1
Q
work of breathing
A
amount of effort required for maintenance
2
Q
signs of difficulty breathing
A
tripod positioning, accessory muscle use
3
Q
what happens with increased work of breathing?
A
- increased energy expenditure and body uses more glucose
4
Q
compliance
A
elasticity and expandability of the lungs and thoracic structures
5
Q
ventilation
A
- diffusion at pulmonary capillaries
- perfusion
- diffusion to cells
6
Q
inspiration
A
- active
- diaphragm lowers and contracts
- intercostal muscles contract
- thoracic cavity expands
- intrapleural and intra-alveolar pressures become negative = air flows into lungs
7
Q
expiration
A
- passive
- diaphragm relaxes
- intercostal muscles relax
- thoracic cavity reduces
- lungs recoiling generates positive intra-alveolar pressure w. air flowing out of lungs
8
Q
O2 in the blood vs alveoli
A
- O2 in blood within capillaries of lungs is lower than in the alveoli; O2 diffuses from the alveoli to the blood
9
Q
CO2 concentration in blood vs alveoli
A
- CO2 has higher concentration in blood than in alveoli - CO2 diffuses from the blood into the alveoli
10
Q
transportation of oxygenated blood
A
- oxygenated blood in pulmonary capillaries is transported via the pulmonary vein to the left side of the heart
- it is then perfused and transported to tissues
11
Q
transportation of CO2
A
- transported via the vena cava to the right side of the heart and into pulmonary capillaries
- diffuses into alveoli and is eliminated through expiration
12
Q
what do the pons and medulla control?
A
rate, depth, and rhythm of ventilation
13
Q
what stimulates respirations (increases rate/depth to blow it out)
A
hypoxia or increased partial pressure of CO2
14
Q
what diminishes respirations
A
too much ventilation, decreased partial pressure of CO2
15
Q
factors that determine compliance
A
- surface tension of alveoli, connective tissue and water content of lungs + compliance of the thoracic cavity
16
Q
increased compliance
A
lungs have lost their elastic recoil and become over-distended = emphysema
- more distended lungs requires lower pressures during ventilation; can collapse during expiration
17
Q
decreased compliance
A
lungs and thorax are stiff
causes = morbid obesity, pneumothorax, hemothorax, pleural effusion, pulmonary edema, atelectasis, pulmonary fibrosis, + ARDS
- requires greater-than-normal energy expenditure to create negative pressure to inflate lungs
18
Q
resistance
A
- opposition to flow of gasses in the airways
19
Q
reasons for resistance
A
- Contraction of bronchial smooth muscle (asthma)
- thickening of bronchial mucosa (chronic bronchitis)
- obstruction of the airway by mucus, a tumor, or foreign body
- loss of lung elasticity
20
Q
tidal volume (symbol, normal value, significance)
A
- VT or TV
- 500 mL
- may not vary, even with severe disease
21
Q
tidal volume description
A
volume of air inhaled and exhaled with each breath
22
Q
inspiratory reserve volume (symbol, normal value)
A
- IRV
- 3000 mL
23
Q
inspiratory reserve volume description
A
maximum volume of air that can be inhaled after a normal inhalation
24
Q
expiratory reserve volume (symbol, normal value, significance)
A
- ERV
- 1100 mL
- decreased with restrictive conditions (obesity, ascites, pregnancy)
25
expiratory reserve volume description
- maximum volume of air that can be exhaled forcible after a normal exhalation
26
residual volume (symbol, normal value, significance)
- RV
- 1200 mL
- may be increased with obstructive disease
27
residual volume description
volume of air remaining in lungs after maximum exhalation
28
vital capacity (symbol, normal value, significance)
- VC
- 4600 mL
