6. Indications
Acute Respiratory Failure (ARF):
- Hypoxemic respiratory failure (oxygenation failure):
PaO2<60mmHg on FiO2>0.5 and SaO2<90%
- Hypercapnic respiratory failure (ventilation failure):
PaCO2>5OmmHg or acutely above normal baseline in
COPD with pH<7.30
7. Indications
cardiopulmonary arrest
During general anesthesia
Altered conscious level GCS<8, inability to
protect the airway
Airway protection following drug overdose
Control of intracranial pressure in head injury
Cardiovascular failure with hypotension
For recovery after prolonged major surgery or
trauma
8. Classifications of Ventilator
1. Volume Cycled: Inspiration ends when preset
tidal volume has been delivered
2. Pressure Cycled: Inspiration ends when preset
inspiratory pressure has been reached
9. Volume Cycle
Advantages
•Independent of Airway Resistance
• Independent of Lung Compliance
Disadvantages
• Limited Current Use
• Alveolar Stretch Injury
• High-Pressure Limit Alarm
10. PRESSURE Cycle
1. Constant Inspiratory Pressure
2. Tidal Volume Becomes Variable
3. Volume is determined by set inspiratory
pressure, respiratory rate and inspiratory time.
4. Volume is Affected by Airway Resistance,
Lung Compliance, Patient Effort
5. Common in pediatric population
6. Common in stiff lungs
12. Modes of ventilators
MODE FUNCTION Clinical use
Control mode
Ventilation (CMV)
Delivers preset volume or
pressure regardless of
patient’s own inspiratory
efforts
Usually used for
patients who are apneic
Assist-Control
Ventilation (A/C)
Delivers breath in response
to patient effort and if
patient fails to do so within
preset amount of time
used for spontaneously
breathing patients with
weakened respiratory
muscles
Synchronize
Intermittent Mandatory
Ventilation ( SIMV)
Ventilator breaths are
synchronized with patient’s
respiratory effort
Usually used to wean
patients from
mechanical ventilation
Pressure Support
Ventilation (PSV)
Preset pressure that
augments the patient’s
inspiratory effort and
decreases the work of
breathing
Often used with SIMV
during weaning
13. Modes of ventilators
MODE FUNCTION Clinical use
Constant Positive
Airway Pressure
(CPAP)
(Conti, flow ,no TV no
rate)
Similar to PEEP but
used only with
spontaneously
breathing patients
Maintains constant
positive pressure in
airways so resistance
is decreased
Inverse Ratio
Ventilation (IRV)
(I:E =2:1)
I:E ratio is reversed to
allow longer
inspiration; requires
sedation/ paralysis
Improves oxygenation
in patients who are
still hypoxic even with
PEEP; keeps alveoli
from collapsing
14. Setting of ventilators
Setting Function Parameters
Respiratory Rate (RR)
or frequency
No. of breaths
delivered by the
ventilator /min
12-20 breaths/min
Tidal Volume (VT) Volume of gas
delivered during each
ventilator breath
10-12 ml/kg
6-8 ml/kg in acute lung
injury
Fractional Inspired
Oxygen (FIO2)
Amount of oxygen
delivered by ventilator
to patient 21% to
100%
set to keep PaO2 > 60
mmHg or SaO2 > 90%
Inspiratory: Expiratory
(I:E) Ratio
Length of inspiration
compared to length of
expiration
1:2 or 1:1.5
unless inverse ratio
ventilation is required
15. Setting of ventilators
Setting Function Parameters
Pressure Limit 10-20 cm H2O above
peak inspiratory
pressure; maximum is
35 cm H2O
Pressure Limit
Maximum amount of
pressure the ventilator
can use to deliver
breath
Positive End
Expiratory Pressure
(PEEP)
Positive pressure
applied at the end of
expiration
Used with CV, A/C,
and SIMV to improve
oxygenation and lung
compliance by
opening collapsed
alveoli
16. Initial Settings
Pressure Limited
FiO2
Rate
I-time or I:E ratio
PEEP
PIP or PAP
Volume Limited
FiO2
Rate
I-time or I:E ratio
PEEP
Tidal Volume
17. Changing the Ventilation Settings
when you are changing the settings, you need to think
about what you are trying to achieve.
Change Oxygenation (PaO2)
- Alter the FiO2 (turn the knob!)
- Alter the PEEP
Change Ventilation (PaCO2)
- Change the tidal volume (OR changing the pressure
control)
- Change the frequency of breaths
18. Complications to Mechanical
Ventilation
Ventilator Induced Lung Injury (VILI)
Induced by excessive pressure (barotrauma)
Induced by excessive Volume (volutrauma
19. Complications to Mechanical
Ventilation
Nosocomial Infection:
Most infections of the
body will travel to the
lungs and result in a
pneumonia. These
are referred to as
Ventilator Associated
Pneumonia (VAP)
20. Complications to Mechanical
Ventilation
Decreased Cardiac
Output and Blood
Pressure
pressure in the
lungs= pressure
surrounding the heart
and major vessels
results in decreased
CO/BP
22. TROUBLESHOOTING
Is it working ?
Look at the patient !!
Listen to the patient !!
