Joshi Abhishek Ashvinbhai

S.Y.P.B.B.Sc.Nursing
Gov.College of Nursing
Jamnagar
 Definition & Introduction of Mechanical
Ventilation
 Goals
 Purposes
 Indication of Mechanical Ventilation
 Essential Terminologies
 Types of Mechanical Ventilation/Ventilator
 Ventilator Alarms
 Complications of Ventilation
 Weaning
 Nursing Care of Ventilated Clients
 YESTERDAY’S A PAST…

…..TOMORROW IS A FUTURE….

…. BUT….

TODAY IS A GIFT

...THAT’S WHY IT’S CALLED PRESENT….!

 “Mechanical ventilation is the use of a
ventilator to move room air or oxygen
enriched air into and out of the lungs
mechanically to maintain proper levels of
oxygen and carbon dioxide in the blood.”
 Mechanical ventilation alone does not treat
or reverse the underlying pathology leading
to the need for ventilator support. Rather, it
is applied as one of the support systems
until the reversal of the pathological
condition, so that the patient may then
become weaned from mechanical
ventilation.
  TARGET
 Reverse
hypoxemia/Relieve
 GOAL
acute respiratory
 Improve gas acidosis
exchange  Reverse respiratory
 Relive respiratory muscle fatigue
distress Prevent and reverse
 Improve pulmonary atelectasis
mechanics  Improve lung
 Permit lung and compliance/Maintain
airway healing lung and airway
 Avoid complication function
 Prevent disuse
respiratory muscle
dystrophy
 To maintain gas exchange in case of acute
and chronic respiratory failure.
 To maintain ventilator support after CPR.
 To reduce pulmonary vascular resistance.
 To excrete increased CO2 production.
 To give general anesthesia with muscle
relaxants.
 Acute respiratory failure
 Apnea or impending inability to breath
 Severe Hypoxia/Hypoxemia
 Respiratory muscle fatigue
 Cardiac Insufficiency
 Neurological problems
 Therapeutic and prophylactic
 Respiratory failure: An inability of the heart and
lungs to provide adequate tissue oxygenation or
removal of carbon dioxide.
 Hypoxemic respiratory failure – lung failure
 Hypercapnic respiratory failure – pump failure
 Neuromuscular diseases : Myasthenia Gravis,
Guillain-Barre Syndrome, and Poliomyelitis
(failure of the normal respiratory neuromuscular
system)
 Musculoskeletal abnormalities :Such as chest
wall trauma .
 Infectious diseases of the lung such as
pneumonia, tuberculosis.
 Obstructive lung disease in the form of
asthma, chronic bronchitis or emphysema.

 Conditions such as pulmonary edema,

atelectasis, pulmonary fibrosis.

 Patients who has received general

anesthesia as well as post cardiac arrest
patients requires ventilatory support until
they have recovered from the effects of the
anesthesia or out from a Danger.
 Parameters Ventilation Normal
indicated range

A- Pulmonary function
studies:
• Respiratory rate > 35 15-20
(breaths/min).
• Tidal volume (ml/kg <5 5-7
body wt)
• Vital capacity (ml/kg < 15 65-75
body wt)
• Maximum Inspiratory <-20 75-100
Force (cm HO2)
 Parameters Ventilation Normal
indicated range

B- Arterial blood
Gases

• PH < 7.25 7.35-7.45

• PaO2 (mmHg) < 60 75-100
• PaCO2 (mmHg) > 50 35-45
 Independent variables : “The parameters that
are set by clinician.”

 Dependentvariables : “The parameters

measured by the ventilators.”

 Fractionof inspired oxygen (FiO2): “The

concentration of O2 in the inspired gas,
usually between 21% and 100% O2. The
lowest possible fraction of inspired oxygen
(FiO2) necessary to meet oxygenation goals
should be used. “
 Tidal volume (TV): “The amount of air
delivered to the patient per breath. It is
expressed in milliliters.”
 A starting point for the VT setting is 8 to
10ml/kg of ideal weight.

 Respiratory rate/frequency (f): “The number

of breaths per minute. This can be from the
ventilator, the patient, or both. “
 The RR is set as near to physiological rates
(14 to 20 breaths/min) as possible.
 Minute ventilation (V E): “The product of V and
respiratory frequency (VT * f). It is usually
expressed in liters/minute.”

