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Mechanical Ventilation
Purposes:
Indications:
<-20 75-100
Arterial blood Gases
> 50 35-45
NB. These parameters are used in making judgments about the adequacy of
respiratory function.
1- Negative-pressure ventilators
2- Positive-pressure ventilators.
Negative-Pressure Ventilators
- COPD,
- Diseases of the chest wall (kyphoscoliosis),
- Neuromuscular diseases (Duchenne’s muscular
dystrophy, amyotrophic lateral sclerosis [ALS]).
- The iron lung is cumbersome to use and very large. Most negative-pressure
ventilators in use today are more portable. To improve mobility and
comfort, there is a device that fits like a tortoise shell, forming a seal over
the chest. A hose connects the shell to a negative-pressure generator. The
thoracic cage is literally pulled outward to initiate inspiration.
Positive-pressure ventilators
Positive-Pressure Ventilators
Volume Ventilators.
- The volume ventilator is commonly used in critical care settings. The basic
principle of this ventilator is that a designated volume of air is delivered
with each breath.
- With this mode of ventilation, a respiratory rate, inspiratory time, and tidal
volume are selected for the mechanical breaths.
Pressure Ventilators.
High-Frequency Ventilators.
- Gas trapping
Volume-cycled ventilator,
Pressure-cycled ventilator,
Time-cycled ventilator,
Ventilator Modes
- The term “ventilator mode” refers to the way the machine ventilates the
patient .i.e. how much the patient will participate in his own ventilatory
A- Volume Modes
- The ventilator provides the patient with a pre-set tidal volume at a pre-set
rate and the patient may initiate a breath on his own, but the ventilator
assists by delivering a specified tidal volume to the patient.
- Client can initiate breaths that are delivered at the preset tidal volume.
- Client can breathe at a higher rate than the minimum number of
breaths/minute that has been set.
- The total respiratory rate is determined by the number of spontaneous
inspiration initiated by the patient plus the number of breaths set on the
ventilator.
- In A/C mode, a mandatory (or “control”) rate is selected.
- If the patient wishes to breathe faster, he or she can trigger the ventilator
and receive a full-volume breath.
- Often used as initial mode of ventilation
-This mode of ventilation is often used fully to support a patient, such as
- When the patient is first intubated
- When the patient is too weak to perform the work of breathing
(e.g., when emerging from anesthesia).
Advantages:
Disadvantages:
- Hyperventilation,
- Air trapping
- Work of breathing may be increased if sensitivity or flow rate is too low.
- Between machine breaths, the client can breathe spontaneously at his own
tidal volume and rate with no assistance from the ventilator.
Disadvantages:
B- Pressure Modes
1- Control Mode CM
Continuous Mandatory Ventilation( CMV)
-Ventilator totally controls the patient’s ventilation i.e. the ventilator initiates
and controls both the volume delivered and the frequency of breath.
closely monitored.
- Sedation and the use of neuromuscular blocking agents are frequently
indicated, because any patient–ventilator asynchrony usually results in
profound drops in the SaO2.
- This is especially true when inverse ratios are used. The “unnatural”
feeling of this mode often requires muscle relaxants to ensure patient–
ventilator synchrony.
- Most ventilators operate with a short inspiratory time and a long expiratory
time (1:2 or 1:3 ratio). This promotes venous return and allows time for air
to exit the lungs passively.
- Inverse ratio ventilation (IRV) mode reverses this ratio so that inspiratory
time is equal to, or longer than, expiratory time (1:1 to 4:1).
- Inverse I:E ratios are used in conjunction with pressure control
to improve oxygenation in patients with ARDS by expanding stiff
alveoli by using longer distending times,
thereby providing more opportunity for gas exchange and
preventing alveolar collapse.
Disadvantages:
Monitor
Disadvantages:
Monitor for
a- Auto-PEEP,
b- Barotrauma,
c- Hemodynamic instability.
- In PSV mode, the inspired tidal volume and respiratory rate must be
monitored closely to detect changes in lung compliance.
- In general, if compliance decreases or resistance increases, tidal volume
decreases and respiratory rate increases.
- PSV mode should be used with caution in patients with
- Bronchospasm
- other reactive airway conditions.
- PEEP & CPAP are used in patients with hypoxemia refractory to oxygen
therapy. They improve oxygenation by opening collapsed alveoli &
preventing them from collapsing at the end of expiration.
- CPAP allows the nurse to observe the ability of the patient to breathe
spontaneously while still on the ventilator.
Advantages:
Disadvantages:
- Neuromuscular disease,
- Chest wall deformity,
- Obstructive sleep apnea,
- COPD;
Advantages:
Disadvantages:
a- Gastric distension,
b- Air leaks from mouth
- The percent of oxygen concentration that the patient is receiving from the
ventilator. (Between 21% & 100%) (room air has 21% oxygen content).
