Mechanical Ventilation

Nagwa Sabrah, PhD

Lecturer of Critical Care and Emergency Nursing
Faculty of Nursing-Mansoura University
Outlines
• Definition
• Purposes of mechanical Ventilation
• Indications of mechanical Ventilation
• Criteria for intubation
• Types of Mechanical Ventilation
• Ventilator Setting
• Modes of Mechanical Ventilation
• Weaning
• Complications of Mechanical Ventilation
• Nursing Care of Mechanically Ventilated Patients
 Mechanical ventilation

• Mechanical ventilation is the process of

using artificial means usually a ventilator to
facilitate O2 and CO2 transport between
the atmosphere and alveoli (lungs
ventilation) that deliver gas to the lung with
either negative or positive pressure.
 Purposes of Mechanical Ventilation

• Supporting the pulmonary system until the cause is

corrected.
• Providing appropriate oxygen supplementation.
• Assuring adequate alveolar minute ventilation.
• Reducing the work of breathing.
• Increasing patient comfort during respiration.
Indications of Mechanical Ventilation
Criteria for Initiation of Ventilatory Support
 Types of Mechanical Ventilation

• Noninvasive techniques of ventilation

▪ Noninvasive techniques do not require intubation.
▪ It provides ventilation via a nasal, oral mask, or mouthpiece
with a tight seal.
▪ It is primarily used in home care settings.
 Types of Mechanical Ventilation
• Negative Pressure Ventilator (old fashion)
o Negative pressure ventilator is an external vent that does not require
intubation.
o It creates negative pressure on the chest by a vacuum thus allowing
air to flow into the lungs.
o It is used mostly for patients with chronic respiratory failure or
neuromuscular diseases.
o Example of this type is iron lung.
 Types of Mechanical Ventilation

• Positive pressure ventilator (most commonly used)

o Positive pressure ventilator is a bedside machine that requires
intubation (artificial airway as ETT).
o It forces a positive pressure on the chest via artificial airway.
o Inspiration can be initiated either by the patient or the machine.

• It is used mostly for patients with chest wall trauma, chronic

respiratory failure or neuromuscular diseases.
Types of Positive Pressure Ventilators
 Ventilator Settings

1. Input Panel (settings)

 Ventilator Settings
2. Trouble Shooting Mechanical Ventilator Alarms
 Ventilator Settings
2. Trouble Shooting Mechanical Ventilator Alarms
 Ventilator Settings
2. Trouble Shooting Mechanical Ventilator Alarms
 Modes of Mechanical Ventilation
1. Control Mandatory Ventilation (CMV)
• Ventilation is completely provided by the ventilator.
• Preset tidal volume and maximum ventilator rate.
• No patient interaction with ventilator.
• Advantages: rests muscles of respiration
• Disadvantages: requires sedation/neuromuscular blockade,
potential adverse hemodynamic effects
 Modes of Mechanical Ventilation
2. Assist-control Ventilation (A/C)
• Additional patient-initiated breaths receive preset tidal volume.
• Preset tidal volume and minimal ventilator rate.
• The patient may need to be sedated to limit the number of breaths due to
hyperventilation.
• Advantages: reduced work of breathing; allows patient to modify minute
ventilationby increasing respiratory rate.
• Disadvantages: potential adverse hemodynamic effects or inappropriate
hyperventilation as dy-synchrony or respiratory alkalosis.
 Modes of Mechanical Ventilation
3. Intermittent Mandatory Ventilation (IMV)
• Specified preset tidal volume, a preset rate and fio2.
• Advantages: in between the ventilator-delivered breaths, the
patient is able to breathe spontaneously.
• The ventilator dose not assist the spontaneous breaths.
• The mandatory breathing (ventilator) is not synchronized with
the patient's spontaneous breathing (Fighting).
 Modes of Mechanical Ventilation
4. Synchronized Intermittent Mandatory Ventilation (SIMV)
• Preset tidal volume with a minimum preset rate.
• Additional spontaneous breaths at tidal volume and rate determined by patient.
• Often used with pressure support.
• Advantages: each ventilator breath is delivered in synchrony with the patient’s breaths. The
ventilator attempts to synchronize the set number of mandatory breaths with the patient’s
respiratory efforts.