 Exhaled Tidal Volume:(E TV): “It is the amount

of gas that comes out of the patients lungs on
exhalation.”
 This is the most accurate measure of the
volume received by the patient
 If the ETV deviates from the set TV by 50ml or
more, troubleshoot the system to identify the
source of gas loss.
 Inspiratory to Expiratory ratio (I:E): “The I:E ratio
is usually set to mimic the pattern of
spontaneous ventilation.”
 During spontaneous breathing, the normal I:E
ratio is 1:2, indicating that for normal patients
the exhalation time is about twice as long as
inhalation time.
 If exhalation time is too short “breath stacking”
occurs resulting in an increase in end-
expiratory pressure also called auto-PEEP.
 Depending on the disease process, such as in
ARDS, the I:E ratio can be changed to improve
ventilation.
 Inverse Inspiratory to Expiratory ratio:
 “I:E ratios such as 1:1,2:1 and 3:1 are called
inverse I:E ratios”
 Inverse I:E ratio allows unstable alveoli time to
fill and also prevents collapse by shortened
expiratory phase.

 Sigh: A deep breath , A breath that has a

greater volume than the tidal volume.
 It provides hyperinflation and prevents
atelectasis.
 Sigh volume :Usual volume is 1.5 –2 times tidal
volume.
 Positive end-expiratory pressure (PEEP): “The
amount of positive pressure that is maintained
at end-expiration.”
 Typical settings for PEEP are 5 to 20 cm H2O
 PEEP increases oxygenation by preventing
collapse of small airways
 It increases the functional residual capacity of
the lungs
 A typical initial applied PEEP is 5 cmH2O.
However, up to 20 cmH2O may be used in
patients undergoing low tidal volume
ventilation for acute respiratory distress
syndrome (ARDS)
 Auto PEEP: “Auto PEEP is the spontaneous
development of PEEP caused by gas trapping
in the lung resulting from insufficient
expiratory time and incomplete exhalation.”

 Causes of auto PEEP formation include rapid

RR, high VE demand, airflow obstruction and
inverse I:E ratio ventilation.

 Auto PEEP = Total PEEP - Set PEEP

 Sensitivity ( Trigger Sensitivity) : “The sensitivity
function controls the amount of patient effort needed
to initiate an inspiration.”

 Increasing the sensitivity (requiring less negative

force) decreases the amount of work the patient must
do to initiate a ventilator breath.

 Decreasing the sensitivity increases the amount of

negative pressure that the patient needs to initiate
inspiration and increases the work of breathing.
 The most common setting for pressure sensitivity are
-1 to -2 cm H2O
 The more negative the number the harder it to
breath.
 Peak airway pressure (Paw): “The pressure
that is required to deliver the TV to the
patient. It has a unit of centimeters of water
(cm H2O).”

 Plateaupressure (Pplat): “The pressure that is

needed to distend the lung. This pressure can
only be obtained by applying an end
inspiratory pause. It also has a unit of cm
H2O.”
 Peak inspiratory Pressure (PIP): 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.

 “Increasing PIP is also sign of Blockage of

airway and needed to suctioning or change Et
/TT.”
 Mean airway pressure: “The time-weighted
average pressure during the respiratory cycle.
It is expressed in cm H2O.”
 (i) Invasive ventilation or conventional
mechanical ventilation (MV) &
 (ii) non invasive ventilation (NIV).

OR

 (i) Positive Pressure Ventilation &

 (ii) Negative pressure ventilation.
 Non Invasive Ventilation: “Ventilatory support
that is given without establishing endo-
tracheal intubation or tracheostomy is called
Non invasive mechanical ventilation.”

