CARE OF PATIENT

ON
VENTILATOR
 VENTILATOR
 It is a machine designed to mechanically
move air into and out of lungs .

 To provide breathing for a patient who is

physically unable to breathe or breathing
insufficiently.
 INDICATIONS

1)VENTILATORY FAILURE-
Is the inability of the pulmonary system to
maintain proper removal of carbon dioxide
(hypercapnia).
 INDICATIONS
2) OXYGENATION FAILURE-

It is defined as severe hypoxemia

(pao2 < 40mmhg) that does not respond to
moderate to high levels of supplemental
oxygen
 VENTILATORY & OXYGEN FAILURE

4 Mechanisms
 Hypoventilation (depression of CNS)
 Persistent intrapulmonary shunting
(atelectasis) N – 10%
 Ventilation /perfusion mismatch (ILD,
airway obstruction, ARDS, pneumonia)
 Diffusion defect (pulmonary fibrosis)
 CLINICAL CONDITIONS

 DEPRESSED RESPIRATORY DRIVE

 EXCESSIVE VENTILATORY
WORKLOAD

 FAILURE OF VENTILATORY PUMP

 CLINICAL CONDITION
1)DEPRESSED RESPIRATORY DRIVE-

-Here the patients have normal pulmonary function

but the respiratory muscles do not have adequate
neuromuscular impulses to function properly.
Example :
 Degenerative: G.B.S., MG
 Drug overdose
 Acute spinal injury
 Neurology – Coma, Head injury, CVA
 CLINICAL CONDITION
2)EXCESSIVE VENTILATORY WORKLOAD-
Influenced by clinical condition such as:
-Acute air flow obstruction - COPD
-Pulmonary embolism
-Acute lung injury (ARDS)
-Shock
-Cardiovascular decompensation
-Decreased compliance (atelectasis, post thoracic
surgery)
 CLINICAL CONDITION
3)FAILURE OF VENTILATORY PUMP-
Is structural dysfunction of respiratory muscles or
parenchyma.

Example in
-Flail chest
-Tension pneumothorax
-Premature birth - IRDS
-Geriatric patient (fatigue of
respiratory muscles.
 Brain teasers
 Low compliance limits the patients ability to
provide ______, whereas high compliance
hinders the patients ability to support _____
a. deadspace ventilation, intrapulmonary
shunting
b. intrapulmonary shunting, deadspace
ventilation
c. gas exchange, lung expansion
d. lung expansion, efficient gas exchange
 Brain teasers
 Airway resistance may be increased in all of the
following conditions except:
a. Airway obstruction
b. ETT
c. Condensation in ventilatory circuit
d. tachycardia
 METHODS OF VENTILATION
 NON – INVASIVE METHODS OF VENTILATION

( do not require an artificial airway).

- Negative pressure ventilation
- Non – invasive positive pressure
ventilation

 INVASIVE METHODS OF VENTILATION

(require a stable artificial airway)
- Positive pressure ventilation
 TYPES OF VENTILATORS

TWO TYPES

• NEGATIVE PRESSURE VENTILATOR

• POSITIVE PRESSURE VENTILATOR

NEGATIVE PRESSURE VENTILATOR

 Works by applying sub-atmospheric

pressure at a prescribed rate, around the
thorax.

 Creates a pressure gradient for the air to

move passively into the lungs.

 Advantage- does not require artificial

airway.
IRON LUNG
BODY WRAP /CHEST CUIRASS
POSITIVE PRESSURE VENTILATOR
 Employs an artificial airway through which air is
delivered into the lungs (endotracheal intubation or
tracheostomy).

 Expiration occurs passively as a result of elastic

recoil of lung and chest wall.
 POSITIVE PRESSURE
VENTILATOR
 Classified according to cycling mechanism:

1. Volume cycled ventilator

2. Pressure cycled ventilator

3. Flow cycled ventilator

4. Time cycled ventilator

 Phases of Ventilation

 Change from expiration to inspiration

 Inspiration
 Change from inspiration to expiration
 Expiration
 BASIC PHASE VARIABLES ARE-

 Trigger variable- what initiates breath. (P, F, T)

 Limit variable- the variable that is not allowed to rise

above the preset value. Held at fixed pre-set value
 Cycle variable- what terminates the breath.
 Baseline Variable – The variable that controls the
expiratory phase.
 Change from expiration to inspiration

Trigger variable- what initiates

breath.

