Portable Ventilator

7/29/2019 Portable Ventilator

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Using a Ventilator at Home

Introduction

Only a few years ago, it seemed very uncommon for a person on a ventilator to be living at home. It

was thought that knowing how to work this machine might be too hard for non-medical people.However, because people on ventilators with spinal cord injury are living long, healthy and full lives, ithas now become important to teach families how to do this.

With a little training and practice, most people can learn how to take care of a person who ison a ventilator at home.

This lesson will explain important issues about the ventilator. There are many other skills related tocaring for the person on the ventilator such as suctioning, trach care, assist coughing and using an in-exsufflator. All of the information about these areas can be found in the lessons of this Module.Please review them as well.

What is a ventilator?

A ventilator is a machine that moves air through a persons lungs. It is attached to a trach tube in thepersons throat. It blows air or air with extra oxygen in to the lungs. It has many settings and alarms.Each person's ventilator has different settings that are determined by the doctor. Some people need aventilator all of the time while others only use it part of the time. It depends on the persons needs andwhat the doctor orders.

This is a common type of home ventilator. Yours may differ depending on your supplier.Always refer to your "Owner's Manual" and your home care company for operatinginstructions.

Why is a Ventilator Necessary?


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People with a spinal cord injury in the neck area may require a ventilator.This is true because the spinal cord and its nerves help control breathing.It does so by helping the diaphragm, abdominal and rib muscles move toallow air in and out of the lungs. Helping these muscles also provides thebody with the ability to cough and move mucous out of the lungs andthroat.

The amount of breathing problems a person has depends on the level ofinjury, the persons general physical condition or if the person was aheavy smoker.

People with a C1 or C2 injury will require a ventilator all of the timebecause the injury is so high in the cord that it cannot send any messages

to the diaphragm, rib or abdominal muscles.

Some people with C3 injuries may need a ventilator all of the time or part of the time.

People with C4 - C8 injuries may not need the ventilator at all but are still at high risk for breathing

problems.

What do the Controls Do?

On/Off Switch: The switch is located at the bottom left row on this machine. The gray squarebox must be pressed to turn machine on or off.If you have 2 portable ventilators at home,keep the bedside ventilator plugged into an electrical outlet. The second portable ventilatorshould be hooked up to your power chair and attached to chair battery.

Mode of Ventilation: The doctor will determine which method of ventilation will best benefit thepatients respiratory system. The doctor will order the Assist / Control or the SIMV / CPAPmode.

Breath Rate: controls how many breaths are given each minute. The amount of breaths willalso be ordered by your doctor. It is important to always check the rate to make sure enoughbreaths are being given.

Tidal Volume: controls how much air is given in each breath. The setting is ordered by yourdoctor. It is important to know the tidal volume setting when doing routine ventilator checks.

Inspiratory Time: controls how fast to deliver the set tidal volume during inhalation. The

respiratory therapist will set the time.


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Pressure Support: Pressure Support control can only be used in the SIMV/CPAP mode,to help wean the patient off the ventilator. This control supports each spontaneous

breath the patient takes by providing extra pressure which will reduce the patients work ofbreathing. This setting will be ordered by the doctor.

Oxygen control will read 21% oxygen, unless the patient is receiving extra oxygen in thehospital setting.

Sensitivity allows the ventilator to be set according to the person's breathing effort. Theventilator can provide 100% of the breathing work or it can be set to "assist" a person whohas some breathing. This setting will be set by the respiratory therapist.

LOCK can be pressed to lock the settings. This control will prevent children from changingventilator settings in the home.

What do the Alarms Do?

Alarms are indicators that will let you know if something is wrong with the ventilator. When analarms sounds it is important that you respond to it immediately.

Here are some immediate actions youcan take:

Check the person to make sure they arenot in distress. If they are, take them offthe ventilator and use the Ambu Bag tobreathe for the person. Bag the personuntil you find the problem. If the ventilatortubing has popped off the trach tube,simply re-attach it. If it is not somethingobvious, continue bagging the person andbegin checking the tubing starting where itconnects to the person and search thetubing all the way back to the machine. If

tubing has become disconnected, re-connect it.

Check the trach cuff as you were taught. If


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it is low, insert a little more air and see ifthis stops the alarm. If you still cannot findthe problem, keep bagging and call 911 forhelp. You will also need to call yourhomecare company and respiratorytherapist after the emergency situation is

over.

High Pressure Limit: alarm tells you that there has been an increase in air pressuredelivered to the lungs. It could mean that the person has too much mucous in the lungs andneeds to be suctioned. It can also mean that the ventilator tubing has become kinked.

Low Pressure: alarm tells you that there has been a drop in air pressure delivered to thelungs. It could mean that the ventilator tubing has popped off the trach tube or that there is a

leak or a piece of tubing has disconnected. Sometimes there could even be a problem with

the trach cuff. This is not a ventilator problem, but it will still sound the alarm because notenough air pressure is being given to the person.

Low Min. Vol:This setting with be set by the respiratory therapist. When this alarm sounds it

indicates that the lung volume has dropped. Check trach cuff pressure and ventilator tubingfor leak

Silence / Reset: this control performs two functions: When pressed to silence ringing alarm,it will do so for 60 seconds. Silence should only be pressed after the problem has beenfixed.

Reset: is pressed to return ventilator back to patients ventilator settings.

Set Value Dial: large gray dial below the alarm section. When any of the settings in thecontrol panel need to be changed, the gray square box under the setting must be press, andthe Set Value dial is turned to lower or increase the number setting. You will notice that thesetting number will be highlighted and the rest of the numbers on the panel will be dimmeddown. Once the desired number is set, press the gray square box again. To preventanyone from making any changes to the settings, the CONTROL LOCK can be pressed tolock the settings. This control will prevent children from changing ventilator settings in thehome.


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The low pressurenumber and lowminute volumenumbers will blinkwhen there is adisconnection or

leak.

Check connection attrach and all tubingconnections.Check the cuffpressure of the trachtube. It might needmore air.Move the vent tubingto make sure it is lyingon the patient's chest.

The high pressurealarm will beep whena patient needs to besuctioned.

