A

SEMINAR ON

MECHANICAL VENTILATION

PRESENTED BY
Nirupama.K.S
st
1 YearM.ScNursing
College of Nursing
Thiruvananthapuram

INTRODUCTION

The respiratory system is both remarkable and complicated. Its overall

function is to provide life sustaining oxygen to all the cells of the body
and to remove the byproduct of cellular metabolism. Therefore the

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efficient pulmonary system, along with the cardio vascular system is
intimately related to the body’s metabolic processes. This becomes even
more evident with an understanding of humoral control of ventilation.
Knowledge of pulmonary anatomy provides a sound foundation for
understanding the complex process of respiration. Respiratory support
forms a major part of an intensive care work load, and is rarely required
in isolation from other problems which may have their own adverse
effects on respiratory function. There is a wide diversity of conditions
leading to acute respiratory failure requiring mechanical ventilation. The
classic indications for ventilatory support is reversible acute respiratory
failure. Guidelines for instituting ventilation may be based on respiratory
mechanics, oxygenation and ventilation.

MECHANICAL VENTILATION
Mechanical ventilation is the process by which room air or oxygen-
enriched air is moved into and out of the lungs mechanically.
It is a means of supporting patients until they recover the ability to
breathe independently or a decision is to make to withdraw ventilatory
support.

INDICATIONS FOR MECHANICAL VENTILATION

 Lung or airway disorders or trauma e.g. Pneumonia, ARDS, rib
fractures, asthma, pulmonary edema, pneumothorax.
 Circulatory disorders e.g. MI, cardiogenic shock, heart failure,
 Acute exacerbation of COPD
 Neuromuscular disorders and trauma e.g. GBS, Myasthenia gravis,
head injury.
 Airway obstruction e.g. facial trauma, aspiration, head / neck /
chest burns, oral cavity burns.
 Intra-operatively & Post-operativel
 Respiratory acidosis / Respiratory rate > 30- 40 / minute
 Poor oxygenation
 Poisoning / certain drugs
 Unconsciousness

TYPES OF VENTILATORS

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1.Invasive: Includes the use of an endotracheal tube or tracheostomy.
2.Non invasive:
Non invasive techniques, that is, those that do not require the use of an
ETT or tracheostomy.it provide ventilation via a nasal or oral mask, or
mouth piece with a tight seal. It is used in conjunction with a portable
ventilator. on invasive positive pressure ventilation is primarily used in
home care setting to treat individuals with chronic respiratory failure ,
often only at night.
 Negative pressure ventilators:
Negative pressure ventilation involves the use of chambers that
encase the chest or body and surround it with intermittent sub
atmospheric or negative pressure. Intermittent negative pressure around
the chest wall causes the chest to be pulled outward. This reduces intra
thoracic pressure. Air rushes the upper airway , which is outside the
sealed membrane. Expiration is passive.
Eg: Iron lung, Cuirass ventilators
 Positive pressure ventilators :
Positive pressure ventilation is the most common method for
providing ventilation in acute care setting. This method of mechanical
ventilation forces air into the lungs , usually through an ETT or
tracheostomy tube, via positive pressure. Unlike spontaneous ventilation,
intra thoracic pressure is raised during lung inflation rather than lowered.
Expiration occurs passively as in normal expiration.
Eg. CPAP, BiPAP, NIPPV
Positive pressure ventilators are categorised into;
 Volume cycled ventilators: With volume ventilators , a
predetermined tidal volume ( VT ) is delivered with each
inspiration, and the amount of pressure needed to deliver the breath
varies based on the compliance and resistance factors of the
patient- ventilator system.
 Time cycled ventilators: With a time cycled ventilator, inspiration
and expiration is are terminated by a preset time duration. Many of
the infant ventilators used are time cycled ventilators. Primary time
cycled ventilators deliver a tidal volume in the time allotted for
inspiration. These machines have a wide range of available flow
rates, thus they can accommodate changes in lung compliance and
airway resistance.
 Pressure cycled ventilators: With pressure ventilators, the peak
inspiratory pressure is predetermined, and the VT delivered to the
patient varies based on the selected pressure and the compliance
and resistance factors of the patient-ventilator system.

