Airway Management
and Mechanical Ventilation
Chapter 65
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Case Study
(©iStockphoto/Thinkstock)
• B.A., a 73-year-old female, arrives in
the ED in acute decompensated
heart failure (ADHF).
• Her respiratory rate is 30
beats/minute and she is using all of
her accessory muscles to breathe.
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Case Study
(©iStockphoto/Thinkstock)
• She has bilateral crackles in her lung
apices.
• Her SpO2 is 85% on a nonrebreather
mask.
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Case Study
(©iStockphoto/Thinkstock)
• The health care provider orders
STAT ABGs on B.A.
• The results are as follows:
pH 7.28, PaCO2 55 mm Hg, PaO2
60 mm Hg, HCO3 25 mEq/L.
• How would you interpret these
ABGs?
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Artificial Airways
• Placement of a tube into trachea to
bypass upper airway and laryngeal
structures
• Endotracheal (ET) intubation
• Via mouth or nose past larynx
• Tracheostomy
• Via stoma in neck
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Artificial Airways
• Indications
• Upper airway obstruction (e.g., tumor)
• Apnea
• Inability to protect airway
• Ineffective clearance of secretions
• Respiratory distress
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Endotracheal Tube
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Artificial Airways
• Oral ET intubation
• Procedure of choice
• Airway can be secured rapidly
• Larger-diameter tube can be used
• Decreases work of breathing (WOB)
• Easier to remove secretions and perform
bronchoscopy
• Associated risks
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Artificial Airways
• Nasal ET intubation
• ET tube placed blindly
• Use of oral intubation is not possible
• Unstable cervical spine injury
• Dental abscess
• Epiglottitis
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Case Study
(©iStockphoto/Thinkstock)
• The health care provider identifies
the need to immediately intubate
B.A. and place her on a mechanical
ventilator.
• How would you prepare for this
procedure?
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ET Intubation Procedure
• Preparation
• Consent
• Patient teaching
• Equipment
• Self-inflating bag-valve-mask (BVM)
attached to oxygen
• Suctioning equipment
• IV access
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ET Intubation Procedure
• Before intubation
• Sniffing position
• Preoxygenate using BVM with 100%
O2 for 3–5 minutes
• Limit each intubation attempt to
<30 seconds
• Ventilate patient between successive
attempts using BVM with 100% O2
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ET Intubation Procedure
• Rapid sequence intubation (RSI)
• Rapid, concurrent administration of
sedative and paralytic agents
• Decreases risks of aspiration and injury
to patient
• Not indicated for cardiac arrest or
difficult airway
• Monitor oxygenation status
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Case Study
(©iStockphoto/Thinkstock)
• The health care provider successfully
inserts an oral endotracheal tube
into B.A.
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Case Study
(©iStockphoto/Thinkstock)
• How would you confirm proper
placement of the ET tube?
• What nursing interventions would
you plan to prevent complications
associated with intubation?
