INTRODUCTION TO VENTILATORS A mechanical ventilator is simply a machine used to replace or supplement the natural function of breathing.

Ventilation carries in oxygen and carries off carbon dioxide.  Mechanical ventilation is a method to mechanically assist or replace spontaneous breathing when patients cannot do so on their own. Negative Pressure Ventilation : The iron lung, also known as the Drinker and Shaw tank, was developed in 1929 and was one of the first negative-pressure machines used for long-term ventilation.

Positive pressure ventilation machines : The design of the modern positive-pressure ventilators were mainly based on technical developments by the military during World War-II to supply oxygen to fighter pilots in high altitude.  Positive pressure through manual supply of 50% oxygen through a tracheostomy tube led to a reduced mortality rate among patients with polio and respiratory paralysis.  However, because of the sheer amount of man-power required for such manual intervention, mechanical positive-pressure ventilators became increasingly popular.  Positive-pressure ventilators work by increasing the patient's airway pressure through an endotracheal or tracheostomy tube.  The positive pressure allows air to flow into the airway until the ventilator breath is terminated.  Subsequently, the airway pressure drops to zero, and the elastic recoil of the chest wall and lungs push the tidal volume -- the breath -- out through passive exhalation. MECHANICAL VENTILATION: WHY DO WE VENTILATE?  Inadequate Ventilation (C02 too high)  Inadequate Oxygenation (02 too low)  Patients intubated for Airway protection

 HOW DO WE VENTILATE?  Invasively  Via Endotracheal  Tracheostomy tube  Non-invasively  Via mask  INDICATIONS FOR MECHANICAL VENTILATION: Elective :- To allow for sedation and paralysis during major surgery  Therapeutic  Inadequate Alveolar Ventilation  Refractory Hypoxemia  Airway protection (indication for intubation) INADEQUATE ALVEOLAR VENTILATION : Apnea Respiratory Failure Impending Respiratory Failure Resuscitation Neuromuscular Disorders CNS disorders

- Poliomyelitis - Cerebral trauma - Guillian-Barre syndrome - Spinal cord injury - Phrenic Nerve Paralysis - Narcotic / barbiturate poisoning

Chest Wall Diseases Excessive Work of Breathing Acute Airway Obstruction COPD exacerbation Severe Asthma Excessive Secretions Intra-thorax Pleural disease

REFRACTORY HYPOXEMIA:  Pneumonia  Atelectasis  Pulmonary Edema  ARDS AIRWAY PROTECTION:Inadequate cough / gag Tracheal obstruction / trauma Severe Allergic Reaction

SIGNS OF RESPIRATORY FAILURE: Subjective signs  Increasing breathlessness  Fatigue  Change in level of consciousness  Use of accessory muscles  Diaphoresis

COMMON MEDICAL INDICATIONS:Acute lung injury (including ARDS, trauma) Apnea with respiratory arrest, including cases from intoxication Chronic obstructive pulmonary disease (COPD) Acute respiratory acidosis with partial pressure of carbon dioxide (pCO2) > 50 mmHg and pH < 7.25, which may be due to paralysis of the diaphragm due to: -Guillain-Barr syndrome, - Myasthenia Gravis, - Spinal cord injury, - The effect of anaesthetic and - Muscle relaxant drugs. Increased work of breathing as evidenced by significant tachypnea, retractions, and other physical signs of respiratory distress

Hypoxemia with arterial partial pressure of oxygen (PaO2) with supplemental fraction of inspired oxygen (FiO2) < 55 mm Hg Hypotension including sepsis, shock, congestive heart failure.

TYPES OF VENTILATORS :1. Negative pressure ventilators 2. Positive pressure ventilators A) ANESTHESIA VENTILATOR Controlled Ventilation only. Aim is to control patients oxygenation during surgery under General Anesthesia (GA). B) CRITICAL CARE VENTILATOR- Both Controlled and Spontaneous ventilation modes are available. Aim is to synchronize with the patient effort and helping patient to win off from ventilator.