• SIMV is used as a primary mode of ventilation, as well as a weaning mode.

• Disadvantage: this mode is that it may increase the work of breathing and respiratory muscle
fatigue.
 Modes of Mechanical Ventilation
5. Pressure-Support Ventilation (PSV)
• Positive support pressure assists used in combination with other
ventilator modes during spontaneous inspiration.
• Positive support works by responding to a patient’s inspiratory effort
with a positive pressure breath delivered at a set pressure.
• Pressure assist continues until inspiratory effort decreases.
• Pressure support breath is pressure controlled, patient triggered,
pressure limited, and patient cycled.
• Delivered tidal volume dependent on inspiratory effort and resistance,
compliance of lung and thorax wall.
 Modes of Mechanical Ventilation
5. Pressure-Support Ventilation (PSV)
• Advantages: the flow rate, inspiratory time, and frequency are
variable and determined by the patient.
• Decreased inspiratory work and enhanced muscle reconditioning.
• A mode used primarily for weaning from mechanical ventilation.
• Disadvantages: require spontaneous respiratory effort.
• Delivered volumes affected by changes in lung compliance.
 Modes of Mechanical Ventilation
6. Continuous Positive Airway Pressure (CPAP)
• No machine breaths or tidal volume delivered.
• Allows spontaneous breathing at elevated baseline pressure
• Patient controls rate and tidal volume.
• Advantages: mode used primarily for weaning from mechanical ventilation.
• Disadvantages: requires spontaneous respiratory effort.
• Delivered volumes affected by changes in lung compliance.
 Adjuncts Ventilator Modes
1. Positive End Expiratory Pressure (PEEP)
• PEEP is a positive pressure that is applied by the ventilator at the end
of expiration.
• PEEP does not deliver breaths, but is used as an adjunct to mode for
improving oxygenation by opening collapsed alveoli at the end of
expiration and may decrease the work of breathing
 Adjuncts Ventilator Modes
1. Positive End Expiratory Pressure (PEEP)
• Advantages: method of improving the patient’s oxygenation without increasing
the FiO2.
• Decreasing physiological shunting and increased lung compliance.
• Disadvantages: increased incidence of pulmonary barotrauma.
• Potential decreasing venous return and may increasing intracranial pressure.
 Adjuncts Ventilator Modes
2. Constant Positive Airway Pressure (CPAP)
• CPAP is similar to PEEP except that it works only with patients who are
breathing spontaneously.
• No mandatory breaths are delivered in this mode.
• All ventilation is spontaneously initiated by the patient.
 Adjuncts Ventilator Modes
2. Constant Positive Airway Pressure (CPAP)
• Advantages: allows the nurse to observe the ability of the patient to breathe
spontaneously while still on the ventilator.
• CPAP can also be administered using a mask and CPAP machine
(noninvasive ventilation) for patients who do not require mechanical ventilation,
but need respiratory support, for example, patients with sleep apnea.
 Weaning from Mechanical Ventilation

Weaning is the process whereby a patient is transferred from mechanical

ventilation support to spontaneous breathing i.e Weaning is the gradual process
of removing the patient from mechanical ventilation therapy.
 Methods of Weaning

• Synchronized intermittent mandatory ventilation (SIMV) weaning.

