airways Flashcards
indications for artificial airways
- Upper airway obstructions
- Apnea
- High risk for aspiration
- Ineffective clearance of secretions
- Respiratory distress
equipment used for endotracheal intubation
o Self-inflating BVM/ambu bag and mask and oxygen
o ET tube, guide wire, lubricant, securement device, End Tidal CO2 detector
o Suctioning equipment
o IV access and medications as indicated
preparation for endotracheal intubation
o Consent/resuscitation status
o Client teaching
o Position client
o Preoxygenate
what to do during endotracheal intubation
o Limit each intubation attempt to less than 30 seconds
o Ventilate client between successive attempts
o Rapid sequence intubation (RSI) (administer sedative and Paralytic agents)
o Monitor oxygenation status
o Assess for signs of hypoxia, dysrhythmias, aspiration
what do you do after endotracheal intubation
- confirm placement of ET tube with: end-tidal CO2 detector (turns gold means its in correct placement
- Auscultate lung bilaterally
- Observe chest wall movement
- Check O2 saturation
what to do after placement of endotracheal intubation was verified
- Inflate cuff
- Secure airway
- Suction oropharynx and ET tube as needed
- Obtain chest x-ray (2-6 cm above carina)
- Record and mark position of tube in cm at teeth or gums
- Monitor oxygen saturation continuously, may monitor end-tidal CO2 continuously
- Obtain ABGs as ordered
2 types of artificial airways
endotracheal tube and trachestomy
what is a tracheostomy
surgically created stoma in anterior wall of trachea
(shorter in length and wider in diameter to make it easier to keep tube clean and facilitates better oral and bronchial hygiene; less risk for long-term damage to vocal cords; increase patient comfort)
indications for tracheostomy
- establish patent airway
- bypass upper airway obstruction
- facilitate removal of secretions
- permit long term ventilation
- assist with weaning from mechanical ventilation
what are the types of tracheostomy
- Single versus double cannula
- Fome-cuff
- Fenestrated tracheostomy tube
- Speaking tracheostomy valves
prior to insertion of tracheostomy
- Percutaneous insertion or surgical placement
- Verify consent
- Check coagulation status
- Baseline assessment vital signs, O2 saturation
- Confirm IV access and prepare medications
- Gather equipment
after insertion of tracheostomy
- Immediately after trach tube placement, inflate cuff
- Confirm placement (auscultate breath sounds, end-tidal CO2, pass suction catheter thru tube
- Secure tracheostomy tube
insertion of tracheostomy
- Percutaneous insertion
- Surgical placement
- Check coagulation status
what is the assessment for ETT and Trach
ETT: look at tube type (oral or nasal); size of airway, location at teeth/gums (marking on the tube)
Trach: tubę type and size; assess insertion site/stoma
interventions for ETT and Trach
- maintain correct tube placement (securement)
- maintain proper chug inflation (minimal occluding volume/MOV; minimal leak technique/MLT)
- monior O2 and ventilation (RRR, work of breathing, use accessory muscles, ABGs, signs hypoxemia)
- Maintain tube patency
- Assess need for suctioning q 1-2 hours and suction only as needed
- Manage thick secretions
- Provide oral care and maintain skin integrity q2-4 hrs
- Provide for communication method
- Perform trach care q shift & prn
- Keep trach obturator and spare trach at bedside
- Monitor oxygen source
- Monitor for complications (unplanned extubation and aspiration)
indications for suctioning
- Visible secretions in ET tube
- Sudden onset of respiratory distress
- Suspected aspiration of secretions
- Increased respiratory rate or frequent coughing
- Sudden decrease in SpO2
- ↑ Peak airway pressures
- Adventitious breath sounds
procedure for suctioning
- Hyperoxgenate before and after
- Limit suctioning time 10 sec or less
- Monitor SpO2 and ECG
- Limit suction pressure <120 mmHg
- Insert until client coughs or meet resistance (whichever comes first)
complications of suctioning
- Hypoxemia
- bronchospasm
- Increased intracranial pressure
- Dysrhythmias
- ↑ or ↓ BP
- Mucosal damage
- Pulmonary bleeding
- Pain
- infection
how to manage thick secretions
