Anda di halaman 1dari 117

VENTILATOR

THE BASICCOURSE

HISTORY OF
VENTILATOR

Early History of Ancient times

Old testament there is a mention of Prophet Elisha


Inducing pressure breathing from his mouth into the mouth of a child
who was dying(Kings 4:34-35).

Hippocrates (460-375 BC) wrote


the first description of endotracheal intubation his book Treatise on Air
One should introduce a cannula into the trachea along
the jaw bone so that air can be drawn into the lungs.

Negative Pressure Ventilators

Two successful designs became popular;


In one - the body of the patient was enclosed in an iron box or cylinder
and the patients head protruded out of the end.
The second - design was a box or shell that fitted over the thoracic area only
(chest cuirass).

IRON LUNG- DRINKER LUNG


(Philip Drinker and Louis Agassiz Shaw) mid-1900s

The first iron lung was used on October 12, 1928 at


Children's Hospital, Boston,
-used in a child unconscious from respiratory failure;
-her dramatic recovery, within seconds
popularize the "Drinker Respirator."

In 1949, John Haven Emerson


Developed a mechanical assister for anesthesia at Harvard University.

Iron lung ward filled with Polio patients,


Rancho Los Amigos Hospital, ca. 1953

Woman lying in negative pressure ventilator (iron lung).

During the 1950's

Mechanical ventilators used increasingly in


Anesthesia and intensive care.
-To treat polio patients and
-The increasing use of muscle relaxants
during anesthesia

MODERN VENTILATOR

THE COURSE DEALS WITH

INTRODUCTION
INDICATION FOR MECHANICAL VENTILATION
MECHANICAL VENTILATOR- WHAT IT IS ?
MECHANICAL VENTILATORS- CLASSIFICATION
VENTILATOR MODES
HOW TO INITIATE MECHANICAL VENTILATION?
VENTILATOR SETTINGS
NURSING CARE
SEDATION AND NEUROMUSCULAR BLOCKADE
ASSESMENT CRITERIA
WEANING AND EXTUBATION

FAILURE TO WEAN
METHODS OF WEANING
POST EXTUBATION CARE

P0ST-TEST EVALUATION
HANDS ON VENTILATOR
HANDS ON INTUBATING MANNIQUINE

WHAT A MOST IMPORTANT THING


A DOCTOR SHOULD KNOW
AFTER THIS COURSE ?
MONITORING THE PROGRESS

WHAT A MOST IMPORTANT THING


A ICU STAFF SHOULD KNOW
AFTER THIS COURSE ?

ALARMS AND CARE OF THE PATIENT

VENTILATOR
THE BASIC

Mechanical ventilation is used when


a patient is unable to breathe
adequately on his or her own.
The ventilator can either completely
take over respiratory function, or
it can be used to support the
patients own respiratory efforts

MECHANISM OF RESPIRATION
A mechanism for telling the body that it is time to breath:
This involves CO2 sensors in the brainstem, which signal diaphragmatic
movement via the cervical nerves.

The phrenic nerves


The diaphragm contracts
it increases the volume of the thorax,
by moving down into the abdomen,
making the intra-pleural and intra-alveolar pressure more negative,
creating a pressure gradient between the atmospheric and the alveoli,
and allowing air to pass down through a series of narrowing bronchi into the
alveoli.

The alveoli and the pulmonary capillary network,


Derived from the main pulmonary arteries,
oxygen and carbon dioxide diffuse across the concentration gradient
out of and into the alveoli respectively.
The diffusion of CO2 is more effective due to its higher solubility.

Indications for mechanical ventilation:

Ventilation Failure
Oxygenation Failure

Failure to Ventilate

haracterized by reduced alveolar ventilation


which manifests
as an increase in the PaCO2 > 50 mmHg

Indications for mechanical ventilation:

Is it

failure to ventilate (is the PCO2 > 50mmHg), or


failure to oxygenate (is the PO2 <50mmHg)?
Remember that a low O2 is much more significant
than a high PCO2,

If it is ventilatory failure, where is the injury


in the brain (the medulla),
- in the spinal cord,
- in the peripheral nerves,
- at the neuromuscular junction,
- in the muscle itself or in the chest cage?

If the problem is oxygenation failure, where is the


injury:
- Is it in the blood supply,
- at the alveolar-capillary interface or
- in the upper, middle or lower
airways?

Neurological Problems ( Ventilatory


failure )

Central:
stroke
Spinal:

Loss of ventilatory drive due to sedation, narcosis,


or brain injury.

Spinal cord injury, cervical loss of diaphragmatic


function,
thoracic loss of intercostals.
Peripheral: Nerve injury (e.g. phrenic nerve in surgery),
Guillain-Barre syndrome (demyelination),
poliomyelitis,
motor
neurone disease.
Muscular Problems
myasthenia gravis, steroid induced myopathy,
protein
malnutrition.
Anatomical Problems
Chest Wall rib fractures or flail chest, obesity, abdominal
hypertension,
restrictive dressings
Pleura
pleural effusions, pneumothorax, hemothorax.
Airways
airway obstruction (in lumen, in wall, outside wall),
laryngeal edema,
inhalation of a foreign object,
bronchospasm

Failure to Oxygenate
Diffusion abnormality

Thickening of the alveoli (fibrosis)


Increased extracellular fluid pulmonary edema.
This obstructs gas exchange.
Ventilation/Perfusion Mismatch : Dead Space Ventilation

(or high V/Q)


Alveoli are ventilated but not perfused
Eg; pulmonary
embolus
Dead space may
be anatomical - the conducting
airways(150ml)
physiological, for example in hemorrhage or hypotension
Shunt (or low V/Q) where alveoli are perfused but not ventilated
occurs in airway collapse,
pneumonia,
pulmonary hemorrhage (contusion),
ARDS/ALI.
Inability to extract O2 at cellular level sepsis, cyanide
or carbon monoxide
poisoning

Mechanical
Ventilator
What is it?

