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AN INTRODUCTION

TO MECHANICAL

VENTILATION

Dana Bartlett, BSN, MSN, MA, CSPI

Dana Bartlett is a professional nurse and author. His

clinical experience includes 16 years of ICU and ER

experience and over 20 years of as a poison control

center information specialist. Dana has published

numerous CE and journal articles, written NCLEX

material, written textbook chapters, and done

editing and reviewing for publishers such as

Elsevire, Lippincott, and Thieme. He has written widely on the subject of toxicology

and was recently named a contributing editor, toxicology section, for Critical Care

Nurse journal. He is currently employed at the Connecticut Poison Control Center and

is actively involved in lecturing and mentoring nurses, emergency medical residents

and pharmacy students.

ABSTRACT

Mechanical ventilation is a life-saving treatment to support patients

that are unable to ventilate and oxygenate on their own. The skills

required by health teams to manage a ventilation unit are typically

standardized to ensure safe handling of ventilation equipment and for

proper management of patients during their course of care.

Mechanically ventilated patients often receive medication for sedation

and pain control that require a qualified interdisciplinary team to

administer and evaluate outcomes. Therapeutic modalities of

mechanical ventilation and pharmacology needed to support treatment

and patient comfort are reviewed.


Continuing Nursing Education Course Planners

William A. Cook, PhD, Director, Douglas Lawrence, MA, Webmaster,

Susan DePasquale, MSN, FPMHNP-BC, Lead Nurse Planner

Policy Statement

This activity has been planned and implemented in accordance with

the policies of NurseCe4Less.com and the continuing nursing education

requirements of the American Nurses Credentialing Center's

Commission on Accreditation for registered nurses. It is the policy of

NurseCe4Less.com to ensure objectivity, transparency, and best

practice in clinical education for all continuing nursing education (CNE)

activities.

Continuing Education Credit Designation

This educational activity is credited for 2.5 hours. Nurses may only

claim credit commensurate with the credit awarded for completion of

this course activity.

Pharmacology content is 0.5 hours (30 minutes).

Statement of Learning Need

Health clinicians require up-to-date information about basic aspects of

mechanical ventilation, specifically, the indications for use,

complications, basic care, medication management and weaning of the

patient from the ventilator. Clinicians working in the Intensive Care

Unit need to know the commonly used terms of mechanical ventilation

and respiratory care.


Course Purpose

To provide clinicians working in the Intensive Care Unit with basic

knowledge of how to care for the mechanically ventilated patient.

Continuing Nursing Education (CNE) Target Audience

Advanced Practice Registered Nurses and Registered Nurses

(Interdisciplinary Health Team Members, including Vocational Nurses

and Medical Assistants may obtain a Certificate of Completion)

Course Author & Planning Team Conflict of Interest Disclosures

Dana Bartlett, BSN, MSN, MA, CSPI, William S. Cook, PhD,

Douglas Lawrence, MA, Susan DePasquale, MSN, FPMHNP-BC

all have no disclosures

Acknowledgement of Commercial Support

There is no commercial support for this course.

Please take time to complete a self-assessment of knowledge,

on page 4, sample questions before reading the article.

Opportunity to complete a self-assessment of knowledge

learned will be provided at the end of the course.


1. The amount of oxygen delivered by a ventilator is

a. fraction of inspired oxygen.

b. positive expiratory volume. c. inspiratory pressure.

d. tidal volume.

2. Which of the following is a complication of mechanical ventilation?

a. Cellulitis.

b. Atrial fibrillation. c. Barotrauma.

d. Pulmonary fibrosis.

3. True or False: High arterial oxygen levels are always

benign.

a. True b. False

4. Common complications of mechanical ventilation include

a. ventricular arrhythmias and hypotension.

b. delirium and hypothermia. c. stress ulcers and renal failure.

d. sinus infections and ventilator-associated pneumonia.

5. Suctioning a mechanically ventilated patient should be

done

a. every two hours.

b. only when it is clinically indicated. c. if the patient has a temperature > 102° F.

d. when the patient is receiving sedation with a benzodiazepine.


Introduction

Mechanical ventilation is a life-saving treatment to support patients

when they are unable to ventilate and oxygenate on their own. The

skills required by health teams, in particular of nurses, to manage a

ventilation unit are typically standardized to ensure safe handling of

ventilation equipment and for proper management of patients during

their course of care. This article discusses various components of care,

pharmacological approaches to calm and treat pain and methods to

wean the patient from mechanical ventilation. Appendix A, at the end

of the course, explains some of the commonly used terms of

mechanical ventilation and respiratory care.

What Is Mechanical Ventilation?

Mechanical ventilation uses endotracheal intubation and a ventilator to

replace spontaneous respiration and ventilation. The ventilator

provides the functions of the respiratory muscles; the endotracheal

tube establishes a patent and unobstructed airway; and, the

exogenous oxygen source gives a patient a therapeutic concentration

of the gas. (Note: The terms respiration and ventilation will be

discussed in Appendix A at the end of the article).

Learning Break:

Mechanical ventilation can be done non-invasively by using a facemask

and oxygen, and endotracheal intubation can be used without a

ventilator. In this module mechanical ventilation refers to endotracheal

intubation and the use of a ventilator.


