Ventilator and Respiratory Support

A ventilator is the machine families find most frightening and understand least. It is worth being clear about what it does. It does not treat the illness. It moves air in and out of the lungs so that the body keeps receiving oxygen while whatever damaged the lungs is being treated.

The levels of support

Respiratory support is a ladder, and patients move up and down it as their condition changes.

• Supplemental oxygen through nasal prongs or a mask, for patients who are breathing adequately but not oxygenating well
• High flow oxygen, delivering warmed and humidified oxygen at higher rates
• Non invasive ventilation through a tight fitting mask, which supports breathing without a tube and suits some patients well
• Invasive mechanical ventilation through a tube in the windpipe, for patients who cannot breathe adequately or cannot protect their airway
• Tracheostomy, a tube placed through the front of the neck, considered when ventilation is likely to be prolonged

Why the patient is sedated

A breathing tube in the windpipe is not tolerable while fully awake. Patients on invasive ventilation are therefore sedated, and often given pain relief alongside it.

Sedation is kept at the lightest level that is safe and comfortable, and is reduced regularly to assess the underlying neurological state. This is why a family may find their relative more responsive at some visits than others. It usually reflects the sedation schedule rather than a sudden change in condition.

Weaning

Coming off a ventilator is a process rather than an event. As the lungs recover, the machine is asked to do progressively less and the patient progressively more, and the patient's ability to sustain their own breathing is tested at intervals.

Weaning can take days or weeks, and setbacks are normal rather than a sign that something has gone wrong. When the patient can maintain adequate breathing, oxygenation and airway protection independently, the tube is removed. Some hoarseness and a sore throat afterwards is expected.

A tracheostomy is not a defeat

Where ventilation is likely to continue for an extended period, a tracheostomy is often the better option. It is more comfortable than a tube through the mouth, needs less sedation, makes weaning easier and reduces the risk of damage to the vocal cords.

Families frequently hear the word and assume it signals deterioration. Usually it signals the opposite: a plan for a longer recovery rather than a shorter one. Most tracheostomies placed for this reason are temporary and are removed once the patient no longer needs them.