supporting ventilation

SpO₂ vs. EtCO₂

These are two important measurements used to evaluate respiratory function. They measure DIFFERENT things.

Measurement	SpO₂	EtCO₂
Full name	Peripheral capillary oxygen saturation	End-tidal carbon dioxide
Measures	Oxygenation	Ventilation
Normal range	95–100%	35–45 mmHg
Equipment	Pulse oximeter	Capnograph
Reflects	Oxygen delivered to blood	CO₂ eliminated from lungs
Response	Delayed (30–60 seconds)	Almost immediate

SpO₂ — Pulse Oximetry

What does it measure?

• Percentage of hemoglobin molecules carrying oxygen.

• Shows how well oxygen is being delivered from the lungs into the bloodstream.

• Normal range: 95–100%.

• Some patients with COPD may have a target of 88–92%.

Common uses:

• Postoperative monitoring.

• Respiratory distress.

• Sedated patients.

• Patients receiving oxygen.

• Patients at risk for hypoxemia.

Limitations — when can the reading be inaccurate?

• Poor perfusion (shock or hypothermia).

• Patient movement.

• Nail polish or artificial nails.

• Carbon monoxide poisoning (can give falsely high readings).

EtCO₂ — Capnography

What does it measure?

• The amount of CO₂ in exhaled air at the end of expiration.

• Reflects how effectively the patient is ventilating and eliminating CO₂.

• Normal range: 35–45 mmHg.

• Provides real-time feedback.

Common uses:

• Procedural sedation.

• Anesthesia.

• Mechanical ventilation.

• Confirming endotracheal tube placement.

• Monitoring CPR effectiveness.

• Detecting hypoventilation, hyperventilation, and airway obstruction.

Important clinical points:

• A sudden absence of the waveform may indicate tube dislodgement, obstruction, or apnea.

• During CPR, EtCO₂ greater than 10–20 mmHg during compressions indicates adequate circulation, according to the lecture.

• EtCO₂ may not accurately correlate with PaCO₂ in severe ventilation-perfusion mismatch, such as ARDS or pulmonary embolism.

What do changes in EtCO₂ and SpO₂ mean?

Finding	Possible Meaning	Nursing Action
SpO₂ decreases	Hypoxemia or decreased oxygenation	Check oxygen source, reposition, suction, encourage deep breathing, titrate O₂
EtCO₂ increases	Hypoventilation or CO₂ retention	Stimulate patient, check airway patency, evaluate ventilation
EtCO₂ decreases	Hyperventilation or poor perfusion	Assess circulation, ventilation, and possible tube dislodgement
EtCO₂ absent	No exhaled CO₂ detected	Immediately assess airway and circulation

HIGH-YIELD TAKEAWAY:

• SpO₂ tells you whether the patient is oxygenating.

• EtCO₂ tells you whether the patient is ventilating.

• EtCO₂ changes more quickly than SpO₂.

Memory trick: SpO₂ = OXYGEN. EtCO₂ = EXHALED CO₂.

Respiratory Physiotherapy

Purpose: Breathing exercises improve ventilation, promote gas exchange, and strengthen respiratory muscles.

Commonly used after surgery or in patients with chronic respiratory illnesses.

Diaphragmatic (Abdominal) Breathing

Purpose:

• Encourages use of the diaphragm instead of accessory muscles.

• Promotes deeper inspiration.

• Slows respiratory rate.

• Reduces work of breathing.

Indications:

• Post-thoracic surgery.

• Post-abdominal surgery.

• Anxiety control.

• Prevention of atelectasis.

Technique:

1. Place one hand on the abdomen and one hand on the chest.

2. Slowly inhale through the nose.

3. Focus on making the abdomen rise.

4. Exhale gently through pursed lips.

Caution: In moderate-to-severe COPD, diaphragmatic breathing may worsen dyspnea due to hyperinflation.

Pursed-Lip Breathing (PLB)

Purpose:

• Prolongs exhalation.

• Prevents bronchiolar collapse.

• Helps prevent air trapping.

• Promotes CO₂ elimination.

Indications:

• COPD.

• Dyspnea.

• Anxiety.

• Shortness of breath with activity.

Technique:

1. Inhale slowly through the nose.

2. Purse lips as if blowing out a candle.

3. Exhale slowly.

4. Make exhalation approximately 3 times longer than inhalation.

Teaching cue: "Smell the roses, blow out the candle."

