mechanical ventilation

5/20/2018 Mechanical Ventilation

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Mechanical Ventilatio


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Endotracheal (ET) intubation Placement of a tube into trachea via mouth or

past larynx

Most common type of short-term airway

Tracheostomy

Need for artificial airway >10-14 days

Reduce tracheal vocal cord damage

Artificial Airways


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Indications for intubationMaintain patent airway

Provide means to remove secretions

Provide ventilation and oxygen

Upper airway obstruction

ApneaHigh risk aspiration

Ineffective clearance of secretions

Respiratory distress

Artificial Airways


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Long, polyvinyl chloride tube

Passed via the mouth or nose into trachea with us______________________

Proper position: tip tube rests about ______________

Large-bore diameter used

In nasal ET intubation,

the ET is placed blindly (i.e., without seeing the larynx) tthe nose, nasopharynx, and vocal cords.

Endotracheal Tube


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Endotracheal Tube


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Nasal tube intubation

In nasal ET intubation,

the ET is placed blindly (i.e., without seeing the larynx) tthe nose, nasopharynx, and vocal cords.

Reserved: Facial or oral traumas and surgeries;

oral intubation is not possible Indicated when head and neck manipulation is

Contraindicated: facial fx, suspected fx at basepost-op cranial surgeries, blood clotting problem

Endotracheal Tube


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Bag valve mask (BVM) (AMBU BAG)

O2, suction equipment, IV access

Code cart, airway equipment box

During intubation:

Monitor for vs changes,signs hypoxia or hypoxemiadysrhythmias and aspiration

Intubation attempt should not last longer than 30 sepreferably less than 15 seconds

After 30 sec: oxygenate via Ambu to prevent hypocardiac arrest

Preparing for Intubation


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Preparing for Intubation.

Premedication Sedative-hypnotic amnesic

Lorazepam (Ativan); midazolam (Versed):

Agitated, disoriented or combative

Rapid sequence intubation (RSI) Both paralytic and sedative agent

Decrease risks of aspiration, combativeness, injury to pt

Not indicated for comatose or during cardiac arrest

Fentanyl (Sublimaze)

Succinylcholine (Anectine)

Atropine

Pulse oximetry


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Preparing for Intubation

Position:

SUPINEw/head EXTENDED& neck FLEXED (SNIFFINGPOSITION)


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Inflate cuff and confirm placement of ET tube while manually ventpatient with 100% O2

Most accurate way to verify placement:

End-tidal CO2 detector measures amount of exhaled CO2 from

Bite block, suction Et tube or pharynx

Upon confirmation

Tube position at the lip or teeth is recorded & marked

Portable CXR

Confirm location

Position: Adult: 2 cm above CARINA

Following Intubation


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Assess for B/L BS at bases & apices

Assess for symmetrical chest wall movement and aemerging from ET

ABSENT BS ON LEFT SIDE:

_______________________________

TUBE IN STOMACH:

________________________________

Following Intubation


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Stabilized at mouth or nose

Marked at level where it touches the incisor tooth

Use head halter technique for securing

Upon securing: verify and document level of tubepresence of BS and chest movement.

Stabilizing the Tube: 34-9
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Stabilizing the Tube


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Complications of ET or Nasotrachea

Intubation

TraumaFace, eyes, nasal and paranasal areas, o

pharyngeal, bronchial, tracheal and pulmareas

Risk for pneumothoraxUnplanned extubation

Aspiration


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Obtain ABG 25 minutes post

Continuous Pulse ox monitoringAssess tube placement, minimal cuff leak, breath

chest wall movement Prevent movement of tube by patientCheck pilot balloon Soft wrist restraints: LAST RESORTChemical sedationMeticulous oral careCommunication via various methods

Endotracheal Tubes: Nursing Car


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Maintaining tube patencyAssess patient routinely to determine need for

suctioning, but do not suction routinely

Indication for suctioning

Visible secretions in ET tube

Sudden onset of respiratory distress

in peak airway pressures

Auscultation of adventitious breath sounds otrachea and/or bronchi

secretions

Nursing Management.


