1. Critical Care

2. Airway Management & Mechanical Ventilation Basics
• The goal of airway management is to ensure that
the patient has a patent airway through which
effective ventilation can take place.
• An obstructed airway causes the body to be
deprived of oxygen and, if ventilation isn’t
reestablished, causes brain death within minutes.
• Mechanical Ventilation is ventilation of the lungs
by artificial means usually by a ventilator.
• A ventilator delivers gas to the lungs with either
negative or positive pressure.

3. Indications
1. The patient experiencing respiratory failure or
arrest .
2. Any patient experiencing respiratory distress with
impaired gas exchange or increased work of
breathing before they reach the point of respiratory
arrest.
3. Hypercapnia & hypoxemia.
Airway Compromise –
airway
patency is in doubt or
patient may
be at risk of losing patency
Need to Protect the Airway
For some reason the
patient’s ability to sneeze,
gag or cough has been
dulled and aspiration is
possible.

4. When a patient’s desire to not be resuscitated
has been expressed and is documented in the
patient’s chart

5. Role of the Nurse
• Monitoring the patient’s respiratory status.
• Keep an eye on any equipment required by the patient, including
ventilators and monitoring equipment, and to respond to monitor
alarms.
• Notifying the respiratory therapist when mechanical problems occur
with the ventilator, and when there are new physician orders that call
for changes in the settings or the alarm parameters
• The nurse is responsible for documenting frequent respiratory
assessments.

6. Adult female
Adult male
8.0
9.0

8. Check and Assemble Equipment:
Oxygen flowmeter and O2 tubing
Suction apparatus and tubing
Suction catheter or yankauer
Ambu bag and mask
Laryngoscope with assorted blades
3 sizes of ET tubes
Stylet
Stethoscope
Tape
Syringe
Magill forceps
Towels for positioning

9. • Position your patient into the sniffing
position
• Pre-oxygenate with 100% oxygen to
provide apneic or distressed patient with
reserve while attempting to intubate.
• Do not allow more than
30 seconds to any
intubation attempt.
• If intubation is
unsuccessful, ventilate
with 100% oxygen for
3-5 minutes before a
reattempt.

10. After displacing the epiglottis insert the
ETT.
• The depth of the tube for a male patient on
average is 21-23 cm at teeth
• The depth of the tube on average for a female
patient is 19-21 at teeth.

11. Confirm tube
position:
By auscultation of the chest
Bilateral chest rise
Tube location at teeth
CO2 detector – (esophageal
detection device)
Stabilize the ETT

12. Ventilators
There are two general kinds of ventilators:
• Pressure-cycle
• Volume-cycle

13. Operation and Maintenance
• Many ventilators are now computerized and have a user-
friendly control panel. Toactivate various modes, settings, and
alarms, the appropriate key need only be pressed.
• Ventilators are electrical equipment and must be pluggedin.
• There should be a manual resuscitation bag at the bedside of
every patient receiving mechanical ventilation, so they can be
manually ventilated if needed.
• When mechanical ventilation is initiated, the ventilatorgoes
through a self-test to ensure that it’s working properly.
The ventilator tubing should be changed every 24 hours
and another self-test run afterwards.
The bacteria filters should be checked for occlusions or
tears and the water traps

14. Ventilator Settings
• Ventilator settings are ordered by the physician
and are individualized for each patient.
• Ventilators are designed to monitor many
components of the patient’s respiratory status.
Various alarms and parameters can be set to warn
healthcare providers that the patient is having
difficulty with the settings.

15. Respiratory Rate (RR)
• The respiratory rate is the number of breaths thatthe
ventilator delivers to the patient each minute.
• The rate chosen depends on the tidal volume, the typeof
pulmonary pathology, and the patient’s targetPaCO2.
Tidal Volume (VT)
The tidal volume is the volume of gas the ventilator
delivers to the patient with each breath.
The usual setting is 5-15 cc/kg, based oncompliance,
resistance, and type of pathology.
Inspiratory: Expiratory (I:E) Ratio
The I:E ratio is usually set at 1:2 or 1:1.5 toapproximate
the normal physiology of inspiration and expiration.

