Airway Management and Mechanical Ventilation

  1. The ET tube
    • Oral ET intubation is procedure of choice
    • Airway can be secured rapidly
    • Larger-diameter tube can be used Decreases work of breathing (WOB)
    • Assist with removing secretions
    • Fiberoptic bronchoscopy easier

    ET tube comes in different sizes for different anatomical sizes, we’re all different sized. “Stylet” goes into pliable tube so that the doc can insert into theairway while it’s stiff. Sleeve at end of airway gets inflated with air to sit against trachea. Like a foley balloon except it’s full of air  (so tube doesn’t slip up and down trachea). Too much air can cause pressure ulcer: stops circulation and causes endotracheal damage.

    -Pilot pigtail that you attach leurlock syring to

    -Lipline marking to resassess every 4 hours. If it goes down too far or gets pulled too high: you can’t adequately ventilate your pt.

    Preferable way is oral intubuation: we can go through the nares and surgical intervention of tracheototomy

    • Oral: open up the airway and provide ventilation quickly and relatively painlessly
    • Use largest tube to allow for minimal escapage of air and allows suction cath to go down or a bronchoscopy down the ET tube.
  2. Laryngeal Mask Airway
    OR: intubated patient, most using LMA’s because it was short term “big tongue in back of throat” not the whole big “ET tube”

    “LMA”:A laryngeal mask airway — also known as laryngeal mask— is a medical device that keeps a patient's airway open during anaesthesia or unconsciousness. It is a type of supraglottic airway.A laryngeal mask is composed of an airway tube that connects to an elliptical mask with a cuff which is inserted through the patient's mouth, down the windpipe, and once deployed forms an airtight seal on top theglottis (unlike tracheal tubes which pass through the glottis) allowing a secure airway to be managed by a health care provider.They are most commonly used by anaesthetists to channel oxygen or anaesthesia gas to a patient's lungs during surgery and in the pre-hospital setting (for instance by paramedics and emergency medical technicians) for unconscious patients
  3. Artificial Airway Indicatios
    • Indications
    • Upper airway obstruction (examples ?)
    • Apnea
    • High risk of aspiration (examples ?)
    • Ineffective clearance of secretions Respiratory distress/failure (acute diagnosis examples ?)

    • Apnea or high risk of aspiration from:
    • Respiratory center depression due to:Stroke; Brain injury; Trauma;Neuromuscular disturbances caused by:Guillain-Barré syndrome; Multiple sclerosis; Myasthenia gravis; Spinal cord injury;CNS depression

    Respiratory failure: ARDS; Pneumonia, Acute exacerbation of COPD; Pulmonary embolism; Heart failure; Trauma; Drug overdose;

    Why: High risk for aspiration pt: stroke, spinal injury and paralysis, Dementia (lost capability to swallow), Cant’ effectively clear their secretions so it’s pooling up—COPD. Pneumonia. Acute Bronchitis. Atelectasis. Trauma.
  4. Nasal Intubation or Tracheotomy
    • Nasal ET intubation
    • Indicated when head and neck manipulation is risky

    • Tracheotomy
    • Surgical procedure Long term

    Smaller tube down nose and into trachea if head/neck injury

    Trache: for long term ventilation. Every pt is different in regars to when would we decide to put that trache in-do we want to trache a pt who’s young w/o cormidities or can we wait it out

    When is best time to trache patient: after that 1st week if they’re still orally intubated and we’re having a difficulty to wean them off. 7-10 days is discussion period.

    COPD: you wouldn’t jump to trache that patient.
  5. ET Intubation Procedure
    • Equipment
    • Self-inflating bag-valve-mask (BVM) attached to oxygen
    • Suctioning equipment
    • Intravenous access

    • Nurse is responsible to assist physican in process: and that the doctor has all the equipment needed.
    • Each room should have a bag-valve-mask  (in case of disloged)
    • Oxygen and nipple or tree Suctioning equip: if they start to vomit.
    • -yaunker: hand held-straight suction cath
    • Check if there’s a patent IV: to give for sedation or ACLS meds.

    • Premedication depends on Patient’s level of consciousness & Nature of Procedure
    • Awake or Obtunded

    Nature of procedure: Emergent or Nonemergent

    • Planned intubation requires premedication: Versed and some narcotic (for conscious sedation)
    • -Propofol is much better
    • -If not oriented: we can intubated with minimal meds, but we still need narcotics b/c pain ful procedure
    • -Rapid sequence Induction: in ER. Give antianxiety med and a paralytic immediately.
    • For paralytics: they can’t breathe on their own, so make sure everything’s available.
  6. Rapid sequence intubation (RSI)
    Rapid, concurrent administration of a paralytic agent and a sedative agent during emergency airway management

    Indicated for risk of aspiration

    Used with risk for combativeness injury to pt.

    Not indicated for comatose or cardiac arrest patients
    -Before & AFter
    • Before intubation
    • 1. Preoxygenate with 100% O2 per BVM for 3-5 minutes
    • 2. Limit each intubation attempt to <30 seconds

    • 15-20 of oxygenation
    • LIMIT TIME FOR DOC TO INTUBATE: <30 seconds. You can hold your breath.
    • Fibrotic laryngoscope (camera on side to visualize the vocal cords to pass the ET tube) if airway is restricted or chubby neck-make sure the light source works-blades come in different sizes and curvatures; depends on anatomy of the patient.
    • -straight and curved.

    • OPA: oral Pharyngeal airways (oropharyngeal airway (also known as an oral airway, OPA or Guedel pattern airway) is a medical device called an airway adjunct used to maintain or open a patient's airway. It does this by preventing the tonguefrom covering the epiglottis, which could prevent the person from breathing. When a person becomes unconscious, the muscles in their jaw relax and allow the tongue to obstruct the airway)
    • -different sizes and anatomies.
    • -Rapid Sequence induction: put OPA and then intubate the patient. Must be available. -In case pt becomes extubated.
    • -Put in cheek and turn it down (to the side and down)
    • -Sizes: measure jaw to mandible: The correct size OPA is chosen by measuring from the first incisors to the angle of the jaw. (note: improper sizing can cause bleedingin in the airway)
    • -The device is removed when the person regains swallow reflex and can protect their own airway, or it is substituted for an advanced airway. It is removed simply by pulling on it without rotation
    • Ventilate the patient if not successful the first time, the ET tube can be reused if not successful the first time. 3-5 minutes, give them time to rest and make sure they’re oxygenated well and see constant BP, pulse ox and EKG monitoring

    • Ventilate patient between attempts
    • ==================
    • AFTER: 
    • Safety: Wrist restraints, sedation, Ventilator alarms, Secure ET tube, humidification of oxygen, mark exit length
    • HOB elevated 30 degrees at least.

    Monitor tube Q2-4 hours to confirm no change in exit site (reevaluate when you move pt.

    Listen to lung  sounds.

