Mechanical Ventilation A mechanical ventilator is a machine that helps people breathe when they are not able to breathe

he enough on their own. The mechanical ventilator is also called a ventilator, respirator, or breathing machine. A mechanical ventilator is a positive- or negative-pressure breathing device that can maintain ventilation and oxygen delivery for a prolonged period. Mechanical ventilation is a life support treatment. A mechanical ventilator is a complex system consisting of a power supply, compressed air and oxygen, a drive mechanism to provide motive force to push oxygen into the patients lungs and a control mechanism to manage the gas flow, volume, pressure and timing. It is connected to the patients lungs through breathing hoses and a special tube inserted into the patients airway

Indications for Mechanical Ventilation Respiratory failure o Apnoea / respiratory arrest o Inadequate ventilation(acute vs chronic) o Inadequate oxygenation o Chronic respiratory insufficiency with FTT Cardiac insufficiency o Eliminate the work of breathing o To reduce the oxygen consumption Neurologic dysfunction o Central hypoventilation and frequent apnoea o Comatose patient with GCS < 8 o Inability to protect the airway ABG Results o PaO2 < 50 mm Hg with FiO2 > 0.60 o PaO2 > 50 mm Hg with pH < 7.25 o Vital capacity < 2 times tidal volume o Negative inspiratory force < 25 cm H2O o Respiratory rate > 35/min Normal values: pH = 7.35 7.45 PaO2 = 75 100 mmHg PaCO2 = 35 55 mmHg RR = 12 20 cpm

Classification of Mechanical Ventilation Negative-Pressure Ventilators o Negative-pressure ventilators exert a negative pressure on the external chest. Decreasing the intrathoracic pressure during inspiration allows air to flow into the lung, filling its volume. Physiologically, this type of assisted ventilation is similar to spontaneous ventilation. o It is used mainly in chronic respiratory failure associated with neuromuscular conditions, such as poliomyelitis, muscular dystrophy, amyotrophic lateral sclerosis, and myasthenia gravis. It is inappropriate for the unstable or complex patient or the patient whose condition requires frequent ventilator changes. o Negative-pressure ventilators are simple to use and do not require intubation of the airway; consequently, they are especially adaptable for home use. o Types : IRON LUNG (DRINKER RESPIRATOR TANK) The iron lung is a negative-pressure chamber used for ventilation. It was used extensively during polio epidemics in the past and currently is used by polio survivors and patients with other neuromuscular disorders. BODY WRAP (PNEUMOWRAP) AND CHEST CUIRASS (TORTOISE SHELL) Both of these portable devices require a rigid cage or shell to create negative-pressure chamber around the thorax and abdomen. Because of problems with proper fit and system leaks, these types of ventilators are used only with carefully selected patients. Positive Pressure Ventilation o Positive-pressure ventilators inflate the lungs by exerting positive pressure on the airway, similar to a bellows mechanism, forcing the alveoli to expand during inspiration. Expiration occurs passively. o Endotracheal intubation or tracheostomy is necessary in most cases. o These ventilators are widely used in the hospital setting and are increasingly used in the home for patients with primary lung disease. o Types: Invasive Positive - Pressure Ventilators PRESSURE-CYCLED VENTILATORS o The pressure-cycled ventilator ends inspiration when a preset pressure has been reached. In other words, the ventilator cycles on, delivers a flow of air until it reaches a predetermined pressure, then cycles off. Its major limitation is that the volume of air or oxygen can vary as the patients