When the PIP level incrases from it's normal level, it also means that the patient needs to besuctioned.

Airway Pressure Display this is the long,rectangle window, that when Select is pressedyou will be able to read several pieces of

information, for example , the three mostimportant homecare readings are:

PIP is for airway pressure, exhaled tidalvolume, and breath rate.

An increase or decrease in airway pressure (PIP)can indicate that the patient needs suctioning orhas an airway leak.The exhale tidal volume mightneed to be monitored if the patient is weaning offthe ventilator.

Power Indicator (upper right hand corner in front of the ventilator )

During the day time hours while the converter box is on the EXTERNAL POWER LIGHTshould be ON AND GREEN.

During the night time hours while ventilator is being charged, the CHARGE STATUS light willblink iuntil it is fully charged, then it becomes a STEADY AMBER LIGHT.

Important Things to Remember


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Alert the power company, fire & police departments and other emergency personnel (911) that youhave a person at home on a ventilatorprior to discharge from the rehabilitation facility.Have the home care company check the power in your home before the person comes home fromrehabilitation.

Consider having alternative electrical equipment such as a generator and batteries in case of powerfailure.Place the ventilator on a sturdy utility cart. You can buy this at your local discount store. Make sure itis sturdy and that it has wheels.If you use a wood burning stove in your home, never stay in the same room as the stove

Always give extra breaths (bag) with the Ambu Bag if the person has trouble breathing or there isequipment failure

Always call 911 & the home care company for help if there is equipment failure. If the person isunresponsive, call 911, open the front door, get back to the person and begin CPR.

If the person is using oxygen, please note the following:

never smoke while oxygen is in use never place oxygen equipment near heat, electrical appliances (battery shavers are ok) or the furnace never use petroleum jelly (like vaseline) products on oxygen equipment or the person

Mechanical Ventilation: What Is It?

Mechanical ventilation is a method for using machines to help patientsbreathe when they are unable to breathe sufficiently on their own.

Most often, mechanical ventilation is used for a few days to help a patientbreathe during a serious illness. This type of breathing support is usuallydone in an intensive care unitan ICU for short.

Sometimes patients still can't breathe on their own after the acute illnessis over, despite efforts to restore spontaneous breathing. Patients may nolonger need to be in the ICU but still require mechanical ventilationbecause of an extended need for the breathing assistance of theventilator.

Other patients may have stable, longer-term (chronic) conditions thatmake them unable to breathe on their own.

Due to a variety of reasons, including the cost of hospital care and thepatient's quality of life, for the patient who is dependent on a ventilatorfor breathing assistance, it may be better to receive mechanicalventilation at home or at a nonhospital institution offering specializednursing or rehabilitation services.

Over time, with the professional support of physicians and respiratorytherapists, some ventilator-assisted individuals are able to become less

dependent on the ventilator and breathe on their own for substantialportions of every day. Other patients have medical conditions that require


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24-h mechanical ventilation for many months or years, or even for alifetime.

The method of long-term mechanical ventilation that is best for thepatient will be determined by the physician, respiratory therapist, and the

patient. A patient capable of some independent activities and severalhours a day off the ventilator will have different requirements than thepatient who needs ventilator assistance 24 h a day.

Invasive methods use a tracheostomya surgical hole in the windpipethrough which a tube is channeled to assist breathing.

Noninvasive methods use masks, nasal tubes, and other techniques thatdo not require surgical entry into the respiratory tract. Some applypositive pressure to the mouth and/or nose. Others apply negative

pressure to the chest or body by lowering the pressure outside the body.

All methods of ventilation require an initial assessment of comfort andefficacy and follow-up monitoring of daytime and nighttime breathing. Thepatient and caregivers should be educated in use and maintenance of theequipment needed to provide the support.

Noninvasive Methods

Positive Pressure Ventilation: Mouth and/or Nose

Positive pressure ventilation delivers air (and sometimes extra oxygenwhen medically necessary) to the patient through a face mask,mouthpiece, or nasal mask. Patients who can be independent of theventilator for portions of the day may use noninvasive positive-pressureventilation to assist nighttime breathing.

Negative Pressure Ventilation

Entry of air into the lungs is assisted by applying intermittent negativepressure (like a vacuum) to the chest and abdomen by means of a bodytank (iron lung), a chest shell, or a body jacket.

Rocking Bed

A bed with rocking motion assists ventilation by intermittently causing thediaphragm to move up and down, creating a "pumping" motion in thechest, and thus, helping air to go in and out of the lungs.

Pneumobelt

An inflatable band around the abdomen presses on the abdomen and

forces air in and out of the lungs. The pneumobelt may be used incombination with other noninvasive methods of ventilation. It may not be


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suitable for some patientsfor example, patients who are excessivelyunderweight or overweight. The patient must be sitting up for this deviceto work. It is often used by patients in a wheelchair.

Diaphragm Pacing

An electronic pacer stimulates the diaphragm to contract, thus assistingbreathing by "bellows" motion of the diaphragm. This method is used bypatients who have high (C1-C2) spinal cord injury, and with tracheostomyin some children who cannot breathe spontaneously because of a problemwith central control of breathing.

Glossopharyngeal Breathing

Sometimes called "frog" breathinga technique in which the patient

learns to "gulp" air into the lungs. Some patients use this technique inorder to spend more time off the ventilator and to have "free" time incase of ventilator failure.

Manually Assisted Coughing

A caregiver helps the patient to exhale and clear mucus from the lungs bydelivering a thrust similar to a Heimlich maneuver. Thorough training ofthe patient and caregivers is required to make this technique effectiveand to avoid injury to the patient.

Invasive Methods

Invasive methods may be needed for patients who are unable to usenoninvasive methods. Invasive mechanical ventilation requires atracheostomy for placement of a tracheostomy tube into the windpipe todeliver air directly into the lungs. The patient and caregivers are trainedin care of the tracheostomy and tube to prevent complications such asinfection around the tracheostomy tube or clogging of the tube.


