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UKCC category: Care enhancement.

Mechanical ventilation
Article 503. Henderson N (1999) Mechanical ventilation. Nursing Standard. 13, 44, 49-53. Date of acceptance: June 7 1999

Nigel Henderson RGN, BSc(Hons), DipN, RNT, is Project Nurse, Havering Hospitals NHS Trust.

In this article Nigel Henderson discusses the nursing role in the mechanical ventilation of patients. He describes the different ventilator modes, and the physical and psychological care required by ventilated patients.
Aims and intended learning outcomes The aim of this article is to equip the reader with a basic knowledge of the use of mechanical ventilators in respiratory support. Such knowledge includes the different types of ventilator, the modes available and the nursing care required. After reading this article you should be able to: I Describe the different types of ventilator. I Describe the basic modes of ventilation which are available. I Give a basic description of how each ventilator mode functions. I Discuss the basic physical care required for a ventilated patient. I Discuss the importance of the psychological care required by the ventilated patient. TIME OUT 1 To understand how mechanical ventilators operate, a basic understanding of the normal anatomy and physiology of breathing is required. Refer to a good physiology book of your choice and familiarise yourself with the concepts involved in normal breathing. Write down your understanding of the terms tidal volume and minute volume.

This article is the last in a series looking at new skills in nursing.

Basic concepts of mechanical ventilation To move a volume of air from one area to another, it is necessary to develop a pressure gradient where there is one area of high pressure and one area of low pressure. Once this is achieved, gas will move from the high to the low pressure area. In normal respiration the area of low pressure, the lungs, is generated by the use of respiratory muscles. When the chest wall expands, the increased volume of the lungs lowers the pressure in relation to atmospheric pressure. This causes the lungs to inflate as gas moves from the atmosphere into the lungs. This is the concept of negative pressure ventilation. This process was employed in early mechanical ventilation and the use of tank ventilators, or iron lungs, was common in the poliomyelitis epidemic of the late 1950s (Hinds 1987). The principle here was to generate a negative pressure around the patients body, thereby pulling the rib cage outwards and lowering the pressure within the lungs, causing air to be drawn in. The patient was required to be enclosed in a large metal tube attached to external pumps, with the patients head outside. This obviously presented a problem if physical care was required. Smaller devices, which just enclosed the chest, were also designed. All presented problems in that to july 21/vol13/no44/1999 nursing standard 49

Introduction The use of mechanical ventilation in intensive care units is a vital component of the care of critically ill patients. The novice to this area is usually overawed by the apparent complexity of such equipment. Ventilators have come a long way from the simple bellows type often visualised when discussing life support machines. Todays ventilators are far more complex. They are controlled by microprocessors and offer distinct advantages over those used during the early days of intensive care. While these machines are highly complex, the principles involved in their function and use are based on quite simple concepts, which can be understood by those new to this area of patient treatment. Development of non-invasive methods of ventilation has led to the use of such techniques within general ward areas and in the community. This dictates that nurses within these areas of care require the basic knowledge normally only held by those working in intensive care settings.

keywords
I Ventilation: mechanical I Intensive care nursing These key words are based on subject headings from the British Nursing Index. This article has been subject to double-blind review.