- In adult patients who can tolerate higher levels of oxygen for a period of
time, the initial FiO2 may be set at 100% until arterial blood gases can
document adequate oxygenation.
1- Flushed face
2- Dry cough
3- Dyspnea
4- Chest pain
5- Tightness of chest
6- Sore throat
Tidal Volume (VT)
- For this reason, lower tidal volume targets (6 to 8 mL/kg) are now
recommended.
- Peak flow is the velocity/ spead of air flow (delivering air) per unit of time,
and is expressed in liters per minute. On many volume ventilators, this is a
separate dial.
- The higher the flow rate, the faster peak airway pressure is
reached and the shorter the inspiration;
- The lower the flow rate, the longer the inspiration.
- A very high flow rate may produce turbulence, shallow inspirations, and
uneven distribution of volume.
Respiratory Rate/ Breath Rate / Frequency ( F)
- With ARDS --- a more reduced 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)
- VE = (VT x F)
In this case, the tidal volume and respiratory rate are increased to
achieve the desired alkalotic pH by manipulating the PaCO2.
These patients usually have a large carbonic acid load, and lowering
their carbon dioxide levels rapidly may result in seizures.
Rate adjustments may also be necessary to enhance patient comfort or
when rapid rates cause air trapping that result in auto-PEEP.
Sigh:-
- A deep breath.
- A breath that has a greater volume than the tidal volume.
- It provides hyperinflation and prevents atelectasis.
- In infants and children it is unclear what level of peak pressure may cause
damage. In general, keeping peak pressures below 30 is desirable.
Pressure Limit
- Coughing,
- Accumulation of secretions,
- kinked ventilator tubing,
- Pneumothorax,
- Decreasing compliance
- A pressure limit set too low.
Positive End-Expiratory Pressure (PEEP)
- The PEEP control adjusts the pressure that is maintained in the lungs at the
end of expiration.
- ABGs,
- SaO2,
- Compliance,
- Hemodynamic pressures (cardiac output & blood pressure)
- Hypotension
- Dysrhythmias.
- If these occur, the PEEP is reduced. If higher PEEP is tolerated, the patient
is stabilized on the new PEEP settings for approximately 15 minutes. The
monitored parameters are then repeated.
- Cardiac output [ CO ],
- Pulmonary artery pressure [PAP],
- Central venous pressure [CVP],
- Attempts are made to minimize removing the patient from the ventilator
when using high levels of PEEP. Oxygenation can deteriorate and be slow
to rebound because it takes a significant amount of time for the effects of
PEEP to be reestablished. Therefore, if the patient is being oxygenated
using an MRB, it must be equipped with a valve that allows levels of
PEEP to be dialed in. An inline suction apparatus may be helpful to
prevent breaking the PEEP circuit to suction the patient.
- PEEP is used to keep alveoli stented open and it may recruit alveolar units
that are totally or partially collapsed.
- The patient who does not have adequate circulating blood volume,
institution of PEEP decreases venous return to the heart, decreases cardiac
Sensitivity
- All air delivered by the ventilator passes through the water in the
humidifier, where it is warmed and saturated. Because of this, insensible
water loss is decreased.
- As air passes through the ventilator to the patient, water condenses in the
corrugated tubing. This moisture is considered contaminated and must be
drained into a receptacle and not back into the sterile humidifier.
- If the water is allowed to build up, resistance is developed in the circuit and
- PEEP is generated. In addition, if moisture accumulates near the
endotracheal tube, the patient can aspirate the water.
- The nurse and respiratory therapist jointly are responsible for preventing
this condensation buildup. The humidifier is an ideal medium for bacterial
growth. Institutional policies should describe the frequency of ventilator
circuit changes.
Ventilator alarms:-
I- Airway Complications,
I- Mechanical complications,
I- Airway Complications
1- Aspiration
2- Decreased clearance of secretions
3- Nosocomial or ventilator-acquired pneumonia
1- Fluid overload with humidified air and sodium chloride (NaCl) retention
2- Depressed cardiac function and hypotension
3- Stress ulcers
4- Paralytic ileus
5- Gastric distension
6- Starvation
Assessment:
● Vital signs.
● Respiratory status
- Respiratory rate for a full minute & compared with the set ventilatory rate.
(To identify whether they are machine-controlled breaths or combined
machine-controlled and spontaneous breaths.)
- Symmetry of chest movement during machine breath
- Synchronization of chest movement with the ventilator during machine
breath
- Breath sounds q2–4h and PRN. (lack of breaths sounds may indicate that
the ETT is displaced)
- Pulse oximetry and end-tidal CO2.
- ABGs as indicated by changes in noninvasive parameters, patient status, or
weaning protocol. ( to evaluate oxygenation status & acid-base status)
- Need for suctioning. (As secretions heard during respiration, a
rise in ventilator peak inspiratory pressures, assess color, amount,
consistency & odor of sputum.)
