Chest & Lower Respiratory Tract Disorders Part II

Problems of Diffusion

• Pulmonary Edema

• Acute Adult Respiratory Syndrome (ARDS)

• Pneumoconioses

  • Asbestosis

  • Silicosis

  • Black Lung

• Sarcoidosis

Pulmonary Edema

• Abnormal accumulation of fluid in the lung tissue that can move into the alveoli

• Fluid in the alveoli → impaired gas exchange and difficulty breathing

• Often a medical emergency

• Flash pulmonary edema = develops very rapidly

Pulmonary Edema - Cardiogenic

• Caused by a cardiac problem

• Common with:

  • Left-sided heart failure (LVF)

  • MI

  • Pulmonary fluid overload

Pulmonary Edema - Non-cardiogenic

• Not primarily caused by heart failure

• Causes include:

  • Direct lung injury → smoke inhalation, aspiration, trauma

  • Hematogenous injury → sepsis, pancreatitis, multiple transfusions, cardiac bypass

Pulmonary Edema - Clinical Manifestations

• Respiratory distress

• Frothy pink sputum**

• Tachypnea

• Tachycardia

• Anxious/agitated/ confused/ stuporus

• Cough

• Air hunger; Central cyanosis

  • Early sign will be confusion/agitation- late sign will be cyanosis.

• Pt is literally drowning in their own fluids.

Pulmonary Edema - Assessment

• Crackles to auscultation

  • inspiratory

  • bases, ascending

  • Ascending crackles as fluid progresses upward

Pulmonary Edema - Diagnosis

• CXR

• ABGs

• BNP

• Echo

• Pulse ox

Pulmonary Edema - Medical Treatment

Goal: Treat the underlying cause and improve oxygenation/respiratory status.

• Oxygen

  • Often NRB (nonrebreather mask)

  • Intubation/mechanical ventilation if severe

• Diuretics

  • Lasix (furosemide) → loop diuretic

  • Removes excess fluid

• Vasodilators

  • Nitroglycerin (nitro) or nitroprusside IV

  • Helps reduce cardiac workload/vascular pressure

  • Only use if BP is stable

  • Closely monitor BP, HR, and SpO₂

• Positive inotropes

  • Increase the force of cardiac contraction

  • Helps the heart pump blood more effectively

  • Example: digoxin

• Morphine

  • No longer routinely recommended for acute pulmonary edema

• Balloon pump

  • May be needed if the patient does not respond to medications

Pulmonary Edema - Nursing Management

• Position client for comfort

  • High-Fowler’s

  • Legs dependent/dangling over the side of the bed

  • Helps decrease venous return and ease the workload on the heart

• 1:1 monitoring

  • Often cared for in ICU/CC setting

• Bed rest / encourage rest

  • Reduce oxygen demand

• Strict I&O

  • Monitor fluid balance closely

• Continuous cardiac monitoring

• Monitor respiratory status

  • RR, SpO₂, lung sounds, work of breathing

• Diuretic therapy

  • Bedside commode (BSC) may be needed because of increased urination

• Provide emotional support

  • Address anxiety after immediate physical needs are managed

Acute Respiratory Distress Syndrome (ARDS)

• Acute = sudden onset and life-threatening

• Begins after exposure to a trigger/risk factor

• Trigger → inflammatory response

• Inflammation causes lung damage and alveolar collapse

Acute Respiratory Distress Syndrome (ARDS) - Syndrome characterized by:

• Pulmonary edema

• Progressive hypoxemia

  • Refractory to O₂ → oxygen does not adequately correct the low oxygen level

• Reduced lung compliance

  • Lungs become stiff/hard to expand

• High mortality rate

ARDS - Chest X Ray

Risk Factors/Causes of ARDS

Direct Injury

• Smoke inhalation

• Chest trauma

• Aspiration

• TB

• Obstructed airways

• Burns

• Cardiac bypass

• Radiation

Indirect Injury

• Sepsis

• Multiple transfusions

• Pneumonia

• Shock

• Burns

• Head trauma

• Pancreatitis

• Overdose ingestions

All causes damage alveolar-capillary membrane

ARDS - Clinical Manifestations

• Rapid onset of severe dyspnea, usually within 72 hours of the triggering event

• May initially look like pulmonary edema

  • Crackles

  • Intercostal retractions

  • Severe respiratory distress

• Arterial hypoxemia that does NOT improve adequately with O₂

• Lung injury → fibrosing alveolitis

  • Thickening of alveolar walls

  • Lungs become stiff

  • ↓ lung compliance

  • Causes persistent, severe hypoxemia

• High mortality

  • Death commonly occurs from MODS (multiple organ dysfunction syndrome)

