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Lippincott Nursing Pocket Card - September 2021

Caring for the Mechanically Ventilated Patient

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About Mechanical Ventilation

Mechanical ventilation is utilized in intensive care and long-term care settings to assist patients who require additional respiratory support. This handy reference guide provides critical patient care essentials, tips for trouble-shooting ventilator alarms, and potential complications.

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Care Essentials for Patients on Mechanical Ventilation

  • Maintain a patent airway. Per policy, note endotracheal (ET) tube position (centimeters) and confirm that it is secure.
  • Assess oxygen saturation, bilateral breath sounds for adequate air movement, and respiratory rate per policy.
  • Check vital signs per policy, particularly blood pressure after a ventilator setting is changed. Mechanical ventilation increases intrathoracic pressure, which could affect blood pressure and cardiac output.
  • Assess patient’s pain, anxiety and sedation needs and medicate as ordered.
  • Complete bedside check: ensure suction equipment, bag-valve mask and artificial airway are functional and present at bedside. Verify ventilator settings with the prescribed orders.
  • Suction patient only as needed, per facility policy; hyperoxygenate the patient before and after suctioning and do not instill normal saline in the ET tube; suction for the shortest time possible and use the lowest pressure required to remove secretions. Monitor for upper airway trauma as evidenced by new blood in secretions.
  • Monitor arterial blood gas (ABG) after adjustments are made to ventilator settings and during weaning to ensure adequate oxygenation and acid-base balance.
  • To minimize the risk for ventilator-associated pneumonia (VAP), implement best practices such as strict handwashing; aseptic technique with suctioning; elevating head of bed 30-45 degrees (unless contraindicated); providing sedation vacations and assessing patient’s readiness to extubate; providing peptic ulcer disease prophylaxis; providing deep vein thrombosis prophylaxis; and performing oral care with chlorhexidine, per your facility policy.

VENTILATOR ALARMS
ALARM POTENTIAL CAUSES INTERVENTIONS
High peak inspiratory pressure (PIP) 
  • Blockage of ET tube (secretions, food, kinked tubing, patient biting on ET tube)
  • Coughing
  • Bronchospasm
  • Lower airway obstruction
  • Pulmonary edema
  • Pneumothorax
  • Ventilator/patient dyssynchrony 
  • Assess lung sounds.
  • Suction airway for secretions.
  • Insert bite block or administer sedation per orders if patient is agitated or biting on ET tube.
  • Assess breath sounds for increased consolidation, wheezing, and bronchospasm; treat as ordered.
Low pressure alarm
  • Air leak in ventilator circuit or in the ET tube cuff
  • Locate leak in ventilator system.
  • Check pilot balloon as an indicator of ET tube cuff failure.
  • Replace tubing as needed, per policy.
Low minute ventilation
  • Low air exchange due to shallow breathing or too few respirations
  • Check for disconnection or leak in the system.
  • Assess patient for decreased respiratory effort.
Low O2 saturation (SpO2)
  • Pulse oximeter malpositioned
  • SpO2 cable unplugged
  • Connective tissue disorder, such as Raynaud’s disease or scleroderma
  • Ensure ventilator oxygen supply is connected.
  • Observe pulse oximeter waveform on the monitor.
  • Ensure pulse oximeter is positioned correctly.
  • Verify all cables are plugged in.
  • Assess patient for respiratory distress. 
  • Assess for perfusion.

Apnea
  • Breaths are not being taken by the patient or triggered on the ventilator
  • Assess patient effort.
  • Check system for disconnections.
 
COMPLICATIONS RELATED TO MECHANICAL VENTILATION
PATIENT COMPLICATION POTENTIAL CAUSES INTERVENTIONS
Cardiovascular issues
  • Decrease in venous return to the heart due to positive pressure applied to the lungs.
  • Assess for adequate volume status by checking heart rate, blood pressure, central venous pressure and urine output. 
  • Assess patient for increasing autopeep, which can increase risk for cardiac tamponade.
Barotrauma/pneumothorax 
  • Positive pressure applied to lungs.
  • Elevated mean airway pressures may rupture alveoli.
  • Notify healthcare provider.
  • Prepare patient for possible chest tube insertion.
  • Avoid high pressure settings for patients with chronic obstructive pulmonary disease (COPD), acute respiratory distress syndrome (ARDS), or history of pneumothorax.
Infection
  • Breaks in ventilator circuit.
  • Decreased mobility.
  • Impaired cough reflex.
  • Use aseptic technique.
  • Provide frequent mouth care.
  • Support proper nutritional status.

References:

Han, M. (2019, June 21). Management and prognosis of patients requiring prolonged mechanical ventilation. UpToDate. https://www.uptodate.com/contents/management-and-prognosis-of-patients-requiring-prolonged-mechanical- ventilation

Hyzy, R. & Sparron, J. (2020, April 5). Overview of mechanical ventilation. UpToDate. https://www.uptodate.com/contents/overview-of-initiating-invasive-mechanical-ventilation-in-adults-in-the-intensive-care-unit
 
Kane, C., & York, N. (2012). Understanding the Alphabet Soup of Mechanical Ventilation. Dimensions of Critical Care Nursing, 31(4), 217-222. https://doi.org/10.1097/DCC.0b013e318256e2fd
 
Miller, N. (2013). Set the Stage for Ventilator Settings. Nursing Made Incredibly Easy!, 11(3), 44-52. doi: 10.1097/01.NME.0000428429.60123.f7

Weigand, D. (2017). Procedure Manual for High Acuity, Progressive and Critical Care (7th ed.). Elsevier. St. Louis.

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