Consist of Definition of mechanical ventilator Purpose of mechanical ventilator Indications of mechanical ventilations Normal cycle of Respiration Lung volumes Modes of ventilator Types of mechanical ventilators Describe the alarms of mechanical ventilator Contraindications of mechanical ventilation Complication of mechanical ventilator Role of nurses during weaning and care of patient with VAP

1. Demonstration
on
Mechanical ventilator
Presented by:
Shashi Prakash
M. Sc. Nursing II Year
CON, ILBS

2. Objectives
 Definition of mechanical ventilator
 Purpose of mechanical ventilator
 Indications of mechanical ventilations
 Normal cycle of Respiration
 Lung volumes
 Modes of ventilator Types of mechanical ventilators
 Describe the alarms of mechanical ventilator
 Contraindications of mechanical ventilation
 Complication of mechanical ventilator
 Role of nurses during weaning and care of patient with VAP

3. DEFINITION
• Mechanical ventilation is the medical term for artificial
ventilation where mechanical means is used to assist or
replace spontaneous breathing
• Mechanical ventilation is ventilation of the lungs by artificial
means usually by a ventilator

4. PURPOSE

5. INDICATIONS
1. Acute respiratory failure due to:
• Mechanical failure, includes neuromuscular diseases as Myasthenia
Gravis, Guillian-Barre Syndrome, and poliomyelitis (failure of the
normal respiratory neuromuscular system ).
• Musculoskeletal abnormalities, such as chest wall trauma (flial
chest)
• Infectious diseases, of the lungs such as Pneumonia,Tuberculosis.

6. CONT...
2. Abnormalities of Pulmonary gas exchage as in:
• Obstructive lung disease in the form of Asthma, Chronic
bronchitis emphysema
• Conditions such as Pulmonary edema, atelectasis
Pulmonary fibrosis.
• Patient who has received general anaesthesia as well as
post cardiac arrest patients often require ventilatory
support until they have recovered from the effects of the
anaesthesia or the insult of an arrest.

7. Two basic forms of respiratory failure
Hypoxic
• Sao2 < 90% at Fio2 > or 60%
• Examples are acute exacerbation of COPD, severe pneumonia,
and pulmonary edema.
Hypercapnic
• PaCO2 > 50 mm Hg & pH < 7.3
• Hypercapnic respiratory failure includes neuromuscular disease,
such as myasthenia gravis, and other diseases causing
respiratory muscle fatigue, such as asthma and COPD.

8. The physical parameters that indicate use of
Ventilators-
• PaO2 < 50 mm Hg with FiO2 > 0.60
• PaCO2 > 50 mm Hg with pH < 7.25
• Vital Capacity < 2 times Tidal Volume
• Negative Inspiratory Force < 25 cm H2O
• Respiratory Rate > 35/min.

9. NORMAL CYCLE OF RESPIRATION

11. LUNG CAPACITIES AND VOLUMES
• Tidal volume (TV) – air that moves into and out of the lungs with each breath
(approximately 500 ml)
• Inspiratory reserve volume (IRV) – air that can be inspired forcibly beyond
the tidal volume (2100–3200 ml)
• Expiratory reserve volume (ERV) – air that can be evacuated from the
lungs after a tidal expiration (1000–1200 ml)
• Residual volume (RV) – air left in the lungs after strenuous expiration (1200
ml)

12. CONT...
• Inspiratory capacity (IC) – total amount of air that can be
inspired after a tidal expiration (IRV + TV)
• Functional residual capacity (FRC) – amount of air remaining in
the lungs after a tidal expiration (RV + ERV)
• Vital capacity (VC) – the total amount of exchangeable air (TV +
IRV + ERV)
• Total lung capacity (TLC) – sum of all lung volumes
(approximately 6000 ml in males)

14. Types/ classification of ventilators
• According to the method by which they support
ventilation two general categories are-
I. Negative pressure ventilators
II. Positive pressure ventilators

15. Negative pressure ventilators
I. Negative pressure ventilators
– Exert a negative pressure
– Decrease the intrathoracic pressure
– No tracheostomy or endotracheal tube.

16. Disadvantages…
– Limits access to the patient by health care providers.
– It is cumbersome and leads to patient discomfort
– Cardiac output tends to decrease from pooling of venous
blood in the lower torso.

17. Types of negative – pressure ventilators
Iron Lung (drinker respirator tank)

19. • Body wrap ( pneumo- wrap)
• Chest Cuirass (tortoise shell)
A cuirass, or shell unit, allows
negative pressure to be applied
only to the patient's chest by using
a combination of a form-fitted shell
and a soft bladder.

20. Positive pressure ventilators
II Positive pressure ventilators
• The positive nature of the pressure causes the gas to
flow into the lungs until the ventilator breath is
terminated. As the airway pressure drops to zero,
elastic recoil of the chest accomplishes passive
exhalation by pushing the tidal volume out.

