MECHANICAL VENTILATIONMECHANICAL VENTILATION

INTUBATIONINTUBATION

Endotracheal Intubation:Endotracheal Intubation: Placement of tube into trachea through Placement of tube into trachea through

mouth or nosemouth or nose

Indications:Indications: Upper airway obstructionUpper airway obstruction Facilitate secretion removalFacilitate secretion removal For positive pressure ventilationFor positive pressure ventilation

Endotracheal TubeEndotracheal Tube

Endotracheal Tube PlacementEndotracheal Tube Placement

Complications of Endotracheal Complications of Endotracheal IntubationIntubation

Improper placementImproper placement

Esophageal intubationEsophageal intubation

Right mainstream intubationRight mainstream intubation

Management: auscultate, CXR, bilateral Management: auscultate, CXR, bilateral respiration, mark point at lips/noserespiration, mark point at lips/nose

Complications of Endotracheal Complications of Endotracheal IntubationIntubation

Cuff problemsCuff problems

Ineffective seal leads to aspirationIneffective seal leads to aspiration

Too much pressure leads to tracheal Too much pressure leads to tracheal necrosisnecrosis

Use minimal occluding volume (keep Use minimal occluding volume (keep pressure <20 mm Hg)pressure <20 mm Hg)

Suction throat before deflationSuction throat before deflation

Nursing Role: IntubationNursing Role: Intubation

Maintain correct placementMaintain correct placement Maintain proper inflationMaintain proper inflation Maintain/monitor ventilation and Maintain/monitor ventilation and

oxygenationoxygenation Maintain tube patencyMaintain tube patency Mouth care; repositioning ET; promote Mouth care; repositioning ET; promote

communicationcommunication

Complications of ExtubationComplications of Extubation

Laryngeal edema or spasmLaryngeal edema or spasm

Respiratory failureRespiratory failure

Mechanical VentilationMechanical Ventilation Air/O2 moves in and out of lungs via machine

Types VentilatorsTypes Ventilators

Negative PressureNegative Pressure Positive Pressure*Positive Pressure*

Ventilator Settings

Rate Tidal volume FIO2 Pressure limit PEEP Alarms etc

Mechanical VentilationMechanical Ventilation

Three types Positive Pressure Ventilators Volume-cycled: terminates breath when

preset volume delivered Time-cycled: terminates breath after

preset time elapsed Pressure-cycled: terminates when

present airway pressure achieved

Volume-Cycled Ventilators:Volume-Cycled Ventilators:ModesModes

Controlled mechanical ventilationControlled mechanical ventilation

Preset volumePreset volume

Preset ratePreset rate

Unable to trigger (initiate a breath)Unable to trigger (initiate a breath)

Volume-Cycled Ventilators:Volume-Cycled Ventilators:ModesModes

Assist-Control ventilationAssist-Control ventilationPreset volumePreset volumePresent ratePresent rateCan trigger and receive more Can trigger and receive more

than preset rate than preset rate Patient-triggered breaths are Patient-triggered breaths are

delivered at preset volumedelivered at preset volume

Volume-Cycled Ventilators:Volume-Cycled Ventilators:ModesModes

Synchronized Intermittent Mandatory Synchronized Intermittent Mandatory ventilation (SIMV)ventilation (SIMV)

Preset volume and ratePreset volume and rate

Spontaneous breathingSpontaneous breathing

Spontaneous breaths not assisted Spontaneous breaths not assisted (patient’s own volume)(patient’s own volume)

Often used for weaningOften used for weaning

Other Ventilation Other Ventilation ManeuversManeuvers

PEEP PEEP Positive end-expiratory pressurePositive end-expiratory pressure

Application positive pressure during Application positive pressure during ventilationventilation

Increases distension of alveoliIncreases distension of alveoli

Prevents alveolar collapse Prevents alveolar collapse

““Recruits” previously collapsed alveoliRecruits” previously collapsed alveoli

Other Ventilation Other Ventilation ManeuversManeuvers

PEEPPEEP

Increases surface area available for gas Increases surface area available for gas exchangeexchange

Allows delivery lower FIOAllows delivery lower FIO22: reducing risk O: reducing risk O22 toxicitytoxicity

