Airway and Airway and Ventilation Ventilation

ManagementManagement

Learning outcomes□List indications for intubation and

mechanical ventilation□Differentiate between modes of ventilation

and advantages and disadvantages of each□List complications of mechanical

ventilation□Describe nursing assessment and care of

ventilated patient □Discuss methods used for weaning

patients

Indications for intubation

1. Elective: for general anesthesia2. Urgent:

A. Relive upper airway obstructionB. Isolate/protect airwayC. For suctioning of tracheobronchial

treeD. For assisted ventilation

Routes for intubation

□Endotracheal□Nasotracheal□Tracheal

1.Tracheostomy-elective2.Cricoidotomy-urgent

Role of nurse in endothacheal intubation

1. Manage Airway

Obstructed Head tilt/chin lift

Jaw thrust

Role of nurse in endothacheal intubation

2. Ventilation : bag valve mask device with self inflating bag

3. Oxygenation with 100% oxygen

Role of nurse in endothacheal intubation

4. Removal of obstructing foreign material using suction & Yankauer

Role of nurse in endothacheal intubation

5. Insert nasal or oral pharyngeal airway if necessary (oral airway used only in unconscious patient because it can stimulates gagging, vomiting, laryngospasm if patient conscious)

Guedel oral airway Nasal airway

Role of nurse in endothacheal intubation

6. Prepare equipment:A. Face mask and oxygen supplyB. AirwayC. Suctioning equipmentD. LaryngoscopeE. LubricantF. Malleable wire guide or

introducerG. Magill forcepsH. End tidal CO2 detector

Role of nurse in endothacheal intubation

7. Assist with procedure:A. Ventilate and oxygenate (allow15-

30 seconds for intubation)B. Monitor vital signsC. Suction when necessaryD. Provide cricoid pressure if

requested (press below Adams apple, will push trachea back and collapse esophagus making intubation easier)

Role of nurse in endothacheal intubation

7. Auscultate over lung and air fields8. Inflate cuff of ET or NT tube

A. Ensure cuff pressure does not exceed 20mmHg—it can cause tissue death and fistula formation if higher

B. If lower than 15mmHg increased risk of aspiration.

9. Secure ET tube10.Follow up Chest X ray

A. ET tube at front teeth between 19-23cm in adult

B. On X ray should be 2cm above carina

Position of ET tube

Endotracheal tube position

Indications for Mechanical Ventilation

A. Inability to maintain adequate ventilation (ability to remove CO2)

- PaCO2 > 55mmHg and pH < 7.25 criterion for mechanical ventilation

B. Inability to maintain adequate oxygenation (hypoxemia)

- Patient may have normal PaCO2 and low PaPO2

- O2 supplement may help- PaO2 < 50mmHg on FiO2 > 0.5 criterion

for mechanical ventilationC. Work of breathing greater than

patient can maintain

Types of ventilation1. Non-invasive positive pressure

ventilation – NIPSV

2. Mechanical ventilation

Ventilators

Ventilator tubing set up

Ventilatory modes□CMV—controlled mechanical

ventilation

Disadvantages of CMV

IMV & SIMV□Mandatory breath at preset VT

and rate□Patient can breath above rate

without assistance from ventilator

□Difference between IMV an SIMV…

IMV & SIMV

Advantages & disadvantages of SIMV

Pressure support ventilation-PSV

□A pressure assisted mechanical ventilation helping patient with his own efforts

□Instead of selecting VT we select positive airway pressure

□May use for weaning or with SIMV

Advantage & disadvantages of PSV

Pressure controlled ventilation- PCV

□Mechanical inhalation phase is pressure limited to prevent trauma to lungs

□Can have longer inspiration than expiration (I : E ratio up to 4:1)

Advantages and disadvantages of PCV

Positive end expiratory pressure PEEP

□Airway pressure maintained in lungs after end of exhalation

□Keeps alveoli open increasing area of gas exchange

□May reduce cardiac output, increase cerebral pressure, risk of pneumothorax incresed

