Lecture Notes Complex Respiratory Conditions- ARF/ARDS
HEMODYNAMIC MONITORING REVIEW
Hemodynamic measurements help determine whether the patient is:
Adequately perfusing.
Fluid overloaded or volume depleted.
Adequately oxygenating. Pasted text.txtTXT
Hemodynamic reference ranges may vary by:
Clinical site.
Monitoring equipment.
⚠ TRAP Do not become overly focused on minor variations in reference ranges.
The instructor stated that exam questions will make the intended hemodynamic interpretation clear.
The major concepts to understand with hemodynamic measurements are:
Perfusion.
Preload.
Afterload.
Contractility.
Oxygenation.
Central venous pressure (CVP) reflects the patient's volume status.
🔢 Normal CVP: 2–6 mm Hg.
An increased CVP indicates increased fluid/volume.
High CVP can indicate:
Right ventricular failure.
Fluid overload.
A decreased CVP indicates the patient is on the "drier" side.
Low CVP can indicate hypovolemia.
💎 CLINICAL GEM When determining whether a patient is fluid overloaded or dry, look at the CVP.
Continuous cardiac output (CCO) reflects systemic perfusion from cardiac pumping.
🔢 Normal CCO: 4–8 L/min.
💎 CLINICAL GEM When evaluating whether the left ventricle is effectively sending blood systemically, look at cardiac output.
Continuous cardiac index (CCI) adjusts cardiac output for body surface area.
🔢 Normal CCI: 2.2–4 L/min/m².
Stroke volume (SV) is the amount of blood ejected with each heartbeat.
🔢 Normal SV: 60–150 mL/beat.
Stroke volume provides information related to cardiac contractility.
Stroke volume variation (SVV) evaluates variation in stroke volume.
🔢 Normal SVV: <13%.
Central venous oxygen saturation (ScvO₂) provides information about the patient's oxygenation.
🔢 Reference ScvO₂: approximately 70%.
ScvO₂ helps evaluate whether oxygen is actually reaching and being used at the tissue/cellular level.
‼ A patient can receive 100% oxygen and still fail to adequately oxygenate at the tissue level.
Oxygen delivery alone does not prove that the patient is responding.
Additional ventilatory pressure support may be necessary.
Medication support may also be necessary.
Systemic vascular resistance (SVR) represents systemic resistance/afterload.
🔢 Normal SVR: 800–1200 dynes/sec/cm⁻⁵.
Mean arterial pressure (MAP) is used to evaluate and guide perfusion support.
Vasopressor therapy is commonly titrated using MAP.
🔢 The instructor emphasized a general MAP goal of >65 mm Hg.
The instructor acknowledged that some references/settings may use >60 mm Hg.
The course textbook uses >65 mm Hg.
‼ For this course, the instructor stated to use >65 mm Hg.
MAP goals may change according to the patient's condition.
Cerebral perfusion may require a MAP >70 mm Hg or higher depending on the clinical goal.
ARTERIAL BLOOD GAS REVIEW
ABG interpretation from previous semesters is expected knowledge.
Fourth semester will reinforce ABG interpretation rather than reteach it from the beginning.
Case-study exam questions may provide an ABG that must be interpreted quickly to determine the patient's clinical direction.
‼ Begin ABG interpretation with the pH.
🔢 Normal pH: 7.35–7.45.
Decreased pH indicates acidosis.
Increased pH indicates alkalosis.
🔢 Normal PaCO₂: 35–45 mm Hg.
🔢 Normal HCO₃⁻: 22–26 mEq/L.
The kidneys regulate/produce bicarbonate.
🔢 Normal PaO₂: 80–100 mm Hg.
🔢 Normal SaO₂: >95%.
Respiratory failure secondary to sepsis may produce acidosis.
The patient may simultaneously have respiratory and metabolic acidosis.
💎 CLINICAL GEM Interpret the entire ABG in relation to what is happening clinically rather than viewing one value in isolation.
ARTERIAL LINE MONITORING
An arterial line is an invasive arterial catheter used for continuous hemodynamic monitoring.
It provides a second-by-second representation of the patient's blood pressure.
It measures:
Systolic pressure.
Diastolic pressure.
MAP.
It provides access for obtaining ABGs.
Hemodynamically unstable patients may have both:
An invasive arterial-line pressure.
A noninvasive blood-pressure cuff.
Comparing invasive and noninvasive pressures helps determine whether an abnormal reading reflects:
The patient's actual condition.
A problem with the monitoring equipment.
🔢 Invasive and noninvasive measurements may differ by approximately 10–20 mm Hg.
‼ If the blood-pressure reading does not fit the patient's clinical presentation, reassess before acting on the number.
Recheck the blood pressure.
Verify correct cuff size.
Verify appropriate cuff alignment over the artery.
Verify appropriate patient positioning.
💎 CLINICAL GEM Assess the patient first.
A patient with true hypotension should demonstrate findings consistent with impaired perfusion.
If the monitor indicates severe hypotension but the patient does not clinically appear hypotensive, troubleshoot the equipment.
⚠ TRAP Treating an inaccurate arterial-line reading can result in inappropriate escalation of vasopressors.
Arterial lines are inserted by appropriately trained clinicians.
Providers who may insert them include:
Physicians.
NPs.
PAs.
Surgeons.
Nurses generally do not insert arterial lines unless specifically trained.
Nurses are responsible for preparing arterial-line equipment during emergency situations.
Know where arterial-line equipment is stored.
Equipment may be located with or near the crash cart.
The nurse may need to:
Obtain the equipment.
Set up the system.
Zero the system.
Connect the system to the monitor.
Ongoing nursing management includes verifying that the hemodynamic readings are accurate.
The arterial-line system is a continuously pressurized system.
Normal saline provides continuous slow flow through the system.
🔢 Continuous flush rate: approximately 3 mL/hr.
A pigtail allows the system to be flushed.
🔢 The pressure bag is inflated to 300 mm Hg.
The transducer must remain correctly positioned relative to the patient's heart.
The reference point is the phlebostatic axis.
The zero-reference stopcock is aligned at the phlebostatic axis.
Incorrect transducer positioning can produce an inaccurate pressure reading.
‼ Verify transducer position before escalating treatment based solely on an abnormal arterial-line pressure.
The instructor described a patient whose falsely low pressure readings led to:
Medication titration upward.
Addition of another vasopressor.
The problem was incorrect transducer positioning rather than the patient's actual blood pressure.
⚠ TRAP Never assume the monitor is correct simply because it displays a number.
The arterial waveform is displayed alongside the ECG.
The dicrotic notch represents aortic valve closure.
The arterial waveform should appropriately correspond with the cardiac cycle.
Students are not required to interpret arterial waveforms in detail.
Students should recognize what an arterial-line waveform looks like when encountered clinically.
⛔ NEVER DO Administer medications through an arterial line.
The arterial line is used for:
Hemodynamic measurement.
Obtaining arterial blood samples/ABGs.
It is not a peripheral IV.
The instructor described an event in which epinephrine was mistakenly administered through an arterial line with a poor outcome.
ARTERIAL LINE COMPLICATIONS AND NURSING MANAGEMENT
Major arterial-line complications include:
Hemorrhage.
Infection.
Circulatory impairment.
Loss of line patency.
‼ These complications require ongoing nursing assessment because arterial-line management is a nursing responsibility.
Hemorrhage can occur if an arterial line becomes dislodged.
A radial arterial catheter can produce significant bleeding because it is located directly within an artery.
‼ Apply direct manual pressure immediately when an arterial line is inadvertently removed.
🔢 Recommended pressure duration discussed: 5–10 minutes.
‼ The instructor personally emphasized holding uninterrupted pressure for 10 minutes.
⛔ NEVER DO Substitute a sandbag for direct manual pressure.
Anticoagulated patients may have increased bleeding risk.
Infection is a complication of prolonged arterial-line placement.
Assess for signs and symptoms of infection.
Remove the arterial line as soon as it is no longer necessary.
Circulatory impairment can occur when arterial blood flow becomes compromised.
The catheter may interfere with arterial circulation.
Collateral circulation should be evaluated before arterial-line placement.
The instructor referenced testing perfusion through both arteries to verify adequate collateral circulation before insertion.
‼ An arterial line should not be placed at that site when adequate collateral circulation is absent.
Ongoing distal circulation must be assessed after placement.
Line patency must be maintained.
Loss of patency can interfere with accurate monitoring and arterial access.
Nurses may remove an arterial line after receiving an order and appropriate facility training.
Nursing students should not remove arterial lines.
‼ Removal requires immediate direct manual pressure.
🔢 Hold pressure 5–10 minutes.
The instructor emphasized 10 minutes.
Arterial lines are ideally placed at the wrist when appropriate.
Other arterial sites may be used when necessary.
Groin placement carries increased risk for:
Dislodgement.
Infection.
Bleeding.
The instructor's arterial-line complication images reinforce bedside recognition.
Left image:
The depicted arterial-line technique/setup was unsafe.
Gloves were absent.
Appropriate equipment/controlled technique was not demonstrated.
‼ The instructor characterized this setup as "absolutely not."
