Mechanical Ventilation

Endotracheal (ET) intubation

Placement of a tube into trachea via mouth or nose
past larynx
Most common type of short-term airway
Tracheostomy
Need for artificial airway >10-14 days
Reduce tracheal vocal cord damage
Artificial Airways
Indications for intubation
Maintain patent airway
Provide means to remove secretions
Provide ventilation and oxygen
Upper airway obstruction
Apnea
High risk aspiration
Ineffective clearance of secretions
Respiratory distress

Artificial Airways
Long, polyvinyl chloride tube
Passed via the mouth or nose into trachea with use of a
______________________
Proper position: tip tube rests about ____________________
Large-bore diameter used
In nasal ET intubation,
the ET is placed blindly (i.e., without seeing the larynx) through
the nose, nasopharynx, and vocal cords.
Endotracheal Tube

Endotracheal Tube
Nasal tube intubation
In nasal ET intubation,
the ET is placed blindly (i.e., without seeing the larynx) through
the nose, nasopharynx, and vocal cords.
Reserved: Facial or oral traumas and surgeries; or when
oral intubation is not possible
Indicated when head and neck manipulation is risky
Contraindicated: facial fx, suspected fx at base of skull,
post-op cranial surgeries, blood clotting problem


Endotracheal Tube
Bag valve mask (BVM) (AMBU BAG)
O2, suction equipment, IV access
Code cart, airway equipment box
During intubation:
Monitor for vs changes,signs hypoxia or hypoxemia,
dysrhythmias and aspiration
Intubation attempt should not last longer than 30 seconds,
preferably less than 15 seconds
After 30 sec: oxygenate via Ambu to prevent hypoxia and
cardiac arrest



Preparing for Intubation
Preparing for Intubation.
Premedication
Sedative-hypnotic amnesic
Lorazepam (Ativan); midazolam (Versed):
Agitated, disoriented or combative
Rapid sequence intubation (RSI)
Both paralytic and sedative agent
Decrease risks of aspiration, combativeness, injury to pt
Not indicated for comatose or during cardiac arrest
Fentanyl (Sublimaze)
Succinylcholine (Anectine)
Atropine
Pulse oximetry

Preparing for Intubation
Position:
SUPINE w/head EXTENDED & neck FLEXED (SNIFFING
POSITION)


Inflate cuff and confirm placement of ET tube while manually ventilating
patient with 100% O2
Most accurate way to verify placement:
End-tidal CO2 detector measures amount of exhaled CO2 from lungs
Bite block, suction Et tube or pharynx
Upon confirmation
Tube position at the lip or teeth is recorded & marked
Portable CXR
Confirm location
Position: Adult: 2 cm above CARINA


Following Intubation
Assess for B/L BS at bases & apices
Assess for symmetrical chest wall movement and air
emerging from ET
ABSENT BS ON LEFT SIDE:
_______________________________
TUBE IN STOMACH:
________________________________

Following Intubation
Stabilized at mouth or nose
Marked at level where it touches the incisor tooth or naris
Use head halter technique for securing
Upon securing: verify and document level of tube,
presence of BS and chest movement.

Stabilizing the Tube: 34-9
Stabilizing the Tube
Complications of ET or Nasotracheal
Intubation
Trauma
Face, eyes, nasal and paranasal areas, oral
pharyngeal, bronchial, tracheal and pulmonary
areas
Risk for pneumothorax
Unplanned extubation
Aspiration
Obtain ABG 25 minutes post
Continuous Pulse ox monitoring
Assess tube placement, minimal cuff leak, breath sounds,
chest wall movement
Prevent movement of tube by patient
Check pilot balloon
Soft wrist restraints: LAST RESORT
Chemical sedation
Meticulous oral care
Communication via various methods

Endotracheal Tubes: Nursing Care
Maintaining tube patency
Assess patient routinely to determine need for
suctioning, but do not suction routinely
Indication for suctioning
Visible secretions in ET tube
Sudden onset of respiratory distress
in peak airway pressures
Auscultation of adventitious breath sounds over
trachea and/or bronchi
secretions
Nursing Management.
Maintaining tube patency
Open-suction technique
Closed-suction technique (CST)
Enclosed in a plastic sleeve connected
directly to patient-ventilator circuit
CST maintains oxygenation and ventilation
and decreases exposure to secretions
Nursing Management

