This slide include information regarding ventilators, modes of ventilators , its parts, weaning process, nursing care of patient in mechanical ventilation.

1. Sonali & Rachana 1

2. Mechanical Ventilation
Prepared By-
Sonali Koiri
Rachana Shrestha
BNS 3rd Year

3. Contents
1. Introduction of Mechanical Ventilation
2. Goals of Mechanical Ventilation
3. Indication of Mechanical Ventilation
4. Criteria for institution of Mechanical Ventilation
5. Introduction of Mechanical Ventilator and its parts
6. Common ventilator settings
7. Classification of ventilation
8. Modes of ventilation
9. Nursing Management of patient in mechanical
ventilation
Sonali & Rachana 3

4. Introduction
Mechanical Ventilation:
The mechanical ventilation is the process by
which gas is moved into the lungs by creating
a pressure gradient artificially.
Respiratory support is needed to correct
hypoxemia and hypercapnia and to reduce
work of breathing.
Sonali & Rachana 4

5. Goals
• Treat hypoxemia.
• Treat acute respiratory acidosis.
• Relief of respiratory distress.
• Prevention or reversal of atelectasis.
• Resting of ventilatory muscles.
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6. Indications
• Neurological impairment (drugs, poisions ,
snake bite, trauma) with “Glasgow Coma Scale
“ (GCS) ≤ 8.
• Respiratory Failure
a. Arterial PaO2 <60 mm Hg (on supplemental
Oxygen).
b. Arterial PaCO2 >50 mm Hg (in the absence of
chronic airway disease)
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7. Contd
c. Evidence of elevated work of breathing:
Respiratory rate > 35 breaths/minute.
Tidal volume < 5ml/kg.
Vital Capacity < 15ml/kg.
Presence of retraction or nasal flaring.
Paradoxical or divergent chest motion.
• Cardiopulmonary arrest.
• Neuromuscular disorders.
• Lung Diseases.
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8. Criteria for institution of ventilatory support:
Normal
range
Ventilation
indicated
Parameters
10-20
5-7
65-75
75-100
> 35
< 5
< 15
<20
A- Pulmonary function
studies:
• Respiratory rate
(breaths/min).
• Tidal volume (ml/kg
body wt)
• Vital capacity (ml/kg
body wt)
• Maximum Inspiratory
Force (cm HO2)

9. Cont..
Normal
range
Ventilation
indicated
Parameters
7.35-7.45
75-100
35-45
< 7.25
< 60
> 50
B- Arterial blood
Gases
• PH
• PaO2 (mmHg)
• PaCO2 (mmHg)

10. Introduction
Mechanical Ventilator:
• A mechanical ventilator is a positive or
negative pressure breathing device that can
maintain ventilation and oxygen delivery for a
prolong period.
• It is a machine that generates a controlled flow
of gas into a patient’s airway.
10Sonali & Rachana

11. Sonali & Rachana 11

12. PARTS OF
VENTILATOR

13. Monitor/ Screen

14. Heat & Moisture Exchanger (HME)
Filter

15. Contd…

16. Humidifier

17. Flow Sensor

18. Y- Piece/ Connector

19. Catheter Mount

21. Common Ventilator Settings
parameters/ controls
• Fraction of inspired oxygen (FIO2)
• Tidal Volume (VT)
• Peak Flow/ Flow Rate
• Respiratory Rate/ Breath Rate / Frequency ( F)
• I:E Ratio (Inspiration to Expiration Ratio)
• PEEP

22. Fraction of inspired oxygen
(FIO2)
• The percent of oxygen concentration that the patient
is receiving from the ventilator. (Between 21% &
100%)
• Initially a patient is placed on a high level of FIO2
(60% or higher).
• Subsequent changes in FIO2 are based on ABGs and
the SaO2.
• The lowest possible fraction of inspired oxygen
(FiO2) necessary to meet oxygenation goals should
be used.