    High pressure sounds going from ventilator)

    Monitor Q2-4 H for equal rise and wall

    If it goes into lung, it can perforate either lung or trachea

    Ausc Q2H for breath sounds then Q4H eventually

    • If it eases out: validate you’re having adequate oxygenation but don’t push in because it can go into Right lung !
    • Check your orders: if advance by 1 cm: don’t forget to deflate, move the tube and reinflate the cuff!

    Your ICU pt will have complete Head to Toe evualatuon Q4H!

    If it comes out at 30 degree elevations, then bag mask valve won’t help. You have to flatten them out and do BLS style.
  8. Endotracheal Intubation Steps
    The patient should be prepared by removing any dental appliances (ex. dentures).

    Then proper sedation (and neuromuscular blockers, if used) administered.

    The patient must be positioned so that easy access is obtained. The head is placed in the “sniffing position” with the lower portion of the cervical spine flexed.

    Preoxygenation is then performed with 100% oxygen for 2 to 3 minutes via bag-mask ventilation.The laryngoscope must be held with the left hand.

    The patient’s mouth opened with the right hand and the blade placed into the right side of the patient’s mouth, sweeping the tongue to the left. The tip of the straight blade is inserted posterior to the epiglottis, while the tip of the curved blade placed anterior to the epiglottis into the vallecula. The handle is then raised up and away from the patient without leverage until the vocal cords are visualized. The clinician’s wrist should not be bent as this may cause damage to the teeth.

    Once the vocal cords are seen, the ETT is passed through cords with the right hand and advanced to 20-26 cm, as measured at the teeth or with the cuff just below the vocal cords.

    The laryngoscope is then withdrawn and the cuff is inflated.

    If intubation is delayed, no more than 30 seconds should pass without ventilation.3Therefore, if intubation is not performed within this time period, the procedure should be stopped and the patient ventilated with bag-mask ventilation prior to reattempting the procedure.
  9. Maintaining the ET tube

    -Incorrect placement?
    -Proper Cuff Inflation Maintanance
    Monitor ET tube every 2 to 4 hours

    Confirm exit mark on ET tube remains constant while: At rest, During patient care, Repositioning, Transporting patient

    • Observe for symmetric chest wall movement
    • Auscultate to confirm bilateral breath sounds

    • Incorrect tube placement is an emergency
    • Stay with patient and maintain airway
    • Support ventilation: Airway alignment
    • Secure help immediately
    • If necessary, ventilate with BVM and 100% O2

    • Maintaining proper cuff inflation
    • Cuff is an inflatable, pliable sleeve encircling outer wall of ET tube
    • Stabilizes and seals ET tube within trachea Prevents escape of ventilating gases
    • High cuff pressure can cause tracheal damage
  10. Measures to avoid tracheal damage
    Normal arterial tracheal perfusion is estimated at 30 mm Hg Cuff pressure should be maintained at 20 to 25 mm Hg

    Cuff pressure is measured and recorded after intubation and on a routine basis (every ET tube placement check) 

    Two techniques: MOV and MLT (SEE next slides)

    • MOV:
    • For mechanically ventilated patients
    • Place stethoscope over trachea Inflate cuff by adding air until no air leak is heard at peak inspiratory pressure
    • Use manometer to verify cuff pressure is between 20 and 25 mm Hg.

    • For spontaneously breathing patients
    • Inflate cuff until no sound is heard after a deep breath or after inhalation with an BVM

    • put stet over trachea, inflate the cuff by adding air until no leak is heard at the peak inspiratory pressure that the machine is delivering that amount of air. They then have mamometer hooked up and validate pressure to 20-25
    • NOTE: If the patient is spontenaous breathing (no machine): we would inflate cuff until no sound is heard after a deep breath. And then hook up mammometer.

    • MLT: 95% (similar: machine or BMV):
    • Small amount of air is removed from cuff until a slight leak is auscultated at peak inspiration

    • Hear no air leak at that point of maximum inspiration: but then we withdraw air to hear just a small escape of air. Applies to spontaneous or machine.
    • When Resp Therapist comes around and does ventilator chescks Q4H: they should be checking. Decrease air and inflate. Watch for bronchospasms (because you’re mainipualting)– the ET tube will

    MOV technique and MLT help prevent risks of tracheal trauma due to high cuff pressures

    • If cuff pressure cannot be maintained or larger volumes of air are needed
    • Cuff could be leaking
    • May be tracheal dilation at cuff site
    • Physician should be notified
    • ET tube should be repositioned or changed

    Check your cuffs for leaks: could be holes. See dilation on xray if you’re adding air
  11. Monitoring Oxygenation?

    Monitoring Ventilation
    • Oxygenation: 
    • -ABG's, SpO2, SvO2/ScvO2(mixed and Central venous oxygenation)Clinical signs of hypoxemia, Change in mental status (e.g., confusion), anxiety, dusky skin, dysrhythmias

    Iniitial ET process: check ABGs (no rules of when, but based on pt’s changing process), SaO2, s/s hypoxemia

    Dysryhtmias for hypoxemia: Tachycardia and Ventricuallar dystrhmias, frequent PVCs

    Montior cuff pressure: 20-25

    Continous End Tidal CO2 wave form (capnography), in addition to EKG, BP, RR, pulse ox. REQURIED b/c they’ve shove through data that changes in CO2  are quicker signs of hypoxemia!!

    Monitoring ventilation: Assessment

    • PaCO2
    • EtCO2
    • Clinical signs of respiratory distress: Use of accessory muscles, hypoventilation with dusky skin, hyperventilation with
    • circumoral/peripheral numbness/tingling
    • Accessory: intercostal retractions, belly goes up and down, muscles used in neck and scapula (look at this)Dusky skin around the lips!!
    -Two kinds
    -Complications and how to manage/avoid them?
    Indication for suctioning: Visible secretions in ET tubeSudden respiratory distressSuspected aspiration↑ in peak airway pressures, Adventitious breath sounds↑ in respiratory ratesustained coughingSudden or gradual ↓ in PaO2 and/or SpO2

    • Do not suction routinely (can cause damage)
    • Assess patient routinely to determine need for suctioning
    • Gurgling: suction your patient and then listen again, make sure you have a change. If not suction again.

    • TWO KINDS OF SUCTIONING: Open and CLosed
    • 1. Closed (CST): Enclosed in a plastic sleeve connected directly to patient-ventilator circuit CST maintains oxygenation and ventilation and decreases exposure to secretions
    • 2. Open: Sterile. when intubated but not on ventilator. Go down with the tube, keeping one hand sterile. Also on trache.

    • Potential Complications of Suctioning: 
    • Hypoxemia BronochospasmIncreased intracranial pressureDysrhythmias Hyper/hypotension Mucosal damage, bleedingInfection
    • -ICP: don’t suction neuro pts (try to not suction at all. Coughing raises ICP)Look at output to determin if pt has infection.
    • Assess pt before, during and after that suctioning procedure.
    • -If they don’t tolerate suctioning: stop and give sup oxygen or bag valve. Or press button OVERRIDE button that last 3minutes that applies 100% oxygen into ventilation cycle and then revert back to normal.