VENTILATOR SETTINGS/ PARAMETERS: FiO2 (Fraction of inspired oxygen concentration) Tidal volume Respiratory rate Sensitivity Flow rate/ Peak Flow Inspiratory to expiratory ratio (I:E ratio) Positive end expiratory pressure (PEEP) Plateau or Inspiratory Pause Sigh

FRACTION OF INSPIRED OXYGEN (FIO2): Use high FiO2 in the beginning (.7 1.0) FiO2 may be reduced after achieving a clinically acceptable goal An FiO2 of .5 or less minimizes oxygen toxicity For infants, and especially in premature infants, avoiding high levels of FiO2 (>60%) is important When using 100% FiO2, the degree of shunting is estimated by subtracting the measured PaO2 (from an arterial blood gas) from 700 mmHg. For each difference of 100 mmHg, the shunt is 5%. A shunt of more than 25% should prompt a search for the cause of this hypoxemia, such as mainstem intubation or pneumothorax, and should be treated accordingly.

 If such complications are not present, other causes must be sought after, and PEEP should be used to treat this intrapulmonary shunt. Other such causes of a shunt include:  Alveolar collapse from major atelectasis  Alveolar collection of material other than gas, such as pus from pneumonia, water and protein from acute respiratory distress syndrome, water from congestive heart failure, or blood from haemorrhage

TIDAL VOLUME: Volume of the gases in each cycle of respiration Generally a tidal volume of 10-15 ml/kg is recommended during mechanical ventilation The exhaled tidal volume (EVt) is the most accurate measurement of the volume received by the patient The difference between set & actual received tidal volume should not be more than 100 ml For adult patients and older children: - Tidal volume is calculated in mls/kg. - Traditionally 10mls/kg was used but has been shown to cause barotrauma, or injury to the lung by overextension. 6-8 mls/kg is now common practice in ICU. - Hence a patient weighing 70 kg would get a TV of 450- 500 ml. In adults a rate of 12 is generally used. With acute respiratory distress syndrome (ARDS) -- A tidal volume of 6-8 mL/kg is used with a rate of 10-12/minute. - This reduced tidal volume allows for minimal volutrauma but may result in an elevated pCO2 (due to the relative decreased oxygen delivered) but this elevation does not need to be corrected (termed permissive hypercapnia) For infants and younger children Without existing lung disease -- a tidal volume of 4-8 ml/kg to be delivered at a rate of 30-35 breaths per minute With RDS -- decrease tidal volume and increase respiratory rate sufficient to maintain pCO2 between 45-55. Allowing higher pCO2 (sometimes called permissive hypercapnia) may help prevent ventilator induced lung injury As the amount of tidal volume increases, the pressure required to administer that volume is increased. This pressure is known as the peak airway pressure. If the peak airway pressure is persistently above 45 cmH2O for adults, the risk of barotrauma is increased and efforts should be made to try to reduce the peak airway pressure.

In infants and children it is unclear what level of peak pressure may cause damage. In general, keeping peak pressures below 30 is desirable. Monitoring for barotrauma can also involve measuring the plateau pressure, which is the pressure after the delivery of the tidal volume but before the patient is allowed to exhale. Normal breathing pattern involves inspiration, then expiration. The ventilator is programmed so that after delivery of the tidal volume (inspiration), the patient is not allowed to exhale for a half a second. Therefore, pressure must be maintained in order to prevent exhalation, and this pressure is the plateau pressure. Barotrauma is minimized when the plateau pressure is maintained < 30-35 cmH2O. RESPIRATORY RATE (RR): The RR set on ventilator should be close to physiological RR: 10-20 breaths/min Frequent adjustments are often required to reduce work of breathing as well as adjustment of pH & PaCO2

