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Mechanical Ventilation
• The mechanical ventilator device functions as a substitute for
  the bellows action of the thoracic cage and diaphragm.

• The mechanical ventilator can maintain ventilation
  automatically for prolonged periods.

• It is indicated when the patient is unable to maintain safe
  levels of oxygen or CO2 by spontaneous breathing even with
  the assistance of other oxygen delivery devices.

• When a patient is unable to maintain a patent
  airway, adequate gas exchange, or both, despite aggressive
  pulmonary management, more invasive support with
  intubation and mechanical ventilation must be considered.
The Goal
• The goal of mechanical ventilation is to maintain
  alveolar ventilation appropriate for the patient’s
  metabolic needs and to correct hypoxemia and
  maximize oxygen transport.
Desired clinical outcomes of mechanical ventilation may
  include:
• Reversal of hypoxemia
• Reversal of acute respiratory acidosis
• Relief of respiratory distress
• Prevention or reversal of atelectasis
• Resting of ventilatory muscles
• Reduction in systemic oxygen consumption, myocardial
  oxygen consumption, or both
• Stabilization of the chest wall
Clinical Indications of Mechanical
Ventilation
• Failure of Ventilation
• Neuromuscular disease
• Central nervous system (CNS) disease
• CNS depression (drug intoxication, respiratory depressants,
  cardiac arrest)
• Musculoskeletal disease
• Inefficiency of thoracic cage in generating pressure gradients
  necessary for ventilation (chest injury, thoracic malformation)
Disorders of Pulmonary Gas Exchange
• Acute respiratory failure
• Chronic respiratory failure
• Left ventricular failure
• Pulmonary diseases resulting in diffusion abnormality
• Pulmonary diseases resulting in ventilation-perfusion
  mismatch.
Overview of Mechanical Ventilation

• Ventilators are classified as either negative-pressure or
  positive-pressure ventilators.
• Negative-pressure ventilators encase the patient’s body
  and exert negative pressure that pulls the thoracic cage
  outward to initiate inspiration.
• In current clinical practice, use of negative-pressure
  ventilators is limited.
• Positive-pressure ventilators, which are much more
  commonly used, deliver air by pumping it in to the
  patient’s lungs. With positive-pressure ventilation, the
  normal relationship between intrapulmonary pressures
  during inspiration and expiration is reversed
  (ie, pressures during inspiration are positive and
  pressures during expiration are negative).
There are three major modes of positive-pressure ventilation:
• Volume ventilation.
   With volume ventilation, a designated volume of air (tidal volume) is
   delivered with each breath. Volume ventilation is commonly used in
   critical care settings.
• Pressure ventilation.
    With pressure ventilation, a selected gas pressure is delivered to the
   patient and sustained throughout the phase of ventilation.
• High-frequency ventilation.
• Accomplishes oxygenation by the diffusion of oxygen and carbon dioxide
   from high to low gradients of concentration.
• Diffusion is increased when the kinetic energy of the gas molecules is
   increased.
• High-frequency ventilation uses small tidal volumes (1–3 mL/kg) at
   frequencies greater than 100 breaths/minute.
• The breathing pattern of a person receiving high-frequency ventilation is
   somewhat analogous to that of panting, which entails moving small
   volumes of air at a very fast rate ( High-frequency ventilation is used to
   achieve lower peak ventilatory pressures, which reduces the risk for lung
   injury caused by high pressures.
Ventilator Settings
Although the respiratory therapist may share or have complete
   responsibility for managing the ventilator settings, the nurse
   must still assess and understand the ventilator settings to
   provide effective nursing care.
Common settings include:
 Fraction of inspired oxygen (FiO2).
• The FiO2 is the percentage of oxygen in the air delivered to the
   patient.
• The FiO2 is adjusted to maintain an SaO2 of greater than 90%.
• Initially, the patient is placed on a high level of FiO2 (60% or
   higher), but because oxygen toxicity is a concern when anFiO2 of
   greater than 60% is required for more than 24 hours, strategies
   are implemented to maintain the FiO2 at 60% or less after the
   initial intubation.
• Subsequent changes in FiO2 are based on arterial blood gases
   and the SaO2.
Tidal volume.
The tidal volume is the amount of air to be delivered with each breath.
With volume ventilators, the tidal volume is set by the clinician. Tidal
volumes of 5 to 8 mL/kg of body weight are recommended.


Respiratory rate.
• The respiratory rate (ie, the number of breaths per minute delivered
to the patient) is set on most ventilator models.
•Because minute ventilation, which determines alveolar ventilation, is
equal to the respiratory rate multiplied by the tidal volume,
adjustments in either of these parameters affect the PaCO2.
•Increasing the minute ventilation decreases the PaCO2, whereas
decreasing it increases the PaCO2.
•Slowing the respiratory rate may also be necessary to enhance
patient comfort or when rapid rates cause air trapping in the lungs
(due to decreased exhalation time).
Positive end-expiratory pressure (PEEP)

•PEEP control adjusts the pressure that is maintained in the lungs at
the end of expiration.
•PEEP increases the functional residual capacity (FRC) by re-inflating
collapsed alveoli, maintaining the alveoli in an open position, and
improving lung compliance.
•This decreases shunting and improves oxygenation.
•It is common practice to use low levels of PEEP (5 cm H2O) in the
intubated patient.
•PEEP is increased in 2- to 5-cm H2O increments when FiO2 levels
greater than 50% are required to attain an acceptable SaO2 (greater
than 90%) or PaO2 (greater than 60 to 70 mm Hg).
•High levels of PEEP should rarely be interrupted (eg, by disconnecting
the ventilator tubing from the airway) because it may take several
hours to recruit alveoli again and restore the FRC.
•Reduction of PEEP is considered when the patient has a PaO2 of 80 to
100 mm Hg or an FiO2 of 50% or less, is hemodynamically stable, and
Peak flow.
Peak flow is the velocity of gas flow per unit of time and is expressed
as liters per minute. On many volume ventilators, peak flow can be set
directly. Very high peak flow is associated with increased turbulence
(reflected by increasing airway pressures), shallow inspirations, and
uneven distribution of volume.
Peak inspiratory pressure limit (high-pressure alarm).
•The peak inspiratory pressure (PIP) limit is the highest pressure
allowed in the ventilator circuit.
•With volume ventilators, once the high pressure limit is reached, the
high-pressure alarm sounds and the inspiration is terminated.
•If the inspiratory pressure limit is being constantly reached, the
patient will not receive the designated tidal volume, steps must be
taken to identify and address the underlying cause
•(eg, coughing, accumulation of secretions, kinked ventilator
tubing, pneumothorax, decreasing compliance, or a high pressure
alarm that is set too low).
Sensitivity.
•The sensitivity function controls the amount of patient effort needed to initiate an
inspiration, as measured by negative inspiratory effort.
•Increasing the sensitivity (requiring less negative force) decreases the amount of
work the patient must do to initiate a ventilator breath.
•decreasing the sensitivity increases the amount of negative pressure that the
patient needs to initiate inspiration and increases the work of breathing.

Inspiratory:expiratory (I:E) ratio.

