Upgrade to remove ads
Only $2.99/month

Nursing Care of the Patient with Respiratory Failure

Terms in this set (199)

What 2 things cause respiratory insufficiency?
1) Increased work of breathing with gas exchange function near normal
2) Inability to maintain normal ABGs with development of hypoxemia & acidosis as a result of CO2 retention
Terminology
Apnea
Respiratory Failure
Respiratory Arrest
What is respiratory distress?
Difficulty breathing, also causes psychological issues with inability to breathe
Apnea is?
Temporary cessation of breathing, especially during sleep
Respiratory failure is?
The end result from inadequate gas exchange by the respiratory system (arterial O2, CO2, or both O2 & CO2 can't be kept at normal levels)
(results in hypoxemia & hypercapnia)
Alveoli
Normally increase in number from 20-70 million at birth to as many as 300-400 million at 2-8 yo
Types of Alveolar Cells
Type I alveolar cells
Type II alveolar cells
Type III alveolar cell macrophages
Surfactant
-Is made up of Lipoproteins
-Provides alveolar stability
-Adequate levels lead to better lung compliance & decrease work of breathing
What do lipoproteins do?
Coat inner surfaces of alveoli
V/Q Ratio (Normal Ventilation & Perfusion)
-When ventilation & perfusion are matched, un-oxygenated blood from the venous system returns to the RT Ventricle through the Pulmonary Artery to the Lungs.
-Carrying CO2.
Where does gas exchange occur?
In the alveolar capillaries
Low V/Q Ratio
-Pulmonary circulation is adequate but not enough oxygen is available to the alveoli for normal diffusion
-A portion of the blood flowing through the pulmonary vessels does not become oxygenated
What is Low V/Q ratio called?
Inadequate ventilation/shunt
Disorders Resulting in Low V/Q Ratios?
(Any obstruction of distal airways)
-PNA, Atelectasis, Tumor, & Mucus plug
High V/Q Ratio
-Ventilation is normal, but alveolar perfusion is reduced or absent.
-Capillaries narrow, indicating poor perfusion
What causes capillaries to narrow from high V/Q ratio?
(A perfusion defect)
-Pulmonary embolism
-Pulmonary infarction or any d/o that decreases CO
What is High V/Q ratio called?
Inadequate perfusion/dead-space ventilation
Disorders Resulting in High V/Q Ratios
-Pulmonary emboli
-Pulmonary infarct
Silent Unit is?
-Absence of ventilation & perfusion to the lung area
-May help compensate for a V/Q imbalance by delivering blood flow to better ventilated lung areas.
What is a Silent Unit referred to as?
Inadequate ventilation & perfusion
Disorders Resulting in Silent Unit
-Pneumothorax
-Severe acute respiratory distress syndrome (ARDS)
Effective gas exchange is dependent on?
-Lung volume & capacity
-Compliance
-Resistance to air flow
-Diffusion & perfusion
-Responsiveness of respiratory center in brain
What does the responsiveness of the respiratory center in the brain consist of?
Chemoreceptors & integrity of respiratory centers in brain
Patient assessment for respiratory failure/distress
-History (any co-morbidities: asthma, trauma, cardiac issues, meds)
-Onset (sudden or gradual)
-Duration
-Precipitating factors
-Aggravating factors
-Alleviating factors
-Risk factors
-Signs & symptoms
As a nurse, what would you assess in a patient with respiratory failure/distress?
-Behavior changes
-Fatigue/Weakness
-Dyspnea
-Tachypnea
-Orthopnea
-Pain
-Cough
-Sputum production
-Edema of lower extremities
-Lung sounds
-Asymmetrical chest movement
-Use of accessory muscles
-Skin
When assessing the patient for respiratory insufficiency, what are you looking for in the skin?
You're looking to see if the patient is cyanotic, looking for skin color changes.
Use of accessory muscles in pedi patients with respiratory distress/failure consists of?
-Retractions
-Flaring of nares
-Grunting
What is Hypoxemia?
A drop in the oxygen that's carried in the blood (oxygenation failure)
What is Hypercapnia?
-A rise in arterial carbon dioxide levels
(Failure of ventilation causes inadequate CO2 removal from the lungs/Ventilatory Failure)
What are the early s/s of Hypoxia?
-Mood change (subtle mental status changes)
-Headache
-Respiratory depth & pattern change
-Hypertension
-Exertional dyspnea (DOE)
-Anorexia
RTTD are signs of what condition, & what are they?
Hypoxia, & they are the cardinal s/s of hypoxia (restlessness, tachypnea, tachycardia, diaphoresis)
what are the cardinal s/s of Hypoxia?