o Adequate hydration o Supplemental humidification o No saline instillation o Mobilize and turn client o Antibiotics as needed
how to provide. oral care. and maintain skin integrity q2-4 hrs
o Brush teeth BID
o Oral swabs with 1.5% hydrogen peroxide and/or mouthwash
o Chlorhexidine oral rinse twice/day
o Moisturizer- lips, tongue, gums
o Oropharyngeal suctioning
o Reposition and retape ET tube every 24 hours
how to prevent unplanned extubation
manifestations and actions
Manifestation: : low pressure alarm ventilator, decreased or absent breath sounds, respiratory distress, audible cuff leak
- Ensure securement of ET tube/Trach tube
- Support ET tube/trach tube during repositioning and procedures
- Provide sedation and analgesia as ordered
- Use soft wrist restraints as needed (requires HCP order)
actions: Stay with client, call for help, ventilate with BVM and 100% O2 as indicated
how to prevent aspiration
- cuff inflation
- epuglottic suction
- increased secretions are to be suction through oral cavity
- prevent vomiting by NGT or OGT, increase HOB to 30-45 degrees
what to. assess for with unplanned extubation
- Patient vocalization
- Activation of low-pressure alarm
- Diminished or absent breath sounds
- Respiratory distress
- Gastric distention
what to do with incorrect tube placement/unplanned extubation
- Rapid client assessment
- Call for help
- Stay with client
- Maintain airway and Support ventilation
- If necessary, manually ventilate with ambu bag & 100% O2
Process by which air/O2 is moved into and out of lungs by a mechanical ventilator
mechanical ventilation
mechanical device designed to provide all or part of the work of the body to move gas in and out of the lungs
mechanical ventilator
indications for mechanical ventilation
- Apnea
- impending inability to breathe or protect airway
- Acute respiratory failure
- Severe hypoxia (refractory hypoxemia)
- Respiratory muscle fatigue
- Respiratory arrest
what is a positive pressure ventilation (PPV)
movement of gas into lungs through positive pressure
- Used primarily for acutely ill adults
- Delivers air into lungs under positive pressure during inspiration → intrathoracic pressure ↑ during lung inflation (opposite of normal)
2 categories volume and pressure ventilation
o Volume ventilation – preset volume delivered with each breath and pressure varies
o Pressure ventilation – peak inspiratory pressure is Predetermined and volume varies breathe to breathe
mechanical ventilator settings
- rate
- tidal volume (VT)
- Fraction of inspired oxygen (FiO2)
- positive end-expiratory pressure (PEEP)
- Pressure support (PS)
- I:E ratio
- inspiratory flow rate and time
- sensitivity
- Alarm settings
describe the setting rate
- Definition – number of breaths the ventilator delivers
* Usual setting: 12– 20 breaths/min
describe the setting tidal volume (VT)
- Definition – volume of gas delivered with each ventilator breath
- Usual setting: 6-8 mL/kg (based on client’s ideal weight); 4-6 mL/kg ARDS
describe the setting fraction of inspired oxygen (FiO2)
- Definition – fraction of inspired oxygen delivered to client
- Set between 21 - 100%
describe the setting positive end-expiratory pressure (PEEP)
- Definition – positive pressure applied at end of expiration of ventilator breaths
- Usual setting: 5 cm H2O
describe the setting pressure support (PS)
- Positive pressure used to augment the client’s inspiratory Pressure
- Usual setting: 5-10 cm H2O
describe the setting I:E ratio
- Duration of inspiration to duration of expiration
* Usual setting 1:2 to 1:1.5
describe mechanical ventilator modes
- Based on how much work of breathing (WOB) client should or can perform
- Determined by client’s ventilatory status, respiratory drive, & ABGs
(determines how breaths delivered to client)
what are the 3 types of mechanical ventilator modes
- assist-control ventilation (A/C)
- Synchronized intermittent mandatory ventilation (SIMV)
- Continuous positive airway pressure (CPAP)
what is assist-control ventilation and the disadvantages
- Used for clients who have weak respiratory muscles and may be unable to maintain adequate ventilation
- disadvantages: Risk of hyperventilation, Risk of respiratory alkalosis, Muscle fatigues
