MECHANICAL VENTILATOR

VENTILATION:-Ventilation or breathing is the process of moving air into and out of the
lungs.
MECHANICAL VENTILATION: -It is the process of artificial respiration through the
device “Mechanical Ventilator”.
MECHANICAL VENTILATOR: - Mechanical ventilator is an apparatus which can
replace normal mechanism of breathing either by providing intermittent or continuous flow of
oxygen or air under pressure, which is connected to the patient by a tube inserted through
mouth, the nose or an opening in the trachea.

INDICATIONS FOR MECHANICAL VENTILATION:-“ An opening must be attempted

in the trunk of the trachea, into which a tube or cane should be put; you will then blow into
this so that lung may rise again…..And the heart becomes strong….”
INDICATIONS:-
 Primary Indication
 Prophylactic Indication
 Therapeutic Indication
Primary Indications:
1. Acute Respiratory Failure (66%)
  Acute respiratory distress syndrome
 Heart failure
 Pneumonia
 Sepsis
 Complication of surgery
 Trauma
2. Coma (15%)
3. A/c Exacerbation of COPD (13%)
4. Neuromuscular Disease (5%)
Prophylactic Indication:
1. Shock
2. Postoperatively
 Extreme obesity
 Possibility of sepsis
 COPD with upper abdominal surgery
 Cardiovascular and neurological surgeries
3. Acid aspiration syndrome
Therapeutic Indication:
1. Resuscitation from cardio respiratory arrest
2. Hypoventilation/ Apnea
3. Drug over Dosage
4. Neurological dysfunction
5. Trauma to chest and lacerated diaphragm
OBJECTIVES OF MECHANICAL VENTILATION:-
 Improves Pulmonary Gas Exchange
 Relieves respiratory distress
 Alter pressure volume relations
 Permit lung and airway healing
 Avoid complication
 Improve oxygenation
TYPES OF MECHANICAL VENTILATOR:-
 Negative- pressure ventilators
 Positive- pressure ventilator
Negative-Pressure Ventilator:
 Negative pressure applied to chest wall increase the volume of the thoracic cage
 Mimics spontaneous ventilation
 Negative intrathoracic pressure gradient causes air to enter lungs
 No need for artificial airway
 Use mainly for chronic care of patients with neuromuscular disorders
 Examples: iron lung, pulmowrap chest cuirass
Positive-Pressure Ventilator:
  Intrathoracic pressure remains positive throughout respiration
 Force oxygen into thepatients lungs through an endotracheal or tracheostomy tube to
initiate respiration.
 Gas is distributed to non- dependent, less-perfuse lung regions.
MODES OF VENTILATORS:-
1. Controlled mode
RR and TV by ventilator
2. Assist control mode ( Mixed Mode)
Both got their role
3. Spontaneous mode
RR and TV by patient
 Controlled Mode Ventilation:
 Pressure controlled ventilation
 Volume controlled ventilation
 Time controlled ventilation
Pressure Controlled Ventilation:
 Pressure cycled breathing, fully ventilator controlled
 Suited for patients with neuromuscular diseases
 Inspiratory phase stops when preset inspiratory pressure is reached
Volume Controlled Ventilation:
 Volume targeted ventilation
 Inspiratory cycle ends when TV is delivered
 Ventilator generates sufficient pressure to deliver set volume
Time Controlled Ventilation:
 Normal I:E ratio-> 1:2
 Prolonged expiratory phase according to the underlying pathology i.e; up to 1:3 or 1:4
Inverse Ratio Ventilation:-
 Helps prevent alveolar collapse
 Hyperinflation, auto-PEEP and decreased cardiac output
 Use: ARDS with refractory hypoxemia or hypercapnia
 Assist Control Mode Or Mixed Mode:-
 Intermittent mendatoryventilation [IMV]
Mandatory breaths
 Synchronized intermittent mandantory ventilation [SIMV]
Synchronized breaths
 SIMV+Pressure Support
Pressure support too along with
 Spontaneous mode:-
 Pressure Support Ventilation:
Spontaneous inspiratory efforts trigger the ventilator to provide a variable
flow of gas in order to attain a preset airway pressure. Machine assist and
augument the spontaneous breathing efforts of patient
 Continuous positive airway pressure [CPAP]:
No machine breaths delivered
 Allow spontaneous breathing at elevated baseline pressure
Patient controls rate and tidal volume
VENTILATOR SETTING:-
Tidal volume [VT]: 8-10ml/kg
Small tidal volume in ARDS and Bronchospasm
Large tidal volume causes Increased airway pressure and Barotraumas.