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 SETTINGS OF MECHANICAL VENTILATION

PARAMETER DESCRIPTION

Respiratory rate ( f ) Number of breaths the ventilator delivers per

minute ; usual setting is 4 – 20 breaths / minute.
Volume of gas delivered to patient during each
Tidal Volume ( VT ) ventilator breath ; usual volume is 5 – 15 ml / kg
Fraction of inspired oxygen delivered to patient ;
Oxygen Concentration may be set between 21 % and 100 % ; usually
( FIO2 ) adjusted to maintain PaO2 level > 60 mm Hg or
SaO2 level > 90 %
Duration of inspiration ( I ) to duration of
I : E ratio expiration ( E ) ; usual setting is 1 : 2 to
Speed with which the VT is delivered ; usual
Flow rate setting 40 – 100 L / min
Determines the amount of effort the patient must
Sensitivity / Trigger generate to initiate a ventilator breath ;
Regulates the maximal pressure the ventilator can
Pressure limit generate to deliver the VT ; when the pressure is
reached , the ventilator terminates the breath and
spills the undelivered volume into the atmosphere ;
usual setting is 10 – 20 cm H2O above peak
inspiratory pressure.
Sigh The lungs are hyperinflated periodically to open
collapsed alveoli. The sigh is given by a machine
or manual hand bag ventilation. Sigh volume is 2
times tidal volume every 5-10 minutes.
Humidification Helps to prevent atelectasis and secondary
infection. Bubble diffusion humididifiers provide
molecules of water and saturate the inspired gas to
100% humidity.

MODES OF MECHANICAL VENTILATION

The variable methods by which the patient and the

ventilator interact to deliver effective ventilation are called modes. The

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ventilator mode selected is based on how much ‘work of breathing’
(WOB) the patient ought to or can perform and is determined by the
patient’s ventilatory status, respiratory drive and ABGs. Generally,
ventilator modes are controlled or assisted.
1. Controlled Mandatory Ventilation (CMV ) : With CMV , breaths
are delivered at a set rate per minute and VT , which are
independent of the patient’s ventilatory efforts. It is used when the
patient has no drive to breathe ( eg. Anaesthetised patient ) or is
unable to breathe spontaneously ( e.g paralyzed patient ). The
patient performs no WOB in this mode and cannot adjust
respirations to changing demands.
2. Assist Control Mechanical Ventilation (ACV ) : With ACV.the
ventilator delivers a preset frequency ,and when the patient initiates
a spontaneous breath, a full VT is delivered.The ventilator senses a
decrease in intrathoracic pressure and then delivers the preset
VT.This mode has the advantage of allowing the patient some
control over ventilation while providing assistance. ACV is used in
patients with a variety of conditions, including neuromuscular
disorders ( e.g. Guillain-Barre syndrome ), pulmonary oedema, and
acute respiratory failure.
3. Intermittent Mandatory Ventilation: IMV allows patient to
breathe on his own, determining his own rate and tidal volume. A
mandatory breath is supplied by the machine at a predetermined
volume and frequency without regard to patient’s demand. In this
mode, the patient is responsible for regulating his own ventilatory
pattern, which may provide more normal ABG values and provide
more psychologic satisfaction. Also the mean intra thoracic
pressure is lower and venous return is less impeded than with
controlled ventilation .IMV is usually used in weaning process
.The main disadvantages are: If the patient becomes apnoeic during
IMV mode, adequate ventilation may not be delivered by the
ventilator .Also the patient’s own breath and the machine delivered
breath may occur simultaneously. Thus the patient receives a larger
breath than the normal. This is regarded as “sigh” and is usually
not thought to be a problem.
4. Synchronised Intermittent Mandatory Ventilation
( SIMV );The SIMV deliver a preset VT at a preset respiratory
rate and permit the patient to breathe spontaneously at his or her
own respiratory rate and depth between the ventilator breaths, the
SIMV mode delivers preset breaths that are synchronised with the
patient’s spontaneous efforts .SIMV mode prevents the patient
from competing with the ventilator during spontaneous efforts.
This mode is commonly used in weaning patients from mechanical

