Lesson 4 Airway ManagementFrom American Association of Critical Care NursesEssentials of Critical Care Orientation

PRESENTED BY:

KATY ZAHNER RN, BSN, CCRN

NURSE EDUCATOR STUDENT

GEORGETOWN UNIVERSITY

Objectives

Identify indications, complications, and management methods for artificial airways and oxygen delivery devices

Describe and discuss monitoring devices used to determine oxygenation

Identify indications, complications, and management methods for non-invasive pressure ventilation

Oxygen

Why do we administer oxygen? Delivery systems

High, low and reservoir systems

Administration Nursing Assessment

Complications O2 toxicity, absorption atelectasis, CO2 retention

(COPD)

Noninvasive positive pressure ventilation (NPPV)

Used to deliver PPV with or without o2 BiPAP – 2 levels of pressure = IPAP and EPAP Requires the patient to maintain spontaneous ventilation Use of face or nasal mask Chronic vs. acute use Patient populations

COPD

Hypoxemic respiratory failure – hemodynamically stable

Extubation failure

Cardiogenic pulmonary edema

AACN Practice Pearls

Room Air (RA) 21% SpO2 tells nothing about CO2 Change in LOC is a sensitive indicator for

hypoxemia Patients with Fio2 > 50% for longer than 24

hours are at high risk for complications related to o2 toxicity

Artificial Airways

Endotracheal tube

Requires endotracheal intubation

Indications

Anesthesia/Surgery

Protect airway

Removal of secretions

Respiratory failure

Characteristics

7.0 – 9.0mm diameter

Radiopaque line

Low pressure high-volume balloon with inflation port

Equipment Needed for Intubation

Intubation tray

Suction

Manual resuscitation bag with mask and O2

Water-soluble lubricant

10ml syringe for inflation of cuff

Tape or ETT device

Stethoscope

Monitoring equipment

Secondary confirmation device

Medications

Ventilator

Anesthetic spray

Intubation Procedure

https://www.youtube.com/watch?v=0VGiBwyfuNI

Nursing Interventions

Prevent skin breakdown around tube Evaluate for inflammation and ulceration of the nose

or mouth Implement treatment for sinus or ear infections Assess for airway injury and/or displacement of ETT

Tracheostomy

Placed when long-term mechanical ventilation is expected (>10-14 days)

Neuromuscular disease

Obstruction of upper airways

Facilitates airway maintenance

Increases patient comfort

**Research shows that early transition (<48 hours) of the patient from ETT to tracheostomy tube offers improved outcomes

Tracheostomy Tubes Characteristics

Sized by inner diameter Inner cannula Universal adapter Decannulation plug

Placing Tracheostomy Tube

Complications – Not the same as ETT

Either surgically or placed percutaneous at bedside

Complication –hemorrhage, wound infection, subcutaneous emphysema

Additional complications Displacement or obstruction

Tracheal stenosis

Tracheoesophageal fistula

Tracheoinonimate artery fistula

Tracheal malascia

Scarring after decannulation

Nursing Interventions

Monitor for tube positioning and patency Assess skin surrounding tracheostomy Evaluate secretions Cuff management Assess breath sounds Sterile suctioning Oral care

Lesson 6Thoracic Surgical Procedures

Objectives

Discuss the types of and indications for, and common complications of thoracic surgical procedures

Describe different systems and principles of management for chest tubes Discuss the indications for, common complications of and nursing

management of patients undergoing video-assisted thoracoscopy, thoracotomy, and pneumonectomy

Compare and contrast the different types of closed chest drainage systems

Describe the nursing management of patients with chest tubes

Thoracic Surgery

Why? Remove tumor and abscess

Surgically resect a segment, lobe or full lung

Repair esophagus or thoracic vessels

Types Pneumonectomy

Lobectomy

Segmental resection

Open lung biopsy

Lung volume reduction surgery

Decortication

Bullectomy

VATS

Drainage of empyema

Preoperative Conditions

Lung function Cardiac function Tumor removal Pain management

Clinical Approach

Incision usually posterolateral

Depends on location of operative area

ETT with double-lumen common

When full lung removed, evaluation of position of mediastinum and trachea before surgical site closed

Postoperative Complications

Hemorrhage

Acute respiratory failure

Pneumonia

Pain

Mediastinal shift Development of bronchopleural fistula, hemorrhage, and

cardiovascular compromise

Postoperative ComplicationsHemorrhage

Life threatening

Most likely to occur during immediate postoperative period

Potential causes: Dislodged suture or clip

Bleeding from intercostal or bronchial artery

Potential indicators: Fresh red blood

Sudden increase in drainage

Drainage volume exceeding 100ml/hr

Postoperative ComplicationsBronchopulmonary Fistula

Suture line does not hold Can be compromised by mechanical ventilation and high

airway pressures

Early weaning is a priority

Indicators: Shortness of breath, cough, hemoptysis

High postoperative mortality rate

Postoperative ComplicationsMediastinal Shift

Accumulation of fluid or an increase in pressure on the surgical side

Remove air or fluid on surgical side Chest tubes

Postoperative ComplicationsCardiovascular

Can occur as a result of large volume of lung tissue and pulmonary vascular bed is resected