Airway Clearance Techniques

Purpose: Mobilize secretions, maintain airway patency, and improve gas exchange.

Commonly used for:

• COPD.

• Cystic fibrosis (CF).

• Bronchiectasis.

• Pneumonia.

Huff Coughing

Purpose: Moves secretions from smaller airways into larger airways so the patient can cough them out.

Technique:

1. Take a deep diaphragmatic breath.

2. Hold for 2–3 seconds.

3. Exhale forcefully with an open mouth, as if fogging a mirror.

4. Repeat 3–5 cycles until mucus is cleared or the patient becomes fatigued.

Clinical benefit:

• Especially effective in COPD and emphysema.

• Helps clear secretions.

• Helps prevent airway collapse.

Chest Physiotherapy (CPT)

Includes three main techniques:

1. Postural Drainage

• Uses gravity to drain secretions from affected lung lobes.

• Requires specific patient positioning.

• Perform before meals or several hours after meals.

2. Percussion

• Rhythmic striking of the chest wall using cupped hands.

• Helps loosen mucus so it can be coughed out.

• Avoid in patients with rib fractures, bleeding disorders, or osteoporosis.

3. Vibration

• Gentle shaking applied during exhalation.

• Helps move mucus into larger airways for expectoration.

Airway Clearance Devices

Examples include:

• Flutter valve.

• Acapella.

• TheraPEP.

• High-frequency chest wall oscillation vest.

Nursing Management of Respiratory Physiotherapy

1. Assess patient tolerance and contraindications.

   • Recent surgery.

   • Trauma.

   • Head injury.

   • Unstable hemodynamics.

2. Administer bronchodilators and hydration before therapy as appropriate.

3. Assess lung sounds before and after therapy.

4. Evaluate sputum characteristics.

5. Monitor for complications.

Possible complications:

• Rib fractures.

• Hypoxemia.

• Bruising.

Nursing tip: Bronchodilators before chest physiotherapy can help open the airways and improve secretion mobilization.

Oxygen Therapy

Purpose: Oxygen therapy treats hypoxemia and hypoxia.

It increases the partial pressure of oxygen (PaO₂) in the alveoli, allowing more oxygen to diffuse into the bloodstream.

Oxygenation Goals

• General goal: SpO₂ ≥ 92%.

• Chronic CO₂ retainers: SpO₂ ≥ 88%.

• General PaO₂ goal: greater than 80 mmHg.

• COPD PaO₂ goal: greater than 60 mmHg.

Low-Flow Oxygen Systems

Low-flow systems deliver a variable FiO₂, meaning the exact oxygen concentration received can vary depending on the patient's breathing pattern.

Device	Flow Rate	Approximate FiO₂	Important Nursing Considerations
Nasal cannula	1–6 L/min	24–44%	Comfortable; allows eating and talking
Simple face mask	6–12 L/min	35–50%	Minimum 6 L/min to prevent CO₂ rebreathing
Partial/non-rebreather mask	10–15 L/min	60–90%	Keep reservoir bag inflated

nasal cannula

• Commonly used for patients needing low levels of supplemental oxygen.

• Assess nares for irritation.

• Humidify oxygen when flow is greater than 5 L/min

Simple Face Mask

• Must receive at least 6 L/min.

• Prevents rebreathing of excessive CO₂.

• Remove for meals.

Partial/Non-Rebreather Mask

• Provides a higher oxygen concentration.

• Keep the reservoir bag inflated.

• Monitor closely for bag collapse, which indicates inadequate flow.

High-Flow Oxygen Systems

High-flow systems provide a more precise FiO₂ regardless of the patient's breathing pattern.

Device	Oxygen Delivery	Important Information
Venturi mask	24–50%	Ideal for COPD patients who need controlled FiO₂
High-flow nasal cannula	Up to 60 L/min	Provides warm, humidified oxygen
Trach collar/T-piece	Humidified O₂	Delivers oxygen directly to tracheostomy

Important distinction:

• Low-flow = variable FiO₂.

• High-flow = fixed/precise FiO₂.

Combustion

• Oxygen supports fire.

• Keep oxygen away from flames, heat, and smoking.

• Avoid oil-based products around oxygen equipment.

