A SEMINAR ON

MECHANICAL VENTILATION

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

CENTRAL OBJECTIVE
On completion of seminar, the group gets a thorough knowledge regarding mechanical ventilation, appreciates its importance and apply its various aspects un clinical practice.

SPECIFIC OBJECTIVE
On completion of seminar, the group Defines mechanical ventilation Explains historical evolution of mechanical ventilator List down indications of mechanical ventilation Describe the modes of mechanical ventilators Discuss the settings of mechanical ventilators Explore the complications of mechanical ventilators Analyse the nursing management of patient on mechanical ventilator Identify the nursing diagnosis of patient on mechanical ventilator Explain weaning from mechanical ventilator List down the causes for failure to wean from mechanical ventilators

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 efficient pulmonary system, along with the cardio vascular system is intimately related to the bodys 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
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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 oxygenenriched 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.

EVOLUTION OF MECHANICAL VENTILATION

AD 175 Galen used a fire place bellows to inflate the lungs of a deceased animal. 1555 - Vasalius resurrected the technique to keep an experimental animal alive while he examined its thoracic contents. 1776 - John Hunter, an avid proponent of manual ventilation, constructed a double bellows device so that one could insufflate air and the other could evacuate air from the lungs through a tracheostomy tube 1826 - Leory developed a bellows ventilator with a graduated scale and a two way valve that permitted inhalation and exhalation 1882 - Dr.Joseph. ODweyer investigated translaryngeal intubation of trachea in cadavers. He constructed plaster casts of the trachea to determine the appropriate size and configuration of the tubes and used his tubes for translaryngeal intubation of patients 1893 - Dr.George.E.Fell, described a ventilator that he used to maintain artificial breathing in several cases of optimum toxicity.The breathing device became known as the Fell O Dweyer apparatus. Later Meltzer and Auer introduced a method of artificial ventilation for experimental thoracic operations that they are called respiration by continuous intra tracheal insufflation of air 1913 - Jane Way developed an automatic intermittent positive pressure ventilator that could provide mandatory or patient initiated

breaths during thoracic operations 1929- Drinker, Louis shaw, and Charles.E.Mckhann developed first Iron Lung for resuscitation after industrial asphyxial accidents. It was constructed using sheet metal cylinder that was sealed at one end. The tank accommodated the patients lower body and chest up to the neck leaving head out side. The neck opening provided an airtight seal enabling a suction device to generate negative pressure around chest and lower body within the tank. The use of the cabinet ventilator was associated with a variety of problems. Patients suffered from lack of nursing care, neck sores, venous engorgement of neck and face and adverse psychological effects of being partially enclosed in cabinet. A simplified version of Tank ventilator, Cuirass ventilator was developed later. It consists of a rigid cylindrical shell placed around patients chest and abdomen. It was covered with a nylon or plastic coat that produces an airtight seal between ambient air and the space between the cylinder and chest wall. Intermittent negative pressure ventilation using Iron lung continued in wide spread use through the mid 1950s, during the epidemics of poliomyelitis. 1953 - Bang developed an automatic ventilator that could be used to administer a given minute volume with controlled or patient limited pressure breaths. ( The Clause Bang Ventilator ) 1967 - HFV developed by Sjostrand 1977 - Hewlett discovered mandatory minute ventilation 1980 - Seimens- Elma introduced Pressure supported ventilation( Servo 900 series ) 1987 Ventilator Downs and Stock introduced Airway Pressure Release

1983- Puritan Bennett 7200 was introduced 1984- Puritan Bennett 7200 AE was introduced 1991- SensorMedics 3100A High Frequency Oscillatory Ventilator 1994- SensorMedics 3100B High Frequency Oscillatory Ventilator,

2010 - Drger Babylog VN500 was Introduced Drger Evita XL,

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Drger Savina 300, Drger Carina, Drger Babylog 8000 plus,

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
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
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 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.