Middle image:
The extremity demonstrated severe circulatory compromise/discoloration.
Prolonged high-dose vasopressor therapy was discussed as a potential cause of severely reduced peripheral circulation.
💎 CLINICAL GEM Vasopressor-supported patients require assessment of the distal extremities and peripheral circulation, not merely the blood-pressure response.
⚠ TRAP An acceptable MAP achieved with vasopressors does not eliminate the need to assess peripheral perfusion.
🔑 KEY TAKEAWAYS
Hemodynamic measurements are used to evaluate perfusion, volume status, contractility, afterload, and oxygenation.
CVP helps distinguish fluid overload from volume depletion.
Cardiac output reflects systemic perfusion from cardiac pumping.
ScvO₂ helps evaluate whether oxygen delivery is meeting tissue needs.
A patient can receive 100% oxygen and still have inadequate tissue oxygenation.
MAP greater than 65 mm Hg is the general course target emphasized by the instructor.
Begin ABG interpretation with the pH.
Sepsis-related respiratory failure can produce both respiratory and metabolic acidosis.
Arterial lines provide continuous blood-pressure monitoring and access for ABGs.
Invasive and noninvasive blood-pressure measurements may differ by 10–20 mm Hg.
Assess the patient before treating an unexpected monitor reading.
Incorrect arterial-line transducer positioning can produce false pressure readings and inappropriate vasopressor escalation.
The arterial-line pressure bag is maintained at 300 mm Hg.
Medications must never be administered through an arterial line.
Major arterial-line complications are hemorrhage, infection, circulatory impairment, and loss of patency.
An inadvertently removed arterial line requires immediate direct manual pressure for 5–10 minutes; the instructor emphasized 10 minutes.
Nursing students do not remove arterial lines.
Vasopressor-supported patients require ongoing assessment of distal peripheral circulation.
The right arterial-line complication image demonstrates a hematoma. Pasted text.txtTXT
Hematomas can occur when bleeding continues underneath the skin.
Risk is especially important in:
Older adults.
Patients receiving anticoagulants.
‼ Control the bleeding with direct pressure.
Apply pressure at or slightly above the insertion site where the bleeding originates.
Notify the provider.
Additional compression may be required.
After bleeding is controlled, a heat pack may be used to help the body absorb the accumulated blood.
When an arterial line is removed:
The RN immediately applies pressure.
Nursing students should not take over pressure during the removal process.
⚠ TRAP Do not switch people immediately after arterial-line removal because uninterrupted pressure is required.
ICU assessment includes assessment of the equipment connected to the patient.
Students should become familiar with arterial-line equipment during ICU rotations.
Assess the monitor.
Assess the arterial-line system with the RN.
Assess the patient for complications previously discussed.
Ask the RN questions about unfamiliar equipment.
⚠ TRAP Students should not independently manipulate unfamiliar ICU equipment.
Arterial lines should be clearly labeled as arterial lines.
💎 CLINICAL GEM Connect the patient's perfusion status with the medications being administered to maintain that perfusion.
Evaluate the patient's MAP.
Identify which medications are supporting the MAP.
Understand why those medications are required.
ScvO₂/SvO₂ INTERPRETATION
ScvO₂ and SvO₂ are different measurements, although the terms may sometimes be used interchangeably in clinical discussion.
The instructor emphasized understanding the simplified interpretation rather than focusing on the technical distinction.
‼ ScvO₂/SvO₂ interpretation evaluates whether the patient's oxygen supply is meeting tissue oxygen demand.
Oxygen can be provided through:
Increased oxygen concentration.
Volume support.
Pressure support.
The nurse must determine whether the patient is actually responding to those interventions.
ScvO₂/SvO₂ values may be provided on exam questions.
Interpret the value in relation to the patient's overall oxygenation and clinical condition.
🔢 ScvO₂/SvO₂ ≥80% represents a high measurement.
The instructor described this as potentially indicating that excessive oxygen is being supplied.
The nurse may anticipate reducing or weaning oxygen support when appropriate for the patient.
❓ LECTURE INCONSISTENCY
Version A: The PowerPoint identifies ≥80% as increased oxygen supply with decreased oxygen demand.
Version B: The instructor verbally described ≥80% as increased oxygen supply with increased oxygen demand, then characterized the patient as receiving too much oxygen.
🔢 ScvO₂/SvO₂ 60–80% represents the normal or "golden zone."
Oxygen supply and oxygen demand are balanced.
The instructor described this range as indicating no supply-demand mismatch.
💎 CLINICAL GEM 60–80% = balanced oxygen supply and demand.
‼ Do not interpret a single ScvO₂/SvO₂ measurement in isolation.
Trend measurements over time.
Continuous hemodynamic monitoring allows the nurse to evaluate the patient's response to interventions.
🔢 ScvO₂/SvO₂ <60% indicates inadequate oxygen supply relative to demand.
Causes of inadequate oxygen supply include:
Low hemoglobin.
Consider anemia or bleeding.
Low arterial oxygen saturation.
Consider hypoxemia.
Low cardiac output.
Consider impaired perfusion/cardiogenic shock.
Increased oxygen demand.
💎 CLINICAL GEM A low ScvO₂/SvO₂ requires identifying why oxygen supply is failing to meet demand, not merely recognizing that the number is low.
Hemodynamic measurements must be interpreted with additional patient data.
Assess the patient for signs of decompensation.
Evaluate ABGs.
Evaluate oxygen therapy.
Evaluate trends rather than isolated measurements.
ABG frequency depends on the patient's clinical status.
ABGs may be obtained routinely, such as every morning, to evaluate trends.
A decompensating patient may require more frequent ABGs.
⚠ TRAP ABGs are not drawn simply because an arterial line makes them easy to obtain.
CAPNOGRAPHY
Capnography is a noninvasive bedside method for continuously monitoring ventilation.
Capnography was historically used frequently during conscious sedation.
Capnography is now used more broadly, including on regular nursing units.
Specialized nasal cannulas can continuously measure capnography.
Nursing responsibilities include:
Monitor the capnography waveform.
Monitor the measured end-tidal CO₂.
Evaluate trends.
Assess the patient in conjunction with the monitor.
🔢 Normal end-tidal CO₂ (EtCO₂): 35–45 mm Hg according to the PowerPoint.
❓ LECTURE INCONSISTENCY
Version A: The PowerPoint identifies the normal range as 35–45 mm Hg.
Version B: The instructor verbally stated 35–45 centimeters of mercury.
Hypoventilation causes increased EtCO₂.
The patient is retaining CO₂.
An increased EtCO₂ requires assessment and intervention based on the cause.
Potential support discussed includes:
Oxygen.
Pressure support.
Medication therapy.
Hyperventilation causes decreased EtCO₂.
The patient is blowing off increased amounts of CO₂.
‼ Never interpret the capnography number without assessing the patient.
Assess respiratory rate.
Assess respiratory depth.
Assess work of breathing.
Assess neurological status when respiratory distress is significant.
Increased work of breathing can precede rapid decompensation.
Elderly patients may decompensate especially quickly.
‼ Increased work of breathing requires early intervention.
Capnography waveforms should also be evaluated.
An upward-trending waveform indicates increasing EtCO₂.
Patient movement can create artifact.
Assess what the patient is doing when the waveform appears abnormal.
🔢 A resuscitation EtCO₂ goal of >10 mm Hg was presented.
The overall goal remains moving EtCO₂ toward the normal 35–45 mm Hg range when clinically appropriate.
Capnography findings do not identify a single automatic treatment.
The patient may require:
Oxygen support.
Oxygen plus medications.
Pressure support.
Escalation toward intubation.
Capnography is useful during conscious sedation.
Excessive sedation can decrease respiratory depth and ventilation.
Capnography can identify ventilatory deterioration before relying solely on oxygen saturation.
Additional uses of capnography include:
Mechanical-ventilator weaning.
Head-injury monitoring.
PCA therapy.
Other sedating medications.
💎 CLINICAL GEM Capnography provides another safety layer when medications or conditions can suppress ventilation.
INTUBATION: THE 8 Ps
The nurse does not normally perform endotracheal intubation.
An appropriately trained provider performs the procedure.
Nurse practitioners may perform intubation when trained and credentialed.
‼ The RN is a pivotal member of the intubation team.
Nursing responsibilities center on:
Anticipation.
Preparation.
Prioritization.
Patient assessment.
Medication administration.
Equipment readiness.
Team coordination.
Plan means anticipating respiratory deterioration before the patient reaches complete decompensation.
Determine what needs to be prioritized.
Determine what equipment may be required.
Determine whom to call.
Rapid response activation remains appropriate when indicated.
💎 CLINICAL GEM Earlier recognition and intervention are preferred over waiting until the patient deteriorates enough to require a rapid response.
Know where rescue equipment is located before an emergency occurs.
A 60-second situational assessment should include locating:
Ambu bag.
Suction equipment.
Other emergency airway equipment.
‼ Nurses must know how to correctly set up suction equipment.
Incorrect suction setup can result in secretions being pulled into the wall suction system.
If unfamiliar with the equipment, practice the setup before an emergency occurs.
