6.3 Intubation and Ventilation Flashcards
Flash Pulmonary Edema
- Dramatic presentation of acute decompensated HF which can cause acute respiratory distress
- Rapid accumulation of fluid in the lungs causes elevated cardiac filling pressure which results in severe dyspnea and hypoxia
Risk Factors
- Hypertension, Coronary Ischemia, Valvular Heart Disease, Diastolic Dysfunction
Treatment
- CPAP/Bi-PAP
- High Dose NTG
Nurses Role in Endotracheal Tubes
- Know the proper equipment and its use
- Verify equipment is available and functional
- Anticipate Health Providers Needs
- Position Patient
- Preoxygenate patient
- Provide suction
- Monitor patient
- Provide information
Endotracheal Tube
- Temporary artificial airway to create open pathway to improve ventilation and gas delivery.
- Also protects trachea and lungs from aspiration in patients who have lost protective reflexes (gag reflex)
- Patients are unable to vocalize because tube passes through vocal cords
- Can be inserted nasally or oral but oral is most frequent in emergencies.
- Cuff sites below vocal cords
- STABILIZATION OF ET TUBE IS IMPORTANT
DOPE
- Displacement
- Obstruction
- Pneumothorax
- Equipment failure
(Most common cause of hypoxia/deterioration of intubated patients)
Documentation for ET Tubes
- Size of ET tube
- Location of ET tube in the airway
- Medications administered
- Patients tolerance of procedure
- Cuff pressure should be maintained at 20-25 mmHg and checked on q8h
Mechanical Ventilation
Ventilation - Movement of air in and out of airways
Mechanical Ventilation
- Used to control patients respirations during surgery/treatment, oxygenate blood when patients ventilatory efforts are inadequate, and to rest respiratory muscles.
- Patients can breathe spontaneously but effort needed to do so may be exhausting
Failing Mechanical Ventilation
- Decreased O2, Increased CO2, Persistent Acidosis
Ventilators
- Positive/Negative pressure machines that maintain ventilation and oxygen delivery for a client
- Negative pressure systems are no longer used because lungs are naturally negative pressure breathing systems.
How Ventilators Work
- Monitors RR, Pressure, Volume
- Delivers Specified Volume, Pressure, Or Both
- Controls concentration of oxygen
- Mixes compressed air with oxygen to reach desired FIO2
Volume Cycled Ventilator
- Volume is constant in inspiration but variable on expiration depending on the client
Complications
- Barotrauma due to client requiring a lot of force to inspire
Pressure Cycled
- Pressure is constant but volume depends on airway resistance and compliance
Complications
- Compromised ventilation because of inadequate tidal volume
High Frequency Oscillatory Support (HFOS)
- Very high respiratory rate but low tidal volume and high pressure. Pulses oxygen into airways to help expand alveoli so oxygenation can occur
Complications
- Decrease cardiac output, decreased venous return, intraventricular hemorrhage, increased intrathoracic pressure
Non-invasive CPAP and BiPAP
CPAP
- Continuous positive airway pressure all the way through breathing cycle
Problems
- Client must be able to breath on their own (can be used in adjunct to mechanical ventilation support)
BiPAP
- Bilevel positive airway pressure for independent control of inspiration/expiration depending on how machine is set. Prompt for client to breath on their own
Problems
- Motivated Clients Only
Ventilators
- Ventilators deliver gas to lungs on positive pressure limited at a certain rate
- The amount of gas delivered is limited by time, pressure, or volume
- Duration can be cycled by time, pressure, flow.
VOLUME LIMITED
- Preset Tidal Volume
PRESSURE LIMITED
- Preset PIP or PAP
Ventilator Modes
Continuous Mandatory Ventilation
- Preset volume and rate, clients can’t take spontaneous breaths
Assist-Control Ventilation (IMV)
- Combination of preset and spontaneous but preset intervals and volumes so that client can try but machine still uses its presets
Synchronized Intermittent Mandatory Ventilation (SIMV)
- Preset volume and rate but if client initiates breaths, ventilator will adjust so there is no “fighting”
Pressure Support Ventilation (PSV)
- Client breathes on their own and the machine applies pressure to the airway
- Nurse needs to assess and adjust rates/tidal volumes
PEEP
- Positive End Expiratory Pressure
- NOT A SETTING IT IS A MODE
- Provides resistance at the end of exhalation
- Prevents alveoli from collapsing (at least 5cm of H2O required to prevent alveolar collapse)
- Greater than 5cm of H2O can cause decreased cardiac output
- Pneumothorax at higher levels of PEEP (barotrauma)
Nursing Process
Assess everything because client cannot talk to you while intubated.