 InvasiveVentilation: “Ventilatory support that

is given through endotracheal intubation or
tracheostomy is called as Invasive mechanical
ventilation.”
Negative pressure: Positive pressure:

• Producing Neg. pressure • Delivering air/gas with

intermittently in the positive pressure to the
pleural space/ around airway.
the thoracic cage.
• e.g.: BIPAP & CPAP ( O2
• e.g.: Iron Lung mask , Nasal cannula
etc.
 Elongated tank, which encases the patient up to
the neck. The neck is sealed with a rubber
gasket, the patient's face are exposed to the
room air.
 These exert negative pressure on the external
chest decreasing the intra-thoracic pressure
during inspiration, allows air to flow into the
lungs, filling its volume.
 The cessation of the negative pressure causes
the chest wall to fall and exhalation to occur.
 The patient’s body was encased in an iron
cylinder and negative pressure was generated
 The iron lung are still occasionally used
today.
 These are simple to use and do not require
intubations of the airway; consequently, they
are especially adaptable for home use.
 It is used mainly in chronic respiratory failure
associated with neuromuscular conditions
such as poliomyelitis, muscular dystrophy
and myasthenia gravis.
 The use of negative-pressure ventilators is
restricted in clinical practice, however, because
they limit positioning and movement and they
lack adaptability to large or small body torsos
(chests).
 Positive pressure ventilation inflate the lungs by
exerting positive pressure on the airway forcing
the alveoli to expand during inspiration.
 Expiration occurs passively.
 Positive-pressure ventilators require an
artificial airway (Endotracheal or tracheostomy
tube) in invasive ventilation and in NIV includes
BiPAP Mask , O2 mask , Nasal mask/cannula ,
O2 high concentrated reservoir mask etc.
 Inspiration can be triggered either by the
patient or the machine.
 Invasive mechanical ventilation is
implemented once a cuffed tube is inserted
into the trachea to allow conditioned gas
(warmed, oxygenated, and humidified) to be
delivered to the airways and lungs at
pressures above atmospheric pressure.

 Ventilatory support that is given through

endotracheal intubation or tracheostomy is
called as Invasive mechanical ventilation
 Positive invasive pressure ventilation deliver
gas to the patient under positive-pressure,
during the inspiratory phase.
 A/C: Assist-Control Ventilation
 V/C: Volume-Control Ventilation
 T/C: Time-Control Ventilation
 IMV: Intermittent Mandatory Ventilation
 SIMV: Synchronized Intermittent Mandatory
Ventilation
 BiPAP ( Bi-level/Biphasic ): Non-invesive
Pressure Ventilation with Pressure Support
(consists of 2 levels of pressure)
 PRVC: Pressure Regulated Volume Control
 CPAP: Continuous Positive Airway Pressure
 PSV: Pressure Support Ventilation
 NIPPV: Non-Invasive Positive Pressure
Ventilation
 PIP : Peak Inspiratory Pressure
 FiO2 : Fraction of inspiratory O2
 PEEP: Peak End Expiratory Pressure
 Modes of mechanical ventilation are the
 techniques that the ventilator and patient
 work together to perform the respiratory
 cycle.
 (1) Pressure Cycled Modes
 (2) Volume Cycled Modes
 (3) Time Cycled Modes
 Pressure- Controlled Ventilation
 (i) Continuous Positive Airway Pressure(CPAP)
 (ii) Bi-Level (Bi-Phasic) positive airway-
pressure (BiPAP)
 (iii) Pressure Support Ventilation (PSV)
 (iv) Pressure Assist/ Control Ventilation (PCV)
 (v)Pressure- Controlled Inverse Ratio-
Ventilation
 CPAP is positive pressure applied throughout
the respiratory cycle to the spontaneously
breathing patient.
 A continuous level of elevated pressure is
provided through the patient circuit to
maintain adequate oxygenation, decrease the
work of breathing.
 CPAP may be used invasively through an
endotracheal tube or tracheostomy or
noninvasively with a face mask or nasal
prongs.
 provides pressure at end expiration, which
prevents alveolar collapse and improves the
functional residual capacity and oxygenation.

 CPAP allows the nurse to observe the ability

of the patient to breath spontaneously while
still on the ventilator.

 It may used as a Weaning Mode.

 The ventilator is used to deliver CPAP during
weaning the nurse can monitor the adequacy
of the patient’s TV.

 Alarms should be set to detect ETV and apnea.