FiO2 (oxygen concentration): express as percentage or decimals settings from 21% to 100%
(0.21 to 1.0) FiO2 of 0.5 or less-minimize oxygen
Target PaO2 is
60 mg of Hg or
SpO2 90% in ABG
SpO2 95% in pulse oximeter with minimum possible FiO2.
Respiratory rate (RR) or Frequency:
Set rate depends on age of patient
Newborn- 30-40/mt
Children-20-30/mt
Adult-10-15/mt
Reduce rate in patients with COPD.
Minute Volume [MV]:
Minute volume= Tidal volume*R.R.
I:E Ratio and Inspiratory time: Determines duration of inspiration and oxygenation
Newborn 0.3-0.5 sec
Infant and Children 0.5-0.8 sec
Adult up to 1.5 sec
Normal I:E- 1:2 (is physiological)
COPD- 1:3 to 1:4
1:1 or 2:1 or more is called Inverse Ratio Ventilation.
Trigger sensitivity
Flow rate: 40-60 L/Mt
End Expiratory Pressures (EEP)
PEEP [Positive End Expiratory Pressure]
ZEEP [Zero End Expiratory Pressure]
NEEP [Negetive End Expiratory Pressure]
Initial Ventilator Setting For An Adult:-
Mode PCV/VCV
FiO2 0.7-1 decrease to 0.5 or less
Tidal Volume (VT) 10 ml/kg
RR 10-15 breaths/mt
Trigger -2 cm of H2O
Flow rate 40-60 L/mt
I:E 1:2 to 1:3
PEEP 5 cm of H2O
Analyze Arterial Blood Gas 20 minutes later and adjust.
CARE DURING MECHANICAL VENTILATION:-
 Sedation and muscle paralysis
 Humidification
 Chest physiotherapy
 Suctioning event
 Nutritional support
 Other general care
 Prevention of infection
DISCONTINUE MECHANICAL VENTILATION:-
 Death
 Weaning: Up to 25% of patients have respiratory distress severe enough to require
reinstitution of ventilator.
 Extubation: 10-20% of extubated patients who were successfully weaned require
reintubation.
THE WEAN: Weaning is the gradual withdrawal from mechanical
ventilation.
Techniques of wean:
SIMV Wean
PS Wean
T-Piece Trial
ROLE OF NURSE IN CARE OF MECHANICALLY VENTILATED PATIENT:-
Hand hygiene: Wash hands before direct contact. 40% of infections are transmitted
by the hands of hospital staff.
Recording of vital signs:
 Record vital signs
 Observe respiratory pattern and auscultate lung sound
 Observe for breathing pattern in relation to voluntary cycle
 Assess the changes in mental status and LOC
 Continuous pulse oximetry
 Observe ABG
Endotracheal Tube Care:
 Introduce an orophyngeal airway
 Maintain inflation of the cuff at 15-20 mmHg
 Institute endotracheal suctioning as appropriate
 Change endotracheal tapes every 24 hours
 Inspect the skin and oral mucosa
 Stop feeding during 30-60 minutes before suctioning and chest physiotherapy
 Observe the type, color and amount of secretion, notify the changes
 Watch for the side effects: hypoxemia, bradycardia, hypotension
 Avoid drawing of arterial blood sample immediately after suctioning
Oral hygiene:
 Provide careful oral hygiene
 Apply lubricant to lips to prevent drying, cracking and excoriation
 Rotate the ET tube from one corner of mouth to the other side at least every
24 hours
Arterial blood gas analysis:
 ABG reflects oxygenation adequacy of gas exchange in the lungs and
acid-base status
 Avoid taking sample immediately after suctioning, nebulization and
baging
 Send immediately ABG sample to laboratory
Positioning:
 Turn and reposition the patient every 2nd hourly
 Positioning prevents complications such as pneumonia and atelectasis
Personal hygiene:
 Frequent oral hygiene must be done
 Eye care to be given every 4 hourly to prevent corneal ulcer and
dryness of conjunctiva
 Provide skin care
 Provide catheter care using sterile technique
Allaying anxiety and fear:
  Explain all the procedures to the patient and relatives to win their
confidence
 Talk and clear the doubts of patient and attainders. Never ignore their
feelings
 Use therapeutic touch
 Encourage the family members to visit the patient as per hospital policy
Care of ventilator circuit:
 Keep the water level in humidifier in normal limit.
 Sterile water should be used only
 Humidification during mechanical ventilation required to prevent
hypothermia, destruction of airway secretions etc.
 A heated humidifier should be set to deliver an inspired gas temperature
of 33-/+2degree Celsius
 Change the circuit when it is visibly soiled or mechanically
malfunctioning
 Bacterial filters should not be used for more than 48 hours
 Use universal precaution when involved in circuit changes.