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ANCC CONTACT HOURS

Building a solid understanding of

Mechanical
ventilation

22

Nursing2009

June

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Learn how to determine if your

patient is adequately oxygenated,
and what to do if he isnt.
By Chris Kallus, RRT, MEd
KNOWING THE BASICS of mechanical
ventilation is the key to caring for a
patient whos endotracheally intubated
and on mechanical ventilation. With

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more ventilated patients on general

units, you need to be able to stay in
tune with the day-to-day aspects of
ventilator care. In this article, Ill outline what you need to know about
mechanical ventilation. Follow your
facilitys procedures and protocols
when caring for your patient, assess
the patient first when problems arise,
obtain a physicians order as appropri-

ate, and work with the respiratory

therapist when making ventilator
changes.
Lets start with assessing the relationship between ventilator settings
and arterial blood gas (ABG) values for
a hypothetical patient, Arthur White,
68, who was put on mechanical ventilation because of persistent apnea following his partial colectomy. He has no

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history of lung disease. His ventilator

settings are:
Synchronized intermittent mandatory
ventilation (SIMV) at 10 breaths/
minute. (More on this ventilator
mode later.)
Tidal volume (VT) of 700 mL. Tidal
volume represents the volume of gas
exchanged during each ventilated
breath. Normal tidal volume in a
patient whos breathing spontaneously
is 5 to 8 mL/kg. In mechanically ventilated patients, the tidal volume is set to
prevent lung injury; the value depends
on the patients lung condition. A
patient with normal lungs would be
ventilated at 10 to 12 mL/kg, one with
chronic obstructive pulmonary disease
(COPD) at 8 to 10 mL/kg, and one
with acute repiratory distress syndrome at 4 to 8 mL/kg.
The fraction of inspired oxygen
(FIO2) is 1.0, meaning that hes receiving 100% oxygen.
Positive end-expiratory pressure
(PEEP) is 5 cm H2O. PEEP is a measure of the pressure remaining in the
lungs at end-expiration; in normal,
nonventilated patients, 3 to 5 cm H2O
of PEEP is considered physiologically
normal.
Mr. Whites latest ABGs are: pH,
7.38 (normal, 7.357.45); PaCO2,
42 mm Hg (normal, 3545 mm Hg);
PaO2, 225 mm Hg (normal, 80100
mm Hg); and HCO3-, 24 mEq/L (normal, 2226 mEq/L). What implications
do these results have for your patient,
and the nursing care youll provide for
him? Follow the steps below to look at

If atelectasis causes a
low PaO2, your patient
wont respond as he
should no matter how
much oxygen you
administer.

key ABG values and how they relate to

ventilation and ventilatory care.
Step 1: Evaluate pH and PaCO2
Mr. Whites pH is within the normal
range, and hes not compensating for a
metabolic or respiratory disorder.
Hypoventilation causes the patients pH
to drop below 7.35 and his PaCO2 to
rise above 45 mm Hgthe level of
ventilation is insufficient to maintain a
normal PaCO2. In hyperventilation, the
patients pH is greater than 7.45 and
PaCO2 is less than 35 mm Hgthe
level of ventilation is excessive.
Because his pH and PaCO2 are both
normal, Mr. Whites level of ventilation
is satisfactory.
If Mr. Whites PaCO2 werent normal,
youd try to get it back into the normal
range by working with the respiratory
therapist to change the minute ventilation, which is determined by multiplying the tidal volume by the ventilator
rate and is expressed as VE. The PaCO2
is the respiratory component affecting
pH (the kidneys and the HCO3- value
are the metabolic component). In a

Calculating IBW
Patients of different weights can have the same lung size, so calculating IBW
helps healthcare providers choose the right tidal volume for the patient. The
following formulas give you IBW in pounds.
For men: 106 + 6(height in inches-60)
For women: 105 + 5(height in inches-60)

