Respiratory System

What should you check for in an ICU respiratory assessment?

• lung sounds

• secretions

• ventilator compliance

• resp. distress

• mental status

What does a pleural effusion sound like?

diminished

What do rhonchi mean?

secretions in larger/upper airways that can clear with suctioning

Do crackles clear with suctioning?

no

Ventilator synchrony

ventilator compliance measured by a good O2 sat and not breathing over the vent (otherwise, they may need more sedation)

What are early and late resp. changes in vital signs?

early → high RR + low O2; late → high HR

Progression of oxygen delivery devices

NC (up to 6L) → venturi mask (specific % of oxygen) → non-rebreather mask (at least 10L)

What percentage of oxygen does nasal cannula go up to?

45%

High flow NC - oxygen concentration

21-100%

High flow NC - rate

60-70L

What is the benefit of high flow NC?

the oxygen can be humidified and heated

Bipap vs Cpap

bipap → gives two different levels of pressure, depending on inhalation + exhalation (so it focuses on allowing inhalation of O2 and exhalation of CO2)

cpap → gives the same (continuous) pressure throughout both inspiration and expiration (so it focuses on keeping the alveoli open)

Is bipap used for ventilation or oxygenation?

ventilation

Which ABG values should you measure with bipap?

CO2 and O2

Is cpap used for ventilation or oxygenation?

oxygenation

Which ABG value is measured with cpap?

O2

When is bipap most commonly used?

COPD exacerbations (to reverse hypercapnia)

When is cpap commonly used?

obstructive sleep apnea + hypoxia

When should bipap and cpap NOT be used?

• patients with facial trauma

• patients with an inability to control their airway

• e.g. a drowsy or vomiting patient

What should you assess for when placing bipap or cpap on a patient?

• ability to control airway

• ensure the mask is sealed on the patient’s face

• skin breakdown, esp. on bridge of nose

What is the purpose of artificial airways?

to support the respiratory system until the underlying issue is resolved

When is an oropharyngeal airway used?

unconscious patients to maintain or open the airway

When should you NOT use an oropharyngeal airway?

• facial trauma

• restricted mouth opening

• if the patient is conscious

When is a nasopharyngeal airway (“nasal trumpet”) used?

• patient is awake/has an intact gag reflex (since it doesn’t reach that area)

• if frequent nasopharyngeal suctioning is needed

Which tube is used for intubation?

endotracheal tube

Which supplies should be present for intubation?

• laryngoscope (to open the airway)

• yaunkauer w/ suction

• ambu bag with a face mask

• ET tube

• etc.!

What are some nursing jobs when a patient is being intubated?

• gather supplies + meds

• ensure IV is patent

• monitor vitals + verbalize changes

• document → meds, time, tube size + location, vent settings

In which order are meds given for intubation?

sedative, then paralytic

How is an ETT placement verified?

CO2 detector, chest xray, and bilateral breath sounds/chest expansion

Which color does the CO2 detector turn when air is moving into the lungs?

yellow (so if it doesn’t change, it’s in the wrong place)

What is a sign of the sedative wearing off before the paralytic?

increased HR

When is a tracheostomy considered?

if the patient is unable to wean off the ventilator after 14 days

Is switching trach cannulas a sterile or clean procedure?

clean

Is suctioning a tracheostomy clean or sterile?

sterile

Which supplies should be present at the bedside for a patient with a trach?

obturator, extra trach same size and smaller, ambu bag, + suction

Respiratory rate (vent)

the number of breaths delivered by the ventilator per minute

Tidal volume

the volume of air delivered with each breath; shows how large of a breath the patient is actually taking

Average tidal volume

4-8mL/kg of body weight

FiO2

the percentage of oxygen being delivered to the patient

Normal FiO2

21% (.21)

Which two stats are looked at when weaning a patient on FiO2?

