Critical Care Nursing Theory

Mechanical ventilation

Mechanical Ventilation
Mechanical Ventilation is ventilation of the lungs by artificial means usually by a ventilator. Once a patients PaO2 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: Mechanical ventilation is instituted to: 1- Maintain or improve ventilation, i.e. for adequate tissue oxygenation. 2- Decrease the work of breathing and improve patients comfort. Indications: Acute respiratory failure due to: Mechanical failure, includes neuromuscular diseases as Myasthenia Gravis, Guillain-Barr 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. Sahar Hossni El-Shenawi-

Assistant Professor Of Critical Care Nursing

Critical Care Nursing Theory

Mechanical ventilation

**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 HO2) Arterial blood Gases PH Pa2 (mmHg) PaCO2 (mmHg) > 35 <5 < 15 <-20 10-20 5-7 65-75 75-100 Ventilation indicated Normal range

< 7.25 < 60 > 50

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:
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Negative-pressure ventilators Positive-pressure ventilators.

Dr. Sahar Hossni El-Shenawi-

Assistant Professor Of Critical Care Nursing

Critical Care Nursing Theory

Mechanical ventilation

Negative-Pressure Ventilators - Early negative-pressure ventilators were known as iron lungs. The patients 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 (Duchennes 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. - 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.

Dr. Sahar Hossni El-Shenawi-

Assistant Professor Of Critical Care Nursing

Critical Care Nursing Theory

Mechanical ventilation

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 :- Patients lung compliance - Patientventilator resistance factors. - Therefore, PIP must be monitored in volume modes because it varies from breath to breath. - 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 patients 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.

Dr. Sahar Hossni El-Shenawi-

Assistant Professor Of Critical Care Nursing

Critical Care Nursing Theory

Mechanical ventilation

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 - 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.

Dr. Sahar Hossni El-Shenawi-

Assistant Professor Of Critical Care Nursing

Critical Care Nursing Theory

Mechanical ventilation

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 (VT), 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. 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.

Dr. Sahar Hossni El-Shenawi-

Assistant Professor Of Critical Care Nursing

Critical Care Nursing Theory

Mechanical ventilation

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 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
Dr. Sahar Hossni El-ShenawiAssistant Professor Of Critical Care Nursing

Critical Care Nursing Theory

Mechanical ventilation

- 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. 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 fio2. 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 patients 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.
Dr. Sahar Hossni El-ShenawiAssistant Professor Of Critical Care Nursing

Critical Care Nursing Theory

Mechanical ventilation

- 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: Patientventilator asynchrony possible B- Pressure Modes - Pressure modes include :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 patients 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

Dr. Sahar Hossni El-Shenawi-

Assistant Professor Of Critical Care Nursing

Critical Care Nursing Theory

Mechanical ventilation

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 FIO2 and high levels of PEEP.
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- The inspiratory pressure level, respiratory rate, and inspiratoryexpiratory (I:E) ratio must be selected. - Tidal volume varies with compliance and airway resistance and must be closely monitored. - Sedation and the use of neuromuscular blocking agents are frequently indicated, because any patientventilator asynchrony usually results in profound drops in the SaO2. - 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 patients hemodynamic status must be monitored closely.
Dr. Sahar Hossni El-ShenawiAssistant Professor Of Critical Care Nursing

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Critical Care Nursing Theory

Mechanical ventilation

- Used to limit plateau pressures that can cause barotrauma Severe ARDS Disadvantages: Patientventilator asynchrony possible, necessitating sedation/paralysis Monitor abcTidal volume at least hourly. Barotraumas Hemodynamic instability

Inverse ratio ventilation (IRV) Usually used in conjunction with PCV Increases ratio I:E to aAllow for recruitment of alveoli bImprove oxygenation Disadvantages: - Almost always requires paralysis Monitor for abcAuto-PEEP, Barotrauma, 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 patients 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
Dr. Sahar Hossni El-ShenawiAssistant Professor Of Critical Care Nursing

11

Critical Care Nursing Theory

Mechanical ventilation

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 patients 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 - 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

Dr. Sahar Hossni El-ShenawiAssistant Professor Of Critical Care Nursing

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Critical Care Nursing Theory

Mechanical ventilation

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 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:

Dr. Sahar Hossni El-Shenawi-

Assistant Professor Of Critical Care Nursing

13

Critical Care Nursing Theory

Mechanical ventilation

- 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 :Patients with chronic respiratory insufficiency to manage acute or chronic respiratory failure without intubations and conventional mechanical ventilation. bUsed as a bridge to weaning patients from mechanical ventilation, cAs an alternative to conventional mechanical ventilation in patients who are ventilated in their homes.
a-

- The system allows the clinician to select two levels of positive-pressure support:
ab-

An inspiratory pressure support level (referred to as IPAP) 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;

Dr. Sahar Hossni El-Shenawi-

Assistant Professor Of Critical Care Nursing

14

Critical Care Nursing Theory

Mechanical ventilation

- Thick or copious secretions and poor cough may be relative contraindications to BiPAP.

Advantages: abDecreased cost when patients can be cared for at home; No need for artificial airway

Disadvantages: - Patient discomfort or claustrophobia - The patient should be monitored for :ab-

Gastric distension, Air leaks from mouth

Dr. Sahar Hossni El-Shenawi-

Assistant Professor Of Critical Care Nursing

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