    • Assess patient before, during, and after suctioning
    • If patient does not tolerate suctioningStop procedure and manually hyperventilate with 100% oxygen via BVM
    • If performing CST, hyperoxygenate using 100% O2 setting on machine

    • Hyperoxygenate before and after
    • Limit each suctioning pass to ≤10 seconds
    • Assess trends in SpO2 throughout suctioningLimit suction pressures to <120 mm Hg
    • Avoid overly vigorous catheter insertion

    • Managing thick secretions
    • Provide adequate hydration (e.g., oral, NG/GT, or intravenous fluids) and supplemental humidification
    • Installation of normal saline into ET tube is discouraged
    • Treat infection with antibiotics
    • Provide postural drainage (drain lungs by gravity , changing positions to fascillatate that)
    • Percussion (by RT on that lung area to help mobilize those secrtions. There’s beds that allow for percussion (Vibrates))
    • Turn patient every 2 hours
  13. Closed Suctoning
    Closed suctioning technique is used whenHigh levels of positive end-expiratory pressure (PEEP) are being utilizedBloody or infected pulmonary secretions Frequent suctioning needed

    -Blood or infected pulm: don’t do open! It’ll go in air and in your face :x

    Sleeve covers suction cath, press thumb controlled suction device to apply suction

    • -look to see secretions and the colors

    Irrigation pig tail at end: put sterile NS (around 1 mL): irrigate production through lavage pig tail

    -Adjust humidification: make sure there is enough water and it doesn’t go dry.  Mucinex to liquefy their secretions. Bronchodilators.
  14. Oral Care
    • -yaunker to suction oral cavity-brush teeth BID to get rid of film to the point where they aspirate.
    • -IF NPO pt: Oral care Q2H. Give green tip sponges.
    • -Assess oral for thrush or breakdown.
    • -Securing device for ET tube pulls it away from the lip to avoid from pressure ulcers on the lip! Teach family members.  Apply water soluble lubricants.
    • -When changing tape: have a buddy with you because they can cough and bronchconstrict from manipulation on tube on trachea.
    • -Retape ET tube If patient is anxious or uncooperative, two caregivers needed to reposition ET tube/tape
  15. Fostering comfort and communication
    Anxiety due to inability to communicate requires emotional support

    Physical discomfort associated with ET intubation and mechanical ventilation necessitates sedation and analgesia

    Consider alternative therapies to complement drug therapy

    Examples of alternatiave therapies?Whiteboards, Pictures they can point to,Tablets they can write on

    Do they look comfortable on that bed?Are they muscuskeletally aligned?

    Make sure you provide comfort: call lights (even if sedated by propofol)

    Communicate with family: they know the patient best.

    Use analgesia with sedation b/c intubation is unnatural and painful.  LOOK for signs of pain. (RSI is when you’re putting in tube, intubation process)

    With a prolonged intubation process, their body adjusts to the pain, they might need less pain meds as time continues. What’s causing their anxiety? Fear. Anxiety. Stress of environment. In pain? Neuro change? Know the root!
  16. Complicatons of ET intubation
    • Complications of ET intubation
    • Unplanned extubation
    • Patient vocalization complications
    • Activation of pressure ventilator alarms
    • Diminished or absent breath sounds
    • Respiratory distress
    • Gastric distention

    • Unplanned: now you have to secure an airway.
    • Patient vocalization: now you have to guess what’s going on?
    • Pressure alarm going on…only turns it off for 3 min, so silence button is only temp!Alarms can be the machine issue itself…
    • Gastric distension: gas escaping into esophagus and into belly, assess that gas is going into the lungs and not the stomach.
    • Use soft wrist restraints!
  17. Unplanned extubation
    -If it happens?
    • Ensure adequate securement of ET tube
    • Support ET tube during repositioning and procedures
    • Use soft wrist restraints
    • Provide sedation and analgesia as ordered

    Damage to cuff especially if the pt tries to escape from under the soft wrist ties: stay with pt, give adeq sedation, analgesia. Call for help and give oxygen and Respiration appropriately

    • Should an unplanned extubation occur
    • Stay with patient
    • Call for help
    • Manually ventilate patient with 100% O2
    • Provide psychologic support
  18. Aspiration
    • Risk factors
    • Improper cuff inflation
    • Patient positioning
    • Tracheoesophageal fistula

    • Prevention
    • Suction oral cavity frequently
    • Insert orogastric or nasogastric tube and connect to low, intermittent suction
    • If receiving enteral feedings, elevate HOB 30 to 45 degrees
    • Provide continuous suctioning of secretions above cuff if necessary

    Fistula: highway b/w the esophagus and the trachea

    Old days: methylene blue die into feedings so that if when suctioning, if blue stuff came out, then that mean they had aspirated on feeding contents. We don’t do that anymore. Suction.

    NG or OG tube: suction can be continuous or low intermittent. ET tube has subglottal (SP?) suctioning
  19. Mechanical Ventilation
    Process by which fraction inspired oxygen (FIO2) at ≥21% (room air) is moved into and out of lungs by a mechanical ventilator

    • Notes:
    • It’s going to deliver air at a predetermined rate and volume
    • Oxygen delivered at predetermined at percentage.
    • Room air: oxygen 21%
    • Severe hypoxia or resp

    • Indications
    • Apnea or impending inability to breathe
    • Acute respiratory failure
    • Severe hypoxia
    • Respiratory muscle fatigue
  20. Mech Vent Settings
    • Settings of mechanical ventilators
    • Regulate rate, depth, volume, pressure and oxygen delivery
    • Based on patient’s status (e.g., ABGs, body weight, level of consciousness, muscle strength)
    • Ventilator is tuned to match patient’s ventilatory pattern

    • Other characteristics?Volume
    • FIO2
    • Pressure

    Rate: how often breaths are given. Depth. Volume of breath. Pressure that it takes to give that volume of breath and actual percentage of breath.

    • Look at clinical parameters that pt gives us to determine the type of mech ventilation that the patient will need
    • 1.Abg
    • 2.Ch xray
    • 3.Resp insuff
    • 4.Workload  of breathing

    We want to match the patient's best ventilator pattern: if we don’t, the patient will have hard time breathing WITH ventilator and will breathe AGAINST vent. “Bucking the ventilator”. Meaning not enough adequate ventilation. Not doing it in sync with vent settings.
  21. TYPES of Mech Ventilation
    • 1. Negative pressure ventilation
    • Uses chambers that encase chest or body and surround it with intermittent subatmospheric or negative pressure
    • Noninvasive ventilation that does not require an artificial airway
    • Not used extensively for acutely ill patients

    Like an IRON lung: allow diaphragm to breath in and out. Not invasive. Doesn’t require airway.

