VENTILATORY ASSISTANCE
CHAPTER 9
Lung Volume and Capacity Definitions and Normal Values
Title Definition Normal/Average Values
*Tidal volume (Vt) Volume of a normal breath 500mL or 5-7 mL/kg
Inspiratory reserve volume Max amt of gas that can be 3000mL
(IRV) inspired at end of normal
breath
Expiratory reserve volume Max amt of gas that can be 1200mL
(ERV) forcefully expired at end of a
normal breath
Residual Volume (RV) Amt of air remaining in lungs 1300mL
after max expiration
Inspiratory capacity (IC) Max volume of gas that can be 3500mL
inspired at normal resting
expiration; the IC distends the
lungs to their max amt
*Functional residual Volume of gas remaining in 2500mL
capacity (FRC) the lungs at normal resting
expiration
Vital capacity (VC) Max volume of gas that can be 4700mL
forcefully expired after max
inspiration
*Total lung capacity (TLC) Volume of gas in the lungs at 6000mL
end of max inspiration
(* = emphasized in class)
Respiratory Mechanic Definitions:
Work of Breathing (WOB): is the amount of effort required for the maintenance of a given
level of ventilation
Compliance: is a measure of dispensability, or stretch ability, or the lung and chest wall.
Resistance: refers to the opposition to the flow of gases in the airway
Geriatric Considerations involving ventilation:
Decreased alveolar surface area Decreased alveolar elasticity
Decreased chest wall dispensability Decreased physiological compensatory
mechanisms (respiratory, renal, cardiac,
immune)
Assessment changes: Normal findings RT aging process
Kyphosis Barrel chest
Decreased chest expansion Lower paO2 levels on ABG
Increased Risk for: RT aging
Poor gas exchange
Respiratory distress
Respiratory failure
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Adventitious Breath Sounds
Sound/Description Cause Clinical Significance Additional
Comments
Crackles – Air bubbling through Atelectasis, fluid Fine: soft, short
discontinuous, fluid or mucus, or retention in small duration
explosive, bubbling alveoli popping open airways (pulm edema), Coarse: loud, longer
sounds of short on inspiration retention of mucus, duration
duration (bronchitis, Wet or dry
pneumonia), May disappear after
interstitial fibrosis coughing, suctioning,
or deep inspiration if
alveoli remain inflated
Rhonchi – coarse, Air movement Diseases resulting in Inspiratory and/or
continuous, low- through excess airway inflammation expiratory; may clear
pitched, sonorous, or mucus, fluid, or and excess mucus or diminish with
rattling sound inflamed airways (pneumonia, coughing if caused by
bronchitis, pulm airway secretions
edema)
Wheezes – high or Air movement Bronchospasm High or low pitched;
low-pitched whistling, through narrowed (asthma), airway Inspiratory and/or
musical sound heard airway, which causes obstruction (tumor, expiratory
during inspiration airway wall to foreign body),
and/or expiration oscillate or flutter inflammation,
stenosis
Pleural friction rub – Inflamed pleura Pleural inflammation Occurs during
coarse, grating, rubbing against each (pleuritis, pneumonia, breathing cycle and is
squeaking, or other tuberculosis, chest eliminated by breath
scratching sound tube insertion, pulm holding
infarction) Need to discern from
pericardial friction
rub, which continues
despite breath
holding
Stridor – high- Air flowing through Partial obstruction of Potentially life-
pitched, continuous constricted larynx or upper airway, as in threatening
sound heard over trachea laryngeal edema,
upper airway, a epiglottitis, or
crowing sound obstruction by a
foreign body
Abnormal breathing patterns:
Cheyne-Stokes: cyclical with apneic periods
Biot’s: cluster breathing
Kussmaul’s: deep, regular, and rapid
Apneustic: gasping inspirations
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Signs and symptoms of Hypoxemia:
Integumentary: Pallor, cool, dry skin, cyanosis and diaphoresis
Respiratory: Dyspnea, tachypnea, and use of accessory muscles
Cardiovascular: Tachycardia, dysrhythmias, chest pain, hypertension early followed by
hypotension, increased followed by decreased heart rate
Central Nervous System: Anxiety, restlessness, confusion, fatigue, combativeness/agitation,
and coma
Arterial Blood Gas Values:
Parameter Arterial Normals
pH 7.35 – 7.45
PaCO2 35 – 45 mm Hg
HCO3- 22 – 26 mEq/L
PaO2 80-100 mm Hg
Oxygen saturation 96% - 100%
Critical Values!
