mechinical-ventillator.ppt DESASAAAAAAAAA

PP

1. Powerpoint Templates
Page 1
CARE OF PATIENTS IN
VENTILATOR

2. Powerpoint Templates
Page 2

3. Powerpoint Templates
Page 3
Definition
•A mechanical ventilator is a positive pressure or
negative pressure breathing device that can
maintain ventilation and oxygen delivery for a
prolonged period of time.
• It is needed for the variety of reasons i.e. to
control the patients respiration during surgery,
during treatment of severe head injury ,to
oxygenate the blood when the patient’s
ventilatory effort are inadequate and to rest the
respiratory muscle etc.

4. Powerpoint Templates
Page 4

5. Powerpoint Templates
Page 5
Purposes
To maintain gas exchange in case of acute and
chronic respiratory failure.
To maintain ventilatory support after CPR.
To reduce pulmonary vascular resistance.
To excrete increased CO2 production.
To give general anesthesia with muscle
relaxants.

6. Powerpoint Templates
Page 6
INDICATIONS
•Upper airway obstruction or lower airway
obstruction as a result of blockage caused by
blood or pus or bronchospasm and edema.
•Neuromuscular disorders as in Myasthenia
gravis, Poliomyelitis, Gullian-Barre syndrome,
Snake bite and inadequate reversal of anesthesia.
•Lung diseases which prevent proper exchange of
O2 and CO2 as in chest injuries, pneumothorax,
lung infections, COPD, Acute Respiratory
Distress Syndrome (ARDS).

7. Powerpoint Templates
Page 7
Conti….
• Respiratory arrest.
• Post-operative cardiac surgery, any other
surgery, shock & trauma.
• Circulatory failure- MI , cardiogenic shock

8. Powerpoint Templates
Page 8
Classifi
cation of Ventilators
ventilator
Positive pressure
ventilator




Negative pressure
• ventilator

9. Powerpoint Templates
Page 9
Negative pressure
ventilator
9

10. Powerpoint Templates
Page 10
•Positive pressure ventilators: Positive
pressure ventilators inflate the lungs by
exerting positive pressure on the airway,
forcing the alveoli to expand during
inspiration.
• These require an artificial airway
(endotracheal and tracheostomy tube).

11. Powerpoint Templates
Page 11
11

12. Powerpoint Templates
Page 12
Clinical indication of mechanical
ventilator:
•Partial pressure of oxygen<50 mm of Hg and fraction of
inspired air>60%
•Partial pressure of oxygen>50mm of Hg with
pH<7.25(persistent acidosis)(normal pH= 7.35 to 7.45)
•Increase in arterial carbon dioxide (PaCO
2>50-55
mmHg)
•Vital capacity<2 times tidal volume
•Respiratory rate>35/min

13. Powerpoint Templates
Page 13
3 types of positive-pressure ventilators
1.Pressure-cycled
2.Time-cycled
3.Volume-cycled

14. Powerpoint Templates
Page 14
I
nitiating Mechanical
Ventilation
Initial ventilator settings:
FiO
2 100 initially but then reduce
PEEP 5 -7 cmH
2O
Tidal volume 7-10 ml/kg
Inspiratory pressure 20 cmH
2
O (15cmH
2
O above PEEP)
Frequency 10 - 15 breaths per minute
Pressure support (ASB) 20 cmH
2
O (15cmH
2
O above PEEP)
I:E Ratio 1:2
Flow trigger 2 l/min
Pressure trigger -1 to -3 cmH
2O
Inspiratory flow 60 L/min
These settings should be titrated against the pt.'s clinical state and
level of comfort 14

15. Powerpoint Templates
Page 15
Ventilator Parameters
Parameter Definition Ventilator setting before
use
Tidal Volume (Vt)Amount of air inspired and expired
with each breath
Approx. Body weight × 10 ml (
not applicable in every case)
Breaths/min No. of breaths delivered per minuteIn adult 10-16 breaths per
minute
In children 16-22 breaths per
minute
Fraction of
Inspired Oxygen
(FiO2)
Amount of O2 the patient receives21% -100% to maintain PaO2
80 -100
Positive End
Expiratory
Pressure (PEEP)
Positive pressure applied at the end
of expiration to improve oxygenation
and prevent alveolar collapse
Generally is 5 cm of H2O
If applicable (5-15 cm of H2O)
I:E Ratio Comparison of inspiratory to
expiratory time
Normally set 1:1 or 1:2
Pressure Support
Level (PSV)
Provides Positive pressure during the
inspiratory cycle
10 -12 cm of H2O