PaO2 and O2 sat

PEEP

the pressure maintained in the lungs at the end of expiration; shows the pressure needed to keep the alveoli open

Normal PEEP

3-5

What are some complications of a PEEP that’s too high?

barotrauma (lung trauma) + decreased CO (from increased pressure, allowing less filling)

Which vital sign change might mean that the PEEP is too high?

hypotension

What are the two types of assist control on vents?

volume control (ACVC) + pressure control (ACPC)

ACVC (volume control) vent setting

every breath is given the same amount of tidal volume (mL of air breathed in)

ACPC (pressure control) vent setting

every breath is given the same amount of pressure (PEEP), no matter how long or short the breath is

SIMV (vent mode)

used to wean patients off of ventilation; it gives a set number of breaths with a set volume, but the patient can make independent breaths w/out rate or volume assistance (so the patient determines how large each breath is)

How are patient-initiated breaths assisted in SIMV mode?

fiO2 and PEEP (but not rate or volume)

Pressure support (vent mode)

used to wean patients off the vent; it gives a set PEEP to limit the discomfort of breathing through a small tube, but the patient’s effort determines the rate and volume

TRUE or FALSE: the ventilator is still giving breaths on pressure support mode.

false

Low volume ventilator alarm

the breaths aren’t big enough

Low volume alarm - example causes

cuff leak or decrease in patient-initiated breaths

High pressure vent alarm

decreased lung or ventilator compliance, or a kinked tube

High pressure alarm - examples

decreased lung compliance → COPD

decreased vent compliance → coughing, biting tube, secretions

kinked tubing

Circuit disconnect vent alarm

the ventilator is disconnected from the patient!

Apnea vent alarm

the patient doesn’t initiate breaths for >20 seconds (causing the ventilator breaths to kick in)

TRUE or FALSE: it is fine to disarm a ventilator arm under special circumstances.

false

What should you do if a ventilator alarm is still going off and you can’t troubleshoot the problem?

manually ventilate the patient with an ambu bag

Which acronym helps to remember possible causes for ventilator alarms?

DOPE

DOPE acronym for ventilator alarms

D-dislodged ETT (circuit disconnect/low pressure)

O-obstruction (high pressure)

P-pneumothorax (high pressure)

E-equipment failure (start bagging patient)

How should you titrate neuromuscular blocking agents like rocuronium?

train of four

How should you titrate sedatives or benzodiazepines?

RAAS score

Which drug requires IV tubing to be changed frequently and how often?

propofol; q12h

How is epoprostenol typically given and why?

nebulization/inhalation; it's a pulmonary vasodilator

What should you always do with epoprostenol and why?

keep extra of the medication at bedside, since it has a really short half-life

TRUE or FALSE: sedatives like propofol usually contain sedatives.

false

What is an example of an anesthetic?

ketamine

Sedative example

propofol

Benzodiazepine example

midazolam

Bronchodilator examples

albuterol, ipratropium

Vasodilator example

epoprostenol

What is the goal when using the train of four?

1-2 twitches at baseline

Nursing priorities for intubated patients

• mobility (passive ROM, keeping head in line with body, q2h turns)

• restraints if needed

• skin integrity (watch lines + switch all equipment to the other side q few hrs)

• nutrition (BM frequency)

Why should you specifically watch BM frequency of intubated patients?

they’re taking a lot of opioids → increased constipation risk

Which labs or sats should you monitor for oxygen + vent settings in intubated patients?

O2 sat, paO2/CO2

Which conditions should you prevent + look out for in intubated patients?

• ventilator-associated pneumonia (VAP)

• DVTs

• stomach ulcers

How can you prevent VAP?

elevate HOB >30 and perform oral care q4h

What criteria must a patient meet to be extubated?

• reversal or improvement of underlying cause for resp failure

• hemodynamically stable

• already on minimal vent settings

• passes spontaneous awakening + breathing trials (SAT/SBTs)

• conscious + can maintain airway

Extubating a patient - steps

• suction

• remove the ETT securing device

• deflate the cuff

• remove the tube quickly while the patient coughs

• suction the mouth

• apply oxygen