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Complex Care Exam 1 > Artificial Airways > Flashcards

Artificial Airways Flashcards

1
Q

Compliance

A
  • The ability of the lungs to stretch & expand
    > low compliance = stiff lungs
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2
Q

Resistance

A
  • The resistance of the resp tract to airflow during inhalation & exhalation
    > asthma & bronchospasm: narrows the airways
    > secretions: narrow the airway & makes it harder for air to be inhaled & exhaled
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3
Q

What meds affect resistance?

A
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4
Q

Endotracheal Tube (ETT)

A

A flexible plastic tube w/ a cuff on the end which sits inside the trachea & terminates 3-4 cm above the carina secured w/ a commercial tube holder

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5
Q

Endotracheal Tube (ETT) - Placement

A
  • Through the orotracheal route via direct laryngoscopy, video laryngoscopy, or nasotracheal route via blind nasal intubation
    > fully secures the airway: the gold standard of airway management
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6
Q

Endotracheal Tube (ETT) - Uses

A
  • Maintenance of airway patency
  • Protection of airway from aspiration
  • Application of positive-pressure ventilation
  • Facilitation of pulmonary hygiene
  • Use of high oxygen concentrations
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7
Q

ETT Complications - During Intubation

A
  • Nasal & oral trauma
  • Pharygneal & hypopharyngeal trauma
  • Vomiting w/ aspiration
  • Cardiac arrest
  • Hypoxemia & hypercapnia: bradycardia, tachycardia, dysrhythmias, HTN, & hypotension
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8
Q

ETT Complications - After Intubation

A
  • Nasal & oral inflammation & ulceration
  • Sinusitis & otitis
  • Laryngeal & tracheal injuries
  • Tube obstruction & displacement
  • Laryngeal & tracheal stenosis and a cricoid abscess
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9
Q

Tube Obstruction - Causes

A
  • Pt biting tube
  • Tube kinking during respositioning
  • Cuff herniation
  • Dried secretions, blood, or lubricant
  • Tissue from tumor
  • Trauma
  • Foreign body
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10
Q

Tube Obstruction - Prevention & Treatment

A
  • Prevention
    > place bite block
    > sedate pt PRN
    > suction PRN
    > humidify inspired gases
  • Treatment
    > replace tube
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11
Q

Tube Displacement - Causes

A
  • Movement of pt’s head
  • Movement of tube by pt’s tongue
  • Traction on tibe from ventilator tubing
  • Self-extubation
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12
Q

Tube Displacememt - Prevention & Treatment

A
  • Prevention
    > secure tube to upper lip
    > sedate pt PRN
    > ensure tht only 2 in of tube extend beyond lip
    > support vent tubing
  • Treatment
    > replace tube
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13
Q

Sinusitis & Nasal Injury - Causes

A
  • Obstruction of paranasal sinus drainage
  • Pressure necrosis of nares
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14
Q

Sinusitis & Nasal Injury - Prevention & Treatment

A
  • Prevention
    > avoid nasal intubation
    > cushion nares from tube & tape or ties
  • Treatment
    > remove all tubes from nasal passages
    > administer antibiotics
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15
Q

Tracheoesophageal Fistula - Causes

A

Pressure necrosis of posterior tracheal wall, resulting from overinflated cuff & rigid nasogastric tube

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16
Q

Tracheoesophageal Fistula - Prevention & Treatment

A
  • Prevention
    > inflate cuff w/ minimal amnt of air necessary
    > monitor cuff pressure q8
  • Treatment
    > position cuff of tube distal to fistula
    > place gastrostomy tube for enteral feedings
    > place esophageal tube for secretion clearance proximal to fistula
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17
Q

Mucosal Lesions - Causes

A

Pressure at tube & mucosal interface

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18
Q

Mucosal Lesions - Prevention & Treatment

A
  • Prevention
    > inflate cuff w/ minimal amnt of air necessary
    > monitor cuff pressures q8
    > use appropriate size tube
  • Treatment
    > may resolve spontaneously
    > peform surgical intervention
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19
Q

Laryngeal or Tracheal Stenosis - Causes

A

Injury to area from end of tube or cuff, resulting in scar tissue formation & narrowing of airway

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20
Q

Laryngeal or Tracheal Stenosis - Prevention & Treatment

A
  • Prevention
    > inflate cuff w/ minimal amnt of air necessary
    > monitor cuff pressures q8
    > suction area above cuff frequently
  • Treatment
    > perform tracheostomy
    > place laryngeal stent
    > perform surgical repair
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21
Q