Indications For The Use Of Mechanical Ventilation

Mechanical ventilation improves gas exchange and decreases a

patient’s work of breathing, and it is used to treat patients who are

having acute or chronic respiratory distress.1 The definition of

respiratory distress is somewhat fluid, but it can reasonably be

described as insufficient oxygenation and/or insufficient alveolar

ventilation, reflected by a PaO2 of less than 60 mm Hg, sometimes in

conjunction with a PaCO2 of >50 mm Hg.1,2

General indications for the use of mechanical ventilation are listed in

Table 1.2 These indications primarily refer to patients in acute

respiratory distress.

Table 1: Indications for Mechanical Ventilation

Apnea

Clinical signs of increased work of breathing

Hypoxemic respiratory failure

Hypercapnic respiratory failure

Post-operative respiratory failure

Clinical Signs of Increased Work of Breathing

Clinical signs where the patient exhibits increased work of breathing

include diaphoresis, nasal flaring, tachypnea, use of accessory

muscles, and (possibly) elevations of blood pressure and heart rate.


Hypoxemia

Hypoxemia is defined as a decrease in partial pressure of oxygen in

the blood (PaO2) causing insufficient oxygenation. Hypoxemic

respiratory failure can be caused by asthma, acute respiratory distress

syndrome, a cerebrovascular accident (CVA, aka, stroke), drug

overdose, pulmonary edema, and pulmonary embolism. Hypoxemic

respiratory failure is manifested by cyanosis, neurological changes

such as confusion and/or drowsiness, loss of consciousness, and

seizures, tachycardia, and tachypnea.

Hypercapnia

Hypercapnia is an elevation of the arterial carbon dioxide level

(PaCO2). Hypercapnic respiratory failure can be caused as a result of a

CVA, drug overdose, chronic obstructive pulmonary disease (COPD),

neurological disorders such as amyotrophic lateral sclerosis and

Guillain Barré syndrome, obstructive sleep apnea, pneumonia, and

pulmonary vascular disease. Signs of hypercapnic respiratory failure

include confusion, diaphoresis, drowsiness, dyspnea, elevated blood

pressure, tachycardia, and tachypnea. A PaCO2 > 45 mm HG is

diagnostic for hypercapnia.

Post-Operative Respiratory Failure

Post-operative respiratory failure has been defined by Laghi and Tobin

as “... the need for intubation and mechanical ventilation in the 48

hours after surgery.”2 Post-operative respiratory failure can be caused

by pulmonary issues such as acute respiratory distress syndrome

(ARDS) and atelectasis or by non-pulmonary issues such as sepsis or

shock.


Mechanical ventilation is clearly needed in certain emergencies and

there are accepted clinical indications for intubation and mechanical

ventilation. However, these indications are somewhat imprecise and

open to interpretation and Laghi and Tobin write: “We believe that the

most honest description of a physician’s judgment at this juncture is:

‘The patient looks like he (or she) needs to be placed on the

ventilator.’ That is, a physician institutes mechanical ventilation based

on his or her gestalt of disease severity as opposed to slotting a

patient into a particular diagnostic pigeonhole.”2

Modes Of Mechanical Ventilation And Ventilator Settings

There are a wide variety of mechanical ventilation modes and it is

beyond the scope of this module to review them all. Commonly used

modes of mechanical ventilation are outlined in the section below.

Assist-Control

Respiratory rate and tidal volume are adjusted to deliver a specific

minute ventilation. The patient’s spontaneous inspiratory efforts can

initiate (trigger) the ventilator to deliver breaths that have the same

tidal volume as the breaths delivered by the ventilator. Ventilator-

delivered and patient-initiated breaths are ended when a set volume of

air has been delivered or when a specific duration of inspiration is

reached. Assist-control (AC) is used for patients who are in acute

respiratory failure.

Controlled Mechanical Ventilation


minute ventilation. A patient cannot trigger the ventilator to deliver a


breath. Ventilator-delivered breaths end when a set volume of air has

been delivered or when a specific duration of inspiration is reached.

Controlled mechanical ventilation (CMV) is used for patients who are

pharmacologically paralyzed or comatose.

Synchronized Intermittent Mandatory Ventilation


minute ventilation. A patient can breathe spontaneously between the

ventilator-delivered breaths, but with synchronized intermittent

mandatory ventilation (SIMV) the ventilator is adjusted so that

spontaneous breathing and ventilator breaths do not interfere with one

another.

Basic Ventilator Settings

The basic ventilator settings are outlined below.

Fraction of inspired oxygen:

Fraction of inspired oxygen (FiO2) is the percentage of oxygen in

each ventilator breath.

Positive end-expiratory pressure:

Positive end-expiratory pressure (PEEP) is the pressure in the

alveoli at the end of expiration.

Respiratory rate:

The number of breaths delivered each minute. The abbreviation

for the frequency of respiratory rate is f.


Tidal volume:

Tidal volume (TV) is the amount of air delivered with each

ventilator breath.

Complications Of Mechanical Ventilation

Barotrauma

Pulmonary barotraumas are uncommon, potentially serious

complications of mechanical ventilation, usually caused by over-

distention of the alveoli. This creates a pressure difference that

precipitates a rupture of the alveolar walls and movement of air into

the adjacent interstitial lung tissue. Pneumomediastinum and

pulmonary interstitial emphysema are seen most often;

intraparenchymal air cysts, pneumopericardium, pneumoperitoneum,

pneumothorax, subcutaneous emphysema, and systemic air embolism

have been reported, as well.3-7

The incidence of pulmonary barotraumas in patients who are

mechanically ventilated has been reported to be between 1.4% to

13%.3-7 The risk appears to be greatest for patients who have

interstitial lung disease. It is not clear if specific ventilator settings

such as the amount of PEEP increase the risk of developing pulmonary

barotrauma.

