Intubation and Ventilation

Endotracheal Intubation

  • purpose of intubation is to maintain a patent airway, provide means to remove secretions, & provide ventilation & oxygen.

Mechanical Ventilation

Nursing Management for Mechanical Ventilation

Ventilation Alarms Nursing Interventions

Assess the patient's respiratory status at least every 4 hours for the first 24 hours and then prn
-Take vital signs q4h
-Assess the pt's color (especially lips and nail beds)
-Observe the pt's chest for bilateral expansion
-Assess the placement of the nasotracheal or endotracheal tube
-Obtain pulse oximetry reading
-Evaluate ABGs as available
-Maintain HOB more than 30 degrees when pt is supine to prevent aspiration and ventilator-associated pneumonie

  • Document pertinent observations in the patient's medical record
  • Check at least q8h to be sure the ventilator setting is prescribed
  • Check to be sure alarms are set (especially low-pressure and low-exhaled volume)
  • If the pt is on a PEEP, observe the peak airway pressure dial to determine the proper level of PEEP.
  • Check the exhaled volume digital display to be sure the pt is receiving the prescribed tidal volume

Endotracheal Tube

  • a long polyvinyl chloride tube passed through the mouth or nose & into the trachea.



  • Obtain consent before unless in emergent situation

  • Explain to patient reason for intubation, also explain that pt will not be able to speak while intubated , other forms of communication will be enforced
  • Have an ambu bag available & attached to O2, suction equipment, & an IV access.
  • Remove any dentures and administer medications as ordered
  • Rapid-sequence intubation (RSI) --administration of sedative and paralytic agent to decrease risk of aspiration and injury to patient.
  • before intubation pre oxygenate the pt with ambu bag for about 3-5 min.
  • Oral route -- place the pt in supine w/ head extended & neck flexed (sniffing position), this allows visualization of vocal cords
  • Nasal route -- do not use in patients w/ blood clotting problems, nasal passage may be sprayed w/ local anesthetic & vasoconstrictor
  • each intubation attempt is limited to 30 secs. or less, ventilate the pt between attempts
  • Nurse should monitor for changes in VS, signs of hypoxia, hypoxemia, dysrhythmias & aspiration
  • After intubation, inflate the cuff & confirm placement -- 2cm above the carina
  • ET tube is connected to either humidified air, O2, or a mechanical ventilator
  • 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

Mechanical ventilators have alarm systems that warn of a problem with either the patient or the ventilator. The Alarm system should always be activated and functioning at all times. If the cause of the alarm is undetermined, ventilating the patient manually with a resuscitation bag until the problem has been corrected by other health care professionals.
The major alarms on a ventilator are caused by high pressure or a low exhaled volume 🚩

Maintain a patent airway by suctioning for the following complications and assess and care for ET or tracheostomy tube which ensures a patent airway:

  • Secretions
  • Increased peak airway pressure (PIP)
  • Rhonci (wheezes)
  • Decreased breath sounds

Alarms and Nursing Intervention ⚠

  • 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

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

  • 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)

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

Verifying Tube Placement

  • Check end-tidal carbon dioxide levels (35-45 mmHg)
  • Chest X-Ray
  • Auscultate lungs for bilateral breath sounds & the epigastrium for the absence of air sounds. Observe for symmetric chest wall movement.

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

Who needs intubation/ventilation?

  • Patients w/ hypoxemia and progressive alveolar hypoventilation with respiratory acidosis
  • Patients who need ventilatory support after surgery
  • Patients who expend too much energy with breathing and barely maintain adequate gas exchange
  • Patients who have general anesthesia or heavy sedation

Stabilizing the Tube

  • Tube is marked at the level where it touches the incisor tooth or naris
  • Use the head halter technique to secure tube -- Table 34-9
  • Insert a a bite block

Nursing Management
✅ maintain correct tube placement

  • prevent tugging or pulling on the tube
  • suctioning, coughing, & speaking can cause dislodgment
    ✅ maintain proper cuff inflation
  • measure & record the cuff pressure on a routine basis using the MOV or MLT technique
  • maintain cuff pressure at 20-25 cm H2O
    ✅ monitor oxygen & ventilation
  • ABGs, SpO2, ScvO2/ SvO2
  • assess for signs of hypoxemia
  • assess respirations for rate, rhythm, & use of accessory muscles
  • PETCO2
    ✅ maintain tube patency
  • do not routinely suction a pt, assess to determine if suctioning is needed
    ✅ provide oral care & maintain skin integrity
  • moisten the lips, tongue, & gums w/ saline or water swabs to prevent mucosal drying
  • retape the ET tube as needed
    ✅ foster comfort & communication
  • pt may experience anxiety
  • pt may need morphine, lorazepam, propofol, or other sedatives to relieve anxiety & discomfort

Complications 🚩
Unplanned Extubation

  • pt talking
  • activation of the low-pressure ventilator alarm
  • diminished or absent breath sounds
  • respiratory distress
  • gastric distention

Aspiration

  • ET tube passes through the epiglottis, splitting it in a open position
  • improper cuff inflation
  • pt positioning
  • tracheoesophageal fistula

types

Possitive Pressure
During inspiration ventilator pushes air in.

Negative Pressure
• Chamber that encases chest
• Surrounds it with sub atmospheric pressure
• Causes chest to be pulled outward
• Pressure inside decreases pulling air in
Neuromuscular disorders, CNS disorders, spinal cord, severe COPD

types

volume ventilation

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.

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.

nutritional therapy

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.

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

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

  • 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.