This document provides information on ventilator care, including: 1. It describes the types of mechanical ventilators used to move breathable air in and out of the lungs for patients unable to breathe on their own. 2. The main purposes and outcomes of mechanical ventilation are to establish effective ventilation, prevent complications, and ensure proper positioning of endotracheal and tracheostomy tubes. 3. Various modes, settings, and equipment used in ventilator care are discussed, as well as indications for mechanical ventilation, types of lung injuries that can occur, and how to properly care for patients on ventilators.

1. CRITICAL NURSING CARE
UNIT II (C) VENTILATOR CARE
PRESENTED TO:
MAM ROHI
PRESENTED BY :
RUBI MUMTAZ
SHANZA BATOOL
ASIA SAIF
SHARIF COLLEGE OF NURSING
BSC Nursing 4th Year

2. MECHANICAL
VENTILATOR
A medical ventilator (or simply ventilator in
context) is a mechanical ventilator, machine
designed to move breathable air into and out of the
lungs, to provide breathing for a patient who is
physically unable to breathe, or breathing
insufficiently.

3. MECHANICAL VENTILATION
Mechanical ventilation can be
defined as the technique through
which gas is moved toward and
from the lungs through an
external device connected directly
to the patient.

4. PURPOSE
To establish and maintain effective ventilation
To prevent complication associated with artificial
ventilation
To ensure position and patency of endotracheal
and tracheostomy tube
To clear and remove secretions from airway

5. EQUIPMENTS
Bed locker with necessary articles,
ventilator
Suction apparatus
Continuous monitoring apparatus
Resuscitation chart with defibrillators
 oxygen setup
Manual ventilation bag (embu bag)
 Endotracheal intubations set

6. PURPOSE/
OUTCOMES
• Reversal of hypoxemia
• Reversal of acute respiratory acidosis
• Relief of respiratory distress
• Prevention or reversal of atelectasis
• Resting of ventilatory muscles

7. INDICATIONS
 Respiratory Failure
 Cardiopulmonary arrest
 Trauma (especially head, neck, and chest)
 Cardiovascular impairment (strokes,
tumors, infection, emboli, trauma)
 Neurological impairment (drugs, poisons,
myasthenia gravis, GBS)
 Pulmonary impairment (infections, tumors,
pneumothorax, COPD, trauma, pneumonia,
poisons)

8. RR>25/min
PCO2>50mmHg
PO2< 50mmHg
SpO2<90%
pH < 7.25
CONT….

10. TYPES OF
VENTILATION
Positive pressure ventilation
Negative pressure ventilation

11. NEGATIVE PRESSURE
VENTILATION
Encase the patient’s body and exert negative
pressure that pulls the thoracic cage outward
to initiate inspiration

12. POSITIVE PRESSURE
VENTILATION
Much more commonly used, deliver air by pumping
it into the patient’s lungs.
With positive pressure ventilation, the normal
relationship b/w intrapulmonary pressures during
inspiration and expiration is reversed (i.e pressure
during inspiration are positive and pressure during
expiration are negative

13. TYPES/MODES OF POSITIVE
PRESSURE VENTILATORS
Volume-cycled ventilators
Pressure-cycled ventilators
Time-cycled ventilators
High-frequency ventilation.

14. VOLUME-
CYCLED
VENTILATORS
With volume ventilation, a
designated volume of air (tidal
volume) is delivered with each
breath.
This type is ideal for patients with
acute respiratory distress
syndrome or bronchospasm, since
the same tidal volume is delivered
regardless of airway resistance or
compliance.