Closed Tracheal Suction System
Fig. 66-19
Mechanical Ventilation
Normal breathing is controlled by a negative
pressure system--air is drawn into the lungs.
Mechanical ventilation is delivered by positive
pressure, forcing air into the lungs in one of two
ways:
1. Invasively via endotracheal (ET) tube or
tracheostomy
2. Noninvasively via mask: BIPAP, CPAP

Mechanical Ventilation
Process by which fraction inspired oxygen
(FIO2) at 21% (room air) is moved into and
out of lungs by a mechanical ventilator

Mechanical Ventilation
Why would a patient need MV?:
Apnea or impending inability to breathe
Acute respiratory failure
Severe hypoxia
Respiratory muscle fatigue
Secretion/airway control failure
Mechanical Ventilation (Contd)
Pulmonary edema
Pulmonary embolism
Pneumonia
Multiple trauma
Shock
Multisystem failure
Coma
Thoracic/abdominal
surgery
Drug overdose
Neuromuscular disorders
Inhalation injury
Status asthmaticus
Chronic obstructive
pulmonary disease
(COPD)
Why a patient may need mechanical
ventilation
24
Continuous in PaO2
in PaCO2 levels
Persistent ACIDOSIS (ph<7.25)

MECHANICAL VENTILATION
MAY BE NECESSARY
Parameters or Indication for MV
25
PaO2 < 60mmHg with FiO2 > 60%
PaCO2 >50mmHg with ph <7.35
Negative inspiratory force <(-) 25cm H2O
RR >35 breaths/minute
Criteria for Mechanical Ventilation
26
Positive Pressure (most common)
Inflate the lungs by exerting positive pressure on the
airway, forcing alveoli to expand during inspiration
Widely used vents in hospitals
Requires an artificial airway: ETT or tracheostomy
Classified by mechanism that ends inspiration and starts
expiration
Types of Ventilators
27

Negative Pressure: i.e. Iron Lung, Body Wrap (Pneumo-
Wrap) & Chest Cuirass (Tortoise Shell)
Exert a negative pressure on the external chest
Physiologically similar to spontaneous ventilation
Used in chronic respiratory failure associated with
neuromuscular conditions: Polio, MD, AML, MG
Types of Ventilators
29
30

Ventilator Settings
The variable methods by which the patient and
the ventilator interact to deliver effective
ventilation
The ways in which the patient receives breath
from the ventilator include:
Assist-control ventilation (AC)
Synchronized intermittent mandatory ventilation
(SIMV)
Bi-level positive airway pressure (BiPAP)
Other modes of ventilation
PEEP-Positive End Expiratory End Pressure
Continuous Positive Airway Pressure [CPAP]
Pressue Support [PS]
Modes of Ventilation
Selected Vent mode is based on
How much Work of breathing (WOB) pt ought to or
can perform
Determined by pt ventilatory status, resp drive and
ABGs
Controlled or assisted
Ventilator Modes
With assist-control ventilation, the ventilator delivers a
preset VT at a preset frequency. When the patient initiates
a spontaneous breath, the preset VT is delivered
Advantage: allows the patient some control over
ventilation while providing some assistance
In a nutshell, Vet & patient share work of breathing
Disadvantage: spontaneous breathing rate increases,
preset Vt continue to be deliver w/each breath.
Hyperventilation, respiratory alkalosis
Hypoventilation
Assist Control (AC)
Require vigilant assessment and monitoring of ventilatory
status, including respiratory rate, ABGs, SpO2, and
SvO2/ScvO2.
It is also important that the sensitivity or amount of
negative pressure required to initiate a breath is
appropriate to the patient's condition.
For example, if it is too difficult for the patient to initiate a
breath, the WOB is increased and the patient may tire
and/or develop ventilator asynchrony (i.e., the patient
fights the ventilator).
AC
Breaths delivered at a set rate per minute and Vt
(independent of pts ventilatory effort)
Used when pt has NO DRIVE to BREATHE or UNABLE to
BREATHE SPONTANEOUSLY
With controlled ventilatory support, the ventilator does all
of the WOB
Clinician sets the
Rate
Vt
Inspiratory time
PEEP
Volume Control (VC) (Control Ventilation, CV) Controlled
Mandatory Ventilation (CMV)
Usually combined w/ Pressure support Ventilation (PSV)
Vent delivers preset Vt at a preset frequency in synchrony
w/pts spontaneous breathing
Weaning parameter
# mechanical breaths is gradually decreased (i.e. 12-2)
& pt gradually resumes spontaneous breathing
Mandatory ventilation is delivered when pt is ready to
inspire
Coordinates breathing b/w vent & pt.