Continuous Positive Airway Pressure—CPAP

□Patient breathes independently through ventilator circuit, or with CPAP mask

□No VT is present□Only FIO2 and gas pressure at end-

exhalation are controlled□Term CPAP used when the patient

breathing spontaneously□Used most often with patients requiring

intubation but not ventilatory support□May also be used as last stage of

weaning in select patients□CPAP and non-invasive positive airway

pressure masks used for sleep apnea Rx

Complications of mechanical ventilation

1. Complications from ET/NT tube□Lip, tongue, nasal, pharyngeal,

tracheal or laryngeal pressure ulcers

□Mucous plugs impairing ventilation□Obstruction by biting tube□Sinusitis and otitis with NT tube□Tracheal-esophageal fistula□Infection

Complications of mechanical ventilation

2. Complications from ventilator□ Auto-PEEP – unintended air trapping can

cause hypotension, reduce cardiac output-- mostly seen in patients with asthma, obstructive lung disease

□ Hemodynamic instability from positive pressure ventilation

□ ADH secretion positive H2O balance□ Infection□ GI bleeding due to stress ulcer□ Barotrauma□ Oxygen toxicity—when on settings

greater than 0.5-0.6 FiO2 in adults for long time

How to determine ventilator settings

□Tidal volume (VT) 8-12 ml/kg adults□Respiratory rate □RR X VT = VE (minute volume)--the

higher the VE the lower the PaCO2□FiO2 set to maintain and SaO2 >

90%□PEEP 5-15 cmH2O (useful in

pnenumonia and ARDS)

Nursing Management1. Observe for S&S of inadequate

ventilation□ Rising PaCO2/falling PaO2□ Shallow respirations□ Irregular respirations/chest-abdominal

dyssynchrony□ Dyspnea, tachypnea, bradypnea, apnea□ Headache, restlessness, confusion, lethargy□ Rising BP (early sign), or falling BP (late sign) □ Tachycardia, arrhythmeas□ Cyanosis□ Agitation, anxiety

Normal ABGs

□pH 7.4 +/- 0.05 pH □PaO2 90 +/- 10 Oxygenation □PaCO2 40 +/- 5 

Respiratory Mechanism □HCO3 24 +/- 2  Metabolic Mechanism □SaO2 97 +/- 3 Oxygenation

Nursing Management2. Observe for

pneumothorax/tension pneumothorax

□ Increased anxiety□ Dyspnea, Tachycardia, Hypotension□ Unequal breath sounds□ Sudden CVS collapse

3. Guard against dislodgment of ET tube

Nursing Management4. Help patient to cope• Remove airway secretions by

suctioning when:i. Audible airway noiseii. Coughingiii. Respiratory distressiv. Assess and improve airway patency

• Allow for different method of communication

• Remove accumulated water in tubing• Comforting measures/sedation

Suction technique□ Sterile technique□ Catheter Size□ Suction pressure –not lower than -120cmH2O for

adults and -60-80 pediatric□ Preoxygenation (100%), hyperventilation□ Don’t suction when inserting catheter□ Suction time no longer than 15 seconds□ Hyperoxygenate and hyperventilate between

suction passes□ Saline should not be used—infection and reduce

O2 saturation□ Use closed ET suction system with

preoxygenation

Nursing management5. Troubleshoot ventilator□ Check against incorrect ventilator

settings□ Ventilator disconnect is common□ High pressure alarm may be due to:

□ Suction needed□ Biting tube□ Displaced tube□ Compliance decreased□ Barotrauma

□ If problem not found disconnect patient and manually ventilate with 100% O2 until problem corrected

Nutrition very importantMalnourishment will cause:

Weaning from ventilator□Adequate PaO2, pH and PaCO2□FIO2 is .4 to .5□Very low or no PEEP□Reasonable respiratory rate

Prepare patient for weaning

Weaning techniques

□T-tube

□SIMV

□PSV

Nursing Responsibilities in Weaning

Weaning Failure□When two or more:

□BP deviation of 20mmHG or more□Alteration in heart rate of 20bpm or

more□Cardiac dysrhythmeas deviating

from patient’s baseline□Change in level of consciousness

□Or when RR greater than 35 bpm

Learning outcomes□List indications for intubation and

mechanical ventilation□Differentiate between modes of ventilation

and advantages and disadvantages of each□List complications of mechanical

ventilation□Describe nursing assessment and care of

ventilated patient □Discuss methods used for weaning

patients