ARDS - Diagnostics

• Pulse oximetry

  • Monitors oxygen saturation

• ABGs

  • Shows hypoxemia and other oxygenation/ventilation problems

• CXR

  • May show patchy → diffuse opacities

  • Severe “white-out” appearance = ominous sign

• BNP

  • Helps differentiate cardiogenic pulmonary edema from ARDS

  • Higher BNP suggests a cardiac cause such as heart failure

• Echocardiogram (ECHO)

  • Evaluates heart function and helps assess for a cardiac cause

• PFTs

  • May be used to evaluate lung function

• Assess respiratory effort

  • Use of accessory muscles indicates increased work of breathing

Medical Management of ARDS

Treat the underlying cause + improve oxygenation + support organ function + prevent further lung damage.

• Treat underlying condition/cause

  • Identify and treat what triggered the ARDS

• Supplemental O₂

  • May require ETT + mechanical ventilation

• PEEP (Positive End-Expiratory Pressure)

  • Keeps alveoli open at the end of expiration

  • Prevents alveolar collapse

  • Improves gas exchange/oxygenation

  • Does not cure ARDS; it supports oxygenation

  • PEEP is a critical component of ARDS treatment

• Circulatory support

  • Maintain adequate blood pressure and perfusion

  • Vasopressors may be needed for hypotension

• Fluid management

  • Give enough fluid to maintain circulation

  • Avoid fluid overload because excess fluid can worsen pulmonary edema

• Nutritional support

  • Important because ARDS is a severe, high-metabolic-stress condition

• Monitor

  • ABGs

  • SaO₂/SpO₂

  • PFTs as ordered

Medical Management of ARDS - Meds

Treatment is mainly supportive and may include medications based on the patient's condition:

• Antibiotics → if infection is the cause/suspected

• Steroids

• Diuretics → help manage excess fluid

• Bronchodilators → if indicated

• Anxiolytics/sedation → e.g., Ativan, Versed, Diprivan

• Paralytics may be used in severe cases to facilitate mechanical ventilation

Nursing Management - ARDS

Close monitoring and supportive nursing care are critical.

• Close respiratory + cardiac monitoring

  • SpO₂, ABGs, respiratory status, HR, BP

  • Monitor PA pressures if available

• Mechanical ventilation

  • Manage PEEP

• Positioning

  • Prone positioning or HOB elevated as ordered

  • Prone positioning can improve oxygenation and help recruit alveoli

  • Helps drain secretions and reduce ventilator-associated lung injury

• Frequent turning/repositioning

• CPT (chest physiotherapy)

• Suctioning

  • Suction only when needed to remove secretions

• Nebulizer treatments as ordered

ARDS - Prone Positioning

May:

• Improve oxygenation

• Keep improvement in oxygenation sustained

• Reduce lung injury/barotrauma

• Reduce ventilator time

• Reduce ICU stay

• Help drain pulmonary secretions

• Reduce compression of the lungs by the heart

ARDS - Nursing Care

• Skin care

  • High risk for pressure injuries because of immobility/ventilation

• Oral care

• Eye care

  • Sedated/paralyzed patients may not blink → eye drops and/or tape eyes closed as ordered

• Foley catheter

  • Monitor urine output

• Nutrition

  • Enteral or parenteral nutrition as needed

  • 35–45 kcal/kg/day

• Fluid management

  • Crystalloids as ordered while avoiding fluid overload

• Anxiety/Agitation

  • Provide reassurance and communication

  • Medications may include:

    • Versed

    • Ativan

    • Fentanyl

• Neuromuscular blocking agents

  • May be used with severe mechanical ventilation needs

  • Closely monitor

  • Remember: paralysis does not mean loss of hearing/sensation

Hemodynamic Support

• Vasopressors

  • Used for hypotension

  • Cause vasoconstriction → increase BP

ARDS

• Care is aggressive and supportive

• Survival and prevention of complications depend heavily on nursing care

• Can cause permanent injury and scarring of the alveolar-capillary membrane

• Amount of scarring varies:

  • Minimal → severe/crippling

• Severe permanent lung damage may result in being oxygen-dependent long-term or for life