Tracheostomy Tube

A

Preferred method of airway maintenance in a pt who requires long-term intubation (>7 days)

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22
Q

Trach Complications - During Surgery

A
  • Misplacement of tracheal tube
  • Hemorrhage
  • Laryngeal nerve injury
  • Pneumothorax
  • Pneumomediastinum
  • Cardiac arrest
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23
Q

Trach Complications - After Surgery

A
  • Stomal infection
  • Bleeding/hemorrhage
    > bleeding may occur after surgery & traumatic suctioning
  • Tracheoesophageal fistula
  • Tube obstruction & displacement
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24
Q

Open Suctioning

A

The pt is disconnected from the vent & the suction catheter is introduced in the ETT/Trach

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25
Q

Closed Suctioning

A

A sterile, closed tracheal suction system (CTSS) allows the pt to remain on the vent when suctioned

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26
Q

Subglottic Suctioning

A
  • Deep oropharyngeal suctioning at least q12 & before deflating the cuff or moving the tube
    OR
  • Continuous (-20 to -30 cm H2O) or intermittent suction using the aspiration lumen tht ends w/ an opening above the cuff
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27
Q

Artificial Airway: Nursing Interventions

A
  • Provide humidification
  • Manage the cuff (balloon)
    > cuff pressure are maintained w/in 20-30 cm H2O
  • Establish a method of communication
  • Provide oral hygiene
    > follow protocol
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28
Q

Suctioning Complications - Hypoxemia

caused by
prevented by

A
  • Caused by: disconnected from vent, during suctioning
  • Prevented by: hyper-oxygenate 30-60 sec before & 60 sec after suctioning
  • hyper-oxygenate if pt is known to de-sat
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29
Q

Suctioning Complications - Atelectasis

caused by
prevented by

A
  • Caused by: large suction cath greater than one half of diameter of ETT, causes excessive negative pressure, promoting collapse of distal airways
  • Prevented by: using appropriate size suction cath; less than one half of internal diameter of ETT
30
Q

Suctioning Complications - Infection

caused by
prevented by

A
  • Caused by: cross contamination, poor hand hygiene, pooling of sections in back of throat, poor sterile technique
  • Prevented by: aseptic technique
31
Q

Suctioning Complications - Bronchospasm

caused by
prevented by

A
  • Caused by: irritation/stimulation from plastic introduced
  • Prevented by: lower suctioning, limit duration, limit amnt of passes
32
Q

Suctioning Complications - Airway Trauma

caused by
prevented by

A
  • Caused by: cath bumps into airways, excessive negative pressure
  • Prevented by:
33
Q

Suctioning Complications - Dysrhythmias

caused by
prevented by

A
  • Caused by: particularly bradycardias, attributed to vagal stimulation
  • Prevented by:
34
Q

Using 150 mmHg or less of suction dcr chances of…

A
  • Hypoxemia
  • Atelectasis
  • Airway trauma
35
Q

Limiting duration of each suction pass to 10-15 secs helps minimize…

A
  • Hypoxemia
  • Airway trauma
  • Cardiac dysrhythmias
36
Q

Normal Cuff Pressure

A

15-20 mmHg

37
Q

Too much cuff pressure…

A

Cause a pressure ulcer, fistula = infection

38
Q

Mechanical Ventilation: Indications

A
  • To facilitate the transport of oxygen & CO2 btwn the atmosphere and the alveoli for the purpose of enhancing pulmonary gas exchange
39
Q

Mechanical Ventilation: Physiologic Indications

A
  • Supporting cardiopulmonary gas exchange
    > alveolar ventilation & arterial oxygenation
  • Incring lung vol
40
Q

Mechanical Ventilation: Clinical Indications

A
  • Reversing hypoxemia & acute resp acidosis
  • Relieving resp distress
  • Preventing or reversing atelectasis & resp muscl fatigue
  • Permitting sedation & neuromuscular blockade
  • Dcring oxygen consumption
  • Reduce intracranial pressure
  • Stabilizing chest wall
41
Q

Positive Pressure Ventilation

A
  • Invasive
    > mechanical ventilator
  • Non-invasive
    > CPAP: constant pressure
    > BiPAP: need a tight fitting mask
42
Q

