Placement of a tube into trachea via mouth or nose past larynx Most common type of short-term airway Tracheostomy Need for artificial airway >10-14 days Reduce tracheal vocal cord damage Artificial Airways Indications for intubation Maintain patent airway Provide means to remove secretions Provide ventilation and oxygen Upper airway obstruction Apnea High risk aspiration Ineffective clearance of secretions Respiratory distress
Artificial Airways Long, polyvinyl chloride tube Passed via the mouth or nose into trachea with use of a ______________________ 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) through the nose, nasopharynx, and vocal cords. Endotracheal Tube
Endotracheal Tube Nasal tube intubation In nasal ET intubation, the ET is placed blindly (i.e., without seeing the larynx) through the nose, nasopharynx, and vocal cords. Reserved: Facial or oral traumas and surgeries; or when oral intubation is not possible Indicated when head and neck manipulation is risky Contraindicated: facial fx, suspected fx at base of skull, post-op cranial surgeries, blood clotting problem
Endotracheal Tube 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 hypoxemia, dysrhythmias and aspiration Intubation attempt should not last longer than 30 seconds, preferably less than 15 seconds After 30 sec: oxygenate via Ambu to prevent hypoxia and cardiac arrest
Preparing for Intubation 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
Inflate cuff and confirm placement of ET tube while manually ventilating patient with 100% O2 Most accurate way to verify placement: End-tidal CO2 detector measures amount of exhaled CO2 from lungs 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 Assess for B/L BS at bases & apices Assess for symmetrical chest wall movement and air emerging from ET ABSENT BS ON LEFT SIDE: _______________________________ TUBE IN STOMACH: ________________________________
Following Intubation Stabilized at mouth or nose Marked at level where it touches the incisor tooth or naris Use head halter technique for securing Upon securing: verify and document level of tube, presence of BS and chest movement.
Stabilizing the Tube: 34-9 Stabilizing the Tube Complications of ET or Nasotracheal Intubation Trauma Face, eyes, nasal and paranasal areas, oral pharyngeal, bronchial, tracheal and pulmonary areas Risk for pneumothorax Unplanned extubation Aspiration Obtain ABG 25 minutes post Continuous Pulse ox monitoring Assess tube placement, minimal cuff leak, breath sounds, chest wall movement Prevent movement of tube by patient Check pilot balloon Soft wrist restraints: LAST RESORT Chemical sedation Meticulous oral care Communication via various methods
Endotracheal Tubes: Nursing Care Maintaining tube patency Assess 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 over trachea and/or bronchi secretions Nursing Management. Maintaining tube patency Open-suction technique Closed-suction technique (CST) Enclosed in a plastic sleeve connected directly to patient-ventilator circuit CST maintains oxygenation and ventilation and decreases exposure to secretions Nursing Management
Closed Tracheal Suction System Fig. 66-19 Mechanical Ventilation Normal breathing is controlled by a negative pressure system--air is drawn into the lungs. Mechanical ventilation is delivered by positive pressure, forcing air into the lungs in one of two ways: 1. Invasively via endotracheal (ET) tube or tracheostomy 2. Noninvasively via mask: BIPAP, CPAP
Mechanical Ventilation Process by which fraction inspired oxygen (FIO2) at 21% (room air) is moved into and out of lungs by a mechanical ventilator
