By Riham Melhem

 Introduction &purpose
 Indications
 Types of Mechanical ventilators
 Classifications of Mechanical ventilators
 Mechanical ventilators modes & settings
 Mechanical ventilators complications
 Weaning process
 ]
 Mechanical Ventilation is ventilation of the lungs
by artificial means , delivered for Patients who are
unable to breathe effectively on their own.
 To maintain or improve ventilation, & tissue
oxygenation.

 To decrease the work of breathing & improve

patient’s comfort.
 INVASIVE Mechanical Ventilation :
 (ETT, TRACHESTMOY )
 ETT ;ORO-TRACHEAL , NASO- TRACHEAL
 NON-INVISIVE (CPAP,BIPAP) FACE MASK
 Respiratory Failure – 2 Types

Hypercapnic Respiratory Failure

Hypoxemic Respiratory Failure

VENTILATION ; The goal of ventilation is to facilitate
CO2 release and maintain normal PaCO2.

 Acute Ventilatory Insufficiency , ACUTE RISE IN

PCo2 &RESPIRATORY ACIDOSIS , pco2 60 mm hg
  CAUSES :
1. PERIPHRAL NERUMUSCULAR DISEASES ;GULLAN
BBARRIE SYNDROME , MYSTHENIA GRAVIS.
2. Musculoskeletal abnormalities, such as chest
wall trauma (flail chest)
3. Therapeutic muscle paralysis, balanced
anesthesia for management status
epileptics.
4. High co2 production , sepsis and burn.
 OXYGENATION , The primary goal of oxygenation
is to maximize O2 delivery to blood (PaO2)
 PO2 less than 60 mmHg
 Cardiac Insufficiency
◦ eliminate work of breathing
◦ reduce oxygen consumption
◦ After cardiac arrest
 Neurologic dysfunction
◦ central hypoventilation/ frequent apnea
◦ patient comatose, GCS < 8,general anesthesia
◦ inability to protect airway
◦ To reduce ICP
 Pa o2 <50 mm Hg
 Pa CO2 >60 mm Hg, with pH<7.35
 Vital capacity <2 times tidal volume
 Respiratory rate >35 per min
 Natural Breathing
◦ Negative inspiratory force
◦ Air pulled into lungs

 Mechanical Ventilation
◦ Positive inspiratory pressure
◦ Air pushed into lungs
 Negative-pressure ventilators (Iron lung).

 Positive-pressure ventilators.
 The use of those vent. restricted in clinical practice,
however, because they limit positioning and
movement and they lack adaptability to large or
small body torsos (chests) .

 Our focus will be on the positive-pressure

ventilators.
 Positive-pressure ventilators deliver gas to the
patient under positive-pressure, during the
inspiratory phase.
1- Volume Ventilators.

2- Pressure Ventilators

3- High-Frequency 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.

 The amount of pressure required to deliver the set

volume depends on :-
- Patient’s lung compliance
- Patient–ventilator resistance factors.
 The use of pressure ventilators is increasing in
critical care units.

 IT delivers a selected gas pressure to the patient

early in inspiration, and sustains the pressure
throughout the inspiratory phase.

 By meeting the patient’s inspiratory flow demand

throughout inspiration, patient effort is reduced
and comfort increased.
 Although pressure is consistent with these modes,
volume is not.

 Volume will change with changes in resistance or

compliance,

 Therefore, exhaled tidal volume is the variable to

monitor closely.

 With pressure modes, the pressure level to be

delivered is selected, and with some mode options
(i.e., pressure controlled [PC], described later), rate
and inspiratory time are preset as well.
 High-frequency ventilators use small tidal volumes
(1 to 3 mL/kg) at frequencies greater than 100
breaths/minute.

 The high-frequency ventilator accomplishes

oxygenation by the diffusion of oxygen and carbon
dioxide from high to low gradients of
concentration.
 This diffusion movement is increased if the kinetic
energy of the gas molecules is increased.

 A high-frequency ventilator would be used to

achieve lower peak ventilator pressures, thereby
lowering the risk of barotrauma.
If volume is set, pressure varies…..if
pressure is set, volume varies…..
….according to the compliance…...

COMPLIANCE =
∆ Volume / ∆ Pressure
Ventilators deliver gas to the lungs using positive
pressure at a certain rate. The amount of gas
delivered can be limited by time, pressure or
volume. The duration can be cycled by time,
pressure or flow.
1- Volume cycled ventilator

2- Pressure cycled ventilator

3- Time cycled ventilator

 Inspiration is terminated after a preset tidal volume
has been delivered by the ventilator.