Mechanical Ventilator What is it?

A mechanical ventilator is a machine that generates a controlled flow of g


into a patients airways
Two kinds of ventilators:
Negative pressure and Positive pressure.
Negative
Pressure :

-iron lung, the Drinker respirator, and the chest shell


-advantage these ventilators didnt require insertion of
an
artificial
airway,

-disadvantage they were noisy and made nursing care


Positive Pressure :
difficult.
-The Emerson Company in Boston developed the
positive pressure ventilator, which was first used at
Massachusetts General Hospital.

Positive pressure ventilators


Require an artificial airway (endotracheal or tracheostomy tube),

and use positive pressure to force oxygen into a patients lun


Inspiration can be triggered either by the patient or the
machine.
Four types of positive pressure ventilators:
volume cycled

-deliver a preset tidal volume


-ideal for patients with bronchospasm since
the
same tidal volume is delivered
regardless of
the amount of airway
pressure cycled resistance
-deliver gases at preset pressure

-decreased risk of lung damage from high inspiratory pre


-disadvantage is that the patient may not receive the
complete tidal volume if he or she has poor
lung
compliance and increased airway resistance

flow cycled-deliver a breath until a preset flow rate


time cycled-deliver a breath over a preset time period

expiration is
passive

These arent
used

gas flows along a pressure


gradient between the upper
airway and the alveoli
Flow is either volume targeted and
pressure variable, or pressure limited and
volume variable.

The pattern of flow may be either sinusoidal (which is


normal), decelerating or constant. Flow is controlled by
an array of sensors and microprocessors.

Mechanical
Ventilators
Classification

Mechanical Ventilators Classification


1) Control

Either
Volume Controlled (volume limited, volume targeted) and Pressure Varia
or
Pressure Controlled (pressure limited, pressure targeted) and Volume Varia
or
Dual Controlled (volume targeted (guaranteed) pressure limited)
2) Cycling:
Time cycled - such in in pressure controlled ventilation
Flow cycled - such as in pressure support

Volume cycled - the ventilator cycles to expiration once a set tidal volu
has been delivered: this occurs in volume controlled vent
-If an inspiratory pause is added,
then the breath is both volume and time cycled
(contd)

3) Triggering:
what causes the ventilator to cycle to inspiration?

Ventilators may be
time triggered,
pressure triggered or
flow triggered.
Time: the ventilator cycles at a set frequency as determined by the
controlled rate.
Pressure: the ventilator senses the patient's inspiratory effort

by way of a decrease in the baseline pressure.

Flow: modern ventilators deliver a constant flow around the circuit

throughout the respiratory cycle (flow-by). A deflection in this


flow by patient inspiration, is monitored by the ventilator and
it delivers a breath.
This mechanism requires less work by the patient than
pressure
triggering.
(Contd)

4) Breaths are either:


what causes the ventilator to cycle from inspiration?

Mandatory (controlled)

Assisted

- which is determined by the respiratory r

- (as in assist control, synchronized intermittent manda


ventilation, pressure support)

Spontaneous- (no additional assistance in inspiration, as in CPAP


CPA

5) Flow pattern:

constant, accelerating, decelerating or sinusoidal

Sinusoidal = this is the flow pattern seen in spontaneous breathing and CP


Decelerating = the flow pattern seen in pressure targeted ventilation:
inspiration slows down as alveolar pressure increases
(there is a high initial flow).
(Contd)

Constant

flow continues at a constant rate


until the set tidal volume is delivered

Accelerating

flow increases progressively


as the breath is delivered. This should not be
used in clinical practice.
Flow Pattern

a reservoir.
2. Loss of chest wall or lung compliance causes reduced FRC.
KEY-POINTS
3. Exhalation below FRC is active causing dynamic airway collapse,
trapping air in the alveoli (auto PEEP)
4. At residual volume it is not possible to empty alveoli of air further,
due to dynamic airway collapse (airway closure)
5. The closing volume (CV) is the point at which dynamic compression of the airways
begins.
6. Such airway closure occurs normally within FRC, and it is known as the closing
volume (CV).
With age and disease the CV moves into the tidal breathing range.
7. The CV increases with age, smoking, lung disease, and body position (supine >
erect).
8. Airway collapse increases the work of breathing and leads to ventilation-perfusion
mismatch
9. In mechanically ventilated patients airway collapse is prevented by applying
positive pressure
to the airway throughout the respiratory cycle CPAP/PEEP
10. PEEP/CPAP works by increasing FRC, maintaining alveolar recruitment facilitating
gas
exchange (and removal of CO2 and replenishment of O2), and
reducing the workload of breathing.
11. The patient requires sufficient PEEP to prevent alveolar de-recruitment, but not so
much PEEP
that alveolar over-distension, dead space ventilation and hypotension occurs.
12. The ideal level of PEEP is that which prevents de-recruitment of the majority of
alveoli,
while causing minimal over-distension.
13. Recruitment maneuvers are used to re-inflate collapsed alveoli, a sustained
pressure above
the tidal ventilation range is applied, and PEEP is used to prevent de-recruitment.
14. Auto-PEEP is gas trapped in alveoli at end expiration, due to inadequate time for

VENTILATOR
WAVE FORMS

Ventilator Waveforms
Airway pressure screen

Step 1: - determine the CPAP level

this is the baseline position from which there is a downward deflection


at least, beginning of inspiration, and to which the airway pressure ret
at the end of expiration.