 If a patient in this mode can maintain his own

respiratory effort without excess work, if the
ABG’s are good, and the patient has good
respiratory mechanics then extubation is at
hand.
 The patient breaths spontaneously while the
ventilator applies a pre-determined amount
of positive pressure to the airways upon
inspiration.
 Pressure support ventilation augments
patient’s spontaneous breaths with positive
pressure boost during inspiration i.e.
assisting each spontaneous inspiration.
 Helps to overcome airway resistance and
reducing the work of breathing.
 Indicated for patients with small
spontaneous tidal volume and difficult to
wean patients.
 Patient must initiate all pressure support
breaths.
 Pressure support ventilation may be
combined with other modes such as SIMV or
used alone for a spontaneously breathing
patient.
 The patient’s effort determines the rate,
inspiratory flow, and tidal volume.
 In PSV mode, the inspired tidal volume and
respiratory rate must be monitored closely
to detect changes in lung compliance.
 It is a mode used primarily for weaning
from mechanical ventilation.
 5 – 10 cm H20 are generally used,
especially during weaning.
 During P-A/C the nurse must be familiar with
all the ventilator settings: the level of
pressure, the set RR, the FiO2, and the level
of PEEP
 The nurse monitors the total RR to evaluate
whether the patient is initiating spontaneous
breaths and ETV for adequacy of volume.
 In pressure controlled ventilation the
breathing gas flows under constant pressure
into the lungs during the selected inspiratory
time.
 The flow is highest at the beginning of
inspiration( i.e when the volume is lowest in
the lungs).
 As the pressure is constant the flow is
initially high and then decreases with
increasing filling of the lungs.
 1.reduction of peak pressure and therefore
the lower risk of barotrauma and tracheal
injury.

 2.effective ventilation.

 3.Improve gas exchange

 4. PCV has traditionally been preferred for

patients with neuromuscular disease .
 Careful attention must be given to the TV to
prevent unplanned hyperventilation and
hypoventilation.

 Sedation and the use of neuromuscular

blocking agents are frequently indicated,
because any patient–ventilator asynchrony
usually results in profound drops in the
SaO2.
 Inverse ratio ventilation (IRV) mode reverses
this ratio so that inspiratory time is equal
to, or longer than, expiratory time (1:1 to
4:1).
 Inverse I:E ratios are used in conjunction
with pressure control to improve
oxygenation by expanding stiff alveoli by
using longer distending times, thereby
providing more opportunity for gas
exchange and preventing alveolar collapse.
 As expiratory time is decreased, one must
monitor for the development of hyperinflation
or auto-PEEP. Regional alveolar over
distension and barotrauma may occur owing
to excessive total PEEP.
 When the PCV mode is used, the mean airway
and intrathoracic pressures rise, potentially
resulting in a decrease in cardiac output and
oxygen delivery . Therefore, the patient’s
hemodynamic status must be monitored
closely.
 Volume Controlled Ventilation:
 (i) Assist/Controlled Ventilation
 (ii) Intermittent Mandatory Ventilation (IMV)
 (iii) Synchronized Intermittent Mandatory
Ventilation (SIMV)
 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 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.

 If the patient wishes to breathe faster, he or

she can trigger the ventilator and receive a
full-volume breath.

 Often used as initial mode of ventilation

When the patient is too weak to perform the
work of breathing (e.g. when emerging
from anesthesia)
 The preset RR ensures that the patient
receives adequate ventilation, regardless of
spontaneous efforts.

 The patient can breath faster than the

preset rate but not slower.
 Respiratory alkalosis may develop if the
patient has a tendency to hyperventilate
because of anxiety, pain or neurological
factors.

 Patient may rely on the ventilator and not

attempt to initiate spontaneous breathing if
ventilatory demands are met.
 Total RR, to determine whether the patient is
initiating spontaneous breaths.

 PIP, to determine whether it is increasing(

indicating a change in compliance or
resistance).

 Patient’s sense of comfort and

synchronization with the ventilator and acid
base status.
 A mode of mechanical ventilation in
which the patient is allowed to breath
independently except during certain
prescribed intervals, when a ventilator
delivers a breath either under positive
pressure or in a measured volume.

 This mode is not use mostly in clinical

practice due to many new tech. Modes.
 The SIMV mode of ventilation delivers a set
number of breaths of a set TV, and between
these mandatory breaths the patient may
initiate spontaneous breaths.