- Perform systematic assessment of the oral mucosa daily, and with
each cleaning.
● Cardiovascular status
- Heart rate
- Blood pressure,
- Cardiac output
- Continuous cardiac monitoring should be initiated. (dysrhythmia may
occur due to:-
- Hypoxia,
- Acidosis,
- Alkalosis,
- Electrolyte imbalance.
● Neurological status
- Level of consciousness;
- Changes in arousability
- Changes in behavior,
- Ability to follow commands,
● Renal status
- Fluid balance
- Intake and output
- Fluid balance
- Hydration status in relation to clinical examination,
- Daily weight
- Urine specific gravity, or serum osmolality
- Electrolyte values
● Gastro-intestinal status
- Mode of ventilation
- Ventilator setting
- Fio2
- Tidal volume VT
- Minute ventilation VE
- Respiratory rate (number of breaths / minute delivered
by the ventilator)
- PEEP level if in use or CPAP
- I:E ratio
- Sigh (frequency / rate & volume)
NB:-
Nursing Diagnosis:
Nursing Interventions:
Nursing Interventions
2- Promote comfort:-
- Respiratory muscles, like all other body muscles, need energy to work. If
energy needs are not met, muscle fatigue occurs, leading to discoordination
of respiratory muscles and a decrease in tidal volume.
- Metabolic needs in critically ill patients are much higher than in normal
subjects. Basic caloric requirements are usually increased by 25% for
hospital activity and stress associated with treatment.
- Many chronically ill patients, such as those with COPD, have long-
standing protein and calorie malnutrition. Initial tube feeding is started
slowly,
. The nurse observes the patient for signs of intolerance, such as diarrhea
and hyperosmolar dehydration. If the patient tolerates feedings, the rate is
gradually increased until the desired rate is achieved.
- Overly large caloric loads increase carbon dioxide production and can
precipitate respiratory failure in a compromised patient.
Mild cathartic
Suppositories
Enemas
Eye care
Oral care
Skin care:
8- Maintain Safety:-
- Provide a means for patient to write notes and use visual tools to facilitate
communication.
- Encourage visitor conversations with patient in normal tone of voice and
subject matter.
- Teach visitors to assist with range-of-motion and other simple care delivery
tasks, to facilitate normal patterns of interaction.
-, provide the patient with his or her eyeglasses or hearing aid (if applicable)
Before assessing the patient’s ability to communicate.
- Once he or she is off the ventilator and tolerating the tracheostomy collar,
the tracheostomy patient can communicate by using “buttons” that occlude
the tracheostomy tube.
- The buttons allow for the passage of air around the tracheostomy to the
vocal chords. The Kirshner button mentioned later in this chapter in
weaning section is one type of button.
- Two other buttons are the Passy-Muir valve and the Shiley speaking valve.
- The Passy-Muir valve is a oneway valve that allows air to enter during
inspiration, then closes to allow the air to flow over the vocal chords with
exhalation.
- The Shiley speaking valve works in the same way as the Passy-Muir valve,
but has a side port for oxygen tubing to be attached, providing oxygen
support without using a tracheostomy collar.
- Patients with copious secretions are at risk for obstruction of these valves.
- They must be monitored very closely. In addition, patients at high risk for
aspiration, and especially patients with laryngeal or pharyngeal
dysfunction, should be carefully assessed before one of these devices is
used.
- The nurse should store these valves in a container clearly identified with
the patient’s name for safekeeping because each type of valve is relatively
costly.
- The patient should be taught to remove the valve with excessive sputum
during cough and call for assistance to clean the valve before reuse.
serious.
- Assess the patient first, while you silence the alarm. If you can not
quickly identify the problem, take the patient off the ventilator and
ventilate him with a resuscitation bag connected to oxygen source until the
physician arrives.
- A nurse or respiratory therapist must respond to every ventilator alarm.
- Alarms must never be ignored or disarmed.
- Ventilator malfunction is a potentially serious problem. Nursing or
respiratory therapists perform ventilator checks every 2 to 4 hours, and
recurrent alarms may alert the clinician to the possibility of an equipment-
related issue.
- When device malfunction is suspected, a second person manually
ventilates the patient while the nurse or therapist looks for the cause. If a
problem cannot be promptly corrected by ventilator adjustment, a different
machine is procured so the ventilator in question can be taken out of
service for analysis and repair by technical staff.
14- Documentation:-
- Patient’s measurements
- Ventilator settings
- Nursing care provided
Methods of Weaning:-
1- T-piece trial,
2- Continuous Positive Airway Pressure (CPAP) weaning,
1- T-Piece trial
- It consists of removing the patient from the ventilator and having him / her
breathe spontaneously on a T-tube connected to oxygen source.
