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Intensive Care Nursing/Mechanical Ventilator Management

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Objectives

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By end of reading, learner will be able to

  1. List different modes of mechanical ventilation
  2. Recognize methods of troubleshooting based on alarms
  3. Remember normal pressure ranges
  4. Recognize critical lab values
  5. Calculate minute ventilation volumes

Terminology

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Common Terminology Associated with Ventilators
Fraction of Inspired Oxygen (FiO2)

Oxygen concentration being administered via ventilator. Ranges from room air (0.21 or 21%) to full oxygen support (1.0 or 100%).[1]

Minute Volume (Ve/MV)

Amount of air inhaled (or exhaled depending on how the ventilator measures) in a minute period of time. Often measured in Liters/minute (L/min).[1] In fully ventilator dependent patients it is calculated as MV = f * Tv

Peak Pressure (PIP/PPeak)

The amount of force required to push a volume of air into the lungs.[1] This is based on various patient specific factors: airway resistance, chest/lung wall recoil, etc. Often measured in centimeters of water (cmH2O).

Plateau Pressure (PPlat)

The amount of force to distend the lung measured by an inspiratory pause.[1] Often measured in centimeters of water (cmH2O).

Positive End-Expiratory Pressure (PEEP)

The amount of force maintained after exhalation.[1] Often measured in centimeters of water (cmH2O).

Respiratory Rate or Frequency (RR/f)

Breaths per minute the ventilator delivers.[1] If the patient is spontaneously breathing this will fluctuate.

Tidal Volume (Vt/TV)

Amount of air inhaled (or exhaled depending on how the ventilator measures) in each breath.[1] Often measured in mL/Kg.

 

Ventilator Modes

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Ventilator modes (table) and settings should be chosen based on the needs of the ventilated patient. Nomenclature of mechanical ventilation may vary based on device and location of care, however modes are typically classified as pressure controlled (i.e. PC-CMV, CPAP, etc.) and volume controlled (i.e. VC-CMV, IMV, etc.).[1][2][3] Pressure-controlled modes will deliver air up to a set pressure limit with variable volumes being delivered, whereas volume-controlled modes will provide a set volume of air but allows for variable airway pressure.[1][2] Ventilator weaning is generally done with a spontaneous breathing trial (SBT) and ventilator setting are adjusted to approximate breathing without the Ventilator and/or artificial airway (i.e. PSV, CPAP, etc.).[1][3]


Common Alarms

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Being aware of the ventilator being utilized settings, alarms, and functionality as it is crucial to being able to troubleshoot alarms as they come up. The first task to perform is to assess the patient, to ensure their safety throughout the time determining and correcting the abnormality with the ventilated patient and/or ventilator. Common alarms are listed with common solutions to correct the abnormality with the patient/ventilator, the wording which appears on the ventilator during alarms may vary from the verbiage listed below. Alarms are grouped together based on similar causes

  • Elevated pressure / high airway pressure / high PIP / high Ppeak: Patient biting on tube, mucous (plug) in tube, patient coughing/hiccupping, kinked tubing, bronchospasm, patient attempting to speak

    [1]
  • Apnea / ventilator disconnect / low minute volume / low pressure: Disconnected/loose circuit connection with air leak, patient not breathing (while on patient driven ventilator modes), patient over sedated, self-extubation

    [1]
  • High minute volume (high MV, etc.) / High respiratory rate (high rate, frequency high, etc.) / Tidal volume elevated (Tv high, Vt high, etc.): Patient anxiety, air leak, patient agitation, increased lung compliance

    [1]

    Arterial Blood Gas Basics

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    Reading and interpreting an arterial blood gas (ABG) after sample collection is crucial to being able to manipulate ventilator settings appropriately for your patient to have adequate ventilation. See table below for normal ranges for arterial blood gas values which are frequently reported.

    Commonly reported ABG items and normal values
    pH 7.35-7.45
    Partial pressure of oxygen (PaO2) 75-100 mmHg
    Partial pressure of carbon dioxide (PaCO2) 35-45 mmHg
    Bicarbonate (HCO3) 22-26 mEq/L
    Oxygen saturation (O2 Sat) 94-100%

    Activities

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    1. ICU Nurse Ventilator Management Worksheet
    2. ICU Nurse Ventilator Management Quiz

    See Also

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    1. Airway Adjuncts
    2. Proning in the ICU

    References

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    1. ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 1.11 1.12 Grossbach, I.; Chlan, L.; Tracy, M. F. (2011-06-01). "Overview of Mechanical Ventilatory Support and Management of Patient- and Ventilator-Related Responses". Critical Care Nurse 31 (3): 30–44. doi:10.4037/ccn2011595. ISSN 0279-5442. http://ccn.aacnjournals.org/cgi/doi/10.4037/ccn2011595. 
    2. ↑ 2.0 2.1 Gallagher, John J. (2018). "Alternative Modes of Mechanical Ventilation". AACN Advanced Critical Care 29 (4): 396–404. doi:10.4037/aacnacc2018372. ISSN 1559-7768. http://acc.aacnjournals.org/lookup/doi/10.4037/aacnacc2018372. 
    3. ↑ 3.0 3.1 Byrd, Ryland (2018-03-20). Mechanical Ventilation. https://emedicine.medscape.com/article/304068-overview. 
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