The document discusses mechanical ventilation and various ventilation modes. It describes how mechanical ventilators work using positive or negative pressure to maintain oxygen delivery. Some key ventilation modes discussed include CPAP which maintains continuous elevated airway pressure, PEEP which applies positive pressure at the end of expiration, and SIMV which provides mandatory breaths at set intervals allowing spontaneous breathing in between.

1. CARE OF THE PATIENT
ON VENTILATOR
1Prof. Dr. RS Mehta, BPKIHS

2. VENTILATOR
A mechanical ventilator is a
positive or negative pressure
breathing device that can
maintain ventilation and oxygen
delivery for a prolonged period.
Mechanical ventilation has been
used for decades to support the
respiratory functions of patients
with various degrees of
respiratory distress or failure.
2Prof. Dr. RS Mehta, BPKIHS

3. 3Prof. Dr. RS Mehta, BPKIHS

4. 4Prof. Dr. RS Mehta, BPKIHS

5. PURPOSES
To maintain gas exchange in case of acute
and chronic respiratory failure.
To maintain ventilatory support after CPR.
To reduce pulmonary vascular resistance.
To excrete increased CO2 production.
To give general anesthesia with muscle
relaxants.
5Prof. Dr. RS Mehta, BPKIHS

6. Indications for Mechanical Ventilation
 Upper airway obstruction and Lower
airway obstruction as a result of
blockage.
 Neuromuscular disorders as in
Myasthenia gravis, Poliomyelitis,
Gullian-Barre syndrome, Snake bite and
inadequate reversal of anesthesia.
6Prof. Dr. RS Mehta, BPKIHS

7. ContD…
 Lung diseases which prevent proper
exchange of O2 and CO2 as in Chest Injuries
Pneumothorax, lung Infections, COPD,
Acute Respiratory Distress Syndrome
(ARDS).
 Post-operative cardiac surgery, any other
surgery, shock & trauma.
 Respiratory arrest.
7Prof. Dr. RS Mehta, BPKIHS

8. Criteriafor institution of ventilator support:
Normal
range
(adult)
Ventilation
indicated
Parameters
10-20
5-7
65-75
75-100
> 35
< 5
< 15
<-20
A- Pulmonary function
studies:
• Respiratory rate
(breaths/min).
• Tidal volume (ml/kg
body wt)
• Vital capacity (ml/kg
body wt)
• Maximum Inspiratory
Force (cm H2O) 8Prof. Dr. RS Mehta, BPKIHS

9. Criteriafor institution of ventilatory support:
Normal
range
Ventilation
indicated
Parameters
7.35-7.45
75-100
35-45
< 7.25
< 60
> 50
B- Arterial blood
Gases
• PH
• PaO2 (mmHg)
• PaCO2 (mmHg)
9Prof. Dr. RS Mehta, BPKIHS

10. Classification of Ventilators
Ventilator
Positive pressure Negative pressure
10Prof. Dr. RS Mehta, BPKIHS

11. NEGATIVE PRESSURE VENTILATOR
Elongated tank, which encases the patient up to the
neck. The neck is sealed with a rubber gasket, the
patient's face are exposed to the room air.
These exert negative pressure on the external chest
decreasing the intra-thoracic pressure during
inspiration, allows air to flow into the lungs, filling
its volume.
The cessation of the negative pressure causes the
chest wall to fall and exhalation to occur.
11Prof. Dr. RS Mehta, BPKIHS

12. 12Prof. Dr. RS Mehta, BPKIHS

13. Contd…
These are simple to use and do not require
intubations of the airway; consequently, they are
especially adaptable for home use.
It is used mainly in chronic respiratory failure
associated with neuromuscular conditions such as
poliomyelitis, muscular dystrophy and myasthenia
gravis.
The use of negative-pressure ventilators is restricted
in clinical practice, however, because they limit
positioning and movement and they lack adaptability
to large or small body torsos (chests).
13Prof. Dr. RS Mehta, BPKIHS

