Respiratory Management & Mechanical Ventilation

Low Flow Oxygen Devices (4)

• Nasal Cannula

• Simple Face Mask

• Partial Rebreather Mask

• Nonrebreather Mask

Nasal Cannula (3)

• FiO2 - 24-44%

• 1-6 LPM

• Disadvantages - Skin breakdown, drying of mucosa, not for nasal obstructions, polyps, or mucosal edema

Simple Face Mask (4)

• FiO2 - 35-60%

• 5-10 LPM - 5 LPM is minimum to ensure flushing of CO2 from mask

• Disadvantages - < 5 LPM can result in CO2 rebreathing, claustrophobia, skin breakdown, aspiration risk caution

• Nasal cannula during meals

Partial Rebreather Mask (5)

• FiO2 - 60-90%

• 10-15 LPM

• Advantages - Reservoir bag allows rebreathing of 1/3 of exhaled/room air, short term use

• Disadvantages - Complete deflation of bag during inspiration cause CO2 buildup

• Actions - Keep bag from deflating by adjusting O2 flow rate & ensure secure seal

Nonrebreather Mask (4)

• FiO2 - 89-95%

• 10-15 LPM - Must keep bag 2/3 full during inspiration & expiration

• Advantages - Delivers HIGHEST O2 concentration possible (except for intubation), allows inhalation of max O2 from bag, room air does not enter mask (flaps)

• Actions - Assess valve & flap every hour to ensure patency & function

High Flow Oxygen Devices (5)

• Venturi Mask

• Aerosol Mask

• Face Tent

• Tracheostomy Collar

• T-Piece

Venturi Mask (4)

• FiO2 - 24-60%

• 4-15 LPM

• Advantages - Delivers most PRECISE O2 concentration w/o intubation, no humidification needed, best for chronic lung disease

• Disadvantages - Expensive

Aerosol Mask, Face Tent & Tracheostomy Collar (4)

• FiO2 - 24-100%

• At least 10 LPM & high humidification

• Face Tents - Facial trauma, burns, thick secretion, monitor frequently dfue to high humidity

• Actions - Empty condensation from tube often, ensure adequate water in humidification canister, ensure aerosol mist leaves vents during ins/expiration

T-Piece

• FiO2 - 24-100%

• At least 10 LPM

• Advantages - For clients with tracheostomies, laryngectomies, or endotracheal tubes (ET), high humidification (monitor frequently)

• Actions - Ensure exhalation port is open/unconvered, ensure mist is evident during ins/expiration

Define Hypoxemia (2)

• Inadequate level of oxygen in the blood.

• Hypovolemia, hypoventilation, & interruption of arterial flow can lead to hypoxemia.

Define Hypoxia

Decrease in tissue oxygenation.

Hypoxia/Hypoxemia Early Findings (5)

• Tachypnea & tachycardia

• Elevated BP

• Restlessness

• Pale skin & mucous membranes

• Respiratory Distress S/S - Use of accessory muscles, nasal flaring, tracheal tugging, & adventitious lung sounds

Hypoxia/Hypoxemia Late Findings (5)

• Confusion & stupor

• Cyanotic skin & mucous membranes

• Bradypnea & bradycardia

• Hypotension

• Cardiac dysrhythmias

Hypercarbia (Excess CO2) S/S (3)

Restlessness

Hypertension

Headache.

Oxygen Therapy - Nursing Actions (5)

• Place client in SF’s or Fowlers

• Use lowest flow rate possible

• Monitor - RR, rhythm, effort, lung sounds, SpO2

• Oral hygiene, turning, coughing, deep breathing, IS, suction

• Monitor skin

Oxygen Therapy - Complications (3)

• Oxygen Toxicity

• Oxygen-Induced Hypoventilation

• Combustion

Oxygen Toxicity (3)

• Results from high concentrations of O2 (>50), long durtations (>24-48 hrs), & degree of lung disease

• S/S - nonproductive cough, substernal pain, nasal stuffiness, N/V, fatigue, headache, sore throat, & hypoventilation.

• Actions - Monitor ABGs, CPAP & BiPAP prn, PEEP prn

Oxygen-Induced Hypoventilation (2)

• Can occur with COPD or chronic hypoxemia with hypercarbia.

• Actions - Use venturi mask for precise O2 levels

Combustion (4)

• No smoking/Oxygen signs

• Educate on fire hazard & avoid smoking during use

• Keep 5 feet away from heat source

• Avoid petroleum based products, acetone, alcohol etc.

Noninvasive Positive Pressure Ventilation (3)

• Continuous Positive Airway Pressure (CPAP)

• Bi-Level Positive Airway Pressure (BiPAP)

• Transtracheal Oxygen Therapy

CPAP (3)

• Provides positive pressure using a leak-proof mask via a noninvasive positive-pressure ventilation device.

• Keeps airways open & improves gas exchange in the alveoli.

• Most effective for sleep apnea as positive pressure acts as a splint to keep upper airway & trachea open during sleep.

BiPAP (3)

• Machine cycles to provide a set positive inspiratory & expiratory pressure (during inspiration/expiration) to deliver a lower set end expiratory pressure.