Gastrointestinal Complications

Patients who are mechanically ventilated are at risk for developing

acalculous cholecystitis, aspiration of enteral feedings, decreased

gastrointestinal motility, gastrointestinal bleeding and stress ulcers.8-12


Oxygen Toxicity

Oxygen toxicity is defined as parenchymal lung injury caused by

supplemental oxygen. This condition of hyperoxia, defined as a PaO2 >

300 mm Hg, can result in significant pathologies: 1) a decreased

cardiac output and vasoconstriction; 2) oxidative stress and an

inflammatory response; and, 3) lung and respiratory tract injuries. The

latter can include atelectasis, diffuse alveolar damage similar to ARDS,

interstitial fibrosis, tracheobronchitis, and ventilator-associated lung

injury.13-18

Sinus Infections

Sinus infections are a common cause of fever in patients who are

mechanically ventilated. The reported incidence is 25%-75%, and

these infections are a cause of ventilator-associated pneumonia and

other respiratory tract and neurological infections.19,20

Ventilator-Associated Lung Injury

Ventilator-associated lung injury is an acute lung disorder that

develops during mechanical ventilation.21,22 Ventilator-associated lung

injury cannot be clinically distinguished from ARDS,21 and it has been

reported to occur in as many as 24% of patients who are mechanically

ventilated.23

The causes of ventilator-associated injury are over-distension of the

alveoli and the speed and time during which the alveoli are

inflated.21,24 Factors that increase the risk of developing ventilator-

associated lung injury are acidemia, ARDS, blood transfusion, high

plateau airway pressure, hyperoxia, tidal volume > 6 mL/kg, and


restrictive lung diseases. High tidal volume has been clearly identified

as a risk factor,23-27 and the level of PEEP and the plateau airway

pressure may increase the risk, as well.

Ventilator-Associated Pneumonia

Ventilator-associated pneumonia (VAP) is defined as a hospital-

acquired pneumonia that occurs 48-72 hours after endotracheal

intubation has been performed.28 The incidence of VAP has been

reported to be 10%-25% and it is associated with a high mortality

rate.29

Factors that increase the risk of developing VAP are listed in Table 2.

The list is not all-inclusive.28-31

Table 2: Risk Factors for Ventilator-Associated Pneumonia

Age > 60 years

Antacids

ARDS

Aspiration

Coma

COPD

Daily ventilator circuit changes

Duration of mechanical ventilation

Enteral nutrition

H2 blockers

Nasogastric tube placement

Proton pump inhibitors

Sinusitis

Supine position

Tracheostomy


Complications Of Intubation

The process of inserting an endotracheal tube will not be discussed,

but there are complications associated with/caused by intubation that

nurses should be aware of.

Table 3: Complications of Intubation

Aspiration of gastric contents

Damage to the lips, teeth, or tongue

Injury to the esophagus or vocal cords

Pneumothorax

Trauma to the larynx, oropharynx, or trachea

Basic Care Of A Patient Who Is Mechanically Ventilated

Suctioning, the use of sedating and analgesic drugs, and psychological

issues of a patient who is mechanically ventilated will be discussed.

The use of ventilator bundles will be covered in a separate section.

Suctioning

Mechanically ventilated patients retain secretions in the lungs and the

endotracheal tube. Retained secretions narrow the airways, increase

the work of breathing, decrease gas exchange, increase the risk of

developing VAP, they can cause atelectasis, and make weaning more

difficult.32 Endotracheal suctioning removes mucous and secretions


and it is considered essential care for a patient who is mechanically

ventilated.32-34

Endotracheal suctioning should be done when needed; it should be not

be done routinely. Indications for endotracheal suctioning include

abnormal sounds auscultated over the trachea, acute respiratory

distress, aspiration of gastric or upper airway secretions, decreased

tidal volume (if pressure-controlled ventilation is being used),

dyspnea, increased peak inspiratory pressure (if volume-controlled

ventilation is being used), oxygen desaturation, and visible

secretions.32,35

The procedure is usually completed uneventfully but endotracheal

suctioning can cause significant complications: See Table 4.32,36

Table 4: Complications of Endotracheal Suctioning

Atelectasis

Bleeding

Bradycardia

Bronchoconstriction

Infection

Hypertension

Hypotension

Increased intracranial pressure

Oxygen desaturation

Trauma


Procedure of Endotracheal Suctioning

Unless otherwise noted the following recommendations are from the

AARC Clinical Practice Guidelines, Respir Care. 2010;55(6):758-764.

1. Measure blood pressure, heart rate, oxygen saturation, and

intracranial pressure (ICP), if ICP is being measured, before,

during, and after suctioning.

2. Pre-oxygenate for 30-60 seconds if suctioning the patient has

caused significant reduction in oxygen saturation or if the patient is

hypoxemic. Adult and pediatric patients should be given 100%

oxygen. Neonates should be given a 10% increase of the baseline

FiO2.

3. Do not instill saline into the endotracheal tube. This may be harmful

and it will not help loosen secretions.37 Mucolytics such as N-

acetylcysteine have been used to help promote mucous clearance

but there is no conclusive evidence that they are effective.