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 ventilation. SIMV has advantages over other modes with respect to
cardiovascular effects. Spontaneous inspiration decreases
intrathoracic pressure and enhances venous blood return to heart.
Thus a patient with an extra cellular fluid volume deficit is better to
maintain cardiac output.
5. Pressure Support Ventilation ( PSV ):With PSV , positive
pressure is applied to the airway only during inspiration and is used
in conjunction with the patient’s spontaneous respirations. As the
patient initiates a breath, the machine senses the spontaneous effort
and supplies a rapid flow of gas at the initiation of the breath and
variable flow throughout the breath. With PSV, patient determines
inspiratory length, VT , and respiratory rate. Advantages of PSV
include increased patient comfort, decreased WOB, decreased
oxygen consumption , and increased endurance conditioning.
6. Pressure Control Inverse Ratio Ventilator( PC-IRV): PC-IRV
combines pressure limited ventilation with an inverse ratio of
inspiration ( I ) to expiration ( E ).This value is normally < 1.With
IRV , the I/ E ratio approaches 1. With IRV , a prolonged positive
pressure is applied , increasing inspiratory time. IRV progressively
expands collapsed alveoli. IRV is indicated for patients with ARDS
who continue to have refractory hypoxemia despite high levels of
PEEP.
7. Positive End-Expiratory Pressure( PEEP ):It is a ventilatory
maneuver in which positive pressure is applied to the airway
during exhalation. Normally during exhalation , airway pressure
drops to zero. And exhalation occurs passively. With PEEP, airway
pressure remains higher than the atmospheric pressure during both
inspiration and expiration( often 3-20 cm H2O ).PEEP keeps the
patient’s airway open at the end of expiration and increases the
functional residual capacity. The mechanisms by which PEEP
increases FRC and oxygenation include , increased aeration of
patent alveoli, aeration of previously collapsed alveoli, and
prevention of alveolar collapse throughout the respiratory cycle.
Often 5 cm of H2O PEEP is used prophylactically to replace the
glottic mechanism, help maintain a normal FRC, and prevent
alveolar collapse.PEEP is indicated in lungs with diffuse disease ,
severe hypoxemia unresponsive to FIO2 > 50% , and loss of
compliance or stiffness.It is contraindicated in patients with highly
compliant lungs ( COPD ), hypovolemia, unilateral diseases, and
low cardiac output.
8. Continuous Positive Airway Pressure( CPAP ): Whereas PEEP is
used to increase the FRC during mechanically assisted breaths,
CPAP is used to augment FRC during spontaneous ventilation and

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 in combination with the spontaneous breaths of IMV and SIMV.
CPAP is also used as a method for weaning patients from
mechanical ventilators. CPAP can be administered via face mask or
mechanical ventilators.It is also used at night by some patients who
suffer from sleep apnoea.
9. High Frequency Ventilation( HFV ): HFV involves delivery of
small tidal volumes ( usually 1-5 ml/kg body weight ) at rapid
respiratory rate ( 100-300 breaths per minute ) in an effort to recruit
and maintain lung volume and reduce intra pulmonary shunting.
One benefit of HFV may be the ability to support gas exchange
while minimizing the risk of barotrauma. Patients receiving HFV
must be paralysed to suppress spontaneous respiration. There are
3 types of HFV.
 High Frequency Jet ventilation : Delivers humidified gas
from a high pressure source through a small-bore cannula
positioned in the airway. With HFJV , precise VT is difficult
to predict and is a function of numerous variable.
 High Frequency Percussive ventilation : attempts to combine
the positive effects of both HFV and conventional
mechanical ventilation. A piston mechanism positioned at
the end of the ET tube is driven by a high-pressure gas
supply at a rate of 200 to900 beats/ minute. These high-
frequency beats are superimposed on a conventional pressure
controlled ventilator mode.
 High Frequency Oscillatory ventilation: Uses a diaphragm
or piston in the ventilator to generate vibrations of sub
physiologic volumes of gas. It can produce respiratory
frequencies in excess of 3000 breaths per minute.