Mechanical Ventilation Why would a patient need MV?: Apnea or impending inability to breathe Acute respiratory failure Severe hypoxia Respiratory muscle fatigue Secretion/airway control failure Mechanical Ventilation (Contd) Pulmonary edema Pulmonary embolism Pneumonia Multiple trauma Shock Multisystem failure Coma Thoracic/abdominal surgery Drug overdose Neuromuscular disorders Inhalation injury Status asthmaticus Chronic obstructive pulmonary disease (COPD) Why a patient may need mechanical ventilation 24 Continuous in PaO2 in PaCO2 levels Persistent ACIDOSIS (ph<7.25)
MECHANICAL VENTILATION MAY BE NECESSARY Parameters or Indication for MV 25 PaO2 < 60mmHg with FiO2 > 60% PaCO2 >50mmHg with ph <7.35 Negative inspiratory force <(-) 25cm H2O RR >35 breaths/minute Criteria for Mechanical Ventilation 26 Positive Pressure (most common) Inflate the lungs by exerting positive pressure on the airway, forcing alveoli to expand during inspiration Widely used vents in hospitals Requires an artificial airway: ETT or tracheostomy Classified by mechanism that ends inspiration and starts expiration Types of Ventilators 27
Negative Pressure: i.e. Iron Lung, Body Wrap (Pneumo- Wrap) & Chest Cuirass (Tortoise Shell) Exert a negative pressure on the external chest Physiologically similar to spontaneous ventilation Used in chronic respiratory failure associated with neuromuscular conditions: Polio, MD, AML, MG Types of Ventilators 29 30
Ventilator Settings The variable methods by which the patient and the ventilator interact to deliver effective ventilation The ways in which the patient receives breath from the ventilator include: Assist-control ventilation (AC) Synchronized intermittent mandatory ventilation (SIMV) Bi-level positive airway pressure (BiPAP) Other modes of ventilation PEEP-Positive End Expiratory End Pressure Continuous Positive Airway Pressure [CPAP] Pressue Support [PS] Modes of Ventilation Selected Vent mode is based on How much Work of breathing (WOB) pt ought to or can perform Determined by pt ventilatory status, resp drive and ABGs Controlled or assisted Ventilator Modes With assist-control ventilation, the ventilator delivers a preset VT at a preset frequency. When the patient initiates a spontaneous breath, the preset VT is delivered Advantage: allows the patient some control over ventilation while providing some assistance In a nutshell, Vet & patient share work of breathing Disadvantage: spontaneous breathing rate increases, preset Vt continue to be deliver w/each breath. Hyperventilation, respiratory alkalosis Hypoventilation Assist Control (AC) Require vigilant assessment and monitoring of ventilatory status, including respiratory rate, ABGs, SpO2, and SvO2/ScvO2. It is also important that the sensitivity or amount of negative pressure required to initiate a breath is appropriate to the patient's condition. For example, if it is too difficult for the patient to initiate a breath, the WOB is increased and the patient may tire and/or develop ventilator asynchrony (i.e., the patient fights the ventilator). AC Breaths delivered at a set rate per minute and Vt (independent of pts ventilatory effort) Used when pt has NO DRIVE to BREATHE or UNABLE to BREATHE SPONTANEOUSLY With controlled ventilatory support, the ventilator does all of the WOB Clinician sets the Rate Vt Inspiratory time PEEP Volume Control (VC) (Control Ventilation, CV) Controlled Mandatory Ventilation (CMV) Usually combined w/ Pressure support Ventilation (PSV) Vent delivers preset Vt at a preset frequency in synchrony w/pts spontaneous breathing Weaning parameter # mechanical breaths is gradually decreased (i.e. 12-2) & pt gradually resumes spontaneous breathing Mandatory ventilation is delivered when pt is ready to inspire Coordinates breathing b/w vent & pt.
