Pulmonary Therapeutic Management Flashcards
Basics: pH, PaO2, PaCO2, HCO3 - pic oxygenation and ventilation
Measurement of oxygenation
Measurement of ventilation (acid-base disorder)
Hypoxemia – inadequate blood O2:
ABG Overview
The PaO2 is a measure of the partial pressure (P) of oxygen dissolved in arterial blood plasma.
Normal range: 80-100 mm Hg
Measurement of oxygenation
The pH is the hydrogen ion (H+) concentration of plasma
Normal range: 7.35 to 7.45
PaCO 2 is a measure of the partial pressure of carbon dioxide dissolved in arterial blood plasma
Normal range: 35 to 45 mm Hg
Bicarbonate (HCO3 −) is the acid–base component that reflects kidney function. The HCO3 − level is reduced or increased in the plasma by renal mechanisms.
Normal range: 22 to 26 mEq/L
Measurement of ventilation (acid-base disorder)
mild (PaO2 60-79)
moderate (PaO2 40-59)
severe (PaO2 less than 40)
Hypoxemia – inadequate blood O2:
Metabolic acidosis or partially compensated metabolic acidosis
DKA
Metabolic alkalosis - Tums and antacids are basics
Chronic indigestion and uses antacids daily
Respiratory acidosis; not usually in a compensated state
Narcotic overdose
Metabolic acidosis
Renal failure
Metabolic alkalosis
Long term nasogastric suctioning
Respiratory alkalosis
Hyperventilating -
Asthma attack - acute respiratory acidosis because not breathing off CO2 - underlying prob with mainstem/bronchus; usually Fast respiratory rate does not usually = acidosis
Anxiety attack
Compliance: The ability of the lungs to stretch and expand; how well the lungs stretch
Resistance: The resistance of the respiratory tract to airflow during inhalation and exhalation; anything that inhibits shuttling of air in and out
Airways
Something wrong with lung not allowing expansion, oxygenation/ventilation not happening: CP, COPD, emphysema - compliance issues
Low compliance = stiff lungs
Compliance: The ability of the lungs to stretch and expand; how well the lungs stretch
Mainstem bronchus in and up
Asthma & bronchospasm – narrows the airway
Secretions – narrow the airway & makes it harder for air to be inhaled and exhaled.
What medication(s) affect Resistance?
Bronchodilators
Expectorants
Steroids
opioids/sedatives
acetylcycstine/mucomist - luquifies secretion, secretions less viscous - cough out or suction out; affects viscosity
Beclamethozone - steroid
Albuterol
Resistance: The resistance of the respiratory tract to airflow during inhalation and exhalation; anything that inhibits shuttling of air in and out
Endotracheal Tube (ETT):
Tracheostomy tube:
Nursing management
Interventions
Artificial airways
A flexible plastic tube with a cuff on the end which sits inside the trachea and terminates ~3 to 4 cm above the carina. Secured with a commercial tube holder.
Tube inserted through mouth/nose depending on what is going on
High risk for sinus infections - anything going via the nose
Cuff inflated after inserted
Terminal end before carina
Use to Maintain airway - pt Losing airway or high risk to go ahead and intubate - easier to intubate when not an emergeny
Have fancy holder that holds the tube in place
Placement: 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
Uses: Maintenance of airway patency, protection of the airway from aspiration, application of positive-pressure ventilation, facilitation of pulmonary hygiene, and use of high oxygen concentrations
ETT complications
Endotracheal Tube (ETT):
Routine but most docs say not routine - different anatomy - tubes quite stiff - little bend to them - same bend going down; when going down are banking against back throat - metal obturator to help shape it with it - not scrape it down with obturator stylus
Cause lot trauma if hard intubation - can bleed - consider getting fiberoptics to help
Suction lot to help
Nasal and oral trauma, pharyngeal and hypopharyngeal trauma, vomiting with aspiration, and cardiac arrest
May become Hypoxemia (low O2) and hypercapnia (high CO2) during intubation - not breathing -> bradycardia, tachycardia, dysrhythmias, hypertension, and hypotension
Not oxygenating during intubation
During intubation - ETT complications
Nasal and oral inflammation and ulceration, lot sinusitis (sinus infections), otitis, laryngeal and tracheal injuries, and tube obstruction and displacement.
Soft tissue trauma in pharynx and lower - over shoot it get little bruise on carina/where large airways bifurcate
Laryngeal and tracheal stenosis and a cricoid abscess
After intubation - ETT complications
Preferred method of airway maintenance in a patient who requires long-term intubation (>7 days). - family conference and discuss going to get PEG and trach; to go to LTACH need trach - no oral or nasal intubation allowed at long term acute care facilities
Placed at bedside
Trach complications
Tracheostomy tube:
Misplacement of the tracheal tube
Hemorrhage
Laryngeal nerve injury
Pneumothorax - put in low can go in and can hit apex of lung
Pneumomediastinum
Cardiac arrest - do with conscious sedation and pt barring down - propofol does not help with pain - cont with on and tweak with extra versed and fentanyl for pain and local lidocaine as inserting it
During surgery - Trach complications
Stomal infection - COMMON; esp after extubation - air pushing in all time too
Bleeding/hemorrhage
Bleeding may occur after surgery and traumatic suctioning.
