Lesson 4
Airway Management
From American Association of Critical Care Nurses
Essentials of Critical Care Orientation
PRESENTED BY:
KATY ZAHNER RN, BSN, CCRN
NURSE EDUCATOR STUDENT
GEORGETOWN UNIVERSITY
Objectives

Identify indications, complications, and management
methods for artificial airways and oxygen delivery
devices

Describe and discuss monitoring devices used to
determine oxygenation

Identify indications, complications, and management
methods for non-invasive pressure ventilation
Oxygen

Why do we administer oxygen?

Delivery systems
 High,

low and reservoir systems
Administration
 Nursing

Assessment
Complications
 O2
toxicity, absorption atelectasis, CO2 retention
(COPD)
Noninvasive positive pressure
ventilation (NPPV)

Used to deliver PPV with or without o2

BiPAP – 2 levels of pressure = IPAP and EPAP

Requires the patient to maintain spontaneous ventilation

Use of face or nasal mask

Chronic vs. acute use

Patient populations

COPD

Hypoxemic respiratory failure – hemodynamically stable

Extubation failure

Cardiogenic pulmonary edema
AACN Practice Pearls
Room Air (RA) 21%
 SpO2 tells nothing about CO2
 Change in LOC is a sensitive indicator for
hypoxemia
 Patients with Fio2 > 50% for longer than 24 hours
are at high risk for complications related to o2
toxicity

Artificial Airways

Endotracheal tube

Requires endotracheal intubation

Indications


Anesthesia/Surgery

Protect airway

Removal of secretions

Respiratory failure
Characteristics

7.0 – 9.0mm diameter

Radiopaque line

Low pressure high-volume balloon with inflation port
Equipment Needed for Intubation

Intubation tray

Suction

Manual resuscitation bag with mask and O2

Water-soluble lubricant

10ml syringe for inflation of cuff

Tape or ETT device

Stethoscope

Monitoring equipment

Secondary confirmation device

Medications

Ventilator

Anesthetic spray
Intubation Procedure

https://www.youtube.com/watch?v=0VGiBwyfuNI
Nursing Interventions

Prevent skin breakdown around tube

Evaluate for inflammation and ulceration of the nose or
mouth

Implement treatment for sinus or ear infections

Assess for airway injury and/or displacement of ETT
Tracheostomy

Placed when long-term mechanical ventilation is expected (>1014 days)

Neuromuscular disease

Obstruction of upper airways

Facilitates airway maintenance

Increases patient comfort

**Research shows that early transition (<48 hours) of the patient
from ETT to tracheostomy tube offers improved outcomes
Tracheostomy Tubes Characteristics

Sized by inner diameter

Inner cannula

Universal adapter

Decannulation plug
Placing Tracheostomy Tube

Complications – Not the same as ETT

Either surgically or placed percutaneous at bedside

Complication –hemorrhage, wound infection, subcutaneous emphysema

Additional complications

Displacement or obstruction

Tracheal stenosis

Tracheoesophageal fistula

Tracheoinonimate artery fistula

Tracheal malascia

Scarring after decannulation
Nursing Interventions

Monitor for tube positioning and patency

Assess skin surrounding tracheostomy

Evaluate secretions

Cuff management

Assess breath sounds

Sterile suctioning

Oral care
Lesson 6
Thoracic
Surgical
Procedures
Objectives

Discuss the types of and indications for, and common
complications of thoracic surgical procedures

Describe different systems and principles of management for chest
tubes

Discuss the indications for, common complications of and nursing
management of patients undergoing video-assisted thoracoscopy,
thoracotomy, and pneumonectomy

Compare and contrast the different types of closed chest drainage
systems

Describe the nursing management of patients with chest tubes
Thoracic Surgery

Why?

Types

Remove tumor and abscess

Pneumonectomy

Surgically resect a segment,
lobe or full lung

Lobectomy

Segmental resection
Repair esophagus or thoracic
vessels

Open lung biopsy

Lung volume reduction surgery

Decortication

Bullectomy

VATS

Drainage of empyema

Preoperative Conditions

Lung function

Cardiac function

Tumor removal

Pain management
Clinical Approach

Incision usually posterolateral

Depends on location of operative area

ETT with double-lumen common

When full lung removed, evaluation of position of mediastinum and
trachea before surgical site closed
Postoperative Complications

Hemorrhage

Acute respiratory failure

Pneumonia

Pain

Mediastinal shift

Development of bronchopleural fistula, hemorrhage, and
cardiovascular compromise
Postoperative Complications
Hemorrhage

Life threatening

Most likely to occur during immediate postoperative period

Potential causes:


Dislodged suture or clip

Bleeding from intercostal or bronchial artery
Potential indicators:

Fresh red blood

Sudden increase in drainage

Drainage volume exceeding 100ml/hr
Postoperative Complications
Bronchopulmonary Fistula


Suture line does not hold

Can be compromised by mechanical ventilation and high
airway pressures

Early weaning is a priority
Indicators:

Shortness of breath, cough, hemoptysis

High postoperative mortality rate
Postoperative Complications
Mediastinal Shift

Accumulation of fluid or an increase in pressure on the
surgical side

Remove air or fluid on surgical side

Chest tubes
Postoperative Complications
Cardiovascular

Can occur as a result of large volume of lung tissue and
pulmonary vascular bed is resected

Use of vasoactive medications may be indicated to
optimize cardiac function
Postoperative Interventions

Goal: Maximize oxygen and ventilation and prevent
complications

Interventions


Patient positioning and pain management

Maintain chest tube system

Assist with progressive patient activity
Pain management
Pain Management


Indicators of pain

Tachypnea

Tachycardia

Increased BP

Grimacing, splinting or moaning

Unwillingness to move and restlessness
Narcotic infusion through epidural of patient-controlled analgesia
device may be indicated

Medicate sufficiently to allow for deep inspiration
Insertion and Management of Chest
Tubes

Why insert a chest tube?

Eliminate air or fluid that has accumulated resulting in compromised ling
function

Placed in the pleural space – 4th or 5th intercostal space

Connects to drainage system

X-ray used for confirmation after placement

Average size 28Fr – 40Fr

https://www.youtube.com/watch?v=Hn0SHGuUVak
Chest Drainage Systems

Drainage chamber

Water seal chamber

Suction control chamber
Patient Care

Regularly assess pulmonary status

Measure and record output regularly

Institutional policies related to “milking the tube”


Stripping entire length is contraindicated – results in transient HIGH
negative pressures in the pleural space and lung entrapment
Inspection

Redness

Swelling

Pain

Purulent drainage
Emergent Response and
Troubleshooting

Have sterile water and package of petroleum gauze
available


If air leak was present before accidental dislodgement of chest
tube, application of occlusive dressing may result in tension
pneumothorax
Troubleshooting

Chest tube dislodgement

Cessation of drainage

Collection chamber falls
Troubleshooting
Water Seal Chamber


Problems present if fluctuation with
inspiration and expiration
Examine entire system beginning at
insertion site of patient
Suction Control Chamber

Problems present if bubbling absent

Address leaks in the system
Chest Tube Removal Preparation

Timing of removal

Explain procedure to patient

Done during deep breath by patient after cleaning site

Chest X-ray

Observe patient for signs of pneumothorax
Lesson 5
Basic Ventilator
management
Objectives

Describe endotracheal intubation and discuss nursing considerations

Discuss the management of patients with tracheostomy tube

Compare and contrast the indications, complications and nursing management considerations for
commonly used ventilator modes including PPV, pressure controlled/inverse ratio ventilation and volume
guaranteed pressure mode ventilation

Discuss nursing care of the mechanically ventilated patient

Describe the common pharmacologic interventions utilized to assist with managing patients

Discuss techniques for the prevention of ventilator acquired pneumonia

Discuss common problems encountered with mechanical ventilators and how to troubleshoot them

Identify key factors that impact ventilator weaning

Describe nursing management of patients who are being weaned from mechanical ventialtion
Mechanical Ventilation

Goal – support gas exchange

Indications

Apnea

Acute impending respiratory failure

Severe hypoxemia

Respiratory muscle fatigue

Support during anesthesia or sedation
Mechanical ventilation

2 types

Negative and positive pressure

Negative referred to as iron lung


No artificial airway

polio
Positive pressure

Most common

Used with artificial airway
Modes of Ventilation

Ventilator cycle functions

Modes
 Volume

or pressure
Ventilator settings
Mechanical Ventilation Modes
Volume

Set amount of volume (Vt) will be delivered to lungs

Common volume modes


Continuous mandatory ventilation (CMV)

Assist – controlled (AC)

IMV/SIMV – intermittent mandatory ventilation/synchronized
Settings

Rate (f)

Tidal volume (Vt)

FIO2

Sensitivity

Positive End Expiratory Pressure (PEEP)
Mechanical Ventilation Modes
Pressure

Desired pressure is set to achieve Vt

Used for lung protective strategies and noncompliant lungs

Modes include


Pressure Support Ventilation

Pressure Control

CPAP
Settings:

RR

FiO2

Inspiratory Pressure Level (IPL)

Inspiratory time

PEEP
Complications of Mechanical
Ventilation

Changes in intrathoracic pressure

Cardiovascular complications

Barotrauma

Volutrauma

GI complications

Patient Ventilator Dysynchrony

Ventilator Associated Pneumonia

Nursing interventions
Troubleshooting Ventilators

1st – Respond to the alarm

2nd – Look at the patient!

