When a Ventilator Is Necessary

What to Expect When A Ventilator is Needed

Anesthesiologist holding oxygen mask over patients face in operating room
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A ventilator, also known as a respirator or breathing machine, is a medical device that provides a patient with oxygen when they are unable to breathe on their own.  The ventilator gently pushes air into the lungs and allows it to come back out, like the lungs would typically do when they are able.

During any surgery that requires general anesthesia, a ventilator is necessary.  There are also times when a ventilator is required after surgery, as the patient may not be able to breathe on their own immediately after the procedure.

 

Why a Ventilator Is Necessary During Surgery

General anesthesia works by paralyzing the muscles of the body temporarily.  This includes the muscles that allow us to inhale and exhale.  Without a ventilator, breathing during general anesthesia would not be possible.  Most patients are on the ventilator while the surgery is taking place, then a drug is given to stop the anesthesia.  Once the anesthesia stops, the patient is able to breathe on their own and they are removed from the ventilator.  

Why a Ventilator May Be Necessary After Surgery

A ventilator is necessary when the patient is unable to breathe well enough to provide oxygen to the brain and body.  

Some patients, due to injury or illness, cannot breathe well enough after surgery to be removed from the ventilator.   This may be due to poor lung function prior to surgery, which can happen when patients have damage to their lungs caused by Chronic Obstructive Pulmonary Disease (COPD).

  Patients who smoke also experience higher rates of requiring a ventilator longer after surgery is completed.  

This also happens when the patient is too ill to breathe for themselves.  This may happen due to trauma (such as a life-threatening car accident), infection or another problem.  A patient who is on the ventilator prior to surgery will likely remain on the ventilator after surgery until they recover enough to breathe well on their own.

Some surgeries require the patient be on the ventilator for a short time after surgery as part of the plan.  For example, patients having open heart surgery are typically maintained on a ventilator until they wake up enough to lift their head off of their pillow and can follow simple commands.  They are not given a drug to stop the anesthesia, rather it is allowed to wear off on its own, and the patient is removed from the ventilator when they are ready to breathe on their own. 

Intubation 

In order to be placed on a ventilator, the patient must be intubated.  This means having an endotracheal tube placed in the mouth or nose and threaded down into the airway.  This tube has a small inflatable gasket which is inflated to hold the tube in place.  The ventilator is attached to the tube and the ventilator provides “breaths” to the patient.  

Sedation While on a Ventilator

If a patient is on the ventilator after surgery, medication is often given to sedate the patient.  This is done because it can be upsetting and irritating to the patient to have an endotracheal tube in place and feel the ventilator pushing air into the lungs.

  The goal is to keep the patient calm and comfortable without sedating them so much that they cannot breathe on their own and be removed from the ventilator.

Ventilator Weaning

Weaning is the term used for the process of removing someone from the ventilator.  Most surgery patients are removed from the ventilator quickly and easily.  They may be provided a small amount of nasal oxygen to make the process easier, but they are typically able to breath without difficulty.

Patients who are not able to be removed from the ventilator immediately after surgery may require weaning, which is a process where the ventilator settings are adjusted to allow the patient to attempt to breathe on their own, or for the ventilator to do less work and the patient to do more.  This may be done for days or even weeks, gradually allowing the patient to improve their breathing.  

CPAP, or continuous positive airway pressure, is a ventilator setting that allows patients to do the work of breathing with the ventilator available to help if the patient isn’t doing well.  A CPAP trial, meaning the patient is placed on the CPAP setting for a set period of time, may be used to determine if the patient can tolerate being removed from the ventilator. 

Some patients who are on the ventilator for an extended period of time may be on CPAP during the day, will full ventilator support at night so they can fully rest and continue to heal without being exhausted by the work of breathing. 

Extubation After Being on a Ventilator

Extubation is the process of having the endotracheal tube removed.  During this process, the nurse removes the air from the inflated gasket on the tube and releases the ties or tape that holds the tube in place.  The tube is then gently pulled from the patient’s mouth or nose.  At this point they are able to breathe on their own and the ventilator is no longer able to provide any breathing assistance.  Most patients are given oxygen to help with this process, either through a mask or nasally.

Most patients cough during the process, but it is not typically painful.  Many patients do complain of a sore throat after being intubated, so throat sprays, lozenges or numbing medications may be used, if the patient can tolerate them and they can be used safely. 

Care While on a Ventilator

Patient care for the individual on a ventilator often consists of preventing infection and skin irritation. These patients are almost always in an intensive care unit (ICU) and receive constant monitoring and attention.  

Tape or a strap is used to keep the endotracheal tube in place, this is changed when dirty and  the tube is regularly moved from one side of the mouth to the other.  Moving the tube is done to prevent skin irritation and breakdown from the tube rubbing against the tissues of the mouth.  

Mouth care is frequently performed to prevent infection.  The mouth is often dry, so the mouth is cleaned and moistened to protect the teeth and reduce any harmful bacteria that could make their way into the lungs and cause pneumonia. 

Oral secretions are suctioned from the mouth to prevent them from draining into the lungs and causing pneumonia.  Secretions from the lungs are suctioned as the patient will be unable to cough these secretions up while on the ventilator. 

Patients who require a ventilator are often too sick or weak to reposition themselves, so frequent turning is also part of routine care.

Breathing treatments are routinely provided by respiratory therapy or nursing staff, to help keep the airways open, thin secretions that may be present and treat any lung conditions that the patient may have.

Long Term Ventilator Care

For patients who are unable to be weaned from the ventilator, a tracheostomy may be necessary.  An endotracheal tube should not be left in place for more than a few weeks as it can eventually cause permanent damage to the vocal cords or windpipe and can make ventilator weaning more difficult. 

For patients who are expected to be on a ventilator long term, a surgically created opening is made in the neck and the ventilator is attached there, rather than functioning through the tube placed in the mouth.  

Patients are often transferred to a Long Term Acute Care (LTAC) facility that provides ventilator care.  These facilities often have units where ventilator weaning is their specialty, and the process of helping the patient relearn how to breathe effectively is part of daily care.  

Source:

What are the risks of being on a ventilator? National Heart, Lung and Blood Institute.  Accessed September, 2015. http://www.nhlbi.nih.gov/health/health-topics/topics/vent/risks

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