airway resistance or compliance changes. As a result, the tidal volume delivered may be inconsistent, possibly compromising ventilation. Consequently, in adults, pressure-cycled ventilators are intended only for short-term use. The most common type is the IPPB machine TIME-CYCLED VENTILATORS o Time-cycled ventilators terminate or control inspiration after a preset time. The volume of air the patient receives is regulated by the length of inspiration and the flow rate of the air. Most ventilators have a rate control that determines the respiratory rate, but pure time-cycling is rarely used for adults. These ventilators are used in newborns and infants. VOLUME-CYCLED VENTILATORS o Volume-cycled ventilators are by far the most commonly used positive-pressure ventilators today. With this type of ventilator, the volume of air to be delivered with each inspiration is preset. Once this preset volume is delivered to the patient, the ventilator cycles off and exhalation occurs passively. From breath to breath, the volume of air delivered by the ventilator is relatively constant, ensuring consistent, adequate breaths despite varying airway pressures. Noninvasive Positive-Pressure Ventilation Can be given via facemasks that cover the nose and mouth, nasal masks, or other nasal devices. This eliminates the need for endotracheal intubation or tracheostomy and decreases the risk for nosocomial infections such as pneumonia. The ventilator can be set with a minimum backup rate for patients with periods of apnea. Patients are considered candidates for noninvasive ventilation if they have acute or chronic respiratory failure, acute pulmonary edema, COPD, or chronic heart failure with a sleep-related breathing disorder. The device also may be used at home to improve tissue oxygenation and to rest the respiratory muscles while the patient sleeps at night. It is contraindicated for those who have experienced respiratory arrest, serious dysrhythmias, cognitive impairment, or head or facial trauma.

Noninvasive ventilation may also be used for patients at the end of life and those who do not want endotracheal intubation but may need short- or long-term ventilator support

Control Modes for Mechanical Ventilation AC (assist control) or VC (Volume Control) o Characteristics: preset rate and tidal volume (sometimes PIP), either on the patients initiative or at the set interval a full mechanical breath is delivered. o Uses: For patients, who have a very weak respiratory effort, allows synchrony with the patient but maximal support. Not a weaning mode, as at any rate they are getting complete mechanical support. o Contraindications: none in particular o Advantages: a fairly comfortable mode, providing a lot of support o Disadvantages: can lead to hyperventilation if not closely monitored, not able to wean in this mode. PC (Pressure Control) o Characteristics: basically IMV, where the breath is controlled by the Pmax or Swing pressure (P)\ and not the set tidal volume o Uses: in neonates, or in patients with high airway pressures(such as ARDS) to avoid barotraumas o Contraindications: none in particular, not a friendly mode in an awake patient o Advantages: Pressure limited, decreases the risk of barotraumas o Disadvantages: no guaranteed tidal volume PRVC (Pressure Regulated Volume Control) o Characteristics: a volume control assist control mode that adjusts the flow rate of the delivered air to deliver the set tidal volume at or below the set maximum pressure. o Uses: in patients with high airway pressures, although it can be used in any patient. o Contraindications: none in particular o Advantages: gives you a guaranteed tidal volume but minimizes barotrauma. o Disadvantages: new, no particular disadvantages. IMV (Intermittent Mandatory Ventilation) o Characteristics: set breath delivered at a fixed interval. No patient interaction, pressureor volume modes o Uses: commonly in neonates on the Sechrist, can be a weaning mode o Contraindications: none really, unfriendly to older patients o Advantages: regular guaranteed breath o Disadvantages: does not allow patient to breath with the ventilator except by chance. Does not work with the patient

SIMV (Synchronous IMV) o Characteristics: set breath delivered within an interval based on the set respiratory rate. Ventilator spends part of the interval waiting for spontaneous breath from the patient, which it will use as a trigger to deliver a full breath. If not sensed it will automatically give a breath at the end of the period. Any other breaths during the cycle are not supplemented. o Uses: commonly used in many settings. Can be a weaning mode Contraindications: none in particular o Advantages: allows work with the patient, somewhat friendlier. o Disadvantages: Any other breaths during the cycle are not supplemented SIMV/PS(Pressure Support) o Characteristics: combination of the previous two modes. Extra breaths in the cycle are supplemented with pressure support. o Uses: useful in most circumstances, including weaning. o Contraindications: none in particular. o Advantages: allows both synchrony with the patient and help in overcoming the resistance in the endotracheal tube, to allow easier spontaneous breathing o Disadvantages: none in particular. PS does not add anything in the patient who is not spontaneously breathing. Sometimes patients will have difficulty with the pressure support on some ventilators.

