Week 2 - Respiratory, ABGs Flashcards
Acute Respiratory Failure Overview
Occurs when oxygenation, ventilation, or both are ___________
- Insufficient O2 transferred to blood
- ___________
- Decreased PaO2 and SaO2
- Inadequate CO2 removal
- ___________
- Increased PaCO2
- ABGs assess pH, PaO2, PaCO2, bicarbonate, SaO2
- Pulse oximetry assesses arterial O2 saturation(SpO2)
Occurs when oxygenation, ventilation, or both are inadequate
- Insufficient O2 transferred to blood
- Hypoxemia
- Decreased PaO2 and SaO2
- Inadequate CO2 removal
- Hypercapnia
- Increased PaCO2
- ABGs assess pH, PaO2, PaCO2, bicarbonate, SaO2
- Pulse oximetry assesses arterial O2 saturation(SpO2)
Hypoxemic (Oxygenation) or Hypercapnic (Ventilatory)
Hypoxemic
PaO2 is less than or equal to 60 mm Hg on 60% or more oxygen
Hypercapnic
PaCO2 is over 50 mm hg and pH is under 7.35
Common Causes of ARF
Hypoxemic:
* ARDS
* Asthma
* Chronic Bronchitis
* Pulmonary Edema
* Emphysema
* Pneumonia
* PE
* Pneumothorax
Hypercapnic:
* ARDS
* Asthma
* Chronic Bronchitis
* Pulmonary Edema
* Emphysema
* COPD
* Cystic Fibrosis
* Hypoventilation syndrome
* Brainstem injury
* Guillain-Barre Syndrome
* Muscular dystrophy
Hypoxemic:
* ARDS
* Asthma
* Chronic Bronchitis
* Pulmonary Edema
* Emphysema
* Pneumonia
* PE
* Pneumothorax
Hypercapnic:
* ARDS
* Asthma
* Chronic Bronchitis
* Pulmonary Edema
* Emphysema
* COPD
* Cystic Fibrosis
* Hypoventilation syndrome
* Brainstem injury
* Guillain-Barre Syndrome
* Muscular dystrophy
Hypoxemic Resp. Failure
- Mismatch between Ventilation (V) and perfusion (Q)
—. V/Q mismatch - Shunt
- Diffusion limitation
- Alveolar hypoventilation
- Mismatch between Ventilation (V) and perfusion (Q)
—. V/Q mismatch - Shunt
- Diffusion limitation
- Alveolar hypoventilation
pH – the measure of ________ balance found in arterial blood
______ - _______
pH – the measure of acid/base balance found in arterial blood
7.35 – 7.45
PaO2 – the partial pressure of O2 found in _______________
_____ - _______ mmHg
PaO2 – the partial pressure of O2 found in arterial blood
80 – 100 mmHg
PaCO2 – the partial pressure of CO2 found in arterial blood
_____ - _____ mmHg
PaCO2 – the partial pressure of CO2 found in arterial blood
35 – 45 mmHg
HCO3 – the measure of __________ found in arterial blood (buffer that helps balance pH)
_____ - _____ MeQ/L
HCO3 – the measure of bicarbonate found in arterial blood (buffer that helps balance pH)
22-26 MeQ/L
SaO2 – O2 saturation in the arterial blood _______ %
95-100
SpO2 – O2 saturation in the peripheral capillaries; estimate of the amount of O2 that is bound to Hbg in the blood versus the total amount of Hbg _______%
95-100
Hypoxemic Respiratory Failure
Etiology and Pathophysiology
Diffusion Impairment
* Gas exchange across alveolarcapillary membrane is compromised by a process that destroys the alveolar membrane or affects blood flow through the pulmonary capillaries
Alveolar-capillary membrane is thicker (fibrotic) and slows gas exchange
Pulmonary fibrosis, interstitial lung disease, ARDS
Pulmonary edema – accumulation of fluid, WBCs or protein in alveoli
Diffusion Impairment
* Gas exchange across alveolarcapillary membrane is compromised by a process that destroys the alveolar membrane or affects blood flow through the pulmonary capillaries
Alveolar-capillary membrane is thicker (fibrotic) and slows gas exchange
Pulmonary fibrosis, interstitial lung disease, ARDS
Pulmonary edema – accumulation of fluid, WBCs or protein in alveoli
Clinical Manifestations of Hypoxemia and Hypercapnia
Signs of respiratory failure are related to
A sudden decrease in PaO2 or rapid increase in PaCO 2 implies a serious condition or lifethreatening emergency
Signs of respiratory failure are related to Extent of changes in PaO2 or PaCO2
Speed of change (acute versus chronic)
Ability for compensation to occur
Failure of compensatory mechanisms leads to resp. failure
Signs of respiratory failure are related to
A sudden decrease in PaO2 or rapid increase in PaCO 2 implies a serious condition or lifethreatening emergency
Signs of respiratory failure are related to Extent of changes in PaO2 or PaCO2
Speed of change (acute versus chronic)
Ability for compensation to occur
Failure of compensatory mechanisms leads to resp. failure
Clinical Manifestations of Hypoxemia & Hypercapnia cont.
Lack of O2 affects all body systems
* Manifestations may be specific or nonspecific
* First sign of hypoxemic ARF is a change in ________________
Decreased O2
_________, _________, agitation
Increased CO2
morning headache, decreased RR, decreased LOC
- Early signs of ARF – tachycardia, tachypnea, pallor, mild increase in work of breathing (WOB)
Heart and lung compensation for decreased O2 and rising CO2 - Cyanosis is an unreliable indicator of hypoxemia
Clinical Manifestations of Hypoxemia & Hypercapnia cont.
Lack of O2 affects all body systems
* Manifestations may be specific or nonspecific
* First sign of hypoxemic ARF is a change in mental status
Decreased O2
restlessness, confusion, agitation
Increased CO2
morning headache, decreased RR, decreased LOC
- Early signs of ARF – tachycardia, tachypnea, pallor, mild increase in work of breathing (WOB)
Heart and lung compensation for decreased O2 and rising CO2 - Cyanosis is an unreliable indicator of hypoxemia
Hypoxemia and Hypercapnia
Observe
* Position: lie down, sit upright, or tripod
* Work of breathing (WOB); effort needed by respiratory muscles to inhale air into the
lungs
- Breathing patterns
_______, shallow (hypoxemia); monitor for fatigue
_____ RR (hypercapnia)
Change from rapid to slow RR indicating severe muscle fatigue and leading to respiratory arrest
Observe
* Position: lie down, sit upright, or tripod
* Work of breathing (WOB); effort needed by respiratory muscles to inhale air into the
lungs
- Breathing patterns
Rapid, shallow (hypoxemia); monitor for fatigue
Slow RR (hypercapnia)
Change from rapid to slow RR indicating severe muscle fatigue and leading to respiratory arrest
Hypoxemia and Hypercapnia
Observe
* Ability to speak
2 to 3 word _______
* _________ breathing
Increased expiratory time; prevents small bronchial collapse
* _________ of intercostal spaces or supraclavicular area; use of accessory muscles
* Paradoxical breathing
Abdomen and chest move outward with exhalation and inward with inhalation (opposite of normal)
May be diaphoretic from increased WOB
Observe
* Ability to speak
2 to 3 word dyspnea
* Pursed-lip breathing
Increased expiratory time; prevents small bronchial collapse
* Retraction of intercostal spaces or supraclavicular area; use of accessory muscles
* Paradoxical breathing
Abdomen and chest move outward with exhalation and inward with inhalation (opposite of normal)
May be diaphoretic from increased WOB
Hypoxemia and Hypercapnia S&S
Auscultate breath sounds
* Fine crackles: ________ edema
* Coarse crackles: ______ in airways
* Absent or diminished: atelectasis, pneumonia, or hypoventilation
* Bronchial: consolidation
* Pleural friction rub: ____________ involving pleura
Auscultate breath sounds
* Fine crackles: pulmonary edema
* Coarse crackles: fluid in airways
* Absent or diminished: atelectasis, pneumonia, or hypoventilation
* Bronchial: consolidation
* Pleural friction rub: pneumonia involving pleura
Manifestations of Hypoxemia - Specific
- Respiratory: ________, tachypnea, prolonged expiration, nasal flaring, intercostal muscle retraction, use of accessory muscles, decreased SpO2 (less than 80%), paradoxic chest or abdominal wall movement with respiratory cycle (late), cyanosis (late)
- Respiratory: dyspnea, tachypnea, prolonged expiration, nasal flaring, intercostal muscle retraction, use of accessory muscles, decreased SpO2 (less than 80%), paradoxic chest or abdominal wall movement with respiratory cycle (late), cyanosis (late)