• Use "No Smoking" signage

Oxygen Toxicity

• Prolonged exposure to FiO₂ greater than 60% for more than 24 hours can cause alveolar damage.

• Oxygen free radicals damage cells.

• Alveoli can become inflamed and fill with fluid.

Nursing interventions:

• Use the lowest effective FiO₂.

• Monitor ABGs and respiratory status.

• Report new cough, chest pain, or dyspnea.

Absorption Atelectasis

• High oxygen concentrations can wash nitrogen out of the alveoli.

• Nitrogen normally helps keep alveoli open.

• Without enough nitrogen, alveoli may collapse.

Nursing interventions:

• Encourage coughing and deep breathing (C&DB).

• Encourage incentive spirometry (IS).

• Titrate oxygen as prescribed.

• Suction if mucus is obstructing the airway

CO₂ Narcosis

• Some patients with chronic COPD and CO₂ retention may have altered respiratory drive.

• Excessive oxygen administration can worsen CO₂ retention in susceptible patients.

Nursing interventions:

• Carefully titrate oxygen.

• Monitor respiratory status and ABGs.

• Follow the prescribed oxygen saturation target

Infection

- Moist oxygen devices can harbor bacteria.

Nursing interventions:

• Maintain device hygiene.

• Use sterile or disposable devices as appropriate.

• Replace equipment according to policy.

management and safety of oxygen therapy

Nursing Management of Oxygen Therapy

• Assess baseline vital signs, SpO₂, and mental status.

• Monitor response to oxygen frequently.

• Adjust oxygen flow to achieve the ordered SpO₂ target.

• Collaborate with respiratory therapy (RT).

• Check tubing for kinks and ensure connections are secure.

• Teach patients proper oxygen use and signs of hypoxia.

Home Oxygen Safety

• Review the prescribed flow rate. Never change it without a provider's order.

• Clean nasal cannula weekly.

• Replace nasal cannula every 2–4 weeks.

• Keep oxygen tanks at least 5 feet from open flames.

• Store oxygen tanks upright.

• Avoid wool or synthetic blankets that can create static.

• Notify the electric company if dependent on an oxygen concentrator.

• Encourage mobility and travel using portable oxygen concentrators when appropriate.

Nasopharyngeal Airway (NPA)

What is it?

• Flexible tube inserted through the nostril.

• Maintains ventilation in conscious or semiconscious patients.

Nursing considerations:

• Measure from the tip of the nose to the earlobe.

• Lubricate before insertion.

• Insert gently toward the ear.

• Position the bevel toward the septum

Oropharyngeal Airway (OPA)

What is it?

• Hard, curved tube that prevents the tongue from obstructing the airway.

• Used ONLY in unconscious patients.

Nursing considerations:

• Measure from the corner of the mouth to the angle of the jaw.

• Insert upside down, then rotate 180°.

• NEVER use in a conscious patient.

Why? It can trigger the gag reflex and cause vomiting or aspiration.

Endotracheal Tube (ETT)

Purpose: Used for short-term mechanical ventilation or airway protection.

Indications:

• Respiratory failure.

• Apnea.

• Airway obstruction.

• Secretion management.

• Aspiration risk.

Nursing responsibilities:

• Confirm bilateral breath sounds and chest rise.

• Maintain cuff pressure at 20–30 cm H₂O.

• Document insertion depth.

• Provide oral care every 2–4 hours.

• Use chlorhexidine according to agency protocol.

• Reposition and secure the tube according to policy.

• Prevent ventilator-associated pneumonia (VAP).

Tracheostomy

What is it?

A surgically created opening through the anterior neck into the trachea.

Purpose:

• Long-term ventilation.

• Relief of airway obstruction.

Main components:

• Outer cannula.

• Inner cannula.

• Flange.

• Cuff, if present.

Chest Drainage System Components

1. Collection Chamber

• Collects drainage from the pleural space.

• Monitor and document drainage amount, color, and consistency.

2. Water-Seal Chamber

• Acts as a one-way valve.

• Allows air to leave the pleural space but prevents air from flowing back in.

• Tidaling reflects pressure changes during breathing.

3. Suction-Control Chamber

• Regulates the amount of suction.

• Wet suction = water column.

• Dry suction = dial regulator.

Nursing Responsibilities During Chest Tube Insertion

• Position patient with the arm raised and HOB approximately 45°.

