Mechanical Ventilation

Mechanical Ventilation Mechanical Ventilation is ventilation of the lungs by artificial means usually by a ventilator. Once a patient s PaO 2 cannot be maintained by the basic methods of oxygen delivery systems, i.e. masks, cannula; endotracheal intubation and mechanical ventilation are instituted. A ventilator delivers gas to the lungs with either negative or positive pressure. It must be understood that no mode of mechanical ventilation can or will cure a disease process but merely supports the patient until resolution of his/ her symptoms is accomplished. Purposes: is instituted to: 1- Maintain or improve ventilation, i.e. for adequate tissue oxygenation. 2- Decrease the work of breathing and improve patient s comfort. Indications: Acute respiratory failure due to: Mechanical failure, includes neuromuscular diseases as Myasthenia Gravis, Guillain-Barré Syndrome, and Poliomyelitis (failure of the normal respiratory neuromuscular system) Musculoskeletal abnormalities, such as chest wall trauma (flail chest) Infectious diseases of the lung such as pneumonia, tuberculosis. Abnormalities of pulmonary gas exchange as in: Obstructive lung disease in the form of asthma, chronic bronchitis or emphysema. Conditions such as pulmonary edema, atelectasis, pulmonary fibrosis. Dr. Abdul-Monim Batiha- Assistant Professor Of Critical Care Nursing 1

**Patients who has received general anesthesia as well as post cardiac arrest patients often require ventilatory support until they have recovered from the effects of the anesthesia or the insult of an arrest. Criteria for institution of ventilatory support: Parameters Pulmonary function studies: Respiratory rate (breaths/min). Tidal volume (ml/kg body wt) Vital capacity (ml/kg body wt) Maximum Inspiratory Force (cm HO 2 ) Arterial blood Gases PH Pa 2 (mmhg) PaCO 2 (mmhg) > 35 < 5 < 15 <-20 < 7.25 < 60 > 50 Ventilation indicated Normal range 10-20 5-7 65-75 75-100 7.35-7.45 75-100 35-45 NB. These parameters are used in making judgments about the adequacy of respiratory function. Types of Mechanical ventilators: 1- Negative-pressure ventilators 2- Positive-pressure ventilators. Dr. Abdul-Monim Batiha- Assistant Professor Of Critical Care Nursing 2

Negative-Pressure Ventilators - Early negative-pressure ventilators were known as iron lungs. The patient s body was encased in an iron cylinder and negative pressure was generated by a large piston to enlarge the thoracic cage. This caused alveolar pressures to fall, and a pressure gradient was formed so that air flowed into the lungs. The iron lung are still occasionally used today. - Intermittent short-term negative-pressure ventilation is sometimes used in patients with chronic diseases. Rarely, this method of support is chosen for patients who are not candidates for aggressive mechanical ventilation as provided through an artificial airway. These patients suffer from a wide variety of conditions such as - COPD, - Diseases of the chest wall (kyphoscoliosis), - Neuromuscular diseases (Duchenne s muscular dystrophy, amyotrophic lateral sclerosis [ALS]). - The iron lung is cumbersome to use and very large. Most negative-pressure ventilators in use today are more portable. To improve mobility and comfort, there is a device that fits like a tortoise shell, forming a seal over the chest. A hose connects the shell to a negative-pressure generator. The thoracic cage is literally pulled outward to initiate inspiration. Dr. Abdul-Monim Batiha- Assistant Professor Of Critical Care Nursing 3

- The use of negative-pressure ventilators is restricted in clinical practice, however, because they limit positioning and movement and they lack adaptability to large or small body torsos. - Our focus will be on the positive-pressure ventilators. Positive-pressure ventilators - Positive-pressure ventilators deliver gas to the patient under positivepressure, during the inspiratory phase. Positive-Pressure Ventilators Volume Ventilators. - The volume ventilator is commonly used in critical care settings. The basic principle of this ventilator is that a designated volume of air is delivered with each breath. - The amount of pressure required to deliver the set volume depends on :- - Patient s lung compliance - Patient ventilator resistance factors. - Therefore, PIP must be monitored in volume modes because it varies from breath to breath. Dr. Abdul-Monim Batiha- Assistant Professor Of Critical Care Nursing 4

- With this mode of ventilation, a respiratory rate, inspiratory time, and tidal volume are selected for the mechanical breaths. Pressure Ventilators. - The use of pressure ventilators is increasing in critical care units. A typical pressure mode delivers a selected gas pressure to the patient early in inspiration, and sustains the pressure throughout the inspiratory phase. By meeting the patient s inspiratory flow demand throughout inspiration, patient effort is reduced and comfort increased. - Although pressure is consistent with these modes, volume is not. With changes in resistance or compliance, volume will change. - Therefore, exhaled tidal volume is the variable to monitor closely. - With pressure modes, the pressure level to be delivered is selected, and with some mode options (i.e., pressure controlled [PC], described later), rate and inspiratory time are preset as well. High-Frequency Ventilators. - The high-frequency ventilator accomplishes oxygenation by the diffusion of oxygen and carbon dioxide from high to low gradients of concentration. This diffusion movement is increased if the kinetic energy of the gas molecules is increased. - High-frequency ventilators use small tidal volumes (1 to 3 ml/kg) at frequencies greater than 100 breaths/minute. The breathing pattern of a person on a high-frequency ventilator is somewhat analogous to the breathing pattern of a panting dog; panting entails moving small volumes of air at a very fast rate. - A high-frequency ventilator would be used to achieve lower peak ventilatory pressures, thereby Dr. Abdul-Monim Batiha- Assistant Professor Of Critical Care Nursing 5

