Mechanical Ventilation

• Tidal volume: the amount of air milliliters to be delivered with each breath describes which ventilator setting
• Nurse’s responsibility related to intubation: monitor the patient’s SaO2 and alert the team of any complications during intubation attempts
• Pressure modes deliver breaths with a set amount of pressure measured in cmH2O
• Interventions for the prevention of VAP:

  • Keep the patient’s HOB elevated 30-45 degrees
  • Provide scheduled daily oral care with chlorhexidine (0.12%) solution to decrease bacteria in secretions
  • Wash hands frequently before and after patient care to prevent spread of microbes
  • Give prescribed daily Lovenox injections to prevent DVTs
  • Administer daily Histamine 2 blockers to reduce acid reflux
  • Implement daily sedation vacations to assess extubation readiness
• FiO2 describes how much O2 is in the air delivered to the patient
• A patient has just been intubated emergently at the bedside. An appropriate way to confirm placement of the ET tube is a Chest x-ray.
• When placing the CO2 detector on the ET tube after placement, Yellow means that the tube was placed correctly.
• Some important considerations for the nurse once the ET tube has been inserted and placement confirmed are:

  • Document the depth of the tube
  • Ensure the tube is secured to the patients face
• PEEP is: the amount of pressure delivered at the end of exhalation aimed ay keeping the alveoli open.
• Indications for mechanical ventilation:

  • Support oxygen
  • CO2 clearance
  • Reduce WOB
• Nasal Cannula

  • Deliver between 24-44% or 0.24-0.44% FiO2 oxygen
  • Flow meter rate 1-6 L/min unless high flow
  • 1 L/min increases O2 by ~3-4%
  • High flow systems available (longer/non-compliant tubing)
• Simple Face Mask

  • Deliver between 30-60% O2 or 0.30-0.60 FiO2
  • Flow meter rate 5-12 L/min
• Nonrebreather

  • Meter flow rate 15 L/min
  • Delivers 60-80% or 0.60-0.80 FiO2
  • Reservoir bag allows

  ·       Inspiration O2 flows into mask and bag

  ·       One-way valves on expiration – ensuring highest O2 delivery
• Bag Valve Mask

  • AKA the “Ambu Bag” or “Bag Valve Mask”
  • 15 L/min = 100% O2 or 1.00 FiO2
• Common Causes of O2 failure with need for mechanical ventilation

  • Pulmonary edema
  • ARDS
  • Aspiration
  • Atelectasis
  • Pneumothorax
  • Pneumonia
  • Pulmonary embolism
  • Asthma/obstructive lung disease
• Nursing process for client intubation

  • Cardiac and pulmonary assessment
  • Settings and tube placement
  • Monitor ABGs, other labs, CXR
  • Sedation
  • Restraints not routinely used
  • Nutrition (Tube feeding and Low carbs)
  • Securing tube safely
  • Mouth care
  • Avoiding complications
  • Weaning
• High pressure alarms

  • Secretions, kinks, biting tubing
  • Worsening condition
  • Interventions:

  1. Assess pt, suction, instruction sedation, empty condensation
• Low pressure alarms

  • Tubing disconnected
  • Interventions:

  1. Listen for bilateral breath sounds, check connections & ETT placement
• V-AC-Assist Control Ventilation

  • Patients will receive a breath at a set rate, however, the breath can be triggered by the patient also
  • Preset tidal volume (Vt) or pressure

  1. Volume AC (V-A/C) or Pressure AC (P-A/C)
  2. Each set breath gets the minimum VT or pressure
  3. Each spontaneous breath ASLO gets the minimum VT or pressure

  • Highest level of support – ventilator performs most of the WOB
• SIMV

  • Patients will receive a breath at a set rate (usually lower), however, the breath can be triggered by the patient also
  • Preset tidal volume (Vt) or pressure

  1. Each set breath gets the minimum VT or pressure
  2. Each spontaneous breath is the client’s own VT

  • Variable support – ventilator performs some of the WOB, client does some of the WOB
• CPAP (On vent)

  • Patients will receive no set breaths. All breaths are triggered by the patient
  • No preset VT

  1. Each spontaneous breath is the client’s own VT
  2. Minimum support – ventilator performs very little of the WOB, client does all the WOB

  • Pressure support provided – overcome resistance of tubing
• Complications of mechanical ventilation:

  • VAP
  • Increased thoracic pressure
  • GI bleeding
  • Increased ICP
  • DVT/PE
  • Psychological stress
• Patients A and B are both on a mechanical ventilatory support. Patient A is receiving and FiO2 of 70% and patient B is receiving an FiO2 of 30%. Which statement about these patients is most accurate?

  • 70% of the air being delivered to patient B is NOT oxygen
  • In the AC mode, the patient receives a full tidal volume with ever triggered breath, so reducing the number of supported breaths could address respiratory alkalosis
• The patient is on a Pancuronium drip, a Fentanyl drip, and a Propofol drip. When assessing train of four, your patient has a 1 twitch response. The nursing action to take is:

  • Turn down the Pancuronium
• The patient is on a Pancuronium drip, a Fentanyl drip, and a Propofol drip. When assessing train of four, your patient has a 4 twitch response. The nursing action to take is:

  • Turn up the Pancuronium
• A patient with a

  • SIMV: RR: 7,      Vt: 400 mL,    FiO2: 40%,    PEEP: 7 cm H2O
  • ABG: pH: 7.19,    CO2: 59,        HCO3: 22,      PaO2: 70

  Nurse should turn up the respiratory rate setting
• A patient with the ventilator settings:

  • AC: RR 11,     Vt: 600 mL,     FiO2: 80%.     PEEP: 7 cm H2O
  • ABG: pH: 7.59,          CO2: 24,          HCO3: 22,        PaO2: 119
  • Pt’s RR is 20, O2sats are 100%, and appear somewhat anxious.

  The nurse should:  Change the mode to SIMV