Preparation includes gathering the required supplies and personnel.
Bring the crash cart when appropriate.
Intubation supplies are commonly stored within the crash cart.
Ensure the necessary team members are present.
Positioning requires the nurse to assist with placing the patient appropriately for intubation.
Positioning may occur as sedation and paralytic medications are administered.
Preoxygenation provides maximal oxygen immediately before intubation.
🔢 Preoxygenate with 100% oxygen.
An Ambu bag may be used to provide oxygenation while preparing for intubation.
Pretreatment addresses physiologic problems that may complicate intubation.
Hypotension may require:
Fluids.
Vasopressors.
Bronchospasm may require medication support.
Topical anesthetic agents may be used during airway management.
The instructor discussed agents such as:
Lidocaine.
Benzocaine.
⚠ TRAP Topical airway medications can rarely produce significant reactions.
The instructor described laryngeal edema.
Tongue swelling may occur.
Airway closure can occur.
🔑 KEY TAKEAWAYS
An arterial-line hematoma requires bleeding control with direct pressure and provider notification.
ICU assessment includes assessment of the equipment connected to the patient.
Connect the patient's MAP with the medications being used to maintain perfusion.
ScvO₂/SvO₂ 60–80% represents balanced oxygen supply and demand.
ScvO₂/SvO₂ below 60% indicates oxygen supply is inadequate relative to demand.
Low hemoglobin, low arterial saturation, low cardiac output, and increased oxygen demand can produce a low ScvO₂/SvO₂.
ScvO₂/SvO₂ values should be trended rather than interpreted in isolation.
Normal EtCO₂ is 35–45 mm Hg according to the PowerPoint.
Hypoventilation increases EtCO₂.
Hyperventilation decreases EtCO₂.
Assess respiratory rate, depth, and work of breathing along with capnography.
A resuscitation EtCO₂ goal greater than 10 mm Hg was presented.
Increased work of breathing can precede rapid decompensation.
The RN is responsible for anticipating and preparing for intubation even though the RN does not perform the procedure.
Know the location of the Ambu bag, suction, crash cart, and other rescue equipment.
Preoxygenation before intubation uses 100% oxygen.
Intubation pretreatment may include fluids, vasopressors, and treatment for bronchospasm.
Topical airway medications can rarely cause laryngeal edema and airway compromise.
Intubation pretreatment may require additional medications based on the patient's physiologic status. Pasted text.txtTXT
Decreasing cardiac output may require additional hemodynamic support.
Impaired contractility may require additional medication support.
‼ Intubation occurs within an interdisciplinary team.
The nurse should anticipate what support the patient may require.
For NCLEX-style questions:
Prioritize the information directly in front of you.
Determine the most important immediate intervention.
Determine the safest immediate intervention.
⚠ TRAP Multiple answers may appear appropriate, but the nurse must identify the highest-priority action.
Paralysis and induction require medications to be administered in the correct sequence.
‼ Administer the sedative BEFORE the paralytic.
A patient may remain cognitively intact and aware before sedation.
Paralysis removes the patient's ability to move or respond.
⛔ NEVER DO Administer the paralytic first and leave an aware patient unable to move.
The provider determines which medications are administered.
The nurse administers the ordered medications.
💎 CLINICAL GEM Sedative first → paralytic second.
Placement with proof requires confirmation that the ET tube is correctly positioned.
‼ Chest x-ray is the gold standard for ET tube placement confirmation.
Immediate bedside assessment includes:
Bilateral lung sounds.
Equal chest rise and fall.
CO₂ detection.
A colorimetric CO₂ detector may change from purple to yellow.
💎 CLINICAL GEM "Yellow is gold; gold is good."
Evaluate the patient's clinical response after intubation.
Determine whether the patient is improving.
⚠ TRAP Failure to immediately improve does not automatically mean the ET tube is incorrectly placed.
The tube may be correctly positioned while the patient still requires additional medication or physiologic support.
Post-intubation management requires continued nursing management rather than considering intubation the endpoint.
Anticipate suctioning.
Anticipate ongoing medication management.
A severely ill patient may require an arterial line.
A severely ill patient may require a central line.
Prepare appropriate hemodynamic monitoring when invasive lines are placed.
Ongoing sedation is generally required while the patient remains intubated.
Neuromuscular blockade may also continue depending on severity.
Spontaneous awakening trials (SATs) and spontaneous breathing trials (SBTs) are used during weaning.
⚠ TRAP SATs and SBTs are not performed immediately simply because the patient has been intubated.
The patient should be progressing toward ventilator weaning.
Weaning may involve modes that allow the patient to perform more of the work of breathing.
APRV was discussed.
CPAP was discussed.
During these modes, the patient remains intubated but may initiate/take their own breaths.
‼ Avoid intubation when the patient's condition can be safely managed with less-invasive support.
Prolonged intubation can injure the lungs.
The artificial airway creates a direct internal pathway that can contribute to infection.
Intubation carries multiple additional complications.
BiPAP may be attempted before progressing to intubation.
The instructor described BiPAP as a "last check" before intubation when clinically appropriate.
BiPAP provides inspiratory pressure support.
BiPAP provides expiratory pressure support.
Expiratory pressure creates PEEP.
PEEP helps open alveoli.
Opening alveoli supports oxygen exchange.
If BiPAP fails to provide adequate support, intubation may be required.
RAPID SEQUENCE INTUBATION AND MEDICATION MANAGEMENT
Rapid sequence intubation (RSI) is used to rapidly establish an artificial airway.
The RN functions as part of the RSI team.
The provider selects the medications used during RSI.
⚠ TRAP The nurse does not independently choose which sedative or paralytic to administer.
‼ RSI medication sequence is sedation first → neuromuscular blockade second.
Common sedatives listed by the instructor include:
Etomidate.
Ketamine.
Propofol.
Midazolam.
Propofol has a rapid/short effect that makes it useful in this setting.
Common neuromuscular blockers listed include:
Succinylcholine.
Rocuronium.
Students should recognize the commonly used medications and their role in the sequence.
Students are not expected to select one RSI medication over another.
Medication selection is the provider's responsibility.
After RSI, the provider may order continuous medication infusions.
Continuous sedation may be required.
Continuous neuromuscular blockade may be required depending on the patient's condition.
Pain medication may also be required.
A paralyzed patient cannot verbally or physically communicate normally.
The nurse must continue evaluating whether sedation is adequate.
The nurse must continue evaluating whether paralysis is adequate.
Train-of-four monitoring can evaluate neuromuscular blockade.
It evaluates nerve stimulation to determine the degree of paralysis.
The instructor identified this as more advanced critical-care content.
‼ Paralysis does not eliminate the need to assess for pain or inadequate sedation.
Assess facial expression.
Assess agitation or other observable responses.
Assess eye-related responses when applicable.
If findings suggest inadequate sedation or pain:
Communicate with the provider/intensivist.
Medication doses may require adjustment.
Depending on the patient's condition, simultaneous therapy may include:
Analgesic.
Sedative.
Neuromuscular blocker.
Succinylcholine can trigger malignant hyperthermia in susceptible patients.
Susceptibility may involve a rare autosomal dominant genetic condition.
Malignant hyperthermia involves a profound increase in metabolic activity.
Findings discussed include:
Severe hyperthermia.
Muscle rigidity.
‼ Dantrolene is used to treat malignant hyperthermia.
Treatment must occur rapidly.
Medication-selection errors can occur during high-pressure emergencies.
The instructor discussed a fatal medication error involving similarly named medications.
Medication-dispensing systems now commonly require entry of approximately the first 4–5 letters of a medication name before selection.
‼ Emergency conditions do not eliminate the requirement for medication verification.
⚠ TRAP Similar medication names can contribute to catastrophic selection errors.
Post-intubation analgesics discussed include:
Fentanyl.
Hydromorphone.
Morphine.
These medications are opioids.
Opioids provide analgesia.
Opioids are also sedating.
Opioids can suppress respiratory effort.
Appropriateness depends on the individual patient's condition.
Orders may use:
A set infusion rate.
Titration to patient comfort.
‼ The nurse's responsibility is continuous assessment and evaluation of the patient's response.
Post-intubation sedatives discussed include:
Propofol.
Dexmedetomidine.
Brand name: Precedex.
Midazolam.
Brand name: Versed.
Dexmedetomidine/Precedex is commonly used for sedation.
Low-dose Precedex may be used for patients experiencing alcohol withdrawal.
Some progressive-care/step-down units may manage Precedex infusions.
🔢 The instructor stated that they try not to use Precedex for more than 24 hours.
Use particular caution in older adults.
Midazolam/Versed can remain in the patient's system for an extended period.
🔢 The instructor described effects/persistence of approximately 24–48 hours, depending on metabolism and excretion.
Older adults require particular caution.
A continuous Versed infusion is not considered ideal in an elderly patient.
Fentanyl and Versed are nevertheless frequently used together clinically.
🔑 KEY TAKEAWAYS
NCLEX intubation questions require prioritizing the safest and most important immediate intervention.
Sedation must occur before neuromuscular paralysis.
Chest x-ray is the gold standard for confirming ET tube placement.