16. Fractional Inspired Oxygen (FIO2)
• The fractional inspired oxygen is the amount of
oxygen delivered to the patient.
• It can range from 21% (room air) to 100%.
• It’s recommended that the FIO2 be set at 1.0
(100%) upon the initiation of mechanical
ventilation.
Most ventilators have a temporary 100%
oxygen setting that delivers 100% oxygen for
only a few breaths. This should always be used
prior to and after suctioning; during
bronchoscopy, chest physio-therapy, or other
stressful procedures; and during patient
transport.

17. Pressure Limit
• The pressure limit regulates the amount of
pressure the volume-cycled ventilator can
generate to deliver the preset tidal volume.
• Because high pressures can cause lung injury, it’s
recommended that the plateau pressure not
exceed 35 cm H20.
High pressure can be that the patient’s airway
is obstructed with mucus.
It can also be caused by the patient coughing,
biting on the ETT, breathing against the
ventilator, or by a kink in the ventilator tubing.
The high pressure is usually resolved with
suctioning

18. Ventilators Settings
SETTING FUNCTION USUAL PARAMETERS
Respiratory Rate (RR) Number of breaths delivered
by the ventilator per minute
Usually 4-20 breaths
per minute
Tidal Volume (VT) Volume of gas delivered
during each ventilator breath
Usually 5-15 cc/kg
Maximum amount of
pressure the ventilator can
use to deliver breath
Amount of oxygen delivered
by ventilator to patient
21% to 100%; usually set to
keep PaO2 > 60 mm Hg or SaO2
> 90%
Inspiratory: Expiratory (I:E)
Ratio
Length of inspiration
compared to length of
expiration
Usually 1:2 or 1:1.5 unless
inverse ratio ventilation is
required
Pressure
Limit
Maximum amount of
pressure the ventilator can
use to deliver breath
10-20 cm H2O above peak
inspiratory pressure; maximum
is 35 cm H2O

19. Ventilator Modes
• Mode refers to how the machine will ventilate the
patient in relation to the patient’s own respiratory
efforts.
• There is a mode for nearly every patient situation, plus
many can be used in conjunction with each other.
Control Ventilation (CV)
• CV delivers the preset volume or pressure regardless of
the patient’s own inspiratory efforts. This mode is used
for patients who are unable to initiate a breath.

20. Assist-Control Ventilation (A/C)
• A/C delivers the preset volume or pressure in response to the
patient’s own inspiratory effort, but will initiate the breath if the
patient does not do so within the set amount of time.
• Any inspiratory attempt by the patient triggers a ventilator breath.
• The patient may need to be sedated to limit the number of
spontaneous breaths since hyperventilation can occur.
• This mode is used for patients who can initiate a breath but who have
weakened respiratory muscles.

21. Synchronous Intermittent
Mandatory Ventilation (SIMV)
• SIMV was developed as a result of the problem of high
respiratory rates associated with A/C.
• SIMV delivers the preset volume or pressure and rate
while allowing the patient to breathe spontaneously in
between ventilator breaths.
• is used as a primary mode of ventilation, as well as a
weaning mode.
• The disadvantage of this mode is that it may increase
the work of breathing and respiratory muscle fatigue.

22. Pressure Support Ventilation (PSV)
• PSV is preset pressure that augments the patient’s
spontaneous inspiratory effort and decreases the
work of breathing.
• The patient completely controls the respiratory
rate and tidal volume.
• PSV is used for patients with a stable respiratory
status and is often used with SIMV to overcome
the resistance of breathing through ventilator
circuits and tubing.

23. Positive End Expiratory Pressure (PEEP)
• PEEP is positive pressure that is applied by the
ventilator at the end of expiration.
• This mode does not deliver breaths, but is used as
an adjunct to CV, A/C, and SIMV to improve
oxygenation by opening collapsed alveoli at the
end of expiration.
• Complications from the increased pressure can
include decreased cardiac output, pneumothorax,
and increased intracranial pressure.