Sarcoidosis

• Interstitial lung disease

• Cause is unknown

• Usually develops slowly/insidiously

• Most common in adults around 20–40 years

  • More common African-American

• Lungs are most commonly affected, but any organ can be involved

• May involve an abnormal hypersensitivity/inflammatory response to triggers such as bacteria, fungi, viruses, or chemicals

• Causes granulomas and eventually fibrosis in the lungs

  • Fibrosis → lungs can become stiff/hard

  • ↓ lung function

Sarcoidosis - Clinical Manifestations

• Often has few obvious respiratory symptoms

• General symptoms may include:

  • Fatigue

  • Fever

  • Joint pain

  • Anorexia/loss of appetite

• May go into remission without treatment

Sarcoidosis - Diagnosis

• CT scan

• Lung biopsy

Sarcoidosis - Management

• Usually symptomatic/supportive

• Corticosteroids

• Methotrexate may be used

• Outpatient follow-up/monitoring

Pneumoconioses

• Lung diseases caused by repeated exposure to harmful/noxious substances

  • Dust

  • Mineral particles

  • Metal particles

  • Fumes/chemicals

• Inhaled substance → immune/inflammatory response

• Insidious (slow) onset

  • May develop over many years

• Causes lung scarring/pulmonary fibrosis

• Fibrosis → restrictive lung disease

  • Lungs become stiff

  • Difficulty fully expanding the lungs

• Cigarette smoking can worsen the disease

• Can lead to chronic disease and disability

Management/Goal

• Prevention is the main goal

• Reduce or eliminate occupational exposure

• Control exposure to harmful substances

Pneumoconioses - Silicosis

• inhalation exposure to silica dust

• glass manufacture, stone cutting, pottery

• enlarging nodular lesions throughout lung

• 20 yrs before onset

Pneumoconioses - Asbestosis

• inhalation to asbestos dust

• mining, roofing, demolition

• asbestos fibers become surrounded by fibrous tissue

• associated with lung cancer

Pneumoconioses - Black lung

• inhalation of coal dust

• coal mining

• fibrotic lesions form due to over-exposure

• development of emphysema

Pneumoconioses- H&P

• History- inquire about exposure/time frame

• Physical Exam:

  • May be symptomatic for many years as this onset is insidious

  • Dyspnea, chronic cough

  • Loss of appetite

  • Hypoxemia

  • Cor pulmonale

  • Respiratory failure

  • Diagnostics: H&P; CT; CXR

Pneumoconioses- Nursing Management

• Maintain oxygenation

  • Monitor respiratory status and O₂ saturation

• Supportive care

• Lifestyle changes

• Teach patient to stop further exposure

  • Avoid/reduce exposure to dust, minerals, metals, fumes, etc.

• Stop smoking

  • Smoking can worsen the condition

• Monitor for:

  • Cor pulmonale

  • Respiratory failure

• Employee advocate

  • Help protect the patient from continued workplace exposure

Problems of Transport

• Pulmonary embolism

• Cor pulmonale

• Pulmonary Hypertension

Problems of Transport - Examples of Nursing Diagnoses

• Decreased Cardiac Output

• Decreased Tissue Perfusion

Pulmonary Embolism - PE

Obstruction of the pulmonary vasculature by:

• Blood clot

• Air

• Fat

• Septic material

• Amniotic fluid

• Foreign bodies (e.g., IV catheter fragments)

Effects of PE

• ↓ Systemic oxygenation

• Pulmonary tissue hypoxia

• Severe can lead to death

• May recur

• Outcomes depend on the patient’s co-morbidities

PE - Origin

• Usually originates in the venous system, most commonly from a DVT

• Can also originate from the right side of the heart

PE – Pathophysiology

• One of the most common acute pulmonary diseases among hospitalized clients

• Most frequent etiology: DVT (deep vein thrombosis) ⭐

• A clot can break loose → travel through the right side of the heart → pulmonary artery

• Can cause sudden obstruction of pulmonary blood flow

• Severe PE can cause rapid cardiovascular/respiratory collapse

• Saddle embolism: embolus becomes lodged at the bifurcation of the pulmonary artery

PE - Risk Factors

• Prolonged immobilization

• Surgery

• Obesity

• Advancing age

• Hypercoagulability → blood is more likely to form clots

  • Dehydration

  • Malignancy (cancer)

• History of thromboembolism

• Sickle cell disease (SCD)

