Airway and Mechanical Ventilation

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Pennsylvania State University *

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405B

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Mechanical Engineering

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Apr 3, 2024

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Airway and Mechanical Ventilation Airway Management MRB: Manual Resuscitation Bag - Tilt the patient’s head back to open the airway, if any neck injury is present, utilize jaw thrust. - It takes two people to perform correctly: o one to keep the airway open and the mask tightly sealed o one to squeeze the bag. Head Position MRB: Manual Resuscitation Bag - Make sure the MRB is connected to 100% oxygen. - If the patient has dentures, ventilation may be easier to perform if the dentures are left in place. - Manual breaths should be coordinated with the patient’s own breaths. Signs of Effectiveness: IMPORTANT/KNOW - The patient’s chest rises with each squeeze of the bag. - Condensation present in the mask. - Breath sounds heard throughout lung fields. - CO2 detector. Color change from purple to yellow if CO2 is present. Case Study - You are sitting at the nurse’s station charting when you hear another nurse yelling, “I need help in here!” She presses the code blue button in the room. You run to the room and find Mr. Hill, a 72-year-old male admitted yesterday for Acute Respiratory Failure, has respiratory arrested. One nurse is trying to ventilate Mr. Hill with a Manual Resuscitation Bag, but she is having a hard time keeping his airway open and bagging him at the same time. You hear air rushing out around the mask, and you don’t see his chest rising. - Another nurse is trying to find the endotracheal tubes in the crash cart. A nursing assistant is attempting to shove a backboard under Mr. Hill in case chest compressions are needed. A third nurse is frantically charting on the code record. In the midst of everything, no one else notices that Mr. Hill isn’t receiving adequate ventilation. You grab the mask with both hands to ensure a tight seal and tilt his head back to open the airway. The nurse who is bagging looks relieved when you both see Mr. Hill’s chest rise and hear a ‘whoosh’ enter his lungs. - You and your co-worker have been successfully manually ventilating (bagging) him until now. 1

- Dave, CRNA, arrives to intubate Mr. Hill. The Respiratory Therapist (RT) arrives at the same time and takes over bagging. Mr. Hill has remained a Sinus Tachycardia on the cardiac monitor with a pulse. - You are the most experienced nurse in the room, so you step in to assist Dave with the intubation. Nurse’s Preparation - Gather necessary equipment - Ensure suction is set up and operational - Remove the head of the bed - Pull the bed away from the wall - Remove extra equipment - Ask visitors to step out of the room Endotracheal Tube - The endotracheal tube (ETT) is the most common artificial airway used for short term (usually14 days) airway management or mechanical ventilation Endotracheal tubes Nasal Tracheal Tube Indications for ETT - airway maintenance - secretion control - oxygenation and ventilation - administration of emergency medications during cardiopulmonary arrest Oral vs Nasal ETT - oral route : o preferred during emergency placement 2

o insertion is easier o a larger-diameter tube can be used. - nasal route: o used if the patient has a jaw fracture o a history of recent oral surgery o trauma to the mouth or lower face. Nasal ETT - provides greater patient comfort - Contraindications: o nasal obstruction o fractured nose o sinusitis o a bleeding disorder - Extreme caution should be used if the patient has a basal skull fracture. Sizes - Adults: general tubes with an inner diameter of 6 mm to 8.5 mm - Recommended for adult: at least a size 7 to decrease the work of breathing when the patient is weaning from the ventilator - Nasal tube size is generally smaller than oral (6-7.5) - Breathing spontaneously through an ETT has been compared to breathing through a straw. Obviously, a smaller tube may have to be used for nasal intubation, but most patients can tolerate tube sizes between 6 and 7.5 for this Yankaeur Insertion of ETT 3

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CO2 Detector: helps determine if endotube is in the lung ETAD: Endotracheal Tube Attachment Device ETT Nursing Care - Maintain a patent airway - Suction pulmonary and oral secretions and - Provide frequent oral and/or nasal care - Repositioning ETT during a time when the pt is calm (refer to hospital policy) - Prevent accidental extubation - Pre-oxygenate before and between each suction pass of catheter How long can an ETT be left in place? - Varies: most say 14 days Tracheal Stenosis if ETT is left in place for too long Case Study - What should be done to confirm correct placement of the ETT? o Chest x-ray, listen to breathe sounds o The intubation goes smoothly. Breath sounds are heard bilaterally and the CO2 detector indicates the ETT is in the lungs. o A chest x-ray should also be done to confirm the position of the ETT. o Dave orders the initial ventilator settings until the pulmonologist can be called. The RT sets up the vent. Mr. Hill’s VS are stable and he is sedated from the Versed given prior to intubation. 4

