Critical Care Respiratory Flashcards
Inserted into the trachea via the mouth or nose. Tip should rest 2-3 cm (1/2-1 in) above carina
More common. Performed at the bedside
Endotracheal tube
Inserted into the trachea via a stoma in the neck.
Surgical procedure used when an airway is needed long-term
Tracheotomy
Guide wire. Radio-opaque line (seen on X-ray to confirm placement). Depth markings. Cuff (inflate cuff, causes seal in trachea so that when air goes into trachea it does leak (goes to lungs) and keep saliva from going down). Pilot balloon with 1 way valve (squeeze each shift to make sure it is firm). Universal adapter. Adult size is usually 7-9 mm.
Endotracheal tube
Placed with aid of laryngoscope. Preferred (easiest, quickest). Uses a large diameter tube (less airway resistance).
Risks: chipped or lost teeth, tube can be obstructed by biting on it, mouth care is difficult.
Oral ETT
Placed blindly. Used when head or neck manipulation is risky. Contraindicated in severe nasal/midface fracture, basilar skull fracture, postop after cranial surgery, coagulopathies.
Risks: can press on the septum, more likely to kink, increased work of breathing, sinus infection, VAP
Nasal ETT
ETT Intubation procedure
Obtain consent if not emergent. Explain to the pt that they will NOT be able to speak while the ETT is in and their hands may be restrained. Have ambu bag, O2, suction, IV access available. Remove the pt’s dentures. Pre oxygenate with 100% O2 for 3-5 minutes. Give premeds if not comatose or in cardiac arrest (rapid sequence intubation [RSI]- Versed, fentanyl, succinylcholine; may also give atropine). Monitor O2 sats throughout the procedure. Place pt supine with head extended, neck flexed.
For nasal, spray with local anesthetic and vasoconstrictor. Each attempt should be
After ETT intubation
Inflate the cuff and confirm placement with end-tidal CO2 detector (capnography) while manually ventilating. Auscultate for bilateral breath sounds. Observe chest for symmetric movement. Observe for improved SpO2. Connect to ventilator. Secure per policy.
Portable CXR to confirm tube location. Once confirmed, mark the position of the tube at the lip or teeth or nose. Obtain ABGs (baseline)
Maintaining correct tube placement
Confirm exit mark on ETT
Maintaining proper cuff inflation (20-25 mmHg) to ensure not necrosing tissue under the cuff
Measure/record q8 hrs using MOV (minimal occluding volume: when vent pushes air down [tidal volume], put stethoscope on trachea. syringe on balloon, uninflate tiny bit until hear squeek, wait, another TV, push air to hear leak stop) or MLT (minimal leak technique)- do mouth care and suction above cuff first!
Monitor oxygenation and ventilation
ABGs, PaCO2, SpO2, SvO2, end-tidal CO2.
Breath sounds, signs of hypoxemia, chest wall movement
Maintain tube patency
Do NOT routinely suction pts; only suction if there are visible secretions, sudden onset of resp. distress, suspected aspiration, increase in peak airway pressures, adventitious breath sounds, increase in resp. rate or constant cough, decrease in O2 sats.
Closed and open-suction techniques
Adequately hydrate pt (dehydration=thick mucus)
Provide supplemental humidification
NO NS into the ETT!
Provide oral care and maintain skin integrity
Moisten lips, tongue, gums with swabs q2-4 hrs
Reposition/retape the ETT q24 hrs
Perform oral care using a soft toothbrush atlas 2x/day
Suction oral cavity/pharynx frequently
Change all oral suction equipment and tubing q24 hrs
Rinse oral suction equipment with sterile NS after each use
Foster comfort and communication
Often need sedation and analgesia.
Can’t talk
Cx of intubation: Unplanned extubation
Can be catastrophic.
S/S: pt speaking, low-pressure alarm, decreased or absent breath sounds, resp. distress, gastric distention
Stay with pt, call for help, maintain the airway and support ventilation
Cx of intubation: aspiration
ETT keeps the epiglottis open. Suction the pt’s mouth frequently and ensure proper cuff inflation, prevent vomiting (often have an NGT), keep HOB up 30-45 degrees if pt has enteral feedings.
Goals: increase oxygenation and ventilation, decrease work of breathing.
Indicated with: apnea, acute respiratory failure. Severe hypoxia. Respiratory muscle fatigue. Resp support after surgery. During anesthesia/heavy sedation.