 Pressure triggered
 Flow triggered
 Time triggered
 Inspiration
Limit variable: maintains inspiration

 Pressure limited breath

 Flow limited breath
 Volume limited breath
 Inspiration to Expiration

Cycle variable- what terminates the breath.

 Volume cycle

 Pressure cycle

 Flow cycle

 Time cycle
 Expiration
Baseline varible : controlled during expiration.

Pressure is always used

It may be set at 0 i.e. atmospheric pressure or
above atmospheric pressure i.e. PEEP
 Brain teaser

MODE-
When the ventilator assumes all of the ventilatory
work, this is termed as :

 FULL VENTILATOR SUPPORT

 NO VENTILATOR SUPPORT
 PARTIAL VENTILATOR SUPPORT
 INCOMPLETE VENTILATOR SUPPORT
 MODES-

 A pattern in which breaths are

delivered to patient and it is
characterized by a group of different
variable setting.
 Positive pressure ventilator:
MODES:
 Controlled mandatory ventilation

 Assist control ventilation

 Pressure support
 IMV
 Synchronized intermittent ventilation (SIMV)
 Auto Mode
 pressure control inverse ratio ventilation
 Negative pressure ventilator

MODES:
 CPAP

 BiPAP
 CONTROL MANDATORY
VENTILATION
 Delivers pre-set volumes at a pre-set respiratory rate and
provides an expected minute ventilation.

 The patient cannot generate spontaneous breaths, volumes

or pressure in this mode.
 USED FOR
 Have no/ poor inspiratory effort. Eg. High cervical spine
injury, Post operative heart surgery, Crushed chest injury
or head injury.

 Receive chemical paralysis & sedation as a part of medical

treatment.
CMV MODE-
 PRESSURE CONTROLLED
VENTILATION (PCV)
 In PCV, pressure controlled breaths are time
triggered by a preset respiratory rate.

INDICATIONS
 Severe ARDS
 determined by patients overall lung compliance

 Reduces the risk of barotraumas

 Patients needing PCV should be sedated to
promote comfort and avoid ventilator dyschrony.
 VOLUME CONTROL

 - Each breath has a pre-set volume.

-The inspiratory pressure becomes the
dependent variable.
 ASSIST –CONTROL MODE
 Delivers pre-set volumes at a pre-set rate and whenever
patient exerts a negative inspiratory effort.

 Patient cannot generate spontaneous volumes in this mode.

 A preset respiratory rate ensures that the patient receives

adequate ventilation regardless of spontaneous efforts.

 Uses-
 For patients with normal respiratory drive who are unable
to sustain normal tidal volume.

 Used for patient having spontaneous breathing with muscle

weakness.
ASSIST-CONTROL MODE
 PRESSURE SUPPORT
VENTILATION (PSV)
 A preset level of positive pressure is applied for the duration
of a spontaneous breath and allows a more even distribution
of inspired gas.
Uses
 In this it augments patient’s spontaneous tidal volume and
decreases the work of the work of breathing through an
artificial airway.

 Increase patient comfort and provides conditioning to the

diaphragm- to facilitate weaning from the ventilator.

 PSV is used to enhance others modes of ventilation or as a

stand-alone mode to ventilate a spontaneously breathing
patients.
Pressure support ventilation
includes:
 Volume assisted pressure support:
- a set tidal volume to ensure that patient
receives minimum tidal volume with each
pressure support breath.
- facilitates weaning.
OR
 Pressure regulated volume control PRVC:
-delivers pre-set tidal volume using the lowest
possible airway pressure.
 INTERMITTENT MANDATORY
VENTILATION- IMV MODE

 Ventilator delivers control breaths & allows

patient to breath spontaneously at any tidal
volume the patient is capable of, in between
mandatory breaths.

 Complication-breath stacking.
IMV MODE
 SYCHRONIZED INTERMITTENT
MANDATORY VENTILATION (SIMV):
 Delivers a pre-set number of breaths at a set
volume synchronizing with the patient’s breath.