SENSITIVITY: The sensitivity setting allows the triggering of ventilator to deliver the inspiratory flow This may be pressure triggered or flow triggered The normal setting: -2 cm H2O (2 cm H2O below the base line pressure)

FLOW RATES/ PEAK FLOW: Speed with which the tidal volume is delivered The tidal volume should be delivered within an appropriate & comfortable time It is measured in liter/min Generally a flow rate of 40-60 L/min is adequate to achieve the patients need

INSPIRATORY-TO-EXPIRATORY RATIO (I:E RATIO) Duration of inspiration in comparison to expiration Generally I:E ratio is set 1:2 (i.e. 33% of respiratory cycle is spent in inspiration) This IE ratio is similar to spontaneous respiration

Inverse ratio ventilation (I:E of 1:1,2:1 or higher are used in ARDS patients

PEEP (POSITIVE END EXPIRATORY PRESSURE): PEEP is an adjuvant to the mode of ventilation used to help maintain functional residual capacity (FRC).  At the end of expiration, the PEEP exerts pressure to oppose passive emptying of the lung and to keep the airway pressure above the atmospheric pressure.  The presence of PEEP opens up collapsed or unstable alveoli and increases the FRC and surface area for gas exchange, thus reducing the size of the shunt.  For example, if a large shunt is found to exist based on the estimation from 100% FiO2 then PEEP can be considered and the FiO2 can be lowered (< 60%) in order to maintain an adequate PaO2, thus reducing the risk of oxygen toxicity.  This prevents the atelectasis and thus improves the oxygenation  PEEP ranges from 5-20 cm H2O  Higher level of PEEP may lead to haemodynamic changes  It treats a shunt, reduses requirement of Fio2  PEEP may also be useful to decrease the work of breathing.  PEEP can cause significant haemodynamic consequences through decreasing venous return to the right heart and decreasing right ventricular function.  As such, it should be judiciously used and is indicated for adults in two circumstances. o If a PaO2 of 60 mmHg cannot be achieved with a FiO2 of 60% o If the initial shunt estimation is greater than 25% * If used, PEEP is usually set with the minimal positive pressure to maintain an adequate PaO2 with a safe FiO2.  A PEEP of less than 10 cmH2O is usually safe in adults if intravascular volume depletion is absent.  Lower levels are used for pediatric patients.  When putting a patient of PEEP a close hemodynemic monitoring is required.

 PEEP should be withdrawn from a patient until adequate PaO2 can be maintained with a FiO2 < 40%.  When withdrawing, it is decreased through 1-2 cmH2O decrements while monitoring haemoglobin-oxygen saturations.  Any unacceptable haemoglobin-oxygen saturation should prompt reinstitution of the last PEEP level that maintained good saturation. INSPIRATORY PAUSE OR PLATEAU: Measured in seconds, this parameter delays exhalation, therefore lengthening inspiration. SIGHS: An adult patient breathing spontaneously will usually sigh about 6-8 times/hr to prevent microatelectasis, And this has led some to propose that ventilators should deliver 1.5-2 times the amount of the preset tidal volume 6-8 times/hr to account for the sighs.  However, such high quantity of volume delivery requires very high peak pressure that predisposes to barotrauma.  Currently, accounting for sighs is not recommended if the patient is receiving 10-12 mL/kg or is on PEEP.  If the tidal volume used is lower, the sigh adjustment can be used, as long as the peak and plateau pressures are acceptable.  Sighs are not generally used with ventilation of infants and young children.