23. Tidal Volume (VT)
• The volume of air delivered to a patient during a
ventilator breath.
• The amount of air inspired and expired with each
breath.
• Usual volume selected is between (5 to 15 ml/ kg
body weight)
• In the volume ventilator, Tidal volumes of 10 to 15
mL/kg of body weight were traditionally used.
• The large tidal volumes may lead to (volumtrauma)
aggravate the damage inflicted on the lungs.
• For this reason, lower tidal volume targets (6 to 8
mL/kg) are now recommended.

24. Respiratory Rate/ Breath
Rate / Frequency ( F)
• The number of breaths the ventilator will
deliver/minute (10-16 b/m).
• Total respiratory rate equals patient rate plus
ventilator rate.
• An optimal method for setting the respiratory rate has
not been established. For most patients, an initial
respiratory rate between 12 and 16 breaths per minute
is reasonable
• The nurse double-checks the functioning of the
ventilator by observing the patient’s respiratory rate.

25. Positive End-Expiratory Pressure
(PEEP)
• PEEP is the pressure in the lungs (alveolar pressure)
above atmospheric pressure (the pressure outside of
the body) that exists at the end of expiration.
• Applied PEEP is generally added to mitigate end-
expiratory alveolar collapse. A typical initial applied
PEEP is 5 cmH2O. However, up to 20 cmH2O may
be used in patients undergoing low tidal volume
ventilation for acute respiratory distress syndrome
(ARDS).

26. Peak Flow/ Flow Rate
• The velocity of gas flow or volume of gas delivered
by the ventilator per minute (L/min)
• The higher the flow rate, the faster peak airway
pressure is reached and the shorter the inspiration;
• The lower the flow rate, the longer the inspiration.

27. I:E Ratio (Inspiration to
Expiration Ratio)
• During spontaneous breathing, the normal I:E ratio is
1:2, indicating that for normal patients the exhalation
time is about twice as long as inhalation time.
• If exhalation time is too short “breath stacking”
occurs resulting in an increase in end-expiratory
pressure also called auto-PEEP.

28. CLASSIFICATION
• Negative Pressure Ventilation
• Positive Pressure Ventilation
Volume Controlled
Pressure Controlled
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29. Negative Pressure Ventilation
• These exert negative pressure on external
chest decreasing the intra-thoracic pressure
during inspiration, allows air to flow into the
lungs, filling its volume.
• These are simple to use and do not require
intubations of the airways; consequently, they
are especially adaptable for home use.
• It is used mainly in chronic respiratory failure
associated with neuromuscular conditions.
Sonali & Rachana 29

30. Contd
• Examples: Iron lung, body
wrap and chest cuirass
• Disadvantages
Limited access for patient
care
Inability to properly monitor
pulmonary mechanics
Patient discomfort

31. Positive Pressure Ventilation
• A positive pressure ventilation inflate the
lungs by exerting positive pressure in the
airway forcing the alveoli to expand during
inspiration. Expiration occurs passively.
• It requires an artificial airway (endotracheal
or tracheostomy tube) and use positive
pressure to force gas into patient’s lungs.
• Inspiration can be triggered either by the
patient or machine.

32. Positive Pressure Ventilation

35. Classification of Positive
Pressure Ventilation
1. Volume controlled
 Deliver a preset tidal volume
 Allows pressure to vary with changes in
resistance and compliance
 Volume delivery remains constant
2. Pressure controlled
 Deliver a preset inspiratory pressure during each
inspiration
 Volume delivery may vary
35

36. Pressure and Gradients
• Peak inspiratory pressure (Ppeak)
• Plateau pressure (Pplateau)
• Baseline pressure
• Mean airway pressure (Pmean)
36

37. Peak Pressure (PPeak)
37

38. PHASES OF VENTILATORY CYCLES
1. TRIGGERING (Initiation of
inspiration)
1. INSPIRATION
2. CYCLING (Change over
from inspiration to
expiration)
3. EXPIRATION
CONTROL VARIABLE
1. PRESSURE (cm H2O)
2. FLOW (L/min)
3. VOLUME (ml)
4. TIME (sec)