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function, an airtight seal was often difficult to obtain. During 1952 in Copenhagen, the use of positive pressure ventilation was described and this has now become the accepted way that people are ventilated (Hinds 1987). Here, the concept is to generate a higher pressure outside of the patient, causing the gas to be literally blown into the patients lungs, which have a lower pressure. This does present problems however, which will be discussed later. To generate the necessary pressure, access to the patients airway is required. This is normally obtained using an endotracheal (ET) or tracheostomy tube or, if non-invasive ventilation is desirable, by a tight, well sealed mask. The principle here is that a tight seal, either by inflation of the cuff found on ET tubes, or inflatable seals on face masks, is required to allow the generation of the pressures required. Positive pressure ventilation is the most common method of providing ventilatory support in the acute care setting (Sole and Fowler Byers 1997). The ventilator providing support can be grouped into three main types (Meyer Holloway 1993): I Volume cycled. I Time cycled. I Pressure cycled. Volume cycled ventilators In volume cycled machines, the controls are set to deliver a predetermined volume of gas. This is what is termed the tidal volume. The tidal volume is the amount of gas that is transferred during one inspiration, usually about 500ml for an average adult. However, with these ventilators, tidal volumes are controlled to deliver an amount, which may be greater than the patients normal tidal volume when unaided. This type of ventilator is used most commonly in critical care environments (Sole and Fowler Byers 1997). Timed cycled ventilators Here, the times of the inspiratory and expiratory components of a breath are controlled. Volume is dependent on the timings of the respiratory cycle. The timings of both phases are preset. Inspiration takes place during the whole of the inspiratory phase until the time limit is reached. It is not dependent on reaching a preset volume or pressure. Pressure cycled ventilators These ventilators use the pressure reading generated within the lungs as gas is being introduced. This pressure level is pre-set. Tidal volumes are therefore dependent on the time it takes to reach the pre-set pressure before expiration begins. With the introduction of microprocessors, leading to advanced forms of ventilation, modern ventilators may incorporate one or more of the above forms of ventilation (Sole and Fowler Byers 1997). TIME OUT 2 Visit your intensive care unit or, if working on a unit, investigate with the aid of an experienced practitioner and determine what types of ventilators are present. What type of modes can the ventilator be placed in? Write a list of such modes before reading the next section. Modes of ventilation Modern ventilators have been developed with different modes which allows an individualised ventilatory treatment plan responsive to the patients presenting pathology and needs. Within this article, the most common modes will be presented. These are intermittent positive pressure ventilation (IPPV), synchronised intermittent mandatory ventilation (SIMV), pressure controlled ventilation (PCV) and pressure support ventilation (PSV). IPPV In this mode, the ventilator is pre-set to deliver a volume of gas at a set rate, irrespective of what the patient is doing. This is volumed cycled ventilation. Once the pre-set volume is delivered, the expiratory phase is initiated allowing the patient to breathe out. Due to different manufacturers and ventilator models, it is often found that IPPV is labelled as either CMV (controlled mandatory ventilation) or VC (volume controlled). Often these terms are used interchangeably which may confuse the practitioner rather than clarify the functions. SIMV This mode is used to assist the patient in breathing, rather than fully controlling the respiratory cycle. In many respects it is the same as IPPV. A preset rate and volume is set, but between breaths, the patient can breathe unaided and unimpeded. However, a trigger window is present before the next pre-set breath is delivered. Should the patient begin to inspire during this window, the ventilator synchronises with the patient and the next pre-set breath is brought forward to coincide with the patients own inspiration. This form of ventilation is used as a weaning mode, since the amount of pre-set breaths can be decreased as patients become more effective in their respiratory effort. As time progresses, the preset breaths are decreased, leading to more patient breaths. This leads to increasing respiratory muscle tone and effectiveness. Pressure controlled ventilation In this mode, a preset pressure is set. Gas is then delivered until this preset pressure is achieved within the patients lungs. Tidal volume, therefore, is dependent on the volume of the lungs and the time taken to reach the pre-set pressure. Indeed this is useful where a condition can change the compliance of the patients lungs, and the generation of high pressures can have disastrous effects. For example, in patients with asthma or chronic lung pathologies, it can lead to the condition called barotrauma damage caused by pressure leading to a pneumothorax. Pressure support ventilation This mode not only provides a ventilatory mode in itself, but can also be used as an adjunct to another mode, such as SIMV. Here, there is no pre-set rate or volume. Instead a pressure level is set at which gas is delivered. For simplicity, there is the creation of a steeper pressure gradient between the ventilator and the patient. The patient creates a negative pressure within his or her lungs, as in a normal breath, thus creating the pressure gradient. Breathing therefore becomes easier, with larger tidal volumes being generated, requiring less energy expenditure by the patient. A good analogy is to imagine standing with a gale