4. The vacuum level should be ≤ 150 mm Hg if you are suctioning an

adult and ≤ 80-100 mm Hg if you are suctioning an infant.

5. Closed suctioning should be used if a patient is receiving a high

FiO2, a high level of PEEP, is at risk for alveolar de-recruitment, or if

you are suctioning a neonate. It has been proposed that closed

suctioning can reduce the risk of developing VAP; there is evidence

that supports and refutes this. 38-41 Closed suctioning will be

discussed in more detail in the section on ventilator bundles.

http://www.ncbi.nlm.nih.gov/pubmed/?term=Enodtracheal+suctioning+of+mechanically+ventilated+patients+with+artificial+airway+2010


6. Insert the suction catheter until the tip is at the end of the

endotracheal tube; this is called shallow suctioning. Deep suctioning

- inserting the suction catheter until resistance is met - may be

harmful.42,43

7. Apply suction and withdraw the suction catheter, rotating it

continuously as it is removed. Do not apply suction for more than

15 seconds.

8. Consider hyper-oxygenation after finishing.

9. Consider a lung recruitment technique after finishing.

10. Document the amount, color, and consistency of the secretions.

Learning Break:

Suctioning may collapse alveoli and contribute to acute lung injury.

Recruitment techniques such as maximum insufflation that increase

airway pressure may prevent this and their use should be

considered.44,45

Sedation During Mechanical Ventilation

Anxiety, confusion, drug and or alcohol withdrawal, post-operative

pain, and discomfort from endotracheal intubation are common

problems for patients who are mechanically ventilated, and these


patients need sedation. Benzodiazepines, butyrophenones,

dexmedetomidine, ketamine, fentanyl, and propofol are commonly

used for this purpose.46,47 Each drug has a different onset and duration

of effects, indications for use, and side effects.

Benzodiazepines

Benzodiazepines are potent anxiolytics and they are central nervous

system and respiratory depressants. These drugs also relax smooth

muscle and cause venodilation. Diazepam, lorazepam and midazolam

can be given as a single dose, intermittent infusion, or as a continuous

infusion (lorazepam). Diazepam has a rapid onset and short duration

of effects; lorazepam has a slow onset but its effects last for 6-8

hours; and, midazolam has an immediate onset of effects and duration

of effects of 2-4 hours.

Side effects of the benzodiazepines include paradoxical agitation and

delirium, confusion, hypotension, sedation, tolerance, withdrawal

syndromes, and anion gap metabolic acidosis caused by the propylene

glycol diluent in lorazepam.47-49 The benzodiazepines should be used

with caution in patients who have hepatic or renal impairment as

decreased metabolism and excretion and drug accumulation may

occur.

Butyrophenones

Butyrophenones are a specific class of typical anti-psychotics that

includes droperidol and haloperiodol. Haloperidol is used off-label for

prevention and treatment of delirium in critically ill patients, and

haloperidol should only be used for short-term management of acutely

agitated patients.46,50 The onset of action of IV haloperidol is very


quick, 2 to 5 minutes. Side effects include drowsiness, extrapyramidal

effects, neuroleptic malignant syndrome, orthostatic hypotension, QTc

prolongation, and torsades de pointes.

Dexmedetomidine

Dexmedetomidine is an alpha2-adrenergic antagonist and a sedative

and it also has analgesic properties. It has a labeled use for sedating

patients who are mechanically ventilated, and studies have proven its

effectiveness for this purpose.51,52 Dexmedetomidine can be given as a

single dose or as a continuous infusion; in certain circumstances a

loading dose is given prior to starting a continuous infusion.

The onset of effects is 5 to 10 minutes and the duration of effects after

a single dose is 30 to 60 minutes. Side effects include bradycardia and

hypotension and hypertension after loading doses.

Ketamine

Ketamine is a general anesthetic, it has strong analgesic properties,

and it produces a dissociative state in which perception and sensation

are separated; the patient is conscious and feels as if she/he is

observing surrounding events but not experiencing them. After an IV

bolus the onset of effects is within one minute and the duration of

action is 10 to 15 minutes.

Side effects of ketamine include amnesia, delirium, hallucinations,

hypotension and hypertension, and tachycardia. It should be used

cautiously if a patient’s blood pressure is elevated.


Ketamine is not commonly used to sedate patients who are

mechanically ventilated,47 but some research has shown it to be

effective for this purpose and having a side effect profile comparable

to that of benzodiazepines and propofol.54,55 Using ketamine to sedate

a patient who is mechanically ventilated is an off-label use of the drug

and there are no standardized dosing regimens for a continuous IV

infusion in this situation.

Fentanyl

Fentanyl is a powerful opioid analgesic. It is an effective sedative for

patients who are mechanically ventilated,47,56 and there is evidence

that using analgesics for these patients, a technique called

analgosedation, is superior to using hypnotic sedatives.56,57 A

continuous infusion of fentanyl is dosed in mcg/kg/hour.

Fentanyl has a rapid onset of action (minutes), and it is less likely to

cause hypotension than other opioid analgesics. Side effects include

drowsiness, respiratory depression, and tolerance. Fentanyl is lipophilic

and metabolized by cytochrome P450 enzymes, so if a patient has

hepatic impairment the drug can accumulate after prolonged use.

Propofol

Propofol is a general anesthetic and it is commonly used to sedate

patients who are mechanically ventilated. It is especially useful when

rapid onset and short duration of anesthesia is desired, and propofol

also has anxiolytic properties. The onset of effects is < 1 minute, the

duration of action after a single dose is 2 to 8 minutes, and the

anesthetic effect is effectively ended 60 minutes after an infusion has

been discontinued.


