NUR4090 Critical care Exam 1 notes

Factors that can interfere with pulse oximetry readings

• Nail polish 

• Carbon monoxide (can cause false high reading)

• Vasopressor 

• Shivering 

• Patient pulls it off 

Assessment of the pulmonary system

• Assessment of the lung field (auscultation) 

  • Anterior 

  • Posterior [preferred] 

• Work of breathing (visual inspection) 

  • Rate and rhythm [tachypnea]

  • Accessory musculature 

  • Level of consciousness 

    • RASS score, make sure level of sedation matches score

• Patients requiring artificial ventilation 

  • *common medications used for rest/agitation and decreased WOB (work of breathing)

Intravenous Medications that are common in the ICU for sedation/pain artificial ventilation in place

• Propofol (Diprivan)

• Precedex (Dexmedetomidine)

• Benzo’s

  • Valium (diazepam)

  • Ativan (Lorazapam)

  • midazolam (versed)

• Paralytics

  • Norcurin, Pavulon, Nimbex

Propofol (Diprivan)

• sedation and amnesic 

  • Patient needs to be on a vent

  • Commonly used for sedation (fast acting) 

  • May cause hypotension and bradycardia 

    • If BP goes up pause/stop and monitor 

      • When stabilized, notify provider 

  • Oversedation (can stick around)

  • Metabolized in the liver, high fat emolument intravenous tubing changed every 12 hours 

    • High likelihood of infection

Precedex (Dexmedetomidine)

• Preferred by providers 

  • Works very well with alcoholics 

• Reverses faster 

• Decreased chance of delirium 

• Bradycardia and hypotension 

RASS Score - Richmond Agitation Sedation Scale

• A 10 point scale used to assess a patient’s level of agitation and sedation 

• Positive score (+1 to +4): indicates increasing aggression 

  • +4 combative: overly violent and danger to staff 

  • +3 very agitated: pulls at tubes or is aggressive towards staff

  • +2 agitated: frequent non-purposful movements, may fight the ventilator

  • +1 restless: anxious and apprehensive but not aggressive 

• Zero score: patient is alert and calm 

• Negative score (-1 to -5): indicates increasing sedation 

  • -1 drowsy: not fully alert but can maintain eye contact for over 10 seconds when addressed 

  • -2 light sedation: briefly awakens with eye contact for less than 10 seconds when addressed

  • -3 moderate sedation: movement or eye opening to voice but without eye contact 

  • -4 deep sedation: no response to voice but there is movement or eye opening to physical stimuli 

  • -5 unarousable: no response to any verbal or physical stimulation 

• If provider ordered -2 and it is not enough/goes away quick, contact provider for different order or additional meds 

• Your order must match the sedation score

Benzo’s

• Valium (diazepam)

  • Alcohol detoxification 

  • Hypotension oversedation 

  • Romazicon (Flumazenil) 

• Ativan (Lorazapam) 

  • Fat pink needle (18g) bc very thick 

  • Seizure control 

  • Hypotension, respiratory depression 

• Midazolam (Versed)

  • Short acting 

  • Hypotension, respiratory depression 

• Reversal agent for benzos: romazicon 

• Reversal agent for opioids: narcan, may need narcan drip

• Know the half life of medications, narcan may be out of system before opioids are therefore may need narcan drip

Paralytics

• Norcuron, Pavulon, Nimbex (more) 

• The client MUST BE ON A VENTILATOR 

• MUST BE on continuous IV sedation 

  • Initiated before and continued after until paralytic is cleared

• Monitored with Train of Four

  • Provider ordered level of response follow your hospital policy 

  • Usually two or one out of four. Document every hour 

Anatomy of the Lungs

• Warmth, air and oxygen exchange 

• Upper respiratory tract: filters impurities and warms the air 

• Lower respiratory tract: lungs, 3 lobes on the right, 2 lobes on the left. Right lung is more likely to be intubated by mistake (straight path)

  • Straight path 

• Pleura: Visceral: vital (closest to lung); parietal lines pleural cavity 

Respiration and Ventilation

• What is the difference? 