40. Modes of Mechanical Ventilation
40

41. Selection of Modes of
Ventilation
Regardless of which operating mode is selected, it
should achieve four main goals:
• Provide adequate ventilation and oxygenation.
• Avoid ventilator-induced lung injury.
• Provide patient-ventilator synchrony.
• Allow successful weaning from mechanical
ventilation.
41

42. Modes
• Continuous mandatory mode
– Control (CMV)
– Assist control (AC)
• Intermittent Mandatory mode
– IMV (Intermittent Mandatory Ventilation)
– SIMV ( synchronized Intermittent Mandatory
Ventilation)
• Spontaneous mode
– Continuous Positive Airway Pressure (CPAP)
– BiLevel Positive Airway Pressure (BiPAP) 42

43. Controlled Mandatory Ventilation
(CMV)
 The ventilator initiates and controls both the
volume delivered and the frequency of breaths.
Patient cannot trigger ventilation. Patient should
be sedate and possibly paralyzed.
 This mode is used for the patient who is unable
to initiate breath.
 Not often used in ICU as it does not allow any
synchronisation with the patient's own
breathing
43

44. CMV
44

45. Contd…
Advantages
• Guaranteed volume(or pressure ) with each
breath
• Low patient workload
Disadvantages
• Spontaneous breath not allowed
• Needs deep sedation & Paralysis
• Apnea & Hypoxia if accidentally disconnected
• Ventilator dependence
45

46. Assist Control Mode (AC)
 Assist-control ventilation allows the patient to initiate a
ventilator breath (assisted or patient-triggered
ventilation), but if this is not possible, ventilator breaths
are delivered at a preselected rate (controlled or time-
triggered ventilation).
 The ventilator breaths during ACV can be volume-
controlled or pressure-controlled.
 Used for the patients who can initiate a breath but who
have weakened respiratory muscles such as Gullain
Barre Syndrome, post cardiac or respiratory arrest,
pulmonary oedema, ARDS etc. 46

47. AC mode
47

48. Contd…
Advantages
• Increase Patients comfort
• Patients work of breathing is low
• Patient can control the frequency
Disadvantages
• Risk of Hyperventilation
48

49. Intermittent Mandatory Ventilation
 Intermittent mandatory ventilation provides a
combination of mechanical breaths and
spontaneous breaths .
 Mechanical breaths are delivered at preset
intervals and a preselected tidal volume,
regardless of patient’s efforts.
 Patient is allowed to breath independently
except during certain prescribed intervals.
49

50. IMV
50

51. Contd…
Advantages
• Allows spontaneous breath of any tidal volume
Disadvantages
• Increase work of breathing
• Asynchrony
51

52. Synchronized Intermittent Mandatory
Ventilation (SIMV)
 SIMV also delivers a preset tidal volume and
number of breaths per minute .
 Between ventilator delivered breaths the
patient can breath spontaneously.
 Mandatory breaths are synchronised with the
patient's own inspiratory effort which is more
comfortable for the patient
52

53. Contd…
Advantages
• The mandatory breath is delivered in synchrony with patient
effort. This makes greater comfort during breathing.
• The patients respiratory muscles remain active, and so disuse
atrophy is less common.
Disadvantages
• Hypoventilation is possible if the patient is not capable of
spontaneous breathing.
• Excessive work of breathing is possible during spontaneous
breaths unless an adequate level of pressure support is applied.
53

54. Spontaneous mode
1. Continuous positive airway
pressure(CPAP)
2. Noninvasive bilevel positive airway
pressure ventilation (BiPAP)

55. Continuous Positive Airway
Pressure (CPAP)
 Constant positive airway pressure during spontaneous
breathing
 This is a mode and simply means that a preset
pressure is present in the circuit and lungs throughout
both the inspiratory and expiratory phases of the
breaths.
 CPAP serves to keep alveoli from collapsing, resulting
in better oxygenation and less work of breathing.
 It is very commonly used as a mode to evaluate the
patients readiness for weaning or extubation.
 CPAP can be used for intubated and nonintubated