Step 2: is the patient triggering?


-There will be a negative deflection into the CPAP line just before inspi

Step 3: what is the shape of the pressure wave?


-If the curve has a flat top, then the breath is pressure limited,
if it has a triangular or sharks fin top, then it is not pressure
limited
and is a volume breath.

Flow screen:

Step 4: what is the flow pattern?


If it is constant flow (square shaped) this must be volume controlle
if decelerating, it can be any mode.

Is the patient gas trapping?

-expiratory flow does not return to baseline before inspiration comm


(i.e. gas is trapped in the airways at end-expiration).

Step 4: the patient is triggering


is this a pressure supported or SIMV or VAC breath?
-This is easy, the pressure supported breath looks completely differently
than the volume control or synchronized breath:
the PS breath has a decelerating flow pattern, and has a flat topped
airway pressure wave. The synchronized breath has a triangular
shaped pressure wave.
Airway
pressure

Flow
pattern

Step 5: the patient is triggering is this pressure support or pressure control?


-The fundamental difference between pressure support and pressure control
is the length of the breath in PC, the ventilator determined this (the inspired time)
and all breaths have an equal i time. In PS, the patient determined the
duration of inspiration, and this varies from breath to breath.

Step 6: is the patient synchronizing with the ventilator?


-Each time the ventilator is triggered a breath should be delivered.
If the number of triggering episodes is greater than the number of
breaths,
the patient is asynchronous with the ventilator. Further, if the peak flow
rate of
the ventilator is inadequate, then the
inspiratory flow will be "scooped"
inwards, and the patient appears to be
fighting the ventilator.
Both of these problems are illustrated below

Ventilator
Modes

Ventilator Modes
Control Ventilation (CV)
Assist-Control Ventilation (A/C)
Synchronous Intermittent Mandatory Ventilation (SIMV)
Pressure Support Ventilation (PSV)
Positive End Expiratory Pressure (PEEP)

Constant Positive Airway Pressure (CPAP)


Independent Lung Ventilation (ILV)
High Frequency Ventilation (HFV)
Inverse Ratio Ventilation (IRV)
Advanced Pressure Control Modes
-Inverse Ratio Ventilation (IRV) and
-Airway Pressure Release Ventilation (ARPV),
-Bilevel and Proportional Assist Ventilation?

1)Control Ventilation (CV)


-CV delivers the preset volume or pressure regardless of the
patients own inspiratory efforts.
-This mode is used for patients who are unable to initiate a
breath.
-If it is used with spontaneously breathing patients, they
must be
sedated and/or pharmacologically paralyzed so
they dont
breathe out of synchrony with the
ventilator.

2)Assist-Control Ventilation (A/C)


-A/C delivers the preset volume or pressure in response to the
patients own inspiratory effort but will initiate the
breath if the patient does not do so within the set amount of
time.
-This means that any inspiratory attempt by the patient
triggers a
ventilator breath.
-The patient may need to be sedated to limit the number of
spontaneous breaths since hyperventilation can
occur.
-This mode is used for patients who can inititate a breath but
who
have weakened respiratory muscles.

3) Synchronous Intermittent Mandatory


Ventilation
(SIMV)

-SIMV was developed as a result of the problem of high


respiratory
rates associated with A/C.
-SIMV delivers the preset volume or pressure and rate while
allowing
the patient to breathe spontaneously in between
ventilator breaths.
-Each ventilator breath is delivered in synchrony with the
patients
breaths, yet the patient is allowed to completely
control the
spontaneous breaths.
-SIMV is used as a primary mode of ventilation, as well as a
weaning mode.
-The disadvantage of this mode is that it may increase the
work of
breathing and respiratory muscle fatigue.

4) Pressure Support Ventilation (PSV)


-PSV is preset pressure that augments the patients
spontaneous inspiratory effort and decreases the work of
breathing.

tidal

-The patient completely controls the respiratory rate and


volume.

-PSV is used for patients with a stable respiratory status


and is
often used with SIMV to overcome the resistance of
breathing
through ventilator circuits and tubing.

5) Positive End Expiratory Pressure (PEEP):


-PEEP is positive pressure that is applied by the ventilator at the
end of
expiration.
-Used as an adjunct to CV, A/C, and SIMV to improve oxygenation
by
collapsed alveoli at the end of expiration.
-Complications
decreased cardiac output,
pneumothorax, and
increased intracranial pressure.

6) Constant Positive Airway Pressure (CPAP)

who

-CPAP is similar to PEEP except that it works only for patients


are breathing spontaneously.

-The effect of both is comparable to inflating a balloon and


not letting
it completely deflate before inflating it again. The
second inflation is
easier to perform because resistance is
decreased.
-CPAP can also be administered using a mask.

7) Independent Lung Ventilation (ILV)


-This method is used to ventilate each lung separately in patients
with
unilateral lung disease or with a different disease
process in each lung.
-It requires a double-lumen endotracheal tube and two ventilators.
optimal

-Sedation and pharmacological paralysis are used to facilitate


ventilation and increased comfort for the patient.

8) High Frequency Ventilation (HFV)


100

-HFV delivers a small amount of gas at a rapid rate (as much as 60breaths per minute.)

-This is used when conventional mechanical ventilation would


compromise
hemodynamic stability, during short-term procedures, or
for patients who
are at high risk for pneumothorax.
-Sedation and pharmacological paralysis are required.

9) Inverse Ratio Ventilation (IRV)


-The normal inspiratory:expiratory ratio is 1:2 but this is reversed
during IRV to
2:1 or greater (the maximum is 4:1).
-This mode is used for patients who are still hypoxic even with the
use of PEEP.
-The longer inspiratory time increases the amount of air in the lungs
at the end
of expiration (the functional residual capacity) and improves
oxygenation by
reexpanding collapsed alveoli.
-The shorter expiratory time prevents the alveoli from collapsing
again.
-Sedation and pharmacological paralysis are required since its very
uncomfortable for the patient.