Mechanical Ventilation - Used as supportive therapy to facilitate gas exchange while the lung pathology is treated or resolved. - Any means in which physical devices or machines are used to either assist or replace spontaneous respirations Mechanical Ventilation - Indications o Need for high levels of inspired oxygen (Hypoxic Respiratory Failure) o Need for assisted ventilation (Hypercapnic Respiratory Failure or surgical procedures) o Protection of airway (drug OD or aspiration) o Relief of upper airway obstruction (head or neck trauma, anaphylaxis) Mechanical Ventilation - Clinical Indicators o Respiratory rate > 30/minute o PaCO2 > 50 mmHg with pH < 7.25 o PaO2 < 55 mmHg with supplemental oxygen Assessment parameters to determine need for intubation and mechanical ventilation: - ABG’s - CXR - Clinical signs of hypoxemia - Mechanical ventilation is delivered by either positive or negative pressure. Positive pressure vents force air into the lungs, reversing normal breathing pressures and applying alveolar ventilation support Types of Ventilators: Negative Pressure Ventilator (1 st one developed) - Does not require the use of an artificial airway, such as an Endotracheal tube or Tracheostomy - Pt is placed in a device that applies negative pressure to the trunk or body - Not used for acute respiratory failure - Inflation of the lung occurs when the difference between pressure inside versus outside the lung overcomes tissue and airway factors that impede distention - Such transpulmonary pressure represents the difference between the pressure in the alveolus (i.e., inside the lung) versus that in the pleural cavity (i.e.,outside the lung). - With positive-pressure ventilation (PPV), the transpulmonary pressure is increased by making the alveolar pressure more positive; in contrast, with negative-pressure ventilation (NPV), the transpulmonary pressure is increased by making the pleural pressure more negative. Types of Ventilators: Negative Pressure Ventilator (1 st one developed) - Negative pressure causes the chest wall to be pulled outward, causing inspiration to occur as a result of pressure changes in the pleural space. - Examples include the iron lung, chest cuirass, poncho, and body wrap. - The body wrap and chest cuirass are portable devices that require a rigid cage or shell to create a negative pressure chamber around the thorax or abdomen. Because of problems with proper fit and system leaks, these types of ventilators are used only with carefully selected patients Types of Ventilators: Positive Pressure Ventilator 5

- More commonly used in the acute care setting - Requires an artificial airway - Forces air into the lung, via positive pressure - Examples include time cycled, pressure cycled, and volume cycled Time Cycled: Time triggered breaths - Allows flow of air into the lungs until a preset amount of time has elapsed. Used more frequently with neonates and children. - Not used often because of difficulty delivering consistent Tidal Volume when respiratory dynamics are changing. - If rate is set at 12 breaths per minute, the vent will cycle every 5 seconds - Used more with neonates Pressure Cycled : Pressure triggered breaths - Allows flow of air into the lungs until a preset pressure has been reached - Delivered tidal volumes varies widely - Best for short term use i.e., in Emergency Room, and in Recovery Room - Does not adapt well to changes in lung compliance and resistance Volume Cycled: Volume triggered breaths - Most common - Allows flow of air into the lungs until a preset volume has been reached - Major advantage: delivers set tidal volume regardless of changes in compliance or resistance Volume cycled: - When the pressure limit is exceeded, the ventilator will spill off the remaining volume out of the system and an alarm will sound. - Newer generation ventilators are equipped with computers which allow for a choice of various modes. i.e., pressure and volume cycled capabilities. Ventilator Settings - TV: 500, Rate 12, FIO2 50% - The ventilator is set up and managed by respiratory therapy (in this institution). - The nurse needs to know the ventilator settings and check the vent for proper settings at least once a shift. - Settings are written on the Kardex and would be given in report o Ex.) 40% 800 X 12 FIO2 : - Fraction of inspired oxygen - This is the amount of O2 delivered to the pt by the ventilator - Range is from .21 (21% room air) to 1.00 (100% oxygen) - Should not be 100% for long period because of risk of oxygen toxicity. The FiO2 should only be as high as needed to keep the PaO2 in the desired range - FiO2: percentage of oxygen the patient needs Tidal Volume - The volume of gas delivered by the ventilator to the patient with each breath. Usual setting is 5- 15 ml/kg (varies with compliance, pathology, etc.) Rate: 6

