Ventilation (modes will be in another)

When CO2 rises chemorecepteors send message to the medulla, stimulating

breath

Respiratory Drive

Knowledge to breathe

Respiratory muscles can manage the

unlabored breaths

Lungs and Chest wall have the

stretchability

Early S/S of Hypoxemia

Pallor, cool Dry

Dyspnea, Tachypnea, accessory muscle use

High HR, BP, Dysrhthmias, chest pain

Anxiety, Restless, Confusion, Combative, Fatigue

late S/S of Hypoxemia

Cyanosis, Diaphoreis

Dyspnea, Tachypnea, Acessory muscle use

Bradycardia, hypotensive, chest pain

Anxiety, restless, confusion, combative, solmnolence, coma

A shift to the left in oxyHemoglobin Dissociation Curve is…

Alkalosis

Hypothermia

PRBC

HGB increases affinity for O2

A shift to the right in oxyHemoglobin Dissociation Curve is…

Acidosis

Hyperthermia

Anemia

Low cardiac output

HGB decreases affinity for O2

Concerning SATS

(SAO2-PAO2)

90-60

85-50

75-40

Shift to the Right or to the Left?

58 y. o. patient who has a temperature of 102.9 F, a pH of 7.28, and

an elevated PaCo2.

Right (Release)

Shift to the Right or to the Left?

A patient anxious and hyperventilating; their ABG shows a PaCO2

of 25 and a pH of 7.54

Left (Latch on)

Shift to the Right or to the Left?

Your patient is working hard with Cardiac Rehab, walking around

the unit for the first time after surgery.

Right (Release)

Which of the following conditions is most likely to cause a shift to the right in the OxyHemoglobin Dissociation Curve, indicating lower affinity for oxygen?

Anemia

(FiO2)

Fraction of Inspired Oxygen

0.21-1.00 (21%-100%)

Respiratory Rate (RR) Determined by

(WOB)

PCO2

pH

Tidal Volume (Vt)

4-8ml/Kg of ideal body weight

Volume of a normal breath

Positive End-Expiratory Pressure (PEEP)

Set 5-20 cm H2O

Helps to hold airways open and

improve gas exchange

Total Lung Capacity (TLC)

maximum volume inspired and forcefully expired

Functional Residual Capacity (FRC)

Volume remaining in the lungs after resting expiration

Modes of Mechanical Ventilation

Volume Assist / Controlled

Pressure Controlled

Volume Ventilation

Assist Control / Volume Control (AC/VC, V-AC)

Volume Intermittent Mandatory Ventilation (VIMV)

Pressure ventilation

Pressure Assist/Control

Continuous Positive Airway Pressure (CPAP)

Pressure Support (PSV)

Hybrid Ventilation

Airway Pressure Release Ventilation (APRV)

Pressure Regulated Volume Control (PRVC)

Mechanical Ventilation Troubleshooting Alarms

HIGH

Kings Eat Big Cakes

K – Kinked tubing

E – Excess secretions

B – Biting the tube

C – Coughing

Mechanical Ventilation Troubleshooting Alarms

Low

Cut Cake Everyday

C – Cuff Leak

C – Circuit Disconnect

E – Extubation

Complications part 1:

Displacement of ETT

Unplanned Extubation & Tracheal Injuries

Barotrauma/Volutrauma

VAP

What is a key difference between the ventilator modes AC/VC, V-AC, and V-IMV, IMV, SIMV in terms of how they support breathing?

AC/VC, V-AC always deliver the full tidal volume regardless of patient effort

while V-IMV, IMV, SIMV allow for variation in tidal volume based on the patient's spontaneous breaths

Displacement of ETT

Right main bronchus intubation

get an xray

Unplanned Extubation & Tracheal Injuries

oral care

ET tube repositioing

changing securement device

attempt to self extube

Barotrauma/Volutrauma

• Overdistension of the alveoli from positive pressure ventilation, PEEP, and high Vt

• s/s: high PIP and mean airway pressures, decreased lung sounds,

tracheal shift (tension pneumo), hypoxemia, tachycardia, hypotension

VAP Prevention Bundle:

• HOB 30-45 degrees

• Daily sedation vacation

• Prophylactic DVT

• Peptic ulcer prevention

• Q2 Hr oral hygiene

• Reposition ETT (right/left) daily or Q4 hr

Complciations Part 2:

Dysphagia

Cardiovascular

Gastrointestinal

“Riding the Vent”

“Bucking/Fighting the Vent”

Safety Considerations:

