Mechanical Ventilation Flashcards
The correct placement of an endotracheal tube is:
A. 2cm above the bifurcation of the main stem bronchi
B. @ the 2nd tracheal ring
C. 1cm below the level of inominate artery
D. 2cm above the carina
D. 2cm above the carina
To confirm placement, after insertion of an endotracheal tube which of the following assessments should be performed? Select all that apply A. Auscultate breath sounds B. Obtain CXR C. Obtain a pulse ox reading D. Schedule the pt. for a bronchoscopy E. Obtain a RR
A and B
Which of the following are components of a standar trach tube? Select all that apply A. Speaking valve B. Inner cannula C. Obturator D. Outer cannula E. Tracheal button
B, C and D
What is the obturator used for?
Placement during insertion
What is the function of a cuff on a trach tube or endotracheal tube?
A. Prevents dislodgement of the tube
B. Allows the use of mechanical ventilation in adults
C. Decreases pressure on the tracheal wall
D. Decreases pt’s work of breathing
B. Allows the use of mechanical ventilation in adults
The nurse is to place a speaking valve on a pt w/ a cuffed trach tube. What action must the nurse take first?
A. Place the pt. on mechanical ventilation
B. Asses vital capacity
C. Deflate the cuff
D. Remove the inner cannula
C. Deflate the cuff
True or false.
Fenestrated trach tubes are packaged w/ 2 inner cannulas? and why?
True bc can’t suction through fenestrated cannula bc can go through hole and damage trachea
Non-fenestrated trach tubes is used for what?
Suctioning and to put pt on mechanical ventilation
What is the purpose of cuffs?
To seal tubes and seal walls of trachea so air that’s being pushed in can’t turn around and come back out through mouth/nose (ensures air is being delivered to lungs
Test pilot tubes are the little projection sring like thing from the balloon (cuff) what are they used for?
To tell you that a cuff tube is in place and inflated by feeling @ the end b/t fingers and observing for a spongy-air like feel; if flat means cuff is deflated
Why is it important to provide humidity and to sometimes warm the air when providing O2 to pts w/ artificial airways?
Bc bypassing the normal ways of warming and humidifying air
When do we want an inflated cuff?
If pt is on mechanical ventilation or are unable to protect lower airway Ex. unconscious, stroke/aspiration pts
What is the most common trach used?
Universal Trach tube
What is the inner cannula used for?
Holds mucous plugs if occur
Single cannula trach tube has what piece only?
Outer cannula
Single cannula trach tubes can’t be used if?
There are excessive secretions or pt has difficulty clearing secretions
What is a fenestrated trach?
Opening on curvature of outer cannula to permit airflow through upper airways, speech and more effective cough
Fenestrated trachs can be what?
Cuffed or uncuffed
What are speaking valves?
A 1 way valve that allows airflor past vocal cords and upper airways during exhalation
What must be done when a speaking valve is in place?
Cuff must be deflated so pt can exhale when speaking valve is placed on
What is a trach button?
Used to occlude trach for period of times to see if pt. is ready to be decannulated
When are fenestrated trachs used?
For weaning or prolonged trach use
What is the trach button used for?
To prevent air from entering and exiting the trach forcing pt to breathe through upper airway to assess readiness to get off
Trach buttons are used when and w/ what?
During weaning and w/ fenestrated tubes
What are GI complications r/t mechanical ventilation?
Paralytic ileus, gastric distention, stress ulcers
How do you prevent stress ulcers?
PPIs
What are renal complications r/t mechanical ventilation?
Renal failure due to sepsis, hypotension
How do you prevent renal complications?
Admin nephrotoxic drugs: vancoMYCIN, gentaMYCIN
What are important labs to monitor w/ nephrotoxic drugs?
BUN/CRT and troph levels
When should you measure troph levels?
Right before next dose
What are cardiovascular complications r/t mechanical ventilation?
Dysrhythmias due to hypoxemia, decreased BP; thrombocytopenia
What are the goals of mechanical ventilation?
Correct ABGs and acid abnormalities; rest the muscles of respiration
What does negative pressure ventilation do?
Stimulates spontaneous breathing. Ex. Iron lung and Pulmowrap
What must pt be able to do w/ negative pressure ventilation?
Initiate own breath
Equivalent to normal respiration, has normal intra-thoracic pressure changes, doesn’t require intubation, is useful in pts w/ neuromuscular weakness and CNS abnormalities, for pts who require ventilatory support only during sleep and is portable are all what?
Advantages to negative pressure ventilation
Can’t be used w/ the acutely ill, is unable to deliver high concentration of O2. pt.s thorax is encased in the ventilator shell causing a tight seal, may be uncomfortable or require the pt to stay in 1 position for a long time and precise tidal volume isn’t possible are all what?
