Mechanical ventilation provides artificial breathing support through a machine called a ventilator. There are two main types of ventilators - negative pressure ventilators which apply suction to expand the lungs, and positive pressure ventilators which deliver pressurized gas to expand the lungs. A patient on a mechanical ventilator will have an endotracheal tube in their airway connected to the ventilator to deliver breaths. The ventilator has components to control gas delivery and monitors like pressure and volume to assess the patient's ventilation. Ventilators are classified based on how they determine the end of inhalation, with volume-cycled being most common. Non-invasive ventilation through masks is also used

1. MECHANICAL
VENTILATION
Presented By
Mr. Pradeepsingh B
Asst. Professor
HOD Medical Surgical Nursing

2. Ventilation or breathing, is the movement of air through the conducting
passages between the atmosphere and the lungs. The air moves through the passage
because of pressure gradients that are produced by contraction of the diaphragm and
thoracic muscles.
A ventilator is an appliance or aperture for ventilating or to provide artificial
ventilation to a person.

4. MECHANICAL
VENTILATION,
Mechanical ventilation is a treatment to help a
person to breathe when they find it difficult or are unable to
breathe on their own.
Artificial breathing is supported by a machine called
Mechanical ventilator.

5. PATIENT ON MECHANICAL VENTILATOR,
Patient on a mechanical ventilation is a patient who is not
able to breathe spontaneously on his own and needs assistance for
breathing.
The following equipments are present on the mechanical
ventilator supported patient,
1. Endotracheal tube
2. Nasogastric tube
3. Ventilator pipes attached to the endotracheal tube.

6. 1. ENDOTRACHEAL
TUBE,
Endotracheal tube is a flexible plastic
tube that is placed through the mouth into the
trachea(windpipe) to help a patient breathe. The
endotracheal tube is then connected to the
ventilator which delivers oxygen to the lungs.
The process of inserting the tube is called
Endotracheal intubation.
Types of Endotracheal tube,
1. Single lumen endotracheal tube.
2. Double lumen endotracheal tube.

7. PARTS OF ENDOTRACHEAL TUBE,
1. The Cuff
2. The Bevel
3. The Murphy’s Eye
4. The Connector

8. THE NASOGASTRIC TUBE,
Nasogastric tube is a flexible tube of rubber or plastic that is passed through the
nose, down through the esophagus, and into the stomach.
It can be used to either remove substance from or add them to the stomach. A
Nasogastric tube is meant only for temporary basis and is not for long term use.

9. Types of nasogastric
tube,
• The Levin tube
• The Salem Sump tube
• The Moss Tube

10. Parts of
Nasogastric
tube,

11. MECHANICAL
VENTILATOR,
A Mechanical
Ventilator is a positive or negative
pressure breathing device that
can maintain ventilation and
oxygen delivery for a prolonged
period of time.

12. PARTS OF MECHANICAL VENTILATOR,

13. BASIC VENTILATOR COMPONENTS,
Mechanical ventilator is composed of basic four components. The components
of Mechanical Ventilator are as follows,
The Power Sources
The Controls
The Monitors
The Safety
Measures

15. 1. THE POWER SOURCES,
The power sources consists of something to supply the
gas which will be delivered to the patient, as well as the energy
required to run ventilator components. Thus, this category
encompasses the gas supply system, The batteries and the power
source of the mechanical ventilator.

16. 2. THE
CONTROL,
The controls are some means of regulating the timing and characteristics of the
delivered gas. These components consists of an entire array of parts, each of
which probably merits an entire chapter of their own.
a. A Gas Blender.
b. A Gas Accumulator.
c. Inspirator Flow Regulator .
d. Humidification equipment.
e. The Circuit.
f. Expiratory Pressure Regulator.

17. A. A Gas Blender,
A Gas blender is required to control the mixture of air, oxygen, anaesthetic gas
or whatever else we use to ventilate the patient. One may not need and such gas
blender if one is discussing some sort of stripped-down domiciliary model which run
room alone, which dos not accept an Exogeneous Oxygen Sources.
B. A Gas Accumulator,
A Gas Accumulator might be a component of a ventilator which requires a
precise control of gas mixtures an which cannot rely on proportioning valves to
produces this level of preciousness.
For Example: Where the gas flows are very low.

