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51 Cards in this Set

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- Process by which oxygen (FIO2) is moved in and out of the lungs by a mechanical ventilator

- Indications: apnea, acute resp. failure, severe hypoxia and resp. muscle fatigue

Mechanical Ventilation

- Gets O2 to the alveoli - exchange for CO2


Actually getting the O2 down into the alveoli, lungs, etc...


- inserted into the trachea via the nose or mouth by using a laryngoscope

- ORAL intubation is the preferred route

- Usually done by anesthesia or CRNA

Endotracheal Tubes

-used for upper airway obstruction, apnea, risk for aspiration, ineffective airway clearance and respiratory distress

Indications for Endotracheal Tubes

- should be placed 2-6 cm (1-2") above the carina: pt. will cough/gag a lot

- if only the Right Side of chest is rising the trach is inside the R. mainstem bronchus ... must withdraw a little

Indications for having a Endotracheal Tube inserted:

- difficult to place if head or neck mobility is limited ex: spinal cord injury

- can cause chipped teeth

- increased salivation/difficulty swallowing

- Biting on ET tube: may need a bite blook or oral pharyngeal airway and oral care is difficult due to limited space.

Risk with Oral Intubation

- contraindicated in facial injuries or basilar skull fractures

- WOB more difficult because of smaller tube

- can get kinked

- linked to increase incidence of sinus infections and VAP.

Risk with Nasal Intubation

- explain, consent (if non-emergent), reason, tell them they won't be able to speak while intubated, hands may be restrained for safety

- AMBUbag connected to O2 delivers 90-95% of O2

- suction equipment (make sure its working)

- communication can be very difficult

Explain Intubation procedure to patient

- remove dentures, sedation (versed, fentanyl, succinylcholine), pt. supine with neck flexed (sniffing position)

**- pre-oxygenate for 3-5 min.)**

- each try is limited to 30 seconds

-ventilate between each attempt

Intubation Procedures (con't)

- inflate cuff and confirm placement

- continue to manually ventilate

- listen to bilateral breath sounds

**- End tidal CO2 detector** FIRST

If NO CO2 detected, tube is in the esophagus)

- secure ET tube - Tape or Velcro holder

- assess for rise and fall of chest

intubation Procedure (con't)

- once proper placement is confirmed - mark position on ET tube at lip line

- 21 for women and 23 for men.

- ET tube connected to ventilator or O2

- OBTAIN ABG: baseline then to guide ventilator adjustments

Intubation Procedures (con't)

- check marked LIP line

- document in cm

- symmetric chest wall movement

- Auscultate bilateral breath sounds

Maintaining Correct Tube Placement of Endo Tubes

- balloon cuff on ET tube:

- seals the trachea

- prevents escape of oxygen

- excess inflation can cause tissue damage to trachea

- use manometer to maintain cuff pressure between 20-25 cm of H20

Maintaining proper cuff inflation

- Minimal occluding volume (MOV)

- place steth over trachea and inflate until no air leak is present

- Minimal leak technique (MLT)

- place steth over trachea and remove air- a slight air leak is noted at peak inflation.

Maintain proper cuff inflation

- assess ABGs & Spo2

- lower values may be seen in COPD pts.

- assess for sign of hypoxemia

- mental status changes, anxiety, dusky skin, dysrhythmias, KEEP HOB 30-45 (helps prevent VAP)

Best ways to Monitor Oxygenation while pt. has an endotube

- monitor RR, accessory muscle use, and PaCO2

- PaCO2 is the best indicator of alveolar ventilation - indicates hypo/hyperventilation (45-35 is normal)

Best ways to Monitor Ventilation while pt. has an endotube

- looks to see how well CO2 is being removed from the body

- analyzes gas directly

- assess patency of airway and ventilation and gradual changes in CO2

- CO2 increases = sepsis, hypoventilation

- CO2 decrease = hypothermia, decreases in CO


- Suctioning - PRN only (no suction for wheezing)

- visible secretions

- suspected aspirations of secretions (ask the pt.)

- sudden onset respiratory distress (pt. anxious)

- increase in peak airway pressure

- ausc. for adventitious breath sounds

- increase in RR or sustained coughing

- sudden or gradual decrease in PaO2 or SpO2

Maintaining Tube Patency

- non-sterile

- inline suctioning

- stays on the patient 24-48 hours

- flush to clear

Closed suctioning

- sterile technique

- pre O2 before suction

Open suctioning

- hypoxemia, bronchospasm, INCREASE ICP, dysrhythmias, hyper/hypotension, pulmonary tissue trauma, pain, infection


Complications associated with suctioning

- provide adequate hydration (is the pt. getting enough IV fluids), humidification, mobilization (turn q2h), postural drainage, percussion

How to treat thick secretions

- moisten lips, tongue and gums with saline and water to prevent drying (H202 2-4hours, & chlorhexidine - 2/day)

- meticulous skin care to prevent breakdown

- reposition tube q2h and re-tape

- remove bite block and provide oral care

Providing Oral Care and Maintaining Skin integrity

- check cuff inflation - manometer or stethoscope (minimally occlusive or minimal leak)

- secure tube - tape/tube holder

- use 2 people to reposition ET tube

For NASAL intubation - clean skin and re-tape q24h

Providing oral care and maintaining skin integrity

- major stressor- can cause stomach stress ulcers - pt. should be on protonix or other PPI