• Most often for clients who have COPD & require ventilatory assistance.

• Check percentage of O2 for both inspiratory & expiratory pressure

Transtracheal Oxygen Therapy

Delivers oxygen directly into the lungs via a small, flexible catheter passed through the trachea via a small incision.

Endotracheal Tube & Intubation - Indications (3)

• Tube is inserted through nose or mouth into the trachea for emergency airway management

• Oral intubation is the easiest & quickest form of intubation

• Nasal intubation is performed with facial or oral trauma; NOT used if the client has a clotting problem.

Endotracheal Tube & Intubation - Placement (4)

• CXR verifies correct placement of the endotracheal (ET) tube.

• ET tubes can be cuffed or uncuffed; Cuff on the tracheal end is inflated to ensure proper placement & formation of a seal between the cuff & tracheal wall to prevent air from leaking around the ET tube.

• The seal ensures an adequate amount of tidal volume is delivered by the mechanical ventilator when attached to the external end of the ET tube.

• The client is unable to talk when the cuff is inflated.

Endotracheal Tube & Intubation - Actions (6)

• Resuscitation equipment at bedside including a manual resuscitation bag with a face mask

• Ensure intubation attempts last no longer than 30 seconds & reoxygenate before another attempt

• Monitor vitals & verify ET tube placement by checking end-tidal carbon dioxide levels & CXR

• Auscultate breath sounds bilaterally after intubation & observe for symmetric chest movement.

• Stabilize endotracheal tube with a tube-holding device or secure with tape.

• Monitor for hypoxemia, dysrhythmias, & aspiration.

Mechanical Ventilation (3)

• Provides breathing support until lung function is restored, delivering 100% oxygen that is warmed (body temp 37° C/98.6° F) & humidified at FiO₂ levels between 21-100%.

• Delivered via ET tube & tracheostomy tube

• Cycled based on pressure, volume, time, &/or flow. 

Positive- Pressure Ventilators (2)

• Deliver air to lungs under pressure throughout inspiration to keep alveoli open & prevent alveolar collapse during expiration.

• Benefits - Forced/enhanced lung expansion, improved gas exchange (oxygenation) & decreased work of breathing

Mechanical Ventilation - Potential Diagnoses (12)

1. Hypoxemia, hypoventilation with respiratory acidosis

2. Airway trauma

3. Exacerbation of COPD

4. Acute pulmonary edema due to MI or heart failure

5. Asthma attack

6. Head injuries, CVA, or coma

7. Traumatic Brain Injury

8. Obstructive sleep apnea

9. Acute Respiratory Distress Syndrome (ARDS)

10. Covid-19

11. Respiratory support following surgery (decrease workload)

12. Respiratory support while under general anesthesia or heavy sedation

Mechanical Ventilation - Actions (11)

1. Establish method of client to communication

2. Ongoing Care - Assess placement/position of tube, keep tubing clear or water & empty prn, 2 staff for repositioning

3. Suction oral & tracheal secretions for tube patency & suction tracheal tube to clear secretions from airway

4. Assess respiratory status q1-2 hrs, monitor vent settings hourly

5. Have a manual resuscitation bag with a face mask available & reintubation equipment at the bedside at all times

6. Monitor Ventilator Alarms

7. Verify provider prescription each shift (rate, tidal volume, mode, adjuncts, PIP)

8. Maintain adequate (not excessive) volume in cuff of endotracheal tube.

9. Administer meds prn - analgesics, sedatives, neuromuscular blocks, antibiotics

10. Reposition oral endotrach tube q24h & perform oral care q12h

11. Assess GI function q8h

Mechanical Ventilation - Weaning Actions (8)

• Continually monitor during weaning process & watch for signs of weaning intolerance.

• Respirations > than 30/min or < than 8/min

• BP or HR changes more than 20% of baseline

• SaO₂ less than 90%

• Dysrhythmias, elevated ST segment

• Significant decrease in tidal volume

• Labored respirations, increased use of accessory muscles, & diaphoresis

• Restlessness, anxiety, & decreased LOC

Mechanical Ventilation - Extubation Actions (8)

• Suction the oropharynx & trachea.

• Deflate cuff on endotracheal tube & remove tube during peak inspiration.

• Following extubation, monitor for signs of respiratory distress or airway obstruction (ineffective cough, dyspnea, stridor).

• Assess SpO₂ & vitals every 5 min.

• Encourage coughing, deep breathing, & use of IS

• Reposition client to promote mobility of secretions.

Older a=Adult - Considerations (3)

• Decreased respiratory muscle strength & chest wall compliance

• More susceptible to aspiration, atelectasis, & pulmonary infections.

• Require more frequent position changes to promote mobility of secretions. 

Ventilator Alarms (5)

• Signal if client is not receiving correct ventilation & must never turn off

• There are three types of ventilator alarms.

• Volume (low pressure) alarms - indicate a low exhaled volume due to a disconnection, cuff leak, &/or tube displacement.

• Pressure (high pressure) alarms - indicate excess secretions, client biting tubing, kinks, coughing, pulmonary edema, bronchospasm, or pneumothorax.