18. C. Inspiratory Flow Regulator,
Inspiratory Flow Regulator is any device which ensures that the respiratory
circuit receives the prescribed gas flow . This thing sits in front of the gas supply and
ensures that the patient is only exposed to carefully measured amounts of that gas. In
ICU piping outlets is supplied at the standard pressure of 400 KPa (4 atm), it is
obviously an essential component.
D. Humidification Equipment,
Humidification equipment is an equipment that can take the shape of a
active humidifier ( i.e., a device which heats and evaporates water into the supplied gas
mixture) or a passive humidifier like a heat/moisture exchanger. Generally, domiciliary
CPAP machines which supply room air via some sort of face mask can rely on patient’s
own upper way for humidifier.

19. E. The Circuit,
It plays an important role in ventilating the patient. Its characteristics are its
compliance and resistance to air flow, are its important.
F. Expiratory Pressure Regulator,
Expiratory Pressure Regulator ( i.e., PEEP valve) is a means of maintaining and
controlling positive airway pressure. These are basically carefully controlled expiratory
flow obstructions, usually in the form of Solenoid Valve (Though crude mechanical
models also exist for old-school ventilators).

20. 1. The
Monitors,
The monitors are the means of sensing
and presenting the characteristics of the gas
delivery so that one might be able to access the
ventilators performance ( probably the patient’s
condition).
• Gas concentration
• Flow
• Pressure
• Volume

22. A. Gas Concentration,
Gas concentration is usually measured by either voltaic cells or
Spectophotometers.
For Example, The oxygen supply sensor is usually an Oxygen cell, which
produces an output voltage proportional to the partial pressure of oxygen
in the inspiratory gas pipe.
B. The Flow,
Flow is pretty much main thing the ventilator supplies, so it makes
sense to want to monitor it in the some way. All commercially available
mechanical ventilators have some method of monitoring flow. These
methods include,
• Hot Wire Anemometer.
• Variable orifice flowmeter.
• Screen Pneumotachography.
• Ultrasonic flowmeters.

23. C. Pressure,
Pressure in the circuit had historically been accomplished by the manometers,
i.e., pressure sensors that measure air pressure by the action of the air in deforming
the elastic lid of an evacuated box. In modern ventilators, these have been suspected
by integrated Silicon wafer pressure transducers, at a fraction of the cost and with
greatly unproved accuracy.
D. Volume,
Volume is not measured directly in modern ventilators it is calculated from
flow measurements. In older ventilator designs (e.g., the bellows and the piston
models) a directly measure volume was the main variable over which the intensivist
had any control.

24. 4. THE
SAFETY
FEATURES,
The safety features are some devices and measures
which ensure that the patient does not come to any
additional harm from being ventilated ( Beyond the
already brutal effects which are integrated to the process ).
These consists of filters and alarms.
A. Inspiratory filters.
B. Expiratory filters.
C. Alarms.

25. A. Inspiratory regulators,
Inspiratory filter of the ventilator promote purity of inspired gas (E.g., by
removing airborne particles and bacteria from the inspired gas mixture).
B. Expiratory regulators,
Expiratory filter protect the ICU staff. Expired gas is filtered to prevent the
ventilator from constantly belching out great clouds of aerosolized pathogens
generated in the horrific toilet-like bog water of the patient airways.
Expiratory filters are also usually needed to protect the ventilator
components from the necessarily hot and humid expired gases, which would degrade
the quality of sensor measurements and decrease the lifespan of the device.

26. C. Alarms,
Alarms are usually integrated into the software as safeguards against
unintentional changes to the ventilator settings and weird misapplications of the
ventilation. Broadly, these are the systems to let us know what the patient condition 0r
ventilator performance has trespassed the parameters which are safe. Non software
alarm-like features are also integrated into ventilators.
For Example: Mechanical blow-off valves to release excess pressure when the
patient coughs.

27. CLASSIFICATION OF VENTILATORS,
Mechanical ventilators are classified according to the method by which they
supported ventilation.
The two main general categories of mechanical ventilator are as follows,
Negative pressure ventilator
Positive pressure ventilator

28. 1. Negative
pressure
ventilator,
A Negative pressure ventilator(NPV) is a type of
mechanical ventilator that stimulates an ill person’s breathing by
periodically applying the negative air pressure to their body to
expand and contract the chest cavity.
Types of Negative Pressure ventilator,
A. Iron lung ventilator.
B. Cuirass ventilator .
C. Exovent ventilator.
D. Jacket Ventilator .
E. Pulmotor Ventilator.

29. A. Iron Lung Ventilator,
An Iron lung ventilator, also known as a tank ventilator or drinker tank, is a
type of negative pressure ventilator; a mechanical respirator which encloses most of a
person’s body and varies the air pressure in the enclosed space, to stimulate breathing.

