MECHANICAL VENTILATION

INTUBATION
 Endotracheal Intubation:
 Placement of tube into trachea through
mouth or nose

 Indications:
 Upper airway obstruction
 Facilitate secretion removal

 For positive pressure ventilation

Endotracheal Tube
Endotracheal Tube Placement
 Complications of Endotracheal
Intubation
 Improper placement

 Esophageal intubation

 Right mainstream intubation

 Management: auscultate, CXR, bilateral

respiration, mark point at lips/nose
 Complications of Endotracheal
Intubation

 Cuff problems

 Ineffective seal leads to aspiration

 Too much pressure leads to tracheal

necrosis

 Use minimal occluding volume (keep

pressure <20 mm Hg)

 Suction throat before deflation

 Nursing Role: Intubation
 Maintain correct placement
 Maintain proper inflation
 Maintain/monitor ventilation and
oxygenation
 Maintain tube patency
 Mouth care; repositioning ET; promote
communication
 Complications of Extubation

 Laryngeal edema or spasm

 Respiratory failure
 Mechanical Ventilation
 Air/O2 moves in and out of lungs via machine

 Types Ventilators

 Negative Pressure
 Positive Pressure*

 Ventilator Settings

 Rate
 Tidal volume
 FIO2
 Pressure limit
 PEEP
 Alarms etc
 Mechanical Ventilation
 Three types Positive Pressure
Ventilators
 Volume-cycled: terminates breath
when preset volume delivered
 Time-cycled: terminates breath after
preset time elapsed
 Pressure-cycled: terminates when
present airway pressure achieved
 Volume-Cycled Ventilators:
Modes

 Controlled mechanical ventilation

 Preset volume

 Preset rate

 Unable to trigger (initiate a breath)

 Volume-Cycled Ventilators:
Modes
 Assist-Control ventilation
 Preset volume
 Present rate

 Can trigger and receive more

than preset rate
 Patient-triggered breaths are
delivered at preset volume
 Volume-Cycled Ventilators:
Modes
 Synchronized Intermittent Mandatory
ventilation (SIMV)

 Preset volume and rate

 Spontaneous breathing

 Spontaneous breaths not assisted

(patient’s own volume)

 Often used for weaning

 Other Ventilation
Maneuvers
 PEEP
 Positive end-expiratory pressure

 Application positive pressure during

ventilation

 Increases distension of alveoli

 Prevents alveolar collapse

 “Recruits” previously collapsed alveoli

Other Ventilation Maneuvers
 PEEP

 Increases surface area available for gas

exchange

 Allows delivery lower FIO2: reducing risk O2

toxicity

 Complications
 Reduced CO
 Barotrauma
Other Ventilation Maneuvers
 CPAP

 Continuous positive airway pressure

 Continuous (i.e., inspiration and

expiration) positive pressure applied
to airway

 For spontaneously breathing patients

Other Ventilation Maneuvers
 Pressure Support Ventilation
(PSV)
 Positive pressure applied only on
inspiration
 Applied to spontaneous breaths only

 Supports inspiratory effort

 Patient determines inspiratory length

and rate
 Often used for weaning
 Mechanical Ventilation:
Complications
 CVS
 Increased intrathoracic pressure
 Reduced CO

 Pulmonary
 Barotrauma (trauma d/t pressure)
 Pneumothorax
 Pneumomediastinum
 Subcutaneous emphysema
 Mechanical Ventilation:
Complications

 Pulmonary
 Alveolar hypoventilation

 Cuff leak

 Ventilator settings

 Secretions
 Atelectasis
 Mechanical Ventilation:
Complications
 Pulmonary

 Alveolar hyperventilation
 Due to hypoxemia, fear, pain, anxiety → alkalosis
 RX: sedate, analgesia, communication, correct
hypoxemia

 Due to inappropriate ventilator settings

 high tidal volume
 High rate

 Pulmonary Infection
 Upper airway defenses bypassed
 Mechanical Ventilation:
Complications
 Neurological complications
 Positive pressure ventilation → increased
intrathoracic pressure

 interferes with venous drainage; increased ICP

 GI
 Stess ulcers and GI bleeds; Rx with H2 receptor
blockers

 MV → Gastric and bowel dilation

 Mechanical Ventilation:
Complications
 Musculoskeltal
 Muscle atrophy d/t immobilization
 Mobilize
 ROM

 Psychologic
 Stress
 Communication very important
 Sedate, explain, family visits, pain
management
 Facilitate expression of needs
 Weaning
 Criteria
 Effective cough
 Adequate respiratory muscle
strength
 Weaning
 Approaches to weaning
 T-piece (spontaneous breathing for
short periods of time)
 SIMV, PSV
 Weaning
 Monitor closely
 resp rate
 accessory muscle use
 shallow respirations
 paradoxical breathing
 ABGs
 rising PCO2 → acidosis
 falling PO2
 BP (↓ or ↑)
 LOC (restless, tiring, somnolence, anxiety)
 Pulse oximeter