T2: Airway and O2 Mgmt (2) Flashcards
6 complications of artificial airway:
1) tube OBSTRUCTION
2) tube DISPLACEMENT
3) SINUSITIS, nasal injury
4) tracheoesophageal FISTULA
5) mucosal LESIONS
6) laryngeal or tracheal STENOSIS
How can we look for signs of laryngeal stenosis after extubating a pt?
listen for hoarseness or stridor;
stridor is serious - call MD
What 2 additional complications do we see with trachs?
- tracheoinnominate artery fistual
- subcutaneous emphysema
Why is a tracheoinnominate artery fistual so dangerous?
the pt could bleed out…there’s nowhere to apply pressure
What 6 steps are taken to extubate?
1) Hyperoxygenate pt
2) Suction ET and oral cavity
3) Deflate ET cuff
4) Remove tube at peak inspiration
5) Instruct pt to cough
6) Monitor every 5 min for respiratory distress
What is a surgical incision into trachea for purpose of establishing an airway?
tracheotomy
What is a stoma (opening) that results from tracheotomy and is more comfortable for the pt?
tracheostomy
Remember: stoma sounds like tracheoSTOMY
5 priority pt problems with artificial airway:
(Remember: M-COIN)
- damaged oral MUCOSA
- inadequate COMMUNICATION
- reduced OXYGENATION
- potential for INFECTION
- inadequate NUTRITION
Other possible complications of an artificial airway:
- pneumothorax
- subcutaneous emphysema
- bleeding
- infection!!!
5 ways to prevent tissue damage with trach:
1) Use minimal leak and occlusive techniques
2) Check cuff pressure often
3) Prevent tube friction and movement
4) Prevent/treat malnutrition, hemodynamic instability, hypoxia
Why do we need to warm, humidify, and filter trach air?
tracheostomy tube bypasses nose and mouth which normally does those things
Why do we need to ensure adequate hydration with trachs?
To keep secretions thin
Common causes of hypoxia in the trach:
- ineffective oxygenation when suctioning
- catheter too large
- suctioning too long
- excessive suction pressure
- suctioning too frequently
T/F: Tracheostomy tube and nutrition: most pts get nutrition through a G-tube or NG tube
True
How long do we elevate the HOB after eating with a trach? Why?
at least 30 min
Prevent aspiration during swallowing
Bronchial and Oral Hygiene: Reposition pt every ___ to ___ hrs
1 to 2 hrs
Bronchial and Oral Hygiene: Ways to break up mucus and promote drainage
- coughing and deep breathing
- chest percussion and vibration
- postural drainage
How do we wean someone from a tracheostomy tube?
- change to uncuffed tube
- gradually decrease the tube size
- trach button has potential for dislodging
When is the cuff deflated?
when pt can manage secretions and does not need assisted ventilation
What are the 2 types of ventilators?
- negative-pressure
- positive-pressure
What are the 3 versions of POSITIVE-pressure vents?
- pressure-cycled
- time-cycled
- volume-cycled
There are 3 main MODES of ventilation:
- AC (Assist-Control Ventilation)
- SIMV (Synchronized Intermittant Mandatory Ventilation)
- BiPAP (Bi-level Positive Airway Pressure)
What are the ventilator CONTROL and SETTINGS?
- Vt (Tidal Volume)
- Rate (breaths per min)
- FiO2 (fraction of inspired O2)
- PIP
- CPAP
- PEEP
- Flow rate
What are 4 indications for mechanical ventilation?
- acute impending ventilatory failure
- refractory hypoxemia
- secretion/airway control
- apnea/respiratory arrest
Automatic mechanical device designed to provide all or part of the work the body must produce to move gas into and out of the lungs:
ventilator (the machine itself)
Ventilator delivers gas through a set of tubes connected to an airway either an ETT or trach tube:
Circuit (tubes that connect vent to pt)
Which mode of ventilation delivers a preset number of breaths at preset tidal volume?
AC (assist control) or CMV (continuous mandatory ventilation)
AC or CMV: If pt ____ a breath, machine delivers presest ____ ____ for every breath. (This means the machine takes over after ____ of each breath.)
initiates
tidal volume
initiation
Which mode of ventilation delivers a preset Vt using the lowest possible airway pressure? Airway will not exceed preset maximum pressure limit. (to protect the lungs by not forcing air)
PRVC (pressure-regulated volume control)
What types of pts are put on a vent with the PRVC setting?
those with airway resistance or decreased lung compliance such as ARDS
Which mode of ventilation has preset inspiratory and expiratory pressure?
BiPAP (bi-level positive airway pressure)
What are the 2 levels of expiratory pressure used in BiPAP?
