Week 11 Respiratory care modalities: care of the artificially ventilated patient

ventilator modes will be on exam i think. alarms too

Do you need an order to administer oxygen?

yes, it is a medication

Oxygen is administered at what concentrations?

21% (higher than room air)

How long does it take for brain damage to occur d/t no/low oxygen?

3 minutes

Goal with oxygen therapy

• decrease workload of heart and lungs

• increase tissue perfusion

• adequate transport of oxygen

• adjuvant for pain relief

How much oxygen does nasal cannula deliver low flow?

• 1-2 L/min= 24-28%

• 3-5 L/min= 32-40%

• 6L/min= 44%

Which form of oxygen therapy is better tolerated by children?

nasal cannula high flow

10L/min= 65%

15L/min= 90%

How much oxygen does Simple Mask deliver?

low flow 5-8L/min= 40-60%

Nursing interventions for Simple Mask

may need nasal cannula at meals

vents for exhaled CO2 claustrophobia

How much oxygen does Partial Rebreather mask deliver?

low flow 8-11L/min= 50%-75%

Nursing interventions for Partial Rebreather mask

• watch for kinks in bags, tubing, skin checks

• helps conserve oxygen- exhaled air trapped in bag and mixes with oxygen

How much oxygen does Nonrebreather mask deliver?

low flow 10-15L/min= 80%-95%

Nursing interventions for Nonrebreather mask

delivers the highest O2 concentration, do not rebreathe exhaled air

How much oxygen does Venturi Mask deliver?

high flow 2-15L/min= 24-60%

Nursing interventions for Venturi mask

most precise delivery of O2

exception for COPD patients

Other oxygen therapy include

• nebulizer

• intermittent positive pressure breathing

• continuous positive airway pressure (C-pap)

• Bi level positive airway pressure (Bi-pap)

• ventilator

Noninvasive Positive Pressure Ventilation (NPPV) is good for patients who

cannot undergo intubation or invasive ventilation with the goals of decreasing the work of the respiratory muscles and relieve dyspnea

NPPA refers to

BiPAP and CPAP

Continuous Positive Airway Pressure (CPAP)

• method of keeping airways open by providing constant milk air pressure

• helps to hold the airway open, mobilize secretions, treat atelectasis, and ease the work of breathing

Bilevel Positive Airway Pressure (BiPAP) is also called

pressure support ventilation

Pressure delivery during inspiration vs expiration in BiPAP

BiPAP delivers higher pressure during inspiration and a lower pressure during expiration

Key mechanical feature of BiPAP

2 distinct pressure settings that changes depending on whether the patient is in inspiration or expiration

Basis for adjusting inspiratory and expiratory pressure in BiPAP

independently adjusted based on patient’s condition and target inspiratory-to-expiratory ratio (I:E)

Inspiratory Positive Airway Pressure (IPAP) is set higher to

aid airflow in

Expiratory Positive Airway Pressure (EPAP) is set lower to

make exhalation easier

When to use supplemental oxygen?

• hypoxemia

• hypoxia

• dyspnea

• other S/S respiratory distress

  • dyspnea on exertion (DOE)

  • changes in respiratory pattern

  • abnormal arterial blood gas (ABG)

  • fatigue

  • level of consciousness (LOC) changes

  • trauma

  • pain

Hypoxemia is

decrease arterial oxygen in blood

Hypoxia is

decrease in oxygen supply to cells and tissues (cellular level condition/systemic)

Dyspnea is

shortness of breath from hypoxia

Cautions of supplemental oxygen

• hypercapnia

• oxygen toxicity

Hypercapnia is

high amounts of CO2 in the blood (seen in COPD patients)

What is the primary drive to breathe in a healthy individual vs. a patient with chronic hypercapnia?

• Healthy individual: High CO2 levels (hypercapnic drive).

• Chronic hypercapnia patient: Low O2 levels (hypoxic drive).

Why do patients with severe chronic hypercapnia shift to a hypoxic drive to breathe?

