 The connections that supply the interface between the patient and the ventilator consist of three hoses along with several other pre-assembled pieces that are termed the ventilator circuit. Turn the ventilator on by turning the mode to the desired mode of ventilation. The display window will show the current setting of the ventilator parameters directly adjacent to the control knob. Of note, the inspiratory time will automatically adjust an I to E ratio of 1 to 2 if turned counterclockwise completely. Those that supply the ventilator with power and supplemental oxygen and those that provide an interface between the patient and the ventilator. The external connections that provide oxygen and power to this ventilator are the following. Power cord, the external supplemental oxygen reservoir system. Turn the ventilator on by first turning on the power switch located on the back of the unit and by turning the mode to the desired mode of ventilation on the control panel. Now look at the control panel on the unit located under the protective flap. Title volume, 600 cc. Supplemental oxygen can be adjusted by increasing or decreasing the flow on the flow metering device. Silence the audible alarm by depressing alarm button on the control panel. The low pressure limit should be adjusted to 5 to 10 cm of water above the pressure noted at the end of the expiratory phase. Reset the high pressure alarm 10 to 15 cm of water above the average peak airway pressure noted. A high pressure alarm could also mean that there is a buildup of secretions in the lungs or airways. Commonly, a high pressure alarm indicates obstruction of the endotracheal tube or ventilator circuit. When this alarm is displayed, quickly evaluate tubing and verify that there are no kinks or obvious obstructions. A low pressure alarm can mean that there is a leak or disconnect in the tubing. Therefore, the oxygen flow needs to be set at a minimum of 15 liters per minute. To determine proper function of the bag itself, occlude the bag at the outlet with your thumb. Squeeze the bag with your other hand. You should feel resistance in the bag as a result of your thumb occluding the outlet, simultaneously listening for air leaks. No air leaks should be detected with your thumb occluding the outlet. This assures that the bag's valves are functioning correctly. Remove your thumb. Squeeze the bag again. With the bag deflated, place your thumb over the outlet again. If oxygen flow is adequate, the bag should re-inflate completely and quickly within a few seconds. Drawing oxygen from the reservoir attached to the rear end of the bag. Bagging patients is required prior to and following intubation, during suctioning, during ventilator malfunctioning, and during patient transport. Additionally, bagging patients is required during emergency situations such as respiratory or cardiac arrest. Connect the patient connector on the bag to the connector on the endotracheal tube, or on the connector of the tracheostomy tube. Being careful to not pull, tug, or dislodge the tube. Also be careful not to crimp the endotracheal tube. While you must provide adequate ventilation at all times, studies have shown that there is a tendency to over ventilate while bagging. So you must be careful not to hyperventilate the patient. High pressures can be very dangerous and even cause severe injury to the patient's lungs. To help determine adequate ventilation, you should observe the patient's chest rising with each squeeze of the bag. Remember that you must also provide adequate time to allow for exhalation. The patient's color should remain normal or pinkish, indicating adequate oxygenation. Pulse oximetry may be used to monitor the patient during bagging. A pulse oximeter reading should be maintained greater than 90% throughout the procedure. Practice squeezing the bag so pressures remain less than 35 centimeters of water. Unless otherwise specified by the physician, he will usually squeeze the bag 12 to 16 times each minute or once every 4 to 5 seconds. The size of the breath, referred to as tidal volume, that you deliver to the patient is determined by how hard you squeeze the bag and whether you use one hand or two hands to squeeze the bag. Squeeze the bag with one hand and observe the volume delivered. As you can see in this demonstration, 500cc or .5L were delivered with a one hand squeeze of the bag. Now squeeze the bag with two hands and again observe the volume delivered. As you can see, 1000cc or .5L of air were delivered with two hands squeezing the bag. The volume and pressure delivered to actual patients will vary based on the patient's condition. In the event of ventilator malfunctioning, immediately disconnect the patient from the ventilator