Manifestations of Hypoxemia - Nonspecific
- CNS: agitation; _________; disorientation; restless, combative behavior; delirium; decreased level of consciousness; coma (late)
- Cardiovascular: ___________; hypertension; skin cool, clammy, and diaphoretic; dysrhythmias (late); hypotension (late)
- Other: ________, inability to speak in complete sentences without pausing to breathe
- CNS: agitation; confusion; disorientation; restless, combative behavior; delirium; decreased level of consciousness; coma (late)
- Cardiovascular: tachycardia; hypertension; skin cool, clammy, and diaphoretic; dysrhythmias (late); hypotension (late)
- Other: fatigue, inability to speak in complete sentences without pausing to breathe
Manifestations of Hypercapnia - Specific
- Respiratory: ________, ________ position, pursed-lip breathing, __________ RR or rapid rate with shallow respirations, decreased tidal volume, decreased minute ventilation
- Respiratory: dyspnea, tripod position, pursed-lip breathing, decreased RR or rapid rate with shallow respirations, decreased tidal volume, decreased minute ventilation
Manifestations of Hypercapnia - Nonspecific
- CNS: morning __________, disorientation, confusion, progressive somnolence, increased intracranial pressure, coma (late)
- Cardiovascular: __________, HTN, dysrhythmias, bounding pulse
- Neuromuscular: muscle _________, decreased deep tendon reflexes, Tremors, seizures (late)
- CNS: morning headache, disorientation, confusion, progressive somnolence, increased intracranial pressure, coma (late)
- Cardiovascular: tachycardia, HTN, dysrhythmias, bounding pulse
- Neuromuscular: muscle weakness, decreased deep tendon reflexes, Tremors, seizures (late)
Nursing and Interprofessional Management: ARF
Management and care will vary; factors to consider:
Age
Severity of onset
Underlying comorbidities
Suspected or most likely cause
Acute care requires collaboration between nursing, physicians, respiratory therapists,
pharmacists, and others is essential
Management and care will vary; factors to consider:
Age
Severity of onset
Underlying comorbidities
Suspected or most likely cause
Acute care requires collaboration between nursing, physicians, respiratory therapists,
pharmacists, and others is essential
Mild to moderate ARF
* __________ O2
* Non-invasive ventilation (Bi-PAP) for patients who are awake, alert, able to maintain a patent airway, able to clear own secretions
Mild to moderate ARF
* High-flow O2
* Non-invasive ventilation (Bi-PAP) for patients who are awake, alert, able to maintain a patent airway, able to clear own secretions
Severe ARF - ICU care
_________ ventilation
Continuous pulse oximetry
_________ blood pressure (ABP) monitoring
Frequent ABGs
______________________ (CVP) monitoring
Advanced hemodynamic monitoring
Mechanical ventilation
Continuous pulse oximetry
Arterial blood pressure (ABP) monitoring
Frequent ABGs
Central venous pressure (CVP) monitoring
Advanced hemodynamic monitoring
Clinical Problems (ARF)
Impaired ___________ system function
Inadequate tissue _________
__________ imbalance
Impaired respiratory system function
Inadequate tissue perfusion
Acid-base imbalance
ARF - Overall goals
- Independently maintain a patent _______
- Absence of _______ or recovery to baseline breathing patterns
- Effectively _____ and able to clear secretions
- Normal ____ values or values within patient’s baseline
- _______ sounds within patient’s baseline
- Independently maintain a patent airway
- Absence of dyspnea or recovery to baseline breathing patterns
- Effectively cough and able to clear secretions
- Normal ABG values or values within patient’s baseline
- Breath sounds within patient’s baseline
ARF Prevention
- Thorough history and physical assessment to identify at-risk patients and initiate early ____________
Special attention to patients with neuromuscular, cardiac or respiratory problems
Deep __________ and coughing, incentive spirometry, early _________
- Frequent assessment of __________ patients
Prevent: atelectasis, pneumonia, complications of immobility, and optimize hydration and nutrition
- Thorough history and physical assessment to identify at-risk patients and initiate early interventions
Special attention to patients with neuromuscular, cardiac or respiratory problems
Deep breathing and coughing, incentive spirometry, early ambulation
- Frequent assessment of high-risk patients
Prevent: atelectasis, pneumonia, complications of immobility, and optimize hydration and nutrition
ARF - Implementation: Acute Care
Identify and treat ________ ______ of ARF
Continuous monitoring of patient response to therapy: changes in _________ status,
trends in ABG, signs of clinical improvement
Modifications may be indicated for patients with V/Q mismatch, shunting, diffusion impairment
Identify and treat underlying cause of ARF
Continuous monitoring of patient response to therapy: changes in respiratory status,
trends in ABG, signs of clinical improvement
Modifications may be indicated for patients with V/Q mismatch, shunting, diffusion impairment
ARF - Respiratory therapy
* Goals
Maintain adequate oxygenation and ________
Correct ________ imbalance
- Interventions
____ therapy
Mobilizing _____________
Positive pressure ventilation (PPV)
- Goals
Maintain adequate oxygenation and ventilation
Correct acid-base imbalance - Interventions
O2 therapy
Mobilizing secretions
Positive pressure ventilation (PPV)
Oxygen Therapy
Goal: correct _________
Apply O2 at ________ possible FiO2 to keep SpO2, PaO2 and SaO2 within patient-specific goals
Never withhold ________ from a hypoxic patient
Observe response and monitor for changes in ________ status, RR, and ABGs
Goal: correct hypoxemia
Apply O2 at lowest possible FiO2 to keep SpO2, PaO2 and SaO2 within patient-specific goals
Never withhold oxygen from a hypoxic patient
Observe response and monitor for changes in mental status, RR, and ABGs
Oxygen Therapy cont.
Delivery system
* Selected on patient’s overall condition, degree of respiratory failure, ability to maintain patent ________, amount of FIO2 the device delivers, patient’s ability to
_______ spontaneously
* Maintain PaO2 at 60 mm Hg or more and SaO2 at ____% or higher at lowest O2 concentration possible
Patient with hypoxemia is often agitated, disoriented, restless; ________ can worsen the problem
- Adjust approach, use of face mask accordingly
Delivery system
* Selected on patient’s overall condition, degree of respiratory failure, ability to maintain patent airway, amount of FIO2 the device delivers, patient’s ability to
breathe spontaneously
* Maintain PaO2 at 60 mm Hg or more and SaO2 at 90% or higher at lowest O2 concentration possible
Patient with hypoxemia is often agitated, disoriented, restless; anxiety can worsen the problem
- Adjust approach, use of face mask accordingly
Oxygen Therapy cont.
High FiO2 for prolonged periods can lead to adverse effects
* Oxygen ________ (greater than ____% O2 for longer than 48 hours); inflammation and cell death by disrupting the alveolar capillary membrane
* Absorption atelectasis; lack of nitrogen to help maintain size and shape of alveoli
* Increased pulmonary capillary permeability
* Decreased surfactant production or inactivation
* Fibrotic changes in the alveoli
High FiO2 for prolonged periods can lead to adverse effects
* Oxygen toxicity (greater than 60% O2 for longer than 48 hours); inflammation and cell death by disrupting the alveolarcapillary membrane
* Absorption atelectasis; lack of nitrogen to help maintain size and shape of alveoli
* Increased pulmonary capillary permeability
* Decreased surfactant production or inactivation
* Fibrotic changes in the alveoli
Oxygen Therapy cont.