30. B. Cuirass Ventilator,
A cuirass ventilator is a molded shell that fits tightly around a person’s
thorax. It’s light fit makes possible a good degree of negative-pressure ventilation, that
is, negative pressure within the shell causes expansion of the chest wall with resultant
inspiration.

31. C. Exovent
Ventilator,
The Exovent ventilator
is a non invasive, which means
that patients do not need to have
their windpipes intubated, so they
don’t need to be anaesthetisized
and oxygen mask or nasal prongs
rather than through high-flow
Oxygen device that puts hospital
Oxygen supplies under pressure.

32. D. Jacket
Ventilator,
The jacket Ventilator,
also known as Poncho or Raincoat
Ventilator, is a lighter version of
Iron Lung or the Cuirass
Ventilator, constructed of an
airtight material(Such as Plastic or
rubber) arranged over a light
metal or plastic frame, or screen,
and depressurized and
repressurized by a portable
ventilator.

33. E. Pulmotor
Ventilator,
Pulmotor ventilator
is used pressure from a tank of
compressed Oxygen to operate a
valve system that alternately
forced air into and out of a
person’s airway, using alternating
positive and negative air pressure.

34. 2. POSITIVE
PRESSURE
VENTILATOR,
Positive pressure ventilator inflate the lungs by
exerting positive pressure on the airway, pushing the air in,
similar to a bellows mechanism, and forcing alveoli to expand
during inspiration. Expiration occurs passively.
Endotracheal intubation and tracheostomy is usually necessary in
positive pressure ventilator. These ventilator are widely used in
hospitals and are increasingly used in home for patients with
primary lung disease.

35. Types of Positive Pressure Ventilator
There are three types of positive pressures ventilator are classified by the method of
ending the inspiratory phase of respiration. They are ass follows,
Volume Cycled
Ventilator Pressure Cycled
Ventilator
High Frequency Oscillatory
Support Ventilator
Non-Invasive Positive
Pressure Ventilator
(NIPPV)

36. A. Volume –
cycled
ventilators,
The Volume – Cycled Ventilators deliver a preset volume of
air with inspiration. These Ventilators are better developed
and introduced by Amitei and Sinert.
Once the preset volume is delivered to the patient, the
ventilator cycles off and exhalation occurs passively. From
breath to breath, the volume of the air delivered by the
ventilator is relatively constant, ensuring consistent,
adequate breathe despite varying airway pressure.
A major disadvantage to using volume-cycled ventilator is
that patients may experience Barotrauma because the
pressure required to deliver the breathes may be excessive.

37. B. Pressure
Cycled
Ventilator,
Pressure cycled ventilator was developed and modified
by German scientists.
Pressure cycled ventilator delivers a flow of air(inspiration)
until it reaches a preset pressure, and expiration occurs. The
major limitations is the volume of air or Oxygen can vary as
patient’s airway resistance or compliance changes. As a result, the
tidal volume delivered may be inconsistent , possibly
compromising ventilation.

38. C. High
Frequency
Oscillatory
support
ventilator,
The high frequency oscillatory ventilators are believed to
be modified and used by Stewart, Jagelman and Webster, Bio-
mechanical scientists.
The high frequency Oscillatory Support Ventilators,
deliver very high respiratory rates (i.e., 180-900 breaths/minute)
that are accompanied by very low tidal volumes and high airway
pressures.
These small pulses of Oxygen-enriched air moves down
the center of the airways, allowing alveolar air to exit the lungs
along the margins of the airways.
This ventilatory mode is used to open the alveoli in
situations characterized by the closed small airways, such as
Atelectasis and ARDS, and it is also thought to protect the lung
from Pressure Injury.

39. D. Non-
Invasive
Positive-
Pressure
Ventilator,
The Non-Invasive Positive Pressure ventilator was
modified Bauman, Jallu and Salzman.
The Non-Invasive Positive Pressure Ventilator is a
method of positive pressure ventilator provision. This
type of ventilation can be given via face masks that
cover nose and mouth, nasal mask or other nasal
devices such as nasal devices such as Nasal Pillow.