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patient with hypoventilation, youd

adjust the minute ventilation by
increasing the tidal volume or ventilatory rate. These interventions reduce
the PaCO2 back to normal and bring
the pH back within the acceptable
range.
However, before adjusting the tidal
volume, you need to be sure that the
tidal volume used is appropriate for the
patient, based on his ideal body weight
(IBW), which is used to approximate
lung size. (For more information, see
Calculating IBW.) Normal lungs typically require a tidal volume between
10 and 12 mL/kg of IBW. Mr. Whites
IBW is 154.4 pounds (70 kg) and his
lungs are normal, so a tidal volume
between 700 and 840 mL is appropriate. (An even quicker way to set tidal
volume for a patient with normal lungs
is to add a zero to the patients IBW in
kilograms.)
So far, so good for Mr. White. His
pH and PaCO2 are normal, and his tidal
volume is appropriate for his IBW.
Before we move on to the next step,
lets look at what youd do if his tidal
volume were inappropriate: For example, suppose Mr. Whites tidal volume
was set at 1,000 mL and his ventilator
rate was set at 7 breaths/minute. The
minute ventilation is the same, 7,000
mL (or 7 liters). But the tidal volume
exceeds the maximum 840 mL recommended for a patient of Mr. Whites
IBW. Large tidal volumes can cause
ventilator-induced lung injury.
In this situation, youd reduce the
tidal volume to 700 mL and increase the
ventilatory rate to 10 breaths/minute.
This change retains the same minute
ventilation value (7 liters), wont
change Mr. Whites pH or PaCO2, and
avoids the dangers of excessive delivered tidal volumes. For more on pressure and the risk of ventilator-induced
lung injury, see Lungs under pressure.
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Step 2: Evaluate PaO2 and FIO2

Next, assess your patients oxygenation
status by calculating the P/F ratio,
which is PaO2 divided by FIO2. For
example, if the patients PaO2 is 225
mm Hg and the FIO2 is 1.0, the P/F
ratio is 225. A number greater than
300 is considered normal. Values
between 200 and 300 indicate acute
lung injury, and values less than 200
indicate refractory hypoxemia, or
hypoxemia thats not responsive to
oxygen therapy.
Note that the FIO2 value is always
expressed as a decimal, not a percentage. An FIO2 of 1.0 can also be
expressed as 100% oxygen; an FIO2 of
0.5 can also be expressed as 50% oxygen, but its incorrect to say the patient
is on an FIO2 of 50%.
Lets return to assessing Mr. Whites
oxygenation status. His PaO2 is 225
mm Hgtoo high. The only reasons to
keep a patients PaO2 above 100 mm Hg
is if youre treating carbon monoxide
poisoning, and a patients FIO2 shouldnt exceed 0.5 (more on that later).
However, given that Mr. White is
receiving 100% oxygen, his PaO2
should be 500 mm Hg, or five times
the percentage of oxygen hes receiving.
(Because room air is 21% oxygen, multiplying the FIO2 by 5 is a quick way of
estimating PaO2.) For example, a
patient breathing 40% oxygen should
have a PaO2 of about 200 mm Hg. As
you increase the delivered FIO2 you
should see a corresponding increase in
PaO2if not, the patient has refractory
hypoxemia.
Mr. Whites P/F ratio of 225 already
has alerted you that he has acute lung
injury. The P/F ratio tells you if theres a
good relationship between how much
oxygen the patient is breathing (FIO2)
and how much is moving through the
alveoli into the circulation (PaO2). If a
significant amount of atelectasis causes
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Lungs under pressure

The best indicator of alveolar overdistension (or too much pressure from
mechanically delivered breaths) is peak alveolar pressure, which can be
assessed by measuring the plateau pressure, or the pressure applied to small
airways and alveoli during inspiration.
Heres how to measure plateau pressure:
Following delivery of the tidal volume, youll see a number on the ventilator
called PIP, or the amount of pressure it takes to deliver that volume. As you
may know, this number doesnt mean a whole lot and shouldnt be used for
trending or evaluation. For example, a PIP of 45 cm H2O doesnt give you any
clinical information, because any change in airway resistance or compliance will
change the PIP.
If you set the ventilator to achieve a breath hold following delivery of the
tidal volume, then you should see the pressure drop from the peak to a holding
pressure. This holding pressure is the plateau pressure, and should be 30 cm
H2O or less. If the value is higher, overdistension is likely.
Every time you perform a patient and ventilator assessment (sometimes
called a ventilator check), assess the plateau pressure. If this value is trending
upward or exceeds 30 cm H2O, talk to the respiratory therapist about alternative,
lung-protective strategies, a relatively new but important part of mechanical ventilation. Alternative strategies may include permissive hypercapnia, airway pressure release ventilation, or changing the mode to pressure control ventilation.
If the patients PIP is increasing but the plateau stays the same, then the reason for the pressure increase is in the ventilator tubing or the patients tracheobronchial tree. Suppose the patients PIP is 35 cm H2O and the plateau pressure
is 25 cm H2O. An hour later, the peak pressure is 65 cm H2O, but the plateau
pressure is still 25 cm H2O. The patient isnt in danger of lung damage, because
the reason for the high PIP is an increase in airway resistance. The patient may
be biting on the endotracheal (ET) tube, or may need an inline bronchodilator
treatment or suctioning. This is why PIP doesnt mean much by itself, and
plateau pressure is the more important ventilator pressure to monitor.
Transairway pressure is the difference between the PIP and the plateau
pressure, and typically is less than 10 cm H2O. Investigate any pressure above
this level. For example, a sudden increase means an ET tube may be occluded;
a more gradual increase may mean that the patient is developing bronchoconstriction and may need an inline bronchodilator.