21. Classifications of Positive-Pressure
Ventilators
• They are classified by their method of cycling from the
inspiratory phase to the expiratory phase. That is, after
that parameter that signals the termination of the positive-
pressure inspiration cycle of the machine. Include-
• Time-cycled ventilators
• Pressure-cycled ventilators
• Volume-cycled ventilators

22. Time-cycled ventilators
• Time-cycled ventilation occurs as the Inspiratory phase begins
and gas flows through the ventilator circuit into the patient's lungs
until a timing mechanism in the ventilator reaches a preset
duration.
• Once the preset time is reached, the Inspiratory phase ends and
the patient passively exhale.
• During time-cycled ventilation, tidal volume is not controlled
directly.

23. Time-cycled ventilators
• tidal volume dependent on gas flow rate and lung
compliance.
• A higher flow rate results in a shorter Inspiratory time and
vice versa.
• As lung compliance decreases, the peak Inspiratory
pressure and potential for alveolar hyperinflation increase.

24. Pressure-cycled ventilators
• inspiratory phase begins and gas flows through the
ventilator circuit into the patient's lungs until a pressure-
sensing mechanism in the ventilator reaches a preset level.
• Once this level is reached, the inspiratory phase ends and
the patient passively exhale.
Delivery of adequate tidal volume during pressure-cycled
ventilation is determined by the initial cycling pressure
selected, the flow rate (L/min), and lung characteristics,
including both pulmonary compliance and airway
resistance.

25. Pressure-cycled ventilators
• In the clinical setting, reduced lung compliance and
increased airway resistance shorten the inspiratory
phase, thus lowering the tidal volume delivered.
• Pressure-cycled ventilators are used as portable
ventilators in health care facilities, mobile intensive care
units, and life-flight helicopters.

26. Volume-cycled ventilators
• In volume-cycled ventilation, the most common form of
ventilation cycling used for adult patients, the signal to
terminate the Inspiratory activity of the machine is a
preset volume.
– variable modes of ventilation
– improved patient-ventilator synchrony
– simplicity of tidal volume adjustment to better facilitate the
ventilation process.

27. Noninvasive Positive Pressure Ventilation
• Delivered by nasal or face mask, therefore eliminating the
need for endotracheal intubation.
• Includes-
– Bi-level positive airway pressure (BiPAP)
– Continuous Positive Airway Pressure

28. Bi-level positive airway pressure
Inspiratory positive airway pressure the pressure support
ventilation level
Expiratory positive airway pressure the CPAP
• It integrates inspiratory with expiratory positive airway pressure to
achieve adequate alveolar ventilation.
• Is the mode of choice for NIPPV because it provides continuous
high-flow positive airway pressures that cycle between preset high
and low pressure levels.
• Clinically indicated for patients with chronic stable or slowly
progressing respiratory failure, such as those with COPD plus
severe hypercapnia, acute pulmonary edema, asthma,
hypoxemia, or pneumonia, and those who refuse intubation.
• With BiPAP, two pressures (inspiratory and expiratory) are used.

29. Bi-level positive airway pressure
• As the patient is inclined to an angle of at least 45 degrees,
inspiratory positive airway pressure is usually started at 8–10 cm
H2O; a mask is placed over the patient's nose or mouth and fitted
for comfort.
• A back-up mandatory ventilator rate is typically set at 4–12
breaths/minute in case the patient experiences apnea.
• Expiratory positive airway pressure is started at 4–6 cm H2O,
which can be increased in increments of 2–3 cm H2O for patients
experiencing hypoxia.
• Oxygen may be titrated into the circuit at 0.5–6 L/minute to
alleviate hypoxemia.

30. Continuous Positive Airway Pressure
• Continuous positive airway pressure is used for patients with
obstructive sleep apnea and heart failure with respiratory muscle
weakness. It is usually started at 2.5–15 cm H2O, based on
ventilatory goals. Oxygen may be titrated into the circuit at 0.5–6
L/minute to alleviate hypoxemia.
• Traditional weaning mode
• Both CPAP and BiPAP devices have limitations, including poor
patient compliance due to discomfort of the device.

31. Diaphragm Pacing
• An electronic pacer stimulates the diaphragm to contract, thus
assisting breathing by "bellows" motion of the diaphragm.
• This method is used by patients who have high (C1-C2) spinal
cord injury, and with tracheostomy in some children who cannot
breathe spontaneously because of a problem with central control
of breathing.

32. Contra indications of Noninvasive Positive
Pressure Ventilation
• Patients who have experienced respiratory arrest
• Serious dysrhythmias
• Cognitive impairment
• Head or facial trauma

33. Articles
• Laryngoscope
• Endotracheal tube
• Stylet
• Syringe
• Suction catheter
• Carbon dioxide detector
• Oral airway
• Nasal airway

34. cont....
• Bag-valve-mask
• Nasal cannula
• Stethoscope
• Magills forcep
• Ambu bag
• with reserviour
• HME filter
• Catheter mount
• Ventilator circuit

36. Ventilator Modes
Traditional Modes of Invasive Mechanical Ventilation
• Traditional modes of invasive mechanical ventilation use volume, pressure,
and time to cycle from the inspiratory to the expiratory phase and can be
administered as full or partial ventilator support.
• Full support provides the patient with adequate ventilatory requirements to
meet metabolic demands without supplementation by the patient.
• Partial support provides partial ventilator assistance but requires patients to
actively participate in their own spontaneous ventilation.