40. Advantages
NIPPV eliminates the needs for Endotracheal
Intubation or Tracheostomy and decreases
the risk of nosocomial infection such as
pneumonia.
It is the most comfortable ventilatory
support to the patient.
This eases the work of breathing and
enhances gas exchange.
The ventilator can be set with a minimum
backup rate for patients with periods of
apnea.
The technique may also be used at
home setting to improve tissue
oxygenation and rest to the respiratory
muscles while patient sleep at night.
NIPPV may also be used for obstructive
sleep apnea, for patients at the end of
life, and for those who don’t want
endotracheal intubation but may need
short or long-term ventilatory support.

41. Contraindications of NIPPV,
* NIPPV is contraindicated for those who have
experienced respiratory arrest, serious
dysrhythmias, cognitive impairment, head or facial
trauma.

42. E.
Continuous
Positive
Airway
Pressure
(CPAP),
CPAP provides positive pressure to the airways
throughout the respiratory cycle. Although it can be used as an
adjunct to mechanical ventilation with a cuffed endotracheal tube
or tracheostomy tube to open the alveoli, it is also used with a
leak proof mask to keep alveoli open, thereby preventing
respiratory failure. CPAP can be used in a patient who can breath
independently.

43. F. Bilevel
Positive
Airway
Pressure,
BiPAP ventilation offers independent control of
inspiratory and expiratory pressure while providing positive
Pressure Support Ventilation(PSV). It delivers two levels of
positive airway pressure provided via a nasal or oral mask, nasal
pillow, or mouth piece with a tight seal and a portable ventilator.
Each respiration can be initiated either by the
patient or by the machine if it is programmed with a backup rate.
The backup rate ensures that the patient receives a set number of
breathes per minute.
BiPAP is most often used in patients who require
ventilation at night, such as those with severe COPD or Sleep
apnea.

44. Caring for a patient on mechanical ventilation has become an integral
part of nursing care in critical care or general medical-surgical units, extended care
facilities, and the home.
Some conditions that require the ventilatory support as follows,
• If the patient has evidence of respiratory failure or a compromised airway,
endotracheal intubation and mechanical ventilation are indicated.
• A continuous decrease in Oxygenation(PaO2), an increase in arterial
Carbondioxide levels (PaCO2).
• A persistent Acidosis

45. Conti…
• Conditions such as,
Thoracic and abdominal surgery
Drug Overdose
COPD
Multiple Trauma
Shock
Multisystem failure
Shock
Coma leading to respiratory failure

46. General
Conditions such
as,
Laboratory values,
PaO2 < 55mmHg
PaCO2 > 50 mmHg
pH > 7.32
Vital Capacity < 10 mL/Kg
Presence of negative inspiratory force is less than 25 cmH2O

47. Ethical Considerations,
Apnea or Bradypnea
Respiratory distress with confusion
Increased work of breathing not relieved by other interventions
Confusion with the need for airway protection
Circulatory Shock

48. VENTILATORY
MODES,
Ventilator modes refers to how breathes are
delivered to the patient. The most commonly used modes are
as follows,
1. Continuous Mandatory Ventilation (CMV)
2. Intermittent Mandatory Ventilation (IMV)
3. Synchronized Intermittent Mandatory Ventilation (SIMV)
4. Pressure Support Ventilation (PSV)
5. Airway Pressure Release Ventilation (ARPV)
6. Proportional Assist Ventilation (PAV)

49. 1.
Continuous
Mandatory
Ventilation
(CMV),
CMV provides full ventilatory support by
delivering a preset tidal volume and respiratory rate. This mode
of ventilation is indicated for patients who are apneic.

51. 2. Assist control (A/C) Ventilation,
Assist Control Ventilation is similar to CMV in the ventilator will deliver
preset volume tidal volumes & rate of respiration. However, If the patient initiates a
breath between the machine’s breaths, the ventilator delivers at the preset volume
(assisted breath). Therefore, every breathe is the Preset volume .

53. 3. Intermittent Mandatory Ventilation (IMV),
IMV provides a combination of mechanically assisted breathes and
spontaneous breaths. Mechanical breaths are delivered at present intervals and
preselected tidal volume, regardless of the patient’s efforts. Although the patient can
increase the respiratory rate by initiating inspiration between ventilator-delivered
breaths, these spontaneous breathes are limited to the tidal volume generated by the
patient.
IMV allows the patient to breathe using own muscles for ventilation to help
prevent muscle atropy. It lowers the mean airway pressure preventing Barotrauma.
However, “fighting the ventilator” or “Bucking the ventilator” may be increased.

