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Intubation and Ventilation (Endotracheal Intubation purpose of…

- - - - types
        
        volume ventilation
        
        Volume Modes
        Assist-Control (AC) or Assisted Mandatory
        Ventilation (AMV)
        • Requires that rate, VT, inspiratory time, and PEEP be set for the patient.
        • The ventilator sensitivity is also set, and when the patient initiates a spontaneous breath, a full-volume breath IS delivered.
        Intermittent Mandatory Ventilation (IMV) and
        Synchronized Intermittent Mandatory Ventilation (SIMV)
        • Requires that rate, VT, inspiratory time, sensitivity, and PEEP are set for the patient.
        • In between "mandatory breaths," patients spontaneously breathe at their own rates and VT. With SIMV, the ventilator synchronizes the mandatory breaths with the patient's own inspirations.
        
        pressure ventilation
        
        Pressure Modes
        Pressure Support Ventilation (PSV)
        • Provides an augmented inspiration to a spontaneously breathing patient.
        • The clinician selects an inspiratory pressure level, PEEP, and sensitivity.
        When the patient initiates a breath, a high flow of gas is delivered
        to the preselected pressure level, and pressure IS maintained throughout inspiration.
        • The patient determines the parameters of VT, rate, and inspiratory time.
        Pressure-Control Inverse Ratio Ventilation (PC-IRVI
        • Combines pressure-limited ventilation with an inverse ratio of inspiration to expiration.
        • The clinician selects the pressure level, rate, inspiratory time (121, 31, 411), and the PEEP level. With the prolonged inspiratory times, auto-PEEP may result.
        • The auto-PEEP may be a desirable outcome of the inverse ratios.
        • Some clinicians use PC without IRV.
        • Conventional inspiratory times are used and rate, pressure level, and PEEP are selected.
        Airway Pressure Release Ventilation (APRV,I
        • Provides two levels of continuous positive airway pressure (CPAP) with timed releases, and permits spontaneous breathing throughout the respiratory cycle.
        • The clinician selects both pressure high and pressure low along with time high and time low. Tidal volume is not a set variable and depends on the CPAP level, the patient's compliance and resistance, and spontaneous breathing effort.
      - other modes
        Positive End-Expiratory Pressure (PEEP) and Continuous Positive Airway Pressure (CPAP) PEEP
        • Creates positive pressure at end exhalation and restores functional residual capacity (FRC)_
        • The term PEEP IS used when end-expiratory pressure is provided during ventilator positive pressure breaths.
        CPAP
        • Similar to PEEP, CPAP restores FRC.
        • This pressure IS continuous during spontaneous breathing; no positive pressure breaths are present.
      - nutritional therapy
        
        Nutrition
        
        • If tracheostomy, patient might be able to eat
        
        • Preferably soft foods
        
        • If not able to eat for 3-5 days or more, then nutritional assessment and enteral feeding
        
        • Preferred method is enteral gastric or small bowel feeding
        
        Verification of tube placement by X-ray, exit markings and aspirate
      - Complications
        
        • Cardiovascular
        
        ○ Blood vessel compression by increased pressure
        
        ○ Compromised venous return
        
        ○ Decreased Cardiac Output
        
        ○ Hypotension
        
        • Pulmonary system
        
        ○ Barotrauma
        
        ○ Volutrauma
        
        ○ Alveolar hypoventilation
        
        ○ Alveolar hyperventilation
        
        ○ Ventilator-associated pneumonia
        
        • Sodium and water imbalances
        
        • Neurologic system
        
        ○ Impaired cerebral blood flow
        
        • GI
        
        ○ Ulcers from stress
        
        ○ GI dilation from gas accumulation
        
        • Musculoskeletal
        
        ○ Loss of muscle strength
        
        • Psychosocial
        
        Machine disconnection or malfunction
- - - - Empty ventilator tubings when moisture collects.Never empty fluid in the tubing back into the cascade.
        
        Ensure humidity by keeping delivered air temperature maintained at body temperature
        
        Be sure the tracheostomy cuff (or endotracheal cuff) is adequately inflated to ensure tidal volume
        
        Auscultate the lungs for crackles, wheezes, equal breath sounds, and decreased or absent breath sounds.
        