- Lowering the risk of barotrauma - Improving ventilation perfusion matching because. - Potential adverse effects associated with high-frequency ventilators include: - Gas trapping - Necrotizing tracheobronchitis, when used in the absence of adequate humidification. Classification of positive-pressure ventilators: - Ventilators are classified by their method of cycling from the inspiratory phase to the expiratory phase (changeover from inspiratory to expiratory phase), that is to say according to how the inspiratory phase ends. The factor which terminates the inspiratory cycle reflects the machine type. - They are classified as: pressure, volume or time cycled machines. Volume-cycled ventilator, - In which inspiration is terminated after a preset volume has been delivered by the ventilator. i.e. the ventilator delivers a preset tidal volume (V T ), and inspiration stops when the preset tidal volume is achieved. Pressure-cycled ventilator, - In which inspiration is terminated when a specific airway pressure has been reached. i.e. the ventilator delivers a preset pressure; once this pressure is achieved, end inspiration occurs. Dr. Abdul-Monim Batiha- Assistant Professor Of Critical Care Nursing 6

Time-cycled ventilator, - In which inspiration is terminated when a preset inspiratory time, has elapsed. Time cycled machines are not used in adult critical care settings. They are used in pediatric intensive care areas. Ventilator Modes - Several different modes of ventilatory control are available on ventilators. - There is no one best mode for managing patients in respiratory failure, although each mode has its advantages and disadvantages. Modes of mechanical ventilation - The term ventilator mode refers to the way the machine ventilates the patient.i.e. how much the patient will participate in his own ventilatory Dr. Abdul-Monim Batiha- Assistant Professor Of Critical Care Nursing 7

pattern. Each mode is different in determining how much work of breathing the patient has to do. A- Volume Modes 1- Assist-control (A/C) mode 2- Synchronized intermittent mandatory ventilation (SIMV) mode. 1- Assist Control Mode A/C - The ventilator provides the patient with a pre-set tidal volume at a pre-set rate and the patient may initiate a breath on his own, but the ventilator assists by delivering a specified tidal volume to the patient. - Client can initiate breaths that are delivered at the preset tidal volume. - Client can breathe at a higher rate than the minimum number of breaths/minute that has been set. - The total respiratory rate is determined by the number of spontaneous inspiration initiated by the patient plus the number of breaths set on the ventilator. - In A/C mode, a mandatory (or control ) rate is selected. - If the patient wishes to breathe faster, he or she can trigger the ventilator and receive a full-volume breath. - Often used as initial mode of ventilation -This mode of ventilation is often used fully to support a patient, such as - When the patient is first intubated - When the patient is too weak to perform the work of breathing (e.g., when emerging from anesthesia). Advantages: - Ensures ventilator support during every breath - Each breath has the same tidal volume Disadvantages: - Hyperventilation, - Air trapping - Work of breathing may be increased if sensitivity or flow rate is too low. Dr. Abdul-Monim Batiha- Assistant Professor Of Critical Care Nursing 8

2- Synchronized Intermittent Mandatory Ventilation SIMV - The ventilator provides the patient with a pre-set number of breaths/minute at a specified tidal volume and fio 2. In between the ventilator-delivered breaths, the patient is able to breathe spontaneously. The ventilator does not assist the spontaneous breaths i.e. the patient determines the respiratory rate and tidal volume. - Between machine breaths, the client can breathe spontaneously at his own tidal volume and rate with no assistance from the ventilator. - In SIMV mode, the rate and tidal volume are preset. - If the patient wants to breathe above this rate, he or she may. - However, unlike the A/C mode, any breaths taken above the set rate are spontaneous breaths taken through the ventilator circuit. - The tidal volume of these breaths can vary drastically from the tidal volume set on the ventilator, because the tidal volume is determined solely by the patient s spontaneous effort. - Adding pressure support during spontaneous breaths can minimize the risk of increased work of breathing. In the past, SIMV has been used as a popular weaning mode. - Same as intermittent mandatory ventilation except stacking is avoided i.e. ventilators breaths are synchronized with the patient spontaneous breathe. - Used to wean the patient from the mechanical ventilator. - To wean the patient, the mandatory breaths were gradually decreased, thereby allowing the patient to assume more and more of the work of breathing. - Often used as initial mode of ventilation and for weaning Advantages: - Allows spontaneous breaths (tidal volume determined by patient) between ventilator breaths; - Weaning is accomplished by gradually lowering the set rate and allowing the patient to assume more work Disadvantages: Patient ventilator asynchrony possible Dr. Abdul-Monim Batiha- Assistant Professor Of Critical Care Nursing 9

- Pressure modes include :- B- Pressure Modes 1- Pressure-controlled ventilation (PCV) mode, 2- Pressure-support ventilation (PSV) mode, 3- Continuous positive airway pressure (CPAP)/PEEP mode, 5- Noninvasive bilevel positive airway pressure ventilation (BiPAP) mode. 1- Control Mode CM Continuous Mandatory Ventilation( CMV) - Ventilation is completely provided by the mechanical ventilator with a preset tidal volume, respiratory rate and oxygen concentration prescribed by the physician. -Ventilator totally controls the patient s ventilation i.e. the ventilator initiates and controls both the volume delivered and the frequency of breath. - Client does not breathe spontaneously. - Client can not initiate breathe 1- Pressure-Controlled Ventilation Mode( PCV) The PCV mode is used - to control plateau pressures in conditions such as ARDS where compliance is decreased and the risk of barotrauma is high. - It is used when the patient has persistent oxygenation problems despite a high FIO 2 and high levels of PEEP. - The inspiratory pressure level, respiratory rate, and inspiratory expiratory (I:E) ratio must be selected. - Tidal volume varies with compliance and airway resistance and must be closely monitored. Dr. Abdul-Monim Batiha- Assistant Professor Of Critical Care Nursing 11

