Home care nursing has advanced greatly in recent years. Many patients, from infants to adults, are discharged on mechanical ventilators in order to survive.
Over the years, these ventilators have changed in many ways. For example, ventilators used 10 years ago were considered portable but weighed about 40 pounds. Today's ventilators weigh about 15 pounds maximum and are truly portable. This allows patients to participate in more of life's daily activities and social events.
Since ventilators are so commonly used in the home, it is necessary for nurses to possess in-depth assessment skills and knowledge of these "high-tech" machines to deliver competent care.
Additionally, there is governmental concern that there are not enough professionals trained in the use of ventilators should a disaster occur, such as a flu pandemic.1,2 The government has made available education materials on DVD and CD related to ventilator management and patient care.
For purposes of this article, we will focus on the new touch-screen ventilators with digital displays such as laptop ventilators (LTVs) and the older, knob controlled ventilators, such as the LP10 ventilator (these ventilators commonly are utilized in the home and are on standby for widespread use if needed). There are also patients who have been on the LP10 ventilator and do not want to switch to a newer model. (However, production of the LP10 ventilator was discontinued as of November 2006 and parts, technical support and factory service will reportedly only be available through Oct. 31, 2011.)3
Project Xtreme, the result of a collaboration between the U.S. Department of Health and Human Services' Office of Public Health Emergency Preparedness and Agency for Healthcare Research and Quality, has been called a "model for health professionals' cross-training for mass casualty respiratory needs."1
The objective was to develop, implement and evaluate a model to cross-train non-respiratory therapy healthcare professionals in providing basic respiratory care and ventilator management in the event of a mass casualty disaster resulting in a surge of patients needing mechanical ventilation. This objective came in response to the recognition that there is likely insufficient surge capacity among trained respiratory therapists to meet staffing needs in such an event."1
While the respiratory therapist sets up the ventilator and usually makes major changes per physician's orders, there are basic principles that apply to all ventilators that every nurse should be familiar with when working with any ventilator.
First, for nurses caring for the ventilator-dependent patient, there are nursing skills required to safely care for these patients. These include:
• understanding the illness which causes the patient to require a ventilator;
• interpretation of the basic principles of blood gases in relation to ventilator settings;
• knowing and demonstrating the appropriate times to notify a physician in regards to the status of a patient;
• knowing the signs, symptoms and treatment of a pneumothorax;
• demonstrating how to check breath sounds and observe for dislocation of the tracheostomy tube;
• demonstrating how to change a tracheostomy tube;
• demonstrating how to use an ambu bag;
• demonstrating proper suctioning techniques;
• knowing the reasons for weaning appropriately and how to wean, as well as the need for increasing ventilator settings;
• being familiar with the ventilator, its tubings, heater and various alarms;
• being familiar with the humidification systems;
• demonstrating how to troubleshoot some ventilator problems;
• demonstrating basic care such as bathing, turning, positioning, ambulation and current procedural terminology when the patient is on a ventilator; and
• knowing and demonstrating basic life support for healthcare providers.
Understanding the proper functioning and the adverse effects that can occur to the respiratory and cardiovascular systems (such as respiratory acidosis, hypoxemia, and pulmonary hypertension), are just a few examples of the knowledge nurses should have.4
It also is important to be aware of potential complications of mechanical ventilation, such as:
• The development of acidosis or alkalosis due to ventilator settings. (For example, the retention of CO2, leading to acidosis if the patient is hypoventilated or the excretion of too much CO2; leading to alkalosis if the patient is hyperventilated).
• Blocked airway or plugging of the tracheostomy tube with secretions due to insufficient humidification or inadequate suctioning.
• Bronchospasm, if the humidification is too warm, leading to the inspired air being too warm.
• Development of infections caused by the improper care and suctioning of the tracheostomy tube, poor hand washing or contaminated equipment.
• Various types of barotraumas due to the ventilator or aggressive hand bagging, such as pneumomediastinum (air in the mediastinum) and pneumothorax (partial or complete collapse of a lung).
• Damage to the tracheal tissues caused by suctioning too vigorously or improperly, such as suction pressures that are too high.
• Oxygen toxicity.
• Interference with cardiovascular return if too much positive pressure is used, such as excessive positive end-expiratory pressure (PEEP).
• Atelectasis due to inadequate lung expansion or mucus plugs.
• Gastric distension and/or ileus from air swallowing in the dyspneic patient, excessive "bagging" with manual ventilator bag or air swallowing in the patient with poor GI sphincter tone.
• Respiratory muscle fatigue due to the patient being on controlled ventilation. (On controlled ventilation, the patient doesn't use his muscles, resulting in atrophy of the muscle.)
• Obstructed airways due to multiple problems such as mucus plugged tracheostomy tubes, kinked tracheostomy tubes or ventilator tubing, or too much water accumulated in the ventilator circuit.