    • 2. Positive pressure ventilation (PPV)
    • Used primarily in acutely ill patients
    • Pushes air into lungs under positive pressure during inspiration
    • Need artificial airway (invasive)
    • Expiration occurs passively
  22. Two MODES of Postive Pressure Ventilation (PPV)
    • 1)volume ventilation
    • -Tidal Volume: amount of air being pushed into the patient with each breath.
    • -Predetermined tidal volume (VT) delivered with each inspiration

    • 2) pressure ventilation
    • -Amount of pressure needed to deliver each breath (volume) varies based on compliance and resistance factors of patient ventilator system
    • -Not set in 100% of the patient
    • Sometimes they don’t need pressure support for all patients, it’s just the normal change of positive pressure with the machine that delivers the volume of air
    • IF they have pressure support: it will say how much pressure (or be dialed to) is needed based on the impedance of the lungs—how compliant are our lungs? Are they resistive b/c they don’t have that capability to relax and to widen.
    • -They will look at work load of breathing to determine what the volume is.
  23. Volume Ventilation Modes
    • Predetermined tidal volume (VT) delivered with each inspiration
    • Based on how much work of breathing (WOB) patient should or can perform.
    • -They will look at work load of breathing to determine what the volume is.
    • Determined by patient’s ventilatory status, respiratory drive, and ABGs 

    • 1. CMV: controlled Ventillator Support
    • 2. Assistive Ventillation
    • -Assist/Controlled (A/C)
    • -Synchronized Intermittent Mandatory Ventilation (SIMV)
  24. Controlled Mechanical Ventilation (CMV)
    • The vent does 100% of breathing for the pt, the pt isn’t doing anything (not even initiating their breath)-that’s controlled
    • CMV: controlled mech vent

    -must be sedated and paralyzed in ICU. They have no WOB, so no problem of bucking the vent
  25. Assistive Ventillation
    • Volume Ventilation Modes
    • Both machine and pt share the work of breathing
    • -the pt able to initate breaths on their own but maybe not enough volume, or they need pressure b/c too much resistance inside, maybe not enough oxygen b/c alveolie collapsed, or maybe  they’re not getting enough rates of breath to sustain oxygenation

    1. Assist/Controlled (A/C)

    2. Synchronized intermittent mandatory ventilation (SIMV)
  26. Assist/Controlled (A/C):
    Volume Ventilation Mode

    -Delivers preset Tidal Volume at preset frequency (rate)

    When patient initiates a spontaneous breath, preset VT is delivered Can breathe faster but not slower

    Allows some control over ventilation Used for a variety of conditions (e.g., acute respiratory failure)

    volume of air is set. Rate (Breath/min) is set. You can add pressure behind that. The patient can breath above the rate set, all on their own. When pt takes breath with ventilator, the vent will push that volume of air with that pressure programmed in conjunction to their breathing pattern. Ex: rate of 12. If the pt doesn’t breath 12 breaths, the vent will recognize that and, give it a breath. If 14 breaths happen, 2 of those breaths, won’t be supported by the machine, but they will still get that prescribed amount of oxygen.

    The min the resp rate falls below prescribed rate, the machine will say, “uh oh. You fell behind. You need more RR. I’m going to give you more”

    The Problem: that artificial breath that isn’t initiated with the patient. They can start to buck that process.. Because they’re awake.

    IF there’s extra breaths: you’re looking for changes in ABGs and EKGS, cos maybe over time you can decrease the volume and rate b/c those breaths may become adequate enough that they’re getting enough volume and can get weaned off the machine.

    “Tidal volume”: generally started at 500, maybe high with vent assist. On pt’s own breath, maybe they’re only getting 250-300—that’s nothing and not strong enough to wean off the vent. But if their breath is getting above the tidal volume, then there’s probably a chance, they can get weaned off and extubated pretty soon :D

    Note: with A/C: The pts has their own WOB but need help
  27. Synchronized intermittent mandatory ventilation (SIMV)
    • Volume Ventilation Mode
    • Delivers preset VT at preset frequency in synchrony with patient’s spontaneous breathing

    Between ventilator-delivered breaths, patient is able to breathe spontaneously

    Patient receives preset FIO2 during spontaneous breaths but self-regulates rate and volume of breaths

    • Potential benefits
    • Improved patient-ventilator synchrony
    • Lower mean airway pressure
    • Prevention of muscle atrophy
    • Same thing as A-C: Dial in the volume of the abreath. When the pt breath, the machine gives that volume.

    • -You don’t have to have a rate. Every single breath can be assisted.
    • -For Ex: Let’s say I’m breathing 16 RR/min. And the volume I can do by myself without the ventilator is 400. Maaye the machine volume is set at 350. Now everytime I breathe during those 16 breaths, total volume exchange is about 750 which is good!  You can set a rate, where you can add a “rate of 8” for additional volumes.

    With SIMV: you don’t have to give a rate

    Same as A/C: dial in volume of breath, and when pt breaths, give that volume

    You don’t need a rate here. Every breath will get a volume.

    More of a play, can do a lower rate.

    If the pt. breathes above the volume, that volume won’t get applied to those breaths.

    Often rates of 6, because rates in between are adequate enough and their volume/gas exchange is adequate enough. BUT not enough, to not have mech vent assisting the patient.

    AC can be stepped down to CPAP (skipping SIMV and that’s fine).  

    Sensing the respiratory drive, in regards to PaO2 and CO2 levels and oxygenation levels, that is bascically the driving point of initiating the breaths. SO you have to look at the ABGs as well. If you mask that ability to breathe on your own because you’ve overcorrected the ABGs then you’re not going to be able to extubate your pt.
  28. Pressure Ventilation Modes
    • Modes of pressure ventilation : Positive pressure applied to airway only during
    • 1. Pressure Support Ventilation (PSV) 
    • 2. Pressure-controlled/inverse ratio ventilation (PC-IRV)
  29. Pressure support ventilation (PSV)
    Used in conjunction with spontaneous respirations

    • Advantages
    • ↑  Patient comfort
    • ↓ WOB
    • ↓ Oxygen consumption
    • ↑ Endurance conditioning

    Patient must be able to initiate a breath

    Preset level of positive airway pressure selected so gas flow rate is less than patient’s inspiratory flow rate

    If patients lung become less complaint and lose elasticity , we're going to have to increase pressure to forcefully push in air. Pay attention to volume of air being forced into pressure to prevent overventillaton and underventillation. Make sure alveoli stay appropriately enlarged. Pressure support will help the patient comfort, decrease their WOB, decrease amt of oxygen consumption (reduce oxygen toxicity) and increase endurance conditioning
  30. Pressure-controlled/inverse ratio ventilation (PC-IRV)
    Combines pressure-limited ventilation with an inverse ratio of inspiration (I) to expiration (E)

    Normal I/E is 1:2

    BUT With IRV; I/E ratio begins at 1:1 and may progress to 4:1

    Progressively expands collapsed alveoli and has a PEEP-like effect

    • Requires sedation and usually paralysis
    • For patients with ARDS continuing refractory hypoxemia despite high levels of PEEP

    Normally when we breathe: inspiration time is shorter than expiration time. BUT we can adjust the machine to reverse this so that we bring in MORE air over LONGER period of time, but our exhalation time is shorter-More difficult to do naturally!