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- The number of breaths the vent delivers to the patient each minute - Will set rate higher when you want to blow off CO2 Sigh Rate: (May be included) - Sigh - A breath that has a greater volume than the preset tidal volume. Usually 1.5 - 2.0 times the tidal volume (6 to 10 per hour) - Rationale is to prevent atelectasis. However, may not be used because higher than normal tidal volume may cause barotrauma - Not routinely used with PEEP, because it is associated with higher complications Sensitivity : - Used to determine the amount of effort the patient needs to exert in order to initiate an assisted breath Peak Inspiratory Pressure (PIP): - Used to set the high- and low-pressure alarm limits. - The PIP registers on the airway pressure gauge during normal ventilation. - Peak inspiratory pressure increases with any airway resistance. - Peak inspiratory pressure increase with any airway resistance High Pressure Alarm Limit: - The maximum pressure the ventilator can generate in order to deliver the preset tidal volume - Usually set 10 to 20 cm H2O above the PIP - If pressure exceeds the set limit the high-pressure alarm will sound and the vent will cease delivering the breath. Causes of high-pressure alarm include: KNOW - biting on the tube - kinks in vent circuit - coughing as the machine cycles - gagging - attempting to talk - *Bucking the Vent Causes of high-pressure alarm include: KNOW - secretions in the artificial airway - mucus plugs - fighting the ventilator (the patient breathes out as the ventilator cycles) - pulmonary edema - external pressure on the chest wall Causes of low-pressure alarm: KNOW - Patient becomes disconnected from the ventilator - Leak in the cuff of the Endotube or trach tube - Disconnection of any part of the circuit Modes of Ventilators - How the machine ventilates the patient in relation to the patient’s own respiratory effort Ventilator Modes - Selection of mode is determined by patient condition and preference of the physician 7

- Examples include: o Control o Assist/Control o Intermittent Mandatory Ventilation Control Ventilation - Delivers a preset volume (TV) or pressure regardless of patient’s own respiratory efforts - Used for patients who are unable to initiate a breath. (Only the set rate is delivered. If the patient needs more, they will not get it.) - Patient is unable to initiate breaths or change the breathing pattern in any way. - Rarely used Control Ventilation - Used for: o Apneic patients (high cervical spine injuries) o Drug induced paralysis  Cisatracurium besylate (Nimbex): Neuromuscular blocker. Paralyzes patient to prevent any respiratory effort from the patient. Patient can hear but can’t move. - *Ventilator delivers the preset VT at the preset rate without sensitivity to patient inspiratory effort. CV Example - TV 500, Rate 12, FIO2 40%, and Peep 5cmH20 - Pt will receive TV of 500ml, 12 times per minute for a minute ventilation of 6000mL. (TV X RR = MV) - Minute ventilation is the volume of gas inhaled (inhaled minute volume) or exhaled (exhaled minute volume) from a person’ lungs per minute Assist control ventilation (A/C) (Volume controlled) - Delivers a preset volume in response to the patient’s own inspiratory effort but will initiate the breath if the patient does not do so within the set amount of time. - This means that any inspiratory attempt by the patient will trigger a ventilator breath. - Example: 40% / 800 / 10. If the pt initiates an inspiratory effort 16 times the pt would receive 16 cycles from the ventilator. If the pt would not exert any effort the patient would still receive 10 cycles. Assist control ventilation (A/C) - Patient can initiate more breaths, but they will be delivered at the preset Tidal Volume - Patient can alter the respiratory rate and pattern. Not the Tidal Volume - Any inspiratory attempt by the patient triggers a ventilator breath. - May need to sedate patient to limit number of spontaneous breaths since hyperventilation can occur. Assisted Control Ventilation (A/C) - Complication: Respiratory alkalosis Hyperventilation causes pCO2 to be blown off. The pt may therefore need sedated or may need IMV mode. - Advantage of AMV is a reduction in the work of breathing - Can be used in weaning from mechanical ventilation by incorporating a breathing trial with a T- piece or CPAP trials. 8