 The ventilator delivers a preset tidal volume (VT),

and inspiration stops when the preset tidal volume
is achieved.
 In which inspiration is terminated when a specific
airway pressure has been reached.

 The ventilator delivers a preset pressure; once this

pressure is achieved, end inspiration occurs.
 In which inspiration is terminated when a preset
inspiratory time, has elapsed.

 Time cycled machines are not used in adult critical

care settings. They are used in pediatric intensive
care areas.
 The way the machine ventilates the patient

 How much the patient will participate in his own

ventilatory pattern.

 Each mode is different in determining how much

work of breathing the patient has to do.
 Volume Modes , Pressure Modes

 Our focus will be on volume modes , as it is most

commonly used .
1- Continues Mandatory Ventilation (CMV)
2- Assist-control (A/C)
3- Synchronized intermittent mandatory ventilation
(SIMV)
4- Intermittent Mandatory ventilation (IMV)
 Ventilation is completely provided by the
mechanical ventilator with a preset tidal volume,
respiratory rate and oxygen concentration

 Ventilator totally controls the patient’s ventilation

i.e. the ventilator initiates and controls both the
volume delivered and the frequency of breath.

 Client does not breathe spontaneously.

 Client can not initiate breathe

 should only be used when the pt. is properly
medicated with a combination of sedatives,
respiratory depressants and neuromuscular
blockers
 Indicated if pt. “fights” the vent., seizure, complete
rest for pt. for 24 hr., chest injury
 Disadvantages , can lead to a lazy diaphragm.
 The ventilator provides the patient with a pre-set
tidal volume at a pre-set rate .

 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 preset

number of breaths/minute
 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.
 In AC mode, the vent is not synchronized with the
pt. If the patient attempts a breath or is exhaling as
the vent is delivering a breath, then peak pressures
rise will rise above the pre-established limits and
the vent will stop short of delivering the full
volume.

 If the timing of the pt's own breath happens to be

synchronized with the vent's delivery of one, then
you may see higher volumes than what the vent
was set for.
 When the patient is too weak to perform the work
of breathing (e.g., when emerging from
anesthesia).

 Disadvantages:
 Hyperventilation,
 It's not natural to take the exact same sized breath
each time.
 Can lead to a lazy diaphragm .
 The ventilator provides the patient with a pre-set
number of breaths/minute at a specified tidal
volume and FiO2.

 In between the ventilator-delivered breaths, the

patient is able to breathe spontaneously at his own
tidal volume and rate with no assistance from the
ventilator.

 However, unlike the A/C mode, any breaths taken

above the set rate are spontaneous breaths taken
through the ventilator circuit.
 The tidal volume of these breaths can vary
drastically from the tidal volume set on the
ventilator, because the tidal volume is determined
by the patient’s spontaneous effort.

 Adding pressure support during spontaneous

breaths can minimize the risk of increased work of
breathing.

 Ventilators breaths are synchronized with the

patient spontaneous breathe.
 ( no fighting)
 Advantages include maintaining resp. muscle
strength.
 Used to wean the patient from the mechanical
ventilator.

 Weaning is accomplished by gradually lowering the

set rate and allowing the patient to assume more
work.
 Disadvantages of SIMV are increased work of
breathing and a tendency to reduce cardiac output,
which may prolong ventilator dependency.
 A preset mandatory rate is set but Pt.s are free to
breathe spontaneously between set ventilator
breaths.

 Intermittent mandatory ventilation modes - breaths

“above” set rate not supported.

 In IMV, the patient will get his time-triggered

breaths right on schedule. If he happens to be
exhaling during his spontaneous breath, then he
will ‘stack breaths.’ this leads to air trapping &
patient discomfort.
 In SIMV, the patient’s time-triggered mandatory
breath will come in just a fraction of a second early
so that the patient and the ventilator are
‘synchronized’ to avoid stacking breaths
 Weaning
◦ Using IMV to wean is no faster or better than
classical weaning or any other mode
 Controlling PaCO2
◦ IMV Ve is titrated with patient’s spontaneous Ve
◦ Often done with neuro patients
 To get a lower mean intrathoracic pressure than
A/C
 Fraction of inspired oxygen (FIO2)
 Tidal Volume (VT)
 Peak Flow/ Flow Rate
 Respiratory Rate/ Breath Rate / Frequency ( F)
 Minute Volume (VE)
 I:E Ratio (Inspiration to Expiration Ratio)
 The percent of oxygen concentration that the
patient is receiving from the ventilator. (Between
21% & 100%)
(room air has 21% oxygen content).