37. Control Mode Ventilation
• Control mode ventilation (CMV) is a time-cycling process used primarily with
patients unable or not required to generate a voluntary respiratory effort.
• The timing mechanism generates the inspiratory tidal volume breath
independent of the patient's respiratory effort.
• the ventilator does not allow the patient to self-generate a tidal volume
breath.
• Patients waking from sedation or pharmacologic paralysis may experience
agitation and "air hunger" since they cannot interface with the ventilator.

38. Assist Control Ventilation
• During assist control ventilation (A/C) the patient receives a predetermined
mechanical respiratory rate and tidal volume, as with CMV, but is able to self-
generate additional tidal volume breaths.
• Negative pressure starts the inspiratory breath. By tradition, a pressure of -2
cm H2O is selected.
• Patients who have apnea or are unable to self-generate a tidal volume breath
are guaranteed the predetermined mechanical respiratory rate and tidal
volume.

39. • Control mode and A/C ventilation are differentiated only by the preset
triggering threshold for A/C ventilation.
• Assist control is highly successful as a primary ventilator mode but has
limitations.
– The ventilator delivers a preset tidal volume breath and respiratory rate, resulting in an
expired minute ventilation (e.g., tidal volume 500 ml x 14 breaths/min = 7 L/min).
– Patients can also self-generate additional tidal volume breaths (e.g., tidal volume 500 ml
x 10 breaths/min = 5 L/min).
– The result is hyperventilation and possible respiratory alkalosis due to excessive minute
ventilation (e.g., 500 ml x 24 breaths/min = 12 L/min).

40. Synchronized Intermittent Mandatory
Ventilation
• Synchronized intermittent mandatory ventilation is almost identical to IMV;
the difference is that the patient's own spontaneous breathing pattern is
synchronous with the SIMV rate.
• Machine breaths plus self-generated additional breaths equal the total
respiratory rate (e.g., a SIMV preset rate of 8 breaths/min and 4 self-
generated spontaneous breaths would be documented as 8/12).
• This prevents the "stacking"
• Synchronized intermittent mandatory ventilation, like A/C ventilation, is used
primarily as an initial ventilator mode.

41. Synchronized Intermittent Mandatory
Ventilation

42. Pressure Control Ventilation
• Pressure control ventilation is a pressure-limiting, time-cycled mode in which a constant
pressure is maintained throughout the preset inspiratory time.
• As gas flows through the ventilator circuit and into the patient's lungs, the airway pressure
rises, resulting in increased alveolar volume. The outcome is that delivered airway pressure
equals intrapulmonary pressure, ending the inspiratory phase.
• Clinicians often change the ventilation mode from volume controlled (CMV, A/C, or SIMV) to
pressure control ventilation if adequate ventilation or oxygenation goals are not achieved, or
if excessive peak airway pressures are required to optimize gas exchange.
• Patients with acute lung injury or acute respiratory distress syndrome often require pressure
control ventilation, primarily due to difficulties in optimizing ventilation and oxygenation goals
with conventional volume-controlled ventilation.

43. Pressure Support Ventilation
• Pressure support ventilation provides preset pressure assistance during each
spontaneous patient breath to overcome airway resistance of the
endotracheal tube and dead space of the ventilator circuit to decrease the
patient work of breathing.
• Pressure support ventilation is used as a tool for ventilator weaning since it
requires full spontaneous respiratory effort by the patient.
• Pressure support ventilation is widely used in the critical care setting in
combination with other modes, such as SIMV. This combination provides
mandated mechanical ventilator breaths from SIMV augmented with pressure
support ventilation during spontaneous breathing by the patient.

44. volume pressure curve for-
low lung volume and stiff non-compliant lung
Normal lung

45. pressure support ventilation

46. Continuous Positive Airway Pressure
• Continuous positive airway pressure (CPAP) allows for constant pressure
maintained above atmospheric pressure throughout the respiratory cycle.
• A CPAP of 5 cm H2O is traditionally started to maintain pressure above
atmospheric pressure.
• Continuous positive airway pressure can be provided alone or in
combination with pressure support ventilation.
• Continuous positive airway pressure by itself or in combination with pressure
support ventilation is the primary mode used to promote spontaneous
ventilation to assist with discontinuation of mechanical ventilation.

47. Inverse ratio ventilation ( IRV)
• proportion of inspiratory to expiratory time is greater than 1:2
• Can be initiated using pressure controlled breaths (PC- IRV) or volume
controlled breaths ( VC-IRV)
• IRV is used in clients with hypoxemia refractory to PEEP. the longer
inspiratory time increases functional residual capacity and improves
oxygenation by opening collapsed alveoli, and the shorter expiratory time
induces auto- PEEP that prevent alveoli from re-collapsing.
– Increase intra- thoracic pressure can result in excessive air trapping and
– decrease cardiac output.