• Continuous positive airway pressure (CPAP) weaning,
• Pressure support ventilation (PSV) weaning.
• T-piece trial
 Weaning criteria / parameters
according to Burns weaning assessment program (BWAP)
(1991)
• Awake and alert.
• Hemodynamically stable, adequately resuscitated, and not requiring
vasoactive support
• Arterial blood gases (ABGs) normalized or at patient’s baseline
o PaO2 > 60 mm Hg on FiO2 < 50%
o PaCO2 acceptable with PH of 7.35 – 7.45
 Weaning criteria / parameters
• Pulmonary function
o F < 25 / minute
o VT 5 ml/kg
o VE 5- 10 L/m (f x VT)
o VC > 10- 15 ml/kg
• Lung mechanics
o Positive end-expiratory pressure (PEEP) ≤5 cm H2O
o PEP (positive expiratory pressure) > - 20 cm H2O (indicates patient’s
ability to take a deep breath & cough),
o Chest x-ray reviewed for correctable factors; treated as indicated,
 Weaning criteria / parameters
• Laboratory values
o Major electrolytes within normal range,
o Hematocrit >25%,
• General parameters
o Core temperature >36°C and <39°C,
o Adequate management of pain/anxiety/agitation,
o Adequate analgesia/ sedation (record scores on flow sheet),
o No residual neuromuscular blockade.
• Burns Weaning Assessment Program (BWAP)
• To score BWAP: divide the number of "yes" responses by 26
 Weaning criteria / parameters
• Threshold:
• > 65% = weaning probable
• < 65% = weaning improbable
 Nursing Care
Nursing role before weaning
• Assess readiness for weaning.
• Wean only during the day.
• Explain the process of weaning to the patient and offer reassurance to the
patient.
• Elevate the head of the bed & place the patient upright
• Instruct the patient to relax and breathe.
• Ensure a patent airway and suction, if necessary, before a weaning trial.
 Nursing Care
Nursing role before weaning
• Provide a rest period on a ventilator for 15 – 20 minutes after suctioning.
• Monitor patient’s response.
• Record:
✓Use of accessory muscle
✓ABGs & O2 saturation
✓Spontaneous respiratory rate
✓Patient’s response
✓Date, time, and Method of weaning
 Nursing Role During Weaning
• Remain with the patient during the initiation of weaning.
• Instruct the patient to relax and breathe normally.
• 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.
• Monitor for signs of weaning Intolerance:
✓Dysrhythmia
✓Increase or decrease in heart rate of > 20 beats /min. or heart rate > 110b/m.
✓Increase or decrease in blood pressure of > 20 mm Hg.
✓Increase in respiratory rate of > 10 above baseline or > 30.
 Nursing Role During Weaning
• Monitor for signs of weaning Intolerance:

o Tidal volumes of < 250 ml. o Diaphoresis

o Decrease in LOC o Dyspnea
o Restlessness o SaO2 < 90%
o Increase in PaO2 with a decrease in PH o PaO2 < 60 mmHg
of < 7.35.
 Nursing Role After Weaning

• Ensure that extubation criteria are met.

• Decannulate or extubate the patient.
• Documentation for all patient parameters and responses.
 Weaning Steps
• Evidenced-based clinical guidelines recommend a spontaneous breathing
trial (SBT) in patients who demonstrate weaning readiness.
• SBT should be at least 15- 30 minutes but no longer than 120 minutes.
• Explain the procedures to the patient and family.
• The patient should be enough rested and positioned comfortably.
• Observe the patient during weaning for tolerance or intolerance to the
weaning process.
 Complications of MV
1. Barotrauma
2. Volutrauma
3. Intubation of right mainstem bronchus
4. ETT displacement or extubation
5. Tracheal damage
6. Oxygen toxicity
7. Acid-base disturbances
8. Aspiration
9. Hypotension
10.Increased intracranial pressure
11.Stress ulcer and GIT bleeding
 Complications of Positive Pressure Ventilation

1. Pulmonary System
A. Barotrauma
- Patients with high level of PEEP, diseases (e.g. COPD) or stiff (e.g. ARDS)
lungs with high VT are more risky for barotrauma → extra alveolar air → ↑
Airway pressure → lungs over distended → tension pneumothorax,
emphysema → may alveolar rupture occur.
 Complications of Positive Pressure Ventilation