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ET Intubation Procedure
• Inflate cuff and confirm placement
of ET tube
• End-tidal CO2 detector
• Auscultate lungs bilaterally
• Auscultate epigastrium
• Observe chest wall movement
• Monitor SpO2
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ET Intubation Procedure
• Following proper ET tube placement
• Connect tube to mechanical ventilator
• Secure airway
• Suction ET tube and pharynx
• Insert bite block
• Obtain chest x-ray
• 2–6 cm above carina
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Protocol for Securing ET Tube
with Adhesive Tape
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ET Intubation Procedure
• Following intubation
• Record and mark position of tube
• Cut off excess tubing
• Obtain ABGs
• Continuously monitor pulse oximetry
and end-tidal CO2
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Nursing and Interprofessional
Management
• Maintaining correct tube placement
• Continuously monitor
• Confirm exit mark on ET tube remains
constant
• Observe chest wall movement
• Auscultate bilateral breath sounds
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Nursing and Interprofessional
Management
• Incorrect tube placement is an
airway emergency
• Stay with patient and maintain airway
• Support ventilation with BVM and
100% O2
• Call for help immediately
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Nursing and Interprofessional
Management
• Maintaining proper cuff inflation
• Serves to stabilize and “seal” ET tube
within trachea
• Excess volume → tracheal damage
• Cuff pressure 20–25 cm H2O
• Measure and record on routine basis
• Minimal occluding volume (MOV)
technique
• Minimal leak technique (MLT)
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Nursing and Interprofessional
Management
• MOV technique
• For mechanically ventilated patients:
• Place stethoscope over trachea
• Inflate cuff to MOV by adding air until no air
leak is heard at peak inspiratory pressure
• For spontaneously breathing patients:
• Inflate cuff until no sound is heard after a
deep breath or after inhalation with a BVM
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Nursing and Interprofessional
Management
• Minimal leak technique (MLT)
• Similar to MOV technique with one
exception
• Small amount of air is removed from
cuff until a slight leak is auscultated at
peak inflation
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Nursing and Interprofessional
Management
• Maintain cuff inflation
• Use manometer to verify cuff pressure
• If cannot maintain pressure or need
higher volumes → cuff leaking or
tracheal dilation → reposition or
change ET tube
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Nursing and Interprofessional
Management
• Monitoring oxygenation: assessment
• ABGs
• SpO2
• SvO2/ScvO2
• Clinical signs of hypoxemia
• Change in mental status (e.g., confusion),
anxiety, dusky skin, dysrhythmias
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Nursing and Interprofessional
Management
• Monitoring ventilation: assessment
• PaCO2
• Continuous partial pressure of endtidal CO2 (PETCO2)
• Respiratory rate and rhythm
• Use of accessory muscles
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Nursing and Interprofessional
Management
• Maintaining tube patency
• Do not routinely suction patient
• Assess for need
•
•
•
•
Visible secretions in ET tube
Sudden onset of respiratory distress
Suspected aspiration of secretions
↑ Respiratory rate with or without sustained
coughing
• Sudden ↓ in SpO2
• ↑ Peak airway pressure
• Adventitious breath sounds
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Nursing and Interprofessional
Management
• Maintaining tube patency
• Open suction technique
• Closed-suction technique (CST)
• Enclosed in a plastic sleeve connected
directly to patient-ventilator circuit
• Maintains oxygenation and ventilation
• Decreases exposure to secretions
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Closed Tracheal Suction
System
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Nursing and Interprofessional
Management
• Potential complications of
suctioning
• Hypoxemia, bronchospasm
• Increased intracranial pressure
• Dysrhythmias
• ↑ or ↓ BP
• Mucosal damage
• Bleeding, pain, infection
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Nursing/Interprofessional Mgmt
Artificial Airway
• Prevent hypoxemia and
dysrhythmias during suctioning
• Hyperoxygenate before and after
• Limit each pass to < 10 seconds
• Monitor ECG and SpO2 before, during,
and after suctioning
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Nursing and Interprofessional
Management
• Prevent tracheal mucosal damage