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Maintaining tube patencyOpen-suction technique

Closed-suction technique (CST)

Enclosed in a plastic sleeve connected

directly to patient-ventilator circuitCST maintains oxygenation and ventila

and decreases exposure to secretions

Nursing Management


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Closed Tracheal Suction System

Fig. 66-19


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Mechanical Ventilatio


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Normal breathing is controlled by a negativpressure system--air is drawn into the lungs.

Mechanical ventilation is delivered by positipressure, forcing air into the lungs in one of tways:

1. Invasively via endotracheal (ET) tube or

tracheostomy

2. Noninvasively via mask: BIPAP, CPAP

Mechanical Ventilation


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Process by which fraction inspired oxyg(FIO2) at 21% (room air) is moved intoout of lungs by a mechanical ventilator



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Why would a patient need MV?:Apnea or impending inability to brea

Acute respiratory failure

Severe hypoxia

Respiratory muscle fatigue

Secretion/airway control failure

Mechanical Ventilation (Contd)


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Pulmonary edema

Pulmonary embol

Pneumonia

Multiple trauma

Shock

Multisystem failure

Coma

Thoracic/abdominalsurgery

Drug overdose

Neuromuscular disorders

Inhalation injury

Status asthmaticusChronic obstructive

pulmonary disease(COPD)

Why a patient may need mechanic

ventilation


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Continuous in PaO2 in PaCO2levels

Persistent ACIDOSIS(ph


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PaO2 < 60mmHg with FiO2 > 60%PaCO2 >50mmHg with ph


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Positive Pressure (most common)

Inflate the lungs by exerting positive pressure onairway, forcing alveoli to expand during inspirat

Widely used vents in hospitals

Requires an artificial airway: ETT or tracheostom

Classified by mechanism that ends inspiration aexpiration

Types of Ventilators


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Negative Pressure: i.e. Iron Lung, Body Wrap (PneuWrap) & Chest Cuirass (Tortoise Shell)

Exert a negative pressure on the external chest

Physiologically similar to spontaneous ventilatio

Used in chronic respiratory failure associated wi

neuromuscular conditions: Polio, MD, AML, MG

Types of Ventilators


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Ventilator Settings


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The variable methods by which the patienthe ventilator interact to deliver effectiveventilationThe ways in which the patient receives brefrom the ventilator include:Assist-control ventilation (AC)Synchronized intermittent mandatory ven

(SIMV)Bi-level positive airway pressure (BiPAP)Other modes of ventilationPEEP-Positive End Expiratory End PressureContinuous Positive Airway Pressure [CPAPressue Support [PS]

Modes of Ventilation


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Selected Vent mode is based on

How much Work of breathing (WOB) pt ougcan perform

Determined by pt ventilatory status, resp drivABGs

Controlled or assisted

Ventilator Modes


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With assist-control ventilation, the ventilator delive

preset VT at a preset frequency. When the patient a spontaneous breath, the preset VT is delivered

Advantage: allows the patient some control overventilation while providing some assistance

In a nutshell, Vet & patient share work of breathing

Disadvantage: spontaneous breathing rate increapreset Vt continue to be deliver w/each breath. Hyperventilation, respiratory alkalosis

Hypoventilation

Assist Control (AC)


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Require vigilant assessment and monitoring of venstatus, including respiratory rate, ABGs, SpO2, andSvO2/ScvO2.

It is also important that the sensitivity or amount ofnegative pressure required to initiate a breath isappropriate to the patient's condition.

For example, if it is too difficult for the patient to inbreath, the WOB is increased and the patient mayand/or develop ventilator asynchrony (i.e., the pafights the ventilator).

