When Is a Ventilator Needed?

A ventilator is a medical device that helps you breathe when you have trouble breathing on your own. A ventilator may be needed when an injury or an illness like COVID-19 impairs your lung function. Ventilators are also used to help you breathe during surgery.

Ventilators work by gently pushing air into the lungs and allowing it to come back out like the lungs would typically do in normal breathing.

This article explains when and why a ventilator is needed and details the process by which a person is connected and removed from mechanical ventilation.

When Is a Ventilator Needed?

A ventilator helps support a person with impaired lung function during the recovery process. It delivers oxygen through a tube inserted through the mouth and into the windpipe. 

A ventilator may be needed when certain illnesses like COVID-19 progress to a condition known as acute respiratory distress syndrome (ARDS). In people with ARDS, the air sacs in the lungs fill with fluid, making breathing difficult.

A ventilator may also be required when a COVID-19 patient is breathing too slow, too fast, or stops breathing altogether.

COVID-19 patients may need supplemental oxygen when their oxygen saturation falls below 90%. This does not always mean mechanical ventilation. Often, the supplemental oxygen is delivered non-invasively through small tubes inserted into the nostrils. Mechanical ventilation is reserved for patients with severe breathing difficulties.

During Surgery

General anesthesia lowers the level of a patient's consciousness during surgery. A paralytic that paralyzes the muscles of the body temporarily may be necessary depending on the patient's respiratory needs or the needs of the operation. This includes the muscles that allow us to inhale and exhale. Without a ventilator, breathing during general anesthesia would not be possible. 

Most people are on the ventilator while the surgery is taking place. A drug is given after the operation is complete to stop the effects of the anesthesia. Once the anesthesia stops, the person is able to breathe on their own and is removed from the ventilator.

After Surgery

A ventilator is necessary when a person who has undergone surgery is unable to breathe well enough to provide oxygen to the brain and body. 

Some people, 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 things like chronic obstructive pulmonary disease (COPD).

This can also happen due to trauma, infection, or another serious medical problem. A person 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 a person to be on a ventilator for a short time after surgery. For example, people having open heart surgery are typically maintained on a ventilator until they wake up enough to lift their head off their pillow and follow simple commands. They are not given a drug to stop the anesthesia; rather, the anesthesia is allowed to wear off on its own.

Intubation

In order to be placed on a ventilator, the person must be intubated. Intubation means having an endotracheal tube placed in the mouth or nose and threaded down into the airway.

This tube has a small inflatable gasket that is inflated to hold the tube in place. The ventilator is attached to the tube and provides “breaths” to the person needing respiratory assistance.

If a ventilator is needed after surgery, a sedative may be used to relax the person. This is done because it can be upsetting to have an endotracheal tube in place and feel the ventilator pushing air into the lungs.

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

Patient Care During Ventilation

Patient care consists of preventing infection and skin irritation while a person is on a ventilator. These individuals are almost always in an intensive care unit (ICU) and require 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 to prevent sores or ulcers.

Mouth care is also frequently performed. The mouth is often dry, so it needs to be cleaned and moistened to protect the teeth and reduce harmful bacteria that can make their way into the lungs and cause pneumonia.  Oral secretions are also suctioned from the mouth to prevent them from draining into the lungs and causing pneumonia.

People who require a ventilator often find it hard to reposition themselves because they are sedated, so frequent turning is also part of routine care.

Extubation

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 person’s mouth or nose. 

Once the tube is removed, the person is able to breathe on their own. Many, however, are given oxygen through a mask or nasal cannula to help transition to normal breathing.

Extubation may cause coughing or sore throat but is not typically painful.

Weaning

Weaning is the term used for the process of decreasing ventilatory support. Most surgery patients are removed from the ventilator quickly and easily. Those who cannot be may require weaning.

During weaning, the ventilator setting levels are gradually reduced to allow the person to attempt to breathe on their own. This may take place over the course of days or even weeks. The continuous positive airway pressure (CPAP) setting is one in which the ventilator adjusts the level of support according to the strength of a person's breath.

People who have been on a ventilator for a long time may only be on CPAP during the day and on full ventilator support at night. This allows the person to rest comfortably at night without having to work to breathe.

CPAP is also the setting that allows doctors to determine if a person no longer needs mechanical ventilation. This trial period is often referred to as the CPAP trial.

Long-Term Care

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. It can also make ventilator weaning more difficult.

For people who are unable to be weaned from the ventilator or are expected to require long-term mechanical ventilation, a surgical procedure called a tracheostomy may be used to create an opening in the neck to bypass the mouth or nose. One end of the tube is inserted through the opening, while the other is connected to a ventilator.

People who require long-term mechanical ventilation are often transferred to a long-term acute care facility. These facilities specialize in ventilator weaning and can help a person relearn how to breathe effectively once a ventilator is no longer needed.

Summary

A ventilator is used to support breathing during surgeries that require general anesthesia as well as after surgery for those who need longer respiratory support. The process of inserting the breathing tube through the mouth or nose is called intubation, while the removal of the tube is called extubation.

People who require long-term respiratory support may undergo a tracheostomy in which an opening is created in the neck so that the tube can bypass the mouth or nose.