RESPIRATORY

MONITORING AND
MANAGEMENT

N467
Fall 2017
https://www.youtube.com/watch?v=kacMYexDgHg
 VENTILATION/PERFUSION
MATCH

• Physiological Shunt
• Low ventilation - perfusion ratio

• Alveolar Dead Space

• High ventilation - perfusion ratio

• Silent Unit
• Both perfusion and ventilation are
diminished
 • https://www.youtube.com/wat
ch?v=StpQmmuVnTA

OXYGEN
DISSOCIATION
CURVE
 Shift to the left – high affinity of
hemoglobin for oxygen but
decreased release at tissues
• Hgb binds more readily to oxygen under
these conditions.
• Increase PH, decreased Co2, decreased
body Temp, and decreased 2,3DPG (
diphosphoglycerate).
OXYHEMOGLOBIN
DISSOCIATION CURVE
Shift to the right – low affinity of
hemoglobin for oxygen but
increased release at tissues
• Hgb more readily releases oxygen
• See decreased PH, increased
Co2,increased body temp and release of
oxygen to the tissues.
 END-TIDAL • Indications: exhaled carbon dioxide

CARBON ETCO2 can be used to estimate

PaCO2!

DIOXIDE Normal EtCO2 35-45

MONITORIN • Typically 2-5 mm Hg difference

G • EtCO2 lower than PaCO2

Accuracy of readings may be affected by:

• Water vapor in ventilator tubing
• High FiO2
• Measures the level of carbon dioxide at
the end of exhalation
• Can be used to measure approximate
levels of PaCO2.
ABG
REVIEW
Normal Ranges
pH 7.35-7.45
PaCO2 35-45
HCO3- 22-26
PaO2 80-100
ABGS MADE EASY
ROME:

Respiratory= Opposite:
· pH is high, PCO2 is down (Alkalosis).
· pH is low, PCO2 is up (Acidosis).

Metabolic= Equal:
· pH is high, HCO3 is high (Alkalosis).
· pH is low, HCO3 is low (Acidosis).
COMPENSATION

01 02 03 04
Is it What side is What system Has the other
uncompensated, the pH leaning? matches the system started
partially
compensated, or leaning pH? to compensate?
completely
compensated?
 Practice ABGS
pH 7.54 pH 7.33 pH 7.38
PaO2 64 PaO2 78 PaO2 78
PaCO2 20 PaCO2 50 PaCO2 54
HCO3 22 HCO3 30 HCO3 32

pH 7.28 pH 7.54 pH 7.42

PaO2 84 PaO2 50 PaO2 50
PaCO2 40 PaCO2 30 PaCO2 25
HCO3 16 HCO3 16 HCO3 15

pH 7.32 pH 7.47 pH 7.43

PaO2 74 PaO2 65 PaO2 80
PaCO2 48 PaCO2 52 PaCO2 51
HCO3 26 HCO3 30 HCO3 33

pH 7.50 pH 7.24 pH 7.36

PaO2 80 PaO2 78 PaO2 78
PaCO2 41 PaCO2 28 PaCO2 28
HCO3 34 HCO3 18 HCO3 17
ARTIFICIAL
AIRWAYS
Who needs an artificial airway?

How do we assess airway?

ESTABLISH AIRWAY
• Head-tilt-chin-lift
• Jaw thrust
• Bite block
• Oral airway
ARTIFICIAL AIRWAYS

Endotracheal
Oropharyngeal Nasopharyngeal Suctionning
Tubes
• Unconscious • Use cautiously • Must confirm • No longer
patients only! in severe proper than 15 sec at
craniofacial placement a time.
injuries
ENDOTRACHEAL
INTUBATION
• Oral Vs Nasal!

• Equipment needed

• Nurses Role

• Complications box 25-5

 AIRWAY
ANATOMY

• https://www.youtube.com/watch?v=Vl5IB
NzIlfU
INTUBATION MEDICATIONS

• Sedatives
1. Versed 0.3-0.35 mg/kg IV
2. Diprivan (Propofol) 2-2.5 mg/kg for RSI induction. Ventilator sedation 5-50
mcg/kg.min
3. Etomidate does 0.3-0.6 mg/kg
4. Ketamine dose: 1-2 mg/kg ; produces a dissociative state for 5- 10 minutes
• Neuromuscular Blocking Agents