  • Respiration is the whole process of gas exchange between the atmosphere and the blood including the cellular exchange of O2 and CO2 

  • Ventilation is the movement of air in and out of the lungs. Inspiration is active, expiration is passive 

    • Too much sedation can cause issues (diaphragm issues) 

Blunt chest trauma

• More common, more difficult to treat, vague symptoms so may not seek treatment immediately 

• Sternal/rib fracture: most of the time we address pain only, there is not much we can do 

• Flail chest: 3 or more continuous ribs having 2 or more fractures causing a floating space

  • Opposite movement can be fatal

  • Need binder 

  • Encourage deep breathing 

  • Gentle chest PT

Pulmonary contusion: chest PT, antibiotics

Penetrating chest trauma

• Gunshot/stab wound 

• Pneumothorax

  • Need chest tube 

    • Only 2 reasons to clamp 

      • Turn off to remove

      • When container is full/needs to be changed 

    • No stripping to move clots down (can damage tools) 

  • Tension pneumothorax, tracheal deviation to undamaged side 

    • Dangerous bc it can compress the heart 

• Cardiac tamponade

  • Layer around heart punctured and starts filling with fluid

  • Beck’s triad: JVD, muffled heart sounds, hypotension 

  • Need to decompress, take a needle to pull out fluid

• Subcutaneous emphysema 

  • Tracheostomy 

Life threatening Injuries

• Hypoxemia: low O2 

• Hypovolemia: low blood volume  

• Cardiac failure 

Chest trauma: Assessment

• Time is critical 

• Mechanism of injury 

  • How serious the injury is (baseball vs car accident)

• Responsiveness 

• Specific injuries 

• Estimated blood loss 

• Recent alcohol use 

• Pre-hospital treatment 

  • Anything they did in the field

• Diagnostics 

Chest Trauma: Management

• Airway 

  • Chest tube:

    •  continuous bubbling means leak or other issue, intermittent bubbling is normal 

    • Keep on floor, below heart level 

    • Keep tubes away from side rails 

    • Record drainage 

    • No stripping

    • Never clamp, especially when suction 

      • Only clamp when changing receptacle or pulling out 

      • Turn off suction first then clamp

• Need for O2 

• Reestablish fluid volume 

• Reestablish negative pressure 

• Drainage of intrapleural fluid/blood 

Pulmonary embolism

• Obstruction of the pulmonary artery or one of its branches by a thrombus 

• Originates in the venous system 

  • DVT

  • DVT + PE = VTE

• Associated with: 

  • Trauma 

  • Surgery 

  • Pregnancy 

  • Heart failure 

  • Age (>50)

  • Hypercoagulable states

  • Prolonged immobility 

  •  Atrial fibrillation 

  • Birth control pills 

  • Clotting disorder 

PE: Pathophysiology

• Can be a complete blockage of the pulmonary vasculature or a partial blockage

• A DEAD space issue ventilation continues 

• Right heart strain 

• Varying degrees of hemodynamic instability depending on the size

PE: Clinical manifestations

• Size dependent 

• Dyspnea, tachypnea (most common side effect) 

• Chest pain 

• Cough, hemoptysis (secondary to cell death) 

• Anxiety, apprehension 

• Fever, tachycardia, diaphoresis 

PE: tests 

• Diagnostic tests: a spiral CAT scan with contrast dye 

  • Contrast dye can cause an allergic reaction

• Other test: 

  •  VQ (ventilation perfusion) scan is not as precise but may be considered when patients have an allergy to contrast dye or are pregnant. It requires a chemical tracer, which carries a slight chance of a minor reaction and passes quickly without intervention 

    • Radioactive compounds inhaled into airspaces of lungs, in a normal lung this will distribute evenly to all regions 

    • Radioactive compound injected into vein. Travels to lung tissues in blood vessels 

    • “Mismatch” of inhaled and injected compounds on the lung scan images = pulmonary embolus 

  • CXR, EKG, pulmonary angiogram, D-Dimer 

  • Arterial blood gas/pulse oximetry

PE: Medical treatment and nursing care

• TPA (clot buster)/heparin therapy 

  • coordinate blood draws to minimize bleeding 

  • Heparin antidote: protimine sulfate 

• Prevent new clots from forming 

  • Anticoagulant therapy

  • Thrombolytics 

  • Ambulation, let exercises in bed

  • Make sure they don’t dangle their feet, have feet planted on floor (blood return)

• Using the pulse oximetry for monitoring 

• Prevent bleeding after TPA therapy 

• Prevention: assessment, ambulation, SCD (sickle cell), adopt a healthy lifestyle, quit smoking, oral anticoagulants 

  • Anti X antibody [ASSAY]: new more accurate than PTT

PE: Prevention (DVT/VTE)

