Critical Care: Airway Management Notes Flashcards
What is the difference between a CPAP and BiPAP?
CPAP delivers continuous oxygen to the patient, increases work of breathing and used for OSA.
BiPAP has 2 functions: high inspiratory positive airway pressure and low expiratory positive airway pressure. It is used for COPD with HF, Acute Respiratory Failure, and sleep apnea
Endotracheal intubation (ET) indications
Only used for short period of time Upper Airway obstruction Apnea High risk of Aspiration Ineffective secretion clearance Respiratory distress
How do you set the patient up for intubation? Explain intubation process.
Obtain consent if not emergent
Have a self-inflated bag-valve-mask (BVM) attach to oxygen and suctioning nearby
Ensure patient has an IV access
Remove patient’s dentures or partial plates
Place patient in sniffling position - supine with head extended and neck flexed
Preoxygenate patient with BVM for 3-5 minutes or give rapid-sequence intubation (RSI) if emergent
Monitor O2 status
Intubate patient and confirm placement
Inflate the cuff
Connect ET tube to ventilator and secure it.
Obtain chest x-ray
Obtain ABGs 15-30 minutes after
How does a BVM or Ambu bag work?
The slower the bag is deflated and inflated, higher O2 concentration
How do you confirm ET tube placement during the intubation process?
EtCO2 detector - how much CO2 is expelled from the lungs. Should be consistent after 5-6 exhalations
Auscultate lungs for bilateral breath sounds and epigastrium for absence of air sounds
X-ray location is 2-6cm above carina
What is an Rapid-sequence intubation (RSI)?
Combination of sedatives and paralytic to make the patient unconscious for intubation.
How can you detect CO2 with end tidal CO2 (EtCO2) detector?
The color or number changes with more exhaled oxygen
What are the nursing responsibilities for patients with artificial airways?
Maintain correct tube placement Maintain proper cuff inflation Monitoring oxygenation and ventilation Maintaining tube patency Providing oral care and maintaining skin integrity Provide comfort and communication
How do you maintain correct tube placement?
Mark where the tube is after intubation process and ensure it is in the same place. (21 cm for women, 23 cm for men)
Observe for chest wall symmetry and auscultate for bilateral lung sounds
What do you do if the tube was misplaced?
This is a MEDICAL EMERGENCY
Stay with patient and give oxygen via BVM and 100% O2
Call for help
How do you maintain cuff pressure?
20-25 cm H2O
Measure and record cuff pressure after intubation and on a routine basis (q8hrs).
How do you monitor for oxygenation and ventilation with ET?
Monitor ABGs, SpO2, ScvO2 or SVO2.
Assess for hypoxemia
Assess respiratory rate, depth, rhythm and use of accessory muscles
Monitor PaCO2 and PETCO2
Suctioning indications
When you can see secretions in the ET tube
Sudden onset of Respiratory distress
When you suspect patient is aspirating on their own secretions
Tachypnea or frequent coughing
SpO2 decreases
Peak airway pressure increases
Auscultated adventitious breath sounds
What is the difference between closed-suctioning technique (CST) or open-suctioning technique (OST)?
OST comes in a kit and requires a new single-use catheter every time.
CST is the most common choice and a catheter can be used multiple times within 24 hours. Additionally, oxygenation and ventilation are maintained during suctioning and decreases exposure to secretions.
What do you do when a patient can not tolerate suctioning?
Stop immediately
How do you prevent hypoxemia when suctioning?
Give patient a lot of oxygen before suctioning and after each suctioning pass.
Limit each pass to 10 seconds or less
Assess ECG and SpO2 before, during and after suctioning.
Tracheal damage signs and symptoms
Blood streaks or tissue shreds in secretions
How do you prevent tracheal damage?
Limit pressure to less than 120 mm Hg
Slow and adequate suctioning and catheter insertion
Assess secretions that are coming out
Notify HCP
How do you manage thick secretions?
Maintain adequate hydration and supplemental humidification
No saline instillation
Mobilize and turn patient every 2 hours
Antibiotics PRN
Why is oral care important?
The mouth is always open and dry.
What is RASS scale?
A medical scale to assess agitation and sedation in a patient.
Why is the RASS scale used for intubated patients?
They receive around the clock pain medications and you need to assess effectiveness.
What do you need to monitor in patients when giving sedatives?
Respiratory rate and oxygen saturation.
BiPAP contraindications
Patients with shock, altered mental status, increased airway secretions
What is the mechanism for negative pressure ventilation?
The ventilator pulls the chest wall outwards and reduces intrathoracic pressure. It allows for passive expiration.
What is the mechanism for positive pressure ventilation (PPV)?
It utilizes volume ventilation (Vt) and pressure ventilation.
Ventilator pushes air into lungs during inspiration. and raises intrathoracic pressure.
What is alarm fatigue and how do we prevent it?
Alarm fatigues are for the care team who got used to hearing unnecessary amount of alarms and causes them to delay their response.
Set alarms based on patient’s specific needs
Positive End Expiratory Pressure (PEEP)
Positive pressure is applied during the expiration phase.
It increases lung volume, functional residual capacity (FRC) and oxygenation of the lungs.
FIO2 can be reduced
Pressure falls between 3-20 cm H2O.