-Restlessness
-Tachypnea
-Tachycardia
-Diaphoresis
Signs of More Severe Hypoxia
-HTN changing to hypotension
-Vision changes
-Change in LOC
-Dyspnea
-Bradypnea
-Bradycardia
-Cyanosis that's peripheral &/or central
Decompensation/changes of initial s/s of Hypoxia indicate what?
Respiratory failure
What is the goal for managing Hypoxia?
Decrease dyspnea & promote gas exchange
What interventions do you perform when trying to decrease dyspnea & promote gas exchange with Hypoxia?
-Oxygen therapy
-Positioning
-Pharmacologic therapy (give meds as ordered)
-Energy conservation (frequent rest periods, pursed lip breathing?)
-Nutritional therapy
What are the immediate nursing interventions for Hypoxia?
-Elevate HOB (1st thing to do is this!)
-Administer O2 (2nd thing to do is this!)
-Check VS & SpO2 (at least q ~15 min & prn)
-Lung sounds
-Do head to toe assessment
-Notify MD & family of change in patient status
-Obtain IV access
What are the ongoing nursing interventions for Hypoxia?
-Constant reassessment (looking for trends of VS, alert MD if changes)
-Monitor: VS, I&O, Fluid status, Nutritional status, labs, & responsiveness to treatment & care
With regards to ongoing nursing interventions with Hypoxia, what do you do if there's a change in the patient's status?
Notify MD!
Diagnostic testing for respiratory distress/failure?
-Pulse oximetry
-ABGs
-Chest X-ray
-CBC with differential
-Electrolytes
-Bronchoscopy
-Sputum studies
-PFTs
-V/Q scan
-CT
-CTA
Acute Respiratory Failure is?
-When oxygenation &/or ventilation is inadequate to meet the body's needs.
-Not a disease but a condition resulting from other disease processes
What's an important thing to consider with Acute Respiratory Failure?
Assess clinical assessment findings as well as the patient's baseline
What does Acute Respiratory Failure result from?
Inadequate gas exchange via:
-Hypoxemia
-Hypercapnia
What is the PaO2 range in Hypoxemia?
-PaO2 <60 mm Hg on inspired -O2 concentration >60%
What is the PaCO2 range in Hypercapnia?
Increase in PaCO2 above normal (>45 mm Hg)
Hypoxemic Respiratory Failure (Etiology & Pathophysiology)
Causes:
-Ventilation-perfusion (V/Q) mismatch
-Diffusion limitation
-Alveolar hypoventilation
V/Q Mismatch (hypoxemic respiratory failure) happens from?
COPD, Pneumonia, Asthma, Atelectasis, Pulmonary embolus
Diffusion Limitation (hypoxemic respiratory failure) happens from?
-Severe emphysema
-Pulmonary fibrosis
Alveolar Hypoventilation (hypoxemic respiratory failure) happens from?
-Restrictive lung disease
-CNS disease
-Chest wall dysfunction
-Neuromuscular disease
Hypercapnic Respiratory Failure (Etiology & Pathophysiology ) is caused from?
-Airways & alveoli
-CNS
-Neuromuscular conditions
-Chest wall
What are the airway & alveoli causes for Hypercapnic?
Asthma, Emphysema, Chronic Bronchitis, Cystic Fibrosis
CNS causes for Hypercapnic Respiratory Failure?
Drug overdose, Brainstem infarction, Spinal Cord injuries
Neuromuscular conditions that cause Hypercapnic Respiratory Failure?
Muscular dystrophy, Multiple sclerosis
Chest wall causes for Hypercapnic Respiratory Failure?
Fractures, Mechanical restriction, trauma
What is the major threat with Acute Respiratory Failure?
The inability of the lungs to meet the oxygen demands of the tissues
Consequences of Hypoxemia & Hypoxia
-Metabolic acidosis & cell death
-Decreased cardiac output
-Impaired renal function
-GI tissue ischemia
Metabolic Acidosis & cell death cause what to happen?
A build up of lactic acid
A build up of lactic acid causes what to happen & how?
Shock results from cells shifting from aerobic to anaerobic metabolism
Acute Respiratory Failure (Clinical Manifestations)
-Has a sudden or gradual onset (can be from mins, to hours, to days)
-Signs may be specific or nonspecific (low O2, slight mental status changes)
When compensatory mechanisms fail, what results?
Respiratory Failure
What is extremely important to monitor in Acute Respiratory Failure?
The patient's VS (trends) & behavior
Early signs of respiratory failure
-Mental status changes
-Restlessness, fatigue, HA
-Tachycardia, tachypnea, & mild HTN
-Dyspnea
Late signs of respiratory failure
-Cyanosis, diaphoresis, confusion, lethargy
-Worsening tachycardia &/or tachypnea
-Use of accessory muscles
-Decreased breath sounds
-Finally respiratory arrest
Respiratory Failure results in?
