following:

1. Identify the indications for mechanical ventilation.

2. List the steps in preparing a patient for intubation.
3. Determine the FIO2, tidal volume, rate and mode of ventilation on a given
ventilator.
4. Describe the various modes of ventilation and their implications.
5. Describe at least two complications associated with patient’s response to
mechanical ventilation and their signs and symptoms.
6. Describe the causes and nursing measures taken when trouble-shooting
ventilator alarms.
7. Describe preventative measures aimed at preventing selected other
complications related to endotracheal intubation.
8. Give rationale for selected nursing interventions in the plan of care for the
ventilated patient.
9. Complete the care of the ventilated patient checklist.
10. Complete the suctioning checklist.

1. To review indications for and basic modes of mechanical ventilation, possible

complications that can occur, and nursing observations and procedures to detect
and/or prevent such complications.
2. To provide a systematic nursing assessment procedure to ensure early
detection of complications associated with mechanical ventilation.

Indication for Intubation

1. Acute respiratory failure evidenced by the lungs inability to maintain arterial
oxygenation or eliminate carbon dioxide leading to tissue hypoxia in spite of low-
flow or high-flow oxygen delivery devices. (Impaired gas exchange, airway
obstruction or ventilation-perfusion abnormalities).
2. In a patient with previously normal ABGs, the ABG results will be as follows:
PaO2 > 50 mm Hg with pH < 7.25
PaO2 < 50 mm Hg on 60% FIO2 : restlessness, dyspnea, confusion, anxiety,
tachypnea, tachycardia, and diaphoresis
PaCO2 > 50 mm Hg : hypertension, irritability, somnolence (late), cyanosis
(late), and LOC (late)
3. Neuromuscular or neurogenic loss of respiratory regulation. (Impaired
ventilation)
4. Usual reasons for intubation: Airway maintenance, Secretion control,
Oxygenation and Ventilation.

Types of intubation: Orotracheal, Nasotracheal, Tracheostomy

Preparing for Intubation
1. Recognize the need for intubation.
2. Notify physician and respiratory therapist. Ensure consent obtained if not
emergency.
3. Gather all necessary equipment:
a. Suction canister with regulator and connecting tubing
b. Sterile 14 Fr. suction catheter or closed in-line suction catheter
c. Sterile gloves
d. Normal saline
e. Yankuer suction-tip catheter and nasogastric tube
f. Intubation equipment: Manual resuscitator bag (MRB), Laryngoscope and
blade, Wire guide, Water soluble lubricant, Cetacaine spray
g. Endotracheal attachment device (E-tad) or tape
h. Get order for initial ventilator settings
i. Sedation prn
j. Soft wrist restraints prn
k. Call for chest x-ray to confirm position of endotracheal tube
l. Provide emotional support as needed/ ensure family notified of change in
condition.

Intubation

Types of Ventilators
Ventilator Settings
Modes of Mechanical Ventilation
Complications of Mechanical Ventilation
1. Associated with patient’s response to mechanical ventilation:

A. Decreased Cardiac Output

1. Cause - venous return to the right atrium impeded by the dramatically
increased intrathoracic pressures during inspiration from positive pressure
ventilation. Also reduced sympatho-adrenal stimulation leading to a decrease in
peripheral vascular resistance and reduced blood pressure.
2. Symptoms – increased heart rate, decreased blood pressure and perfusion to
vital organs, decreased CVP, and cool clammy skin.
3. Treatment – aimed at increasing preload (e.g. fluid administration) and
decreasing the airway pressures exerted during mechanical ventilation by
decreasing inspiratory flow rates and TV, or using other methods to decrease
airway pressures (e.g. different modes of ventilation).

B. Barotrauma
1. Cause – damage to pulmonary system due to alveolar rupture from excessive
airway pressures and/or overdistention of alveoli.
2. Symptoms – may result in pneumothorax, pneumomediastinum,
pneumoperitoneum, or subcutaneous emphysema.
3. Treatment - aimed at reducing TV, cautious use of PEEP, and avoidance of
high airway pressures resulting in development of auto-PEEP in high risk patients
(patients with obstructive lung diseases (asthma, bronchospasm), unevenly
distributed lung diseases (lobar pneumonia), or hyperinflated lungs
(emphysema).

