1. Mechanical Ventilation for Nursing
Melissa Dearing, BS, RRT-NPS, RCP
Associate Professor of Respiratory Care
Curtis Shelley, BS, RRT-NPS, RCP
Respiratory Educator – Hermann Children’s Hospital

2. Indications for Mechanical Ventilation
Airway Compromise – airway
patency is in doubt or patient may
be at risk of losing patency

3. Indications for Mechanical Ventilation
Respiratory Failure – 2 Types
Hypoxemic Respiratory Failure
Hypercapnic Respiratory Failure

4. Hypoxemic Respiratory Failure
PaO2 < 60 mmHg in an otherwise healthy individual

5. Hypercapnic Respiratory Failure
PaCO2 > 50 mmHg in an otherwise
healthy individual
AKA “Ventilatory Failure”
Caused by increased WOB, ↓ventilatory
drive, or muscle fatigue

6. Indications for Mechanical Ventilation
Need to Protect the Airway
For some reason the patient’s ability to sneeze, gag or cough has been dulled and aspiration is possible.

7. Contraindications for an Artificial Airway
When a pt’s desire to not be resuscitated has been expressed and is documented in the pt’s chart

8. Establishing an Artificial Airway
Once the need for an artificial airway has been established you must select the appropriate size ETT for the patient. The largest tube that will fit into the airway should be used. The smaller the tube the harder it is for the patient to breathe. Just a reduction of 16% of the radius of an ETT will double the WOB for the patient.
Another thing to consider is what type of blade to use for the intubation….
Adult female
Adult male

9. Miller vs. MacIntosh Blades
Miller Blade is straight – directly lifts the epiglottis to allow visualization of the vocal cords.
MacIntosh – blade is curved; inserted into the vallecula to indirectly lift the epiglottis.
Infants are always intubated with the Miller die to the floppy airway.

10. Intubation Procedure Check and Assemble Equipment:
Oxygen flowmeter and O2 tubing
Suction apparatus and tubing
Suction catheter or yankauer
Ambu bag and mask
Laryngoscope with assorted blades
3 sizes of ET tubes
Stylet
Stethoscope
Tape
Syringe
Magill forceps
Towels for positioning

11. Position your patient into the sniffing position
Intubation Procedure
Position your patient into the sniffing position

12. Do not allow more than 30 seconds to any intubation attempt.
Intubation Procedure
Preoxygenate with 100% oxygen to provide apneic or distressed patient with reserve while attempting to intubate.
Do not allow more than 30 seconds to any intubation attempt.
If intubation is unsuccessful, ventilate with 100% oxygen for 3-5 minutes before a reattempt.

13. Intubation Procedure Insert Laryngoscope
Laryngoscope is always held in the left hand and is used to displace the tongue to the left so that the epiglottis may be seen.

14. Intubation Procedure
Laryngoscope is always held in the left hand and is used to displace the tongue to the left so that the epiglottis may be seen.

15. Intubation Procedure After displacing the epiglottis insert the ETT.
The depth of the tube for a male patient on average is cm at teeth
The depth of the tube on average for a female patient is at teeth.
An easy trick to use is tube size X 3 – works almost all the time.

16. Intubation Procedure Confirm tube position:
By auscultation of the chest
Bilateral chest rise
Tube location at teeth
CO2 detector – (esophageal
detection device)
You must rule out an esophageal intubation with capnography or by BS. Always listen over the epigastrium after listening to the chest. These are bedside procedures that must be done immediately after intubation prior to an XRAY.

17. Intubation Procedure Stabilize the ETT
Can be done with tape or a commercially available ETT stabilizer.
Always tape above the ETT and never to the chin.

18. Intubation Procedure Video on Intubation:

19. Mechanical Ventilators
Different Types of Ventilators Available:
Will depend on you place of employment

20. Mechanical Ventilators

21. Mechanical Ventilators

22. Mechanical Ventilators

23. Mechanical Ventilators

24. Mechanical Ventilators

25. High Frequency Mechanical Ventilator

26. Ventilator Settings Terminology
A/C: Assist-Control
IMV: Intermittent Mandatory Ventilation
SIMV: Synchronized Intermittent
Mandatory Ventilation
Bi-level/Biphasic: Non-inversed Pressure Ventilation with Pressure Support (consists of 2 levels of pressure)

27. Ventilator Settings Terminology (con’t)
PRVC: Pressure Regulated Volume Control
PEEP: Positive End Expiratory Pressure
CPAP: Continuous Positive Airway
Pressure
PSV: Pressure Support Ventilation
NIPPV: Non-Invasive Positive Pressure Ventilation

28. VOLUME vs. PRESSURE VENTILATION
Volume ventilation: Volume is constant and pressure will vary with patient’s lung compliance.
Pressure ventilation: Pressure is constant and volume will vary with patient’s lung compliance.

29. MODES of VENTILATION

30. Control Mode
Delivers pre-set volumes at a pre-set rate and a pre-set flow rate.
The patient CANNOT generate spontaneous breaths, volumes, or flow rates in this mode.

31. Control Mode

32. Assist/Control Mode
Delivers pre-set volumes at a pre-set rate and a pre-set flow rate.
The patient CANNOT generate spontaneous volumes, or flow rates in this mode.
Each patient generated respiratory effort over and above the set rate are delivered at the set volume and flow rate.

