MS SL Advanced Airway Management

Why is oxygen administration a dependent nursing action?

It needs a doctor's order before a nurse can give it. In an emergency a nurse can start it, but the doctor must document the order afterward.

What can happen if a nurse gives emergency oxygen and it never gets charted by the doctor afterward?

The nurse can be charged with malpractice.

What are the earliest and latest signs of hypoxia?

Earliest sign: restlessness. Late sign: cyanosis.

Nasal cannula: flow rate and O2 concentration?

1 to 6 LPM, delivering about 21 to 45% O2.

Why must the nares be cleaned every 8 hours with a nasal cannula?

The device dries the nasal mucosa.

Why is nasal cannula the preferred low-flow device for COPD patients?

Low-flow O2 stimulates breathing without inhibiting the hypoxic drive.

Simple face mask: flow rate and O2 concentration?

5 to 10 LPM, delivering 40 to 60% O2

Why is a simple face mask contraindicated in a CO2-retaining patient?

It doesn't prevent rebreathing of exhaled CO2.

Partial rebreathing mask: flow rate, FiO2, and how does its valve work?

6 to 10 LPM, 60 to 90% O2. A two-way valve lets one-third of exhaled air return to the bag and two-thirds vent to the atmosphere

Non-rebreathing mask: flow rate, FiO2, and valve type?

10 to 15 LPM, 80 to 90% O2. A one-way valve lets the patient inhale oxygen while blocking CO2 accumulation. The reservoir bag must stay inflated.

How does a Venturi mask deliver such a precise FiO2?

Color-coded entrainment ports mix room air with oxygen in a fixed ratio, giving a precise FiO2 of about 24 to 50% based on flow.

High-flow nasal cannula (HFNC): flow rate, FiO2, and key uses?

50 to 60 L/min at up to 100% FiO2. Non-invasive and as effective as mechanical ventilation without intubation. Used in hypoxemic respiratory failure, hypercapnia, and COVID-19.

What is a face tent, and what FiO2 range does it deliver?

A device that fits under the chin and sweeps around the face, delivering about 21 to 50% O2.

What is an O2 hood used for, and what nursing consideration goes with it?

Mainly used for infants, delivering close to 100% O2. Cluster nursing activities to prevent oxygen from escaping.

What is a croupette, and what side effect of its humidification should you watch for?

A tent for children that allows freedom of movement in bed or crib. Humidification can leave clothing and linens damp.

What are the three basic oxygen devices and their maximum deliverable concentrations?

Nasal cannula (up to 40%), simple face mask (up to 60%), and Venturi mask (up to 50%).

What distinguishes basic from advanced airway management?

Basic only accesses the upper respiratory tract and needs the client's spontaneous breathing. Advanced accesses the lower respiratory tract, uses positive pressure and a machine, and is for airway obstruction.

What are the two exceptions that give passive but patent airway access without being classified as oxygen delivery devices?

The nasal trumpet and the oral airway.

How is a nasopharyngeal airway (nasal trumpet) measured, how long can it stay in, and who is it for?

Measured earlobe to nose. Used for up to 5 to 7 days only, in conscious patients, to bypass a nasopharyngeal obstruction.

Why can a nasal trumpet only stay in for 5 to 7 days?

It is a foreign object that can harbor infection.

How is an oropharyngeal (oral) airway measured and inserted, and who is it used for?

Measured from the corner of the mouth to the oropharynx, inserted sideways then rotated 90 to 180 degrees. Used for unconscious patients, since it would trigger the gag reflex in a conscious one.

Why might an oral airway be added for a mechanically ventilated patient?

To stop the patient from biting and obstructing the softer ET tube.

Summarize the three advanced-airway indications: inability to oxygenate, ventilate, and maintain airway.

Oxygenate: PaO2 below 60 mmHg (hypoxia, e.g. CHF, ARDS). Ventilate: PaCO2 above 55 mmHg (hypercarbia, e.g. asthma, COPD, ARDS, anaphylaxis). Maintain airway: GCS 8 or less (obstruction, e.g. spinal cord injury, encephalitis, meningitis, anaphylaxis).

What is a laryngeal mask (supraglottic airway), and how does it differ from an ET tube?