machine and begin providing manual ventilation. Call a respiratory therapist, physician or nurse for help. Pulse oximetry may be used to monitor the patient during bagging. A pulse oximeter reading should be maintained greater than 90% throughout the procedure. Although uncommon, complications of airway sectioning can be severe if proper care is not taken. Some hazards include hypoxia, hypoxemia or low oxygen levels, tissue trauma to the airways or mucosa layers, cardiac arrest or dysrhythmias, respiratory rest, collapsed lung, airway irritation, infection, bleeding, excessively high or low blood pressure, elevated intracranial pressure or pressure in the brain. For adults, a pressure of negative 100 to 120mm of mercury is considered as safe and adequate. Several signs may be present that help the caregiver determine the need for sectioning. The need to section secretions may be evident by one or more of the following. Coarse breath sounds or rumbling in the chest and in the tubing often described as noisy breathing. Increased peak pressures during mechanical ventilation. Visible secretions in the airway. The need to maintain the patency of the artificial airway. Suspected aspiration of gastric or upper airway secretions. Apparent increased work of breathing or excessive coughing. One for most adults, a 12 or 14 French catheter can be used. The last three steps can be repeated as necessary. However, each event should last no longer than 10 to 15 seconds and sufficient time should be allowed in between events. Provide 100% oxygen for at least 30 seconds. This is known as hyperoxygenation by one of the following methods. Increasing oxygen on mechanical ventilator or if the previous recommendation is not an option. Hyperoxygenation can be accomplished by manual resuscitation as discussed earlier to prepare the patient for sectioning the following steps should occur. Provide 100% oxygen for at least 30 seconds. This is known as hyperoxygenation. When complete, the patient should once again be hyperoxygenated for at least one minute following the sectioning procedure. Advance catheter with sterile hand into the endotracheal tube slowly and gently until the patient coughs or the slightest amount of resistance is felt, whichever is first. Given the potentially cumbersome nature of this procedure, it is recommended that these steps be practiced before performing on patients. It is also recommended that appropriate help of an experienced clinician is available to manage potentially adverse events if needed. When complete, the patient should once again be hyperoxygenated for at least one minute following the sectioning procedure. Once the procedure is complete, disconnect catheter from section tubing, avoiding contact with the patient and other surfaces to prevent contamination. Next, carefully remove gloves and wrap catheter in gloves then wrap gloves in packaging for disposal. Careful monitoring should take place after all ventilator changes, especially when switching ventilation modes. Sometimes respiratory rate is abbreviated with RR or F for frequency. Title volume is the amount of air that is delivered with each breath. Inspiratory time is the time and seconds required to achieve one full inspiratory tidal breath. IOTE ratios of less than 1 to 1.5 should only be used in highly specialized circumstances to avoid ill effects of mechanical ventilation. In general, lung pressures above 35 cm of water are considered to be unsafe and should be avoided. It may be thought of as the opposite of stiffness, i.e. as compliance decreases, lungs become stiffer. This calculated value changes greatly with lung characteristics. Usually the set value for adults is 2 to 3 cm of water below the set end expiratory pressure or PEEP. PEEP is an acronym that stands for positive end expiratory pressure. PEEP is pressure left in the lungs even after exhalation of a tidal breath has occurred. FIO2 is the fraction of inspired oxygen concentration delivered by the ventilator. Wash your hands with plain soap and water or with antimicrobial soap and water if your hands are visibly soiled, visibly contaminated with blood or body fluids before eating and after using the restroom. If hands are not visibly soiled or contaminated with blood or body fluids, use an alcohol-based hand rub for routinely cleaning your hands before having direct contact with patients, after having direct contact with patients skin, after having direct contact with body fluids, wounds or broken skin, after touching equipment or furniture near the patient, and after removing gloves. If you applied a sufficient amount of alcohol hand rub, it should take at least 10 to 15 seconds of rubbing before your hands feel dry. Wearing gloves is not a