Chest Drains, Mechanical Ventilation, and Airway Suctioning

Reasons to use a chest drain

remove fluids and air from pleural spaces, prvent drained fluid and air from returning, restore negative pressure in pleural space to re-expand lungs

Chest tube is connected to a drainage device that…..

allows air/fluid to leave chest, contains a one way vlve to prevent backflow, designed for device to be below level of chest tube for gravity drainage

How does chest tube drain work?

there are three bottles to help with pressure, suctions, ect.

What to keep in mind when managing a pt with a chest tube?

Don’t knock over the thing, you can hook it onto something, keep below level of insertion point, assess the water seal for an air leak,

how to tell if someone has an air leak? and what should you do?

bubbles in the water seal, compare findings to physician orders for suction, communicate any discrepancy to team to facilitate patient mobility

indications for mechanical ventilation

Respiratory Failure:

Type 1- hypoxemia

Type 2- hypercapnia

OR airway protection

Type 1 Respiratory Failure

Hypoxemia, PaO2 < 60mmHg, (we should increase FiO2 or incrase airway pressure)

Type 2 Respiratory Failure

Hypercapnia, PaCO2 > 45 mmHg, (we should increase Ve or tidal volume )

Types of non-invasive ventilation

CPAP and BiPAP

CPAP

continuous positive airway pressure; for hypoxemic respiratory failure, heart failure, obstructive sleep apnea, a SINGLE CONSTANT pressure setting (5-30 cm H20)

BiPAP

bi-level positive airway pressure; hypercapnic or mixed respiratory failure, healt failure, COPD

inspiratory 5-30cm H20

IPAP

expiratory 0-30 cm H20 but less than XXXX

EPAP (XXX is IPAP)

IPAP - EPAP =

pressure support

Invasive Mechanical Ventilation Indications

Apnea- neurologic or neuromuscular issues

GCS of 8 or less OR unconscious and unable to protect airway

Hemodynamic instability or cardiovascular collapse

Acute ventilatory failure

PaCO2 > 50 mmHG OR respiratory acidosis with pH < 7.25 OR acute rise in PaCO2 from baseline with acidosis

impending ventiatory failure (delining status from ABGs and symptoms of increasing work of breathing)

unresponsive to other treatments

PaO2 <60

PaO2/FiO2 = 300

Respiratory muscle fatigue (increased PaCOs, tidal volume <5ml/kg)

RR <10 or >35

relief of obstruction

anaphylaxis

airway edema

head and nech trauma

basic principals of mechanical ventilation

only a means of support, full or partial

two primary categories (negative pressure, rarely used; positive pressure, all forms in use are positive pressure)

therapeutic benefits of mechanical ventilation

Guaranteed delivery of high FiO2, positive pressure can reduce intrapulmonary shunt, recruits alveoli to allow participation in gas exchange, performance of the work of breathing until the pt is capable themselves

complications of mechanical ventilation

injury secondary to artificial airway, impaired airway clearance (mucociliary function impaired, inability to fully close glottis impairs cough mechanism), atelectasis, hemodynamic compromise, barotrauma

barotrauma

damage as a result of alveolar rupture due to excessive pressure or over-distention of alveoli

volutrauma

damage as a result of large colume ventilation, espcially in pts with ARDS

how to prevent pneumonia with a ventilated person

keep HOB elevated 30-45 degrees, subglottis suctioning, maintain airway cuff pressure, good oral care, delay sedation ‘vacation’ , proper nutrition, good hand hygiene, minimize circuit disconnections

ventilator alarms (from most to least serious)

-oxygen/system failure (indicates low to no O2 supply; get nursing!!)