Synchronized Intermittent Mandatory
Ventilation (SIMV)
Benefits
Improve pt-vent synchrony, lower mean airway pressure &
prevent muscle atrophy (as result pt taking on more WOB)
Disadvantages
Decrease in spontaneous breathing when preset rate is low,
ventilation might not be adequately supported.
Require close monitoring
May take longer because rate of breathing is gradually reduced
Increased muscle fatigue associated w/spontaneous breathing
effort
SIMV
Positive pressure applied to airway only during inspiration
Used in conjunction w/pts spontaneous respirations
Provides an augmented inspiration to a spontaneously
breathing patient
Used w/continuous ventilation & during weaning w/SIMV
Advantages:
Increased pt comfort
Decreased WOB
Decreased O2 consumption
Increased endurance conditioning

Pressure Support
Similar to PEEP, CPAP restores FRC. This pressure is continuous
during spontaneous breathing; no positive pressure breaths are
present.
The patient receiving SIMV with PEEP receives CPAP when
breathing spontaneously.
CPAP is commonly used in the treatment of obstructive sleep
apnea.
CPAP can be administered noninvasively by a tight-fitting
mask or an ET or tracheal tube.
CPAP increases WOB because the patient must forcibly exhale
against the CPAP and so must be used with caution in patients
with myocardial compromise
Continuous positive airway pressure
breathing [CPAP]
Positive End Expiratory Pressure (PEEP)
Positive pressure exerted during expiratory phase of
ventilation
Improves oxygenation by enhancing gas exchange &
preventing atelectasis
Used to tx hypoxemia that does not improve w/an O2
(ARDS)
Prevents alveoli from collapsing
Amt. PEEP: 5-15 cm H2O; read on peak airway pressure
dial
Titrated to the point that oxygenation improves w/out
compromising hemodynamics: Best or optimal PEEP
Often added to other settings

the major purpose of PEEP is to maintain or improve
oxygenation while limiting risk of O2 toxicity. FIO2 can
often be reduced when PEEP is used.
PEEP is indicated in lungs with diffuse disease, severe
hypoxemia unresponsive to FIO2 greater than 50%, and
loss of compliance or stiffness.
It is used in pulmonary edema to provide a
counterpressure opposing fluid extravasation.
The classic indication for PEEP therapy is ARDS
PEEP
Positive End Expiratory Pressure (PEEP)..
5 cm H2O PEEP (PHYSIOLOGIC PEEP)
Used prophylactically to replace the glottic mechanism
Help maintain/and or restore normal FRC (functional residue
capacity)
Prevent alveolar collapse