15. PRESSURE-
CYCLED
VENTILATORS
With pressure ventilation, a selected gas
pressure is delivered to the patient and
sustained throughout the phase of
ventilation
The benefit is a decreased risk of lung
damage from high inspiratory pressures.
The disadvantage is that the tidal volume
delivered can vary with changes in lung
resistance and compliance if the patient
has poor lung compliance and increased

16. TIME-CYCLED
VENTILATORS
Terminate or control inspiration after a preset
time.
The volume of air the patient receives is
regulated by the length of inspiration and the
flow rate of the air.
Used very rarely

17. HIGH FREQUENCY
VENTILATORS
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-
3ml/kg) at frequencies greater than 100 breaths/minute

18. VARIOUS TYPES OF LUNG INJURY CAN
OCCUR WITH POSITIVE PRESSURE
VENTILATION:
• Barotrauma can result from high pressures. With barotrauma, air can leak from the
alveoli into the pleural space, resulting in pneumothorax or pneumomediastinum.
• Volutrauma is caused by the delivery of large tidal volumes. The alveoli develop
fractures that allow fluid and protein to seep into the lungs, resulting in a form of non
cardiogenic pulmonary edema.
• Atelectrauma is a shear-induced injury resulting from repeated opening and
closing of the alveoli.
• Biotrauma is damage to the alveoli caused by the release of cytokines and other
chemical mediators of the inflammatory response in response to positive-pressure
ventilation.

19. CONT…
• Ventilator-associated lung injury (VALI) and ventilator-induced lung injury
(VILI) are terms used to describe damage to the lungs resulting from prolonged
ventilation. Prolonged high levels of oxygen, high volumes, and pressures may lead
to loss of surfactant and increased inflammation of the lung parenchyma and
alveoli. The increase in inflammatory mediators damages the alveolar capillary
membrane, resulting in fluid leaking into the lungs and non cardiogenic pulmonary
edema.

20. VENTILATOR
SETTINGS
Fraction of inspired oxygen(FIO2)
Tidal volume
Respiratory rate
Positive end-expiratory pressure(PEEP)
Peak flow
Peak inspiratory pressure limit (high pressure
alarm)
Sensitivity
Inspiratory:expiratoray ratio
Humidification and temperature
sighs

21. POSITIVE END-EXPIRATORY PRESSURE(PEEP)
Control and adjust the pressure that is
maintained in the lungs at the end of
expiration
PEEP increases the functional residual
capacity by re inflating collapsed alveoli
Maintaining the alveoli in an open
position
Improve lung compliance

22. Peak flow
Is the velocity of gas flow per unit
of time and is expressed as liters
per minute

23. HUMIDIFICATION AND
TEMPERATURE
Inspiratory gas must be filtered, warmed and
humidified before delivery to the patient
Humidifier humidifies the inspired gas by passing it
over or bubbling it through a head water.
Condensation should be seen in the inspiratory
ventilator circuit or the proximal ETT or both which
indicates that the inspired gas is fully saturated with
water vapors.

24. Copyright © 2017 by Tanzeel Ul Rahman

25. VENTILATORS
MODES
1 Volumes Modes
With volume modes of ventilation, a
respiratory rate , inspiratory time and
tidal volume are selected for the
mechanical breaths
Nurse Must Monitor PIP

26. 1. CONTROLLED
The client receives a set tidal volumes at a set
rate.
Used for clients who cannot initiates respiratory
efforts.
Least used mode; if the client attempts to initiate a
breath, the ventilator blocks the efforts,

27. 2.ASSIST – CONTROL
MODE
A respiratory rate and tidal volumes are
preset if the patient attempts to initiate a
breath, the ventilator is triggered and
delivered the full preset tidal volumes with
every breath.

28. 3. SYNCHRONIZED
INTERMITTENT MANDATORY
VENTILATION
Allows clients to breath spontaneously at
own rate and tidal volume between the
ventilator breaths.
Can be used as a primary ventilator mode or
as a weaning mode.

29. 2 PRESSURE
MODES
A typical pressure mode of ventilation sets a
maximum PIP, not a tidal volumes. When the
ventilator delivers a breath it continues delivering
the volumes until the preset pressure limit is
reached, then it stops delivering the breath
Risk of hypoventilation and respiratory acidosis

30. 1 PRESSURE CONTROLLED
VENTILATION(PCV) MODE
Delivers breaths at a preset pressure limit
The “unnatural”feeling of this mode
often requires sedation and the use of
NMB agents to ensure patient–ventilator
synchrony
When the PCV mode is in use, the
mean airway and intrathoracic pressures rise,
potentially resulting in a decrease in cardiac output.
Therefore, it is necessary to monitor the patient’s
hemodynamic status closely.