-pressure alarms (high or low; could be from coughing, agitation,

-volume alarms (when inspired/expired volumes dont match)

-rate alarms

goals of care for patient on mechanical vent

• Protect the lung from iatrogenic injury

• provide appropriate nutrition

• early mobilization if possible

• Frequent assessment of readiness to extubate

• Speak to patients even if they can’t speak back or if you’re not sure that they can hear you

• be respectful of them even if they are not respectful to you

Modes of mechanical ventiltion

volume control

• volume of air patient receives is constant

• airway pressure changes in response

pressure control

• pressure delivered to patient is constant

• lung volume changes in response

settings of a mechanical ventilator that can be changed

tidal volume (Vt)

• volume of air set to be delivered to patient with each breath

Frequency (f or RR)

• breaths per minute being delivered

• based on time window

• for example if f=12 there is a 5 sec time window

• if pt does not take a breath in that window, then ventilator will deliver a breath

oxygen concentration (FiO2)

• fraction of inspired oxygen

• expressed as a decimal

• typically 0.35-1.0 for MV

PEEP

• positive end-expiratory pressure

• keeps alveoli from collapsing

Pressure Support

• extra push of air that assists pt with taking a spontaneous breath

Ventilator settings that are displayed but not manipulated

minute ventilation (Ve)

• amount of air being delivered to the patient each minute

• directlu impacts CO2 clearance

• usually 5-10lpm at rest

peak inspiratory pressure

• maximum pressure reached during inspiration

• ideal is less than 35 cm H20

Plateau pressure (Pplat)

• indicated lung compliance

• 
  

Assist Control Mode

The ventilator is doing all the work, mode of maximum support

• Vt, minimum f, FiO2, PEEP are set

• vent provides the entire breath

• pt receives guaranteed minimum number of breaths and can take additional breaths

Disadvantages: excessive ventilation potential, can contribute to inspiratory muscle atrophy and weakness, challenging to wean from

SIMV

Synchronized intermittent mandatory ventilation

• Overcomes some disadvantages of AC

• common weaning mode

• patients work is variable

• Vt, minimum f, FiO2, and PEEp are set

• when pt takes a breath, the pt determines the Vt

weaning from mechanical vent occurs in _______ of patients

majorety (70-80%)

Information on weaning from vent

no one set protocol

• SIMV rate must be reduced to allow the patient to gradually take over work

• FiO2 must be reduced

• PEEP must be reduced

• Patient should be hemodynamicially stable

• Pt should be alert enough to protect airway

• cause for respiratory failure should be resolved

• pt should exhibit minimal use of accessory muscles during inspiration

Thresholds associated with successful weaking

FiO2 < 0.40

PaO2/FiO2 >200

PEEP <= 5 cm H2O

RR <30

resting ventilation < 10 L/min

maximum inspiratory pressure < -30cm H2O

Indications for suctioning

• requires pt to have an endotracheal or tracheostomy tube

• airway suctioning can be performed without these but not by a PT usually

• a partial obstructed airway is a niosy airway

• this procedure is performed on as as-needed basis to maintain airway patency

signs and symptoms that may indicate need for airway suctioning

• decreased SpO2

• audible/auscultated wheezing or crackles

• weak/congested cough

• secretions visible around tracheostomy opening

• cyanosis (late)

• shortness of breath

• a cognitively capable patient indicates their need for airway suctioning

equiptment needed for suctioing

• vacuum source

• oxygen source

• suction catheter kit (saline container, gloves, catheter)

• sterile saline

• manual resuscitation bag/bag valve mask/Ambu bag

airway suctioing steps

• check vitals

• gather equipment

• wash hands

• explain procedure

• attach vacuum source to catheter

• test vacuum

• pre-oxygenate patient

• insert catheter without suction

• withdraw catheter 1 cm

• apply suction while withdrawing catheter, 15 sec max

• ensure adequate oxygenation

• reassess vitals and need for suction

how much vacuum suction?

-80-100mmHg

where does the suction catheter go to usually?

the chorina

possible complications of suctioing

hypoxemia/death, vasovagal response, increased ICP, bacterial contamination, bacterial contamination, atelectasis, mechanical trauma