- Sedation and the use of neuromuscular blocking agents are frequently indicated, because any patient ventilator asynchrony usually results in profound drops in the SaO 2. - This is especially true when inverse ratios are used. The unnatural feeling of this mode often requires muscle relaxants to ensure patient ventilator synchrony. - Most ventilators operate with a short inspiratory time and a long expiratory time (1:2 or 1:3 ratio). This promotes venous return and allows time for air to exit the lungs passively. - Inverse ratio ventilation (IRV) mode reverses this ratio so that inspiratory time is equal to, or longer than, expiratory time (1:1 to 4:1). - Inverse I:E ratios are used in conjunction with pressure control to improve oxygenation in patients with ARDS by expanding stiff alveoli by using longer distending times, thereby providing more opportunity for gas exchange and preventing alveolar collapse. - As expiratory time is decreased, one must monitor for the development of hyperinflation or auto-peep. Regional alveolar overdistension and barotrauma may occur owing to excessive total PEEP. - When the PCV mode is used, the mean airway and intrathoracic pressures rise, potentially resulting in a decrease in cardiac output and oxygen delivery. Therefore, the patient s hemodynamic status must be monitored closely. - Used to limit plateau pressures that can cause barotrauma Severe ARDS Disadvantages: Patient ventilator asynchrony possible, necessitating sedation/paralysis Monitor a- Tidal volume at least hourly. b- Barotraumas c- Hemodynamic instability Inverse ratio ventilation (IRV) Usually used in conjunction with PCV Dr. Abdul-Monim Batiha- Assistant Professor Of Critical Care Nursing 11

Increases ratio I:E to a- Allow for recruitment of alveoli b- Improve oxygenation Disadvantages: - Almost always requires paralysis Monitor for a- Auto-PEEP, b- Barotrauma, c- Hemodynamic instability. 2- Pressure Support Ventilation ( PSV) - The patient breathes spontaneously while the ventialtor applies a predetermined amount of positive pressure to the airways upon inspiration. - Pressure support ventilation augments patient s spontaneous breaths with positive pressure boost during inspiration i.e. assisting each spontaneous inspiration. - Helps to overcome airway resistance and reducing the work of breathing. - Patient must initiate all pressure support breaths. - Pressure support ventilation may be combined with other modes such as SIMV or used alone for a spontaneously breathing patient. - Indicated for patients with small spontaneous tidal volume and difficult to wean patients. - It is a mode used primarily for weaning from mechanical ventilation. - PSV mode augments or assists spontaneous breathing efforts by delivering a high flow of air to a selected pressure level early in inspiration, and maintaining that level throughout the inspiratory phase. - The patient s effort determines the rate, inspiratory flow, and tidal volume. - When PSV mode is used as a stand-alone mode of ventilation, the pressure support level is adjusted to achieve the approximate targeted tidal volume and respiratory rate. - At high pressure levels, PSV mode provides nearly total ventilatory support. - Specific uses of PSV are - To promote patient comfort Dr. Abdul-Monim Batiha- Assistant Professor Of Critical Care Nursing 12

- To promote synchrony with the ventilator, - To decrease the work of breathing necessary to overcome the resistance of the endotracheal tube, - For weaning. As a weaning tool, - PSV is thought to increase the endurance of the respiratory muscles by - Decreasing the physical work - Decreasing oxygen demands during spontaneous breathing. - Because the level of pressure support can be gradually decreased, endurance conditioning is enhanced. - In PSV mode, the inspired tidal volume and respiratory rate must be monitored closely to detect changes in lung compliance. - In general, if compliance decreases or resistance increases, tidal volume decreases and respiratory rate increases. - PSV mode should be used with caution in patients with - Bronchospasm - other reactive airway conditions. Intact respiratory drive in patient necessary Used as a weaning mode, and in some cases of dyssynchrony 2- Continuous Positive Airway Pressure CPAP (a variation of PEEP) - Positive pressure applied at the end of expiration during spontaneous breaths i.e. for patients breathing spontaneously. - No mandatory breaths (ventilator-initiated are delivered in this mode) - All ventilation is spontaneously initiated by the patient. - PEEP & CPAP are used in patients with hypoxemia refractory to oxygen therapy. They improve oxygenation by opening collapsed alveoli & preventing them from collapsing at the end of expiration. - CPAP allows the nurse to observe the ability of the patient to breathe Dr. Abdul-Monim Batiha- Assistant Professor Of Critical Care Nursing 13

spontaneously while still on the ventilator. - CPAP is supplied during spontaneous breathing. PEEP is the term used to describe positive end-expiratory pressure with positive-pressure (machine) breaths. CPAP assists spontaneously breathing patients to improve their oxygenation by elevating the end-expiratory pressure in the lungs throughout the respiratory cycle. - CPAP can be used for intubated and nonintubated patients. - It may be used as a weaning mode and for nocturnal ventilation (nasal or mask CPAP) to splint open the upper airway, preventing upper airway obstruction in patients with obstructive sleep apnea. - Constant positive airway pressure for patients who breathe spontaneously Advantages: - Used in intubated or nonintubated patients Disadvantages: - On some systems, no alarm if respiratory rate falls - Monitor for increased work of breathing. 4- Noninvasive Bilateral Positive Airway Pressure Ventilation (BiPAP) - BiPAP is a noninvasive form of mechanical ventilation provided by means of a nasal mask or nasal prongs, or a full-face mask. - It is used in the treatment of :- a- Patients with chronic respiratory insufficiency to manage acute or chronic respiratory failure without intubations and conventional mechanical ventilation. b- Used as a bridge to weaning patients from mechanical ventilation, c- As an alternative to conventional mechanical ventilation in patients who are ventilated in their homes. Dr. Abdul-Monim Batiha- Assistant Professor Of Critical Care Nursing 14