•Most ventilators operate with a short inspiratory time and a long expiratory time
(1:2 or 1:3 ratio).
This allows time for air to passively exit the lungs, lowering pressures in the thoracic
cavity and allowing for increased venous return.
•However, in conditions of reduced compliance (eg, acute respiratory distress
syndrome [ARDS], sarcoidosis), the I:E ratio may be reversed so that the inspiratory
time is equal to, or greater than, the expiratory time (eg, 1:1, 2:1, 3:1, 4:1).
•The inverse I:E ratio improves oxygenation by expanding stiff alveoli using longer
inspiratory times, thereby providing more opportunity for gas exchange and
preventing alveolar collapse.
Ventilatory        Common Uses        Advantages            Disadvantages        Nursing
Mode                                                                             Considerations

Volume Modes       As an initial      Ensures ventilator    Increased risk for   Work of
A/C                mode of            support during        hyperventilation     breathing may
A respiratory      ventilation        every breath          and air trapping     be
rate and tidal     For patients too   Delivers consistent   May require          increased if
volume are         weak to            tidal volumes         sedation and         sensitivity or
preset.            perform            Allows patient to     Paralysis,           flow rate is too
                   the work of        rest                  Ventilatory          low.
If the patient     breathing                                muscle atrophy
attempts to                                                 with longer use.
initiate breath,
the ventilator
is triggered
and delivers
the full preset
tidal volume
with every
breath
Ventilatory       Common Uses   Advantages             Disadvantages       Nursing
Mode                                                                       Considerations


SIMV           As a long-term   Allows spontaneous     Patient–            Work of
               mode of          breaths                ventilator          breathing may
As with the    ventilation      (tidal volume          asynchrony          be
A/C mode the As a weaning       determined by          possible            increased if
respiratory    mode             patient) between       Work of             sensitivity or
rate and tidal                  ventilator             breathing is        flow rate is too
volume are                      breaths                increased           low.
preset,                         Allows patient to      through
                                use own                artificial airway
If the patient                  respiratory muscles,
attempts to                     preventing muscle
initiate a                      atrophy
breath above
this preset
rate , the
ventilator
allows a
patient to take
spontaneous
breath.
Ventilatory   Common Uses              Advantages        Disadvanta    Nursing
Mode                                                     ges           Considerations

Pressure      PCV For patients with    Lower peak        Patient–      Monitor tidal volumes.
Modes         conditions               inspiratory       ventilator    Monitor for barotrauma
PCV           in which compliance is   pressures         asynchrony    and
              decreased and the risk   reduce risk for   necessitats   hemodynamic instability
              for barotrauma is high   barotraumas       sedation/
              For patients with        Improved          paralysis
              persistent hypoxemia     oxygenation.
              despite a high FiO2

PSV           As a weaning mode,       Decreases work                  Patient must have an
              and in some              of breathing                    intact respiratory drive.
              cases of dyssynchrony    Increases                       PSV mode cannot be
              Used in combination      patient comfort                 used in patients with
              with SIMV                                    ----        acute bronchospasm.
              to decrease work of                                      Monitor respiratory rate
              breathing by helping                                     and tidal volume at
              to overcome                                              least
              resistance created by                                    hourly.
              the endotracheal tube                                    Monitor for changes in
                                                                       compliance, which can
                                                                       cause tidal volume to
Ventilatory    Common Uses        Advantages              Disadvantages   Nursing
Mode                                                                      Considerations

IRV (Inverse   Used to improve    Longer inspiratory      Almost always   Usually used in
ratio          oxygenation        time provides           requires        conjunction
ventilation)   in patients with   more opportunity        sedation/       with PCV
               conditions         for gas                 paralysis       Monitor for
               characterized by   exchange and            Auto-PEEP may   auto-PEEP,
               decreased          shorter                 develop         barotrauma, and
               compliance         expiratory times                        hemodynamic
                                  prevent                                 instability.
                                  alveolar collapse.
APRV(Airway    For patients       Allows lung
Pressure       with high          protective strategies
Release        airway             by limiting plateau
Ventilation)   pressures to       and peak pressures
               reduce airway      Allows spontaneous
               pressure and       breathing                 -----           ----
               lower minute       Need for
               volume while       paralysis/sedation is
               allowing           decreased
               spontaneous
               breathing
               As a weaning
Ventilatory      Common Uses          Advantages     Disadvantages        Nursing
Mode                                                                      Considerations

VGPO (Volume     For acutely ill,     Ensures a      Requires             Monitor for auto-
guaranteed       unstable patients    delivered      sophisticated        PEEP,
pressure         to provide           tidal volume   knowledge of the     barotrauma, and
options)         pressure             while          mode and             hemodynamic
                 ventilation while    limiting       waveform             instability
                 guaranteeing         pressures      analysis
                 tidal volume and
                 minute
                 ventilation at a
                 set rate.
PEEP( Positive   Used to maintain     Improves       High levels of       Monitor total PEEP
end expiratory   alveoli infl ation   oxygenation    PEEP may             (set PEEP and auto-
pressure)        at end expiration    Increases      cause barotrauma     PEEP)
                 and decrease         FRC,           Increases            and hemodynamics
                 the work of          allowing       intrathoracic        Limit disconnection
                 breathing            lower          pressures, leading   from ventilator
                 For patients on      FiO2 levels    to decreased         (eg,for suctioning),
                 high levels of                      venous               because of time
                 FiO2                                return and           required to
                 with refractory                     cardiac              reestablish PEEP.
                 hypoxemia                           output
Ventilatory   Common Uses                Advantages Disadvantages         Nursing
Mode                                                                      Considerations

CPAP          For spontaneously          May be        On some            Monitor for
              breathing patients to      used in       systems, no        increased work
              improve oxygenation        intubated     alarm if           of breathing.
              As a weaning mode          or            respiratory
              For nocturnal              nonintubat    rate decreases
              ventilation to prevent     ed
              upper airway               patients
              obstruction in patients
              with sleep apnea
Noninvasive   For nocturnal              No need        Patient           Thick or copious
BiPap         hypoventilation in         for artificial discomfort or     secretions
              patients with              airway         claustrophobia    and poor cough
              neuromuscular disease,                    Use of full       may be relative
              chest wall deformity,                     facemask          contraindications
              obstructive sleep apnea,                  increases risk    for BiPap.
              and COPD                                  for aspiration    Monitor for
              To prevent intubation                     and               gastric
              To prevent re-intubation                  rebreathing       distention,
              initially after extubation                carbon dioxide.   air leaks from
                                                                          mouth,
                                                                          aspiration risk.
Collaborative Nursing Care                    INTERVENTIONS
OUTCOMES
Oxygenation/Ventilation                       • Auscultate breath sounds q2–4h and PRN.
A patent airway is maintained.                • Suction as needed for crackles, coughing, or
Lungs are clear to auscultation.              oxygen desaturation.
Patient is without evidence of atelectasis.   • Hyperoxygenate before and after each
Peak, mean, and plateau pressures are         suction pass.
within normal limits.                         • Monitor airway pressures q1–2h.
ABGs are within normal limits                 • Monitor airway pressures after suctioning.
                                              • Administer bronchodilators and mucolytics
                                              as ordered.
                                              • Perform chest physiotherapy if indicated by
                                              clinical examination or chest x-ray.
                                              • Turn side to side q2h.
                                              • Consider kinetic therapy or prone
                                              positioning as indicated by clinical scenario.
                                              • Get patient out of bed to chair or standing
                                              position when stable.
                                              • Monitor pulse oximetry and end-tidal CO2.
                                              • Monitor ABGs as indicated by changes in
                                              noninvasive parameters,patient status, or
                                              weaning protocol.
OUTCOMES                               INTERVENTIONS

