Pulmonary Therapeutic Management Flashcards by Kelsey Klipfel

Basics: pH, PaO2, PaCO2, HCO3 - pic oxygenation and ventilation
Measurement of oxygenation
Measurement of ventilation (acid-base disorder)
Hypoxemia – inadequate blood O2:

ABG Overview

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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

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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)

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mild (PaO2 60-79)
moderate (PaO2 40-59)
severe (PaO2 less than 40)

Hypoxemia – inadequate blood O2:

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Metabolic acidosis or partially compensated metabolic acidosis

DKA

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Metabolic alkalosis - Tums and antacids are basics

Chronic indigestion and uses antacids daily

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Respiratory acidosis; not usually in a compensated state

Narcotic overdose

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Metabolic acidosis

Renal failure

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Metabolic alkalosis

Long term nasogastric suctioning

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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

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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

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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

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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

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Endotracheal Tube (ETT):
Tracheostomy tube:
Nursing management
Interventions

Artificial airways

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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):

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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

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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

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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:

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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

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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

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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

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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?

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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:

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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:

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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?