Download 83. Leasure AR, Stirlen J, Lu SH. Prevention of ventilator

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.
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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.
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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.
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1. The amount of oxygen delivered by a ventilator is
a.
b.
c.
d.
fraction of inspired oxygen.
positive expiratory volume.
inspiratory pressure.
tidal volume.
2. Which of the following is a complication of mechanical
ventilation?
a.
b.
c.
d.
Cellulitis.
Atrial fibrillation.
Barotrauma.
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.
b.
c.
d.
ventricular arrhythmias and hypotension.
delirium and hypothermia.
stress ulcers and renal failure.
sinus infections and ventilator-associated pneumonia.
5. Suctioning a mechanically ventilated patient should be
done
a.
b.
c.
d.
every two hours.
only when it is clinically indicated.
if the patient has a temperature > 102° F.
when the patient is receiving sedation with a benzodiazepine.
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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.
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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.
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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.
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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. Ventilatordelivered 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
Respiratory rate and tidal volume are adjusted to deliver a specific
minute ventilation. A patient cannot trigger the ventilator to deliver a
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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
Respiratory rate and tidal volume are adjusted to deliver a specific
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.
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
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 overdistention 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
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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 ventilatorassociated lung injury are acidemia, ARDS, blood transfusion, high
plateau airway pressure, hyperoxia, tidal volume > 6 mL/kg, and
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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 hospitalacquired 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
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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
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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
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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 Nacetylcysteine 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.
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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
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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
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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.
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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.
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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.
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
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
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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
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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) evidencebased 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,
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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, socalled 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
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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
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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.
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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
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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
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disconnected from the ventilator for 30 minutes and placed on a Tpiece 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.
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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.
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Hypercapnia:
Hypercapnia is an elevation of the arterial carbon dioxide level (P aCO2).
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.
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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 P aCO2.
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.
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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.
b.
c.
d.
2.
Which of the following is a complication of mechanical
ventilation?
a.
b.
c.
d.
3.
fraction of inspired oxygen.
positive expiratory volume.
inspiratory pressure.
tidal volume.
Cellulitis.
Atrial fibrillation.
Barotrauma.
Pulmonary fibrosis.
True or False: High arterial oxygen levels are always
benign.
a. True
b. False
4.
Common complications of mechanical ventilation include
a.
b.
c.
d.
ventricular arrhythmias and hypotension.
delirium and hypothermia.
stress ulcers and renal failure.
sinus infections and ventilator-associated pneumonia.
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5.
Suctioning a mechanically ventilated patient should be
done
a.
b.
c.
d.
6.
Drugs used to sedate patients who are mechanically
ventilated are
a.
b.
c.
d.
7.
Bipolar disorder
Dissociative state
Delirium
Major depression
Patients who are mechanically ventilated will benefit from
a.
b.
c.
d.
9.
benzodiazepines and propofol.
selective serotonin re-uptake inhibitors and haloperidol.
fentanyl and dextromethorphan.
ketamine and lithium carbonate.
Which of these is a common complication of mechanical
ventilation?
a.
b.
c.
d.
8.
every two hours.
only when it is clinically indicated.
if the patient has a temperature > 102° F.
when the patient is receiving sedation with a benzodiazepine.
continual use of sedation until immediately before weaning.
abrupt cessation of sedative drugs.
low doses of sedative and high doses of analgesics.
sedation vacations.
Oral care with _______________ can reduce the
incidence of ventilator-associated pneumonia.
a.
b.
c.
d.
bacitracin
chlorhexidine
hydrogen peroxide
isopropyl alcohol
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10.
Readiness to wean from a ventilator is assessed, in part,
by
a.
b.
c.
d.
11.
________________ should be used cautiously in patients
who have hepatic or renal impairment as decreased
metabolism, excretion and drug accumulation may occur.
a.
b.
c.
d.
12.
Controlled mechanical ventilation (CMV)
Assist-control (AC) ventilation
A spontaneous breathing trial
Synchronized intermittent mandatory ventilation (SIMV)
Using ______________ to sedate a patient who is
mechanically ventilated is an off-label use of the drug.
a.
b.
c.
d.
14.
Ketamine
Benzodiazepines
Propofol
Dexemedetomidine
______________________________is used for patients
who are pharmacologically paralyzed or comatose.
a.
b.
c.
d.
13.
a lung scan.
an FiO2 requirement of < 30%.
a spontaneous breathing trial.
successive normal chest x-rays.
fentanyl
benzodiazepines
ketamine
butyrophenones
Fentanyl is a powerful opioid analgesic
a.
b.
c.
d.
but is inferior to using hypnotic sedatives.
and has a slow onset of action.
but is more likely to cause hypotension.
and an effective sedative for mechanically ventilated patients.
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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
6. a
11. a
2. c
7. c
12. a
3. b
8. d
13. c
4. d
9. b
14. d
5. b
10. c
15. a
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