Sedatives, Analgesics, Paralytics

use BIS for sedatives, TOF for paralytics

weaning criteria: Underlying cause for respiratory failure resolving

• Check CXR

• Normal breath sounds

• Minimal secretions

weaning criteria: hemodynamically stable

• Limited use of pressors or no pressors

• Stable HR

weaning criteria: Adequate Respiratory muscle strength

• RR <25

• Spontaneous tidal volume 5ml/Kg

• Minute Ventilation (VE) 5-8L/min

weaning criteria: Adequate Oxygenation

PaO2 >60 and FiO2 <.40

• P/F ratio >150 (ideally >250)

• PEEP < 5-8

SBT- Spontaneous Breathing Trial (SBT)

RT / Provider weans vent settings

• RN titrates sedation

• Patient can follow commands

• Ventilator changed to Pressure Support or CPAP

• Work of breathing and RR per patient

• ABG to follow

• Successful when Pt remains stable for 30-120min

What might the RN expect to be happening in this situation?  Consider the ventilator settings and patient blood gas results, then indicate your interventions to help correct this:

Mode:  bipap/CPAP

FiO2 40%

PEEP (Positive End Expiratory Pressure) 5

PS (Pressure Support) 10

RR (Resp. Rate) 16

 

ABG:

pH 7.32

pCO2 48

pO2 80

HCO3 24

This is respiratory acidosis, so I would increase PEEP and increase the RR

Inspiratory pressure settings are set lower when you are dealing with a patient with healthy lungs T/F

TRUE

In caring for a patient who is being emergently intubated with an endotracheal tube, which complication should the nurse assess for?

Tube placed in the right mainstem bronchus

Oxygen toxicity

Tension pneumothorax

Community-acquired pneumonia

Tube placed in the right mainstem bronchus

If the low-exhaled volume alarm is sounding on a mechanical ventilator, the nurse should:

contact the respiratory therapist to set the tidal volume at a higher level.

assess to see that the ventilator is attached to the endotracheal tube. 

 extubate the patient and ventilate with a bag-valve device.

see whether the patient is biting the endotracheal tube.

assess to see that the ventilator is attached to the endotracheal tube. 

The nurse prepares to suction the endotracheal tube of an intubated patient. Which action is important for the nurse to take?

Keep suction time to less than 10 to 15 seconds. 

 Set the suction vacuum as high as possible.

 Instill normal saline before the procedure.

Avoid hyperoxygenation during the procedure.

Keep suction time to less than 10 to 15 seconds. 

Assess and interpret the following arterial blood gases: pH 7.48, PaCO2 33 mm Hg, HCO2 20 mEq/L, PaO2 85 mm Hg.

Uncompensated respiratory alkalosis; normal oxygenation

When dealing with a vented patient with in-line suctioning, there is no need to wear gloves as all of the tubing for suctioning is contained, thus you will have no contact with their bodily secretions. T/F

FALSE

The nurse is caring for a mechanically ventilated patient with acute respiratory failure. Which intervention is most beneficial in reducing the duration of mechanical ventilation and its complications?

Daily interruption of sedation and assessment of readiness to wean/extubate

Regardless of when a previous ABG was drawn, a new one must be drawn after a spontaneous breathing trial (SBT) T/F

TRUE

Your patients ventilator is alarming "high pressure". What reasons may be the cause of this alarm?

Patient is agitated and fighting the ventilator. 

Patient needs suctioned.
The ET tube is kinked or the patient is biting the ET tube

The nurse is caring for a patient in the ICU. Lab results show a PaCO₂ greater than 45 mm Hg. How should the nurse interpret this?

Respiratory acidosis

If the low-exhaled volume alarm is sounding on a mechanical ventilator, the nurse should:

assess to see that the ventilator is attached to the endotracheal tube

In caring for a patient who is just intubated with an endotracheal tube, which complication should the nurse assess for?

Tube placed in the right mainstem bronchus

The nurse is caring for a patient who has positive end-expiratory pressure (PEEP) as an adjunct to the ventilation. When PEEP is increased, the nurse is prepared for which assessment finding?

A decrease in cardiac output

When performing a spontaneous breathing trial, a RR of 32 for my patient isn't concerning in this case because they have known anxiety and they are really nervous about being in the ICU on a ventilator.  We should proceed with extubation. T/F

FALSE

The charge nurse is reviewing the patients on the critical care floor. Which patients does the charge nurse anticipate as benefiting from noninvasive positive pressure ventilation?

Pulmonary edema

Acute respiratory distress syndrome

Obstructive sleep apnea

Chronic obstructive pulmonary disease exacerbation

Pulmonary edema

Obstructive sleep apnea