MODE
USE

FUNCTION

Control Ventilation (CV)


apneic
regardless of patients own

Delivers preset volume or pressure

CLINICAL
Usually used for patients who

inspiratory efforts

Assist-Control Ventilation (A/C)


spontaneously

Delivers breath in response to


patient effort and if patient fails to

Usually used for

breathing patient

with weakened
do so within preset amount of time

respiratory

muscles

Synchronous Intermittent Mandatory


patients from

Ventilator breaths are synchronized

Usually used to wean

mechanica
ventilation
with patients respiratory effort
Ventilation (SIMV)

Pressure Support Ventilation (PSV)


during

Preset pressure that augments the

Often used with SIMV

weaning
patients inspiratory effort and
decreases the work of breathing
Positive End Expiratory Pressure
(PEEP)
opening collapsed
alveoli

Positive pressure applied at the end

Used with CV, A/C, and SIM


Improve oxygenation

MODE
Independent Lung Ventilation (ILV)
lung

FUNCTION
Ventilates each lung separately;

CLINICAL USE
Used for patients with unilateral
disease or different disease

process

In each lung
requires two ventilators and
sedation/paralysis
High Frequency Ventilation (HFV)
instability,

Delivers small amounts of gas at a

Used for hemodynamic


during short-term

procedures, or if

patient is at risk for

pneumothorax
rapid rate (60-100 breaths/minute);
requires sedation/paralysis
Inverse Ratio Ventilation (IRV)
patients

I:E ratio is reversed to allow longer

Improves oxygenation in
who are still hypoxic even

with PEEP;

keeps alveoli from

collapsing
inspiration; requires sedation/
paralysis

Volume Control Ventilation


Anesthesiologists use mechanical ventilators in the operating room.

These are bag in bottle mechanical bellows which are controlled by three f
1) tidal volume, 2) respiratory rate, 3) I:E ratio.

Conventional anesthesia ventilator: the patient is delivered mandatory breaths from a bag in bottle ve
He can also draw unsupported spontaneous breaths from an in-line reservoir bag:

-Longer inspiratory times and faster respiratory rates predispose to alveolar ga

Pressure-assist ventilation
Pressure assist ventilation is pressure control without a set rate.
Patients take pressure controlled breaths at the rate of their choosin
and the volumes derived are determined by the pressure preset lev
the Ti and the flow demanded.
This is a very comfortable mode,
and is used in weaning from pressure control (the pressure limit is w

Pressure Controlled Ventilation


controlled (CMV)
pressure
control.

assist-controlled

SIM at a set rate.


-A pressure limited breath is delivered
V the preset
The term
pressure by
control
referspressure
to an assist
control mode
-The tidal volume
is determined
limit.
-The flow waveform is always decelerating in pressure control
-Gas flows into the chest along the pressure gradient.
-As the airway pressure rises with increasing alveolar volume the rate of
flow
drops off (as the pressure gradient narrows) until a point is reached.
when the delivered pressure equals the airway pressure: flow stops.
-The pressure is maintained for the duration of inspiration .
Obviously, longer inspiratory times lead to higher mean airway
pressures
(the i time (Ti) is a pressure holding time after flow has stopped).
-The combination of decelerating flow and maintenance of airway pressure
over time means that stiff, noncompliant lung units (long time con
which are difficult to aerate are more likely to be inflated.
-Drawbacks of pressure control? -Pressure control does not guarantee
minute
ventilation. change in the compliance,

Volume Assist Control

In volume assist-control -often labelled volume control


-patients may receive either controlled or assisted brea
-When the patient triggers the ventilator,
he/she receives a breath .
-The patient receives a breath of this type irrespective o
actual minute ventilation requirement, so patie
tend to hyperventilate as they emerge.
Assist control (AC) ventilation involves the use of four variables:
-tidal volume
-respiratory rate
- inspiratory flow (as an alternative to I:E ratio)
-trigger sensitivity

If the flow rate is too high, the volume is rapidly delivered to only the
most compliant lung tissues (and not to the inelastic diseased ti
If the peak flow is too low, the patient will demand more gas than the
ventilator is set up to supply and dysynchrony with the machine oc

The inspiratory flow rate is measured in liters per minute, and it determines
how quickly the breath is delivered.
The time required to complete inspiration is determined by the tidal volume
delivered and the flow rate:
Ti = VT/Flow Rate.
controlled breaths

decelerating flow
pattern

assisted
breaths

tidal volume is identical

Ventilation How
to Initiate
Mechanical
Ventilation

Ventilation How to Initiate Mechanical Ventilation


The ventilation strategy
-is determined by whether the patient has
failure
to ventilate or failure to
oxygenate.
the
units
pressure.
Sedation-

-The first problem is managed by increasing


patients minute ventilation,
-the second by recruiting collapsed lung
and controlling mean airway
fentanyl
or
morphine

with lorazepam, midazolam

or

For profoundly hypoxemic patients, the addition of a


neuromuscular blocking agent

The Procedure of Rapid Sequence Induction


Preparation:
Drugs: thio/ propofol/ etomidate/ midazolam, succinyl choline,
atropine, ephedrine/phenylephrine.

Endotracheal tubes: a variety of sizes available and cuff checked


(to make sure that the cuff is intact -ie. Not punctures)
Laryngoscopes 2 functioning laryngoscopes with a variety of blades.
Suction on and under the pillow.