• AVOID VENOUS STASIS 

• Activity/leg exercise 

• Early mobilization 

• Anti embolic stockings

• Sequential compression devices 

• Anticoagulant therapy

  • Medication interactions

  • Leafy greens, need to be consistent especially if on coumadin 

• Greenfield filter 

  • Helps catch clots and prevent it from traveling to brain or lungs 

  • Prevents pulmonary embolism or stroke  

Acute respiratory failure

• Sudden and life threatening 

• Decline in gas exchange 

• Failure to provide oxygenation 

• pH < 7.35

• PaO2 < 60mmHg (hypoxemia)

• PaCO2 > 50mmHg (hypercapnia)

Lung failure vs Pump failure

• Lung failure: gas exchange failure manifested by hypoxaemia (low O2 in blood)

• Pump failure: ventilatory failure manifested by hypercapnia (high CO2 in blood)

ARF: Assessment

• Early: restlessness, fatigue, headache, dyspnea, tachycardia, hypertension, hypoxemia

• Progression: confusion, lethargy, tachycardia, tachypnea, central cyanosis, diaphoresis, respiratory arrest 

ARF: Management/Treatment 

• Correct underlying causes

• Restore gas exchange in the lungs

• Intubation/mechanical ventilation 

• ABG

  • Will be taken everyday 

• SaO2

• VS 

• ICU care 

ARF: Nursing Management

• Assist with intubation 

  • Watch pulse Ox to notify provider at around 92-90 

  • Have suction (yankour) ready if need to clear patients oropharyngeal area

  • Respiratory therapist should have capnography tester on the end of the bag valve mask and give a couple of amboos, if they see color change that means there is CO2 which is a pretty good indicator of placement 

  • 3 point check: listen to right lung, left lung and stomach while ambooing 

  • CXR for confirmation, recommend feeding tube before 

• Maintain mechanical ventilation 

• Assess respiratory status: 

  • LOC, ABG, VS, respiratory system 

• Care of the vented patients

  • The ventilator bundle 

    • HOB 30-45 degrees

    • Sedation vacation

    • GI prophylaxis

    • DVT prophylaxis Heparin [SC]

    • Oral care, chlorhexidine 

  • High pressure alarm: secretion or biting tube 

  • Low pressure alarm: not weaning well, circuit error 

• Communication and education (for family and patients)

Chronic respiratory failure

• Deterioration in the gas exchange function 

• Hypoxemia and hypercapnia develops gradually and is harmful

• Persisted for a long period of time after an episode of acute respiratory failure 

• Absence of acute symptoms 

• COPD and neuromuscular disease 

Arterial Blood Gas

• Normal pH: 7.35-7.45

• Normal PCO2: 35-45

• Normal PAO2: 80-100

  • COPD patients may be extubated under 80 (around 70s)

• Normal Bicarbonate: 22-26

• The lungs work much faster than the kidney

• Oxygenation is not part of the blood gas pH analysis but is just as important 

Metabolic acid base abnormalities

• Metabolic Alkalosis 

  • Causes: vomiting, excessive antacid use, contraction alkalosis 

• Metabolic Acidosis

  • Causes: any condition that causes a reduction in bicarbonate or in which the body’s metabolic processes outpace bicarbonate production 

Kidney disease, DKA, Sepsis, lactic acidosis, aspirin overdose

Respiratory acid base abnormalities

• Respiratory Alkalosis 

  • Causes: hyperventilation 

• Respiratory Acidosis 

  • Causes: respiratory failure, hypoventilation syndrome

Acute respiratory distress syndrome (ARDS)

• Severe form of acute lung injury 

  • Severe inflammatory process

  • Associated with lung trauma 

  • PaFIO2 ratio test: ABG oxygen level/oxygen given by ventilator (convert % to decimal) 

    • 300-500: normal 

    • <300: acute lung injury, mild ARDS 

    • <200: moderate ARDS

    • <100: severe ARDS

• Sudden and progressive pulmonary edema 

• Bilateral infiltrates on chest x-ray 

  • Can look like CHF

  • Do BNP (brain natriuretic peptide) blood test, if positive then its CHF, if zero its ARDS

• Hypoxemia unresponsive to oxygen 

  • Regardless of the amount of  PEEP

    • Bronchial trauma 

• Reduced lung compliance 

• Death from non pulmonary multisystem organ failure, with sepsis 

Spectrum of disease

• pulmonary edema —> acute lung injury —> ARDS

• severity is based on the damage of the alveolar membrane which leads to pulmonary fibrosis, vascular destruction, and MODS (multi organ dysfunction syndrome)  