It sits above the trachea; its cuff is a seal, not an anchor. It's shorter than an ET tube and keeps the esophagus closed while the glottis stays open, allowing airway access.

What is an esophageal mask (retroglottic airway) used for?

A temporary airway used when intubation is difficult, playing a similar role to a laryngeal mask but seated in the esophagus.

How long can an ET tube stay in before a tracheostomy is considered?

Up to 14 days. A tracheostomy is suggested if ventilatory support is needed beyond that.

Who performs intubation, and what does the nurse do?

Physicians intubate; nurses assist.

How long should you pre-oxygenate a patient with an ambu bag before intubation?

Up to 1 minute.

During intubation, which side of the tongue does the laryngoscope go over, and which way is the tongue displaced?

Over the right side of the tongue, displacing it to the left.

At what angle is the laryngoscope handle held, and in what direction do you lift?

45 degrees, lifting up and away (not rocking back) to expose the vocal cords and laryngeal opening.

Where should the ET tube markings sit for the average adult once placed?

Between 21 and 24 cm.

How much air typically inflates the ET tube cuff after placement?

About 10 cc, or per the manufacturer's instructions.

What oxygen flow rate is used to bag-ventilate right after intubation, before confirming placement?

12 to 15 L/min via the bag-valve device.

Where should you auscultate to confirm correct ET tube placement?

Lung apices, axillae, and stomach. Breath sounds should be bilateral.

If the ET tube is too far in and only the right lung is being ventilated, what do you do?

Deflate the cuff, withdraw the tube 2 to 3 cm, reinflate the cuff, and recheck placement.

Is the ET tube cuff meant to anchor the tube in place?

No. It's inflated for a minimal leak/seal, not to anchor the tube.

What can under- or over-inflation of the ET cuff cause?

Asymmetrical inflation leading to tracheomalacia from necrosis (erosion) of tracheal cells.

List the steps of suctioning in order.

Wash, Prepare, Explain, Assess, Gloves, Oxygenate, Suction, Reassess, Repeat steps 6 to 7 as needed, Document.

Should you hyperoxygenate or hyperventilate before suctioning, and why?

Hyperoxygenate. It's needed to prevent hypoxemia, irregular heart rhythms, and lung collapse during suctioning.

What does the FDAR charting format stand for when documenting suctioning?

Focus (the nursing diagnosis), Data (assessment findings), Action (what was done), Response (the patient's outcome after the action).

What do the letters in ISBAR stand for?

Introduction, Situation, Background, Assessment, Recommendation.

In ISBAR, what goes in the Situation section?

A brief description of the patient's current condition or the event that led to the call.

In ISBAR, what goes in the Background section?

Relevant background, such as the patient's diagnosis or recent events leading up to the current situation.

Why should a nurse repeat a doctor's recommendation back to them during an ISBAR call?

To confirm the order was received and understood correctly.

What is Minute Volume (MV) and how is it calculated?

The total volume of air moved per minute. MV = Tidal Volume (TV) x Respiratory Rate (RR).

What is the normal tidal volume per kilogram of body weight?

6 to 8 mL per kg of body weight.

What does FiO2 mean, and what is its normal room-air value?

Fraction of Inspired Oxygen, the concentration of O2 delivered. Normally 21% in room air.

What is PEEP, and what is its normal range?

Positive End-Expiratory Pressure, the pressure kept in the lungs after exhalation during mechanical ventilation. Normally 5 to 10 cm H2O.

What's the difference between Pressure Support (PS) and Peak Inspiratory Flow (PF)?

PS is a set amount of positive pressure added during inhalation to assist the patient. PF is the fastest speed at which air enters the lungs.

Why is FiO2 often started high and then weaned down?

To prevent oxygen toxicity and begin weaning the patient off the ventilator.

What is Peak Inspiratory Pressure (PIP/Paw), and what's its normal range?

The highest pressure measured in the airway during a breath. Normal is 10 to 20 cm H2O.

What typically causes a LOW pressure alarm (below 10)?

A leak: disconnected tubing, a busted cuff, or a deflated balloon.

What typically causes a HIGH pressure alarm (above 20)? Give the mnemonic.

Obstruction. Remember PBSCK: Pneumothorax, Bronchospasm, Secretions, Cough, Kink.