    • Reason?
    • Starts progressively: 1 to 1 goes to a 4-1 ration
    • -allows for alveoli to stay open and not to collapse. But it’s difficult to maintain, so PARALYSIS of the patient is required for this mode.
    • Exhalation is still happening passively.
    • -For non compliant lungs: COPD, ARD so that oxygenation can occur at the capillary bed within the alveoli.

     Increased pressure in thoracic cage can decrease our cardiac output: causing hemodynamic instability problems
  31. Other Ventilatory Maneuvers
    • 1. PEEP
    • 2. CPAP
    • 3. BiPAP
  32. Positive end-expiratory pressure (PEEP)
    Positive pressure applied to airway during exhalation

    Exhalation remains passive, but pressure falls to preset level >0, often 3 to 20 cm H2O

    Maintain or improve oxygenation while limiting risk of O2 toxicity

    • Contraindications
    • Patients with highly compliant lungs
    • Unilateral or nonuniform disease
    • Hypovolemia
    • Low cardiac output↑
    • Functional residual capacity (FRC)

    Optimal PEEP : PEEP titrated to point oxygenation improves without compromising hemodynamics

    Physiologic PEEP = 5 cm H2O; Replaces glottic mechanism, helps maintain normal FRC, and prevents alveolar collapse

    • Be aware of Auto-PEEP: Result of inadequate exhalation time
    • Body creates additional PEEP over what is set
    • Interventions to limit auto-PEEP
    • Provide sedation and analgesia
    • Use large-diameter ET tube
    • Administer bronchodilators
    • Set short inspiratory times with longer expiratory times
    • ↓ Respiratory rate
    • ↓ Water accumulation in ventilator tubing

    • Results
    • ↑ WOB
    • Barotrauma
    • Hemodynamic instability 

    PEEP: at the end of expiration process, instead of allowing pressure to go to zero….we only allow the pressure to be at a level HIGHER than zero (3-20 normally)

    -To maintain the alveoli to be open.

    Problem: when you have PEEP, and that extra pressure inside our lungs and inside our thoracic cage. SO EXTRA PRESSURE: pressing on heart, major vessels: causing DECREASED Cardiac Output.

    Don’t use for compromised Cardiac Output, because it’ll only worsen it.

    Helps to decrease amount of oxygen when patients are requiring more and more levels of oxygen.

    ARDS: they need more oxygen to allow for exchange of oxygen in capillary membrane bed. Lungs are no longer compliant anymore: the alveoli are either collapsed or the lungs are hard as a rock so more oxygen is needed.

    -In order to minimize oxygen needs: we’ll add PEEP to keep alveoli open.

    We Worry about absorption atelectasis with ANY of the ventilator settings.

    At the very end of expiration. Normally at the end, the pressure inside the thoracic cage is ZERO.

    But we maintain higher level of pressure to keep the alveoli open and NOT collapse all the way But we have to be careful b/c our body can look at that extra pressure, and add pressure on top of it. “Auto-PEEP” causing an increased workload of breathing, and trauma to tissue (air escapes out of lung tissue into pleural cavity and space, causing pneumothorax)

    -To limit autoPEEP: Sedation, analgesia, large enough diameter ET tube to avoid additional pressure through that ET tube, bronchodilators, set shorter inspiratory times and long expiratory times, and decreasing respiratory rate and any pressure w/in the tubing..

    Reservoir: accumulation of water inside tubing will cause pressure and occlusion of air within tubing (both air coming in and leaving is blocked) so think about that as well.
  33. Continuous positive airway pressure (CPAP)
    • Restores FRC
    • Similar to PEEP
    • Pressure delivered continuously during spontaneous breathing
    • Use with caution in patients with myocardial compromise
    • Used to treat obstructive sleep apnea Administered noninvasively by mask, ET, or tracheal tube 

    Now if have a patient we’re getting ready to wean off or extubate: we change to the next mode: CPAP

    CPAP is often used at night or through day

    -Can be either through a mask (like on MS floor) OR ventilated patient through the ET tube.

    This will deliver continuous positive pressure during the inhalation proves (whether passive by pt or not)

    Similar to PEEP: continuously going.

    Sleep apnea: Number 1 reason and then used for the weaning process.

    CPAP, like PEEP, can cause internal thoracic cage pressure: compromise pt with decreased C.O as well Be conscious of that.

    CPAP happens on inhalation and PEEP occurs at the very end (maintaining pressure)
  34. Bilevel positive airway pressure (Bi-PAP)
    Two levels of positive pressure support

    • Higher inspiratory positive airway pressure
    • Lower expiratory positive airway pressure along with oxygen

    Noninvasive-Delivered through a tight-fitting face mask, nasal mask, or nasal pillows

    Must breathe spontaneously and cooperate

    • Indications
    • Acute respiratory failure with COPD and heart failure
    • Sleep apnea  

    • Other notes:
    • Another way to allow pressure type of ventilation, two levels of positive pressure being delivered
    • High on inspiration, lower on expiration
    • Only delivered through mask, NC kind cannula
    • -NOT invasive: no ET tube or trache. (So you can’t turn the machine to BIPAP!)

    Used for COPD, better tolerated for pts with HF already due to decrease in change of pressure at the end, so we don’t have as much pressure at the end in the thoracic cage that would compromise or add to a pt with already compromised HF, and used for sleep apnea
  35. High-frequency ventilation (HFV)
    Involves delivery of a small tidal volume (usually 1 to 5 ml per kg of body weight) at rapid respiratory rates (100 to 300 breaths per minute)

    • Goals                                            
    • Recruit and maintain lung volume
    • ↓ Intrapulmonary shunting
    • Mechanical Ventilation

    • Types
    • High-frequency jet ventilation
    • High-frequency percussive ventilation
    • High-frequency oscillatory ventilation
    • Patients must be paralyzed and sedated and receive analgesia

    • Other notes
    • Seen more in NICU or PICU, not in typical ICU
    • Delivers small tidal volues of air at a HIGH rate: 100-300/min. Push push push air.
    • For preemies. Their lungs aren’t compliant at all, have to push and push and push the air in to allow for lungs to start to build and respond on their own

    Jet: pounds on chest

    Sedated and paralyzed to tolerate!
  36. Prone Positoning
    • Repositioning of patient from a supine or lateral prone position to prone position
    • Improved lung recruitment
    • Used in critically ill patients with acute lung injury or ARDS

