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Introduction   

Portable Mechanical Ventilators are used more frequently in various settings. In the pre-hospital setting, they are used to help stabilize the patient. Within the hospital, they are used to transport patients. They are seen more often in rehabilitation and long-term care environments and are frequently used for home care. With the increased use of portable mechanical ventilators, more nurses encounter them in their work environments.  

Nurses who care for patients using portable mechanical ventilators must be competent in working with these machines, have sharp critical thinking skills, and communicate with other healthcare team members. Nurses also educate caregivers who will be providing ventilator care at home. A nurse’s knowledge should include fundamental aspects of portable mechanical ventilation, causes of alarms, and safety concerns related to portable mechanical ventilation. Providing competent care for patients using portable mechanical ventilators is the nurse’s duty and provides a safer care experience for the patient.  

Definition 

A portable mechanical ventilator is a machine that moves air in and out of the patient’s lungs at predetermined settings via a facemask, tracheostomy, or endotracheal tube. It can be used when mobility is required, such as patient transport or home care [1]. 

History 

Mechanical ventilation has come a long way since the Iron Lung was developed at Harvard Medical School in 1928. This device was a negative pressure system that required the patient to be fully encapsulated, except for their head, in a chamber that allowed two vacuum cleaner pumps to change the pressure in the chamber, pulling air in and out of the lungs.  

Predecessors of the iron lung were used as early as the 17th century and have progressed through the centuries [2].  In the mid-1950s, a former U.S. Army pilot, Forrest Bird, created the Bird Mark 7 respirator, a positive pressure device considered the first modern medical respirator [3]. Improvements in technology and understanding of respiratory support have made mechanical ventilators more efficient, customizable, and portable. Mechanical ventilators used to occupy large spaces and now can fit in a backpack or on the back of a wheelchair.   

Indications For Use 

Who Needs a Ventilator? 

A patient who is unable to take in enough air to oxygenate their body or who is unable to exhale enough air to breathe out a sufficient amount of carbon dioxide requires mechanical ventilation [1]. Usually, this ventilation is weaned in the hospital as the body heals; however, long-term mechanical ventilation is necessary in some circumstances. This could be due to spinal cord injury, traumatic brain injury, prematurity, congenital condition, or other factors.  

Why Use a Portable Mechanical Ventilator? 

Portable mechanical ventilators have improved over the years, and software advances have made them effective and compact.  

Transport 

Before the advent of portable ventilators, patients requiring ventilation had to be hand-ventilated when transferred between units, testing, imaging, and procedures. While hand ventilation accomplished the necessary task, it relied on human effort, did not allow for accurate pressure or prescribed volumes, and could not meaningfully assist the patient’s natural breath. A portable ventilator enables the medical team to transport the patient safely with more accurate and effective ventilatory support. 

Home Care 

Patients who receive a portable mechanical ventilator for home use can live at home with family rather than in a facility. Children’s parents/guardians can be trained to manage the ventilator, enabling children to live at home with their families, usually with the assistance of home health nurses and respiratory therapists. Patients can attend school/work and enjoy being part of their community. In the rehabilitation environment, ventilator settings can be weaned under the supervision of a provider. The mechanical ventilation weaning process can be lengthy, and accomplishing this at home is cost-effective and more satisfactory for the patient and their family.  

What Types of Portable Mechanical Ventilation are Available? 

The type of mechanical ventilation needed depends on the cause of respiratory failure in the patient. There are two basic types of mechanical ventilation we will discuss: invasive and non-invasive. 

Invasive mechanical ventilation requires the establishment of an artificial airway, either through an endotracheal tube or tracheostomy placement. This type of ventilation is used when the patient is unable to protect their airway or when their airway is compromised by disease processes or trauma. Patients who are ventilated via an endotracheal tube for a long time often eventually have a tracheostomy placed and may be transitioned to a portable mechanical ventilator for home use.  Portable mechanical ventilation can be used with endotracheal intubation for transport within a hospital or EMS setting [4].  

Non-invasive mechanical ventilation is used when there is an issue with inspiration and expiration, but the natural airway is able to be utilized effectively with mechanical assistance. Non-invasive mechanical ventilation uses a facemask over the patient’s nose and mouth (or sometimes just their nose), secured with straps to the patient’s head. A seal around the edges of the mask allows the ventilator to efficiently push and pull air from the lungs, either in a full respiratory support mode or to assist the natural breath of the patient. Continuous Positive Airway Pressure (CPAP) is an example of a commonly used type of non-invasive portable mechanical ventilator used for sleep apnea [4]. 

Nursing Care 

How It Works 

The portable mechanical ventilator can be set in different modes to support the patient’s respiratory effort. There are three basic modes: Assist/Control, Synchronous Intermittent Mandatory Ventilation (SIMV), and Pressure Support Ventilation (PSV). In Assist/Control mode, the patient receives a set number of breaths per minute from the mechanical ventilator. The patient can initiate their breath, and the ventilator will support their effort with a full mechanical breath. Still, additional breaths are provided to maintain the set respiratory rate if needed. SIMV is similar to Assist Control mode, but when a patient initiates a breath between the mechanical breaths, that effort is not necessarily assisted. Sometimes, those breaths can be enhanced with pressure support, but the tidal volume is up to the patient. This is the mode used when ventilatory support is weaned. Pressure Support Ventilation (PSV) provides a set inspiratory pressure but does not control respiratory rate, tidal volume, or inspiratory time [5]. 