Propofol is not an analgesic. The drug can cause ventilatory depression

and hypotension is a common side effect of the drug. Propofol uses

intralipid as its carrier and triglyceride levels should be monitored.

Intralipid is a good medium for bacterial growth, so strict aseptic

technique must be used when IV tubing is changed, and it is

recommended to change IV tubing and discard unused portions of

propofol every 12 hours.

The propofol infusion syndrome is a rare complication of propofol. It is

usually associated with high doses (> 4 mg/kg/hour) or a prolonged

infusion (> 48 hours), but lower doses and a shorter duration of

therapy can cause the syndrome as well.58 The propofol infusion

syndrome is characterized by bradycardia, Brugada-like ECG changes,

cardiovascular collapse, hyperkalemia, hyperlipidemia, metabolic

acidosis, renal failure, and rhabdomyolysis.46,47,58 The incidence of

propofol infusion syndrome is reported to be very low, probably

< 1%,47 but different defining criteria for the syndrome have been

used so the true incidence is not known.59 Mortality rates of the

propofol infusion syndrome as high as 80% have been reported.59

Pain Assessment And Control

Pain assessment and pain control is a vital aspect of treating patients

who are mechanically ventilated46,47 and the following points

emphasize its importance.

Pain is very common in patients who are mechanically ventilated.

These patients are often unable to tell you that they are having

pain.


Pain can be mistaken for agitation, confusion, or delirium. If this

happens, treatment with sedatives further reduces the patients’

ability to tell you about their pain and may result in over-sedation

and continued pain.

Pain can cause many adverse physiological and psychological

effects such as anxiety, confusion, sleep deprivation, increased

metabolic demands, and an increase in levels of endogenous

catecholamines. The last of these is particularly bad for the

mechanically ventilated patient because a high circulating level of

endogenous catecholamines can cause vasoconstriction, increased

oxygen demand, impaired tissue perfusion, and ischemia.

Opioids such as fentanyl, morphine, and remifentanil are often used to

treat mechanically ventilated patients who are having pain. These

drugs are reliable and easy to titrate, and single doses or a continuous

IV infusion can be used. If the patient has a functioning gut that can

be accessed via a nasogastric tube, oral opioids are an option. The side

effects of opioids include decreased peristalsis, hypotension,

pharmacologic ileus, respiratory depression, sedation, serotonin

syndrome (fentanyl), tolerance, and withdrawal.

Psychological Care

Three psychiatric issues are often found in patients who are

mechanically ventilated: delirium, depression, and post-traumatic

stress disorder.60

Delirium is a disturbance in awareness and attention. Delirium is not

caused by a pre-existing neurocognitive disorder: it is the direct result

of a physiological condition or stimulus such as drug or alcohol


withdrawal, dehydration, infection, or in this case, mechanical

ventilation. Delirium has been reported to affect 75%-80% of patients

who are mechanically ventilated,61 and it is an independent risk factor

for increased duration of hospital stay, long-term cognitive

impairment, death, and other complications.61-63

Delirium develops quickly, in hours to days, and it is characterized by:

1) an inability to focus or sustain attention; 2) a disturbance in

awareness, i.e., disorientation in relation to the environment that

fluctuates throughout the day, often being worse at night; and,

3) other cognitive disturbances such as delusions, hallucinations,

illusions, perceptual disorders, and memory loss. A delirious patient

may ask the same questions again and again, he/she may think that

the staff is trying to cause her/him harm, mistake objects in the

environment for something else, or imagine he/she is hearing

conversations.

Treatment for delirium can include early mobilization and judicious use

of analgesics, sedatives, antipsychotics, and other medications.60,64-67

Unfortunately, there is very little evidence and only a small amount of

research on the effectiveness of medications for treating delirium in

this patient population.

Less is known about depression and post-traumatic stress disorder in

patients who are mechanically ventilated. Both have been identified as

common complications of weaning from mechanical ventilation and

from prolonged mechanical ventilation.68-70 However, Skobrik notes

that there are few studies of depression in mechanically ventilated

patients, confounding factors make establishing a diagnosis of


depression difficult in this situation, and there are no established

therapies for the management of depressed, mechanically ventilated

patients.60

Ventilator Bundles

Ventilator bundles are evidence-based, systematic approaches for the

prevention of the common complications of mechanical ventilation.

Ventilator bundles “ ... are groupings of best practices (and) evidence-

based strategies that may prevent or reduce risk of these

complications, and the bundle is an effort to design a standard

approach to delivering these core elements.”71

Several ventilator bundles have been developed and when they are

properly and consistently used they can be effective.72-74 The primary

focus of ventilator bundles has been preventing ventilator-associated

pneumonia but some include advice for preventing other complications

as well, and their specific care recommendations do vary from each

other.

Aspects of ventilator bundles that will be discussed here are: 1) daily

sedative interruption, 2) deep vein thrombosis prophylaxis, 3) in-line

and subglottic suctioning, 4) endotracheal tube cuff pressure

monitoring, 5) oral care with chlorhexidine and chlorhexidine bathing,

6) peptic ulcer prophylaxis; and, 7) patient positioning.