31. 2 PRESSURE SUPPORT
VENTILATION PSV
Assist spontaneous breathing efforts by
delivering a high flow of gas to a selected
pressure level early in inspiration maintain
that level throughout the inspiratory phase
Patient effort reduced and comfort level is
increased
PSV mode is also used with SIMV mode
and as weaning technique.

32. INVERSE RATIO VENTILATION
(IRV).
• This type of ventilation inverses the I:E ratio so that
inspiratory time is equal to, or longer than, expiratory
time (eg, 1:1 to 4:1; see Fig. 10-8C). Because the
expiratory time is decreased, the nurse must monitor
for the development of auto- PEEP

33. AIRWAY PRESSURE RELEASE VENTILATION
(APRV) MODE.
• A high-pressure and a low pressure are set. Alveolar recruitment and
oxygenation occur during the high-pressure setting

34. NON INVASIVE VENTILATOR
MODES
Continuous positive airway pressure
(CPAP)
Bi-level positive pressure (BiPAP)

35. CONTINUOUS
POSITIVE AIRWAY
PRESSURE (CPAP)
Similar to PEEP
Supplies pressure throughout the respiratory cycle, help to
improve oxygenation in spontaneously breathing patients.
Used for intubated or nonintubated patients.
Weaning mode from mechanical ventilation and for nocturnal
ventilation to splint open the upper airway
Preventing upper airway obstruction in patients with obstructive sleep
apnea

37. BI-LEVEL
POSITIVE
PRESSURE (BIPAP)
Provided by means of nasal mask, nasal
prongs, or full facemask
Two levels of positive pressure support
 An inspiratory pressure referred to IPAP
An expiratory pressure referred to as EPAP
Used in patient with acute, short term
respiratory problems to avoid intubation and
mechanical ventilation

39. TA B L E 1 0 - 2 MODES
OF VENTILATION
• Please review the table
Copyright © 2017 by Tanzeel Ul Rahman

40. TYPES OF
ALARMS
• High peak pressure
• Low pressure; low PEEP/CPAP
• Low exhaled tidal volume
• Low minute ventilation
• Apnea
• Heater alarm
• Table 10.4
52

41. CARE OF ETT/
TRACHEOSTOMY
Secure positioning of ETT/ tracheostomy tube with
adhesive plaster
Inflate cuff once correct positioning has been
confirmed
Cuff is inflated with air using syringe

43. MAINTAINING
VENTILATION
Effects of ventilation are assess by
observing pt color, chest movements, BP,
pulse rate, oxygen saturation
Ventilator make characteristics sound
during inspiration and expiration which
nurse must be capable of identifying

44. Administer sedation as
prescribed to ensure adequate
artificial ventilation and
promotion of rest
CONT…

45. SUCTIONING
Explain procedure to patient
and family
Frequency of suction to be
carried out depending on pt’s
pulmonary state
Tracheal suction is an aseptic
procedure

46. STERILE CATHETER AND ONE
STERILE GLOVE TO BE USED
FOR EACH SUCTIONING
SESSION SUCTION IS
APPLIED WHILE CATHETER IS
BEING WITHDRAWN USING
INTERMITTENT TECHNIQUE
NOT MORE THAN 10 TO 15
SECONDS

48. Measure blood, IV infusions
and fluid intake every hour
Measure blood loss, urine,
chest drainage bottles,
Maintain intake and output
every shift
Assess bowel action every
third day
8 hourly wound dressing
should be done

49. Change IV administration sets and
dressing of puncture sites everyday
Change suction bottle and
connecting tubing everyday
Record pt’s conditions and events that
have occurred during each shift in
nurse progress sheet
Give detailed hand over to nurse
on following shift

50. PSYCHOLOGICAL ASPECTS OF
PATIENT CARE
promote good relationship
with patient and family
Encourage them to express
fear, stress factors and feelings
Motivate patient and relatives
t0 participate in daily care
activities