ComplicationsComplications Reduced COReduced CO BarotraumaBarotrauma

Other Ventilation Other Ventilation ManeuversManeuvers

CPAP CPAP

Continuous positive airway pressureContinuous positive airway pressure

Continuous (i.e., inspiration and Continuous (i.e., inspiration and expiration) positive pressure applied to expiration) positive pressure applied to airwayairway

For spontaneously breathing patientsFor spontaneously breathing patients

Other Ventilation Other Ventilation ManeuversManeuvers

Pressure Support Ventilation (PSV)Pressure Support Ventilation (PSV) Positive pressure applied only on Positive pressure applied only on

inspirationinspiration Applied to spontaneous breaths onlyApplied to spontaneous breaths only Supports inspiratory effortSupports inspiratory effort Patient determines inspiratory length Patient determines inspiratory length

and rateand rate Often used for weaningOften used for weaning

Mechanical Ventilation: Mechanical Ventilation: ComplicationsComplications

CVSCVS Increased intrathoracic pressureIncreased intrathoracic pressure Reduced COReduced CO

PulmonaryPulmonary Barotrauma (trauma d/t pressure)Barotrauma (trauma d/t pressure)

PneumothoraxPneumothorax PneumomediastinumPneumomediastinum Subcutaneous emphysemaSubcutaneous emphysema

Mechanical Ventilation: Mechanical Ventilation: ComplicationsComplications

PulmonaryPulmonary

Alveolar hypoventilationAlveolar hypoventilation

Cuff leakCuff leak

Ventilator settingsVentilator settings

SecretionsSecretions

AtelectasisAtelectasis

Mechanical Ventilation: Mechanical Ventilation: ComplicationsComplications

PulmonaryPulmonary

Alveolar hyperventilationAlveolar hyperventilation Due to hypoxemia, fear, pain, anxiety → alkalosisDue to hypoxemia, fear, pain, anxiety → alkalosis

RX: sedate, analgesia, communication, correct hypoxemiaRX: sedate, analgesia, communication, correct hypoxemia

Due to inappropriate ventilator settings Due to inappropriate ventilator settings high tidal volumehigh tidal volume High rateHigh rate

Pulmonary InfectionPulmonary Infection Upper airway defenses bypassedUpper airway defenses bypassed

Mechanical Ventilation: Mechanical Ventilation: ComplicationsComplications

Neurological complicationsNeurological complications

Positive pressure ventilation → increased Positive pressure ventilation → increased intrathoracic pressureintrathoracic pressure

interferes with venous drainage; increased ICPinterferes with venous drainage; increased ICP

GIGI

Stess ulcers and GI bleeds; Rx with HStess ulcers and GI bleeds; Rx with H22 receptor receptor blockersblockers

MV → Gastric and bowel dilationMV → Gastric and bowel dilation

Mechanical Ventilation: Mechanical Ventilation: ComplicationsComplications

MusculoskeltalMusculoskeltal Muscle atrophy d/t immobilizationMuscle atrophy d/t immobilization

MobilizeMobilize ROMROM

PsychologicPsychologic StressStress Communication very importantCommunication very important Sedate, explain, family visits, pain Sedate, explain, family visits, pain

managementmanagement Facilitate expression of needsFacilitate expression of needs

WeaningWeaning

Criteria Criteria Effective coughEffective cough Adequate respiratory muscle strengthAdequate respiratory muscle strength

WeaningWeaning

Approaches to weaningApproaches to weaning T-piece (spontaneous breathing for short T-piece (spontaneous breathing for short

periods of time)periods of time) SIMV, PSVSIMV, PSV

WeaningWeaning Monitor closelyMonitor closely

resp rateresp rate accessory muscle useaccessory muscle use shallow respirationsshallow respirations paradoxical breathingparadoxical breathing ABGsABGs

rising PCOrising PCO22 → acidosis → acidosis falling PO2falling PO2 BP (↓ or ↑)BP (↓ or ↑) LOC (restless, tiring, somnolence, anxiety)LOC (restless, tiring, somnolence, anxiety) Pulse oximeterPulse oximeter