Synchronous Intermittent Mandatory Ventilation (SIMV) - Delivers a preset respiratory rate and TV but allows the patient to breathe spontaneously between the preset VT and rate. - Ventilator is synchronized to patient's ventilatory effort to reduce competition between the ventilator and the patient. - Will initiate breath if patient fails to do so. - Controversies: o May increase the work of breathing at a low respiratory rate of 6 breaths per minute or less because the patient performs most of the work of breathing through the high- resistance ventilator circuit o If used in adjunct with weaning, could lead to respiratory fatigue. - Delivers a pre-set T.V. at a preset rate. - Permits the pt to breathe O2 between ventilator breaths at their own T.V. SIMV - Preset breaths are delivered regardless of the patient’s respiratory effort - Often use Pressure support setting in addition to other settings. - Settings: 40%, 800, 6. If patient breaths 16 times/minute, 6 breaths will be delivered with a TV 800 and 10 breaths will be whatever TV the patient is breathing, i.e. 300. SIMV - Effectiveness as a weaning tool is controversial. May increase workload because of muscle fatigue associated with spontaneous breathing because of the artificial airway. Adjunct modes to mechanical ventilation to enhance oxygenation and or ventilation PEEP, CPAP, Pressure Support PEEP - Positive End Expiratory Pressure - Keeps the small airway (alveoli) open at the end of expiration. It increases the functional residual capacity. It therefore increases oxygenation. - Allows more time for gas exchange to take place. - Used in mechanically ventilated breaths. PEEP - Positive End Expiratory Pressure - Used at times to decrease the amount of FiO2 needed. o i.e. FiO2 of 80% is needed to maintain PaO2 at 85. If we add 10 cm Peep, we may be able to maintain a PaO2 of 85 with only 60% FiO2. PEEP - Positive End Expiratory Pressure - Usual range of PEEP is 5 - 20 cm H2O - Adjustments in PEEP are made at 3 - 5 cm H2O pressure at a time. Abrupt changes can create problems associated with cardiac output and hypoxemia - Peep increases the risk of barotrauma CPAP – Continuous positive airway pressure - Maintains constant positive pressure in airways so resistance is decreased - Similar to PEEP but used only with spontaneously breathing patients - Normal levels are 0 - 15 cm - Applied during inspiration and expiration 9

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CPAP (Continued): - Most newer vents can deliver both CPAP and PEEP i.e. IMV with rate of 10 with 8 CM peep and 8 cm CPAP - Can also be delivered via face mask, to delay intubation and also for sleep apnea Pressure Support Ventilation: - Positive pressure applied during inspiration - Preset level of pressure is used to augment or assist spontaneous breaths - When triggered, the vent applies a small amt of positive pressure to the airways. The intent is to overcome resistance - Decreases the work of breathing Pressure Support Ventilation: - Used for weaning spontaneously breathing patient, frequently combined with SIMV - Preset pressure that augments the patient’s spontaneous inspiratory effort and decreases the work of breathing. The patient completely controls the RR and Tidal Volume. Pressure Support Example: - TV 500, Respiratory rate 12, FIO2 40%, PEEP 5cms H20, and Pressure Support: 10 cm H20 - The patient will receive 12 breaths per minute with a TV of 500 ml. - This time, for each additional breath the patient takes, he will receive 10 cms H2O of pressure support to help him with the inspiration. Pressure Support Example - Spontaneous TV will vary depending on patient effort and the amount of pressure support that is set. The pressure support will cycle on during the spontaneous inhalation cycle only. Case Study - Mr. Hill has been on the ventilator for 24 hours. The settings are: A/C, TV700, FIO2 60%, Rate 14. Mr. Hill has been assisting the ventilator with a RR of 24 since 0700. It is now 1100. - Describe the ventilator settings. o The ventilator delivers 14 breaths per minute, each with a VT of 700ml. o The A/C mode delivers the breaths in response to Mr. Hill’s own respiratory effort but will initiate the breath if he doesn’t within the set amount of time. o He is currently breathing above the vent setting. o The oxygen concentration is 60%. Case Study - Mr. Hill’s pulse oximetry has consistently been 100% since intubation. You notice his RR is quite high, he’s fidgety, doesn’t follow commands, and doesn’t maintain eye contact when you talk to him. He has not had any sedation since he was intubated. - What lab tests should you check to assess true ventilatory status of Mr. Hill? Which two parameters on the ABG will give you a quick overview of Mr. Hill’s status? o PaCo2(which affects the pH) and PaO2. o With his high RR, he is at risk for hypocapnia from blowing off the CO2. If the PaO2 is adequate, the FIO2 could be decreased. SaO2 has been 100% - What are some possible causes of Mr. Hill’s increased RR? o Secretions o Anxiety o Pain 10