Patients with chronic hypercapnia, (COPD)
* Blunts response of chemoreceptors to high CO2 levels as respiratory stimulant
* Provide O2 at ____ flow (nasal cannula at 1 to 2 L/min or Venturi mask at 24% to 28%)
* Consider __________ ventilation with higher FIO2 for inadequate response
Patients with chronic hypercapnia, (COPD)
* Blunts response of chemoreceptors to high CO2 levels as respiratory stimulant
* Provide O2 at low flow (nasal cannula at 1 to 2 L/min or Venturi mask at 24% to 28%)
* Consider mechanical ventilation with higher FIO2 for inadequate response
Secretions can block or limit the exchange of _______, causing or worsening ARF
Secretions can be mobilized by
Proper _________
Effective _________
Chest physiotherapy
_________
Humidification
Hydration
Early _________ when possible
Secretions can block or limit the exchange of gases, causing or worsening ARF
Secretions can be mobilized by
Proper positioning
Effective coughing
Chest physiotherapy
Suctioning
Humidification
Hydration
Early ambulation when possible
Position patient upright; HOB should be raised to at least ___ degrees; reclining chair or chair bed
—Increases respiratory expansion, decreases dyspnea, and mobilizes secretions
Risk of aspiration: use side-lying position
Unilateral lung disorders
–Lateral or side-lying position; “_____ lung down” to improve V/Q matching by draining secretions to remove with suctioning
Bilateral lung disorders – Reposition at regular intervals on __________
Position patient upright; HOB should be raised to at least 30 degrees; reclining chair or chair bed
—Increases respiratory expansion, decreases dyspnea, and mobilizes secretions
Risk of aspiration: use side-lying position
Unilateral lung disorders
–Lateral or side-lying position; “good lung down” to improve V/Q matching by draining secretions to remove with suctioning
Bilateral lung disorders – Reposition at regular intervals on both sides
Effective Coughing
Encourage patients to cough to clear ________
Augmented coughing (quad coughing)
* Used when patient unable to cough productively (weak)
* Place one or both hands at anterolateral base of lungs; have patient take a deep breath and move hands forcefully ___ as expiration begins
* Increased abdominal pressure and helps patient cough
* Increases expiratory flow and promotes secretion clearance
Encourage patients to cough to clear secretions
Augmented coughing (quad coughing)
* Used when patient unable to cough productively (weak)
* Place one or both hands at anterolateral base of lungs; have patient take a deep breath and move hands forcefully up as expiration begins
* Increased abdominal pressure and helps patient cough
* Increases expiratory flow and promotes secretion clearance
Chest Physiotherapy
For all patients who are producing sputum, have severe atelectasis or pulmonary infiltrates (on CXR)
_______ drainage
__________
__________
–Helps move secretions to larger airways for more effective coughing or suctioning
Contraindicated in TBI with ICP, unstable orthopedic injuries, and recent hemoptysis
For all patients who are producing sputum, have severe atelectasis or pulmonary infiltrates (on CXR)
Postural drainage
Percussion
Vibration
–Helps move secretions to larger airways for more effective coughing or suctioning
Contraindicated in TBI with ICP, unstable orthopedic injuries, and recent hemoptysis
Suctioning
If patient unable to expectorate secretions
Done in an _______, non-intubated patient using a soft-tip suction catheter through a nasopharyngeal tube
Proceed with caution to avoid stimulating the ____ reflex (vomiting)
Suctioning through an artificial airway is only done as ________
If patient unable to expectorate secretions
Done in an awake, non-intubated patient using a soft-tip suction catheter through a nasopharyngeal tube
Proceed with caution to avoid stimulating the gag reflex (vomiting)
Suctioning through an artificial airway is only done as needed
Humidification and Hydration
Adjunct in secretion management
Thin secretions
* Aerosols of sterile normal saline or mucolytic drugs via nebulizer
* O2 via aerosol mask
* Monitor for bronchospasm and severe coughing
Hydration
* Oral intake ______ L/day (unless contraindicated)
* IV ______
* Monitor for fluid overload – crackles, dyspnea, increased weight or CVP
Thin secretions
* Aerosols of sterile normal saline or mucolytic drugs via nebulizer
* O2 via aerosol mask
* Monitor for bronchospasm and severe coughing
Hydration
* Oral intake 2 to 3 L/day (unless contraindicated)
* IV fluids
* Monitor for fluid overload – crackles, dyspnea, increased weight or CVP
Positive Pressure Ventilation (PPV)
Noninvasive positive pressure ventilation (NIPPV)
* Provides O2 and decreases WOB with spontaneous breathing; must be awake,
alert, and VS stable
* Contraindicated for decreased LOC, high O2 requirements, facial trauma, hemodynamic instability, or excess
Two forms
* _______ —continuous positive airway pressure
* Constant pressure during inspiration and expiration
- ________—bilevel positive airway pressure (more common)
- Uses 2 different levels of positive pressure – one with ________ & _____________
Noninvasive positive pressure ventilation (NIPPV)
* Provides O2 and decreases WOB with spontaneous breathing; must be awake,
alert, and VS stable
* Contraindicated for decreased LOC, high O2 requirements, facial trauma, hemodynamic instability, or excess
Two forms
* CPAP—continuous positive airway pressure
* Constant pressure during inspiration and expiration
- BiPAP—bilevel positive airway pressure (more common)
- Uses 2 different levels of positive pressure – one with inspiration; another with expiration
Drug Therapy
Consider: comorbidities & presence of infection
Goals of drug tx:
Reduce airway __________ and therapy bronchospasm
Relieve pulmonary _________
Treat infection
Reduce anxiety, pain, and restlessness
Reduce airway inflammation and therapy bronchospasm
Relieve pulmonary congestion
Treat infection
Reduce anxiety, pain, and restlessness
Drug Therapy cont.
Reduce airway inflammation and _________
- Acute bronchospasm
Short-acting __________ repeated every 15-30 minutes until a response is achieved using hand-held nebulizer or metered-dose inhaler with a spacer
Monitor VS and _____ changes for signs of dysrhythmias or cardiac ischemia - ____________ help with inflammation
Effects may take hours when given IV; 4-5 days when inhaled
See: Drug Alert – hypokalemia, adrenal insufficiency, hyperglycemia
Reduce airway inflammation and bronchospasm
- Acute bronchospasm
Short-acting bronchodilators repeated every 15-30 minutes until a response is achieved using hand-held nebulizer or metered-dose inhaler with a spacer
Monitor VS and ECG changes for signs of dysrhythmias or cardiac ischemia - Corticosteroids help with inflammation
Effects may take hours when given IV; 4-5 days when inhaled
See: Drug Alert – hypokalemia, adrenal insufficiency, hyperglycemia
Drug Therapy cont.
Relieve pulmonary congestion
Injury to alveolar capillary membrane from HF or fluid overload can cause interstitial fluid accumulation in lungs
Decrease pulmonary congestion caused by HF
- IV _______
- Morphine
- Nitroglycerine
** Use w/ caution – can cause changes in HR & rhythm & significant decreases in BP
Relieve pulmonary congestion
Injury to alveolar capillary membrane from HF or fluid overload can cause interstitial fluid accumulation in lungs
Decrease pulmonary congestion caused by HF
- IV diuretics
- Morphine
- Nitroglycerine
** Use w/ caution – can cause changes in HR & rhythm & significant decreases in BP
Drug Therapy cont.
Treat infections
* Cause excessive mucus production; fever; increased O2 consumption; inflamed, fluidfilled and/or collapsed alveoli
* Cause or worsen ARF
* Diagnosed with CXR and sputum cultures
* Treated with IV ________
Reduce anxiety, pain, and restlessness
* Address ______; do not depend solely on use of medications
* Benzodiazepines and Opioids – use _______ dose possible (RR)
* See Safety Alert
Treat infections
* Cause excessive mucus production; fever; increased O2 consumption; inflamed, fluidfilled and/or collapsed alveoli
* Cause or worsen ARF
* Diagnosed with CXR and sputum cultures
* Treated with IV antibiotics
Reduce anxiety, pain, and restlessness
* Address cause; do not depend solely on use of medications
* Benzodiazepines and Opioids – use lowest dose possible
* See Safety Alert
Nutrition Therapy
Collaborate with _______
Maintain _______ and _______ stores
Critically ill: hypermetabolic state
Start enteral nutrition within ______ hours to avoid depletion and delayed recovery
Collaborate with dietician
Maintain protein and energy stores
Critically ill: hypermetabolic state
Start enteral nutrition within 24 to 48 hours to avoid depletion and delayed recovery
Expected outcomes
* Independently maintain a patent _______
* Maintain adequate __________
* Have normal __________ stability
* Achieve a return to baseline respiratory system function
- Independently maintain a patent airway
- Maintain adequate oxygenation
- Have normal hemodynamic stability
- Achieve a return to baseline respiratory system function
Acute Respiratory Distress Syndrome (ARDS)
Sudden _________ form of acute respiratory failure
________ capillary membrane becomes damaged and more _________ to intravascular fluid
Sudden progressive form of acute respiratory failure
Alveolar capillary membrane becomes damaged and more permeable to intravascular fluid
Acute Respiratory Distress Syndrome (ARDS)
- One of most common conditions seen in the adult ICU (___% of all ICU admissions)
- More than 200,000 cases per year in United States
- Mortality rate about ___%
- One of most common conditions seen in the adult ICU (10% of all ICU admissions)
- More than 200,000 cases per year in United States
- Mortality rate about 35%
ARDS: Etiology - Predisposing factors
- Most common: _______
Other: multiple organ dysfunction syndrome (MODS)
Multiple risk factors means 3 to 4 times likely to develop ARDS - Direct lung ______
Common: pathogen in lungs; aspiration, virus, bacteria, or sepsis - ________ lung injury
Common: problem (e.g., sepsis or massive trauma) from elsewhere in the body move toward favorable lung environment and proliferate > acute lung injury > ARF > ARDS
- Most common: sepsis
Other: multiple organ dysfunction syndrome (MODS)
Multiple risk factors means 3 to 4 times likely to develop ARDS - Direct lung injury
Common: pathogen in lungs; aspiration, virus, bacteria, or sepsis - Indirect lung injury
Common: problem (e.g., sepsis or massive trauma) from elsewhere in the body move toward favorable lung environment and proliferate > acute lung injury > ARF > ARDS
ARDS Pathophysiology
Pathophysiologic changes divided into 3 phases
* _______ or exudative phase
* Reparative or __________ phase
* ________ or fibroproliferative phase
- Injury or exudative phase
- Reparative or proliferative phase
- Fibrotic or fibroproliferative phase
ARDS
Injury or exudative phase
* Begins 24 to 72 hours after initial lung injury (direct or indirect); lasts _____days
Interstitial edema occurs from engorgement of peribronchial and perivascular interstitial space
Fluid surrounding alveoli crosses membrane and enters alveolar space; capillary blood cannot be oxygenated resulting in V/Q mismatch and intrapulmonary shunt
7 – 10
ARDS Injury or exudative phase cont.
- Exact cause of damage to alveolar-capillary membrane unknown; may be stimulation of ___________ and immune systems
Stimulation attracts neutrophils to pulmonary interstitium which release biochemical, humoral, and cellular mediators leading to increased pulmonary capillary permeability, destruction of collagen, formation of pulmonary microemboli, and pulmonary artery vasoconstriction
inflammatory
ARDS Injury or exudative phase cont.
- Hypoxemia and stimulation of juxtacapillary receptors in stiff lung parenchyma (J
reflex) leading to increased RR and decreased tidal volume (VT), causing increased CO2 removal, resulting in respiratory alkalosis - Increased cardiac output (CO)—compensatory mechanism to increase pulmonary blood flow
- As pulmonary edema and pulmonary shunt increase, compensation fails, causing hypoventilation, decreasing CO, and decreasing tissue O2 perfusion
- Hypoxemia and stimulation of juxtacapillary receptors in stiff lung parenchyma (J
reflex) leading to increased RR and decreased tidal volume (VT), causing increased CO2 removal, resulting in respiratory alkalosis - Increased cardiac output (CO)—compensatory mechanism to increase pulmonary blood flow
- As pulmonary edema and pulmonary shunt increase, compensation fails, causing hypoventilation, decreasing CO, and decreasing tissue O2 perfusion
ARDS Injury or exudative phase cont.