• Maintain sterile setup.

• Monitor for respiratory distress.

• Provide analgesia and reassurance.

• Apply an occlusive dressing after insertion.

• Confirm placement with chest X-ray (CXR).

Nursing Management of Chest Drainage

Monitor drainage:

• Record color, consistency, and amount.

• Assess hourly initially.

• Report drainage greater than 100 mL/hr or sudden bright-red output.

Maintain the drainage system:

• Keep the drainage system BELOW chest level.

• Avoid dependent loops and kinks.

• Do NOT routinely milk or strip the tubing.

Encourage:

• Coughing and deep breathing.

• Range-of-motion exercises.

• Mobility as appropriate.

Assess for subcutaneous emphysema:

• Feels like crackling or bubbling under the skin.

• May indicate an air leak.

Chest Tube Emergencies

If the chest tube becomes disconnected from the drainage system:

1. Place the distal end of the tube into sterile water, approximately 2–3 cm deep.

2. This temporarily re-establishes a water seal.

3. Reconnect to the drainage system as soon as possible.

If the chest tube is accidentally pulled out:

1. Apply an occlusive dressing taped on THREE sides.

2. Notify the provider immediately.

3. Monitor for respiratory distress.

If the water-seal chamber stops tidaling:

• Assess for kinks.

• Check for dependent loops.

• Consider lung re-expansion.

• CXR can help confirm lung re-expansion.

Important: Never routinely clamp a chest tube.

Chest Tube Removal

• Premedicate for pain.

• Tube is removed during the Valsalva maneuver.

• Apply an occlusive dressing.

• Obtain a post-removal CXR.

Types of Chest Surgery

Procedure	Description	Common Indications	Nursing Considerations
Thoracotomy	Surgical incision into chest wall	Lung cancer, trauma, cardiac surgery	High pain risk; teach splinting and IS
Lobectomy	Removal of one lung lobe	Tumor, bronchiectasis, infection	Chest tubes post-op; promote lung expansion
Pneumonectomy	Removal of an entire lung	Extensive malignancy	No chest tube or gravity drainage; position on operative side
Wedge/segmental resection	Removal of part of a lobe	Small lesions, biopsy	Encourage deep breathing and pain control
Decortication	Removal of fibrous pleural layer	Empyema	Chest tubes post-op
VATS	Minimally invasive thoracoscopy	Biopsy, nodule resection	Less pain, shorter stay, faster recovery

pre/post op nursing care

Preoperative Nursing Care

• Assess cardiopulmonary status.

• Review CXR, ECG, ABGs, and pulmonary function tests (PFTs).

• Teach breathing exercises.

• Teach splinting.

• Teach incentive spirometer use.

• Provide reassurance and manage anxiety.

Postoperative Nursing Care

• Manage pain aggressively (PCA or epidural as prescribed).

• Monitor vital signs and oxygenation.

• Assess drainage and lung sounds.

• Encourage ambulation and range of motion.

• Prevent DVT and pneumonia.

• Assess incision for infection or dehiscence.

Memory trick:

• Lobectomy = one lobe removed.

• Pneumonectomy = entire lung removed.

• VATS = minimally invasive approach.

Noninvasive Ventilation (NIV)

Noninvasive ventilation provides respiratory support without inserting an endotracheal tube.

Two important types are CPAP and BiPAP.

CPAP — Continuous Positive Airway Pressure

How it works:

• Provides one continuous pressure throughout the respiratory cycle.

• Keeps alveoli open.

Common uses:

• Sleep apnea.

• Heart failure.

Nursing considerations:

• Monitor tolerance.

• Assess skin integrity around the mask.

• Monitor cardiac status.

• Some patients may have difficulty exhaling against the pressure.

Contraindications:

• Vomiting risk.

• Altered level of consciousness.

• Cardiac or respiratory arrest.

• Acute MI.

• Shock.

• Maxillofacial trauma.

BiPAP — Bilevel Positive Airway Pressure

How it works:

• Provides higher inspiratory pressure (IPAP).

• Provides lower expiratory pressure (EPAP).

• Helps improve ventilation and CO₂ removal.

Common indications:

• COPD exacerbation.

• Acute CHF.

• Post-extubation respiratory support.

Contraindications:

• Vomiting risk.

• Altered level of consciousness.

• Facial trauma.