Respiratory Arrest
Diagnostic Testing for Acute Respiratory Failure
-History & physical assessment (any hx that could trigger ARF)
-Diagnostic Studies (is specific to what's going on)
+ABG analysis
+Chest x-ray
+CBC, sputum/blood cultures, electrolytes
+ECG
+V/Q lung scan
+Pulmonary artery catheter
A pulmonary artery catheter is used as a diagnostic tool in?
Severe cases of Acute Respiratory Failure
Acute Respiratory Failure Treatment
-Treat the underlying cause
-Restore adequate gas exchange
-Oxygen therapy
-Mobilization of secretions
-Positive pressure ventilation (PPV)
In Acute Respiratory Failure, what is used to help restore adequate gas exchange while the cause of failure is being corrected?
Intubation & mechanical ventilation
What is the main objective with treating Acute Respiratory Failure?
Restore adequate gas exchange
Acute Respiratory Failure: Oxygen Therapy
-Delivery system needs to be tolerated by the patient
-Maintain PaO2 at 55-60 mmHg or more & SaO2 at 90% or more at the lowest O2 concentration possible
What should the PaO2 & SaO2 be maintained at when treating Acute Respiratory Failure?
-PaO2: greater than or equal to 55-60mmHg
-SaO2: greater than or equal to 90% at the lowest O2 concentration possible
Acute Respiratory Failure: Mobilization of Secretions
-Hydration & humidification (IV fluids!)
-Chest PT
-Airway suctioning
-Encourage effective coughing & positioning
Acute Respiratory Failure: Positive Pressure Ventilation (PPV)
BIPAP & CPAP (allows you to give respiratory support without invasive intubation)
Acute Respiratory Failure: Pharmacologic Therapy
-Bronchodilators (albuterol)
-Corticosteroids (solumedrol)
-Diuretics
-IV antibiotics
-BZD/Narcotics (relax the pt & decrease anxiety & pain)
Acute Respiratory Failure: Nutritional Therapy
-Maintain protein & energy stores
-Enteral or parenteral nutrition
-Nutritional supplements
Acute Respiratory Failure: Nursing Management
-Assist with intubation & maintaining mechanical ventilation
-Assess respiratory status
-Monitor:
+Level of response
+ABGs
+Pulse oximetry (SpO2) (document if O2 goes up or stays down)
+Vital signs
+Assess respiratory system
-Implement strategies to prevent complications
-Assess patient's understanding of management strategies
-Initiate some form of communication to enable patient to express needs to team
-Address problems that led to respiratory failure
-As improves, assess knowledge of underlying disorder
-Provide teaching as appropriate
-Continuous reassessment
-Notify physician if unable to maintain adequate oxygenation
-Position for comfort
-Encourage relaxation, guided imagery, & diversion
-Administer medications as ordered to promote gas exchange & maximize oxygenation
-Address nutritional needs
What do you need to monitor with Acute Respiratory Failure?
-Level of response
-ABGs
-Pulse oximetry (SpO2) (document if O2 goes up or stays down)
-Vital signs
-Assess respiratory system (lung sounds, symmetrical breathing, accessory use, pain?)
Prevention of Acute Respiratory Failure consists of?
-Thorough H&P to ID at-risk patients
-Early recognition of respiratory distress
-The biggest thing to do, prevention**
What s/s would a nurse ID as early Acute Respiratory Failure?
AMS, tachycardia, tachypnea, HTN
Acute Respiratory Distress Syndrome (ARDS) is?
-Sudden, progressive form of acute respiratory failure
-Alveolar capillary membrane becomes damaged & more permeable to intravascular fluid
-Alveoli fill with fluid
-150,000 causes annually
-50% mortality rate
ARDS is formerly called what?
Adult Respiratory Distress Syndrome, Noncardiogenic Pulmonary Edema & Shock Lung
With ARDS, alveoli no longer function resulting in?
-Severe dyspnea
-Hypoxia
-Decreased lung compliance
-Diffuse pulmonary infiltrates
-Pulmonary artery vasoconstriction
ARDS Pathophysiology & Etiology
-Develops from a variety of direct or indirect lung injuries
-Most common cause is sepsis
-Exact cause for damage to alveolar-capillary membrane not known
-Pathophysiologic changes of ARDS thought to be due to stimulation of inflammatory & immune systems
-Inflammatory trigger initiates release of cellular & chemical mediators
-Neutrophils are attracted & release mediators producing changes in lungs
-↑ Pulmonary capillary membrane permeability
-Destruction of elastin & collagen
-Formation of pulmonary microemboli
(Results in Pulmonary artery vasoconstriction)
What are examples of direct lung injuries resulting in ARDS?