Lot stuff inside neck and hemorrhage risk
Tracheoesophageal fistula - erodes through and direct communication through trachea and esophagus
Tube obstruction and displacement - mucous plug; dressed: and pull on it
After surgery - Trach complications
What is the difference between shallow and deep suctioning?
Open suctioning:
Closed suctioning:
Suctioning is a sterile procedure that is performed only when the patient needs it and not on a routine schedule - keep track ventilator associated infections - keep sterile; may be tasked to check to see if need it on schedule but only do it if necessary
Complications
Suctioning - Nursing management
Deep suctioning
Down just above the carina - down and out of ETT
Not into trees
Down until resistance then pull back and apply suction
Shallow
Depth of ETT self
What is the difference between shallow and deep suctioning?
The pt. is disconnected from the ventilator and the suction catheter is introduced in the ETT/Trach.
Risk for hypoxemia and hypercapnia
Painful
Sterile procedure
Go in and out - cannot touch anything
Open suctioning:
a sterile, closed tracheal suction system (CTSS) allows the patient to remain on the ventilator when suctioned
Ted off is a suction tube and suction tube and bag suctions up - apply suction and slowly pull out
Contained and not contaminante it
Sucking out air and O2 so can cause hypoxia - more convenient, fast, reduces risk for infection
Closed suctioning:
Hypoxemia
Infection
Bronchospasm
Airway Trauma
Dysrhythmias
Complications
Caused by: take O2 off; suctioning (hold breath while suctioning)
Prevent: hyperoxgenating before each pass; vent: 100%; nonrebreather: 1min
Hypoxemia
Caused by: variety of things; people touching it; not sterile technique; not changing dressing when necessary
Prevent: sterile/aseptic technique
Infection
Caused by: cough when suction them - foreign object in large airways and causes a spasm; trachea or bronchi - not need do deep; not gag reflex because below that
Bronchospasm
Caused by: catheter tip - blunt tip and not rounded - scraping lungs and soft tissue; airway damage with suction all the way up or too high
Prevent: keep in the yellow/green - suck against side wall because trauma
Airway Trauma
Caused by: vagal response and they cough - something foreign in airway and need get rid of it
Prevent: only deep suctioning PRN and do shallow suctioning more; not touching airways
Dysrhythmias
Provide humidification
Manage the cuff (balloon)
Establish a method of communication
Provide oral hygiene: Follow oral care protocol
Subglottal suctioning:
Interventions
Why is Humidity needed?
Not dry out throat
Bypassing mouth - brings in humidity - even with tube/trach - must be provided
Provide humidification
Cuff pressures are maintained within 20 to 30 cm H2O
What will happen if the cuff pressure is too high or too low?
High enough to 100% occlussive - damage of trachea and cause necrosis
Low enough - oozes around and into lungs; aspiration pneumonia
Manage the cuff (balloon)
Try keep to yes/no questions
Trying talk - Vocal cords moving against tube - can cause more damage
Can write - have write it out
Establish a method of communication
Suctioning is a sterile procedure that is performed only when the patient needs it and not on a routine schedule
Done on ETT and trach - balloon holding it in place - usually port that comes off side: 1) inflate cuff, 2) suction - gets all fluid settling above balloon so not go all way down orally to get secretions
Balloons not 100% occlusive
Can hook up to low intermittent suction
Minimize suctioning because can damage
Deep oropharyngeal suctioning at least every 12 hours and before deflating the cuff or moving the tube OR Continuous (−20 to −30 cm H2O) or intermittent suction using the aspiration lumen that ends with an opening above the cuff.
Sounding rattly - do shallow then deep - minimize suctioning because damaging soft tissue every time suction
Subglottal suctioning:
Lubricant
Oral airways
Nasal trumpet - inserted in nose and stays in there - when doing suction and not scraping soft tissue when go down - holding jaw up to where can breath; in nose and leave it; suction to where no soft tissue damage; flexible and floppy; not to point where go to gag reflex - beyond touch pharynx - have airway available because opens it
Oral airway - hard plastic - cannot use these if somewhat conscious - rests by glottis and vomit on you - sedated sig or completely asleep - not move; stick suction catheter beside it because sides hollow - serves as a combo bite lock because hard plastic
The nurse is caring for a patient who is orally intubated with a 7.0 ETT that is 21cm at the lip. The cuff pressure is 35 mmHG. The patient has copious amounts of oral secretions and requires frequent NT suctioning.
What device(s) can the nurse use to decrease the nasopharyngeal trauma when suctioning?