 Initially a patient is placed on a high level of FIO2

(60% or higher).

 Subsequent changes in FIO2 are based on ABGs and

the SaO2.
 Pao2 4-5 times of the FIO2
 An FiO2 of 100% for an extended period of time can
be dangerous ( oxygen toxicity) but it can protect
against hypoxemia

 Usually the FIO2 is adjusted to maintain an SaO2 of

greater than 90% (roughly equivalent to a PaO2 >60
mm Hg).

 Oxygen toxicity is a concern when an FIO2 of

greater than 60% is required for more than 25
hours
Signs and symptoms
1- Flushed face

2- Dry cough

3- Dyspnea

4- Chest pain

5- Tightness of chest

6- Sore throat
 Low saturation with 100% FIO2:
 ARDS
 HEMORAGE
 ALVELOAR COLLAPSE
 P. EMBOLI
 The number of breaths the ventilator will
deliver/minute (12-20 b/m).

 Total respiratory rate equals patient rate plus

ventilator rate.

 The nurse double-checks the functioning of the

ventilator by observing the patient’s respiratory
rate.
 The volume of air delivered to a patient during a
ventilator breath.

 The amount of air inspired and expired with each

breath.

 Usual volume selected is between 6-8ml/ kg body

weight).
 the large tidal volumes may lead to (volutrauma)
 In special cases, hypoventilation or hyperventilation
is desired

 In a patient with head injury,

 Respiratory alkalosis may be required to promote

cerebral vasoconstriction, with a resultant decrease
in ICP.
 High PCO2 will dilates the cerebral blood vessels in
the brain , which will increase the volume og blood
then increasing the ICP
 In this case, the tidal volume and respiratory rate
are increased

 In a patient with COPD

 Baseline ABGs reflect an elevated PaCO2 should not
hyperventilated. Instead, the goal should be
restoration of the baseline PaCO2. permissive
hypercapnia

 These patients usually have a large carbonic acid

load, and lowering their carbon dioxide levels
rapidly may result in seizures.
 In COPDS , we decrease the tidal volume, and the
respiratory rate to avoid hyperventilation and
hyperinflation .

 In ARDS , we decrease the tidal volume and

increase the respiratory rate to have normal minute
volume.
 The volume of expired air in one minute .

 Respiratory rate times tidal volume equals minute

ventilation VE = (VT x F)
 The ratio of inspiratory time to expiratory time
during a breath
 (Usually = 1:2)
 In adults if the peak airway pressure is persistently
above 45 cmH2O, the risk of barotrauma is
increased and efforts should be made to try to
reduce the peak airway pressure.

 INCCREASED PAP means obstructive problem :

 Tube is kinked
 Secretions , need for suction .
 Pt. biting the tube , need for sedation
 Water in the ventilator tubing.
 ETT advanced into right main stem bronchus.

 INCREASED PAP &P mean means retractive problem

like P.E
 DECREASED PAP means :
 Tube disconnection from machine circuit or from
pt.
 Leak in ETT cuff.

 AMBU BAGGING 100% When you are in doubt of the

causes of alarm.
 Provides positive pressure on inspiration to
decrease the work of breathing.

 10-20 cm H20
 Positive pressure applied at the end of expiration
during mandatory \ ventilator breath
 Normal physiological PEEP 3-5

◦ Increases distension of alveoli

◦ Prevents alveolar collapse

◦ “Recruits” previously collapsed alveoli

◦ Increases surface area available for gas exchange

◦ Allows delivery lower FIO2: reducing risk O2
toxicity.
◦ Treat pulmonary edema ( pressure help expulsion
of fluids from alveoli

◦ PEEP usually is set at 5 mmH2O and then

increased as needed to achieve acceptable
oxygen saturation with a FiO2 <0.6.
 High levels of PEEP may be bad in brain-injured
patients:
1. Decreased venous drainage
2. Transmission of intra-thoracic pressure which
will lead to Increased ICP
3. Deceased Cardiac Output which will lead to
Decreased cerebral blood flow.
◦ Other complications
◦ Barotrauma
◦ Hypotension
◦ CVP readings will be affected when giving PEEP over 5
(give CVP one to one ratio )
◦ While high PEEP is contraindicated for head
injuries it is recommended for patients with ARDS
and P.EDEMA <5-12 CM H2O
1. Airway Complications, like decreased clearance of
secretion, Nosocomial or ventilator-acquired
pneumonia
2. Mechanical complications, like Barotrauma
3. Physiological Complications, like Stress ulcers
Gastric distension.
4. Artificial Airway Complications, like Laryngeal
edema
Assessment:

1- Assess the patient

2- Assess the artificial airway (tracheostomy
or endotracheal tube)
3- Assess the ventilator
1-Maintain airway patency & oxygenation
2- Promote comfort
3- Maintain fluid & electrolytes balance
4- Maintain nutritional state
5- Maintain urinary & bowel elimination
6- Maintain eye , mouth and cleanliness and
integrity.
7- Maintain mobility/ musculoskeletal function:-
8- Maintain safety:-
9- Provide psychological support
10- Facilitate communication
11- Provide psychological support & information to
family
12- Responding to ventilator alarms /Troublshooting,
ventilator alarms
13- Prevent nosocomial infection
14- Documentation
 High pressure alarm
 Low pressure alarm

 High respiratory rate alarm

 Episodes of tachypnea,
 Anxiety,
 Pain,
 Hypoxia,
 Fever.
 Apnea alarm

 During weaning, indicates that the patient has a

slow Respiratory rate and a period of apnea.
 Awake and alert

 Hemodynamically stable, adequately resuscitated,

and not requiring vasoactive support

 Arterial blood gases (ABGs) normalized or at

patient’s baseline
- PaCO2 acceptable
- PH of 7.35 – 7.45
- PaO2 > 60 mm Hg ,
- SaO2 >92%
- FIO2 ≤40%
 Positive end-expiratory pressure (PEEP) ≤5 cm
H2O
 F < 25 / minute
 Vt 5 ml / kg
 VE 5- 10 L/m (f x Vt)
 Chest x-ray reviewed for correctable factors;
treated as indicated,
 Major electrolytes within normal range,
 Adequate management of pain/anxiety/agitation,
 Adequate analgesia/ sedation (record scores on
flow sheet),
 No residual neuromuscular blockade.
1- Ensure that indications for the implementation of
Mechanical ventilation have improved.

2- Ensure that all factors that may interfere with

successful weaning are corrected:
 Acid-base abnormalities
 Fluid imbalance
 Electrolyte abnormalities
 Infection
 Fever
 Sleep deprivation
3- Assess readiness for weaning

4- Ensure that the weaning criteria / parameters are

met.

5- Explain the process of weaning to the patient and

offer reassurance to the patient.

6- Initiate weaning in the morning when the patient

is rested.
7- Elevate the head of the bed & Place the patient upright

8- Ensure a patent airway and suction if necessary before a

weaning trial.

9- Provide for rest period on ventilator for 15 – 20 minutes

after suctioning.

10- Ensure patient’s comfort & administer

pharmacological agents for comfort, such as
bronchodilators or sedatives as indicated.
11- Support and reassurance help the patient
through the discomfort and apprehension
as remains with the patient after initiation
of the weaning process.

13- Evaluate and document the patient’s

response to weaning.
1- Wean only during the day.
2- Remain with the patient during
initiation of weaning.
3- Instruct the patient to relax and breathe
normally.
4- Monitor the respiratory rate, vital signs,
ABGs, diaphoresis and use of accessory
muscles frequently.
If signs of fatigue or respiratory distress develop.
Discontinue weaning trials.
 SMIV , CPAP , T-Piece , face mask , nasal canula ,
room air
1. SIMV is the most common method of weaning.

 It consists of gradually decreasing the number of

breaths delivered by the ventilator to allow the
patient to increase number of spontaneous
breaths.
 Decrease Fio2 <40%
 Constant positive airway pressure during
spontaneous breathing

 CPAP allows the nurse to observe the ability of the

patient to breathe spontaneously while still on the
ventilator.
 It consists of removing the patient from the
ventilator and having him / her breathe
spontaneously on a T-tube connected to oxygen
source.
 During T-piece weaning, periods of ventilator
support are alternated with spontaneous breathing.

 The goal is to progressively increase the time spent

off the ventilator.
 Allow T- piece (20-30) minutes
 Mask-Nasal Cannula-Room air.
 ABGS after 20-30 minutes .
 Keep monitoring the pt. for any deterioration.
 Documentation