Case Study - ABG results: o PaCO2 28 o pH 7.48 o PaO2 120 - Normal o pH 7.35-7.45 o PCO2 35-45 o PO2 80-100 - Based on the ABG results, the pulmonologist changes the vent settings to SIMV, rate 10, Pressure Support 10 and FIO2 40%. The TV remains 700. He also orders midazolam (Versed) for sedation. How will these settings and sedation order help Mr. Hill? o 10 breaths will be delivered per minute, but in synchrony with Mr. Hill’s efforts. o Pressure Support decreases the work of breathing. Complications of Ventilator Support Barotrauma: Lung damage from excessive pressure - Air can escape into: o pleural space: o pneumothorax o Mediastinum: o pneumo mediastinum o under the skin: o subcutaneous emphysema or crepitus - Most commonly see with: o pressure ventilators o High tidal volumes o Peep Barotrauma - Increased incidence with o older persons, o history of COPD, and o infection which destroys the alveoli Barotrauma Signs and Symptoms: - increased Peak inspiratory pressure - decreased breath sounds - tracheal shift - S&S of hypoxemia Tension Pneumo - Life Threatening - Pressurized air enters the pleural space - Air is unable to exit pleural space and continues to accumulate - Collapse of CVS occurs rapidly - Treatment: chest tube 11

Important: - When pneumo is suspected, remove the patient from the ventilator and manually ventilate with a manual resuscitation bag until a chest tube is inserted. Complications of Mechanical Ventilation - Positive Pressure Vents. o Increased intra-thoracic pressure:  Decreased venous return  decreased preload  decreased cardiac output (CO)  Decreased CO  impaired renal and hepatic function.  Decreased cerebral venous return  increased ICP.  Respiratory alkalosis possible  alveolar hyperventilation Complications of Mechanical Ventilation - Increased intra-thoracic pressure: (con’t) o Gastric distention (air leaks around ET tube or trach). o Barotrauma: alveolar rupture   Pneumothorax  Subcutaneous emphysema  Pneumomediastinum “Bucking the Vent" - Client coughing and/or fighting the machine - May need reassuring or sedation - Complications of Mechanical Ventilation Oxygen Toxicity - May occur in clients receiving > 50% FiO2 - Hyperoxia creates toxic metabolites of O2 metabolism (oxygen-free radicals) which cause alveolar cell damage & pulmonary edema - Atelectasis - ARDS Signs and Symptoms of Oxygen Toxicity - Substernal chest pain (increase with inspiration) - Dry cough/tracheal irritation - Dyspnea - Nasal stuffiness/sore throat - Eye/ear irritation - Symptoms reverse when decrease O2 concentration. Oxygen Toxicity - Nursing Management o Prevention and detection o Know limits of exposure to oxygen o Know who is at risk o Continual assessment Hypotension 12

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- Secondary to decreased cardiac output - Secondary to hypovolemia Ventilator-Assisted Pneumonia (VAP) - Nosocomial pneumonia up to 21 times more common in ventilated patients - Interventions o Sterile technique with good hand hygiene o HOB >30 degrees o Aggressive oral hygiene o Weaning ASAP o Changing circuits as needed Ventilator Dependency - Patients especially at risk: o COPD o Diseases which result in neuro muscular impairment Remember : - Anytime there is a problem i.e., absent breath sounds, remove the patient from the ventilator and manually ventilate the patient Weaning from Mechanical Ventilation: - Correct underlying pathology: Original cause of patient being intubated and ventilated Determinants to Wean - Level of oxygenation (FiO2) o Less or equal to 40% to 50% - CO2 elimination o pH > 7.25 - Mechanical efficiency (of lungs) Determinants to Wean (Cont’d)) - Muscle Efficiency o VT 2-5ml/kg o Respiration rate <30/minute - Oxygenation o PaO2 >60mmHg on FIO2 <.40 o Cardiac Index > 2.5 L/min - PF Ratio (Horowitz index) o PaO2/FIO2 - Carbon Dioxide Elimination o PaCO2 35-45 mmHg or at the pt baseline level to maintain pH between 7.35-7.45 o Dead space/tidal volume <60% PF Ratio ARDS Severity PaO2/FiO2 Mortality Mild 200 -300 27% Moderate 100 – 200 32% Severe < 100 45% 13