o Pa02 < 60 mm Hg
o PaC02 > 50 mm Hg
o pH < 7.25 or > 7.60
Reasons for Acid-Base Imbalances:
Respiratory Acidosis: Retention of CO2 Respiratory Alkalosis: Hyperventilation
Hypoventilation Hypoxemia
CNS depression (anesthesia, narcotics, Anxiety/fear
sedatives, drug O.D.) Pain
Respiratory neuromuscular disorders Fever
Trauma to spine, brain, chest wall Stimulants
Restrictive lung diseases CNS irritation
COPD Excessive ventilator support (bag-valve-mask,
Acute airway obstruction in the late phase mechanical ventilation)
Metabolic Acidosis Metabolic Alkalosis
Diabetic ketoacidosis Excess ingestion of antacids
Renal failure Excess administration of sodium bicarbonate
Lactic acidosis Citrate in blood transfusions
Drug O.D. Vomiting
Diarrhea NG suctioning
Pancreatic or small bowel fluid loss Low potassium and/or chloride (diuretics)
Oxygen Administration:
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Humidification: recommended when the oxygen flow is greater than 4 L/min to prevent the
mucous membranes from drying.
Oxygen delivery devices: Nasal cannula can provide oxygen concentrations between 24% and
44% oxygen at flow rates up to 6 L/min. An increase in oxygen flow rate by 1 L/min
generally increases oxygen delivery by 4%. The simple face mask is to be set to at least 5
L/min to avoid rebreathing of carbon dioxide. Face masks with reservoirs (partial rebreather and
nonrebreathers) has a bag on the bottom that increases the amount of oxygen available during
inspiration and allows for Fi02 of 35% to 60% for the partial rebreather and 60% to 80% for
nonrebreathers. The nonbreather has a one-way valve between the mask and reservoir bag
and over one of the exhalation ports to ensure the pt breathes a high concentration of oxygen
enriched gas from the reservoir with each breath. The Venturi has various jets that offer a
different percentage of oxygen to be administered. The air entrainment with aerosol and
humidity delivery system the T-piece and tracheostomy mask/collar. The initial flow for these
systems begins at 10 L/min. Manual resuscitation bag is used with 15 L/min.
Advantages and disadvantages of oral intubation vs. nasotracheal intubation
Advantages Disadvantages
Oral: Oral:
Quickly performed Discomfort
Large tube facilitates secretion removal and Mouth care more difficult to perform
creates less airway resistance Impairs ability to swallow
Less kinking of tube May cause irritation and ulceration
Preferred method; less sinusitis and otitis Greater risk of self extubation
media More difficult to communicate
Pt may bite on airway
Nasotracheal: Nasotracheal:
Greater comfort and tolerance More difficult to place
Better mouth care Possible epistaxis
Fever oral complications Increases risk of sinusitis and otitis media
Less risk of accident extubation Secretion removal more difficult RT smaller
Facilitates swallowing tube diameter
Communication by mouthing is better than Increases work of breathing RT smaller tube
oral diameter
MECHANICAL VENTILATION
Indications for Mechanical Ventilation:
o PaO2 < or = 60 mm Hg on a FiO2 greater than 50%
o PaCO2 > or = 50 mm Hg, which a pH of 7.25 or less
Positive-Pressure Ventilation –
Opposite of normal spontaneous breathing, most common form of mechanical ventilation in
the acute care setting
Negative-Pressure Ventilation –
Idea of the “iron lung”, more used for chronic conditions
Ventilator settings:
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Setting Definition
Fraction of Inspired Oxygen (Fi02) Percentage of inspired oxygen delivered to the
patient by the ventilator. It is set from 21% to
100%.
