Chapter 66 1

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Case Study
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The health care provider orders

Airway Management STAT ABGs on B.A.
and Mechanical Ventilation The results are as follows: pH 7.28,
PaCO2 55 mm Hg, PaO2 60 mm Hg,
HCO3 25 mEq/L.
Chapter 66 How would you interpret these
ABGs?
Copyright 2014 by Mosby, an imprint of Elsevier Inc. Copyright 2014 by Mosby, an imprint of Elsevier Inc.
Case Study Artificial Airways

B.A., a 73-year-old female, arrives in Placement of a tube into the trachea

the ED in acute decompensated to bypass upper airway and
heart failure (ADHF). laryngeal structures
Her respiratory rate is 30 Endotracheal (ET) intubation
beats/minute and she is using all of Via mouth or nose past larynx
her accessory muscles to breathe. Tracheostomy
Via stoma in neck
Case Study
She has bilateral crackles to her lung

apices.
Her SpO2 is 85% on a nonrebreather

mask.
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Artificial Airways Artificial Airways
Indications Nasal ET intubation

Upper airway obstruction (e.g., tumor) ET tube placed blindly
Apnea Used when head and neck manipulation
High risk of aspiration is risky
Ineffective clearance of secretions Contraindicated with facial and basilar
Respiratory distress skull fractures
Also used after cranial surgery
Associated risks
Endotracheal Tube Case Study

The health care provider identifies

the need to immediately intubate
B.A. and place her on a mechanical
ventilator.
How would you prepare for this
procedure?
Artificial Airways ET Intubation Procedure
Oral ET intubation Preparation

Procedure of choice Consent
Airway can be secured rapidly Patient teaching
Larger-diameter tube can be used Equipment
Decreases work of breathing (WOB) Self-inflating bag-valve-mask (BVM)
Easier to remove secretions and perform attached to oxygen
bronchoscopy Suctioning equipment
Associated risks IV access
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ET Intubation Procedure Case Study

Rapid sequence intubation (RSI) How would you confirm proper

Rapid, concurrent administration of placement of the ET tube?
sedative and paralytic agents
Decreases risks of aspiration and injury
to patient What nursing interventions would
Not indicated for cardiac arrest or you plan to prevent complications
difficult airway associated with intubation?
Monitor oxygenation status
ET Intubation Procedure ET Intubation Procedure
Before intubation Inflate cuff and confirm placement

Sniffing position of ET tube
Preoxygenate using BVM with 100% End-tidal CO2 detector
O2 for 35 minutes Auscultate lungs bilaterally
Limit each intubation attempt to Auscultate epigastrium
<30 seconds Observe chest wall movement
Ventilate patient between successive Monitor SpO2
attempts using BVM with 100% O2
Case Study ET Intubation Procedure

The health care provider successfully Following proper ET tube placement

inserts an oral endotracheal tube Connect tube to O2 source
into B.A. Secure airway
Suction ET tube and pharynx
Insert bite block
Obtain chest x-ray
26 cm above carina
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Protocol for Securing ET Tube Nursing Management

with Adhesive Tape Artificial Airway
Incorrect tube placement is an
emergency
Stay with patient and maintain airway
Support ventilation
Secure help immediately
If necessary, ventilate with BVM and
100% O2
Nursing Management
ET Intubation Procedure
Artificial Airway
Following intubation Maintaining proper cuff inflation
Record and mark position of tube Serves to stabilize and seal ET tube
Cut off excess tubing within trachea
Obtain ABGs Excess volume tracheal damage
Continuously monitor pulse oximetry Cuff pressure 2025 cm H2O
and end-tidal CO2 Measure and record on routine basis
Minimal occluding volume (MOV)
technique
Minimal leak technique (MLT)
Nursing Management Nursing Management