Synchronized Intermittent Mandatory Ventilation (SIMV) Benefits Improve pt-vent synchrony, lower mean airway pressure & prevent muscle atrophy (as result pt taking on more WOB) Disadvantages Decrease in spontaneous breathing when preset rate is low, ventilation might not be adequately supported. Require close monitoring May take longer because rate of breathing is gradually reduced Increased muscle fatigue associated w/spontaneous breathing effort SIMV Positive pressure applied to airway only during inspiration Used in conjunction w/pts spontaneous respirations Provides an augmented inspiration to a spontaneously breathing patient Used w/continuous ventilation & during weaning w/SIMV Advantages: Increased pt comfort Decreased WOB Decreased O2 consumption Increased endurance conditioning
Pressure Support Similar to PEEP, CPAP restores FRC. This pressure is continuous during spontaneous breathing; no positive pressure breaths are present. The patient receiving SIMV with PEEP receives CPAP when breathing spontaneously. CPAP is commonly used in the treatment of obstructive sleep apnea. CPAP can be administered noninvasively by a tight-fitting mask or an ET or tracheal tube. CPAP increases WOB because the patient must forcibly exhale against the CPAP and so must be used with caution in patients with myocardial compromise Continuous positive airway pressure breathing [CPAP] Positive End Expiratory Pressure (PEEP) Positive pressure exerted during expiratory phase of ventilation Improves oxygenation by enhancing gas exchange & preventing atelectasis Used to tx hypoxemia that does not improve w/an O2 (ARDS) Prevents alveoli from collapsing Amt. PEEP: 5-15 cm H2O; read on peak airway pressure dial Titrated to the point that oxygenation improves w/out compromising hemodynamics: Best or optimal PEEP Often added to other settings
the major purpose of PEEP is to maintain or improve oxygenation while limiting risk of O2 toxicity. FIO2 can often be reduced when PEEP is used. PEEP is indicated in lungs with diffuse disease, severe hypoxemia unresponsive to FIO2 greater than 50%, and loss of compliance or stiffness. It is used in pulmonary edema to provide a counterpressure opposing fluid extravasation. The classic indication for PEEP therapy is ARDS PEEP 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 residue capacity) Prevent alveolar collapse
Flow How fast each breath is delivered; set at 40L/min
Cardiovascular wise BP, CO Mean airway pressure increased w PEEP > 5 cm H20. Pulmonary Complications: Barotrauma Pneumothorax, subcutaneous emphysema and pneumomediastinum Negative Effects & Complications of PEEP Cardiovascular system Intrathoracic pressure compresses thoracic vessels Venous return to heart, left ventricular end- diastolic volume (preload), cardiac output Hypotension Mean airway pressure is further if PEEP >5 cm H2O Complications of PPV Complications of PPV (contd) Pulmonary system Barotrauma leading to pneumothorax Subcutaneous emphysema Pneumomediastinum Volumtrauma Damage to lungs by excess volume delivered to one lung over the other PP Mechanical Ventilation (Contd) Complications of PPV (contd) Volutrauma Relates to lung injury that occurs when large tidal volumes are used to ventilate noncompliant lungs Results in alveolar fractures and movement of fluids and proteins into alveolar spaces PP Mechanical Ventilation (Contd) Complications of PPV (contd) Hypoventilation Causes Inappropriate ventilator settings Leakage of air from ventilator tubing or around ET tube or tracheostomy cuff Lung secretions or obstruction Low ventilation/perfusion ratio Mechanical Ventilation (Contd) Complications of PPV (contd) Hypoventilation (contd) Interventions Turn patient every 1 to 2 hours Provide chest physical therapy to lung areas with increased secretions Encourage deep breathing and coughing Suction PRN Mechanical Ventilation (Contd) Complications of PPV (contd) Respiratory alkalosis Respiratory rate or Vt is set too high (mechanical overventilation) or if pt receiving assisted ventilation is Hyperventilation Determine cause (e.g., hypoxemia, pain, anxiety, or compensation for metabolic acidosis) and treat Mechanical Ventilation (Contd) Complications of PPV (contd) Fluid retention Occurs after 48 to 72 hours of PPV, especially PPV with PEEP May be due to cardiac output Results Diminished renal perfusion Release of renin-angiotensin-aldosterone Leads to sodium and water retention Mechanical Ventilation (Contd) Complications of PPV (contd) Neurologic system In patients with head injury, PPV (especially with PEEP) can impair cerebral blood flow Elevating HOB and keeping patients head in alignment may decrease effects of PPV on intracranial pressure Mechanical Ventilation (Contd) Complications of PPV (contd) Gastrointestinal system 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 Mechanical Ventilation (Contd) Complications of PPV (contd) 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 Mechanical Ventilation Pneumonia occurring 48 h or more post ET intubation Sputum c/s: gram negative bacteria Clinical evidence Fever and/or elevated white blood cell count Purulent or odorous sputum Crackles or rhonchi on auscultation Pulmonary infiltrates on chest x-ray
Ventilator-Associated Pneumonia Three care actions: VENTILATOR BUNDLE HAND HYGIENE METICULOUS ORAL CARE HEAD OF BED ELEVATION
OTHER PREVENTATIVE MEASURES: No routine changes of ventilator circuit tubing as per agency protocol (book: no more frequent than q 48 h) Continously removing subglottic secretions Guidelines for VAP Prevention Continuous Subglottal Suctioning Adjusted so that patient is comfortable & breathes 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 58 BUCKING THE VENT FIGHT OR OUT OF SYNC WITH MACHINE PATIENT ATTEMPTS TO BREATHE OUT DURING THE VENTS MECHANICAL INSPIRATORY PHASE OR WHEN THERE IS JERKY AND INCREASED ABDOMINAL MUSCLE EFFORT FACTORS: Anxiety, hypoxia, increased secretions, hypercapnia, inadequate minute volume, pulmonary edema Tx: Muscle relaxants, tranquilizers, analgesics paralyzing agents Purpose: increase patient-machine synchrony Problems with Mechanical Ventilation 59 If ventilator system malfunctions/or disconnected and the problem cannot be identified and corrected immediately, the nurse must ventilate the patient with a manual resuscitation bag (Ambu-Bag) until the problem is resolved. Nursing Alert 60 ALARMS must be activated and functional at all times. Cause of an alarm cannot be identified or determined, ventilate the pt manually until the problem is corrected by respiratory therapy.