A Gum elastic bougie to railroad the ETT if there is difficulty in placing th


An intravenous cannula, with a free-flowing drip

Monitoring:
blood pressure, ECG, pulse oximetry, end tidal CO2 (if available)

Options:

1. Awake intubation +/- local anesthesia applied topic


2. Sedation with midazolam +/- local anesthetic.
3. Midazolam + succinylcholine
4. Ketamine + succinylcholine (small babies).
5. Thiopental or propofol + succinylcholine
6. Etomidate + succinylcholine

Ventilator
Settings

Ventilator Settings
Respiratory Rate (RR)
-The respiratory rate is the number of breaths the ventilator delivers
to the
patient each minute.
-The rate chosen depends on the
tidal volume
the type of pulmonary pathology
the patients target PaCO2.
-Obstructive lung disease, the rate should be set at 6-8
breaths/minute to avoid
the development of auto-PEEP
and hyperventilation
-Restrictive lung disease usually tolerate a range of 12-20
breaths/minute.
- Patients with normal pulmonary mechanics can tolerate a rate of 812Tidal Volume (VT)
breaths/minute.
-The tidal volume is the volume of gas the ventilator delivers to the
patient with
each breath.
-The usual setting is 5-15 cc/kg, based on compliance, resistance, and
type of
pathology.
-Patients with normal lungs can tolerate a tidal volume of 12-15 cc/kg,
-Patients with restrictive lung disease may need a tidal volume of 5-8
cc/kg.

To start a patient on assist-control


one must select
-a PEEP (as determined by lung
compliance),
-a minute volume (MV 100ml/kg),
-a tidal volume (TV 6ml/kg), and a peak
flow.
-The respiratory rate is the MV/TV.
-The peak flow is usually four times the
minute
ventilation.
-The trigger is either set as flow-by or a
negative pressure of -2cmH2O

Fractional Inspired Oxygen (FIO2)


-The fractional inspired oxygen is the amount of oxygen delivered to the
patient.
It can range from 21% (room air) to 100%.
-Oxygen toxicity causes structural changes at the alveolar-capillary
membrane,
pulmonary edema, atelectasis, and decreased PaO2.
Inspiratory:Expiratory (I:E) Ratio
-The I:E ratio is usually set at 1:2 or 1:1.5
Pressure Limit
-The pressure limit regulates the amount of pressure the volume-cycled
ventilator can generate to deliver the preset tidal volume.
-High pressures can cause lung injury, its recommended that the plateau
pressure not exceed 35 cm H20.
-Caused by airway is obstructed with mucus,the patient coughing, biting
on the ETT, breathing against the ventilator, or by a kink in the ventilator
tubing.

Flow rate
-The flow rate is the speed with which the tidal volume is delivered. The
usual setting is 40-100 liters per minute.
Sensitivity/Trigger
-The sensitivity determines the amount of effort required by the patient to
initiate inspiration.
-It can be set to be triggered by pressure or flow
-Sigh
-The ventilator can be programmed to deliver an occasional sigh with a
larger tidal volume.
-it prevents collapse of the alveoli (atelectasis)
-Minute volume (VE)
Minute volume is the total volume of air inhaled and exhaled in one
minute. The patients minute volume should be less than 10 liters per
minute.

Ventilator Settings
The following is a summary of the settings that nurses deal with the
most.
SETTING
PARAMETERS
Respiratory Rate (RR)
breaths/mt

FUNCTION
Number of breaths delivered

USUAL
usually 4-20

by the ventilator per minute


Tidal Volume (VT)
15cc/kg

Volume of gas delivered during

usually 5-

each ventilator breath


Fractional Inspired
keep
Oxygen(FIO2)
or

Amount of oxygen delivered by


ventilator to patient

21%-100% to
PaO2>60mmHg
SaO2>90%

Inspiratory:Expiratory
1:1.5

Ratio Length of inspiration

usually 1:2 or

Alarms and Common Causes

High Pressure
Exhaled Volume

Low Pressure

Secretions in
tubing not
ETT/airway or
connected
condensation in
cuff or
tubing
seal

-vent tubing not


connected
-displaced ETT
or trach tube

Kink in vent
Tubing
of
Patient biting on
alarm
ETT
Patient coughing,
breath
gagging, or trying

High Respiratory Rate


patient anxiety or

Low
-vent

pain
-secreations in ETT/
airway
- Hypoxia
- Hypercapnia

-Leak in
inadequate cuff

-Occurrence
another
preventing full
delivery of

Noninvasive
Forms
of
Mechanical
Ventilation

Noninvasive Forms of Mechanical Ventilation


Noninvasive positive pressure ventilation (NIPPV) include
- patients who dont have oxygenation problems,
- who are able to manage their secretions, and
- who dont have an upper airway obstruction.
CPAP
Continuous Positive Airway Pressure (CPAP)
CPAP can also be delivered through either a nasal mask or a full face
mask.
Full face masks - minimize air leaks,
-more claustrophobic- must be removed for the patient to
speak or
expectorate
secretions.
- a smaller air leak leads to greater pressure buildup and
gastric
distention
Nasal masks - less claustrophic and dont have to be removed to speak or
expectorate,
- they usually have large air leaks BiPAP

Bi-level Positive Airway Pressure (Bi-PAP)


- similar to CPAP
- BiPAP maintains positive airway pressure during both
inspiration and
expiration.
-The two levels are referred to as
inspiratory positive airway pressure (IPAP) and
expiratory positive airway pressure (EPAP).
-Benefits of IPAP
increased tidal volume and minute ventilation,
decreased PaCO2 level,
relief of dyspnea, and
reduced use of accessory muscles.
-Benefits of EPAP
increased functional residual capacity,
resulting in an increased PaO2 level.
-Bi-Pap is usually delivered through a nasal mask, allowing
exhalation
through the mouth

IPPB
for a

-Intermittent Positive Pressure Breathing (IPPB) is used after surgery or


short time after mechanical ventilation has been discontinued.