Artificial Airway Artificial Airway
Maintaining correct tube placement MOV technique
Continuously monitor For mechanically ventilated patients:
Confirm exit mark on ET tube remains Place stethoscope over trachea
constant Inflate cuff to MOV by adding air until no air
Observe chest wall movement leak is heard at peak inspiratory pressure
Auscultate bilateral breath sounds For spontaneously breathing patients:
Inflate cuff until no sound is heard after a
deep breath or after inhalation with a BVM
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Minimal leak technique (MLT) Monitoring ventilation: assessment
Similar to MOV technique with one PaCO2
exception Continuous partial pressure of end-
Small amount of air is removed from tidal CO2 (PETCO2)
cuff until a slight leak is auscultated at Respiratory rate and rhythm
peak inflation Use of accessory muscles

Maintain cuff inflation Maintaining tube patency
Use manometer to verify cuff pressure Do not routinely suction patient
If cannot maintain pressure or need Assess for need
Visible secretions in ET tube
higher volumes cuff leaking or Sudden onset of respiratory distress
tracheal dilation reposition or Suspected aspiration of secretions
Peak airway pressures
change ET tube
Adventitious breath sounds
Respiratory rate and/or coughing
in PaO2 and/or SpO2

Monitoring oxygenation: assessment Maintaining tube patency
ABGs Open suction technique
SpO2 Closed-suction technique (CST)
SvO2/ScvO2 Enclosed in a plastic sleeve connected
Clinical signs of hypoxemia directly to patient-ventilator circuit
Change in mental status (e.g., confusion), Maintains oxygenation and ventilation
anxiety, dusky skin, dysrhythmias Decreases exposure to secretions
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Closed Tracheal Suction Nursing Management

System Artificial Airway
Prevent mucosal damage
Limit suction pressures to <120 mm Hg
Avoid overly vigorous catheter
insertion

Potential complications of Managing thick secretions
suctioning Adequate hydration
Hypoxemia, bronchospasm Supplemental humidification
Increased intracranial pressure No saline instillation
Dysrhythmias Antibiotics PRN
or BP Mobilization, etc.
Mucosal damage
Bleeding, pain, infection

Prevent hypoxemia and Oral care
Brush teeth BID
dysrhythmias during suctioning
Oral swabs with 1.5% hydrogen peroxide
Hyperoxygenate before and after
Chlorhexidine oral rinse
Limit each pass to < 10 seconds
Moisturizer
Monitor ECG and SpO2 before, during,
Oropharyngeal suctioning
and after suctioning
Reposition and retape ET tube every 24
hours
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Fostering comfort and Should an unplanned extubation
communication occur
Anxiety Stay with patient
Use variety of methods to Call for help
communicate Manually ventilate patient with 100%
Sedatives O2
Relaxation therapy Provide psychologic support

Complications of ET intubation Aspiration
Unplanned extubation Cannot protect airway with ET tube
Patient vocalization Inflate cuff
Activation of low-pressure alarm Continuous epiglottic suctioning
Diminished or absent breath sounds Salivation
Respiratory distress Suction oral cavity frequently
Gastric distention Prevent vomiting
Orogastric or NG tube and connect to
low, intermittent suction
Copyright 2014 by Mosby, an imprint of Elsevier Inc.
HOB 30 to 45 degrees
Nursing Management Continuous Subglottal

Artificial Airway Suctioning
Preventing unplanned extubation
Ensure adequate securement of ET tube
Support ET tube during repositioning
and procedures
Provide sedation and analgesia as
ordered
Use standardized weaning protocols
Use soft wrist restraints
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Mechanical Ventilation Negative Pressure Ventilator
Process by which fraction inspired

oxygen (FIO2) at 21% (room air) is
moved into and out of lungs by a
mechanical ventilator
Not curative
Mechanical Ventilation Case Study

Indications The health care provider orders B.A.

Apnea or impending inability to to be placed on a mechanical
breathe ventilator using positive pressure
Acute respiratory failure ventilation.
Severe hypoxia
How does this type of ventilation
Respiratory muscle fatigue
compare to normal breathing?
May be ethical decision to use or not
Mechanical Ventilation: Mechanical Ventilation:

Types Types
Negative pressure ventilation Positive pressure ventilation (PPV)
Encases chest or body Used primarily in acutely ill patients
Intermittent negative pressure pulls Delivers air into lungs under positive
chest outward air rushes in pressure during inspiration
passive expiration intrathoracic pressure during lung
Similar to normal ventilation inflation (opposite of normal)
Noninvasive ventilation that does not Expiration occurs passively
require an artificial airway
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Mechanical Ventilation:
Patient Receiving PPV
Settings
Regulate rate, depth, and other
characteristics of ventilation
Based on patients status
Tuned to match patients ventilatory
pattern
Case Study
Modes of PPV
Volume ventilation B.A. is placed on a mechanical

Predetermined tidal volume (VT) ventilator with the following
delivered with each inspiration settings:
Amount of pressure needed to deliver A/C mode
each breath varies VT 500 ml
Tidal volume same with each breath FIO2 50%
RR 18
PEEP 5 cm
Describe these settings.

Modes of PPV Settings
Pressure ventilation Respiratory rate
Predetermined peak inspiratory Tidal volume (VT)
pressure Fraction of inspired oxygen (FIO2)
VT varies Positive end-expiratory pressure
Careful attention needed to prevent
(PEEP)
hyper/hypoventilation
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Settings Modes
Pressure support Controlled ventilatory support
I:E ratio Ventilator does all the WOB
Inspiratory flow rate and time
Sensitivity Assisted ventilatory support
High-pressure limit Ventilator and patient share WOB
Mechanical Ventilation
Alarms
High-pressure limit Assist-control (A/C) ventilation
Low-pressure limit Delivers preset VT at preset frequency
High tidal volume, minute When patient initiates a spontaneous
breath, preset VT is delivered
ventilation, or respiratory rate Can breathe faster but not slower
Low tidal volume or minute Allows some control over ventilation
ventilation Risk for hypoventilation or
Ventilator inoperative or low battery hyperventilation
Continuous monitoring required
Modes
Based on how much work of Synchronized intermittent
breathing (WOB) patient should or mandatory ventilation (SIMV)
can perform Delivers preset VT at preset frequency
Determined by patients ventilatory in synchrony with patients
status, respiratory drive, and ABGs spontaneous breathing
Between ventilator-delivered breaths,
patient is able to breathe
spontaneously
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Pressure Modes
SIMV Pressure-controlled/inverse ratio
Patient receives preset FIO2 but self- ventilation (PC-IRV)
regulates rate and volume of Combines pressure-limited ventilation
spontaneous breaths with an inverse ratio of inspiration (I)
Potential benefits to expiration (E)
Improved patient-ventilator synchrony Normal I/E is 1:2
Lower mean airway pressure With IRV, I/E ratio begins at 1:1 and
Prevention of muscle atrophy
may progress to 4:1

Pressure Modes Pressure Modes
Pressure support ventilation (PSV) PC-IRV
Positive pressure applied to airway Progressively expands collapsed
only during inspiration in conjunction alveoli and has a PEEP-like effect
with spontaneous respirations Requires sedation with or without
Machine senses spontaneous effort paralysis
and supplies rapid flow of gas at For patients with ARDS and continuing
initiation of breath refractory hypoxemia despite high
Patient determines inspiratory length, levels of PEEP
VT, and respiratory rate

Pressure Modes Pressure Modes
PSV used for continuous ventilation Airway pressure release ventilation
and weaning (ARPV)
Advantages Permits spontaneous breathing
Patient comfort Preset CPAP with short timed pressure
WOB releases
Oxygen consumption VT varies
Endurance conditioning Patients with ARDS who need high
pressure levels
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PEEP PEEP
Positive end-expiratory pressure Auto-PEEP
(PEEP) Result of inadequate exhalation time
Positive pressure applied to airway Additional PEEP over what is set
during exhalation, preventing Results
WOB
alveolar collapse Barotrauma
Lung volume and functional residual Hemodynamic instability
capacity (FRC) improves oxygenation

PEEP PEEP
Maintain or improve oxygenation Interventions to limit auto-PEEP
while limiting risk of O2 toxicity Provide sedation and analgesia
Contraindications Use large-diameter ET tube
Patients with highly compliant lungs Administer bronchodilators
Unilateral or nonuniform disease Set short inspiratory times
Hypovolemia Respiratory rate
Low cardiac output Water accumulation in ventilator
tubing