Disadvantages of negative pressure ventilation
What does positive pressure ventilation do?
Pumps air into chest; positive pressure during inspiration Ex. Puritan Bennet 7200 and Bear, CPAP/BiPAP
What are the circulatory effects of positive pressure breathing?
Decreases venous return, BP, pulmonary blood flow and CO
How do you treat decreased BP from positive pressure breathing?
Fluids
Can use lower O2 levels and can deliver a set O2 and volume are what?
Advantages of positive pressure ventilation
Pulmonary: airway trauma, sinusitis, atelectasis, ventilator induced injury, ventilator associated pneumonia (VAP) and O2 toxicity are what?
Disadvantages of positive pressure ventilation
Hypotension, dysrhythmias, fluid retention, resp. alkalosis, stress ulcers and malnutrition are what?
Complications of positive pressure ventilation
W/ ventilatory settings what stops automatically bc a preset volume, pressure or time value has been reached?
Inspiratory cycle
Mode, tidal volume, respiratory rate (of machine), FiO2, PEEP (if used) and pressure limit are all what?
Ventilator settings
What is FiO2?
Fraction inspired oxygen; measured in percentage
What is the pressure limit?
What sets off the alarm when it goes to a certain set level
What is the usual setting for PEEP?
5
What is the bag valve for?
Used if the machine has a problem
Assist/Control (A/C) mode is what?
Respiratory rate and tidal volume are set, BUT pt can increase RR @ a set tidal volume (can initiate breaths on top of what is being delivered)
Control (CMV) mode is what?
RR and tidal volume are set (pt can’t increase RR by initiating breaths)
When is control mode used?
For unconscious, paralyzed, drug OD, anesthetic pts in ICU
Pressure support (PSV) is what?
A preset positive pressure is added to pts spontaneous breaths. Doesn’t have RR or TV so pt needs to breathe on their own
What does a higher pressure support mean?
Pt is more sicker and needs more help
What is pressure support for?
To overcome resistance of breathing through an artificial airway
What does PSV mode need? and who is it mainly used for?
A cuff; pts who have an artificial airway
Positive End Expiratory Pressure (PEEP) mode is what?
Positive pressure is maintained at the end of expiration
What does it mean when a pt needs more PEEP?
Need more O2
BiPAP mode is what?
Alternates the level of pressure; pressure is decreased during expiration (IPAP/EPAP-is lower)
CPAP mode is what?
PEEP is applied to pts spontaneous breaths
What equipment is needed at the bedside of the pt on mechanical ventilation?
Same size ET or trach tube, bag/valve/mask connected to O2 source, trach kits/ET tape, sterile water/NSS and suction kits
What causes high pressure alarms?
SECRETIONS, atelectasis/pneumonia, ET slippage, ARDS
What causes low pressure alarms?
DISCONNECTION, cuff leak
What are the interventions to secretions?
Suction- hyperoxygenate before doing so and press alarm silence and O2 suction
What are the interventions to an ET slippage?
Pull ET tube up until bilaterl lung sounds are heard then inflate cuff and send for a CXR
Which pressure alarm is worse high or low?
Low=lethal alarm
Interventions for a disconnected tube?
Find disconnection starting at pt and following tubing to machine until found
Interventions for a cuff leak?
Check for air coming out of nose/mouth and if pt. can talk (means positive cuff leak)
What is the nursing assessments of the ventilated patients?
Pt. assessment (head to toe), monitor ventilator settings, monitor labs (all labs)
What is the nursing care of the ventilated pt?
Suction if needed, mobilize pt, skin/oral care, nutrition, relieve anxiety, communication about procedure/reassurance and providing a comforting/positive environment
Prevention of ventilator associated pneumonia?
HOB elevation, oral care, ventilator equipment changes only when needed, continuous removal of subglottic secretions (CASS), hand washing, and lift sedation peridoically
What is the care for CASS?
Suction out area around epiglottis?
What is the oral care thats provided for VAP?
Brush teeth w/ chlorhexidine q12h, use swabs q2hr
Acceptable ABGs, tidal volume greater than 6-10ml/kg, minute ventilation less than 10L/min, RR less than 30 breaths/min, FiO2 less than 0.5, hemodynamic stability, normal H/H and electrolytes, free of infection and adequate protein levels are what?
Weaning criteria
What is the weaning guide?
Short periods of spontaneous breathing, provide psychological support and monitor closely
Which of the following pts might take the longest time to wean from the ventilator?
A. 54 y/o man w/ metastatic colon cancer intubated for 6days
B. 32 y/o female recovering from general anesthesia after a tubal ligation
C. 25 y/o male intubated for 28hrs following an anaphylactic reaction
D. 49 y/o male w/ a gunshot wound to the chest and intubated for 8hrs
A. 54 y/o man w/ metastatic colon cancer intubated for 6days