AC


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Breaths delivered at a set rate per minute and Vt

(independent of pts ventilatory effort)Used when pt has NO DRIVE to BREATHE or UNABL

BREATHE SPONTANEOUSLY

With controlled ventilatory support, the ventilator dof the WOB

Clinician sets the

Rate

Vt

Inspiratory time

PEEP

Volume Control (VC) (Control Ventilation, CV) Cont

Mandatory Ventilation (CMV)

S h i d I t itt t M d t


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Usually combined w/ Pressure support Ventilation

Vent delivers preset Vt at a preset frequency in synw/pts spontaneous breathing

Weaning parameter

# mechanical breaths is gradually decreased (

& pt gradually resumes spontaneous breathingMandatory ventilation is delivered when pt is re

inspire

Coordinates breathing b/w vent & pt.

Synchronized Intermittent Mandator

Ventilation (SIMV)


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Benefits

Improve pt-vent synchrony, lower mean airway pressureprevent muscle atrophy (as result pt taking on more WO

Disadvantages

Decrease in spontaneous breathing when preset rate isventilation might not be adequately supported.

Require close monitoring

May take longer because rate of breathing is gradually

Increased muscle fatigue associated w/spontaneous beffort

SIMV


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Positive pressure applied to airway only during insp

Used in conjunction w/pts spontaneous respiration

Provides an augmented inspiration to a spontaneobreathing patient

Used w/continuous ventilation & during weaning w

Advantages: Increased pt comfort

Decreased WOB

Decreased O2 consumption

Increased endurance conditioning

Pressure Support

Continuous positive airway pressure


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Similar to PEEP, CPAP restores FRC. This pressure is cont

during spontaneous breathing; no positive pressure brpresent.

The patient receiving SIMV with PEEP receives CPAP wbreathing spontaneously.

CPAP is commonly used in the treatment of obstructivapnea.

CPAP can be administered noninvasively by a tight-fitmask or an ET or tracheal tube.

CPAP increases WOB because the patient must forcibagainst the CPAP and so must be used with caution inwith myocardial compromise

Continuous positive airway pressure

breathing [CPAP]


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Positive End Expiratory Pressure (P

Positive pressure exerted during expiratory phase

ventilation Improves oxygenation by enhancing gas exchang

preventing atelectasis

Used to tx hypoxemia that does not improve w/an(ARDS)

Prevents alveoli from collapsing

Amt. PEEP: 5-15 cm H2O; read on peak airway predial

Titrated to the point that oxygenation improves w/compromising hemodynamics: Best or optimal PEE

Often added to other settings


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the major purpose of PEEP is to maintain or improv

oxygenation while limiting risk of O2 toxicity. FIO2 often be reduced when PEEP is used.

PEEP is indicated in lungs with diffuse disease, sevehypoxemia unresponsive to FIO2 greater than 50%loss of compliance or stiffness.

It is used in pulmonary edema to provide acounterpressure opposing fluid extravasation.

The classic indication for PEEP therapy is ARDS

PEEP


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Positive End Expiratory Pressure (PEEP

5 cm H2O PEEP (PHYSIOLOGIC PEEP)

Used prophylactically to replace the glottic mechanism

Help maintain/and or restore normal FRC (functional rescapacity)

Prevent alveolar collapse

Flow

How fast each breath is delivered; set at 40L/min


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Cardiovascular wise

BP, CO

Mean airway pressure increased w PEEP > 5 cm H

Pulmonary

Complications:

Barotrauma

Pneumothorax, subcutaneous emphysemapneumomediastinum

Negative Effects & Complications of


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Cardiovascular system

Intrathoracic pressure compresses thoracic

Venous return to heart, left ventricular ediastolic volume (preload), cardiac outp

Hypotension

Mean airway pressure is further if PEEP >5H2O

Complications of PPV


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Complications of PPV (contd)

Pulmonary system

Barotrauma leading to pneumothorax

Subcutaneous emphysema

Pneumomediastinum

VolumtraumaDamage to lungs by excess volume delive

one lung over the other

PP Mechanical Ventilation (Cont


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Volutrauma

Relates to lung injury that occurs when tidal volumes are used to ventilatenoncompliant lungs