PEEP CPAP
Optimal or best PEEP Continuous positive airway pressure
PEEP titrated to point oxygenation (CPAP)
improves without compromising Restores FRC
hemodynamics Similar to PEEP
Physiologic PEEP = 5 cm H2O Pressure delivered continuously
Replaces glottic mechanism, helps during spontaneous breathing
maintain normal FRC, and prevents
alveolar collapse
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CPAP Bi-PAP
Used to treat obstructive sleep Noninvasive
apnea Via tight-fitting face mask, nasal
Administered noninvasively by mask, or nasal pillows
mask, ET, or tracheal tube Patient must be able to breathe
WOB: use with caution in patients spontaneously and cooperate
with myocardial compromise Indications
Contraindications

ATC HFOV
Automatic tube compensation (ATC) High-frequency oscillatory
Used to overcome WOB associated ventilation
with artificial airway Delivery of a small VT at rapid
During inspiration and during respiratory rates
expiration Used for refractory hypoxemia and
Set by entering internal diameter of ARDS
patients airway and desired % of Must sedate and paralyze patient
compensation
Nitric Oxide (NO)
Bi-PAP
Bilevel positive airway pressure Continuous inhaled NO
Delivers oxygen and two levels of + pulmonary vasodilation
pressure support Given via ET tube, tracheostomy, or
Higher inspiratory positive airway face mask
pressure Treat ARDS
Lower expiratory positive airway Dx testing for pulmonary
pressure hypertension
Cardiac surgery
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Prone Positioning Complications of PPV
Positioning patient on stomach with Barotrauma

face down Air can escape into pleural space from
Improves lung recruitment alveoli or interstitium, accumulate,
Gravity reverses effects of fluid in and become trapped pneumothorax
dependent parts of lungs Patients with compliant lungs are at
Heart rests on sternum uniformity of risk
pleural pressures Chest tubes may be placed
Nurse-intensive therapy prophylactically
Extracorporeal Membrane
Complications of PPV
Oxygenation (ECMO)
Alternative form of pulmonary Pneumomediastinum
support Rupture of alveoli into lung
Partially remove blood from patient, interstitium
infuse O2, return blood back to Progressive air movement into
mediastinum and subcutaneous neck
patient
tissue
Intensive therapy Followed by pneumothorax
Complications of PPV Complications of PPV
Cardiovascular system Volutrauma

Mean airway pressure Lung injury that occurs when large VT
transmitted to thoracic cavity are used to ventilate noncompliant
vessels compressed decreased lungs
venous return to heart Alveolar fractures and movement of
Preload fluids and proteins into alveolar spaces
Cardiac output
Blood pressure
PEEP increases effect
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Alveolar hypoventilation Ventilator-associated pneumonia

Inappropriate ventilator settings (VAP)
Leakage of air from ventilator tubing Occurs 48 hours or more after intubation
or around ET tube or tracheostomy Risk factors
cuff Contaminated respiratory equipment
Lung secretions or obstruction Inadequate hand washing
Low ventilation/perfusion ratio Environmental factors
Impaired cough
Colonization of oropharynx
Alveolar hyperventilation Guidelines to prevent VAP

Rate or VT set too high HOB elevation
Patients with COPD at risk No routine changes of ventilator circuit
Alkalosis develops if decrease PaCO2 to tubing
standard normal Continuous subglottic suctioning
Determine cause if spontaneous Strict hand hygiene
hyperventilation Drain water from tubing
Case Study Complications of PPV

B.A. is admitted to the critical care Sodium and water imbalance

unit for monitoring and treatment of Progressive fluid retention
her heart failure. Urinary output
Sodium retention
What nursing interventions will you Etiology
plan to specifically prevent Decreased CO
ventilator-associated pneumonia Intrathoracic pressure changes
(VAP)? Stress response
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Neurologic system Musculoskeletal system

Impaired venous drainage and Loss of muscle strength and problems
cerebral volume increased ICP associated with immobility
Elevate HOB Interventions to prevent
Keep patients head in alignment Adequate analgesia and nutrition
Early and progressive ambulation
Physical and occupational therapy
Complications of PPV Psychosocial Needs
Gastrointestinal system Physical and emotional stress due to