Circulation/Perfusion                  • Assess hemodynamic effects of initiating
Blood pressure, heart rate, cardiac    positive-pressure ventilation
output, central venous pressure, and   (eg, potential for decreased venous return
pulmonary artery pressure remain       and cardiac output).
stable on mechanical ventilation       • Monitor ECG for dysrhythmias related to
                                       hypoxemia.
                                       • Assess effects of ventilator setting changes
                                       (inspiratory pressures, tidal volume, PEEP, and
                                       FiO2) on hemodynamic and oxygenation
                                       parameters.
                                       • Administer intravascular volume as ordered
                                       to maintain preload.
Fluids/Electrolytes                    • Monitor hydration status in relation to
I & O measurements are balanced.       clinical examination, auscultation,
Electrolyte values are within normal   amount and viscosity of lung secretions.
limits.                                • Assess patient weight, I & O totals, urine
                                       specific gravity, or serum osmolality to
                                       evaluate fluid balance.
                                       • Administer electrolyte replacements (IV or
                                       enteral) per physician’s order.
OUTCOMES                       INTERVENTIONS

Mobility                       • Collaborate with physical/occupational
Patient maintains or regains   therapy staff to encourage
baseline                       patient effort/participation to increase
                               mobility.
functional status related to
                               • Progress activity to sitting up in chair,
mobility and self-care.        standing at bedside, ambulating with
 Joint range of motion is      assistance as soon as possible.
maintained                     • Assist patient with active or passive
                               range-of-motion exercises of all
                               extremities at least every shift.
                               • Keep extremities in physiologically
                               neutral position using pillows or
                               appropriate splint/support devices as
                               indicated.
OUTCOMES                                INTERVENTIONS

Safety                                  • Securely stabilize endotracheal tube in
Endotracheal tube will remain in        position.
proper                                  • Note and record the “cm” line on
position.                               endotracheal tube position at lip or teeth.
Proper inflation of endotracheal tube   • Use restraints or sedation per hospital
cuff is maintained.                     protocol.
Ventilator alarm system remains         • Evaluate endotracheal tube position on
activated                               chest x-ray daily (by viewing film or by
                                        report).
                                        • Keep emergency airway equipment and
                                        manual resuscitation bag readily available,
                                        and check each shift.
                                        • Inflate cuff using minimal leak technique,
                                        or pressure <25 mm Hg by manometer.
                                        • Monitor cuff inflation/leak every shift and
                                        PRN.
                                        • Protect pilot balloon from damage.
                                        • Perform ventilator setting and alarm
                                        checks q4h (minimum) or per facility
                                        protocol.
OUTCOMES                               INTERVENTIONS
Skin Integrity                         • Assess and document skin integrity at
Patient is without evidence of skin    least every shift.
breakdown.                             • Turn side to side q2h; reassess bony
                                       prominences for evidence of pressure
                                       injury.
                                       • When patient is out of bed to chair,
                                       provide pressure relief to sitting surfaces at
                                       least q1h.
                                       • Remove self-protective devices from
                                       wrists, and monitor skin per hospital
                                       policy.
Nutrition                              • Consult dietitian for metabolic needs
Nutritional intake meets calculated    assessment and recommendations.
metabolic need (eg, basal energy       • Provide early nutritional support by enteral or
                                       parenteral feeding, start within 48 hours of
expenditure equation).
                                       intubation.
Patient will establish regular bowel
                                       • Monitor actual delivery of nutrition daily with
elimination pattern                    I&O calculations.
                                       • Weigh patient daily.
                                       • Administer bowel regimen medications as
                                       ordered, along with adequate hydration.
OUTCOMES                             INTERVENTIONS
Comfort/Pain Control                 • Document pain assessment, using
Patients will indicate/exhibit       numerical pain rating or similar scale
adequate
relief of discomfort/pain while on
                                     when possible.
mechanical ventilation               • Provide analgesia as appropriate,
                                     document efficacy after each dose.
                                     • Prevent pulling and jarring of the
                                     ventilator tubing and endotracheal or
                                     tracheostomy tube.
                                     • Provide meticulous oral care q1–2h
                                     with oropharynx suctioning and
                                     application of mouth moisturizer as
                                     needed; teeth brushing scheduled at
                                     least three times daily; antimicrobial
                                     rinse twice daily; oral assessment at
                                     least daily.
                                     • Administer sedation as indicated.
OUTCOMES                            INTERVENTIONS
Psychosocial                        • Encourage patient to move in bed and attempt to meet
Patient participates in self-care   own basic comfort/hygiene needs independently.
and                                 • Establish a daily schedule for bathing, time out of bed,
decision making related to own      treatments, and so forth with patient input.
ADLs                                • Provide a means for patient to write notes and use
(eg, turning, bathing). Patient     visual tools to facilitate communication.
communicates with healthcare        • Encourage visitor conversations with patient in normal
providers and visitors.             tone of voice and subject matter.
                                    • Teach visitors to assist with range-of-motion and other
                                    simple care delivery tasks, to facilitate normal patterns of
                                    interaction.


Teaching/Discharge Planning         • Provide explanations to patient and family regarding:
Patient cooperates with and         • Rationale for use of mechanical ventilation
indicates                           • Procedures such as suctioning, airway care, chest
understanding of need for           physiotherapy
mechanical ventilation.             • Plan for and progress toward weaning and extubation
Potential discharge needs are       • Initiate early social work to screen for needs, resources,
assessed.                           and support systems.
Abnormal Arterial Blood Gases in the Mechanically Ventilated Patient

Abnormality                    Possible Causes                 Action


Hypoxemia                      Patient-related                 Suction. Increase FiO2.
                               Secretions                      Evaluate patient and chest
                               Increase in disease pathology   radiograph.
                               Positive fluid balance          Evaluate intake and output.