 If the patient initiates a breath near the time a

mandatory breath is due, the delivery of the
mandatory breath is synchronized with the
patient’s spontaneous effort to prevent
patient ventilator dyssynchrony.
 SIMV is indicated when it is desirable to allow
patients to breath at their own RR and thus
assist in maintaining a normal PaCo2,or when
hyperventilation has occurred in the A/C
mode.
 SIMV mode helps to prevent respiratory
muscle weakness associated with mechanical
ventilation.
 Self regulates the rate and volume of
spontaneous breath
 It is used as a mode for weaning
 In between the ventilator-delivered breaths ,
the patient is able to breath spontaneously at
his own tidal volume and rate with no
assistance from the ventilator.

 Ventilators breaths are synchronized with the

patient spontaneous breath.
 Monitor RR to determine whether the patient
is initiating spontaneous breaths, and the
patients ability to manage the WOB.

 Assess PIP, patient’s sense of comfort and

synchronization with the ventilator and acid
base status.
 If the total RR increases, the TV of the
spontaneous breaths is assessed for
adequacy. A rising total RR may indicate that
the patient is beginning to fatigue, resulting
in a more shallow and rapid respiratory
pattern and that may lead to atelectasis.
 “Ventilator Alarms defined as a Voice or
sound to alert Nurse/Doctor and caused by
any abnormal value of either in client or in
Ventilator.”
 These Alarms have 4 main Types as below…

 (i)Pressure alarms
 (ii)Volume alarms
 (iii)Apnea alarms
 They are triggered when there is increased
airway resistance or decreased lung
compliance.

 Low pressure alarms and high pressure

alarms
 Volume alarms are valuable for ensuring
adequate alveolar ventilation, particularly in
the patient receiving a pressure mode of
ventilation
 This alarm is very important when the patient
is on a spontaneous breathing mode such as
PS or CPAP, and no mandatory breaths are
set.
 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
 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
 An alarm should never be silenced until the
cause has been investigated and corrected.

 If the source of the alarm cannot be

determined, disconnect the client from the
ventilator and use a hand-held resuscitation
bag for manual ventilation with 100% oxygen
until the problem can be resolved
I Airway Complications

II Mechanical complications,

III Physiological Complications,

IV Artificial Airway Complications

 Aspiration

 Decreased clearance of secretions

 Nosocomial or ventilator-acquired pneumonia

(VAP)
 Hypoventilation with atelectasis with
respiratory acidosis or hypoxemia.
 Hyperventilation with hypocapnia and
respiratory alkalosis
 Barotrauma
 - Closed pneumothorax,
 - Tension pneumothorax,
 - Subcutaneous emphysema.
 Alarm “turned off”
 Failure of alarms or ventilator
 Inadequate nebulization or humidification
 Overheated inspired air, resulting in
hyperthermia
 Fluidoverload with humidified air and
sodium chloride (NaCl) retention
 Depressed cardiac function and
hypotension
 Stress ulcers
 Paralytic ileus
 Gastric distension
 Starvation
 Dyssynchronous breathing pattern
 (A) In Endotracheal Tube :

 Tube kinked or plugged

 Tracheal stenosis or tracheomalacia
 Main stem intubation with contralateral (located
on or affecting the opposite side of the lung)
 lung atelectasis

 Cuff failure
 Sinusitis
 Otitis media

 Laryngeal edema
 (B) In Tracheostomy Tube :
 Acute hemorrhage at the site
 Air embolism
 Aspiration
 Tracheal stenosis
 Failure of the tracheostomy cuff
 Laryngeal nerve damage
 Obstruction of tracheostomy tube
 Pneumothorax
 Subcutaneous and mediastina emphysema
 Swallowing dysfunction
 Tracheoesophageal fistula
 Infection
 Accidental decannulation with loss of airway
 CVS:
◦ Increased intrathoracic pressure
◦ Reduced CO2

 Pulmonary:
◦ Barotrauma (trauma r/t pressure)
 Pneumothorax
 Subcutaneous emphysema
◦ Alveolar hypoventilation

