Caring patient on

Mechanical Ventilator

By: Ms. Shanta Peter

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 Indications for Mech. Vent

• PaO2 <50 mm Hg with FiO2 > 0.60

• PaO2<50mmHg with pH <7.25
• Vital Capacity <2 times TV
• Negative inspiratory force < 25 cm, H2O
• Respiratory >35/min

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• Pt has continuous ↓in oxygenation (PaO2 )
• Increase in PaCO2
• Persistent acidosis ( Decreased pH)
• Abdominal/ Thorasic Surgery
• Drug overdose
• Neuromuscular disease
• Inhalation injury
• COPD
• Pt with apnea –not readily reversible
• Multiple trauma
• Multi system failure
• Coma
All these will lead to Resp Failure 3
Mechanical ventilator … Nursing
Interventions
Unique technical and
interpersonal skill

Assess patient first

then ventilator
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GOAL
• Patient will be supported on mechanical
ventilation without complication- then weaned ,
extubated . The complications will be detected,
treated timely

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Two important Nsg interventions while caring
a patent on ventilator are :

Interpretation of ABG
&
Pulmonary Auscultation

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 General Nursing Interventions
• Assess for decreased cardiac output and
administer appropriate Nursing Care
• Monitor for positive water balance – Pressure
breathing may cause increase in ADH- Anti
Diuretic Hormone and retention of water
• Auscultate chest for altered breath sounds
-Take CVP /PCWP reading as ordered
-Observe /assess for peripheral edema
-Maintain accurate I & O
-Assess Daily weights

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 Nsg Intervention .…

• Monitor for barotrauma – tension pneumothorax

• Assess ventilator checking every 4 hrs
• Auscultate breath sounds every 2 hrs
• Monitor ABGs
• Perform complete pulmonary-physical
assessment every shift
• Monitor for GI problems- stress ulcer
• Administer muscle relaxants . tranquilizers,
analgesics or paralyzing agents as ordered , to
increase client machine synchronized by relaxing
the client
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 Gas Exchange
• Judicious administration of analgesics
without suppressing the respiratory
drive
• Frequent re-positioning – to diminish
pulm. effects of immobility
• Monitor adequate Fluid balance –
observe peripheral edema, I& O chart,
weight
• Pot. side effects of medications
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Promoting Effective Airway Clearance
Positive pressure increase secretion
• Auscultate lungs Q2-4 hrs
• Suctioning – physiotherapy, position changes,
- not as scheduled – but clinically related
Observe for barotrauma/ pneumothorax
• Humidification –
• Bronchodilators, mucolytic agents – dilate
bronchioles and liquefy secretions

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 Preventing trauma and infection
• Maintain ET /tracheostomy tube – position
ventilator --- no pulling on tube
• Monitor cuff pressure Q8hrly – 25cm H2O
• Tracheostomy/tube care Q6hrs
• More care to immuno compromised patients
• Replace Vent Circuits/ inline suction tubing – as
peer policy
• Oral hygiene
• NGT and use of antacids—cause nosocomial
pneumonia from aspiration of tube feeding and
gastric contents
• Semi-fowlers position
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 Promote optimal level of mobility
• When stable -after weaning -- assist him to
sit up in chair
• Mobility of muscle activity – stimulate
respiration and improve morale
• Active /passive ROM exercise if bed bound –
prevent muscle atrophy , contractures and
venous stasis

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 Promote optimal Communication

• Evaluate his abilities—Conscious?- can

communicate ? he node or move hand ?
• Can he write? – right – left hand
• Understand patient

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 Promoting coping ability
• Encourage family to communicate – and
verbalize fears
• Explain procedures every time to patient
• Restore sense of control- encourage to
participate in his care
• Inform his progress – if long time on vent
• Stress reduction techniques – rubbing back ,
relaxation techniques ……………