48. High frequency ventilation (HFV)
• delivers a small volume of gas at rapid rate.
• HFPPV ( high frequency positive pressure ventilation) delivers 60-
100 breaths / minute.
• High frequency jet ventilation ( HFJV):
– delivers 100-600 cycles / minute.
• High frequency oscillation (HFO)
– delivers 900- 3000 cycles / minute

49. High frequency ventilation (HFV)
• Compromised hemodynamic stability
• Bronco pulmonary fistula
• During short term procedures
• Diseases that create risk of volutrauma.
– sedation and/ or pharmacological paralysis required.
– assessment of breath sounds is difficult.

50. Independent lung ventilation (ILV)
• each lung is ventilated separately.
• ILV s used in patients with unilateral lung disease,
broncho pleural fistulas, and B/L asymmetric lung
disease.
– Requires a double lumen endotracheal tube,
– Two ventilators,
– Sedation and/ or pharmacological paralysis.

51. Proportional assist ventilation (PAV)-
• It provides partial ventilatory support in which the ventilator generates
pressure in proportion to the patients ventilatory efforts.
• With every breath, the ventilator synchronizes with the patients ventilatory
efforts.
• The more inspiratory pressure the patient generates, the more pressure the
ventilator generates, amplifying the patients inspiratory effort without any
specific preselected target pressure or volume.
• It generally adds “additional muscle” to the patients effort: the depth and
frequency of breath are controlled by the patient.

52. Volume assured pressure support
• This mode has been called pressure augmentation according to various manufacturers.
• This mode can switch from pressure control to volume control within a single specific breath
cycle.
• After a breath is triggered, rapid and variable flow creates pressure to reach the set level of
pressure support.
• The tidal volume that is delivered from the machine is monitored. If the tidal volume equals
the minimum set tidal volume, the patient receives a typical pressure-supported breath,
which makes this mode essentially like volume support.
• However, if the tidal volume is less than the set tidal volume, the ventilator switches to a
volume-controlled breath with constant flow rate until the set tidal volume is reached.

53. Ventilator settings
• A variety of settings on the ventilator allows the
ventilator parameters to be individualized to patients
needs and the mode of ventilation selected.

54. Settings
• PEEP
– The purpose of peep is to expand collapsed small airways and atelectic
alveoli, thus improving alveolar ventilation.
• PEEP is generally administered at pressure not exceeding 7-10
cm H2O.
• PEEP up to 20 cm H2O may occasionally be given in some ARDS
patients with very low compliance and severe respiratory
insufficiency.

55. Optimal PEEP is characterized by-
• A decrease in the percentage of shunt
• An increase in FRC
• No significant increase in PCWP as monitored by swan
Ganz catheter.
• Maintenance of BP
• increase in Pao2
• increase in lung compliance
• an improvement in serial cardiac outputs.

56. Settings
• RATE
– Usually set around 10-14 / min.
• TIDAL VOLUME
– 10- 15 cc/kg
• PEAK PRESSURE
– Preferably not to exceed 35 cm H2o
• Sensitivity
– 2 cm H2O Inspiratory Force

57. Settings
• SIGH VOLUME
– Usually 1.5 times the tidal volume, 1-3 times / hour.
• CIRCUIT TEMPERATURE
– The inspiratory air temperature should not exceed 39 degree Celsius at
the point of entry into the patient.
• Fio2
– Titrated to the lowest required for normal pao2 ( 80-100 mm Hg )
• Minute volume
– Tidal volume x respiratory rate, usually 6-8 L/ min

58. Complications of Mechanical Ventilation
• Volutrauma
• Barotrauma
• Oxygen toxicity
• Ventilator-associated pneumonia
• Intrinsic PEEP or auto-PEEP
• Sinusitis
• Gastrointestinal Complications
• Cardiovascular Effects

59. Problems with mechanical ventilation
• Increase in peak airway pressure
It can be a result of coughing or plugged airway tube, patient
“bucking” ventilator, decreasing lung compliance, tubing kinked,
pneumothorax, atelectasis or bronchospasm.
• Decrease in pressure or loss of volume
It can result due to increase in compliance or leak in ventilator or
tubing; cuff on tube/ humidifier not tight.

60. TROUBLESHOOTING ALARMS
• HIGH CONTINOUS PRESSURE
• Possible Cause-
– airway pressure higher than set PEEP plus 15 cm H2O for
more than 15 seconds.
• Remedy-
– check client
– check circuit
– check ventilator settings and alarm limits

61. TROUBLESHOOTING ALARMS
• CHECK TUBING
• Possible Cause
– disconnected pressure transducer ( expiratory)
– blocked pressure transducer
– water in expiratory limb of ventilator
– wet bacterial filter
– clogged bacterial filter
Remedy-
– check ventilator internals on expiratory side
– check heated wires in humidifier if present
– refer to service
– replace filter
– remove water from tubing and check humidifier settings ( relative humidity)

62. TROUBLESHOOTING ALARMS
• AIRWAY PRESSURE TOO HIGH
• Possible Cause-
– kinked or blocked client tubing
– mucus or secretion plug in ET tube or in airway
– client coughing or fighting ventilator.
– inspiratory flow rate too high
– improper alarm setting
• Remedy-
– check client
– check ventilator settings and alarm limits.

