Endotracheal Intubation/mv - Sja

Front 1

- 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

Back 1

Mechanical Ventilation

Front 2

- Gets O2 to the alveoli - exchange for CO2

Back 2

Oxygenation

Front 3

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

Back 3

Ventilation

Front 4

- 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

Back 4

Endotracheal Tubes

Front 5

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

Back 5

Indications for Endotracheal Tubes

Front 6

- 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

Back 6

Indications for having a Endotracheal Tube inserted:

Front 7

- 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.

Back 7

Risk with Oral Intubation

Front 8

- 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.

Back 8

Risk with Nasal Intubation

Front 9

- 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

Back 9

Explain Intubation procedure to patient

Front 10

- 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

Back 10

Intubation Procedures (con't)

Front 11

- 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

Back 11

intubation Procedure (con't)

Front 12

- 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

Back 12

Intubation Procedures (con't)

Front 13

- check marked LIP line

- document in cm

- symmetric chest wall movement

- Auscultate bilateral breath sounds

Back 13

Maintaining Correct Tube Placement of Endo Tubes

Front 14

- 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

Back 14

Maintaining proper cuff inflation

Front 15

- 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.

Back 15

Maintain proper cuff inflation

Front 16

- 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)

Back 16

Best ways to Monitor Oxygenation while pt. has an endotube

Front 17

- monitor RR, accessory muscle use, and PaCO2

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

Back 17

Best ways to Monitor Ventilation while pt. has an endotube

Front 18

- 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

Back 18

Capnography

Front 19

- 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

Back 19

Maintaining Tube Patency

Front 20

- non-sterile

- inline suctioning

- stays on the patient 24-48 hours

- flush to clear

Back 20

Closed suctioning

Front 21

- sterile technique

- pre O2 before suction

Back 21

Open suctioning

Front 22

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

- PT. HAS TO HAVE AN OPEN AIRWAY - SUCTION CAUTIOUSLY

Back 22

Complications associated with suctioning

Front 23

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

Back 23

How to treat thick secretions

Front 24

- 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

Back 24

Providing Oral Care and Maintaining Skin integrity

Front 25

- 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

Back 25

Providing oral care and maintaining skin integrity

Front 26

- 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

Back 26

Fostering Comfort

Front 27

- 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

Back 27

How to prevent a unplanned extubation

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

Front 28

- epiglottis constantly open due to ET

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

- ET balloon inflation - BLUE TIP IS ALWAYS FOR AIR INFLATION.

Back 28

Complications of endotracheal intubation-

ASPIRATION

Front 29

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

Back 29

NEGATIVE pressure ventilation

Front 30

- used for acutely ill patient

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

Back 30

Positive Pressure Ventilation PPV

Front 31

- 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

- CONSISTENT FROM BREATH TO BREATH BUT THE AIRWAY PRESSURE WILL VARY

- Alarms sound if pressure gets to high or low

Back 31

VOLUME ventilation

Front 32

- 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.

Back 32

PRESSURE ventilation

Front 33

- BASED ON ABGs

- ideal body weight

- LOC

- 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

Back 33

How the settings on a Mechanical Ventilator are adjusts

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

Front 34

Number of breaths the ventilator delivers per minutes

- 6-20 bpm

Back 34

RR

Front 35

Volume of gas delivered to patient during each ventilator breath

- 6-10 ml/kg

- 400-800 normal

Back 35

VT = Tidal Volume

Front 36

Fraction of inspired O2

Back 36

FIO2

21% = room air

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

Front 37

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

Back 37

Positive End Expiratory Pressure = PEEP

Front 38

- can cause cardiovascular problems by increasing intrathoracic pressure which decreases Cardiac Output = increase HR, decrease BP

Back 38

Problems with PEEP

Front 39

Positive pressure used to augment patient's inspiratory pressure

- 6-18 cm H20

Back 39

Pressure Support

Front 40

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

Back 40

I:E ratio

Front 41

Speed with which the VT is delievered

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

Back 41

Inspiratory flow rate & time

Front 42

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

Back 42

Sensitivity

Front 43

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)

Back 43

High Pressure Limit

Front 44

- 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)

Back 44

How the MODES of VOLUME VENTILATION are determined

Front 45

- 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!!

Back 45

Assist Control Ventilation (ACV)

Front 46

Indicated for: pt. with weakened or NO respiratory effort

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

Complications: hyperventilation-alkalosis

hypoventilation-acidosis.

- 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

Back 46

Assist Control Ventilation (ACV)

Front 47

- 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

Back 47

Synchronized Intermittent Mandatory Ventilation (SIMV)

Front 48

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

Back 48

SIMV

Front 49

- 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

Back 49

PRESSURE SUPPORT VENTILATION

Front 50

Indications: Weaning

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

NOT indicated for pts. in respiratory failure

WEANING CAN TAKE HOURS TO DAYS!

Back 50

PRESSURE SUPPORT VENTILATION