Tidal Volume (Vt) Amount of air delivered with each preset
breath. It is dictated by the patient’s body
weight and lung characteristics (compliance
and resistance). This is set to avoid excessive
pressure (PIP and plateau airway pressure –
Pplat), which should remain below 40 cm H20
and 30 cm H20 respectively. Starting point is 8
to 10 mL/kg of IDEAL body weight.
Respiratory Rate (RR) Frequency of breaths, normally around 14-20.
PEEP The addition of positive pressure into the
airways during expirations. It typically at 5 to
20 cm H20, which physiological PEEP usually at
5.
Exhaled Tidal Volume (EVt) Amt of air that comes out of the pt’s lungs
upon expirations
Inspiratory to Expiratory Ratio (I:E ratio) In spontaneous ventilation, inspiration is
shorter than expiration. Generally, on the vent,
the ratio is set to 1:2
Inverse Inspiratory to Expiratory Ratio (inverse It is used to improve oxygenation in pts with
I:E ratio) noncompliant lungs, such as with ARDS
Sensitivity Determines the amount of pat effort needed
to initiate gas flow through the circuitry on a
pt-initiated breath
Sigh Mechanically set breath with greater volume
than the present Vt, usually 1.5 to 2x greater
than the Vt.
Patient data includes EVt, PIP, and total RR.
Peak Inspiratory Pressure (PIP) Max pressure that occurs during inspiration.
This number should never exceed 40 cm H20
because the higher pressure can result in
ventilator-induced lung injury.
Total Respiratory Rate Equals the number of breaths delivered by the
vent plus the number of breaths the pt takes.
Modes of Mechanical Ventilation:
Volume controlled
Pressure controlled
Dual controlled ventilation
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Volume Controlled Ventilation: Vt is constant for every breath delivered by the vent. A major
advantage is that Vt is delivered regardless of changes in lung compliance or resistance.
Assist/Control Ventilation Synchronized Intermittent Mandatory Vent
Delivers a present number of breaths of a Delivers a set number of breaths of a set Vt
preset Vt. When the pt initiates a breath, the and between these mandatory breaths; the pt
vent delivered an assisted breath of the preset may initiate spontaneous breaths. The main
Vt. The preset RR makes sure the pt takes the difference b/t SIMV and A/C mode is the
required amount of breaths per minute volume of the patient initiated breaths.
regardless of their spontaneous efforts. This During a spontaneous breath on SIMV, the pt
mode is useful for someone with a normal provides the Vt. This mode is associated with
respiratory drive, but whose muscles are too the longest weaning and lowest success rate.
weak to perform the WOB. A disadvantage is
that respiratory alkalosis may develop if the pt
hyperventilates RT anxiety or pain. Another
disadvantage is that the pt may rely on the
vent and not attempt to initiate spontaneous
breaths.
MONITOR MONITOR
The nurse monitors total RR, EVt, PIP, and the The nurse monitors the total RR, the Vt of
pt’s sense of comfort and synchronization with spontaneous breaths, and the pt’s ability to
the vent, and acid-base balance. manage the WOB. Also, the EVt of both
mandatory and spontaneous breaths is
monitored. Assess PIP and the pt’s sense of
comfort and synchronization with the vent,
and the acid-base balance.
Pressure Controlled Ventilation: Inspiratory pressure levels are constant for each breath. The
vent is set to allow air to flow into the lungs until a preset pressure has been reached, and the Vt
the pt receives is variable and depends on the pt’s lung compliance, airway, and circuit
resistance. An advantage is that the PIP can be reliably controlled for each breath the vent
delivers. A disadvantage is that hypoventilation and respiratory acidosis occur since Vt is
variable.