a low PaO2, your patient wont respond

as he should no matter how much oxygen you administer.
In a critically ill patient, the three
most common causes of refractory
hypoxemia are:
pneumothorax, characterized by a
rapid deterioration in the patients condition, absent breath sounds, and a
high-pressure alarm on the ventilator
atelectasis, which develops gradually
and usually is identified by chest X-ray

pulmonary edema, which may occur

in patients with a history of heart failure and decreasing SpO2 accompanied
by fine crackles auscultated in the lung
bases.
The healthcare provider will want
to rule out pneumothorax first,
because increasing ventilator volume
delivery will worsen the pneumothorax. If the problem is atelectasis or
pulmonary edema, the treatment is to
add PEEP.
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Lets look a little closer at PEEP.

After delivery of the tidal volume during inspiration, the mechanically ventilated patient is allowed to exhale to a
baseline pressure of zero cm H2O. Low
levels of PEEP (3 to 5 cm H2O) are
added to restore the normal volume
loss that occurs with intubation, and
these levels are well-tolerated by
almost all intubated patients. A PEEP
level over 5 cm H2O is considered therapeutic, and is used to treat refractory
hypoxemia: PEEP restores or maintains lung volume at end-expiration by
either recruiting collapsed alveoli or
preventing further loss of lung volume
and atelectasis. Remember that in
patients with refractory hypoxemia
caused by significant atelectasis, increasing the FIO2 wont raise the PaO2 appreciably. In these patients, PEEP is indicated to recruit collapsed alveoli and prevent further loss of lung volume.
Using PEEP also lets you use a
lower FIO2 to reach a target PaO2. For
example, if a patient requires 60%
oxygen (an FIO2 of 0.6) to maintain a
PaO2 of 90 mm Hg, adding 5 cm H2O
of PEEP will raise the PaO2 to 130 mm
Hg. Now the FIO2 can be decreased
to bring the PaO2 into the clinically
accepted range of 60 to 100 mm Hg,
as Ill describe shortly. Generally, to
reduce the risk of oxygen toxicity, the
FIO2 should be below 0.5, provided
the PaO2 is acceptable and the patients
SpO2 is 92% or higher.
Step 3: Determining the solution
Lets go back to our patient now and
see what we can do to fine-tune his
oxygenation status.
Mr. White is on 5 cm H2O of PEEP,
which is being used to prevent volume
loss due to intubation. Our approach
now is to wean the FIO2 out of the
toxic range and keep the PaO2 between
60 and 100 mm Hg. If youre monitor26

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June

Assist/control mode can be

used for any patient needing
mechanical ventilation, except
for a patient with COPD.
ing SpO2 values, youll want to keep
the value above 92%remember that
pulse oximeters generally have a 2percentage-point margin of error if
the SaO2 is 90% or above, so aiming for
92% ensures that his actual SpO2 stays
above 90%, the lowest clinically
accepted level. Pulse oximetry values
are best used for trending, rather than
spot-checking your patients oxygenation (remember that a patient in acute
respiratory acidosis can have an SpO2
above 90%.)
Instead of guessing how much to
decrease the FIO2, well use the P/F ratio
to set up a prediction formula to make
sure we dont wean too slowly or overdo it. Follow your facilitys protocol or
work with the respiratory therapist to
make the actual ventilator changes.
The formula is a proportion problem:
PaO2/FIO2 = desired PaO2/new FIO2. For
Mr. White, these numbers are: 225/1.0
= 100/X, where X represents the new
FIO2 value. Solving for X, you get a new
FIO2 value of 0.44.
Mr. Whites current FIO2 is 1.0, so
your initial goal is to reduce the level
to 0.5. Decrease the oxygen percentage
by 10 points every 5 to 10 minutes
(from 100% to 90%, then to 80% and
so on) while observing the patients
oxygen saturation via pulse oximeter.
Because our target PaO2 is 100 mm Hg,
keep weaning the oxygen as long as
the SpO2 is 95% or greater.
Mr. Whites P/F ratio was 225. If this
value were less than 200, youd follow
your facilitys protocol for adjusting the