Pulmonary Disease & Sepsis (sepsis is the most common cause)
ARDS has 3 phases
-Injury or exudative phase
-Reparative or proliferative phase
-Fibrotic phase
ARDS (Injury or Exudative Phase)
-Occurs 1-7 days after direct lung injury or host insult
-Neutrophils adhere to pulmonary microcirculation
-Damage to vascular endothelium
-↑ Capillary permeability
-Fluid crosses into alveolar space
-Intrapulmonary shunt develops as alveoli fill with fluid
-Blood passing through cannot be oxygenated
-Alveolar cells type 1 & 2 are damaged
-Severe V/Q mismatch & shunting of pulmonary capillary blood result in hypoxemia
-Lungs become less compliant (↑ Work of breathing, ↑ RR)
Severe V/Q Mismatch & shunting of pulmonary capillary blood resulting in Hypoxemia is what?
Unresponsive to increasing O2 concentration interventions because lungs are less compliant further increasing work of breathing & RRs.
What alveolar cell types are damaged in the Injury/Exudative Phase of ARDS?
Type I & II, causing surfactant dysfunction, leading to atelectasis
ARDS (Reparative or Proliferative Phase (scar tissue forms) )
-Occurs 1-2 weeks after initial lung injury
-Influx of neutrophils, monocytes, & lymphocytes
-Lung becomes dense & fibrous
-Lung compliance continues to ↓
-Hypoxemia worsens
The Reparative/Proliferative Phase of ARDS causes what to develop in the lungs?
Scar tissue/widespread fibrosis forms if the phase continues, if phase is stopped, lesions/scarring resolves
ARDS (Fibrotic or Chronic/Late Phase)
-Occurs 2-3 weeks after initial lung injury
-Lung is completely remodeled by sparsely collagenous & fibrous tissues
-Decrease in lung compliance & area for gas exchange
-Pulmonary HTN
The Fibrotic/Chronic-Late Phase of ARDS results from?
Pulmonary vascular destruction & fibrosis (survival chances are poor for patients in this phase_
ARDS Early S/S
-Dyspnea, tachypnea, cough, restlessness (early general respiratory failure signs)
-Lung sounds: initially may be normal or fine, scattered crackles (as alveoli fill with fluid)
-ABGs
-Mild hypoxemia & respiratory alkalosis caused by hyperventilation (increased RR)
-Chest x-ray needed (may be normal or show minimal scattered interstitial infiltrates)
(there's no specific test to dx respiratory hypoxemia/failure)
ARDS Late S/S
-Symptoms worsen with progression of fluid accumulation & decreased lung compliance
-Increased work of breathing
-Hypoxemia
-ARDS continues to progress
-Chest x-ray shows whiteout or white lung because of consolidation & widespread infiltrates throughout lungs
As ARDS progresses, what develops & what's needed?
Severe Respiratory Distress requiring ET intubation & PPV to maintain PaO2 at an acceptable level (>60mmHg)
ARDS Treatment (Supportive Therapy)
-Supplemental O2 (O2 sats will not improve the way they normally would in a person without ARDS)
-Intubation & mechanical ventilation
-Circulatory support
-Adequate fluid volume
-Nutritional support
What is the goal for ARDS treatment?
To identify ARDS & treat underlying condition & to support respiratory function
ARDS Collaborative Treatment (Oxygenation)
-Correct hypoxemia
-Initially, use NC or face mask with high-flow systems used to maximize O2 delivery
-SpO2 is continuously monitored
-Give lowest concentration that results in PaO2 >60mmHg
-As ARDS progresses, intubation with mechanical ventilation to maintain the PaO2 at acceptable levels will be required
What is the primary goal with ARDS Oxygenation treatment?
To correct hypoxemia, by giving the lowest concentration of O2 that results in PaO2 >60mmHg
What should you set the oxygen concentration at with ARDS?
Give lowest concentration that results in PaO2 > 60 mmHg
ARDS Collaborative Treatment (Mechanical Ventilation)
Admin Positive End-Expiratory Pressure (PEEP)
What does treatment of ARDS using PEEP do?
Improves oxygenation & keeps alveoli open minimizing collapse, improving gas exchange, & reducing V/Q imbalance
What is the goal for mechanical ventilation with ARDS?
PaO2 >60 mm Hg or SaO2 >90% at lowest possible FiO2
ARDS Collaborative Treatment (Prone Position)
This position shifts fluid from dorsal part of lungs & allows undamaged alveoli to be ventilated, thus improving oxygenation
What does the prone position maintain & improve?