Daily Sedative Interruption

Patients who are mechanically ventilated need sedation but benefits

come with risks, and sedation therapy is associated with delirium,


increased duration of intensive care unit stay, increased duration of

mechanical ventilation, and ventilator-associated pneumonia.75,76

Daily, scheduled interruptions in the delivery of sedative drugs, so-

called sedation vacations, can reduce the incidence of these and other

complications 75,76 and sedation vacations are typically included in

ventilator bundles. Sedation vacations also encourage planned,

judicious use of sedation and can help avoid under- and over-sedating

patients.

Deep Vein Thrombosis Prophylaxis

The connection between deep vein thrombosis (DVT) and mechanical

ventilation is not clearly defined. Ibrahim, et al., noted that 26 of 110

patients (23.6%) who were mechanically ventilated developed a

DVT,77 and Gaspard, et al., found that an incidence of 0.3%-3.0% of

DVT and pulmonary embolism (PE) in their study group of

mechanically ventilated patients,78 but the topic has not been well

researched.

However, mechanical ventilation itself, the clinical conditions that

precipitated the need for mechanical ventilation, bed rest, and time

spent in an intensive care unit are all risk factors for the development

of DVT, and prophylactic measures to prevent DVT are a standard part

of ventilator bundles. Prophylaxis can be done using intermittent

pneumatic compression devices, graduated compression stockings, or

treatment with heparin or low-molecular weight heparin.78


Closed Suctioning and Subglottic Suctioning

Disconnecting a patient from the ventilator to perform endotracheal

suctioning can cause a loss of PEEP, decreased arterial oxygen content

and increased carbon dioxide content, and bacterial contamination.

Closed suctioning (also called in-line suctioning) allows for removal of

secretions without disconnecting the patient from the ventilator. It is

often included in ventilator bundles as part of the effort to reduce the

incidence of ventilator-associated pneumonia. The American

Association for Respiratory Care recommends closed suctioning for

adults who require a high FiO2, adults who require PEEP, adults who

are at risk for lung decruitment, and for neonates.35 There is evidence

that closed endotracheal suctioning can be effective for this

purpose,39,79 but recent reviews (2014, 2015) have been less positive.

Kuriyama, et al., write: “Whether closed tracheal suctioning systems

(CTSS) reduce the incidence of ventilator-associated pneumonia (VAP)

compared with open tracheal suctioning systems (OTSS) is

inconclusive.”38 Hamishekar, et al., write that “ ... impact of suctioning

is similar between CTSS and OTSS regarding the occurrence of VAP. It

seems that physicians must consider many factors such as duration of

mechanical ventilation, comorbidities, oxygenation parameters,

number of required suctioning, and the cost prior to using each type of

tracheal suction system.”80

Endotracheal tubes are available that have a lumen above the cuff.

This lumen can be connected to continuous or intermittent suction,

and this process of subglottic suctioning removes secretions that

accumulate above the cuff. Subglottic suctioning has been shown to be

an effective way to prevent VAP and can help decrease the amount of

time a patient needs mechanical ventilation.81-84 There is some


evidence that subglottic suctioning may decrease the duration of

mechanical ventilation in patients who will be mechanically ventilated

for 48-72 hours or longer.85 Removing a standard endotracheal tube

and replacing it with one that has a subglottic aspiration lumen port

would not be recommended.85

Endotracheal Cuff Pressure

Endotracheal cuff pressure should be maintained at 20-30 cm H2O to

prevent VAP and to prevent damage to the surrounding tissues.86

Maintaining appropriate cuff pressure has been mentioned by some

authors as part of a ventilator bundle,86,87 and continuous endotracheal

cuff pressure monitoring has been shown in several studies to reduce

the incidence of VAP.86,88

Oral Care with Chlorhexidine and Chlorhexidine Bathing

Oral care with chlorhexidine can decrease the risk of developing

VAP.89-91 Chlorhexidine is an antibacterial agent and a 0.12%-0.2%

solution is applied to a sponge and the patient’s mouth is swabbed

four times a day; the frequency of use and the protocol may vary from

hospital to hospital. Some researchers have found that chlorhexidine

bathing can reduce the incidence of VAP but others have not.92,93

Peptic Ulcer Prophylaxis

Patients who are mechanically ventilated are at risk for stress ulcers

and gastrointestinal bleeding.3 Antacids, histamine-2 blockers, proton

pump inhibitors, and sulcralfate have all been successfully used to

prevent stress ulcers in this patient population,3,94,95 but it is not clear

which of these is the most effective.


Decreasing gastric pH can be an effective prophylaxis for stress ulcers,

but it can allow for bacterial growth in the gut, and research has

shown that stress ulcer prophylaxis may increase a patient’s risk of

developing VAP.8,94-99

Patient Positioning, Enteral Feedings, and Aspiration

Patients who are mechanically ventilated and who are receiving enteral

nutrition are at risk for aspiration, and aspiration is a common and

potentially serious complication of enteral nutrition.100-102 Not all cases

of aspiration cause significant harm but preventing this complication

should be a priority.