• Limit suction pressures to <120 mm Hg
• Avoid overly vigorous catheter
insertion
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Nursing and Interprofessional
Management
• Managing thick secretions
• Adequate hydration
• Supplemental humidification
• No saline instillation
• Antibiotics PRN
• Mobilize and turn patient
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Nursing and Interprofessional
Management
• Oral care
• Brush teeth BID
• Oral swabs with 1.5% hydrogen peroxide
• 0.12% chlorhexidine oral rinse
• Mouth moisturizer
• Oropharyngeal suctioning
• Reposition and retape ET tube
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Nursing and Interprofessional
Management
• Fostering comfort and
communication
• ↑ Anxiety
• Use variety of methods to
communicate
• Sedatives
• Relaxation therapy
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Nursing and Interprofessional
Management
• Complications of ET intubation
• Unplanned extubation
• Patient talking
• Activation of low-pressure alarm
• Diminished or absent breath sounds
• Respiratory distress
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Nursing and Interprofessional
Management
• Preventing unplanned extubation
• Ensure adequate securement of ET tube
• Support ET tube during repositioning
and procedures
• Provide sedation and analgesia as
ordered
• Use standardized weaning protocols
• Use soft wrist restraints
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Nursing and Interprofessional
Management
• Should an unplanned extubation
occur
• Stay with patient
• Call for help
• Manually ventilate patient with BVM
and 100% O2
• Provide psychologic support
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Nursing and Interprofessional
Management
• Aspiration
• ET tube passes through epiglottis
• Inflate cuff
• Continuous epiglottic suctioning
• ↑ Salivation
• Suction oral cavity frequently
• Prevent vomiting
• NG or OG tube
• HOB ↑ 30 to 45 degrees
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Continuous Subglottal
Suctioning
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Mechanical Ventilation
• Process by which FIO2 (≥ 21% room
air) is moved into and out of lungs by
a mechanical ventilator
• Not curative
• Means of supporting patients until
they recover ability to breathe
• Bridge to long-term mechanical
ventilation
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Mechanical Ventilation
• Indications
• Apnea or impending inability to
breathe or protect the airway
• Acute respiratory failure
• Severe hypoxia
• Respiratory muscle fatigue
• May be ethical decision to use or not
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Mechanical Ventilation:
Types
• Negative pressure ventilation
• Encases chest or body
• Intermittent negative pressure pulls
chest outward → air rushes in →
passive expiration
• Similar to normal ventilation
• Noninvasive ventilation that does not
require an artificial airway
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Negative Pressure Ventilator
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Case Study
(©iStockphoto/Thinkstock)
• The health care provider orders B.A.
to be placed on a mechanical
ventilator using positive pressure
ventilation.
• How does this type of ventilation
compare to “normal” breathing?
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Mechanical Ventilation:
Types
• Positive pressure ventilation (PPV)
• Used primarily in acutely ill patients
• Delivers air into lungs under positive
pressure during inspiration →
intrathoracic pressure ↑ during lung
inflation (opposite of normal)
• Expiration occurs passively
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Patient Receiving PPV
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Mechanical Ventilation:
Modes of PPV
• Volume ventilation
• Predetermined tidal volume (VT)
delivered with each inspiration
• Amount of pressure needed to deliver
each breath varies
• Tidal volume same with each breath
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Mechanical Ventilation:
Modes of PPV
• Pressure ventilation
• Predetermined peak inspiratory
pressure
• VT varies
• Careful attention needed to prevent
hyper/hypoventilation
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Mechanical Ventilation:
Settings
• Regulate rate, VT, oxygen
concentration, other characteristics
• Based on patient’s status
• Adjusted until oxygenation and
ventilation targets are reached
• All ventilator alarms should be on
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Case Study
• B.A. is placed on a mechanical
ventilator with the following
settings:
•
•
•
•
•
A/C mode
VT 500 ml
FIO2 50%
RR 18
PEEP 5 cm
• Describe these settings.