14. 14Prof. Dr. RS Mehta, BPKIHS

15. 15Prof. Dr. RS Mehta, BPKIHS

16. POSITIVE PRESSURE VENTILATION
Positive pressure ventilators inflate
the lungs by exerting positive
pressure on the airway forcing the
alveoli to expand during inspiration.
Expiration occurs passively.
16Prof. Dr. RS Mehta, BPKIHS

17. ContD…
Positive-pressure ventilators require an
artificial airway (Endotracheal or tracheostomy
tube) and use positive pressure to force gas
into a patient's lungs.
Inspiration can be triggered either by the
patient or the machine.
17Prof. Dr. RS Mehta, BPKIHS

18. Origins of mechanical ventilation
•Negative-pressure ventilators
(“iron lungs”)
• Non-invasive ventilation first
used in Boston Children’s
Hospital in 1928
• Used extensively during polio
outbreaks in 1940s – 1950s
•Positive-pressure ventilators
• Invasive ventilation first used at
Massachusetts General Hospital
in 1955
• Now the modern standard of
mechanical ventilation
The era of intensive care medicine began with positive-pressure ventilation
The iron lung created negative pressure in abdomen
as well as the chest, decreasing cardiac output.
Iron lung polio ward at Rancho Los Amigos Hospital
in 1953.
18Prof. Dr. RS Mehta, BPKIHS

19. Mechanical Ventilators Classification
19Prof. Dr. RS Mehta, BPKIHS

20. 1. Control:
How the ventilator knows how much flow to deliver?
Volume Controlled
(volume limited, volume targeted) and Pressure
Variable
Pressure Controlled
(pressure limited, pressure targeted) and Volume
Variable
Dual Controlled
(volume targeted, pressure limited)
20Prof. Dr. RS Mehta, BPKIHS

21. 2. Cycling
how the ventilator switches from inspiration to
expiration
Time, flow, volume & pressure cycling
mechanism.
Time cycled:
- is terminated to the expiratory phase once a
predetermined inspiratory time elapses
- it is used for neonates and in the operating
room
21Prof. Dr. RS Mehta, BPKIHS

22. Flow cycled:
- When the flow reaches to a predetermined level, the
ventilator cycles from inspiration into expiration
irrespective of inspiratory time & VT.
- Have pressure and flow sensors.
Pressure-cycled:
- Terminate into the expiratory phase when airway
pressure reaches to a predetermined level, irrespective
of VT, inspiratory time or inspiratory flow rate.
-Pressure-cycled ventilators are generally most
useful for short-term use only (transport).
22Prof. Dr. RS Mehta, BPKIHS

23. Volume cycled:
 Terminate in inspiration when a preselected
volume is delivered.
 Many adult ventilators are volume cycled but
also have secondary limits on inspiratory
pressure to guard against pulmonary
barotrauma.
 If inspiratory pressure exceeds the pressure
limit, the machine cycles into expiration even
if the selected volume has not been delivered.
23Prof. Dr. RS Mehta, BPKIHS

24. 3. Triggering
(What causes the ventilator to cycle to inspiration? )
Time: The ventilator cycles at a set frequency as
determined by the controlled rate.
Pressure: The ventilator senses the pt's inspiratory effort
by way of a ↓ in the baseline pressure.
Flow: Modern ventilators deliver a constant flow around
the circuit throughout the respiratory cycle. A
deflection in this flow by patient inspiration, is
monitored by the ventilator and it delivers a breath,
requires less work by the patient than pressure
triggering.
24Prof. Dr. RS Mehta, BPKIHS

25. VENTILATION STRATEGIES
1. Assisted spontaneous breathing:
a) Continuous Positive Airway Pressure (CPAP)
b) Positive End Expiratory Pressure (PEEP)
2. Supported spontaneous breathing:
(Pressure or volume support in spontaneous
breathing)
a) Pressure Support Ventilation
b) Volume Support Ventilation
25Prof. Dr. RS Mehta, BPKIHS