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blowing in ones face: when the mouth is opened and a breath is taken, maximum inspiration takes place very quickly. controlled). Synchronisation can take place during inspiratory phases (SIMV) and also during expiratory phases. The authors experience has shown that this mode is gaining increased popularity in the intensive care area. Finally, one other mode of ventilation can be found within the community and ward setting. This is called non-invasive positive pressure ventilation (NIPPV), often called NIPPY. It is used in obstructive sleep apnoea and nocturnal home ventilation (Bersten 1997a). Another ventilatory support approach also includes the use of high frequency jet ventilation. While this is not a new form of ventilation, its use is limited to specialised units. Further developments in ventilatory support include the introduction of liquid ventilation using perfluorocarbon fluid (Tan and Oh 1997). Scientific validation of this method is still being undertaken. TIME OUT 3 Before reading the next section, try to observe the setting up of a ventilator. List all the values and items that require the attention of the operator before being commencing ventilation.

Adjuncts to ventilation Other controls often present on a ventilator are seen as an adjunct to the main ventilation mode, and as such, do not provide ventilation, but rather assist in spontaneous breathing or mechanical ventilation (Tan and Oh 1997). Such adjuncts include assist mode (Meyer Holloway 1993) or triggering (Tan and Oh 1997), positive end expiratory pressure (PEEP) and continuous positive airway pressure (CPAP). Assist mode Not all patients have their respiratory efforts depressed and it may sometimes be desirable to support their effort. Assist mode is one such adjunct. When the patient initiates a breath, a ventilator breath is delivered at the same time, provided the negative pressure the patient creates equals or exceeds a pre-set value. This is useful for occasional patient-initiated breaths. However, the breath delivered is at the pre-set volume for the mandatory breaths. This could cause an increase in overall breaths, leading to hyperventilation, and might suggest that the SIMV mode should be initiated. Positive end expiratory pressure (PEEP) Following expiration, the pressure within the lungs falls, and collapse of the alveoli may occur. This can be difficult to overcome and lead to decreased oxygenation and an increase in the amount of de-oxygenated blood entering the arterial system. To correct this, a pressure level is pre-set. This ensures that the lungs will always have a positive pressure at either the pre-set level or above. This maintains alveolar patency, ensuring adequate oxygenation of the blood. It serves, therefore, to increase lung volumes and may reduce the respiratory work required during spontaneous or patient-initiated breaths (Bersten 1997a). Continuous positive airway pressure (CPAP) To all intents and purposes, CPAP is PEEP. When PEEP is applied without other forms of ventilation it is called CPAP. Here lung pressures are always maintained at a pre-set level, as in PEEP, but the patient carries out all other respiratory functions. Experience has now shown that with the introduction of small flow generators and circuits, CPAP can be provided outside critical care environments. It can be performed noninvasively using tight fitting masks. This may make intubation and full mechanical ventilation unnecessary, and avoid the necessity of admission to intensive care. This form of ventilation can also be used in the community. Due to the tight fitting nature of the mask, patient compliance may be difficult, especially if the patient is disoriented. While the more basic forms of support have been discussed here, other forms of ventilation are also available. One such mode is that called biphasic positive airways pressure, or BIPAP. Ventilators with this function combine many of the properties found in other modes. Here the patient is cycled between two levels of CPAP. There is a pre-set minimum pressure level (PEEP/CPAP) and a maximum level (pressure

Preparation of ventilatory support Depending on the services provided within an intensive care unit, preparation of the ventilator might be the responsibility of adequately trained and experienced nurses. Checks that are undertaken are based on the manufacturers recommendations. Some ventilators perform electronic self-tests to determine that functions are within safe parameters. Once testing is complete, modes and settings can be selected. This will be determined by the anaesthetist and based on the requirements of the patients condition. Initial ventilator parameters may require adjustment depending on the patients response to these settings. Another consideration is whether humidification is required. It should be remembered that with the introduction of an endotracheal tube, the natural processes of humidification are bypassed and artificial humidification of inspired gases may be required (Bersten1997b). The choice of humidification device will be based on clinical need. Often a simple heat moisture exchange (HME) filter is utilised. Here, the patient gains humidification from a filter that uses the heat and moisture of expired gases to warm and humidify inspired gases as they pass through the filter. The added benefit is that some filters also provide microbial filtration. Electronic water baths placed within the ventilator circuit are also used. They use sterile water that is heated to a pre-set level. Inspired gases are passed over this heated water and become laden with moisture. Once the ventilator has been checked, settings adjusted and confirmation of parameters checked with medical personnel, the patient can be connected. The setting of alarms that monitor pressure levels and july 21/vol13/no44/1999 nursing standard 51