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(©iStockphoto/Thinkstock)
Mechanical Ventilation:
Settings
•
•
•
•
Respiratory rate
Tidal volume (VT)
Fraction of inspired oxygen (FIO2)
Positive end-expiratory pressure
(PEEP)
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Mechanical Ventilation:
Settings
•
•
•
•
•
Pressure support
I:E ratio
Inspiratory flow rate and time
Sensitivity
High-pressure limit
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Mechanical Ventilation:
Alarms
• High-pressure limit
• Low-pressure limit
• High tidal volume, minute
ventilation, or respiratory rate
• Low tidal volume or minute
ventilation
• Ventilator inoperative or low battery
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Mechanical Ventilation:
Modes
• Based on how much work of
breathing (WOB) patient should or
can perform
• Determined by patient’s ventilatory
status, respiratory drive, and ABGs
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Mechanical Ventilation:
Modes
• Controlled ventilatory support
• Ventilator does all the WOB
• Assisted ventilatory support
• Ventilator and patient share WOB
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Mechanical Ventilation
• Assist-control ventilation (ACV)
• Delivers preset VT at preset frequency
• When patient initiates a spontaneous
breath, preset VT is delivered
• Can breathe faster but not slower
• Allows some control over ventilation
• Potential for hyperventilation
• Continuous monitoring required
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Mechanical Ventilation
• Synchronized intermittent
mandatory ventilation (SIMV)
• Delivers preset VT at preset frequency
in synchrony with patient’s
spontaneous breathing
• Between ventilator-delivered breaths,
patient is able to breathe
spontaneously
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Mechanical Ventilation
• SIMV
• Patient receives preset FIO2 but selfregulates rate and volume of
spontaneous breaths
• Potential benefits
• Improved patient-ventilator synchrony
• Lower mean airway pressure
• Prevention of muscle atrophy
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Mechanical Ventilation:
Pressure Modes
• Pressure support ventilation (PSV)
• Positive pressure applied to airway
only during inspiration in conjunction
with spontaneous respirations
• Machine senses spontaneous effort
and supplies rapid flow of gas at
initiation of breath
• Patient determines inspiratory length,
VT, and respiratory rate
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Mechanical Ventilation:
Pressure Modes
• PSV used for continuous ventilation
and weaning
• Advantages
• ↑ Patient comfort
• ↓ WOB
• ↓ Oxygen consumption
• ↑ Endurance conditioning
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Mechanical Ventilation:
Pressure Modes
• Pressure-control ventilation (PCV)
• Provides pressure-limited breath at a
set rate
• May permit spontaneous breathing
• VT is not set; determined by the set
pressure limit set
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Mechanical Ventilation:
Pressure Modes
• Pressure-controlled/inverse ratio
ventilation (PC-IRV)
• Combines pressure-limited ventilation
with an inverse ratio of inspiration (I)
to expiration (E)
• Normal I/E is 1:2 or 1:3
• With IRV, I/E ratio begins at 1:1 and
may progress to 4:1
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Mechanical Ventilation:
Pressure Modes
• PC-IRV
• Progressively expands collapsed
alveoli and has a PEEP-like effect
• Patient needs sedation with or without
paralysis
• For patients with ARDS and continuing
refractory hypoxemia despite high
levels of PEEP
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Mechanical Ventilation:
Pressure Modes
• Airway pressure release ventilation
(ARPV)
• Permits spontaneous breathing
• Preset CPAP with short timed pressure
releases
• VT varies
• Patients with ARDS who need high
pressure levels
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Mechanical Ventilation:
PEEP
• Positive end-expiratory pressure
(PEEP)
• Positive pressure applied to airway
during exhalation, preventing
alveolar collapse
• ↑ Lung volume and functional residual
capacity (FRC) improves oxygenation
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Mechanical Ventilation:
PEEP
• Optimal PEEP
• PEEP titrated to point oxygenation
improves without compromising
hemodynamics
• Physiologic PEEP = 5 cm H2O
• Replaces glottic mechanism, helps
maintain normal FRC, and prevents
alveolar collapse
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Mechanical Ventilation:
PEEP
• Auto-PEEP
• Result of inadequate exhalation time
• Additional PEEP over what is set
• Results
• ↑ WOB
• Barotrauma
• Hemodynamic instability
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Mechanical Ventilation:
PEEP
• Interventions to limit auto-PEEP
• Provide sedation and analgesia
• Use large-diameter ET tube
• Administer bronchodilators
• Set short inspiratory times
• ↓ Respiratory rate
• ↓ Water accumulation in ventilator
tubing
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Mechanical Ventilation:
PEEP
• Maintain or improve oxygenation
while limiting risk of O2 toxicity
• Indicated in
• All mechanically ventilated patients
• Patients with ARDS
• Use with caution with increased ICP,
low cardiac output, hypoventilation
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Mechanical Ventilation:
CPAP
• Continuous positive airway pressure
(CPAP)
• Restores FRC
• Similar to PEEP
• Pressure delivered continuously
during spontaneous breathing
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Mechanical Ventilation:
CPAP
• Used to treat obstructive sleep
apnea
• Administered noninvasively with
mask, ET, or tracheal tube
• ↑ WOB: use with caution in patients
with myocardial compromise
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Mechanical Ventilation:
ATC
• Automatic tube compensation (ATC)
• Used to overcome WOB associated
with artificial airway
• ↑ During inspiration and ↓ during
expiration
• Set by entering internal diameter of
patient’s airway and desired % of
compensation
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Mechanical Ventilation:
BiPAP
• Bilevel positive airway pressure
• Delivers oxygen and two levels of +
pressure support
• Higher inspiratory positive airway
pressure
• Lower expiratory positive airway
pressure
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Mechanical Ventilation:
BiPAP
• Noninvasive
• Via tight-fitting face mask, nasal
mask, or nasal pillows
• Patient must be able to breathe
spontaneously and cooperate
• Indications
• Contraindications
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Mechanical Ventilation:
HFOV
• High-frequency oscillatory
ventilation (HFOV)
• Delivery of a small VT at rapid
respiratory rates
• Used for refractory hypoxemia
• Must sedate and paralyze patient
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Nitric Oxide (NO)
• Continuous inhaled NO →
pulmonary vasodilation
• Given via ET tube, tracheostomy, or
face mask
• Diagnostic screening for pulmonary
hypertension and to improve
oxygenation during mechanical
ventilation
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Prone Positioning
• Positioning patient on stomach with
face down
• Improves lung recruitment
• Gravity reverses effects of fluid in
dependent parts of lungs
• Heart rests on sternum→ uniformity of
pleural pressures
• Nurse-intensive therapy
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Extracorporeal Membrane
Oxygenation (ECMO)
• Alternative form of pulmonary
support
• Partially remove blood from patient,
infuse O2, return blood back to
patient
• Intensive therapy
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Complications of PPV
• Cardiovascular system
• ↑ Mean airway pressure
transmitted to structures of
thorax → vessels compressed →
decreased venous return to heart
• ↓ Preload
• ↓ Cardiac output
• ↓ BP
• PEEP increases effect
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Complications of PPV
• Barotrauma
• Air can escape into pleural space from
alveoli or interstitium, accumulate,
and become trapped pneumothorax
• Patients with compliant lungs are at ↑
risk
• Chest tubes may be placed
prophylactically
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Complications of PPV
• Pneumomediastinum
• Rupture of alveoli into lung
interstitium
• Progressive air movement into
mediastinum and subcutaneous neck
tissue
• Followed by pneumothorax
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Complications of PPV
• Volutrauma
• Lung injury that occurs when large VT
are used to ventilate noncompliant
lungs
• Alveolar fractures and movement of
fluids and proteins into alveolar spaces
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Complications of PPV
• Alveolar hypoventilation
• Inappropriate ventilator settings
• Leakage of air from ventilator tubing
or around ET tube or tracheostomy
cuff
• Lung secretions or obstruction
• Low ventilation/perfusion ratio
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Complications of PPV
• Alveolar hyperventilation
• Rate or VT set too high
• Patients with COPD at risk
• Alkalosis develops if decrease PaCO2 to
standard normal
• Determine cause if spontaneous
hyperventilation
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Case Study
(©iStockphoto/Thinkstock)
• B.A. is admitted to the critical care
unit for monitoring and treatment of
her heart failure.
• What nursing interventions will you
plan to specifically prevent
ventilator-associated pneumonia
(VAP)?