- decreased in neuromuscular disease, generalized fatigue, atelectasis, pulmonary edema, COPD, obesity
29
vital capacity description
maximum volume of air exhaled from the point of maximum inspiration
VC = TV + IRV + ERV
30
inspiratory capacity (symbol, normal value, significance)
- IC
- 3500 mL
- decrease may indicate restrictive disease; obesity
31
inspiratory capacity description
maximum volume of air inhaled after normal expiration
IC = TV + IRV
32
functional residual capacity (symbol, normal value, significance)
- FRC
- 2300 mL
- may be increased with COPD; may be decreased in ARDS and obesity
33
functional residual capacity description
- volume of air remarking in lungs after normal expiration
FRC = ERV + RV
34
total lung capacity (symbol, normal value, significance)
- TLC
- 5800 mL
- decreased with restrictive disease (atelectasis and pneumonia); increased in COPD
35
total lung capacity description
volume of air in lungs after maximum inspiration
TLC = TV + IRV + ERV + RV
36
hypoxemic respiratory failure
- oxygenation failure
- PaO2 less than/equal to 60 mmHg on more than/equal to 60% oxygen
37
hypercapnic respiratory failure
- ventilatory failure
- PACO2 greater than 45 mmHg and pH <7.35
38
fine crackles description
high pitched, crackling sounds (fire crackling, or velcro coming apart)
39
fine crackles causes
previously deflated airways that are popping back open
40
fine crackles example
pulmonary edema, asthma, obstructive diseases, atelectasis
41
coarse crackles description
low pitched, wet bubbling sound
42
coarse crackles causes
inhaled air collides with secretion in the trachea or large bronchi
43
coarse crackles example
pulmonary edema, pneumonia, depressed cough reflex
44
pleural friction rub decription
low-pitched, harsh/grating sounds
45
pleural friction rub causes
pleura is inflamed and loses its lubricant fluid
46
pleural friction rub example
pleuritis, pneumonia, TB
47
wheezes description
high-pitched musical instrument with more than one type of sound quality (polyphonic)
48
wheezes causes
air moving through a narrow airway
49
wheezes examples
asthma, bronchitis, chronic emphysema
50
stridor description and what does it require
high pitched whistling or gasping with harsh sound quality
- requires medical attention!!!
51
stridor causes
disturbed airflow in larynx or trachea
52
stridor example
croup, epiglottis, any airway obstruction
53
geriatric considerations
- decreased chest wall dispensability
- decreased alveolar surface area
- decreased alveolar elasticity
- decreased lung volume
- decreased physiologic compensatory mechanism for hypercapnia and hypoxia
- weaker respiratory muscles
- decreased cough and gag reflex
- kyphosis
- barrel chest
- lower PaO2 levels on ABGs
- increased risk for secretion retention, pneumonia, poor gas exchange, mental status changes, aspiration, respiratory distress and failure
54
respiratory acidosis
pH low, PaCO2 high
55
causes for respiratory acidosis
hypoventilation, anesthesia/sedatives, overdoses, neuromuscular disorder, spine/brain/chest wall trauma, restrictive lung disease (COPD), later phase of acute airway obstruction
56
treatment for respiratory acidosis
increase RR
57
respiratory alkalosis
pH high, PaCO2 low
58
respiratory alkalosis causes
hypoxemia, anxiety, fear, pain, fevers, stimulants, CNS irritation (CNS hyperventilation), excessive ventilatory support (vent with a rate that is way too high or bagging them too fast with a bag valve mask)
59
respiratory alkalosis treatment
decrease RR, administer sedatives, rebreather mask
60
critical values, pt cannot tolerate, ADDRESS IMMEDIATELY
- PaO2 <60
- PaCO2 > 50
- pH <7.25 or > 7.6
61
stop and address the pt when oxygen evaluated by ....