PE - Clinical Manifestations: Respiratory

• Sudden onset

• Dyspnea

• Tachypnea

• Chest pain

• Cough

• Hemoptysis

• Crackles

• Pleural friction rub

PE - Clinical Manifestations: Cardiovascular

• Tachycardia

• Distended neck veins

• Syncope

• Cyanosis

• Hypotension

PE - Diagnosis

• H&P → health history + physical assessment

• CXR

  • Mainly used to rule out other causes of symptoms

• CT / Spiral CT

• Chest CTA (CT pulmonary angiography) ⭐

  • Visualizes the pulmonary blood vessels

  • Common/important test for PE

• V/Q scan

  • Used when CTA cannot be performed or is unavailable

  • Compares ventilation (airflow) with perfusion (blood flow)

• EKG

  • May show sinus tachycardia

  • May show T-wave inversion

• Pulse oximetry / ABGs

  • May show hypoxemia

  • ABGs can sometimes be normal

• D-dimer

  • Elevated D-dimer can indicate increased clot formation/breakdown

  • Not specific for PE

• Coagulation studies

PE - Medical Treatment

• Goal: Improve respiratory and vascular status

• Supplemental O₂

• IV fluids

• IV vasopressors if needed

• Anticoagulation therapy

  • Heparin

  • Warfarin

  • Low-molecular-weight heparin (LMWH)

• Monitor for bleeding

  • Bleeding gums

  • Heavier menstrual period

  • Unusual bleeding

  • Bleeding anywhere

• Thrombolytic therapy

  • tPA

  • Breaks up the clot

• Surgical intervention

  • Embolectomy → removes clot

  • IVC filter (Greenfield/umbrella)

    • Helps prevent clots from traveling to the lungs

    • May be used for recurrent/chronic PE or when anticoagulation cannot be used

PE - Nursing Management

• Monitor oxygenation

  • Pulse oximetry

  • Respiratory status

• Monitor anticoagulation

  • IV Heparin

    • Monitor PTT/aPTT

    • Goal: 1.5–2.5 × normal per lecture

  • Warfarin

    • Takes about 4–5 days to become effective

    • Monitor PT/INR

    • Goal: INR 2.0–3.0

    • Heparin is continued while warfarin becomes therapeutic, then heparin is decreased/stopped as ordered

• Thrombolytic therapy - ase

  • Used for severe, unstable PE

  • Contraindications:

    • Recent CVA/stroke (lecture: within 2 months)

    • Active bleeding

    • Recent surgery (lecture: within 10 days)

    • Recent trauma

    • Severe hypertension

  • Monitor closely for bleeding

• Surgical intervention

  • Clot removal (embolectomy)

  • Transvenous/IVC filter insertion

  • Monitor for bleeding and infection

  • Monitor WBC/CBC as ordered

PE – Prevention

• Overall goal: Prevention

• Identify patients at risk for DVT/PE

• Early ambulation/walking

• SCDs (sequential compression devices)

• Compression stockings as ordered

• Hydration

• Prevent prolonged immobility

• Anticoagulant prophylaxis when ordered:

  • Low-dose heparin

  • Lovenox (enoxaparin) SQ

  • Other prophylaxis as prescribed

Pulmonary Hypertension (PHT)

• “The other high blood pressure”

• Elevated pressure in the pulmonary arteries

• Pulmonary artery pressure is normally much lower than systemic blood pressure

  • Normal mean pulmonary artery pressure is about 14 mmHg

  • Reflects the pressure the heart needs to pump blood from the heart to the lungs

• Narrowing of pulmonary arteries → harder for blood to flow

• Heart must work harder to pump blood to the lungs

• Increased workload → right ventricular hypertrophy/weakening → right-sided heart failure

• Can be fatal

• Usually not curable, but treatment can improve symptoms and quality of life

• May not be recognized until late in the disease

• Suspect with DOE (dyspnea on exertion) without another obvious cause

Pulmonary Hypertension - Risk Factors / Causes

• Idiopathic → cause unknown

• Sickle cell disease

• Altered immune response/HIV

• COPD

• Obesity

• Sarcoidosis

• Smoking

• Valvular heart disease

• Congenital heart defects

Pulmonary Hypertension - S/S

• Dyspnea

  • Begins as dyspnea on exertion (DOE)