CPAP vs. BiPAP

CPAP	BiPAP
One continuous pressure	Two pressure levels
Keeps alveoli open	Supports inhalation and exhalation
Commonly used for sleep apnea	Commonly used for COPD exacerbation
Supports oxygenation	Helps improve ventilation and CO₂ removal

Memory trick:

• CPAP = Continuous pressure.

• BiPAP = TWO pressure levels.

Nursing Management of NIV

• Assess level of consciousness.

• Assess hemodynamic stability.

• Ensure proper mask fit.

• Patient must be able to remove the mask independently.

• Do NOT use restraints to keep the mask on.

• Provide frequent mouth and skin care.

• Relieve pressure points.

• Elevate HOB 30–45° to reduce aspiration risk.

• If the patient's condition worsens, notify the provider for possible intubation evaluation.

Mechanical Ventilation

Mechanical ventilation supports or takes over breathing when a patient cannot adequately ventilate independently.

Types of Ventilators

Negative-Pressure Ventilation

• Encases the chest or body.

• Creates subatmospheric pressure to help air enter the lungs.

• Example: iron lung.

• Rarely used today.

Positive-Pressure Ventilation

• Forces air into the lungs.

• Exhalation is passive.

• Can be volume-controlled or pressure-controlled.

Mechanical Ventilation Modes

Mode	How It Works
Volume Control (VC)	Delivers a preset tidal volume; pressure varies
Pressure Control (PC)	Delivers a preset pressure; tidal volume varies
Assist-Control (AC)	Delivers set breaths; patient can trigger additional full-volume breaths
SIMV	Allows spontaneous breaths between machine-delivered breaths
Pressure Support (PS)	Augments the patient's spontaneous breaths

Important distinctions:

• Volume control = set volume, variable pressure.

• Pressure control = set pressure, variable volume.

• Assist-control = patient can trigger additional supported breaths.

• SIMV = patient can breathe spontaneously between machine breaths.

• Pressure support = helps the patient's spontaneous breaths.

PEEP — Positive End-Expiratory Pressure

What is PEEP?

PEEP is the pressure that remains in the lungs at the end of exhalation while the patient is receiving mechanical ventilation.

Purpose:

• Prevents alveoli from collapsing between breaths.

• Improves oxygenation.

• Increases surface area available for gas exchange.

• Decreases work of breathing.

• Improves lung compliance and functional residual capacity (FRC).

PEEP Settings:

PEEP Level	Typical Use
3–5 cm H₂O	Normal physiologic PEEP
5–10 cm H₂O	Common therapeutic range
10–20+ cm H₂O	May be used for severe alveolar collapse, such as ARDS

Important nursing consideration:

Higher PEEP can increase intrathoracic pressure and decrease venous return to the heart. This can cause hypotension.

Memory trick: PEEP = Prevents alveoli from collapsing.

Endotracheal Intubation

Purpose: Establishes an airway for patients who cannot maintain adequate ventilation or protect their airway.

Steps of Intubation

1. Preoxygenate with 100% oxygen for 2 minutes.

2. Rapid sequence intubation (RSI) may be performed using a sedative and paralytic.

3. Insert the endotracheal tube using a laryngoscope.

4. Confirm placement with EtCO₂ and auscultation.

5. Secure the tube and document insertion depth.

6. Obtain a chest X-ray.

Nursing Responsibilities

• Monitor SpO₂ continuously.

• Assess bilateral chest rise.

• Auscultate breath sounds.

• Monitor for tube dislodgement.

• Maintain cuff pressure at 20–30 cm H₂O.

• Provide oral care every 2–4 hours.

• Elevate HOB 30–45° to help prevent VAP.

• Assess pain, anxiety, and sedation needs.

• Use a sedation assessment tool such as the RASS scale.

• Collaborate with respiratory therapy for ventilator adjustments.

HIGH-PRESSURE VENT ALARM

Means the ventilator is meeting increased resistance when delivering a breath.

Possible causes:

• Secretions.

• Kinked tubing.

• Patient biting the tube.

• Bronchospasm.

• Obstruction.

Nursing actions:

• Assess the patient first.

• Check tubing for kinks.

• Assess for secretions.

• Suction if indicated.

• Check for biting or obstruction.

• Insert a bite block if appropriate.

LOW-PRESSURE VENT ALARM

Means the ventilator is detecting a loss of pressure, often due to a leak or disconnection.