Because their central chemoreceptors become desensitized to chronically high PaCO2 levels, forcing the body to rely on peripheral oxygen sensors instead.

What condition commonly causes patients to adapt to a hypoxic drive to breathe?

Chronic Obstructive Pulmonary Disease (COPD) and other severe chronic lung diseases.

What is the clinical danger of severely elevated PaCO2 in chronic lung disease?

It can cause CO2 narcosis/toxicity and lead to respiratory arrest

Oxygen toxicity is held

in the lungs

Oxygen toxicity occurs when patient is given

long term percentages of O2, causing lung damage (50-60%)

Oxygen toxicity destroys

lung surfactant

Why is lung surfactant important?

• helps to maintain alveoli and keep open

• kills pathogens in respiratory tract

• aid in immune response

S/S Oxygen Toxicity

• fibrotic changes

• increased capillary congestion

• interstitial space thickening

• paresthesia

• dyspnea

• restlessness

• pulmonary edema

Treatment for oxygen toxicity

• Positive End Expiratory Pressure (PEEP)

• Continuous Positive Airway Pressure (CPAP)

Treatments that help increase oxygenation

• incentive spirometer

• chest physiotherapy (PT)

How does incentive spirometer increase oxygenation?

encourages deep inspiration

How does Chest Physiotherapy (PT) increase oxygenation?

• postural drainage

  • position that uses gravity to drain secretions

  • mobilizes secretions from bottom of lungs

• chest percussion

  • hand clapping to chest wall loosen secretions

• vibration

  • device used to mobilize secretions

Artificial Airways include

Endotracheal tube and Tracheostomy tube

What is the primary method of choice for establishing a patent airway in emergency care?

Endotracheal Tube

How is an Endotracheal Tube (ETT) inserted?

Inserted through the mouth or nose

How long should you keep Endotracheal Tube (ETT) in for?

no longer than 3 weeks

What is the difference in aspiration protection between a cuffed vs. uncuffed Endotracheal Tube (ETT)?

• Cuffed provides better secretion clearance and some aspiration protection

• Uncuffed provides airway clearance but no aspiration protection

What are five main reasons to use a Tracheostomy Tube?

1. by pass upper airway obstruction

2. permit long-term mechanical vent

3. permit oral intake and speech

4. replace an endotracheal tube

5. remove tracheobronchial secretions

How is the Tracheostomy Tube inserted?

into the trachea

Duration for Tracheostomy Tube

can be temporary or permanent

Who can place an Endotracheal Tube (ETT)?

• need special training

• anesthesia provider

• paramedic

• respiratory therapist

• provider with ACLS training

Characteristics of Endotracheal Tube (ETT)

• flexible tube that is placed with laryngoscope into trachea

• cuff inflated and taped/secured with collar to assure placement

• multiple sizes

How is Endotracheal Tube (ETT) placement checked?

with lung sounds, end-tidial carbon dioxide levels, and with chest x-ray

Characteristics of Tracheostomy Tube

• semi-flexible, rigid, or metal tube that is surgically inserted that is placed into an artificial opening made into the trachea at the 2nd or 3rd tracheal ring

• tube has a plate that is secured with sutures and/or with trach ties

• multiple sizes

What do we call the artificial opening that is made to place Tracheostomy Tube?

tracheostomy

Advantages of Endotracheal Intubation

• keeps airway open

• able to administer O2 directly to lungs

• ability to perform tracheal suctioning

• short-term therapy (usually less than 3 weeks)

• can attach to ventilator

Advantages of Tracheostomy Tube

• keeps airways open

• able to administer O2 directly to lungs

• ability to perform tracheal suctioning

• can be long term

• can attach to ventilator, humidified oxygen, or room air

• can permit oral intake and speech (if not on vent)

Disadvantages of Endotracheal Intubation

• discomfort

• patient unable to speak

• cough reflex depressed

• closure of glottis inhibited

• thicker secretion- requires suctioning

• swallowing reflexes depressed

• risk of aspiration and ventilator-associated pneumonia (VAP)