MODES OF MECHANICAL VENTILATION: Controlled mechanical ventilation (CMV) Assist/control mode (A/C) Synchronized intermittent mandatory ventilation (SIMV) Continuous Positive Airway Pressure (CPAP) Pressure support ventilation (PSV)

CONTROLLED MECHANICAL VENTILATION (CMV): Patient receives preset number of breath/min Can be classified as volume control or pressure control Volume control ventilation delivers a fixed tidal volume at a preset number of respiratory rate Pressure control ventilation delivers a tidal volume at a preset pressure depending on lung condition. These modes are used to in patients with minimal or no respiratory efforts, ARDS or flail chest Patient needs adequate sedation & muscle relaxant ASSIST/CONTROL MODE (A/C MODE): In this mode the ventilator provides a mechanical breath with either a pre-set tidal volume or peak pressure every time the patient initiates a breath. Traditional assist-control used only a pre-set tidal volume--when a preset peak pressure is used this is also sometimes termed Intermittent Positive Pressure Ventilation or IPPV. Synchronized intermittent mandatory ventilation (SIMV): Patient is guaranteed a preset number of breaths of a preset tidal volume Between these mandatory breath patient may initiate spontaneous breath This mode allows a synchronization between patient & ventilator CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP): Positive pressure is applied throughout the respiratory cycle The patient should have respiratory drive and an adequate tidal volume This prevent the alveolar collapse & thus improves the oxygenation This also improves the respiratory muscle strength PRESSURE SUPPORT VENTILATION (PSV): This mode is for spontaneously breathing patients The inspiratory pressure augments the tidal volume during each breath

PSV may be used alone or in conjunction with SIMV The pressure support level should be adjusted to minimize the work of breathing & provide maximum comfort NON-INVASIVE VENTILATION (NIPPV):-

 This refers to all modalities that assist ventilation without the use of an endotracheal tube.  Non-invasive ventilation is primarily aimed at minimizing patient discomfort and the complications associated with invasive ventilation.  It is often used in cardiac disease, exacerbations of chronic pulmonary disease, sleep apnea, and neuromuscular diseases.  Non-invasive ventilation refers only to the patient interface and not the mode of ventilation used; modes may include spontaneous or control modes and may be either pressure or volume modes. Some commonly used modes of NIPPV include: - Continuous positive airway pressure (CPAP). - Bi-level Positive Airway Pressure (BIPAP). - Intermittent positive pressure ventilation (IPPV) via mouthpiece or mask BI-LEVEL POSITIVE AIRWAY PRESSURE (BIPAP): Pressures alternate between Inspiratory Positive Airway Pressure (IPAP) and a lower Expiratory Positive Airway Pressure (EPAP), triggered by patient effort. On many such devices, backup rates may be set, which deliver IPAP pressures even if patients fail to initiate a breath.(Wheatley 2000 et all). NEURALLY ADJUSTED VENTILATORY ASSIST (NAVA): NAVA is a new positive pressure mode of mechanical ventilation, where the ventilator is controlled directly by the patient's own neural control of breathing.  The neural control signal of respiration originates in the respiratory center, and are transmitted through the phrenic nerve to excite the diaphragm.  These signals are monitored by means of electrodes mounted on a nasogastric feeding tube and positioned in the esophagus at the level of the diaphragm.  As respiration increases and the respiratory center requires the diaphragm for more effort, the degree of ventilatory support needed is immediately provided.

 This means that the patient's respiratory center is in direct control of the mechanical support required on a breath-by-breath basis, and any variation in the neural respiratory demand is responded to by the appropriate corresponding change in ventilatory assistance.

WEANING FROM VENTILATOR: Withdrawal from mechanical ventilationalso known as weaningshould not be delayed unnecessarily, nor should it be done prematurely.  Patients should have their ventilation considered for withdrawal if they are able to support their own ventilation and oxygenation, and this should be assessed continuously.  There are several objective parameters to look for when considering withdrawal, but there is no specific criteria that generalizes to all patients.  The best measure of when a patient may be extubated is the Rapid Shallow Breathing Index(Tobin Index).  This is calculated by dividing the respiratory rate by the tidal volume in liters(RR/TV).  A rapid shallow breathing index of less than 100 is considered ideal for extubation. Certainly, other measures such as patient's mental status such be considered. WEANING CRITERIA & ASSESMENT Oygenation & Ventilation Respiratory mechanics eg. tidal volume, vital capacity Respiratory rate Haemodynamic stability Neurological status Nutritional status Infection, fever or other hypermetabolic state Psychological readiness

