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Definition;-
§ Mechanical Ventilator is a machine that generates a controlled flow of gas into a patient’s airways. Oxygen and air are received from cylinders or wall outlets, the gas is pressure reduced and blended according to the prescribed inspired oxygen tension (FiO2), accumulated in a receptacle within the machine, and delivered to the patient using one of many available modes of ventilations.
PURPOSE
§ To establish and maintain effective ventilation.
§ To prevent complications associated with artificial ventilation.
§ To ensure position and patency of endotracheal and tracheotomy tube.
§ To clear and remove secretions from airway.
§ Need for sedation/ neuromuscular blockage.
§ Need to decrease systemic or myocardial oxygen consumption.
§ Use of hyperventilation to reduce intracranial pressure.
EQUIPMENTS
ü Bed, locker with necessary articles, ventilator. Suction apparatus, continuous monitoring apparatus, resuscitation crash cart with defibrillator. Oxygen giving set and manual ventilation bag ( Ambu bag ).
GENERAL INSTRUCTIONS
§ Assigned nurse for patient on ventilator to have basic knowledge of pulmonary physiology, complete understanding of ventilator functions and awareness of anticipated complications and interventions to be taken in emergencies.
§ Patient on continuous mechanical ventilation to never be left unattached.
§ Vital signs to be checked and recorded every hour unless otherwise prescribed
§ Suctioning to be performed under aseptic technique.
§ Sterile catheter and gloves to be used for each time of suctioning.
§ Size of catheter to be less than half the diameter of endotracheal or tracheostomy tube
§ Suction tubing and catheter to be transparent so that nature of aspirate can be observed.
§ Ensure that vacuum pressure is not more than 120 mm Hg in children.
§ Endotracheal tube to be rotated daily, to prevent pressure ulcer on patient’s lip or tongue.
§ Inflation of endotracheal tube to be monitored regularly.
§ Positioning of endotracheal /tracheotomy tube to be monitored regularly.
§ Symptoms to be reported immediately.
§ Aseptic technique to be used when carrying out procedures involving tracheotomy or endotracheal tube.
§ Functioning of ventilator alarms to be checked at beginning of each shift.
§ Ventilator should be checked and every hour.
§ Tubings leading from ventilator to patient must be checked at least every hour and accumulated moisture to be removed.
§ Humidifier to be kept adequately filled with sterile distilled water.
§ Tuning and water in humidifier must be kept scrupulously clean, including connections and adapters, which are to be removed for sterilization every 24 hours.
§ If patient show signs of insufficient ventilation, nurse must start manual ventilation
§ Avoid positioning ventilation tubes above patient’s head to avoid water entering lungs.
§ Humidifier to be changed daily and sterile water to be used.
§ Weaning is usually commenced in day time rather than at night.
PROCEDURE
CARE OF ETT/ TRACHEOSTOMY
ü Secure positioning of ETT/ tracheotomy tube with tape or adhesive plaster.
ü Inflate cuff once correct positioning has been confirmed.
ü Cuff is inflated with air using a syringe until a hiss’’ is heard on auscultation.
MAINTAINING VENTILATION
ü Effects of ventilation are assessed by observing patient’s color, chest movement, blood pressure, pulse rate, and ventilatory measurement such as expired minute and tidal volume and air pressure and rate of ventilation.
ü Ventilators make characteristics sounds during inspiration and expiration which nurse must be capable of identifying.
ü Ensure patient has adequate fluid and calorie intake.
ü Administer sedation as prescribed to ensure adequate artificial ventilation and promotion of rest.
SIGNS OF ADEQUATE VENTILATION
ü Improvement in skin color and oxygen saturation more than 90%.
ü Normal pulse, change in pulse rate may indicate decreased cardiac output due to increased in intrathoracic pressure.
ü Steady blood pressure . a drop in blood pressure may reflect deceased cardiac output.
ü Audible respiratory rhythm
ü Absence of any abnormal neurological signs.
ü Absence of hyperventilation or hypoventilation.
SIGNS OF INADEQUATE VENTILATION
ü Breathing occurs out of sequence with ventilation and patient is restlessness, and cyanosed
ü Hypoxia , trachycardia and hypertension.
ü If incease in minute volume, check for leak in cuff seal, connections and tubings.
ü If decrease in airway pressure occur check leak in circuit.
ü If increase in peak airway pressure occur check for obstruction such as secretion, kinking , pooling of water, patient biting tube slipped into a main stem of bronchus, pneumothorax.
SUCTIONING
ü Explain procedure to the patient/ family
ü Frequency of suction to be carried out depending on patient’s pulmonary state.
ü Tracheal suction is an aseptic procedure. Sterile catheter and one sterile glove to be used for each suctioning episode/session.
