure (CPAP)

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INITIAL SETTINGS
 Select your mode of ventilation
 Set sensitivity at Flow trigger mode
 Set Tidal Volume
 Set Rate
 Set Inspiratory Flow (if necessary)
 Set PEEP
 Set Pressure Limit
 Inspiratory time
 Fraction of inspired oxygen

z Nursing Care Essentials for Patients on
Mechanical Ventilation
 Maintain a patent airway. Per policy, note endotracheal (ET) tube
position (centimeters) and confirm that it is secure.
 The depth of the tube for a male patient on average is 21-23 cm
at teeth and for a female patient, it is 19-21 cm at teeth.
 • Assess oxygen saturation, bilateral breath sounds for adequate
air movement, and respiratory rate

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Nursing Care Essentials for Patients on
 Check vital signs per policy, particularly blood pressure after a ventilator setting is
changed. Mechanical ventilation increases intrathoracic pressure, which could
affect blood pressure and cardiac output.
 • Assess patient’s pain, anxiety and sedation needs and medicate as ordered.
 Complete bedside check: ensure suction equipment, bag-valve mask and artificial
airway are functional and present at bedside. Verify ventilator settings with the
prescribed orders.

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 • Suction patient only as needed, per facility policy;Use closed suction system.
 hyper oxygenate the patient before and after suctioning and do not instil normal
saline in the ET tube;
 suction for the shortest time possible and use the lowest pressure required to
remove secretions.
 suction pressure 80-100 cmH2O max 200
 should not exceed 6 seconds to prevent hypoxaemia

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 Monitor arterial blood gas (ABG) after adjustments are made to ventilator
settings and during weaning to ensure adequate oxygenation and acid-base
balance.

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 To minimize the risk for ventilator-associated pneumonia (VAP), implement best
practices such as
 strict handwashing;
 aseptic technique with suctioning;
 elevating head of bed 30-45 degrees (unless contraindicated);
 providing sedation vacations and assessing patient’s readiness to extubate;
 providing peptic ulcer disease prophylaxis;
 providing deep vein thrombosis prophylaxis;
 performing oral care with chlorhexidine, per your facility policy.

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z VENTILATOR ALARMS
Alarm Potential Causes Interventions
High Peak Inspiratory
Pressure (PIP)
40 ABOVE
• Blockage of ET tube
(secretions, kinked tubing,
patient biting on ET tube)
• Coughing
• Bronchospasm
• Lower airway obstruction
Pulmonary oedema
• Pneumothorax
• Ventilator/patient
desynchrony
• Assess lung sounds.
• Suction airway for secretions.
• Insert bite block or administer
sedation per orders if patient
is agitated or biting on ET
tube.
• Assess breath sounds for
increased consolidation,
wheezing, and
bronchospasm; treat as
ordered.

z VENTILATOR ALARMS
Low Pressure Alarm
Air leak in ventilator circuit or in
the ET tube cuff
• Locate leak in ventilator
system.
• Check pilot balloon as an
indicator of ET tube cuff
failure.
• Replace tubing as needed,
per policy.

z VENTILATOR ALARMS
Low Minute Ventilation
NORMAL5-8 L/MIN
Low air exchange due to
shallow breathing or too
few respirations
• Check for disconnection or
leak in the system.
• Assess patient for decreased
respiratory effort.

z VENTILATOR ALARMS
Low O2 Saturation (SpO2)
MUST BE ABOVE 90%
• Pulse oximeter mispositioned
• SpO2 cable unplugged
• Inadequate oxygen delivery
• Ensure ventilator oxygen
supply is connected.
• Ensure pulse oximeter is
positioned correctly.
• Verify all cables are plugged
in.
• Assess patient for respiratory
distress.

z VENTILATOR ALARMS
Apnea
Breaths are not being taken by
the patient or triggered on the
ventilator
• Assess patient effort.
• Check system for
disconnections.

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Closed suction
system

Caring for the mechanically ventilated patient

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