what are the 2 types of assist-contol ventilation (A/C)
- Volume assist-control (V A/C): Delivers preset tidal volume and pressure varies
- Pressure assist-control (P A/C): Predetermined peak inspiratory pressure and volume varies
what is Synchronized intermittent mandatory ventilation (SIMV)
Ventilator synchronizes the mandatory breaths with the client’s own inspirations
what is Continuous positive airway pressure (CPAP)
Provides continuous positive airway pressure during spontaneous breathing
measurement of client/ventilator produced data
- exhaled tidal volume (EVt): Should not be more than 50 mL difference from set VT
- Peak inspiratory pressure (PIP)
- minute ventilation
- Amount of gas moved in and out of lung per minute
- RR x TV = MV Normal 5–8 L/MIN
- 12 bpm x .600 (or 600 TV) = 7.2 L/min
what. to do with ventilator alarms
- Never shut alarms off; silence only
- Manually ventilate if uncertain of problem until problem identified and resolved
different kinds of mechanical ventilation alarms
high pressure limit low pressure limit high tidal volume high minute ventilation high respiratory rate low tidal volume or low minute ventilation ventilator inoperative
complications of mechanical ventilation
- Misplaced ETT right mainstem bronchus
- Cardiovascular – Hypotension, decreased preload, decreased CO
- Barotrauma – pneumothorax
- Pneumomediastinum – pneumothorax
- Volutrauma – movement of fluids and proteins into alveolar spaces
- Alveolar hypoventilation – inappropriate vent settings, leakage air from tubing, obstruction
- Alveolar hyperventilation rate or VT too high
- Stress Ulcers and GI bleeding
- Ventilator-associated pneumonia
manifestations of ventilator-associated pneumonia
fever increased WBC purulent sputum crackles or wheezes pulmonary infiltrates
guidelines to prevent Ventilator-associated pneumonia
o Minimize sedation and spontaneous breathing trials
o Early exercise and mobilization (turn q 2hrs)
o Subglottic secretion drainage port
o Elevate HOB 30-45 degrees
o Oral care with chlorhexidine
o No routine changes of ventilator circuit tubing
o Good hand hygiene
nursing diagnosis for mechanical ventilation
- Ineffective airway clearance
- Ineffective breathing pattern
- Impaired gas exchange
- Risk for infection
- Decreased cardiac output
- Impaired verbal communication
- Dysfunctional weaning
- Risk for aspiration
- Risk for impaired mucous membranes
- Risk for constipation
Assessment for mechanical ventilation
o Respiratory rate, pattern of breathing, breath sounds, ventilator settings and mode, oxygen saturation
o Level of consciousness, sedation level (sedation scale)
o Heart rate, blood pressure, dysrhythmias
actions to take with mechanical ventilation
o Prevent and manage delirium o Manage sedation, analgesia, paralytics o Collaborate with other disciplines o Implement vent bundle o Monitor for complications and troubleshoot vent alarms o Implement VTE and GI prophylaxis o Determine need for suctioning o Provide enteral nutrition
client criteria for weaning off mechanical ventilation
- Reversal of underlying cause of respiratory failure
- Adequate oxygenation
- Hemodynamic stability
- Adequate respiratory muscle strength
methods of weaning off mechanical ventilation
- Spontaneous breathing trial (SBT)
o Pressure support
o CPAP
o T-piece trials
procedure of extubation of mechanical ventilation
o Hyperoxgenate
o Suction
o Deflate cuff and have client cough as remove tube
o Supplemental oxygen
assessment for extubation of mechanical ventilation
o Vital signs, continuous pulse oximetry
o Cardiac status
o Respiratory status including rate and effort
o Signs client not tolerating extubation: decreased SpO2, tachypnea, or bradypnea, tachycardia, decreased LOC, decreased PaO2, increased PCO2
actions to take for extubation of mechanical ventilation
- Encourage to cough and deep breathe
- Encourage use of incentive spirometer
- Monitor for signs of airway obstruction. (Dyspnea, cyanosis, coughing, stridor)
* Notify HCP immediately for reintubation of client
complications following extubation of mechanical ventilation
- Respiratory distress
- Airway obstruction
- Aspiration
- Sore throat
- Hoarseness
