Nurses’ experiences of caring
for critically ill, non-sedated,
mechanically ventilated
patients in the Intensive Care
Unit: A qualitative study

Mechanical Ventilation
‫الطالب‬ ‫أعداد‬
‫حسين‬ ‫علي‬ ‫حيدر‬
‫الدكتورة‬ ‫أشراف‬
‫باقر‬ ‫هدى‬

Introduction About Mechanical
Ventilation
Mechanical ventilation is typically used after an
invasive intubation, a procedure wherein an
endotracheal or tracheostomy tube is inserted into
the airway. It is used in acute settings such as in
the ICU for a short period of time during a serious
illness. It may be used at home or in a nursing or
rehabilitation institution if patients have chronic
illnesses that require long-term ventilation
assistance.

DEFINITION
Mechanical ventilation is a positive or negative pressure
artificial breathing device that can maintain ventilation
and oxygen delivery for prolonged periods. (It is
indicated when the patient is unable to maintain safe
levels of oxygen or CO2 by spontaneous breathing even
with the assistance of other oxygen delivery devices

Indications
Lung or airway disorders or trauma e.g.
Pneumonia, ARDS, rib fractures, asthma,
pulmonary edema, pneumothorax.
Circulatory disorders e.g. MI, cardiogenic shock,
heart failure,
Acute exacerbation of COPD
Neuromuscular disorders and trauma e.g. GBS,
Myasthenia gravis, head injury.
Airway obstruction e.g. facial trauma, aspiration,
head / neck / chest burns, oral cavity burns.

Indications
Intra-operatively & Post-operativel
Respiratory acidosis / Respiratory rate > 30- 40 /
minute
Poor oxygenation
Poisoning / certain drugs
Unconsciousness

Types or Forms Of Mechanical
Ventilation
The two major types of Mechanical Ventilation are
Negative pressure and positive Pressure
ventilation
The main form of mechanical ventilation is
positive pressure ventilation, which works by
increasing the pressure in the patient's airway
and thus forcing air into the lungs. Less common
today are negative pressure ventilators (for
example, the "iron lung") that create a negative
pressure environment around the patient's
chest, thus sucking air into the lungs.

Types or Forms Of Mechanical Ventilation
Negative Pressure
Ventilator
Positive Pressure
Ventilator

Settings of Mechanical
Ventilation
• Mechanical Ventilator Settings
regulates the rate, depth and
other characteristics of ventilation.
Settings are based on the
patient’s status (ABGs, Body
weight, level of consciousness
and muscle strength)

PARAMETERS OF MECHANICAL
VENTILATION ARE
Respiratory Rate (f) :-Normally 10-20b/m
Tidal Volume (VT) :-5-15ml/kg
Oxygen Concentration(FIO2):-b/w 21-90%
I:E Ratio:-1:2
Flow Rate:-40-100L/min
Sensitivity/Trigger:- 0.5-1.5 cm H2O
Pressure Limit:-10-25cm H2O
PEEP :- Usually, 5-10 cmH2O

Indications for Mechanical
Ventilation
Respiratory Failure – 2 Types
Hypoxemic Respiratory Failure
Hypercapnic Respiratory Failure

Hypoxemic Respiratory
Failure
PaO2 < 60 mmHg in an
otherwise healthy individual

Hypercapnic Respiratory
Failure
PaCO2 > 50 mmHg in an otherwise
healthy individual
•AKA “Ventilatory Failure”
•Caused, ↓ventilatory
drive, or muscle fatigue

Miller vs. MacIntosh Blades

Connection to Ventilators
• Face Mask
• Airway
• Laryngeal Mask
• Tracheal Intubation
• Tracheostomy

Intubation Procedure
Check and Assemble Equipment:
Oxygen flowmeter and O2 tubing
Suction apparatus and tubing
Suction catheter or yankauer
Ambu bag and mask
Laryngoscope with assorted blades
3 sizes of ET tubes
Stylet
Stethoscope
Tape
Syringe
Magill forceps
Towels for positioning

Intubation Procedure
Position your patient into the sniffing
position

Intubation Procedure
Preoxygenate with 100% oxygen to
provide apneic or distressed patient
with reserve while attempting to
intubate.
Do not allow more than 30 seconds to
any intubation attempt.
If intubation is unsuccessful, ventilate
with 100% oxygen for 3-5 minutes
before a reattempt.

Intubation Procedure
Insert Laryngoscope

Intubation Procedure

Intubation Procedure
After displacing the epiglottis
insert the ETT.
The depth of the tube for a male
patient on average is 21-23 cm at teeth
The depth of the tube on average for a
female patient is 19-21 at teeth.

Intubation Procedure
Confirm tube position:
By auscultation of the chest
Bilateral chest rise
Tube location at teeth
CO2 detector – (esophageal
detection device)

Intubation Procedure
Stabilize the ETT

Complication
• Hypotension
• Pneumothorax
• Decreased Cardiac Output
• Nosocomial Pneumonia
• Increased Intracranial Pressure (ICP)
• Alarms turned off or nonfunctional
• Sinusitis and nasal injury
• Mucosal lesions
• Aspiration, GI bleeding, Inappropriate ventilation (respiratory
acidosis or alkalosis, Thick secretions, Patient discomfort due to
pulling or jarring of ETT or tracheostomy, High PaO2, Low
PaO2, Anxiety and fear, Dysrhythmias or vagal reactions during
or after suctioning, Incorrect PEEP setting, Inability to tolerate
ventilator mode.