Use of vasoactive medications may be indicated to optimize cardiac function

Postoperative Interventions

Goal: Maximize oxygen and ventilation and prevent complications

Interventions Patient positioning and pain management

Maintain chest tube system

Assist with progressive patient activity

Pain management

Pain Management

Indicators of pain Tachypnea

Tachycardia

Increased BP

Grimacing, splinting or moaning

Unwillingness to move and restlessness

Narcotic infusion through epidural of patient-controlled analgesia device may be indicated Medicate sufficiently to allow for deep inspiration

Insertion and Management of Chest Tubes

Why insert a chest tube?

Eliminate air or fluid that has accumulated resulting in compromised ling function

Placed in the pleural space – 4th or 5th intercostal space

Connects to drainage system

X-ray used for confirmation after placement

Average size 28Fr – 40Fr

https://www.youtube.com/watch?v=Hn0SHGuUVak

Chest Drainage Systems

Drainage chamber

Water seal chamber

Suction control chamber

Patient Care

Regularly assess pulmonary status

Measure and record output regularly

Institutional policies related to “milking the tube” Stripping entire length is contraindicated – results in transient HIGH

negative pressures in the pleural space and lung entrapment

Inspection Redness

Swelling

Pain

Purulent drainage

Emergent Response and Troubleshooting

Have sterile water and package of petroleum gauze available If air leak was present before accidental dislodgement of

chest tube, application of occlusive dressing may result in tension pneumothorax

Troubleshooting Chest tube dislodgement

Cessation of drainage

Collection chamber falls

Troubleshooting

Water Seal Chamber Problems present if fluctuation with

inspiration and expiration

Examine entire system beginning at insertion site of patient

Suction Control Chamber Problems present if bubbling absent

Address leaks in the system

Chest Tube Removal Preparation

Timing of removal

Explain procedure to patient

Done during deep breath by patient after cleaning site

Chest X-ray

Observe patient for signs of pneumothorax

Lesson 5Basic Ventilator management

Objectives

Describe endotracheal intubation and discuss nursing considerations

Discuss the management of patients with tracheostomy tube

Compare and contrast the indications, complications and nursing management considerations for commonly used ventilator modes including PPV, pressure controlled/inverse ratio ventilation and volume guaranteed pressure mode ventilation

Discuss nursing care of the mechanically ventilated patient

Describe the common pharmacologic interventions utilized to assist with managing patients

Discuss techniques for the prevention of ventilator acquired pneumonia

Discuss common problems encountered with mechanical ventilators and how to troubleshoot them

Identify key factors that impact ventilator weaning

Describe nursing management of patients who are being weaned from mechanical ventialtion

Mechanical Ventilation

Goal – support gas exchange Indications

Apnea

Acute impending respiratory failure

Severe hypoxemia

Respiratory muscle fatigue

Support during anesthesia or sedation

Mechanical ventilation

2 types Negative and positive pressure

Negative referred to as iron lung

No artificial airway

polio

Positive pressure

Most common

Used with artificial airway

Modes of Ventilation

Ventilator cycle functions Modes

Volume or pressure

Ventilator settings

Mechanical Ventilation ModesVolume

Set amount of volume (Vt) will be delivered to lungs

Common volume modes

Continuous mandatory ventilation (CMV)

Assist – controlled (AC)

IMV/SIMV – intermittent mandatory ventilation/synchronized

Settings

Rate (f)

Tidal volume (Vt)

FIO2

Sensitivity

Positive End Expiratory Pressure (PEEP)

Mechanical Ventilation ModesPressure

Desired pressure is set to achieve Vt

Used for lung protective strategies and noncompliant lungs

Modes include

Pressure Support Ventilation

Pressure Control

CPAP

Settings:

RR

FiO2

Inspiratory Pressure Level (IPL)

Inspiratory time

PEEP

Complications of Mechanical Ventilation

Changes in intrathoracic pressure

Cardiovascular complications

Barotrauma

Volutrauma

GI complications

Patient Ventilator Dysynchrony

Ventilator Associated Pneumonia

Nursing interventions

Troubleshooting Ventilators

1st – Respond to the alarm

2nd – Look at the patient!