Flow
How fast each breath is delivered; set at 40L/min

Cardiovascular wise
BP, CO
Mean airway pressure increased w PEEP > 5 cm H20.
Pulmonary
Complications:
Barotrauma
Pneumothorax, subcutaneous emphysema and
pneumomediastinum
Negative Effects & Complications of PEEP
Cardiovascular system
Intrathoracic pressure compresses thoracic vessels
Venous return to heart, left ventricular end-
diastolic volume (preload), cardiac output
Hypotension
Mean airway pressure is further if PEEP >5 cm
H2O
Complications of PPV
Complications of PPV (contd)
Pulmonary system
Barotrauma leading to pneumothorax
Subcutaneous emphysema
Pneumomediastinum
Volumtrauma
Damage to lungs by excess volume delivered to
one lung over the other
PP Mechanical Ventilation (Contd)
Complications of PPV (contd)
Volutrauma
Relates to lung injury that occurs when large
tidal volumes are used to ventilate
noncompliant lungs
Results in alveolar fractures and movement of
fluids and proteins into alveolar spaces
PP Mechanical Ventilation (Contd)
Complications of PPV (contd)
Hypoventilation
Causes
Inappropriate ventilator settings
Leakage of air from ventilator tubing or
around ET tube or tracheostomy cuff
Lung secretions or obstruction
Low ventilation/perfusion ratio
Mechanical Ventilation (Contd)
Complications of PPV (contd)
Hypoventilation (contd)
Interventions
Turn patient every 1 to 2 hours
Provide chest physical therapy to lung areas with
increased secretions
Encourage deep breathing and coughing
Suction PRN
Mechanical Ventilation (Contd)
Complications of PPV (contd)
Respiratory alkalosis
Respiratory rate or Vt is set too high
(mechanical overventilation) or if pt receiving
assisted ventilation is
Hyperventilation
Determine cause (e.g., hypoxemia, pain,
anxiety, or compensation for metabolic
acidosis) and treat
Mechanical Ventilation (Contd)
Complications of PPV (contd)
Fluid retention
Occurs after 48 to 72 hours of PPV, especially PPV
with PEEP
May be due to cardiac output
Results
Diminished renal perfusion
Release of renin-angiotensin-aldosterone
Leads to sodium and water retention
Mechanical Ventilation (Contd)
Complications of PPV (contd)
Neurologic system
In patients with head injury, PPV (especially
with PEEP) can impair cerebral blood flow
Elevating HOB and keeping patients head in
alignment may decrease effects of PPV on
intracranial pressure
Mechanical Ventilation (Contd)
Complications of PPV (contd)
Gastrointestinal system
Risk for stress ulcers and GI bleeding
Risk of translocation of GI bacteria
Cardiac output may contribute to gut ischemia
Peptic ulcer prophylaxis
Histamine (H2)-receptor blockers, proton pump
inhibitors, tube feedings
Gastric acidity, risk of stress
ulcer/hemorrhage
Mechanical Ventilation (Contd)
Complications of PPV (contd)
Musculoskeletal system
Maintain muscle strength and prevent
problems associated with immobility
Progressive ambulation of patients receiving
long-term PPV can be attained without
interruption of mechanical ventilation
Mechanical Ventilation
Pneumonia occurring 48 h or more post ET intubation
Sputum c/s: gram negative bacteria
Clinical evidence
Fever and/or elevated white blood cell count
Purulent or odorous sputum
Crackles or rhonchi on auscultation
Pulmonary infiltrates on chest x-ray


Ventilator-Associated Pneumonia
Three care actions: VENTILATOR BUNDLE
HAND HYGIENE
METICULOUS ORAL CARE
HEAD OF BED ELEVATION

OTHER PREVENTATIVE MEASURES:
No routine changes of ventilator circuit tubing as per
agency protocol (book: no more frequent than q 48 h)
Continously removing subglottic secretions
Guidelines for VAP Prevention
Continuous Subglottal
Suctioning
Adjusted so that patient is comfortable & breathes
IN SYNC with machine
Monitoring Ventilator:
Type of vent
Mode/settings:
Alarms: ON AT ALL TIMES
PEEP/PS IF APPLICABLE: PEEP 5-15 CM H20
Adjusting Ventilator
58
BUCKING THE VENT
FIGHT OR OUT OF SYNC WITH MACHINE
PATIENT ATTEMPTS TO BREATHE OUT DURING THE VENTS
MECHANICAL INSPIRATORY PHASE OR WHEN THERE IS
JERKY AND INCREASED ABDOMINAL MUSCLE EFFORT
FACTORS:
Anxiety, hypoxia, increased secretions, hypercapnia,
inadequate minute volume, pulmonary edema
Tx:
Muscle relaxants, tranquilizers, analgesics
paralyzing agents
Purpose: increase patient-machine synchrony
Problems with Mechanical Ventilation
59
If ventilator system malfunctions/or disconnected
and the problem cannot be identified and
corrected immediately, the nurse must ventilate
the patient with a manual resuscitation bag
(Ambu-Bag) until the problem is resolved.
Nursing Alert
60
ALARMS must be activated and functional at all
times.
Cause of an alarm cannot be identified or
determined, ventilate the pt manually until the
problem is corrected by respiratory therapy.