26. ContD…
3. Mixed respiratory support:
a) Intermittent Mandatory Ventilation (IMV)
b) Synchronized Intermittent Mandatory
Ventilation (SIMV).
4. Controlled mechanical ventilation:
a) Pressure Controlled Ventilation
b) Volume Controlled Ventilation
c) Controlled Ventilation
d) High Frequency Ventilation
26Prof. Dr. RS Mehta, BPKIHS

27. important ventilation modes
 Controlled Mechanical Ventilation (CMV)
- Pressure Controlled Ventilation (PCV)
- Volume Controlled Ventilation (VCV)
 Intermittent Positive Pressure Ventilation (IPPV)
 Pressure Support Ventilation (PSV)
 Synchronized Intermittent Mandatory Ventilation
(SIMV)
 Bi-level Positive Airway Pressure (BIPAP)
 Continuous positive airway pressure (CPAP)
 Inverse Ratio Ventilation (IRV)
27Prof. Dr. RS Mehta, BPKIHS

28. Pressure-cycled modes
• Pressure Support Ventilation (PSV)
• Pressure Control Ventilation (PCV)
• CPAP
• BiPAP
Volume-cycled modes
• Assist/Control Ventilation
• Intermittent Mandatory Ventilation (IMV)
• Synchronous Intermittent Mandatory Ventilation
(SIMV)
28Prof. Dr. RS Mehta, BPKIHS

29. CPAP
The effect of CPAP is compared to inflating a
balloon but not letting it completely deflate
before inflating it again. The second inflation is
easier to perform because resistance is decreased.
A continuous level of elevated pressure is provided
through the patient circuit to maintain adequate
oxygenation, decrease the work of breathing.
CPAP may be used invasively through an
endotracheal tube or tracheostomy or non-
invasively with a face mask or nasal prongs.
29Prof. Dr. RS Mehta, BPKIHS

30. PEEP
 PEEP is positive pressure that is applied
by the ventilator at the end of expiration.
 This mode does not deliver breaths but is
used as an adjunct to CV and SIMV to
improve oxygenation by opening
collapsed alveoli at the end of expiration.
30Prof. Dr. RS Mehta, BPKIHS

31. CONTd…
Complications from the increased pressure can
include decreased cardiac output, lung rupture,
and increased intracranial pressure.
It is used to increase the surface area to prevent
collapse of alveoli and to prevent atelectasis.
PEEP is functionally the same as CPAP, but refers to
the use of an elevated pressure during the expiratory
phase of the ventilatory cycle.
31Prof. Dr. RS Mehta, BPKIHS

32. INTERMITTENT MANDATORY VENTILATION (IMV)
A mode of mechanical ventilation in
which the patient is allowed to breathe
independently except during certain
prescribed intervals, when a ventilator
delivers a breath either under positive
pressure or in a measured volume.
32Prof. Dr. RS Mehta, BPKIHS

33. SynchronizedIntermittent Mandatory Ventilation (SIMV)
In this mode the ventilator provides a pre-set mechanical
breath (pressure or volume limited) every specified
number of seconds (determined by dividing the
respiratory rate into 60 - thus a respiratory rate of 12
results in a 5 second cycle time).
Within that cycle time the ventilator waits for the
patient to initiate a breath using either a pressure or
flow sensor. When the ventilator senses the first
patient breathing attempt within the cycle, it delivers
the preset ventilator breath.
If the patient fails to initiate a breath, the ventilator
delivers a mechanical breath at the end of the breath
cycle. 33Prof. Dr. RS Mehta, BPKIHS

34. CONTD…
SIMV is used as a primary mode of ventilation as
well as a weaning mode. (During weaning, the
preset rate is gradually reduced, allowing the patient
to slowly regain breathing on their own.)
The disadvantage of this mode is that it may
increase the effort of breathing and cause respiratory
muscle fatigue.
When patient is breathing independently and
adequately, ventilator does not support.
Note: The ventilator initiates each breath in
synchrony with the patient's breaths .
34Prof. Dr. RS Mehta, BPKIHS