10.Airway Pressure Release Ventilation: It is described as two levels of

CPAP that are applied for a set period of time and combines the features
of CPAP and PCV. APRV differs conceptually from all other ventilatory
modalities because it effects movement of gas by decreasing airway
pressure below some constant baseline inflation pressure which maintains
resting lung volume above FRC. The inspiratory flow valve is open
throughout the ventilatory cycle such that the patient is able to breathe
spontaneously in a manner similar to CPAP. However at preset intervals,
ventilator support is superimposed on spontaneous respirations by
releasing the positive pressure at the airway opening and allowing the
lungs to deflate to some volume above FRC determined by a preset end
expiratory pressure. Augmentation of alveolar ventilation with low peak
airway pressure and without over distension of lung parenchyma appears
to be a major advantage of APRV. Other advantages include low

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intrathoracic pressure and improved matching of ventilation and
perfusion.
11 . Partial Liquid Ventilation: Currently clinical trials are investigating
the use of perflubron ( Liqui Vent ) in partial liquid ventilation for
patients with ARDS. Perflubron is an inert, biocompatible, clear,
odourless liquid derived from organic compounds that has an affinity for
both oxygen and carbon dioxide and surfactant like quality. Perflubron is
trickled down a specially designed ET tube through a side port into the
lungs of a mechanically ventilated patients. The amount used is usually
equivalent to patient’s FRC. PLV has demonstrated few detrimental
effects on hemodynamics and may evolve as an important adjunct in the
management of ARDS.
12. Independent Lung Ventilation: It is achieved by using a double
lumen endo bronchial tube to ventilate each lung separately. Two
ventilators are usually required and settings and ventilatory modes can be
selectively applied without need for synchronisation. ILV is an acceptable
form of ventilatory support in respiratory failure with a unilateral or
different lung pathology such as unilateral edema, aspiration or chest
trauma.

PROBLEMS WITH MECHANICAL VENTILATORS

Ventilator CAUSE SOLUTION

problems:

Increase in peak air - coughing or -suction air way

way pressure plugged air way - Adjust sensitivity
tube -Manually ventilate
- patient bucking patient
ventilator -asses for hypoxia or
- decreased lung bronchospasm
compliance -check ABGs
-sedate if necessary

-tubing kinked -check tubing

-reposition the patient
-insert oral air way if
necessary

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 -atelectasis , -clear secretions
bronchospasm
-decrease in pressure -leak in ventilator or -check entire
or loss of volume tubing ventilator circuit for
patency.

COMPLICATIONS OF MECHANICAL
VENTILATION

1.Pulmonary System:
 Barotrauma
 Volu-pressure trauma
 Alveolar hypo ventilation
 Alveolar hyperventilation
 Ventilator associated Pneumonia
 Intubation of right main stem bronchus
 Unplanned extubation
 Tracheal damage
 Associated with oxygen administration
 Aspiration
 Ventilator Dependance/ Inability to wean

2. Cardiovascular system
3. Sodium and Water Imbalance
4. Gastrointestinal system
5. Neurologic System
6. Psychosocial complications

NURSING MANAGEMENT
MAINTAINING A PATENT AIRWAY

o Assess theneed for suctioning e.g. noisy respirations,

restlessness, increased pulse.
o Ausculate the chest for equal air entry, presence of abnormal
breath sounds, observe for asymmetrical chest expansion.
o Provide chest physiotherapy in the form of nebulisation,
humidification, adequate hydration, positioning, percussion,
vibrations and tapotment, postural drainage.(to prevent RTI).
o Suction the patient :-

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 o Maintain sterility at all times.
o Check the ET / TT is well secured and inflated, prior to
suctioning.
o 100% oxygenation prior to suctioning (ambu / ventilator).

PREVENTION OF INFECTION

o Practice proper hand washing.

o Any health personnel having RTI should avoid caring for
these patients or remember to use a mask while providing
care.
o Use of aseptic technique while suctioning, while changing
tracheostomy dressings, performing invasive procedures /
inserting any device, etc.
o Maintain adequate oral and personal hygiene.
o Avoid entry of water / foreign body into the trachea.
o Change tubing's, bacterial / ventilator filters as per protocol.
o Provide adequate nutrition (HPD, HCD).
o Observe for S/S of infection (local / systemic), device
related.
o Good respiratory hygiene. (suction, chest physiotherapy,
etc).

PREVENTION OF ASPIRATION

o A cuffed endotracheal or tracheostomy tube should be used in a

patient
o who requires mechanical ventilation.
o The cuff inflation pressure should be adjusted until there is no
audible air
o leak while using normal inspiratory airway pressures. An
endotracheal cuff pressure of at least 20cm H2O should be
maintained.
o In patients requiring prolonged ventilatory support, cuff deflation
should be considered when the patient is alert, has normal
swallowing and is tolerating trials of spontaneous breathing.
o Aspiration of subglottic secretions should be considered in patients
who are expected to be mechanically ventilated for more than 48
hours.
o Mechanically ventilated patients should be nursed in the semi-
recumbent position (elevation of the head of the bed to 30-45°),
unless contraindicated.