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Complications of PPV
• Ventilator-associated pneumonia
(VAP)
• Occurs 48 hours or more after intubation
• Risk factors
• Contaminated respiratory equipment
• Inadequate hand washing
• Environmental factors
• Impaired cough
• Colonization of oropharynx
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Complications of PPV
• Ventilator-associated pneumonia
(VAP)
• Clinical manifestations
• Fever, elevated WBC count
• Purulent or odorous sputum
• Crackles or wheezes
• Pulmonary infiltrates
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Complications of PPV
• Guidelines to prevent VAP
• Minimizing sedation
• Early exercise and mobilization
• Subglottic secretion drainage port
• HOB elevation 30- 45 degrees
• No routine changes of ventilator circuit
tubing
• Strict hand washing, wear gloves
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Complications of PPV
• Sodium and water imbalance
• Progressive fluid retention
• ↓ Urinary output
• ↑ Sodium retention
• Etiology
• Decreased CO
• Intrathoracic pressure changes
• Stress response
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Complications of PPV
• Neurologic system
• Impaired venous drainage and ↑
cerebral volume → increased ICP
• Elevate HOB
• Keep patient’s head in alignment
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Complications of PPV
• Gastrointestinal system
• Risk for stress ulcers and GI bleeding
• Stress ulcer prophylaxis
• Histamine (H2)-receptor blockers
• Proton pump inhibitors
• Enteral nutrition
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Complications of PPV
• GI system
• Gastric and bowel dilation
• NG or orogastric tube for decompression
• ↓ Peristalsis → constipation
• Bowel regimen
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Complications of PPV
• Musculoskeletal system
• Loss of muscle strength and problems
linked with immobility
• Interventions to prevent
• Adequate analgesia and nutrition
• Early and progressive ambulation
• Physical and occupational therapy
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Psychosocial Needs
• Physical and emotional stress due to
inability to speak, eat, move, or
breathe normally
• Pain, fear, and anxiety related to
tubes/machines
• Usual ADLs are extremely
complicated
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Psychosocial Needs
• Need to feel safe
• Need to know (information)
• Need to regain control
• Need to hope
• Need to trust
• Encourage hope and build trust
• Involve patients and caregivers in
decision making
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Psychosocial Needs
• Agitation and anxiety
• Assess cause
• Provide sedation and/or analgesia
• Assess for delirium, initiate
prevention strategies, and treat
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Psychosocial Needs
• If necessary, induce paralysis to
achieve more effective synchrony
with ventilator and increase
oxygenation
• Paralyzed patient can hear, see,
think, feel
• Sedation and analgesia must always
be given concurrently
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Psychosocial Needs
• Assessment of paralyzed patient
• Train-of-four (TOF) peripheral nerve
stimulation
• Noninvasive electroencephalogram
technology
• Avoid excessive paralysis
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Placement of Electrodes Along
Ulnar Nerve
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Mechanical Ventilation
• Ventilator disconnection
• Most frequent site for disconnection is
between tracheal tube and adapter
• ALWAYS keep ALARMS ON
• If alarms are paused during suctioning or
removal from ventilator → reactivate
before leaving
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Mechanical Ventilation
• Ventilator malfunction
• Malfunction may be due to power
failure, failure of oxygen supply, etc.
• If machine malfunctions
• Disconnect patient from ventilator
• Manually ventilate with BVM and 100% O2
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Nutritional Therapy
• PPV and hypermetabolism →
inadequate nutrition
• Difficulty with oral intake
• ET tube
• Tracheostomy
• Consult speech therapist for
swallowing study
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Nutritional Therapy
• Nutritional assessment within 24–48
hours
• Inadequate nutrition can ↓:
• O2 transport
• Exercise tolerance
• Serum protein
• Weaning
• Resistance to infection
• Speed of recovery
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Nutritional Therapy
• Enteral gastric or small bowel
feeding preferred
• Verify tube placement
• X-ray
• Exit site
• Aspirate
• Limiting carbohydrate content may
lower CO2 production
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Case Study
(©iStockphoto/Thinkstock)
• B.A. responds well to medical
treatment of her heart failure.