Hypocapnia                     Patient-related                 Evaluate ABGs and patient.
                               Hypoxia                         Evaluate for wean potential.
                               Increased lung compliance’      Decrease respiratory rate,
                               Increased minute ventilation    tidal volume, or minute
                               Ventilator-related              ventilation.
                               Incorrect ventilator settings


Hypercapnia                    Patient-related                 Increase respiratory rate or
                               Sedation                        tidal volume settings.
                               Fatigue                         Increase respiratory rate, tidal
                               Decreased minute ventilation    volume, or minute
                               Ventilator-related              ventilation.
                               Incorrect ventilator settings
Troubleshooting the Ventilator

Problem               Possible Causes                Action

Volume or low         Patient-related                Reconnect STAT.
pressure              Patient disconnected from      •Auscultate neck for possible leak
alarm                 Ventilator Loss of delivered   around endotracheal tube cuff.
                      tidal volume Decrease in       •Review chest film for endotracheal
                      patient-initiated breaths      tube placement—may be too high.
                      Increased compliance           •Check for loss of tidal volume through
                      Ventilator-related             chest tube.
                      Leaks                          •Evaluate patient for cause: check
                                                     respiratory rate, ABGs, last sedation.
                                                     •Evaluate patient for clearing of
                                                     secretions or relief of bronchospasms.
                                                     •Check all tubing for loss of connection,
                                                     starting at patient and moving toward
                                                     humidifier.
                                                     •Check for change in ventilator settings.
                                                     (Note: If problem is not corrected STAT,
                                                     use MRB until ventilator
                                                     problem is corrected.)
Troubleshooting the Ventilator

Problem          Possible Causes            Action

High-pressure    Patient-related            •Suction patient.
or               Decreased compliance       •Administer inhaled β-agonists.
peak-pressure    Decreased dynamic          •If sudden, evaluate for pneumothorax.
alarm            Compliance
                                            •Evaluate chest film for endotracheal tube
                 Decreased static
                                            displacement in right mainstem bronchus.
                 compliance
                 Ventilator-related         •Sedate if patient is bucking the ventilator
                 Tubing kinked              or biting the endotracheal tube.
                 Tubing filled with water   •Evaluate ABGs for hypoxia, fluids for
                 Patient–ventilator         overload, chest film for atelectasis.
                 asynchrony                 •Auscultate breath sounds.
                                            •Check tubing.
                                            •Empty water into a receptacle.
                                            •Recheck sensitivity and peak flow settings.
                                            •Provide sedation/paralysis if indicated.
Troubleshooting the Ventilator

Problem        Possible Causes                  Action
Heater alarm   Adding cold water to             Wait.
               humidifier.                      Reset.
               Altered setting                  Redirect airflow.
               Cold air blowing on humidifier
Complications of Mechanical Ventilation
Airway
• Aspiration
• Ventilator-acquired pneumonia (VAP)
• Complications of endotracheal intubation or tracheostomy

Mechanical
• Lung injury (eg, barotrauma, volutrauma)
• Atelectasis (resulting from hypoventilation)
• Hypocapnia and respiratory alkalosis (resulting from
   hyperventilation)
• Hyperthermia (resulting from overheated inspired air)
• Hypercapnia and respiratory acidosis (hypoventilation)

Physiological
• Depressed cardiac function, resulting in hypotension
• Fluid overload
• Respiratory muscle weakness and atrophy
• Complications of immobility
• Gastrointestinal problems (eg, paralytic ileus, stress ulcers, distention)
Nursing Action                                   Rationale


Obtain baseline samples for blood gas            Baseline measurements serve as a guide in
determinations (pH, PaO2, Paco2, HCO3-) and      determining progress of therapy.
chest X-ray
Give a brief explanation to the patient          Emphasize that mechanical ventilation is a
                                                 temporary measure. The patient should be
                                                 prepared psychologically for weaning at the
                                                 time the ventilator is first used.
Establish the airway by means of a cuffed        A closed system between the ventilator and
endotracheal or tracheostomy tube                patient lower airway is necessary for positive
                                                 pressure ventilation
Prepare the ventilator. (Respiratory therapist
does this in many facilities.)
Set up desired circuitry.


Connect oxygen and compressed air source


Turn on power.
Set tidal volume (usually 5-7 mL/kg body            Adjusted according to pH and Paco2
weight) or peak pressure.


Set oxygen concentration                            Adjusted according to PaO2



Set ventilator sensitivity



Set rate at 12-14 breaths/minute (variable).        This setting approximates normal ventilation.
                                                    These machines' settings are subject to
                                                    change according to the patient's condition
                                                    and response, and the ventilator type being
                                                    used.

Adjust flow rate (velocity of gas flow during       The slower the flow, the lower the peak
inspiration). Usually set at 40-60 L/minute.        airway pressure will result from set volume
Depends on rate and tidal volume. Set to            delivery. This results in lower intrathoracic
avoid inverse inspiratory:expiratory (I:E) ratio.   pressure and less impedance of venous
Usual I:E ratio is 1:2.                             return. However, a flow that is too low for the
                                                    rate selected may result in inverse inspiratory:
                                                    expiratory ratios
Select mode of ventilation.


Check machine function—measure tidal           Ensures safe function
volume, rate, I:E ratio, analyze oxygen, check
all alarms.
Couple the patient's airway to the ventilator    Make sure all connections are secure. Prevent
                                                 ventilator tubing from “pulling― on
                                                 artificial airway, possibly resulting in tube
                                                 dislodgement or tracheal damage.
Assess patient for adequate chest movement       Ensures proper function of equipment
and rate. Note peak airway pressure and
PEEP. Adjust gas flow if necessary to provide
safe I:E ratio.
Set airway pressure alarms according to
patient's baseline

High pressure alarm                              High airway pressure or “pop off― pressure is
                                                 set at 10-15 cm H2O above peak airway pressure.
                                                 An alarm sounds if airway pressure selected is
                                                 exceeded. Alarm activation indicates decreased
                                                 lung compliance (worsening pulmonary disease);
                                                 decreased lung volume (such as pneumothorax,
                                                 tension pneumothorax, hemothorax, pleural
                                                 effusion); increased airway resistance (secretions,
Low pressure alarm                               Low airway pressure alarm set at 5-10 cm H2O
                                                 below peak airway pressure. Alarm activation
                                                 indicates inability to build up airway pressure
                                                 because of disconnection or leak, or inability
                                                 to build up airway pressure because of
                                                 insufficient gas flow to meet the patient's
                                                 inspiratory needs.

Assess frequently for change in respiratory
status by way of ABGs, pulse oximetry,
spontaneous rate, use of accessory muscles,
breath sounds, and vital signs. Other means of
assessing are through the use of exhaled
carbon dioxide (see “Capnography,―
“Mixed venous oxygen saturation
monitoring,―). If change is noted, notify
appropriate personnel


Monitor and troubleshoot alarm conditions.       Priority is ventilation and oxygenation of the
Ensure appropriate ventilation at all times.     patient. In alarm conditions that cannot be
                                                 immediately corrected, disconnect the patient
                                                 from mechanical ventilation and manually
                                                 ventilate with resuscitation bag.
Positioning                                       For patients on long-term ventilation, this
Turn patient from side to side every 2 hours,     may result in sleep deprivation. Follow a
or more frequently if possible. Consider          turning schedule best suited to a particular
continuous lateral rotational therapy (CLRT) as   patient's condition. Reposition may improve
early intervention to improve outcome.            secretion clearance and reduce atelectasis
Lateral turns are desirable; from right
semiprone to left semiprone.

Sit the patient upright at regular intervals if   Upright posture increases lung compliance
possible

Carry out passive range-of-motion exercises of To prevent contractures
all extremities for patients unable to do so.