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 o The use of rotating beds may be considered in mechanically
ventilated patients who cannot tolerate the semi-recumbent
position.
o Gastric distension should be avoided in mechanically ventilated
patients who are being fed enterally.

NUTRITIONAL NEEDS

o HPD and high carbohydrate / fiber diet through Ryle’s tube.

o Points to be remembered while giving RT feeds :-
o Check for presence of gastric motility by auscultation.
o Confirm placement of RT.
o Assess amount of residual feed.
o Administer feeds in PUP. Maintain this position for half an
hour after feeds.
o Prevent air entry into the RT.
o Aspirate after 1 hour to confirm digestion of feeds.
o Perform suctioning prior to feeds.
o Provide nasal care / oral care.
o Prepare a diet plan based on patient’s needs.(proteins /
calories/ fluids).

POSITIONING

o Provide change of poistion every two hours along with back

massage and limb physiotherapy.
o Use comfort devices to prevent bed-sores, contractures&
footdrop (> in unconscious patients )

ACTIVITY

o Provide active & passive ROM excercises.

o Plan care to provide periods of activity & rest.
o Encourge early ambulation .
MEETING THE HYGIENIC NEEDS

o Provide oral care every 2 - 4 hourly.

o Also provide sponge bath, back care, eye care, nasal care,
etc.

MEETING THE ELIMINATION NEEDS

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 o Catheter care.
o Hydration of the patient.
o Provide bedpan and clean patient, as required.
o Provide privacy.
o Observe for constipation / diarrhea (modify diet).

MEETING THE SPIRIUAL & PSYCHOSOCIAL NEEDSss

 Make provisions for meeting spiritual leaders and for prayers.

 Plan for visiting hours without unnecessary disturbances.
 Facilitate communication between patient, family,healthpersonnel .
CUFF CARE

o Deflate the cuff every 1 hour for 5 mins. Be with

the patient at this time. (varies with hospital policy).
o Inflate cuff at all other times. Especially when suctioning,
giving trach. care, positioning, mouth
care, change of tapes, feeding.
o Assess for cuff leak – by ascultating, checking TV,
excessive movement of tube.(hazards - reduced
TV, aspiration, accidental extubation)
o Check cuff pressures – 20 – 24 mmHg (hazards of high/
prolonged pressures - necrosis, bleeds, fistula)

ENDOTRACHEAL / TRACHEOSTOMY TUBE CARE

o Check the ET level intermittently and after suctioning and

positioning.
o Secure the tube well with tape / tie. Alternate sides
every 24 hours.
o Use the appropriate size to prevent injury.
o Assess for bilaterally equal air entry at all times.

HANDLING AN ALARM

o NEVER PUT OFF AN ALARM

WITHOUT DETERMINING IT’S CAUSE
o After silencing the alarm, attend to it IMMEDIATELY
o Find the problem and solve it before re-setting the alarm
again.

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 o If alarm sounds again, DO NOT ASSUME it is for the same
reson. Investigate it.
o Set limits appropriately.
o Suspend alarms only
when required e.g. suctioning. At these times, obeserve patie
nt and monitor readings closely.

WEANING FROM MECHANICAL VENTILATOR

Weaning is the gradual withdrawal of mechanical ventilation. The client’s
ability to breathe independently is the most important criterion for
successful weaning. The length of time required for successful weaning
generally relates to the underlying disease process and to the client’s state
of health, before the ventilator was used. Weaning should be instituted
after paralytics are discontinued, and sedation is tapered off. During
weaning process, the client should be observed for increased respiratory
rate, shallow breathing and decreased tidal volume , which may indicate
muscle fatigue.