Bilateral lung sounds, equal chest rise and fall, and CO₂ detection provide immediate bedside evidence of placement.
A correctly placed ET tube does not guarantee immediate clinical improvement.
Post-intubation care includes suctioning, medications, sedation, and possible invasive hemodynamic monitoring.
SATs and SBTs are part of ventilator weaning.
BiPAP may provide inspiratory and expiratory pressure support before intubation becomes necessary.
RSI uses sedation first and neuromuscular blockade second.
The provider selects the specific RSI medications.
Paralysis does not eliminate the need to assess sedation and pain.
Succinylcholine can trigger malignant hyperthermia in susceptible patients.
Dantrolene is used to treat malignant hyperthermia.
Fentanyl, hydromorphone, and morphine are opioid analgesics that can suppress respiratory effort.
Precedex is a commonly used sedative; the instructor discussed avoiding use beyond 24 hours when possible.
Versed may persist for 24–48 hours depending on metabolism and excretion and requires additional caution in older adults.
Artificial-airway management is performed collaboratively with respiratory therapy. Pasted text.txtTXT
The ET tube has centimeter markings that allow the nurse to monitor its position.
Document the centimeter marking at the:
Lips.
Teeth.
‼ Compare the current ET tube depth with the previously documented depth.
Include ET tube depth in bedside handoff report.
💎 CLINICAL GEM A change in the documented centimeter marking may indicate that the ET tube has moved.
The ET tube has an inflatable cuff.
The cuff helps maintain the tube's position/seal within the airway.
Respiratory therapy assesses and manages cuff inflation.
The nurse is not responsible for independently inflating the cuff.
The pilot balloon can be assessed to determine whether the cuff remains inflated.
A cuff leak can interfere with effective ventilation.
Findings may include:
Low-pressure ventilator alarms.
Low-volume ventilator alarms.
Inadequate oxygenation.
The ET tube must be positioned in the trachea.
⛔ NEVER DO Accept esophageal placement as correct placement.
Esophageal intubation may occur inadvertently.
Findings suggesting esophageal placement include:
Absent or minimal detected CO₂.
Absent appropriate chest rise and fall.
Abdominal distention.
‼ These findings require immediate recognition that the tube may be incorrectly positioned.
An ET tube can also be advanced too deeply.
The tube commonly enters the right mainstem bronchus when advanced too far.
The right side provides a more direct anatomical pathway.
Chest x-ray confirms the location.
The provider may order the tube withdrawn a specified number of centimeters.
💎 CLINICAL GEM An ET tube that is too deep commonly goes into the right lung.
OG/NG tubes may be placed after intubation.
An OG tube may be used for gastric decompression.
Tube insertion may require troubleshooting because patient anatomy varies.
⚠ TRAP Difficulty inserting an OG/NG tube does not justify forcing it.
During insertion, remain aware of the existing ET tube and avoid disrupting it.
Students should take supervised opportunities to participate in emergency airway care.
The instructor encouraged students to move toward learning opportunities rather than away from them.
Appropriate staff should remain present to guide the student.
Prolonged ET tube placement can injure airway tissue.
Continuous cuff/tube pressure can damage mucosa.
Prolonged pressure may contribute to fistula formation.
‼ This is another reason to avoid unnecessary or prolonged intubation.
SATs and SBTs help determine whether the patient can progress toward removal of the artificial airway.
🔢 The instructor described approximately 2 weeks as the absolute maximum general rule of thumb for prolonged ET intubation.
Approaching prolonged support of this duration may prompt consideration of a tracheostomy.
A tracheostomy allows continued ventilatory support without prolonged oral ET intubation.
⚠ TRAP Do not assume an ET tube should remain indefinitely simply because the patient still requires mechanical ventilation.
INTUBATION EQUIPMENT
Intubation supplies are commonly located in the crash cart.
Exact drawer location varies by facility.
Common equipment includes:
ET tubes.
Laryngoscope.
CO₂ detector.
Laryngoscope blades.
GlideScope.
Laryngoscope blades include:
MAC blade.
Curved blade.
💎 CLINICAL GEM The instructor remembers MAC = C for curved.
Miller blade.
Straight blade.
The provider determines the required blade and size.
The nurse obtains and opens the requested equipment.
The GlideScope provides real-time video visualization during intubation.
It is commonly available in areas such as:
ED.
ICU.
‼ Part of airway planning is knowing where the GlideScope is located before it is urgently needed.
Keep the device charged/plugged in when possible.
Position it where the provider can easily use the screen.
The provider determines the preferred exact bedside position.
Real-time visualization improves the likelihood of successful first-pass intubation.
ARTIFICIAL AIRWAY NURSING MANAGEMENT
‼ Proper ET tube placement must be continuously evaluated.
Chest x-ray is the gold standard for confirming ET tube placement.
The provider evaluates the radiographic position.
Before radiographic confirmation, bedside findings supporting appropriate placement include:
End-tidal CO₂ detection.
Purple-to-yellow color change supports CO₂ detection.
💎 CLINICAL GEM "Yellow is gold; gold is good."
Equal chest rise and fall.
Bilateral lung sounds.
Proper cuff inflation must also be evaluated.
Assess the pilot balloon.
Monitor for low-volume alarms.
Monitor for low-pressure alarms.
Assess whether the patient is adequately oxygenating.
‼ Intubation treats the immediate airway/ventilatory problem but does not eliminate the underlying cause.
Continue determining why the patient developed respiratory failure.
Trend ABGs to evaluate oxygenation and ventilation.
Determine whether ABGs are:
Improving.
Worsening.
Assessment findings should guide anticipation of further treatment.
Significant abnormal lung sounds may indicate an underlying pulmonary problem.
Fluid overload may require diuretic therapy.
Severe inflammatory pulmonary disease may require anti-inflammatory therapy such as Solu-Medrol.
Pneumonia may require antibiotics.
‼ When blood cultures are indicated, obtain them before antibiotics.
💎 CLINICAL GEM The nurse does not prescribe treatment but should anticipate what the provider is likely to order.
Think ahead.
Prepare needed interventions.
Organize and prioritize care.
ORAL CARE AND SKIN INTEGRITY WITH AN ARTIFICIAL AIRWAY
Oral care is part of ventilator-associated pneumonia prevention.
Intubated patients cannot independently perform adequate oral hygiene.
Comprehensive oral care includes cleaning:
Teeth.
Tongue.
Around the ET tube.
Behind/adjacent to the ET tube.
Chlorhexidine was identified by the instructor as the oral-care product used in the ventilator bundle.
🔢 The instructor emphasized comprehensive oral care with chlorhexidine at least every 4 hours.
ET tube position within the mouth should be documented.
Document whether the tube is:
Midline.
Shifted right.
Shifted left.
Assess how the securing device and ET tube contact surrounding tissues.
ET tube pressure can compromise oral tissue integrity.
The securing device may pull against the lips.
The tube may place pressure on the tongue.
Fluid shifts can cause significant tongue swelling.
The tongue provides a path of least resistance for edema.
Prolonged pressure can contribute to:
Oral ulcers.
Lip injury.
Tongue injury.
Facial skin breakdown.
‼ Continuously assess tissue beneath and around artificial-airway securing devices.
Advocate for interventions when pressure or skin injury develops.
Keep the lips and surrounding tissues moisturized.
⛔ NEVER DO Use petroleum-based products around the artificial airway.
Use water-soluble moisturizing products.
Skin-integrity assessment extends beyond the airway.
Assess bony prominences.
Critically ill patients are at significant risk for pressure injuries.
Nursing care should protect pressure points whenever clinically possible.
Some pressure injuries may occur despite appropriate nursing efforts because the patient's condition prevents repositioning.
The instructor described a patient with:
Severe MI.
Cardiogenic shock.
Mechanical cardiac support.
Multiple vasoactive/inotropic medications.
A femoral device requiring the patient to remain flat.
The patient could not safely be repositioned for an extended period.
The patient subsequently developed a severe sacral/gluteal pressure injury.
Vasopressors further compromised peripheral/capillary perfusion.
💎 CLINICAL GEM Pressure-injury risk in critical illness reflects both immobility and impaired tissue perfusion.
‼ Reposition and protect pressure points whenever the patient's hemodynamic condition allows.
⚠ TRAP Do not jeopardize lifesaving hemodynamic or mechanical support solely to accomplish routine repositioning.
🔑 KEY TAKEAWAYS
Document ET tube depth in centimeters at the lips or teeth and include it in handoff.
A change in ET tube depth can indicate tube migration.
A cuff leak may produce low-pressure or low-volume ventilator alarms.
The ET tube belongs in the trachea, not the esophagus.
Absent CO₂, absent appropriate chest rise, and abdominal distention can indicate esophageal intubation.
An ET tube advanced too deeply commonly enters the right mainstem bronchus.
Chest x-ray is the gold standard for confirming ET tube placement.
Prolonged ET tube pressure can cause mucosal injury and fistula formation.
The instructor described approximately 2 weeks as the general absolute maximum for prolonged ET intubation before tracheostomy becomes a consideration.
MAC blades are curved and Miller blades are straight.