Stages of ARDS

• The acute exudative phase (about 1 week) 

  • Injury 

  • Pretentious flooding nullifies surfactant 

  • Decreased gas exchange 

• Proliferative phase (Up to 3 weeks)

  • Resolution of phase one/may recover or move to next phase 

• Normal lung tissue changes into fibrotic tissue 

  • Ventilator dependent/death is common 

  • Usually resulting in sepsis, overwhelming infection, and MODS

Factors Commonly associated with the Development of ARDS

• 40% mortality rate 

• Direct lung injury

  • Pneumonia 

  • Aspiration of gastric contents

  • Pulmonary contusion 

  • Near drowning 

  • Toxic inhalation injury

• Indirect lung injury 

  • Sepsis

  • Severe trauma 

  • Multiple bone fractures 

  • Flail chest 

  • Head trauma 

  • Burns multiple transfusion 

  • Drug overdose 

  • Pancreatitis 

  • Post cardiopulmonary bypass

ARDS Pathophysiology

• Inflammation 

• Injury to the alveolar capillary membrane

• Severe ventilation - perfusion mismatch occurs 

• Alveolar collapse 

• Lung compliance decreased (the ability the lungs can stretch) 

• Loss of surfactant 

ARDS: Clinical manifestations

• Resembles severe pulmonary edema 

• Rapid onset dyspnea 

  • Less than 72 hours after the precipitating event 

• Arterial hypoxemia (manifests)

• Visible bilateral infiltrates (xray)

• Decreased pulmonary compliance: stiff 

• Recovery: oxygenation and CXR improve, better lung compliance 

ARDS: Assessment

• Develops over 48-72 hours 

• Crackles 

• Rapid onset dyspnea 

• Arterial hypoxemia: refractory to oxygen therapy 

• White patches on CXR

• Pulmonary Edema or ARDS

  • Brain natriuretic peptide (BNP)

ARDS: Management 

• Intubate/Mechanical Ventilation 

  • PEEP to improve oxygenation 

  • Low tidal volumes (bc alveoli are filled with fluid)

• Vasopressor therapy 

• Fluid volume 

• Nutrition 

• Pharmacology 

  • Sedatives, analgesics, neuromuscular blockage, inhaled nitric oxide heliox

• Specialty bed/pronation 

ECMO therapy

• Used in severe cases of ARDS/COVID 19/Sepsis

• Open heart surgery

• VV mode (venus system) 

  • General for lungs

• VA mode (arterial system and venous)

  • For lungs and heart 

• Multiple additional sub settings 

• Gas exchange machine

  • Decannulation 

  • Clots 

  • Infection

  • Fluid compromise/ must have anticoagulation 

    • Applies in every case where blood is taken outside the body 

Oxygen

• Room air is 21% oxygen

• Oxygen is a drug 

• Obtain an order for the least amount of oxygen to stabilize the patient 

  • Each L of O2 SpO2 goes up about 4% 

• Many devices are used 

• Be careful when giving oxygen to COPD patients

• Oxygen toxicity 

  • 40 is the goal

  • Should not be weaning anyone over 40% oxygen 

Emergency airway management

• Upper airway obstruction has multiple causes 

  • Food, vomitus, angioedema (swelling of throat, typically caused by anaphylaxis or medication i.e. ace inhibitors), altered LOC, loss of tone (pharyngeal muscle, tongue) post stroke 

• Vomiting, place the HOB up to a high Fowlers, turn the patient’s to the side, and suction out the mouth with a rigid catheter (aka Yankhower)

Airway management devices: Advanced airways

• Oral airway

• Nasal airway

• Laryngeal mask airway (LMA)

  • Done in field, not done in ICU (not common)

• Tracheostomy

  • Reserved for those who have been intubated (ETT) for more than 2-3 weeks 

• Endotracheal tube (ETT)

• Mechanical ventilation

Oral airway

(often used with unconscious patients) 

• Need to be very careful with oral cleaning, be aware of placement and proper cleaning to prevent VAP (ventilation acquired pneumonia) 

• Sized from mouth to corner of jaw 

Nasal airway

• Sized from nose to earlobe

• Goes in bevel facing septum 

• Clean as ordered, can remove to wash and replace 

Endotracheal tube (ETT)

• Is an issue if patient removes newly placed tube, need to get help and inform physician to replace/see if there was any damage done 

  • If established tube pops out can clean with sterile water/saline and replace, need to notify physician

• Note diameter of tube (9/10 7 or 7.5 size, depending on size of patient) 