-Maintains perfusion/no decrease in blood flow to aerated areas
-Improves V/Q match & decreases shunting, resulting in better oxygenation
Where is perfusion greater in the lungs, with a patient that has ARDS?
The dorsal aspects of the lung regardless of position
Where is lung damage & edema greatest in patients with ARDS?
The dorsal areas
What is the prone position reserved for in patients that have ARDS?
Refractory hypoxemia that's not responding to other therapies
ARDS Collaborative Treatment (Maintenance of cardiac output & tissue perfusion)
-Hemodynamic monitoring
-Treatment of systemic hypotension, hypovolemia via PEEP ventilation
-Inotropic or vasopressor agents used to increase BP
What do you monitor with admin of inotropic & vasopressor agents?
Fluid status
Hemodynamic monitoring is done via what devices & are they used for?
Central Venous or Pulmonary Artery Catheter used to monitor CO, BP, & sample blood for ABG tests
ARDS Collaborative Treatment (Maintenance of nutrition/fluid balance)
-Enteral or parenteral feedings are started (early enteral feedings if tolerated)
-Monitor daily weight, I&O
ARDS Treatment Complications
1) Hospital-acquired pneumonia
2) Barotrauma
3) Volu-pressure trauma
4) Stress ulcers
5) Renal failure
Renal Failure with ARDS occurs from?
Decreased renal tissue oxygenation
What nursing interventions are done with renal failure resulting from ARDS?
Support kidney function, monitor trends, short term dialysis
Stress Ulcers with ARDS are caused from?
-Bleeding from stress ulcers occurs in 30% of patients with ARDS on mechanical ventilation
What nursing interventions do you perform with GI stress ulcers resulting from mechanical ventilation?
-Correction of predisposing conditions
-Prophylactic anti-ulcer agents (PPIs, H2 blockers for pts who can't tolerate PPIs)
-Early initiation of enteral nutrition (to increase GI motility to prevent ulcer formation)
What is barotrauma?
Rupture of over distended alveoli during mechanical ventilation (monitor ventilator to prevent this from happening)
What is Volu-pressure trauma?
-Occurs when large tidal volumes are used to ventilate noncompliant lungs.
-Alveoli fractures & allows movement of fluids & proteins into alveolar spaces
What is Hospital-Acquired PNA?
Fluid that sits in lungs
What strategies are used to prevent Ventilator-Associated PNA?
Strict aseptic techniques used at all times
ARDS Overall Nursing Management
-Patient centered care
-Continuous monitoring
-Respiratory therapy
-Implementing medical plan of care
-Positioning (turn q2h)
-Explain procedures & plan of care (include teaching this to families)
-Encourage rest
-Bronchodilators, corticosteroids, BBs, antibiotics (as stated in earlier slide)
What are artificial airways used for & what types are there?
-Used for patients with difficulty breathing or that need assistance maintaining their airway or that may require mechanical ventilation
1) Endotracheal (ET) intubation (via mouth or nose past larynx)
2) Tracheostomy (via stoma in neck)
3) Tracheotomy (surgical incision in neck)?
What is considered an artificial airway?
When there's a placement of a tube into the trachea to bypass the upper airway & laryngeal structures (*maintain patent airway at all times!)
Indications for artificial airways
-Upper airway obstruction (tumor/cancer dx)
-Apnea
-Inability to protect airway (drug overdose)
-Ineffective clearance of secretions (PNA & non-productive cough)
-Respiratory distress
Oral ET Intubation
(Procedure of choice/best procedure)
-Airway can be secured rapidly
-Larger diameter tube can be used
-Decreases work of breathing (WOB)
-Easier to remove secretions & perform bronchoscopy
-Explain associated risks
What are the associated risks with oral ET intubation?
Cervical spine injury, dislodging of teeth, risk of infection
Nasal ET intubation
-ET tube placed blindly
-Used when oral intubation is not possible
ET Intubation Procedure
-Requires informed consent/pt teaching
-elective intubation: for COPD
-non-elective: respiratory distress/failure
-Equipment:
+Self-inflating bag-valve-mask (BVM) attached to oxygen (AMBU bag needed to give breaths to patient)
+Suctioning equipment available
+IV access (especially if sedation is needed prior to intubation)
ET Intubation Procedure (before procedure)
-Pre-oxygenate using BVM with 100% O2 for 3-5 minutes
-Limit each intubation attempt to <30 seconds
-Ventilate patient between successive attempts using BVM with 100% O2
-(Priority: maintaining airway over IV access!)