Assess for need of suctioning at least every 2    Patients with artificial airways on mechanical
hours                                             ventilation are unable to clear secretions on
                                                  their own. Suctioning may help to clear
                                                  secretions and stimulate the cough reflex.
Assess breath sounds every 2 hours:


Listen with stethoscope ot the chest in all       Auscultation of the chest is a means of
lobes bilaterally.                                assessing airway patency and ventilatory
                                                  distribution. It also confirms the proper
Humidification.                                 Humidity may improve secretion mobilization



Assess airway pressures at frequent intervals   Monitor for changes in compliance, or onset
                                                of conditions that may cause airway pressure
                                                to increase or decrease
Monitor cardiovascular function. Assess for
abnormalities.

Monitor for pulmonary infection                 This technique allows for the earliest
                                                detection of infection or change in infecting
                                                organisms in the tracheobronchial tree.
Evaluate need for sedation or muscle            Sedatives may be prescribed to decrease
relaxants                                       anxiety, or to relax the patient to prevent
                                                “competing― with the ventilator. At
                                                times, pharmacologically induced paralysis
                                                may be necessary to permit mechanical
                                                ventilation
Report intake and output precisely and obtain
an accurate daily weight to monitor fluid
balance
Monitor nutritional status
Test all stools and gastric drainage for occult   Stress may cause some patients requiring
blood                                             mechanical ventilation to develop GI
                                                  bleeding.

Measure abdominal girth daily.                    Abdominal distention occurs frequently with
                                                  respiratory failure and further hinders
                                                  respiration by elevation of the diaphragm.
                                                  Measurement of abdominal girth provides
                                                  objective assessment of the degree of
                                                  distention.


Maintain a flow sheet to record ventilation       Establishes means of assessing effectiveness
patterns, ABGs, venous chemical                   and progress of treatment.
determinations, hemoglobin and hematocrit,
status of fluid balance, weight, and
assessment of the patient's condition. Notify
appropriate personnel of changes in the
patient's condition.


Change ventilator circuitry every 24 hours;       Prevents contamination of lower airways
assess ventilator's function every 4 hours or
more frequently if problem occurs.
Mechanical ventilation