24. Constant Positive Airway Pressure (CPAP)
• CPAP is similar to PEEP except that it works only
for patients who are breathing spontaneously.
• The effect of both is comparable to inflating a
balloon and not letting it completely deflate
before inflating it again.
• CPAP can also be administered using a mask and
CPAP machine for patients who do not require
mechanical ventilation, but who need respiratory
support

25. Ventilators Modes
MODE FUNCTION CLINICAL USE
Control Ventilation (CV)
Delivers preset volume or pressure
regardless of patient’s own
inspiratory efforts
Usually used for
patients who are apneic
Assist-Control Ventilation (A/C)
Delivers breath in response to
patient effort and if patient fails to
do so within preset amount of time
Usually used for spontaneously
breathing patients with weakened
respiratory muscles
Synchronous Intermittent
Mandatory Ventilation (SIMV)
Ventilator breaths are synchronized
with patient’s respiratory effort
Usually used to wean patients from
mechanical ventilation
Pressure Support Ventilation (PSV)
Preset pressure that augments the
patient’s inspiratory effort and
decreases breathing work
Often used with SIMV during
weaning
Positive End Expiratory Pressure
(PEEP)
Positive pressure applied at the
end of expiration
Used with CV, A/C, and SIMV to
improve oxygenation by opening
collapsed alveoli
Constant Positive Airway Pressure
(CPAP)
Similar to PEEP but used only with
spontaneously breathing patients
Maintains constant positive
pressure in airways so resistance is
decreased

26. Alarms and Common Causes
High PressureLimit Low Pressure High Respiratory Rate Low Exhaled Volume
•Secretions in ETT/airway
or condensation in tubing
• Kink in vent tubing
• Patient biting on ETT
•Patient coughing,
gagging, or trying to talk
•Increased airway
pressure from
bronchospasm or
pneumothorax
•Ventilator tubing not
connected
• Displaced ETT or
tracheostomy tube
• Patient anxiety or pain
• Secretions in ETT/airway
• Hypoxia
• Hypercabnia
•Ventilator tubing not
connected
• Leak in cuff or
inadequate cuff seal
•Occurrence of another
alarm preventing full
delivery of breath

27. Weaning & Extubation
• It is usually a gradual process.
• The modes of mechanical ventilation are gradually
changed to allow the patient to initiate more
breaths while the ventilator provides less.
• Weaning should not be attempted until the
patient’s respiratory status is stable and they are
arousals and able to follow commands.
• Weaning is accomplished by decreasing the number
of breaths supplied by the ventilator, as well as by
changing the way in which those breaths are
delivered to the patient.

28. Role of Nurse Before Weaning:
 Assess readiness for weaning
 Ensure that the weaning criteria / parameters are met.
 Explain the process of weaning to the patient and offer reassurance to the patient.
 Initiate weaning in the morning when the patient isrested.
 Elevate the head of the bed & Place the patientupright
 Ensure a patent airway and suction if necessary before a weaningtrial,
 Provide for rest period on ventilator for 15 – 20 minutes after suctioning.
 Ensure patient’s comfort & administer pharmacological agents for comfort, suchas
bronchodilators or sedatives as indicated.
 Help the patient through some of the discomfort andapprehension.
 Support and reassurance help the patient through the discomfort andapprehension
as remains with the patient after initiation of the weaningprocess.
 Evaluate and document the patient’s response toweaning.

29. Extubation
• The nurse should obtain the ABG prior to the weaning.
• Once the physician’s order to extubate is received, the
nurse and RT coordinate a time when they can both be
in the patient’s room.
• The RT is usually responsible for assembling the oxygen
delivery system to be used after extubation.
• The nurse should explain the procedure to the patient
and prepare suction. The patient should be sitting up at
least 45 degrees.
• Prior to extubating, the patient should be suctioned
both via the ETT and orally.
• All fasteners holding the ETT should be loosened.

30. Post-Extubation Care
• Humidified oxygen
• Respiratory exercises
• Assessment and monitoring
• Prepare for intubation

31. TROUBLESHOOTING
• Anxious Patient
• Can be due to a malfunction of the ventilator
• Patient may need to be suctioned
• Frequently the patient needs medication for anxiety or sedation
to help them relax
• Attempt to fix the problem
• Call your RT

32. Accidental Extubation
• Role of the Nurse:
• Ensure the Ambu bag is attached to the oxygenflowmeter
and it is on!
• Attach the face mask to the Ambu bag and after ensuringa
good seal on the patient’s face; supply the patient with
ventilation.
• Bag the patient and call for your RT.

33. OTHER
• Anytime you have concerns, alarms,
ventilator changes or any other problem
with your ventilated patient.
– Call for your RT
– NEVER hit the silence button!