33. A/C cont. Negative deflection, triggering assisted breath
Notice how the patient’s breath reflects the ventilator breath. Not for conscious patients!

34. SYCHRONIZED INTERMITTENT MANDATORY VENTILATION (SIMV):
Delivers a pre-set number of breaths at a
set volume and flow rate.
Allows the patient to generate
spontaneous breaths, volumes, and flow
rates between the set breaths.
Detects a patient’s spontaneous breath
attempt and doesn’t initiate a ventilatory
breath – prevents breath stacking

35. SIMV cont.
Machine Breaths
Spontaneous Breaths

36. PRESSURE REGULATED VOLUME CONTROL (PRVC):
This is a volume targeted, pressure limited mode. (available in SIMV or AC)
Each breath is delivered at a set volume with a variable flow rate and an absolute pressure limit.
The vent delivers this pre-set volume at the LOWEST required peak pressure and adjust with each breath.

37. PRVC

38. POSITIVE END EXPIRATORY PRESSURE (PEEP):
This is NOT a specific mode, but is rather an adjunct to any of the vent modes.
PEEP is the amount of pressure remaining in the lung at the END of the expiratory phase.
Utilized to keep otherwise collapsing lung units open while hopefully also improving oxygenation.

39. PEEP cont. Pressure above zero
PEEP is the amount of pressure remaining in the lung at the END of the expiratory phase.

40. Demonstration of PEEP

41. Continuous Positive Airway Pressure (CPAP):
This IS a mode and simply means that a pre-set pressure is present in the circuit and lungs throughout both the inspiratory and expiratory phases of the breath.
CPAP serves to keep alveoli from collapsing, resulting in better oxygenation and less WOB.
The CPAP mode is very commonly used as a mode to evaluate the patients readiness for extubation.
Please note that the patient has to be spontaneously breathing to use this mode!
Often used in conjunction with weaning the patient from the ventilator.

42. HIGH FREQUENCY VENTILATION
Used for patient’s that cannot be oxygenated.

43. & Conventional Ventilation
Comparison of HFOV
& Conventional Ventilation
Differences CMV HFOV
Rates
Tidal Volume ml/kg ml/kg
Alveolar Press 0 - > 50 cmH2O cmH2O
End Exp Volume Low Normalized
Gas Flow Low High

44. Oxygenation
Oxygenation is primarily controlled by the Mean Airway Pressure (Paw) and the FiO2.
Mean Airway Pressure is a constant pressure used to inflate the lung and hold the alveoli open.
Since the Paw is constant, it reduces the injury that results from cycling the lung open for each breath
This is the primary reason for using a HFV.

45. Video on HFOV http://youtube.com/watch?v=jLroOPoPlig
9 minute video – I just want to show how the oscillator sounds and what it looks like.

46. Initial Settings Select your mode of ventilation
Set sensitivity at Flow trigger mode
Set Tidal Volume
Set Rate
Set Inspiratory Flow (if necessary)
Set PEEP
Set Pressure Limit
Humidification
Flow Trigger allows the patient to pull a spontaneous breath from the vent whenever he wants.
Tidal Volume is the amount of air the patient is given with each breath (10-12 ml/kg IBW)
Rate is normally set at bpm (adults) and then changed via ABG
Flow – most new vents set the flow to deliver a set I:E ratio. Flow of L/min to achieve an I:E of approximately 1:2.
PEEP – 3-5 cmH20 is physiologic peep
Pressure Limit – set at 10 – 20 cmH20 above pt’s own PIP
Humidification – heated to 35-37°C to provide humidification due to bypassed upper airways

47. Post Initial Settings
Obtain an ABG (arterial blood gas) about 30 minutes after you set your patient up on the ventilator.
An ABG will give you information about any changes that may need to be made to keep the patient’s oxygenation and ventilation status within a physiological range.

48. ABG Goal: Keep patient’s acid/base balance within normal range:
pH – 7.45
PCO mmHg
PO mmHg
Any variance in these values will require a change made to this patient’s ventilator.

49. TROUBLESHOOTING

50. TROUBLESHOOTING Attempt to fix the problem Call your RT
Anxious Patient
Can be due to a malfunction of the ventilator
Patient may need to be suctioned
Frequently the patient needs medication for anxiety or sedation to help them relax
Attempt to fix the problem
Call your RT

51. Low Pressure Alarm Usually due to a leak in the circuit.
Attempt to quickly find the problem
Bag the patient and call your RT.

52. High Pressure Alarm Usually caused by:
A blockage in the circuit (water condensation)
Patient biting his ETT
Mucus plug in the ETT
You can attempt to quickly fix the problem
Bag the patient and call for your RT.

53. Low Minute Volume Alarm
Usually caused by:
Apnea of your patient (CPAP)
Disconnection of the patient from the ventilator
You can attempt to quickly fix the problem
Bag the patient and call for your RT.

54. Accidental Extubation
Role of the Nurse:
Ensure the Ambu bag is attached to the oxygen flowmeter and it is on!
Attach the face mask to the Ambu bag and after ensuring a good seal on the patient’s face; supply the patient with ventilation.
Bag the patient and call for your RT.

55. OTHER Call for your RT NEVER hit the silence button!
Anytime you have concerns, alarms, ventilator changes or any other problem with your ventilated patient.
Call for your RT
NEVER hit the silence button!