Monitor Settings and Patient Responses 

Ventilator settings are ordered by the provider and set by the respiratory therapist. The nurse should monitor settings, ensuring they match the orders. In situations where the settings are weaned, a thorough respiratory assessment can inform the nurse of changes in the patient’s breath sounds, activity, or vital signs. A decline in these areas may indicate the patient is not tolerating changed settings [6]. 

What Are the Settings? 

• Respiratory Rate- This is the rate at which the portable ventilator will deliver breaths 

• FiO2- Fraction of inspired oxygen 

• Inspiratory time- The amount of time it takes for the ventilator to deliver the full breath  

• Tidal Volume- The amount of air breathed in measured in milliliters 

• Peak inspiratory pressure- The highest pressure needed to deliver each breath 

• Positive-end expiratory pressure (PEEP)- The pressure at the end of expiration 

• Alarms- Alert the healthcare team or caregivers that there is a problem [7] 

Assess Airway and Breathing 

The airway should be closely monitored, taking note of any skin breakdown and ensuring artificial airways are patent and secured. Auscultation allows the nurse to ensure the patient is ventilated throughout their lungs. Diminished lung sounds in one area could indicate a problem. Chest movement should be symmetrical with each breath [6]. Pulse oximetry and carbon dioxide monitoring are used to determine the effectiveness of the mechanical ventilation [8][7]. 

Suctioning and Airway Management 

If the patient is unable to cough effectively, their secretions may need to be removed from the airway via suctioning. Low pressure should be used to suction the airway to avoid damaging the mucosa. Monitor for bradycardia and hypoxia during the suctioning event [7]. If there is a mucus plug in the tracheostomy tube, the tracheostomy tube will need to be changed to maintain the airway.  

Manage Complications 

As with any mechanical device, errors in functioning can occur. The nurse should be prepared at any moment to implement a backup plan. In the hospital setting, this may mean using a different portable ventilator. If another ventilator is unavailable, the patient may need to be hand-ventilated until a replacement ventilator can be provided. It is recommended that patients who live more than two hours from a hospital should have a backup ventilator available in the home. The respiratory therapist is the best resource for troubleshooting issues with the portable ventilator [7]. Medical complications can occur as a result of using a portable mechanical ventilator. They include bacterial infections, lung damage, and cardiovascular changes [4]. 

Communicate 

Nursing care of a patient using a portable mechanical ventilator requires effective communication between members of the health care team. If the patient is transported, the respiratory therapist must be notified to transfer the patient from the ICU ventilator to the portable ventilator. If the patient is using a portable mechanical ventilator at home, the nurse will need to report any changes in status to the provider, as well as any equipment concerns to the Durable Medical Equipment (DME) agency that supplies the ventilator. Communication with the family when changes are made to ventilator settings is important to keep them informed and involved in the care of the patient [7]. 

Educate 

Before hospital discharge, the patient’s caregivers are trained in using the portable mechanical ventilator. It is important that they are able to demonstrate skills to provide care, as well as verbalize safety precautions and how to respond to an emergency [7]. This will be discussed further.  

Safety Considerations 

Since the portable mechanical ventilator provides respiratory support, safety is paramount. Portable ventilator settings and alarms should not be changed without a provider’s order. If the respiratory therapist is available, they should make any ordered changes to the settings. Communication between all members of the healthcare team is vital to maintaining safe care for the patient [7]. 

An ambu bag and face mask should always be present with the patient while the portable mechanical ventilator is used. In the event of the loss of an artificial airway, the facemask can be used to ventilate the patient by hand. Respiratory status can decline quickly, so an oxygen source must always be present even if the patient is not receiving supplemental oxygen [7]. 

What Supplies are Needed When Using a Portable Mechanical Ventilator? 

Consult your employer’s policy regarding what supplies must accompany the patient when using the portable mechanical ventilator. The following is a list of items you may usually find within that policy: 

• Mechanical Ventilator 

• Power Source 

• Backup ventilator (if policy indicates) 

• Backup battery 

• Airway supplies, including extra tracheostomy tube or endotracheal tube in the size in use and also a size smaller for invasively ventilated patients 

• Supplies needed to secure the airway 

• An extra ventilator facemask for non-invasively ventilated patients 

• Ambu bag and face mask 

• Oxygen source with the regulator 

• Portable monitoring equipment, such as pulse oximeter or carbon dioxide monitor 

• Portable suctioning equipment 

• Gloves 

• Respiratory medications as ordered 

• Communication device (In-house communicator, radio, phone, etc.) 

What Do the Alarms Mean? 