55. 4. Synchronized Intermittent Mandatory
Ventilation (SIMV),
SIMV also delivers a preset tidal volume and number of breaths per minute.
Between the ventilator-delivered breaths, from the ventilator on those extra breaths.
Because the ventilator senses the patient breathing efforts and does not initiate a
breath in opposition to the patient’s efforts, fighting the ventilator is reduced. As the
patient’s ability to breathe spontaneously increases, the preset number of ventilator
breathes is decreased and the patient does more of the work of breathing.

57. 5. Pressure Support Ventilation (PSV),
PSV applies a pressure plateau to the airway throughout the patient-
triggered inspiration to decrease resistance within the tracheal tube and ventilator
tubing. Pressure Support is reduced gradually as the patient’s strength increases. An
SIMV backup rate may be added for extra support. The nurse must closely observe the
patient’s respiratory rate and tidal volumes on initiation of PSV. It may be necessary to
adjust the pressure support to avoid tachypnea or large tidal volumes.

59. 6. Airway Pressure Release Ventilation
(APRV),
APRV was first designed by Maung and Kaplan.
APRV is a time-triggered, pressure-limited, time-cycle mode of mechanical
ventilation that allows unrestricted, spontaneous breathing throughout the ventilatory
cycle. The inflation period is long , and breaths may be initiated spontaneously as well
as by the ventilator. APRV allows alveolar gas to be expelled through the lung’s natural
recoil. APRV has the important advantages of causing less ventilator-induced lung
injury and fewer adverse effects on cardiocirculatory function and being associated
with the lower need for sedation and neuromuscular blockade.

61. 7. Proportional Assist Ventilation (PAV),
PAV was first designed by Stewert Et El.
PAV provides partial ventilatory support in which the ventilator generates
pressure in proportion to the patient’s inspiratory efforts. With every breath, The
ventilator synchronizes with the patient efforts. The more inspiratory pressure that
patient generates, the more pressure the ventilator generates, amplifying the patient’s
inspiratory effort without any specific preselected target pressure or volume. It
generally adds ‘additional muscles’ to the patient’s effort; the depth and frequency of
breaths are controlled by the patient.

63. ADJUSTING
THE
VENTILATOR,
The ventilator is adjusted so that the patient is
comfortable and breaths synchronously with the machine.
Minimal alteration of the normal cardiovascular and
pulmonary dynamics is desired. If the volume ventilator is
adjusted appropriately, the patient’s arterial blood gas
values will be satisfactorily normal and there will be little or
no cardiovascular compromise.

64. Initial
Ventilator
Settings,
Set Set mode and rate according to order given by the primary provider. Set the
Positive End Expiratory Pressure (PEEP) and pressure support if ordered.
Record Record Peak Inspiratory pressure
Adjust
Adjust the machine to deliver lowest concentration of Oxygen to maintain
normal PaO2. The setting may be high initially but will gradually be reduced
based on ABG results.
Set Set the machine to deliver the tidal volume (10-15 mL/Kg).

65. Conti…
Adjust the sensitivity so that the patient can trigger the ventilator with minimal effort (Usually
2mmHg negative inspiratory force).
Record the minute volume and obtain ABG’s to measure PaO2 and PaCO2 after 20 minutes of
continuous mechanical ventilation.
Adjust the setting(FiO2 and rate) according to the results of the ABG analysis to provide the
normal values to those set by the primary provider.
If there is poor concentration of Oxygen and poor coordination between the patient’s breathing
rhythms and the ventilator (i.e., if the patient is ‘fighting’ or ‘bucking the ventilator’), asses the
hypoxia and manually ventilate on 100% oxygen with a resuscitating bag.

66. MONITORING THE EQUIPMENT,
The ventilator needs to be monitored to make sure that its functioning
properly and that settings are appropriate. The nurse may not be primarily responsible
for adjusting the settings on the ventilator or measuring ventilator parameters (these
are usually responsibilities of the Respiratory therapist), the nurse is responsible for the
patient and therefore needs to evaluate how the ventilator effects the patient’s overall
status.

67. When monitoring the ventilator, the nurse
notes the following,
• Controlling mode ( e.g., A/C Ventilation, SIMV).
• Tidal volume and rate settings (tidal volume is usually set at 6 to 12mL/Kg[ideal
body weight] : rate is usually set at 12-16 breathes per minute).
• FiO2 Setting.
• Inspiratory pressure reached the pressure limit (Normal is 15-20 cm H2O ; this
increases if there is increased airway resistance or decreased compliance).
• Senitivity.
• Inspiratory to Expiratory ratio ( 1:3 or 1:2).
• Minute volume ( Tidal volume x Respiratory rate).
• Sigh settings, if applicable.