 Allows the patient to generate spontaneous breaths,

volumes, and flow rates between the set breaths.

 Detects a patient’s spontaneous breath and doesn’t

initiate a ventilatory breath – prevents breath
stacking.
SIMV MODE-
 AUTO MODE

 The ventilator recognizes the patient’s actions

(spontaneous ventilation) or inactions (apnea) and
provides the appropriate level of support based on
pre established parameters of tidal volume and
minute ventilation.
 PRESSURE – CONTROLLED
INVERSE – RATIO VENTILATION
(PC-IRV)
 Ventilator is set to provide longer inspiratory
times to increase the mean airway pressure while
maintaining peak inspiratory airway pressures at
lower levels than conventional volume ventilation.

 Lower PIP are less damaging to the lung, and the

longer inspiratory time improves oxygenation.

Severe ARDS
 ADJUNCT SETTING
 CONTINUOUS POSITIVE AIRWAY PRESSURE
(CPAP):

 This is a mode and simply means that a pre-set pressure is

present in the circuit and lungs throughout both the
inspiratory and expiratory phases of the breath.

 CPAP serves to keep alveoli from collapsing, resulting in

better oxygenation .

 The CPAP mode is very commonly used in COPD patient

who have adequate lung compliance.

 When PEEP applied to spontaneous breath-CPAP..

C PAP MACHINE
BILEVEL POSITIVE AIRWAY PRESSURE
(BiPAP)

 The operator sets two pressure levels

 IPAP (inspiratory positive airway pressure)
 IPAP is always set higher than EPAP
 EPAP (expiratory positive airway pressure)
 Prevents early airway closure and alveolar
collapse at the end of expiration by increasing
(and normalizing) the functional residual
capacity (FRC) of the lungs
 Facilitates better oxygenation
BIPAP LEVEL AIRWAY PRESSURE
 INITIAL SETTING
1)Select your mode of ventilation
2)Set sensitivity at flow trigger mode
3)Set PEEP (CVS)
4)Set respiratory rate 10-15

5)Set tidal volume 10-15 ml/kg

6)FiO2 40-!00%

7)I: E ratio – 1:2 1:4

8) Pressure limit

9) Alarms
INITIAL VENTILATOR SETTING

2) SENSITIVITY-
This determines the level of patient effort to
initiate the inspiration.

Trigger-is the variable that initiates inspiration.

-Pressure trigger
-Flow trigger
-Time trigger
INITIAL VENTILATOR SETTING
3) POSITIVE END EXPIRATORY PRESSURE
(PEEP)
 Increases fractional residual capacity

 Useful to treat refractory hypoxemia

 Initial peep level- 5cmh2o.

 Makes changes
- Blood gas result
- FiO2 Requirement
-Tolerance to peep
-Cardiovascular response
 ADJUNCT SETTING FOR
MECHANICAL VENTILATION
 PEEP (POSITIVE END EXPIRATORY
PRESSURE “According to its purest definition, the
term peep is defined as positive pressure at the end of
exhalation and increases the functional residual capacity
during either spontaneous breathing or mechanical
ventilation”.
NOT A STAND ALONE MODE.
-Peep becomes the baseline variable during mechanical
ventilation
INITIAL VENTILATOR SETTING
4) RESPIRATORY RATE (RR)
 Number of breaths delivered per minute.

 10 to 12 per minute.
 RR is the primary control to alter the PaCO2.
INITIAL VENTILATOR SETTING

5) TIDAL VOLUME (VT)

 Volume of gas delivered during each

ventilator breath.

 Tidal volume set between – 10 to

15/kg
INITIAL VENTILATOR SETTING

6) FRACTIONAL INSPIRED OXYGEN

 Amount of oxygen delivered to patient by

ventilator.

 Initial setting-100%

 Adjusted accordingly (PaO2-80-100 mmhg)

 INITIAL VENTILATOR
SETTING
7) INSPIRATORY:EXPIRATORY
RATIO
(I:E RATIO)

 It is length of inspiration compared to

length of expiration

 Initial setting - 1:2, 1:4.