  • Progresses to dyspnea at rest

• Weakness

• Fatigue/tiredness

• Dizziness

• Syncope (fainting) may occur

• Anorexia/loss of appetite

• Signs of right-sided heart failure:

  • Pedal/peripheral edema

  • Ascites

  • JVD

  • Liver enlargement/congestion

  • Weight gain

  • Swelling of extremities

• Murmur may be present

• Symptoms are generally insidious (develop slowly)

Pulmonary Hypertension - Diagnosis

• H&P

• Pulmonary artery pressure (PAP)

• Echocardiogram

• EKG

• CXR

• PFTs

• V/Q scan

• CTA may also be used

• Pulmonary Hypertension - Medical Management

• Manage underlying disease

• Long term medication

• Heart-lung transplant

• Cure?

Pulmonary Hypertension - Nursing Management

• Identify at risk

• Teaching re: lifestyle changes, medications, travel, support groups

• Nursing Assessment

  • O₂/oxygenation

  • Edema

  • JVD

  • Daily weight/weight gain

  • Swelling of extremities

  • Monitor for right-sided heart failure

Cor Pulmonale - Pathophysiology

• Right-sided heart failure caused by pulmonary hypertension (PH)

• Usually related to chronic lung disease, especially COPD

• Chronic lung disease can cause:

  • Hypoxemia → low O₂

  • Hypercapnia → high CO₂

  • ↑ pulmonary vascular resistance/ pulmonary hypertension

• Increased pressure in pulmonary circulation makes the right ventricle work harder

• Right ventricle enlarges (hypertrophies) → eventually weakens and fails

• Leads to right-sided heart failure

• Also called pulmonary heart disease

Cor Pulmonale - Medical Management

• Improve ventilation

• Improve heart failure

  • Bed rest, sodium restriction, digitalis (get rid of fluids)

• Improve underlying disease

• Pulmonary hygiene and CPT

Cor Pulmonale - Nursing Management

• Observe for acute respiratory failure

• Teaching re: activity, diet, medications

Acute Respiratory Failure

• Failure of any component of breathing

  • ventilation

  • diffusion

  • transport of gases

  • Rapid – minutes to hours

Acute Respiratory Failure - ABG 50/50 rule

• pH < 7.35

• Pa O2 < 50

• PCO2 > 50

Causes of Respiratory Failure - Ventilatory Failure

• Extra-pulmonary

  • Neuromuscular disorders

  • Spinal cord injuries (SCI)

  • CNS dysfunction

  • Chemical depression (O.D.)

  • Others

• Intra-pulmonary

  • Airway disease

  • Pulmonary edema

  • Pneumonia

  • COPD

Causes of Respiratory Failure - Oxygenation Failure

• Low atmospheric oxygen concentration

• Abnormal hemoglobin

• Pulmonary embolism

• HF

• Hypovolemic shock

• Hypoventilation

• Mechanical obstruction

S&S of Respiratory Failure

• Restlessness/confusion/headache- early signs

• Pallor advancing to cyanosis (Central cyanosis is a late sign)

• Diaphoresis (sweating)

• Anxiety

• Tachycardia/Tachypnea

• Shallow respirations with accessory muscle usage

• Diminished Lung Sounds- no lung sounds (late)

• Lethargy/Fatigue (later)

Treatment- Mechanical Ventilation Indications:

• Airway protection

  • Compromised or at risk

• Acute respiratory failure

  • Diagnosed emergently on clinical presentation or based on diagnostics

Treatment- Mechanical Ventilation Goals:

• Identify and correct the underlying cause

• Improve oxygenation and gas exchange

• Eliminate/remove excess CO₂

• Reduce work of breathing (WOB)

• Minimize risk of lung injury

• Improve patient comfort

• ETT insertion + mechanical ventilator may be required

• Ventilator air is warmed and humidified

Intubation Steps

“Before we vent them, we have to tube them.”

1. Preparation

   • Gather equipment and medications

   • Position patient

2. Pre-oxygenation

   • Give O₂ before intubation

3. Pretreatment

   • Medications may be given before induction

4. Paralysis with induction

   • RSI (Rapid Sequence Intubation)

5. Protection and positioning

   • Protect airway and position appropriately

6. Placement with proof

   • Insert ETT

   • Confirm correct placement

7. Post-intubation management

   • Connect to mechanical ventilator

   • Monitor patient closely

Nursing Role

• Nurse usually does not intubate

• Nurse assists with intubation according to hospital policy

• Respiratory therapist commonly performs/assists with intubation depending on facility protocol

Intubation Preparation

• Gather all equipment needed- crash cart

• Light source

• Skilled personnel

• Difficult airway cart

• Glide scope

• Ensure sx properly working!!