So they know where it is; be consistent and charted where measuring
Why is the measurement of the ETT provided?
Yes; cuff pressure is way too high
Even if showing signs not enough pressure - not within defined limits need notify someone and need note that notified someone in chart
Is the cuff pressure concerning? Why or why not?
Start with subglottal - get the mess out of the way since it is the mouth
Secretions based lowers - just above balloon - do both
Start up high so not go balloon and into lungs
The nurse is caring for a patient who is orally intubated with a 7.5 ETT that is 19cm at the lip. The patient shows signs of respiratory distress, is coughing, and has oral secretions bubbling out of his mouth. The nurse completes a focused assessment by auscultating the lungs and over the trachea. Coarse crackles are auscultated over the lung fields and over the trachea. There are visible secretions in the ETT.
Does this patient require subglottal suctioning or regular suctioning?
Yes both suctioning
Does this patient require suctioning?
It is never scheduled
It is routine
The nurse finds themselves suctioning this patient frequently and decides to obtain an order for scheduled suctioning.
Is this the correct course of action?
To facilitate the transport of oxygen and CO2 between the atmosphere and the alveoli for the purpose of enhancing pulmonary gas exchange; maintain airway; trauma pts: higher PEEP - internal splint to keep ribs in place
On to maintain airway
Physiologic
Clinical
Mechanical ventilation: indications
Supporting cardiopulmonary gas exchange (alveolar ventilation and arterial oxygenation)
Increasing lung volume
Physiologic
Reversing hypoxemia and acute respiratory acidosis
Relieving respiratory distress
Preventing or reversing atelectasis and respiratory muscle fatigue
Permitting sedation and neuromuscular blockade
Decreasing oxygen consumption
Reduce intracranial pressure
Stabilizing the chest wall
Clinical
Used to be external where manipulated outside the lung
Negative Pressure Ventilation
Positive Pressure Ventilation
Types of ventilators
Applied externally to the patient and decrease the atmospheric pressure surrounding the thorax to initiate inspiration.
Negative Pressure Ventilation
Invasive: Use a mechanical drive mechanism (Mechanical Ventilator) to force air into the patient’s lungs through an ETT or tracheostomy tube. Tube down throat to keep that pressure in - tube with long-term trach - trade out that is un-cuffed trade for one that is cuffed if want do PEEP - do balloon to keep pressure in
Non-invasive: Delivery of positive pressure ventilation via a tight-fitting mask that covers the nose or both the nose and mouth.
Positive Pressure Ventilation
CPAP: Constant pressure is maintained throughout the respiratory cycle with no additional inspiratory support; can be button on vents without extubating them and using CPAP machine
BiPAP: the primary care provider sets both the expiratory positive airway pressure (EPAP) and the inspiratory positive airway pressure (IPAP), with respirations triggered by the patient; hate with awake and alert; pushing air in while trying exhale: often fighting it and suffocating them; chronic lung disease that not want intubation do this because harder get off vents because body gets lazy quickly
What are some common patient complications with using CPAP or BiPAP?
Skin breakdown
Anxiety - esp not been on BiPAP - shove air in when not trying to breathe in
Non-invasive: Delivery of positive pressure ventilation via a tight-fitting mask that covers the nose or both the nose and mouth.
A ventilator uses four different variables to begin, sustain, and terminate each phase of ventilation. These variables are described in terms, pressure, flow, and time
Pressure-cycled
Time-cycled
Volume-cycled
Ventilator mechanics
How much pressure going in
Can be combined with something else
Pressure-cycled
Usually seen
Time-cycled
The selected of a mode of ventilation determines how much the patient participates in their own ventilatory pattern
Depends on what going on and physician preference and depends on why intubating them - consider situation
The choice depends on the patient’s situation and the goals of treatment
Sometimes unsedated - does help; helps to have ventilator - propofol so not fighting against machine
Continuous mandatory (volume or pressure) ventilation (CMV) - seen lot, also known as assist/control (AC) ventilation
Intermittent mandatory (volume or pressure) ventilation (IMV), also known as synchronous intermittent mandatory ventilation (SIMV)
Pressure Support Ventilation (PSV)
Modes of ventilation
Guaranteed rate and volume
Delivers gas at preset tidal volume or pressure or both in response to patient’s inspiratory efforts and initiates breath if the patient fails to do so within a preset time.
Sicker - helps have on propofol, fentanyl or versed drips - not fighting against machines and not feel like suffocating when fighting machine
TV determined based on pts weight; can change if weaning method
Get certains breaths/min at preset TV guaranteed; can always overbreathe it
Coma - exactly what set at - not fight it
Breathing on own - fighting it - High pressure alarms if out of sync with it - give sedation to help not fight it
Preset minimum (guaranteed) respiratory rate and guaranteed tidal volume
Patient can initiate own respirations over the preset rate
Patient’s initiated respiration is delivered at the ventilator’s set tidal volume.