Used temporarily to support until underlying problems are resolved.
Can be used long-term with chronic, progressive neuromuscular disease (i.e. muscular dystrophy)
Mechanical ventilation
Negative pressure mechanical ventilation
Noninvasive. Doesn’t require an artificial airway. Involves chambers that encase the chest or body. Works by changing pressure within the chest cavity. Used for home use for pts with neuromuscular disease, CNS disease, spinal cord injury
Positive pressure mechanical ventilation
Most commonly used. Pushes air into the lungs to expand the chest. Different types-pressure, time, or volume cycled.
What causes the vent to deliver a breath. Can be negative pressure (trying to breathe, push air down), high sensitivity (very small change stimulates. if it is too high, very small changes trigger a breath and if the pt is still expiring barotrauma can occur). Low sensitivity (pt has to work to get machine to realize they are taking a breath)
Trigger
Volume the patient receives with each breath (usually 7-10 mL/kg). Key to control CO2
Tidal volume
Delivered slow long time for inhalation and less time for exhalation (less time for exhalation esp in COPD)
Breaths per minute (usually 12-16). Key to control CO2
Rate
RRXTV. Increased=decreased CO2 Total amount of air into body and CO2 off/minute
Minute ventilation
Volumes of air that are 1 1/2 to 2 times the set tidal volume, given 6-10 times/hour (extra air helps increase O2 and get rid of CO2)
Sighs
Oxygen level delivered (21-100%). Amount of O2 into pt (out of TV)
Fraction of inspired O2 (FiO2)
How fast the vent gives each breath (usually 40L/min).
Flow
Pressure to push the TV into the lungs
Peak Inspiration Pressure (PIP). Increases if suction is needed.
How much pressure in lungs after exhalation.
ARDS- alveoli collapse at end of exhalation. Def. in surfactant- alveoli collapse- shunt- decrease in PA02. This keeps the alveoli open
Can improve O2, decreases FiO2 (decreases chance for O2 toxicity)
Peak end expiratory pressure.
What % of air is O2. Start at 100% to get PaO2 as high as possible. Crank down to minimum while meeting PAO2 goal. Avoid O2 toxicity
FiO2
Reading of the pressure needed to deliver a set tidal volume, highest pressure reached during inspiration. Reflects changes in resistance of the lungs and the ventilator. Will set high pressure alarms to prevent barotrauma.
Peak inspiratory pressure (PIP)
Positive pressure is applied during exhalation. Increases oxygenation by opening the alveoli. Used with ARDS and pulmonary edema.
Positive End-Expiratory Pressure (PEEP)
Similar to PEEP, but the pressure is delivered continuously during spontaneous breathing. Commonly used to treat obstructive sleep apnea. Can be done invasively or non-invasively. Increases to WOB so be cautious in pts with CV compromise.
Continuous Positive Airway Pressure (CPAP)
Provides 2 levels of pressure support- higher inspiratory pressure and lower expiratory pressure along with oxygen.
Non-invasive.
Used with acute respiratory failure in some pts with COPD and HF and sleep apnea.
Can also be used after extubation.
Bilevel Positive Airway Pressure (BiPAP)
Cx of mechanical ventilation: CV
Decreased CO and BP, fluid retention. High PEEP, RR, TV. High mean intrathoracic pressure. Reduced venous blood return, reduced RA filling, increased pulmonary vascular resistance/ high RS after load, LV impaired diastolic filling
Cx of mechanical ventilation: Pulmonary
Barotrauma or volutrauma. High TV/PEEP. Alveoli stretched/burst- pneumomediastinum/pneumothorax. Releases cytokines- neutrophils/inflammatory cells. Damage type II pneumocytes. Capillary permeability. ALI/ARDS
Ventilator-Associated pneumonia: elevate HOB 30-45 degrees. Don’t interrupt the pt’s ventilator circuit tubing. Brush the pt’s teeth 2x/shift. Hand washing, gloves. Suction as needed. Drain the water that collects in the tubing.
Cx of mechanical ventilation: O2 toxicity
High FiO2- steal electrons=free radicals causing damage. Absorptive atelectasis (O2 diffuse NO2 keeps alveoli from collapsing)
Cx of mechanical ventilation: Auto PEEP
RR, TV, trigger sensitive. Air coming in lungs (TV) faster than passive exhalation. Exhalation selective. Lung pressure increased=barotrauma. Decrease CO