- The system allows the clinician to select two levels of positive-pressure support: a- An inspiratory pressure support level (referred to as IPAP) b- An expiratory pressure called EPAP (PEEP/CPAP level). - BiPAP is beneficial in worsening nocturnal hypoventilation in patients with - Neuromuscular disease, - Chest wall deformity, - Obstructive sleep apnea, - COPD; - To avoid intubation in patients with respiratory failure & hypercarbia - To avoid reintubation after extubation in borderline cases. - Ventilation with a full-face mask should be used cautiously because it may increase the risk of aspiration and of rebreathing carbon dioxide; - Thick or copious secretions and poor cough may be relative contraindications to BiPAP. Advantages: a- Decreased cost when patients can be cared for at home; b- No need for artificial airway Disadvantages: - Patient discomfort or claustrophobia - The patient should be monitored for :- a- Gastric distension, b- Air leaks from mouth Dr. Abdul-Monim Batiha- Assistant Professor Of Critical Care Nursing 15

Common Ventilator Settings Fraction of inspired oxygen (FIO 2 ) - The percent of oxygen concentration that the patient is receiving from the ventilator. (Between 21% & 100%) (room air has 21% oxygen content). - Most ventilators allow for easy adjustment of oxygen percentage (FIO 2 ) by means of a dial. Oxygen analyzers, either in-circuit or external, allow the nurse to ascertain the FIO 2 that is being delivered. - Initially a patient is placed on a high level of FIO 2 (60% or higher). Subsequent changes in FIO 2 are based on ABGs and the SaO 2. - In adult patients who can tolerate higher levels of oxygen for a period of time, the initial FiO 2 may be set at 100% until arterial blood gases can document adequate oxygenation. - An FiO 2 of 100% for an extended period of time can be dangerous ( oxygen toxicity) but it can protect against hypoxemia from unexpected intubation problems. - For infants, and especially in premature infants, high levels of FiO 2 (>60%) should be avoided. -Usually the FIO 2 is adjusted to maintain an SaO 2 of greater than 90% (roughly equivalent to a PaO 2 >60 mm Hg). Oxygen toxicity is a concern when an FIO 2 of greater than 60% is required for more than 25 hours; therefore, most clinicians attempt to use strategies to allow for maintenance of an FIO 2 of 60% or less. Signs and symptoms of oxygen toxicity :- 1- Flushed face 2- Dry cough 3- Dyspnea 4- Chest pain 5- Tightness of chest Dr. Abdul-Monim Batiha- Assistant Professor Of Critical Care Nursing 16

6- Sore throat Tidal Volume (V T ) - The volume of air delivered to a patient during a ventilator breath. - The amount of air inspired and expired with each breath. (Usual volume selected is between 5 to 15 ml/ kg body weight) - In the volume ventilator, Tidal volumes of 10 to 15 ml/kg of body weight were traditionally used. - Research has identified a phenomenon of iatrogenic lung injury (volutrauma) in which forces produced in the lungs by the large tidal volumes may aggravate the damage inflicted on the lungs by the pathological process that necessitated mechanical ventilation. - For this reason, lower tidal volume targets (6 to 8 ml/kg) are now recommended. Peak Flow/ Flow Rate - Peak flow is the velocity/ spead of air flow (delivering air) per unit of time, and is expressed in liters per minute. On many volume ventilators, this is a separate dial. - If auto-peep (due to inadequate expiratory time) is present, peak flow is increased to shorten inspiratory time so that the patient may exhale completely. - However, increasing peak flow increases turbulence, which is reflected in increasing airway pressures. - In the pressure ventilator, the inspiratory time determines the duration of inspiration by regulating the air flow rate. - The higher the flow rate, the faster peak airway pressure is reached and the shorter the inspiration; - The lower the flow rate, the longer the inspiration. - A very high flow rate may produce turbulence, shallow inspirations, and Dr. Abdul-Monim Batiha- Assistant Professor Of Critical Care Nursing 17

uneven distribution of volume. Respiratory Rate/ Breath Rate / Frequency ( F) - The number of breaths the ventilator will deliver/minute (10-16 b/m). - Total respiratory rate equals patient rate plus ventilator rate. - The nurse double-checks the functioning of the ventilator by observing the patient s respiratory rate. For adult patients and older children:- - Without existing lung disease --- a tidal volume of 12 ml per kg body weight is set to be delivered at a rate of 12 times a minute - With COPD ---A reduced tidal volume of 10 ml/kg is to delivered 10 times a minute to prevent overinflation and hyperventilation. - With chronic pulmonary disease, however, should be ventilated to stay relatively close to their normal ABG values. This usually means accepting relatively high carbon dioxide levels, lower-than average oxygenation, or both. - With ARDS --- a more reduced tidal volume of 6-8 ml/kg is used with a rate of 10-12/minute. This reduced tidal volume allows for minimal volutrauma but may result in an elevated PCO 2 (due to the relative decreased oxygen delivered) but this elevation does not need to be corrected (termed permissive hypercapnia) For infants and younger children:- - Without existing lung disease -- a tidal volume of 4-10 ml/kg to be delivered at a rate of 30-35 breaths per minute. - With ARDS -- decrease tidal volume and increase respiratory rate sufficient to maintain PCO 2 between 45-55. Allowing higher PCO 2, may help prevent ventilator induced lung injury Minute Volume (V E ) - The volume of expired air in one minute. Dr. Abdul-Monim Batiha- Assistant Professor Of Critical Care Nursing 18