Nitric Oxide (NO)
Gaseous molecule that increases vasodilation.
Diagnostic tool for pulmonary HTN and to improve oxygenation during mechanical ventilation
Prone Positioning
Repositioning patient onto their stomachs. face down.
Improves lung recruitment
Requires sedation
Used with severe ARDS
Extracorporeal Membrane Oxygenation (ECMO)
Alternative form of pulmonary support for patient with severe respiratory failure.
Removes blood from patient, infuse O2, remove waste and put the blood back to patient
Requires systemic anticoagulation and time-limited intervention
Needs a specialists
Cardiovascular complications of PPV (positive pressure ventilation)
Hypotension
Increased MAP
Negative hemodynamics
Hypovolemia and decreased venous tone
Pulmonary complications of PPV (positive pressure ventilation)
Barotrauma Pneumothorax Pneumomediastinum Volutrauma Alveolar Hypoventilation and Hyperventilation Ventricular-Associate Pneumonia (VAP)
VAP clinical signs
Occurs 48 hours or more after ET Fever High WBC Purulent or odorous sputum Crackles or Wheezes Pulmonary infiltrates on xray
Prevention of VAP
Hand wash before and after touching equipment
Wear gloves
Minimize sedation
Early exercise and mobilization
ET tubes with subglottic secretion drainage ports for patients likely to be intubated for more than 72 hours
HOB elevated 30-45 degrees
Oral care with chlorohexidine
No routine changes with patient’s ventricular circuit tubing.
Drain the water that collects in the ventilator tubing away from the patient as it collects.
ABCDEF Bundle for psychosocial needs
Assessment Both SATs and SBTs are done Choice of analgesia and sedation Delirium prevention and management Early mobility Family engagement
Before starting sedation or analgesia, what should the nurse do?
Identify cause of distress.
When a neuromuscular blocking agent is administered, what are the nursing responsibilities?
Address patient as if they were awake and alert.
Assess Train of Four (TOF) peripheral nerve simulation
Observe for anxiety (Physiologic signs)
Ventilator synchrony
Neurologic System Complications and how do you treat it?
With head injury, impaired cerebral blood flow
JVD
Increase ICP
Elevate HOB and keep head in alignment
Sodium and Water Complications
Fluid retention Sodium retention Decreased urine output Decreased renal perfusion ADH and cortisol release
GI complications
Stress ulcers
GI bleeding
Gastric and bowel dilation
Constipation
How do you prevent stress ulcers?
H2-receptor blockers, PPI, EN to decrease gastric acidity
PPI increases risk for C. diff infection
Musculoskeletal complications
Contractures
Pressure injuries
Foot drop
Muscle wasting
Nutritional Therapy
Do a nutritional assessment
Start EN within 24-48 hours of admission
Check serum proteins everyday
Limit carbohydrates
How do you know if the patient is ready to be weaned off ventilator?
Patient is trying to breathe on their own
Using their respiratory muscles well
Stable O2 levels
3 phases of weaning:
Preweaning
Weaning
Outcome
Preweaning phase. How do you know if the patient is ready to be extubated?
Looks at patient’s ability to breathe spontaneously
Primary problem is solved
Clear lung sounds and chest xray
Assess muscle strength and endurance.
Minimal secretions in ET tube
Ability to cough and gagged
Assess neuro status, hemodynamics, fluid and electrolyte balances, nutrition, hemoglobin.
Weaning phase
Assess SAT and SBT
SAT - stopping all sedatives
SBT - last 30-120 minutes, low levels of PEEP, PSV
or FIO2.
Use weaning protocol
Rest in between weaning
Comfortable sitting or semi recumbent position.
Obtain baseline v/s and respiratory parameters
Monitor for symptoms to end trial period.
Outcome phase or Extubating process: How do you remove ET from the patient?
Hyperoxygenate and suction prior to extubation
Loosen ET tapes or commercial holder
Patient takes deep breath and peak inspiratory phase, deflate the ET tube cuff and remove
Encourage deep breathing and coughing
Assess vocalization
Give supplemental O2 PRN
Provide naso-oral care
Monitor v/s for one hour after extubation process.
Norepinephrine IV
Vasoconstrictor that will increase heart and peripheral perfusion.
Increase SVR, HR, BP
Interpreting ScvO2 and SvO2
Normal: 60-80%
High: 80-95%
Low: <60%
What are some medications that can cause delirium?
sedatives (benzodiazepines)
Analgesics (opioids)
Vasopressors
Common problems of Critical Care Problems
Anxiety Pain Impaired communication Sleep Sensory-Perceptual Problems Nutrition
Supporting caregivers
Provide information, communication and access
Recognize caregivers feelings, listen to them openly, acknowledge their decisions
Consult other team members as needed to help caregivers cope.
Prepare caregivers during their first visit
Be allowed to stay with patient undergoing treatment and procedures as long as both parties are willing.
Let them take part in patient’s care
Alveolar Hyperventilation Causes
Respiratory rate or Vt is set too high or patient is hyperventilating
Spontaneous
High Risk Factor patients for alveolar hyperventilation
COPD patients or those who have chronic alveolar hypoventilation and CO2 retention
Main complication for alveolar hyperventilation
Respiratory alkalosis