ventilator settingsthis is where PEEP

levels over 5 cm H2O come into play.
The techniques to find the best or optimal PEEP and to provide significant
lung recruitment are beyond the scope
of this article.
Staying a la mode
Now lets look at ventilator modes,
which determine the respiratory rate
during mechanical ventilation.
Terminology varies depending on the
ventilator manufacturer, but in general,
mode of ventilation is selected based
on the patients condition.
If the patient is apneic on a ventilator, it doesnt really matter what mode
of ventilation is selected as long as it
can deliver a tidal volume at a set time
interval. The mode will determine how
the ventilator responds when the
patient makes an inspiratory effort.
In assist/control mode, the machine
delivers a tidal volume in response to
every patient effort. This mode also
may be called continuous mandatory
ventilation. Assist/control can be used
for any patient needing mechanical
ventilation, except for patients with
COPD. Because patients with COPD
cant fully exhale each mechanical
breath, this mode raises the risk of
hyperinflation. This mode also doesnt
let the patient breathe spontaneously,
raising the risk of air-trapping.
In SIMV mode, the machine responds
to patient effort by delivering a tidal
volume only at a set time interval; in
between these breaths, the ventilator
will let the patient take spontaneous
breaths. This mode is suitable for all
patients, including those with COPD.
In continuous positive airway pressure
(CPAP) mode, the machine doesnt
respond to patient effort for volume
delivery, and lets spontaneous breathing occur. As you know, CPAP is used
for patients with obstructive sleep
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apnea, but in critically ill patients, its

used for ventilatory weaning.
A mechanically ventilated patient
who has a positive-pressure baseline
has PEEP. But a positive-pressure baseline during spontaneous breathing only is
CPAP. For example, Mr. White is on
SIMV mode at 10 breaths/minute and a
PEEP of 5 cm H2O. Changing the rate
to 6 breaths/minute and keeping the
PEEP at 5 cm H2O means that Mr.
White is still on PEEP. But changing
the rate to zero breaths per minute and
keeping the PEEP at 5 cm H2O, means
the patient is now on CPAP. So CPAP
basically is PEEP with a rate of zero
breaths per minute. Most ventilators
wont let healthcare providers set a rate
of zero breaths per minute; instead, the
mode must be changed to CPAP, which
means no mechanical breaths.
When its time to wean Mr. White
from the ventilator, the ventilator rate
will be changed from 10 breaths/minute
to 8, and so on, depending on patient
tolerance, until the rate is zero and Mr.
White is on CPAP.
For a patient on assist/control mode,
CPAP is used during a spontaneous
breathing trial before extubation. If the
patients vital signs, hemodynamics,
and ABGs are stable, he can be placed
on CPAP for 5 minutes while his respiratory rate and pattern, SpO2, and vital
signs are assessed. If hes stable after
5 minutes, the trial can continue for up
to 2 hours and he may be extubated.
Ventilator strategies
Now lets look at ventilator strategies,
which determine how tidal volume is
delivered:
Volume control ventilation sets the
tidal volume so that the patient
receives the same tidal volume with
each mechanical breath. This strategy
also is called volume target, volume
cycled, and volume limited ventilation.
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Mr. Whites status

Summarize Mr. Whites status with the values from the ventilator and his ABGs:
Mode: volume control SIMV (VC-SIMV) pH: 7.38
VT: 700 mL
PaCO2: 42 mm Hg
Ventilation rate: 10 breaths/minute
PaO2: 225 mm Hg
FIO2: 1.0
HCO3-: 24 mEq/L
PEEP: 5 cm H2O
P/F: 225
Spontaneous VT: 250 mL
Spontaneous respiratory rate:
8 breaths/minute

Total VE: 9 L (this value includes

Mr. Whites spontaneous breathing
in SIMV mode)