16. Powerpoint Templates
Page 16
Modes of Mechanical Ventilator
Mode Definition Considerations
Control
Ventilation
(CV)
Preset tidal volume and preset rate is
delivered to the client, spontaneous
respiratory effort of the client is locked out.
Sedation and Paralyzing
drugs is must for such
patients to prevent bucking.
Assit-
control (A/C)
Ventilation
Preset tidal volume and preset rate is
delivered to the client. If client initiates a
breath between the machine’s breath, the
ventilator delivers at the preset volume
(assisted breath). Provides full ventilator
support.
Chances for bucking the
ventilator is increased so
sedation may be needed to
reduce spontaneous breaths.
Intermittent
Mandatory
Ventilation
(IMV)
Provides a combination of mechanically
assisted breaths and spontaneous breaths.
Between machine breaths the client can
breathe spontaneously at their own tidal
volume.
Allows patients to use their
own muscles for ventilation
thus help prevent muscle
atrophy.
Primary ventilator mode
used to wean the client.
Sedation may be required to
prevent bucking.

17. Powerpoint Templates
Page 17
Modes of Mechanical VentilatorMode Definition Considerations
Synchronized
Intermittent
Mandatory
Volume (SIMV)
Similar to IMV
Here the ventilator senses patient
breathing efforts and does not initiate a
breathe in opposition to the patient’s
effort, bucking the ventilator is reduced.
Primary ventilator mode used to wean
the clients.
Monitor clients inspiratory effort to
synchronize with ventilator effort.
Continuous
Positive Airway
Pressure (CPAP)
Allows the patient to breath
spontaneously by applying positive
pressure to the airways throughout the
respiratory cycle to keep alveoli open
and promote oxygenation..
Mode preferred before weaning from
ventilator.
Must assess for fatigue, period of
apnea, hypoxia, tachypnea,
tachycardia, reduced tidal volume,
increasing CO2 level, decreasing
saturation.
Pressure Support
Ventilation (PSV)
Augments patient’s Inspiratory effort
with a selected amount of Inspiratory
pressure. This pressure is maintained
through out the Inspiratory cycle,
allowing the patient to select rate, tidal
volume and the timing.
Mostly used in conjunction with SIMV
and CPAP

18. Powerpoint Templates
Page 18
Ventilator Alarms
Alarm Cause Solution
High PIP (positive
Inspiratory
pressure) means
pressure required
to ventilate
exceeds preset
pressure
Coughing or plugged airway
tube
Excessive secretion
Kinking of the tube
Patient bucking the ventilator
Decreasing lung compliance
Suction airway for secretion
Empty condensation fluid from
circuit.
Check tubing, filter, reposition the
patient, Insert oral airway
Adjust sensitivity
Sedate if necessary
Manually ventilate patient, notify
physician
Assess for hypoxia
Check ABG values
Low PIP or loss of
volume or circuit
fault
Leak or break in ventilator
circuit
Increase in airway resistance
Decrease in lung compliance
Check entire ventilator circuit for
patency, correct leak
Decreased RR/
Apnea
Client fatigue
Resulting from medication
Change the ventilator settings
O2 range error Decreased central supply of
O2
Adjust the central supply

19. Powerpoint Templates
Page 19
DIFFERENT MODES OF
VENTILATORS
Mode refers to how the machine will ventilate the patient in
relation to the patient's own respiratory efforts.
• Controlled Ventilation: The ventilator initiates and
controls both the volume delivered and the frequency of
breaths.
• Assisted Control Ventilation (A/C): In this mode, the
ventilator provides a mechanical breath with either a pre-set
tidal volume or peak pressure every time the patient initiates
a breath.
•Intermittent Mandatory Ventilation (IMV): It allows the
patient to breath spontaneously with the ventilator providing
mandatory breaths at a predetermined rate at a preset tidal
volume.