See chart 34-4 Nursing Alert
Keep emergency equipment at the bedside. Assess patient for level of consciousness (LOC), vital signs, lung sounds regularly. Monitor ET tube placement. Perform suctioning as needed. Monitor pulmonary secretions. Assess patients ability to synchronize breathing with the ventilator. Monitoring your patient 63 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, mental status change, respiratory rate, diaphoresis, or other signs and symptoms of increased work of breathing. Once a shift(at least) checklist 64 Respiratory weaning: process of withdrawing the patient from 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 significant hypotension (no vasopressor therapy or low dose) Weaning from Ventilator 65 Assess patients & familys understanding of weaning process; address any concerns Assess patients mental status, SaO 2 , SpO 2 , PaO 2 , pH, PaCO 2 , heart rate, blood pressure (BP), respirations. Elevate head of bed 35-45 degrees. Prior to weaning 66 Adequate oxygenation: PaO2/FiO2:>150-200 PEEP: <5-8 cm H2O Ph: > 7.25 Tidal volume-7-9 mL/kg: index for weaning: >5 mL/kg Minute ventilation- <10/L min Rapid/shallow breathing index-below 105/L PaO2 > 60mmHg with FiO2 < 50% Hemodynamically stable Pt able to initiate inspiratory effort Criteria for Weaning 67 Respiratory rate >30 breaths/minute (or changing 50% or more) SpO 2 <90% Signs of increased work of breathing--dyspnea, accessory muscles use Diaphoresis Fatigue or pain Sustain Vt < 5 ml/kg Decreased LOC Systolic BP >180 mm Hg (or increase of 20% or more) or diastolic BP >100 mm Hg or hypotension Heart rate >120 beats/minute (or increase of 20% or more) Dysrhythmias Signs of weaning intolerance 68 1. Explain procedure to pt 2. Emergency intubation kit at bedside 3. 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 Monitor vs q 5 min at first Assess ventilatory pattern for s/s resp distress Hoarseness & sore throat common Teach pt to sit in semi-Fowlers, take deep breaths q 1/2h Incentive spirometer use q 2h Limit speaking after extubation. Observe closely for resp fatigue and airway obstruction STRIDOR: HIGH PITCH CROWING SOUND DURING INSPIRATION: LARYNGOSPASM OR EDEMA ABOVE OR BELOW GLOTTIS: LATE MANIFESTATION OF NARROWED AIRWAY. Post Extubation Explain purpose of ventilation to pt or family Encourage family/pt to express concerns PT FIRST, VENT SECOND Suction as needed-HYPEROXYGENATE PRIOR TO SUCTION MAIN NURSING PRIORITIES Evaluating & monitoring pt responses Managing vent system safely Preventing complications Nursing Stab wound at the cricothyroid cartilage ring b/w thyroid cartilage and cricoid cartilage ring Trache tube can be place via opening to keep airway open until a tracheostomy is done Cricothyroidotomy http://www.youtube.com/watch?v=cQYJp6U_jVI