63. TROUBLESHOOTING ALARMS
• LIMITED PRESSURE (alarm active only in PRVC and VS mode)
• Possible Cause-
– kinked or blocked client tubing
– mucus or secretion plug in ET tube or in airway
– client coughing or fighting ventilator.
– improper alarm setting
– client's lung/ thorax compliance decreasing
– client's airway resistance increasing
• Remedy-
– check client
– check ventilator settings and alarm limits.

64. TROUBLESHOOTING ALARMS
• EXPIRED MINUTE VOLUME TOO HIGH
• Possible Cause-
– Increased client activity
– ventilator self- triggering ( auto cycling)
– improper alarm limit setting
– wet flow transducer
• Remedy-
– check client
– check trigger sensitivity setting
– check alarm limit setting
– dry the flow transducer

65. TROUBLESHOOTING ALARMS
• EXPIRED MINUTE VOLUME TOO LOW
• Possible Cause-
– low spontaneous client breathing activity
– leakage in cuff
– leakage in client circuit
– improper alarm limit setting
• Remedy-
– check client
– check cuff pressure
– check client circuit ( perform leakage test if necessary)
– check pause time and graphics to verify
– consider more ventilatory support for client

66. TROUBLESHOOTING ALARMS
• EXPIRED MINUTE VOLUME DISPLAY READS ZERO
• Possible Cause-
– flow transducer faulty
– circuit disconnected from patient.
• Remedy-
– replace flow transducer
– connect Y- piece to client

67. TROUBLESHOOTING ALARMS
• APNEA ALARM
• Possible Cause-
– time between two consecutive inspiratoey efforts exceeds……
– adult: 20 seconds
– pediatric: 15 seconds
– Neonate : 10 seconds
• Remedy-
– check client
– check ventilator settings

68. TROUBLESHOOTING ALARMS
• PEEP/ CPAP AND/ OR PLATEAU PRESSURE FAILS TO BE MAINTAINED.
• Possible Cause-
– leakage in cuff
– leakage in client circuit
– improper alarm limit setting
• Remedy-
– check cuff pressure
– check client circuit ( perform leakage test if necessary)
– check pause time and graphics to verify
– consider more ventilatory support for client

69. Weaning
• Respiratory weaning, the process of withdrawing the patient from
dependence on the ventilator, takes place in three stages: the
patient is gradually removed from the ventilator, then from the
tune, and finally from oxygen. Weaning from mechanical
ventilation is performed at the earliest possible time consistent
with patient safety.

70. Weaning Criteria
• weaning can be done if client tolerates spontaneous
breathing without undue anxiety or inadequate
cardiopulmonary function.
• The following indicate readiness for weaning-

71. Weaning Criteria
• Fio2 < 50%
• PEEP of < 5 CM H2O
• Respiratory Rate < 30/ minute
• Minute Volume < 10 liter / minute
• Static compliance > 25 – 30 cm
H2O
• Max inspiratory pressure < -20 cm
H2O
• Vital Capacity > 10 -15 ml /kg
• Spontaneous Tidal Volume > 4 -5
ml / kg
• Max voluntary ventilation> twice
minute ventilation
• Alveolar arterial O2 tension
difference < 350 torr on an FiO2 of
100%
• Shunt < 15% - 20%
• PaCo2 within normal limit
• PaO2 > 60% on an FiO2 of < 50%

72. Weaning include….
• Weaning from ventilator
• Weaning from the tube
• Weaning from oxygen

73. Weaning from ventilator
• Assist-control ventilation
• SIMV
• PAV
• CPAP
• When the patient can breath spontaneously, weaning trials using
a T-Piece are conducted with the patient disconnected from the
ventilator, receiving humidified oxygen only and performing all
work of breathing

74. Weaning from ventilator
• During weaning, the patient is maintained on the same or a higher oxygen
concentration than when receiving mechanical ventilation.
• While the patient is using the T- piece, he or she is observed for signs and
symptoms of hypoxia, increasing respiratory muscle fatigue or systemic
fatigue.
• These include
– restlessness
– increased respiratory rate
– use of accessory muscles
– tachycardia with PVC and
– paradoxical chest movements.

75. Weaning from ventilator
• If clinically stable the patient usually can be extubated within 2 or
3 hours after weaning and allowed spontaneous ventilation by
means of a mask with humidified oxygen.
• Patients who have had prolonged ventilatory assistance usually
require more gradual weaning. It may take days or even weeks.
– They are weaned primarily during the day and placed back on
the ventilator at night to rest.

76. Weaning from ventilator
• Because, patients respond in different manners to the various weaning
methods there is no definite way to assess which method is best.
• ongoing assessment of respiratory status is essential to monitor patient
progress.
• These patients still have borderline pulmonary function and need vigorous
supportive therapy before their respiratory status returns to a level that
supports activities of daily living.

77. supplemented by intensive pulmonary care
• Oxygen therapy
• Arterial blood gas evaluation
• Pulse oxymetry
• Broncodilator therapy
• CPT
• Adequate nutrition, hydration and humidification
• Incentive spirometry

78. Weaning from the tube
• Weaning from the tube is considered when the patient can
breathe spontaneously, maintain an adequate airway by
effectively coughing up secretions, swallow and move the jaw.
• If frequent suctioning is needed to clear secretion, the tube
weaning may be unsuccessful.
• Secretions clearance and aspiration risk are assessed to
determine weather active pharyngeal and laryngeal reflexes are
intact.