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Caring for the Patient on a Ventilator

The nurse must be able to do the following:

1. Identify the indications for mechanical ventilation.

2. List the steps in preparing a patient for intubation.

3. Determine the FIO2, tidal volume, rate and mode of ventilation on a given

ventilator.

4. Describe the various modes of ventilation and their implications.

5. Describe at least two complications associated with patients response to

mechanical ventilation and their signs and symptoms.

6. Describe the causes and nursing measures taken when trouble-shootingventilator alarms.

7. Describe preventative measures aimed at preventing selected othercomplications related to endotracheal intubation.

8. Give rationale for selected nursing interventions in the plan of care for the

ventilated patient.

9. Complete the care of the ventilated patient checklist.

10. Complete the suctioning checklist.

1. To review indications for and basic modes of mechanical ventilation,possible complications that can occur, and nursing observations and

procedures to detect and/or prevent such complications.

2. To provide a systematic nursing assessment procedure to ensure early

detection of complications associated with mechanical ventilation.

Indication for Intubation

1. Acute respiratory failure evidenced by the lungs inability to maintain arterial

oxygenation or eliminate carbon dioxide leading to tissue hypoxia in spite of low-flow or high-flow oxygen delivery devices. (Impaired gas exchange, airwayobstruction or ventilation-perfusion abnormalities).

2. In a patient with previously normal ABGs, the ABG results will be as follows:

PaO2 > 50 mm Hg with pH < 7.25


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PaO2 < 50 mm Hg on 60% FIO2 : restlessness, dyspnea, confusion, anxiety, tachypnea,

tachycardia, and diaphoresis

PaCO2 > 50 mm Hg : hypertension, irritability, somnolence (late), cyanosis (late), and LOC

(late)

3. Neuromuscular or neurogenic loss of respiratory regulation. (Impaired

ventilation)

4. Usual reasons for intubation: Airway maintenance, Secretion control,

Oxygenation and Ventilation.

Types of intubation: Orotracheal, Nasotracheal, Tracheostomy

Preparing for Intubation

1. Recognize the need for intubation.

2. Notify physician and respiratory therapist. Ensure consent obtained if not

emergency.

3. Gather all necessary equipment:

a. Suction canister with regulator and connecting tubing

b. Sterile 14 Fr. suction catheter or closed in-line suction catheter

c. Sterile gloves

d. Normal saline

e. Yankuer suction-tip catheter and nasogastric tube

f. Intubation equipment: Manual resuscitator bag (MRB), Laryngoscope and blade,Wire guide, Water soluble lubricant, Cetacaine spray

g. Endotracheal attachment device (E-tad) or tape

h. Get order for initial ventilator settings

i. Sedation prn

j. Soft wrist restraints prn

k. Call for chest x-ray to confirm position of endotracheal tube


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l. Provide emotional support as needed/ ensure family notified of change in

condition.

Intubation

Types of Ventilators

Ventilator Settings

Modes of Mechanical Ventilation

Complications of Mechanical Ventilation

1. Associated with patients response to mechanical ventilation:

A. Decreased Cardiac Output

1. Cause - venous return to the right atrium impeded by the dramatically increasedintrathoracic pressures during inspiration from positive pressure ventilation. Also

reduced sympatho-adrenal stimulation leading to a decrease in peripheral vascular

resistance and reduced blood pressure.

2. Symptomsincreased heart rate, decreased blood pressure and perfusion to vital

organs, decreased CVP, and cool clammy skin.

3. Treatmentaimed at increasing preload (e.g. fluid administration) and

decreasing the airway pressures exerted during mechanical ventilation by

decreasing inspiratory flow rates and TV, or using other methods to decreaseairway pressures (e.g. different modes of ventilation).

B. Barotrauma

1. Causedamage to pulmonary system due to alveolar rupture from excessive

airway pressures and/or overdistention of alveoli.

2. Symptomsmay result in pneumothorax, pneumomediastinum,pneumoperitoneum, or subcutaneous emphysema.

3. Treatment - aimed at reducing TV, cautious use of PEEP, and avoidance of high

airway pressures resulting in development of auto-PEEP in high risk patients

(patients with obstructive lung diseases (asthma, bronchospasm), unevenlydistributed lung diseases (lobar pneumonia), or hyperinflated lungs (emphysema).

C. Nosocomial Pneumonia


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1. Causeinvasive device in critically ill patients becomes colonized with

pathological bacteria within 24 hours in almost all patients. 20-60% of these,

develop nosocomial pneumonia.

2. Treatmentaimed at prevention by the following:

Avoid cross-contamination by frequent handwashing

Decrease risk of aspiration (cuff occlusion of trachea, positioning, use of small-bore NG tubes)

Suction only when clinically indicated, using sterile technique

Maintain closed system setup on ventilator circuitry and avoid pooling of

condensation in the tubing

Ensure adequate nutrition

Avoid neutralization of gastric contents with antacids and H2 blockers

D. Positive Water Balance

1. Syndrome of Inappropriate Antidiuretic Hormone (SIADH)due to vagal

stretch receptors in right atrium sensing a decrease in venous return and see it as

hypovolemia, leading to a release of ADH from the posterior pituitary gland andretention of sodium and water. Treatment is aimed at decreasing fluid intake.

2. Decrease of normal insensible water loss due to closed ventilator circuitpreventing water loss from lungs. This fluid overload evidenced by decreased urine

specific gravity, dilutional hyponatremia, increased heart rate and BP.

E. Decreased Renal Perfusioncan be treated with low dose dopamine therapy.

F. Increased Intracranial Pressure (ICP)reduce PEEP

G. Hepatic congestionreduce PEEP

H. Worsening of intracardiac shuntsreduce PEEP

2. Associated with ventilator malfunction:

A. Alarms turned off or nonfunctionalmay lead to apnea and respiratory arrest

Troubleshooting Ventilator Alarms


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Low exhaled volume: Cuff leak, Tubing disconnect, Patient disconnected

Evaluate cuff; reinflate prn; if ruptured, tube will need to be replaced. Evaluateconnections; tighten or replace as needed; check ETT placement, Reconnect to

ventilator

High pressure: Secretions in airway, Patient biting tubing, Tube kinked, Cuffherniation, Increased airway resistance/decreased lung compliance (caused by

bronchospasm, right mainstem bronchus intubation, pneumothorax, pneumonia),Patient coughing and/or fighting the ventilator; anxiety; fear; pain.