51. •Review pages 127 to 130
for comprehensive
ventilator patient care

52. WEANIN
G
the term "weaning" is used to describe the gradual
process of decreasing ventilator support.

53. READINESS TO
WEAN
• Underlying cause for mechanical ventilation resolved
• Hemodynamic stability; adequate cardiac output
• Adequate respiratory muscle strength
• Adequate oxygenation without a high FiO2 and/or highPEEP
• Absence of factors that impair weaning
• Mental readiness
• Minimal need for medicines that cause respiratory depression
65

54. GUIDELINES FOR
WEANING
• weaning is generally initiated in the morning when the patient is rested
• The use of sedatives and narcotics during weaning is limited
• The nurse raises the head of the bed, ensures a patent airway, and provides
suction if necessary.
• The nurse remains with the patient throughout the weaning trial to provide
support and reassurance
• At the conclusion of the trial, the nurse also evaluates and documents the
patient’s response to weaning

55. WEANING
METHODS
• Synchronized intermittent mechanical ventilation
• Pressure support
• T-piece trials
• CPAP
67

56. STOP THE WEANING PROCESS
Respiratory
• Respiratory rate > 35 or < 8 breaths/min
• Low spontaneous VT < 5 mL/kg
• Labored respirations
• Use of accessory muscles
• Abnormal breathing pattern
• Low oxygen saturation < 90%
Cardiovascular
• HR or BP changes > 20% from baseline
• Dysrhythmias (e.g., PVCs)
• ST-segment elevation
• Blood pressure changes more than 20% from baseline
• Diaphoresis
Neurologic
• Decreased level of consciousness
• Anxiety/agitation
• Subjective discomfort
68

57. AIRWAY MANAGEMENT

58. AIRWAY MANAGEMENT
• Positioning
 Devices
• Oral airway: An oropharyngeal airway is a hard plastic device
that is inserted through the mouth and extends to the
pharynx to prevent the tongue from occluding the airway
when muscle tone is decreased. Never insert in conscious
patient
• Nasopharyngeal airway: A nasopharyngeal airway (nasal
trumpet) is a flexible tube that is inserted nasally past the
base of the tongue to maintain airway patency.
• Endotracheal intubation: An endotracheal tube is a semi-rigid
tube that is inserted through the nose or mouth and extends
into the trachea
• Tracheostomy: A tracheostomy tube is inserted directly into the
trachea through a stoma made in the neck
70

59. ENDOTRACHEAL
INTUBATION
• Insertion of an endotracheal tube (ETT) through the mouth or nose
• Orotracheal route preferred to reduce infections
• Used to:
• Maintain an airway
• Remove secretions
• Prevent aspiration
• Provide mechanical ventilation
71

60. ENDOTRACHEAL TUBE
72
Figure 9-17. A. Endotracheal tube. B. Hi-Lo Evac endotracheal tube. Note suction port above the cuff for removal of pooled
secretions. (From Shilling A, Durbin CG. Airway management. In: Cairo JM, ed. Mosby’s Respiratory Care Equipment. 9th ed.
St. Louis: Mosby; 2013.)

61. INTUBATION
EQUIPMENT
73

62. ENDOTRACHEAL
INTUBATION
• Right size tube
• 7.5 to 8.0 mm female; 8.0 to 9.0 mm
male
• Check balloon on tube for leak
• Stylet
• Lubricate tube
• Laryngoscope and blade
• Sniffing position
• Premedicate prn
• Topical anesthetic/ paralytic
medication
• Ventilate patient
• Suction oropharynx
• Intubate within 30 sec
• Inflate balloon
• Verify placement
74

63. VERIFY
PLACEMENT
• Auscultate epigastric area
• Auscultate bilateral breath sounds
• ETCO2 detector
• Esophageal detector device
• Chest x-ray—3 to 4 cm above carina
• Secure tube when placement is verified
• Record cm at the lip line for reference
75

64. ENDOTRACHEAL
SUCTIONING
• Suction as indicated by assessment
• Visible secretions
• Coughing
• Rhonchi
• High PIP on ventilator
• Ventilator alarm
• Conventional versus closed suction
• Procedures
• Hyperoxygenate throughout procedure
• Avoid normal saline instillation
76

66. TRACHEOSTOM
Y
• Performed in the operating room or bedside (percutaneous)
80

68. THANK
YOU