79. Weaning from the tube
• Once the patient can clear secretions adequately, a trial period of
mouth breathing or nose breathing is conducted. This can be
accomplished by several methods.
• The first method requires changing to a smaller size tube to
increase the resistance to air flow or plugging the tracheostomy
tube. The smaller tube is sometimes replaced by a cuffless
tracheostomy tube, which allows the tube to be plugged at
lengthening intervals to monitor patient progress.

80. Fenestrated Tube
• A second method involves
changing to a fenestrated
tube. This permits air to flow
around and through the tube
to the upper airway and
enables talking.

81. Tracheostomy Button
• A third method involves
switching to a smaller
tracheostomy button. A
tracheostomy button is a plastic
tube approximately one inch long
that helps keep the wind pipe
open after the larger
tracheostomy has been removed.

82. Weaning from the tube
• Finally, when the patient demonstrates the ability to
maintain a patent airway, the tube can be removed.
• An occlusive dressing is placed over the stoma, which
heals in several days to weeks.

83. Weaning from oxygen
• The patient who has been successfully been weaned from the
ventilator, cuff and tube and has adequate respiratory function is
then weaned from oxygen.
• The Fio2 is gradually reduced until the Pao2 is in the range of 70
– 100 mm Hg.
• While the patient is breathing room air, if the Pao2 is less than 70
mm Hg on room air, supplemental oxygen Is recommended.

84. Complications of weaning
• Complications of weaning include-
– CO2 retention
– hypoxemia
– cardiovascular instability.
Do not attempt weaning in-
• A client who has too little strength to inspire.
• Hypovolemia
• Life threatening dysrhythmias
• A low cardiac index

85. Do not attempt weaning in
• An increased oxygen consumption
• Uncorrected acidosis or alkalosis
• Severe catabolism
• A Vd/ Vt ratio of 60% or greater.
– Normal is 30
• When patients with COPD are weaned their PaO2 and
PaCo2 should be as close to their normal levels as
possible.

86. Intolerance Indicators
• Increase or decrease of heart rate by 20 beats,
respiratory rate by 10 breaths or blood pressure by 20
mm Hg from baseline. ( or a difference of 10% from
baseline)
• Tidal volume of less than 300ml
• PaO2 less than 60 mm Hg.
• PaCo2 more than 55 mm of Hg.

87. Intolerance Indicators
• Ph less than 7.35
• Spo2 less than 90%
• Increase in minute ventilation more than 5 liter/ minute.

88. Failure to wean a patient from ventilator is usually
caused by
• An increase in the alveolar ventilation requirement in the presence
of an increase in Vd/ Vt ratio or an increase in the Paco2 level.
• A decrease in muscle strength secondary to metabolic wasting,
inadequate nutrition, or respiratory disco-ordination.
• An increase in the work of breathing after a decrease in lung
compliance or an increase in airway resistance due to
bronchospasm or mucous obstruction or narrowing of the air
conduits with edema.

89. Nursing Management of a Client on Ventilator
• Nursing care of the mechanically ventilated patient
requires expert technical and interpersonal skills.
• Two general nursing interventions important are-
– Pulmonary auscultation and
– Interpretation of ABG measurements.

90. Impaired gas exchange and ineffective breathing pattern R/T
underlying disease process and artificial airway and ventilator
system.
• The alteration in gas exchange may be caused by the underlying illness or by mechanical factors related to
adjustment of the machine to the patient.
• Assess the patient for adequate gas exchange, signs and symptoms of hypoxia and response to treatment.
• Nursing interventions to promote optimal gas exchange include judicious administration of analgesic
agents to relive pain without suppressing the respiratory drive and frequent repositioning to diminish the
pulmonary effects of immobility.
• The nurse also monitor s for adequate fluid balance by assessing for presence of peripheral edema,
calculating daily initial and output and monitoring daily weight.
• The nurse administers medications prescribed to control the primary disease and monitors for their side-
effect
Enhancing gas exchange

91. Ineffective airway clearance R/T inability to cough and
stimulation of increased secretion formation in the
lower tracheobronchial tree from the ET tube.
• Continuous positive pressure ventilation increases the production of secretions regardless of the
patients underlying condition.
• The nurse assess for the presence of secretions by lung auscultation at least every 2-4 hours.
Measures to clear the airway of secretions include suctioning, chest physiotherapy, frequent position
changes and increased mobility as soon as possible. Frequency of suctioning should be determined by
patient assessment.
• Humidification of the airway via the ventilator is maintained to help liquefy secretions so that they are
more easily removed.
Promoting effective airway clearance

92. • Bronco dilatators administered to dilate the bronchioles and are classified as adrenergic or
anti- cholinergic. Adrenergic are mostly inhaled and work while stimulating the beta receptor
sites, mimicking the effects of epinephrine in the body. The desired effect is smooth muscle
relaxation, which dilates the constricted bronchial tube. Medications include albuterol,
isoproterenol, metaproterenol, salmeterol and terbutalin.
• Tachycardia, heart palpitations and tremors have been reported with use of these
medications. Anti- cholinergic bronco dilatators such as ipratropium and ipratropium with
albuterol produce airway relaxation by blocking cholinergic induced bronco-constriction.
Promoting effective airway clearance