The GlideScope provides real-time visualization and can improve first-pass intubation success.
Intubation does not treat the underlying cause of respiratory failure.
Trend ABGs to determine whether oxygenation and ventilation are improving or worsening.
Obtain indicated blood cultures before administering antibiotics.
Comprehensive oral care with chlorhexidine was emphasized at least every 4 hours.
Assess the lips, tongue, face, and tissues around the ET tube for pressure injury.
Use water-soluble rather than petroleum-based moisturizing products around the artificial airway.
Critically ill patients are at risk for pressure injury from both immobility and impaired tissue perfusion.
Critically ill ICU patients should be repositioned when repositioning is not contraindicated. Pasted text.txtTXT
‼ Do not avoid repositioning simply because the patient has extensive equipment or multiple lines.
Repositioning critically ill patients requires a team.
Before moving the patient:
Identify all lines.
Identify all tubes.
Organize equipment.
Protect devices from accidental dislodgement.
Proning also requires a coordinated team approach.
⚠ TRAP Some patients cannot be safely repositioned because of severe hemodynamic instability.
Patient stability takes priority when movement is contraindicated.
COMMUNICATION AND COMFORT IN CRITICAL CARE
Communication and comfort remain essential when caring for critically ill patients.
Intubation does not eliminate the patient's need for communication.
Sedation does not eliminate the patient's need for communication.
Paralysis does not eliminate the patient's need for communication.
‼ Continue talking to an intubated, sedated, or paralyzed patient.
Explain what you are doing.
Keep the patient informed throughout care.
Family and friends at the bedside also require communication.
Prepare family members before they enter the ICU room.
Explain what they are going to see.
Avoid unnecessary medical jargon.
Instead of simply saying "ET tube," explain that the patient has a breathing tube.
Explain that a machine may be breathing for the patient.
Explain that lines and machines are being used to deliver medications and support the patient.
Explain that the patient may:
Hear them.
Be unable to respond.
Encourage family members to:
Talk to the patient.
Touch the patient when appropriate.
Explain additional tubes and drains that may be present.
ICU visitation policies may establish specific visitation periods.
Know the facility's visitation policy.
Communicate restrictions clearly to the family.
Family agitation may originate from fear.
💎 CLINICAL GEM Approach distressed family members from a place of concern rather than interpreting their behavior as a personal attack.
Explain the situation.
Use the chain of command when additional support is required.
Psychological care is part of comprehensive critical-care nursing.
Communication and comfort matter to the patient's and family's experience and outcomes.
Family presence during patient decompensation requires individualized clinical judgment.
⚠ TRAP Do not automatically remove the family simply because the patient begins deteriorating.
Be transparent about what is happening.
Explain that the healthcare team is doing everything possible.
Family may be asked to temporarily step outside when necessary to safely provide care.
When appropriate, family may remain nearby or at the bedside.
A staff member who is not directly performing resuscitation may:
Remain with the family.
Explain what the team is doing.
Translate clinical actions into understandable language.
Family presence can allow loved ones to see that appropriate interventions are being attempted.
This may help families understand when treatment is no longer effective.
This may help families make difficult decisions when appropriate.
‼ Family needs should not be discounted during a critical event.
Some family members may want to witness care.
Some may not want to witness it.
Severe emotional distress may require moving the family to a quieter area and providing additional explanation/support.
There is no single approach appropriate for every family or every resuscitation.
When the patient's primary nurse is involved in a resuscitation:
The primary nurse should remain actively involved in direct patient care.
Responsibilities may include:
Providing report.
Administering medications.
Helping identify reversible causes.
Evaluating the Hs and Ts when applicable.
Other available staff can assume the family-support role.
💎 CLINICAL GEM During an emergency, the patient and family are both experiencing the event, but the primary nurse's immediate responsibility remains active management of the patient.
SUCTIONING THE ARTIFICIAL AIRWAY
Intubated patients require airway suctioning when indicated.
Open suction may be used in certain artificial airways, including tracheostomies.
Intubated patients commonly use a closed suction system.
The closed circuit remains sterile.
‼ Keep the ventilator circuit closed.
Do not routinely disconnect or change the circuit unnecessarily.
Maintaining the closed system helps protect the airway from contamination.
Closed suction requires the catheter to be advanced through the ET tube.
After the suction pass, withdraw the catheter completely.
The catheter tip should return completely out of the ET tube/circuit airway pathway.
‼ Hyperoxygenate the patient before suctioning.
🔢 Increase FiO₂ to 100% using the ventilator's hyperoxygenation/100% O₂ function.
Then perform the suction pass.
During withdrawal, assess the secretions.
Assess color.
Assess consistency.
Evaluate whether secretions are:
Improving.
Worsening.
Respiratory therapy may instill normal saline when clinically indicated to loosen difficult secretions.
Monitor the patient's physiologic response during suctioning.
Monitor blood pressure.
Monitor heart rate.
Monitor respiratory rate.
Assess overall tolerance.
Deep suctioning commonly triggers coughing.
Coughing is expected as the airway is stimulated.
The patient's face may become red during vigorous coughing.
Between suction passes:
Allow the patient time to recover.
Reoxygenate/hyperoxygenate as needed before another pass.
‼ Suctioning is an intervention that requires ongoing assessment, not simply catheter insertion and removal.
Closed suction may not remove deep mucus plugs.
Persistent deep mucus plugging may require bronchoscopy.
Bedside bronchoscopy may be performed in the ICU.
The scope allows direct visualization of mucus plugs.
Sterile saline may be used during bronchoscopy to help clear plugs.
Removing mucus plugs improves the opportunity for ventilation and oxygenation.
Bronchoscopy can also provide diagnostic specimens.
Secretions can be sent to microbiology.
Identification of the causative organism can guide antibiotic therapy.
Bronchoscopy may also obtain tissue samples.
Chest physiotherapy may be used to mobilize secretions.
It may be used when patients have excessive secretions associated with pulmonary disease.
Suctioning requires additional consideration in patients with head injury.
Suctioning can affect intracranial pressure.
If ICP is being continuously monitored:
Evaluate the ICP response during suctioning.
Determine whether ICP returns to baseline afterward.
Failure of ICP to recover may alter whether additional suctioning is appropriate.
‼ Oxygenation must still be maintained.
💎 CLINICAL GEM In head injury, balance the neurologic effect of suctioning against the patient's need for adequate oxygenation.
MECHANICAL VENTILATION
Mechanical ventilation may use:
Negative pressure.
Positive pressure.
Negative-pressure ventilation uses a chamber around the chest to create ventilation.
The iron lung is an example.
Negative-pressure ventilation is not the primary focus of this lecture.
‼ The lecture focuses on positive-pressure ventilation.
Positive pressure pushes air into the patient's airway.
Mechanical ventilation can provide:
Pressure support.
Volume support.
A combination of pressure and volume.
Pressure helps deliver the provided volume into the alveoli.
The nurse does not independently prescribe ventilator settings.
Ventilator management is interdisciplinary.
The nurse works collaboratively with:
Respiratory therapy.
The provider.
Nursing responsibilities include:
Understand the basic settings.
Assess the patient.
Recognize changes.
Determine whether changes indicate improvement or deterioration.
Communicate abnormalities to the interdisciplinary team.
MECHANICAL VENTILATOR SETTINGS
Respiratory rate (RR) is the number of breaths delivered/taken per minute.
🔢 Reference ventilator RR: 12–20 breaths/min.
Some modes have a prescribed minimum/set respiratory rate.
In full ventilatory support, the ventilator may perform essentially all of the work of breathing.
A patient requiring complete ventilatory control may also require:
Sedation.
Neuromuscular blockade.
Other modes allow the patient to breathe above the set ventilator rate.
Compare:
The prescribed/set ventilator rate.
The patient's actual respiratory rate.
Tidal volume (VT) is the volume delivered with each breath.
Tidal volume is selected according to patient characteristics such as body weight.
The respiratory therapist/provider determines the appropriate setting.
The instructor does not expect students to calculate tidal volume.
🔢 General tidal volume: 6–8 mL/kg.
ARDS requires a lower tidal-volume strategy.
🔢 ARDS tidal volume: 4–8 mL/kg.
ARDS lungs become stiff and poorly compliant.
‼ Lower tidal volumes are used because the ARDS lung cannot safely tolerate excessive volume.
💎 CLINICAL GEM Stiff/noncompliant ARDS lungs → lower tidal volume.
🔑 KEY TAKEAWAYS
Reposition ICU patients when repositioning is not contraindicated.
Moving or proning critically ill patients requires coordinated teamwork and protection of all lines and tubes.
Continue communicating with patients even when they are intubated, sedated, or paralyzed.
Prepare families for what they will see before bringing them into the ICU room.
Avoid medical jargon when explaining critical-care equipment to families.
Family agitation may reflect fear rather than hostility.
Family presence during decompensation should be individualized rather than automatically prohibited.
The primary nurse remains actively involved in direct patient management during resuscitation.
Intubated patients commonly use a sterile closed suction circuit.
Hyperoxygenate with 100% FiO₂ before suctioning.