SETTINGS OF MECHANICAL VENTILATION

PARAMETER Respiratory rate ( f ) DESCRIPTION Number of breaths the ventilator delivers per minute ; usual setting is 4 20 breaths / minute. Volume of gas delivered to patient during each ventilator breath ; usual volume is 5 15 ml / kg

Tidal Volume ( VT ) Oxygen ( FIO2 )

Fraction of inspired oxygen delivered to patient ; Concentration may be set between 21 % and 100 % ; usually adjusted to maintain PaO2 level > 60 mm Hg or SaO2 level > 90 %

I : E ratio Flow rate Sensitivity / Trigger Pressure limit

Duration of inspiration ( I ) to duration of expiration ( E ) ; usual setting is 1 : 2 to Speed with which the VT is delivered ; usual setting 40 100 L / min Determines the amount of effort the patient must generate to initiate a ventilator breath ; Regulates the maximal pressure the ventilator can 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. 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. Helps to prevent atelectasis and secondary infection. Bubble diffusion humididifiers provide molecules of water and saturate the inspired gas to 100% humidity.

Sigh

Humidification

MODES OF MECHANICAL VENTILATION

The variable methods by which the patient and the ventilator interact to deliver effective ventilation are called modes. The ventilator mode selected is based on how much work of breathing (WOB) the patient ought to or can perform and is determined by the patients 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 patients 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
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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 patients 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 patients 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 patients 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 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 patients 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 patients 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 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 highfrequency 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 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 patients FRC. PLV has demonstrated few detrimental effects on hemodynamics and may evolve as an important adjunct in the management of ARDS.

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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 problems:
Increase in peak air way pressure

CAUSE

SOLUTION

- coughing or plugged air way tube - patient bucking ventilator - decreased lung compliance

-suction air way - Adjust sensitivity -Manually ventilate patient -asses for hypoxia or bronchospasm -check ABGs -sedate if necessary

-tubing kinked

-atelectasis bronchospasm

-check tubing -reposition the patient -insert oral air way if necessary , -clear secretions

-decrease in pressure -leak in ventilator or -check entire or loss of volume tubing ventilator circuit for patency.

COMPLICATIONS VENTILATION
1.Pulmonary System:

OF

MECHANICAL

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Barotrauma: Barotrauma is the presence of extra-alveolar air. This air may escape into the pleura, mediastinum, pericardium, or under the skin . Barotrauma may occur when the alveoli are over distended, such as with positive pressure ventilation, high VT (>15 ml/kg), and PEEP. Signs and symptoms include high peak inspiratory pressure, decreased breath sounds, high mean airway pressure, tracheal shifts and symptoms associated with hypoxemia. A life threatening complication is tension pneumothorax.When tension pneumothorax occurs, pressurised air enters the pleural space. Air is unable to exit from the pleural space and continues to accumulate. Collapse of cardiopulmonary system occurs rapidly. Treatment consists of immediate insertion of a chest tube. Volu-pressure trauma: It relates to the lung injury that occurs when large tidal volumes are used to ventilate non-compliant lungs.( eg. ARDS ).Volupressure trauma results in alveolar fractures and movement of fluids and proteins into the alveolar spaces. To limit this complication , it is recommended that smaller tidal volumes or pressure ventilation be used in patients with stiff lung. Alveolar hypo ventilation: Hypoventilation can be caused by inappropriate ventilator settings, leakage of air from the ventilator tubing or around the ET tube or trSIMV rate in a patient who is unable to produce adequate spontaneous respirations causes hypoventilation, respiratory acidosis, and additional problems related to acidosis such as cardiac arrhythmias. Alveolar hyperventilation: Respiratory alkalosis can occur if the respiratory rate or VT is set too high or if the patient receiving assisted ventilation is hyper ventilating. Alkalosis, especially if onset is abrupt, can have additional serious consequences including hypokalemia, hypocalcemia and arrhythmia. Ventilator associated Pneumonia: Patients with artificial airways are at an increased risk for pulmonary infection because normal defense mechanisms in the nose are bypassed. Additionally, procedures such as endotracheal suctioning also predispose the patient to an increased risk of infection. Intubation of right main stem bronchus: The right main stem bronchus is straighter than the left. If the ETT is manipulated, such as occurring during changing of the tapes or repositioning of the tube in the mouth, it may move into the right main stem bronchus. Symptoms include absent or diminished breath
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sounds in the left lung. Whwnever the ETT is manipulated , the nurse must auscultate the chest for bilateral breath sounds after the procedure is completed. Unplanned extubation: The ETT can become dislodged if it is not secured properly, if the patient moves or during tape changes on ETT.The ETT may end up in the back of throat, in the esophagus, or completely removed.Auscultation of bilateral breath sounds can be used to verify that the ETT is in the airway. Tracheal damage: Damage to the trachea can occur because of pressure from the cuff. However, the risk of tracheal damage has decreased since all ETTs and tracheostomy tubes have low pressure cuffs. An intervention for preventing tracheal damage is monitoring of cuff pressure on a routine basis; pressures should not exceed 30 cm H2O . Associated with oxygen administration: If 100 % oxygen is administered , there is lack of nitrogen in the distal air spaces. Nitrogen is needed in order to prevent collapse of the airway. Therefore the patient is prone for absorption atelectasis. Other complications associated with oxygen administration include tracheo-bronchitis,ARDS, and chronic pulmonary dysplasia.As a rule, an FiO2 up to 1.0 can be tolerated up to 48 hours.After that period, the goal is to lower the FiO2 less than 0.60 to prevent further lung damage. Aspiration: Most patients require tube feedings.Gastric distention, impaired gastric emptying with large amounts of gastric residua, and esophageal reflux predispose patients to aspiration. Ventilator Dependance/ Inability to wean: Patients who require long-term mechanical ventilation are usually very challenging to wean from ventilators. E.g.: patients with COPD and neuromuscular disease. 2. Cardiovascular system: PPV can affect circulation because of transmission of increased mean airway pressure to the thoracic cavity. With increased intra thoracic pressure, thoracic vessels are compressed. This results in decreased venous return to heart, decreased left ventricular end diastolic volume ( preload ), decreased cardiac output and hypotension. 3. Sodium and Water Imbalance : Progressive fluid retention often occurs after 48-72 hours of PPV. Fluid balance changes may be due to decreased CO, which in turn results in diminished renal perfusion. Consequently rennin release is stimulated with subsequent production of angiotensin and aldosterone. This results in sodium water retention. It is
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also possible that pressure changes within the thorax are associated with decreased release of atrial natriuretic peptide, also causing sodium retention. In addition, as a part of stress response, release of antidiuretic hormone and cortisol may be increases, contributing to sodium water retention. 4. Gastrointestinal system: Patients receiving PPV are often stressed because of serious illness, immobility, and discomforts associated with the ventilator. Thus the ventilator patient is at risk for developing stress ulcers and GI bleeding. Any kind of circulatory compromise, including reduction of CO caused by PPV, may contribute to ischemia of gastric and intestinal mucosa and possibly increase the risk of translocation of GI bacteria. Gastric and bowel dilation may occur as a result of gas accumulation in the GI tract from swallowed air.This may put pressure on the vena cava, decrease CO and prohibit adequate diaphragmatic excursion during spontaneous breathing. Elevation of the diaphragm as a result of paralytic ileus or bowel dilation leads to compression of the lower lobes of the lungs, which may cause atelectasis and compromise respiratory function Immobility, sedation, circulatory impairment, decreased oral intake, use of opioid pain medications and stress contribute to decreased peristalsis, and as a result, the ventilatory patient could be predisposed to constipation. 5. Neurologic System: In patients with head injury, PPV, especially with PEEP, can impair cerebral blood flow. This is related to increased intra thoracic positive pressure impeding venous drainage from the head, as evidenced by jugular venous distension.As a result of the impaired venous return and increase in cerebral volume, the patient may exhibit increases in intra cranial pressure. Elevating the head of the bed and keeping the patients head in alignment may decrease the deleterious effects of PPV on intra cranial pressure. 6. Psychosocial complications: The patients receiving mechanical ventilation may experience physical and emotional stress. Usually the critical care milieu is one of continuous, excessive sensory stimulation for the patient. An attitude by the practitioner of confidence and knowledge of the equipment will help allay the patients fears of safety. Communication becomes an almost intolerable problem for the patient receiving ventilator therapy. The patient must have some means of communication to relay his needs and feelings to his family and the health care team.Continuity of the care givers who are compatable and accustomed to the patient is also important in fostering the sense of independence and control . A trusting relationship is needed if behaviour modification techniques are used with the patient, most imporatantly when the ventilator weaning process is begun.
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NURSING MANAGEMENT
MAINTAINING A PATENT AIRWAY
o o o

o o o o

Assess the need for suctioning e.g. noisy respirations, restlessness, increased pulse. Ausculate the chest for equal air entry, presence of abnormal breath sounds, observe for asymmetrical chest expansion. Provide chest physiotherapy in the form of nebulisation, humidification, adequate hydration, positioning, percussion, vibrations and tapotment, postural drainage.(to prevent RTI). Suction the patient :Maintain sterility at all times. Check the ET / TT is well secured and inflated, prior to suctioning. 100% oxygenation prior to suctioning (ambu / ventilator).