Withholding enteral feeding if the residual gastric volume is above a

certain level (checking residual volume) has been used as a method

for preventing aspiration. This technique may still have value for

selected patents,102 but there is significant evidence suggesting that it

does not prevent aspiration100-103 and it is not generally

recommended.100,104 Elevating the head of the head (if possible) to

30°-45° is the only proven technique for preventing aspiration in

critically ill patients who are receiving enteral nutrition.100 Elevating

the head of the bed is also a recommendation of many ventilator

bundles as a method of preventing ventilator-associated

pneumonia.85,105,106

Weaning From Mechanical Ventilation

Prolonged use of mechanical ventilation increases a patient’s exposure

to complications so weaning is a high priority. The three steps of

weaning from mechanical ventilation are: 1) recognizing when a


patient is ready to be weaned; 2) recognizing when a patient is ready

to be extubated; and, 3) the weaning process itself.107,108

Epstein (October, 2015) recommends using these objective criteria to

determine if a patient is ready to be weaned.108

Arterial pH is > 7.25

Hemodynamic stability, i.e., a systolic blood pressure > 90

mm Hg

Adequate oxygenation, i.e., oxyhemoglobin saturation >

90% with an FiO2 of ≤ 40% and a level of PEEP ≤ 5-8 cm

H2).

The patient can initiate an inspiratory effort.

The cause of respiratory failure has resolved.

Readiness to be extubated is determined by: 1) assessing the patient’s

ability to produce a cough; 2) assessing the patient’s level of

consciousness; 3) checking the amount of secretions he/she is

producing; and, 4) checking for a reduced cuff leak.110

The cuff leak test is done by deflating the endotracheal tube cuff and

assessing for an air leak; any air leak is inversely related to the

amount of laryngeal edema.111 Some authors recommend the cuff leak

test110,112 and if there is a significant leak, delaying extubating and

giving the patient a short course of glucocorticoid therapy, but the test

is not universally accepted as useful or sensitive.113,114

If the patient is ready to wean and ready to be extubated the next

step is a spontaneous breathing test (SBT). The patient is


disconnected from the ventilator for 30 minutes and placed on a T-

piece or CPAP (there are several methods for performing an SBT) and

the patient’s tolerance for this is assessed.107 There is objective criteria

for determining tolerance for the SBT, parameters such as heart rate,

respiratory rate, respiratory distress, and desaturation.110 If the

patient tolerates the SBT and the clinician’s judgment is that the

patient appears ready to be extubated, the endotracheal tube can be

removed.

Summary

Mechanical ventilation uses endotracheal intubation and a ventilator to

replace spontaneous respiration and ventilation. It improves gas

exchange and decreases a patient’s work of breathing, and it is used

to treat patients who are having acute or chronic respiratory distress.

Mechanical ventilation can be a life-saving therapy. However, there are

significant risks associated with its use. In addition, patients who are

mechanically ventilated often have serous pre-existing medical

problems and they need intubation and ventilation because of a

serious acute process. Careful, vigilant monitoring and in-depth

understanding of the complications of mechanical ventilation and their

treatment is essential for a good outcome.


Appendix I: Pulmonary Terminology

Alveolar-arterial oxygen gradient:

The alveolar-alveolar oxygen gradient is the difference between the

calculated amount of oxygen in the alveoli and the PaO2, and it is used to

measure oxygenation. The alveolar-arterial oxygen gradient is

abbreviated as A-a.

An abnormally high A-a can help indicate the source of hypoxemia, and a

high A-a gradient (i.e., a higher than expected difference between the

amount of oxygen in the alveoli and the amount of oxygen in the arterial

blood) is commonly caused by a ventilation-perfusion (V/Q) mismatch or

a right-to-left shunt.

A V/Q mismatch can result from poor ventilation caused by pneumonia or

COPD or from poor perfusion caused by a pulmonary embolism.

A right-to-left shunt occurs when blood circulates from the right side of

the heart to the left side without being oxygenated. This can occur when

alveoli are being perfused but are not ventilated, as with adult respiratory

distress syndrome (ARDS) or pneumonia.

A V/Q mismatch and a right-to-left shunt can occur concurrently.

Dead space:

Dead space is the part of the respiratory tract that does not participate in

gas exchange. Dead space can be anatomic, i.e., the bronchi, or it can be

physiologic.

In the latter there are parts of the respiratory tract that normally

participate in gas exchange but do not. This may occur if the alveoli are

not perfused or if gas exchange in the alveoli is hindered by an

exacerbation of COPD or other disease processes such as pulmonary

edema or pneumonia.


Hypercapnia:

Hypercapnia is an elevation of the arterial carbon dioxide level (PaCO2).

The PaCO2 is determined by the amount of carbon dioxide that is produced

and the amount that is eliminated by the lungs – alveolar ventilation.

Hypercapnia is usually caused by decreased alveolar ventilation or an

increase in dead space.

Hypercapnia from decreased alveolar ventilation often results from

decreased minute ventilation. Minute ventilation is the amount of air

moved inhaled (or exhaled) in one minute and conditions such as drug

overdose or stroke decrease the respiratory rate, which in turn, decreases

minute ventilation and alveolar ventilation. Alveolar ventilation is also

determined in part by the amount of dead space. Dead space is increase

by conditions such as atelectasis, exacerbations of COPD, and pneumonia.

Hypoxemia:

Hypoxemia is defined as a decrease in partial pressure of oxygen in the

blood (PaO2) causing insufficient oxygenation. (Oxygenation is defined

later in this list). Hypoxemia is caused by hypoventilation, a right-to-left

shunt, or a ventilation-perfusion mismatch. (These terms are explained in

this section, as well)

Hypoxia:

Hypoxia is abnormally low oxygen content in an organ or a tissue.

Hypoventilation: A reduced amount of air entering the alveoli. Common

causes of hypoventilation would be a drug overdose or a CVA; both which

depress the respiratory center in the brain, decreasing the rate and depth

of breathing.