Monitor blood pressure, heart rate, respiratory rate, and patient tolerance during suctioning.
Persistent deep mucus plugs may require bedside bronchoscopy.
Bronchoscopy can remove mucus plugs and obtain specimens for microbiology.
Suctioning can increase ICP in patients with head injury and requires monitoring of the patient's response.
Positive-pressure ventilation is the primary mechanical-ventilation method emphasized in this lecture.
Nurses collaborate with respiratory therapy and providers rather than independently prescribing ventilator settings.
General ventilator respiratory rate is 12–20 breaths/min.
General tidal volume is 6–8 mL/kg.
ARDS uses lower tidal volumes of 4–8 mL/kg because the lungs are stiff and poorly compliant.
Excessive tidal volume can injure a noncompliant lung. Pasted text.txtTXT
ARDS produces stiff, noncompliant lungs.
Delivering excessive volume can cause volutrauma.
Excessive volume can contribute to lung rupture and pneumothorax.
‼ ARDS patients should receive a lower tidal volume than patients with normally compliant lungs.
Tidal volume is determined according to patient weight.
The instructor does not expect students to calculate the tidal volume.
Other patient characteristics can affect appropriate tidal volume.
COPD.
Emphysema.
Advanced age.
Low body weight.
FiO₂ is the concentration of oxygen delivered to the patient.
FiO₂ represents the fraction of inspired oxygen.
🔢 General PaO₂ goal discussed: 60–80 mm Hg.
Certain clinical conditions may require a higher PaO₂ goal.
Cerebral perfusion/head injury may require a PaO₂ closer to 100 mm Hg.
🔢 General SpO₂ goal: >92%.
SpO₂ is a noninvasive measurement of oxygenation.
🔢 The instructor emphasized that SpO₂ may be approximately ±4% inaccurate.
‼ Interpret SpO₂ in the context of the entire patient assessment.
Example:
A 68-year-old patient with COPD has:
Respiratory rate 28/min.
Significant work of breathing.
Tripod positioning.
SpO₂ 89% on room air.
The SpO₂ reading should not be dismissed simply because the patient has COPD.
The patient's respiratory distress indicates a significant oxygenation problem.
⚠ TRAP Do not allow a history of COPD or a single SpO₂ value to override obvious signs of respiratory distress.
🔢 FiO₂ 100% means the ventilator is delivering the maximum oxygen concentration available.
‼ Receiving 100% FiO₂ does not mean the patient is successfully oxygenating.
Example:
FiO₂ = 100%.
SpO₂ = 89%.
ScvO₂ = 50%.
These findings indicate that oxygen delivery is not translating into adequate oxygenation.
Impaired gas exchange at the alveolar-capillary level requires additional intervention.
Increasing PEEP may be considered depending on the patient's condition.
💎 CLINICAL GEM High FiO₂ + persistently poor oxygenation = investigate gas exchange failure and the need for additional support.
PEEP is positive end-expiratory pressure.
PEEP applies pressure at the end of expiration.
PEEP helps keep alveoli open.
Keeping alveoli open supports oxygen exchange at the alveolar-capillary interface.
PEEP may be increased when oxygenation remains inadequate.
PEEP may be particularly useful with conditions such as ARDS.
🔢 Common examples discussed: 5–10 cm H₂O.
‼ Excessive PEEP can produce excessive alveolar pressure and barotrauma.
Patients with stiff/noncompliant lungs require particular attention to this risk.
💎 CLINICAL GEM PEEP improves alveolar recruitment, but excessive pressure increases barotrauma risk.
Pressure support (PS) provides inspiratory pressure.
Pressure support assists movement of the delivered breath into the lungs.
🔢 General pressure-support range: 5–10 cm H₂O.
I:E ratio represents the inspiratory-to-expiratory time relationship.
Inspiratory time may be shorter or longer than expiratory time depending on the patient's needs.
Adjustments can influence CO₂ retention or removal.
The instructor placed less emphasis on memorizing detailed I:E settings.
🔢 General I:E range presented: 1:2 to 1:1.5, unless inverse-ratio ventilation is used.
Inspiratory flow rate and time determine how rapidly the breath volume is delivered.
🔢 Inspiratory flow: 40–80 L/min.
🔢 Inspiratory time: 0.8–1.2 seconds.
Sensitivity determines how easily patient effort triggers ventilator assistance.
Pressure and flow triggers may be adjusted according to patient breathing.
🔢 Pressure trigger: 0.5–1.5 cm H₂O below baseline.
🔢 Flow trigger: 1–3 L/min below baseline.
Pressure limits establish the maximum allowable pressure during ventilation.
🔢 High-pressure limit: approximately 10–20 cm H₂O above peak inspiratory pressure.
‼ The instructor explicitly stated that students should know the major ventilator ranges and concepts.
Know respiratory rate.
Know tidal volume.
Recognize when a volume is excessive for a stiff lung.
Know PaO₂.
Use it to evaluate oxygenation.
Know SpO₂.
Recognize it as noninvasive oxygenation monitoring.
Know ScvO₂/SvO₂.
Relate these measurements to oxygen supply and demand.
Know PEEP.
Understand its role in alveolar recruitment.
Understand its relationship to barotrauma.
Detailed I:E settings are a lower priority.
⚠ TRAP Nurses are expected to recognize and interpret ventilator settings even though the provider/respiratory therapist determines or adjusts them.
MECHANICAL VENTILATION MODES
Assist-Control (AC) can deliver breaths using:
Volume control.
May appear as AC-V.
Pressure control.
May appear as AC-P.
Assist-Control has prescribed ventilator parameters that may include:
Respiratory rate.
Tidal volume or pressure.
Inspiratory time.
PEEP.
Sensitivity.
The ventilator performs the majority of the patient's work of breathing in Assist-Control.
💎 CLINICAL GEM Think of Assist-Control as a mode for the sicker patient who requires substantial ventilatory support.
A patient who must be completely dependent on the ventilator may require:
Sedation.
Neuromuscular blockade.
Analgesia as indicated.
‼ A newly intubated, critically ill, decompensating patient would be expected to receive Assist-Control rather than a mode requiring greater spontaneous respiratory effort.
SIMV is synchronized intermittent mandatory ventilation.
The ventilator provides a prescribed number of mandatory breaths.
The patient can spontaneously breathe between mandatory breaths.
The ventilator senses the patient's effort and synchronizes support with that effort.
Settings may include:
Respiratory rate.
Tidal volume.
Inspiratory time.
Sensitivity.
PEEP.
The instructor stated that SIMV is seen less frequently in her current clinical experience.
Pressure Support Ventilation (PSV) requires the patient to initiate the breath.
The ventilator then delivers prescribed pressure and flow.
The patient performs more of the work of breathing.
PSV can be used as the patient progresses toward weaning.
💎 CLINICAL GEM Patient initiates breath + ventilator assists with pressure = pressure-support ventilation.
Pressure-Control Inverse-Ratio Ventilation (PC-IRV) reverses the usual inspiratory-expiratory relationship.
Inspiration is prolonged.
Expiration is shortened.
Prolonged inspiration can retain more oxygen within the lungs.
Shortened expiration can contribute to air trapping.
Auto-PEEP may result.
The instructor stated this mode is not commonly used.
Airway Pressure Release Ventilation (APRV) allows the patient to perform more spontaneous breathing.
APRV can use two pressure levels.
The instructor compared its pressure concept with:
BiPAP.
CPAP.
Lower levels of support allow the patient to perform more of the work of breathing.
PEEP may still be provided.
‼ The instructor framed APRV as a step toward extubation/weaning.
💎 CLINICAL GEM As support decreases during weaning, the nurse evaluates whether the patient can tolerate increasing respiratory work.
Spontaneous awakening and spontaneous breathing trials evaluate readiness to continue weaning.
During an SAT:
Sedation is reduced/removed so the patient can awaken.
During an SBT:
The patient performs more of the respiratory work.
Findings indicating poor tolerance of a weaning trial include:
Increasing respiratory rate.
Increasing work of breathing.
Increasing respiratory effort.
Clinical deterioration.
‼ Increasing respiratory distress during a weaning trial indicates that the trial is not successful.
Notify the provider.
Report how the patient responded.
The provider may restore additional ventilatory support.
Sedation may be restarted at a lower level if indicated.
The patient may be allowed to rest on greater ventilator support.
The weaning trial may be attempted again the following day.
⚠ TRAP A failed weaning trial does not mean the entire ventilator course must restart from the beginning.
Support can be increased enough to allow recovery.
Weaning can be attempted again when appropriate.
🔑 KEY TAKEAWAYS
Excessive tidal volume in a stiff noncompliant lung can cause volutrauma and pneumothorax.
ARDS requires a lower tidal-volume strategy.
General PaO₂ goal is 60–80 mm Hg.
General SpO₂ goal is greater than 92%.
SpO₂ may be approximately plus or minus 4% inaccurate and must be interpreted with the patient assessment.
FiO₂ 100% does not guarantee adequate oxygenation.
Poor oxygenation despite 100% FiO₂ indicates the need to evaluate gas exchange and additional ventilatory support.