20. Powerpoint Templates
Page 20
•Synchronized Intermittent mandatory
ventilation:The IMV mode is synchronized with the
client’s spontaneous breathing to reduce the
competition between machine-delivered and client
spontaneous breaths.
•Pressure support ventilation(ASV): Provides
positive pressure during the inspiratory cycle of a
spontaneous inspiratory effort.
•Positive End Expiratory Pressure(PEEP):PEEP is
positive pressure that is applied by the ventilator at
the end of expiration.

21. Powerpoint Templates
Page 21
•Continuous Positive Airway
Pressure(CPAP): A continuous level of
elevated pressure is provided through the
patient circuit to maintain adequate
oxygenation, decrease the work of
breathing, and decrease the work of the
heart (as in left-sided heart failure-CHF)

22. Powerpoint Templates
Page 22
Commonly used in our ward setting are
Pressure support ventilation(ASV)
•Provides positive pressure during the
inspiratory cycle of a spontaneous
inspiratory effort.
•Indicated for weaning the clients.
•No preset respiratory rate, clinician must
assess for muscle fatigue and potential
periods of apnea.

23. Powerpoint Templates
Page 23
Positive End Expiratory Pressure(PEEP)
PEEP is positive pressure that is applied by the
ventilator at the end of expiration.
It is used to increase the surface area to
prevent collapse of alveoli and to prevent
atelectasis.
Physiologic PEEP 3to5cm of H2O
For ARDS, >5 cm of H2O.

24. Powerpoint Templates
Page 24
Continuous Positive Airway Pressure(CPAP)
•A continuous level of elevated pressure is
provided through the patient circuit to
maintain adequate oxygenation, decrease
the work of breathing, and decrease the
work of the heart (as in left-sided heart
failure-CHF)

25. Powerpoint Templates
Page 25
Complications of Mechanical
Ventilation
1. Associated with patient’s response to mechanical ventilation:
A. Decreased Cardiac Output
B. Barotrauma
C. Nosocomial Pneumonia
D. Positive Water Balance
E. Decreased Renal Perfusion
F. Increased Intracranial Pressure (ICP)
G. Hepatic congestion
H. Worsening of intracardiac shunts
 

26. Powerpoint Templates
Page 26
2. Associated with ventilator malfunction:
A. Alarms turned off or nonfunctional –
may lead to apnea and respiratory arrest
B. Low exhaled volume
3. Other complications related to
endotracheal intubation.
A. Sinusitis and nasal injury
B. Tracheoesophageal fistula
C. Mucosal lesions

27. Powerpoint Templates
Page 27

D. Laryngeal or tracheal stenosis
E. Cricoid abcess
4. Other common potential problems related
to mechanical ventilation: Aspiration, GI
bleeding, respiratory acidosis or alkalosis,
Thick secretions, Anxiety and fear,
Dysrhythmias or vagal reactions during or
after suctioning, Incorrect PEEP setting,
Inability to tolerate ventilator mode

28. Powerpoint Templates
Page 28
Nursing Care Of The Ventilated
Patient

29. Powerpoint Templates
Page 29
1) Care of the airway:
•It is of paramount importance that all cares and
procedures are carried out with maintaining a
patent airway always in mind.
•Always check the patient first. Observe the
patient’s facial expression, colour, respiratory
effort, vital signs and ECG tracing.
•Ensure the endotracheal tube (ETT) or
tracheostomy tube is held securely in position
but not too tightly to result in pressure area
lesions.

30. Powerpoint Templates
Page 30
•Check the placement of the ETT by
listening for equal bilateral breath sounds,
checking the CXR and noting the distance
marks on the tube @ the teeth, checking
the previously documented level.
•Check and adjust (if necessary) the cuff
pressure of the ETT/trachi. In order to
minimize tracheal damage, the cuff
pressure should be at the lowest pressure
necessary to prevent an air leak.