1. Succinylcholine dose: 1mg/kg; onset 1-3 minutes; duration: 4-6 minutes; will elevate
serum potassium level
2. Rocuronium ( Zemuron)
3. Vecuronium (Norcuron) dose: 0.1mg/kg; onset: 3-5 minutes; duration: 20-30 min
 MECHANICAL
VENTILATORS

• Negative-Pressure Ventilators
• Iron lung- rarely used

todayhttps://www.youtube.com/watch?v=xUOlLN
KBHiY
MECHANICAL
VENTILATORS
• Positive-Pressure Ventilators

• Volume Ventilators – most common

• With this mode ventilation, RR, inspiratory time
and Tidal Volume are selected for the pt.
• Pressure Ventilators – common
• A typical pressure mode delivers a selected gas
pressure to the patient throughout the
inspiratory phase. By meeting the patients
inspiratory flow demand throughout inspiration-
patient effort is reduced.
• High-Frequency Ventilators
• Use small tidal volumes, move small volumes of
air in at a fast rate.
 VOLUME
MODES
Assist- • Rate and tidal volume preset
Control
• Will give full-volume breath at set
(A/C)– full rate and for spontaneous patient
support breaths

Synchronized • Rate and tidal volume preset

Intermittent
• Any breaths taken above set rate
Mandatory are not given volume breath
Ventilation support
(SIMV) –
• Has the ability to allowed the
great for patient to assume more of the work
weaning of breath to assist with weaning.
PRESSURE MODES
Pressure-Support (PSV) Pressure-Controlled

• No preset tidal volume or • No set tidal volume but set

rate rate
• High flow of gas during • Must monitor for tidal
inspiration volume and RR
• As a weaning tool PSV is • Used for ARDS and where
thought to increase the you have high levels of PEEP
endurance of the
respiratory muscles by
decreasing the physical
work and oxygen
demands.
POSITIVE END-EXPIRATORY PRESSURE

• Positive-pressure exerted at end-expiration

• Prevention of oxygen toxicity
• Alveoli recruitment

• Keep the alveoli stent open and recruit alveoli units that
are totally or partially collapsed during any mode of
ventilation.

• Complications!
• Decreased cardiac output
• Barotrauma
CONTINUOUS POSITIVE AIRWAY PRESSURE
(CPAP)

• Exerts positive airway pressure throughout respiratory cycle

• Patient must have spontaneous tidal volumes and respirations

Great for weaning!

PHYSICIAN ORDERS

• Rate
• Tidal Volume – usually 5-8 ml/kg
• FiO2 % - watch for oxygen toxicity!
• PEEP 5-10 except in certain difficult cases
• Pressure Support (PS)
TROUBLE-SHOOTING ALARMS!
PG 534 TABLE 25-5
• High Pressure Alarm
1. Patient related
2. Vent related

• Low Pressure Alarm

1. Patient Related
2. Vent Related

When in Doubt, BAG the patient!

 ALARMS

• High pressure
• Warning of rising pressure
• Asses for pneumo
• Suction the patient
• Administer B- agonist
• Evaluate ABG
• Provide sedation or paralysis if needed
• Check peak flow settings.

• Low pressure
• Disconnection of the patient from the ventilator
• Check for leak around the ET tube, ETT may be to high
• May be due to clearing of secretions or relief of bronchospasm.
NURSING
ASSESSMENT Assess connections

Monitor for infection

Note and Document ET placement

Check cuff pressures

Assess skin

Respiratory assessment at least every

2-4 hours
Restraints??
NURSING INTERVENTIONS – BOX 25-16
Change ET position frequently
Good oral hygiene
Elevate HOB 30-45 degrees
Frequent Oral Suctioning
Skin Care
Nutrition
Comfort/Pain
Accidental Extubation
Family/Patient Education
TRACHEOSTOMY TUBES
• Current practice promotes early
tracheostomy at 72 hours.
• 3-7 days on a ventilator.

• Complications of ETT
• Easier weaning with Tracheostomy
due to decreased dead space
• Tracheostomy complications
• Box 25-17
NURSING ASSESSMENT AND
INTERVENTIONS
Secure connections
Tubing length
Site care and dressing changes
Patient education
Cuff pressures
Suctioning
Accidental Removal
 WEANING –
BOX 25-18
Patient Readiness Criteria

CPAP/PS trials

T-tube trials

Short-Term vs. Long-Term

Failed Trial – stop and put back

on vent!
Extubation Criteria