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 Nurse should assess /monitor
the ventilator
• Check type of ventilator—Volume cycled, Pres
Cycled, -ve pres
• Controlling mode- ( Controlled vent, A/C , SIMV)
• TV and rate settings- ( TV is usually 10-15 ml/Kg ,
rate 12-16;lmt
• FiO2 – (Fraction of inspired O2) – setting
• Inspiratory pressure reached and pressure limit
( normal 15- 20 cm of H2O (This increase in
conditions where there is increased Airway
resistance or decreased compliance)
• Sensitivity:( 2cm H2O Inspiratory force should
trigger the ventilator
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Ventilator…….
• Insp to Exp Ratio(IE) usually 1:3 ( 1 second of
insp to 3 sec of expiration) or 1:2
• Minute Volume ( TV X RR ) usually 6-8 L/min
• SIGH setting – usually 1.5 times the TV ..and
range from 1-3 /hr… if applicable
• Tubing. Water in the tubing – disconnection or
kinking of the tubing
• Humidification( Humidifier filled with water)
and temperature
• Alarms ( Functioning properly)
• PEEP and/or Pressure support level, if applicable
PEEP is usually 5-15 cm of H2O
Observe for Complications
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 BUCKING the Ventilator
Patient struggles out of phase of ventilator
• Patient try to breathe out during the
ventilators inspiratory phase , or when there
is a jerky and abd. muscle effort
Causes:
• Anxiety, hypoxia, increased secretions
hypercarbia, inadequate minute volume ,
pulm edema…………….

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 Bucking the ventilator …contd
Correct these problems before giving
paralyzing agents …..otherwise the underlying
problem will mask the condition and condition
become worse
• Muscle relaxants, tranquilizers, analgesics
and paralyzing agents are administered – to
increase Patient – machine synchrony
• Obtain Baseline ABG – To monitor progress of
therapy

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 ALARMS……Causes
High pressure alarms
• Increased secretions in airway
• Decreased A Way size due to wheezing or
bronchospasm
• Displacement of ET tube
• Obstructed ET tube – water/kink in tubing
• Pt coughs gags, or bites the ET tube
• Anxious pts – fights(Bucking) on Vent
LOW Pressure alarm
• Disconnection /leak in the ventilator or airway cuff
• Pt stops spontaneous breathing
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 COMPLICATIONS
• Hypotension caused by +ve pressure – which increase
intra thoracic pressure and inhibit blood return to
heart
• Air leak
• Airway obstruction
• Respiratory complications…. pneumothorax,
subcutaneous emphysema due to +ve pressure
(Barotrauma ), resp failure
• G.I alterations – stress ulcers bleeding
• Malnutrition – if not supported
• Infections
• Muscular deconditioning
• Ventilator dependence or inability to wean
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 WEANING …………….
The process of going OFF from ventilator dependence
to spontaneous breathing
3 stages………pt gradually weaned from ------------
• Ventilator
• Tube
• Oxygen

• Decision is made on the physiologic view point by

the physician considering his clinical status.
• It’s a joined effort of Physician – Resp Therapist
& Nurse
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 Criteria for weaning
The ventilator capacities include—
Ability to generate Vital Capacity of 10-15 ml/kg
(The minimum required volume is usually range of 1000ml in
adult)
• A spontaneous resp. force at least 20 cmH20
• PaO2 > 60mmHg with an FiO2 of < 40%
• Stable vital signs ..When the Baseline Measurements
• above ventilator capacity is adequate • Vital Capacity
• Insp . Force
• Resp Rate
CHECK → • Resting TV
• Minute Ventilation
• ABG levels
• FiO2 22
 Patient Preparation
must consider patient as a whole
Consider factors that--
• impair the deliver the O2
• impair elimination of CO2
• increase O2 demand ( sepsis, seizures, thyroid imbalance)
• Decrease in pts over all strength ( Nutrition, Neuro-
muscular disease)
Adequate psychological preparations
• Pt need to know what is expected of them during
procedure Explain properly..
• Assure the availability of Nurses near him at all time to
answer his questions…
• Often frightened --- reassure that they are improving and
well enough to handle his own spontaneous breathing
Proper preparation will reduce the weaning time
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Methods of WEANING

• There is NO BEST method –

success depends on –
• Adequate patient preparation ,
• Available equipment, and
• Interdisciplinary approach to solve problems