- Alveolar cells type I and II are damaged
Surfactant dysfunction leading to atelectasis
Widespread _________ causing decreased compliance, compromised gas exchange, and increased hypoxemia - Necrotic cells, protein, and fibrin form thick hyaline membranes that line alveoli
Contribute to fibrosis and atelectasis, resulting in decreased gas exchange capability and lung compliance
atelectasis
ARDS Injury or exudative phase cont.
- Refractory hypoxemia
Severe V/Q mismatch and shunting of pulmonary capillary blood
Classic sign of ARDS
Unresponsive to increasing O2 concentrations - Diffusion Impairment worsens _________
- Lungs become less compliant
Higher airway pressures must be generated to inflate “stiff” lungs, increasing WOB requiring mechanical ventilation
hypoxemia
ARDS Reparative or proliferative phase
- 1 to 2 weeks after initial lung injury
- Influx of neutrophils, monocytes, lymphocytes, and fibroblasts continues leading to increased pulmonary vascular resistance and pulmonary HTN as pulmonary vasculature is destroyed
- Lung compliance continues to ________
decline
ARDS Reparative or proliferative phase cont.
- Hypoxemia worsens due to thickened alveolar membrane causes V/Q mismatch, diffusion impairment, and shunting
- Airway resistance severely increased
- Proliferative phase complete when diseased lung replaced by dense, fibrous tissue
- If reparative phase persists, widespread fibrosis results
- If reparative phase is stopp
- Hypoxemia worsens due to thickened alveolar membrane causes V/Q mismatch, diffusion impairment, and shunting
- Airway resistance severely increased
- Proliferative phase complete when diseased lung replaced by dense, fibrous tissue
- If reparative phase persists, widespread fibrosis results
- If reparative phase is stopp
ARDS Fibrotic or fibroproliferative phase
* Patients with ARDS may not enter this stage
* Poorer prognosis for those who do
* Chronic or late phase
* 2 to 3 weeks after initial lung injury
* For those that don’t fully recover, the lung is completely __________ by collagenous
and fibrous tissues
remodeled
ARDS Fibrotic or fibroproliferative phase cont.
- Diffuse scarring and fibrosis cause
Decreased lung compliance
Decreased area for ____________ - Hypoxemia continues
Pulmonary hypertension - Results from pulmonary vascular destruction and fibrosis
gas exchange
ARDS Clinical Progression
Some patients survive acute phase of lung injury; pulmonary edema resolves
* Complete recovery within _______
Survival chances are poor for those who enter _______ phase
* Require long-term mechanical ventilation
Factors determining recovery versus progression
* Nature of initial injury, comorbidities, how quickly patient received care, pulmonary complications, genetic predisposition
Some patients survive acute phase of lung injury; pulmonary edema resolves
* Complete recovery within a week or so
Survival chances are poor for those who enter fibrotic phase
* Require long-term mechanical ventilation
Factors determining recovery versus progression
* Nature of initial injury, comorbidities, how quickly patient received care, pulmonary complications, genetic predisposition
Complications of ARDS
Ventilator-associated _________ (VAP)
* Implement ventilation bundle protocol reduces the incidence of VAP in mechanically ventilated patients
- Strategies for prevention of VAP
Good _______ hygiene
Elevate HOB _______ degrees
Daily _____ care with chlorhexidine (0.12%) solution
Daily assessment for readiness for __________
Stress ulcer prophylaxis
Venous thromboembolism prophylaxis
Ventilator-associated pneumonia (VAP)
* Implement ventilation bundle protocol reduces the incidence of VAP in mechanically ventilated patients
- Strategies for prevention of VAP
Good hand hygiene
Elevate HOB 30 to 45 degrees
Daily oral care with chlorhexidine (0.12%) solution
Daily assessment for readiness for extubation
Stress ulcer prophylaxis
Venous thromboembolism prophylaxis
Complications of ARDS
Venous ___________ (VTE)
* Immobility and venous stasis leading to increased risk of deep vein thrombosis (DVT) and pulmonary emboli
* Prophylactic management Intermittent pneumatic ________ stockings
______________
Early ambulation, if possible
Venous Thromboembolism (VTE)
* Immobility and venous stasis leading to increased risk of deep vein thrombosis (DVT) and pulmonary emboli
* Prophylactic management Intermittent pneumatic compression stockings
Anticoagulants
Early ambulation, if possible
Complications of ARDS
Acute _______ injury (AKI)
* Occurs from decreased renal __________ and subsequent decreased delivery of O2 to kidneys
From hypotension in septic shock, hypoxemia, or nephrotoxic drugs used to treat ARDS-related infections
- Management
Monitor input and output
Daily weight
Daily BUN and creatinine
Dialysis or continuous renal replacement therapy (CRRT)
Acute kidney injury (AKI)
* Occurs from decreased renal perfusion and subsequent decreased delivery of O2 to kidneys
From hypotension in septic shock, hypoxemia, or nephrotoxic drugs used to treat ARDS-related infections
- Management
Monitor input and output
Daily weight
Daily BUN and creatinine
Dialysis or continuous renal replacement therapy (CRRT)
Survivors of ARDS may have
Anxiety
Memory and attention issues
Inability to focus
Nightmares
Depression
PTSD (up to 5 years later)
Anxiety
Memory and attention issues
Inability to focus
Nightmares
Depression
PTSD (up to 5 years later)
Because _____ is the most severe form of ARF, the subjective and objective data you need for both is the same
ARDS
ARDS planning
With appropriate therapy, goals include:
* PaO2 of __ mmHg or higher and adequate lung ventilation to help correct any acid-base imbalance
Longer term goals for ARDS
* PaO2 within normal limits for age or at baseline on room air
* SaO2 >90%
* Resolution of the cause(s)
* Clear lungs on auscultation
60
ICU care for patients with moderate to severe ARDS
> Complex and _________ clinical courseNeed _________ ventilation until resolution of inflammation and fluid accumulation begins
_________ HR RR BP SpO2 monitoring EtCO2 monitoring
> Complex and unpredictable clinical courseNeed mechanical ventilation until resolution of inflammation and fluid accumulation begins
Continuous HR RR BP SpO2 monitoring EtCO2 monitoring
ARDS Best practices (ARDSNet protocol)
- ____ administration
- ___________ ventilation
- Low tidal volume (VT) ventilation
- Permissive hypercapnia
- Positive end expiratory pressure (PEEP)
- _____ positioning
- Extracorporeal membrane oxygenation (ECMO)
- O2 administration
- Mechanical ventilation
- Low tidal volume (VT) ventilation
- Permissive hypercapnia
- Positive end expiratory pressure (PEEP)
- Prone positioning
- Extracorporeal membrane oxygenation (ECMO)
ARDS Respiratory Therapy
Oxygen administration
* Primary goal is to correct _________
* Initially high-flow systems (BiPAP) that deliver high O2 concentrations to maximize O2 delivery
Usually temporary
Unable to keep PaO2 within acceptable ranges
* SpO2 continuously monitored
* Mechanical ventilation with FiO2 (70% or higher) to keep PaO2 at least 60 mmHg
hypoxemia
ARDS Respiratory Therapy cont.
Mechanical ventilation
* Pressure-control type of ventilation
Keeps inspiratory and plateau pressures from becoming too high
Prevents alveolar overdistention and __________
Reducing pressure going into stiff, noncompliant lungs helps to revent further lung injury
rupture
ARDS Respiratory Therapy cont.
Low tidal volume (Vt) ventilation
* Low tidal volume 4 to 8 mL/kg
Avoids volutrauma and barotrauma leading to lower mortality
Volutrauma causes alveolar fracture and movement of fluids and protein into alveolar spaces
Low tidal volume (Vt) ventilation
* Low tidal volume 4 to 8 mL/kg
Avoids volutrauma and barotrauma leading to lower mortality
Volutrauma causes alveolar fracture and movement of fluids and protein into alveolar spaces
ARDS Respiratory Therapy cont.
__________ hypercapnia
* Low tidal volumes leads to slow increase in PaCO2
* PaCO2 up to 60 mmHg is acceptable in early phase ARDS
* Brain and systemic circulation compensate with gradual increase
Contraindicated with TBI or ICP
* Requires frequent ABGs; keep pH 7.30 to 7.45
* Patient usually has continuous IV analgesia and sedation
Permissive
ARDS Respiratory Therapy cont.
_________________ pressure (PEEP)
* During PPV, apply PEEP at 5 cm H2O to compensate for loss of glottic function with an ET
* PEEP functional residual capacity and helps to open up collapsed alveoli
* Apply PEEP at 3 to 5 cm H2O increments until oxygenation is adequate with FiO2 less than or equal to 60%
Higher levels may be needed but no identified optimal level of PEEP
Positive end expiratory
ARDS Respiratory Therapy cont.
Positive end expiratory pressure (PEEP) * Complications
Increased intrathoracic and intrapulmonic pressures generated in the lungs and to the surrounding structures at end expiration can compromise venous return leading to _________ preload, CO, and BP
High PEEP or excess inspiratory pressures can lead to barotrauma and volutrauma
decreased
ARDS Respiratory Therapy cont.