Rapid sequence intubation (RSI) in a pt whose awake (ET Intubation)
-Rapid, concurrent admin of a paralytic agent & sedative agent during emergency airway management
-Has increased risks of aspiration, combativeness, & injury to patient
RSI is contraindicated in which type of patients?
Comatose or cardiac arrest patients
Following ET intubation
-Inflate cuff & confirm placement of ET tube while manually ventilating patient with 100% O2
-End-tidal CO2 detector measures amount of exhaled CO2 from lungs
+Place it between BVM & ET tube
+Observe for a color change or a number indicating CO2
+If no CO2 is detected, ET tube is in esophagus & needs to be re-positioned
-Record & document position of tube at the lip of the pt in cm to observe for migration of tube
-Auscultate lung for bilateral breath sounds
-Observe chest for symmetric chest wall movement
-Obtain portable chest x-ray to confirm tube location
-Connect ET tube to either humidified air, O2, or mechanical ventilator
-Obtain ABGs within 25 minutes after intubation to determine oxygenation & ventilation status
-Continuously monitor pulse oximetry as estimate of arterial oxygenation
What is very important to do with ET intubation placement?
Record & document position of tube at the lip of the patient in cm to observe for migration of the tube
End-tidal CO2 detector shows color change or number indicating what?
CO2
With ET intubation, what do you continuously monitor as an estimate of arterial oxygenation?
Pulse oximetry
When do you obtain ABGs with ET intubation?
Within 25 minutes after intubation to determine oxygenation & ventilation status
How do you confirm proper ET tube placement?
Obtain a portable chest x-ray
If the End-Tidal CO2 detector doesn't show color or number change, what does this indicate?
No CO2 is detected, meaning the ET tube is in the esophagus & will need to be repositioned
Maintaining correct tube placement
-Monitor ET tube every 2-4 hours
-Confirm exit mark on ET tube remains constant
-Observe for symmetric chest wall movement
-Auscultate to confirm bilateral breath sounds
What do you do if the ET tube is placed incorrectly?
-Stay with patient & maintain airway
-Support ventilation
-Secure help immediately
-If necessary, ventilate with BVM & 100% O2/Incorrect ET tube placement is an emergency!
Maintaining proper ET cuff inflation
-Cuff is an inflatable, pliable sleeve encircling outer wall of ET tube
-Stabilizes & seals ET tube within trachea
-Prevents escape of ventilating gases
-Cuff can cause tracheal damage
Measures to avoid tracheal damage with ET intubation
-Cuff pressure is measured & recorded after intubation & on a routine basis (often q8H usually by respiratory therapy)
-Normal arterial tracheal perfusion is estimated at 30 mm Hg
-Cuff pressure should be maintained at 20-25 mm Hg
What is the normal arterial tracheal perfusion rate with ET intubation?
30mmHg
What is the normal cuff pressure maintained at with ET intubation?
20-25mmHg
Monitoring oxygenation & ventilation with ET intubation
-Assessment
-ABGs
-SpO2
-Clinical signs of hypoxemia
-Clinical signs of respiratory distress
-Remember to monitor trends
Maintaining tube patency in an artificial airway
Assess patient routinely to determine need for suctioning, but do not suction routinely
What are indications for suctioning the artificial airway?
-Visible secretions in ET tube
-Sudden onset of respiratory distress
-Increased RR, adventitious lung sounds, decreased SaO2, accessory muscle use etc..
-Suspected aspiration of secretions
Closed-suction technique (CST) for artificial airway
Used for mechanically ventilated patients
-Enclosed in a plastic sleeve connected directly to patient-ventilator circuit (Less risk of infection)
-CST maintains oxygenation & ventilation & decreases exposure to secretions
What are potential complications associated with suctioning with artificial airways?
-Hypoxemia
-Bronchospasm
-Increased intracranial pressure
-Dysrhythmias (especially if hypoxemia during suction)
-HTN/hypotension
-Mucosal damage, bleeding
-Infection (highest risk)
What is the highest complication associated with suctioning an airway?
Infection
How do you prevent suctioning complications with artificial airways?
-Assess patient before, during, & after suctioning
-If patient does not tolerate suctioning:
+Stop procedure & manually hyperventilate with 100% oxygen
+If performing CST, hyper oxygenate (ventilator setting...maintains closed system between ET tube & ventilator, decreased risk of infection)
How do you limit suctioning complications with artificial airways?
-Hyper oxygenate before & after each suctioning pass
-Limit each suctioning pass to ≤10 seconds
-Assess trends in SpO2 throughout suctioning
-Limit suction pressures to <120 mm Hg
-Avoid overly vigorous catheter insertion
How do you manage thick secretions with artificial airways?