What's the difference between pressure-cycled and volume-cycled ventilation?

Pressure-cycled delivers air until a preset pressure is reached, then cycles to expiration, and varies with lung compliance. Volume-cycled delivers a preset tidal volume, then cycles to expiration.

What's the difference between positive-pressure and negative-pressure ventilation?

Positive pressure actively pushes air into the lungs via the airway (modern ventilators). Negative pressure creates a vacuum around the body to pull air in (e.g. the iron lung — older, obsolete).

By approach, what two broad categories does ventilation fall into, and what do they share?

Invasive versus non-invasive airway establishment. Both use positive pressure.

Compare non-invasive and invasive ventilation on sedation, speaking, eating, and infection risk.

Non-invasive: not sedated, can speak, can eat, low infection risk. Invasive: sedated, can't speak, can't eat (may need NGT/PEG), high infection risk, increased bleeding risk, barotrauma risk.

In Controlled/Continuous Mandatory Ventilation (CMV), who controls inspiration and expiration?

The machine controls both. Used for patients with no spontaneous breathing.

In Assist-Control (A/C) mode, who triggers breaths and who is it used for?

The patient triggers inhalation, but the machine controls exhalation and delivers a backup rate/volume if the patient doesn't breathe enough on their own. Used for patients who can exert little effort but can't breathe alone.

In SIMV, what can the patient do between machine breaths?

Breathe spontaneously, at volumes that may differ from the machine-set breaths.

In Pressure Support Ventilation (PSV), who controls rate, flow, and tidal volume?

The patient controls all three. Used for awake, stable patients who can breathe spontaneously.

What does CPAP do, and how does pressure compare between inspiration and expiration?

Applies the same positive pressure through the whole respiratory cycle, keeping alveoli open at end-expiration to improve oxygenation.

What is BiPAP, and how does it differ from CPAP?

Bilevel Positive Airway Pressure — uses two pressure levels: higher during inspiration, lower during expiration.

What is Pressure-Regulated Volume Control (PRVC)?

A hybrid mode that delivers a preset tidal volume at the lowest possible airway pressure, never exceeding a preset maximum pressure.

What is Airway Pressure Release Ventilation (APRV)?

Two different CPAP pressure levels are applied for set periods of time, allowing spontaneous breathing to occur at both levels.

In the mode-comparison table, which mode has the machine controlling BOTH inspiration and expiration?

Only CONTROL (CMV) mode.

Which mode has the patient triggering inspiration while the machine controls expiration?

Assist-Control (A/C).

Which two modes have the patient controlling both inspiration and expiration, with a variable minute volume?

SIMV and PSV.

What does Cstat (static compliance) measure, and what does a HIGH value mean?

How compliant/expandable the lungs are. A high Cstat means the lungs are more expandable (a good thing).

What does Rinsp (inspiratory resistance) measure, and what does a HIGH value mean?

How patent the airway is. A high Rinsp means there is obstruction; the goal is a low Rinsp.

Compare normal, ARDS, and COPD values for Cstat and Rinsp.

Normal: Cstat 50 to 60, Rinsp 10 to 15. ARDS: Cstat 35 to 45 (low), Rinsp 10 to 15. COPD: Cstat 50 to 70 (normal), Rinsp 15 to 30 (high).

Why is Cstat lower in ARDS while Rinsp is higher in COPD?

ARDS is primarily a lung-compliance problem (stiff lungs). COPD is primarily an obstruction problem (airway resistance), not a compliance problem.

What ventilator complication results from prolonged high pressure and volume?

Barotrauma.

Why are ventilated patients often placed on PPIs or given antacids?

To prevent stress ulcers caused by compressed GI arteries and the stress response of prolonged ventilation.

How does a high tidal volume affect blood pressure, and by what mechanism?

It can cause hypotension, via vasovagal stimulation: vagus nerve activation leads to parasympathetic activation.

What is bucking on the ventilator, and how is it managed?

Asynchrony between the patient and the ventilator (e.g. the patient exhales while the machine pushes air in). Managed by teaching a conscious patient to synchronize with the vent, or by sedation.

What is VAP, and within what time frame can it occur?