Suction patient, Insert bite block, Reposition patients head/neck; check all tubinglengths, Deflate and reinflate cuff, Auscultate breath sounds, Evaluate compliance

and tube position; stabilize tube, Explain all procedures to patient in calm,

reassuring manner, Sedate/medicate as necessar

Low oxygen pressure: Oxygen malfunction

Disconnect patient from ventilator; manually bag with ambu; call R.T

3. Other complications related to endotracheal intubation.

A. Sinusitis and nasal injuryobstruction of paranasal sinus drainage; pressurenecrosis of nares

1. Prevention: avoid nasal intubations; cushion nares from tube and tape/ties.

2. Treatment: remove all tubes from nasal passages; administer antibiotics.

B. Tracheoesophageal fistulapressure necrosis of posterior tracheal wallresulting from overinflated cuff and rigid nasogastric tube

1. Prevention: inflate cuff with minimal amount of air necessary; monitor cuffpressures q. 8 h.

2. Treatment: position cuff of tube distal to fistula; place gastrostomy tube for

enteral feedings; place esophageal tube for secretion clearance proximal to fistula.

C. Mucosal lesionspressure at tube and mucosal interface

1. Prevention: Inflate cuff with minimal amount of air necessary; monitor cuff

pressure q. 8 h.; use appropriate size tube.

2. Treatment: may resolve spontaneously; perform surgical interventions.


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D. Laryngeal or tracheal stenosisinjury to area from end of tube or cuff, resulting

in scar tissue formation and narrowing of airway

1. Prevention: inflate cuff with minimal amount of air necessary; monitor cuff

pressure q. 8.h.; suction area above cuff frequently.

2. Treatment: perform tracheostomy; place laryngeal stint; perform surgical repair.

E. Cricoid abcessmucosal injury with bacterial invasion

1. Prevention: inflate cuff with minimal amount of air necessary; monitor cuff

pressure q. 8 h.; suction area above cuff frequently.

2. Treatment: perform incision and drainage of area; administer antibiotics.

4. Other common potential problems related to mechanical ventilation:

Aspiration, GI bleeding, Inappropriate ventilation (respiratory acidosis or alkalosis,

Thick secretions, Patient discomfort due to pulling or jarring of ETT ortracheostomy, High PaO2, Low PaO2, Anxiety and fear, Dysrhythmias or vagal

reactions during or after suctioning, Incorrect PEEP setting, Inability to tolerate

ventilator mode.

PLAN OF CARE FOR THE VENTILATED PATIENT

Patient Goals:

1. Patient will have effective breathing pattern.2. Patient will have adequate gas exchange.3. Patients nutritional status will be maintained to meet body needs.4. Patient will not develop a pulmonary infection.5. Patient will not develop problems related to immobility.

6. Patient and/or family will indicate understanding of the purpose formechanical ventilation.

Nursing Diagnosis Nursing Interventions Rationale


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Ineffective breathing pattern r/t

____________________________.

Observe changes in

respiratory rate and

depth; observe for SOB

and use of accessory

muscles.

An increase in the work

of breathing will add to

fatigue; may indicate

patient fighting

ventilator.

Observe for tube

misplacement- note and

post cm. Marking at

lip/teeth/nares after x-

ray confirmation and q.

2 h.

Indicates correct

position to provide

adequate ventilation.

Prevent accidental

extubation by taping

tube securely, checkingq.2h.;

restraining/sedating as

needed.

Avoid trauma from

accidental extubation,

prevent inadequateventilation and

potential respiratory

arrest.

Inspect thorax for

symmetry of

movement.

Determines adequacy

of breathing pattern;

asymmetry may

indicate hemothorax or

pneumothorax.

Measure tidal volume

and vital capacity.

Indicates volume of airmoving in and out of

lungs.

Asses for pain

Pain may prevent

patient from coughing

and deep breathing.

Monitor chest x-rays

Shows extent and

location of fluid or

infiltrates in lungs.

Maintain ventilator

settings as ordered.

Ventilator provides

adequate ventilator

pattern for the patient.

Elevate head of bed 60-

90 degrees.

This position moves

the abdominal contents

away from the

diaphragm, which

facilitates its

contraction.


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Impaired gas exchange r/t alveolar-

capillary membrane changesMonitor ABGs.

Determines acid-basebalance and need for

oxygen.

Assess LOC,

listlessness, and

irritability.

These signs may

indicate hypoxia.

Observe skin color and

capillary refill.

Determine adequacy of

blood flow needed tocarry oxygen to tissues.

Monitor CBC.

Indicates the oxygen

carrying capacity

available.

Administer oxygen as

ordered.

Decreases work of

breathing and supplies

supplemental oxygen.

Observe for tubeobstruction; suction

prn; ensure adequate

humidification.

May result ininadequate ventilation

or mucous plug.

Reposition patient q. 1-

2 h.

Repositioning helps all

lobes of the lung to be

adequately perfused

and ventilated.

Potential altered nutritional status:

less than body requirements r/tNPO status

Monitor lymphocytes

and albumin.

Indicates adequate

visceral protein.

Provide nutrition as

ordered, e.g. TPN,

lipids or enteral

feedings.

Calories, minerals,

vitamins, and protein

are needed for energy

and tissue repair.

Obtain nutrition

consult.

Provides guidance and

continued surveillance.

Potential for pulmonary infection Secure airway and Prevent mucosal


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r/t compromised tissue integrity. support ventialtor

tubing.

damage.

Provide good oral care

q. 4 h.; suction when

need indicated using

sterile technique;

handwashing with

antimicrobial for 30

seconds before and

after patient contact; do

not empty condensation

in tubing back into

cascade.

Measures aimed at

prevention of

nosocomial infections.

Use disposable salineirrigation units to rinse

in-line suction; ensure

ventilator tubing

changed q. 7 days, in-

line suction changed q.