• Apnea alarms - indicate ventilator does not detect spontaneous respiration

Cuff Pressure (4)

• Assess cuff pressure q8h

• Maintain cuff pressure below 20 (or 20-30 cm H₂O) to reduce risk of tracheal necrosis.

• Assess for an air leak around cuff (client speaking, air hissing, or decreasing SaO₂).

• Inadequate cuff pressure can result in inadequate oxygenation &/or accidental extubation.

Mechanical Ventilation - Meds (4)

• Analgesics - morphine & fentanyl

• Sedatives - propofol, diazepam, midazolam, & haloperidol; Require sedation/paralytic agents to prevent competition between extrinsic & intrinsic breathing & the effects of hyperventilation

• Neuromuscular blocking agents - pancuronium, atracurium, & vecuronium; Paralyze muscles, but do not sedate or relieve pain.

• ​​​​​​​​​​​​​​​​​​​​​Antibiotics - infections

Modes of Ventilation (6)

• Assist-Control (AC)

• Synchronized Intermittent Mandatory Ventilation (SIMV)

• Inverse Ratio Ventilation (IRV)

• Airway Pressure Release Ventilation (APRV)

• Independent Lung Ventilation (ILV)

• High Frequency Ventilation

AC (3)

• Preset rate & tidal volume. Client initiates breath & ventilator takes over for the intubated client.

• Hyperventilation can result in respiratory alkalosis.

• Client can require sedation to decrease respiratory rate.

SIMV (4)

• Preset rate & tidal volume for machine breaths.

• Client initiates breath & tidal volume will depend upon client’s effort.

• Ventilator initiated breaths are synchronized to reduce competition between ventilator & client.

• Used as a regular mode of ventilation or a weaning mode (rate decreased to allow more spontaneous ventilation)

• Can increase work of breathing, causing respiratory muscle fatigue.

IRV (4)

• Lengthens inspiratory phase to maximize oxygenation in the intubated client.

• Used for hypoxemia refractory to PEEP.

• Uncomfortable for clients & requires sedation &/or neuromuscular blocking agents.

• High risk of volutrauma & decreased cardiac output due to air trapping.

APRV (4)

• Allows alveolar gas to be expelled by the lungs own natural recoil

• Time-triggered & pressure-limited

• Breaths can be initiated spontaneously or by ventilator

• Causes less ventilator-induced lung injury & fewer adverse effects on the cardiovascular system

ILV (3)

• Double-lumen ET tube allows ventilation of each lung separately.

• Used for clients who have unilateral lung disease.

• Requires 2 ventilators, sedation &/or use of neuromuscular blocking agents.

High Frequency Ventilation (4)

• Delivers small amount of gas at rates of 60-3,000 cycles/min.

• High frequency ventilation often used in children.

• Client must be sedated &/or receiving neuromuscular blocking agents.

• Breath sounds difficult to assess.

Adjunctive Therapy - PEEP (4)

• Preset pressure delivered during expiration.

• Added to prescribed ventilator settings to treat persistent hypoxemia.

• Improves oxygenation by enhancing gas exchange & preventing atelectasis.

• Amount of PEEP added is typically 5-15 cm H₂O.

Weaning Modalities (2)

• PRESSURE SUPPORT VENTILATION (PSV)

• CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP)

PSV - Weaning (4)

• Works to keep alveoli from collapsing during expiration & allows for greater oxygenation making work of breathing easier.

• Allows for lower levels of FiO₂ to be used.

• Can be used with IMV or AC modes to treat or prevent atelectasis.

• Settings 5-20 cm H₂O (> 20 can cause lung damage).

CPAP - Weaning (2)

• Positive pressure supplied during spontaneous breathing. No ventilator breaths delivered unless in conjunction with SIMV.

• Risks include volutrauma, decreased cardiac output & ICP.

Mechanical Ventilation - Complications (7)

1. Barotrauma - Damage to the lungs by positive pressure; Can occur due to a pneumothorax, subcutaneous emphysema or pneumomediastinum.

2. Volutrauma - damage to the lungs by volume delivered from one lung to the other

3. Fluid Retention - Due to decreased CO, activation of renin-angiotensin-aldosterone system, &/or ventilator humidification; Monitor I&O, weight, breath sounds & endotrach secretions

4. O2 Toxicity - Results from high concentrations of O2 (> than 50%), long durations of use (> 24-48 hr), &/or degree of lung disease

5. Hemodynamic Compromise - MV increases risk of increased thoracic pressure (positive pressure), which can result in decreased venous return.

6. Aspiration - Keep HOB elevated 30 at all times, check residuals q4h if enteric feeds

7. Infection - RT ventilator intubation or suction, monitor for fever, change in sputum color, consistency, quantity, crackles, rhonchi, WBCs, aseptic technique during suctioning

O2 Toxicity - Findings (6)

• Fatigue

• Restlessness

• Severe dyspnea

• Tachycardia & tachypnea

• Crackles

• Cyanosis.

Hemodynamic Compromise - Findings (6)

• Tachycardia

• Hypotension

• Urine output < 30 mL/h

• Cool, clammy extremities

• Decreased peripheral pulses

• Decreased LOC