Manually ventilate patient if needed

DOPE

Ensure alarms are set within safe parameters

Common alarms include:

High peak inspiratory pressure (PIP)

Low Vt

Apnea

Nursing Assessment

Assess for effectiveness of mechanical ventilation

Monitor for changes that would indicate a presence of infection

Monitor ventilator function according to unit policy

Assess airway position and suction requirements

Position patient to provide the best opportunity for ventilation-perfusion

Ensure that ventilator alarms are set and functioning and that ventilator connections are intact

Evaluate for adequate hydration and nutritional support

Evaluate for anxiety and ventilator synchrony

Managing the Ventilated Patient

Sedation – Balance

Too much vs. Too little

Consequences of pain and anxiety

Stress response vasoconstriction increased HR, BP, RR release of aldosterone by adrenal cortex increased reabsorption of Na+ and Cl-

But Before Sedation …

Consider nonpharmacological interventions Establishing nonverbal communication

Calm voice and gentle touch

Frequent repositioning

Use of distraction

Noise or light reduction

Improving sleep

Guided imagery or massage therapy

Sedation

Goal of sedation Patient comfort

Control physiologic effects of anxiety

Patient management

Ordering of sedatives Collaborative decision

No single agent is adequate in critical care setting

Assessment of Sedation

Continuous vs. Bolus administration Use sedation “holidays”

Dependent on institution

Several scales are available RASS

Pitfalls of Over/Undersedation

Liver failure Can result in over or undersedation

Oversedation Respiratory depression, hypotension, bradycardia and potential

thromboembolism

Undersedation Patient aware of situation, decreased comfort and increased

agitation and combativeness

Attempt to pull out tubes and lines

Neuromuscular Blockade Agents (NMBA)

May be necessary WITH sedatives and analgesics

ARDS

Increased intracranial pressure (ICP)

Use Train of Four (TOF) for patients receiving NMBA

NMBA associated with prolonged neuropathies and myopathies and increased patient morbidity

Paralytic agents may ONLY be used in patients who are mechanically ventilated

No sedative or analgesic properties

Weaning from Mechanical Ventilation

Starts when patient intubated and mechanical ventilated Underlying illness is improved

Patient must be hemodynamically stable

Helped by having correct size ETT Evaluation of mechanics of ventilation and muscle

strength CPAP, PSV, T-piece

Nutritional support

Weaning

Use standardized protocols

Reconditioning the muscles of ventilation

Especially if patient has been on mechanical ventilator for long period of time

Specific patient prerequisites ABG WNL – FiO2 < 0.50, minute ventilation < 10L/min, PEEP < 5cmH20

Negative inspiratory pressure at least -20cmH2O

Spontaneous Vt > 5ml/kg

Vital Capacity > 10ml/kg

RR < 30 breaths/min

Rapid shallow-breathing index < 100-105 (RR/Vt)

Weaning Methods/Modes

Spontaneous Breathing Trials (SBT): Humidified O2 30-120 minutes

SIMV: Gradually reduce the number of ventilator induced breaths

Pressure Support Ventilation (PSV) – Gradually reduce PSV level

Facilitating Weaning Process

Explain process to patient and family

Optimal positioning

Decrease sedation

Analgesia as indicated

Remain with patient

Avoid physical exertion or painful procedures during this time

Optimize environment

Assess breath sounds and secretions

VS

Trend O2 saturation

Evaluate WOB

Weaning Intolerance

Need to return to vent to “rest” Dyspnea

Increased RR, HR, BP

Shallow breaths or decrease in Vt

Accessory muscle use

Anxiety

Deterioration in SpO2 or ETCO2

Weaning Long-term Ventilator Patients

Can take up to weeks or months Weaning is goal since long-term mechanical

ventilation is associated with high morbidity and mortality

Use of protocols helpful Collaborative approach Specialized units Clear decisions with patient and family required

ReviewQuiz

Review Questions

When the nurse monitors the chamber with the water seal, which finding suggests that the system is functioning correctly?

a) The fluid rises and falls with respirations

b) The fluid level is lower than when first filled

c) The fluid bubbles continuously

d) The fluid looks frothy white

Answer = a

Review Question

Nursing interventions related to care of the tracheostomy include which of the following? (Select all that apply)

a) Suction Q1 hour

b) Pre-oxygenate and suction using sterile technique

c) Oral care

d) Perform tracheostomy change Every 72 hours

e) Suction patient with catheter until resistance is met and patient coughs

f) Assess skin surrounding tracheostomy

Answer – b, c, f

Review Question

True or False: Tracheal deviation to non-surgical side is a normal finding post pneumonectomy

Answer - False

Review Question

The nurse is caring for a patient in the emergency room who has been intubated and placed on mechanical ventilator. An ABG is obtained with the following results: pH – 7.32, PaCO2 – 60, PaO2 – 126, HCO3 – 28. Based on these results, which ventilator settings would be appropriate to be adjusted? Select all that apply.

a) FiO2

b) Rate

c) VT

d) PEEP

e) PIP

Answer – b, c

Modes commonly used when weaning from mechanical ventilation include which of the following? Select all that apply.

a) PSV

b) CPAP

c) Pressure control

d) Spontaneous breathing trial

e) Assist/control

Answer – a, b, d