    • Used for ARDS
    • We can rotate the bed 360-devices that we can place on pt, that protects patient, that allows them to lie on stomach but still allow for diaphraphm to work as air comes in
  37. Extracorporeal membrane oxygenation
    Alternative form of pulmonary support for patient with severe respiratory failure

    Modification of cardiopulmonary bypass

    Involves partially removing blood through use of large-bore catheters, infusing oxygen, removing CO2, and returning blood back to patient

    • LUNG BYPASS Machine: take out the blood, oxygenate it, and then return it back to the child. Connected to pulm artery
    • It is pulmonary support

    2 nurses to one baby And Tech that will run the machine. So 3 people take care of one baby. Short term: echmo for babies.
  38. Complications of PPV: Cardiovascular
    • Cardiovascular system: PPV affects circulation due to transmission of ↑ mean airway pressure to thoracic cavity
    • ↑ Intrathoracic pressure compresses thoracic vessels
    • ↓ cardiac output
    • Hypotension

    • -With cardio: putting air in thoracic cage: increasing pressure.
    • Monitor changes in CO: BP, EKG, oxygenation, circulation, hemodynamic stability,
    • Anytime we have compromised heart: the heart will shunt the blood to vital organs: brain, heart and lungs.

    Decreased cardiac output results from decreased venous return,&  decr left vent end-diastolic volume (preload)

    Mean airway pressure is further ↑ if PEEP >5 cm H2O
  39. PPV Pulm System Complications
    IN THE LUNGS:You’re forcefully doing something to viable tissue, so you can cause trauma anytime we put air into those lungs

    • Barotrauma= Air can escape into pleural space from alveoli or interstitium, accumulate, and become trapped pneumothorax Patients with compliant lungs are at ↑ risk
    • Chest tubes may be placed prophylactically
    • -Collapse will occur with enough air escape.

    Pneumomediastinum=ruptured alveoli with prgressive air movemnt into mediastinum and subcut tissues followed by pneumothorax. If alveoli ruptured, out of pleural into the MEDIASTINUM (SUBCUT tissue): subcuteanous emphysema.

    Volutrauma= with large volumes used to ventilate results in alveolar fractures and movement of fluids and protiens into alveolar spaces-once alvelli ruptured, the fluid in alveoli will build up inside pleural cavity causing pneumothorax. -Look for s/s

    • SX: anytime we go into thoracic cage
    • during sx, we are destroying or changing pressure inside, so to avoid pneumothorax, they’d put a prophylactic chest tube (no collapsed lung) b/c we’ve alt the pressuresON VENT: Listen to lung sounds Q4H, and before and after any type of exam or movmeent
  40. PPV Complication: Hypoventilation
    • Not giving enough volume
    • -Inappropriate ventilator settings
    • Leakage of air in ET Tube
    • Lung secretions or obstruction
    • Low ventilation/perfusion ratio  

    -Leakage of air: maybe cuff isn’t inflated all the way so air leaks around there, you can hear it when you go into the pt room (Squaky rustling)

    -Lung secretions: cause hypo, we look for s/s of hypoxema, changes in SaO2, listen to lung sounds,, gurgling sounds of ET tubes or treach

    Don’t routinely suction. If we have low vent: set w/in vent settings: how are we monitoring they’re adequately ventilated: BY ABGS!! Once staballized, ABGs should be checked once a day. Changes: pt condtion, when weaning pt: based on interventions of that process.

    Long term vent pts don’t get ABG’s

    • Chest xray (for ICU, acute care, on vent) should be taken: right after being intubated (for placement and atelectasis, any lung traumas): should be taken once a day
    • -Stable pt/LTC: when it’s need, when nurse identifies there’s  problem

    • Turn patient every 1 to 2 hours
    • Provide chest physical therapy to lung areas with increased secretions
    • Encourage deep breathing and coughing Suction PRN
    • (Mobilizing secretions, turning pt, chest physiotherapy if excessive secretion, bronchodilation, expectorants, increased fluids, if breathing on own: encourage pt to take breaths on their own (EVEN when ventilated).)
  41. Complication: Resp Alkalosis
    When they first get intubated: respiratory acidosis. As we get ventilator settings going: they go into alkalosis.Be conscientious of that: we’re overventillating. So adjust based on ABG’s.

    If hyperventilating on their own: maybe the pt is taking too many breaths  in addition to machine (panic, anxiety, fear can be causes and treat) Determine cause (e.g., hypoxemia, pain, anxiety, or compensation for metabolic acidosis) and treat
  42. Complication: Ventilator associated Pneumonia (VAP
    Clinical evidenceFever and/or elevated white blood cell countPurulent or odorous sputumCrackles or rhonchi on auscultation Pulmonary infiltrates on chest x-ray

    Pneumonia that occurs 48 hours or more after ET intubationPNEUMONIA:  where they get intubated and WBC is fine w/ no underlkyibg infection but 2 days later, WBC shoot up. Secretions are now yellow, purelent.-Crackles/Rhonhi-Pulm infiltrates

    • Guidelines to prevent VAP
    • HOB 30 to 45 degrees unless contraindicated
    • Routine changes of ventilator circuit tubing ET that allows continuous suctioning of secretions in subglottic area
    • Drain condensation that collects in ventilator tubing

    Minimize risk of pathogen transmission, HOB elevated, decreased aspiration risk

    *Routine changes of ventilator circuit tubing: they’re continuously breathing through this tube. Should be changed depending on facility. Talk to RT what their policy is for chaging circuit tubing. Make sure there is no water, and it’s being drained!!
  43. PPV Complications:  Fluid Retention
    • Occurs after 48 to 72 hours of PPV, especially PPV with PEEP
    • May be due to ↓ cardiac output
    • Results: Diminished renal perfusion and Release of renin-angiotensin-aldosterone

    Pressure changes within thorax are associated with ↓ release of atrial natriuretic peptide, also causing sodium retention

    • As part of the stress response, antidiuretic hormone and cortisol may be ↑
    • Contributes to sodium and water retention

    FLUID RETENTIION:-Some sort of Edema. -Anasarca: generalized Edema-Occurs when you’re increasing thoracic pressure, decreasing Cardiac Ouput (pressure support associating) SO you decrease RENAL PERFUSION (Becausse <3 only cares about vital organs. DUH)SO now there’s no capacity to filter all the fluids. Result in Water and sodium retention-Decreased release of Atrial Nat Peptide SO it looks like our pt is going into heart failure because their BNP will go up.

    Make sure you’re looking for thsese  S/S

    Anasarca can turn into weeping edema: all the fluid has nowhere to go, so it would just leak out of the skin.
  44. PPV Complications: Neuro
    In patients with head injury, PPV (especially with PEEP) can impair cerebral blood flow

    Elevating HOB and keeping patient’s head in alignment may decrease effects of PPV on intracranial pressure

    Increased Intracranial pressure or any neuro injury: we need to make sure we don’t have too much pressure during mech ventilation process (because we’re also increasing the ICP now)

    -fine line when looking at oxygenation of our pts

    -Mech ventilation or head injury pts.