Oxygenation:

Oxygenation is the process of oxygen moving through the alveoli into the

pulmonary capillaries, and then binding to hemoglobin or dissolving in

plasma.


Partial pressure of carbon dioxide:

The partial pressure of carbon dioxide (sometimes referred to as arterial

carbon dioxide tension) measures the amount of carbon dioxide that is in

arterial blood. The partial pressure of carbon dioxide is abbreviated PaCO2.

The normal PaCO2 is 35-45 mm Hg.

Partial pressure of oxygen:

The partial pressure of oxygen (sometimes referred to as arterial oxygen

tension) measures the amount of oxygen that dissolved in arterial blood.

It does not measure the amount of oxygen bound to hemoglobin. The

partial pressure of oxygen is abbreviated as PaO2. There is no defined

normal range for PaO2 as there is no PaO2 level below which hypoxia will

always occur. However, for most people the PaO2 should be > 80 mm Hg.

Respiration: Respiration is the exchange of gases in the lung; transport of

carbon dioxide and oxygen in the blood; and the movement of gases from

the cells to the blood (carbon dioxide) and the blood to the cells (oxygen).

Respiration is the exchange of carbon dioxide and oxygen between the

cells of the body and the atmosphere, and respiration and ventilation are

obviously intimately linked. Cellular respiration is the process by which

the cells use oxygen to produce adenosine triphosphate (ATP) and

eliminate carbon dioxide.

Ventilation:

Ventilation is the process of breathing, moving air in and out of the lungs.

Ventilation is defined as the exchange of air between the environment and

the lungs; in simpler terms ventilation can be understood as inhalation

and exhalation. Ventilation is divided into alveolar ventilation and

pulmonary ventilation.

Alveolar ventilation is the amount of air that reaches the alveoli and is

available for gas exchange with the blood. Pulmonary ventilation is the

rate of ventilation, measured in liters of air per minute that are exchanged

between the ambient air and the lungs.


Please take time to help NurseCe4Less.com course planners

evaluate the nursing knowledge needs met by completing the self-assessment of Knowledge Questions after reading the

article, and providing feedback in the online course evaluation.

Completing the study questions is optional and is NOT a course

requirement.

1. The amount of oxygen delivered by a ventilator is

a. fraction of inspired oxygen.

b. positive expiratory volume. c. inspiratory pressure.

d. tidal volume.

2. Which of the following is a complication of mechanical ventilation?

a. Cellulitis.

b. Atrial fibrillation. c. Barotrauma.

d. Pulmonary fibrosis.

3. True or False: High arterial oxygen levels are always

benign.

a. True b. False

4. Common complications of mechanical ventilation include

a. ventricular arrhythmias and hypotension.

b. delirium and hypothermia. c. stress ulcers and renal failure.

d. sinus infections and ventilator-associated pneumonia.


5. Suctioning a mechanically ventilated patient should be

done

a. every two hours. b. only when it is clinically indicated.

c. if the patient has a temperature > 102° F. d. when the patient is receiving sedation with a benzodiazepine.

6. Drugs used to sedate patients who are mechanically

ventilated are

a. benzodiazepines and propofol. b. selective serotonin re-uptake inhibitors and haloperidol.

c. fentanyl and dextromethorphan. d. ketamine and lithium carbonate.

7. Which of these is a common complication of mechanical

ventilation?

a. Bipolar disorder b. Dissociative state

c. Delirium d. Major depression

8. Patients who are mechanically ventilated will benefit from

a. continual use of sedation until immediately before weaning.

b. abrupt cessation of sedative drugs. c. low doses of sedative and high doses of analgesics.

d. sedation vacations.

9. Oral care with _______________ can reduce the

incidence of ventilator-associated pneumonia.

a. bacitracin b. chlorhexidine

c. hydrogen peroxide d. isopropyl alcohol


10. Readiness to wean from a ventilator is assessed, in part,

by

a. a lung scan. b. an FiO2 requirement of < 30%.

c. a spontaneous breathing trial. d. successive normal chest x-rays.

11. ________________ should be used cautiously in patients

who have hepatic or renal impairment as decreased metabolism, excretion and drug accumulation may occur.

a. Ketamine

b. Benzodiazepines c. Propofol

d. Dexemedetomidine

12. ______________________________is used for patients who are pharmacologically paralyzed or comatose.

a. Controlled mechanical ventilation (CMV)

b. Assist-control (AC) ventilation c. A spontaneous breathing trial

d. Synchronized intermittent mandatory ventilation (SIMV)

13. Using ______________ to sedate a patient who is

mechanically ventilated is an off-label use of the drug.

a. fentanyl b. benzodiazepines

c. ketamine d. butyrophenones

14. Fentanyl is a powerful opioid analgesic

a. but is inferior to using hypnotic sedatives.

b. and has a slow onset of action. c. but is more likely to cause hypotension.

d. and an effective sedative for mechanically ventilated patients.


15. True or False: Side effects of butyrophenones include

drowsiness, extrapyramidal effects, neuroleptic malignant syndrome, orthostatic hypotension, QTc prolongation, and

torsades de pointes.

a. True b. False

Correct Answers:

1. a

2. c

3. b

4. d

5. b

6. a

7. c

8. d

9. b

10. c

11. a

12. a

13. c

14. d

15. a


References Section

The References below include published works and in-text citations of

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