Definition of Mechanical Ventilation
Mechanical ventilation or artificial ventilation is the technique through which gas is moved toward and from the lungs through an external device/machine to assist or replace spontaneous breathing.
The ventilator generates and moves a controlled flow of gas into a patient’s lungs through a tube connected to an endotracheal tube that is placed into the trachea to inflate and deflate the lungs.
Purpose for Mechanical Ventilation
- To achieve and maintain adequate pulmonary gas exchange.
- To minimize the risk of lung injury.
- To reduce patient’s work of breathing.
- To optimize patient comfort.
Indications for Mechanical Ventilation
| Cardiopulmonary disease | Central nervous system disease | Neuromuscular disease |
| Cardiogenic shock | Cerebral trauma | Guillain-Barre syndrome |
| Acute respiratory failure | Cerebrovascular accident | Multiple sclerosis |
| Exacerbation of chronic pulmonary disease | Spinal cord injury | Poliomyelitis |
Modes of Mechanical ventilation
Different modes of Mechanical ventilation are available and are based on various permutations which will deliver the different range of rates, volumes, and pressures.
Control-Based Modes
- Volume Control (VC): Delivers a preset tidal volume, ensuring stable gas exchange.
- Pressure Control (PC): Maintains a set pressure, adjusting volume based on lung compliance.
Volume/ Pressure modes
- Controlled mandatory ventilation (CMV).
- Assist/control ventilation.
- Intermittent mandatory ventilation (IMV).
- Volume Controlled Ventilation (VCV)
- Synchronized intermittent mandatory ventilation (SIMV- VC)
- Pressure control ventilation (PCV).
- Pressure support ventilation (PSV).
- Pressure control inverse ration ventilation (PC-IRV).
- Synchronized intermittent mandatory ventilation (SIMV- PC)
Other Ventilator Measures
- Continuous positive airway pressure (CPAP).
- Bi-level positive airway pressure (Bi PAP).
- High frequency ventilation.
Initial ventilator setting
- Type of ventilator has to be chosen.
- Set the machine to deliver the tidal volume, rate setting and FiO₂ required.
- Adjust the machine to deliver the lowest concentration of oxygen to maintain normal PaO2.
- Record peak inspiratory pressure.
- Set mode based on patient requirement.
- Record minute volume and obtain arterial blood gas (ABG) analysis.
- Adjust setting according to ABG.
- Set for the alarm.
Basic ventilator parameters
| Parameters | Values |
| Respiratory rate (f) | 10-20 beats/minute |
| Tidal volume (VT) | 5-15 mL/kg |
| Oxygen concentration (FIO₂) | 21-90% |
| I:E ratio | 1:2 |
| Flow rate | 40-100 L/min |
| Pressure limit | 10-25 cm H₂O |
| Peak inspiratory pressure | 18-22 cm H₂O |
| Positive end-expiratory pressure | 5-10 cm H₂O |
Procedure for Mechanical Ventilation
| Nursing action | Rationale | |
| Daily assessment: Assess patient q4 hourly for the following: | ||
| 1. | Assess the patient’s response to mechanical ventilation. | It helps in adjustment of mode of ventilator and other ventilator settings. |
| 2. | Assess for the ventilator setting. | To ensure that patients receive the oxygenation based on requirement. |
| 3. | Assess for the vital signs. | To evaluate the patient progress. |
| 4. | Assess for oxygen saturation. | To evaluate the adequacy of ventilation. |
| 5. | Listen to breath sounds and note changes from previous findings. | It helps to identify complications if any. |
| 6. | Assess the patient’s pain and anxiety levels and need for sedation. | Pain and anxiety increases the oxygen demand. |
| 7. | Assess for the nutritional status. | Poor nutritional status contributes to impaired respiratory muscle function, ventilator response, and resistance to infection. |
| 8. | Assess for presence of signs which indicate infection such as fever, tachycardia, excessive and foul smelling secretions from endotracheal/tracheostomy tube. | It helps to initiate early intervention and avoid complications. |
| 9. | Assess for the early signs of development of pressure ulcers. | It helps to initiate early interventions. |
| Respiratory care: | ||
| 1. | Keep the head of the bed elevated 30-40″ at all times to prevent aspiration of oral secretions. | To prevent the infection of lungs (ventilator-associated pneumonia). |