- Respiratory rate times tidal volume equals minute ventilation - V E = (V T x F) - Minute volume determines alveolar ventilation. - Increasing the minute volume decreases the PaCO 2. Conversely, decreasing the minute volume increases the PaCO 2. - In special cases, hypoventilation or hyperventilation is desired. In a patient with head injury, Respiratory alkalosis may be required to promote cerebral vasoconstriction, with a resultant decrease in ICP. In this case, the tidal volume and respiratory rate are increased to achieve the desired alkalotic ph by manipulating the PaCO 2. In a patient with COPD Baseline ABGs reflect an elevated PaCO 2 should not hyperventilated. Instead, the goal should be restoration of the baseline PaCO 2. These patients usually have a large carbonic acid load, and lowering their carbon dioxide levels rapidly may result in seizures. Rate adjustments may also be necessary to enhance patient comfort or when rapid rates cause air trapping that result in auto-peep. I:E Ratio (Inspiration to Expiration Ratio):- - The ratio of inspiratory time to expiratory time during a breath (Usually = 1:2) Sigh:- - A deep breath. - A breath that has a greater volume than the tidal volume. - It provides hyperinflation and prevents atelectasis. Dr. Abdul-Monim Batiha- Assistant Professor Of Critical Care Nursing 19

Sigh volume :------------------Usual volume is 1.5 2 times tidal volume. Sigh rate/ frequency :---------Usual rate is 4 to 8 times an hour. Peak Airway Pressure:- - In adults if the peak airway pressure is persistently above 45 cmh 2 O, the risk of barotrauma is increased and efforts should be made to try to reduce the peak airway pressure. - In infants and children it is unclear what level of peak pressure may cause damage. In general, keeping peak pressures below 30 is desirable. Pressure Limit - On volume-cycled ventilators, the pressure limit dial limits the highest pressure allowed in the ventilator circuit. - Once the high pressure limit is reached, inspiration is terminated. - Therefore, if the pressure limit is being constantly reached, the designated tidal volume is not being delivered to the patient. - The cause of this can be :- - Coughing, - Accumulation of secretions, - kinked ventilator tubing, - Pneumothorax, - Decreasing compliance - A pressure limit set too low. Positive End-Expiratory Pressure (PEEP) - Positive pressure applied at the end of expiration during ventilator breaths. - The PEEP control adjusts the pressure that is maintained in the lungs at the end of expiration. - PEEP can be visualized on the respiratory pressure gauge or display. Instead of returning to zero (atmospheric pressure) at the end of Dr. Abdul-Monim Batiha- Assistant Professor Of Critical Care Nursing 21

expiration, the pressure value drops to the PEEP level. - Reduction of PEEP is considered if - PaO 2 is 80 to 100 mm Hg on an FIO 2 of 50% or less, - Hemodynamic stablility, - Stabilization or improvement of the underlying illness. - Monitor the effects of PEEP before and after changes in PEEP by evaluating :- - ABGs, - SaO 2, - Compliance, - Hemodynamic pressures (cardiac output & blood pressure) - PEEP is usually USED IN low levels increased in increments of 2 to 5 cm H 2 O in the intubated patient. - Monitor the patient for adverse effects, such as :- - Hypotension - Dysrhythmias. - If these occur, the PEEP is reduced. If higher PEEP is tolerated, the patient is stabilized on the new PEEP settings for approximately 15 minutes. The monitored parameters are then repeated. - Hemodynamic measurements are taken at end-expiration with the patient on PEEP. - Cardiac output [ CO ], - Pulmonary artery pressure [PAP], - Central venous pressure [CVP], - Pulmonary artery wedge pressure [PAWP] - Accuracy in selecting the point of end-expiration on the waveform tracing Dr. Abdul-Monim Batiha- Assistant Professor Of Critical Care Nursing 21

is facilitated by using continuous airway monitoring ( PEEP does not need to be discontinued before obtaining hemodynamic measurements. - Hemodynamic measurements can be inaccurate (as an indicator of volume status) if a patient is on high PEEP or the position of the transducer is not leveled at the phlebostatic axis. - Attempts are made to minimize removing the patient from the ventilator when using high levels of PEEP. Oxygenation can deteriorate and be slow to rebound because it takes a significant amount of time for the effects of PEEP to be reestablished. Therefore, if the patient is being oxygenated using an MRB, it must be equipped with a valve that allows levels of PEEP to be dialed in. An inline suction apparatus may be helpful to prevent breaking the PEEP circuit to suction the patient. - PEEP is increased in 2- to 5-cm H 2 O increments when FIO 2 levels are greater than 50% to attain an acceptable SaO 2 (<90%) or PaO 2 (>60 to 70 mm Hg). - PEEP is most often necessary in patients with refractory hypoxemia (e.g., those with ARDS), where the PaO 2 deteriorates rapidly despite greater concentrations of oxygen administration. - PEEP is used to keep alveoli stented open and it may recruit alveolar units that are totally or partially collapsed. - This end-expiratory pressure increases the functional residual capacity (FRC) by reinflating collapsed alveoli, maintains the alveoli in an open position, and improves lung compliance. This decreases shunt and improves oxygenation enhances surfactant regeneration by keeping the alveoli open. - High levels of PEEP should rarely be interrupted because it may take several hours to recruit alveoli again and restore the FRC; until this occurs, oxygenation may suffer. - The patient who does not have adequate circulating blood volume, institution of PEEP decreases venous return to the heart, decreases cardiac output, and decreases oxygen delivery to the tissues. - If hypotension or decreased cardiac output results from PEEP application, Dr. Abdul-Monim Batiha- Assistant Professor Of Critical Care Nursing 22

restoring circulating intravascular volume with administration of intravenous fluids may correct the hypotension. - Another serious complication of PEEP is barotrauma. It can occur in any mechanically ventilated patient but is most common when high levels of PEEP are used ( 10 to 20 cm H 2 O) in lungs with high ventilating pressures and low compliance, and in patients with obstructive airway disease. - The development of barotrauma is an emergency and usually requires placement of a chest tube. Sensitivity - The sensitivity function controls the amount of patient effort needed to initiate an inspiration, as measured by negative inspiratory effort. - Increasing the sensitivity (requiring less negative force) decreases the amount of work the patient must do to initiate a ventilator breath. - Decreasing the sensitivity increases the amount of negative pressure that the patient needs to initiate inspiration and increases the work of breathing. Ensuring humidification and thermoregulation - All air delivered by the ventilator passes through the water in the humidifier, where it is warmed and saturated. Because of this, insensible water loss is decreased. - Humidifier temperatures should be kept close to body temperature 35 ºC- 37ºC. - In some rare instances (severe hypothermia), the air temperatures can be increased. Caution is advised because prolonged inhalation of air at high temperatures can cause tracheal burns. - The humidifier should be checked for adequate water levels - An empty humidifier contributes to drying the airway, often with resultant dried secretions, mucus plugging and less ability to suction out secretions. Dr. Abdul-Monim Batiha- Assistant Professor Of Critical Care Nursing 23