24 h.; ambu bags

changes between

patients and whenever

become soiled.

IAW Infection Control

Policy and Respiratory

Therapy Standards of

Care for CCNS.

Potential for complications r/t

immobility.

Assess for psychosocial

alterations.

Dependency onventilator with

increased anxiety when

weaning; decreased

ability to communicate;

social

isolation/alteration in

family dynamics.

Assess for GI

problems. Preventative

measures includerelieving anxiety,

antacids or H2 receptor

antagonist therapy,

adequate sleep cycles,

adequate

communication system.

Most serious is stress

ulcer. May develop

constipation.


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Observe skin integrity

for pressure ulcers;

preventative measures

include turning patient

at least q. 2 h.; keepHOB < 30 degrees with

a 30 degree side-lying

position; use pressure

relief mattress or

turning bed if

indicated; follow

prevention of pressure

ulcers plan of care;

maintain nutritional

needs.

Patient is at high riskfor developing pressure

ulcers due to

immobility and

decreased tissue

perfusion.

Maintain muscle

strength with

active/active-

assistive/passive ROM

and prevent

contractures with use

of span-aids or splints.

Patient is at risk for

developing

contractures due to

immobility, use of

paralytics and

ventilator related

deficiencies.

Knowledge deficit r/t intubation

and mechanical ventilation

Explain

purpose/mode/and all

treatments; encouragepatient to relax and

breath with the

ventilator; explain

alarms; teach

importance of deep

breathing; provide

alternate method of

communication; keep

call bell within reach;

keep informed of

results ofstudies/progress;

demonstrate

confidence.

Reduce anxiety, gain

cooperation and

participation in plan of

care.


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Mechanical ventilationFrom Wikipedia, the free encyclopedia

Inarchitectureandclimate control,mechanical orforced ventilation is the use of powered

equipment, e.g.fansand blowers, to move air seeventilation (architecture).

Mechanical ventilation

Intervention

ICD-9: 93.9096.7

MeSH D012121

OPS-301 code: 8-71

Inmedicine,mechanical ventilation is a method to mechanically assist or replace spontaneousbreathing.

This may involve a machine called aventilatoror the breathing may be assisted by aphysician,respiratory

therapistorothersuitable person compressing abagor set of bellows. Traditionally divided intonegative-

pressure ventilation, where air is essentially sucked into the lungs, orpositive pressure ventilation, where

air (or another gas mix) is pushed into thetrachea. There are two main divisions of mechanical ventilation:

invasive ventilation and non-invasive ventilation.[1]

There are two mainmodes of mechanical

ventilationwithin the two divisions: positive pressure ventilation and negative pressure ventilation.
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Contents

[hide]

1 History2 Complications

3 Application and duration

o 3.1 Negative pressure machines

o 3.2 Positive pressure machines

4 Indications for use

5 Associated risk

6 Types of ventilators

o 6.1 Mechanical ventilators

7 Breath delivery

o 7.1 Trigger

o 7.2 Cycle

o 7.3 Limit

8 Breath exhalation

9 Modes of mechanical ventilation

o 9.1 Volume controlled continuous mandatory ventilation

o 9.2 Volume controlled intermittent mandatory ventilation

o 9.3 Pressure controlled continuous mandatory ventilation

o 9.4 Pressure controlled intermittent mandatory ventilation

o 9.5 High frequency ventilation

o 9.6 Continuous spontaneous ventilation

9.6.1 Pressure Support Ventilation

9.6.2 Continuous positive airway pressure

10 Choosing amongst ventilator modes11 Modification of settings

o 11.1 Weaning from mechanical ventilation

12 Respiratory monitoring

13 Artificial airways as a connection to the ventilator

14 References

15 External links

[edit]History
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The Roman physicianGalenmay have been the first to describe mechanical ventilation: "If you take a dead

animal and blow air through its larynx [through a reed], you will fill its bronchi and watch its lungs attain the

greatest distention."[2]

Vesaliustoo describes ventilation by inserting a reed or cane into the tracheaof

animals.[3]

In 1908George Poedemonstrated his mechanical respirator by asphyxiating dogs and

seemingly bringing them back to life.[4]

[edit]Complications

Mechanical ventilation is often a life-saving intervention, but carries many potential complications

includingpneumothorax, airway injury, alveolar damage, and ventilator-associated pneumonia.[5]

In many healthcare systems prolonged ventilation as part ofintensive careis a limited resource (in that

there are only so many patients that can receive care at any given moment). It is used to support a single

failing organ system (the lungs) and cannot reverse any underlying disease process (such as terminalcancer). For this reason there can be (occasionally difficult) decisions to be made about whether it is

suitable to commence someone on mechanical ventilation. Equally many ethical issues surround the

decision to discontinue mechanical ventilation.[6]

[edit]Application and duration

It can be used as a short term measure, for example during an operation or critical illness (often in the

setting of anintensive care unit). It may be used at home or in a nursing or rehabilitation institution if

patients have chronic illnesses that require long-term ventilatory assistance. Owing[clarification needed]

to the

anatomy of the humanpharynx,larynx, andesophagusand the circumstances for which ventilation is

required then additional measures are often required to secure theairwayduring positive pressure

ventilation to allow unimpeded passage of air into the trachea and avoid air passing into the esophagus

and stomach. Commonly this is byinsertion of a tube into the tracheawhich provides a clear route for the

air. This can be either anendotracheal tube, inserted through the natural openings of mouth or nose or

atracheostomyinserted through an artificial opening in the neck. In other circumstances simpleairway

maneuvres, anoropharyngeal airwayorlaryngeal mask airwaymay be employed. If the patient is able to

protect their own airway and non-invasive ventilation ornegative-pressure ventilationis used then aairway

adjunctmay not be needed.

[edit]Negative pressure machines
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An iron lung

Main article:Iron Lung

Theiron lung, also known as the Drinker and Shaw tank, was developed in 1929 and was one of the first

negative-pressure machines used for long-term ventilation. It was refined and used in the 20th century

largely as a result of thepolioepidemicthat struck the world in the 1940s. The machine is effectively a

large elongatedtank, which encases the patient up to the neck. The neck is sealed with a rubbe rgasketso

that the patient's face (and airway) are exposed to the room air.