• unintentional displacement of the tube

Disadvantages of Tracheostomy Tube

• discomfort

• patient unable to speak (if on vent)

• cough reflex depressed

• secretions tend to be thicker

• risk of aspiration and ventilator-associated pneumonia (VAP)

• unintentional displacement of the tube

• can be long term

Disadvantages of Endotracheal Tube

• requires patient cooperation or restraint use

• requires special training of nursing staff

• oral assessment and care needed frequent

Disadvantages of Tracheostomy tube

• requires special training of nursing staff

• oral assessment and care needed frequently

Complications with Endotracheal Tube

• Tube dislodgement

• accidental removal

• high cuff pressure

• low cuff pressure

• trauma to tracheal lining

• vocal cord paralysis

Accidental removal of Endotracheal Tube can lead to

laryngeal swelling, hypoxemia, bradycardia, hypotension, death

High cuff pressure d/t Endotracheal Tube can lead to

tracheal bleeding, ischemia, or necrosis

Low cuff pressure d/t Endotracheal Tube can lead to

risk of aspiration and hypoxia

Early Complications with Tracheostomy Tube

• tube dislodgement

• accidental decannulation

• bleeding

• pneumothorax

• air embolism

• aspiration

• subcutaneous emphysema

• laryngeal nerve damage

• posterior tracheal wall penetration

Later Complications with Tracheostomy Tube

• airway obstruction from secretions

• infection

• dysphagia

• tracheoesophageal fistula

• tracheal dilation, ishcemia, or necrosis

Nursing care of pt with ET or Trach

• monitor O2

• cuff management

• maintain patent airway (tube)

• oral care

• skin care

• safety and comfort

Monitoring oxygenation

• assess for signs and symptoms of hypoxemia

• change in mentation, anxiety, dusky skin, dysrhythmias

• ABGs

• continuous SpO2

Gee, Clap, I Can See Nasty Respirations, Too stand for?

• Grunting

• Change in LOC

• Intercostal spaces evident

• Color (Cyanosis, Circumoral Pallor)

• Seesaw chest movement

• Nasal flaring

• Retractions/dysRhythmias

• Tachypnea

Managing the cuff

• needs to be inflated if pt requires mechanical ventilation or high risk for aspiration

• cuff pressure should be maintained at 20-25 mmHg

• check every 6-8 hours

Promoting effective airway clearance

• chest physiotherapy

• frequent position changes

• increased mobility

• suctioning

Indications for suctioning

• visible secretions in the tube

• sudden onset of respiratory distress

• suspected aspiration of secretions

• auscultation of adventitious breath sounds over bronchi or trachea

• increased respiratory rate & sustained coughing

• sudden or gradual decrease in SpO2

• changes in LOC, restlessness, tachycardia

• cyanosis or pallor

• increased peak airway pressure

Incline/closed suctioning

• allow suctioning without disconnection from vent

• decreases hypoxemia

• sustains PEEP

• decrease patient anxiety

• protection of staff from secretions

Open suctioning

• sterile procedure needing sterile gloves

• staff needs PPE

• higher risk for hypoxia

Preventing Complications for a patient with an ET or Trach Tube

• administer warmed humidity- should see mist in tubing

• maintain appropriate cuff pressure

• suction as needed

• maintain skin integrity

• auscultate lung sounds

• monitor for signs and symptoms of infection (temp, secretions, WBC)