• Usually is 20-21 sonometers 

• Nutrition

  • Want to get dietitian involved, need calories 

    • Need to adjust feed to accommodate for comorbidities/existing conditions (i.e. diabetes)

  • Recommend placing NG tube as well

    • Only require 1 CXR, pt is still sedated

    • Have physician change order/contact pharmacy for oral to NG meds if needed 

• Cough reflex suppressed 

• Family education, cannot eat or drink 

• Need to figure out a form of communication 

• Lavage sparingly

• Suction as needed, excessive suction can cause more secretions  

Ventilator bundle 

• GI prophylaxis 

• DVT prophylaxis 

• raise HOB to 30-45 degrees 

• oral care, chlorohexidine 

• sedation vacation, let them relax 

Ventilator management

• Oxygen is a drug use as little as possible 

  • Above 50% can lead to oxygen toxicity 

• PEEP can be used as additional therapy. Using PEEP decreases venous return to the heart 

  • Can help need less oxygen 

• Sedation is used to decrease WOB, BMR and agitation 

  • Match to RASS score 

• Alarms 

  • High: will go off with cough, biting tube, thick secretions/plugs, drop a lung

  • Low: usually on weaning trial, not exhaling enough, something has disconnected

• Ventilator bundle

Endotracheal intubation

• Placement of a tube (usually orally)

  • To provide a patent airway for mechanical ventilation 

  • Removal of secretions

• Inserted by the provider or a respiratory therapist

• Nurses gather the proper equipment 

• Sedation 

• Monitor pulse oximetry.

• Three point check: right lung, left lung and stomach (if stomach is getting bigger, might be in the wrong place)

• Capnography, Xray

Advanced Airway: Risk Benefit - Advantages

• Patent airway 

• Mechanical ventilation 

  • Need to be sedated 

• Suctioning 

• Decreased work of breathing 

• Improved oxygenation 

  • Rest muscles 

  • Goal is <50% oxygenation 

Advanced Airway: Risk Benefit - Disadvantages

• Discomfort 

• Cough and swallowing reflex are depressed

• Secretions become thicker

• Increased risk of aspiration 

• Ventilator associated pneumonia (VAP)

Tracheostomy

• Bypass the upper airway (obstruction)

  • Bypasses dead space 

• Allow removal of secretions 

• Permit long-term mechanical ventilation 

• Limited aspiration of oral secretions

• To replace an endotracheal tube 

  • Less complications

  • More comfortable 

• Types 

  • Cuffless: lot of secretions, long term 

  • Cuffed 

  • Fenestrated: can eat and drink, maybe speak 

• Surgical procedure 

  • Ventilation can be well controlled 

  • Can be done in ICU, if complicated move to OR

• Indwelling tube inserted into the trachea

  • Tracheostomy 

  • Temporary or permanent 

• Secured by ties around the patients neck

  • Check back for fungal rash 

Tracheostomy: Complications

• Bleeding, pneumothorax, aspiration, subcutaneous or mediastinal emphysema, laryngeal nerve damage, posterior tracheal wall penetration 

  • False passage 

  • Medical emergency if patient pulls out tube within 10 days of operation 

Tracheostomy: Long term complications

• Airway obstruction infection, rupture of the innominate artery, dysphagia, fistula formation, tracheal dilation, and tracheal ischemia and necrosis 

  • Inner cannula needs to be changed once a shift 

Tracheostomy: Nursing Management

• Requires continuous monitoring and assessment 

  • Especially in the beginning 

  • Comes with rigid operator, used to help with placement need to be placed in a biohazard bag with pt name and taped to wall 

  • Have access to 10cc syringe in case need to add some air 

  • Have bag valve mask in room (amboo)

• Early interventions 

  • Proper suctioning trach care once a shift, change/clean inner cannula 

  • HOB at 30 degrees

  • Analgesia, sedatives

  • Extra trach at bedside, rigid obturator in plastic bag secured over client’s head 

    • With name on it 

• Administer O2 and humidified warm air 

• Maintain cuff pressure 

• Suction 

• Maintain skin integrity around tracheostomy 

• Auscultate lung sounds

• Monitor for infection 

  • Use sterile technique when suctioning, teach care 

  • Change inner cannula at least once every shift 

• Keep the tracheostomy ties snug

Mechanical ventilation

• Oxygenate the blood for patient with poor ventilation 

• Control respirations during surgery (sedated, paralyzed)