While the exchange ofoxygenandcarbon dioxidebetween the bloodstream and the pulmonary airspace

works bydiffusionand requires no external work, air must be moved into and out of thelungsto make it

available to thegas exchangeprocess. In spontaneous breathing, a negative pressure is created in

thepleural cavityby the muscles of respiration, and the resulting gradient between theatmospheric

pressureand the pressure inside thethoraxgenerates a flow of air.

In the iron lung by means of a pump, the air is withdrawn mechanically to produce a vacuum inside the

tank, thus creating negative pressure. This negative pressure leads to expansion of the chest, which

causes a decrease in intrapulmonary pressure, and increases flow of ambient air into the lungs. As the

vacuum is released, the pressure inside the tank equalizes to that of the ambient pressure, and the elastic

coil of the chest and lungs leads to passive exhalation. However, when the vacuum is created, the

abdomen also expands along with the lung, cutting off venous flow back to the heart, leading to pooling of

venous blood in the lower extremities. There are large portholes for nurse or home assistant access. The

patients can talk and eat normally, and can see the world through a well-placed series of mirrors. Some

could remain in these iron lungs for years at a time quite successfully.

Today, negative pressure mechanical ventilators are still in use, notably with the polio wing hospitals

inEnglandsuch asSt Thomas' Hospitalin London and theJohn RadcliffeinOxford. The prominent device

used is a smaller device known as thecuirass. The cuirass is a shell-like unit, creating negative pressure

only to the chest using a combination of a fitting shell and a soft bladder. Its main use is in patients with

neuromuscular disorders who have some residual muscular function. However, it was prone to falling off

and caused severe chafing and skin damage and was not used as a long term device. In recent years this

device has re-surfaced as a modernpolycarbonateshell with multiple seals and a high pressureoscillation

pumpin order to carry outbiphasic cuirass ventilation.
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[edit]Positive pressure machines

Neonatal mechanical ventilator

The design of the modern positive-pressure ventilators were mainly based on technical developments by

the military during World War II to supply oxygen to fighter pilots in high altitude. Such ventilators replaced

the iron lungs as safe endotracheal tubes with high volume/low pressure cuffs were developed. The

popularity of positive-pressure ventilators rose during the polio epidemic in the 1950s in Scandinavia and

the United States and was the beginning ofmodern ventilation therapy. Positive pressure through manual

supply of 50% oxygen through atracheostomytube led to a reduced mortality rate among patients with

polio and respiratory paralysis. However, because of the sheer amount of man-power required for such

manual intervention, mechanical positive-pressure ventilators became increasingly popular.

Positive-pressure ventilators work by increasing the patient's airway pressure through an endotracheal or

tracheostomy tube. The positive pressure allows air to flow into the airway until the ventilator breath is

terminated. Subsequently, the airway pressure drops to zero, and the elastic recoil of the chest wall and

lungs push thetidal volume the breathout through passive exhalation.

[edit]Indications for use

Mechanical ventilation is indicated when the patient's spontaneousventilationis inadequate to maintain life.

It is also indicated as prophylaxis for imminent collapse of other physiologic functions, or ineffective gas

exchange in the lungs. Because mechanical ventilation only serves to provide assistance for breathing and

does not cure a disease, the patient's underlying condition should be correctable and should resolve over

time. In addition, other factors must be taken into consideration because mechanical ventilation is not

without its complications (see below)

Common medical indications for use include:

Acute lung injury (includingARDS, trauma)
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Apneawith respiratory arrest, including cases fromintoxication

Chronic obstructive pulmonary disease (COPD)

Acuterespiratory acidosiswith partial pressure of carbon dioxide (pCO2) > 50 mmHg and pH < 7.25,

which may be due to paralysis of thediaphragmdue toGuillain-Barr syndrome,Myasthenia

Gravis,spinal cordinjury, or the effect ofanaestheticandmuscle relaxantdrugs

Increased work of breathing as evidenced by significanttachypnea, retractions, and other physical

signs of respiratory distress

Hypoxemiawith arterial partial pressure of oxygen (PaO2) < 55 mm Hg with supplemental fraction of

inspired oxygen (FiO2) = 1.0

Hypotensionincludingsepsis,shock,congestive heart failure

Neurological diseases such asMuscular DystrophyandAmyotrophic Lateral Sclerosis

[edit]Associated riskBarotraumaPulmonary barotraumais a well-known complication of positive pressure mechanical

ventilation.[7]

This includespneumothorax,subcutaneous emphysema,pneumomediastinum,

andpneumoperitoneum.[7]

Ventilator-associated lung injuryVentilator-associated lung injury(VALI) refers to acute lung injury

that occurs during mechanical ventilation. It is clinically indistinguishable fromacute lung injuryoracute

respiratory distress syndrome(ALI/ARDS).[8]

Diaphragm Controlled mechanical ventilation may lead to a rapid type of disuseatrophyinvolving the

diaphragmatic muscle fibers, which can develop within the first day of mechanical ventilation.[9]

This cause

of atrophy in the diaphragm is also a cause of atrophy in all respiratory related muscles during controlled

mechanical ventilation.[10]

Motility of mucocilia in the airways Positive pressure ventilation appears to impair mucociliary motility

in the airways.Bronchialmucus transport was frequently impaired and associated with retention of

secretions andpneumonia.[11]