- Humidifier should not be overfilled as this may increase circuit resistance and interfere with spontaneous breathing. - As air passes through the ventilator to the patient, water condenses in the corrugated tubing. This moisture is considered contaminated and must be drained into a receptacle and not back into the sterile humidifier. - If the water is allowed to build up, resistance is developed in the circuit and - PEEP is generated. In addition, if moisture accumulates near the endotracheal tube, the patient can aspirate the water. - The nurse and respiratory therapist jointly are responsible for preventing this condensation buildup. The humidifier is an ideal medium for bacterial growth. Institutional policies should describe the frequency of ventilator circuit changes. Ventilator alarms:- - Mechanical ventilators comprise audible and visual alarm systems, which act as immediate warning signals to altered ventilation. - Mechanical ventilators are used to support life. Alarm systems are necessary to warn the nurse of developing problems. Alarm systems can be categorized according to volume and pressure (high and low). - High-pressure alarms warn of rising pressures. Electrical failure alarms are necessary for all ventilators. - Low-pressure alarms warn of disconnection of the patient from the ventilator or circuit leaks. - Complications of Mechanical Ventilation:- I- Airway Complications, I- Mechanical complications, III- Physiological Complications, Dr. Abdul-Monim Batiha- Assistant Professor Of Critical Care Nursing 24

IV- Artificial Airway Complications. I- Airway Complications 1- Aspiration 2- Decreased clearance of secretions 3- Nosocomial or ventilator-acquired pneumonia II- Mechanical complications 1- Hypoventilation with atelectasis with respiratory acidosis or hypoxemia. 2- Hyperventilation with hypocapnia and respiratory alkalosis 3- Barotrauma a- Closed pneumothorax, b- Tension pneumothorax, c- Pneumomediastinum, d- Subcutaneous emphysema. 4- Alarm turned off 5- Failure of alarms or ventilator 6- Inadequate nebulization or humidification 7- Overheated inspired air, resulting in hyperthermia III- Physiological Complications 1- Fluid overload with humidified air and sodium chloride (NaCl) retention 2- Depressed cardiac function and hypotension 3- Stress ulcers 4- Paralytic ileus 5- Gastric distension 6- Starvation 7- Dyssynchronous breathing pattern Dr. Abdul-Monim Batiha- Assistant Professor Of Critical Care Nursing 25

IV- Artificial Airway Complications A- Complications related to Endotracheal Tube:- 1- Tube kinked or plugged 2- Rupture of piriform sinus 3- Tracheal stenosis or tracheomalacia 4- Mainstem intubation with contralateral lung atelectasis 5- Cuff failure 6- Sinusitis 7- Otitis media 8- Laryngeal edema B- Complications related to Tracheostomy tube:- 1- Acute hemorrhage at the site 2- Air embolism 3- Aspiration 4- Tracheal stenosis 5- Erosion into the innominate artery with exsanguination 6- Failure of the tracheostomy cuff 7- Laryngeal nerve damage 8- Obstruction of tracheostomy tube 9- Pneumothorax 10- Subcutaneous and mediastinal emphysema 11- Swallowing dysfunction 12- Tracheoesophageal fistula 13- Infection 14- Accidental decannulation with loss of airway Dr. Abdul-Monim Batiha- Assistant Professor Of Critical Care Nursing 26

Nursing care of patients on mechanical ventilation Assessment: - Assess the patient - Assess the artificial airway (tracheostomy or endotracheal tube) - Assess the ventilator Assessment of the mechanically ventilated patient 1- Assess the patient at least hourly for the following: Vital signs. - Regularly monitor the vital signs (according to policy) Respiratory status - Respiratory rate for a full minute & compared with the set ventilatory rate. (To identify whether they are machine-controlled breaths or combined machine-controlled and spontaneous breaths.) - Symmetry of chest movement during machine breath - Synchronization of chest movement with the ventilator during machine breath - Breath sounds q2 4h and PRN. (lack of breaths sounds may indicate that the ETT is displaced) - Pulse oximetry and end-tidal CO 2. - ABGs as indicated by changes in noninvasive parameters, patient status, or weaning protocol. ( to evaluate oxygenation status & acid-base status) - Need for suctioning. (As secretions heard during respiration, a rise in ventilator peak inspiratory pressures, assess color, amount, consistency & odor of sputum.) - Perform systematic assessment of the oral mucosa daily, and with each cleaning. Cardiovascular status - Heart rate - Blood pressure, Dr. Abdul-Monim Batiha- Assistant Professor Of Critical Care Nursing 27

- Cardiac output - Continuous cardiac monitoring should be initiated. (dysrhythmia may occur due to:- - Hypoxia, - Acidosis, - Alkalosis, - Electrolyte imbalance. - Central venous pressure measurement (reflect right heart function) - Pulmonary artery pressure - Hemodynamic effects of initiating positive-pressure ventilation (e.g., potential for decreased venous return and cardiac output). - Electrocardiogram (ECG) for dysrhythmias related to hypoxemia. - Assess effects of ventilator setting changes (inspiratory pressures, tidal volume, positive end-expiratory pressure[peep], and fraction of inspired oxygen [FIO2]) on hemodynamic and oxygenation parameters. Neurological status - Level of consciousness; - Changes in arousability - Changes in behavior, - Ability to follow commands, Renal status - Fluid balance - Intake and output - Fluid balance - Hydration status in relation to clinical examination, - Daily weight - Urine specific gravity, or serum osmolality - Electrolyte values Gastro-intestinal status - Gastric secretions for bleeding. - Bowel sound Dr. Abdul-Monim Batiha- Assistant Professor Of Critical Care Nursing 28