| 2. | Perform endotracheal/ tracheostomy tube suctioning whenever required. | To maintain airway patency. |
| 3. | Suction only as needed not according to the schedule. | Prevents undue trauma to respiratory tract. |
| 4. | Pre-oxygenation with 100% oxygen should be initiated prior to suctioning. | To prevent hypoxia that is precipitated by suctioning. |
| 5. | Limit suctioning pressure to the lowest level needed to remove secretions. | Increased pressure may cause injury to the mucus membranes and can cause bleeding. |
| 6. | Suction for shortest duration possible. | Longer duration of suctioning may cause injury to mucus membrane, and it also may cause hypoxia and bradycardia. |
| 7. | Perform oral suctioning after endotracheal/ tracheostomy suctioning. | |
| 8. | If your patient has an endotracheal tube check for tube slippage into the mainstream bronchus. | To find the presence of proper placement of endotracheal tube. |
| 9. | If your patient has tracheotomy, perform routine tracheostomy dressing and change of ties if it is soiled according to facility policies and procedures. | To prevent infection. |
| 10. | Assess for complication related to tracheostomy tube such as dislodgement, bleeding and infection. | |
| 11. | Follow hospital policies to inflate the cuff and measure for proper inflation pressure using the minimal leak technique or minimal occlusive volume. | These techniques help to prevent tracheal irritation and drainage caused by high cuff pressure. |
| 12. | With assistance from an experienced colleague, change the tracheostomy tube ties and endotracheal tube securing devices if they become soiled or loose. | Incorrect technique could cause extubation. |
| 13. | Endotracheal tube can be kept in patient’s trachea for up to 2 weeks at the most, unless there are special and rare circumstances. | It helps to prevent subglottic stenosis. |
| 14. | The endotracheal tube and other lines should be safeguarded during turning the patient while giving care. | To avoid accidental extubation and tube displacement. |
| 15. | Disposable components such as catheters, ventilator tubing and fittings need to be changed as per hospital protocol. | To prevent infection. |
| Prevent hemodynamic instability: | ||
| 1. | Monitor the patient’s blood pressure q2-q4 hourly, especially after ventilator settings are changed or adjusted. | Mechanical ventilation causes thoracic cavity pressure to rise on inspiration which puts pressure on blood vessels and may reduce blood flow to heart. |
| 2. | Increase intravenous (IV) fluids or administer drugs such as dopamine or norepinephrine if prescribed. | To maintain hemodynamic stability. |
| 3. | Monitor hourly urine outputs and central venous pressures. | To assess fluid volume status of the patient. |
| 4. | Assess breath sounds and oxygenation status q₂ hourly. | High levels of inspiratory pressure with pressure support ventilation (PSV) and positive end expiratory pressure (PEEP) increase the risk of barotrauma and pneumothorax. |
| 5. | Use the lowest pressure level for ventilator delivered breaths and adjust the level as tolerated. | To prevent risk of barotrauma and pneumothorax. |
| 6. | Maintain blood glucose levels within normal limits. | Stress of mechanical ventilation may elevate blood glucose levels. |
| Prevention of infection: | ||
| 1. | Keep head of the bed elevated to 30-40° for all mechanically ventilated patients unless contraindicated. | Helps to prevent aspiration of oral secretions and development of ventilator associated pneumonia (VAP). |
| 2. | Follow strict hand washing before and after each procedure. | Prevents cross infection. |
| 3. | Follow aseptic techniques for performing endotracheal/ tracheostomy tube suctioning or use a closed suction system. | It prevents the risk of infection. |
| 4. | Perform oral suctioning using clean techniques. | |
| 5. | Assess for signs of infections such as excessive foul smelling, respiratory secretions, fever, tachycardia, low peripheral capillary oxygen saturation (SpO2) levels, etc. | It helps to initiate intervention and avoid complications. |