PREVENTION OF INFECTION

o o

o o o o o o

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

PREVENTION OF ASPIRATION o A cuffed endotracheal or tracheostomy tube should be used in a patient

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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 semirecumbent position (elevation of the head of the bed to 30-45), unless contraindicated. 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 o o o o o o o o o o

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

POSITIONING
o

Provide change of poistion every two hours along with back massage and limb physiotherapy.

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Use comfort devices to prevent bed-sores, contractures& footdrop (> in unconscious patients )

PREVENTION OF COLONISATION OF THE AERODIGESTIVE TRACT Histamine receptor 2 antagonists and proton pump inhibitors should be used in mechanically ventilated patients at high risk of developing upper gastrointestinal bleeding. Sulcralfate may be considered in patients at low to moderate risk of bleeding. o Regular oral hygiene should be carried out in all mechanically ventilated patients. A soft toothbrush should be used to clean the oral mucosa, except where contraindicated (e.g., increased risk of bleeding, thrombocytopenia) at least 12-hourly. o The topical application of chlorhexidine gluconate (0.12%- 2%) should be considered in such an oral care programme. Povidoneiodine (10%) should be considered for use in patients with severe head injury. No recommendation is made for selective decontamination of the digestive tract.
o

ACTIVITY
o o o

Provide active & passive ROM excercises. Plan care to provide periods of activity & rest. Encourge early ambulation

MEETING THE HYGIENIC NEEDS

o o

Provide oral care every 2 - 4 hourly. Also provide sponge bath, back care, eye care, nasal care, etc.

MEETING THE ELIMINATION NEEDS

o o o o o

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

MEETING THE SPIRIUAL & PSYCHOSOCIAL NEEDSss

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 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 o

Deflate the cuff every 1 hour for 5 mins. Be with the patient at this time. (varies with hospital policy). Inflate cuff at all other times. Especially when suctioning, giving trach. care, positioning, mouth care, change of tapes, feeding. Assess for cuff leak by ascultating, checking TV, excessive movement of tube.(hazards - reduced TV, aspiration, accidental extubation) Check cuff pressures 20 24 mmHg (hazards of high/ prolonged pressures - necrosis, bleeds, fistula)

ENDOTRACHEAL / TRACHEOSTOMY TUBE CARE

o o o o

Check the ET level intermittently and after suctioning and positioning. Secure the tube well with tape / tie. Alternate sides every 24 hours. Use the appropriate size to prevent injury. Assess for bilaterally equal air entry at all times.

HANDLING AN ALARM
o o o o o o

NEVER PUT OFF AN ALARM WITHOUT DETERMINING ITS CAUSE After silencing the alarm, attend to it IMMEDIATELY Find the problem and solve it before re-setting the alarm again. If alarm sounds again, DO NOT ASSUME it is for the same reson. Investigate it. Set limits appropriately. Suspend alarms only when required e.g. suctioning. At these times, obeserve patie nt and monitor readings closely.

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WEANING FROM MECHANICAL VENTILATOR

Weaning is the gradual withdrawal of mechanical ventilation. The clients 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 clients 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. 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.
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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 patients 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. 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.
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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