C. Nosocomial Pneumonia
1. Cause – invasive device in critically ill patients becomes colonized with
pathological bacteria within 24 hours in almost all patients. 20-60% of these,
develop nosocomial pneumonia.
2. Treatment – aimed at prevention by the following:
Avoid cross-contamination by frequent handwashing
Decrease risk of aspiration (cuff occlusion of trachea, positioning, use of small-
bore NG tubes)
Suction only when clinically indicated, using sterile technique
Maintain closed system setup on ventilator circuitry and avoid pooling of
condensation in the tubing
Ensure adequate nutrition
Avoid neutralization of gastric contents with antacids and H2 blockers

D. Positive Water Balance

1. Syndrome of Inappropriate Antidiuretic Hormone (SIADH) – due to vagal
stretch receptors in right atrium sensing a decrease in venous return and see it
as hypovolemia, leading to a release of ADH from the posterior pituitary gland
and retention of sodium and water. Treatment is aimed at decreasing fluid
intake.
2. Decrease of normal insensible water loss due to closed ventilator circuit
preventing water loss from lungs. This fluid overload evidenced by decreased
urine specific gravity, dilutional hyponatremia, increased heart rate and BP.

E. Decreased Renal Perfusion – can be treated with low dose dopamine therapy.

F. Increased Intracranial Pressure (ICP) – reduce PEEP

G. Hepatic congestion – reduce PEEP

H. Worsening of intracardiac shunts –reduce PEEP

2. Associated with ventilator malfunction:

A. Alarms turned off or nonfunctional – may lead to apnea and respiratory arrest
Troubleshooting Ventilator Alarms
Low exhaled volume: Cuff leak, Tubing disconnect, Patient disconnected
Evaluate cuff; reinflate prn; if ruptured, tube will need to be replaced. Evaluate
connections; tighten or replace as needed; check ETT placement, Reconnect to
ventilator
High pressure: Secretions in airway, Patient biting tubing, Tube kinked, Cuff
herniation, Increased airway resistance/decreased lung compliance (caused by
bronchospasm, right mainstem bronchus intubation, pneumothorax, pneumonia),
Patient coughing and/or fighting the ventilator; anxiety; fear; pain.
Suction patient, Insert bite block, Reposition patient’s head/neck; check all
tubing lengths, Deflate and reinflate cuff, Auscultate breath sounds, Evaluate
compliance and tube position; stabilize tube, Explain all procedures to patient in
calm, reassuring manner, Sedate/medicate as necessar
Low oxygen pressure: Oxygen malfunction
Disconnect patient from ventilator; manually bag with ambu; call R.T

3. Other complications related to endotracheal intubation.

A. Sinusitis and nasal injury – obstruction of paranasal sinus drainage; pressure
necrosis of nares
1. Prevention: avoid nasal intubations; cushion nares from tube and tape/ties.
2. Treatment: remove all tubes from nasal passages; administer antibiotics.
B. Tracheoesophageal fistula – pressure necrosis of posterior tracheal wall
resulting from overinflated cuff and rigid nasogastric tube
1. Prevention: inflate cuff with minimal amount of air necessary; monitor cuff
pressures q. 8 h.
2. Treatment: position cuff of tube distal to fistula; place gastrostomy tube for
enteral feedings; place esophageal tube for secretion clearance proximal to
fistula.
C. Mucosal lesions – pressure at tube and mucosal interface
1. Prevention: Inflate cuff with minimal amount of air necessary; monitor cuff
pressure q. 8 h.; use appropriate size tube.
2. Treatment: may resolve spontaneously; perform surgical interventions.
D. Laryngeal or tracheal stenosis – injury to area from end of tube or cuff,
resulting in scar tissue formation and narrowing of airway
1. Prevention: inflate cuff with minimal amount of air necessary; monitor cuff
pressure q. 8.h.; suction area above cuff frequently.
2. Treatment: perform tracheostomy; place laryngeal stint; perform surgical
repair.
E. Cricoid abcess – mucosal injury with bacterial invasion
1. Prevention: inflate cuff with minimal amount of air necessary; monitor cuff
pressure q. 8 h.; suction area above cuff frequently.
2. Treatment: perform incision and drainage of area; administer antibiotics.
4. Other common potential problems related to mechanical ventilation:
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.

PLAN OF CARE FOR THE VENTILATED PATIENT

Patient Goals:
Patient will have effective breathing pattern.
Patient will have adequate gas exchange.
Patient’s nutritional status will be maintained to meet body needs.
Patient will not develop a pulmonary infection.
Patient will not develop problems related to immobility.
Patient and/or family will indicate understanding of the purpose for mechanical
ventilation.

