INSTRUCTIONAL DESIGN TABLE: AACN ECCO RESPIRATORY LESSON 4 - 6
Objectives
LESSON 4: Airway
Management
At the completion of the
presentation, the learner will be
able to:
4A. Identify indications,
complications, and management
methods for artificial airways and
oxygen delivery devices.
4B. Describe and discuss
monitoring devices used to
determine oxygenation
4C. Identify indications,
complications, and management
methods for non-invasive
pressure ventilation
Content
(Detailed Outline – not script)
4A. Why do we administer oxygen?
- Decrease WOB, oxygenate tissues, O2 is a
medication
4A. Delivery systems
High, low and reservoir systems
- High = Venturi system, HFNC, Trach collar
- Low = NC, SM, NRB
- Reservoir = NRB, ambu
4A. 4B. Nursing assessment
- WOB, RR, SPO2
- Assess with pulse oximeter
- Some patients do not tolerate masks
- Device related pressure ulcers (behind ears with
NC)
4A. Complications
- O2 toxicity
- Absorption atelectasis (nitrogen washout)
- CO2 retention (COPD)
4A. Artificial Airway
- ETT and tracheostomy
- Requires intubation
- Indications
- Equipment needed for intubation
Nursing assessment – prevent skin breakdown,
implement sinus prophylaxis, assess for airway
injury or displacement of ETT
4A. Tracheostomy
- Indications – placed when long term
mechanical ventilation expected, neuromuscular
disease, airway obstruction
- Placement of trach (surgical or bedside
percutaneous)
- Complications – (tracheoinominate fistula,
tracheal malacia, displacement of obstruction,
scarring)
Nursing assessment
- Monitor for tube position and patency
- Assess secretions
- BBS
- Sterile suctioning
- Oral care
- VAP prevention
4C. NIPPV
- Deliver PPV with or without O2
- BiPAP – 2 levels IPAP and EPAP
- Patient must be spontaneously breathing
Teaching/Learn
ing Strategies
Lecture –
Enhanced
Pass around O2
delivery devices
Evaluation
Methods
FORMATIVE
EVALUATIO
N
COMPLETED
AT END OF
LESSON 4-6
Formative –
Quiz at the end
of presentation
Summative–
Respiratory
Exam
administered
through
AACN at the
end of the
respiratory
module
INSTRUCTIONAL DESIGN TABLE: AACN ECCO RESPIRATORY LESSON 4 - 6
Objectives
LESSON 6
Thoracic Surgical Procedures
At the completion of the
presentation, the learner will be
able to:
6A. Discuss the types of and
indications for, and common
complications of thoracic surgical
procedures
6B. Discuss the indications for,
common complications of and
nursing management of patients
undergoing video-assisted
thoracoscopy, thoracotomy, and
pneumonectomy
Content
(Detailed Outline – not script)
- Patient populations (COPD, hypoxemic
respiratory failure, cardiogenic pulmonary
edema, extubation failure)
- Uses face or nasal mask
Teaching/Learn
ing Strategies
LESSON 6
6A. Indication for and types of thoracic surgeries
Why
- Remove tumor and abscess
- Surgically resect segment, lobe or full lung
- Repair esophagus or thoracic vessels
Types
- Pneumonectomy
- Lobectomy
- Open lung bx
- Decortication
- VATS
- Empyema drainage
6B. Surgical considerations
- Lung function
- Cardiac function
- Tumor removal
- Pain management
- 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
6B. Complications
Hemorrhage
- Life threatening
- Most likely to occur during immediate
postoperative period
- Potential causes:
- Dislodged suture or clip – esp. if on PPV
- Bleeding from intercostal or bronchial artery
- Potential indicators:
- Fresh red blood
- Sudden increase in drainage
- Drainage volume exceeding 100ml/hr
Other complications
- Acute respiratory failure
- Pneumonia
- Pain
- Mediastinal shift – Normal for slight shift to
Enhanced lecture
Use of chest
tube, chest tube
drainage system
Video – Atrium
video imbedded
in PowerPoint
Evaluation
Methods
INSTRUCTIONAL DESIGN TABLE: AACN ECCO RESPIRATORY LESSON 4 - 6
Objectives
6C. Describe different systems
and principles of management for
chest tubes
6D. Compare and contrast the
different types of closed chest
drainage systems
6E. Describe the nursing
management of patients with
chest tubes
Content
(Detailed Outline – not script)
affected side/surgical side. NOT normal is shift
is to good lung, prompt surgical intervention
indicated.
- Development of bronchopleural fistula – can be
caused from mechanical ventilation
- Signs: SOB, cough, hemoptysis
- HIGH mortality rate
Postoperative interventions
- Goal – maximize oxygenation and ventilation
- Interventions – pain management, chest tube,
early mobility/activity
- PAIN MANAGEMENT! Tachycardia,
tachypnea, increased BP, facial effects.
- Opiate through PCA or epidural may be
indicated
6C. 6D. 6E. Chest Tubes
Why?