Common Complications of CPAP or BiPAP

A
  • Pressure ulcers on face
  • Bloody noses
    > too dry/no humidification
43
Q

Ventilator Settings: Respiratory Rate

A
  • Number of breaths the ventilator delivers per minute
  • Typical settings: 6-20 bpm
44
Q

Ventilator Settings: Tidal Volume (Vt)

A
  • Volume of gas delivered to a pt during each ventilator breath
  • Typical settings: 6-10 mL/kg (500mL in an average healthy adult male & approx 400mL in healthy female)
  • Too much air = pneumo
  • Not enough air = atelectasis
45
Q

Ventilator Settings: Fraction of Inspired Oxygen (FiO2)

A
  • Oxygen concentration delivered to pt
  • Typical settings: may be set btwn 21-100%; adjusted to maintain PaO2 lvl > 60mHg or SpO2 lvl > 92%
46
Q

Ventilator Settings: (I)nspiration:(E)xpiration Ratio

A
  • Ratio of the duration of inspiration to the duration of expiration
  • Typical settings: 1:2 to 1:1.5 unless inverse ratio ventilation is desired
47
Q

Ventilator Settings: PEEP

A
  • Positive pressure applied at end of expiration of ventilator breaths
    > this is pressure tht remains in alveoli at end of expiration
    > assists in keeping alveoli open: improves oxygenation
    > not a mode of mech vent
    > added to other modes of ventilation
  • Typical settings: 3-5 cm H2O
    > can go higher
48
Q

Modes of Ventilation

A
  • Mode refers to how the machine ventilates the pt
  • The mode of ventilation determines how much the pt participates in their own ventilatory pattern
  • The mode depends on the pt’s situation & goals of treatment
49
Q

Modes of Ventilators: Pressure-Cycled

A

Vent delivers a breath until a preset pressure is reached w/in the pt’s airways

50
Q

Modes of Ventilators: Time-Cycled

A

Vent delivers a breath over a preset time interval

51
Q

Modes of Ventilators: Volume-Cycled

A

Vent is designed to deliver a breatth until a preset vol is delivered

52
Q

Modes of Mech Vent: Continuous Mandatory (vol or pressure) Ventilation (CMV)

this one on test

A
  • aka Assist/Control (AC) ventilation
  • Delivers gas at preset tidal volume or pressure in response to pt’s inspiratory efforts & initiates breath if the pt fails to do so w/in a preset time
    > preset minimum (guaranteed) RR
    > vent-initiated breaths are at set tidal vol
    > pt’s initiated respirs are delivered at vent’s set tidal vol (gauranteed tidal vol)
  • Clinical application
    > primary mode of ventilation
53
Q

Can CMV be used in a weaning trial?

54
Q

CMV: Settings Used

A
  • FiO2
  • Tidal volume (TV)
  • Rate
  • PEEP
    > optional based on pt condition
55
Q

CMV: Nursing Implications

A
  • Hyperventilation can occur in pts w/ incrd resp rates
  • These pts require sedation
  • Monitor for complications
    > high lvls of PEEP: pneumo
    > high lvls of FiO2: oxygen toxicity
56
Q

Major Factors tht Affect the Pt’s Ability to Wean

A
  • The ability of the lungs to participate in ventilation & respiration
  • Secretions
  • Cardiovascular performance
  • Psychological readiness
57
Q

Weaning Methods

A
  • IM V (SIM V)
    > guaranteed rate & tidal vol
  • Spontaneous Breathing Trials
    > CPAP
    > T-tube, T-piece; pt does all the work
    > Pressure support ventilator (PSV)
58
Q

T-Tube/T-Piece

A
  • Pt initiates breaths & tidal vol
  • Ventilator is turned off, pt is placed on a T-Piece thts attached to wall O2
59
Q

Pressure Support

A
  • No set respiratory rate or tidal vol
  • Pt’s breaths are supplemented w/ positive pressure tht overcomes the impedance of the endotacheal tube
60
Q

CPAP

A
  • The pt initiates breaths & tidal vol
  • Low lvls of CPAP (5 cm H2O) while the pt breathes spontaneously
  • PaCO2 & respiratory effort are monitored for s/s of fatigue
61
Q

Weaning

A
  • Weaning is the withdrawal of the mechanical ventilator & the resstablishment of spontaneous breathing
  • Conside the length of time on the vent, sleep deprivation, & nutritional status
62
Q