- The T-piece is connected to the patient at the desired FIO2 (usually slightly
higher than the previous ventilator setting). The patient’s response to and
tolerance of the trial are continuously observed.
- The goal is to progressively increase the time spent off the ventilator.
- Weaning with the SIMV method entails a gradual reduction in the number
of delivered breaths until a low rate is reached (usually 4 breaths/minute).
The patient is then extubated if all other weaning criteria are met.
- However, low levels of SIMV (fewer than 4 breaths/ minute) may result in
a high level of work and fatigue.
3-Continuous Positive Airway Pressure ( CPAP)Weaning
- CPAP is very similar to T-piece trial, except the patient is placed on the
CPAP mode instead of a T-tube.
- When placed on CPAP, the patient does all the work of breathing without
the aid of a back up rate or tidal volume.
- CPAP entails breathing through the ventilator circuit with a small amount
(or zero amount) of positive pressure.
- During weaning using the PSV mode the level of pressure support is
gradually decreased based on the patient maintaining an adequate tidal
volume (8 to 12 mL/kg) and a respiratory rate of less than 25
breaths/minute.
- PSV is associated with less work of breathing than with volume modes, so
longer weaning trials may be tolerated
CPAP & PSV are modes of mechanical ventilation that are completely
dependent on the spontaneous effort of the patient for initiation of
inspiration. These modes are often used for weaning purposes.
Weaning readiness Criteria
- Awake and alert
- PaCO2 acceptable
- PH of 7.35 – 7.45
- PaO2 > 60 mm Hg ,
- SaO2 >92%
- FIO2 ≤40%
- F < 25 / minute
- Vt 5 ml / kg
- VE 5- 10 L/m (f x Vt)
- VC > 10- 15 ml / kg
- Hematocrit >25%,
1-Short term weaning for patient requiring short-term ventilation (≤3 days)
2-Long term weaning for patient requiring long-term ventilation (>3 days).
- The process of long term weaning often takes weeks. Usually this process
is complicated, and involves multiple delays and setbacks.
- During long-term weaning, the patient may fail a weaning trial and should
then be rested on the ventilator before another trial is attempted. The rest
period is to allow the recovery of the respiratory muscles.
- Patients who fail a weaning trial often exhibit rapid, shallow breathing
patterns consistent with their respiratory muscle weakness.
11- Provide for rest period on ventilator for 15 – 20 minutes after suctioning.
12- Ensure patient’s comfort.,
13- Administer pharmacological agents for comfort, such as bronchodilators
or sedatives as indicated.
14- Help the patient through some of the discomfort and apprehension.
15- Support and reassurance help the patient through the discomfort and
apprehension as remains with the patient after initiation of the weaning
process.
16- Evaluate and document the patient’s response to weaning.
- Diaphoresis
- Dyspnea
- Labored respiratory pattern
- Increased anxiety
- Restlessness
- Decrease in level of consciousness
- Dysrhythmias
- Increase or decrease in heart rate of > 20 beats /min.
or heart rate > 110b/m
- Sustained heart rate >20% higher or lower than baseline
- Increase or decrease in blood pressure of > 20 mm Hg
- Systolic blood pressure >180 mm Hg or <90 mm Hg
- Increase in respiratory rate of > 10 above baseline or > 30
- Sustained respiratory rate greater than 35 breaths/minute
- Tidal volume ≤5 mL/kg
- Sustained minute ventilation <200 mL/kg/minute
- SaO2 < 90%
- PaO2 < 60 mmHg
- A decrease in PH of < 7.35.
- Increase in PaCO2
6- Stop the weaning trial and return the patient to “rest” settings if the
patient displays any of the signs of weaning intolerance.
If tolerated,
- The goal is to increase the length of the trials and reduce the PSV level
needed on an incremental basis.
- The pace of weaning is patient-specific and tolerance may vary from day to
day.
- Review readiness criteria for correctable factors daily and each time
the patient “fails” a weaning trial.
- FIO2 ≤40%,
- Continue the trials two to three times per day with daily
increases in time on tracheostomy collar by 1 to 2 hours per
trial until total time off the ventilator reaches 18 hours
per day.
- Both of these factors are affected by physiological changes that change the
resting position of the diaphragm. With COPD, the resting length is shorter
(weakening force of contraction), and with diaphragmatic distension
ascites, or morbid obesity, the diaphragm must push down
abdominal contents as it contracts.
- Reactive airway disease increases the resistance to air flow, with increased
workload for muscles of respiration. Any of these abnormalities can lead to
significant fatigue of these muscles and respiratory distress.
Extubation Criteria
- Difficult intubation,
- Reactive airway disease.
NB
(Absence of a leak can indicate edema, and may predict laryngeal stridor
post-extubation. )
If the cuff leak test fails,
Documentation:-