68. Conti…
• Water in the tubing, disconnection or kinking in the tubing.
• Humidification and temperature.
• Alarms.
• PEEP and Pressure Support Level, if applicable .

69. NURSING
PROCESS,
The Patient
receiving Mechanical
Ventilation

70. The Nurse plays a vital role in assessing the patient’s status and functioning
of the ventilator. In assessing the patient’s physiological status and how he or she is
coping with mechanical ventilation.
Physical assessment includes,
• Systematic assessment of all body systems, with an in-depth focus on the respiratory
systems .
• Respiratory Assessment includes Vital Signs, Respiratory Rate and pattern, breathe
patterns and sounds, evaluation of spontaneous ventilatory efforts, and potential
evidence of hypoxia.
• Increased adventitious breathe sounds, may indicate a need for suctioning. The nurse
also evaluates the settings and functioning of a mechanical ventilator.

71. Conti…
• Assessment also includes patients neurological status examination and
effectiveness and coping with the need for assisted ventilation and changes that
accompany it.
• The nurse assess patient’s comfort level and ability to communicate as well.

72. Nursing Diagnosis,
Based on the assessment data, major nursing diagnosis may include,
1. Impaired gas exchange related to underlying illness, ventilator settings
adjustments, or weaning.
2. Ineffective airway clearance related to increased mucus production associated
with the presence of the tube in the trachea or continuous positive-pressure
mechanical ventilation.
3. Risk for trauma and infection related to endotracheal intubation or
tracheostomy.
4. Impaired physical mobility related to ventilator dependency.
5. Impaired verbal communication related to endotracheal tube or tracheostomy
tube.
6. Defensive coping and powerlessness related to ventilator dependency.

73. Collaborating problems/ potential
complications,
Based on the assessment data, potential complication may include the
following,
1. Ventilator Problems.
2. Alterations in Cardiac Function.
3. Barotrauma and Pneumothorax.
4. Pulmonary infection.
5. Sepsis.

74. Planning and Goals,
The major goals for the patient may include achievement of optimal gas
exchange, maintenance of a patient airway, absence of trauma or Infection,
attainment of optimal mobility, adjustment to nonverbal methods of
communication, acquisition of successful coping measures, and absence of
complication.

75. Nursing Intervention,
Nursing care of the patient who is mechanically ventilated requires expert
technical and interpersonal skills. Nursing interventions are similar regardless of the
setting; however, the frequency of the interventions and the stability of the patients
vary from the setting to setting. Nursing interventions for the patient who is
mechanically ventilated are not uniquely different from those patient with other
pulmonary disorder, but Astute nursing assessment and the therapeutic nurse-patient
relationship is critical. The specific interventions used by the nurse are determined by
underlying disease process and the patient’s response.

76. 1. Impaired gas exchange related to underlying
illness, ventilator setting adjustment or weaning.
Goal,
Enhancing gas exchange,
• Judicious administration of analgesic agents to relieve pain without suppressing the
respiratory drive.
• Frequent repositioning to diminish the pulmonary effects of immobility.
• Monitor adequate fluid balance by assessing for the presence of peripheral edema.
• Monitor daily intake and output chart.
• Monitor daily weights.
• Administration of medications prescribed to control the primary disease and monitor
their side effects.

77. 2. Ineffective airway clearance related to
increased mucus production associated with the
presence of the tube in trachea.
Goal, Promoting airway clearance.
• Assess for the presence of secretions by the lung auscultation atleast every 2 to 4
hours.
• Suctioning can be performed to clear the secretions.
• CPT an ACT can be done by referring the concerned physician.
• Frequent position changes of the patient.
• Humidification of the airway via the ventilator is maintained to help liquefy
secretions so that they are more easily removed.
• Bronchodialators may be indicated to dilate the bronchioles in patients with ALI or
COPD.

78. 3. Risk for trauma and infection related to
endotracheal intubation or tracheostomy,
Goal, Prevent trauma and infection.
• Maintaining the endotracheal or tracheostomy tube.
• Positioning the ventilator tubing so that there is minimal pulling or distortions of
the tube in the trachea, reducing the risk for trauma to the trachea.
• Monitor the cuff pressure every 6 to 8 hours to maintain the pressure less than 25
mmHg and also assess for the presence of Cuff leak at the same time.
• Administer oral hygiene frequently to avoid any infection.
• Position the patient’s head elevated above the stomach level.