Clinical Application:
Volume Controlled: Primary mode of ventilation in spontaneously breathing patients with weak respiratory muscles
Continuous mandatory (volume or pressure) ventilation (CMV) - seen lot, also known as assist/control (AC) ventilation
Delivers gas at preset tidal volume or pressure (depending on selected cycling variable) and rate, while allowing the patient to breathe spontaneously; ventilator breaths are synchronized to the patient’s respiratory effort.
We set Preset (minimum) resp rate
Not have guaranteed TV anymore - pt determines own tidal volume
Pt’s initiated respirations are at the pt’s own tidal volume.
Clinical Application
Used as a weaning method (pop) - exercise diaphragm - 12-10 breaths/min to see if can do it; anything beyond 10 - initiate on own and get TV - if becoming hypoxic or CO2 goes up, not ready for weaning and move up rate
Weaning trial: 30 mins - ABG before and ABG after; chronic pt and using exercise diaphragm - 30 min; sometimes 1 hour, and sometimes until when go downhill; pay attention to how doing
ETT/trach still in - push buttons on vents to change settings
Primary mode of ventilation: Used in patients with decreased lung compliance or increased airway resistance when the need to preserve the patient’s spontaneous efforts is important
Weaning mode: Used in weaning trials to determine if pt’s have sufficient tidal volume and are able to initiate their own respirations at a rate compatible with life.
Intermittent mandatory (volume or pressure) ventilation (IMV), also known as synchronous intermittent mandatory ventilation (SIMV)
ETT/trach necessary
All about + pressure - occlussive mask with the BiPAP
All other work on the pt - initiate every breath on own and TV - everything on own
Cannot be deeply sedated - can be on precedex - need own respiratory drive
Mode of positive pressure mechanical ventilation in which the patient triggers every breath.
Deliverable with invasive (through an endotracheal tube) or non-invasive (via full face or nasal mask) mechanical ventilation.
Preset positive pressure used to augment the patient’s inspiratory efforts
Patient controls rate, inspiratory flow, and tidal volume.
Clinical Application
Primary mode of ventilation: Spontaneous breathing mode in patients with a stable respiratory drive to overcome any imposed mechanical resistance (e.g., artificial airway)
Can be used with IMV to support spontaneous breaths
Weaning mode: Used in weaning trials to facilitate achieving a spontaneous tidal volume by augmenting the patient’s spontaneous breaths with a positive pressure boost during inspiration; weaning mode option
Pressure Support Ventilation (PSV)
Respiratory Rate: Number of breaths the ventilator delivers per minute
Tidal volume (Vt): Volume of gas delivered to a patient during each ventilator breath.
Fraction of inspired oxygen (FIO2):
I:E ratio:
PEEP:
Ventilator settings - the basics
Typical Settings: 6-20 breaths/min
Weaning - lower rates
Respiratory Rate: Number of breaths the ventilator delivers per minute
Typical Settings: 400-500 mL
Smaller person - smaller
Larger person - larger
Tidal volume (Vt): Volume of gas delivered to a patient during each ventilator breath.
Oxygen concentration delivered to the patient; % of oxygen; 21% is room air
Typical Settings: May be set between 21% and 100%; adjusted to maintain PaO2 level >60 mm Hg or SpO2 level >92%
Going up on FiO2 to keep SpO2 - getting sicker - change mode or add PEEP
Fraction of inspired oxygen (FIO2):
Ratio of the duration of inspiration to the duration of expiration
Is present
Can set
Ventilator settings that are inverse
Breathing in shorter than exhaling
Setting where inverse
Typical Settings: 1:2 to 1:1.5 unless inverse ratio ventilation is desired
I:E ratio:
NOT A VENTILATOR SETTING
IS AN ADD ON TO THE VENTILATOR
FRIES TO THE HAMBURGER
INTUBATOR WITH CMV WITH PEEP
Not a ventilator setting
Positive pressure applied at end of expiration of ventilator breaths
This is the pressure that remains in the alveoli at the end of expiration.
End expiratiration pressure: alveoli not collapse; if alveoli collapsed encourages to open; collapsed alveoli does not exchange oxygen/CO2 - collapsed alveoli = dead space = not good
Assists in keeping the alveoli open (improves oxygenation)
NOT a mode of mechanical ventilation
Added to other modes of ventilation
Typical Settings: 3–5 cm H2O. Can go higher with sicker pts - FiO2 increases with PEEP
Conditions seen PEEP in:
ARDS
Even though on rotation beds and on vents - get atelectasis - esp if at end of life and on vent - not turn q2hrs because not hemodynamically stable - creep up on PEEP
PEEP:
Nursing actively participates in
Considering extubation - going in and out with tube - can cause damage and swelling; not pull ETT out unless fairly certain will stay out
Pts better; FiO2 down; PEEP not present; Sats good; ABG normal - time get off
Longer on vent harder get extubated
Weaning is the withdrawal of the mechanical ventilator and the reestablishment of spontaneous breathing.