_______ positioning
* In early ARDS, fluid moves freely in lungs and pools in gravity-dependent regions
* When in supine position, mediastinal contents and heart place more pressure on lungs and predispose to atelectasis
* Prone positioning is an option for refractory hypoxemia when other strategies fail to increase PaO2
Prone
ARDS Respiratory Therapy cont.
______ positioning
* Perfusion may be better matched to ventilation
Air-filled alveoli in anterior lung become dependent; posterior alveoli may reexpand leading to increased oxygenation
May be able to reduce FiO2 or PEEP
Monitor for dysrhythmias or hypotension from fluid shifts
Suctioning may be required more often
Prone
ARDS Respiratory Therapy cont.
Prone positioning
* Best practice: position prone in early ARDS
* Up to ___ hours per day
* Positioning requires an ICU intensivist, respiratory therapist, and 3 to 4 nurses
* Be attentive to securing the airway
* Once prone, position in a side-lying position
16
ARDS Respiratory Therapy cont.
___________ membrane oxygenation (ECMO)
* Large blood vessel cannulated and catheter inserted; catheter connected to a device that allows blood to exit the patient and pass across a gas-exchanging membrane outside the body to the ECMO unit ; O2 is delivered and CO2 is removed; oxygenated blood is returned to the patient
* Extracorporeal CO2 removal (ECCO2R): used to enhance oxygenation; blood flow rate is lower
Extracorporeal
Alternatives to Prone Position
Continuous lateral _________ therapy (CLRT)
* Continuous, slow, side-to-side turning of bed frame less than 40 degrees; 18 of every 24 hours
* Simulates postural drainage and mobilizes secretions; may also have vibrator pack for CPT
Kinetic therapy
* Patient rotated side-to-side at 40 degrees or greater
Monitor pulmonary status and patient
rotation
ARDS Supportive Therapy
Analgesia and sedation
* Given direct IV or continuous IV
* Decrease discomfort from ET tube, reduces WOB, and prevents ventilator dyssynchrony
* Asynchronous ventilation considerations
Adjust inspiratory flow rates or other setting
Consider neuromuscular blocking agent
Always give simultaneous analgesia and sedation and monitor levels of sedation
Analgesia and sedation
* Given direct IV or continuous IV
* Decrease discomfort from ET tube, reduces WOB, and prevents ventilator dyssynchrony
* Asynchronous ventilation considerations
Adjust inspiratory flow rates or other setting
Consider neuromuscular blocking agent
Always give simultaneous analgesia and sedation and monitor levels of sedation
ARDS Supportive Therapy cont.
Promoting tissue __________
* Risk for hemodynamic compromise
* Hemodynamic monitoring via a central venous or pulmonary artery catheter
See trends, detect changes, and adjust therapy
Monitor MAP and BP to determine adequate CO
* Inadequate: give IV fluids, drugs, or both
Monitor tissue perfusion (SaO2 , mixed venous oxygen saturation)
perfusion
ARDS Supportive Therapy cont.
Maintaining fluid balance and __________
* Challenges: pulmonary edema and intravascular depletion
* Monitor hemodynamic parameters, daily weights, hourly I & O
* Maintain protein and energy stores to avoid loss of muscle mass and delayed recovery
* Start enteral or parenteral nutrition in 24 to 48 hours
nutrition
ARDS Evaluation
Expected outcomes (similar for patients with ARF)
* Maintain and sustain adequate ___________ & ____________ with decreasing amounts of O2
* Be hemodynamically stable
* Be free of complications
oxygenation and ventilation
ARF is not a _________ , it is a symptom of insufficient lung function
disease
Indications for ABG’s
- Evaluate adequacy of ________
- Evaluate the _________ status
- Evaluate _________ balance
- Evaluate adequacy of ventilation
- Evaluate the oxygenation status
- Evaluate acid-base balance
Obtaining an Arterial Blood Sample
- Arterial puncture is made at the radial, brachial or ______ artery
- May be drawn from an _________
- Samples drawn by RN or RCP - check with your facility for policy
- Collateral circulation must be assessed before doing a puncture by using the ___________
- Arterial puncture is made at the radial, brachial or femoral artery
- May be drawn from an arterial line
- Samples drawn by RN or RCP - check with your facility for policy
- Collateral circulation must be assessed before doing a puncture by using the Allen’s test
Allen’s Test
- Patient forms tight ______ forcing blood from the hand causing blanching
-Pressure is applied to ____________ arteries to obstruct blood flow to the hand
-Pressure to ulnar artery is released, patient opens hand…if palm turns pink within __ seconds, collateral flow is adequate
- Patient forms tight fist forcing blood from the hand causing blanching
-Pressure is applied to radial and ulnar arteries to obstruct blood flow to the hand
-Pressure to ulnar artery is released, patient opens hand…if palm turns pink within 6 seconds, collateral flow is adequate
Normal ABG Values
pH:
CO2:
HCO3:
BE [base excess]:
PaO2:
SpO2:
pH: 7.35-7.45
CO2: 35-45
HCO3: 22-26
BE [base excess]: -2 to +2
PaO2: 80-100
SpO2: 94-100%
How the pH is Balanced
Lungs regulate>CO2 = ACID
Kidneys regulate>HCO3 = BASE
Lungs regulate>CO2 = ACID
Kidneys regulate>HCO3 = BASE
Analysis of ABG’s - Six Step Process
Step #1: Analyze the ___
Step #2: Analyze the ___
Step #3: Analyze the ___
Step #4: Match either the PaCO2 or the HCO3 with the pH
Step #5: Assess for Compensation
Step #6: Analyze the PaO2 and SaO2 for Hypoxemia
Step #1: Analyze the pH
Step #2: Analyze the PaCO2
Step #3: Analyze the HCO3
Step #4: Match either the PaCO2 or the HCO3 with the pH
Step #5: Assess for Compensation
Step #6: Analyze the PaO2 and SaO2 for Hypoxemia
If the pH is low and the PaCO2 is high, the HCO3 is normal, the patient has __________________
If the pH is high and the PaCO2 is low, the HCO3 is normal, the patient has __________________
If the pH and HCO3 are low and the PaCO2 is normal, the patient has __________________
If the pH and HCO3 are high but the PaCO2 is normal, the patient __________________
If the pH is low and the PaCO2 is high, the HCO3 is normal, the patient has respiratory acidosis
If the pH is high and the PaCO2 is low, the HCO3 is normal, the patient has respiratory alkalosis
If the pH and HCO3 are low and the PaCO2 is normal, the patient has metabolic acidosis
If the pH and HCO3 are high but the PaCO2 is normal, the patient has metabolic alkalosis
Step #5 ABG analysis: Assess for Compensation
- Determine whether the PaCO2 or the HCO3 go in the opposite direction of the pH
- If so, then the patient has __________
- Example: when the respiratory system (CO2) becomes acidotic, the metabolic system (HCO3) will become alkalotic in an attempt to bring the pH back to normal
compensation
Step #5: Compensation Continued
-Fully Compensated: pH _________
-Partially Compensated: pH is ABNORMAL and both the CO2 or HCO3 are ABNORMAL
-Non-Compensated: pH is ABNORMAL and either the CO2 or HCO3 are the problem
normal
Step #6: Analyze the PaO2 and SaO2 for Hypoxemia
* If the PaO2 is less than ___, the patient has hypoxemia
* If the SpO2 is less than ____%, the patient has hypoxemia
* A patient on supplemental oxygen may have a PaO2 of more than 100 mmHg
- If the PaO2 is less than 80, the patient has hypoxemia
- If the SpO2 is less than 90%, the patient has hypoxemia
- A patient on supplemental oxygen may have a PaO2 of more than 100 mmHg
low VS high pH
High pH - alkalosis
Low pH- acidosis
[Cheat sheet]
Respiratory acidosis
Respiratory alkalosis
Metabolic acidosis
Metabolic alkalosis
Case study 1 -
Mr. Blue, a 67 year old man with a history of chronic obstructive pulmonary disease, arrives to the ED complaining of shortness of breath. He is barrel-chested, has cyanotic nail beds, with distant breath sounds and crackles on inspiration. He sits on the edge of the chair, learning forward, with both hands
on his knees.
ABG:
pH 7.25
PaO2 52 (room air)
PaCO2 54
HCO3- 30
=
respiratory acidosis
Case Study #2: Mr. Money, a 32 year old international banker returns from a vacation in Guatemala. He complains of severe vomiting for five days. He is very fatigued, has sunken eyes, dry mucus membranes, HR 110 and BP is 85/50. On
standing his pressure falls and his heart rate
increases to 125.
ABG:
pH 7.50
PaCO2 47
PaO2 80
HCO3- 38
O2 sat 94%
=
metabolic alkalosis
Case Study #3: Mr. Bad-Luck, a 32 y.o. man, was
injured in a bicycle accident suffering multiple
fractures having been hit by a bus. Surgery has been
delayed due to coagulopathy. He is intubated and
placed on the ventilator due to aspiration pneumonia, compromised airway, and increasing confusion. FIO2 50%.