-Provide adequate hydration & supplemental humidification
-No installation of NS into ET tube
-Treatment of infections with antibiotics
-Provide postural drainage, percussion, & turn patient q2h
Providing oral care & maintaining skin integrity with artificial airways
-Mouth care
-Suction oral/pharyngeal cavity every 2-4 hours & PRN
Providing comfort & communication with artificial airways
-Anxiety d/t inability to communicate requires emotional support (letter boards, paper/pencil, electronic methods of communication)
-Physical discomfort associated with ET intubation & mechanical ventilation necessitates sedation & analgesia
-Consider alternative therapies to complement drug therapy (relaxation & pain control)
Preventing unplanned extubation with artificial airways
-Ensure adequate securement of ET tube
-Support ET tube during repositioning & procedures
-Use soft wrist restraints
-Provide sedation & analgesia as ordered
What do you do if an unexpected extubation occurs?
-Stay with patient
-Call for help
-Manually ventilate patient with 100% O2 (ambu bag)
-Provide psychologic support
What are the risk factors for aspiration with artificial airways?
-Improper cuff inflation
-Patient positioning
How do you prevent aspiration with artificial airways?
-Proper patient positioning
-Proper cuff inflation
-Suction oral cavity frequently
-Keep HOB elevated 30-45 degrees
What is a Tracheotomy?
Surgical incision into the trachea to establish an airway
What is a tracheostomy?
Stoma that results from tracheotomy
Tracheostomy Indications
-Bypass upper airway obstruction
-Facilitate removal of secretions
-Long-term mechanical ventilation
-Permit oral intake & speech in patients who require long-term mechanical ventilation
Tracheostomy Advantages
-Less risk of long-term damage to airway
-Increased comfort
-Patient can eat.
-Increased mobility because tube is more secure
Tracheostomy care involves?
-Suctioning the airway to remove secretions
-Cleaning around stoma (monitor skin integrity around the stoma)
-Changing ties (have someone else helping secure teach while you're cleaning & changing it)
-Providing inner cannula care
-Tube with inflated cuff is used for risk of aspiration or in mechanical ventilation.
-Inflate cuff with minimum volume required to create an airway seal.
-When patent, can protect against aspiration & does not require mechanical ventilation, a cuff less tube is used.
What are the precautions for tracheostomy tube placement?
-Tube of equal or smaller size kept at bedside for emergency reinsertion (have emergency trach tray at bedside at all times even if they already have a trach inserted)
-Tapes not changed for at least 24 hours after insertion
What is mechanical ventilation?
Process by which fraction inspired oxygen (FIO2) at ≥21% (room air) is moved in & out of lungs by a mechanical ventilator
What are indications for mechanical ventilation?
-Apnea or impending inability to breathe
-Acute respiratory failure
-Severe hypoxia
-Respiratory muscle fatigue
Settings of mechanical ventilators
-Regulate rate, depth, & other characteristics of ventilation
-Are based on patient's status (ABGs, body weight, LOC, muscle strength)
-Ventilator is tuned to match patient's ventilatory pattern/status
What are the different types of mechanical ventilators?
Negative Pressure (NPV) & Positive Pressure Ventilation (PPV)
Negative Pressure Ventilation (NPV)
-Uses chambers that encase chest or body & surround it with intermittent negative pressure
-It's a noninvasive ventilation that does not require an artificial airway (like an iron lung?)
NVP isn't used extensively for what type of patients?
Acutely ill patients
Positive pressure ventilation (PPV)
-Pushes air into lungs under positive pressure during inspiration
-Expiration occurs passively
-PPV has many different settings (which can cause complications?)
What is PPV used primarily for what type of patients?
Acutely ill patients
What are complications of PPV (*cardiovascular effects)?
PPV affects circulation due increased intra-thoracic pressure causing:
-↑ Intrathoracic pressure compresses thoracic vessels
-↓ Venous return to heart, ↓ left ventricular end- diastolic volume (preload), ↓ cardiac output
-Hypotension because of lack of blood flow return
What are complications of PPV (pulmonary effects)
1) Barotrauma
2) Pneumo-mediastinum
3) Volu-trauma
4) Ventilator-associated pneumonia
What is Baro-trauma?
-Is when air can escape into pleural space from alveoli & become trapped causing pneumothorax
-Chest tubes may be placed prophylactically for barotrauma
What is Pneuma-Mediastinum?
-Begins with rupture of alveoli into lung interstitium
-Progressive air movement into mediastinum & subcutaneous neck tissue & is commonly followed by pneumothorax
What are the clinical s/s of VAP?
fever &/or elevated WBCs, crackles or rhonchi on auscultation, & pulmonary infiltrates on chest x-ray
What is Ventilator-Associated PNA (VAP)?