METHODS OF WEANING: SIMV with PSV SIMV PSV CPAP T-Piece trial

COMPLICATIONS OF MECHANICAL VENTILATION 1. Associated with patients response to mechanical ventilation: A. Decreased Cardiac Output Cause - venous return to the right atrium impeded by the dramatically increased intrathoracic pressures during inspiration from positive pressure ventilation. Also reduced sympatho-adrenal stimulation leading to a decrease in peripheral vascular resistance and reduced blood pressure. Symptoms increased heart rate, decreased blood pressure and perfusion to vital organs, decreased CVP, and cool clammy skin. Treatment aimed at increasing preload (e.g. fluid administration) and decreasing the airway pressures exerted during mechanical ventilation by decreasing inspiratory flow rates and TV, or using other methods to decrease airway pressures (e.g. different modes of ventilation). B. Barotrauma Cause damage to pulmonary system due to alveolar rupture from excessive airway pressures and/or overdistention of alveoli. Symptoms may result in pneumothorax, pneumomediastinum, pneumoperitoneum, or subcutaneous emphysema. Treatment - aimed at reducing TV, cautious use of PEEP, and avoidance of high airway pressures resulting in development of auto-PEEP in high risk patients (patients with obstructive lung diseases (asthma, bronchospasm), unevenly distributed lung diseases (lobar pneumonia), or hyperinflated lungs (emphysema).

Nosocomial Pneumonia Cause invasive device in critically ill patients becomes colonized with pathological bacteria within 24 hours in almost all patients. 20-60% of these, develop nosocomial pneumonia. Treatment aimed at prevention by the following:  Avoid cross-contamination by frequent handwashing  Decrease risk of aspiration (cuff occlusion of trachea, positioning, use of small-bore NG tubes)  Suction only when clinically indicated, using sterile technique  Maintain closed system setup on ventilator circuitry and avoid pooling of condensation in the tubing  Ensure adequate nutrition  Avoid neutralization of gastric contents with antacids and H2 blockers D. Positive Water Balance 1. Syndrome of Inappropriate Antidiuretic Hormone (SIADH) due to vagal stretch receptors in right atrium sensing a decrease in venous return and see it as hypovolemia, leading to a release of ADH from the posterior pituitary gland and retention of sodium and water. Treatment is aimed at decreasing fluid intake. 2. Decrease of normal insensible water loss due to closed ventilator circuit preventing water loss from lungs. This fluid overload evidenced by decreased urine specific gravity, dilutional hyponatremia, increased heart rate and BP. E. Decreased Renal Perfusion can be treated with low dose dopamine therapy. F. Increased Intracranial Pressure (ICP) reduce PEEP G. Hepatic congestion reduce PEEP H. Worsening of intracardiac shunts reduce PEEP

2. ASSOCIATED WITH VENTILATOR MALFUNCTION: A. Alarms turned off or nonfunctional may lead to apnea and respiratory arrest Troubleshooting Ventilator Alarms Low exhaled volume: Cuff leak, Tubing disconnect, Patient disconnected