ABG:
pH 7.39
PaCO2 37
PaO2 58
HCO3- 22
O2 sat 91%
=
hypoxemia (apply oxygen)
Upper Airway Functions:
-Filtration
-Humidification
-Heat Supply
*These are __________ when a patient is on a ventilator
-Filtration
-Humidification
-Heat Supply
*These are bypassed when a patient is on a ventilator
OXYGENATION is reflected in the PaO2 (dissolved/free oxygen)
*Normal range PaO2= ________ mmHg
OXYGENATION is reflected in the PaO2 (dissolved/free oxygen)
*Normal range PaO2= 80-100 mmHg
VENTILATION is reflected by PaCO2 levels
*HYPO- ventilation usually causes ______ PaCO2 > retaining/not blowing it off
*HYPER- ventilation usually causes ______ PaCO2 > blowing too much off
*Normal range PaCO2 = 34-45 mmHg
*HYPO- ventilation usually causes HIGH PaCO2 > retaining/not blowing it off
*HYPER- ventilation usually causes LOW PaCO2 > blowing too much off
*Normal range PaCO2 = 34-45 mmHg
Oxygen Transport
Oxygen is carried into the blood two ways:
1. (SaO2) = % of oxygen bound to ___________________ (i.e. 98%)
2. (PaO2) = dissolved/free oxygen molecules in _______
Oxygen is carried into the blood two ways:
1. (SaO2) = % of oxygen bound to hemoglobin in erythrocyte (i.e. 98%)
2. (PaO2) = dissolved/free oxygen molecules in plasma
Oxyhemoglobin Dissociation Curve
1. Shows relationship between _______________________
2. Describes ability of hemoglobin to _____ O2
- Shows relationship between O2 saturation and PaO2
- Describes ability of hemoglobin to bind O2
PaO2 versus SaO2
PaO2 is the amount of free form dissolved ______________
-Determined using blood gases (ABG’s)
-Normal range is 80-100 mmHg
-No benefit if greater than 100 > can actually be harmful (can lead to ______ )
-If greater than 100 > turn down the FiO2 on ventilator or oxygen device
oxygen particles in the blood
- toxicity
PaO2 Versus SaO2 Continued
SaO2 is the % of _______________
-Determined using a pulse oximeter
-Reading is affected by various conditions
oxygen BOUND to HEMOGLOBIN
General Indications for Mechanical Ventilation
- Failure to adequately __________
- Failure to adequately __________
- To facilitate diagnostic, surgical, and therapeutic procedures
- Failure to protect the airway
- Failure to adequately oxygenate
- Failure to adequately ventilate
- To facilitate diagnostic, surgical, and therapeutic procedures
- Failure to protect the airway
Specific Indications for Mechanical Ventilation
-Acute Respiratory Failure (Inability of a pt to maintain adequate PaO2, PaCO2 and potentially acidic pH)
- Impending Respiratory Failure (Pt is barely maintaining normal blood gases at the expense of significant WOB)
- Prophylactic Ventilatory Support (to decrease WOB, minimize O2 consumption and hypoxemia, reduce cardiopulmonary stress, &/or control airway with sedation)
- Hyperventilation Therapy (Acute head injury)
-Acute Respiratory Failure (Inability of a pt to maintain adequate PaO2, PaCO2 and potentially acidic pH)
- Impending Respiratory Failure (Pt is barely maintaining normal blood gases at the expense of significant WOB)
- Prophylactic Ventilatory Support (to decrease WOB, minimize O2 consumption and hypoxemia, reduce cardiopulmonary stress, &/or control airway with sedation)
- Hyperventilation Therapy (Acute head injury)
CONTRAINDICATIONS TO INVASIVE VENTILATORY SUPPORT
Absolute
- Untreated tension __________
- Patient’s informed ________
Relative
- Medical futility
- Patient pain and suffering
Absolute
- Untreated tension pneumothorax
- Patient’s informed refusal
Relative
- Medical futility
- Patient pain and suffering
Mechanical Ventilation
- __________ tube (ETT)
-Oral or nasal
-Passes through the vocal cords into the trachea
-Patients cannot ______
ETT Cuff inflated to protect airway
-20-25 cm H2O; check once a shift
_________ to verify placement of tip
-Should be at least 2 cm – 6 cm above carina
-Quick method is to use ETCO2
-Check placement at teeth level; 21 cm for women and 23 cm for men
-Consider sedation and pain meds
Mechanical Ventilation
- Endotracheal tube (ETT)
-Oral or nasal
-Passes through the vocal cords into the trachea
-Patients cannot talk
ETT Cuff inflated to protect airway
-20-25 cm H2O; check once a shift
Chest x-ray to verify placement of tip
-Should be at least 2 cm – 6 cm above carina
-Quick method is to use ETCO2
-Check placement at teeth level; 21 cm for women and 23 cm for men
-Consider sedation and pain meds
Tidal volume (VT)
- The volume of air moved into and out of the lungs during each ventilation cycle
- _____ mL/kg
8-10
Positive End Expiratory Pressure (PEEP)
- The positive pressure that will remain in the airways at the ___________ that is greater than the atmospheric pressure in mechanically ventilated patients
- 5 cmH20
end of exhalation
Fraction of Inspired O2 (Fi02)
- Fraction of oxygen in the inhaled gas
- 0.30-1.00
- Fraction of oxygen in the inhaled gas
- 0.30-1.00
Respiratory Rate - _____
12-20
Peak Inspiratory Pressure (PIP)
- Highest level of pressure applied to the lungs during ________
- Keep it below 40 cmH20
inhalation
End-tidal Carbon Dioxide (ETCO2)
- A noninvasive technique which measures the partial pressure or maximal concentration of carbon dioxide (CO2) at the ____________
- ______ mmHg
end of an exhaled breath
35-45
Ventilator Alarms
High Pressure
-Increased or thicker _______
-Bronchospasm
-Fighting the vent
-_______in the ventilator circuit
-Tubing _______
-Decreased lung compliance
Low Pressure
-Leak in the ETT or Removal of the ETT tube
Alarm Fatigue
High Pressure
-Increased or thicker secretions
-Bronchospasm
-Fighting the vent
-Water in the ventilator circuit
-Tubing kinked
-Decreased lung compliance
Low Pressure
-Leak in the ETT or Removal of the ETT tube
Alarm Fatigue
Vent Modes
________ Control
-Pressure Regulated Volume Control (PRVC)
-A mode of ventilation in which the ventilator attempts to achieve a set tidal volume at the lowest possible airway pressure
_______
- Pressure Support (PS)
- A level of support pressure is set to assist every spontaneous effort. The patient determines the tidal volume, respiratory rate, and flow rate
Assist Control
-Pressure Regulated Volume Control (PRVC)
-A mode of ventilation in which the ventilator attempts to achieve a set tidal volume at the lowest possible airway pressure
Wean
- Pressure Support (PS)
- A level of support pressure is set to assist every spontaneous effort. The patient determines the tidal volume, respiratory rate, and flow rate
Assessment of Ventilated Patients
- Breath sounds
- Spontaneous respiratory rate, volume, and pattern
-Placement/level of ETT at teeth measured in cm - ETT cuff pressure and apparent stability of the tube
- Chest motion
- Skin color
- Level of consciousness (LOC)
- Secretions > Suction as needed, document color, consistency, amount & frequency of suctioning > this prevents ventilator acquired pneumonias (VAP)
- Breath sounds
- Spontaneous respiratory rate, volume, and pattern
-Placement/level of ETT at teeth measured in cm - ETT cuff pressure and apparent stability of the tube
- Chest motion
- Skin color
- Level of consciousness (LOC)
- Secretions > Suction as needed, document color, consistency, amount & frequency of suctioning > this prevents ventilator acquired pneumonias (VAP)
More Assessments
- Prevent untoward effects of disconnection from ventilator during
bedside procedures (restraints?) - Documentation of oxygenation and ventilation status (e.g., arterial blood gas results, exhaled PCO2 measurements)
- Documentation of patient-ventilator synchrony during assisted or supported breaths
- Prevent untoward effects of disconnection from ventilator during
bedside procedures (restraints?) - Documentation of oxygenation and ventilation status (e.g., arterial blood gas results, exhaled PCO2 measurements)
- Documentation of patient-ventilator synchrony during assisted or supported breaths
Ventilator - Safety Concerns
- How can you tell if ETT is in correct position?
- What are s/s that ETT is NOT in correct position?
- If patient pulls out ETT what should you do?
- If ETT is pushed in by several centimeters what should you do?
- Ventilated patients are at high risk for aspiration. How is this prevented?
- How does your facility prevent ventilator acquired pneumonias (VAP)?
- How can you tell if ETT is in correct position?
- What are s/s that ETT is NOT in correct position?
- If patient pulls out ETT what should you do?
- If ETT is pushed in by several centimeters what should you do?
- Ventilated patients are at high risk for aspiration. How is this prevented?
- How does your facility prevent ventilator acquired pneumonias (VAP)?