-The IPPB machine is a pressure-cycled ventilator that delivers


compressed
gas under positive pressure into the patients airway.
-Its triggered when the patient inhales,but it allows passive expiration.
-Usually, 10-20 breaths are given every 1-2 hours for 24 hours.
-Benefits of IPPB include
prevention of atelectasis,
promotion of full-lung expansion,
improved oxygenation, and
administration of nebulized medications.

Nursing Care of the


Mechanically Ventilated
Patient

Nursing Care of the Mechanically Ventilated Patient

Nursing Care of the Endotracheal Tube (ETT)


ETT management consists of
- ensuring a patent airway,
- suctioning pulmonary and oral secretions, and
- providing frequent oral and/or nasal care.
-secure ETT in place

Oral cavity should also be suctioned separately


-oral care should be provided every eight hours and as
needed.

Bite block -If the patient has a bite block to prevent them from biting on
the tube, it must be removed and cleaned or replaced every
eight hours.
-If the tube is taped to the patients face, the tape must be
removed and replaced on the opposite side of the face at least
once per day .
-The amount of air in the cuff should be checked every eight
hours to ensure that the cuff is not exerting too much pressure
on the
trachea walls.
-ETT should be confirmed to be the same as prior to the
procedure

Endotracheal tube care Tray


This includes

-a sterile suction kit;


(two separate suction catheters for oral and ETT)
-a bottle of sterile 0.9% sodium chloride;
-sterile gloves;
-a clean bite block, and
-tape torn into appropriately sized pieces.

Nursing Care of the Tracheostomy Tube


-Tracheostomy (trach) care should be done every eight hours
and involves cleaning around the incision,
as well as replacing the inner cannula if the patient has
a double-lumen tube.
-prevent breakdown of the skin surrounding the site,
and prevent infection.
-Using sterile technique, the skin and external portion of
the tube is cleaned with hydrogen peroxide.
- inner cannula must be cleaned with hydrogen peroxide, rinsed with
0.9% sodium chloride, and reinserted using sterile technique

Sterile suctioning
- Suctioning should be performed only when the patient needs
it; the need should be assessed at least every two hours.
- Pre-oxygenation with 100% O2
- two separate suction catheters for oral and ETT
- size of suction catheter should be 1/3rd of ETT diameter
- Duration of each suction pass should be limited to ten seconds
-The number of passes should be limited to three or less
- saline installation should not be used routinely

Eyes
Eyes

should be covered with a


sterile gauze after applying a
eye ointment.

This

is to avoid dryness of
cornea & subsequent
development of any ulceration.

Naso gastric tubes


Instituted

for gastric decompression


Administration of medications.
Nutritional support
Should be irrigated every 4 hours.
Position should be verified before
administration of any fluids.
After administration flush with 10ml
of water.

Care of Bladder
Continuous bladder drainage

Catheter should changed


once in 72 hours check
patency

GIT Care
Oral

cavity examination
Abdominal Examination
Per Rectal Examination

Care to avoid
development of bed sore

Constant

changing position
of patient
Avoid pressure points
Alpha bed or Water bed

Psychological care
Good

communication
Alleviate anxiety and
promote emotional well
being
Orientation of patient to
surrounding, Time and
Persons

Sedation &
Neuromuscular
Blockade

Sedation & Neuromuscular Blockade


-Patients require sedation in order to tolerate mechanical
ventilation
Common Medications
- sedatives
decrease anxiety and produce amnesia
- neuroleptics,
- analgesics, and
- paralytics
SEDATIVES
Lorazepam
Dexmedetomidine

Midazolam

Onset of action
Immediately

5-15 minutes

1-3 minutes

Half-life
hours

6-15 hours

1 hour

Loading Dose
mcg/kg

0.05 mg/kg

0.03 mg/kg

Propofol
1 minute
< 30 minutes
0.5 mg/kg

1.5-3
1

NEUROLEPTICS
-Given to patients who are experiencing delirium or
ICU psychosis.
Symptoms -disorganized thinking,
- audio and visual hallucinations, and
- disorientation.
Haloperidol - intravenously in 2-10 mg doses every 2 to 4 hours
ANALGESICS
Intravenous narcotics Morphine,fentanyl or hydromorphone
PARALYTICS AGENTS or neuromuscular blocking agents (NMBs)
- must always be administered with other sedatives and
narcotics
Two classes of NMBs:
intubation)

- Nondepolarizing (Succinylcholine for

- Depolarizing
( Atracurium,Pancuranium,Vecuranium)

Assessment
Criteria

Assessment Criteria
Breath Sounds
- Breath sounds should be assessed at least every four hours
Crackles (rales)
Rhonchi
Wheeze
Pleural friction rub
Spontaneous Respiratory Rate and Tidal Volume
-If the spontaneous tidal volume is low
-the patient may not do well with weaning attempts.
-If the respiratory rate is high, particularly with weaning modes
indicate
-the patient isnt tolerating the mode,
-needs suctioning,
-or he or she is anxious or trying to communicate.
Pulse Oximetry
-The machine detects the percent of hemoglobin that is fully
saturated.
-pulse oximetry can be a helpful guide when titrating FIO2
-In general, a SpO2 of 92% in white patients, and 95% in black
patients
indicates adequate oxygenation (PaO2 > 60 mmHg).