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volumes is of equal importance: these detect changes in the patient, allowing for adjustments in therapy to be initiated. Alarms can protect the patient, especially if accidental disconnection takes place. Conscious patients may be difficult to ventilate mechanically, so the use of sedation may be required. Hinds (1987) suggests that most patients will require sedation and that the past practice of bolus dosing with sedatives and accompanying peaks and troughs of conscious level are undesirable. Administration of sedation via a syringe pump is much more appropriate, providing a more constant level of consciousness. Indeed, experience has shown that the ideal level for sedation is where the patient is relaxed and pain free, but easily rousable. Muscle relaxation may be required, but this is dependent on patient needs and not for routine care. TIME OUT 4 Observe the physical care of a ventilated patient and list those components of the nursing role which specifically relate to ventilation. demands an aseptic technique and requires psychomotor and observation skills to detect adverse reactions. Physiotherapy and manual hyperinflation of the lungs is a valuable component of care with the mechanically ventilated patient (Hinds 1987). Regular monitoring of the ventilator parameters is required to determine any changes. These include tidal volumes, rate, pressure readings and whether the correct oxygen levels are being administered. Other parameters may include patient breathing activity, and some ventilators may provide a separation of patient and ventilator levels of respiratory activity. Technical means of observation may include the use of pulse oximetry and arterial blood sampling for blood gas analyses. Accurate fluid balance and haemodynamic monitoring is essential because of the effects of placing a positive pressure within the lungs. These include hypotension and inappropriate production of antidiuretic hormone (ADH), leading to fluid overload. The care outlined above is by no means complete, and ventilated patients will of course require attention to their hydration, nutritional state, nasal care and pressure sore prevention. Sedated patients will, of course, require the care normally provided for patients with altered levels of consciousness. Other side effects of mechanical ventilation are shown in Box 1. TIME OUT 5 Discuss the possible side effects of mechanical ventilation with an experienced ITU colleague. List these and then consult an appropriate text for the reasons they occur and their appropriate treatment.

Consideration now needs to be given to the care that a ventilated patient requires. Care can be placed into two areas, physical and psychological.

Physical care Patient safety is paramount and, as stated earlier, alarm parameters require adjustment to match the needs of the patient. Effective securing of the ventilator circuit and ET tube will ensure that disconnection and the risk of self-extubation is reduced. Care of the mouth and lips will necessitate that regular oral cleaning is undertaken. Experience has shown that ET tubes inserted orally can lead to pressure sores developing in the corners of the mouth and lips. Regular repositioning to alternate sides can alleviate this. Lips may become dry and require the application of a moisturising agent. Tapes used in securing the ET tube may require attention, since they can also lead to pressure sore development if too tight. The art of observation, that is, viewing the patient, cannot be understated. Skin colour and level of relaxation are good indicators of response to ventilation. Observing the rise and fall of the chest can determine whether the ET tube is correctly placed. Use of chest auscultation can determine air entry and allow the detection of bronchial secretions which may impair oxygenation. Observing sudden, abnormal chest movement, may be an indication of coughing and require the physical removal of secretions by suction. Suctioning of the airways is necessary because the patient cannot expectorate normally. The frequency of the procedure will be determined by assessment of the patients needs by the nurse. The procedure