Results in alveolar fractures and movemfluids and proteins into alveolar spaces

PP Mechanical Ventilation (Cont


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Hypoventilation

Causes

Inappropriate ventilator settings

Leakage of air from ventilator tubing

around ET tube or tracheostomy cuffLung secretions or obstruction

Low ventilation/perfusion ratio



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Hypoventilation (contd)

Interventions

Turn patient every 1 to 2 hours

Provide chest physical therapy to lung are

increased secretions Encourage deep breathing and coughing

Suction PRN


h i l il i (C d)


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Respiratory alkalosis

Respiratory rate or Vt is set too high(mechanical overventilation) or if pt recassisted ventilation is

Hyperventilation

Determine cause (e.g., hypoxemia, panxiety, or compensation for metaboacidosis) and treat


M h i l V til ti (C td)


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Fluid retention

Occurs after 48 to 72 hours of PPV, especiallywith PEEP

May be due to cardiac output

ResultsDiminished renal perfusion

Release of renin-angiotensin-aldosterone

Leads to sodium and water retention




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Neurologic system

In patients with head injury, PPV (especwith PEEP) can impair cerebral blood flo

Elevating HOB and keeping patients h

alignment may decrease effects of PPVintracranial pressure




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Gastrointestinal system

Risk for stress ulcers and GI bleeding

Risk of translocation of GI bacteria

Cardiac output may contribute to gut isc

Peptic ulcer prophylaxisHistamine (H2)-receptor blockers, proton p

inhibitors, tube feedings

Gastric acidity, risk of stressulcer/hemorrhage


M h i l V til ti


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Musculoskeletal system

Maintain muscle strength and preventproblems associated with immobility

Progressive ambulation of patients recelong-term PPV can be attained withoutinterruption of mechanical ventilation


V til t A i t d P i


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Pneumonia occurring 48 h or more post ET intubati

Sputum c/s: gram negative bacteria

Clinical evidence

Fever and/or elevated white blood cell co

Purulent or odorous sputum

Crackles or rhonchi on auscultation Pulmonary infiltrates on chest x-ray

Ventilator-Associated Pneumonia

G id li f VAP P ti


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Three care actions: VENTILATOR BUNDLE

HAND HYGIENEMETICULOUS ORAL CARE

HEAD OF BED ELEVATION

OTHER PREVENTATIVE MEASURES:

No routine changes of ventilator circuit tubing as pagency protocol (book: no more frequent than q

Continously removing subglottic secretions

Guidelines for VAP Prevention

Continuous Subglottal

S ti i


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Suctioning

Adjusting Ventilator


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Adjusted so that patient is comfortable & br

IN SYNC with machine

Monitoring Ventilator:

Type of vent

Mode/settings:

Alarms: ON AT ALL TIMES

PEEP/PS IF APPLICABLE: PEEP 5-15 CM H20

Adjusting Ventilator

Problems with Mechanical Ventil


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BUCKING THE VENT

FIGHT OR OUT OF SYNC WITH MACHINE

PATIENT ATTEMPTS TO BREATHE OUT DURING THE MECHANICAL INSPIRATORY PHASE OR WHEN THJERKY AND INCREASED ABDOMINAL MUSCLE EF

FACTORS:

Anxiety, hypoxia, increased secretions, hypeinadequate minute volume, pulmonary edem

Tx:

Muscle relaxants, tranquilizers, analgesics

paralyzing agents

Problems with Mechanical Ventil

Nursing Alert


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If ventilator system malfunctions/or disconne

and the problem cannot be identified andcorrected immediately, the nurse must ventthe patient with a manual resuscitation bag(Ambu-Bag) until the problem is resolved.