ü Suction is applied while catheter is being withdrawn using intermittent technique, not more than 10 to 15 seconds.
ü When secretion are tenacious instill 1 to 3 sterile normal saline 0.9 percent into endotracheal tracheostomy tube to liqufy and make removal.
WEANING
ü Inform patient that this is a progressive step in treatment.
ü Repeatedly encourage and reassure patient to avoid fear or exhaustion.
ü Withhold sedation and muscle relaxant as ordered by doctor.
ü Watch for respiratory distress, hypoxia, tachycardia, tachypnea, cyanosis, hypotension and drop in oxygen saturation.
ROUTINE NURSING CARE
ü Give daily bed bath and change bed linen , if soiled.
ü Provide 2 hourly attention to pressure sites by turning and repositioning of patient.
ü 4 hourly oral hygiene and whenever needed.
ü 4 hourly eye care. Instill artificial tears and cover with jaconet gauze
ü Check and record vital signs every hour.
ü Measure blood, intravenous transfusion and fluid intake every hour.
ü Change drainage bag, chest drainage bottles and tubings as required.
ü Maintain intake out put chart in every shift.
ü 8 hourly aseptic urinary catheter toilet
ü 8 hourly wound dressings
ü Change the tape anchoring ETT and Ryles tube.
ü Change intravenous administration sets and dressing puncture sites every day.
ü Change suction bottle and connecting tubing everyday.
ü Change ventilator circuit tubing, connections and adapters everyday.
ü Record patient’s condition and events that have occurred during each shift in nurse‘s progress sheet.
ü Give detailed hand over to nurse.
PSYCHOLOGICAL ASPECTS OF PATIENT’S CARE
ü Motivate patient and relatives to participate in daily care activities.
ü Promote good relationship with patient and family and encourage them to express fears, stress factors/ feelings.
ENDOTRACHEAL TUBE: NURSING CARE
1. Check placement by:
§ Auscultate for bilateral breath sounds and observe for symmetrical chest expansion. Tube may be incorrectly positioned in R main stem bronchus or esophagus. Positioning in the R main stem bronchus may be indicated by breath sounds heard only on the right side and/or movement of chest wall noted only on the right side
§ Upon initial insertion, placement can also be checked with an end-tidal CO2 detector. To use the end-tidal CO2 detector, connect the ETCO2 between the ET tube and ambu bag. Ventilate the pt. with 6 breaths. Compare color indicator on
Endexpiration
§ to color chart on the product dome. The color should be between Range B and C to indicate tube is in the trachea.
§ All placements must be verified with a PCXR – correct position is tube tip located 3-5 cm above carina. (*For neonates, correct position is T2-T4. **For pediatrics, correct position is three (3) times the ETT size at the lip).
2. Assess for cuff leak:
§ (*Not applicable for neonates, only uncuffed tubes used; For pediatrics, cuffs used only if pt. is > 8 years old.) Cuff on end of tube is high volume, low pressure cuff which is inflated using minimal leak to obtain adequate seal and reduce incidence of tracheal damage (Respiratory therapist will perform minimal leak check). Signs and symptoms of cuff leak: audible inspiratory leak over larynx, pt. talking, pilot balloon deflation and loss of inspiratory and expiratory volumes on ventilator Nursing Actions to take in case of cuff leak: Inject air into the pilot balloon using a TB syringe until pilot balloon re-inflated. Notify respiratory to check STAT and inform them of amount of air injected.
3. Suctioning/Oral care
§ Artificial airways reduce pt’s ability to cough and increase secretion formation in the lower Tracheobronchial tree Secretions increase risk for obstructed airway, atelectasis, pneumonia and infection Suction as pt. condition dictates using closed system Advantages of closed system include: reduced arterial desaturation and infection Oral care (q 2-4 hr and prn) is important to decrease potential for infection such as ventilator associated pneumonia. Remember to suction oropharynx as well as down ET tube.
REFERENCES:-
1. Guidance on the Risk Classification of General Medical Devices (http://www.hsa.gov.sg/publish/etc/medialib/hsa_library/health_products_regulation/medical_devices/guidance_documents.Par.83962.File.tmp/GN13R1% 2520Guidance%2520on%2520the%2520Risk%2520Classification%2520of%2520General%2520Medical%2520Devices.pdf), Revision 1.1. From Health Sciences Authority. May 2014
2. Parker JC, Hernandez LA, Peevy KJ (1993). "Mechanisms of ventilatorinduced lung injury". Crit Care Med 21 (1): 131–43. doi:10.1097/0000324619930100000024. PMID 8420720.
3. International consensus conferences in intensive care medicine: Ventilatorassociated Lung Injury in ARDS. This official conference report was cosponsored by the American Thoracic Society.
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