[edit]Types of ventilators
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al_ventilation#cite_note-pmid12472328-9http://en.wikipedia.org/wiki/Mechanical_ventilation#cite_note-pmid12472328-9http://en.wikipedia.org/wiki/Mechanical_ventilation#cite_note-pmid12472328-9http://en.wikipedia.org/wiki/Bronchialhttp://en.wikipedia.org/wiki/Bronchialhttp://en.wikipedia.org/wiki/Bronchialhttp://en.wikipedia.org/wiki/Pneumoniahttp://en.wikipedia.org/wiki/Pneumoniahttp://en.wikipedia.org/wiki/Mechanical_ventilation#cite_note-pmid8275739-10http://en.wikipedia.org/wiki/Mechanical_ventilation#cite_note-pmid8275739-10http://en.wikipedia.org/wiki/Mechanical_ventilation#cite_note-pmid8275739-10http://en.wikipedia.org/w/index.php?title=Mechanical_ventilation&action=edit&section=8http://en.wikipedia.org/w/index.php?title=Mechanical_ventilation&action=edit&section=8http://en.wikipedia.org/w/index.php?title=Mechanical_ventilation&action=edit&section=8http://en.wikipedia.org/wiki/File:Ballon_ventilation_1.jpghttp://en.wikipedia.org/wiki/File:Ballon_ventilation_1.jpghttp://en.wikipedia.org/wiki/File:Ballon_ventilation_1.jpghttp://en.wikipedia.org/wiki/File:Ballon_ventilation_1.jpghttp://en.wikipedia.org/w/index.php?title=Mechanical_ventilation&action=edit&section=8http://en.wikipedia.org/wiki/Mechanical_ventilation#cite_note-pmid8275739-10http://en.wikipedia.org/wiki/Pneumoniahttp://en.wikipedia.org/wiki/Bronchialhttp://en.wikipedia.org/wiki/Mechanical_ventilation#cite_note-pmid12472328-9http://en.wikipedia.org/wiki/Mechanical_ventilation#cite_note-pmid18367735-8http://en.wikipedia.org/wiki/Atrophyhttp://en.wikipedia.org/wiki/Mechanical_ventilation#cite_note-7http://en.wikipedia.org/wiki/Acute_respiratory_distress_syndromehttp://en.wikipedia.org/wiki/Acute_respiratory_distress_syndromehttp://en.wikipedia.org/wiki/Acute_lung_injuryhttp://en.wikipedia.org/wiki/Ventilator-associated_lung_injuryhttp://en.wikipedia.org/wiki/Mechanical_ventilation#cite_note-pmid8420720-6http://en.wikipedia.org/wiki/Pneumoperitoneumhttp://en.wikipedia.org/wiki/Pneumomediastinumhttp://en.wikipedia.org/wiki/Subcutaneous_emphysemahttp://en.wikipedia.org/wiki/Pneumothoraxhttp://en.wikipedia.org/wiki/Mechanical_ventilation#cite_note-pmid8420720-6http://en.wikipedia.org/wiki/Pulmonary_barotraumahttp://en.wikipedia.org/w/index.php?title=Mechanical_ventilation&action=edit&section=7http://en.wikipedia.org/wiki/Amyotrophic_Lateral_Sclerosishttp://en.wikipedia.org/wiki/Muscular_Dystrophyhttp://en.wikipedia.org/wiki/Congestive_heart_failurehttp://en.wikipedia.org/wiki/Shock_(circulatory)http://en.wikipedia.org/wiki/Sepsishttp://en.wikipedia.org/wiki/Hypotensionhttp://en.wikipedia.org/wiki/Hypoxemiahttp://en.wikipedia.org/wiki/Tachypneahttp://en.wikipedia.org/wiki/Muscle_relaxanthttp://en.wikipedia.org/wiki/Anaesthesiahttp://en.wikipedia.org/wiki/Spinal_cordhttp://en.wikipedia.org/wiki/Myasthenia_Gravishttp://en.wikipedia.org/wiki/Myasthenia_Gravishttp://en.wikipedia.org/wiki/Guillain-Barr%C3%A9_syndromehttp://en.wikipedia.org/wiki/Thoracic_diaphragmhttp://en.wikipedia.org/wiki/Respiratory_acidosishttp://en.wikipedia.org/wiki/Chronic_obstructive_pulmonary_diseasehttp://en.wikipedia.org/wiki/Chronic_obstructive_pulmonary_diseasehttp://en.wikipedia.org/wiki/Substance_intoxicationhttp://en.wikipedia.org/wiki/Apnea


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SMART BAG MO Bag-Valve-Mask Resuscitator

Ventilators come in many different styles and method of giving a breath to sustain life. There are manual

ventilators such asBag valve masksandanesthesia bagsrequire the user to hold the ventilator to the face

or to anartificial airwayand maintain breaths with their hands. Mechanical ventilators are ventilators not

requiring operator effort and are typically computer controlled or pneumatic controlled.

[edit]Mechanical ventilators

Mechanical ventilators typically require power by a battery or a wall outlet (DC or AC) though some

ventilators work on a pneumatic system not requiring power.

Transport ventilators These ventilators are small, more rugged, and can be powered

pneumatically or via AC or DC power sources.

Intensive-care ventilators These ventilators are larger and usually run on AC power (though

virtually all contain a battery to facilitate intra-facility transport and as a back-up in the event of a power

failure). This style of ventilator often provides greater control of a wide variety of ventilation parameters

(such as inspiratory rise time). Many ICU ventilators also incorporate graphics to provide visual

feedback of each breath.

Neonatal ventilators Designed with the preterm neonate in mind, these are a specialized subset of

ICU ventilators which are designed to deliver the smaller, more precise volumes and pressures

required to ventilate these patients.

Positive airway pressureventilators (PAP) These ventilators are specifically designed fornon-

invasive ventilation. This includes ventilators for use at home for treatment of chronic conditions such

assleep apneaorCOPD.

[edit]Breath delivery

[edit]Trigger

The trigger is what causes a breath to be delivered by a mechanical ventilator. Breaths may be triggered by

a patient taking their own breath, a ventilator operator pressing a manual breath button, or by the ventilator

based on the set breath rate and mode of ventilation.

[edit]Cycle

The cycle is what causes the breath to transition from the inspiratory phase to the exhalation phase.

Breaths may be cycled by a mechanical ventilator when a set time has been reached, or when a preset

flow or percentage of the maximum flow delivered during a breath is reached depending on the breath type

and the settings. Breaths can also be cycled when an alarm condition such as a high pressure limit has

been reached, which is a primary strategy inpressure regulated volume control.
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[edit]Limit

Limit is how the breath is controlled. Breaths may be limited to a set maximum circuit pressure or a set

maximum flow.