93. Promoting effective airway clearance
• Patients receiving bronco-dilators therapy of either type should be monitored
for adverse effects, including dizziness, nausea, decreased oxygen
saturation, hypokalemia, increased heart rate and urine retention.
• Mucolytic agents’ acetylcysteine (mucomyst) are administered to liquefy
secretions so that they are more easily mobilized.
• Nursing management of patients receiving mucolytic therapy includes
assessment of adequate cough reflex, sputum characteristic and
improvement in incentive spirometry.
• Side – effect include nausea, vomiting, bronchospasm, stomatitis, urticaria
and rhinorrhea.

94. Risk for infection R/T impaired defenses in respiratory
tract
• Position the ventilator tubing so that there is minimal pulling or distortion of the tube in the
trachea, reducing the risk of trauma to the trachea. Cuff pressure is monitored every 6-8
hours to maintain pressure at less than 25 mmHg.
• Tracheostomy care is performed every 8 hours.
• Ventilator circuit tubing and inline suction tubing to be replaced periodically.
• Administer oral hygiene frequently as it is the primary source of contamination of lungs in the
intubated client
• Position the patient with head elevated above the stomach as much as possible to decrease
incidence of aspiration pneumonia.
Preventing infection

95. Risk for infection R/T impaired defenses in
respiratory tract
• Evaluate color, amount, consistency, and odor of sputum with
each suctioning.
• Collect specimens for culture and sensitivity, as indicated.
• Maintain sterile technique when suctioning.
• Change ventilator tubing q24-72h.
• Perform oral hygiene every shift.
• Monitor vital signs for indications of infection.
• Drain condensed water in ventillator tubing externally away
from airway & humidifier reservoir.
• Wash hands frequently.
• Follow universal precautions.

96. HIGH RISK TO DEVELOP INFECTION
Due to
• CENTRAL LINE
• ET Tubing , NG tubing.
• Catheters
• Drainages
• Wound sites

97. SOURCES OF INFECTION IN ICU

98. • Change every 72 hours (tubing, exhalation valve, and
humidifiers.
• Periodically drain and discard any condensate that
collects in the ventilator tubing's.
• Sterilize reusable breathing circuit between use on
different patients.
• Use sterile water to fill humidifiers.

99. Endotracheal suctioning
• Aseptic technique should be adhered to during suctioning.
• Use single use sterile suction catheters separately for oral
and ET suction.
• While disconnecting ET tube from circuit , keep the open
end of angle connection on a sterile pad.
• Change angle connection and corrugated tubing every 24
hrs. or when visibly soiled.

100. CENTRAL VENOUS CANNULATION
• Asepsis should be maintained during infusion and flushing.
• Do not keep the cap cover unsterile area and care should be
taken not to touch the middle part of the cap.
• Replace the gauze dressing after every 24 hrs.
• Fluids and drugs should not be given through the TPN line.
• Try to keep the IV set and the cannula as a closed system.
Repeat connections and disconnections should be avoided.

101. URINARY CATHETERIZATION
• Avoid raising the level of bag to avoid backflow.
• Hang the urine bag to the hook attached.
• Do not let the bag touch the floor.
• Unnecessary uncorking or disconnecting the bag
should not be done.
• Do not change the catheters routinely unless there is
definitive evidence of infection.

102. PERIPHERAL IV CANNULATION /BLOOD/ SAMPLING
• Do not rub the vein in the hope of facilitating the flow.
• Replace the tubings to administer blood, fat emulsion
within 24 hrs. of use.
• Replace the IV canulla every 72-96 hrs. or earlier if there
is any evidence of phlebitis.

103. High risk for alterations in tissue
perfusion: R/T PPV,PEEP, hypotension.
• Monitor vital signs, LOC, and input and output.
• Hyperoxygenate/hyperventilate prior to suctioning .
• Assess for impaired peripheral circulation: color,
temperature, capillary refill time, numbness.

104. Promote optimal nutrition
Imbalance nutrition: Less than body requirement R/T lack of ability to eat
while on a ventilator and increased metabolic needs.
• provide adequate nutrition (high calorie intake, protein, vitamins, minerals)
• begin tube feeding a ssoon as it is evident that client will remain on CMV for a length time (
usually 2-3 days).
• avoid excessive CHO load.
• monitor intake and output.
• if the client cannot tolerate enteral feeding, consider total parenteral nutrition.
• monitor bowel sounds.

105. • Maintain high caloric intake by tube feedings, total
parenteral nutrition, and intralipids.
• Avoid high carbohydrate loads which can elevate PaCO2
levels during weaning.
• Monitor intake & output.

106. • Monitor the serum electrolyte levels.
• Provide oral hygiene every 2 hrly.
• Observe for evidence of gastrointestinal bleeding.
• Supplemental vitamins and minerals should be
administered as prescribed.

