Professional Documents
Culture Documents
Cardiovascular System
• PPV can affect circulation because of the transmission of increased mean airway pressure to
the thoracic cavity.
• With increased intrathoracic pressure, thoracic vessels are compressed resulting in decreased
venous return to the heart, decreased left ventricular end-diastolic volume (preload),
decreased CO, and hypotension. Mean airway pressure is further increased if titrating PEEP
(>5 cm H2O) to improve oxygenation.
Pulmonary System
• As lung inflation pressures increase, risk of barotrauma increases.
o Patients with compliant lungs (e.g., COPD) are at greater risk for barotraumas.
o Air can escape into the pleural space from alveoli or interstitium, accumulate, and
become trapped causing a pneumothorax.
o For some patients, chest tubes may be placed prophylactically.
• Pneumomediastinum usually begins with rupture of alveoli into the lung interstitium;
progressive air movement then occurs into the mediastinum and subcutaneous neck tissue.
This is commonly followed by pneumothorax.
• Volutrauma in PPV relates to the lung injury that occurs when large tidal volumes are used
to ventilate noncompliant lungs (e.g., ARDS).
o Volutrauma results in alveolar fractures and movement of fluids and proteins into the
alveolar spaces.
• Hypoventilation can be caused by inappropriate ventilator settings, leakage of air from the
ventilator tubing or around the ET tube or tracheostomy cuff, lung secretions or obstruction,
and low ventilation/perfusion ratio.
o Interventions include turning the patient every 1 to 2 hours, providing chest physical
therapy to lung areas with increased secretions, encouraging deep breathing and
coughing, and suctioning as needed.
• Respiratory alkalosis can occur if the respiratory rate or VT is set too high (mechanical
overventilation) or if the patient receiving assisted ventilation is hyperventilating.
o If hyperventilation is spontaneous, it is important to determine the cause (e.g.,
hypoxemia, pain, fear, anxiety, or compensation for metabolic acidosis) and treat it.
Neurologic System
• In patients with head injury, PPV, especially with PEEP, can impair cerebral blood flow.
• Elevating the head of the bed and keeping the patient’s head in alignment may decrease the
deleterious effects of PPV on intracranial pressure.
Gastrointestinal System
• Ventilated patients are at risk for developing stress ulcers and GI bleeding.
• Reduction of CO caused by PPV may contribute to ischemia of the gastric and intestinal
mucosa and possibly increase the risk of translocation of GI bacteria.
• Gastric and bowel dilation may occur as a result of gas accumulation in the GI tract from
swallowed air. Decompression of the stomach can be accomplished by the insertion of an
NG/OG tube.
• Immobility, sedation, circulatory impairment, decreased oral intake, use of opioid pain
medications, and stress contribute to decreased peristalsis. The patient’s inability to exhale
against a closed glottis may make defecation difficult predisposing the patient to
constipation.
Musculoskeletal System
• Maintenance of muscle strength and prevention of the problems associated with immobility
are important.
• Passive and active exercises, consisting of movements to maintain muscle tone in the upper
and lower extremities, should be done in bed.
• Prevention of contractures, pressure ulcers, foot drop, and external rotation of the hip and
legs by proper positioning is important.
Psychosocial Needs
• Patients may experience physical and emotional stress due to the inability to speak, eat,
move, or breathe normally.
• Tubes and machines may cause pain, fear, and anxiety.
• Ordinary activities of daily living such as eating, elimination, and coughing are extremely
complicated.
• Patients have identified four needs: need to know (information), need to regain control, need
to hope, and need to trust. When these needs were met, they felt safe.
• The nurse should encourage hope and build trusting relationships with the patient and
family.
• Patients receiving PPV usually require some type of sedation and/or analgesia to facilitate
optimal ventilation.
• At times the decision is made to paralyze the patient with a neuromuscular blocking agent to
provide more effective synchrony with the ventilator and increased oxygenation.
o If the patient is paralyzed, the nurse should remember that the patient can hear, see,
think, and feel.
o Intravenous sedation and analgesia must always be administered concurrently when
the patient is paralyzed.
o Assessment of the patient should include train-of-four (TOF) peripheral nerve
stimulation, physiologic signs of pain or anxiety (changes in heart rate and blood
pressure), and ventilator synchrony.
• Many patients have few memories of their time in the ICU, whereas others remember vivid
details.
• The most frequent site for disconnection is between the tracheal tube and the adapter.
• Alarms can be paused (not inactivated) during suctioning or removal from the ventilator and
should always be reactivated before leaving the patient’s bedside.
• Ventilator malfunction may also occur and may be related to several factors (e.g., power
failure, failure of oxygen supply).
• Patients should be disconnected from the machine and manually ventilated with 100%
oxygen if machine failure/malfunction is determined.
• Patients likely to be without food for 3 to 5 days should have a nutritional program
initiated.
• Enteral feeding via a small-bore feeding tube is the preferred method to meet caloric
needs of ventilated patients.
• The weaning process differs for patients requiring short-term ventilation (up to 3 days)
versus long-term ventilation (more than 3 days).
o Patients requiring short-term ventilation (e.g., after cardiac surgery) will experience
a linear weaning process.
o Patients requiring prolonged PPV will experience a weaning process that consists of
peaks and valleys.
• Weaning can be viewed as consisting of three phases. The preweaning, or assessment, phase
determines the patient’s ability to breathe spontaneously.
Weaning assessment parameters include criteria to assess muscle strength and
endurance, and minute ventilation and rapid shallow breathing index.
Lungs should be reasonably clear on auscultation and chest x-ray.
Nonrespiratory factors include the assessment of the patient’s neurologic
status, hemodynamics, fluid and electrolytes/acid-base balance, nutrition, and
hemoglobin.
Drugs should be titrated to achieve comfort without causing excessive
drowsiness.
o Evidenced-based clinical guidelines recommend a spontaneous breathing trial (SBT)
in patients who demonstrate weaning readiness, the second phase.
An SBT should be at least 30 minutes but no longer than 120 minutes and
may be done with low levels of CPAP, low levels of PS or a “T” piece.
Tolerance of the trial may lead to extubation but failure to tolerate a SBT
should prompt a search for reversible factors and a return to a nonfatiguing
ventilator modality.
• The use of a standard approach for weaning or weaning protocols have shown to decrease
ventilator days.
• Weaning is usually carried out during the day, with the patient ventilated at night in a rest
mode.
• The patient being weaned and the family should be provided with explanations regarding
weaning and ongoing psychologic support.
• The patient should be placed in a sitting or semirecumbent position and baseline vital signs
and respiratory parameters measured.
• During the weaning trial, the patient must be monitored closely for noninvasive criteria that
may signal intolerance and result in cessation of the trial (e.g., tachypnea, tachycardia,
dysrhythmias, sustained desaturation [SpO2 <91%], hypertension, agitation, anxiety,
sustained VT <5 ml/kg, changes in level of consciousness).
• The weaning outcome phase refers to the period when weaning stops and the patient is
extubated or weaning is stopped because no further progress is being made.
• After extubation, the patient should be encouraged to deep breathe and cough, and the
pharynx should be suctioned as needed.
• Vital signs, respiratory status, and oxygenation are monitored immediately following
extubation, within 1 hour, and per institutional policy.