Critical Care: Airway Management Notes

Question 1

What is the difference between a CPAP and BiPAP?

Answer 1

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

Question 2

Endotracheal intubation (ET) indications

Answer 2

Only used for short period of time
Upper Airway obstruction
Apnea
High risk of Aspiration
Ineffective secretion clearance
Respiratory distress

Question 3

How do you set the patient up for intubation? Explain intubation process.

Answer 3

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

Question 4

How does a BVM or Ambu bag work?

Answer 4

The slower the bag is deflated and inflated, higher O2 concentration

Question 5

How do you confirm ET tube placement during the intubation process?

Answer 5

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

Question 6

What is an Rapid-sequence intubation (RSI)?

Answer 6

Combination of sedatives and paralytic to make the patient unconscious for intubation.

Question 7

How can you detect CO2 with end tidal CO2 (EtCO2) detector?

Answer 7

The color or number changes with more exhaled oxygen

Question 8

What are the nursing responsibilities for patients with artificial airways?

Answer 8

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

Question 9

How do you maintain correct tube placement?

Answer 9

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

Question 10

What do you do if the tube was misplaced?

Answer 10

This is a MEDICAL EMERGENCY
Stay with patient and give oxygen via BVM and 100% O2
Call for help

Question 11

How do you maintain cuff pressure?

Answer 11

20-25 cm H2O

Measure and record cuff pressure after intubation and on a routine basis (q8hrs).

Question 12

How do you monitor for oxygenation and ventilation with ET?

Answer 12

Monitor ABGs, SpO2, ScvO2 or SVO2.
Assess for hypoxemia
Assess respiratory rate, depth, rhythm and use of accessory muscles
Monitor PaCO2 and PETCO2

Question 13

Suctioning indications

Answer 13

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

Question 14

What is the difference between closed-suctioning technique (CST) or open-suctioning technique (OST)?

Answer 14

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.

Question 15

What do you do when a patient can not tolerate suctioning?

Answer 15

Stop immediately

Question 16

How do you prevent hypoxemia when suctioning?

Answer 16

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.

Question 17

Tracheal damage signs and symptoms

Answer 17

Blood streaks or tissue shreds in secretions

Question 18

How do you prevent tracheal damage?

Answer 18

Limit pressure to less than 120 mm Hg
Slow and adequate suctioning and catheter insertion
Assess secretions that are coming out
Notify HCP

Question 19

How do you manage thick secretions?

Answer 19

Maintain adequate hydration and supplemental humidification
No saline instillation
Mobilize and turn patient every 2 hours
Antibiotics PRN

Question 20

Why is oral care important?

Answer 20

The mouth is always open and dry.

Question 21

What is RASS scale?

Answer 21

A medical scale to assess agitation and sedation in a patient.

Question 22

Why is the RASS scale used for intubated patients?

Answer 22

They receive around the clock pain medications and you need to assess effectiveness.

Question 23

What do you need to monitor in patients when giving sedatives?

Answer 23

Respiratory rate and oxygen saturation.

Question 24

BiPAP contraindications

Answer 24

Patients with shock, altered mental status, increased airway secretions

Question 25

What is the mechanism for negative pressure ventilation?

Answer 25

The ventilator pulls the chest wall outwards and reduces intrathoracic pressure. It allows for passive expiration.

Question 26

What is the mechanism for positive pressure ventilation (PPV)?

Answer 26

It utilizes volume ventilation (Vt) and pressure ventilation. Ventilator pushes air into lungs during inspiration. and raises intrathoracic pressure.

Question 27

What is alarm fatigue and how do we prevent it?

Answer 27

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

Question 28

Positive End Expiratory Pressure (PEEP)

Answer 28

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.