Ventilator alarms are in place for safety and should never be ignored or silenced without identifying the source of the alarm. Low-pressure alarms can indicate a disconnection, loose tubing, and issues with the mask for noninvasive ventilation or the tracheostomy or endotracheal tube for invasive ventilation. High-pressure alarms indicate some type of obstruction in the delivery of the mechanical breath. This could be related to secretions, bronchospasm, or agitation. An increased respiratory rate alarm indicates that the patient’s respiratory rate is significantly higher than expected, and potential causes should be assessed. When only pressure support is provided, an apnea alarm indicates that the patient has not taken a breath in a specified amount of time [5]. 

SAFETY NOTE: When a LOW PRESSURE alarm sounds, start troubleshooting at the patient. Visually inspect their airway to ensure the tracheostomy/ETT is in place or the face mask is appropriately secured. Once that is verified, work your way down the tubing, verifying connections, until you get to the ventilator. Repositioning due to a leak may be warranted, but the airway must be visually assessed first.  

Case Study 

Sarah, RN, and Bill, RRT, are transporting their patient, Mr. Juarez, from the ICU to MRI for a scan. Mr. Juarez is intubated and receiving ventilatory support. Bill places Mr. Juarez on the portable ventilator for transport. 

• What should occur immediately after Bill transitions Mr. Juarez to the portable ventilator? 

Bill and Sarah ensure all settings are as ordered, assess Mr. Juarez’s respiratory status and vital signs, and gather supplies to take with them. 

• What supplies should Sarah and Bill gather for this transport? 

Sarah and Bill ensure they have all necessary monitoring and emergency supplies. They begin the eight-minute transport to the MRI unit. Halfway there, a low-pressure alarm sounds on the ventilator.  

• What should Bill do FIRST? 

Bill starts at the airway and confirms that the endotracheal tube remains secure. He then moves down the ventilator tubing to find the source of the alarm. 

• What should Sarah do while Bill is assessing the ventilator circuit? 

Sarah monitors the patient’s vital signs using the portable monitor they brought. She observes Mr. Juarez for respiratory changes. Bill identifies a loose connection in the tubing. He resecures the connection.  

• What should happen next? 

Bill and Sarah observe Mr. Juarez’s vital signs and ensure that the low-pressure alarm on the portable ventilator has been resolved. After confirming that everything is working properly, they continue the transport. 

• What is essential for Bill and Sarah to do during this event? 

Communication is necessary between healthcare team members when the portable ventilator is in use, especially when transporting the patient. Effective communication can make the transport safer for the patient and resolve problems quickly and effectively.  

Machine Assessment 

Before initiating the use of the portable mechanical ventilator, with each physical assessment and as needed, the portable ventilator should be assessed for proper functioning and safety preparedness. The nurse should inspect for visible signs of damage, verify and document all settings, verify that alarms are working, check the oxygen supply if it is in use, ensure the battery is fully charged before disconnecting from the power source, and ensure the maintenance sticker date is current. Any issues should be reported to the respiratory therapist [9].  

Battery Care 

When mobility is not required, the mechanical ventilator should remain plugged into a power source. The nurse should refer to the instruction manual for the particular portable ventilator they are working with to determine how long the internal battery can support functioning. An external emergency battery is often made available in case of internal battery failure. This battery should also be charged so that it can be utilized if needed [9].   

Maintenance 

The filters and circuit tubing will need to be cleaned or changed routinely. Follow manufacturer guidelines for when and how to do this. Notify the respiratory therapist if the date for preventative maintenance has passed. This is typically noted on a sticker on the ventilator [9].  

Patient and Family Education  

What Do Patients and Their Families Need to Know for Hospital Transport? 

In hospital transport, the family must understand that the portable mechanical ventilator supports the patient’s respiratory effort. Alarms can be distressing for families, so a quick explanation of things that could trigger an alarm may be helpful. For example, a cough can cause a high-pressure alarm to sound. Understanding that it does not always indicate distress can be comforting.  

What Do Patients and Their Families Need to Know for Home Care? 

Before being discharged home, the family must demonstrate competency in using the portable ventilator. They will need to understand how to troubleshoot alarms, battery care, what supplies need to accompany the patient at all times, how to apply the facemask and assess the skin if non-invasive ventilation is used, all aspects of tracheostomy care, including suctioning and emergency procedures if invasive ventilation is used, and safety precautions. A checklist is usually utilized for discharge education. Caregivers also need to know who to call for help if there is a problem. It is imperative that they know to call 911 if the patient is in distress and it is not quickly improved by the prescribed interventions.  

Support 

Patients and caregivers using the portable ventilator at home need to know that they are not alone. It is helpful to have emergency phone numbers easily accessible. Having multiple trained caregivers who can care for the patient’s needs is important. This allows the primary caregiver to rest and ensures someone can care for the patient if the primary caregiver becomes ill themselves. Support groups may be available in their area.  

Conclusion

Portable mechanical ventilators provide respiratory support in different ways and in varied settings. To provide competent patient care, healthcare workers must understand the basics of ventilator settings and troubleshooting alarms. Portable mechanical ventilators are a vital part of modern healthcare technology. To take advantage of this technology, healthcare workers should be competent in all aspects of portable ventilator care. Increasing knowledge regarding portable ventilator care allows nurses to provide excellent care and a safe patient environment.  

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