8. PRESSURE LIMITS:
 Regulates maximum pressure the ventilator

can generate to deliver the tidal volume when

the pressure limit is reached the ventilator
terminates breath and spills the undelivered
volume into the atmosphere.
 - 10-20cm of H2O
ALARM SETTING
 VENTILATOR ALARM SETTING

1) LOW EXHALED TIDAL VOLUME/ MINUTE

VOLUME ALARM-
 Set at 100ml lower than expired mechanical
tidal volume.

 Triggered if patient does not exhale

adequate tidal volume.

 Detect system leak or circuit disconnection.

 ALARM SETTING
2)LOW INSPIRATORY PRESSURE -

 Set at-10 TO 15cm H2O below observed

Peak inspiratory volume.

Detects-system leaks
-circuit disconnection.
 ALARM SETTING
3)HIGH INSPIRATORY PRESSURE ALARM-

 Set at-10 TO 15 mm hg above the observed peak

inspiratory pressure.

 If triggered, inspiration is terminated and

ventilator goes in to expiratory cycle.
 CONT…
HIGH INSPIRATORY PRESSURE ALARM-
 Usually caused by:
 A blockage in the circuit (water condensation)
 Patient biting his ETT
 Mucus plug in the ETT
 Secretion in the ETT

 You can attempt to quickly fix the problem

 Bag the patient and call for help.
 ALARM SETTINGS
4)APNEA ALARM

 Set at-15 to 20 sec time delay, with less delay at

higher respiratory rate.

5)HIGH RESPIRATORY RATE ALARM

 Set at-10 to 15 breath per minute over the observed
respiratory rate.

 Indicates –tachypnea-signs of respiratory distress.

 ALARM SETTINGS
6)HIGH AND LOW FiO2 ALARM-
 Set –at 5-10% above/low analyzed FiO2.

7)HIGH PEEP ALARM-

 Set at-above 5cm H2O
Indicates-air trapping
-Insufficient inspiratory flow

8)LOW PEEP/CPAP ALARM-

Triggered when actual peep drops below preset.
Indicates-leakage in circuit of ET cuff.
 ATTENTION-

NEVER hit the silence button!

 PARTS OF VENTILATOR
MACHINE
1) VENTILATOR TUBINGS-

-Runs from breathing machine to breathing tube.

Consist of two parts-

1)Delivers oxygen to patient
2)Carries away the exhaled gas.
VENTILATOR TUBING
PARTS OF VENTILLATOR
2)HUMIDIFIER MOIST FILTER-
To warm and moisten
The air going
Into the lungs.
 PARTS OF VENTILATOR
 3)TRAP –
To collect
unused moisture
from the tubing.
 PARTS OF VENTILATOR
4)CATHETER MOUNT-
It helps in connection of breathing system or
filter to the patient.
 PARTS OF VENTILATOR
 TEST LUNG-
Indicates functioning of ventilator.
 WEANING
 Is the gradual withdrawal of mechanical
ventilation.
 ASSESSMENT OF READINESS-
FOR WEANING
 Reversal of underlying cause of respiratory failure.
 Adequate oxygenation indicated by ABG report.
 Heart rate-100-140 beats/minute.
 Stable blood pressure.
 No myocardial ischemia.
 Temperature-<100.4f
 Hemoglobin->8-10g/dl
 Acceptable electrolyte values
 ASSESSMENT OF READINESS-
FOR WEANING
 Adequate cough.

 Capability to initiate respiration.

 Adequate mentation without continuous IV

sedation.
 METHODS FOR WEANING
 T- Tube (T piece) trials
 Synchronized intermittent ventilation
 Pressure support ventilation

 Order of weaning methods

POST EXTUBATION CARE
1)Humidified oxygen.
2)Respiratory exercise
3)Assessment & monitoring

 Vital sign should be documented

 Every 15 min for 1 hour, 30min for next 1 hour,

every hourly once patient is stable.