Question 29

Nitric Oxide (NO)

Answer 29

Gaseous molecule that increases vasodilation. | Diagnostic tool for pulmonary HTN and to improve oxygenation during mechanical ventilation

Question 30

Prone Positioning

Answer 30

Repositioning patient onto their stomachs. face down. Improves lung recruitment Requires sedation Used with severe ARDS

Question 31

Extracorporeal Membrane Oxygenation (ECMO)

Answer 31

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

Question 32

Cardiovascular complications of PPV (positive pressure ventilation)

Answer 32

Hypotension Increased MAP Negative hemodynamics Hypovolemia and decreased venous tone

Question 33

Pulmonary complications of PPV (positive pressure ventilation)

Answer 33

``` Barotrauma Pneumothorax Pneumomediastinum Volutrauma Alveolar Hypoventilation and Hyperventilation Ventricular-Associate Pneumonia (VAP) ```

Question 34

VAP clinical signs

Answer 34

``` Occurs 48 hours or more after ET Fever High WBC Purulent or odorous sputum Crackles or Wheezes Pulmonary infiltrates on xray ```

Question 35

Prevention of VAP

Answer 35

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.

Question 36

ABCDEF Bundle for psychosocial needs

Answer 36

``` Assessment Both SATs and SBTs are done Choice of analgesia and sedation Delirium prevention and management Early mobility Family engagement ```

Question 37

Before starting sedation or analgesia, what should the nurse do?

Answer 37

Identify cause of distress.

Question 38

When a neuromuscular blocking agent is administered, what are the nursing responsibilities?

Answer 38

Address patient as if they were awake and alert. Assess Train of Four (TOF) peripheral nerve simulation Observe for anxiety (Physiologic signs) Ventilator synchrony

Question 39

Neurologic System Complications and how do you treat it?

Answer 39

With head injury, impaired cerebral blood flow JVD Increase ICP Elevate HOB and keep head in alignment

Question 40

Sodium and Water Complications

Answer 40

``` Fluid retention Sodium retention Decreased urine output Decreased renal perfusion ADH and cortisol release ```

Question 41

GI complications

Answer 41

Stress ulcers GI bleeding Gastric and bowel dilation Constipation

Question 42

How do you prevent stress ulcers?

Answer 42

H2-receptor blockers, PPI, EN to decrease gastric acidity | PPI increases risk for C. diff infection

Question 43

Musculoskeletal complications

Answer 43

Contractures Pressure injuries Foot drop Muscle wasting

Question 44

Nutritional Therapy

Answer 44

Do a nutritional assessment Start EN within 24-48 hours of admission Check serum proteins everyday Limit carbohydrates

Question 45

How do you know if the patient is ready to be weaned off ventilator?

Answer 45

Patient is trying to breathe on their own Using their respiratory muscles well Stable O2 levels

Question 46

3 phases of weaning:

Answer 46

Preweaning Weaning Outcome

Question 47

Preweaning phase. How do you know if the patient is ready to be extubated?

Answer 47

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.

Question 48

Weaning phase

Answer 48

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.

Question 49

Outcome phase or Extubating process: How do you remove ET from the patient?

Answer 49

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.

Question 50

Norepinephrine IV

Answer 50

Vasoconstrictor that will increase heart and peripheral perfusion. Increase SVR, HR, BP

Question 51

Interpreting ScvO2 and SvO2

Answer 51

Normal: 60-80% High: 80-95% Low: <60%

Question 52

What are some medications that can cause delirium?

Answer 52

sedatives (benzodiazepines) Analgesics (opioids) Vasopressors

Question 53

Common problems of Critical Care Problems

Answer 53

``` Anxiety Pain Impaired communication Sleep Sensory-Perceptual Problems Nutrition ```

Question 54

Supporting caregivers

Answer 54

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

Question 55

Alveolar Hyperventilation Causes

Answer 55

Respiratory rate or Vt is set too high or patient is hyperventilating Spontaneous

Question 56

High Risk Factor patients for alveolar hyperventilation

Answer 56

COPD patients or those who have chronic alveolar hypoventilation and CO2 retention

Question 57

Main complication for alveolar hyperventilation

Answer 57

Respiratory alkalosis