Liberation from Mechanical Ventilation (aka: Weaning)
- Daily Screening
Pt. must meet these criteria:
-No vent discontinuation/______ within past 24 hrs
-No active cardiac ischemia or __________ (hemodynamically stable)
-No neuromuscular blocking agents
-Adequate ____ (limited or no sedation)
-Limited/no restlessness or anxiety
-Adequate respiratory drive, cough, & ability to mobilize secretions
-No vent discontinuation/failure within past 24 hrs
-No active cardiac ischemia or arrhythmyias (hemodynamically stable)
-No neuromuscular blocking agents
-Adequate LOC (limited or no sedation)
-Limited/no restlessness or anxiety
-Adequate respiratory drive, cough, & ability to mobilize secretions
Assessments During Weaning
-Monitor for Failure:
- Tachypnea
- Dyspnea
- Agitation/anxiety/restlessness
- Tachycardia
- Dysrhythmias
- SpO2 less than 90%
- Hyper or hypotension
- Changes in LOC
-Monitor for Failure:
- Tachypnea
- Dyspnea
- Agitation/anxiety/restlessness
- Tachycardia
- Dysrhythmias
- SpO2 less than 90%
- Hyper or hypotension
- Changes in LOC
Pleural Space
-Lies between the parietal pleura (membrane lining the chest cavity) and the visceral pleura (surrounds the lungs)
- Holds about 50 ml of lubricating fluid
- Creates a negative pressure that keeps ___________
- Excess fluid or air accumulation in the pleural space limits lung expansion and leads to respiratory distress
the lungs expanded
Why Do We Need Chest Tubes
____________: Air in the pleural space caused by trauma, lung disease, invasive pulmonary procedure, forceful coughing, surgical complication, or may occur spontaneously
–To drain air, the chest tube is placed in anterior chest at the second or third intercostal space
____________: Blood in the pleural space caused by blunt/penetrating trauma or a complication of chest surgery
–To drain fluid, the chest tube is placed at lung base
____________: Excessive fluid in the pleural space caused by pneumonia, left ventricular heart failure, pulmonary embolism, cancer, or complication of surgery
Pneumothorax: Air in the pleural space caused by trauma, lung disease, invasive pulmonary procedure, forceful coughing, surgical complication, or may occur spontaneously
–To drain air, the chest tube is placed in anterior chest at the second or third intercostal space
Hemothorax: Blood in the pleural space caused by blunt/penetrating trauma or a complication of chest surgery
–To drain fluid, the chest tube is placed at lung base
Pleural effusion: Excessive fluid in the pleural space caused by pneumonia, left ventricular heart failure, pulmonary embolism, cancer, or complication of surgery
Why Do We Need Chest Tubes (other reasons)
_________: Pus from an infection, such as pneumonia; must always be drained no matter how small the amount
Other considerations: Preventively after cardiac/pulmonary surgery to drain blood postoperatively and prevent cardiac tamponade
Empyema
Chest Tube Insertion
-Done in patient’s room, ED, interventional radiology, or OR
- Aseptic (sterile) procedure
-Position patient for comfort depending on site to be inserted
-Tube will be anchored with sutures
-Insertion site will have an occlusive dressing applied
–e.g. Petroleum gauze
-Connections securely taped (closure device)
-Chest X-ray to confirm position
-Done in patient’s room, ED, interventional radiology, or OR
- Aseptic (sterile) procedure
-Position patient for comfort depending on site to be inserted
-Tube will be anchored with sutures
-Insertion site will have an occlusive dressing applied
–e.g. Petroleum gauze
-Connections securely taped (closure device)
-Chest X-ray to confirm position
Chest Tube Insertion
- Pain medication
-Heimlich/Flutter Valve
- _________ System: Wet versus Dry System
–– Have this set up and ready before insertion
- Pain medication
-Heimlich/Flutter Valve - Drainage System: Wet versus Dry System
–– Have this set up and ready before insertion
Drainage Collection Chamber
-Receives fluid and air from the pleural space
-The drained fluid stays in this chamber while expelled air vents to the water seal chamber
-Drainage chamber is not emptied – RN to mark amount every shift on the chamber
-When this chamber is full, change out the closed chest drainage system with a new one
-Receives fluid and air from the pleural space
-The drained fluid stays in this chamber while expelled air vents to the water seal chamber
-Drainage chamber is not emptied – RN to mark amount every shift on the chamber
-When this chamber is full, change out the closed chest drainage system with a new one
Water Seal Chamber
- Contains 2 cm of water, which acts as a one-way valve:
– Brisk bubbling of air in this chamber = pneumothorax
– Intermittent bubbling during exhalation, coughing, or sneezing = there is still some air in the pleural space
– No bubbling = air leak resolved, lung expanded
__________: This up and down movement of water in concert with respiration reflects intrapleural pressure changes during inspiration and expiration
– If tidaling stops suddenly - assess the chest tube for occlusion
– If tidaling gradually slows then eventually stops – means the lung has re-expanded
Water Seal Chamber
- Contains 2 cm of water, which acts as a one-way valve:
– Brisk bubbling of air in this chamber = pneumothorax
– Intermittent bubbling during exhalation, coughing, or sneezing = there is still some air in the pleural space
– No bubbling = air leak resolved, lung expanded
Tidaling: This up and down movement of water in concert with respiration reflects intrapleural pressure changes during inspiration and expiration
– If tidaling stops suddenly - assess the chest tube for occlusion
– If tidaling gradually slows then eventually stops – means the lung has re-expanded
Water Suction Control Chamber
- The water suction control chamber uses a column of water to control the amount of suction from the wall regulator
- The chamber is typically filled with 20 cm of water
–– The suction pressure is usually ordered to be - 20 cm H2O
- To start suction, _________ the vacuum source until gentle bubbling is present in the this chamber
- Excessive bubbling does not increase the amount of suction but does increase the rate of evaporation of the water and the amount of noise made by the device
Water Suction Control Chamber
- The water suction control chamber uses a column of water to control the amount of suction from the wall regulator
- The chamber is typically filled with 20 cm of water
–– The suction pressure is usually ordered to be - 20 cm H2O
- To start suction, increase the vacuum source until gentle bubbling is present in the this chamber
- Excessive bubbling does not increase the amount of suction but does increase the rate of evaporation of the water and the amount of noise made by the device
Dry Suction Control Chamber
- Dry suction chest drainage systems do not contain water.
- They often have a visual alert that shows if the suction is working.
- It uses a regulator to dial the desired negative pressure; this is internal in the chest drainage system.
- To increase the suction pressures, turn the dial on the drainage system.
- Increasing the vacuum source does not increase the pressure. When decreasing suction, depress the manual vent to reduce excess vacuum to the lower prescribed level.
Dry Suction Control Chamber
- Dry suction chest drainage systems do not contain water.
- They often have a visual alert that shows if the suction is working.
- It uses a regulator to dial the desired negative pressure; this is internal in the chest drainage system.
- To increase the suction pressures, turn the dial on the drainage system.
- Increasing the vacuum source does not increase the pressure. When decreasing suction, depress the manual vent to reduce excess vacuum to the lower prescribed level.
[chest tubes] Complications
-________: Usually minor, but may require surgery if extensive
- ________: Likelihood increases the longer the chest tube is in place
- Subcutaneous ________: Characterized by swelling in face, neck, and chest; crackles on palpation
-Bleeding: Usually minor, but may require surgery if extensive
- Infection: Likelihood increases the longer the chest tube is in place
- Subcutaneous emphysema: Characterized by swelling in face, neck, and chest; crackles on palpation
Nursing Considerations [chest tubes]
-Monitor vital signs
- Assess breath sounds bilaterally (check for SQ emphysema, crepitus)
- Assess the insertion site
- Encourage the patient to TCDB
-Make sure connections are taped securely
-Keep collection apparatus below level of pt chest; don’t allow tubing to touch floor
-Monitor vital signs
- Assess breath sounds bilaterally (check for SQ emphysema, crepitus)
- Assess the insertion site
- Encourage the patient to TCDB
-Make sure connections are taped securely
-Keep collection apparatus below level of pt chest; don’t allow tubing to touch floor
Nursing Considerations cont. for chest tubes
-Check suction control and water seal chambers frequently
-Assess drainage for color, amount
- Measure drainage every 8 hours or more often depending on patient’s condition
-Document assessment
- Report: drainage greater than 200 mL in the first hour, development of subcutaneous emphysema, or any signs and symptoms of respiratory distress
-Check suction control and water seal chambers frequently
-Assess drainage for color, amount
- Measure drainage every 8 hours or more often depending on patient’s condition
-Document assessment
- Report: drainage greater than 200 mL in the first hour, development of subcutaneous emphysema, or any signs and symptoms of respiratory distress
more Nursing Considerations for chest tubes
-At the bedside: Always keep 2 Kelly clamps- may be needed if the chest tubes accidentally become dislodged/disconnected from the tubing
-Tubing: Avoid aggressive manipulation such as “stripping”
-Patency: To maintain patency, try “gentle” hand-over-hand squeezing of tubing and release
-Clamping: Avoid except when replacing chest drainage unit, locating air leak, or assessing when tube will be removed
-At the bedside: Always keep 2 Kelly clamps- may be needed if the chest tubes accidentally become dislodged/disconnected from the tubing
-Tubing: Avoid aggressive manipulation such as “stripping”
-Patency: To maintain patency, try “gentle” hand-over-hand squeezing of tubing and release
-Clamping: Avoid except when replacing chest drainage unit, locating air leak, or assessing when tube will be removed
more Nursing Considerations for chest tubes
If client must be transported: suction is usually off and air is vented out
– Tubing is not _______ for transport!
- If a tube accidentally pulls out – quickly place a tight occlusive dressing over the insertion site on the chest to prevent air from re-entering
- If chest tube becomes detached from the drainage system – quickly place the end of the chest tube into a bottle of sterile water
If client must be transported: suction is usually off and air is vented out
– Tubing is not clamped for transport!