4)ABG to be done after 30 -60 min after extubation.
DRAGER EVITA II PURITAN
BENNETT
840
 COMPLICATIONS
1)Ventilator induced lung injury
 Oxygen toxicity
 Barotrauma / volutrauma
 Peak pressure
 Plateau pressure
 Shear injury (tidal volume)
 PEEP

 Others:atelectasis, airway obstruction –

secretions, Tracheal stenosis, ETT complications.
 COMPLICATIONS
2)Cardiovascular complications
 Impaired venous return to right atrium.
 Decreased cardiac output.

3)Gastrointestinal disturbances
-Ulcers
-Paralytic ileus
-constipation
-Inadequate nutrition

4) Neurological:
- Increased intracranial pressure
-Cerebral vasoconstriction
-Decreased respiratory drive
 COMPLICATIONS
5)Renal:
-Fluid & sodium retention
-Decrease urine output

6)Psychosocial
-Sensory overload
-No communication
-Dependence
 COMPLICATIONS
 Resp - Barotrauma - pneumothorax, atelectasis, airway
obstruction – secretions.
 Tracheal stenosis, ETT complications
 CVS compromise – CO, dysrhythmias
 GI – ulcers, paralytic ileus, constipation
 Patient/Ventilatory asynchrony
 VAP
 Neuro – ICP, CVS vasoconstriction, decreased respiratory drive,
 Renal – decreased U/o, Na & H2O retention
 Acid-base disturbances, decreased liver function
 Oxygen toxicity
 Psychosocial – sensory overload, dependance, communication
 Nutritional intake
 ASSESSMENT CRITERIA-
1) Record initial setting in the nursing flow chart.

2) The placement of et tube by observing mark on et tube

3) Check cuff pressure.

4) Record vital signs every hourly.

5) Check all the infusion going to patient.

6)Check for nasogastric tube placement.

7) Monitor intake & output in patient

 ASSESSMENT CRITERIA
8) Monitor laboratory values.

9) Monitor sputum for colour, consistency, Odour & amount.

10) GI function- for ulcers

-Blood in stool.

11) Chest inspection and auscultation-

 Chest movement
 Asymmetrical movement-
- Right bronchial intubation
-Atelectasis
-Tension pneumonia.
 Auscultation-
 Diminished or absent breath sound
 Presence of wheezes and crackles.
 ASSESSMENT CRITERIA
12)Arterial blood gas

13)End tidal co2 (capnography)

 Measures carbon dioxide at end of exhalation.

 Normal-1-5 mm hg.

 Useful to confirm ET tube placement in lung.

 POST INITIAL SETTING
 Obtain an ABG (arterial blood gas) about 30
minutes after you set your patient up on the
ventilator.

 An ABG will give you information about any

changes that may need to be made to keep the
patient’s oxygenation and ventilation status
within a physiological range.
CARE FOR VENTILLATED
PATIENT
 CARE FOR VENTILATED
PATIENT
 PRINCIPLES
 The registered nurse is responsible for the
assessment , planning, and delivery of care to the
patient.

 Care of ventilated patients can vary from basic

nursing care , to caring for highly technical
invasive monitoring equipment, and managing and
monitoring the effects of interventions .
 CARE FOR VENTILATED
PATIENT
 CARE OF THE AIRWAY
 Maintain a patent airway.
 Observe patient’s facial expression, colour,
respiratory effect, vital signs, ECG tracing.
 Ensure position of ETT or tracheostomy tube.
 Check placement of ETT by auscultation of breath
sounds and distance mark on the tube.
 Check and adjust cuff pressure.
 CARE FOR VENTILATED
PATIENT
 CHECK THE BEDSIDE EMERGENCY
EQUIPMENT
 An alternative means of ventilation must be
available eg . Laerdel bag.

 Suctions catheters and functioning suction unit ,

airways and masks should be available.
 CARE FOR VENTILATED
PATIENT
 VENTILATION
 Ensure placement of ventilation tubing.

 Document the settings and check alarm parameters.

 Ensure enough room to access the head end of bed

in emergency.

 Check the type of humidification, when filters and

ventilation tubing were last changed. (HME filters ,
ventilator circuits )
 CARE FOR VENTILATED
PATIENT
 SUCTION OF AN ARTIFICIAL AIRWAY

 To maintain a patent airway.