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Mechanical ventilation

  • 1.
  • 2. Mechanical Ventilation • The mechanical ventilator device functions as a substitute for the bellows action of the thoracic cage and diaphragm. • The mechanical ventilator can maintain ventilation automatically for prolonged periods. • It is indicated when the patient is unable to maintain safe levels of oxygen or CO2 by spontaneous breathing even with the assistance of other oxygen delivery devices. • When a patient is unable to maintain a patent airway, adequate gas exchange, or both, despite aggressive pulmonary management, more invasive support with intubation and mechanical ventilation must be considered.
  • 3. The Goal • The goal of mechanical ventilation is to maintain alveolar ventilation appropriate for the patient’s metabolic needs and to correct hypoxemia and maximize oxygen transport. Desired clinical outcomes of mechanical ventilation may include: • Reversal of hypoxemia • Reversal of acute respiratory acidosis • Relief of respiratory distress • Prevention or reversal of atelectasis • Resting of ventilatory muscles • Reduction in systemic oxygen consumption, myocardial oxygen consumption, or both • Stabilization of the chest wall
  • 4. Clinical Indications of Mechanical Ventilation • Failure of Ventilation • Neuromuscular disease • Central nervous system (CNS) disease • CNS depression (drug intoxication, respiratory depressants, cardiac arrest) • Musculoskeletal disease • Inefficiency of thoracic cage in generating pressure gradients necessary for ventilation (chest injury, thoracic malformation) Disorders of Pulmonary Gas Exchange • Acute respiratory failure • Chronic respiratory failure • Left ventricular failure • Pulmonary diseases resulting in diffusion abnormality • Pulmonary diseases resulting in ventilation-perfusion mismatch.
  • 5. Overview of Mechanical Ventilation • Ventilators are classified as either negative-pressure or positive-pressure ventilators. • Negative-pressure ventilators encase the patient’s body and exert negative pressure that pulls the thoracic cage outward to initiate inspiration. • In current clinical practice, use of negative-pressure ventilators is limited. • Positive-pressure ventilators, which are much more commonly used, deliver air by pumping it in to the patient’s lungs. With positive-pressure ventilation, the normal relationship between intrapulmonary pressures during inspiration and expiration is reversed (ie, pressures during inspiration are positive and pressures during expiration are negative).
  • 6. There are three major modes of positive-pressure ventilation: • Volume ventilation. With volume ventilation, a designated volume of air (tidal volume) is delivered with each breath. Volume ventilation is commonly used in critical care settings. • Pressure ventilation. With pressure ventilation, a selected gas pressure is delivered to the patient and sustained throughout the phase of ventilation. • High-frequency ventilation. • Accomplishes oxygenation by the diffusion of oxygen and carbon dioxide from high to low gradients of concentration. • Diffusion is increased when the kinetic energy of the gas molecules is increased. • High-frequency ventilation uses small tidal volumes (1–3 mL/kg) at frequencies greater than 100 breaths/minute. • The breathing pattern of a person receiving high-frequency ventilation is somewhat analogous to that of panting, which entails moving small volumes of air at a very fast rate ( High-frequency ventilation is used to achieve lower peak ventilatory pressures, which reduces the risk for lung injury caused by high pressures.
  • 7. Ventilator Settings Although the respiratory therapist may share or have complete responsibility for managing the ventilator settings, the nurse must still assess and understand the ventilator settings to provide effective nursing care. Common settings include: Fraction of inspired oxygen (FiO2). • The FiO2 is the percentage of oxygen in the air delivered to the patient. • The FiO2 is adjusted to maintain an SaO2 of greater than 90%. • Initially, the patient is placed on a high level of FiO2 (60% or higher), but because oxygen toxicity is a concern when anFiO2 of greater than 60% is required for more than 24 hours, strategies are implemented to maintain the FiO2 at 60% or less after the initial intubation. • Subsequent changes in FiO2 are based on arterial blood gases and the SaO2.
  • 8. Tidal volume. The tidal volume is the amount of air to be delivered with each breath. With volume ventilators, the tidal volume is set by the clinician. Tidal volumes of 5 to 8 mL/kg of body weight are recommended. Respiratory rate. • The respiratory rate (ie, the number of breaths per minute delivered to the patient) is set on most ventilator models. •Because minute ventilation, which determines alveolar ventilation, is equal to the respiratory rate multiplied by the tidal volume, adjustments in either of these parameters affect the PaCO2. •Increasing the minute ventilation decreases the PaCO2, whereas decreasing it increases the PaCO2. •Slowing the respiratory rate may also be necessary to enhance patient comfort or when rapid rates cause air trapping in the lungs (due to decreased exhalation time).
  • 9. Positive end-expiratory pressure (PEEP) •PEEP control adjusts the pressure that is maintained in the lungs at the end of expiration. •PEEP increases the functional residual capacity (FRC) by re-inflating collapsed alveoli, maintaining the alveoli in an open position, and improving lung compliance. •This decreases shunting and improves oxygenation. •It is common practice to use low levels of PEEP (5 cm H2O) in the intubated patient. •PEEP is increased in 2- to 5-cm H2O increments when FiO2 levels greater than 50% are required to attain an acceptable SaO2 (greater than 90%) or PaO2 (greater than 60 to 70 mm Hg). •High levels of PEEP should rarely be interrupted (eg, by disconnecting the ventilator tubing from the airway) because it may take several hours to recruit alveoli again and restore the FRC. •Reduction of PEEP is considered when the patient has a PaO2 of 80 to 100 mm Hg or an FiO2 of 50% or less, is hemodynamically stable, and
  • 10. Peak flow. Peak flow is the velocity of gas flow per unit of time and is expressed as liters per minute. On many volume ventilators, peak flow can be set directly. Very high peak flow is associated with increased turbulence (reflected by increasing airway pressures), shallow inspirations, and uneven distribution of volume. Peak inspiratory pressure limit (high-pressure alarm). •The peak inspiratory pressure (PIP) limit is the highest pressure allowed in the ventilator circuit. •With volume ventilators, once the high pressure limit is reached, the high-pressure alarm sounds and the inspiration is terminated. •If the inspiratory pressure limit is being constantly reached, the patient will not receive the designated tidal volume, steps must be taken to identify and address the underlying cause •(eg, coughing, accumulation of secretions, kinked ventilator tubing, pneumothorax, decreasing compliance, or a high pressure alarm that is set too low).
  • 11. Sensitivity. •The sensitivity function controls the amount of patient effort needed to initiate an inspiration, as measured by negative inspiratory effort. •Increasing the sensitivity (requiring less negative force) decreases the amount of work the patient must do to initiate a ventilator breath. •decreasing the sensitivity increases the amount of negative pressure that the patient needs to initiate inspiration and increases the work of breathing. Inspiratory:expiratory (I:E) ratio. •Most ventilators operate with a short inspiratory time and a long expiratory time (1:2 or 1:3 ratio). This allows time for air to passively exit the lungs, lowering pressures in the thoracic cavity and allowing for increased venous return. •However, in conditions of reduced compliance (eg, acute respiratory distress syndrome [ARDS], sarcoidosis), the I:E ratio may be reversed so that the inspiratory time is equal to, or greater than, the expiratory time (eg, 1:1, 2:1, 3:1, 4:1). •The inverse I:E ratio improves oxygenation by expanding stiff alveoli using longer inspiratory times, thereby providing more opportunity for gas exchange and preventing alveolar collapse.
  • 12. Ventilatory Common Uses Advantages Disadvantages Nursing Mode Considerations Volume Modes As an initial Ensures ventilator Increased risk for Work of A/C mode of support during hyperventilation breathing may A respiratory ventilation every breath and air trapping be rate and tidal For patients too Delivers consistent May require increased if volume are weak to tidal volumes sedation and sensitivity or preset. perform Allows patient to Paralysis, flow rate is too the work of rest Ventilatory low. If the patient breathing muscle atrophy attempts to with longer use. initiate breath, the ventilator is triggered and delivers the full preset tidal volume with every breath
  • 13. Ventilatory Common Uses Advantages Disadvantages Nursing Mode Considerations SIMV As a long-term Allows spontaneous Patient– Work of mode of breaths ventilator breathing may As with the ventilation (tidal volume asynchrony be A/C mode the As a weaning determined by possible increased if respiratory mode patient) between Work of sensitivity or rate and tidal ventilator breathing is flow rate is too volume are breaths increased low. preset, Allows patient to through use own artificial airway If the patient respiratory muscles, attempts to preventing muscle initiate a atrophy breath above this preset rate , the ventilator allows a patient to take spontaneous breath.