PEEP high
PEEP low
Which mode of ventilation delivers a preset number of breaths at preset tidal volume? (If pt initiates breath, machine allows pt to breathe in own Vt.)
SIMV (synchronous intermittent mandatory ventilation)
Which mode of ventilation provides a slow weaning process as the pt relearns to breath on his own?
SIMV
Which mode of ventilation delivers constant positive pressure?
CPAP (continuous positive airway pressure)
What is “pressure support”?
- set pressure delivered upon initiation of breath
- augments pt’s own Vt by assisting movement of air through vent tubing
When does “pressure support” kick in?
at the BEGINNING of INSPIRATION
What does PEEP stand for?
Positive end expiratory pressure
What is PEEP?
Positive airway pressure applied at END of EXPIRATION.
- Keeps alveoli open
- Faciliates O2 transport
What is tidal volume (Vt)?
Amount of air it takes to inflate the lungs with each breath
How much air does it take to inflate the lungs (Vt)?
~ 10-15 ml/kg
What is minute ventilation?
amount of gas moved in or out of lungs PER MINUTE
What is the formula for minute volume?
MV = RR x Vt
What is the normal minute volume?
5 - 8 L/min
What is I:E ratio?
Inspiration to expiration ratio (this is the number on the screen that changes from breath to breath)
What is the normal I:E ratio to start with?
1:2
What is the normal I:E ratio for people with COPD? What do you want to prevent with COPD regarding I:E ratio?
1:4
breath stacking
What is PIP (peak inspiratory pressure)?
amount of pressure it takes for vent to deliver Vt or breath
What is the #1 reason for increased PIP?
mucous in the tube
What are reasons PIP will be increased?
- mucous in tube!!!
- biting (needs more sedation)
- pneumothorax
- developing ARDS
- tube is dislodged
What is FiO2 (fracture of inspired O2)?
percent or fraction of oxygen delivered by the vent
What are the nurse’s jobs with a vent?
(Remember: ARM-P)
- ASSESS…pt 1st, vent 2nd
- Monitor pt RESPONSE
- MANAGE vent system
- PREVENT complications
Troubleshooting Alarms:
“High Pressure Limit”
- circuit tubing kinked
- water collecting in dependent tubing
- fighting vent (“breath stacking”)
- airway secretions, coughing
- ETT in right mainstem bronchus (in too far)
- decreased lung compliance
Troubleshooting Alarms:
“Low Pressure Limit”
- tubing disconnected
- circuit leak
- cuff deflated
Troubleshooting Alarms:
“Low Exhaled Vt”
- leak in the system
- cuff not inflated enough
- leak through chest tube
Troubleshooting Alarms:
“Temperature”
- sensor malfunction
- sensor picking up outside airflow
Troubleshooting Alarms:
“Apnea”
- sedation
- neurologic
- metabolic
Troubleshooting Alarms:
“High Respiratory Rate”
- not tolerating weaning
- neurogenic/metabolic
- anxiety
- pain
Troubleshooting Alarms:
“Mechanical Ventilator Failure”
- check electrical outlet (plug in red outlet)
- needs replacement
What can cause ventilator induced lung injury?
(Remember: VABB…Ventilators Are Bad for Bodies)
- Volutrauma
- Atelectrauma
- Biotrauma
- Barotrauma
Excessive PRESSURE in the alveoli:
BAROTRAUMA
Excessive VOLUME in the alveoli:
VOLUTRAUMA
Shearing due to repeated opening and closing of the alveoli:
ATELECTRAUMA
Inflammatory immune response:
BIOTRAUMA
How do we prevent ventilator induced lung injury?
- plateau pressure kept less than 32 cm H2O
- use PEEP!!!
- TV set at 6-10 ml/kg
Complications of vents:
- ventilator induced lung injury
- CV compromise
- GI disturbance
- Oxygen toxicity
What can cause CV compromise with vents?
Increased intrathoracic pressure
What does increased intrathoracic pressure lead to?
decreased venous return, decreased preload, decreased CO and BP
How does the heart compensate when CO and BP are low?
tachycardia
What additional things can happen regarding CV compromise related to vents?
- hepatic and renal dysfuction
- impairment of cerebral venous return, increased ICP
What GI disturbances can occur with vent usage?
- gastric distention
- hypomotility
- constipation
What can occur if PEEP is set too high?
pneumothorax
Nosocomial pneumonias…the primary risk factor is ____ ____.
mechanical ventilation
Ventilator Associated Pneumonia Prevention:
What is the critical time frame?
First 24 hours
Ventilator Associated Pneumonia Prevention:
Head of bed elevated ___ to ___ degrees.
30 to 45 degrees
How often should oral care be performed on pts on a vent?
Q2hr swab with normal wash and
Q12 hr brush with chlorhexidine