Support Modes for Mechanical Ventilation PS (Pressure Support) o Characteristics: supports each spontaneous breath with supplemental flow to achieve a preset pressure. Gives a little push to get the air in, so to speak. o Uses: In the spontaneously breathing patient this helps overcome the airway resistance of the endotracheal tube. Usually use 5 for older patients and 10 for smaller (smaller ETT has higher resistance, more impediment to flow). Can be very helpful for weaning. o Contraindications: patient who is not spontaneously breathing, i.e. on muscle relaxants o Advantages: helps overcome resistance of tube, making spontaneous breathing easier Volume Support o Characteristics: variable level of pressure support is delivered on each breath in order to maintain minimum set goal minute ventilation. Note: because the goal the ventilator works from is a minute ventilation goal the patient's respiratory rate can fall below the set' rate as long as their breaths are large enough to maintain the goal minute ventilation

o Uses: a weaning mode. The concept is that as the patient becomes stronger, or more awake they will make more respiratory effort on their own. The more effort they make the less support they will need from the ventilator and hence the level of pressure delivered will get smaller, often into the single digits o Contraindications: patient who is not spontaneously breathing, as there is no back-up rate. o Advantages: greatly decreases the number of interventions needed to wean patient from a ventilator versus traditional weaning o Disadvantages: can be tricky on chronically ventilated patients. Takes some experience to understand when a patient is ready to be extubated when in this mode CPAP (Continuous Positive Airway Pressure) o Characteristics: just as it says. This is very similar to PEEP, except that the inspiratory pressure is also maintained at the CPAP level, leading to support on inspiration and resistance on exhalation. o Uses: for patients with upper airway soft tissue obstruction or tendency for airway collapse. As a final mode prior to extubation in some patients. o Contraindications: any patient without spontaneous respiratory effort. Not a good idea in a patient with obstructive pulmonary disease (like asthma, COPD) o Advantages: simple, easy to use o Disadvantages: provides no supportive ventilation. Notes in Modes: o Every patient is different and it is hard to know exactly what a patient will need in terms of ventilatory support until they are actually on the ventilator. So many of us a have preset ideas as to where to start any patient and then adjust the ventilator afterwards to achieve the desired ventilation effect. This has a lot to do with the individual style of the attending physician. o Pressure vs. Volume: I generally choose Volume to start. Why? Generally a more straightforward in terms of meeting goals of ventilation. o Mode: PRVC, if available, otherwise SIMV with or without Pressure Support. Why? PRVC has the advantages of guaranteed tidal volume AND limiting the peak pressure. The decelerating wave pattern on the flow is also generally friendlier. o Rate: 20 Why? This is a good place to start. You can always adjust later. For small children this is lower that their usual spontaneous rate but with the larger tidal volumes that are delivered this increases the minute ventilation. For large children I will decrease this to 15 or even less. For small infants or neonates I may increase this to 30 or higher.

o PEEP: 5mm Hg Why? This is a little above physiologic. Not so high as to cause problems. o FiO2: 100% Why? You can start to wean once you are certain everything is stable. This allows maximal preoxygenation in case anything happens. The only patients who will suffer deleterious effects from 100% for brief periods are those with arterial to pulmonary shunts, such as a modified BlalockTaussig shunt or a central shunt where pulmonary vasodilatation can lead to systemic hypotension. o Tidal Volume: 8-10ml/kg Why? This is above physiologic and gives good distention without significant barotrauma. 10-12ml/kg used to be the standard range, but people are generally using PEEP to maintain lung volume and smaller tidal volumes to avoid baro or volutrauma. o Inspiratory Time: somewhere from 0.5 to 1 second Why? Its physiologic. You want a longer i-time for bigger kids, but this will vary on the situation. Asthmatics for example merit very short I-times to allow maximal time for exhalation