- Eliminate air or fluid that has accumulated
resulting in compromised ling function
Where
- Placed in the pleural space – 4th or 5th
intercostal space
- Average size 28Fr – 40Fr
After placement
- Connects to drainage system
- X-ray used for confirmation after placement
Drainage systems
- Dry seal
- Water seal
3 chambers
- Drainage chamber
- Water seal chamber
- Suction control chamber
Nursing Assessment
- 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 for redness, swelling, pain, purulent
drainage
Troubleshooting
- Chest tube dislodgement
- Cessation of drainage
- Collection chamber falls
- Water seal and suction troubleshooting
- Have sterile water and package of petroleum
gauze available
- If air leak was present before dislodgement of
chest tube, application of occlusive dressing
may result in tension pneumothorax
Teaching/Learn
ing Strategies
Evaluation
Methods
INSTRUCTIONAL DESIGN TABLE: AACN ECCO RESPIRATORY LESSON 4 - 6
Objectives
Content
(Detailed Outline – not script)
- Timing of removal
- Explain procedure to patient
- Done during deep breath by patient after
cleaning site
- Chest X-ray after removal
- Observe patient for signs of pneumothorax
LESSON 5
Basic Ventilator Management
5A. Describe endotracheal
intubation and discuss nursing
considerations
LESSON 5
5A. Goal – support gas exchange – oxygenation and
ventilation
Indications
- Apnea
- Acute impending respiratory failure
- Severe hypoxemia
- Respiratory muscle fatigue
- Support during anesthesia or sedation
2 types
- Negative and positive pressure
- Negative referred to as iron lung - No artificial
airway, commonly used in polio
- Positive pressure
- Most common
- Used with artificial airway
5B. Discuss the management of
patients with tracheostomy tube
5C. 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
5B. See Lesson 4
5C. Ventilator cycle functions
- Modes
- Volume or pressure
VOLUME
- Set amount of volume (Vt) will be delivered to
lungs – regardless of lung compliance
Common volume modes
Continuous mandatory ventilation (CMV)
- Assist – controlled (AC)
- IMV/SIMV – intermittent mandatory
ventilation/synchronized
Ventilator settings VOLUME
- Rate
- Vt
- FiO2
- Sensitivity
- Positive End Expiratory Pressure (PEEP)
PRESSURE
- Desired pressure is set to achieve Vt
- Used for lung protective strategies to manage
high PIP
Common pressure modes
- Pressure Support Ventilation
- Pressure Control
- CPAP
- SIMV and A/C can also be set as pressure
controlled modes of ventilation
Teaching/Learn
ing Strategies
Enhanced lecture
PowerPoint
slides – out of
chairs
demonstration by
respiratory
therapy on
intubation
procedure
Supplemental
video of
intubation
Respiratory
therapist present
to review
ventilator used at
SGMC
Evaluation
Methods
INSTRUCTIONAL DESIGN TABLE: AACN ECCO RESPIRATORY LESSON 4 - 6
Objectives
5D. Discuss nursing care of the
mechanically ventilated patient
5E. Describe the common
pharmacologic interventions
utilized to assist with managing
patients
5F. Discuss techniques for the
prevention of ventilator acquired
pneumonia
Content
(Detailed Outline – not script)
Settings
- RR
- FiO2
- Inspiratory Pressure Level (IPL)
- Inspiratory time
- PEEP
Complications of mechanical ventilation
- Changes in intrathoracic pressure – increases
intrathoracic pressure
- Cardiovascular complications – hypotension
- Barotrauma – pressure
- Volutrauma - volume
- GI complications – stress ulcers
- Patient Ventilator Dysynchrony – potential for
air trapping
5F. Ventilator Associated Pneumonia – Handout
Teaching/Learn
ing Strategies
5D. Nursing Care
- Assess for effectiveness of mechanical
ventilation
- Monitor for changes that would indicate a
presence of infection - VAP
- Monitor ventilator function according to unit
policy – work with respiratory therapy
- Assess airway position and suction
requirements
- Position patient to provide the best opportunity
for ventilation-perfusion – turn Q2, HOB >
30deg
- 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
5E. Pharmacologic interventions
- Before sedation consider nonpharmacologic
methods to reduce agitation
Goal of sedation
- Patient comfort
- Control physiologic effects of anxiety which
can lead to increase in hospital days
- No single agent is adequate in critical care
setting – usually combination of opiate and
sedative (Fentanyl and Versed)
- Use of sedation scale = RAAS
Pitfalls of sedation
Oversedation
- Respiratory depression, hypotension,
bradycardia and potential thromboembolism
Undersedation
- Patient aware of situation, decreased comfort
and increased agitation and combativeness
HANDOUT
AACN practice
alert VAP
Evaluation
Methods
INSTRUCTIONAL DESIGN TABLE: AACN ECCO RESPIRATORY LESSON 4 - 6
Objectives
Content
(Detailed Outline – not script)
- Attempt to pull out tubes and lines
Neuromuscular Blockade Agents
- 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
Teaching/Learn
ing Strategies
5G. Troubleshooting
- 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
5G. Discuss common problems
encountered with mechanical
ventilators and how to
troubleshoot them
5H. Identify key factors that
impact ventilator weaning
5I. Describe nursing management
of patients who are being weaned
from mechanical ventilation
5H. Weaning
- Starts when patient intubated and mechanical
ventilated
- Underlying illness is improved
- Patient must be hemodynamically stable
- Helped by having correct size ETT – too small
(6fr) increases airway resistance and difficult to
wean
- Evaluation of mechanics of ventilation and
muscle strength
- CPAP, PSV, T-piece
- Nutritional support
Considerations and Nursing Management
- 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
Intolerance to weaning indications
- Dyspnea
- Increased RR, HR, BP
- Shallow breaths or decrease in Vt
Lecture –
PowerPoint
Evaluation
Methods
INSTRUCTIONAL DESIGN TABLE: AACN ECCO RESPIRATORY LESSON 4 - 6
Objectives
Content
(Detailed Outline – not script)
- Accessory muscle use
- Anxiety
- Deterioration in SpO2 or ETCO2
Teaching/Learn
ing Strategies
Evaluation
Methods