Care of Ventilator Patients and Complications
As a patient is supported on a ventilator in the ICU, they may develop anxiety, depression, and other mental health concerns. Nursing needs to work closely with the patient and family to answer questions and to provide not only physical care but emotional support as well. When alarms do sound, always assess the patient first to try and establish why the alarm is sounding, and then move to the ventilator. High-pressure alarms typically indicate the tubing is being pinched, there are excess secretions, the patient is anxious, the patient is coughing, or the airway is impacted by wheezing or spasm. Low-pressure alarms typically indicate the tubing may have come apart or developed a hole, a connection is loose, or the cuff is leaking. Nurses working with ventilators should be very knowledgeable about what each setting indicates and what to do if something is not working appropriately. It is also imperative to work with respiratory therapy and the provider to give the patient the best possible care (Ignatavicius et al., 2018).
The ventilated patient needs to be monitored frequently with careful documentation completed. The assessment should include vital signs, oxygen saturation, lung sounds to indicate if the patient is making any respiratory effort on their own, monitoring the weaning process if indicated, and overall observations. The provider will order arterial blood gases as needed, and nursing will need to monitor the results, and contact the provider and/or respiratory therapy as indicated. The ongoing monitoring is crucial to evaluate if the patient is improving or maintaining their oxygenation and gas exchange. As the condition warrants, the patient will likely need consults and treatment with physical, occupational and/or speech therapy, increased activity, and progress towards the weaning process if possible (Ignatavicius et al., 2018).
Patient care while on a ventilator will also include assessment of the artificial airway, either the ETT or tracheostomy tube, and the need for suction. The patient may express the need to be suctioned, have obvious secretions, or the ventilator may indicate increased pressure. The insertion site and placement should also be checked at frequent intervals: at least every four hours or per facility policy. The nurse should monitor the ventilator patient for any adverse signs but also for signs of improvement, especially noting if the patient is working against the ventilator or taking more breaths than previous. The nurse must also consider the patient’s psychosocial and emotional needs. Communication will likely be at least temporarily impaired, so speech therapy should provide communication tools or assist the tracheostomy patient with therapy as the condition of the patient warrants (Ignatavicius et al., 2018; Wilkinson et al., 2016).
Patients maintained on mechanical ventilation can develop many complications, sometimes referred to as ventilator-associated or ventilator-acquired events (VAE). These events indicate the patient has deteriorated regarding their ability to maintain oxygenation. There are three tiers of associated events: ventilator-associated condition (VAC), infection-related ventilator-associated complication (IVAC), and ventilator-associated pneumonia (VAP). In VAC, the patient has hypoxemia that has lasted more than two days, as evidence by increased daily minimum PEEP or FiO2. If this hypoxemia develops concurrently with a fever as a result of some type of infection that requires antibiotic therapy, it is referred to as IVAC. If blood work reveals positive gram stains or positive cultures in a patient diagnosed with IVAC, it is now considered VAP (Ignatavicius et al., 2018).
Infection in the ventilator-dependent patient can be a serious complication, and every effort must be made to decrease the risk of infection. Artificial airways make these patients vulnerable because of the ease of access via the devices for bacteria to descend into the airway rather quickly. Some research indicates that ETT or tracheostomy tubes are colonized with bacteria within 48 hours following insertion. These bacteria (along with bacteria that can be aspirated from the stomach, spread from staff not using appropriate hand hygiene, and introduced via inappropriate technique when suctioning or performing cares) can lead to pneumonia and other infections which increase the patient’s risk of illness and death (Ignatavicius et al., 2018).
Strict adherence to handwashing and the use of sterile technique, as indicated by facility policy, is recommended to prevent VAE. Besides using strict infection control, aspiration precautions should be in place for all patients on a ventilator, such as elevating the head of the bed to at least 30° to prevent aspiration. Oral care, as previously discussed, is essential for general health but also decreases the risk of infection. Continued monitoring of respiratory secretions, and appropriate suctioning and cares are essential to maintain infection control (Ignatavicius et al., 2018).
Multiple body systems can be impacted by mechanical ventilation. Some common cardiac complaints include hypotension and a reduction in the cardiac output, which leads to fluid retention. Nursing should monitor vital signs, intake, output, and daily weights to evaluate fluid changes as well as attempt to maintain appropriate hydration (Ignatavicius et al., 2018).
Trauma to the respiratory system in a variety of forms is one of the concerns with long-term use of ventilators. Traumatic events include:
- Barotrauma, which is damage to the lung tissue caused by positive pressure.
- Volutrauma, which results from too much volume being used and is typically more pronounced in one lung.
- Atelectrauma, which is a shearing injury that occurs to the alveoli from opening and closing.
- Boitrauma, which is damage to the alveoli that arises from an inflammatory response. This can also result in pneumothorax and subcutaneous emphysema and is common in patients who have ARDS (Ignatavicius et al., 2018).
Another injury that can arise from prolonged ventilator use includes ventilator-associated lung injury or ventilator-induced lung injury. This results in a loss of surfactant, inflammation, fluid escape, and edema of the lungs. Using low tidal volume and moderation of PEEP levels reduces the risk of lung trauma or injury for all ventilator patients, especially patients with ARDS or other acute lung injuries. It is also common to see acid-base imbalances in patients on ventilators. If a patient is struggling with acid-base concerns, respiratory therapy should be consulted to adjust the ventilator settings and the provider may adjust fluids and electrolytes to regain balance. It is imperative for electrolyte balance to be monitored and maintained as many electrolytes play an important role in muscle function (Ignatavicius et al., 2018).
The gastrointestinal system is primarily affected by the stress of the illness, and the associated ventilator status. This stress can result in irritation of the mucosal lining and a stress ulcer, which in turn can impair the nutritional status of the patient. Impaired integrity of the gastrointestinal tract further increases the risk of systemic infection. It is common for providers to order gastrointestinal medications prophylactically when a patient is intubated. These medications could include antacids, histamine-2 receptor antagonists such as ranitidine (Zantac), or proton pump inhibitors such as omeprazole (Prilosec). Sucralfate (Carafate) is considered a miscellaneous gastrointestinal medication that covers and protects the ulcer site that could be prescribed. Prevention of stress ulcers is key, as malnutrition can further complicate the patient’s overall condition (Ignatavicius et al., 2018).
Malnutrition contributes to difficulty weaning from the ventilator secondary to poor muscle tone and function not only of the respiratory muscles but of the diaphragm as well. This leaves the patient with decreased ability to expand and contract the lungs successfully. When patients need to exert more energy to breathe, they become fatigued quicker, resulting in a problematic weaning process or leaving the patient dependent on the ventilator. It is essential to start the patient on appropriate caloric intake within 48 hours of intubation. The type of nutrition will need to be individualized based on the patient’s condition and their ability to swallow. Patients with proper ability to swallow can be started on oral intake but may require supplements. Nutrition may be enteral or parenteral in patient unable to swallow effectively. Depending on the underlying etiology, patients may need enteral feedings or supplements that are designed for specific conditions such as chronic obstructive pulmonary disease (COPD). In COPD, the patient needs a formula with fewer carbohydrates and more fat, such as Pulmocare or others (Ignatavicius et al., 2018).
Along with respiratory muscle health, maintaining overall muscle health is equally important in the care of this patient. Activity prescribed by the provider should be strictly adhered to, and nursing needs to cooperate with physical therapy to increase activity or provide range of motion to maintain strength and muscle function (Ignatavicius et al., 2018).