- Nutritional assessment - PH of gastric secretion - urea, creatinine, albumin and total protein blood glucose levels Integumentary system/ skin - Assess skin integrity at least every shift. - Assess bony prominences for evidence of pressure injury. Signs & symptoms of complications - Signs of decreased cardiac output - Signs of pneumothorax (barotrauma): - Decrease in pulse &B.P - Asymmetrical chest movements; - Diminished / absent breath sounds on affected side; - Cyanosis; - Tachycardia with weak pulse; - Hypotension. - Signs of infection:- - Increase temperature above 38ºC, - Heart rate above 100 b/m - Erythema of tracheostomy - Change in secretions characteristics - Blood work - Chest X-ray 2- Assess the tracheostomy or endotracheal tube: - Soiled or loosened tape - Presence of ulcer in tissue around the endotracheal tube Dr. Abdul-Monim Batiha- Assistant Professor Of Critical Care Nursing 29

- Endotracheal tube position through marking the point at which the tube exits the mouth or nose. (to know whether it is moved in or out.) - Cuff inflation pressure. (Inadequate cuff pressure can lead to loss of delivered tidal volume.) 3- Assess the ventilator parameters/ settings at least hourly :- - Mode of ventilation - Ventilator setting - Fio 2 - Tidal volume V T - Minute ventilation V E - Respiratory rate (number of breaths / minute delivered by the ventilator) - PEEP level if in use or CPAP - I:E ratio - Sigh (frequency / rate & volume) - Airway pressures q1 2h. - Airway pressures after suctioning - Alarm settings, that alarms are turned on. - Alarm checks q4h (minimum) or per hospital protocol - Level of water in the humidifying unit - Temperature of the humidifier - Tubing and connections to ensure circuit leaks do not occur - Tubing to ensure that it is well drained and free from water build-up NB:- - Ventilator settings must be frequently evaluated against patient response. Nursing Diagnosis: - Ineffective, airway clearance - Ineffective Breathing Pattern - Comfort, Altered pain Dr. Abdul-Monim Batiha- Assistant Professor Of Critical Care Nursing 31

- Fluid volume excess - Impaired Tissue Perfusion - Impaired Acid Base Status - Nutrition, Altered: less than body requirements - Altered oral mucous membrane - Bowel Elimination, Altered: constipation - Anxiety / Fear - Communication, Impaired verbal - Ineffective Coping - Alteration in Body Image (related to intubation or tracheostomy) - Impaired Thought Processes Agitation or Anxiety - High Risk for Impaired Gas Exchange - High risk for infection - High risk for impaired skin integrity - High Risk for Complications Associated with Mechanical Ventilation - High Risk for Complications Associated with Tracheostomy Nursing Interventions: 1-Maintain airway patency& oxygenation 2- Promote comfort 3- Maintain fluid & electrolytes balance 4- Maintain nutritional state 5- Maintain urinary & bowel elimination 6- Maintain eye, mouth and cleanliness and integrity:- 7- Maintain mobility/ musculoskeletal function:- 8- Maintain safety:- 9- Provide psychological support 10- Facilitate communication 11- Provide psychological support & information to family 12- Responding to ventilator alarms /Troublshooting ventilator alarms 13- Prevent nosocomial infection 14- Documentation Nursing Interventions 1- Maintain patent airway & Oxygenation - Provide adequate humidification and warming - Perform measures to mobilize secretions through chest physiotherapy Dr. Abdul-Monim Batiha- Assistant Professor Of Critical Care Nursing 31

and proper suctioning technique to clear the airway (guideline for proper suctioning technique to be revised.) - Suction as needed for rhonchi, coughing, or oxygen desaturation. - Hyperoxygenate and hyperventilate before and after each suction pass. - Provide tube care through: - Anchoring ETT securely to prevent tube movement - Placing an oral bite block to prevent the patient from biting on tube - Anchoring a large loop of the tube to the bed to facilitate patient movement without tube movement. - Checking the tube cuff pressures. - Administer bronchodilators and mucolytics as ordered. - Perform chest physiotherapy if indicated by clinical examination or chest x-ray. - Turn side to side q2h. - Consider kinetic therapy or prone positioning as indicated by clinical scenario. - Get patient out of bed to chair or standing position when stable. 2- Promote comfort:- - Perform arterial punctures by skilled personnel - Suction tracheal secretions skillfully and gently - Provide meticulous oral care q1 4h. - Change position frequently - Perform range of motion exercises - Assist the patient to a chair as often as possible when he is stable. - Prevent pulling and jarring of the ventilator tubing and endotracheal or tracheostomy tube. - Document pain assessment, using numerical pain rating or similar scale when possible. - Provide analgesia as appropriate, document efficacy after each dose. - Administer sedation as indicated. 3- Maintain fluid and electrolytes balance:- - Administer intravascular volume as ordered to maintain preload - Administer electrolyte replacements (IV or enteral) per physician s order. Dr. Abdul-Monim Batiha- Assistant Professor Of Critical Care Nursing 32