• Rest respiratory muscles 

• Indications 

  • Decreased PaO2 

  • Increased PaCO2

  • Persistent acidosis  

  • Treat respiratory failure

  • Compromised airway

Classification of Ventilation (machine)

[works by volume or pressure or combination of]

• Negative pressure [iron lung]

• Positive pressure 

  • Volume cycled, pressure cycled, flow cycle, time cycled

  • Non invasive 

    • External: BiPAP, CPAP

      • BiPAP good for COPD, works on 2 levels, O2 and CO2

• Modes (how the machine will ventilate) 

• Assist control (AC): complete/total ventilative support 

• Intermittent Mandatory Ventilation (IMV)

  • Stacking of breaths, bad not allowing breaths in between 

• Synchronous (SIMV)

  • Machine will hold off if senses breath in between 

  • Doesn’t stack 

• Contrast positive airway pressure (CPAP)

  • Better for blowing off CO2

• Pressure support (PS)

  • Weaning modality/used for extubating 

  • Used with CPAP to take people off vent 

Mechanical Ventilation Overview

• Ventilator settings (prescriber orders) 

  • Mode (AC, CPAP)

  • Respiratory rate (RR)

  • Tidal volume (TV or Vt)

  • PCV uses pressure 

  • Fractional inspired oxygen (FiO2)

  • Positive-end expiratory pressure (PEEP)

    • Used to give less O2 (as little as possible)

Negative pressure ventilator

• Exert negative pressure on the external chest 

  • “Pulls” at lungs/chest wall

• “Iron lung”

• Chest cuirass

Positive pressure ventilators

• Most common 

• Exerts positive pressure on the airway (push air in) 

• Force alveoli to expand during inspiration 

• Expiration occurs passively 

• Advanced airway required (ETT, Trach) 

• Classified by the method of ending the inspiratory phase of respiration 

  • Volume cycled, pressure cycled, high frequency cycled

  • Noninvasive positive pressure ventilation (mask) 

• BiPAP (non-invasive)

  • treats CO2 and O2 levels 

  • Prone to skin breakdown 

    • Need skin protection for bridge of nose and forehead

  • Do not restrain hands, if patient vomits they need to be able to pull it off 

Volume Cycled Ventilation mode

• Most common 

• Volume of air is preset

• Volume is relatively constant 

  • 395-400

• Once the volume is delivered, the inspiration stops 

High Frequency Oscillatory Ventilator

[needs to be sedated and paralyzed, for ARDS]

• Very high respiratory rate 

  • 180-900 breaths/minute 

• Very low tidal volume 

  • Need CO2 monitoring 

• High airway pressure 

• Small pulses of oxygen enriched air 

• Open the alveoli

  • Atelectasis, ARDS

• Lung protective 

  • From pressure injury 

Noninvasive Positive Pressure Ventilation (NIPPV)

• Use of face mask or other devices to maintain a seal and permit ventilation 

• Indications 

  • Respiratory failure

  • Pulmonary edema

  • COPD

  • Sleep related disorder 

• Continuous positive airway pressure (CPAP)

  • O2 and airway issue 

• Bi-Level positive airway pressure (BiPAP)

  • Inspiration and exhalation pressure 

    • CO2 removal 

    • O2 administration 

Ventilator Modes

• How breaths are delivered: 

  • Assist control (AC) sometimes called CMV

  • Synchronized intermittent mandatory ventilation (SIMV) 

    • Gets O2 and PEEP but only gets tidal volume when they pull

  • Pressure control ventilation 

    • Preset pressure and kick off 

• Constant Positive Airway Pressure (CPAP)

  • Can be used on mask and vent 

• Pressure support (PS)

  • Used together with CPAP

  • Offsets narrow diameter of endotracheal tube 

• Positive End expiratory pressure (PEEP)

AC (assist controlled)

• Also known as Controlled mandatory ventilation (CMV)

• Provides full ventilator support 

• Preset tidal volume, RR

• If patient initiates a breath before the preset rate, the ventilator will deliver the preset volume and “assist” the breath

• Every breath (machine or patient) will receive the preset volume 

SIMV (Synchronized Intermittent Mandatory Ventilation)

• Machine delivers a preset tidal volume and rate 

• Spontaneous breaths can occur 

  • Between machine breaths the patient can determine own tidal volume, no assist 

  • Senses breath and holds back 

• Machine senses the patient breath and will not initiate a machine breath in opposition of the patient breath (synchronized) 

• “Bucking the vent” is decreased 

Pressure Controlled Ventilation mode PCV

• Delivers inspiration until it reaches a preset pressure then kicks off

• Major limitations

  • Volume delivered is varied (tidal volume) 