        Check the pt's need for tracheal, oral, or nasal suctioning q2h and suction as needed
      - Assess the pt's mough around the ET tube for pressure ulcers
        
        Perform mouth care q2h
        
        Change tracheostomy tape or endotracheal tube tape as needed
        
        Carefully move the ET to the opposite side of the mouth once daily to prevent ulcers
        
        Provide tracheostomy care q8h
        
        Assess ventilated pts for GI distress (diarrhea, constipation, tarry stools)
        
        Maintain accurate I&O records to monitor fluid balance
        
        Turn the pt q2h & get the pt out of bed as prescribed to promote pulmonary hygiene and prevent complications of immobility
      - Schedule treatments and nursing care at intervals for rest
        
        Monitor the pt's progress on current ventilator settings, and make appropriate changes, as indicated.
        
        Monitor the pt for effectiveness of mechanical ventilation in terms of his or her physiologic and psychological status
        
        Monitor for adverse effects of mechanical ventilation: infection, barotrauma, reduced cardiac output
        
        Position the pt to facilitate ventilation-perfusion (V/Q matching; "good lung down")
        
        Monitor the effects of ventilator changes on oxygenation and the pt's subjective response
      - Monitor readiness to wean
        
        Explain all procedures and treatments; provide access to a call light; visit the patient frequently
        
        Provide a method of communication. Request consultation with a speech-language pathologist for assistance if necessary.
        
        Initiate relaxation techniques, as appropriate
        
        Administer muscle-paralyzing agents, sedatives, and narcotic analgesics, as prescribed
        
        Include the pt and family whenever possible (especially during suctioning and tracheostomy care)
- - - - Alarms and Nursing Intervention :warning:
        
        Increase mucous plug blocking the airway
        Suction as needed
        
        The patient coughs, gags, or bites on the oral ET tube
        Insert oral airway to prevent biting on the ET tube
        
        The patient is anxious or fights the ventilator
        Provide emotional support to decrease anxiety
        Increase flow rate
        Explain all procedures to the patient
        Provide sedation or paralyzing agent per the physician's prescription
        
        Airway size decreased related to wheezing or bronchospasm
        Auscultate breath sounds
        
        Pneumothorax occurs (Patient could complain of sharp pain and may lead to tightness in the chest)
        Alert the physician or Rapid Response Team about management of bronchospasm
        Auscultate breath sounds
        Alert the physician or Rapid Response Team about a new onset of decreased breath sounds or unequal chest excursion, which may be due to pneumothorax
        
        The artificial airway is displaced or the ET tube may have slipped into the right main stem bronchus
        Assess the chest for unequal breath sounds and chest excursion
        Obtain a chest X-ray as ordered to evaluate the position of the ET tube
        After the proper position is verified, tape the tube securely in place
        
        Obstruction in tubing occurs because the patient is lying on the tubing or there is water or a kink in the tubing.
        Assess the system, moving from the artificial airway towards the ventilator
        
        There is increased PIP (Peak airway {inspiration} pressure) associated with deliverance of a sigh
        Empty water from the ventilator tubing, and remove any kinks.
        Coordinate with respiratory therapist or physician to adjust the pressure alarm.
        
        Decreased compliance of the lungs is noted; a trend of gradually increasing PIP is noted over several hours or a day
        Evaluate the reason for the decrease compliance of the lungs
        Increase PIP occurs in ARDS, pneumonia, or any worsening of pulmonary disease
        
        High pressure Alarm
        (Alarm sounds when pressure is reached at 10-20mm Hg above the patient baseline PIP) :
        
        Low Exhaled Volume (low pressure)
        
        Alarm sounds when there is a disconnection or a leak in the ventilator circuit or a leak in the patients artificial airway cuff
        
        A leak in the ventilator circuit prevents breath from being delivered
        Assess all connections and all ventilator tubing for disconnection
        
        The patient stops spontaneous breathing in the SIMV or CPAP mode or on pressure support ventilation
        Evaluate the patient's tolerance of the mode
        
        A cuff leak occurs in the ET or tracheostomy tube
        Evaluate the patient for a cuff leak
        A cuff leak is suspected when the patient can talk (air escapes from the mouth) or when the pilot balloon on the artificial airway is flat
      - Assessing the tube position at least ever 2 hours
        
        Position the ventilator tubing in such a way that the patient can move without pulling on the ET or the tracheostomy tube.
        
        Mark the tubing where the tube touches the patients teeth or nose
        
        Give mouth care every 8 hours for hygiene and to prevent loosening of the tape that holds the tube.