care of the patient on a ventilator

1. Ventilator Patient
Care
By
G. Thejaswi

2. Terminologies
• Inspiration: movement of air into the lungs from atmosphere.
• Expiration: movement of air out from the lungs.
• Tidal volume (TV): The amount of air passing into and out of the lungs during each
cycle of quiet breathing. (about 500ml)
• Vital capacity (VC): The amount of air that can be forcibly expired after the deepest
possible inspiration. It indicates the largest volume of air that can be exchanged during
respiration. (about 3500ml)
• Pa02:Arterialpartialpressureofoxygen
• PaC02 :Partialpressureofcarbondioxide
• Fio2:Fractionalinspiredoxygenconcentration

3. Ventilator
• Mechanical ventilator as a therapeutic intervention was first widely used during the
poliomyelitis epidemic in Europe and the United States in the 1940s and 1950s.
• Since then, there have been great advances in technology, so that negative pressure
ventilators that were used originally have been replaced by increasingly sophisticated
positive pressure machines.
• Mechanical ventilation is a life support treatment, sometimes referred to as artificial
respiration.
• A mechanical ventilator is a machine designed to provide breathing for a patient who
is physically unable to breathe enough on their own, or breathing insufficiently.
• It is a positive or negative pressure breathing device that can maintain ventilation
and oxygen delivery for a prolonged period.
• The purpose of mechanical ventilation is to provide ventilatory support partially or
fully by an external device to patients who cannot maintain an adequate gas exchange.
• It can be noninvasive involving various types of face masks or invasive involving
endotracheal intubation.

4. Types of ventilators
• Negative Pressure Ventilator
• Positive Pressure Ventilator

5. Negative pressure ventilator
• It applies negative pressure around the chest wall, causes intrathoracic pressure to
become negative, allows air to flow into the lungs and filling its volume.
• 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.

6. Positive pressure ventilator
• Positive pressure ventilators inflate the lungs by exerting positive pressure on the
airway forcing the alveoli to expand during inspiration.
• Expiration occurs passively.
• Positive-pressure ventilators require an artificial airway (Endotracheal or
tracheostomy tube) and use positive pressure to force gas into a patient's lungs.

7. Indications
• Apnea with respiratory arrest
• Tachypnea
• Upper and lower airway obstruction
• Acutelunginjury and acute respiratory distress syndrome
• Acute severe asthma, requiring intubation
• Chronic obstructive pulmonary disease (COPD)
• Neuromuscular disease e.g. Guillain-Barre syndrome,myasthenia gravis,spinalcordinjury
• Post- operative cardiac surgery, shock and trauma
• CNS depression (drug intoxication, respiratory depressants, cardiac arrest)
• Respiratory muscle fatigue

8. Modes of ventilator support
• Controlled mode ventilation
• Assist / Control Ventilation (A/C)
• Intermittent Mandatory V
entilation (IMV)
• Synchronous intermittent mandatory ventilation (SIMV)
• Pressure support ventilation
• Continuous positive airway pressure (CPAP)
• Inverse ratio ventilation (IRV)
• Positive end expiratory pressure (PEEP)
• Bilevel positive airway pressure (BIPAP)

9. Ventilation alarms and causes
Alarm Possible Reasons
High Pressure Limit Secretions, coughing or gaging, kinked or
compressed tubing, bronchospasm,
pneumothorax
Low Pressure Limit ET tube cuff leak, total or partial extubation,
insufficient gas flow
Apnea alarm Respiratory arrest, oversedation, loss of airway
Ventilator inoperative or low battery Machine malfunction, unplugged, power
failure or battery not charged

10. Alarm Definition Potential Cause
High Pressure Pressure required to ventilate
exceeds preset 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
preset level. Apnea period
exceeds set time
Client fatigue, decreased R.R
due to medication
Fl02 Indicates FI02 drift from preset
range
Change in level of
consciousness, disconnected
from 02 source, break in circuit
Ventilator Alarms

11. Complications of ventilator
Related to mechanical ventilation Related to Endotracheal Intubation
Decreased Cardiac Output Sinusitis and nasal Injury
Decreased Renal Perfusion Trachea-esophageal fistula
Positive Water Balance Cricoids abscess
Barotrauma Laryngeal or tracheal Stenosis
Pneumonia

12. Other complications
• Skin: Pressure sore, laceration
• Respiratory system: Hypostatic pneumonia, pulmonary embolism
• CVS: Deep vein thrombosis, thromboembolism
• G a s t r o system: Paralytic ileus, constipation, distention
• Musculo-skeletalSystem: Contracture, dystrophy, weakness
• Urinary system: UTI, stone
• Neurological: foot drop

13. Assess the patient's condition
• Assess patient’s level of pain, anxiety levels 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

14. Manage airway
• Assess respiratory rate and depth.
• Assess patient for oxygenation and signs and symptoms of hypoxia.
• Elevate the head of bed.
• Suction the airway for clearance.
• Provide chest physiotherapy and breathing exercises for secretions mobilization

15. Suction appropriately
• Assess the tube insertion site, breath sounds, vital signs to identify complications.
• Suction only as needed-not according to a schedule.
• Hyperoxygenate the patient before and after suctioning to help prevent oxygen
desaturation.
• Suction for the shortest duration possible.
• Don't instill normal saline solution into the endotracheal tube in an attempt to promote
secretion removal.
• Limit suctioning pressure to the lowest level needed to remove secretions

16. Check ventilator settings and modes
• Read the patient's 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

17. Meet the patient's physiological needs
• Provide eye care, 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

18. 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

19. Prevent hemodynamic instability
• Monitor the patient's blood pressure every 2 to 4 hours, especially after ventilator
settings are changed or adjusted.
• Assess breath sounds and oxygenation status.
• To maintain hemodynamic stability, maintain l.V. fluids or administer a drug such as
dopamine or norepinephrine, if ordered

20. Prevent complications of ventilator
• Wash hands and use appropriate personal protective equipment, such as gloves, when
touching patients, intubation tubes or ventilators.
• Keep the head of the bed elevated 30 to 45 degrees at all times, if patient condition
allows.
• Provide oral care at least twice a day and provide oral moisturizers every 2 to 4 hours.
• Observe skin for pressure sores. Provide back care, use pressure relief mattress and change
the position of the patient frequently.
• Provide deep vein thrombosis prophylaxis, as with an intermittent compression device.
• Provide range-of-motion exercises and patient turning and positioning to prevent the effects
of muscle disuse

21. Thank You