Pt is Ready for a Spontaneous Breathing Trial if the Following Criteria are Met

A
  • Awake, cooperative, & follows commands
  • Good gag reflex
  • Strong cough
  • Minimal secretions
  • Hemodynamically stable off vasopressors
  • Underlying disease leading to intubation has resolved
  • Hgb greater than, equal to 8 g/dL
  • Spontaneously breathing on PEEP < 5-8
  • PaO2/FiO2 ratio greater than, equal to 150-200 (or SaO2 greater than, equal to 90% w/ FiO2 less than, equal to 0.4)
  • Systemic pH greter than, equal to 7.25
  • Minute ventilation < 15 L/minute
  • Rapid shallow breath index < 105
63
Q

Weaning Trial Prep

A
  • Position pt upright to facilitate breathing & suctioned to ensure airway patency
  • Explain the process to the pt, reassure, & provide diversional activities as needed
  • Assess pt immediately before thestrat of & frequently during the weaning period for signs of weaning intolerance
  • Draw ABG before & 30 mins after trial begins
64
Q

Successful Weaning Trial

A
  • RR greater than, equal to 35
  • HR < 120-140/minute
  • SBP > 90 & < 180 mmHg
  • SaO2 greater than, equal to 90% or PaO2 greater than, equal to 55 mmHg on FiO2 less than, equal to 0.4
  • Vt greater than, equal to 4 mL/kg predicted body weight or greater than, equal to 325 mL(in adults)
  • PaCO2 incr < 10 mmHg
  • Absence of agitation, diaphoresis, or incrd work of breathing
65
Q

Weaning Tolerance Indicators

A
  • Dcr in LOC
  • SBP incrd or dcrd by 20 mmHg
  • DBP greater than 100 mmHg
  • HR incrd by 20 beats/min
  • Premature ventricular contractions greater than 6/min, couplets, or runs of ventricular tachycardia
  • Changes in ST segment (usually elevation)
  • RR greater than 30 breaths/min or less than 10 breaths/min
  • RR incrd by 10 breaths/min
  • Spontaneous tidal vol less than 250mL
  • PaCO2 incrd by 5-8 mmHg and/or pH less than 7.30
  • SpO2 less than 90%
  • Use of accessory muscles of ventilation
  • Complaints of dyspnea, fatigue, or pain
  • Paradoxical chest wall motion or chest abdominal asynchrony
  • Diaphoresis
  • Severe agitation or anxiety unrelieved by reassurance
66
Q

Nursing Management

A
  • Pt Assessment: focused pulm assessment
    > resp rate, effort, secretions
    > ABGs
    > pulse ox & EtCO2
    > subcutaneous emphysema
    > ETT/trach placement
  • Symptom Management
    > manage anxiety, pain, SOA, confusion, & agitation
  • Maintain adequate sedation
  • Sedation vacation
67
Q

Big Valve Mask (BVM)

A

Connected to oxygen at bedside

68
Q

Mechanical Ventilation: Patient Safety

A
  • Big valve mask (BVM) connected to oxygen at bedside
  • Vent is free of
    > water
    > kinks
    > obstructions (secretions)
    > disconnections
  • Change tubing per hosp policy
  • Monitor temp of inspired air
  • Vent malfunctions
    > pt is removed from vent -> BVM
    > vent malfunction -> BVM
  • Review alarms
69
Q

Low Pressure Alarm

A
  • Unattached tubing/leak around ETT
  • ETT displaced into pharynx or esophagus
  • Pneumothorax
  • Tracheoesophageal fistula
  • Poor cuff inflation or leak
  • Dcrd airway resistance
    > barotrauma, pneumo
  • Low Vt
70
Q

High Pressure Alarm

A
  • Coughing
  • ETT in right mainstem bronchus or against carina
  • Kinked tubing
  • Incr airway resistance
    > pt trying to speak
  • Dcr lung compliance
    > ARDS, pneumonia, abd distention
71
Q

Points to Remember

A
  • Treat the pt
    > not the machine
  • Vent care is supportive care
    > not a cure
  • Vent delivers oxygen to lungs
    > gas exchange must occur w/in alveoli
  • Called a vent, not respirator
  • If machine malfunctions take pt off vent & ventilate them by hand
    > do not leave them

Complex Care Exam 1 (6 decks)

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