    • Elevate HOB, alignment! To decrease ICP. Monitor s/s of ICP (Review)
    • -Can be on ICP monitor
  45. PPV Complications: GI Systsem
    Risk for stress ulcers and GI bleeding

    ↑ Risk of translocation of GI bacteria

    ↓ Cardiac output may contribute to gut ischemia

    Peptic ulcer prophylaxis:  Histamine (H2)-receptor blockers, proton pump inhibitors, tube feedings -- ↓ Gastric acidity, ↓ risk of stress ulcer/hemorrhage

    • Gastric and bowel dilation as a result of gas accumulation
    • Nasogastric or orogastric tube for decompression

    ↓ Peristalsis from immobility, sedation, circulatory impairment, ↓ oral intake, use of opioid pain medications, and stress


    Compromised b/c not a vital organ

    increased acid production, increases aspiration risk

    Increased ulcers to form (cover for this chance: H2 blockes, PPIMonitor for distention, BS, chages, GI output.

    Make sure no problems with gas accumulation: if there is: NG tube to decompress the stomach. Be conscientious of pain meds. Causes constipation!

    -ALWAYS intermittent suction for decompression!! (unless cancer, or sx where gas buildup is too fast)
  46. PPV: Musculoskeletal System
    Maintain muscle strength and prevent problems associated with immobility

    Progressive ambulation of patients receiving long-term PPV can be attained without interruption of mechanical ventilation

    Paralyzed: not moving their muscles

    You have to maintain muscle integrity OR ELSE: Foot drop, disuses of muscles (atrophy)ROM must be done!Feet in a flexed position to avoid foot drop. (Foot drop is a gait abnormality in which the dropping of the forefoot happens due to weakness, irritation or damage to the common fibular nerve including the sciatic nerve, or paralysis of the muscles in the anterior portion of the lower leg. )

    Progressive ambulation or even just getting the pt up off the side of the bed. Especially when they’re on vent: make sure the tube doesn’t come off disloged and v/s aren’t changing and distressed. That they’re tolerating it well. Give pain meds, but don’t overseddate where they can’t cooperate.

    PROM: Should be done 2x a shift (12 hour shift) minimum. Night shift too.

    Perform passive and active exercises Consisting of movements to maintain muscle tone in upper and lower extremities

    Prevention of contractures, pressure ulcers, footdrop, and external rotation of hip and legs by proper positioning

    EXTERNAL ROTATION of HIPS: be conscientious that this doesn’t happen because it’ll atrophy ad they can’t walk well.
  47. Psychosocial needs
    • Physical and emotional stress due to inability to speak, eat, move, or breathe normally
    • Pain, fear, and anxiety related to tubes/ machines
    • Ordinary ADLs are complicated or impossible

    • Patients have identified four needs
    • Need to know (information)
    • Need to regain control
    • Need to hope
    • Need to trust

    Involve patients in decision making

    • Encourage hope and build trusting
    • relationships with patient and family

    Provide sedation and/or analgesia to facilitate optimal ventilation

    If necessary, provide paralysis to achieve more effective synchrony with ventilator and increase oxygenation

    REMEMBER: A paralyzed patient can hear, see, think, feel, and smell

    Sedation and analgesia must always be administered concurrently

    Family and patient.Educate every step of the way: Whether they are sedated or not. They can still hear you.Minmize any anxiety. Look at them: Are they comfortable in that position? Does it look comfortable?Once the pt does get extubated: go to process of rehabilitation and educate them on that process (that’s where they can get so frustrated. I’m extubated but they can’t do things..they take longer or get too fatigued. Make sure family is educated to support them through rehab process)

    They have right to make decisions and control they’re options.They should trust you as a caregiver to be there for them.  Follow through with what you promise/say. Provide sedation to give optimal ventilation and minimize rest of psych fears they may have.
  48. Machine Disconnection/ Malfunction
    • Machine disconnection or malfunction Most frequent site for disconnection is between tracheal tube and adapter
    • ONLY pause alarms during suctioning or removal from ventilator

    A machine is a machine…it can malfunction. When machine alarms go off: that is a cue that you need to intervene. And determine what the cause of the alarm is. Never ignore it. (Natiional Patient Safety goal)So alarms are set up so you can only silence for so long before they go back on again.  Your job: Before you leave that room: reactivate the alarm. REACTIVATE alarms before leaving

    Malfunction may be due to power failure, failure of oxygen supply, etc.

    If machine malfunctions: Disconnect patient from ventilator Manually ventilate with 100% O2

    If power fails: make sure everything is already plugged into “RED plugs” for generatorThere should be a 5 scond turn around when power dies, before the generator kicks in. Assess in the morning for safety.Rooms should have: flashlight. If machine malfunctions: take them out of commission.  Not adequately deliver air, pressure alarms despite no cause…so manually ventilate, call RT, hook up pt to a new vent and biomed looks at the old vent.
  49. Nutritional Therapy
    PPV and hypermetabolism can contribute to inadequate nutrition

    If patient is likely to be without food for 3 to 5 days, a nutritional program should be initiated

    Metabolism is going through the roof: burning throuogh any reserves that they have.  Increased stress

    W/O nutrional support: we won’t get adequate ventilation or oxygenation or repair

    • NG tube or G tube (increasing aspiration risk, poor GI system functioning) or even
    • TPN/PPN

    • Tube feedings:
    • Look for s/s of intolerance to the food.
    • -Residuals. Q4H
    • -Do your checks appropriately.
    • -Monitor for distension, output,
    • -HOB up
    • -adequate fluids added to feedings
    • -Check for placement
    • -Only time you don’t check residual: JEJUNUM OR PLACMENT (xray is the only way to double check)

    Poor nutrition and disuse of respiratory muscles contributes to decreased muscle strength

    • Inadequate nutrition can
    • Delay weaning
    • Decrease resistance to infection
    • Decrease speed of recovery

    Enteral feeding via a small-bore feeding tube is preferred method to meet caloric needs of ventilated patients

    • Verification of feeding tube placement
    • X-ray confirmation before initial use
    • Marking and ongoing assessment of tube’s exit site
    • Ongoing review of routine x-rays and aspirate
  50. WEANING from PPV and Extubation
    Process of Decreasing ventilator support & Resuming spontaneous ventilation

    Differs for patients requiring short-term ventilation (≤3 days) versus long-term ventilation (>3 days)

    • Short-term PPV is a linear process; 
    • Prolonged PPV involves a process that consists of peaks and valleys

    Can be a positive outcome where they resume spontaneous breathingProcess of exubation: end of their life…until they expire and die D: Short term mech vent: weaning process if quicker and lot less failuresIntubated for quite some time (>3 days to 2 weeks): longer process

    Peaks and valeys: not successful. Vetillate for a few days before trying again. EDUCATE: “Trial or ERROR” process. Be successful  or not (we have to try at another time)
  51. Preweaning or assessment phase
    Determines patient’s ability to breathe spontaneously

    Assess muscle strength & endurance, minute ventilation, and rapid shallow breathing index

    Lungs should be clear on auscultation and chest x-ray

    Maximum inspiratory pressure- used to assess the patent’s respiratory muscle strength. Also know as Negative insp pressure and should be at least -20cm h20

    Tidal Volume + at least more than 3.5mL/kg.