See chart 34-4
Nursing Alert

Keep emergency equipment at the bedside.
Assess patient for level of consciousness (LOC), vital
signs, lung sounds regularly.
Monitor ET tube placement.
Perform suctioning as needed.
Monitor pulmonary secretions.
Assess patients ability to synchronize breathing
with the ventilator.
Monitoring your patient
63
Check all ventilator settings/alarms.
Check tubing for kinks.
Check temperature/humidification.
Check ventilator circuit/change per facility policy.
Check your patient for increased heart rate, mental status
change, respiratory rate, diaphoresis, or other signs and
symptoms of increased work of breathing.
Once a shift(at least) checklist
64
Respiratory weaning: process of withdrawing the patient from
dependence on the ventilator
Three stages:
Patient is gradually removed from the vent
Then removed from the tube
Final removal from 02

***Patient should be hemodynamically stable.
Absence of myocardial ischemia, clinically significant
hypotension (no vasopressor therapy or low dose)
Weaning from Ventilator
65
Assess patients & familys understanding of
weaning process; address any concerns
Assess patients mental status, SaO
2
, SpO
2
, PaO
2
,
pH, PaCO
2
, heart rate, blood pressure (BP),
respirations.
Elevate head of bed 35-45 degrees.
Prior to weaning
66
Adequate oxygenation:
PaO2/FiO2:>150-200
PEEP: <5-8 cm H2O
Ph: > 7.25
Tidal volume-7-9 mL/kg: index for weaning: >5 mL/kg
Minute ventilation- <10/L min
Rapid/shallow breathing index-below 105/L
PaO2 > 60mmHg with FiO2 < 50%
Hemodynamically stable
Pt able to initiate inspiratory effort
Criteria for Weaning
67
Respiratory rate >30
breaths/minute (or
changing 50% or more)
SpO
2
<90%
Signs of increased work of
breathing--dyspnea,
accessory muscles use
Diaphoresis
Fatigue or pain
Sustain Vt < 5 ml/kg
Decreased LOC
Systolic BP >180 mm Hg (or
increase of 20% or more) or
diastolic BP >100 mm Hg or
hypotension
Heart rate >120
beats/minute (or increase
of 20% or more)
Dysrhythmias
Signs of weaning intolerance
68
1. Explain procedure to pt
2. Emergency intubation kit at bedside
3. Hyperoxygenate pt
4. Suction ET and oral cavity or trach
5. Deflate tube cuff
6. Tell pt to take a deep breath
7. Rapidly remove tube at peak inspiration
8. Instruct pt to cough
9. O2 via face mask or nasal cannula
Extubation
Monitor vs q 5 min at first
Assess ventilatory pattern for s/s resp distress
Hoarseness & sore throat common
Teach pt to sit in semi-Fowlers, take deep breaths q 1/2h
Incentive spirometer use q 2h
Limit speaking after extubation.
Observe closely for resp fatigue and airway obstruction
STRIDOR: HIGH PITCH CROWING SOUND DURING INSPIRATION:
LARYNGOSPASM OR EDEMA ABOVE OR BELOW GLOTTIS: LATE
MANIFESTATION OF NARROWED AIRWAY.
Post Extubation
Explain purpose of ventilation to pt or family
Encourage family/pt to express concerns
PT FIRST, VENT SECOND
Suction as needed-HYPEROXYGENATE PRIOR TO SUCTION
MAIN NURSING PRIORITIES
Evaluating & monitoring pt responses
Managing vent system safely
Preventing complications
Nursing
Stab wound at the
cricothyroid cartilage ring
b/w thyroid cartilage and
cricoid cartilage ring
Trache tube can be place
via opening to keep airway
open until a tracheostomy
is done
Cricothyroidotomy
http://www.youtube.com/watch?v=cQYJp6U_jVI