Mechanical Ventilation and ECMO

Continuous positive airway pressure (CPAP) (noninvasive)

delivers pressure continually during spontaneous breathing

Positive pressure increases alveoli capacity, function

Treats OSA

Added pressure increases breathing work since pt forcibly exhales against pressure delivered by it

For a client to be a candidate for CPAP

Pt must independently remove mask due to vomiting and aspiration risk

Pt must maintain own airway

Those w/ high or copious secretion amounts, generally not good candidates for CPAP

Bilevel Positive Airway Pressure (BiPAP)

Delivers positive pressure at 2 levels. 

There’s higher inspiratory pressure, lower expiratory pressure

Ofter used for pt w/ COPD, HF, respiratory failure, sleep apnea.

Like CPAP

those w/ high secretions are not candidates for BiPAP (aspiration risk). 

Those w/ low mental status not good candidates- may not have ability to remove mask (aspiration risk like emesis)

Invasive Mechanical Ventilation

Increase PaO2

Decrease PaCO2

Respiratory muscle rest

Control/Assist ventilation

For Pt unable to protect their airway, invasive mechanical ventilation may

provide adequate respiratory effort or ventilation

Artificial airway known as endotracheal tube or ETT inserted by provider 

Role of nurse

Assist with intubation

Meds

VS

Identify ventilator complications

Check ETT placement

Assess airway patency, lungs, weaning

Suction

Communication

Intubation supplies & Team

Laryngoscope w/ blades, Macintosh/Miller

ETT – size per provider

10 mL syringe

Sedation meds

Team:

Respiratory therapist

Possibly CRNA

Intubation Steps

Immediately after placement, inflate cuff to allow breaths to enter lungs and not leak around ETT back out mouth. 

Ventilate with ambu-bag.

Placement confirmed with end tidal CO2 detector, color change indicates CO2 presence

Auscultate lungs for equal bilateral air

Auscultate epigastrium for absence of air in stomach.

Observe chest wall movement that should be equal and symmetrical.

Note SpO2- should improve, stabilize.

CXR is final confirmation that ETT in place

Part of your assessment will be ETT size, and

how far it’s inserted related to pt’s anatomy. 

Ex: ETT is 22 cm at teeth. So the point where ETT is even with teeth, is 22 cm length marking.

Pilot balloon is where air inserted to inflate cuff which is at end of tube that’ll be in trachea.

The obturator is

a smooth guide to help insert tube. Once inserted it’s removed. 

Obturator kept in case of dislodgement to help insert replacement tube

Tracheostomies

are inserted into neck bypassing mouth & nose. 

Both tracheostomy & endotracheal tubes have pilot balloon and cuff to occlude airway around tube

Tracheostomies much shorter, and size is selected by provider to best meet pt needs

Once a tracheostomy is inserted

Cuff must be inflated then auscultate breaths

Use end tidal CO₂ capnography to ensure color change

Pass suction tube through trach then remove ETT

Once these things confirms placement, secure tube to prevent dislodgement

Once secured, obtain CXR

Items to keep at bedside for obstruction/dislodgement

•Resuscitation bag

•Tracheostomy tube

•Tracheostomy insertion tray

•Obturator

Steps after dislodgment

•Ease tube back into place then re-secure w/ tracheostomy ties

•If necessary, insert obturator & replace tracheostomy tube, then remove obturator

Full Support Mode of Ventilation:

•Assist Control (A/C)

Assists each breath by providing volume or pressure, depending on setting

If RR fall below predetermined setting, ventilator will take over/Control ventilation

Partial Support Mode of Ventilation:

•Synchronized Intermittent Mandatory Ventilation (SIMV

Gives ventilation in conjunction with pt own inspiratory efforts, not all breaths supplemented

Preset rate ensures mandatory delivery of preset number of breaths at fixed tidal volume

Pt can trigger spontaneous breath w/ volume determined by patient effort

Spontaneous Modes of Ventilation:

•Pressure Support Ventilation or CPAP (Continuous Positive Airway Pressure

RR, tidal volume, inspiratory times determined by Pt, not pre-set by ventilator machine.

Spontaneous modes require pt to initiate breath so pt should be awake and alert

FiO2

Fraction of inspired O2 describes percentage of O2 present in air provided to pt

PEEP

Positive end-expiratory pressure applied from ventilator to airways at end of expiration. 

Prevent atelectasis by keeping alveoli open.

Pressure Support (PS):

Preset pressure level that’s delivered when pt initiates breath to make breathing easier

Rate

Setting that indicates lowest RR per minute that pt can maintain before ventilation support begins

May determine number of respirations provided by ventilator

Tidal Volume

Amount of air moved into/out of lungs w/ each respirations

Ventilator alarms are important to

detect problem w/ ventilator or problem w/ pt

If alarm, immediately check Pt & equipment

If problem not quickly determined, disconnect Pt from ventilator & provide manual breaths w/ ambu bag

Call HELP, continue ventilating Pt til help arrives

High pressure

From ventilation circuit.

Coughing- relieved by suctioning, breathing asynchronous to ventilator, condensation buildup drained into collection bag

Kinked tubing- pt lying on tubing, increased resistance (bronchospasms), decreased lung compliance (pulmonary edema)

ARDS, Atelectasis, Tension pneumothorax- may require interprofessional interventions like changes in ventilator settings or Meds

Low Pressure

From decreased pressure in ventilation circuit. 

Like disconnection of ventilator tubing

Accidental Extubation

If tubing disconnects, reconnect tubing and twist to make connections tighter

With both high- and low-pressure alarms

think what may cause change in pressure in circuit. 