Problems with Mechanical Ventilation Assessment o The first priority in dealing with mechanical ventilation problems is to assess the patient. How severe is the problem? Does the patient require immediate resuscitation? o Check: Is the chest moving and is it moving symmetrically? Is the patient cyanotic? What is the arterial saturation? Is the patient haemodynamically stable? Diagnose the problem. Ventilator/circuit problems can be distinguished from endotracheal tube/patient problems by taking the patient off the ventilator and manually bagging the patient. o High airway pressure High airway pressure may cause barotraumas It signifies a deterioration in the patient's clinical state It may result in hypoventilation of the patient

Many ventilators cycle from inspiration to expiration immediately if the upper pressure alarm limit is reached. As a result inspiration is terminated early and the tidal volume is reduced. Cause of High airway Pressure Ventilator problems o Inappropriate settings o Excessive tidal volume o excessive flow or excessively short inspiratory time o high airway pressure alarm limit too low o Ventilator malfunction rare Circuit problems o Fluid pooling in circuit o Fluid pooling in filter o Kinking of circuit Endotracheal tube obstruction i.e. due to sputum, kinking, biting Increased airway resistance i.e. bronchospasm Decreased respiratory system compliance o Parenchymal disease o Pleural disease i.e. pneumothorax o Decreased chest wall compliance i.e. due to patient "fighting" ventilator o Decreased ventilated lung volume sputum plugging lobar/lung collapse endobronchial intubation Management Assess patient. Disconnect patient from ventilator and manually ventilate. o Assess the "feel" of the lungs. Is the patient difficult to ventilate? o If the patient is not difficult to ventilate, it is a problem with the ventilator or the circuit. o If the patient is difficult to ventilate, it is a problem with the endotracheal tube or the respiratory system. For ventilator and circuit problems, check ventilator settings and function, and check circuit for obstruction or kinking. For patient or ETT problems examine the patient looking particularly for bronchospasm, asymmetrical chest expansion and evidence of collapse. Pass a suction catheter through the ETT to check its patency.

 CXR o Hypotension The most important causes of hypotension occurring soon after the initiation of mechanical ventilation are: Relative hypovolemia o Reduction in venous return exacerbated by positive intrathoracic pressure Drug induced vasodilation and myocardial depression o All anesthetic induction agents have some short lived vasodilatory and myocardial depressant effects Gas trapping (dynamic hyperinflation) Tension pneumothorax Hypotension due to relative hypovolemia or anesthetic induction agents usually responds rapidly to fluid. Hypotension due to gas trapping can be diagnosed and treated by disconnecting the patient from the ventilator. This results in a rapid reversal of the hypotension. o Patient-ventilator dysynchrony There are a large number of causes of patient-ventilator dysynchrony which need to beconsidered. It is important to identify and treat these causes and not simply to sedate the patientmore heavily. As well as all the possible causes of agitation there are a number of ventilatorparameters which must be considered. These include: Mode of ventilation o Spontaneous modes are more comfortable than control modes o I:E ratio Ratios that are similar to the 1:2 ratio of a normal breathing pattern are more comfortable. o Triggering if the patient is having difficulty triggering the ventilator despite a sensitive setting consider the possibility that there is auto-PEEP due to dynamic hyperinflation. o Desaturation Causes Endobronchial intubation Accidental extubation Pneumothorax Pulmonary embolus Any cause of increased intrapulmonary shunt