56. CPAP cont…
• The purpose of CPAP is to improve and support the
patient’s oxygenation. CPAP does not improve the
patient’s ventilatory status, so the patient must be
breathing spontaneously if CPAP is in use.
• Indication:
• Hypoxemic respiratory failure
• Obstructive sleep apnea
• Congestive heart failure
• Weaning from ventilation

57. Bilevel Positive Airway
Pressure Ventilation (BiPAP)
• BiPAP is a noninvasive form of mechanical
ventilation provided by means of a nasal mask or
nasal prongs, or a full-face mask.
• The system allows the clinician to select two levels of
positive-pressure support:
• An inspiratory pressure support level (referred to as
IPAP)
• An expiratory pressure called EPAP .

58. BiPAP cont..
• BiPAP can help to improve the patient’s ventilatory
status. So if the patient has an elevated PaCO2,
BiPAP can be administered in order to help decrease
the PaCO2 back into the normal range.
• Indication
• Hypercapnic respiratory failure
• Acute respiratory failure
• COPD
• Heart failure

60. Complications of mechanical
ventilation
• Infections/Ventilator associated pneumonia(VAP)
• Lung Damage/ Pulmonary barotrauma
• Pneumothorax
• Pulmonary edema
• Tracheal stenosis
• Hypoxemia
• Delirium
• Immobility
• Vocal cord problems
• Gastrointestinal problems(paralytic ileus, stress ulcer)

61. Methods of Weaning
T-piece trial
Continuous Positive Airway Pressure (CPAP) weaning
Synchronized Intermittent Mandatory Ventilation
(SIMV) weaning

62. Synchronized Intermittent
Mandatory Ventilation ( SIMV)
Weaning
• SIMV is the most common method of weaning.
• It consists of gradually decreasing the number of
breaths delivered by the ventilator to allow the patient
to increase number of spontaneous breaths

63. Continuous Positive Airway
Pressure (CPAP) Weaning
• When placed on CPAP, the patient does all the work
of breathing without the aid of a back up rate or tidal
volume.
• No mandatory (ventilator-initiated) breaths are
delivered in this mode i.e. all ventilation is
spontaneously initiated by the patient.
• Weaning by gradual decrease in pressure value

64. T-Piece trial
• It consists of removing the patient from the ventilator
and having him / her breathe spontaneously on a T-
tube connected to oxygen source.
• During T-piece weaning, periods of ventilator support
are alternated with spontaneous breathing.
• The goal is to progressively increase the time spent
off the ventilator.

65. T-Piece

66. Role of nurse before weaning:-
• Ensure that indications for the implementation of
Mechanical ventilation have improved
• Ensure that all factors that may interfere with
successful weaning are corrected:-
- Acid-base abnormalities
- Fluid imbalance
- Electrolyte abnormalities
- Infection
- Fever
- Anemia
- Sleep deprivation

67. Role of nurse before weaning:-
• Assess readiness for weaning
• Ensure that the weaning criteria / parameters are met.
• Explain the process of weaning to the patient and
offer reassurance to the patient.
• Initiate weaning in the morning when the patient is
rested.
• Elevate the head of the bed & Place the patient
upright
• Ensure a patent airway and suction if necessary
before a weaning trial,
• Provide for rest period on ventilator for 15 – 20
minutes after suctioning.

68. Cont…
• Ensure patient’s comfort & administer
pharmacological agents for comfort, such as
bronchodilators as indicated.
• Help the patient through some of the discomfort and
apprehension.
• Support and reassurance help the patient through the
discomfort and apprehension as remains with the
patient after initiation of the weaning process.
• Evaluate and document the patient’s response to
weaning.

69. Role of nurse during weaning:-
• Wean only during the day.
• Remain with the patient during initiation of weaning.
• Instruct the patient to relax and breathe normally.
• Monitor the respiratory rate, vital signs, ABGs,
diaphoresis.
If signs of fatigue or respiratory distress develop.
• Discontinue weaning trials.