79. 4. Prevention of Ventilator-Associated
Pneumonia,
• Elevate the head of the bed (30-45 degrees).
• Protocols should be developed so that sedative doses are purposely decreased at a
time of the day when it is possible to assess the patient’s neurological readiness for
extubation.
• Vigilance must be employed during time that sedative doses are lower to ensure
that patient does not self-extubate.
• Daily oral care with Chlorhexidine (0,12% oral rinses).
• Deep vein thrombosis prophylaxis are applied to lower the rates and risk for
Ventilator Associated Pneumoia.

80. Home Care of the patient on Ventilator,
Caring for the patient with the mechanical ventilator support at home can be
accomplished successfully. A home care team consists of the Nurse, Physician, Respiratory
therapist, Social service or home care agency, and equipment supplier is needed.
The nurse prepares the patient and family for home care as the following,
• The nurse educates the patient and family about the ventilator, suctioning,
tracheostomy care, signs of pulmonary infection, cuff inflation and deflation, and
assessment of vital signs. Education begins at the hospitals and continues at home.
• Nursing responsibilities include evaluating the patient’s and family’s understanding of
the information presented.
• The nurse educates the family about cardiopulmonary resuscitation, including mouth-
to-tracheostomy tube (instead of mouth-to-mouth)breathing.

81. Conti…
• The nurse also explains how to handle a power failure, which usually involves
converting the ventilator from an electric power source to the battery power
source. Conversion is automatic in most type of home ventilators or lasts
approximately 1 hour.
• The technical aspects of the ventilator are managed by the vendor follow up. A
respiratory therapist usually assigned to the patient and perform maintenance
check of ventilator.

83. Evaluation,
Expected patient outcomes may include the following,
1. Patient exhibits adequate gas exchange, as evidenced by the normal breath
sounds, acceptable arterial blood gas levels and vital signs.
2. Demonstrates adequate ventilation with minimal mucus accumulation.
3. Patient is free from injury or infection, as evidenced by normal temperature, white
blood cell count, and clear sputum.
4. Patient is mobile within the limits of ability,
a. Gets out of the bed to chair, bears weight, or ambulates as soon as possible.
b. Performs range of motion exercises every 6 to 8 hours.

84. Conti…
5. Communicates effectively through written messages, gestures, or other
communication strategies.
6. Patient copes effectively,
a. Verbalizes fears and concerns about the conditions and equipments.
b. Participates in decision making when possible.
c. Uses stress reduction techniques when necessary.
7. Absence of complications,
a. Absence of cardiac compromise, as evidenced by stable Vital Signs and Adequate
Urine Output.
b. Absence of Pneumothorax or pulmonary infection.

85. WEANING THE PATIENT FROM THE
VENTILATION,
Respiratory weaning,
The process of withdrawing the patient from dependence on the ventilator.
Weaning the patient from ventilator takes place in three stages,
1. The Patient is gradually removed from the ventilator.
2. The Patient is removed from either the endotracheal or tracheostomy tube.
3. The patient is finally removed from Oxygen.

86. Conti…
Weaning from mechanical ventilation is performed at the earliest possible
tie consistent with the patient’s safety. Weaning is started when the patient is
hemodynamically stable and recovering from the acute stage of medical and surgical
problems and when the cause of respiratory failure is sufficiently reversed.

87. Criteria for Weaning,
Careful assessment is required to
determine whether the patient is ready
for/ready to be removed from
mechanical ventilation.
If the patient is stable and showing
signs of improvement or reversal of the
disease or conditions that caused the
need for mechanical ventilation,
weaning indices should be assessed.
Stable Vital Signs and ABG are also
important predictors of successful
weaning. Once readiness has been
determined, The nurse records baseline
measurements of weaning indices to
monitor progress.

88. Patient Preparation,
To maximize the chances of success of weaning, the nurse must consider
the patient as a whole, taking into account factors that impair the delivery of O2 and
elimination of CO2 as well as those that increases Oxygen demand or decrease the
patient’s overall strength. Adequate psychological preparation is necessary before and
during the weaning process.

89. Methods of Weaning,
Successful weaning from the ventilator is supplemented by the Intensive
Pulmonary Care.
The following methods are used,
1. Oxygen Therapy
2. Arterial Blood Gas Evaluation.
3. Pulse oximetry.
4. Bronchodilator Therapy.
5. Chest Physiotherapy.

90. Conti…
6. Adequate nutrition.
7. Hydration and Humidification.
8. Blood Pressure Measurement.
9. Incentive Spirometry.