-Pneumonia that occurs 48 hours or more after ET intubation
-Clinical evidence s/s: fever &/or elevated WBCs, crackles or rhonchi on auscultation, & pulmonary infiltrates on chest x-ray
What is Volu-trauma?
(lung fracture)
-Lung injury that occurs when large tidal volumes are used to ventilate noncompliant lungs
-Results in alveolar fractures & movement of fluids & proteins into alveolar spaces
Overall complications of PPV
-Hypoventilation
-Hyperventilation
What is the best diagnostic test to diagnose respiratory failure?
ABGs
What are the guidelines to prevent VAP?
-HOB elevation at least 30-45 degrees unless medically contraindicated
-No routine changes of ventilator circuit tubing
-Drain condensation that collects in ventilator tubing
Complications of PPV (GI effects)
-Risk for stress ulcers & GI bleeding
-↑ Risk of translocation of GI bacteria
-Gastric & bowel dilation as a result of gas accumulation & constipation
How do you treat stress ulcers & GI bleeding from PPV?
Via peptic ulcer prophylaxis
Histamine (H2)-receptor blockers, proton pump inhibitors, tube feedings, & NG tube for decompression
Nutritional therapy for mechanical ventilation
(Early tube feeding is important)
-If patient is likely to be without food for 3-5 days, a nutritional program should be initiated
-Enteral feeding via a small-bore feeding tube is the preferred method to meet caloric needs of ventilated patients
What can inadequate nutrition do to someone who is on mechanical ventilation?
-Delay weaning
-Decrease resistance to infection
-Decrease speed of recovery
Complications of PPV (Musculoskeletal effects)
(Maintain muscle strength & prevent problems associated with immobility)
-Perform passive & active exercises
-Prevention of contractures, pressure ulcers, & foot drop
Contractures, pressure ulcers, & foot drop are musculoskeletal complications of what?
PPV
Mechanical Ventilation (Psychological Needs)
-Physical & emotional stress due to inability to speak, eat, move, or breathe normally
-Pain, fear, & anxiety related to tubes/machines
-Ordinary ADLs are complicated or impossible
-Involve patients in decision making
-Encourage hope & build trusting relationships with patient & family
-Provide sedation &/or analgesia to facilitate optimal ventilation
-If necessary, provide paralysis to achieve more effective synchrony with ventilator & increase oxygenation
-Paralyzed patient can hear, see, think, feel
Machine disconnection or malfunction interventions
-Pause alarms during suctioning/removal from ventilator
-Reactivate alarms before leaving
-If machine malfunctions:
+Disconnect patient from ventilator
+Manually ventilate with 100% O2
What is the most common site for disconnection of machine disconnection/malfunction?
Between the tracheal tube & adapter
Mechanical Ventilation: Weaning & Extubation
-Process differs for short-term vs long-term ventilated patients
-Requires a team approach
-Occurs in 3 phases:
+Pre-weaning phase
+Weaning process
+Outcome phase
What is weaning & extubation?
The process of decreasing ventilator support & resuming spontaneous breathing
Pre-weaning/Assessment Phase of weaning/extubation
1) Determine the patient's ability to breathe spontaneously via:
-Assess muscle strength & endurance
-Auscultate lungs
-Assess chest x-ray
2) Assess non-respiratory factors preventing weaning/extubation
-Assessment of neurologic status, hemodynamics, fluid & electrolytes/acid-base balance, nutrition, & hemoglobin
Weaning Process Phase of weaning/extubation
(Awakening/Breathing Coordination, Delirium Monitoring/Management, & Early Mobility bundle)
-SBT (spontaneous breathing trial) should be at least 30 minutes but not >120 minutes
-SAT (spontaneous awakening trial) done by stopping all sedatives
-Use of weaning protocol decreases ventilator days
-Important to rest between weaning trials
-Provide explanations regarding weaning & ongoing psychologic support
-Comfortable position (sitting or semi-recumbent)
-Obtain baseline assessment
+Vital signs
+Respiratory assessment
-Monitor for signs & symptoms
+Tachypnea, dyspnea, tachycardia, dysrhythmias
+Sustained desaturation [SpO2 <90%]
+HTN or hypotension, diaphoresis
+Agitation, anxiety or changes in mentation
Weaning Outcome Phase of weaning/extubation
-Weaning stops & patient is extubated
--OR--
-Weaning is stopped because no further progress is made
How to extubate with mechanical ventilation
-Hyper-oxygenate & suction
-Loosen ET tapes or holder
-Deflate cuff & remove tube at peak of deep inspiration
-Encourage patient to deep breath & cough
-Supplemental O2
-Careful monitoring after extubation
THIS SET IS OFTEN IN FOLDERS WITH...