Possible causes:

• Disconnected ventilator tubing.

• Cuff leak.

• Accidental extubation.

Nursing actions:

• Assess the patient.

• Check all connections.

• Assess cuff integrity.

• If the tube is out, manually ventilate and call for help.

APNEA ALARM

• Possible causes include disconnection, respiratory fatigue, or excessive sedation.

• Assess the patient.

• Stimulate the patient if appropriate.

• Initiate manual ventilation if needed.

HIGH RESPIRATORY RATE OR HIGH VOLUME ALARM

• Possible causes include pain, anxiety, or hypoxia.

• Reassure the patient.

• Assess sedation needs.

• Evaluate oxygenation

Suctioning an ETT or Tracheostomy

Purpose: Removes secretions and maintains airway patency.

When Should the Nurse Suction?

Do NOT suction routinely. Suction only when clinically indicated.

Indications include:

• Coarse breath sounds.

• Visible secretions.

• Decreased SpO₂.

• Increased peak inspiratory pressures (PIP).

Suctioning Procedure

1. Assess the patient for signs of retained secretions.

2. Preoxygenate with 100% oxygen.

3. Insert the suction catheter WITHOUT applying suction.

4. Apply suction while withdrawing the catheter using a rotational motion.

5. Limit suctioning to 10 seconds or less.

6. Reoxygenate after each pass.

7. Limit suctioning to no more than 3 passes per episode.

Potential Complications

• Hypoxemia.

• Mucosal injury.

• Dysrhythmias.

Nursing priorities:

• Preoxygenate.

• Limit suction duration.

• Monitor SpO₂ and cardiac rhythm.

• Reassess the patient after each pass

Barotrauma / Volutrauma

• Excessive pressure or volume damages alveoli.

• Can cause alveolar rupture and pneumothorax.

• May lead to subcutaneous emphysema.

Nursing considerations:

• Monitor respiratory status.

• Assess breath sounds.

• Monitor for sudden hypotension.

• Watch for subcutaneous emphysema.

Oxygen Toxicity

• Excessive FiO₂ can cause free-radical damage to the lungs.

• Use the lowest effective FiO₂.

Ventilator-Associated Pneumonia (VAP)

Pneumonia that develops in a patient receiving mechanical ventilation.

Prevention:

• Oral care.

• Elevate HOB 30–45°.

• Subglottic suctioning when indicated.

• Follow infection-prevention protocols.

Hypotension

• Positive-pressure ventilation increases intrathoracic pressure.

• This decreases venous return to the heart.

• Reduced venous return can decrease cardiac output and blood pressure.

GI Ulcers and Venous Thromboembolism (VTE)

• Provide prescribed prophylaxis.

• Encourage early mobility when appropriate.

Ventilator Asynchrony

• Occurs when the patient is not breathing in coordination with the ventilator.

• May be related to discomfort, anxiety, or ventilator settings.

Nursing interventions:

• Assess comfort and sedation.

• Collaborate with RT.

• Evaluate ventilator settings

weaning definition

Gradually reducing ventilator support so the patient can resume independent breathing.

Weaning Readiness Criteria

Criteria	Target
SpO₂	≥ 92%
PEEP	≤ 5–8 cm H₂O
FiO₂	≤ 40%
pH	≥ 7.35
Hemodynamics	Stable
Consciousness	Stable/appropriate
Cough	Strong
Secretions	Minimal

Other steps:

• Perform a spontaneous awakening trial (SAT).

• Then perform a spontaneous breathing trial (SBT) lasting 30–120 minutes.

• Formal readiness assessment every 24 hours.

Weaning Process & Post-Extubation Nursing Care

Ventilator support is gradually reduced.

Example from the lecture:

SIMV → Pressure Support Ventilation (PSV) → CPAP

Post-Extubation Nursing Care

• Provide humidified oxygen.

• Monitor for stridor.

• Encourage coughing.

• Encourage incentive spirometry.

• Monitor oxygenation and respiratory effort.

Important: Stridor after extubation can indicate upper airway narrowing or obstruction and needs prompt assessment.

Tracheostomy Care

Nursing Management

Initial Care

• Maintain airway patency.

• Ensure the tracheostomy tube is secure.

• Keep an emergency replacement kit at the bedside.