- provide: communication boards, note pads, I pads, explain procedures, present a calm reassurance

- Even if pt. is unconscious (coma) talk to pt. and explain what you are doing

Fostering Comfort

- pt. talking, low pressure alarms, diminished breath sounds, respiratory distress

- assess security of ET tube

- PREVENTION: sedation and soft restraints

- HOB 35-40

- stay with pt. and prepare to reintubate

- prior to planned extubation - suction to prevent aspiration

How to prevent a unplanned extubation

- nurses can extubate with an order, however, must suction tube & mouth, back of throat to prevent aspiration

- epiglottis constantly open due to ET

- High risk for aspiration (excessive salivation or gastric secretions, oral suctioning)


Complications of endotracheal intubation-


old fashioned - chambers that encase the chest or body and surround it with intermittent subatmospheric pressure - iron lung, polio epidemic - more for neuromuscular disease

NEGATIVE pressure ventilation

- used for acutely ill patient

- during inspiration the ventilator PUSHES air into lungs under positive pressure

Positive Pressure Ventilation PPV

- predetermined tidal volume(Vt) is delivered with each inspiration but the amount of pressure needed to deliver the breath varies on compliance and resistance of the patient-ventilator system


- Alarms sound if pressure gets to high or low

VOLUME ventilation

- Peak inspiratory pressure is predetermined and tidal volume (Vt) delivered to the patient varies based on the selected pressure and compliance and resistance factors of the system.

- PRESSURE is consistent but the tidal volume (Vt) varies.

PRESSURE ventilation


- ideal body weight


- Muscle strength

- FINE TUNE to reach optimal ventilator support

- Check all alarms to assess function = nurse

- ABGs drawn q15m until optimal ventilation support is reached

How the settings on a Mechanical Ventilator are adjusts

(Nurses don't adjust setting - this is done by RT)

Number of breaths the ventilator delivers per minutes

- 6-20 bpm


Volume of gas delivered to patient during each ventilator breath

- 6-10 ml/kg

- 400-800 normal

VT = Tidal Volume
Fraction of inspired O2


21% = room air

100% = what the ventilator is normally set at when first set up

Positive pressure applied at the end of expiratory

- OPENS up alveoli to allow for better gas exchange

- 5 cm H20 is normal physiological peep

- can go as high at 18

Positive End Expiratory Pressure = PEEP
- can cause cardiovascular problems by increasing intrathoracic pressure which decreases Cardiac Output = increase HR, decrease BP

Problems with PEEP

Positive pressure used to augment patient's inspiratory pressure

- 6-18 cm H20

Pressure Support

Duration of inspiration to duration of expiration

- 1:2 is normal

- machine can change this and reserve

- patient MUST be sedated because is goes against our normal breathing pattern

I:E ratio

Speed with which the VT is delievered

- 40-80 L/min or 0.8- 1.2 seconds

Inspiratory flow rate & time

Determines amount of effort the patient must generate to initiate a ventilator breath


Maximal pressure the ventilator can generate to deliver VT.

- what kind of PRESSURE has to be applied to deliver VT (tidal volume)

(VT= volume of gas delievered to pt. during each ventilator breath)

High Pressure Limit

- Based on WOB the pt. can perform

- WOB: is the inspiratory effort needed to overcome the elasticity and viscosity of the lungs along with airway resistance

- MODE is determined by ventilator status, ABGs & resp. drive (if a pt. has NO resp. drive they can't go on some ventilator modes)

HIGH WOB= Pt. is trying really hard but unable to move much air (THINK ASTHMA)

How the MODES of VOLUME VENTILATION are determined

- vent is doing most of the work but the patient can breath OVER the setting.

- pt. can breath faster than the setting but not slower

- ventilator delivers a preset VT at a preset frequency

- no matter how many breaths the pt takes the preset VT will deliver amount for EACH BREATH

Ex: VT of 500X12 breaths= 500 w/each breath - this can cause HYPERVENTILATION!!

Assist Control Ventilation (ACV)

Indicated for: pt. with weakened or NO respiratory effort

- high level spinal cord injury, Guillain-Barre, pulmonary edema & ARF

Complications: hyperventilation-alkalosis


- Ventilatory Asynchrony (fighting/bucking vent) pt will be coughing/agitated

Interventions: talk pt. down, Are you in pain?, try to get them back into synch w/vent - If unable - must sedate

Assist Control Ventilation (ACV)

- vent. senses that the pt. wants to breath on their own

-delivers preset VT at a preset # of breaths in synch with pt. spontaneous breathing

PT will receive preset O2 but self-regulates rate and volume, thereby reducing chance of hyperventilation

Synchronized Intermittent Mandatory Ventilation (SIMV)

Indication: weaning from vent. norm resp. drive but muscles too weak to perform all WOB

- improves synchrony w/pt. breaths and prevents muscle atrophy

- Complications: if spontaneous breathing decreased or rate gets to low hypoventilation will result.

- may cause increased muscle fatigue


- positive pressure to airway ONLY during inspiration

- Airway pressure is preset so gas flow rate is GREATER than pts. inspiratory flow rate.

- pt. determines inspiratory length and RR


Indications: Weaning

Advantages: increased pt. comfort, decreased WOB (inspiration is augmented), decreased O2 consumption, increased endurance

NOT indicated for pts. in respiratory failure