Evaluate cuff; if ruptured, tube will need to be replaced. Evaluate connections; tighten or replace as needed; check ETT placement, Reconnect to ventilator High pressure: Secretions in airway, Patient biting tubing, Tube kinked, Cuff herniation, Increased airway resistance/decreased lung compliance (caused by bronchospasm, right mainstem bronchus intubation, pneumothorax, pneumonia), Patient coughing and/or fighting the ventilator; anxiety; fear; pain. Suction patient, Insert bite block, Reposition patients head/neck; check all tubing lengths, Deflate and reinflate cuff, Auscultate breath sounds, Evaluate compliance and tube position; stabilize tube, Explain all procedures to patient in calm, reassuring manner, Sedate/medicate as necessar Low oxygen pressure: Oxygen malfunction Disconnect patient from ventilator; manually bag with AMBU. 3. OTHER COMPLICATIONS RELATED TO ENDOTRACHEAL INTUBATION. A. Sinusitis and nasal injury obstruction of paranasal sinus drainage; pressure necrosis of nares 1. Prevention: avoid nasal intubations; cushion nares from tube and tape/ties. 2. Treatment: remove all tubes from nasal passages; administer antibiotics. B. Tracheoesophageal fistula pressure necrosis of posterior tracheal wall resulting from overinflated cuff and rigid nasogastric tube 1. Prevention: inflate cuff with minimal amount of air necessary; monitor cuff pressures q. 8 h. 2. Treatment: position cuff of tube distal to fistula; place gastrostomy tube for enteral feedings; place esophageal tube for secretion clearance proximal to fistula. C. Mucosal lesions pressure at tube and mucosal interface 1. Prevention: Inflate cuff with minimal amount of air necessary; monitor cuff pressure q. 8 h.; use appropriate size tube. 2. Treatment: may resolve spontaneously; perform surgical interventions. D. Laryngeal or tracheal stenosis injury to area from end of tube or cuff, resulting in scar tissue formation and narrowing of airway 1. Prevention: inflate cuff with minimal amount of air necessary; monitor cuff pressure q. 8.h.; suction area above cuff frequently.

2. Treatment: perform tracheostomy; place laryngeal stint; perform surgical repair. E. Cricoid abcess mucosal injury with bacterial invasion 1. Prevention: inflate cuff with minimal amount of air necessary; monitor cuff pressure q. 8 h.; suction area above cuff frequently. 2. Treatment: perform incision and drainage of area; administer antibiotics. 4. OTHER COMMON POTENTIAL PROBLEMS RELATED TO MECHANICAL VENTILATION:           Aspiration, GI bleeding, Inappropriate ventilation (respiratory acidosis or alkalosis, Thick secretions ), Patient discomfort due to pulling or jarring of ETT or tracheostomy, High PaO2, Low PaO2, Anxiety and fear, Dysrhythmias or vagal reactions during or after suctioning, Incorrect PEEP setting, Inability to tolerate ventilator mode.

CARE OF PATIENTS ON VENTILATOR:Goals of care:      Effective breathing pattern Adequate gas exchange Maintain adequate nutritional status Prevention of pulmonary or other infection Prevention of respiratory muscle weakness & problems related with immobility Psychological support to patient & relatives

COMPONENTS OF CARE:   Monitoring ET/ TT suctioning Oral hygiene

          

Positioning Eye care Back care/ pressure sore prevention Physiotherapy Psychological support & communication Infection preventive measures DVT prophylaxis Record maintenance Nutrition Sedation Medications

MONITORING OF PATIENT ON VENTILATOR: Ventilatory parameters  Exipiratory tidal volume  Breath type  Respiratory rate  Minute ventilation  Peak & mean inspiratory pressure  Patient comfort  Haemodynamic monitiring  ECG/ Heart rate  Oxygen saturation  Blood pressure  CVP/PAP  Intake/output

ET/TT SUCTIONING : Use sterile gloves  Use new suction catheter  The diameter of suction catheter should be less than 2/3 of the ET tube diameter  The suction pressure should not be more than 150 mm Hg in adults.  Suction should be done within 10-15 second  Use normal saline for thick secretion  Few breath of 100% oxygen should be given before and after suctioning.

ORAL HYGIENE: Oral suction should be done regularly    The oral care should be done thrice daily The chlorhexidine solution may be used for oral care The colonization of bacteria in oral cavity may cause ventilator associated pneumonia

POSITIONING: The head should be kept at 30 degree elevated position to prevent ventilator-associated pneumonia.  The patients should be kept in lateral position  The position should be changed 2 hourly  All the joints should be kept in neutral or slightly flexed position  The ET tube & other invasive lines should be supported during change of posture  Prone positioning has been used in patients with ARDS and severe hypoxemia.  It improves functional residual capacity (FRC), drainage of secretions, and ventilationperfusion matching (efficiency of gas exchange). It may improve oxygenation in > 50% of patients, but no survival benefit has been documented.