Manually ventilate patient if needed

DOPE

Ensure alarms are set within safe parameters

Common alarms include:

High peak inspiratory pressure (PIP)

Low Vt

Apnea
Nursing Assessment

Assess for effectiveness of mechanical ventilation

Monitor for changes that would indicate a presence of infection

Monitor ventilator function according to unit policy

Assess airway position and suction requirements

Position patient to provide the best opportunity for ventilation-perfusion

Ensure that ventilator alarms are set and functioning and that ventilator
connections are intact

Evaluate for adequate hydration and nutritional support

Evaluate for anxiety and ventilator synchrony
Managing the Ventilated Patient

Sedation – Balance

Too much vs. Too little

Consequences of pain and anxiety

Stress response  vasoconstriction  increased HR, BP, RR release of
aldosterone by adrenal cortex  increased reabsorption of Na+ and Cl-
But Before Sedation …

Consider nonpharmacological interventions

Establishing nonverbal communication

Calm voice and gentle touch

Frequent repositioning

Use of distraction

Noise or light reduction

Improving sleep

Guided imagery or massage therapy
Sedation


Goal of sedation

Patient comfort

Control physiologic effects of anxiety

Patient management
Ordering of sedatives

Collaborative decision

No single agent is adequate in critical care setting
Assessment of Sedation

Continuous vs. Bolus administration

Use sedation “holidays”


Dependent on institution
Several scales are available

RASS
Pitfalls of Over/Undersedation

Liver failure


Oversedation


Can result in over or undersedation
Respiratory depression, hypotension, bradycardia and potential
thromboembolism
Undersedation

Patient aware of situation, decreased comfort and increased
agitation and combativeness

Attempt to pull out tubes and lines
Neuromuscular Blockade Agents
(NMBA)

May be necessary WITH sedatives and analgesics

ARDS

Increased intracranial pressure (ICP)

Use Train of Four (TOF) for patients receiving NMBA

NMBA associated with prolonged neuropathies and myopathies and
increased patient morbidity

Paralytic agents may ONLY be used in patients who are mechanically
ventilated

No sedative or analgesic properties
Weaning from Mechanical Ventilation

Starts when patient intubated and mechanical ventilated

Underlying illness is improved

Patient must be hemodynamically stable

Helped by having correct size ETT

Evaluation of mechanics of ventilation and muscle strength


CPAP, PSV, T-piece
Nutritional support
Weaning

Use standardized protocols

Reconditioning the muscles of ventilation

Especially if patient has been on mechanical ventilator for long period of time

Specific patient prerequisites

ABG WNL – FiO2 < 0.50, minute ventilation < 10L/min, PEEP < 5cmH20

Negative inspiratory pressure at least -20cmH2O

Spontaneous Vt > 5ml/kg

Vital Capacity > 10ml/kg

RR < 30 breaths/min

Rapid shallow-breathing index < 100-105 (RR/Vt)
Weaning Methods/Modes

Spontaneous Breathing Trials (SBT): Humidified O2 30120 minutes

SIMV: Gradually reduce the number of ventilator
induced breaths

Pressure Support Ventilation (PSV) – Gradually reduce
PSV level
Facilitating Weaning Process

Explain process to patient and family

Optimal positioning

Decrease sedation

Analgesia as indicated

Remain with patient

Avoid physical exertion or painful procedures during this time

Optimize environment

Assess breath sounds and secretions

VS

Trend O2 saturation

Evaluate WOB
Weaning Intolerance

Need to return to vent to “rest”

Dyspnea

Increased RR, HR, BP

Shallow breaths or decrease in Vt

Accessory muscle use

Anxiety

Deterioration in SpO2 or ETCO2
Weaning Long-term Ventilator Patients
Can take up to weeks or months
 Weaning is goal since long-term mechanical
ventilation is associated with high morbidity
and mortality
 Use of protocols helpful
 Collaborative approach
 Specialized units
 Clear decisions with patient and family required

Review
Quiz
Review Questions

When the nurse monitors the chamber with the water seal, which finding
suggests that the system is functioning correctly?
a)
The fluid rises and falls with respirations
b)
The fluid level is lower than when first filled
c)
The fluid bubbles continuously
d)
The fluid looks frothy white
Answer = a
Review Question

Nursing interventions related to care of the tracheostomy include which of the
following? (Select all that apply)
a)
Suction Q1 hour
b)
Pre-oxygenate and suction using sterile technique
c)
Oral care
d)
Perform tracheostomy change Every 72 hours
e)
Suction patient with catheter until resistance is met and patient coughs
f)
Assess skin surrounding tracheostomy
Answer – b, c, f
Review Question

True or False: Tracheal deviation to non-surgical side is a normal
finding post pneumonectomy
Answer - False
Review Question
The nurse is caring for a patient in the emergency room who has been
intubated and placed on mechanical ventilator. An ABG is obtained
with the following results: pH – 7.32, PaCO2 – 60, PaO2 – 126, HCO3 –
28. Based on these results, which ventilator settings would be
appropriate to be adjusted? Select all that apply.
a) FiO2
b) Rate
c) VT
d) PEEP
e) PIP
Answer – b, c


Modes commonly used when weaning from mechanical ventilation
include which of the following? Select all that apply.
a)
PSV
b)
CPAP
c)
Pressure control
d)
Spontaneous breathing trial
e)
Assist/control
Answer – a, b, d