| 6. | Follow aseptic techniques while handling IV lines, central venous catheters, urinary catheters, performing wound dressing, surgical drains, etc. | To prevent the risk of infection. |
| Hygienic care: | ||
| 1. | Provide a daily sponge bath for bed-bound patients. | To maintain hygiene and promote comfort. |
| 2. | Provide meticulous oral hygiene for patients on endotracheal or tracheostomy tubes. | Helps to reduce bacteria in oral cavity which helps in maintaining hygiene also helps in prevention of VAP. |
| 3. | Moisturize the lips with water or with lip balm frequently. | To avoid dryness. |
| 4. | Perform eye care using saline soaked gauze for the ventilated patient q2 hourly. Artificial eye drops can also be used. | To prevent dry eyes and exposure keratopathy. |
| 5. | Bed pan and urinals (if patient is not on urinary catheter) should be offered frequently. | |
| Prevention of complication of bed rest: | ||
| 1. | To prevent pressure ulcers: | |
| Assess risk using Braden’s scale. | This tool helps nurses to assess a patient’s risk of developing pressure ulcer. | |
| Assess pressure points. | For early detection of development of ulcers. | |
| Change position q4 hourly. | Helps to offload pressure from pressure points. | |
| Keep pressure points clean and dry. | ||
| Maintain adequate nutrition. | ||
| Ensure that patient receives required macro and micronutrients. | Underweight and overweight patients have higher risk development of pressure ulcer. | |
| Provide air mattress. | ||
| Provide back massage every four hourly. | It improves blood circulation. | |
| 2. | To prevent thromboembolism: | |
| Encourage passive/active range of motion (ROM) exercises. | It improves venous return from lower extremities. | |
| Use of compression stockings/ bandages can be considered. | It promotes venous circulation. | |
| Administer prescribed dose of low molecular weight heparin. | To prevent thromboembolic complications. | |
| 3. | To prevent muscle wasting: | |
| Need to do regular active and passive exercise. | Passive mobilization exercises promote range of motion in the joints such as the ankles, knee, hips, elbows, and shoulders. | |
| Muscle strengthening exercise range of motion exercise can be done. | It prevents muscle atrophy. | |
| 4. | Make sure that patient is getting sufficient fluid intake and fiber content with dietary intake. | To prevent constipation. |
| 5. | Administer prescribed dosage of proton pump inhibitors (e.g. pantoprazole). | To prevent stress ulcers. |
| Pain and sedation: | ||
| 1. | Analgesics can be administered by parenteral routes in guidance with Critical-Care Pain Observation Tool (CCPOT). | It helps in reducing the pain and anxiety. |
| 2. | Sedative drugs should be administered as prescribed by physician (e.g. midazolam and fentanyl). | Pain increases oxygen demand. |
| Nutrition: | ||
| 1. | Nutritional needs should be reassessed frequently as clinical condition changes. | |
| 2. | If patient is on enteral feeding, routinely verify appropriate placement of feeding tube. | It reduces the risk of aspiration of gastric secretions. |
| 3. | Dietician’s suggestions can be considered to plan the diet plan. | Caloric requirements vary based on age, activity level, nutritional status, severity of illness, need for wound healing, and a variety of other factors. |
| 4. | Nutrition and dietary intake related problems need to be carefully addressed and corrected by providing nutrition either by enteral or parenteral route. | It provides energy, protein, and nutrients needed to fuel the immune system, promotes healing and prevents excess breakdown of lean body mass. |
| Early weaning from Mechanical ventilation: | ||
| 1. | Weaning from ventilator can be initiated only after the underlying disease process is resolved or patient condition is improved. | To avoid the risks associated with post-extubation distress and re-intubation. |
| 2. | Weaning parameters need to be considered such as tidal volume, respiratory rate, vital capacity, and minute volume ranges. | To avoid post-extubation distress. |
| 3. | If patient is on ventilator on SIMV mode before weaning off ask the patient take “breath trial” frequently. | Helps to improve the respiratory muscle strength. |
