about mechanical ventilator patient in Nepal

Update:  This one got hundreds of hits, but few clicks on the video and I think I needed to be more focused. I made a separate entry to focus just on the ET tube cuff volume issue.  CLICK HERE for the new one! http://wp.me/p1pDBL-1smBe sure to click on the video!

In this blog, the directions to ET Tube cuff volume amount are near the end. Keep reading!

I think I might do a series of blogs for nurses and Medical Officers in Nepal.

The Snake Man

Yes, that’s me but I don’t take myself as seriously as the title may imply. This is the tenth anniversary of the episode that happened in Tansen at Mission Hospital that gave me the nickname “The Snake Man” and pioneered the use of mechanical ventilation at that place. It was one of the epics of my entire life and the story is told in my first book.

In 2007 I did something that led to one of my nicknames – “the Snake Man” – you can read about it in my first book.

I didn’t actually know anything about snakes or snakebite, at the time. These days I teach about Cardiac resuscitation when I am here in Nepal, but I am sometimes asked if I would talk about nurses responsibility in mechanical ventilation. So recently I spent some time with some nurses. Instead of giving a formal talk I started off by asking questions and having them show me some things to make sure I knew what it was they were doing. I try not to re-teach people stuff they already know.


For my readers not in Nepal, be advised there is no “Respiratory Therapy” profession in Nepal. Ventilators, and indeed critical care, are in the hands of “anesthesiologists” who after all, place ET tubes during surgery. Except of course when they don’t – in many small hospitals anesthesia is supplied by anesthesia technicians. So the doctors are the ones who do the vent settings.

A Canadian friend named Eric Cheng is involved with a small NGO named “Respiratory Care Without Borders,” giving workshops on this field. I don’t think he’s been back lately – RTWB now works in several dozen countries. I am going to browse their site to see what they recommend for books, etc.

This is another example of clinical issues where the nurse needs to be assertive. For example, in the USA if the tube is dislodged, the nurse removes it, uses a Bag-Valve-Mask, and calls the doc. Not every nurse in Nepal is confident or assertive enough to feel comfortable with this decision. Are you? Would you be?

Not every nurse or MBBSW doc knows how to use a BVM for that matter. I specifically require them to learn skills related to this. Including how to clean the darn thing. I wrote an eight-page policy and procedure on this a few years back.

The Pen Drive

In any case, I have decided to create another folder on the pen drive and load some documents and articles there. It’s been awhile since I updated the stuff I give to session participants. I will distribute it from now on. Bring a pen drive to class!

On the internet I found:

a Booklet titled  “Mechanical ventilation for Dummies”:


Here are some video links I liked:

 How to assist at placing an Endotracheal tube (also known as “intubation”)

Here is another. This video goes over care of an endo-tracheal tube including oral care, documenting the proper depth, and repositioning:

Minimal Leak method

Cuffed ET tube

DO NOT PUT 10 cc air in ET Tube cuff. Choose the amount carefully. Use “minimal-leak” procedure:

People asked how much air to put into a cuff. I showed the group how to decide how much air goes into ET tube cuff, using “minimal leak” method.  I think it worthwhile to highlight the need for this specific procedure:


Fifteen minute basic and excellent introductory lecture, first of a series:

Phasing in

There is a zen associated with effective assessment of ventilation. I always referred to this as “Phasing In” but it’s actually got a more technical name, “patient-ventilator dis-synchrony.” It’s when the patient fights the ventilator. A person on a ventilator is ideally mellow and happy; if they are not, you have to figure out why!

Here is an excellent video from Australia about “Patient Ventilator Dis-Synchrony” also known as “phasing in”

I will add to this over coming days, but – this is a start.


About Joe Niemczura, RN, MS

These blogs, and my books, and videos are written on the principle that any person embarking on something similar to what I do will gain more preparation than I first had, by reading them. I have fifteen years of USA nursing faculty background. Add to it fifteen more devoted to adult critical care. In Nepal, I started teaching critical care skills in 2011. I figure out what they need to know in a Nepali practice setting. Then I teach it in a culturally appropriate way so that the boots-on-the-ground people will use it. One theme of my work has been collective culture and how it manifests itself in anger. Because this was a problem I incorporated elements of "situational awareness" training from the beginning, in 2011.
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