• The kit should include an obturator and spare tracheostomy tube.

Suctioning

• Use sterile technique.

• Preoxygenate.

• Limit suctioning to 10 seconds or less.

Inner Cannula Cleaning

• If disposable: remove and replace with a new inner cannula.

• If reusable: clean with sterile saline.

Stoma Care

• Clean with mild soap and water.

• Dry thoroughly.

• Replace ties if soiled.

Humidification

• Prevents airway dryness.

• Helps prevent thick secretions.

Tracheostomy Emergency: Accidental Decannulation

If the tracheostomy is LESS than 7 days old:

• Do NOT blindly reinsert the tube because a false passage may develop.

• Call for emergency assistance.

• Maintain oxygenation and ventilation.

• The lecture describes covering the stoma with a sterile dressing and ventilating over the mouth and nose.

If the tracheostomy is MORE than 7 days old:

• Use a sterile obturator to insert the replacement tracheostomy tube.

• If unsuccessful, ventilate through the stoma with a bag-valve mask.

Always:

• Monitor SpO₂.

• Monitor heart rate.

• Assess level of consciousness.

• Maintain the airway until it is secured

Patient Teaching for a Permanent Tracheostomy

Teach the patient to:

• Perform routine cleaning.

• Follow the prescribed tube-change schedule.

• Maintain stoma hygiene.

• Perform suctioning as instructed.

• Use humidification.

• Use a protective shower cover to prevent water from entering the tracheostomy.

• Keep a spare tracheostomy kit at home.

• Recognize signs of infection or airway obstruction.

• Provide writing materials.

• Use communication boards.

• Introduce speaking valves when appropriate and after cuff deflation.

• Support psychosocial adjustment and body-image concerns.

Sudden Hypotension or Tachycardia During Mechanical Ventilation

Possible causes:

• Excessive PEEP → decreased venous return.

• Barotrauma → tension pneumothorax.

• Ventilator disconnection → hypoxemia.

• Sedation effects.

• Shock.

Nursing actions:

1. Assess chest rise and symmetry.

2. Auscultate breath sounds.

3. Unilateral absence of breath sounds may indicate pneumothorax.

4. Assess the ventilator circuit for disconnection or obstruction.

5. Monitor BP, HR, and oxygenation.

If pneumothorax is suspected:

• The lecture directs the nurse to disconnect from the ventilator and manually ventilate with a bag-valve mask.

• Notify the provider immediately.

• Prepare for possible chest tube insertion.

If tension pneumothorax is suspected:

• Emergency needle decompression may be required.

• This is followed by chest tube insertion.

Why is this dangerous?

Increased intrathoracic pressure can decrease venous return and cause obstructive shock.

Accidental Extubation or Decannulation

Recognize the emergency:

• Sudden ventilator pressure loss or alarm.

• Patient coughing or speaking.

• Respiratory distress.

• Visible displacement of ETT or tracheostomy tube.

Nursing priorities:

1. Stay with the patient.

2. Call for help immediately.

3. Restore oxygenation and ventilation.

4. Activate the emergency airway team when needed.

5. Continuously monitor SpO₂, HR, and level of consciousness.

If an ETT is accidentally removed:

• Manually ventilate with a bag-valve mask and 100% oxygen.

• Prepare for rapid re-intubation.

• Activate the emergency airway team.

If a tracheostomy is accidentally removed:

• Less than 7 days old: Do NOT blindly reinsert. Cover the stoma with a sterile dressing and ventilate over the mouth and nose as described in the lecture.

• More than 7 days old: Use a sterile obturator to insert a replacement tube. If unsuccessful, ventilate through the stoma with a bag-valve mask.

Ventilator Alarms and Malfunctions

f you cannot identify or correct the cause of a ventilator alarm within 30 seconds, disconnect from the ventilator and manually ventilate with 100% oxygen.

Alarm	Possible Cause	Immediate Nursing Response
High pressure	Secretions, kinked tubing, biting, bronchospasm	Assess obstruction, suction if needed, check tubing
Low pressure	Disconnection, cuff leak, extubation	Check connections, assess cuff, evaluate tube placement
Apnea	Disconnection, fatigue, sedation	Assess patient, stimulate, initiate manual ventilation if needed
High RR/high volume	Pain, anxiety, hypoxia	Reassure patient, assess sedation and oxygenation

• High pressure = obstruction or resistance.