4- Maintain nutritional state - Administer the prescribed medication (cimetidine, ranitidine, and antacid prophylactically) - Provide the correct proportions of fats, CHO, and proteins as well as water through enteral or parenteral routes. - Establish regular bowel elimination pattern. - Consult dietitian for metabolic needs &recommendations. - Provide early nutritional support by enteral or parenteral feeding, start within 48 hours of intubation. - Administer bowel regimen medications as ordered, along with adequate hydration. - Respiratory muscles, like all other body muscles, need energy to work. If energy needs are not met, muscle fatigue occurs, leading to discoordination of respiratory muscles and a decrease in tidal volume. - Hypomagnesemia and hypophosphatemia have been implicated in muscle fatigue caused by depleted levels of adenosine triphosphate (ATP). In prolonged starvation, the body cannibalizes the intercostals and diaphragmatic muscles for energy. - Metabolic needs in critically ill patients are much higher than in normal subjects. Basic caloric requirements are usually increased by 25% for hospital activity and stress associated with treatment.. If the gastrointestinal tract is intact, enteral nutrition is preferred and can be provided through a feeding tube. - Many chronically ill patients, such as those with COPD, have longstanding protein and calorie malnutrition. Initial tube feeding is started slowly,. The nurse observes the patient for signs of intolerance, such as diarrhea and hyperosmolar dehydration. If the patient tolerates feedings, the rate is gradually increased until the desired rate is achieved. - If tube feedings cannot be tolerated, parenteral hyperalimentation should be considered. Dr. Abdul-Monim Batiha- Assistant Professor Of Critical Care Nursing 33

- Patients who require long-term mechanical ventilation typically need 2,000 to 2,500 calories per day. - Overly large caloric loads increase carbon dioxide production and can precipitate respiratory failure in a compromised patient. 5- Maintain urinary and bowel elimination:- - Nursing care for urinary catheter - Maintain urinary output at 30-60 ml/hour - Nursing measures to prevent constipation and diarrhea - Avoid constipation by use of :- Mild cathartic Suppositories Enemas 6-Maintain eye, mouth and cleanliness and integrity:- Eye care - Use of artificial tears - Instill lubricating drops or ointment, - Apply antibiotic drops or ointments as ordered - Close the eyelids with tape to prevent corneal ulceration - Apply eye shields, or applying a moisture chamber - Raise the head of the bed may reduce scleral edema. (Scleral edema is common in the ventilated patient). Oral care - Perform regular oral hygiene (every 2 hours) to prevent infection - Establishe a scheduled, regular oral care regimen, using products that remove plaque and cleanse the mouth without causing pain or irritation. - Use a non alcohol-based mouthwash, and brush the teeth a minimum of Dr. Abdul-Monim Batiha- Assistant Professor Of Critical Care Nursing 34

every 8 hours. - Use toothbrushes which have soft bristles with toothpaste - Use foam brush instead of toothbrush in patients with bleeding disorders or a low platelet count - Perform oral suctioning and care to remove subglottic secretions every 1 to 2 hours. Alternatively, Each oral care should include suctioning of the subglottic secretions to prevent aspiration. - Use of a chlorhexidine-based mouthwash, hydrogen peroxide or other antibacterial or antifungal mouthwashes that is compatible with the patient s condition, and should not cause pain due to additives for flavor, alcohol, or strength.) - Use half-strength solutions diluted with water may help the patient tolerate more frequent oral care. - Place the tube in a central position to avoid contact with the corners of the mouth and the lips. or it can be rotated from side to side.) Skin care: - Turn the patient every 2 hours - Provide pressure relief to sitting surfaces at least q1h when patient is out of bed to chair,. - Use special mattresses - Perform complete bed bath for the patient daily and whenever necessary - Keep the patient s clothes clean and dry - Keep the linen clean, dry and unwrinkled - Massage & lubricate the back and over the bony prominences 7- Maintain mobility/ musculoskeletal function:- - Collaborate with physical/occupational therapy staff to encourage patient effort/participation to increase mobility. - Progress activity to sitting up in chair, standing at bedside, ambulating with assistance as soon as possible. - Assist patient with active or passive range-of-motion exercises to all extremities at least every shift. - Keep extremities in physiologically neutral position using pillows or appropriate splint/support devices as indicated. 8- Maintain Safety:- Dr. Abdul-Monim Batiha- Assistant Professor Of Critical Care Nursing 35

- Keep endotracheal tube in proper position. - Stabilize endotracheal tube in positio securely - Note and record the cm line on endotracheal tube position at lip or teeth. - Use patient self-protective devices or sedation per hospital protocol. - Evaluate endotracheal tube position on chest x-ray (by viewing film or by report). - Keep emergency airway equipment and manual resuscitation bag readily available, and check each shift. - Inflate cuff using minimal leak technique, or pressure less than 25 mm Hg by manometer. - Monitor cuff inflation/leak every shift and PRN. - Maintain proper inflated endotracheal tube cuff. - Protect pilot balloon from damage. - Keep ventilator alarm system activated. 9- Provide Psychological support - Provide adequate information and explanation of all procedures before they are initiated. - Answer alarms promptly. - Describe the alarm system and explain that it will alert staff in the event of an accidental disconnection. - Oxygenate the patient before and after suctioning and remain with the patient until his respiratory pattern and vital signs return to normal. - Keep noise levels to a minimum especially during rest periods - Diminish lights during the night to stimulate night and day cycles - Place clocks & calendars within the patient s view & verbally confirm time & date with the patient. - Provide a T.V or radio for the patient. - Communicate a caring and unhurried attitude to the patient. - Patient participates in self-care and decision making related to own activities of daily living (ADLs) (e.g., turning, bathing). - Patient communicates with health care providers and visitors. - Encourage patient to move in bed and attempt to meet own basic comfort/hygiene needs independently. - Establish a daily schedule for bathing, out of bed, treatments, and so forth with patient input. - Provide a means for patient to write notes and use visual tools to facilitate communication. - Encourage visitor conversations with patient in normal tone of voice and Dr. Abdul-Monim Batiha- Assistant Professor Of Critical Care Nursing 36