PEEP keeps alveoli open at end expiration and supports oxygen exchange.
Excessive PEEP can cause barotrauma.
Pressure support provides inspiratory assistance.
Students are expected to know the major ventilator ranges and interpret whether settings fit the patient's condition.
Assist-Control provides substantial ventilatory support and is appropriate for a critically ill newly intubated patient.
SIMV allows spontaneous breaths between mandatory ventilator breaths.
Pressure Support Ventilation requires the patient to initiate the breath.
Inverse-ratio ventilation prolongs inspiration and can produce auto-PEEP.
The instructor framed APRV as a mode used while progressing toward extubation.
Increasing respiratory rate and work of breathing indicate poor tolerance of a weaning trial.
A failed weaning trial may require additional support and another attempt after the patient rests.
MANAGING MECHANICAL VENTILATION
Ventilator alarms require the nurse to identify what the alarm indicates and assess the patient. Pasted text.txtTXT
‼ High-pressure alarm = think blockage or increased resistance.
The ventilator is encountering excessive pressure when attempting to deliver the breath.
Causes discussed include:
Patient biting the ET tube.
ET tube occlusion.
Mucus obstructing the tube.
‼ Low-pressure alarm = think disconnect or loss of the closed system.
Causes discussed include:
Cuff leak.
Ventilator-circuit disconnection.
Self-extubation.
A self-extubated ET tube may be completely outside the patient.
The patient may require reintubation.
⚠ TRAP A patient receiving mechanical ventilation can still experience respiratory arrest.
Mechanical ventilation does not replace ongoing nursing assessment.
💎 CLINICAL GEM Recognize deterioration early enough to intervene before respiratory arrest occurs.
PaCO₂ abnormalities can be corrected by manipulating minute ventilation.
The lungs control PaCO₂ through ventilation.
Respiratory acidosis:
🔢 PaCO₂ is >45 mm Hg.
pH is decreased.
The patient is retaining excessive CO₂.
Increase minute ventilation to decrease PaCO₂.
Increasing respiratory rate increases ventilation.
Increased ventilation allows the patient to blow off more CO₂.
Decreasing PaCO₂ helps correct the pH.
💎 CLINICAL GEM High PaCO₂ → increase ventilation → blow off CO₂.
Respiratory alkalosis:
🔢 PaCO₂ is <35 mm Hg.
pH is increased.
Decrease minute ventilation to increase CO₂ retention.
Decreasing respiratory rate decreases ventilation.
Decreased ventilation allows the patient to retain more CO₂.
💎 CLINICAL GEM Low PaCO₂ → decrease ventilation → retain CO₂.
⚠ TRAP Critically ill patients may have simultaneous metabolic abnormalities.
Correcting ventilation alone may not correct the entire acid-base disturbance.
COMPLICATIONS OF POSITIVE-PRESSURE VENTILATION
Positive-pressure ventilation can affect every body system.
‼ The nurse manages the whole critically ill patient rather than focusing only on the respiratory disorder.
Cardiovascular complications result from increased intrathoracic pressure.
Increased intrathoracic pressure can decrease venous return.
Decreased venous return decreases preload.
Decreased preload can cause hypotension.
💎 CLINICAL GEM Positive pressure → increased intrathoracic pressure → decreased venous return/preload → hypotension.
Neurological complications can include increased intracranial pressure.
Positive-pressure ventilation can interfere with venous return/drainage.
Patients with neurologic injuries require particular attention to ICP.
Additional factors that may worsen neurologic status include:
Sedation.
Poor body alignment.
Existing head injury.
Existing spinal cord injury.
‼ Patients with neurologic compromise may require ICP monitoring while receiving ventilatory support.
Renal/fluid complications may result from altered renal perfusion.
Decreased renal perfusion can activate the renin-angiotensin-aldosterone system.
Sodium and water balance may become abnormal.
Critically ill patients may also develop electrolyte disturbances from:
Fluid shifts.
Electrolyte movement between intracellular and extracellular spaces.
Pulmonary complications include:
Barotrauma.
Excessive airway/alveolar pressure can injure the lung.
Higher PEEP increases pressure exposure.
Stiff/noncompliant lungs are particularly vulnerable.
Volutrauma.
Excessive delivered volume can injure the lung.
Complications from ventilator-associated lung injury may include:
Pneumothorax.
Atelectatic/collapse-related changes.
‼ Mechanical ventilation can simultaneously support the patient and create additional pulmonary injury.
⚠ TRAP Do not assume a therapeutic ventilator intervention is free of physiologic consequences.
Gastrointestinal complications are strongly related to critical illness and immobility.
Decreased mobility contributes to decreased GI motility.
Ileus may develop.
OG or NG tubes may initially be used for gastric decompression.
Gastric decompression helps reduce aspiration risk.
Gastric contents entering the airway can result in aspiration.
Critically ill patients also require nutritional support.
Acid-suppressing medications may alter normal gastric acidity.
The instructor discussed PPIs and H₂-receptor antagonists.
Changing gastric acidity may increase susceptibility to infection.
The instructor discussed concern regarding C. difficile, particularly when patients are also receiving antibiotics.
The use of these medications in critically ill patients is being reexamined because of these potential consequences.
Musculoskeletal complications primarily result from immobility.
‼ Promote mobility as soon as the patient's condition safely allows.
Intubation alone does not automatically prohibit ambulation.
The instructor described ambulating intubated patients with appropriate support.
Patients may ambulate with:
ET tubes.
Chest tubes.
Other necessary equipment.
Early mobility is an evidence-based ICU nursing intervention.
The overall goal remains progressing the patient toward extubation and independence.
An awake intubated patient may experience substantial discomfort.
The instructor compared breathing through an ET tube to breathing through a straw.
Talk the patient through the experience.
Agitation or pulling at equipment may require additional medication when clinically indicated.
The provider determines medication changes.
Psychological/neurological complications can persist during and after critical illness.
Sedative medications can accumulate.
Patients may require repeated reorientation.
Limited daylight can interfere with normal day/night orientation.
Continuous ICU activity interferes with normal sleep.
ICU psychosis/delirium may occur.
Patients may remain disoriented for days.
Reduce/wean sedatives and pain medications as clinically appropriate.
‼ Minimize unnecessary sedation to support neurologic recovery.
Alarm fatigue can occur because ICU alarms operate continuously.
Ongoing exposure to alarms does not eliminate the need to respond appropriately to clinically significant alarms.
VENTILATOR-ASSOCIATED PNEUMONIA PREVENTION
Ventilator-associated pneumonia prevention is a major component of nursing management.
The ABCDEF bundle supports comprehensive critical-care management.
Spontaneous awakening trials are incorporated into ventilator care.
Spontaneous breathing trials are incorporated into ventilator care.
The instructor does not require memorization of the entire bundle.
Facility protocols guide the nurse through specific bundle criteria.
‼ The nurse should still anticipate that bundle interventions and weaning assessment will occur.
Know the relevant patient parameters rather than waiting for the protocol to prompt all clinical thinking.
MECHANICAL VENTILATOR WEANING
🔢 The instructor defined short-term ventilation as approximately 3 days.
🔢 The instructor defined long-term ventilation as >3 days.
‼ Prolonged oral ET intubation should be avoided.
🔢 The instructor described 2 weeks as really pushing the upper limit.
If prolonged ventilatory support is expected, anticipate:
Tracheostomy.
PEG tube placement.
Nutrition is important during critical illness.
🔢 The instructor stated that nutrition is generally started within approximately 24 hours when clinically appropriate.
Timing may vary according to the patient's condition.
Critically ill patients may be hypermetabolic.
Hypermetabolism increases energy requirements.
Nutrition may be provided through:
Gastric/enteral access.
NG tube.
OG tube.
TPN.
TPN is administered intravenously.
TPN is typically administered through a central line.
‼ A patient receiving TPN therefore also requires appropriate central-line management.
💎 CLINICAL GEM Connect each intervention with the additional nursing responsibilities it creates.
Weaning readiness requires determining whether the cause of respiratory failure has improved or become reversible.
Adequate oxygenation is required before progressing with weaning.
The P/F ratio evaluates oxygenation.
P/F ratio = PaO₂ ÷ FiO₂.
‼ FiO₂ is used as a decimal when calculating the P/F ratio.
The P/F ratio will be used again when evaluating ARDS.
💎 CLINICAL GEM A worsening P/F ratio reflects worsening oxygenation despite the amount of oxygen being delivered.
🔑 KEY TAKEAWAYS
High-pressure ventilator alarms suggest blockage, increased resistance, biting, occlusion, or mucus.
Low-pressure ventilator alarms suggest a disconnect, cuff leak, or self-extubation.
A mechanically ventilated patient can still experience respiratory arrest.
Respiratory acidosis with PaCO₂ above 45 mm Hg can be improved by increasing minute ventilation to blow off CO₂.
Respiratory alkalosis with PaCO₂ below 35 mm Hg can be improved by decreasing minute ventilation to retain CO₂.
Positive-pressure ventilation can decrease venous return and preload, causing hypotension.
Positive-pressure ventilation can contribute to increased intracranial pressure.