35. CONTROLLED VENTILATION: IPPV
The ventilator initiates and controls both the
volume delivered and the frequency of breaths.
• This mode is used for patients who are unable to
initiate a breath.
• It is indicated in patients with apnea, drug
overdose, spinal cord injuries, CNS dysfunction,
flail chest, neuromuscular disease, and paralysis
from drugs.
• If it is used with spontaneously breathing patients,
they must be sedated and/or pharmacologically
paralyzed so they don't breathe out of synchrony
with the ventilator.
35Prof. Dr. RS Mehta, BPKIHS

36. ASSIST CONTROL VENTILATION
 This mode is used for pts. who can initiate a breath but
who have weakened respiratory muscles.
 In this mode, the ventilator provides a mechanical breath
with either a pre-set tidal volume or peak pressure every
time the pt. initiates a breath.
 If the pt. fail to initiate inspiration, the ventilator
automatically goes into the back up mode and delivers
the pre set rate and tidal volume until it senses an
inspiratory effort.
 It is used in disease conditions like Myasthenia gravis,
GB syndrome, post cardiac/respiratory arrest, pulmonary
edema, ARDS, etc. 36Prof. Dr. RS Mehta, BPKIHS

37. INVERSE RATIOVENTILATION (IRV)
The normal inspiratory: expiratory ratio
is 1:2, but this is reversed during IRV to
2:1 or greater (the maximum is 4:1).
This method is used for patients who are
still hypoxic, even with the use of PEEP.
37Prof. Dr. RS Mehta, BPKIHS

38. CONTD…
Longer inspiratory time increases the amount of
air in the lungs at the end of expiration (the
functional residual capacity) and improves
oxygenation by re-expanding collapsed alveoli.
The shorter expiratory time prevents the alveoli
from collapsing again.
This method requires sedation and therapeutic
paralysis because it is very uncomfortable for
the patient.
38Prof. Dr. RS Mehta, BPKIHS

39. Time Cycled Ventilators
Time-cycled ventilators terminate or
control inspiration after a pre-set time.
These ventilators are used in newborn &
infants.
39Prof. Dr. RS Mehta, BPKIHS

40. There are several ventilation modes, the most important are: Summary
 Controlled Mechanical Ventilation (CMV)
- Pressure Controlled Ventilation (PCV)
- Volume Controlled Ventilation (VCV)
 Intermittent Positive Pressure Ventilation
(IPPV)
 Pressure Support Ventilation (PSV)
 Synchronized Intermittent Mandatory
Ventilation (SIMV)
 Bi-level Positive Airway Pressure (BIPAP)
 Continuous positive airway pressure (CPAP)
 Inverse Ratio Ventilation (IRV)
40
Prof. Dr. RS Mehta, BPKIHS

41. Summary…
Pressure-cycled modes
• Pressure Support Ventilation (PSV)
• Pressure Control Ventilation (PCV)
• CPAP
• BiPAP
Volume-cycled modes
• Assist/Control
• Intermittent Mandatory Ventilation (IMV)
• Synchronous Intermittent Mandatory
Ventilation (SIMV)
41
Prof. Dr. RS Mehta, BPKIHS

42. Initiating Mechanical Ventilation
Initial ventilator settings:
FiO2 1.0 initially but then reduce
PEEP 5 -7 cmH2O
Tidal volume 7-10 ml/kg
Inspiratory pressure 20 cmH2O (15cmH2O above PEEP)
Frequency 10 - 15 breaths per minute
Pressure support (ASB) 20 cmH2O (15cmH2O above PEEP)
I:E Ratio 1:2
Flow trigger 2 l/min
Pressure trigger -1 to -3 cmH2O
Inspiratory flow 60 L/min
**These settings should be titrated against the pt.'s clinical
state and level of comfort.
42Prof. Dr. RS Mehta, BPKIHS