Nursing Diagnosis
Nursing Interventions
Rationale
Ineffective breathing pattern r/t ____________________________.
Observe changes in respiratory rate and depth; observe for SOB and use of
accessory muscles.
An increase in the work of breathing will add to fatigue; may indicate patient
fighting ventilator.
.
Observe for tube misplacement- note and post cm. Marking at lip/teeth/nares
after x-ray confirmation and q. 2 h.
Indicates correct position to provide adequate ventilation.
.
Prevent accidental extubation by taping tube securely, checking q.2h.;
restraining/sedating as needed.
Avoid trauma from accidental extubation, prevent inadequate ventilation and
potential respiratory arrest.
.
Inspect thorax for symmetry of movement.
Determines adequacy of breathing pattern; asymmetry may indicate
hemothorax or pneumothorax.
.
Measure tidal volume and vital capacity.
Indicates volume of air moving in and out of lungs.
.
Asses for pain
Pain may prevent patient from coughing and deep breathing.
.
Monitor chest x-rays
Shows extent and location of fluid or infiltrates in lungs.
.
Maintain ventilator settings as ordered.
Ventilator provides adequate ventilator pattern for the patient.
.
Elevate head of bed 60-90 degrees.
This position moves the abdominal contents away from the diaphragm, which
facilitates its contraction.

Impaired gas exchange r/t alveolar-capillary membrane changes

Monitor ABG’s.
Determines acid-base balance and need for oxygen.
.
Assess LOC, listlessness, and irritability.
These signs may indicate hypoxia.
.
Observe skin color and capillary refill.
Determine adequacy of blood flow needed to carry oxygen to tissues.
.
Monitor CBC.
Indicates the oxygen carrying capacity available.
.
Administer oxygen as ordered.
Decreases work of breathing and supplies supplemental oxygen.
.
Observe for tube obstruction; suction prn; ensure adequate humidification.
May result in inadequate ventilation or mucous plug.
.
Reposition patient q. 1-2 h.
Repositioning helps all lobes of the lung to be adequately perfused and
ventilated.
Potential altered nutritional status: less than body requirements r/t NPO status
Monitor lymphocytes and albumin.
Indicates adequate visceral protein.
.
Provide nutrition as ordered, e.g. TPN, lipids or enteral feedings.
Calories, minerals, vitamins, and protein are needed for energy and tissue repair.
.
Obtain nutrition consult.
Provides guidance and continued surveillance.
Potential for pulmonary infection r/t compromised tissue integrity.
Secure airway and support ventialtor tubing.
Prevent mucosal damage.
.
Provide good oral care q. 4 h.; suction when need indicated using sterile
technique; handwashing with antimicrobial for 30 seconds before and after
patient contact; do not empty condensation in tubing back into cascade.
Measures aimed at prevention of nosocomial infections.
.
Use disposable saline irrigation units to rinse in-line suction; ensure ventilator
tubing changed q. 7 days, in-line suction changed q. 24 h.; ambu bags changes
between patients and whenever become soiled.
IAW Infection Control Policy and Respiratory Therapy Standards of Care for CCNS.
Potential for complications r/t immobility.
Assess for psychosocial alterations.
Dependency on ventilator with increased anxiety when weaning; decreased
ability to communicate; social isolation/alteration in family dynamics.
.
Assess for GI problems. Preventative measures include relieving anxiety,
antacids or H2 receptor antagonist therapy, adequate sleep cycles, adequate
communication system.
Most serious is stress ulcer. May develop constipation.
.
Observe skin integrity for pressure ulcers; preventative measures include turning
patient at least q. 2 h.; keep HOB < 30 degrees with a 30 degree side-lying
position; use pressure relief mattress or turning bed if indicated; follow
prevention of pressure ulcers plan of care; maintain nutritional needs.
Patient is at high risk for developing pressure ulcers due to immobility and
decreased tissue perfusion.
.
Maintain muscle strength with active/active-assistive/passive ROM and prevent
contractures with use of span-aids or splints.
Patient is at risk for developing contractures due to immobility, use of paralytics
and ventilator related deficiencies.
Knowledge deficit r/t intubation and mechanical ventilation
Explain purpose/mode/and all treatments; encourage patient to relax and breath
with the ventilator; explain alarms; teach importance of deep breathing; provide
alternate method of communication; keep call bell within reach; keep informed
of results of studies/progress; demonstrate confidence.
Reduce anxiety, gain cooperation and participation in plan of care.