Barotrauma results from excessive pressure, while volutrauma results from excessive volume.
Critically ill ventilated patients are at risk for ileus, aspiration, immobility complications, and psychological complications.
Intubation alone does not automatically prohibit early mobility.
ICU psychosis or delirium can be worsened by sedation, sleep disruption, and loss of normal day/night cues.
SATs and SBTs are incorporated into ventilator-associated pneumonia prevention and weaning care.
Short-term ventilation was defined as approximately 3 days and long-term ventilation as greater than 3 days.
The instructor described 2 weeks of oral ET intubation as pushing the upper limit.
Nutrition is generally started within approximately 24 hours when clinically appropriate.
TPN is typically administered through a central line.
P/F ratio is calculated by dividing PaO₂ by FiO₂.
The P/F ratio helps determine the severity of impaired oxygenation and ARDS. Pasted text.txtTXT
P/F ratio = PaO₂ ÷ FiO₂.
🔢 P/F ratio ≥300 indicates relatively adequate oxygenation.
🔢 P/F ratio 200–300 indicates mild ARDS.
🔢 P/F ratio 100–200 indicates moderate ARDS.
🔢 P/F ratio <100 indicates severe ARDS.
Severe ARDS reflects significant difficulty getting oxygen into stiff, noncompliant lungs.
💎 CLINICAL GEM The lower the P/F ratio, the more severe the oxygenation impairment.
Additional findings support readiness for ventilator weaning.
🔢 SpO₂ should be >90%.
🔢 PEEP should be approximately ≤5–7 cm H₂O.
Low PEEP indicates the patient can maintain oxygenation without requiring high end-expiratory pressure.
🔢 FiO₂ should be ≤40–50% according to the lecture slide.
Lower oxygen requirements support readiness to wean.
🔢 pH should be ≥7.25 and progressing toward the normal 7.35–7.45 range.
Additional criteria include:
Adequate hemoglobin.
Appropriate temperature.
Awake or easily arousable.
Ability to respond to commands.
‼ Sedation should be minimized when attempting ventilator weaning.
Sedatives can suppress respiratory drive.
Opioid pain medications can suppress respiratory drive.
An awake intubated patient may find the ET tube uncomfortable.
Provide reassurance.
Explain that the team is working toward removing the tube as soon as safely possible.
PAIN AND SEDATION MANAGEMENT IN CRITICAL CARE
Psychological support is part of critical-care nursing.
Support the patient.
Support family members and friends.
Family presence and communication should be individualized to the clinical situation.
The instructor does not require memorization of the pain/sedation scales.
‼ Students must know which assessment tool is appropriate for the clinical situation.
Signs of pain or anxiety require:
Assessment.
Appropriate documentation.
Selection of the correct assessment tool.
Reassessment after intervention.
Pasero Opioid-Induced Sedation Scale (POSS) is used when evaluating patients receiving opioids.
Assess respiratory status before opioid administration.
Assess neurological/sedation status before opioid administration.
Reassess respiratory status after administration.
Reassess neurological/sedation status after administration.
💎 CLINICAL GEM Opioid administration requires respiratory and sedation assessment before and after the medication.
Critical-Care Pain Observation Tool (CPOT) is used to evaluate pain in critically ill patients.
The instructor referred to it as "C-POT."
CPOT is a primary pain-assessment tool used in critical care.
The nurse scores findings based on the patient's observed responses.
Pain medication is administered according to prescribed therapy and assessment findings.
Richmond Agitation-Sedation Scale (RASS) evaluates the patient's level of agitation or sedation.
Use RASS when a patient is receiving a sedative.
RASS findings help determine whether sedation may need to be increased or decreased.
RASS may also be used with other withdrawal-assessment tools when sedatives are being administered for withdrawal.
🔢 RASS 0 = alert and calm.
🔢 RASS -1 = drowsy but able to sustain awakening/respond.
The instructor described approximately RASS 0 to -1 as a general desired range.
The appropriate target depends on the patient's condition.
Light sedation may be appropriate in some situations.
‼ The goal is to avoid both extremes.
The patient should not be combative.
The patient should not be unarousable from excessive sedation.
💎 CLINICAL GEM RASS helps the nurse titrate sedation toward the desired neurologic response rather than simply keeping the patient deeply sedated.
COMMON CRITICAL-CARE MEDICATIONS
Mechanically ventilated patients may receive numerous medications because they are critically ill and hemodynamically unstable.
The instructor emphasized learning medications by classification and purpose.
Positive inotropes/vasoactive medications discussed include:
Epinephrine.
Norepinephrine.
Vasopressin.
Dopamine.
Dobutamine.
Milrinone.
These medications may be used to support critically ill, hemodynamically unstable patients.
Negative inotropes discussed include:
Calcium-channel blockers.
Beta blockers.
These medications decrease cardiac workload/rate depending on the medication and clinical indication.
Opioids are used for pain management.
Opioid therapy requires ongoing assessment for:
Sedation.
Respiratory suppression.
Sedatives discussed include:
Propofol.
Midazolam/Versed.
Dexmedetomidine/Precedex.
‼ Sedation level should be continually assessed rather than assuming the ordered infusion rate remains appropriate.
Antiarrhythmics discussed include:
Amiodarone.
Diltiazem/Cardizem.
Lidocaine.
Procainamide.
The instructor identified amiodarone and Cardizem as the two antiarrhythmics she sees most commonly.
Amiodarone and Cardizem infusions may be managed on some PCU/step-down units according to facility policy.
Heparin is commonly used in critically ill patients.
‼ Determine why the patient is receiving heparin.
VTE prophylaxis.
Treatment of VTE.
Acute coronary syndrome.
Follow the appropriate heparin protocol for the indication.
Monitoring depends on the facility protocol.
Anti-Xa may be used.
PTT may be used.
💎 CLINICAL GEM Heparin protocols may initially appear complicated, but the nurse should follow the protocol sequentially rather than improvising dosing.
Additional therapies discussed include:
Blood products.
TPN.
Octreotide/Sandostatin.
Octreotide/Sandostatin may be used for GI bleeding.
⚠ TRAP The "-statin" sound in Sandostatin does not mean it is a cholesterol-lowering statin medication.
EXTRACORPOREAL MEMBRANE OXYGENATION
ECMO provides extracorporeal cardiopulmonary support.
The instructor simplified ECMO as essentially a form of bypass support.
ECMO may support:
Severe lung failure.
Severe heart failure.
Combined heart and lung failure.
VV ECMO provides support primarily for severe lung failure/oxygenation failure.
VV = venovenous.
Severe COVID-related respiratory failure was discussed as an example in which VV ECMO was used.
💎 CLINICAL GEM VV = lungs.
VA ECMO provides support when significant cardiac failure is present.
VA = venoarterial.
Decompensated cardiogenic shock was discussed as an example.
VA can provide heart and lung support.
Some severely ill patients may progress from VV support to VA support when cardiovascular failure develops.
💎 CLINICAL GEM VA = heart ± lungs.
ECMO requires specialized training.
‼ A new-graduate ICU nurse would not independently receive an ECMO patient without appropriate specialized training.
Nurses caring for ECMO patients require facility-specific competency and education.
Students should understand:
What ECMO is.
Why it is used.
The difference between VV and VA support.
Major complications.
ECMO is an advanced support strategy used when severe cardiac or pulmonary failure requires additional support.
Major ECMO risks include:
Blood clots.
Infection.
Transfusion-related complications.
Stroke.
Hemorrhage.
Intracranial bleeding.
Critically ill ECMO patients may also be at risk for coagulation abnormalities such as DIC.
Closely monitor for signs of bleeding.
Closely monitor for neurological changes suggesting stroke or intracranial hemorrhage.
‼ ECMO provides lifesaving support but carries substantial thrombotic and bleeding risks.
🔑 KEY TAKEAWAYS
P/F ratio is calculated by dividing PaO₂ by FiO₂.
P/F ratio 200–300 indicates mild ARDS.
P/F ratio 100–200 indicates moderate ARDS.
P/F ratio below 100 indicates severe ARDS.
Lower P/F ratios indicate more severe oxygenation impairment.
Weaning readiness includes SpO₂ above 90%, PEEP approximately 5–7 cm H₂O or less, FiO₂ 40–50% or less, and pH at least 7.25.
Sedatives and opioids can suppress respiratory drive and should be minimized when attempting ventilator weaning.
POSS is used to evaluate sedation in patients receiving opioids.
CPOT is a primary critical-care pain-assessment tool.
RASS evaluates agitation and sedation in patients receiving sedatives.
The instructor described RASS 0 to -1 as a general desired sedation range.
Learn common critical-care medications by classification and clinical purpose.
Heparin may be used for VTE prophylaxis, VTE treatment, or acute coronary syndrome and requires the appropriate protocol.
Octreotide/Sandostatin may be used for GI bleeding.
VV ECMO primarily supports severe lung failure and oxygenation.
VA ECMO supports severe cardiac failure and can provide combined heart-lung support.
ECMO requires specialized nursing training.
ECMO complications include thrombosis, infection, stroke, hemorrhage, and intracranial bleeding.