Care for Patient with Mechanical Ventilator

 Patients who are critically ill and need oxygen support are usually attached to mechanical ventilator.
That’s why, nurses who are in the assigned in the intensive or critical unit should be competent in caring
for the patient with mechanical ventilator. Though there are technicalities that a nurse should consider,
in this article, we will be learning about this machine in a nutshell.

Indication for mechanical ventilator use

 Continuous decrease in oxygenation

 Increase arterial carbon dioxide

 Persistent acidosis

 Other conditions that may lead to respiratory failure

What are the different mechanical ventilator modes?

 Volume-cycled ventilators

 Volume-cycled ventilators guarantees volume at expense of letting airway pressure vary. Once preset
volume is delivered to the patient, the ventilator cycles off and exhalation occurs passively.

 Preset tidal volume is delivered unless a specified pressure limit is exceeded (upper airway pressure
alarm is set) or patient’s cuff or ventilator tubing has air leaks that cause a decrease in tidal volume
delivered. (Grossbach, 2011)

Examples of volume-targeted mechanical ventilator mode are:

1. Controlled mechanical ventilation- the client receives a set tidal volume at a set rate. (Silvestri, 2008)
This is commonly used for patient who cannot initiate his/her own breathing.

2. Assist-controlled (AC )- provides full ventilator support to the patient. A set tidal volume (if set to
volume control) or a set pressure and time (if set to pressure control) is delivered at a minimum rate.
Additional ventilator breaths are given if triggered by the patient.

3. Synchronized intermittent mandatory ventilations (SIMV) – Breaths are given are given at a set minimal
rate, however if the patient chooses to breath over the set rate no additional support is given

4. Continuous positive airway pressure (CPAP) is a form of positive airway pressure ventilator, which
applies mild air pressure on a continuous basis to keep the airways continuously open in people who are
able to breathe spontaneously on their own. It is an alternative to positive end-expiratory pressure
(PEEP).
  One advantage of SIMV is that it allows patients to breath on their own. SIMV is usually associated with
greater work of breathing than AC ventilation and therefore is less frequently used as the initial
ventilator mode

 Like AC, SIMV can deliver set tidal volumes (volume control) or a set pressure and time (pressure
control). Negative inspiratory pressure generated by spontaneous breathing leads to increased venous
return, which theoretically may help cardiac output and function.

 Pressure-cycled ventilator

 Pressure-cycled ventilator guarantees pressure at expense of letting tidal volume vary. Inspiration is also
terminated when preset pressure reached. Volume is variable and determined by set pressure level,
airway resistance, and lung compliance factors, specified time or flow cycling criteria. (Grossbach, 2011)

What are basic ventilator settings and controls?

1. Tidal Volume (TV) – Air that the client receives per breathing. Percentage in the mechanical ventilator is
adjusted depending on client’s needs (40-100%). The normal value of tidal volume is ½ L or 500 ml.

2. Fraction of inspired oxygen (FiO2) – the oxygen concentration delivered to the client. ABG is usually
determined before adjusting FiO2 levels. It is adjusted from 40%-100%.

3. Peak Flow Rate (PFR) – The peak flow rate is the maximum flow delivered by the ventilator during
inspiration. Peak flow rates of 60 L per minute may be sufficient, although higher rates are frequently
necessary.

4. Back-up Rate (BUR) – for spontaneous or time mode ventilator, back-up rate is set so that the client may
receive a minimum number of breaths per minutes if the client fail to breath. If the client’s breathing
rate is slower, it will cycle inhale / exhale pressure at the set rate. The usual setting for BUR ranges from
12-22 breaths per minute, depending on the physician’s order.

How to troubleshoot ventilator alarms?

 Alarms are designed to warn nurses that there is something wrong either to the patient or to the
mechanical ventilator. But sometimes, alarms can give nurses apprehensions especially if the alarm is
non-stop and we don’t know how to troubleshoot the problem.

 So as a nurse, how will you manage if there’s an alarm? First, assess the patient if he/she is in distress.
Identify the alarm whether high pressure or low pressure. Some mechanical ventilators have their own
indicators and shows the cause of the alarm, so it’s important to check your machine as well.