EYE CARE: Eyes should be protected from exposure keratitis is sedated patients  Eye care should be done three times a day  An eye ointment may be used to prevent dryness & exposure keratitis

PRESSURE SORE PREVENTION: All the pressure point should be carefully examined frequently  Regular back care and back cleaning  Air mattresses should be used for all ventilated patients  Frequent change of posture

PHYSIOTHERAPY:Limbs physiotherapy :- due to disuse & nutritional deficiency there may be muscle wasting & contracture formation Chest physiotherapy :- This is required to maintain the respiratory muscle tone. This also prevents atelectasis and helps in secretion mobilization.The chest physiotherapy includes percussion, vibration or postural drainage

PSYCHOLOGICAL SUPPORT & COMMUNICATION: Be sympathetic with patient & relatives  Explain & console before any procedure  Always try to communicate with the patient depending on his condition

INFECTION PREVENTIVE MEASURE: Infection preventive measure  Hand hygiene

   

Aseptic technique for any invasive procedure Appropriate care for invasive lines Disinfection of patient equipment VAP preventive maneuvers

 Terminal disinfections on patients discharge  Regular disinfections of ICUs DVT PROPHYLAXIS: Trauma, sepsis surgery & immobility predisposes the lower limb for venous thrombosis  The prophylaxis is needed to prevent potentially life threatening pulmonary embolism  Heparin (low molecular weight)  Pneumatic compression device with garment  Stockings NUTRITION IN PATIENTS ON VENTILATOR:The maintenance of appropriate nutrition in patients on ventilator is a fundamental part of intensive care nursing. TYPE OF NUTRITION Enteral :- Usually through Nasogastric tube Parenteral :- Central/Peripheral venous route

HOW MUCH NUTRITION IS REQUIRED? Daily energy requirement (Kcal)

Basal energy expenditure (BEE)=25xBody weight (kg) The energy requirement increases in hypermetabolic state, such as fever Daily protein requirement :- 0.8-1.5 gm/kg body weight The nutrition should be supplemented with vitamins, electrolytes and immunomodulators.

How to give nutrition enterally? It can be given as bolus or continuous infusion Check & confirm the position of NG tube before every feed Clean your hands Aspirate the gastric content before giving feed Do not hold the feed if aspiration is less than 150cc Flush the NG tube after every feed with plain water Give right lateral position for 2 hours if there is high aspiration How to give nutrition parenterally? Use a dedicated line (Peripheral or central) for TPN TPN central should never be given through peripheral line Check peripheral line for thrombophlebitis Should not be given fast

SEDATION & ANALGESICS: Adequate sedation & analgesia should be given to all patients on ventilator  The sedation is required to relieve anxiety and the discomfort related with ventilator  Some time muscle relaxants are also required  The dose of sedation should be adjusted on individual patient basis  During day time the sedatives should be reduced/stopped which is helpful in reorientation and appropriate weaning of patient. Sedation Midazolam, diazepam, lorazepam Propofol

Analgesia

Opiods eg fentanyl, morphine etc Non opiods eg ketorolac, diclofenac etc Muscle relaxant

Atracurium, rocuronium, pancuronium etc Medication Following medicines should be administered as per order/ instruction :

 Antibiotics,  Stress ulcer prophylaxis (H2 receptor antagonists or proton pump inhibitors) and  Other medication specifically related with disease  RECORD MAINTENANCE  EVALUATION OF THE PROGRESS  ALTERATION OF MANAGEMENT STRATEGY  ANY CRITICAL EVENT SHOULD BE NOTED  MEDICO LEGAL ISSUES