[edit]Breath exhalation

Exhalation in mechanical ventilation is almost always completely passive. The ventilator's expiratory valve

is opened, and expiratory flow is allowed until the baseline pressure (PEEP) is reached. Expiratory flow is

determined by patient factors such as compliance and resistance.

[edit]Modes of mechanical ventilation

Main article:Modes of mechanical ventilation

Mechanical ventilation utilizes several separate systems for ventilation referred to as the "mode". Modes

come in many different delivery concepts but all modes generally fall into one of the few main flagship

categories such as volume controlled continuous mandatory ventilation, volume controlled intermittent

mandatory ventilation, pressure controlled continuous mandatory ventilation, pressure controlled

intermittent mandatory ventilation, continuous spontaneous ventilation and the high frequency ventilation

systems.

[edit]Volume controlled continuous mandatory

ventilationControlled mechanical ventilation (CMV) In this mode the ventilator provides a mechanical breath on

a preset timing. Patient respiratory efforts are ignored. This is generally uncomfortable for children and

adults who are conscious and is usually only used in an unconscious patient. It may also be used in infants

who often quickly adapt their breathing pattern to the ventilator timing. Since CMV is no longer contained in

its original form the termvolume controlled continuous mandatory ventilationhas consumed it into its

definition and overall has combined any CMV mode for mechanical ventilation into the more accepted term

innomenclature for mechanical ventilation.

Volume controlled continuous mandatory ventilation In this mode the ventilator provides a

mechanical breath with either a pre-set tidal volume or peak pressure every time the patient initiates a

breath. Traditional assist-control used only a pre-set tidal volumewhen a preset peak pressure is used

this is also sometimes termed intermittent positive pressure ventilation (IPPV). However, the initiation

timing is the sameboth provide a ventilator breath with every patient effort. In most ventilators a back-up

minimum breath rate can be set in the event that the patient becomes apnoeic. Although a maximum rate is

not usually set, an alarm can be set if the ventilator cycles too frequently. This can alert that the patient is

tachypneic or that the ventilator may be auto-cycling (a problem that results when the ventilator interprets

fluctuations in the circuit due to the last breath termination as a new breath initiation attempt).
http://en.wikipedia.org/w/index.php?title=Mechanical_ventilation&action=edit&section=13http://en.wikipedia.org/w/index.php?title=Mechanical_ventilation&action=edit&section=13http://en.wikipedia.org/w/index.php?title=Mechanical_ventilation&action=edit&section=13http://en.wikipedia.org/w/index.php?title=Mechanical_ventilation&action=edit&section=14http://en.wikipedia.org/w/index.php?title=Mechanical_ventilation&action=edit&section=14http://en.wikipedia.org/w/index.php?title=Mechanical_ventilation&action=edit&section=14http://en.wikipedia.org/wiki/PEEPhttp://en.wikipedia.org/wiki/PEEPhttp://en.wikipedia.org/wiki/PEEPhttp://en.wikipedia.org/w/index.php?title=Mechanical_ventilation&action=edit&section=15http://en.wikipedia.org/w/index.php?title=Mechanical_ventilation&action=edit&section=15http://en.wikipedia.org/w/index.php?title=Mechanical_ventilation&action=edit&section=15http://en.wikipedia.org/wiki/Modes_of_mechanical_ventilationhttp://en.wikipedia.org/wiki/Modes_of_mechanical_ventilationhttp://en.wikipedia.org/wiki/Modes_of_mechanical_ventilationhttp://en.wikipedia.org/w/index.php?title=Mechanical_ventilation&action=edit&section=16http://en.wikipedia.org/w/index.php?title=Mechanical_ventilation&action=edit&section=16http://en.wikipedia.org/w/index.php?title=Mechanical_ventilation&action=edit&section=16http://en.wikipedia.org/wiki/Volume_controlled_continuous_mandatory_ventilationhttp://en.wikipedia.org/wiki/Volume_controlled_continuous_mandatory_ventilationhttp://en.wikipedia.org/wiki/Volume_controlled_continuous_mandatory_ventilationhttp://en.wikipedia.org/wiki/Nomenclature_for_mechanical_ventilationhttp://en.wikipedia.org/wiki/Nomenclature_for_mechanical_ventilationhttp://en.wikipedia.org/wiki/Nomenclature_for_mechanical_ventilationhttp://en.wikipedia.org/wiki/Volume_controlled_continuous_mandatory_ventilationhttp://en.wikipedia.org/wiki/Volume_controlled_continuous_mandatory_ventilationhttp://en.wikipedia.org/wiki/Volume_controlled_continuous_mandatory_ventilationhttp://en.wikipedia.org/wiki/Nomenclature_for_mechanical_ventilationhttp://en.wikipedia.org/wiki/Volume_controlled_continuous_mandatory_ventilationhttp://en.wikipedia.org/w/index.php?title=Mechanical_ventilation&action=edit&section=16http://en.wikipedia.org/wiki/Modes_of_mechanical_ventilationhttp://en.wikipedia.org/w/index.php?title=Mechanical_ventilation&action=edit&section=15http://en.wikipedia.org/wiki/PEEPhttp://en.wikipedia.org/w/index.php?title=Mechanical_ventilation&action=edit&section=14http://en.wikipedia.org/w/index.php?title=Mechanical_ventilation&action=edit&section=13


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[edit]Volume controlled intermittent mandatoryventilation

Volume controlled intermittent mandatory ventilation(VC-IMV). Formerly known as synchronized

intermittent mandatory ventilation (SIMV). In this mode the ventilator provides a pre-set mechanical breath

(volume limited) every specified number of seconds (determined by dividing the respiratory rate into 60

seconds thus a respiratory rate of 12 results in a 5 second cycle time). Within that cycle time the

ventilator waits for the patient to initiate a breath using either a pressure or flow sensor. When the ventilator

senses the first patient breathing attempt within the cycle, it delivers the preset ventilator breath. If the

patient fails to initiate a breath, the ventilator delivers a mechanical breath at the end of the breath cycle.

Additional spontaneous breaths after the first one within the breath cycle do not trigger another SIMV

Portable Ventilator

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