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Traditional method:
• T-Piece trials( one or more)
Used with short vent assistance ( <2 days) and pt is awake,
alert and breathing without difficulty , good gag reflex,
and hemo-dynamically stable
• Pt breathes spontaneously with humidified O2
• During the process pt is maintained on same or higher
O2 Conc than when on vent

T- Tube (Brigg’s Adaptor) --15 mm connection – Connects

O2 source to an artificial airway. ET, tracheostomy.
• Recommended rate is 10L/min
• Inspired O2 Conc 24-100%
Caution: Clear secretions occlude T-Tube lead to suffocate
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When on T-piece – observe
for signs & Symptoms of
Hypoxia, increasing fatigue, manifested as:
• Tachy cardia- PVCs, Ischemic ECC changes
• Restlessness
• RR > 35/mt
• Use of accessory muscles for breathing
• Paradoxical chest movement

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If tolerating T –piece trial……….ABG – 20mts
after spont. breathing at a constant FiO2
( Alveolar-Arterial equalization occur15-20mins)
• If ABG↓—exhaustion--- hypoxia---→ hook
back to vent
• Wean on and off
(Pt who had prolonged vent support need
gradual weaning process – even weeks)
• Primarily weaned during day time and placed
back on Vent during night

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SIMV – Method
In pts who – satisfies all criteria for weaning but cannot
have spontaneous breathing for long time
SIMV for weaning--- observe the following
• Respiratory Rate
• Minute Volume
• Spont /Machine Breaths & TV
• FiO2
• ABG levels
No deterioration on parameters--- adequate TV , vent
resp gradually decreased-- then weaning is complete
Pressure support is used as an adjunct to SIMV
weaning – to support insp. pressure ,and boost the
spontaneous breaths. PS is reduced gradually as pts
strength increases 28
Successful weaning is supplemented by
intensive pulm care like---
• O2 therapy
• ABG evaluation
• Pulse oxymetry
• Bronchodilator therapy
• Chest physio
• Adequate Nutrition, hydration,
humidification,
• Incentive spirometry

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Weaning from Tube
ET/TT removed only if following criterion met
• Spontaneous ventilation is adequate
• Pharyngeal and laryngeal reflexes are active
• Pt maintain adequate airway and can
swallow, move the jaw clench teeth ,
voluntary cough is effective to bring out
secretion
Before the tube is removed—a trail with
nose/mouth breathing is done – Deflating cuff,
using fenestrated tube etc

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Weaning from O2
• Pt successfully weaned---- and has adequate
respiratory function – weaned from O2
FIO2 is gradually reduced until PO2 is in range
of 80-100 mmHg while breathing in Room air
• If R air PO2 less than 70 supplementary O2
recommended

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• Long tern ventilated pt need aggressive-
judicious NUTRITIONAL support as
Resp. musculature( Diaphragm & intercostal
muscles) quickly become weak or atrophied
after a few days of Mech. Ventilation –
especially if nutrition is inadequate,
• High CHO diet increase CO2—thus
increase the work of breathing –

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What you know about
OXYGEN supplies
& accessories ?

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Through bulk liquid O2 system which store O2 @-
34C (-29F) and deliver it as gas through wall
outlets

Gas Cylinders

Compressed O2 : Non-liquefied gas @

1800-2400 lbs /Sq inch @ 21C (70 F)

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FiO2 through Nasal Simple FACE MASK
Cannula
21--24 % @ 1L/min 40% -- @5-6 L/min
24--28 % @ 2L/min 45—50% @ 6-7 L/min
28--32 % @ 3L/ min 55 –60% @ 7-10L/min
32-- 36% @ 4L/min
Flow rate must be set
36 – 40% @ 5L/min at least
5L/min to flush
40 – 44% @ 6L/min the mask.

VENTI MASK : Delivers exact O2 Conc. between

20-40% --despite patient’s respiratory pattern
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 Partial Re-Breather Mask
70-90% FiO2 is delivered at 6-15L/min
• A flow rate high enough to maintain the bag
2/3rd full during inspiration is needed.
• Make sure the reservoir bag do not twist or
kink – which result in a deflated bag

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GOAL:
• Patient will be supported on mechanical
ventilation without complication- then
weaned , extubated .
• The complications will be detected , treated
timely

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Thank you All

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