  • Volume delivered depends on patient’s airway resistance and compliance

  • Alterations in tidal volume can compromise ventilation

Pressure Support Ventilation (PSV)

[weaning mode]

• Machine applies a pressure to the airway throughout the patient triggered breath

• Decreased resistance in the ETT and machine tubing 

• Decreased work of breathing for the patient

  • Offsets pressure of narrow tube (feeling)

• PS is reduced as patient’s strength increases 

PEEP

• Positive end expiratory pressure

  • Pushes air in 

  • Positive pressure maintained by the ventilator at the end of expiration 

  • Increase functional residual capacity 

  • Opens collapsed alveoli

  • Improves oxygenation and allows for lower FiO2%

    • Can be used in liu of O2

  • Complications: decreased venous return to the heart and barrow trauma and danger of pneumothorax

CPAP

• Continuous positive airway pressure

• Positive pressure applied throughout the respiratory cycle to a spontaneously breathing patient 

• Can decrease need for oxygen therapy

• Administered via ETT, trach, or external mask 

• Patient must breathe spontaneously 

• This can be a weaning mode (invasive) or a therapy (non-invasive)

Mechanical Ventilation: Care of Patients

• Assessment of the patient 

  • In depth respiratory assessment including all indicator of oxygenation status 

  • Comfort 

  • Bundle 

  • Turning and positioning 

  • Coping, emotional needs 

  • Communication 

    • Yes or no questions, alphabet board, writing, etc. 

Mechanical Ventilation: Ventilator settings

• Initial ventilator settings are determined by the provider and set by the respiratory therapist

  • Set tidal volume 

  • Set rate (12-16 bpm) 

  • Set oxygen level

  • Set mode (AC)

  • Set PEEP (5-15cm H2O)

Mechanical Ventilation: Goals

• Optimal gas exchange

• Attainment of optimal mobility

• Absence of trauma or infection 

• Adjustment to nonverbal methods of communication 

  • Alphabet board

  • blinking/pointing 

Mechanical Ventilation: Exchanging Gas Exchange

• Monitoring ABGs and SPO2

  • Do not suction right before ABG

• Auscultate lung sounds posteriorly 

  • Back side first

• Judicious use of analgesics use RASS parameters

• Monitor fluid balance

  • I&O: either zero or slightly negative (more output than input)

Promoting effective airway clearance

• Assess lung sounds every 4hrs 

• Measure to clear airway

  • Suctioning, CPT, position changes, promoting early mobility 

• Humidification (HME)

• Medication’s sedatives, pain control, antibiotics

Optional mobility

• Physical deconditioning and prolonged motor weakness accompanying critical illness have profound and lasting consequences 

• Early mobility is facilitated by change in intensive care unit culture 

Preventing Trauma

• Ventilator Associated Pneumonia (VAP)

  • Daily interruption of sedation 

  • Daily readiness to extubate 

  • DVT and PUD (peptic ulcer disease) prophylaxis

  • Daily oral care with Chlorhexidine 

  • Every 4hrs and PRN oral care 

  • Elevation of HOB about 30 degrees 

• Hand washing protocol

Weaning

• Process of gradual withdrawal from dependence upon the ventilator

• Successful weaning is a collaborative process (between nurse, PT, provider)

• Criteria for weaning 

• Patient preparation 

• Methods of weaning 

  • CPAP trial (1hr)

  • Make sure they are able to maintain their airway  

• Extubation requirement RR <30, tidal volume >300

• Rest (few days)

• Ambulation 

• Lower O2 concentration 

  • Monitor SpO2

• Do ABGs

• Rapid shallow breathing index, low number is good (<105)

  • PaFIO2 ratio: low is bad 

Extubation

• Extubation is described as the discontinuation of an artificial airway 

• Indication for its original placement no longer exists 

• Extubation Criteria 

  • Guidelines of adequate pulmonary mechanical function includes 

    • A successful weaning trial minimum 30 min

    • Rapid shallow breathing index less than 105

    • Normal ABG for that patient 

    • Awake alert and able to support their own airway

      • Afebrile, minimal secretions

Chronic ventilation

• When continuous mechanical ventilation is required 

• Conditions such as stroke and spinal cord injury 

• Chronic stable illnesses, such as neuromuscular disorders and chest wall deformities, and/or advanced age