 Any cause of hypoxic respiratory failure Ventilator malfunction Management Increase FIO2 to 100% Check to make sure chest is moving Briefly examine chest to determine cause of desaturation If cause is not obvious manually ventilate patient with 100% oxygen to exclude ventilator malfunction as the cause Treat underlying cause Alter ventilator settings to improve oxygenation CXR o Weaning process by which a ventilator-dependent patient is removed from ventilator only 10-20% of patients who require ventilation are difficult to wean and most of these have required ventilation for over 1 month potentially reversible reasons for difficult weaning: Inadequate respiratory drive Poor gas exchange Psychological dependency Ventilatory pump failure (usually due to inspiratory muscle weakness or fatigue) Causes for inspiratory muscle weakness or fatigue: Nutritional or metabolic deficiencies: hypokalemia, hypomagnesaemia, hypocalcemia, hypophosphatemia, hypothyroidism Steroids Chronic renal failure Decreased protein synthesis and increased degradation Decreased glycogen stores Anemia Persistently increased work of breathing Cardiovascular failure Neuromuscular blockers Polyneuropathy of critical illness There is no objective data to determine when to attempt weaning. In general, the problem which led to the initiation of mechanical ventilation should have been reversed or stabilized.

Standard criteria for initiating weaning: o Clinically and radiologically resolving lung disease o FiO2 <40% o PEEP 5 o Minimal endotracheal secretions o Patient awake and cooperative o Vital Capacity > 10ml/kg o NIF (negative inspiratory force) > -20cm H20

Nursing Process I. Assessment In assessing the patient, the nurse evaluates the patients physiologic status and how he or she is coping with mechanical ventilation. Physical assessment includes systematic assessment offal body systems, with an in-depth focus on the respiratory system. Respiratory assessment includes vital signs, respiratory rate and pattern, breath sounds, evaluation of spontaneous ventilator effort, and potential evidence of hypoxia. Increased adventitious breath sounds may indicate a need for suctioning. The nurse also evaluates the settings and functioning of the mechanical ventilator, as described previously. Assessment also addresses the patients neurologic status and effectiveness of coping with the need for assisted ventilation and the changes that accompany it. The nurse should assess the patients comfort level and ability to communicate as well. Finally, weaning from mechanical ventilation requires adequate nutrition. Therefore, it is important to assess the function of the gastrointestinal system and nutritional status. II. Nursing Diagnosis 1. Impaired gas exchange related to underlying illness, or ventilator setting adjustment during stabilization or weaning. 2. Ineffective airway clearance related to increased mucus production associated with continuous positive-pressure mechanical ventilation 3. Risk for trauma and infection related to endotracheal intubation or tracheostomy 4. Impaired physical mobility related to ventilator dependency 5. Impaired verbal communication related to endotracheal tube and attachment to ventilator 6. Defensive coping and powerlessness related to ventilator dependency

III. Planning The major goals for the patient may include achievement ofoptimal gas exchange, maintenance of a patent airway, absence of trauma or infection, attainment of optimal mobility, adjustment to nonverbal methods of communication, acquisition of successful coping measures, and absence of complications. E.g. ( after 15 minutes of effective nursing intervention, patient must have an increase comfort and patent airway from ETT connected to the mechanical ventilation as evidenced by decreased mucus production.) IV. Nursing Intervention with Rationale 1. ENHANCING GAS EXCHANGE a. Judicious administration of analgesic agents to relieve pain without suppressing the respiratory drive and frequent repositioning to diminish the pulmonary effects of immobility. b. Monitors for adequate fluid balance by assessing for the presence of peripheral edema, calculating daily intake and output, and monitoring daily weights. c. The nurse administers medications prescribed to control the primary disease and monitors for their side effects 2. PROMOTING EFFECTIVE AIRWAY CLEARANCE a. Continuous positive-pressure ventilation increases the production of secretions regardless of the patients underlying condition. Assess for the presence of secretions by lung auscultation at least every 2 to 4 hours. b. Measures to clear the airway of secretions include suctioning, chest physiotherapy, frequent position changes, and increased mobility as soon as possible. c. Frequency of suctioning should be determined by patient assessment. If excessive secretions are identified by inspection or auscultation techniques, suctioning should be performed. Sputum is not produced continuously or every 1 to 2 hours but as a response to a pathologic condition. Therefore, there is no rationale for routine suctioning of all patients every 1 to 2 hours. Although suctioning is used to aid in the clearance of secretions, it can damage the airway mucosa and impair cilia action. d. The sigh mechanism on the ventilator may be adjusted to deliver at least one to three sighs per hour at 1.5 times the tidal volume if the patient is on assist control. Because of the risk of hyperventilation and trauma to pulmonary tissue from excess ventilator pressure (barotrauma, pneumothorax), this feature is not

e. f.