• SOAP ME (ACLS)

  • S – Suction

    • Turned on and working

  • O – Oxygen

    • Include backup oxygen supply

  • A – Airway equipment

    • Laryngoscope/handles

    • Endotracheal tubes

    • Stylets

    • Supraglottic airways

  • P – Pharmaceuticals

    • Induction agent

    • Muscle relaxant

    • Adjuvant medications

    • Emergency medications

  • M – Monitors

    • Audible SpO₂ tone

    • BP at least every 5 minutes

  • E – Emergency equipment

    • Defibrillator

    • Emergency/invasive airway equipment

Preoxygenation

• Give 100% oxygen for 3–5 minutes

• Can use:

  • NRB (nonrebreather mask)

  • Ambu bag/BVM

• Allow patient to breathe spontaneously when possible

• Position:

  • Prefer head-elevated/sitting position if tolerated

  • If spinal injury is suspected and the patient must remain immobilized → reverse Trendelenburg

• Helps prevent hypoxemia during intubation/apnea

• Helps reduce risk related to aspiration

• May be performed by RN or RT

• With an Ambu bag: 4–8 breaths may be sufficient per lecture

• A healthy patient may only have about 1 minute of safe apnea on room air

Pre-medication

• Purpose: Medications are given before intubation to decrease unwanted effects of intubation

• Often used as part of RSI (Rapid Sequence Induction and Intubation)

LOAD

• L – Lidocaine

  • 1.5 mg/kg IV

  • May help blunt increase in ICP

  • May decrease bronchospasm

• O – Opiates

  • Fentanyl 2–5 mcg/kg IV

  • Helps blunt the response to intubation

• A – Anticholinergics

  • Atropine for children

  • Glycopyrrolate may be used

  • Helps reduce secretions/bradycardia

• D – Defasciculating dose

  • Small dose of a nondepolarizing neuromuscular blocker

  • May be given if succinylcholine is planned

Placement with Proof

• Each attempt should not exceed 30 seconds, maximum of 3 attempts

• If more than one attempt is needed, ventilate the patient 30-60 seconds between

• After intubation, inflate the cuff

• Confirm tube placement with exhaled carbon dioxide detector and CXR

• Have to hear lung sounds on both side when tube is in

• Tape near lips – remember number

Post-intubation Mgmt

• Secure endotracheal tube in place

• Set ventilator settings

• Continue to medicate

• Recheck V/Sand pulse ox

• Malfunctions- what to do?

• Document

  • Sizes

  • Depth markings on shaft/lip line

  • Cuff/ balloon

  • How placement was confirmed

• Work with collaboration with RT!

Vent Settings - Rate & Tidal Volume

• RR-How many breaths will the vent deliver per min?

• The pre-set number of positive pressure breaths per minute.

• The pt can breathe more depending on the mode

• Tidal Volume :The amount of air the ventilator has been set to deliver during a single breath. Reflects the amount of air inspired and expired

  • This is the minimum amount the pt will breath

• V T estimated at 6-12 ml/kg of IBW (may initially be higher).

FiO2 Setting

• FiO₂ = Fraction of inspired oxygen

• Represents the amount/percentage of oxygen delivered by the ventilator

• Range:

  • 0.21 = 21%

  • 1.0 = 100%

• Room air = 20.8% ≈ 21% O₂

• FiO₂ setting is based on:

  • Patient’s condition

  • Recent ABG results

  • How the patient is responding to treatment

• Example:

  • FiO₂ 0.40 = 40% O₂

  • FiO₂ 1.0 = 100% O₂

• May start with a higher FiO₂ for severe hypoxemia and then decrease it as oxygenation improves.

• Goal: Use the lowest FiO₂ necessary to maintain adequate arterial oxygenation.

• Normal PaO₂ = about 80–100 mmHg

• Always look at recent ABGs—do not use an old admission ABG if the patient’s condition has changed.