70. Role of nurse after weaning
1- Ensure that extubation criteria are met .
2- Extubate
2- Documentation

71. Nursing care of patients on
ventilator
1. Check ventilator setting and modes
• When you enter the patient’s room, take vital
signs, check oxygen saturation , listen to breath
sounds and note changes from previous findings.
 Also assess the patient’s pain and anxiety levels.
 Compare current ventilator settings with the
setting prescribed in the order
• Suctioning for airway clearance.
• Chest physiotherapy and breathing exercise for
secretions mobilization

72. Nursing care of patients on
ventilator
2. Communication
• Assessment of the ability of the ventilator-
dependent patient to communicate
• Use non verbal methods of communication
• Be alert to non verbal clues.
• Use of signals, signs, nodding, palms, writing, lip
reading
• Provide paper and pencil, magic slate
• Allow patient to respond and repeat explanations
• Ask simple yes/no questions to which she can nod or
shake her head.

73. Cont…
3. Management of airway
 Assess respiratory rate and depth inspect thorax for
symmetry of movement
 Observe for SOB
 Assess the patient for oxygenation such as oxygen
saturation, signs and symptoms of hypoxia( tachypnea, nail
beds, ABGs analysis and auscultation for air entry)
 Elevate head of bed 60-90 degree.
• Humidification of the airway through the ventilator to help
to liquefy the secretions for easy removal
• Use of bronchodilators
• Administration of mucolytics to liquified

74. Cont…
4. Suctioning
 Suction appropriately
 Suction only as needed not according to a
schedule.
 Hyper oxygenate the patient before and after
suctioning to help prevent oxygen desaturation
 Limit suctioning pressure to the lowest level
needed to remove secretions.
 Suction for the shortest duration possible.

75. Cont…
5. Ensuring humidification and thermoregulation
• All air delivered by the ventilator passes through the
water in the humidifier, where it is warmed and
saturated.
• Humidifier temperatures should be kept close to body
temperature 35 ºC- 37ºC.
• In some rare instances (severe hypothermia), the air
temperatures can be increased.
• The humidifier should be checked for adequate water
levels
• An empty humidifier contributes to drying the airway,
often with resultant dried secretions, mucus plugging

76. Cont…
• Humidifier should not be overfilled as this may increase circuit
resistance and interfere with spontaneous breathing.
• As air passes through the ventilator to the patient, water
condenses in the corrugated tubing. This moisture is
considered contaminated and must be drained into a receptacle
and not back into the sterile humidifier.
• If the water is allowed to build up, resistance is developed in
the circuit and PEEP is generated. In addition, if moisture
accumulates near the endotracheal tube, the patient can
aspirate the water.
• The nurse and respiratory therapist jointly are responsible for
preventing this condensation buildup. The humidifier is an
ideal medium for bacterial growth.

77. Cont…
6. Ventilator alarms
• Mechanical ventilators comprise audible and visual
alarm systems, which act as immediate warning
signals to altered ventilation.
• Alarm systems can be categorized according to
volume and pressure (high and low).
• High-pressure alarms warn of rising pressures.
• Low-pressure alarms warn of disconnection of the
patient from the ventilator or circuit leaks.

78. Cont…
7. Management of fluid imbalances
 Assessment of the patient including presence of
edema, intake and output charting, signs and
symptoms of dehydration.
 Planning of fluid administration carefully
 Central venous pressure monitoring as well as
measuring cardiac output.

79. Cont…
8. Prevention for pulmonary infection
 Provide good oral care
 Suction when need indicated using sterile
technique.
 Handwashing with antimicrobial for 30 seconds
before and after patient contact
 Use sterile saline for suctioning
 Ensuring ventilator tubing changed between
patients and whenever become solled

80. Cont…
9. Oral hygiene
 Oral care frequently because the oral cavity is the
primary source contamination of the lungs in the
intubated and compromised patients
 Provide oral care every 2 hourly as oral mucus
membranes dry in 2 hours

81. Cont…
10. Maintain nutrition
 Assessment of the patient( serum protein)
 Assess bowel sounds
 Provide naso-gastric tube feeding. The naso- gastric
tube can increase the risk of aspiration , leading to
nosocomial pneumonia hence the patient should be
positioned with the head elevated above the stomach.
 Parental nutrition if patient cannot tolerate orally
 Avoid too much carbohydrate feeds as it may
increases CO2 production and may cause
hypercapnia.