Risk for stress ulcers and GI bleeding inability to speak, eat, move, or
Peptic ulcer prophylaxis breathe normally
Histamine (H2)-receptor blockers, proton
pump inhibitors
Pain, fear, and anxiety related to
Enteral nutrition tubes/machines
Ordinary ADLs are complicated or
impossible
Complications of PPV Psychosocial Needs
GI system Need to feel safe

Gastric and bowel dilation Need to know (information)
NG or orogastric tube for decompression Need to regain control
Peristalsis constipation Need to hope
Bowel regimen Need to trust
Encourage hope and build trust
Involve patients and caregivers in
decision making
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Placement of Electrodes Along

Psychosocial Needs
Ulnar Nerve
Agitation and anxiety
Assess cause
Provide sedation and/or analgesia
Assess for delirium
Always address patients as if they
are awake and alert
Psychosocial Needs Mechanical Ventilation
If necessary, induce paralysis to Machine disconnection

achieve more effective synchrony Most frequent site for disconnection is
with ventilator and increase between tracheal tube and adapter
oxygenation ALWAYS keep ALARMS ON
If alarms are paused during suctioning or
Paralyzed patient can hear, see, removal from ventilator reactivate
think, feel before leaving
Sedation and analgesia must always
be administered concurrently
Psychosocial Needs Mechanical Ventilation
Assessment of paralyzed patient Ventilator malfunction

Train-of-four (TOF) peripheral nerve Malfunction may be due to power
stimulation failure, failure of oxygen supply, etc.
Physiologic signs of pain or anxiety If machine malfunctions
Ventilator synchrony Disconnect patient from ventilator
Avoid excessive paralysis Manually ventilate with 100% O2
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Nutritional Therapy Case Study

PPV and hypermetabolism B.A. responds well to medical

inadequate nutrition treatment of her heart failure.
Difficulty with oral intake She is ready to be weaned from the
ET tube ventilator.
Tracheostomy What will you assess before
Consult speech therapist for beginning the weaning process?
swallowing study
Nutritional Therapy
Weaning and Extubation
Nutritional assessment within 2448 Process of:
hours Decreasing ventilator support
Inadequate nutrition can: Resuming spontaneous ventilation
O2 transport Process differs for short-term versus
Exercise tolerance long-term ventilated patients
Serum protein Team approach
Weaning Three phases
Resistance to infection
Speed of recovery Copyright 2014 by Mosby, an imprint of Elsevier Inc.
Nutritional Therapy
Phases of Weaning
Enteral gastric or small bowel Preweaning or assessment phase
feeding preferred Assess muscle strength
Verify tube placement Negative inspiratory force
X-ray Assess endurance
Spontaneous VT, vital capacity, minute
Exit site ventilation, and rapid shallow breathing
Aspirate index
Limit CHO content lower to CO2 Auscultate lungs
production Assess chest x-ray
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Phases of Weaning Phases of Weaning
Preweaning or assessment phase Weaning process
Nonrespiratory factors Extubate if patient tolerates SBT
Assessment of neurologic status, Return to ventilator if patient fails SBT
hemodynamics, fluid and Use weaning protocol
electrolytes/acid-base balance, nutrition, Important to rest between
and hemoglobin weaning trials
Drugs should be titrated to achieve
Provide explanations regarding
comfort but not excessive drowsiness
weaning and ongoing psychological
support
Case Study
Phases of Weaning
What is the most common method Weaning process

for weaning a patient who has been Comfortable position
on the ventilator for <3 days? Sitting or semirecumbent
Obtain baseline assessment
Vital signs
Explain the process. Respiratory parameters

Phases of Weaning Phases of Weaning
Weaning process Weaning process
Guidelines recommend a spontaneous Monitor for signs of intolerance
breathing trial (SBT) Tachypnea, dyspnea
SBT should be at least 30 minutes but Tachycardia, dysrhythmias
not >120 minutes Sustained desaturation [SpO2 <91%]
Hypertension or hypotension
May be done with CPAP, low levels of Agitation or anxiety
PSV, or a T piece Diaphoresis
Sustained VT<5 ml/kg
Changes in mentation
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Audience Response Question