CRITERIA FOR A VENTILATOR WEANING TRIAL

 Reversal of underlying cause of respiratory failure

 Adequate oxygenation, indicated by,
- PaO2 ≥ 60 mm Hg on FiO2 < 40-50 %
- PEEP requirement ≤5-8 cm of H2O
- pH ≥ 7.25
 Heart rate ≤ 140 beats/min
 Stable BP with no or minimal vasopressive medication
 No myocardial ischemia
 Temperature ≤100.4 ◦ F
 Hb ≥ 8-10 g/dL
 Acceptable electrolyte values
 Adequate cough
 Capability to initiate respiration
 Adequate mentation without continuous IV sedation

METHODS OF WEANING

There are two methods of weaning.

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 1. The conventional method is the episodic ventilator with T-piece or
CPAP. Briggs T-piece is used. The patient is disconnected from the
ventilator for a specific period of time and allowed to breath
spontaneously using the Briggs T-piece or CPAP. Weaning starts
with shorter intervals such as 5-10 minutes every hour or more.
The patient requires rest period. Weaning should not be attempted
during night until the patient can maintain spontaneous breathing.
The vital capacity and signs of fatigue are monitored closely during
the weaning period.
2. Intermittent Mandatory Ventilation weaning: IMV is a technique by
which patient can breathe spontaneously and in addition receive
mechanically ventilated breaths at specific pre selected rate. Set
rate, interval and keep sensitivity at maximum setting. Record at
each weaning interval heart rate, blood pressure and respiratory
rate and ABG and pulse oxygenation while IMV is used. The
spontaneous rate should not exceed 30 breaths/ minutes as this
results in fatigue, CO2 retention and respiratory acidosis. Rates
greater than 30 indicate a need to reduce weaning time. Weaning
can continue as long as patient’s condition is stable and arterial pH
is 7.32 – 7.35.
Patient is positioned in sitting or fowlers position during
weaning. All respiratory and other parameters are monitored. Patient is
supported emotionally during weaning process.

CAUSES OF FAILURE TO WEAN

1. Patient Factors:
 Inadequate spontaneous breathing
 Intrinsic pulmonary disease resulting in atelectasis
 Consolidation
 Edema
 Bronchospasm which can be managed with PEEP and chest
physiotherapy
 Chest wall trauma
 Muscle weakness
 Abnormal cardiac functioning
 Starvation (protein loss cause break down of muscle mass
resulting in decreased respiratory muscle function which
may affect weaning process )
2. Ventilator System Factors:
Ventilatory design and PEEP devices are a major source of of
weaning problems. Meticulous attention should be paid to the
appropriate setting of flow and sensitivity when IMV is used.

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 Continuous Positive Pressure should be produced with a system
that provides a minimum of external work for patient.
3. Airway Factors:
The artificial airway also may produce weaning problems. It is
noticed that endotracheal tube of small inter diameter requires
increased patient effort during spontaneous ventilation obstruction
of tube can be a cause of sudden and marked change in weaning
ability.

SIGNS AND SYMPTOMS OF WEANING INTOLERANCE

 Presence of dysrrhythmias
 Increase or decrease in the heart rate > 20 bpm
 Increase or decrease in BP of > 20 mm Hg
 Increase in respiratory rate of > 10 above baseline
 Tidal volume < 250 ml
 Increase in minute ventilation of > 5 litre / minute
 Sp O2 < 90 %
 Pa O2 < 60 mm Hg
 Increase in the PaCO2 with a decrease in pH of < 7.35.
 Sweating
 Shortness of breath
 Restlessness
 Decrease in the LOC

CONCLUSION

Care of critically ill patients requires knowledge of normal anatomy and

physiology and excellent assessment skills. Skills in establishing and
maintaining an open airway and initiating mechanical ventilation are also
essential. Care of the patient requiring mechanical ventilation is an
everyday assignment in critical care unit. Therefore it is essential that the
nurse must apply knowledge and skills in order to effectively care for
these patients.

BIBLIOGRAPHY

1. Linda.D.Urden, Priorities in Critical Care Nursing, 4 th Edition,

Mosby publishers, Missouri,2004, Pp 260-264
2. Lynelle.N.B.Pierce, Mangement of Mechanically ventilated
Patient, 2nd Edition, Saunders Publishers, Missouri, 2007

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3. Lewis, Heitkemper, Medical Surgical Nursing, 6th Edition, Mosby
Publishers, Missuori, 2006, Pp 1780-1792

JOURNALS

1. .American Journal of Nursing, August 2007, Vol.107

2. Journal of Nursing Research Society of India, Vol.1, October
2008

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