Weaning Techniques - T-piece - CPAP/BiPAP - IMV - PSV - Patient off vent and breathes spontaneously with a T piece - Initially 5 – 10 minutes and then progressively longer - Observe for muscle fatigue and respiratory distress (tolerance of weaning) Weaning Techniques - CPAP (Continuous Positive Airway Pressure) - Vent placed in CPAP mode and positive pressure delivered with spontaneous breath only. BiPAP (Bilevel Positive Airway Pressure) - May be used after extubation to prevent re-intubation Weaning Intolerance Indicators - Dysrhythmias - Increase or decrease in HR > 20 beats/min - Increase or decrease in BP > 20 mmHg. - Increase RR > 10 - Diaphoresis/dyspnea/SOB - Restlessness Case Study - Mr. Hill has been intubated and on the ventilator for 3 days. Slight changes to ventilator settings were made. Current settings: - FiO2 30% - RR 4 - SIMV Case Study - ABG results: pH 7.42, PaCO2 39, HCO3 25, PaO2 88 - Is Mr. Hill ready to be weaned? o Yes - What form of Oxygen therapy will you administer to Mr. Hill once he is extubated? o High flow nasal cannula - How will you confirm Mr. Hill’s respiratory status is stable after he is extubated? o ABG, SaO2, look at patient and assess vital signs Nursing Management of a Client on Mechanical Ventilation - Check vent settings at least q Shift. - Check that vent alarms are set. - Perform complete respiratory assessments - VS (at least q 2 hours) - Check inflation of trach/ETT cuff. - Check placement of ETT (at least q 2-4 hours) - Make sure bilateral breath sounds are heard and symmetrically chest movement Nursing Management of a Client on Mechanical Ventilation - Thorough oral care 2x/shift - Trach care q shift 14

- Suction as needed; monitor closely* - Move ET tube to opposite corner of mouth q24 hrs. (prevent ulcers) - I/O - monitor fluid balance - Turn q 2 hrs - Keep HOB >30 degrees - Do not suction on the way down the ETT. Limit - Placement: could dislodge into the right mainstem bronchus, esophagus or larynx Nursing Management of a Client on Mechanical Ventilation - Include patient/family in care if possible - Provide paper/pen for communication - Observe continually for complications (especially GI) - Document accurate and pertinent data Suctioning - Suction when: o Visible secretions o Sudden onset Resp. distress o Increased peak airway pressures o Adventitious breath sounds o Increased RR and/or coughing o Sudden or gradual decrease in PaO2 or SpO2 Important - Suctioning is Not performed routinely. - Normal Saline instillation is discouraged. Suctioning - Hyper oxygenate for at least 30 seconds - When you hit resistance, start to withdraw catheter - Suction 10 seconds or less Potential Complications - Hypoxemia (How do you prevent?) – preoxygenate with the ventilator - Hyper/hypotension - Bronchospasm - Pulmonary bleeding - Trachaeal/mucosal damage (why?) o Too vigorous, too frequent - Infection Closed Suction Kit 15

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Important Information: - Suctioning causes oxygen deprivation for the time that the suction is applied. - Hypoxemia can be minimized by pre-oxygenating the patient with 100% oxygen prior to suctioning and between each pass of the suction catheter. - Push the 100% oxygen button on the ventilator or by using a manual resuscitation bag Nursing Tips - Pulse oximetry should be monitored while suctioning. - The duration of each suction pass should be limited to ten seconds - Number of passes should be limited to three or less, if possible. - Studies have shown that using intermittent suction is no more beneficial than continuous suction. Mouth Care - There are kits that can be used 16

Airway and Mechanical Ventilation

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