Mechanical Ventilation/ECMO

CPAP

Single pressure setting throughout breathing cycle

BiPAP

Separate pressure settings for inhalation and exhalation

After intubating a patient, what are some ways to verify correct placement on endotracheal tube (ETT)?

a. Auscultate lung and bowel sounds — there should be no air sounds when listening to bowel sounds (indicates ET tube is in stomach)

b. EtCO2 detector — gold standard!! Color changes indicate CO2 in being exhaled

c. Symmetrical chest rise and fall — unsymmetrical rise and fall could mean that the tube is on one side only

d. Chest x-ray

e. Noticing fogging in the tube

Ventilator mode — full support

Assist control (A/C) — deliver preset tidal volume (or pressure) at a set rate even if patient initiates a breath

Common uses: sedation or respiratory distress — can causes respiratory alkalosis if patient breaths too frequently

Ventilator mode — partial support

Synchronized intermittent mandatory ventilation (SIMV) — Patient initiates all breaths. Ventilator provides a preset pressure to assist with inhalation. No set rate or tidal volume.

Common uses: ventilation weaning and patient that take spontaneous breaths

Ventilator mode — spontaneous modes

Pressure support ventilation (PSV) or CPAP — continuous level of positive pressure is provided but patient does all the breathing

Common uses: sleep apnea or step down for mechanical ventilation

FiO2 — fraction of inspired oxygen

The percentage of oxygen the ventilator delivers

Normal setting: 21% (room air) to 100% — goal: SpO₂ ≥ 90% or PaO₂ ≥ 60 mmHg while avoiding oxygen toxicity

Respiratory rate (RR)

Number of breaths delivered per minute.

Normal setting: 12–20 breaths/min (adjusted based on CO₂ levels and patient needs)

Tidal volume (Vt)

The amount of air delivered to the lungs with each breath

Normal setting: ~6–8 mL/kg

Positive-end Expiratory Pressure (PEEP)

Pressure left in the lungs at the end of expiration to keep alveoli open.

Normal setting: 5 cm

Pressure support (PS)

Extra pressure given during spontaneous breaths to help reduce the work of breathing.

Normal setting: 5-20 dependent on patient’s effort — commonly used in modes like PSV or SIMV

What could be causing a high-pressure ventilator alarm?

Coughing, asynchrony, condensation, kinked tubing, increased resistance, or decreased compliance

What could be causing a low-pressure ventilator alarm?

Disconnection or extubation

What could be causing a apnea ventilator alarm?

Respiratory arrest or oversedation

What could be causing a high tidal volume/rate ventilator alarm?

Pain, anxiety, increased metabolic demand, hypoxia, or hypercapnia

What could be causing a high tidal volume/rate ventilator alarm?

Disconnection, leak, or cuff leak

What are some cardiovascular complications of mechanical ventilation?

Fluid retention and hemodynamic compromise

What are some pulmonary complications of mechanical ventilation?

Barotrauma, volutrauma, atelectasis, VAP, and oxygen toxicity

What are some ways to reduce ventilator-associated pneumonia?

Minimize sedation, elevated HOB, ROM exercises, oral care with suctioning, skin care, peptic ulcer prevention, nutrition, and daily spontaneous breathing trials/sedation vacation

Extracorporeal Membrane Oxygentation

Oxygenation occurs outside of the body. Blood is removed. Oxygen then added to blood but carbon dioxide is removed.

Therapy damages platelets — increases risk for bleeding so patient will need heparin

Cisatracurium, Rocuronium

Drug Class: neuromuscular blocker/paralytic

Action: paralysis of muscles

Notes: give with sedation medication

Midazolam, Lorazepam

Drug Class: benzodiazepine

Action: sedation

Notes: monitor LOC

Propofol, Dexmedetomidine

Drug Class: anesthesia/sedation

Action: sedation while on mechanical ventilation

Notes: titrate appropriate to RASS

Pantoprazole

Drug Class: proton pump inhibitor

Action: prevention of peptic ulcer

Notes: part of VAP prevention

Enoxaparin

Drug Class: LMWH

Action: anticoagulation — DVT prevention

Notes: part of VAP prevention

Albuterol

Drug Class: beta-2 agonist

Action: bronchodilation

Notes: monitor lung sounds and HR

A nurse is caring for a client who has a tracheostomy and is receiving mechanical ventilation. When the low pressure alarm on the ventilator sounds, it indicates which of the following to the nurse?

a. Excessive airway secretions

b. A leak within the ventilator circuitry

c. Decreased lung compliance

D. The client coughing or attempting to talk

A