Ventilator-Associated Pneumonia, which can occur within 48 hours. Prevented with strict aseptic technique, keeping tubing/condensation dry, and weaning as soon as possible.

What causes tracheomalacia in ventilated patients, and how is it prevented?

Under- or over-inflation of the ET cuff causing tracheal erosion. Prevented with proper cuff placement/sealing and the minimal-air (not overinflating) technique.

What does the mnemonic PBSCK stand for in high-pressure alarms?

Pneumothorax, Bronchospasm, Secretions, Cough, Kink.

For a high-pressure alarm caused by decreased compliance (pneumothorax/hemothorax), what's the intervention?

Needle aspiration or chest tube insertion.

For a high-pressure alarm caused by increased resistance (bronchospasm/wheezing), what's the intervention?

Nebulize the patient and consider the ET tube size.

What are the common causes of a LOW-pressure alarm?

Tube disconnection, self-extubation, a cuff leak (suspect if the patient can talk, or the pilot balloon is flat), or the patient stopping spontaneous breathing on SIMV/CPAP.

How do you manage a patient who is biting the ET tube?

Insert an oral airway or bite block, which is thicker and larger than the tube, to prevent occlusion.

What conditions cause bronchospasm-related ventilator alarms, and what's the treatment?

COPD, asthma, emphysema, and bronchitis; treated with bronchodilators and nebulization. Wheezes and rhonchi are heard on auscultation.

What is the most common cause of a high-pressure alarm from coughing?

Secretions or a blockage in the tubing. Check for secretions and suction accordingly.

How should condensation and water buildup in ventilator tubing be managed?

Drain the water, since it can cause obstruction. The humidifier deliberately adds moisture to prevent dry-air airway irritation, so some buildup is expected.

On the lung/trachea color troubleshooting diagram, what does a RED trachea with normal-colored lungs indicate?

A resistance problem from bronchoconstriction: high Paw, high Rinsp, possible obstruction.

On the troubleshooting diagram, what do RED lungs with a normal-colored trachea indicate?

A lung-compliance problem: low Cstat, low Rinsp, possibly pneumothorax or pulmonary edema.

On the troubleshooting diagram, what does it mean if BOTH the trachea and lungs are shown red?

A combined problem affecting both resistance and compliance: high Rinsp, low Cstat, high Paw.

What does confusion in a ventilated patient usually indicate, and is it early or late?

Hypercarbia (from decreased ventilation); it's a late sign of acidosis.

What do tachypnea and diminished breath sounds each usually indicate?

Tachypnea: hypoxia and hypercarbia (rapid, shallow breathing). Diminished breath sounds: obstruction and hypercarbia (air isn't passing through).

Why does tachycardia occur in a hypoxic or hypercarbic patient?

It's a compensatory mechanism: the heart beats faster so hemoglobin can deliver more oxygen to the tissues.

What causes cramps in a patient with hypercarbia?

Lactic acidosis.

A patient has RR 32, diminished breath sounds, and can't expectorate secretions. What's the nursing diagnosis?

Ineffective airway clearance related to inability to expectorate secretions.

A patient has wheezing, crackles, and an ABG showing respiratory acidosis (CO2 55, HCO3 16, O2 91%). What's the priority nursing diagnosis, and why?

Impaired gas exchange related to alveolo-capillary changes, because the confirmed respiratory acidosis is the more encompassing, graver problem than a breathing-pattern diagnosis.

Why should a nursing diagnosis avoid using a sign like wheezing as the etiology itself?

A sign like wheezing is data, not a cause. Write the actual underlying mechanism, such as bronchospasm, as the etiology instead.

What is V/Q mismatch, and what does a HIGH V/Q mismatch mean?

Ventilation-perfusion ratio. High V/Q means high ventilation but low perfusion: air reaches the alveoli, but blood flow doesn't match it.

What does a LOW V/Q mismatch mean?

Low ventilation but high perfusion: blood is present, but air isn't reaching it.

What Rapid Shallow Breathing Index (RSBI) value suggests a patient is ready for extubation?

Below 105.

Who performs extubation, and what is the nurse's role?

Only doctors perform extubation (at UST, whoever inserted the tube removes it). Nurses assess the patient for successful weaning and readiness for extubation.