| 4. | Gradual reduction in respiratory rate when patient is on ventilation and spontaneous breathing through a T-piece can be initiated as a trial for weaning. | It helps to assess the patient’s ability to breathe while receiving minimal or no ventilator support. |
| Communication: | ||
| 1. | Orient patient to day, date, and time. | Helps patient to be aware of surroundings. |
| 2. | Teach the patient how to use the call light and keep it within easy reach at all times. | |
| 3. | Teach patient other ways to call for attention, such as tapping her table or side rails, or using a bell or clicking device. | Problems in communicating can increase patient anxiety, impairing both the effectiveness of treatment and ability to cope with stress. |
| 4. | Ask yes-or-no questions that can be answered by shaking his/her head or by blinking eyes. | |
| 5. | Note successful strategy and communicate same to other shift nurses so that they also can follow the same. | |
| Patient and family education: | ||
| 1. | Talk to the patient regarding life outside the hospital. | This may help to improve the patient’s condition psychologically. |
| 2. | Address the patient’s and relatives’ anxiety related to patient being in intensive care unit (ICU). | Patient and relatives may be anxious about hospitalization. |
| 3. | Progress of the patient should be informed to family on daily basis and whenever required. | Keeps family up updated on patient’s progress. |
| 4. | Encourage close relatives to visit and spend time with patient during visiting hours. | Research shows that frequent visit by close family helps to faster recovery of the patient. |
Special Consideration
Caring for a patient on mechanical ventilation requires close monitoring and adherence to best practices to prevent complications and ensure optimal outcomes. Here are some special considerations:
- Airway Management: Ensure the endotracheal (ET) tube or tracheostomy is secure and positioned correctly. Regularly assess for signs of airway trauma or obstruction.
- Ventilator Settings & Monitoring: Verify prescribed ventilator settings, including respiratory rate, tidal volume, and oxygen concentration. Monitor alarms and patient-ventilator synchrony.
- Preventing Ventilator-Associated Pneumonia (VAP): Implement strict hand hygiene, elevate the head of the bed 30-45 degrees, provide oral care with chlorhexidine, and follow aseptic suctioning techniques.
- Sedation & Pain Management: Assess the patient’s pain, anxiety, and sedation needs. Use evidence-based strategies to minimize delirium and promote early mobility.
- Hemodynamic Stability: Monitor blood pressure, oxygen saturation, and arterial blood gases (ABGs) to ensure adequate oxygenation and perfusion.
- Communication Support: Provide writing tools or communication boards for awake patients to express their needs.
- Weaning & Extubation: Collaborate with the healthcare team to assess readiness for ventilator weaning, ensuring a gradual transition to spontaneous breathing.
REFERENCES
- Annamma Jacob, Rekha, Jhadav Sonali Tarachand: Clinical Nursing Procedures: The Art of Nursing Practice, 5th Edition, March 2023, Jaypee Publishers, ISBN-13: 978-9356961845 ISBN-10: 9356961840
- Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
- Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwers, ISBN-13:978-9388313285
- Adrianne Dill Linton, Medical-Surgical Nursing, 8th Edition, 2023, Elsevier Publications, ISBN: 978-0323826716
- Donna Ignatavicius, Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care, 11th Edition ,2024, Elsevier Publications, ISBN: 978-0323878265
- Lewis’s Medical-Surgical Nursing, 12th Edition,2024, Elsevier Publications, ISBN: 978-0323789615
- AACN Essentials of Critical Care Nursing, 5th Ed. Sarah. Delgado, 2023, Published by American Association of Critical-Care Nurses ISBN: 978-1264269884
- Ernstmeyer K, Christman E, editors. Nursing Fundamentals [Internet]. 2nd edition. Eau Claire (WI): Chippewa Valley Technical College; 2024. PART IV, NURSING PROCESS. Available from: https://www.ncbi.nlm.nih.gov/books/NBK610818/
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