Weaning trial
Weaning trial methods
Nursing management
Weaning from the ventilator
The original process for which ventilator support was required has been corrected and patient stability has been achieved.
Consider the length of time on the ventilator, sleep deprivation, and nutritional status.
Screened every day for readiness
Major factors that affect the patient’s ability to wean
Weaning is the withdrawal of the mechanical ventilator and the reestablishment of spontaneous breathing.
Assess ABG’s - eval oxygenation and ventilation
LOC - awake, alert, oriented to begin own resp drive
Secretions - under control; before extubate suction deep and shallow one more time
Vital signs - stable
Screened every day for readiness
The ability of the lungs to participate in ventilation and respiration
Cardiovascular performance
Psychological readiness
Major factors that affect the patient’s ability to wean
Clinical manifestations of a failed weaning trial.
The patient doesn’t have to exhibit all symptoms.
Box 20.5: weaning intolerance indicators
The patient is positioned upright to facilitate breathing and suctioned to ensure airway patency. - diaphragm needs to drop; sitting up more likely to stay awake
The process is explained to the patient, and the patient is offered reassurance and diversional activities. - tell what going to happen and when; is anxiety producing because concerned if fail
The patient is assessed immediately before the start of the trial and frequently during the weaning period for signs of weaning intolerance
ABGs are drawn before and ~30 minutes after the trial begins.
Methods
Weaning trial
Decrease in LOC
Systolic BP increased/decreased by 20 mmHg
Diastolic BP greater than 100 mmHg
Heart rate increased by 20 bpm
Premature ventricular contractions greater than 6/min, couplets, or runs of ventricular tachycardia
Changes in ST segment (usually elevation)
RR > 30 breaths/min or <10 breaths/min
RR increased by 10 breaths/min
Spontaneous tidal volume less than 250 mL
PaCO2 increased by 5-8 mmHg and/or pH less than 7.30
SpO2 <90%
Use of accessory muscles to breathe
Complains of dyspnea, fatigue, or pain
Paradoxical chest wall motion/chest abdominal asynchrony
Diaphoresis
Severe agitation/anxiety unrelieved by reassurance
Box 20.5: weaning intolerance indicators
IMV (SIMV)
Pressure Support
CPAP - on vent can change it to CPAP; mode of weaning; not mode of ventilation
Spontaneous breathing trials (T-tube, T-piece)
Take off vent one side to wall to normal oxygen and breathing on own with humidified oxygen but on other side hooked to ventilator
Methods
Synchronized intermittent mandatory ventilation (IMV or SIMV) trial
Pressure Support Ventilation Trial
Spontaneous Breathing Trial
CPAP
Weaning trial methods
The number of mechanical breaths are progressively decreased.
Usually, one to three breaths at a time, until a rate of zero or near-zero is reached
If pressure support is concomitantly used, it should be reduced.
PaCO2 and respiration rate are monitored (PaCO2 < 45 and RR WDL)
Allows pt. to slowly take over spontaneous ventilation.
Synchronized intermittent mandatory ventilation (IMV or SIMV) trial
PSV augments the patient’s spontaneous breaths with a positive pressure boost during inspiration.
Pressure support is gradually decreased in increments of 3 to 6 cm H2O
Tidal volume is maintained at 10 to 15 mL/kg until a level of 5 cm H2O is achieved.
Pressure Support Ventilation Trial
Ventilator is turned off. Pt. is placed on a T-Piece
The pt. initiates breaths and tidal volume.
The ventilator can be left on with CPAP to prevent atelectasis.
Pass trial on T-tube stay extubated because equivalant of nasal cannula
Spontaneous Breathing Trial
Low levels of CPAP (5 cm H2O) while the patient breathes spontaneously
PaCO2 and respiratory effort are monitored for s/s fatigue.
Continuous positive pressure
Not high pressures
Little support
CPAP
Patient Assessment: Focused pulmonary assessment
Symptom management: Manage anxiety, pain, SOA, Confusion, and agitation.
Maintain adequate sedation - lwo enough to where not fighting/out of sync with vent but not too low where so low where lose reflexes
Sedation Vacation - imp to do
Ventilator Assessment
Nursing management
Lung: Respiratory rate, effort, secretions
ABG’s - oxygenation and ventilation
Pulse Ox and EtCO2
Subcutaneous emphysema - barotrauma - crepitus underneath skin
ETT/trach placement - record where it is at
Patient Assessment: Focused pulmonary assessment
Assess tubing location and for kinks, leaks, water, mucous
Assess vent settings – compare to orders - match
Review alarms
Ventilator Assessment
CPAP
T-tube
Pressure support
The nurse is caring for a patient who is scheduled to start a weaning trial.