PIP: 32 cm H2O
Plateau pressure: 24 cm H2O

Breath sounds: bibasilar fine,

late-inspiratory crackles

SpO2, 100%

If the patients lung compliance or airway resistance changes, the pressure will
change to maintain a constant tidal volume. The patients ABG values remain
relatively consistent with this strategy.
Pressure control ventilation sets
the peak inspiratory pressure (PIP)
for each mandatory breath. If the
patients lung compliance or airway
resistance changes, the tidal volume
will change. If this strategy is used,
monitor the patient closely because
of the increased risk for hyperventilation or hypoventilation.
Pressure support ventilation (PSV) is
an add-on strategy on many ventilators. This strategy is used if a patient
has a low spontaneous tidal volume
and is in mild respiratory distressthe
respiratory therapist will titrate pressure support to increase the spontaneous tidal volume. Instead of the
patient performing all the work to
breathe during inspiration, the ventilator adds a pressure boost to help
with inspiration. This added pressure
increases the spontaneous tidal volume
in the same way that you increase volume when you use bag-valve-mask
ventilation. You could start at a pressure of 10 cm H2O and gradually

increase it in increments of 2 (no hard

and fast rule here) until you reach the
minimum spontaneous tidal volume
(5 mL/kg of IBW). Youll know when
you reach the appropriate level because
the patients work of breathing should
decrease. The PSV strategy works only
during a spontaneous breathing mode,
so it cant be used if the patient is in
assist/control mode.
The second use of PSV is to decrease
the work of breathing caused by the
endotracheal tube. Add low levels of
pressure support (5 to 15 cm H2O);
the typical starting point is to set the
PSV at the transairway pressure. Most
ventilators now have a feature called
automatic tube compensation, which
automatically adjusts the amount
of pressure support on a breath-bybreath basis. If your ventilator has
this option, you wont have to readjust
pressure support for changes in transairway pressure.
Summarizing the information
Now you can create a bullet box containing all of the data about Mr. Whites
mechanical ventilation and his clinical
status before any interventions. (See
Mr. Whites status.) Heres what the
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information tells you: Mr. White is in

SIMV mode with volume control strategy, so a set tidal volume is delivered at
a rate of 10 breaths/minute, and spontaneous breathing is allowed between
the mechanical breaths. His acid-base
balance, PaCO2, and HCO3- are normal,
but his high FIO2 puts him at risk for
oxygen toxicity. As discussed earlier,
youll reduce the FIO2. Mr. Whites P/F
ratio indicates some acute lung injury,
possibly developing atelectasis.
Mr. Whites spontaneous tidal volume is too low-it should be at least
5 mL/kg of IBW (350 mL in his case).
Is he groggy? Is he having distress
during spontaneous breathing, as
indicated by accessory muscles of
respiration use and an increase in
spontaneous respiratory rate? If so,

add pressure support as described

above. Mr. Whites transairway pressure is 8 cm H2O (PIP of 32 cm
H2O minus plateau pressure of
24 cm H2O). If the transairway
pressure is above 10 cm H2O, your
patient has a significant amount
of airway resistance and may need
inline bronchodilator therapy or
suctioning. Mr. Whites plateau
pressure is below the maximum
recommended level of 30 cm H2O.
His total minute ventilation of 9 liters
also is fine. (Values greater than 10 liters
are considered high.) Auscultation indicates possible atelectasis, which may be
why the P/F ratio is low, so in addition
to decreasing the FIO2, more PEEP may
be added. Follow your facilitys protocol
for handling this.

By understanding the basics of

mechanical ventilation and how to summarize your patients information, youll
be able to care for him appropriately.

RESOURCES
Jubran A. Pulse oximetry. Crit Care. 1999;3:
R11-R17.
Malley WJ. Clinical Blood Gases. 2nd ed.
W.B. Saunders Co.; 2005.
Oakes D, Shortall S. Ventilator Management: A
Bedside Reference Guide. 2nd ed. Orono, ME:
Respiratory Books; 2005.
Pilbeam S, Cairo JM. Mechanical Ventilation. 4th
ed. Mosby, Inc.; 2006.
Wilkins RL, Stoller JK, Kacmarek RM. Egans
Fundamentals of Respiratory Care. 9th ed.
Mosby, Inc.; 2009.
Chris Kallus is a professor and program coordinator
of the respiratory care program at Victoria College in
Victoria, Tex.
The author has disclosed that he has no financial
relationships related to this article.

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