• Chronic illness that requires recurrent ICU hospitalization 

  • May require frequent repeated treatments with mechanical ventilation and repeated attempts to wean from mechanical ventilation 

Terminal Wean

• Palliative wean 

  • Need to explain to family that dropping stats is normal, can be a difficult situation 

• The removal of ongoing ventilator support is a necessary evil when these devices are hindrances to ending life rather than sustaining a manageable quality of life for a patient 

• Patient wishes

  • Pain free and free of respiratory distresses

  • Make sure they are not air hungry 

  • Make sure they are comfortable 

Hospice care and Palliative care

• All hospice care is palliative care 

• Not all palliative care is hospice care

  • Palliative care focuses on symptom management in serious illness and can last for prolonged time 

  • Hospice care is an option when death is expected within 6 months

Psychosocial and Regulatory issues

• Methods of stating end-of-life preferences

  • Advanced directives (enshrined by law) 

    • DNR

    • Medical durable power of attorney/ Health care proxy/ Living Will 

      • Patient has to be incapacitated to take effect

      • Will see health care proxy most often 

    • POLST/ MOLST (in NYS it’s a MOLST)

      • Goes into effect as soon as it is signed by physician

      • Travels with patient to every facility 

  • Signing as a witness for informed consent 

  • Cultural awareness

  • Autonomy, double affect and coercion 

    • Autonomy: patient has right to make their own medical decision s

    • Double affect: an action caused unintended consequence detrimental to patient life

    • Coercion: comes off as a “threat” 

Communication

• Confronting death is emotionally difficult 

  • Poor communication is the #1 problem vocalized by families 

• Skill development 

  • Families and clients often have an impossible choice to make

  • Therapeutic and non-therapeutic communication

    • Therapeutic: active listening 

    • Non therapeutic: false reassurances 

Spiritual care fostering hope

• Spirituality (may or may not contain elements of religion) 

• Religion 

  • Spiritual assessment is on your nursing assessment

• Hope fostering categories 

  • Love of family and friends; faith; setting goals; staying independent; positive relationships with clinicians; humor; uplifting memories; personal characteristics 

• Hope hindering categories 

  • Abandonment, isolation, uncontrolled pain/discomfort, devaluation of personhood

Managing Physiologic Responses to Terminal Illness

• Pain 

  • Is preventable or treatable 

  • Assess pain using facility’s pain scale tools

  • Use smallest dose possible to alleviate symptoms 

  • Inability to communicate pain should not be mistaken for lack of pain, neither should be sleeping 

Helpful medications in managing terminal illness

• Opioids (can be given SL, oral, or PR)

  • Morphine sulfate (oral Roxinol) 

    • Decreased air hunger (sensation of being SOB)

    • Lowers pain

    • Lowers BP and may depress respirations 

    • GI motility, Establish bowel regime 

      • Colase or laxatives (to keep them regulated/ address constipation)

    • Reversal agent: Narcan (Nalaxone) 

  • Benzodiazepines 

    • Ativan, Xanax

    • Anxiety can increase WOB

    • Reversal agent: Romazicon (Flumazenil)

Physiological responses to terminal illness

• Dyspnea is the uncomfortable awareness of breathing and is very prevalent at end of life 

  • Feeling of can’t get enough air 

  • NOT necessarily associated with tachypnea, diaphoresis or cyanosis 

    • Assess by patient report using a scale of 0-10

    • Manage anxiety 

    • Low flow O2, movement of air (fan), low dose opioids 

      • 1/2L to 1L of O2

    • Reduce demand, energy conservation 

      • Cluster care for less strain 

Impaired secretions at the end of life

• Reassure the family that increased secretions are normal at end of life

• Educate the family on how to differentiate increased secretions from dyspnea 

• Medication for secretions (oral) 

  • Atropine PO or SL 

  • Glycopyrrolate 

  • Hyoscyamine 

  • Scopolamine patch

Depression

• Depression should not be ignored 

• Depression can be treated with medications, but therapeutic blood levels often take time to achieve the desired results

Delirium and Depression

• A disturbance in consciousness, attention, awareness, and cognitive capacity. It is rapid in its onset and different from dementia

  • Delirium is often related to underlying treatable condition s

    • New medication 

    • Impaction 

    • Full bladder

    • Pain 

    • Sleep deprivation/change of environment 

      • change/disturbance in general [changes in meds, treatment, routine (family visits)]

Grief and mourning and palliative sedation

• Unbiased care 

• Ethical dilemma withdrawing of care

• Decision making capacity 

• Palliative sedation is different from euthanasia