• She is ready to be weaned from the
ventilator.
• What will you assess before
beginning the weaning process?
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Mechanical Ventilation:
Weaning and Extubation
• Process of:
• Decreasing ventilator support
• Resuming spontaneous breathing
• Process differs for short-term versus
long-term ventilated patients
• Team approach
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Mechanical Ventilation:
Weaning and Extubation
• Weaning generally consists of three
phases:
• Preweaning phase
• Weaning process
• Outcome phase
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Mechanical Ventilation:
Phases of Weaning
• 1. Preweaning or assessment phase
• Assess muscle strength
• Negative inspiratory force
• Assess endurance
• Spontaneous VT, vital capacity, minute
ventilation, and rapid shallow breathing
index
• Auscultate lungs
• Assess chest x-ray
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Mechanical Ventilation:
Phases of Weaning
• 1. Preweaning or assessment phase
• Nonrespiratory factors
• Assessment of neurologic status,
hemodynamics, fluid and
electrolytes/acid-base balance, nutrition,
and hemoglobin
• Drugs should be titrated to achieve
comfort but not excessive drowsiness
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Case Study
(©iStockphoto/Thinkstock)
• What is the most common method
for weaning a patient who has been
on the ventilator for <3 days?
• Explain the process.
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Mechanical Ventilation:
Phases of Weaning
• 2. Weaning process
• Awakening/Breathing Coordination,
Delirium Monitoring/Management,
and Early Mobility bundle
• SBT should be at least 30 minutes but not
>120 minutes
• SAT done by stopping all sedatives
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Mechanical Ventilation:
Phases of Weaning
• 2. Weaning process
• Use of weaning protocol decreases
ventilator days
• Important to rest between
weaning trials
• Provide explanations regarding
weaning and ongoing psychologic
support
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Mechanical Ventilation:
Phases of Weaning
• 2. Weaning process
• Comfortable position
• Sitting or semirecumbent
• Obtain baseline assessment
• Vital signs
• Respiratory parameters
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Mechanical Ventilation:
Phases of Weaning
• 2. Weaning process
• Monitor for signs and symptoms
• Tachypnea, dyspnea
• Tachycardia, dysrhythmias
• Sustained desaturation [SpO2 <90%]
• Hypertension or hypotension
• Agitation or anxiety
• Diaphoresis
• Sustained VT<5 mL/kg
• Changes in mentation
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Mechanical Ventilation:
Phases of Weaning
• 3. Weaning outcome
• Weaning stops and patient is
extubated
--OR-• Weaning is stopped because no further
progress is made
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Case Study
(©iStockphoto/Thinkstock)
• B.A. tolerates the SBT trial and is
ready to be extubated.
• Explain how you would extubate
B.A.
• What will be your priority
assessment of B.A. postextubation?
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Mechanical Ventilation:
Extubation
• Hyperoxygenate and suction
• Loosen ET tapes or holder
• Deflate cuff and remove tube at
peak of deep inspiration
• Encourage patient to deep breath
and cough
• Supplemental O2
• Careful monitoring after extubation
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Audience Response Question
The ventilator settings for a patient on a volume ventilator
include a synchronized intermittent mandatory ventilation
(SIMV) mode with 5 cm H2O PEEP. After 3 hours of
ventilation, the patient’s PaO2 has dropped from 82 mm Hg
to 74 mm Hg. The most accurate interpretation of this finding
by the nurse is that the
a. patient’s respiratory rate may be decreasing, lowering the
oxygen content of the blood.
b. ventilator is creating high intrathoracic pressure,
suppressing venous return and cardiac output.
c. tidal volume provided by the ventilator is too high,
increasing the amount of CO2 being exhaled.
d. pressure applied by PEEP requires an increased fraction of
inspired oxygen (FIO2) to maintain oxygenation.
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