  • 14. Ventilatory Common Uses Advantages Disadvanta Nursing Mode ges Considerations Pressure PCV For patients with Lower peak Patient– Monitor tidal volumes. Modes conditions inspiratory ventilator Monitor for barotrauma PCV in which compliance is pressures asynchrony and decreased and the risk reduce risk for necessitats hemodynamic instability for barotrauma is high barotraumas sedation/ For patients with Improved paralysis persistent hypoxemia oxygenation. despite a high FiO2 PSV As a weaning mode, Decreases work Patient must have an and in some of breathing intact respiratory drive. cases of dyssynchrony Increases PSV mode cannot be Used in combination patient comfort used in patients with with SIMV ---- acute bronchospasm. to decrease work of Monitor respiratory rate breathing by helping and tidal volume at to overcome least resistance created by hourly. the endotracheal tube Monitor for changes in compliance, which can cause tidal volume to
  • 15. Ventilatory Common Uses Advantages Disadvantages Nursing Mode Considerations IRV (Inverse Used to improve Longer inspiratory Almost always Usually used in ratio oxygenation time provides requires conjunction ventilation) in patients with more opportunity sedation/ with PCV conditions for gas paralysis Monitor for characterized by exchange and Auto-PEEP may auto-PEEP, decreased shorter develop barotrauma, and compliance expiratory times hemodynamic prevent instability. alveolar collapse. APRV(Airway For patients Allows lung Pressure with high protective strategies Release airway by limiting plateau Ventilation) pressures to and peak pressures reduce airway Allows spontaneous pressure and breathing ----- ---- lower minute Need for volume while paralysis/sedation is allowing decreased spontaneous breathing As a weaning
  • 16. Ventilatory Common Uses Advantages Disadvantages Nursing Mode Considerations VGPO (Volume For acutely ill, Ensures a Requires Monitor for auto- guaranteed unstable patients delivered sophisticated PEEP, pressure to provide tidal volume knowledge of the barotrauma, and options) pressure while mode and hemodynamic ventilation while limiting waveform instability guaranteeing pressures analysis tidal volume and minute ventilation at a set rate. PEEP( Positive Used to maintain Improves High levels of Monitor total PEEP end expiratory alveoli infl ation oxygenation PEEP may (set PEEP and auto- pressure) at end expiration Increases cause barotrauma PEEP) and decrease FRC, Increases and hemodynamics the work of allowing intrathoracic Limit disconnection breathing lower pressures, leading from ventilator For patients on FiO2 levels to decreased (eg,for suctioning), high levels of venous because of time FiO2 return and required to with refractory cardiac reestablish PEEP. hypoxemia output
  • 17. Ventilatory Common Uses Advantages Disadvantages Nursing Mode Considerations CPAP For spontaneously May be On some Monitor for breathing patients to used in systems, no increased work improve oxygenation intubated alarm if of breathing. As a weaning mode or respiratory For nocturnal nonintubat rate decreases ventilation to prevent ed upper airway patients obstruction in patients with sleep apnea Noninvasive For nocturnal No need Patient Thick or copious BiPap hypoventilation in for artificial discomfort or secretions patients with airway claustrophobia and poor cough neuromuscular disease, Use of full may be relative chest wall deformity, facemask contraindications obstructive sleep apnea, increases risk for BiPap. and COPD for aspiration Monitor for To prevent intubation and gastric To prevent re-intubation rebreathing distention, initially after extubation carbon dioxide. air leaks from mouth, aspiration risk.
  • 18. Collaborative Nursing Care INTERVENTIONS OUTCOMES Oxygenation/Ventilation • Auscultate breath sounds q2–4h and PRN. A patent airway is maintained. • Suction as needed for crackles, coughing, or Lungs are clear to auscultation. oxygen desaturation. Patient is without evidence of atelectasis. • Hyperoxygenate before and after each Peak, mean, and plateau pressures are suction pass. within normal limits. • Monitor airway pressures q1–2h. ABGs are within normal limits • Monitor airway pressures after suctioning. • Administer bronchodilators and mucolytics as ordered. • Perform chest physiotherapy if indicated by clinical examination or chest x-ray. • Turn side to side q2h. • Consider kinetic therapy or prone positioning as indicated by clinical scenario. • Get patient out of bed to chair or standing position when stable. • Monitor pulse oximetry and end-tidal CO2. • Monitor ABGs as indicated by changes in noninvasive parameters,patient status, or weaning protocol.
  • 19. OUTCOMES INTERVENTIONS Circulation/Perfusion • Assess hemodynamic effects of initiating Blood pressure, heart rate, cardiac positive-pressure ventilation output, central venous pressure, and (eg, potential for decreased venous return pulmonary artery pressure remain and cardiac output). stable on mechanical ventilation • Monitor ECG for dysrhythmias related to hypoxemia. • Assess effects of ventilator setting changes (inspiratory pressures, tidal volume, PEEP, and FiO2) on hemodynamic and oxygenation parameters. • Administer intravascular volume as ordered to maintain preload. Fluids/Electrolytes • Monitor hydration status in relation to I & O measurements are balanced. clinical examination, auscultation, Electrolyte values are within normal amount and viscosity of lung secretions. limits. • Assess patient weight, I & O totals, urine specific gravity, or serum osmolality to evaluate fluid balance. • Administer electrolyte replacements (IV or enteral) per physician’s order.
  • 20. OUTCOMES INTERVENTIONS Mobility • Collaborate with physical/occupational Patient maintains or regains therapy staff to encourage baseline patient effort/participation to increase mobility. functional status related to • Progress activity to sitting up in chair, mobility and self-care. standing at bedside, ambulating with Joint range of motion is assistance as soon as possible. maintained • Assist patient with active or passive range-of-motion exercises of all extremities at least every shift. • Keep extremities in physiologically neutral position using pillows or appropriate splint/support devices as indicated.
  • 21. OUTCOMES INTERVENTIONS Safety • Securely stabilize endotracheal tube in Endotracheal tube will remain in position. proper • Note and record the “cm” line on position. endotracheal tube position at lip or teeth. Proper inflation of endotracheal tube • Use restraints or sedation per hospital cuff is maintained. protocol. Ventilator alarm system remains • Evaluate endotracheal tube position on activated chest x-ray daily (by viewing film or by report). • Keep emergency airway equipment and manual resuscitation bag readily available, and check each shift. • Inflate cuff using minimal leak technique, or pressure <25 mm Hg by manometer. • Monitor cuff inflation/leak every shift and PRN. • Protect pilot balloon from damage. • Perform ventilator setting and alarm checks q4h (minimum) or per facility protocol.
  • 22. OUTCOMES INTERVENTIONS Skin Integrity • Assess and document skin integrity at Patient is without evidence of skin least every shift. breakdown. • Turn side to side q2h; reassess bony prominences for evidence of pressure injury. • When patient is out of bed to chair, provide pressure relief to sitting surfaces at least q1h. • Remove self-protective devices from wrists, and monitor skin per hospital policy. Nutrition • Consult dietitian for metabolic needs Nutritional intake meets calculated assessment and recommendations. metabolic need (eg, basal energy • Provide early nutritional support by enteral or parenteral feeding, start within 48 hours of expenditure equation). intubation. Patient will establish regular bowel • Monitor actual delivery of nutrition daily with elimination pattern I&O calculations. • Weigh patient daily. • Administer bowel regimen medications as ordered, along with adequate hydration.
  • 23. OUTCOMES INTERVENTIONS Comfort/Pain Control • Document pain assessment, using Patients will indicate/exhibit numerical pain rating or similar scale adequate relief of discomfort/pain while on when possible. mechanical ventilation • Provide analgesia as appropriate, document efficacy after each dose. • Prevent pulling and jarring of the ventilator tubing and endotracheal or tracheostomy tube. • Provide meticulous oral care q1–2h with oropharynx suctioning and application of mouth moisturizer as needed; teeth brushing scheduled at least three times daily; antimicrobial rinse twice daily; oral assessment at least daily. • Administer sedation as indicated.
  • 24. OUTCOMES INTERVENTIONS Psychosocial • Encourage patient to move in bed and attempt to meet Patient participates in self-care own basic comfort/hygiene needs independently. and • Establish a daily schedule for bathing, time out of bed, decision making related to own treatments, and so forth with patient input. ADLs • Provide a means for patient to write notes and use (eg, turning, bathing). Patient visual tools to facilitate communication. communicates with healthcare • Encourage visitor conversations with patient in normal providers and visitors. tone of voice and subject matter. • Teach visitors to assist with range-of-motion and other simple care delivery tasks, to facilitate normal patterns of interaction. Teaching/Discharge Planning • Provide explanations to patient and family regarding: Patient cooperates with and • Rationale for use of mechanical ventilation indicates • Procedures such as suctioning, airway care, chest understanding of need for physiotherapy mechanical ventilation. • Plan for and progress toward weaning and extubation Potential discharge needs are • Initiate early social work to screen for needs, resources, assessed. and support systems.