31. Powerpoint Templates
Page 31
2) Ventilation:
•Ensure the ventilation tubing is not kinked and that
it is adequately supported so as not drag on the
ETT/trachi. Take care of the tube while turning or
moving the patient.
•Check the ventilator and document the settings.
Look at the alarm parameters and reset if
necessary.
•Ensure the ventilator and the cardiac monitor are
plugged into emergency power supply in case of
power failure.

32. Powerpoint Templates
Page 32
•Check the type of humidification, and when the filters and
ventilation tubing were last changed.
•HME filters and end expiratory filters are changed routinely
(and marked with the date and time) every 24 hours or more
frequently if there is condensation visible.
•Ventilator circuits are changed weekly.
•Pooled secretions above the ETT/trachi cuff are associated
with ventilator associated pneumonia (VAP). This is a result
of aspiration of bacteria colonizing the oropharynx or GIT
and subsequently leaking below the cuff into the trachea.
Therefore thorough oropharyngeal suctioning should be
performed before letting down the cuff to reposition the ETT
or to check cuff pressure

33. Powerpoint Templates
Page 33
3) Suction of an Artificial Airway:
•To maintain a patent airway
•To promote improved gas exchange
•To obtain tracheal aspirate specimens
•To prevent effects of retained secretions eg. infection,
consolidation , atelectasis, increased airway pressures or a
blocked tube.
•It is important to oxygenate before and after suctioning.
•Closed suction catheters should be rinsed post suctioning to
remove mucous and to reduce the likelihood of bacterial
growth.
•Tracheal suctioning should be attended 2 - 3 hourly, more
often if necessary.

34. Powerpoint Templates
Page 34
4) Monitors:
•Check the level of any invasive monitoring
transducers and zero them.
•Check the alarm parameters and reset if
necessary
•Document the patient’s vital signs hourly and
when there is a deviation from the usual.
•Check and document a manual blood
pressure to assess the accuracy of the
arterial trace once a shift

35. Powerpoint Templates
Page 35
5) Oral Care:
•The aim of oral care and assessment is to promote
normal hygiene while preventing infection and
trauma.
•The presence of an ETT can cause hyper salivation
in some patients and an uncomfortably dry mouth in
others.
•A soft toothbrush can be used for oral hygiene and
a small amount of toothpaste can help the cleansing
action.

36. Powerpoint Templates
Page 36
•The lips should be kept moisturized to stop
them becoming sore and cracked.
•Two hourly oral care is recommended,
using water, not saline, and oral swabs
and thorough suctioning of oral secretions,
a toothbrush & paste should be used at
least once a shift and more often if
indicated.

37. Powerpoint Templates
Page 37Bijaya Dawadi 37

38. Powerpoint Templates
Page 38
6) Eye care:
•The unconscious, sedated or paralyzed patient is at
risk of developing eye problems ranging from mild
conjunctivitis to serious corneal injury and ulceration.
•Sedation and muscle relaxants can lead to
inadequate closure of the eye, lack of random eye
movements and a loss of the blink reflex, all of which
can lead to complications.
•Fluid imbalances and increased permeability can
promote conjunctival oedema.

39. Powerpoint Templates
Page 39
•Constrictive securing tapes can compromise
venous return from the head leading to venous
congestion and maybe an increase in interocular
pressure and therefore an increase in
conjunctival oedema.
•Two

hourly eye care using saline soaked gauze
to clean the eye and the application of lactrilube
regularly in the ventilated patient is
recommended to help reduce the risk of
complications.

40. Powerpoint Templates
Page 40
7) G.I.T:
•Intubated patients must have a nasogastric tube for gastric
decompression or nutritional support.
•The presence of bowel sounds and the turgor of the
abdomen should be assessed during the initial
assessment.
•Patients with a functioning GI tract should be fed enterally.
TPN may be used if there are contraindications to enteral
feeding.
•The enterally fed patient should be monitored for diarrhoea,
dehydration, fluid overload, constipation or abdominal
cramping. These observations can be a guide in
determining the strength and rate of increase of the feeds.