 Cuff leak

 Ventilator settings

 Secretions

 Atelectasis
◦ Alveolar hyperventilation
 Due to hypoxemia, fear, pain, anxiety →
alkalosis
 RX: sedate, analgesia, communication,
correct hypoxemia
 Due to inappropriate ventilator settings
 high tidal volume
 High rate
◦ Pulmonary Infection
 Neurological complications:

◦ Positive pressure ventilation → increased

intrathoracic pressure
◦ interferes with venous drainage; increased
ICP

 GI:

◦ Stress ulcers and GI bleeds; Rx with H2

receptor blockers

Gastric and bowel dilation

 Musculoskeletal:
 Muscle atrophy r/t immobilization
 Mobilize
 ROM

 Psychologic:
 Stress
 Communication very important
 Sedate, explain, family visits, pain management
 Facilitate expression of needs
 Common problems

◦ High peak pressures

◦ Patient with COPD
◦ Ventilator synchrony
◦ ARDS
 If peak pressures are increasing:
◦ Check plateau pressures by allowing for
an inspiratory pause (this gives you the
pressure in the lung itself without the
addition of resistance)
◦ If peak pressures are high and plateau
pressures are low then you have an
obstruction
◦ If both peak pressures and plateau
pressures are high then you have a lung
compliance issue
 High peak pressure differential:

High Peak Pressures High Peak Pressures

Low Plateau Pressures High Plateau Pressures
Mucus Plug ARDS
Bronchospasm Pulmonary Edema
ET tube blockage Pneumothorax
Biting ET tube migration to a
single bronchus
Effusion
 If you have a patient with history of
COPD/asthma with worsening oxygen
saturation and increasing hypercapnia
differential includes:
◦ Given the nature of the disease process, patients have
difficultly with expiration (blowing off all the tidal volume)
◦ Must be concern with breath stacking or auto- PEEP
◦ Management options include:

Decrease respiratory rate Decrease tidal volume

Adjust flow rate for Increase sedation
quicker inspiratory rate
Adjust I:E ratio
 Increase in patient agitation and dis-
synchrony on the ventilator:
◦ Could be secondary to overall discomfort
 Increase sedation
◦ Could be secondary to feelings of air hunger
 Options include increasing tidal volume, increasing
flow rate, adjusting I:E ratio, increasing sedation
 If you are concern for acute respiratory
distress syndrome (ARDS)
◦ Correlate clinically with HPI and radiologic findings
of diffuse patchy infiltrate on CXR
◦ Obtain a PaO2/FiO2 ratio (if < 200 likely ARDS)
◦ Begin ARDSnet protocol:
 Low tidal volumes
 Increase PEEP rather than FiO2
 Consider increasing sedation to promote synchrony
with ventilator
 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.”
 “The process of going OFF from ventilator
dependence to spontaneous breathing”
 3 stages………pt gradually weaned from ---

 From Ventilator
 From Tube
 From 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
 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) and
FIO2 <40%

 Vital capacity 10 to 15 ml/kg.

 When the above ventilator capacity is
adequate…Then CHECK Baseline
Measurements like following…

 Vital Capacity
 Insp . Force
 Resp Rate
 Resting TV
 Minute Ventilation
 ABG levels
 FiO2
 1) T-piece trial,

 2)
Continuous Positive Airway Pressure (CPAP)
weaning,

 3)
Synchronized Intermittent Mandatory
Ventilation (SIMV) weaning,

 4) Pressure Support Ventilation (PSV) weaning

 5) Continuous Positive Airway Pressure (CPAP)

 It consists of removing the patient from the
ventilator and having him / her breathe
spontaneously on a T-piece 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 of f the ventilator.
 for signs & Symptoms of….
 Hypoxia,
 increasing fatigue,
 Tachy cardia- Ischemic ECG changes
 Restlessness
 RR > 35/min
 Use of accessory muscles for breathing
 Paradoxical chest movement
 If tolerating T –piece trial……….ABG – 20mts
 after spont. breathing at a constant FiO2 (
Alveolar-Arterial equalization occur15-
20mins)
 If ABG↓— hypoxia---→ 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
 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.
 In pt’s who – satisfies all criteria for weaning
but cannot have spontaneous breathing for
long time.
 Respiratory Rate
 Minute Volume
 Spont. /Machine Breaths
 FiO2
 ABG levels
 No deterioration on parameters--- adequate
TV, vent resp gradually decreased-- then
weaning is complete
 When placed on CPAP, the patient does all the
work of breathing without the aid of a back
up rate or tidal volume.