TIME OUT 6 Consider the effects that ventilating a patient could have on the patients psychological wellbeing. Try to imagine yourself in such a position and the feelings that you might experience. How might your relatives or friends react to seeing you in such a situation? . Psychological care Patients in the critical care environment can suffer an insult to their person as a result of sensory disturbances that can have profound psychological effects, the most severe of which is the development of ITU psychosis (Barrie-Shevlin 1987, Clifford 1986, Dootson 1990). Mechanical ventilation can increase this insult, but its effects can be lessened with skilled nursing interventions. Loss of verbal communication is problematic. It can increase anxiety and stress, since normal communication lines with family, friends and staff are lost (Sole

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Box 1. Side effects of mechanical ventilation
I Barotrauma, leading to pneumothorax I Tension pneumothorax I Intubation of right main bronchus I Accidental extubation I Tracheal damage due to endotracheal tube cuff I Hypo- and hyper-ventilation I Acid-base balance disturbances I Infection I Ventilator dependency/inability to wean I Aspiration especially with enteral feeding I Hypotension I Fluid overload I Stress ulceration of gastrointestinal tract (Sole and Fowler Byers 1997) and Fowler Byers 1997). The use of communication aids, such as paper and pens, may be helpful here, but will be dependent on the patients ability to use them. Anxiety can be further increased by loss of autonomy and control, or even by the mere presence of the ventilator. This can be further compounded by ventilator alarms which can lead the patient to believe, in error, that he or she is in danger. Conversely, some patients become so dependent on the ventilator that any actions to reduce mechanical ventilatory support can lead to increased anxiety. Frequent explanations, reassurance and encouragement are essential in conscious patients (Hinds 1987). Excessive salivation caused by the endotracheal tube can lead to a feeling of drowning and requires prompt attention and care. Family members and other visitors may also increase patient anxiety by their own worries about seeing a loved one on a life support machine. Another area where skilled nursing can be extremely helpful to the patients psychological wellbeing is the anticipation, and temporary disabling, of alarms for specific events, such as the disconnection of the ventilator from the patient to facilitate suctioning. Explanations of all alarms can go a long way to alleviate any anxiety they may cause. Thoughtful and appropriate interventions with respect to psychological needs may reduce the insult that patients may endure with respect to their psychological wellbeing.
REFERENCES Barrie-Shevlin P (1987) Maintaining sensory balance for the critically ill. Nursing. 16, 597-601 Bersten AD (1997a) Ventilators and resuscitators. In Oh TE (1997) (Ed) Intensive Care Manual. Fourth edition. Oxford, ButterworthHeinemann. Bersten AD (1997b) Humidification and inhalation therapy. In Oh TE (Ed) Intensive Care Manual. Fourth edition. Oxford, ButterworthHeinemann. Clifford C (1986) Patients, relatives and nurses in a technological environment. Intensive Care Nursing. 2, 2, 67-72. Dootson S (1990) Sensory imbalance and sleep loss. Nursing Times. 86, 35, 26-29. Hinds CJ (1987) Intensive Care: A Concise Textbook. London, Baillire Tindall. Meyer Holloway NM (1993) Nursing: the Critically Ill Adult. Fourth edition. Wokingham, Addison-Wesley Publishing Company. Sole ML, Fowler Byers J (1997) Ventilatory assistance. In Hartshorn JC et al (Eds) Introduction to Critical Care Nursing. Second edition. London, WB Saunders. Tan IKS, Oh TE (1997) Mechanical ventilatory support. In Oh TE (1997) (Ed) Intensive Care Manual. Fourth edition. Oxford, ButterworthHeinemann.

support cannot be overestimated. The combination of skills required to manage both the physical and psychological needs of such patients can be pivotal in the success of the subsequent withdrawal of the support to aid the patient in his or her recovery

Conclusion Mechanical ventilation has developed rapidly within the last few years. Mechanical ventilators now involve complex methods for the delivery of respiratory support. Understanding the basic concepts of ventilatory modes will enable nurses to develop a greater understanding of the functions and setting up of ventilators. The importance of the role of the nurse in the care of patients undergoing respiratory july 21/vol13/no44/1999 nursing standard 53