- All body systems, in depth respiratory assessment including all indicators of oxygenation status, comfort or rest, coping, communication needs
- Vent Assessment (ASSESS CLIENT BEFORE MACHINE)
- ETT (bends, patient biting, dislodged)
VENT ALARMS
- High Pressure (Biting or Kink in Tube)
- Low Pressure (Disconnected Tube)
- Apnea
- Circuit Disconnect
- High Exhaled Volume
GOALS
- Optimal gas exchange, patent airways, no trauma, no infection, effective communication, good coping skills
Complications
- Vent issues, barotrauma, pneumothorax, ventilator associated infections, sepsis
Implementation
- Maintain ET tube without kinks or obstructions, maintain sterile technique during suctioning, patient position, monitor VS and ABGs, provide emotional support
Evaluation
- Return to preincubation level of functioning
Weaning Mechanical Ventilation
- Weaning Mechanical Support
- Weaning Airway Support
- Weaning O2
- Assess psychosocial barriers before removing the tube
- Check ABG’s for hemodynamic stability
Medications
- Patient needs sedatives so they do not pull ET tube out
- If patient is on paralytic, they can still hear and feel
Propofol - Neuromuscular Blocking Agent
Lorazepam - Benzodiazepine
- Short acting barbiturates
- Opioids
Neuromuscular Blockers
- Prevents acetylcholine from activating nicotinic receptors on skeletal muscle which causes muscular relaxation
Non-Depolarizing
- Prevents muscles from contracting
Depolarizing
- Causes depolarization (contraction) but then prevents muscles from being stimulated again (contraction followed by flaccid paralysis)
Vecuronium
- Nondepolarizing Neuromuscular Blocker
- Used with anesthesia to facilitate ET intubation to conserve energy and prevent patients fighting the respirator
Antidote - Anticholinesterase (neostigmine, pyridostigmine, edrophonium)
- Excreted in bile
- Paralysis prolonged in obesity or liver disease patients
- Does not depress CNS
- They can still hear and think
ADVERSE EFFECTS
- Hypotension, bradycardia, dysrhythmias, cardiac arrest, respiratory arrest
Succinylcholine
- Depolarizing Neuromuscular Blocker
- Used for short procedures such as endoscopy or ET tube
Adverse Reactions
- Can cause muscle pain (due to MOA)
- Hyperkalemia (Promotes K release from cells)
- Malignant Hyperthermia
OVERDOSE
- Prolonged Apnea
Interactions
- Antibiotics can intensify effects
- Cholinesterase inhibitors potentiate the effects
Propofol
- Non-barbiturate sedative/hypnotic
- Used to sedate clients undergoing mechanical ventilation
- Can also be used as a parental anesthetic
- Rapid loss of consciousness after IV administration (less than a minute)
- Effects are short lived so continuous IV
Adverse Effects
- N/V (most common)
- Involuntary tremors
- Apnea/Anaphylaxis
- GREEN URINE WITH HIGH DOSE
Benzodiazepines
- Sedative hypnotic that target neurotransmitters while suppressing CNS
- Contraindicated in myasthenia gravis, sleep apnea, bronchitis, COPD
- MAY HAVE PARADOXICAL REACTION
Side Effects
- Cognitive impairment and paradoxical reaction (aggression)
- Abuse potential
- Drowsiness, dizziness, lack of concentration (fall risk) (BEERS LIST)
- Mini Tranquilizer that enhances GABA which is a sedative, anxiolytic (anti-anxiety), anticonvulsant, and muscle relaxant.
- Produces amnesia in surgery (Midazolam)
ANTIDOTE - Flumazenil
Prototype - Chlordiazepoxide or Valium
Barbituates
- No longer used (replaced by benzodiazepines)
- Can be used to induce coma to lower ICP or epilepticus