Assessment prior to weaning
Continuous IV sedation is off
Neuro: Awake, alert & oriented x 4. - YES
Vital signs: BP 118/78; HR 76; RR 17; SpO2 95% - YES
Lungs are clear after deep suctioning - YES
ABG: pH 7.41 PCO2: 38 HCO3: 23 PaO2: 85
Interpret this ABG
Normal
EtCO2: 35 - YES
30-43
The ventilator mode is changed from CMV to IMV.
What other mode(s) could we use for weaning?
Yes they are for weaning
Guaranteed 6 breaths but not guaranteed TV - can breathe faster and hope do but 6 guaranteed
Not mess with TV because calculation
If issue - bump FiO2 up but also increase RR
IMV Ventilator settings: FIO2 35%; TV 550 ml; rate 6 breaths/min.
Are these settings normal?
No
HR 110; RR 34; SpO2 89%
EtCO2: 48
Neuro: Drowsy and Oriented to person, place, and time
IMV Ventilator settings: FIO2 35%; TV 550 ml; rate 6 breaths/min.
Assessment:
Neuro: Drowsy and Oriented to person, place, and time. - CHANGED; ABNORMAL; BAD
Vital signs: BP 118/78; HR 110; RR 34; SpO2 89% - CHANGED; HR, RR, SpO2; EVERYTHING BUT BP CONCERNING - COMPENSATORY MECHANISMS FOR HYPOXIC STATE - FAILING TRIAL
30 minutes into the weaning trial an ABG is drawn and resulted.
ABG: pH 7.29; PaCO2 47 mm Hg; HCO3 22 mEq/L; PaO2 77 mm Hg.
Interpret this ABG
Uncompensated respiratory acidosis
Not breathing it off
EtCO2: 48
Increased and higher than supposed to be
Retaining CO2 because not breathing enough to blow it off
Is this an expected finding? What signs and symptoms would this patient have to match the ABG?
Increase FiO2 and RR (first this)
Do not mess with the TV - overinflate - cause pneumothorax
What adjustment should the nurse anticipate?
Related to shuttling air in and out
Low pressure alarm
High-pressure alarm
Ventilator pressure alarms
Altered settings
Unattached tubing or leak around ETT
ETT displaced into the pharynx or esophagus
Poor cuff inflation or leak
To easy to shuttle air in and out - disconnected usually
Tweaking balloon inflation - pop balloon/cuff
TV too low
Tracheoesophageal fistula
Pneumo
Easy
Low VT
Decreased airway resistance (barotrauma, pneumothorax) - normal and PEEP at 20
Usually cuff or disconnected
Low pressure alarm
Improper alarm setting
Something affecting tubing where makes smaller
Mucous plug
Trying to talk
Bite on tube
Harder to push air in
Smaller airway
Airway obstruction resulting from the patient fighting ventilator (holding breath as the ventilator delivers VT, biting the ET tube)
Kinked tubing
ETT in right mainstem bronchus or against carina
Increased airway resistance (bronchospasm, airway secretions, plugs, coughing, patient trying to speak. . .)
Water from humidifier in ventilator tubing
Decreased lung compliance (tension pneumothorax, change in patient position, ARDS, pulmonary edema, atelectasis, pneumonia, or abdominal distention)
Diameter small for some reason
High-pressure alarm
Treat the Patient – not the machine - assess pt after an alarm to see if stable
Ventilatory Care is Supportive Care – not a cure - body time to recover
Ventilator delivers oxygen to the lungs – gas exchange must occur within the alveoli
It is called a ventilator, not a respirator
If the machine malfunctions take the patient off the ventilator and ventilate them by hand (bag them) – do not leave them
Points to remember
Pulmonary disorders
Ability to ventilate
Intrapulmonary shunting (chapter 18): The amount of blood that flows to the lungs without being oxygenated because of nonfunctioning alveoli.
PaO2/FIO2 Ratio also known as P/F ratio (chapter 18)
Pulmonary disorders
Something going on in lungs
Not getting on RBC to circ lungs - enough O2; ventilation is not happen
Nothing wrong with upper airway/RR or oxygenation; at the lower level
Alveolar collapse secondary to atelectasis - most common
Alveolar flooding with pus, blood, or fluid - smushes lung out of way and affects ability of ventilation
Intrapulmonary shunting (chapter 18): The amount of blood that flows to the lungs without being oxygenated because of nonfunctioning alveoli.
Measurement of the efficiency of oxygenation
Measurement of intrapulmonary shunting
Oxygenation and ventilation ratio
Normal: greater than 286
The lower the value, the worse the lung function
PaO2/FIO2 Ratio also known as P/F ratio (chapter 18)
(ALF): A clinical condition in which the pulmonary system fails to maintain adequate gas exchange.
Common that requires intubation and mechanical ventilation
Causes pulm sys to fail
Come in with sys that then results in this
Usually occurs secondary to another disorder that has altered the normal function of the pulmonary system.