• Low pressure = leak or disconnection.

• Apnea = patient may not be breathing adequately.

MOST IMPORTANT: Assess the patient before assuming the ventilator is the problem.

Chest Tube Emergencies

If the chest tube becomes disconnected:

1. Submerge the distal end 2–3 cm in sterile water.

2. This temporarily maintains the water seal.

3. Reconnect to the drainage system as soon as possible.

If the chest tube is pulled out:

1. Apply an occlusive dressing taped on THREE sides.

2. Notify the provider immediately.

3. Monitor for respiratory distress.

If the water-seal chamber stops tidaling:

• Assess for kinks.

• Check for dependent loops.

• Consider lung re-expansion.

• Obtain CXR confirmation as appropriate.

Refractory Hypoxemia

Definition: Hypoxemia that persists despite oxygen therapy.

Possible causes:

• ARDS.

• Pneumothorax.

• Pulmonary embolism (PE).

• Sepsis.

Nursing actions:

• Escalate FiO₂ and PEEP according to protocol.

• Notify the provider.

• Prepare for possible intubation and mechanical ventilation.

• Ensure IV access.

• Anticipate ABGs and CXR.

• Prepare for possible transfer to critical care.

ABCO₂: Emergency Respiratory Assessment

Use ABCO₂ to organize your assessment when a patient is experiencing respiratory distress.

Letter	Meaning	Nursing Action
A	Airway	Is it patent? Suction, reposition, or insert an airway adjunct if needed
B	Breathing	Assess rate, depth, effort, and symmetry
C	Circulation	Monitor BP, HR, and skin color; address oxygenation before hypotension worsens
O	Oxygen delivery	Verify equipment, oxygen source, and FiO₂
2	Two steps ahead	Anticipate escalation: RT, provider, or intubation

Emergency Management: Key Takeaways

• Always assess the PATIENT first, equipment second.

• If in doubt, BAG THE PATIENT.

• Manual ventilation is an immediate intervention when adequate ventilation cannot be maintained.

• Recognize early signs of respiratory failure:

  • Rising EtCO₂.

  • Falling SpO₂.

  • Accessory muscle use.

  • Altered level of consciousness.

• Activate rapid response or code early when oxygenation or ventilation cannot be maintained.

• Document interventions and patient outcomes

KNOW THESE NUMBERS

Topic	Value
Normal SpO₂	95–100%
COPD SpO₂ target in lecture	88–92%
Normal EtCO₂	35–45 mmHg
Nasal cannula	1–6 L/min
Simple face mask minimum	6 L/min
Non-rebreather	10–15 L/min
ETT cuff pressure	20–30 cm H₂O
Suction duration	≤ 10 seconds
Maximum suction passes	3 per episode
HOB for NIV/VAP prevention	30–45°
Chest tube drainage to report	>100 mL/hr
PEEP common therapeutic range	5–10 cm H₂O

KNOW THESE CLINICAL CONNECTIONS

• Decreased SpO₂ = assess oxygenation and ventilation.

• Increased EtCO₂ = possible hypoventilation or CO₂ retention.

• Decreased EtCO₂ = possible hyperventilation or poor perfusion.

• Absent EtCO₂ waveform = immediately assess airway and circulation.

• COPD exacerbation = BiPAP may help improve ventilation and CO₂ removal.

• CPAP = one continuous pressure.

• BiPAP = two pressure levels.

• High-pressure ventilator alarm = obstruction or resistance.

• Low-pressure ventilator alarm = leak or disconnection.

• PEEP = keeps alveoli open.

• Kussmaul respirations = compensation for metabolic acidosis.

• Chest tube disconnected = distal end in sterile water temporarily.

• Chest tube pulled out = occlusive dressing taped on three sides.

• New tracheostomy decannulation = do not blindly reinsert.

• Sudden hypotension + unilateral absent breath sounds during ventilation = suspect pneumothorax.

THE BIGGEST PRIORITY RULES

1. Assess the patient before troubleshooting equipment.

2. Airway and breathing come before routine interventions.

3. Do not ignore a sudden change in EtCO₂ or a flat waveform.

4. Do not routinely suction an intubated patient—suction when indicated.

5. Do not routinely clamp chest tubes.

6. If ventilation cannot be maintained, call for help and prepare to manually ventilate.