43. 43Prof. Dr. RS Mehta, BPKIHS

44. Indications for intubation
•Criteria
• Clinical deterioration
• Tachypnea: RR >35
• Hypoxia: pO2<60mm Hg
• Hypercarbia: pCO2 > 55mm Hg
• Minute ventilation<10 L/min
• Tidal volume <5-10 ml/kg
• Negative inspiratory force <
25cm H2O (how strong the pt
can suck in)
•Initial vent settings
• FiO2 = 50%
• PEEP = 5cm H2O
• RR = 12 – 15 breaths/min
• VT = 10 – 12 ml/kg
• COPD = 10 ml/kg (prevent over-
inflation)
• ARDS = 8 ml/kg (prevent volu-trauma)
• Permissive hyper-capnea
• Pressure Support = 10cm H2O
How the values trend should significantly impact clinical decisions
44Prof. Dr. RS Mehta, BPKIHS

45. Indications for extubation
•Clinical parameters
• Resolution/Stabilization of
disease process
• Hemodynamically stable
• Intact cough/gag reflex
• Spontaneous respirations
• Acceptable vent settings
• FiO2< 50%, PEEP < 8, PaO2
> 75, pH > 7.25
•General approaches
• SIMV Weaning
• Pressure Support Ventilation
(PSV) Weaning
• Spontaneous breathing trials
and use of T-piece
• Demonstrated to be superior
No weaning parameter completely accurate when used alone
Numerical
Parameters
Normal
Range
Weaning
Threshold
P/F > 400 > 200
Tidal volume 5 - 7 ml/kg 5 ml/kg
Respiratory rate 14 - 18 breaths/min < 40 breaths/min
Vital capacity 65 - 75 ml/kg 10 ml/kg
Minute volume 5 - 7 L/min < 10 L/min
Greater Predictive
Value
Normal
Range
Weaning
Threshold
NIF (Negative
Inspiratory Force)
> - 90 cm H2O > - 25 cm H2O
RSBI (Rapid
Shallow Breathing
Index) (RR/TV)
< 50 < 100
Marino P, The ICU Book (2/e). 1998.
45Prof. Dr. RS Mehta, BPKIHS

46. Spontaneous Breathing Trials
•Settings
• PEEP = 5, PS = 0 – 5, FiO2 < 40%
• Breathe independently for 30 –
120 min
• ABG obtained at end of SBT
•Failed SBT Criteria
• RR > 35 for >5 min
• SaO2 <90% for >30 sec
• HR > 140
• Systolic BP > 180 or < 90mm Hg
• Sustained increased work of
breathing
• Cardiac dysrhythmia
• pH < 7.32
SBTs do not guarantee that airway is stable or pt can self-clear secretions
Causes of Failed
SBTs
Treatments
Anxiety/Agitation Benzodiazepines or haldol
Infection Diagnosis and tx
Electrolyte abnormalities
(K+, PO4-)
Correction
Pulmonary edema, cardiac
ischemia
Diuretics and nitrates
Deconditioning,
malnutrition
Aggressive nutrition
Neuromuscular disease Bronchopulmonary hygiene,
early consideration of trach
Increased intra-abdominal
pressure
Semirecumbent positioning,
NGT
Hypothyroidism Thyroid replacement
Excessive auto-PEEP
(COPD, asthma)
Bronchodilator therapy
Sena et al, ACS Surgery: Principles and
Practice (2005).
46
Prof. Dr. RS Mehta, BPKIHS

47. Guidelines Suggestingthe Needfor Mechanical Ventilation
Parameters that help us to guide to take the decision
whether mechanical ventilation is needed or not?
1. Cl. Indices:
 Apnea with respiratory arrest
 RR >35 breaths per minute
 Paralysis of breathing muscle- GBS, MG
 head trauma, coma
- an absent gag or cough reflex.
- Effect of anesthetic and muscle relaxant
- Others: shock, CCF, sepsis
47
Prof. Dr. RS Mehta, BPKIHS

48. 2. Mechanical indices
 Vital capacity <15 mL/kg
 Tidal volume <5 mL/ kg
 Maximum inspiratory force < –25 cm H2O
3. Respiratory gas tensions
Direct indices
 PaO2 (<60 mm Hg)
 PaCO2 (>50 mm Hg with pH <7.25)
Derived indices
PaO2/FIO2 ratio < 300 mm Hg
48
Prof. Dr. RS Mehta, BPKIHS