g.

h.

being used as frequently today. If the patient is on the synchronized intermittent mandatory ventilation (SIMV) mode, the mandatory ventilations act as sighs because they are of greater volume than the patients spontaneous breaths. Periodic sighing prevents atelectasis and the further retention of secretions. Keep Humidification of the airway via the ventilator is maintained to help liquefy secretions so they are more easily removed. Bronchodilators are administered to dilate the bronchioles and are classified as adrenergic or anticholinergic. Adrenergic bronchodilators are mostly inhaled and work by stimulating the betareceptor sites, mimicking the effects of epinephrine in the body. The desired effect is smooth muscle relaxation, thus dilating the constricted bronchial tubes. Anticholinergic bronchodilators such as ipratropium (Atrovent) and ipratropium with albuterol (Combivent) produce airway relaxation by blocking cholinergicinduced bronchoconstriction. Patients receiving bronchodilator therapy of either type should be monitored for adverse effects including dizziness, nausea, decreased oxygen saturation, hypokalemia, increased heart rate, and urine retention. Mucolytic agents such as acetylcysteine (Mucomyst) are administered as prescribed to liquefy secretions so that they are more easily mobilized. Nursing management of patients receiving mucolytic therapy includes assessment for an adequate cough reflex, sputum characteristics, and improvement in incentive spirometry. Side effects include nausea, vomiting, bronchospasm, stomatitis (oral ulcers), urticaria, and runny nose

3. PREVENTING TRAUMA AND INFECTION a. Airway management must involve maintaining the endotracheal or tracheostomy tube. The nurse positions the ventilator tubing so that there is minimal pulling or distortion of the tube in the trachea; this reduces the risk of trauma to the trachea. b. Cuff pressure is monitored every 8 hours to maintain the pressure at less than 25 cm H2O. The nurse evaluates for the presence of a cuff leak at the same time. c. Tracheostomy care is performed at least every 8 hours, and more frequently if needed, because of the increased risk of infection. The ventilator circuit and inline suction tubing is replaced periodically, according to infection control guidelines, to decrease the risk of infection. d. Administers oral hygiene frequently because the oral cavity is a primary source of contamination of the lungs in the intubated and compromised patient. The presence of a nasogastric tube in the intubated patient can increase the risk for aspiration, leading to nosocomial pneumonia. e. The nurse positions the patient with the head elevated above the stomach as much as possible.

f. Antiulcer medications such as sucralfate (Carafate) are given as prescribed of the PIC to maintain normal gastric pH; research has demonstrated a lower incidence of aspiration pneumonia when sucralfate is administered. 4. PROMOTING OPTIMAL LEVEL OF MOBILITY a. The patients mobility is limited because he or she is connected to the ventilator. The nurse should assist a patient whose condition has become stable to get out of bed and to a chair as soon as possible. b. Mobility and muscle activity are beneficial because they stimulate respirations and improve morale. If the patient cannot get out of bed, the nurse encourages the patient to perform active range-of-motion exercises every 6 to 8 hours. If the patient cannot perform these exercises, the nurse performs passive range-of motion exercises every 8 hours to prevent contractures and venous stasis. 5. PROMOTING OPTIMAL COMMUNICATION a. It is important to develop alternative methods of communication for the patient on a ventilator. The nurse assesses the patients communication abilities to evaluate for limitations. Questions to consider when assessing the ventilator-dependent patients ability to communicate include the following: i. Is the patient conscious and able to communicate? Can the patient nod or shake the head? ii. Is the patients mouth unobstructed by the tube so that words can be mouthed? iii. Is the patients hand strong and available for writing? (For example, if the patient is right-handed, the intravenous line is placed in the left arm if possible so that the right hand is free.) b. Once the patients limitations are known, the nurse offers several appropriate communication approaches: lip reading (use single key words), pad and pencil or Magic Slate, communication board, gesturing, or electric larynx. Use of a talking or fenestrated tracheostomy tube may be suggested to the physician; this allows the patient to talk while on the ventilator. If indicated, the nurse should make sure that the patients eyeglasses and hearing aid and a translator are available to enhance the patients ability to communicate. c. The patient must be assisted to find the most suitable communication method. Some methods may be frustrating to the patient, family, and nurse; these need to be identified and minimized