 To promote improved gas exchange.
 To obtain specimens.
 Oxygenate before and after suctioning.
 Care of closed suction catheters.
 Suctioning 2 hourly or as and when needed.
 Suction of oropharynx.
 CARE FOR VENTILATED
PATIENT
 MONITORS

 Hemodynamic monitoring . check transducers and zero

them.

 Check alarm parameters.

 Document patients vital signs hourly.

 Manual blood pressure once a shift.

 CARE FOR VENTILATED
PATIENT
 ORAL CARE
 Oral care and assessment to promote normal
hygiene.

 A soft tooth brush can be used for oral hygiene.

 Moisturize the lips.

 2nd hourly oral hygiene is recommended.

 CARE FOR VENTILATED
PATIENT
 EYE CARE

 To prevent complications due to inadequate

closure of eyes.
 Fluid imbalances and increased permeability can
promote conjuntival edema.
 2nd hourly eye care using saline soaked gauze or
cotton. Eye drops as prescribed.
 CARE FOR VENTILATED
PATIENT
 GASTROINTESTINAL TRACT
 Intubated patients must have a nasogastric tube for
gastric decompression or nutritional support.
 Check for bowel sounds and turgor of abdomen.
 Ng feeds as tolerated and monitor for any
complications.
 If enterally fed patient has large aspirate then
consult physician.
 Elevation of head of bed.
 Elimination to be recorded.
 CARE FOR VENTILATED
PATIENT
 GENITAL/ URINARY TRACT

 Indwelling catheters predisposes urinary tract

infection.
 Routine urinalysis.
 Catheter care .
 Secure the catheter carefully.
 Monitor urine output .(0.5 ml/ kg)
 CARE FOR VENTILATED
PATIENT
 REPOSITIONING AND PRESSURE AREA
CARE
 Attending to patient’s hygiene protects the skin
and promote comfort.
 Repositioning patients regularly.
 If patient has leg splints they should be on for 2
hours and off for 2 hours.
 Safeguard ETT and other lines while positioning.
 Air mattresses if needed.
 NURSING DIAGNOSIS
 IMPAIRED GAS EXCHANGE & INEFFECTIVE
BREATHING PATTERN RELATED TO
UNDERLYING DISEASE PROCESS AND
ARTIFICIAL AIRWAY.
 OUTCOME CRITERIA-no hypoxemia(sp02)
-Normal ABG report

INTERVENTION-
 Auscultate lung sound & respiratory rate & pattern.

 Provide adequate humidity.

 Turn and position client-2 hourly.

 Monitor ABG & pulse oxymeter.

 NURSING DIAGNOSIS
 INEFFECTIVE AIRWAY CLEARENCE RELATED
TO INABILITY TO COUGH &INCREASE
SECREATION IN LOWER ET TUBE.

OUTCOME CRITERIA-fewer crackles & wheezes

INTERVENTION-
-Assess for need for suctioning.
-Suction every 2 hourly
-Maintain sterility through the procedure.
-Hyper oxygenate –before & after suctioning.
 NURSING DIAGNOSIS
 IMPARED SPONTENEOUS VENTILATION
RELATED TO IMBALANCE BETWEEN
VENTILATORY CAPACITY & VENTILATORY
DEMAND.
OUTCOME CRITERIA-normal respiratory rate
-Return of normal ABG value
-Normal Sa02
INTERVENTION-
1)check ventilator setting
2)assess lung sound
3)assess for any obstructed airway
4)sedate and paralyze the client.
 NURSING DIAGNOSIS
 RISK FOR INFECTION R/T PRIMARY DEFENCES
IN RESPIRATORY TRACT.

OUTCOME CRITERIA-normal wbc count

-normal vital sings

INTERVENTION-
1)use sterile technique.
2)monitor for increase breathing effort & auscultate
chest.
3)monitor lab values & sputum
 NURSING DIAGNOSIS
 IMBALANCE NUTRITION LESS THAN BODY
REQUIREMENT.

OUTCOME CRITERIA-normal body weight

-Normal lab values

INTERVENTIONS-
1)Provide adequate nutrition
2)Begin tube feeding as soon as possible.
3)Avoid excessive carbohydrate loads
4)Monitor intake and output
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