NURSING MANAGEMENT
Nursing Diagnosis 1.Ineffective airway clearance related to presence of artificial airway,
accumulation of secretions and immobility as manifested by presence of abnormal breath sounds and presence of thick copious secretions - change patients position 2 hourly and perform postural drainage, vibration and percussion maneuver to prevent pooling of secretions - have patient cough and, if feasible, deep breathe 2 hourly to remove secretions and to prevent hypoventilation. - suction oropharynx - perform tracheo bronchial suctioning to remove retained secretions and improve oxygenation - assess breath sounds - assess for adequate systemic hydration and provide supplemental humidification of ventilator delivered gas because these will assist with thinning of sputum. 2. Impaired gas exchange related to insufficient oxygen levels or inadequate PEEP level. - Monitor ABGs. - Assess LOC, listlessness, and irritability. - Observe skin color and capillary refill. (Determine adequacy of blood flow needed to carry oxygen to tissues.) - Administer oxygen as ordered
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- Observe for tube obstruction; suction ; ensure adequate humidification. - Reposition patient q. 1-2 h.( Repositioning helps all lobes of the lung to be adequately perfused and ventilated.) 3. Decreased cardiac output related to impeded venous return by PPV as manifested by decreased BP, decreased urine output, increased heart rate - monitor vital signs and level of consciousness - observe and monitor for clinical manifestations of decreased cardiac output - monitor hemodynamic parameters especially when > 10 cm of H2O of PEEP is used 4. Imbalanced nutrition less than body requirement related to NPO status - Provide nutrition as ordered, e.g. TPN, lipids or enteral feedings. - Obtain nutrition consult. ( Provides guidance and continued surveillance.) - Administer entera solutions at continual rates by infusion pump as warranted - Observe for muscle wasting - Observe for nausea, vomiting, abdominal distension, and palpability and stool characteristics - Insert nasogastric tubes if needed 6.Impaired verbal communication related to intubation and artificial airway - evaluate patients ability to communicate by other means - ensure that call bell is placed within easy reach of patient at all times - make eye contact with patient at all times - instruct family members in talking with patient to provide information about issues of concern to patient. 7. Risk for infection related to intubation and compromised defense mechanism - evaluate risk factors that would predispose patient to infection - provide oral hygiene Q4H - monitor sputum for changes in characteristics and colour, culture sputum - monitor tracheostomy site for infection - maintain good hand washing technique and isolation precautions when warranted - maintain sterile techniques for all dressing changes and suctioning - -Administer antibiotics as ordered
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8. Risk for injury related to patient deterioration, mechanical break down, increased intrathoracic pressure, or bypassed defence mechanism. - keep ventilator alarms keep on at all times - continually observe whether the patient is breathing in synchrony with the ventilator - monitor the patient on PEEP closely for barotraumas, decreased cardiac output, water retension and if the patient has an ICP monitor, increased ICP - obtain ABG values - monitor patient for signs and symptoms for decreased cardiac output such as hypotension, tachycardia, arrhythmia and deteriorating mental status - drain condensed fluid from the ventilator tubing - maintain sterile technique, good oral care, and careful positioning and observe for signs and symptoms for pulmonary infections 9. Risk for dysfunctional ventilatory weaning response related to lack of physiologic and psychological readiness. - - anticipate weaning when the patient meets all the criteria for weaning - - make sure the patient is rested , well nourished, oriented and able to follow command - - explain weaning to the patient and family - - Obtain baseline vital signs, ABG values and pulmonary function measurements.

RECENT STUDIES

Meticulous mouth care is crucial for preventing VAP. Rincon-Ferrari and colleagues (2004) found that in head-injured patients, 40%-60% of the gramnegative bacilli found were due to endogenous lung colonization after aspiration of oropharyngeal secretions. Twenty percent to forty percent of these bacteria were Staphylococcus aureus, and more than half of the Staphylococcus aureus were methicillin-resistant. This type of