49. S.N Components Values
1. Respiratory rate >35-40/min
2. Tidal capacity < 10-15 ml/kg
3. PaO2 <60-70 mmHg under
O2 therapy
4. PaCO2 >50-55mmHg
5. Inspiratory pressure >20-25 cm H2O
49Prof. Dr. RS Mehta, BPKIHS

50. VENTILATOR ALARMS
ALARM DEFINITION POTENTIAL CAUSE
1. High
pressure
•Pressure required to ventilate
exceeds preset pressure
Pneumothorax, excessive
secretions, decreased lung
compliance.
2.Low pressure •Resistance to inspiratory flow is
less than preset pressure.
Disconnected from ventilator,
break in circuit.
3.Low exhaled
volume
•Exhaled tidal volume drops
below preset amount.
Leak in system, increased
airway resistance, decreased
lung compliance
4.Rate /apnea •Respiratory rate drops below
preset level. Apnea period
exceeds set time
Client fatigue, decreased R.R
due to medication.
5. FIO2 •Indicates FIO2 drift from preset
range.
Change in level of
consciousness, disconnected
from O2 source, break in
circuit. 50Prof. Dr. RS Mehta, BPKIHS

51. COMPLICATIONS OF MECHANICAL
VENTILATION
I. Complication associated with patient’s
response to mechanical ventilation .
II. Complication associated to ventilator
malfunction.
III.Complications related to endotracheal
intubation.
51Prof. Dr. RS Mehta, BPKIHS

52. Complication associated with patient’s
response to mechanical ventilation
1. Decreased cardiac output.
2. Decreased renal perfusion.
3. Positive water balance.
4. Barotraumas.
5. Nosocomial pneumonia.
52Prof. Dr. RS Mehta, BPKIHS

53. Complication associated to ventilator
malfunction
1. Alarms turned off or non-functional
– may lead to apnea and respiratory
arrest.
2. Low exhaled volume.
53Prof. Dr. RS Mehta, BPKIHS

54. Complications related to
endotracheal intubation
1. Sinusitis and nasal injury
2. Tracheoesophageal fistula
3. Laryngeal or tracheal stenosis
4. Cricoid abscess
54Prof. Dr. RS Mehta, BPKIHS

55. NURSINGCARE OF PATIENTS ON VENTILATOR
 PHYSIOLOGICAL NEEDS:
 comfort
 activity
 nutrition
 elimination of wastes
Patients are often not able to fulfill these needs by
themselves, nursing function is then for example
seeing to comfort, determining intake and output
together with blood chemistry to assess adequacy of
intravenous nutrition, and so on.
55Prof. Dr. RS Mehta, BPKIHS

56. CONTD…
 SAFETY NEEDS:
 Threat of injury by person or machines
Medication must be checked. Machines must be in best
working condition.
 NEED TO BELONG:
 Security, means of communication
Staff must communicate with the patient and patient
must be allowed to respond. Patients need constant
reassurance.
56Prof. Dr. RS Mehta, BPKIHS

57. CONTD…
 NEED FOR RECOGNITION:
 Esteem, dignity, respect
Patients must be treated with respect and addressed
correctly.
 NEED TO CREATE:
 Expression of self, need to contribute
Patients must be involved in the choice and
implementation of their treatment.
57Prof. Dr. RS Mehta, BPKIHS

58. CONTD..
 NEED TO KNOW AND UNDERSTAND:
 Need for knowledge and comprehension
An explanation of diagnosis and treatment on the
patient’s level.
 SELF ACTUALIZATION:
 Order, truth, privacy
Patients should have as much privacy as possible —
pull screens or close doors. The patient has the right to
be told the truth.
58Prof. Dr. RS Mehta, BPKIHS

59. Nursing Diagnoses
 Ineffective breathing pattern
 Potential for pulmonary infection
 Impaired water and fluid regulation
 Oral hygiene
 Potential altered nutritional status: less than body
requirement related to NPO status
 Potential for complications related to immobility
59Prof. Dr. RS Mehta, BPKIHS