 No mandatory (ventilator-initiated) breaths

are delivered in this mode i.e. all ventilation is
spontaneously initiated by the patient.

 Weaning by gradual decrease in pressure

value
 The patient must initiate all pressure support
breaths.
 During weaning using the PSV mode the level of
pressure support is gradually decreased based
on the patient maintaining an adequate tidal
volume (8 to 12 mL/kg) and a respirator y rate
of less than 25 breaths/minute.
 PSV weaning is indicated for :-
- Difficult to wean patients
- Small spontaneous tidal volume.
 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
 Diaphoresis
 Dyspnea & Labored respirator y pattern
 Increased anxiety ,Restlessness, Decrease in
level of consciousness
 Dysrhythmia , Increase or decrease in heart
rate of > 20 beats /min. or heart rate >
110b/m , Sustained heart rate >20% higher
or lower than baseline.
 Tidal volume ≤5 mL/kg, Sustained minute
ventilation <200 mL/kg/minute
 Increase or decrease in blood pressure of
> 20 mm Hg Systolic blood pressure >180
mm Hg or <90 mm Hg

 Increase in respirator y rate of > 10 above

baseline or > 30 Sustained respirator y rate
greater than 35 breaths/minute

 SaO2 < 90%, PaO2 < 60 mmHg, decrease in

PH of < 7.35.Increase in PaCO2
 O2 therapy
 ABG evaluation
 Pulse oxymetry
 Bronchodilator therapy
 Chest physio.
 Adequate Nutrition, hydration,
humidification,
 Incentive spirometry
 Pt successfully weaned---- and has adequate
respiratory function – weaned from O2

 FIO2 is gradually reduced until SPO2 is in

range of 80-100 mmHg while breathing in
Room air

 If R air SPO2 less than 70 supplementary O2

recommended
 Ensure that extubation criteria are met .

 Decanulate or extubat

 Documentation
 PHYSIOLOGICAL NEEDS:
 comfort
 activity
 nutrition
 elimination of wastes

 Patients are often not able to fulfill these needs

by themselves, nursing function is then for
example seeing to comfort, determining intake
and output together with blood chemistry to
assess adequacy of intravenous nutrition, and so
on.
 SAFETY NEEDS:
 Threat of injury by person or machines
 Medication must be checked. Machines must
be in best working condition.
 NEED TO BELONG:
 Security, means of communication
 Staff must communicate with the patient and
patient must be allowed to respond. Patients
need constant reassurance.
 NEED FOR RECOGNITION:
 Esteem, dignity, respect Patients must be
treated with respect and addressed correctly.

 NEED TO CREATE:
 Expression of self, need to contribute Patients
must be involved in the choice and
implementation of their treatment.
 NEED TO KNOW AND UNDERSTAND:
 Need for knowledge and comprehension An
explanation of diagnosis and treatment on
the patient’s level.

 SELF ACTUALIZATION:
 Order, truth, privacy Patients should have as
much privacy as possible — pull screens or
close doors. The patient has the right to be
told the truth.
 Ineffective breathing pattern
 Potential for pulmonary infection
 Impaired water and fluid regulation
 Oral hygiene
 Potential altered nutritional status: less than
body requirement related to NPO status
 Potential for complications related to
immobility
 Knowledge deficit related to intubation and
mechanical ventilation
 Elimination care
 Promoting coping ability
 Preventing trauma and infections
 Promoting rest and sleep
 Safety and security needs.
1.LINK“http://www.nhlbi.nih.gov/health/healthtopics
/topi cs/VENT/”

2.LINK http://www.mmcwm.com/BiPAP

3.LINK:“wwwappskc.lonestar.edu/programs/modes.p
pt”

4. WEBPAGE : WWW.WIKIPEDIA.COM & WWW.

ENCYCLOPEDIA.COM , TOPIC OF MECHANICAL
VENTILATOR & THEIR MODES