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staphylococcus is exogenous, usually originating from the hands (Mori et al., 2006). Studies have shown that patients can become colonized with pathogenic bacteria within 24 hours of admission to a critical care unit (Garcia, Jendresky, & Colbert, 2004; Sole, Poalillo, Byers, & Ludy, 2002). The oral cavity and its components-especially dental plaque-are the perfect media in which bacteria can colonize (Garcia et al.). The American Association of Critical-Care Nurses published an evidence-based practice alert in 2006 that offered guidelines for oral care of the mechanically ventilated patient. In addition, Grap and Munro (2004) and Collard and Saint (2004) recommended raising the head of the bed to an elevation of 30[degrees] to 40[degrees], using endotracheal tubes that have a dorsal lumen above the endotracheal cuff, and sporadically changing ventilator circuits. Grap and Munro (2004) presented supporting evidence indicating that critically ill patients who are intubated for more than 24 hours are at higher risk for VAP, and therefore, mouth care and oral health should be an important part of nursing care. Current literature identified a problem with adequate oral care in the intubated patient that included the definition and quantification of oral care (Fourrier et al., 2000). Bergmans and colleagues (2001) provided evidence that prevention of bacterial colonization of the oropharynx is the key to preventing VAP. The Centers for Disease Control and Prevention guidelines (Tablan, Anderson, Besser, Bridges, & Hajjeh, 2004) determined that the primary route of bacterial entry into the lungs is through the oropharynx during episodes of microaspiration. Several studies (El-Solh et al., 2004; Schleder et al., 2002; Shinn, 2004) have verified that removing bacteria from the oropharynx requires the removal of dental plaque, and the only way to remove the plaque is with toothbrushing. Pearson and Hutton (2002) and others found that the majority of nurses use a soft Toothette(R) instead of toothbrushing and that the Toothettes do not remove plaque as effectively as toothbrushes; consequently, oral bacteria can proliferate (Baker, 2007; Binkley, Furr, Carrico, & McCurren, 2004). Pearson and Hutton (2002) completed a controlled trial that compared the ability of foam swabs and toothbrushes to remove dental plaque and to quantify any differences. They concluded that toothbrushing skills must be taught to nurses and clinical support staff. Schleder (2003) reviewed the pathogenesis of bacteria; identified risk factors, including
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colonization of the oropharynx; and recommended the following approaches: 1. Use good oral hygiene, including toothbrushing, on all patients. 2. Implement oral-hygiene assessments and intervention strategies for all patients at risk for developing VAP. 3. Decontaminate devices that come into contact with the respiratory tract. 4. Implement the hand-hygiene guidelines released by the CDC in 2003. The guidelines include decontaminating hands by washing them with antimicrobial soap and water or by using an alcohol-based, waterless antiseptic agent if hands are not visibly contaminated. In addition, gloves should be worn when handling respiratory secretions or objects contaminated with the respiratory secretions of any patient (Schleder, 2003; Tablan et al., 2004). Grap, Munro, Ashtiani, and Bryant (2003) have substantiated the need to standardize oral care for a variety of reasons, the most compelling of which is to prevent or lower VAP rates in mechanically ventilated patients. Oral care is not only part of a standard of care that lowers infection rates by removing plaque-harboring organisms, but is also a comfort care issue (Fourrier et al., 2000; Munro & Grap, 2004). Using evidence-based outcomes and research, the CDC and its Hospital Infection Control Practices Advisory Committee have developed a set of guidelines for VAP prevention that are beneficial for any institution. The guidelines include preferential use of orotracheal tubes over nasotracheal tubes, use of endotracheal tubes with a dorsal lumen to allow drainage, elevating the head of the bed to 30[degrees] or 40[degrees], routinely verifying placement of feeding tubes, and preventing or modulating oropharyngeal colonization with implementation of a comprehensive oral hygiene program (Dodek et al., 2004; Tablan et al., 2004).

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
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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, 4th Edition,

Mosby publishers, Missouri,2004, Pp 260-264 2. Lynelle.N.B.Pierce, Mangement of Mechanically ventilated Patient, 2nd Edition, Saunders Publishers, Missouri, 2007 3. Lewis, Heitkemper, Medical Surgical Nursing, 6th Edition, Mosby Publishers, Missuori, 2006, Pp 1780-1792 4. P.K.Verma, Mechanical Ventilation and Nutrition in Critically ill patients, 1st Edition, Elsevier publishers, NewDelhi, 2005 5. Jaya Kuruvilla, Essentials of Critical Care nursing, 1st Edition, JayPee publishers, Newdelhi,2007 6. T.E.Oh, Intensive care Manual, 3rd Edition, Sydney Butterworth publishers, London, 1990 7. Ake Greenvik, John Downs, Mechanical Ventilation and Assisted Respiration, 1st Edition, Churchill Livingstone publishers, NewYork,1991 8. Paul.L.Marine, The ICU Book, 2nd Edition, Williams and Wilkins company, Pennsylvania, 2000, Pp 420-470 9. C.T.Hinds & C.D.Watson, Intensive Care, 2nd Edition, Saunders Publishers, London, 1996 10. Heartshorn and Sole , Introduction to Critical care Nursing, 3rd Edition, Saunders Publishers, 1997, Philadephia. JOURNALS
1. .American Journal of Nursing, August 2007, Vol.107

2. Nightingale Nursing Times, July 2010, Vol.6 3. Nightingale Nursing Times, December 2010, Vol.6 4. Journal of Nursing Research Society of India, Vol.1, October 2008 INTERNET REFERENCES 1.www.wikepedia.com

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