Positive End Expiratory Pressure -PEEP

• Increases pressure in the lungs at the end of expiration

• Helps keep alveoli open

• Prevents atelectasis

• Improves:

  • Oxygenation

  • Alveolar ventilation

  • Lung compliance

• Used along with other ventilator modes

Complications of PEEP

• Barotrauma → lung injury from excessive pressure

• ↓ Venous return

• ↓ Cardiac output (CO)

• ↑ Intracranial pressure (ICP)

• Pulmonary edema

• Very high PEEP can damage alveoli and cause air leaks/lung injury

Continuous Positive Airway Pressure (CPAP)

• Positive pressure during inhalation and exhalation

• Requires spontaneous breathing

• PEEP ≈ CPAP in terms of continuous positive pressure

Delivery

• Invasive

  • Endotracheal tube

  • Tracheostomy

• Noninvasive

  • Tight-fitting face mask

  • Good seal required

Ventilator

• CPAP is set using the PEEP setting

• Example:

  • FiO₂ = 40%

  • PEEP/CPAP = 10 cm H₂O

Candidates

• COPD

• Pulmonary edema

• Chronic respiratory failure

• Chronic heart failure

• Sleep apnea

• Some patients who do not want intubation

• Can be used for weaning from mechanical ventilation

Noninvasive PPV

• CPAP

• BiPAP

Important

• Patient must be able to breathe spontaneously

• Avoid/use cautiously with head, neck, or facial trauma that prevents a proper mask seal

Synchronized Intermittent Mandatory Ventilation - SIMV

• Often used as a weaning mode

• Patient breathes spontaneously between machine-delivered breaths

• Machine provides a set number of mandatory breaths

• Useful when ABGs and respiratory rate are improving/normal

• Goal is to gradually allow the patient to do more of the breathing

Assist Control - AC

• Used when patient is still breathing but breaths are not effective

• Patient may have shallow or inadequate breaths

• Ventilator delivers a full supported breath when the patient initiates a breath

• Provides more support than SIMV

Controlled Mechanical Ventilation - CMV

• Used for patients who are not breathing adequately or at all

• Example: comatose or overdose patient

• Ventilator provides the patient's breaths

• Used for the sickest patients who cannot adequately breathe on their own

BiPAP – Bilevel Positive Airway Pressure

• Provides 2 levels of positive airway pressure

  • IPAP = inspiratory positive airway pressure

  • EPAP = expiratory positive airway pressure

• IPAP is higher than EPAP

  • More pressure is needed during inspiration

  • Lower pressure during exhalation makes it easier to breathe out

• Example:

  • FiO₂ = 40%

  • IPAP = 10 cm H₂O

  • EPAP = 6 cm H₂O

• Noninvasive ventilation

• Delivery:

  • Nasal/oral mask

  • Nasal pillows

  • Mouthpiece

• Compliments/supports the patient’s own breathing

• Requires the patient to be spontaneously breathing

Indications

• Sleep apnea

• COPD

• Other patients who need noninvasive respiratory support

Tolerance

• Tolerance varies

• Often used at night

Hazards of Mechanical Ventilation

• ETT (Endotracheal Tube) complications

  • Dislodgement/malposition

    • Tube may enter right mainstem bronchus

    • Tube may be positioned too high in the mid-trachea

  • Kinking → obstructs airflow

  • Cuff failure

    • Air leak

    • Inadequate seal

  • Obstruction

    • Secretions

    • Cuff/balloon problems

  • Pressure necrosis

    • Excessive cuff pressure can damage tracheal tissue

  • Aspiration

    • Can lead to aspiration pneumonia

• Children

  • pediatric ETTs may not have a cuff

• Aspiration prevention

  • Anti-ulcer/stress-ulcer medications may be used to help maintain gastric pH and reduce complications if aspiration occurs

  • Maintain appropriate cuff pressure

• Cuff pressure

  • Keep adequate but not excessive

  • Lecture: <20 mm Hg to reduce risk of tracheal necrosis

Hazards of Mechanical Ventilation

• Excessive pressure

  • Barotrauma → lung damage from high pressure

  • Pneumothorax → alveoli can rupture and air enters pleural space

  • Alveoli can rupture

• Decreased cardiac output (CO)

  • Positive pressure compresses the heart and great vessels

  • ↓ Venous return

  • ↓ CO

  • ↓ Tissue perfusion

• Signs of decreased CO

  • ↓ Urine output (UOP)

  • Monitor pulmonary artery catheter readings if present

• Pulmonary infection

  • VAP – Ventilator-Associated Pneumonia

  • HOB 30°

  • Mouth care q4h

  • Turn q2h

  • Hand hygiene

• Key concern

  • Mechanical ventilation can cause a ventilator-acquired pneumothorax

Nursing Care r/t Mechanical Ventilation

• Daily CXR

• Daily ABG

• Daily weight

• Turn/ROM

• I&O

• Lab values

  • Hydration, nutrition, O2 carrying capacity, muscle strength

  • Na+, K+, Mg++, serum osmolality, H&H, BUN, creatinine

• Suctioning PRN

• For all ventilator alarms: Assess patient first!