B. Intubation of the right main bronchus

C. Acid-base disturbance
- Inappropriate ventilator settings, leakage of air from the ventilator tubing or
around the tube cuff, lung secretions or obstruction, and low
ventilation/perfusion ratio → alveolar hypoventilation → ↑ CO2 → respiratory
acidosis.
- ↑ Respiratory rate or VT or A/CMV → alveolar hyperventilation → ↓ CO2
→respiratory alkalosis.
 Complications of Positive Pressure Ventilation
D. Ventilator-associated pneumonia (VAP)
- Intubation → ↓ upper airway defenses and mechanical ventilation → ↑
risk for VAP.
- VAP Prevention
• Semi-recumbent positioning with head elevation 30-45º.
• Sedation vacation with weaning assessment.
• Continuous subglottic secretion removal.
• Oral vs. nasal feeding tubes (aspiration).
• Targeted oral hygiene with chlorohexidine gluconate washes.
• Stress ulcer prophylaxis and selective digestive tract determination.
 Complications of Positive Pressure Ventilation
E. Aspiration
- NGT feeding, impaired gastric emptying → ↑ gastric residual →
aspiration
F. Pulmonary infections
G. Oxygen toxicity
- FiO2 > 60% for more than 48 hours or FiO2 of 100% → pulmonary
change within 6 hours. If continue ˃ 72 hours→ similar ARDS.
 Complications of Positive Pressure Ventilation
H. Ventilator dependence/inability to wean
- Long-term MV, poor nutrition, poor cardiac output, certain drugs,
chronic muscle overload, and acute systemic illness → Ventilatory
muscle atrophy → weaning failure.
 Complications of Positive Pressure Ventilation
2. Cardiovascular System
- ↑ intra-thoracic pressure → thoracic vessels are compressed → ↓
venous return to heart, ↓ left ventricular end-diastolic volume (preload),
↓CO, and hypotension.
- Mean airway pressure is further increased if titrations PEEP (5 cm H2O)
to improve oxygenation.
 Complications of Positive Pressure Ventilation
3. Endocrine System
- PPV → fluid and sodium retention within 48 to 72 hours → ↓ CO→ ↓
renal perfusion → rennin released → production of angiotensin and
aldosterone → ↑ sodium and water retention.
 Complications of Positive Pressure Ventilation
4. Neurologic System
- PPV, especially with PEEP → ↑ intra-thoracic positive pressure →
impaired cerebral blood flow → ↓ venous drainage head → ↑ cerebral
volume → ↑ intracranial pressure (ICP).
- Elevating the head of the bed and keeping the patient's head in
alignment may ↓ effects of PPV on ICP
 Complications of Positive Pressure Ventilation
5. Gastrointestinal System
- PPV → stress ulcer and GI bleeding → ↓ CO → ischemia of the gastric
and intestinal mucosa → ↑ GI bacteria colonization → gas accumulation
in the GIT from swallowed air → ↑ bowel distention.
 Complications of Positive Pressure Ventilation
6. Musculoskeletal System
- Immobility or improper positioning may lead to muscle contractures,
pressures ulcers, foot drop, external rotation of the hip and legs, deep
venous thromboembolism, and skin break down.
7. Psychological Complications
- Intubation and PPV → speaking, eating, moving, or breathing difficulties
→ pain, fear, agitating, and anxiety
 Complications of Positive Pressure Ventilation
8. Machine Disconnection or Malfunction
- Mechanical ventilation may become disconnected or malfunction. →
alarm alert → if alarm is not inactivated → patient deaths can occur.
9. Communication Difficulties
- -Mechanically ventilated patients have communication problems due to
presence of endotracheal tube.
- Communication board can be used as a means of communication with
those patients.
 Care of the Ventilated Patient
• Assess patient status and functioning of ventilator.
• Promote optimal gas exchange.
• Reduce mucus accumulation.
• Prevent trauma.
• Prevent infection.
• Obtain optimal mobility.
• Establish non-verbal communication