(Capnography) End Tidal CO2


measured

-Capnography, also called end tidal CO2, is CO2


at the end of exhalation

-a display where a waveform (capnogram) is


created, along
with a number that closely
approximates the PaCO2
-In a hemodynamically stable patient with a normal
ventilation/perfusion relationship, the end
tidal CO2 (also
called PetCO2) is generally 1-5 mmHg
less than the PaCO2
-The most useful function of end tidal CO2
measurement is to
confirm ETT placement in the lungs.

Arterial Blood Gases (ABG)


pH
Normal pH of body fluids = 7.35-7.45
pH < 7.35 = acidosis
pH > 7.45 = alkalosis
PaCO2
PaCO2 is the partial pressure of dissolved CO2 in blood.
Normal = 35-45 mmHg
PaCO2 is directly related to rate and depth of respiration.
Its a direct indicator of the effectiveness of ventilation.
As PaCO2 rises, the blood becomes more acidic and pH drops.
As PaCO2 decreases, the blood becomes more alkaline and pH rises.
If a change in PaCO2 is the primary alteration, then a respiratory
problem
exists.
HCO3
Bicarbonate (HCO3) is the primary buffer in the body and is able to
take up
and release H+.
Normal = 22-26 mmHg
As HCO3 rises, the blood becomes more alkaline and pH increases.
As HCO3 drops, the blood becomes more acidic and pH decreases.
If a change in HCO3 is the primary alteration, then a metabolic

CO2
Considered a measure of bicarbonate concentration; includes
total of
bicarbonate and carbonic acid.
Normal = 23-27 mEq/L
Base Excess/Deficit
Measures excess amount of acid or base present in blood. This is
independent of changes in PaCO2; therefore, its a measure of
metabolic
acid-base balance.
Increased HCO3 = base excess (alkalosis)
Decreased HCO3 = base deficit (acidosis)
PaO2
The amount of oxygen dissolved in plasma (about 3% of total; the
other 97% is bound to hemoglobin).
Normal is 80-100 mmHg in healthy young people breathing room
air at sea
level; this decreases with age and altitude.
PaO2 > 60 mmHg is considered acceptable in critically ill,
mechanically ventilated adults

Figure out the ABG results

1. pH 7.30, PaCO2 40, HCO3 18


Metabolic acidosis (pH , PaCO2 ok, HCO3 )
2. pH 7.48, PaCO2 30, HCO3 24
Respiratory alkalosis (pH , PaCO2 , HCO3 ok)
3. pH 7.25, PaCO2 54, HCO3 26
Respiratory acidosis (pH , PaCO2 , HCO3 ok)
4. pH 7.50, PaCO2 42, HCO3 33
Metabolic alkalosis (pH , PaCO2 ok, HCO3 )

Weaning and
Extubation

Indications for weaning and extubatio


The patient is able to ventilate
The patient is able to oxygenate

The patient is able to protect his/her airway

Suitability for Weaning


Criteria

Objective measurements

Subjective clinical
assessments

Description

Adequate oxygenation (eg, PO2 >60 mm Hg on FIO2 > 0.4; PEEP <510 cm H2O;
PO2/FIO2 >150300);

Stable cardiovascular system (eg, HR <140; stable BP; no (or minimal) pressors)

Afebrile (temperature < 38C)

No significant respiratory acidosis

Adequate hemoglobin (eg, Hgb >810 g/dL)

Adequate mentation (eg, arousable, GCS >13, no continuous sedative infusions)

Stable metabolic status (eg, acceptable electrolytes)

Resolution of disease acute phase; physician believes discontinuation possible;


adequate cough

INTOLERENCE TO WEANING

Increased HR

Increasrd RR (>30/mt)

Increased work breathing

Sweating (Hypercapnia)

Hypertension

Hypoxia

I wish to evaluate the patient for


discontinuation from the ventilator

Does the patient meet criteria?

Place the patient on a Spontaneous


Breathing Trial

patient is tolerant
How do I know if the
intolerant of the trial?

Watch for 5 or 10 minutes


If acute distress does not occur, continue
for a maximum of 2 hours

Is the patient suitable for extubation?

Weaning / Discontinuation of
Mechanical Ventilation

Is the patient suitable for extubation?

Weaning / Discontinuation of
Mechanical Ventilation

No

Yes
FailuretoVentilate
Sit the patient up in the bed, suction out the
endotracheal tube, explain what you are
going to do and extubate the patient.

Failure to Oxygenate
Other Factors

Rest the patient on the ventilator


Ensure optimal analgesia and
sedation

Reassess failure to wean/discontinue

Attempt Spontaneous Breathing Trial


ONCE every 24 hours

Recurrent Failure

Consider Tracheostomy:
requiring excessive sedation to

tolerate
ETT
marginal mechanics

psychological dependence on

ventilator
mobility

airway trauma.

Weaning & Extubation


Partial Ventilation Support

Normalization of inspiratory
times

Driving pressure is targeted


to
a tidal volume of 4 - 6ml/kg.
Mean airway pressure, the CPAP level and the
FiO2 are reduced to targeted PaO2

As PaCO2 reduces reduce the


controlresp.rate

Failure to Wean

Failure to Wean:
Is the patient able to ventilate?
Is the patient able to oxygenate?
What other factors influence weaning?

Is the patient able to ventilate?


FACTORS THAT MAY INTERFERE WITH WEANING

Neurological

Anatomical Problems

Is the patient able to oxygenate?

Diffusion abnormalities,
ventilation-perfusion mismatch,
dead space and shunt.
Certain factors may limit successful weaning
- persistent lower respiratory tract infection,
-alveolar edema,
-airway/lobar collapse,
-lung fibrosis.

What other factors influence weaning?


