Some carers may be required to care for a service user who relies on a ventilator (ventilator dependency) in order to breathe following a procedure known as a “trachestomy”.
As medical technology and intervention evolves, more patients are faced with temporary and long-term tracheotomy/ventilation as a part of recovery. A tracheotomy is where an incision is made to a person’s windpipe in order to help them breathe. A tracheotomy is usually done for one of three reasons: to bypass an obstructed upper airway; to clean and remove secretions from the airway; to more easily, and usually more safely, deliver oxygen to the lungs.
Conditions that can lead to respiratory failure and the need for a tracheostomy include:
- being unconscious or in a coma as a result of a severe head injury or stroke
- paralysis (an inability to move one or more muscles) after a serious spinal cord injury
- a condition that damages the lungs, such as pneumonia or cystic fibrosis
- a condition that damages the nervous system, such as motor neurone disease or Guillain-Barré syndrome
If a service user has a trachestomy tube, a carer will be required to understand the basic functionality of the device and may be required to assist service users to manage the tube, especially during swallowing and oral communication.
While the respiratory therapist sets up the ventilator and usually makes major changes as per the doctor’s orders, there are basic principles that apply to all ventilators that every carer should be familiar with when working with any ventilator.
Required skills for carers who look after ventilator dependant service users 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 doctor 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.
It also is important to be aware of potential complications of mechanical ventilation. In short these include, but are not limited to; the development of acidosis, blocked airways, bronchospasm, infections, damage to tracheal tissues and oxygen toxicity.
There are several ways in which patients can be weaned off a ventilator. To begin the process, a patient might go from the assist-control setting to a synchronized intermittent mandatory- ventilation setting. The breathing effort can be more negative to exercise the respiratory muscles and the diaphragm to generate negative pressure in the chest and lungs to draw fresh air into the lungs. The breath rate can also be gradually decreased and PEEP can be gradually reduced to zero. A trial of CPAP might also be given. Some doctors will also order increasing times off the ventilator once the settings are low, such as 5 minutes off the ventilator, 5 minutes on, and gradually increase the time off as tolerated by the patient.
The goal in caring for patients at home is to assist them in participating in the most normal life as possible and fulfilling their goals for the best quality of life they can attain.
For more information about ventilator dependency, we recommend looking at The NHS’ guide to Tracheostomy.
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