Conditions that decrease: ventilatory drive - oversedated them with versed and fentanyl, muscle strength - diaphragm (GBS), chest wall elasticity, the lung’s capacity for gas exchange,
Conditions that increase: airway resistance, metabolic oxygen requirements
Clinical manifestations: Hypoxemia (PaO2), hypercapnia (PaCO2), and acidosis
Medical management
Nursing management
Acute lung failure
Treat the underlying cause - focus: improve oxygenation - treat hypoxemia; know if intrapulmonary shunting or in care of someone who cannot care for them and have atelectasis, treat that
Promote adequate gas exchange
Supplemental oxygen
an intrapulmonary shunt is present, pt. will require positive pressure
Explain why supplemental oxygen may not be sufficient to address hypoxia.
Not ventilating - alveoli collapsed
Oxygenation diff than ventilation
Correct issue that causing ventilation issue - atelectasis, GBS, resp drive too low because taking pain control meds for chronic pain - take off narcotic until pain decreases - not all narcotics reversed via narcan
Does the pt. require a mechanical ventilator for positive pressure oxygen?
No - BiPAP
Correct acidosis
Initiate nutrition support
Prevent complications (i.e., ischemic-anoxic encephalopathy, cardiac dysrhythmias, VTE, and gastrointestinal bleeding).
Medical management - Acute lung failure
Optimize oxygenation and ventilation
Position
Head is up
Healthy lung down
Repositioning q2hours - prone to recruit to alveolar on back - prevent atelectasis
Elevate HOB at least 30 degrees or however much tolerate
Prevent desaturation
Perform only necessary procedures - not eligible for clustering care; let rest and recover before next thing do
Hyperoxygenate before suctioning - sick and need oxygenation for ventilation to give best chance to tolerate it
Provide adequate rest and recovery time between procedures - one pass on suction before do something else and give breaks
Minimize oxygen consumption: Limit pt. physical activity, administer sedation to control anxiety and maintain normothermia - takes energy; assess pt if appropriate; awake: stop touching them, turn off TV
Promote secretions clearance
Mucomist - medications
Humidity on - secretions more viscous so not plug up = take deep breath to get alarm off
Awake and laert - turn, cough, deep breathe
Suction
Maintain surveillance for complications
VTE - SCDs
Educate the patient and family
Esp if chronic pulm issue - takes quite bit edu that is diff and why not doing norm regimen at home
Nursing management - Acute lung failure
Sicker
Pulmonary edema - all in the lungs that not related to cardiac - looks same on CXR, end result same; norm CO; pulm edema - all about the alveoli
Alveoli not working and edematous - O2 not across membrane to be transported to rest of the body
Can have pulm edema with CO
ARDS is characterized by noncardiac pulmonary edema and disruption of the alveolar-capillary membrane as a result of injury to the pulmonary vasculature or the airways.
CM
Medical management
Nursing management
Acute respiratory distress syndrome
The hallmark of ARDS is refractory hypoxemia (low level of O2 in the blood)
Timing: Within 1 week of known clinical insult or new or worsening respiratory symptoms
Chest imaging: Bilateral opacities not fully explained by effusions, lobar/lung collapse, or nodules; not dense so blacked out; patchy/white/grayed out on CXR
Origin of edema: Respiratory failure not fully explained by heart failure or fluid overload; objective assessment needed to exclude hydrostatic edema if no risk factor present
P/F ratio low because - ventilation is not happening
Low: think ARDS
Options: increase PEEP; tummy time - on stomach - recruits all alveoli on posterior surface of lung - make sure not something pulled out
Oxygenation:
Mild: P/F ratio: 200 – 300 mm Hg with PEEP or CPAP ≥ 5 cm H2O
Moderate P/F ratio: 100 – 200 mm Hg with PEEP ≥ 5 cm H2O
Ratio low - more and more oxygenation to get ventilation to happen - should not take more and more to get normal to happen - add PEEP to open up alveoli spaces and squish edema out of the way - not cure for pulmonary edema to force it through but to force it through; pulm edema roadblock and keeping O2 in lung and not crossing membrane
Extra pressure with PEEP helps ventilation
Low because ventilation not happening
Severe: P/F ratio: less than 100 mm Hg with PEEP ≥ 5 cm H2O
ARDS is characterized by noncardiac pulmonary edema and disruption of the alveolar-capillary membrane as a result of injury to the pulmonary vasculature or the airways. - Acute respiratory distress syndrome
Respiratory distress
tachypnea, restlessness, apprehension, and moderate increase in accessory muscle use.