Pulse Ox, ABG, EtCO2
Chest X ray
Look at the vent (PIP; expired TV;
alarms
23. Hypoxia
Turn FiO2 to 100%
Take Patient OFF Ventilator
Bag the Patient on FiO2 100%
Rapid Assessment ABC
End tracheal Tube: Position, Patency
Auscultate: Rule Out Tension
Pneumothorax
Ventilator: Circuit, Functional State,
Oxygen
24. Hypoxia
Arterial Blood Gas
Portable CXR
With No Other Proximate Cause, Adjust
Ventilator Settings
Chemically paralyze patient
25. TROUBLESHOOTING
Anxious Patient
Can be due to a malfunction of
the ventilator
Patient may need to be
suctioned
Frequently the patient needs
medication for anxiety or
sedation to help them relax
Attempt to fix the problem
Call your RT
26. TROUBLESHOOTING
Low Pressure Alarm
Usually due to a leak in the circuit.
Attempt to quickly find the problem
Bag the patient and call your RT.
27. High Pressure Alarm
Usually caused by:
A blockage in the circuit (water condensation)
Patient biting his ETT
Mucus plug in the ETT
You can attempt to quickly fix the problem
Bag the patient and call for your RT.
28. Low Minute Volume Alarm
Usually caused by:
Apnea of your patient (CPAP)
Disconnection of the patient from the
ventilator
You can attempt to quickly fix the problem
Bag the patient and call for your RT.
29. Accidental Extubation
Role of the Nurse:
Ensure the Ambu bag is attached to the oxygen flow
meter and it is on!
Attach the face mask to the Ambu bag and after
ensuring a good seal on the patient’s face; supply the
patient with ventilation.
Bag the patient and call for your RT.
30. OTHER
Anytime you have concerns, alarms, ventilator
changes or any other problem with your
ventilated patient.
Call for your RT
NEVER hit the silence button!
31. Weaning
defined as the transition from ventilator support
to complete spontaneous breathing.
Weaning should start when:
1)the underlying disease process is improving;
2) gas exchange is adequate;
3)respiratory mechanics are improving;
4) no conditions exist that imposes an undue
burden on the respiratory muscles
5) the patient is capable of sustaining
spontaneous ventilation as ventilator support is
decreased.
32. Weaning from Ventilator Support
Weaning Methods
Rapid Weaning: Post Surgery
Routine Weaning: RSBI performed daily
Gradual Weaning: T-collar trials
Ventilator Dependent patients
33. Ventilator Discontinuance
Success in discontinuing ventilator support
is related to the patients conditions in four
main areas:
Ventilator workload
Oxygenation status
Cardiovascular function
Psychological factors
40. Indications of NIV
Decompensated COPD (Hypercapnic Respiratory
Failure)
Cardiogenic pulmonary edema
Hypoxic respiratory failure
Other possible indications
• Weaning (post-extubation)
• Obesity hypoventilation syndrome
• Patients deemed not to be intubated
• Post-surgery
• Asthma
41. Contraindication of NIV
Cardiac or respiratory arrest
Nonrespiratory organ failure
Severe encephalopathy (e.g., GCS < 10)
Severe upper gastrointestinal bleeding
Hemodynamic instability or unstable cardiac
arrhythmia
Facial surgery, trauma, or deformity
Upper airway obstruction
Inability to cooperate/protect the airway
Inability to clear respiratory secretions
High risk for aspiration
42. Advantages and Disadvantages of NIV
Advantages
Allows the patients to
maintins normal functions
• Speech
• Eating
Helps avoid the risks and
complications related to:
• Intubation
• Sedation
Less ventilator-
associated pneumonia
Disadvantages
Less airway pressure is
tolerated
Does not protect against
aspiration
No access to airway for
suctioning
43. Interface
Nasal masks
less dead space
less claustrophobia
allow for
expectoration
vomiting and oral
intake
vocalize
facial mask
dysphonic patients
are usually mouth
breathers
More dead space
44. Goals of NIV
Short Term
Relieve symptoms
Reduce work of
breathing
prove or stabilize gas
exchange
Optimize patient
comfort
Avoid intubation
Long Term
Improve sleep
duration and quality
Enhance functional
status
Prolong survival
Maximize quality of
life
45. Main setting
1. IPAP (Inspiratory positive airway pressure).
2. EPAP (Expiratory positive airway pressure).
3. PS (pressure support )= (IPAP – EPAP).
4. back up rate.
5. Fio2 (21% -100%).
6. Flow or inspiratory time.
7. Pattern of breathing or Rise time.
46. Initial settings
• Spontaneous trigger mode with backup rate
• Start with low pressures
- IPAP 8 - 12 cmH2O
- PEEP 3 - 5 cmH2O
• Adjust inspired O2 to keep O2 sat > 90%
• Increase IPAP gradually up to 20 cm H2O (as
tolerated) to:
- alleviate dyspnea
- decrease respiratory rate
- increase tidal volume
- establish patient-ventilator synchrony
47. Monitoring
Response
Physiological a) Continuous oximetry
b) Exhaled tidal volume
c) ABG should be obtained with 1 hour and, as
necessary, at 2 to 6 hour intervals.
Objective a) Respiratory rate
b) blood pressure
c) pulse rate
Subjective
a) dyspnea
b) comfort
c) mental alertness
49. Criteria to discontinue NIV
Inability to tolerate the mask because of
discomfort or pain
Inability to improve gas exchange or dyspnea
Need for endotracheal intubation to manage
secretions or protect airway
Hemodynamic instability
ECG – ischemia/arrhythmia
Failure to improve mental status in those with
CO2 narcosis.