Continuous Positive Airway Pressure Positive pressure applied throughout the
(CPAP) respiratory cycle to the spontaneously
breathing pt. They must have a reliable resp
drive. CPAP provides pressure at the end of
exhalation which prevents alveoli collapse and
improves the FRC and oxygenation.
Pressure Support (PS) Pt’s spontaneous resp activity is augmented by
the delivery of a preset amt of Inspiratory
positive pressure. Pt must generate each
breath. Typical pressures ordered are 6 to 12
cm H20 applied throughout inspiration.
Pressure Assist/Control (P-A/C) There is a set RR and every breath is
augmented by a set amt of inspiratory
pressure. If the pt triggers additional breaths
beyond the mandatory breaths, those breaths
are augmented by the set amt of inspiratory
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pressure. No Vt – The pressure the pt receives
is variable and determined by the set
inspiratory pressure, lung compliance, and
circuit and airway resistance. The typical
pressure is 15 to 25 cm H20, which is higher
than PS because the P-A/C is indicated for pts
with ARDS or those with a high PIP during
traditional volume ventilation. The nurse must
be familiar with all vent settings: level of
pressure, the set RR, the Fi02, and level of PEEP
Pressure-Controlled Inverse-Ratio The pt receives P-A/C ventilation as described,
Ventilation (PC – IRV) and the vent is set to provide longer
inspiratory times. It is inversed to increase the
mean airway pressure, open and stabilize the
alveoli, and improve oxygenation. Indicated
for pt’s with noncompliant lungs, such as
ARDS, when adequate oxygenation is not
achieved despite high Fi02, PEEP, or
positioning.
Airway Pressure-Release Ventilation (APRV) Two levels of CPAP – one during inspiration
and the other during expiration, while allowing
unrestricted spontaneous breathing at any
point during the respiratory cycle. The pt has
unrestricted spontaneous breathing
Noninvasive Positive-Pressure Ventilation (NPPV) is the delivery of mechanical ventilation
without an artificial airway through 1) a face mask that covers the nose, mouth, or both 2) a
nasal mask or pillow or 3) a full face mask. It is indicated for the treatment of acute
exacerbations of COPD and for obstructive sleep apnea. The nurse monitors the total RR, the
EVt to ensure it is adequate, and the PIP.
Management of Common Ventilator Alarms
High Peak Pressure Low Pressure
Assess level of sedation, admin meds Assess for leaks
Empty water from water traps If malfunction is noted, manually ventilate pt
Lung sounds for suctioning with bag-mask device
Assess for kinks Notify RT
Assess for reduction in lung compliance
Notify RT and/or physician if alarm persists
Low Exhaled Volume Apnea Alarm
Asses for disconnection Assess pt for spontaneous respiratory effort,
Assess for leak in cuff of ETT (audible sounds encourage pt to take deep breath
around airway; inflate Manually vent pt while RT and/or physician are
Assess for changes in lung compliance notified.
The “ventilator bundle” should be implemented for all pt’s on mechanical ventilation. It includes
maintaining the HOB at 30 to 45 degrees, interrupting sedation each day to assess readiness to
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wean, providing DVT prophylaxis, and administering medications for peptic ulcer disease
prophylaxis.
Complications related to intubation:
Laryngeal and tracheal injury – Pressures should not exceed 25 to 30 cm H2O in the cuff.
Barotaruma – pressure trauma to the lungs, causing the alveoli to rupture or tear so that air
escapes into various parts of the thoracic cavity, causing subQ emphysema, pneumothorax or a
tension pneumothorax, pneumomediastinum, pneumopericardium or pneumoperitoneum.
When a pneumothorax is suspected, the pt should be removed from the vent and be ventilated
manually. Prevention includes keeping the PIP below 40 cm H20 and the Pplat is kept at less
than 30 cm H20.