107. • If tube feedings cannot be tolerated, parenteral hvperalimentation
is considered. Observe strict aseptic technique to minimize the
risk of infection.
• Basic caloric requirements are usually increased by 25% for
hospital activity and stress associated with treatment.
• High amino acid infusion also increases oxygen consumption. All
ventilator patients who require long-term ventilation need 2,000 to
2,500 calories per day.

108. High risk for injury: R/T mechanical
ventilation, ET tube, anxiety, stress.
• Monitor ventilator for sharp increases on pressure gauge.
• Monitor cuff pressures q2-4h; maintain cuff pressures 20 mm Hg.
• Restrain patient to prevent selfextubation.
• Remove NG ASAP or replace with small feeding tube.
• Position ventilator tubing to prevent traction on endotracheal tube
.

109. • Administer antacids and H2 gastric blockers, as ordered.
• Sedate patient, as needed.
• Monitor patient for abdominal distension, pH of NG
aspirate, Hgb and Hct, auscultate bowel sounds, and
check stool for occult blood.

110. High risk for alteration in fluid volume excess: R/T
positive water balance during mechanical ventilation
• Monitor ventilator temperature and humidifier q2-4h.
• Monitor input and output.
• Weigh patient daily.
• Calculate lung compliance q2-4h.
• Monitor serum sodium.
• Monitor CXR for signs of water retention.
• Check skin turgor and edema.
• Auscultate lungs for rales and wheezes q2h .
• Assess for edema, oliguria & weight gain.

111. Pain: R/T mechanical ventillation, ET placement
• Maintain tubing position to. prevent pulling or jarring of the
endotracheal tube.
• Adjust ventilator flow rates for comfort.
• Adjust ventilator sensitivity to decrease patient's effort to initiate
breathing.
• Position patient with head of bed up unless contraindicated.
Change position q2h.
• Administer analgesic medications as ordered.

112. Impaired verbal communication R/T mute
state when the ET tube is in place
• Offer several appropriate communication approaches like lip
reading, pad and pencil or magic slate, communication board,
gesturing, sign language or electric larynx.
Promoting optimal communication

113. Promoting coping ability
Anxiety R/T dependence on MV for breathing
• Encourage the family to verbalize their feelings about the
ventilator, the patient’s condition and the environment in general.
• Encourage the patient to participate in decision about care,
schedules and treatment when possible.
• Inform the patient about when appropriate. It is important to
provide diversions such as watching T.V, playing music or taking a
walk.

114. High risk for complications of MV and PPV
• Alteration in cardiac function
• Positive intrathoracic pressure during inspiration compresses the heart and great vessels,
thereby reducing venous return and cardiac output. This is usually corrected during
exhalation when the positive pressure is off.
• Observe for signs and symptoms of hypoxia (restlessness, apprehension, tachycardia,
tachypnea, labored breathing, pallor progressing to cyanosis, diaphoresis, transient
hypertension and decreased urine output)
Monitoring and managing potential
complications

115. Monitoring and managing potential
complications
• If a pulmonary artery catheter is in place cardiac output, cardiac index and
other hemodynamic values can be used to assess the patient status.
• Barotrauma and pneumothorax
• Consider any sudden change in oxygen saturation or the onset of respiratory
distress to be a life threatening emergency requiring immediate action.
• Pulmonary infection
• Report fever or a change in the color or odor of sputum to the physician for
follow- up.

116. Promoting optimal level of mobility
• Help patient to get out of bed and move to a chair as soon
as possible. Mobility and muscle activity are beneficial as
they stimulate respiration and improve morale.
• Encourage performance of active range of motion
exercise every 6-8 hours.
Promoting optimal level of mobility

117. The main components of nursing care include:
• 1. Performing frequent assessments including level of consciousness and vital signs.
• 2. Verifying prescribed ventilator settings and appropriate alarm limits. Nurses should also
properly secure the endotracheal tube and respond to and troubleshoot ventilator alarms,
adhere to infection control guidelines, and identify complications or mechanical problems
associated with MV, such as an air leak or kink in the ventilator circuit.
• 3. Ensuring emergency equipment, such as manual resuscitation bags and oropharyngeal
and nasopharyngeal airways, are immediately available.
• 4. Assessing the adequacy of cardiac output. MV compromises hemodynamic status and
predisposes patients to hypotension and renal dysfunction. Maintaining adequate perfusion
is paramount.

118. The main components of nursing care include:
• 5. Evaluating the adequacy of oxygenation. Oxygen saturation and partial
pressure of arterial oxygen (PaO2) are key indicators of oxygenation.
• 6. Assessing the adequacy of ventilation. It is essential to monitor the
patient's PaO2, PaCO2, and acid-base balance.
• 7. Monitoring the patient-ventilator interaction. Using accessory muscles for
breathing suggests increasing work of breathing. Common causes include
increasing airway resistance as a result of bronchospasm, excessive sputum,
or small ETT size.
• 8. Educating patients and their families (with the patient's consent) about the
patient's illness, the need for respiratory support and the application of MV.

123. VIDEOS
• https://youtu.be/NveO8rmpQcs
• https://youtu.be/6JFHiiEkjlk