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
– 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

Mechanical Ventilators

Mechanical Ventilators

Mechanical Ventilators

Mechanical Ventilators

High Frequency Mechanical
Ventilator

Ventilator Settings
Terminology
•A/C: Assist-Control
•IMV: Intermittent Mandatory Ventilation
•SIMV: Synchronized Intermittent
Mandatory Ventilation
•Bi-level/Biphasic: Non-inversed
Pressure Ventilation with Pressure
Support (consists of 2 levels of pressure)

Ventilator Settings
Terminology (con’t)
•PRVC: Pressure Regulated Volume
Control
•PEEP: Positive End Expiratory Pressure
•CPAP: Continuous Positive Airway
Pressure
•PSV: Pressure Support Ventilation
•NIPPV: Non-Invasive Positive Pressure
Ventilation

VOLUME vs. PRESSURE
VENTILATION
Volume ventilation: Volume is
constant and pressure will vary with
patient’s lung compliance.
Pressure ventilation: Pressure is
constant and volume will vary with
patient’s lung compliance.

POSITIVE END
EXPIRATORY PRESSURE
(PEEP):
• This is NOT a specific mode, but is rather an
adjunct to any of the vent modes.
• PEEP is the amount of pressure remaining in
the lung at the END of the expiratory phase.
• Utilized to keep otherwise collapsing lung
units open while hopefully also improving
oxygenation.

Continuous Positive Airway
Pressure (CPAP):
• This is a mode and simply means that a pre-
set pressure is present in the circuit and
lungs throughout both the inspiratory and
expiratory phases of the breath.
• CPAP serves to keep alveoli from collapsing,
resulting in better oxygenation and .
• The CPAP mode is very commonly used as a
mode to evaluate the patients readiness for
extubation.

Nursing Management
How to keep the Ventilator ready to receive the
case ?
Check the Air and oxygen
connections
Connect the Ventilator
tubes to ventilator

How to keep the Ventilator ready to
receive the case ?
• Connect the chest lung to
the ventilator tubing's
Make sure that you correctly
connected the tubing's and check
for any looseness

How to keep the Ventilator
ready to receive the case ?
Connect the servo guard
(From the patient)
Connect the filter
(To the Patient)

How to keep the Ventilator
ready to receive the case ?
• Check the tubing’s for any
leakage
» Change the Bacteria filter

Nursing Interventions
• Observe for tube misplacement-
• Observe for tube obstruction; suction;
ensure adequate humidification.
• Explain purpose/mode/and all treatments;
encourage patient to relax and breath with
the ventilator; teach importance of deep
breathing; provide alternate method of
communication.

Nursing Interventions
• Observe for tube misplacement-
• Observe for tube obstruction; suction;
ensure adequate humidification.
• Explain purpose/mode/and all treatments;
encourage patient to relax and breath with
the ventilator; teach importance of deep
breathing; provide alternate method of
communication.

Nursing Interventions
• Assess for GI problems. Preventative
measures include relieving anxiety,
antacids. therapy.
• Maintain muscle strength.
• Provide nutrition as ordered.

Nursing Diagnosis
1. Ineffective airway related to presence of artificial
airway, accumulation of secretions and immobility.
- change patient’s position 2 hourly.
- Asses for pain
- Monitor chest x-rays
- Maintain ventilator settings as ordered
- Maintain ventilator settings as ordered.
- Observe for tube obstruction; suction; ensure
adequate humidification.

Nursing Diagnosis
2. Impaired gas exchange related to insufficient oxygen
levels.
- Monitor ABG’s.
- Assess LOC,and irritability.
- Observe skin colour .
- Administer oxygen as ordered
- Observe for tube obstruction; suction ; ensure
adequate humidification.

Nursing Diagnosis
• 3. Decreased cardiac output related to impeded
venous return by PPV as manifested by decreased
BP, decreased urine output, increased heart rate
- monitor vital signs and level of consciousness
- observe and monitor for clinical manifestations of
decreased cardiac output
- monitor hemodynamic.

Nursing Diagnosis
4. Imbalanced nutrition less than body requirement
related to NPO status
- Provide nutrition as ordered,
- Observe for muscle wasting
- Observe for nausea, vomiting, abdominal
distension, and stool characteristics
- Insert nasogastric tubes if needed

Nursing Diagnosis
5.Impaired verbal communication related to intubation
and artificial airway
- evaluate patient’s ability to communicate by other
means
- ensure that call bell is placed within easy reach of
patient at all times
- make eye contact with patient at all times

Nursing Diagnosis
7. Risk for infection related to intubation.
- evaluate risk factors that causes patient to infection
- provide oral hygiene.
- monitor sputum for changes in characteristics,
- monitor tracheostomy site for infection
- maintain good hand washing technique.
- maintain sterile techniques for all dressing changes
and suctioning
-Administer antibiotics as ordered

Nursing Diagnosis
8. Risk for injury .
- obtain ABG values
- monitor patient for signs and symptoms for
decreased cardiac output such as hypotension,
tachycardia, arrhythmia
- drain fluid from the ventilator tubing
- maintain sterile technique, good oral care, and
careful positioning and observe for signs and
symptoms for pulmonary infections

Nursing Interventions
1-Maintain airway patency & oxygenation
2- Promote comfort
3- Maintain fluid & electrolytes balance
4- Maintain nutritional state
5- Maintain urinary & bowel elimination
6- Maintain eye , mouth and cleanliness
and integrity:-
7- Maintain mobility/ musculoskeletal
function:-
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Nursing Interventions
8- Maintain safety:-
9- Provide psychological support
10- Facilitate communication
11- Provide psychological support &
information to family
12- Responding to ventilator alarms
/Troublshooting ventilator alarms
13- Prevent nosocomial infection
14- Documentation
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