Overview

• A mechanical ventilator is a machine that helps people breathe when they are not able to breathe enough on their own. Also called a respirator or breathing machine, a ventilator is used to:
  • get oxygen into the lungs and body
  • help the body get rid of carbon dioxide through the lungs
  • ease the work of breathing—some people have difficulty breathing on their own
  • breathe for a person who is not breathing because of injury to the nervous system, like the brain or spinal cord or who has very weak muscles.
• This policy aims to ensure:
  • evidenced-based standards of care are provided for safe and efficient management of mechanically ventilated clients 
  • the needs, comfort and goals set for the patient with an acute ventilator or respiratory failure are met 
  • every patient requiring ventilator management receives appropriate support relevant and proportionate to their individual needs and the specific ventilator used.
• When a person breathes normally (spontaneous breathing), the diaphragm contracts on inhalation, moving toward the abdomen, and the chest wall expands. The space inside the thorax enlarges creating a vacuum that draws air into the lungs and helps to distribute the air evenly. In contrast, a ventilator pushes a warm, humidified mixture of oxygen and air into the lungs and creates positive pressure in the thorax during inhalation. 
• The correct care of a person who relies on mechanical ventilation is critical as they are at a greater risk of death or harm if inadequate or inappropriate care is provided. Key managers must ensure carers follow this policy and that clients have person-centred ventilation management plans.

• As part of the service entry process, a detailed assessment is required for a client with ventilation needs. 
  • Family presence is recommended for the assessment meeting for additional information and support. 
  • This is especially important when verbal communication is difficult. 
  • It is important to determine the level of care required. 
• Close liaison should be maintained with the multidisciplinary team including specialist nurses, physiotherapists, speech therapists and doctors. 
  • A coordinated team approach is the best practice for this specialised area of care.
• There must be a documented plan for assessment, management and review for each individual client using a ventilator. 
  • The type of detail to evaluate at initial assessment includes, but are not limited to, the following:
    • client history—the level of self-care management the client is able to: 
      • learn the ventilator settings and understand what the alarm might mean 
      • can they change their own tube? 
      • how well are they able to clear their own secretions by coughing? 
      • can they swallow?
  •  if they have a tracheostomy?
  • if they have a larynx?
  • do they have a connection between the oral airway and lungs?
  • communication strategy e.g. verbal, non-verbal, pen and paper, communication board or voice synthesiser
  • type and size of the tracheostomy tube and when a routine change of tube is required
  • oxygen dependence
  • how often is suction required
  • routine observations.

• There are many problems that can develop from ventilator use including:
  • infections such as pneumonia—the ET or trach tube allows bacteria to get into the lungs more easily
  • collapsed lung (pneumothorax)—a part of a lung that is weak can become too full of air and start to leak into the chest wall which causes the lung to start to collapse
  • lung damage—the pressure of putting air into the lungs with a ventilator can damage the lungs—this is why health professionals should set the ventilator to the lowest amount of pressure needed
  • side effects of medications—sedatives and pain medications can cause a person to seem confused or delirious while other medications to prevent muscle movement can cause muscle weakness
  • inability to stop using ventilator support—if a person’s conditions do not improve, long term reliance on ventilation may be required.

• People who rely on mechanical ventilation often require monitoring. 
  • Devices for monitoring include pulse oximeter (measures oxygen level and heart rate) or apnea monitor (measures heart rate and breathing rate). 
• The client’s medical practitioner will determine the need for monitoring and what ventilation adjustments are required.

• when clients are supported who require mechanical ventilation
• to all HWH employees and key managers supporting clients with mechanical ventilation needs

• Ventilator Management Prima - Accessible

Policy

• clients requiring ventilation will only receive support from workers trained and proficient in ventilator management
• ventilator and bedside alarms must be on at all times—never leave a client unattended with alarms turned off
• suction equipment, oxygen, and manual ventilation device (MVD) and masks must be readily available at the bedside of all clients with artificial airways
• intubation supplies must be readily accessible for all patients with artificial airways
• the decision to wean a client from ventilation support should only be made by a qualified health professional
• maintain all ventilatory and monitoring equipment according to the manufacturer’s instructions at all times in order to reduce the risk of failure.

• Clients that rely on ventilation are at greater risk of pneumonia (chest infection). Providers are responsible to care for and ensure clients are safe. 
• This includes carers to:
  • read and understand this policy before providing support to ventilated clients 
  • complete all required competencies and training before providing support to ventilated clients
  • work within their scope of practice and qualifications
  • wear appropriate PPE at all times
  • be competent in setting appropriate alarm settings
  • respond immediately to an audible ventilator alarm and assess the client for respiratory distress or a disconnected ventilator
  • suction as required both orally and via the artificial airway
  • ensure the securement device goes around the head/neck and is comfortable for the patient
  • follow instructions of the responsible clinician which include: 
    • set up of the mechanical ventilator, accessories and tubing specific to the client's needs 
    • set up of in-line suction for ventilated clients 
    • how to initiate ventilation, set the alarms and provide adjunctive ventilator equipment 
    • setting the ventilation parameters based on the client's ideal body weight and medical condition 
    • adjusting ventilator settings in conjunction with the medical practitioner’s orders 
    • monitor the ventilator and patient after setting changes and after re-initiating ventilator i.e. post transport 
  • be knowledgeable of current and prescribed ventilator settings
  • follow the medical practitioner’s orders and ventilator setting change requests
  • communicate medical practitioner’s orders promptly with other relevant team members
  • assess the client at regular intervals as directed by a medical practitioner
  • collect blood gases if ordered and the arterial line is present.
  • Report any changes in the client's condition, e.g.cyanosed lips or finger nails.

• Responsibilities of supervisors are to:
  • ensure carers have current knowledge and a training plan to learn the standards of care for clients that require mechanical ventilation
  • provide carers education to provide excellent and confident care
  • ensure carers follow and comply with the Manage ventilator process
  • ensure carers know how to activate emergency support
  • ensure emergency airway equipment is available at all times including resuscitation bag and airway equipment
  • ensure supervisors have accreditation in Basic Life Support
  • regularly audit safe ventilator management practices
  • document all ventilator-related interventions, assessments and care provided in an observation chart including any abnormal findings
  • consider whether the participant needs physical restraints to prevent accidental removal of the ETT/tracheostomy tube.

• Carers must keep clear and legible records on the clients with ventilators. 
• This should include:
  • type, size and location of airway
  • level of an endotracheal tube (ETT) at the teeth/gum once a shift, after any adjustments and daily in any case
  • ventilator settings at the onset of the shift, q4h and with any change in orders or patient’s condition
  • SaO2 and ETCO2 quarter-hourly and with any change in orders or client's condition
  • amount, consistency and colour of tracheal secretions after each suction session on the flowsheet
  • unexpected outcomes and interventions.