82. Cont…
Prevention of bed sore
 Observe skin integrity for presssure ulcers.
 Preventative measures include turning patient at least 2
hourly.
 Use pressure relief mattress for bed if indicated.
Educating family
 Explain purpose and all treatments
 Provide alternative method of communication.
Elimination care
 Catheter care
 Proper cleaning, use of bed pans if possible
Promoting coping ability

83. Cont…
12. Provide rest and sleep
 Keep calm and quiet environment.
 Turn monitor alarm down if possible
 Provide dim light during night and soft music
 Cover patient eyes with clean gauze.
13. Safety and security needs
 Prevent cross infection and nosocomial infection.
 Maintain warm and adequate body temperature
 Put side rails
 Visiting hours should be define

84. Cont…
14. Prevention of contractures
 Maintain muscles strength with active/passive ROM
and prevent contractures with use of splint.

85. Noninvasive Positive Pressure
Ventilation (NIPPV)
• Noninvasive Positive Pressure Ventilation (NPPV)
is medical procedure that involves the use of
ventilatory support without using an invasive
artificial airway such as endotracheal tube or
tracheostomy tube.
• During NPPV, the health care provider administers
air, usually with added oxygen, through a face
mask or nasal mask under positive airway pressure
(external lung pressure being greater than the
pressure inside of the lungs).

88. Benefits of NIPPV
• Adequate ventilation and oxygenation
• Correction of respiratory failure
• Adequate patient tolerance and comfort
• Makes activities of daily living easier because it helps patients
use more of their lung capacity while decreasing the breathing
work load.
• Alleviates a wide array of symptoms such as daytime fatigue,
breathing difficulties, and other symptoms associated with low
oxygen levels.
• It reduces length of hospital stay by providing clients with
adequate ventilation while preventing respiratory failure.
• It’s more convenient compared to invasive ventilation
• It provides greater flexibility in the initiation and removal of

89. Indication
• Acute respiratory failure
• Acute severe asthma
• Acute heart failure
• Breathing impairment
due to a spinal cord
injury
• COPD exacerbations
• Chest wall disorders
• Moderate acidemia (pH
<7.35)
• Moderate hypercarbia
• Neuromuscular disease
• Nocturnal
hypoventilation
• Prevention of
reintubation in high-risk
patients
• Tachypnea
• DNI(Do not intubate)
order

90. Contraindication
• Agitation or lack of cooperation
• Excessive oral and nasal secretions
• Inability to fit the mask
• Inability to maintain a patent airway or protect the
airway
• Respiratory arrest

91. Complication
• Aerophagia (excessive air swallowing)
• Airway dryness
• Aspiration
• Claustrophobia
• Dry mouth
• Eye irritation from an air leak
• Gastric distension and insufflation
• Pressure areas from mask, tubing and strapping
• Secretion build up inside the mask

92. References
• https://www.slideshare.net/doctorshalinigarg/mechanical-ventilation-
3355414
• https://www.slideshare.net/bibinibaby5/mechanical-ventilation-ppt
• https://www.slideshare.net/Harshita89/ventilators-32613130
• https://www.aafp.org/afp/2004/0801/p596.html
• http://www.sle.co.uk/files/library/files/PDFs/howto/How%20to%20clean
%20your%20ventilators.pdf
• http://www.en.carefusion.com.br/documents/international/guides/user-
guides/RC_VELA-Operator-Manual_UG_EN.pdf
• http://rtasap.com/ppt/vela.pdf
• https://ann-clinmicrob.biomedcentral.com/articles/10.1186/1476-0711-5-
7
• https://www.sciencedirect.com/science/article/pii/0002934384905205
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3647488/