  • cause unknown- bag patient and call RT!

  • High-pressure alarm

    • Possible kinked tubing

    • Secretions/obstruction can also increase pressure

  • Low-pressure alarm

    • Possible disconnection from the ventilator

    • Possible leak

• Nutrition

  • Monitor nutrition closely

  • Carbohydrate metabolism produces CO₂

  • Too much carbohydrate can increase CO₂ production

  • Adequate protein is needed for respiratory muscle strength

Troubleshooting

• Identify the problem quickly

  • Is it a patient problem or a ventilator problem?

• Manage the patient, not the alarm! ⭐

• If in doubt → bag the patient

DOPE

• D – Displaced

  • ETT may be displaced/dislodged

• O – Obstructed

  • Secretions

  • Kinked tube

  • Patient biting tube

• P – Pneumothorax

• E – Equipment failure

“Bucking the Vent”

• Patient is out of sync with the ventilator

• Example: patient tries to exhale while the ventilator is delivering inspiration

• May need:

  • Suctioning

  • Sedation adjustment

  • Ventilator adjustment

Low-Pressure Alarm = LEAK

• Tube disconnection

• Cuff leak

• Tube dislodgement/extubation

• Leak in tubing/system

• Gas-flow/equipment problem

High-Pressure Alarm = BLOCKAGE/RESISTANCE

• Secretions

• Kinked tube

• Pulmonary edema

• Patient coughing

• Patient biting the tube

• May need suctioning

• May need sedation if inadequately sedated

If the Cause Cannot Be Identified Quickly

• Assess the patient first

• If becoming deoxygenated:

  • Disconnect from ventilator

  • Use manual resuscitation bag (Ambu/BVM) with 100% O₂

  • Call RT/help

  • Continue manual ventilation until the problem is corrected

Manual Ventilation

• 100% O₂: use 10+ L/min

• Bag-mask ventilation: 1 breath every 5–6 seconds

  • 10–12 breaths/min

• Advanced airway: 1 breath every 6–8 seconds

  • 8–10 breaths/min

Suctioning

• PRN (as needed) — do NOT suction routinely

• Indications:

  • Visible secretions in tubing

  • Coarse crackles

  • ↓ O₂ saturation

  • ↑ Work of breathing (WOB)

  • Asymmetrical chest movement

Before Suctioning

• Pre-oxygenate the patient ⭐

• Monitor:

  • Vital signs

  • Cardiac rhythm

• Watch for:

  • PVCs

  • Bradycardia

During Suctioning

• Insert the catheter without suction

• Apply intermittent suction while withdrawing

• Suction only while coming OUT

• Limit passes according to facility policy/protocol

• Lecture: may go in up to 3 times

After Suctioning

• Post-oxygenate

• Reassess:

  • O₂ saturation

  • Respiratory status

  • Breath sounds

  • VS/rhythm

• Evaluate whether secretions were effectively removed

Saline

• Do NOT routinely instill saline

• May be considered for thick, tenacious secretions per policy

Weaning from the Vent

• Look for trends of improving clinical picture

• Physically & Psychologically ready

• Collaborative Effort- HC Team

• Extubation

• Observe for fatigue and hypoxia

  • Increased WOB

  • Increased RR, HR

  • Diaphoresis/anxiety

  • Falling SpO2, rising BP or falling BP

  • Look for signs of exhaustion!

• Weaning- simply means withdrawing client from vent. Pt must be stable enough to come off.

• 3 stages: 1) vent, 2) ETT 3) oxygen

• Want to wean them as quickly as we can or as they can tolerate for pt safety

Tracheostomy

• Surgical opening in trachea

• Long term ventilation

• By-pass obstruction

• Can only stay down for 2 weeks

• If pt doesn’t get better from ventrilor , put in tracheostomy

• Complications:

  • bleeding

  • pneumothorax

  • aspiration

  • air embolism

  • laryngeal nerve damage

  • tracheal wall damage

  • airway obstruction