91. Care of the patient weaned from
Mechanical Ventilation,
1. Assess the patient for weaning criteria.
a. Vital Capacity
b. Maximum inspiratory Pressure
c. Tidal volume
d. Minute ventilation
e. Rapid/Shallow breathing index
2. Monitor activity level, assess dietary intake and monitor results of laboratory tests
of nutritional status.

92. Conti…
3. Assess the patient’s and family’s understanding of the weaning process, and
address any concerns about the process. Explain that the patient may feel
shortness of breath initially and provide encouragement as needed. Reassure the
patient that he/she will be attended closely and that if the weaning attempt is not
successful it can be tried later.
4. Implement the weaning method as prescribed(e.g., CPAP).
5. Monitor VS, Pulse Oximetry, ECG and respiratory pattern constantly for the first 20-
30 mins and every 5 mins after that until weaning is complete. Monitoring the
patient closely provides ongoing indicators of success or failure.
6. Maintain the patent airway; monitor arterial blood gas levels and pulmonary
function tests. Suctioning of the airway is needed.

93. Conti…
7. In collaboration with the primary provider terminate the weaning process if adverse
reaction occur. These include Tachycardia, increase in systolic BP, decrease in O2
Saturation <90%, Tachypnea or Bradypnea, Ventricular dysrhythmias, Fatigue,
panic, Cyanosis, Erratic or Labored breathing, Paradoxial chest Movement.
8. If weaning process continues, measure Tidal volume and minute ventilation every
20-30 minutes.
9. Assess fir psychological dependence if the physiologic parametera indicate that
weaning is feasible and patient still resists.

94. Removal of Tracheostomy tube,
Removal of the tracheostomy tube is considered when the patient can
breathe spontaneously; maintain an adequate airway by effectively coughing up
secretions, swallow and move the jaw. Secretion clearance and aspiration risks are
assessed to determine whether active pharyngeal or laryngeal reflexes are intact.
Once the patient can clear secretions adequately, a trial period of mouth
breathing is conducted. This can be accomplished by several methods.
1. A method by changing a larger tube by a smaller tube.
2. A method that involves changing to a fenestrated tube.
3. Switching to a smaller tracheostomy.

95. Weaning from Oxygen,
The patient who has been successfully weaned from the ventilator, cuff and
tube has adequate respiratory function is then weaned from Oxygen .
• The FiO2 is gradually reduced until the PaO2 is in the range of 70-100mmHg while
the patient is breathing room air. If PaO2 <70 the patient may need supplemental
oxygen.

96. Nutritional Support,
• High fat and limited carbohydrate diet was long presumed to be therapeutic.
• Adequate protein intake is important in increasing respiratory muscle strength.
Protein intake should be approximately 25% of the total daily kilocalories, or 1.2 –
1.5 g/Kg/day.

97. RESEARCH,
Researcher,
Ms. Ligi Rachel Daniel and his team mates, Final year MSc (Nursing) students of
Sri Gokulam College of Nursing Sciences in the year 2013.
Problem Statement,
A Study to evaluate the effectiveness of Ventilator Bundle on Prevention of
Ventilator associated Pneumonia among the patients on Mechanical Ventilator at
selected Hospitals, Salem.

98. Objectives,
• To assess Ventilator Associated Pneumonia among patients on mechanical
ventilator in Experimental and control group.
• To evaluate the effectiveness of ventilator bundle on prevention of Ventilator
Associated Pneumonia among the patients on mechanical ventilator in
Experimental Group and Control Group.
• To associate the post test score on prevention of ventilator associated pneumonia
among the patients on mechanical ventilator with their selected demographic
variables in experimental and Control group.
Sample,
The Samples of the study comprised of patients on Mechanical Ventilator admitted in
ICU at Sri Gokulam Hospital and Vinayaka mission Kirupananda Variyar Speciality
Hospital, Salem, during the study period and those who met the inclusion criteria.

99. Variables,
Independent Variable- Ventilator Bundle.
Dependent variable- The dependent variables was ventilator Associated Pneumonia.
Tools Used,
The tool was prepared by the investigator after an extensive study of related
literature and with the guidance of Experts. The tool consists of two sections,
• Demographic variable
• Modified Clinical Pulmonary Infection Score (CPIS) for Assessing Ventilator Associated
Pneumonia.
Result,
The result of this study showed that Ventilator bundle was effective in preventing
about 75% chances of the Ventilator Associated Pneumonia among patients on mechanical
Ventilator in Experimental group when compared to the control group.