    Minute ventilation – is equal to the respiratory rate multiplied by TV. Normal is 6L

    Vital Capacity= the amt of air expired after maximum inspiration. Measures ability to take deep breaths and should  be 10-15ml/kg to meat criteria

    Look at capability of breathing through their own. Look at mech vent process.

    You can go from Assist controlled to CPAP.. You don’t have to dial down to SIMV.

    -Assess muscle strength, volume of air they can breathe out on their own, measure volume when they’re breathing on they’re own SHOWS on the ventilator.

    • Look to see if they’re maintaining adequate enough volume
    • -lungs should be clear, normal cxr and clear sounds. -Neuro intact-Hemodynamically stable: ABG’s should be stable FOR THE CONDTION OF THE PT.

    -Meds should be titrated off: that will inhibit their ability to breath effectively on their own. 

    Assessment of neurologic status, hemodynamics, fluid and electrolytes/acid-base balance, nutrition, and hemoglobin

    Drugs should be titrated to achieve comfort but not excessive drowsiness
  52. Weaning readiness
    Guidelines recommend a spontaneous breathing trial (SBT)

    SBT should be at least 30 minutes but not >120 minutes

    May be done with CPAP, low levels of PS, or a “T” piece

    Tolerance of trial may lead to extubation

    Failure of trial requires search for reversible factors and return to nonfatiguing ventilator mode

    They might start off with a spontaneous breathing trial: take pt and put on CPAP.OR just turn off the ventilator itself and have oxygen that they’re breathing through circuit to see if they’re maintaining oxygen and hemodynamically stable

    • SBT: generally 30 mins but can be up to 2 hours.
    • -If pt isn’t fatiguing and everything is okay, sublevel hemodynamic stability. Not getting nervous wher they have to turn on the machine again
    • -each MD has their own guidelines
    • -some ICU will have standardized procedures for vent weaning process or extubation process. Nice b/c standard set of orders. So you don’t need a MD to be there durig that entire process. You’ll see that more in teaching institutions. Nurse is allowed to extubate the pt: trained to take out ET tube. Make sure it’s free of any secretions (Suction first : both tube and oral).

    • TO extubate pt: take out air in cuff: attach 10 cc syringe to pigtail, pull out air and balloon will flatten
    • Have pt breathe in and out
    • PULL ET OUT ON EXHALATION (If you pull out on inhalation and they aspirate: all that goes into their lungs)

    • Failed the weaning process:
    • Go to put the pt on vent: resume SAME settings (the settings you’ve stopped with).
    • Notify the physciians.
    • Educate family every step of way: they don’t understand the weaning process, breathing trials and that there may be failures.
  53. During weaning trial. Monitor for
    • Tachypnea
    • Tachycardia
    • Dysrhythmias
    • Sustained desaturation [SpO2 <91%]
    • Hypertension
    • Agitation or anxiety
    • Sustained T.V. <5 ml/kg
    • Changes in level of consciousness

    DURING WEANING TRIAL: look for cardiovasc and resp compromise: tachypnea, tachycardia, dysrhythmias

    -Change in O2 or stress in heart: PVC!!

    TV < 5 mL/kg. TIDAL VOLUME. Ventillation. Air going into lungs and change in LOC
  54. Weaning outcome phases
    • Weaning stops and patient is extubated
    • After extubation: Encourage deep breathing and coughingOral pharynx should be suctioned as needed

    Weaning is halted because no further progress is made

    Supplemental oxygen: mask or NC

    Maintain Resp integ: TCDB, IS (NURSING INTERVENTION. Not ordered)

    Halted if no further progress is made: the patient has failed

    Supplemental oxygen should be applied and naso-oral care provided Monitor vital signs, respiratory status, and oxygenation immediately following extubation, within 1 hour, and per institutional policy

    Listen to lungs within an hour to make sure nothing happened within that process. No asp. No pneumo. Follow up!
  55. ND's
    • Impaired gas exchange r/t …
    • Ineffective airway clearance r/t…
    • Impaired physical mobility r/t….
    • Impaired verbal communication r/t…
    • Defensive coping and powerlessness r/t…
    • Risk for trauma and infection r/t…

    Impaired gas exchange r/t underlying illness, ventilator setting adjustment during stabilization or weaning

    • Abnormal ABG’s, vent changes being made
    • Ineffective airway clearance r/t inc mucus production associated with prsence of the tube in trachea or continuous ppmv
  56. Ventilator Weaning: Phase 1 Preweaning
    • Assessment
    • ◦Muscle strength
    • –NIP (negative inspiratory pressure)–
    • PEP (positive expiratory pressure)

    • Endurance–
    • SVT   (spontaneous tidal volume)–
    • VC   (vital capacity)

    ◦Lungs - clear to auscultation & CxR

    ◦Neurological - alert◦Hemodynamics - stable

    ◦Fluids & electrolytes/acid-base balance

    ◦Nutrition - adequately nourished

    ◦Hemoglobin - normal
  57. Ventilator Weaning: Phase 1 Preweaning

    • ◦Carried out during the day
    • ◦Place on PSV
    • ◦Place on CPAP trials twice a day
    • ◦Position patient in high or semi-Fowler’s
    • ◦Allow respiratory muscles to rest in between weaning trials
    • ◦Obtain baseline VS & respiratory parameters
    • ◦Monitor for signs of intolerance–: Stop weaning due to no progression
  58. Ventilator Weaning: Phase 3 Weaning Outcome

    ◦Hyperoxygenate & suction before extubation

    ◦Instruct patient to deep breathe at peak inspiration, deflate cuff & remove ETT

    ◦Encourage patent to deep breathe and cough

    ◦Suction PRN

    ◦Apply supplemental O2

    ◦Monitor VS & respiratory status
  59. High Vs. Low Pressure Alarms
    • High-Pressure Alarm
    • Increased secretions are in the airway.
    • Wheezing or bronchospasm causes decreased airway size.
    • The endotracheal tube is displaced.
    • The ventilator tube is obstructed because of water or a kink in the tubing.
    • Client coughs, gags, or bites on the oral endotracheal tube.
    • Client is anxious or fights the ventilator.

    • Low-Pressure Alarm
    • Disconnection or leak in the ventilator or in the client’s airway cuff occurs.
    • The client stops spontaneous breathing.
Card Set
Airway Management and Mechanical Ventilation
Airway and Mech Vent