Circuit should be closed from ventilator to pt lungs. 

Anything that decreases size like resistance of tubing will increase pressure.

Anything that causes pressure to leak will trigger low pressure alarms

Apnea

Alarm sounds when ventilator doesn’t sense breathing.

There are modes that don’t have set RR and all breaths initiated by Pt like PSV. 

If pt develops respiratory arrest, apnea alarm sounds

If pt is over-sedated suppressing respirations, apnea alarm sounds if time between breaths too long. 

Apnea may require provider to change ventilator setting to mode w/ preset rate

For over-sedated client, titrating sedation down may be needed

High Vt or RR

This alarm generally means pt breathing too fast. 

Pain, anxiety- hyperventilation. 

Conditions that increase metabolic demand (infection, fever) can trigger alarm along w/ hypoxia or hypercapnia. 

Treat underlying condition!!!

Anxiety- verbal coaching to slow RR, improve compliance w/ ventilator. 

Hypoxia, Hypercapnia may require ventilator setting changes.

Low Vt (tidal volume)

Similar to low pressure but senses volume. 

Circuit should be closed.

If low volume, then volume is leaking out such as disconnected tubing, circuit leak, cuff leak (ETT), tracheostomy tube 

Reconnect tubing or consult respiratory therapist to assess and resolve air leak to alleviate alarm

Cardiovascular complications

Increased intrathoracic pressure w/ mechanical ventilation can increase pressure on heart = low CO

Also added pressure on great vessels = Low Venous return.

Retention, hemodynamic imbalance

Pulmonary complications

Increased pressure causes, Barotrauma- rupture of lungs from added pressure.

In same way, lungs rupture from high volume of air delivered by ventilator causing volutrauma.

If volume insufficient or not enough PEEP, pt may experience atelectasis.

Oxygen toxicity due to

high FiO2 (over 50%) more than 24-48 hours

Causes -

Fatigue

Restlessness

NV

Coughing

Dyspnea

Hypoxia refractory from increased O2

Cyanosis

To avoid developing oxygen toxicity

give lowest amount of oxygen to keep the SpO2 > 90% or PaO2 > 60 mm Hg. 

Never compromise oxygenation due to risk of oxygen toxicity. 

If pt requires increased oxygen, then pt should receive increased oxygen.

The number one way to prevent VAP

is to remove ventilator! 

Pt can’t develop VAP if NO ventilator. 

Minimize sedation only to what pt needs based on CPOT & RASS assessments.

Recognizing and working with pt to remove ventilator as soon as no longer needed will lower VAP risk

Nurses help prevent infections by

Elevating HOB, perform ROM exercises, oral care, assess, clean skin frequently

Give prescribed Meds that provide prophylaxis against formation of peptic ulcers

Ensure nutritional needs met by communicating w/ interprofessional team about manifestations of malnourishment

Nurses are responsible for

implementing tube feeds via an NG, PEG tube.

If non-functioning gut develops, administer TPN as ordered

Daily, the client will undergo

spontaneous breathing trial & sedation vacation if hemodynamically stable

Helps determine pt’s readiness for ETT removal.

A process called weaning

Takes place, readiness determined by meeting pre-established criteria.

Respiratory therapist should be present.

Can take place over days to weeks.

Extracorporeal membrane oxygenation (ECMO)

is modality of cardiopulmonary support delivered in ICU.

Blood removed from circulatory system, pulled outside pt’s body by mechanical pump,

Passed through oxygenator & heat exchanger, leaves Hgb oxygenated, removes (CO₂).

Blood reinfused back to Pt

Nurse’s role in managing a client receiving ECMO

Assessment, preventive care, timely communication.

Bleeding potentially life-threatening due to platelet-damaging effects of therapy.

Nurse’s responsibility- give heparin as ordered, monitor coagulation-related lab values.

Platelet remain above 150,000

Fibrinogen greater than 200 mg/L, < 1.5 prothrombin ratio,

Activated clotting times 180-240 seconds.

Monitor invasive sites and dressings for bleeding.

In ECMO the client has an established risk of

thrombus formation, developing heparin-induced thrombocytopenia (HIT).

Be aware of clinical manifestations of internal hemorrhaging (low perfusion) like:

Hypotension

Tachycardia

Low urine output

Low central venous pressure.

Types may include Gastrointestinal, Intercranial

The client is at risk for neurological (ECMO)

changes from upper body hypoxia, pt may present with seizures from infarctions. Regularly monitor neurological function and hemodynamic changes

Renal failure and oliguria, which

may lead to dialysis, which is a concern for pt who receiving ECMO.

Monitor urine output, electrolytes, metabolic panel, to identify trends indicating renal impairment.

Sepsis

a concern for pt receiving ECMO

Monitor WBC counts and VS against SIRS (Systemic Inflammatory Response Syndrome) criteria to facilitate early risk factors associated w/ sepsis

In ECMO to help prevent pulmonary complications,

suction secretions every 4 to 6 hr as needed, perform frequent position changes.

Manage blood transfusions if hgb levels drop below 8 g/dL.

Be responsible for transfusing of TPN to assist w/ maintaining nutrition, fluid & electrolyte levels.

Meds

Cistracurium/Rocuronium- give with sedation meds

Midazolam/Lorazepam- monitor LOC, sedated before NMB(Cistracurium/Rocuronium)

Propofol/Dexmedetomidine- sedation for mechanical ventilation, titrate to RASS

Pantoprazole- peptic ulcer, VAP prevention

Enoxaparin- VAP prevention

Albuterol- monitor HR, BP