60. Nursing Diagnoses…
 Knowledge deficit related to intubation and
mechanical ventilation
 Elimination care
 Promoting coping ability
 Preventing trauma and infections
 Promoting rest and sleep
 Safety and security needs.
60Prof. Dr. RS Mehta, BPKIHS

61. 61Prof. Dr. RS Mehta, BPKIHS

62. WEANING:
 Weaning is the process of withdrawing
mechanical ventilator support and transferring
the work of breathing from the ventilator to the
patient.
 It is done only when patient is free from the
cause to be kept on mechanical ventilation.
 Weaning success is defined as effective
spontaneous breathing without any mechanical
ventilation for 24 hours or more.
62Prof. Dr. RS Mehta, BPKIHS

63. Conditions that may hinder successful weaning
Patient/patho-physiologic : fever, infection,
renal failure, sepsis, sleep deprivation.
Cardiac/circulatory: arrhythmias, abnormal
blood pressure, abnormal cardiac output,
fluid imbalance.
Dietary/acid-base/electrolytes: acid-base
imbalance, electrolytes disturbance, anemia.
63Prof. Dr. RS Mehta, BPKIHS

64. Criteria for weaning
Tidal volume be above a given threshold
(greater than 5 ml/kg),
Respiratory frequency be below a given
count (less than 30 breaths/min),
Oxygen partial pressure be above a given
threshold (PaO2 greater than 60mm Hg) and
FIO2 <40%
Vital capacity 10 to 15 ml/kg.
64Prof. Dr. RS Mehta, BPKIHS

65. Since weaning is the graded removal of a
therapeutic modality, the sudden withdrawal
will not be tolerated.
So, weaning from the following 5 modalities
should be independently assessed.
1. Supplemental oxygen
2. PEEP
3. Mechanical ventilation
4. Artificial airway
5. Ionotrops
65Prof. Dr. RS Mehta, BPKIHS

66. Methods of Weaning
1- T-piece trial,
2- Continuous Positive Airway Pressure (CPAP)
weaning,
3- Synchronized Intermittent Mandatory Ventilation
(SIMV) weaning,
4- Pressure Support Ventilation (PSV) weaning.
66Prof. Dr. RS Mehta, BPKIHS

67. Signs of Weaning Intolerance Criteria
Diaphoresis
Dyspnoea & Labored respiratory pattern
Increased anxiety, Restlessness, Decrease in
level of consciousness
Dysrhythmia, Increase or decrease in heart rate
of > 20 beats /min. or heart rate > 110 b/m,
Sustained heart rate >20% higher or lower than
baseline
67Prof. Dr. RS Mehta, BPKIHS

68. Criteria…
 Increase or decrease in blood pressure of > 20 mm Hg
 Systolic blood pressure >180 mm Hg or <90 mm Hg
 Increase in respiratory rate of > 10 above baseline or >
30
 Sustained respiratory rate greater than 35
breaths/minute
 Tidal volume ≤5 ml/kg, Sustained minute ventilation
<200 ml/kg/minute
 SpO2 < 90%, PaO2 < 60 mmHg, decrease in PH of <
7.35.
 Increase in PaCO2.
68Prof. Dr. RS Mehta, BPKIHS

69. NURSING CARE OF THE PATIENT BEING WEANED
 Assess the client for the weaning criteria.
 Monitor the activity level, assess dietary intake and
monitor results of the lab tests.
 Assess client’s & family’s level of understanding of
weaning.
 Explain that patient may feel shortness of breath
initially & provide encouragement as needed.
 Monitor vital signs, pulse oximetry, ECG changes,
ABG analysis & respiratory pattern continuously for
the first 20-30 min & then every 5 min until weaning
is complete. 69Prof. Dr. RS Mehta, BPKIHS