6. PROMOTING COPING ABILITY Dependence on a ventilator is frightening to both the patient andfamily and disrupts even the most stable families. a. Encouraging the family to verbalize their feelings about the ventilator, the patients condition, and the environment in general is beneficial. b. Explaining procedures every time they are performed helps to reduce anxiety and familiarizes the patient with ventilator procedures. c. To restore a sense of control, the nurse encourages the patient to participate in decisions about care, schedules, and treatment when possible. The patient may become withdrawn or depressed while on mechanical ventilation, especially if its use is prolonged. d. To promote effective coping, the nurse informs the patient about progress when appropriate. It is important to provide diversions such as watching television, playing music, or taking a walk (if appropriate and possible). e. Stress reduction techniques (eg, a backrub, relaxation measures) help relieve tension and help the patient to deal with anxieties and fears about both the condition and the dependence on the ventilator. V. Evaluation Expected patient outcomes may include: 1. Exhibits adequate gas exchange, as evidenced by normal breath sounds, acceptable arterial blood gas levels, and vital signs 2. Demonstrates adequate ventilation with minimal mucus accumulation 3. Is free of injury or infection, as evidenced by normal temperature and white blood count 4. Is mobile within limits of ability a. Gets out of bed to chair, bears weight, or ambulates as soon as possible b. Performs range-of-motion exercises every 6 to 8 hours 5. Communicates effectively through written messages, gestures, or other communication strategies 6. Copes effectively a. Verbalizes fears and concerns about condition and equipment b. Participates in decision making when possible c. Uses stress reduction techniques when necessary 7. Absence of complications a. Absence of cardiac compromise, as evidenced by stable vital signs and adequate urine output

b. Absence of pneumothorax, as evidenced by bilateral chest excursion, normal chest x-ray, and adequate oxygenation c. Absence of pulmonary infection, as evidenced by normal temperature, clear pulmonary secretions, and negative sputum cultures

References: 1. Books a. Brunner and Suddarth's Textbook of Medical-Surgical Nursing 12th edition b. Medical Surgical Nursing Clinical Management for Positive Outcomes 8th edition by Joyce Black c. Guyton and Hall Textbook of Medical Physiology d. Kozier & Erb's Fundamentals of Nursing (9th Edition) 2. Websites: a. http://www.globalrph.com/abg_analysis.htm b. http://intensivecare.hsnet.nsw.gov.au/five/doc/westmead/ABG_poster_A3.pdf c. www.thoracic.org d. http://www.ghs.org/upload/docs/Medical%20Education/IM%20UME/MECHANICAL_VE
NTILATION.pdf 3. Journals

a. Basics of Mechanical Ventilation by Alain Broccard, MD and John Marini, MD of University of Minnesota, Regions Hospital St Paul, MN b. Mechanical Ventilation for Nursing by Melissa Dearing, BS, RRT-NPS, RCP and Associate Professor of Respiratory CareCurtis Shelley, BS, RRT-NPS, RCPRespiratory Educator Hermann Childrens Hospital c. Mechanical Ventilation by Dr.Lakshmi Phani Nadella d. Mechanical Ventilation by Doctor Shalini Gar