Fibroproliferative phase:
CM - Acute respiratory distress syndrome
The patient’s signs and symptoms progress to agitation, dyspnea, fatigue, excessive accessory muscle use, and fine crackles as respiratory failure develops
s&s more profound - really struggling
Agitated and irritable because not oxygenating
As pulm edema worse - sound worse
Hear crackles
Hypoxemia and hypercarbia
Same s&s of resp distress
Destruction of type II alveolar cells
Gas exchange compromised
Increased peak inspiratory pressure
Decreased compliance (static and dynamic)
Refractory hypoxemia)
Intraalveolar altelectasis
Increased shunt fraction
Decreased diffusion
Decreased functional residual capacity
Interstitial fibrosis
Increased dead space ventilation
Pulomonary artery pressures: elevated
Increased workload on RV
Increased use of accessory muscles
Fine crackles
Increasing agitation related to hypoxia
CSR: intersititial/alveolar infiltrates; elevated diaphragm
Hyperventilation; hypercarbia
Decreased SVO2
Widening alveolar-arterial gradient
Increased work of breathing
Worsening of hypercarbia and hypoxemia
Lactic acidosis (r/t aerobia metabolism)
Alteration in perfusion:
Increased HR
Decreased BP
Change in skin temp and color
Decrease cap fill
Fibroproliferative phase:
Treat the underlying cause
Promote gas exchange
Ventilation: Mechanical Ventilator - need higher pressures; intubated and sedated
Oxygen therapy
High doses of O2 can cause harm - Nitrogen wash out, O2 toxicity can result - goal: want lowest level O2 - can add nitric oxide to it
Administered at the lowest level possible to support tissue oxygenation
PEEP >5 mmHg - get best response at lowest PEEP - force alveoli space open - only have so much pressure before it pops - then issue of pneumothorax
What is the purpose of adding PEEP to the ventilator settings?
Keep alveoli from collapsing
Get alveoli space open
Every oxygen exchange possible
Could require ECMO (extracorporeal membrane oxygenation)
Not have adequate oxygenation and ventilation - this done outside the lungs
Tissue Perfusion: End organ perfusion
Most of these pts in ARDS but lot other organs start fail rapidly because not oxygenated; not on RBC - acute renal failure; liver enzymes increase; sedated: brain - anoxic brain injury OR if awake - irritable and confused; end organ perfusion: where O2 and ventilation gets off RBC; STEMIs based on oxygenation status and supply and demand
Renal failure - no blood flow
Do more than focused assessment if in ARDS - head to toe to look for organ failure
Not stable for sedation vacation - just to cranial nerves
Prevent complications
Medical management - Acute respiratory distress syndrome
Optimize oxygenation and ventilation
Position, Prevent desaturation, promote secretion clearance – same as ALF
First 2 mins often desat and hope goes back up
Prone the patient
How do we prone the patient?
Same with ALF
Go on tummy and raise head
Why do we prone an ARDS patient?
Recruit posterior alveoli
Provide comfort and emotional support
Maintain surveillance for complications
End organ perfusion
VTE
UTI
VAP
Liver failure
Nursing management - Acute respiratory distress syndrome
An acute inflammation of the lung parenchyma caused by an infectious agent that can lead to alveolar consolidation and can be classified as community acquired or hospital acquired. Characterized by dyspnea, fever, and cough (productive or nonproductive)
Medical management
Nursing actions
Pneumonia
Focuses on the initiation of antibiotic therapy - within 2 hours of dx; start before do abx; mechanical ventilation - not oxygenating or ventilating well with lot lobes (EX: ⅗ lobes) not oxygenating well and affected by the infection
Administer oxygen
Mechanical ventilation
management of fluids and nutrition support
Treat complications
Medical management - Pneumonia
Optimize oxygenation and ventilation
Prevent the spread of infection
Provide comfort and emotional support
Maintain surveillance for complications
Do orders as written
Nursing actions - Pneumonia
ARDS
P/F ratio makes this ARDS
A patient is in the ICU after a near drowning accident 4 days ago. They are placed on a mechanical ventilator: CMV: Rate 14 Tidal Volume 550 mL FIO2 55% PEEP 4 cm H2O. Vital signs: 91/50 RR 18 HR 110 SpO2: 88%. P/F Ratio 130. - should be 286
Assessment: Pt is sedated but wakes agitated during sedation vacation. CV: S1, S2, no advantageous heart tones. Resp: Lungs are diminished with fine crackles throughout.
ABG: pH: 7.28 PaCO2: 50 HCO3: 26 PaO2 70
What is this ABG interpretation?
Uncompensated respiratory acidosis
How would you change this ABG to make it partially compensated?
HCO3 would change to be abnormal
Compensated?
pH would be normal
HCO3 and PaCO2 would be abnormal
What do you suspect is going on?
Intubate
PEEP needs be on there
Scheduled - tummy time/proning
Suctioning imp
ARDS will always have proning and PEEP
What interventions should the nurse prepare for?
End organ perfusion - monitor labs - monitor urine output - acute renal failure/heart issues
Kidney: BUN and Cr
Liver: ALT and AST
What complications should the nurse assess for?