substitute for hand washing. Non-sterile gloves should be worn when entering the room. During patient contact, change gloves after contact with infected material. Dispose of the gloves before leaving the room and wash hands immediately with an antimicrobial agent or waterless hand sanitizer. Being careful to not touch potentially contaminated surfaces, equipment or other items before leaving the room. Clean on sterile gowns should be worn when entering the room. Masks are worn within 3 feet of patient. However, it is best to put the mask on upon entering the room. Patients in air-barned precautions need a private room where the air flows from the hall into the room known as negative air pressure. Respiratory precautions should be worn when entering the room. This protection is known as an N95 particulate respirator. Healthcare worker hands can also become contaminated with bacteria by doing simple tasks like pulling patients up in bed, taking a blood pressure or pulse, touching a patient's hand, rolling or moving patients over in bed, touching the patient's gown or bed sheets, or touching equipment like bedside rails over bed tables and IV pumps. Securing the tube Prior to securing the endotracheal tube, note the depth to which the tube is placed. There are centimeter markings printed on the tube. To do so, check the markings on the side of the tube. Note the centimeter marking nearest to the closest anatomical landmark, such as the nares or nostrils for nasal tubes or the lips for oral tubes. There are many different acceptable methods of taping endotracheal tubes. In the method that will be demonstrated here, the tape is applied in alternating sequence, wrapping the tape around the tube then above the top lip and across to the other side of the face. Be aware that this procedure should never be attempted alone and that at least two people are required with one person holding the endotracheal tube at the predetermined depth and the other person securing the tube with tape, string or other apparatus. Be very cautious of the endotracheal tube shifting during the procedure due to patient movement. A third person may be necessary to maintain tube stability in combative patients. Begin preparing the tape by cutting a length of one inch cloth tape by using your neck as demonstrated. The tape will need to be long enough to go behind the patient's neck and cross over in front of the patient's face. Approximately two feet of tape is required. Tear tape and lay two-foot section of tape flat, sticky side up. Tear a smaller piece of tape approximately four inches in length and place sticky side down in the center of the longer piece of tape. This non-sticky center prevents the tape from adhering to the back of the patient's head. Select one end of the tape and tear in half down the middle, approximately one inch in length. Fold ends down so tape doesn't stick together. Next, fold tape in half over a tongue blade to the center where the four inch piece of tape was placed, starting at torn end. Slide tongue blade behind patient's neck and pull tape up, removing the tongue blade. The cheeks should be clean and dry and shaved if necessary. Tincture of benzoin may be applied with a 4x4 gauze to improve adhesiveness. These risks are noted as follows. Tissue pressure necrosis, tissue granulomas, trachea esophageal or arterial fissula, tracheo-malacia, tracheal stenosis, vocal cord paralysis, vocal cord ulceration. With another person providing manual ventilation, inflate the cuff slowly using a clean, dry, 10cc syringe to inject air into the pilot balloon. Stop injecting air when a leak is no longer heard over the neck or through the mouth. Begin by injecting one cc of air and listen for air leaks during peak inspiration. Continue injecting air in one half to one cc increments while your partner continues to administer maximum inflation breaths with manual ventilation. The difference between MLT and MOV is that once you have obtained a good seal with maximal inspiration, with MLT you now withdraw a small amount of air from the cuff until, using a stethoscope, a slight leak is heard above the cuff on the lateral neck. The cuff of the endotracheal tube is inflated for two reasons, prevent air leaking around the tube during ventilatory support and to prevent aspiration of oral secretions. The physician determines the depth of the airway for proper placement by listening for equal breath sounds bilaterally with a stethoscope, oscultation, observing the patient's bilateral chest expansion and ensuring the breath sounds are not heard over the stomach. Continue injecting air in one half to one cc increments while your partner continues to administer maximum inflation breaths with manual ventilation.