Cardiovascular pulmonary edema,fluid overload
Gastroinestinal recurrent aspiration pneumonitis,
ascites or abdominal wounds leading to
diaphgramatic splinting
Nutrition -protein malnutrition leading to muscular atrophy,
which affects the diaphragm and intercostals
Acid base metabolic alkalosis reduces respiratory drive.
Conversely, muscles perform poorly in an acidic environment

Electrolytes hypophosphatemia, hypomagnesemia, hypokalemia, hypocalce


these all affect muscular function and protein metabolism.

Endocrine muscle weakness due to hypothyroidism or steroid induced myop

Oxygen delivery capacity the circulating hemoglobin concentration:


anemia increases respiratory drive and cardiac outp
Pain control it is very difficult to wean patients who are in pain

Weaning & Discontinuation Algorithm


1. Removing a patient from a ventilator involves discontinuation of
mechanical
ventilation and extubation.
2. There are two parts to weaning: weaning to partial ventilator support
and
weaning to
discontinuation.
3. The single most traumatic event for the patient is conversion from
positive pressure to negative pressure ventilation.
4. To extubated a patient, they need to be awake, able to cough and
protect their airway.
5. If it is possible to wean a patient to extubation, but the patient
cannot protect his/her airway, it is best to perform tracheotomy.

6. For a patient to self ventilate, many body systems must be functioning:


-the cardiopulmonary apparatus,
-the central nervous system,

-the nerves that supply the diaphragm (including the neuromuscular junct
-the muscles themselves.

-Moreover the patient must be willing to breath and maintain their own
functional residual capacity (not if there is diaphragmatic splinting due t

-There must be room in the abdomen for the diaphragm and lungs to mov
-There must be adequate hemoglobin to deliver oxygen to the tissues.

7. Difficult to wean a patient if ongoing inflammatory processes persist in the lu


consolidation, fibrosis, auto-PEEP, diffusion defects

8. Muscles must be trained and nourished, and patient-ventilator interaction en

9. most effective method of weaning to discontinuation is spontaneous breathin


(SBT). SBTs should not be performed more than once daily.

Methods of
weaning

Methods of weaning
There are three primary methods

T piece/CPAP trials,

Synchronized Intermittent Mandatory


Ventilation (SIMV),

Pressure Support Ventilation (PSV).

PSV is often used with SIMV to decrease the


work of
breathing.

T-piece/CPAP trials
-T-piece trials consist of alternating intervals of time on the
ventilator with
intervals of spontaneous breathing.
-T-shaped tube is attached
- endotracheal or tracheostomy tube.
- tubing is attached to an oxygen flowmeter
-the other end is open
-watch for signs of hypercapnia
Tachycardia
Tachypnoea
Sweating
Hypertension

CPAP
- With CPAP, the patient breathes spontaneously, but has the benefit
of the
ventilator alarms if he or she has difficulty.
- CPAP maintains constant positive pressure in the airways, which
facilitates gas
exchange in the alveoli.

SIMV
-SIMV is a ventilator mode that delivers a preset number of breaths
to the
patient but coordinates them with the patients
spontaneous breaths.
-The ventilator may be set to deliver 12 breaths per minute, but the
patients
respiratory rate may be 16 (12 ventilator breaths plus 4
patient-initiated
breaths).
-The ventilator rate is usually decreased by one to three breaths at a
time and
an arterial blood gas (ABG) is obtained 30 minutes after
the change

Pressure support
- Placing the patient on the pressure support mode at a level that
allows the
patient to achieve a spontaneous tidal volume of 10-12
ml/kg.
- During weaning, the level of PS is decreased by 3-5 cm H2O as
long as the

Weaning criteria
Simple bedside pulmonary function tests
Vital capacity (VC)
exhaled

-The vital capacity is the maximal amount of air that can be


after a maximal inhalation.
-The patients vital capacity should be at least 10-15 cc/kg.

Negative inspiratory force (NIF)


and to
secretions.

-Negative inspiratory force is the ability to take a deep breath


generate a cough strong enough to clear
-The patients NIF should be at least 20 cm H20.

Tidal volume (VT)


a normal

-Tidal volume is the volume of air inspired and expired during


respiratory cycle.
-The patients tidal volume should be at least 5 ml/kg

Minute volume (VE)


in one

-Minute volume is the total volume of air inhaled and exhaled


minute.
-The patients minute volume should be less than 10 liters per

minute.
Respiratory rate (RR)
-The respiratory rate is the number of breaths per minute.
The
patients RR should be less than 25
breaths/minute.
Arterial blood gas (ABG)
The PaO2
50% oxygen

-An ABG should be done before the patient is extubated.


should be at least 50 mmHg on less than
and with no more than 5 cm H20 PEEP.

Post Extubation
Care

Post-Extubation Care
Humidified oxygen
-Supplemental oxygen requires humidification to prevent drying
and
irritation of the respiratory tract and to facilitate
removal of secretions.
-oxygen delivered through a mask for a few hours after
extubation.
Respiratory exercises
-coughing and deep breathing.
-incentive spirometry exercises.
IPPB
-is used in some institutions to assist patients to take deeper
breaths,
especially after surgery.
-The IPPB machine is a pressure-cycled ventilator that delivers
compressed
gas under positive pressure into the
patients airway.

-10-20 breaths are given every 1-2 hours for 24 hours.


-Benefits of IPPB
-prevention of atelectasis,
-promotion of full-lung expansion,
-improved oxygenation, and
-administration of nebulized medications

Assessment and monitoring


- Breath sounds, pulse oximetry, and vital signs should be assessed
and
recorded every 15 minutes x 1 hour, every 30
minutes x 1 hour, then
every hour until stable
- ABG to be done 30-60 minutes after extubation
-Dont forget to ask the patient how his or her breathing feels

Thanks to your expert nursing care