70. Nursing Care…
 Implement the weaning method prescribed: ASB,
IMV, SIMV, CPAP, T-piece, etc….
 Maintain a patent airway, suction the airway as
needed.
 Monitor the ABG level & Pulmonary Function Test
as per requirement.
 Terminate the weaning if adverse reactions occur.
 Assess psychological dependence if the physiologic
parameters indicate weaning is feasible or patient
still resists.
70Prof. Dr. RS Mehta, BPKIHS

71. Elimination Care:
Catheter care
Proper cleaning, use of bed pan if
possible.
Optimal Level of Mobility:
The nurse should help active or passive
range of motion every 6-8 hours to
prevent contractures and venous stasis.
71Prof. Dr. RS Mehta, BPKIHS

72. Promoting Optimal Communication:
Assessment of the ability of the ventilator-
dependent patient's to communicate and thus
identify the patient's limitations.
Use non-verbal methods of communication.
Use of signals, signs, nodding, palm writing, lip
reading.
Provide paper & pencil, magic slate.
Be alert to non-verbal clues.
Allow patient to respond and repeat
explanations.
72Prof. Dr. RS Mehta, BPKIHS

73. Preventing trauma and infections:
Positioning of the ventilator tubing
should be such that there is minimal
pulling or distortion of the tube in the
trachea to reduce the risk of trauma to
the trachea.
Monitoring of cuff pressure every 8 hrs
to maintain the pressure less than 25cm
of H2O.
Tracheotomy care at least every 8
hourly & more frequent if need.
73Prof. Dr. RS Mehta, BPKIHS

74. Preventing trauma and infections…
Oral care frequently because the oral cavity is
the primary source of contamination of the
lungs in the intubated and compromised
patients.
The naso-gastric tube can increase the risk
of aspiration, leading to nosocomial
pneumonia hence the patient should be
positioned with the head elevated above the
stomach.
All prescribed medications should be given on
time.
Prof. Dr. RS Mehta, BPKIHS 74

75. Promoting coping Ability:
Encouraging family to verbalize their
feelings about the ventilators, patient's
condition is beneficial.
Explanation about the procedures every
time they are performed helps to reduce
anxiety.
75Prof. Dr. RS Mehta, BPKIHS

76. Rest & Sleep:
Keep calm & quiet environment.
Turn monitor alarm down if possible.
Provide dim light during night & soft music
if possible.
Cover patient eyes with clean gauze.
76Prof. Dr. RS Mehta, BPKIHS

77. Oral Hygiene:
 Provide oral care every 2 hourly as oral mucus
membranes dry in 2 hours.
 Moisten the mouth with solutions that do not
contain alcohol or lemon. Moistens the lips with
lubricant. It prevents drying, cracking &
excoriation.
 Brush the client’s teeth as twice daily as dental
caries are prevented by saliva.
 Suction oral secretions from the mouth as
secretions pool in oro-pharynx because of the
inflated tracheal cuff.
 Assess for pressure areas at the corner of the
mouth.
77Prof. Dr. RS Mehta, BPKIHS

78. SAFETY & SECURITY NEEDS
 Secure physically, mentally, emotionally.
 Prevent trauma & infection
 Perform hand-hygiene & adopt sterile
techniques.
 Prevention of cross-infection & nosocomial
infection.
 Maintain warm & adequate body temperature.
 Put side-rails.
 Visiting hours should be defined.
78Prof. Dr. RS Mehta, BPKIHS

79. ARTIFICIAL AIRWAY:
1. COMBITUBE.
2. LMA (Laryngeal Mask Airway)
3. OROPHARYNGEAL airway
4. NASOPHARYNGEAL airway
5. ETT
6. TRACHEOSOTOMY tube.
79
Prof. Dr. RS Mehta, BPKIHS

80. 0ropharyngeal Airway:
There are A.A. with
length 25-35 cm, sized
5-10 mm (acco. Int.
diameter), vol. capacity
of ET tube is from 35-
45 ml (which is abt.
About half the vol. of
anatomical dead space
in adults 1ml/kg).
80Prof. Dr. RS Mehta, BPKIHS

81. THANK YOU!!! 81
Prof. Dr. RS Mehta, BPKIHS