A. Low Pressure alarm

 Low pressures alarm may indicate leak in the patient’s tube, disconnection of the tube, or the patient
stops to breath.
What are your interventions for low pressure alarm?

1. Check the tube connections.

2. Reconnect patient to the ventilator.

3. Replace leaking tubes by manually ventilating the patient.

4. Auscultate patient’s lung fields for bilateral lung sounds.

5. Monitor respiratory rate and breathing patterns.

6. Evaluate cuff pressure. Reinflate if needed.

B. High Pressure alarm

 High pressure alarm may indicate displacement of the ET tube, increased secretions, obstruction in the
tube, bronchospasms, or the patient is coughing or biting the tube.

1. Assess your patient.

2. Auscultate lung fields for secretions. This should be done at least every 2 hours or more.

3. Suction secretions as needed. Oxygenate patient manually before suctioning.

4. If patient is biting the tube, provide bite block.

5. Sedate patient if necessary especially when patient is fighting the vent. Make sure this is ordered by the
attending physician or hospitalist on duty.

6. Monitor pulse oximeter continuously if cardiac monitor and pulse oximeter devices are present.

How to perform closed system suctioning?

Equipment

 Sterile Closed Suction Kit  Pulse oximeter

 Normal Saline Irrigation  Stethoscope
 Suctioning machine or device: wall or  Procedure
portable
 Oxygen source
 Personal protective equipment
 10 cc syringe
1. Check the guidelines or standard procedure of your unit for closed-suctioning system.

2. Prepare all needed equipment. Position all supplies so that they are easily accessible. Check suction
setup for correct functioning. Read instructions of the closed-suction kit.
 3. Explain the procedure to the client. Explain the benefits of closed-suctioning system and how it can
prevent infection.

4. Assess patient first. Auscultate patient’s lung fields for abnormal breath sounds. Attach patient to
continuous pulse oximeter monitoring device.

5. Wear personal protective equipment. Perform hand washing.

6. Attach closed suction catheter system between ventilator circuit and patient airway.

7. Ensure that wall or portable suction is turned on (no higher than 120 mmHg). Set vacuum setting
according to policy of your unit.

8. Attach suction tubing from setup to suction port of catheter.

9. Hyperoxygenate patient to 100% 02 for 2 – 5 minutes.

10. Attach saline to irrigation port. You may use also a 10 cc syringe for introducing saline irrigation or
depending upon the set-up of your closed-suction kit.

11. Introduce catheter before instilling saline – lavage on inspiration.

12. Introduce catheter until a restriction is met or until you can stimulate cough reflex.

13. Withdraw the catheter slowly while applying intermittent suction. Suction should not be applied for
more than 15-20 seconds.

14. Upon completion of suctioning, withdraw catheter, ensuring that tip is completely withdrawn from
airway.

15. Rinse suction catheter after each suctioning by depressing thumb control and squeezing a new saline
irrigation using the 10cc syringe or depending on the set-up of your close suction kit.

16. Repeat suctioning process until the patient’s airway is clear.

17. Discard personal protective equipment and wash hands.

18. Evaluate patient’s condition by auscultating the lung fields and by monitoring patient’s oxygenation
using pulse oximeter.

References

o Grossbach, I., Chlan, L., & Tracy, M.(2011). Overview of Mechanical Ventilatory Support and
Management of Patient- and Ventilator-Related Responses. Critical Care Nurse Vol 31, No. 3, June 2011
retrieved at ccnonline.org last April 10, 2015

o Myers, E. (2006). RNotes: Nurse’s Clinical Pocket Guide. F. A. Davis Company. Philadelphia. 2nd edition.

o Silvestri, L. (2008). Comprehensive Review for the NCLEX-RN Examination. Saunders Elsevier. 4th edition.

o Smeltzer, S., Bare, B., Hinkle, J., Cheever, K. (2010). Brunner & Suddarth’s Textbook of Medical-Surgical
Nursing. Lippincott Williams & Wilkins. 12th edition