Mechanical Ventilation: The ventilator settings for a patient on a volume ventilator
Phases of Weaning include a synchronized intermittent mandatory ventilation
(SIMV) mode with 5 cm H2O PEEP. After 3 hours of
Weaning outcome ventilation, the patients PaO2 has dropped from 82 mm Hg
to 74 mm Hg. The most accurate interpretation of this finding
Weaning stops and patient is by the nurse is that:
extubated a.The patients respiratory rate may be decreasing, lowering
the oxygen content of the blood.
b.The ventilator is creating high intrathoracic pressure,
--OR-- suppressing venous return and cardiac output.
c.The tidal volume provided by the ventilator is too high,
Weaning is stopped because no further increasing the amount of CO2 being exhaled.
d.The pressure applied by PEEP requires an increased fraction
progress is made of inspired oxygen (FIO2) to maintain oxygenation.
Case Study
B.A. tolerates the SBT trial and is

ready to be extubated.
Explain how you would extubate
B.A.
What will be your priority
assessment of B.A. postextubation?
Extubation
Hyperoxygenate
Suction
Deflate cuff and remove tube at
peak of deep inspiration
Encourage patient to deep breath
and cough
Supplemental O2
Careful monitoring postextubation
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12/14/2016

The health care provider orders

Case Study Artificial Airways

B.A., a 73-year-old female, arrives in Placement of a tube into the trachea

She has bilateral crackles to her lung

Her SpO2 is 85% on a nonrebreather

Artificial Airways Artificial Airways

Indications Nasal ET intubation

Endotracheal Tube Case Study

The health care provider identifies

Artificial Airways ET Intubation Procedure

Oral ET intubation Preparation

ET Intubation Procedure Case Study

Rapid sequence intubation (RSI) How would you confirm proper

ET Intubation Procedure ET Intubation Procedure

Before intubation Inflate cuff and confirm placement

Case Study ET Intubation Procedure

The health care provider successfully Following proper ET tube placement

Protocol for Securing ET Tube Nursing Management

Nursing Management Nursing Management

Nursing Management Nursing Management

Nursing Management Nursing Management

Nursing Management Nursing Management

Closed Tracheal Suction Nursing Management

Nursing Management Nursing Management

Nursing Management Nursing Management

Nursing Management Nursing Management

Nursing Management Nursing Management

Nursing Management Continuous Subglottal

Mechanical Ventilation Negative Pressure Ventilator

Process by which fraction inspired

Mechanical Ventilation Case Study

Indications The health care provider orders B.A.

Mechanical Ventilation: Mechanical Ventilation:

Volume ventilation B.A. is placed on a mechanical

Mechanical Ventilation: Mechanical Ventilation:

Mechanical Ventilation: Mechanical Ventilation:

Mechanical Ventilation: Mechanical Ventilation:

Mechanical Ventilation: Mechanical Ventilation:

Mechanical Ventilation: Mechanical Ventilation:

Mechanical Ventilation: Mechanical Ventilation:

Mechanical Ventilation: Mechanical Ventilation:

Mechanical Ventilation: Mechanical Ventilation:

Mechanical Ventilation: Mechanical Ventilation:

Prone Positioning Complications of PPV

Positioning patient on stomach with Barotrauma

Complications of PPV Complications of PPV

Cardiovascular system Volutrauma

Complications of PPV Complications of PPV

Alveolar hypoventilation Ventilator-associated pneumonia

Complications of PPV Complications of PPV

Alveolar hyperventilation Guidelines to prevent VAP

Case Study Complications of PPV

B.A. is admitted to the critical care Sodium and water imbalance

Complications of PPV Complications of PPV

Neurologic system Musculoskeletal system

Complications of PPV Psychosocial Needs

Gastrointestinal system Physical and emotional stress due to

Complications of PPV Psychosocial Needs

GI system Need to feel safe

Placement of Electrodes Along

Psychosocial Needs Mechanical Ventilation

If necessary, induce paralysis to Machine disconnection

Psychosocial Needs Mechanical Ventilation