41. Powerpoint Templates
Page 41
•Patient in ventilator are
with NG tube,due to this
the cardiac spincter may
be loose leading to
aspiration into the lungs.
Bijaya Dawadi 41

42. Powerpoint Templates
Page 42
•NG tubes should be flushed with 20-30 mls of
water before and after administering
medications.
•Fine bore tubes can not be aspirated but should
be flushed 4 hourly with water.
•If the patient is not being fed enterally the NG
tube should be on free drainage and aspirated
and flushed 6 hourly with water.
•Elevating the head of the bed to 30 - 45 degrees
(unless contraindicated) is effective in reducing
the risk of aspiration.
•• Elimination should be recorded

43. Powerpoint Templates
Page 43
8) Genital/Urinary Tract:
•Routine urinalysis should be twice a day
•Regular penil/perineum catheter care should be
done.
•The catheter should be secured to the leg
carefully and repositioned as necessary to
prevent pressure areas.
•Hourly urine monitoring is carried out and
medical staff informed of abnormally high or low
measurements. Aim for a urine output of
0.5ml/kg.

44. Powerpoint Templates
Page 44
9) Repositioning And Pressure
Area Care:
•Ventilated patients are at a higher risk
of developing nosocomial infections
and pressure areas due to their
immobility, their underlying disease
process and the presence of invasive
monitoring lines and equipment.
•Repositioning the patient regularly
has a number of positive effects:
a. routine turning and positioning
assists in the mobilization of
secretions
b. prevents the development of
pressure areas, joint stiffness and
deformities.

45. Powerpoint Templates
Page 45
c. improves oxygenation and can encourage
weaning from the ventilator.
d. provides a different view on the
environment for the patient the patient
should be repositioned
 2
nd
hourly if possible, taking care to
position the limbs in proper alignment and
supporting them to prevent dependant
oedema.

46. Powerpoint Templates
Page 46
• The head of the bed should be elevated if the
patient’s condition allows to help prevent aspiration
and improve oxygenation.
•If the patient has any signs of developing pressure
areas he/she should be nursed on an air mattress.
•The ETT should be repositioned at alternate sides
of the mouth to prevent pressure areas developing.
•The NG tube should be secured in such a way as to
minimize pressure on the nares and changed at
least daily.

47. Powerpoint Templates
Page 47
Weaning
Weaning is the process of withdrawing
mechanical ventilator support and transferring
the work of breathing from the ventilator to the
patient.
It is done only when patient is free from the
cause to be kept on mechanical ventilation.
Weaning success is defined as effective
spontaneous breathing without any mechanical
ventilation for 24 hours or more.

48. Powerpoint Templates
Page 48
Criteria for weaning
Tidal volume be above a given threshold
(greater than 5 ml/kg),
Respiratory frequency be below a given
count (less than 30 breaths/min),
Oxygen partial pressure be above a
given threshold (PaO2 greater than 60mm
Hg) with FIO2 <40%
Vital capacity 10to15 ml/kg.

49. Powerpoint Templates
Page 49
Nursing care of patient during
weaning:
Assess the client for the weaning criteria.
Monitor the activity level, assess dietary
intake and monitor results of the lab tests.
Assess client’s & family’s level of
understanding of weaning.
 Explain that patient may feel shortness of
breath initially & provide encouragement
as needed.

50. Powerpoint Templates
Page 50
•Monitor vital signs, pulse oxymetry, ECG
changes, ABG analysis & respiratory pattern
continuously for the first 20-30 mins & then
every 5 mins until weaning is complete.
•Maintain a patent airway, suction the airway
as needed.
•Monitor the ABG level & Pulmonary
Function Test as per requirement

51. Powerpoint Templates
Page 51
References
•S.C. Suzanne,B.G. Bremda.Brunner and
Suddarth’s Textbook of Medical-Surgical
Nursing. 23
rd
edn. Lippincott Williams and
Wilkins. vol(1)615-25.
•ICU AND CCU MANUAL: Care of patient
on ventilator.
•Western health sydney. Intensive care
evidence based practice guidelines. 2003

52. Powerpoint Templates
Page 52