Nursing Alert

Nursing Alert


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ALARMS must be activated and functional a

times.Cause of an alarm cannot be identified or

determined, ventilate the pt manually until tproblem is corrected by respiratory therapy

See chart 34-4

Nursing Alert


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Monitoring your patient


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Keep emergency equipment at the bedside

Assess patient for level of consciousness (LOsigns, lung sounds regularly.

Monitor ET tube placement.

Perform suctioning as needed.

Monitor pulmonary secretions.

Assess patients ability to synchronize breathwith the ventilator.

Monitoring your patient

Once a shift(at least) checklist


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Check all ventilator settings/alarms.

Check tubing for kinks.

Check temperature/humidification.

Check ventilator circuit/change per facility policy

Check your patient for increased heart rate, men

change, respiratory rate, diaphoresis, or other signsymptoms of increased work of breathing.

Once a shift (at least) checklist

Weaning from Ventilator


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Respiratory weaning: process of withdrawing the patie

dependence on the ventilator Three stages:

Patient is gradually removed from the vent

Then removed from the tube

Final removal from 02

***Patient should be hemodynamically stable.

Absence of myocardial ischemia, clinically significhypotension (no vasopressor therapy or low dose)

Weaning from Ventilator

Prior to weaning


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Assess patients & familys understanding of

weaning process; address any concernsAssess patients mental status, SaO2, SpO2, P

pH, PaCO2, heart rate, blood pressure (BP),respirations.

Elevate head of bed 35-45 degrees.

Prior to weaning

Criteria for Weaning


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Adequate oxygenation:

PaO2/FiO2:>150-200 PEEP: 7.25

Tidal volume-7-9 mL/kg: index for weaning: >5 mL/kg

Minute ventilation- 60mmHg with FiO2 < 50%

Hemodynamically stable

Pt able to initiate inspiratory effort

Criteria for Weaning

Signs of weaning intolerance


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Respiratory rate >3

breaths/minute (orchanging 50% or m

SpO2180 mm Hg (orincrease of 20% or more) ordiastolic BP >100 mm Hg orhypotension

Heart rate >120beats/minute (or increase

of 20% or more)Dysrhythmias

Signs of weaning intolerance

Extubation


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1. Explain procedure to pt

2. Emergency intubation kit at bedside3. Hyperoxygenate pt

4. Suction ET and oral cavity or trach

5. Deflate tube cuff

6. Tell pt to take a deep breath

7. Rapidly remove tube at peak inspiration

8. Instruct pt to cough

9. O2 via face mask or nasal cannula

Extubation

Post Extubation


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Monitor vs q 5 min at first

Assess ventilatory pattern for s/s resp distressHoarseness & sore throat common

Teach pt to sit in semi-Fowlers, take deep breaths

Incentive spirometer use q 2h

Limit speaking after extubation.

Observe closely for resp fatigue and airway obstru STRIDOR: HIGH PITCH CROWING SOUND DURING INSPI

LARYNGOSPASM OR EDEMA ABOVE OR BELOW GLOTTIS:MANIFESTATION OF NARROWED AIRWAY.

Post Extubation

Nursing


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Explain purpose of ventilation to pt or family

Encourage family/pt to express concerns PT FIRST, VENT SECOND

Suction as needed-HYPEROXYGENATE PRIOR TO SU

MAIN NURSING PRIORITIES

Evaluating & monitoring pt responses

Managing vent system safely

Preventing complications

Nursing

Cricothyroidotomy


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Stab wound at the

cricothyroid cartilage ringb/w thyroid cartilage andcricoid cartilage ring

Trache tube can be placevia opening to keep airway

open until a tracheostomyis done

Cricothyroidotomy

http://www.youtube.com/watch?v=cQYJp6U_jVI
http://www.youtube.com/watch?v=cQYJp6U_jVIhttp://www.youtube.com/watch?v=cQYJp6U_jVI

mechanical ventilation

Documents

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nasal et intubation

placement of et tube

suction et tube

surgeries oral intubation

aspiration intubation

confirmation tube position

polyvinyl chloride tube