Oxygen Toxicity – Injury is related to the duration of exposure and to the Fi02, not to the Pa02.
100% oxygen can be tolerated for only up to 24 hours; 100% oxygen results in a lack of nitrogen
in the distal air spaces, causing atelectasis.
Respiratory Acidosis or Alkalosis - May occur secondary to Vt and RR settings.
Infection – Prevent by elevating HOB to 30 to 45 degrees, preventing drainage of vent circuit
condensation into pt’s airway, practicing proper hand hygiene and wearing gloves, using an ETT
with a lumen for aspirating subglottic secretion that pool above airway cuff, ensuring secretions
are aspirated from above the cuff before deflation or removal, providing great oral hygiene, and
using noninvasive ventilation when possible.
Cardiovascular System – Hypotension and decreased CO can occur with mechanical ventilation
and PEEP secondary to increased intrathoracic pressure, which can result in decreased venous
return. Treat with administration of volume followed by administration of inotropic agents if
necessary.
Gastrointestinal System – Stress ulcers are prevented with prophylactic medications. Excess
C02 production may occur with a high carb feeding and place a burden on the respiratory
system to excrete the C02, increasing the WOB. Formulas are developed for pulmonary
disorders may be indicated.
Weaning methods
SIMV Progressive reduction in the number of
mandatory breaths as the pt can take on more
WOB.
PS Gradual reduction in the level of PS while
monitoring the pt’s ability to maintain an
acceptable Vt and RR. PS of 5 cm H20 is
considered the same as spontaneous
breathing
T-PIECE The pt breaths without any vent support
however can be reinitiated quickly should it
not be tolerated. Breathing through the T-
piece encourages muscle strengthening.
CPAP Useful for when the pt still requires PEEP to
maintain adequate oxygenation. This is tried
when the pt is still connected to the vent
system. The nurse has the advantage of all the
alarm systems to provide early warnings of
apnea, a high RR, and/or inadequate EVt.
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When proceeding with a weaning trial, the nurse obtains baseline vitals, heart rhythm, ABG’s or
pulse ox/ETC02 values, and neurological status. The pt is able to breathe spontaneously for 30-
120 minutes before the decision is made to extubate.
Assessment Indicating Readiness to Wean Criteria for D/C Weaning
Underlying Cause for Ventilation Resolved: Respiratory
o Improved chest x-ray findings o RR >25 or <8 breaths/min
o Minimal secretions o Spontaneous Vt <5 Ml/kg ideal
o Normal breath sounds body weight
Hemodynamic Stability: o Labored respirations
o Absence of hypotension o Use of accessory muscles
o Minimal vasopressor therapy o Abnormal breathing pattern:
Adequate Resp Muscle Strength chest/abdominal asynchrony
o RR <25 to 30 breaths/minute o Oxygen sat < 90%
o Negative inspiratory pressure or force Cardiovascular
that exceeds -20 cm H20 o BP or HR changes more than 20%
o Spontaneous Vt of 5 mL/kg from baseline
o Vital capacity 10-15 mL/kg o Dysrhythmias
o Minute ventilation 5 to 10 L/min o Ischemia
o Rapid shallow breathing index <105 o Diaphoresis
Adequate Oxygenation w/o a High Fi02 and/or a Neurological
High PEEP o Agitation, anxiety
o Pa02 > 60 mm Hg with Fi02 40 to 50 % o Decreased LOC
o Pa02/FiO2 > 150-200 o Subjective discomfort
o PEEP < 5 to 8 cm H20
Absence of Factors that Impair Weaning
o Infection
o Anemia
o Fever
o Sleep Deprivation
o Pain
o Abdominal distention, bowel
abnormalities (diarrhea or constipation)
Mental Readiness to Wean: Calm, Minimal Anxiety
and Motivated
Minimal Need for Sedatives and Other Meds that
May Cause Resp Depression