• administer prescribed O2; monitor O2 sat

• monitor for cyanosis

• maintain adequate hydration

• sterile technique for suctioning and trach and ET tube care

Nursing consideration with Endotracheal Tube

• monitor tube for correct placement at least every 2-4 hours

• confirm the exit mark on the tube

• symmetrical chest expansion- respiratory assessment

• need suction set up at bedside

• head of bed 30-45

• ambu bag at bedside

• if dislodged, may need to manually ventilate- call for necessary help

Nursing consideration with Tracheostomy Tube

• Involve patient or family in teaching for long-term tracheostomy placement

• Need spare tracheostomy (smaller size) at bedside

• Need inner cannulas bedside

• Need suction set up at bedside

• Head of Bed 30 – 45

• Ambu bag at bedside

• If dislodged, may need to manually ventilate – call for necessary help

Mechanical ventilation are

breathing device which maintains ventilation and oxygenation

Mechanical ventilation indications

• compromised airway

• severe decrease in oxygenation

• altered breathing patterns

• drug overdose

• inhalation injury

• shock

• multi-system failure

• COPD

• Thoracic or abdominal surgery

• Trauma or lung injury

• Acute respiratory distress syndrome (ARDS)

• Neuromuscular disorders

• Brain injury or damage

• Rest the respiratory muscles

• Coma

Types of mechanical ventilation

• negative pressure ventilation

• positive pressure ventilation

Negative Pressure Ventilation exerts

negative pressure on external chest

Negative Pressure Ventilation decreases

the intrathoracic pressure during inspiration and allows air to flow into lung

Negative Pressure Ventilation is similar to

spontaneous respiration

When is negative pressure ventilation used?

• chronic respiratory failure

• Neuromuscular conditions (poliomyelitis, MD, ALS, myasthenia gravis)

What is positive about negative pressure ventilation?

it’s simple to use, does not require intubation, adaptable for home use

Positive Pressure ventilation is used in

acute care, operating room, or at home but generally used with an ET tube or tracheostomy

4 types of Positive Pressure ventilation

• volume cycled

• pressure-cycled

• high frequency oscillatory

• noninvasive positive-pressure

How does positive pressure ventilation work?

• the ventilator pushes air into the lungs under + pressure during inspiration

• intrathoracic pressure is raised during lung inflation (unlike normal inspiration)

• patient exhales passively

High pressure alarm is caused by

increased airway secretions, bronchospasm, displaced or obstructed tube, water in tubes, stiff airway (ARDS), kinked tubing

Low pressure alarm is caused by

disconnection or leak in the system

Apnea alarm occurs when

patient is off ventilator, tubing disconnected from patient

Temperature alarm occur when

more water is needed for humidification

Risks Associated with Mechanical Ventilation

• Infection – Ventilator Acquired Pneumonia

• Pneumothorax

• Lung damage

• Side effects of sedation/paralytic meds

• Maintenance of life when not wanted

• Hypotension

• sodium and water imbalance

• stress ulcers, GI bleeding, peptic ulcer prophylaxis

• decreased peristalsis

Why does mechanical ventilation cause hypotension?

increased positive pressure increases intrathoracic pressure, which inhibits blood return to the heart

Nutritional Issues while on a Ventilator

• Hypermetabolism associated with critical illness

• Elimination of normal route for eating

• Inadequate nutrition puts person at risk for poor oxygen transport secondary to anemia and poor exercise

• Decreased total protein, albumin

• Delays weaning

• Decreased response to infections 

• Intervention – enteral feeding tube – what are the complications?

• ↑ risk for stress ulcer

Mechanical ventilator weaning takes place in 3 stages

• Gradual removal from the ventilator

• Removal of ET or tracheostomy tube

• Removal from oxygen

When can you start weaning patient off mechanical ventilator?

• earliest time possible when safe for patient

• Hemodynamically and physiologically stable

  • Stable VS, Stable ABGs

• Spontaneous breathing

• Recovered from acute-stage medical or surgical issues

• Cause of respiratory failure is reversed

Weaning process

Do not abruptly remove patient from ventilator

• May decrease respiratory rate

• May give short times off vent or with 0 rate

• May place on T-piece or Briggs

• Patient may develop psychological dependence on ventilator - anxiety

• Assess for respiratory distress or cardiac compromise

• Not done at night

• Explain that they may feel SOB

• Monitor oxygen status, pulse ox, EKG, and  respiratory pattern