  • 25. Abnormal Arterial Blood Gases in the Mechanically Ventilated Patient Abnormality Possible Causes Action Hypoxemia Patient-related Suction. Increase FiO2. Secretions Evaluate patient and chest Increase in disease pathology radiograph. Positive fluid balance Evaluate intake and output. Hypocapnia Patient-related Evaluate ABGs and patient. Hypoxia Evaluate for wean potential. Increased lung compliance’ Decrease respiratory rate, Increased minute ventilation tidal volume, or minute Ventilator-related ventilation. Incorrect ventilator settings Hypercapnia Patient-related Increase respiratory rate or Sedation tidal volume settings. Fatigue Increase respiratory rate, tidal Decreased minute ventilation volume, or minute Ventilator-related ventilation. Incorrect ventilator settings
  • 26. Troubleshooting the Ventilator Problem Possible Causes Action Volume or low Patient-related Reconnect STAT. pressure Patient disconnected from •Auscultate neck for possible leak alarm Ventilator Loss of delivered around endotracheal tube cuff. tidal volume Decrease in •Review chest film for endotracheal patient-initiated breaths tube placement—may be too high. Increased compliance •Check for loss of tidal volume through Ventilator-related chest tube. Leaks •Evaluate patient for cause: check respiratory rate, ABGs, last sedation. •Evaluate patient for clearing of secretions or relief of bronchospasms. •Check all tubing for loss of connection, starting at patient and moving toward humidifier. •Check for change in ventilator settings. (Note: If problem is not corrected STAT, use MRB until ventilator problem is corrected.)
  • 27. Troubleshooting the Ventilator Problem Possible Causes Action High-pressure Patient-related •Suction patient. or Decreased compliance •Administer inhaled β-agonists. peak-pressure Decreased dynamic •If sudden, evaluate for pneumothorax. alarm Compliance •Evaluate chest film for endotracheal tube Decreased static displacement in right mainstem bronchus. compliance Ventilator-related •Sedate if patient is bucking the ventilator Tubing kinked or biting the endotracheal tube. Tubing filled with water •Evaluate ABGs for hypoxia, fluids for Patient–ventilator overload, chest film for atelectasis. asynchrony •Auscultate breath sounds. •Check tubing. •Empty water into a receptacle. •Recheck sensitivity and peak flow settings. •Provide sedation/paralysis if indicated.
  • 28. Troubleshooting the Ventilator Problem Possible Causes Action Heater alarm Adding cold water to Wait. humidifier. Reset. Altered setting Redirect airflow. Cold air blowing on humidifier
  • 29. Complications of Mechanical Ventilation Airway • Aspiration • Ventilator-acquired pneumonia (VAP) • Complications of endotracheal intubation or tracheostomy Mechanical • Lung injury (eg, barotrauma, volutrauma) • Atelectasis (resulting from hypoventilation) • Hypocapnia and respiratory alkalosis (resulting from hyperventilation) • Hyperthermia (resulting from overheated inspired air) • Hypercapnia and respiratory acidosis (hypoventilation) Physiological • Depressed cardiac function, resulting in hypotension • Fluid overload • Respiratory muscle weakness and atrophy • Complications of immobility • Gastrointestinal problems (eg, paralytic ileus, stress ulcers, distention)
  • 30. Nursing Action Rationale Obtain baseline samples for blood gas Baseline measurements serve as a guide in determinations (pH, PaO2, Paco2, HCO3-) and determining progress of therapy. chest X-ray Give a brief explanation to the patient Emphasize that mechanical ventilation is a temporary measure. The patient should be prepared psychologically for weaning at the time the ventilator is first used. Establish the airway by means of a cuffed A closed system between the ventilator and endotracheal or tracheostomy tube patient lower airway is necessary for positive pressure ventilation Prepare the ventilator. (Respiratory therapist does this in many facilities.) Set up desired circuitry. Connect oxygen and compressed air source Turn on power.
  • 31. Set tidal volume (usually 5-7 mL/kg body Adjusted according to pH and Paco2 weight) or peak pressure. Set oxygen concentration Adjusted according to PaO2 Set ventilator sensitivity Set rate at 12-14 breaths/minute (variable). This setting approximates normal ventilation. These machines' settings are subject to change according to the patient's condition and response, and the ventilator type being used. Adjust flow rate (velocity of gas flow during The slower the flow, the lower the peak inspiration). Usually set at 40-60 L/minute. airway pressure will result from set volume Depends on rate and tidal volume. Set to delivery. This results in lower intrathoracic avoid inverse inspiratory:expiratory (I:E) ratio. pressure and less impedance of venous Usual I:E ratio is 1:2. return. However, a flow that is too low for the rate selected may result in inverse inspiratory: expiratory ratios
  • 32. Select mode of ventilation. Check machine function—measure tidal Ensures safe function volume, rate, I:E ratio, analyze oxygen, check all alarms. Couple the patient's airway to the ventilator Make sure all connections are secure. Prevent ventilator tubing from “pulling― on artificial airway, possibly resulting in tube dislodgement or tracheal damage. Assess patient for adequate chest movement Ensures proper function of equipment and rate. Note peak airway pressure and PEEP. Adjust gas flow if necessary to provide safe I:E ratio. Set airway pressure alarms according to patient's baseline High pressure alarm High airway pressure or “pop off― pressure is set at 10-15 cm H2O above peak airway pressure. An alarm sounds if airway pressure selected is exceeded. Alarm activation indicates decreased lung compliance (worsening pulmonary disease); decreased lung volume (such as pneumothorax, tension pneumothorax, hemothorax, pleural effusion); increased airway resistance (secretions,
  • 33. Low pressure alarm Low airway pressure alarm set at 5-10 cm H2O below peak airway pressure. Alarm activation indicates inability to build up airway pressure because of disconnection or leak, or inability to build up airway pressure because of insufficient gas flow to meet the patient's inspiratory needs. Assess frequently for change in respiratory status by way of ABGs, pulse oximetry, spontaneous rate, use of accessory muscles, breath sounds, and vital signs. Other means of assessing are through the use of exhaled carbon dioxide (see “Capnography,― “Mixed venous oxygen saturation monitoring,―). If change is noted, notify appropriate personnel Monitor and troubleshoot alarm conditions. Priority is ventilation and oxygenation of the Ensure appropriate ventilation at all times. patient. In alarm conditions that cannot be immediately corrected, disconnect the patient from mechanical ventilation and manually ventilate with resuscitation bag.
  • 34. Positioning For patients on long-term ventilation, this Turn patient from side to side every 2 hours, may result in sleep deprivation. Follow a or more frequently if possible. Consider turning schedule best suited to a particular continuous lateral rotational therapy (CLRT) as patient's condition. Reposition may improve early intervention to improve outcome. secretion clearance and reduce atelectasis Lateral turns are desirable; from right semiprone to left semiprone. Sit the patient upright at regular intervals if Upright posture increases lung compliance possible Carry out passive range-of-motion exercises of To prevent contractures all extremities for patients unable to do so. Assess for need of suctioning at least every 2 Patients with artificial airways on mechanical hours ventilation are unable to clear secretions on their own. Suctioning may help to clear secretions and stimulate the cough reflex. Assess breath sounds every 2 hours: Listen with stethoscope ot the chest in all Auscultation of the chest is a means of lobes bilaterally. assessing airway patency and ventilatory distribution. It also confirms the proper
  • 35. Humidification. Humidity may improve secretion mobilization Assess airway pressures at frequent intervals Monitor for changes in compliance, or onset of conditions that may cause airway pressure to increase or decrease Monitor cardiovascular function. Assess for abnormalities. Monitor for pulmonary infection This technique allows for the earliest detection of infection or change in infecting organisms in the tracheobronchial tree. Evaluate need for sedation or muscle Sedatives may be prescribed to decrease relaxants anxiety, or to relax the patient to prevent “competing― with the ventilator. At times, pharmacologically induced paralysis may be necessary to permit mechanical ventilation Report intake and output precisely and obtain an accurate daily weight to monitor fluid balance Monitor nutritional status
  • 36. Test all stools and gastric drainage for occult Stress may cause some patients requiring blood mechanical ventilation to develop GI bleeding. Measure abdominal girth daily. Abdominal distention occurs frequently with respiratory failure and further hinders respiration by elevation of the diaphragm. Measurement of abdominal girth provides objective assessment of the degree of distention. Maintain a flow sheet to record ventilation Establishes means of assessing effectiveness patterns, ABGs, venous chemical and progress of treatment. determinations, hemoglobin and hematocrit, status of fluid balance, weight, and assessment of the patient's condition. Notify appropriate personnel of changes in the patient's condition. Change ventilator circuitry every 24 hours; Prevents contamination of lower airways assess ventilator's function every 4 hours or more frequently if problem occurs.