- If a tube accidentally pulls out – quickly place a tight occlusive dressing over the insertion site on the chest to prevent air from re-entering
- If chest tube becomes detached from the drainage system – quickly place the end of the chest tube into a bottle of sterile water
Chest Tube Removal - Can remove chest tube when:
–There’s little to no ________
–Air leak is gone
–Patient is ________ normally without respiratory distress
–Fluctuations in water seal chamber stopped
–Chest X-ray shows lung re-expansion with no residual air or fluid
–There’s little to no drainage
–Air leak is gone
–Patient is breathing normally without respiratory distress
–Fluctuations in water seal chamber stopped
–Chest X-ray shows lung re-expansion with no residual air or fluid
Chest Tube Removal
-Gather supplies and explain procedure to patient
-Pain meds 30 - 60 minutes prior
-During peak exhalation, the clinician will remove the chest tube in
one quick movement (Valsalva maneuver)
- Immediately apply a sterile gauze dressing containing petroleum
to prevent air from entering pleural space
- Monitor patient’s respiratory status
- Arrange for chest X-ray to confirm lung re-expansion
- Monitor patient’s respiratory status and SpO2 for 1-2 hours after
removal
-Gather supplies and explain procedure to patient
-Pain meds 30 - 60 minutes prior
-During peak exhalation, the clinician will remove the chest tube in
one quick movement (Valsalva maneuver)
- Immediately apply a sterile gauze dressing containing petroleum
to prevent air from entering pleural space
- Monitor patient’s respiratory status
- Arrange for chest X-ray to confirm lung re-expansion
- Monitor patient’s respiratory status and SpO2 for 1-2 hours after
removal
Acute respiratory failure is when one or both happen:
- Oxygen unable to pass from lungs to _____, causing blood oxygen level to
drop (hypoxemia).
-Loss of blood oxygen means tissues and ______ may not function appropriately. - Carbon Dioxide (CO2) unable to pass from blood into _______.
- Body unable to get rid of CO2 (___________).
- Buildup of CO2 can cause damange to tissues and organs.
- Can be classified as two main types based on underlying mechanism
- Oxygen unable to pass from lungs to blood, causing blood oxygen level to
drop (hypoxemia).
-Loss of blood oxygen means tissues and organs may not function appropriately. - Carbon Dioxide (CO2) unable to pass from blood into lungs.
- Body unable to get rid of CO2 (hypercapnia).
- Buildup of CO2 can cause damange to tissues and organs.
- Can be classified as two main types based on underlying mechanism
Type I vs II Respiratory Failure
Hypoxemic Respiratory Failure (Type I)
Hypercapnic Respiratory Failure (Type II)
Hypoxemic Respiratory Failure (Type __)
Known as: Lung Failure, Oxygenation Failure, Respiratory Insufficiency.
Definition: Failure of lungs to provide adequate ___ to meet metabolic needs.
O2 ____, CO2 normal or slightly↓
Causes: Pneumonia, Acute Respiratory Distress Syndrome (ARDS), Pulmonary Edema, Pulmonary Embolism, trauma to lungs, heart attack, sepsis.
Hypoxemic Respiratory Failure (Type I)
Known as: Lung Failure, Oxygenation Failure, Respiratory Insufficiency.
Definition: Failure of lungs to provide adequate O2 to meet metabolic needs.
O2 ↓↓, CO2 normal or slightly↓
Causes: Pneumonia, Acute Respiratory Distress Syndrome (ARDS), Pulmonary Edema, Pulmonary Embolism, trauma to lungs, heart attack, sepsis.
Hypercapnic Respiratory Failure (Type __)
Known as: Pump Failure, __________ Failure.
Definition: Failure of the lungs to _________ adequate CO2. Low O2 levels.
O2 ↓, CO2 ____
Causes: COPD, Muscular Dystrophy, Amyotrophic Lateral Sclerosis (ALS), Drug Overdose (opioids or sedatives), stroke, sepsis.
Hypercapnic Respiratory Failure (Type II)
Known as: Pump Failure, Ventilatory Failure.
Definition: Failure of the lungs to eliminate adequate CO2. Low O2 levels.
O2 ↓, CO2 ↑↑
Causes: COPD, Muscular Dystrophy, Amyotrophic Lateral Sclerosis (ALS), Drug Overdose (opioids or sedatives), stroke, sepsis.
Signs and Symptoms of Acute Respiratory Failure
__________
Tachypnea
Sweating
Cyanosis
Use of ____________
Restlessness
__________
Agitation
Dyspnea
Tachypnea
Sweating
Cyanosis
Use of accessory muscles
Restlessness
Confusion
Agitation
ARDs
- Life threatening condition
- Type of ____.
ARDs
- Life threatening condition
- Type of ARF.
ARDS vs ARF
ARF/ARDS Interventions
_______ therapy
- Supplemental oxygen
- Bilevel positive airway pressure (BIPAP).
- Long-term ventilator therapy may result in tracheostomy placement.
Medications
- ___________
-Corticosteroids
-Antibiotics
Close monitoring
- Continuous monitoring of oxygen levels
- Arterial Blood Gas (ABG)
- Respiratory rate
- Vital signs
Oxygen therapy
- Supplemental oxygen
- Bilevel positive airway pressure (BIPAP).
Mechanical ventilation
- Ventilator
- Long-term ventilator therapy may result in tracheostomy placement.
Medications
- Bronchodilators
-Corticosteroids
-Antibiotics
Close monitoring
- Continuous monitoring of oxygen levels
- Arterial Blood Gas (ABG)
- Respiratory rate
- Vital signs
Mechanical Ventilation
* Usually initiated as pressure-regulated volume control (______).
* Delivers set tidal volume and rate with lowest possible pressure.
- Patients may require for:
- Low _____ (75-100 mmHg) levels
- High ______ (35-45 mmHg)
- Abnormal ____ (7.35-7.45)
- Always check the patient before the equipment.
- Usually initiated as pressure-regulated volume control (PRVC).
- Delivers set tidal volume and rate with lowest possible pressure.
- Patients may require for:
- Low PaO2 (75-100 mmHg) levels
- High PaCo2 (35-45 mmHg)
- Abnormal pH (7.35-7.45)
- Always check the patient before the equipment.
Interventions for Vented Patients
Mobilizing _________
- Assessing need for suctioning.
- Always preoxygenate before suctioning, review patients SpO2, and document amount, color, and consistency of secretions after suctioning.
- Patients with thick secretions on mechanical ventilation.
-Hydration and nutrition important.
_____ Hygiene
-Compliance with VAP bundle
- Prevention of ventilator association pneumonia
- Wash your hands.
- Turn and Reposition patient q__h
- Keep HOB 30degrees and higher
- Administer sedatives if not tolerating ventilator.
- Always assess hemodynamic status prior to extubation.
- Communicate with patients, give simple, clear directions and explanations.
Mobilizing secretions
- Assessing need for suctioning.
- Always preoxygenate before suctioning, review patients SpO2, and document amount, color, and consistency of secretions after suctioning.
- Patients with thick secretions on mechanical ventilation.
-Hydration and nutrition important.
Oral Hygiene
-Compliance with VAP bundle
- Prevention of ventilator association pneumonia
- Wash your hands.
- Turn and Reposition patient q2h
- Keep HOB 30degrees and higher
- Administer sedatives if not tolerating ventilator.
- Always assess hemodynamic status prior to extubation.
- Communicate with patients, give simple, clear directions and explanations.
Mnemonic - indications for chest tube
PEACH
Pneumothorax
Effusion (plueral)
Abscess
Cancer (lung)
Hemothorax
Normal VS Abnormal (Ventilation)
_______ is normal and expected
__________ bubbling is normal (associated with breathing / coughing)
__________ bubbling is NOT normal (may indicate air leak)
Tidaling is normal and expected
Intermittent bubbling is normal (associated with breathing / coughing)
Continuous bubbling is NOT normal (may indicate air leak)
Nursing Considerations for Patients with Chest Tubes
- With new chest tube monitor patients’ vital signs, oxygen saturation, breath sounds, and insertion site every 15 minutes for first 2 hours, and then every shift.
- Ensure an occlusive dressing is at bedside such as (sterile 4X4 gauze or petroleum gauze) * Used in the event of accidental removal or when chest tube is dc’d.
- Monitor chest tube drainage.
- If tube disconnects from drainage system accidentally:
- Immerse tube in sterile water
- With new chest tube monitor patients’ vital signs, oxygen saturation, breath sounds, and insertion site every 15 minutes for first 2 hours, and then every shift.
- Ensure an occlusive dressing is at bedside such as (sterile 4X4 gauze or petroleum gauze) * Used in the event of accidental removal or when chest tube is dc’d.
- Monitor chest tube drainage.
- If tube disconnects from drainage system accidentally:
- Immerse tube in sterile water
Hypoxemic: _________ failure
* Oxygen is not reaching the tissues even if ventilation is normal
* PaO2 ≤ 60 mmHg on FiO2 ≥ 60% oxygen
Hypercapnic: _________ failure
* Imbalance between supply and demand of gas exchange
* Inadequate ventilation even if perfusion is functioning unimpaired
* PaCO2 > 45 mmHg and pH < 7.35
* PaCO2 is ACIDIC above 45
* PH is ACIDIC below 7.35
* ABG interpretation: Respiratory Acidosis
Hypoxemic: Oxygenation failure
* Oxygen is not reaching the tissues even if ventilation is normal
* PaO2 ≤ 60 mmHg on FiO2 ≥ 60% oxygen
Hypercapnic: Ventilatory failure
* Imbalance between supply and demand of gas exchange
* Inadequate ventilation even if perfusion is functioning unimpaired
* PaCO2 > 45 mmHg and pH < 7.35
* PaCO2 is ACIDIC above 45
* PH is ACIDIC below 7.35
* ABG interpretation: Respiratory Acidosis