PaO2 <30 or SaO2 <90 (pulse ox)
62
compensation
regulation of CO2 in lungs and bicarbonate in kidneys
63
uncompensated
if pH is out of range + CO2 or HCO3 is in range
64
partially compensated
if CO2 + HCO3 are BOTH out of range and pH is out of range
65
fully compensated
if pH is in range
66
respiratory alkalosis symptoms
- seizures
- deep, rapid breathing
- hyperventilation
- tachycardia
- low or normal BP
- numbness & tingling of extremities
- lethargy
- light headedness
- nausea, vomiting
67
respiratory acidosis symptoms
- hypoventilation leads to hypoxia
- rapid, shallow respirations
- low BP
- headache
- hyperkalemia
- dysrhythmias (high K+)
- drowsiness, dizziness, disorientation
- muscle weakness, hyperreflexia
68
CO2 in respiratory alkalosis
increase loss of CO2 from lungs
69
CO2 in respiratory acidosis
retention of CO2 by lungs
70
respiratory problem - alkalosis
ph High, CO2 low
71
respiratory problem - acidosis
pH low, CO2 high
72
respiratory problem remember
respiratory opposite
73
metabolic problem - alkalosis
pH high, HCO3 high
74
metabolic problem - acidosis
pH low, HCO3 low
75
metabolic problem remember
metabolic equal
76
making adjustments to ventilator settings according to ABG results: Low PaO2
increase FiO2 or PEEP
77
Making Adjustments to Ventilator Settings According to ABG Results: high PaCO2 and low pH
increase tidal volume, respiratory rate, PIP
78
A 74 kg male patient is intubated and receiving volume-controlled A/C ventilation with the following settings: FiO2 of 50%, set rate of 15 breaths/min, and a set tidal volume of 550 mL. The patient’s total respiratory rate is 29 breaths/min and the following ABG results were obtained: pH 7.53, PaCO2 27, HCO3 23 mEq/L, BE -2, PaO2 82, SaO2 97%.
Which of the following would you recommend?
A. Increase the FiO2
B. Increase the set rate
C. Increase the set tidal volume
D. Add mechanical dead space
answer: D
79
rationale for D. Add mechanical dead space
- pH is increased, PaCO2 is decreased → respiratory alkalosis
- PaO2 and SaO2 values are normal → do not make adjustments to FiO2
- Pt’s spontaneous breathing rate is already too high → do not increase rate
- 50 mL/74 kg = 7.4 mL/kg → falls within normal range of 5-10 mL/kg for tidal volume → confirms that tidal volume setting is appropriate
- Adding mechanical dead space to the circuit is a method for treating hyperventilation. The pt will essentially rebreath the gas from their anatomic dead space, which will increase the PaCO2 level.
- Can also decrease the minute ventilation by decreasing the rate or decreasing the tidal volume
80
52 kg female patient is receiving volume control A/C mechanical ventilation with a tidal volume of 400 mL, a set rate of 10/min, and an FiO2 of 35%. Her blood gas results are as follows: pH 7.31, PaCO2 49, HCO3 24 mEq/L, BE -2 mEq/L, PaO2 84, SpO2 95%
Based on the given information, which of the following changes is appropriate at this time?
A. Increase the FiO2
B. Increase the tidal volume
C. Increase the set rate
D. Maintain the current settings
answer : C
81
Rationale: C. Increase the set rate
pH is decreased, PaCO2 is increased → respiratory acidosis
PaO2 and SaO2 values are normal → do not make adjustments to FiO2
Need to decrease the PaCO2 by blowing off some of that CO2 and increasing the minute ventilation (by increasing the rate or the tidal volume)
400 mL/52 kg = 8 mL/kg → falls within appropriate tidal volume range (set correctly)
82
oxygen therapy administration of O2 greater than.....
- 21% to provide adequate transport of oxygen in the blood, decrease the work of breathing, and reduce stress on the myocardium
83
what does oxygen transport to tissue depend on ?
cardiac output, arterial oxygen content, concentration of hemoglobin, and metabolic requirements
84
indications for oxygen therapy and s/s = hypoxemia
- decrease in arterial oxygen tension in the blood
- s/s = mental status changes (agitation, disorientation, confusion lethargy and coma), dyspnea, increase in BP, changes in HR, dysrhythmias, diaphoresis, cool extremities
85
indications for oxygen therapy= hypoxia
decrease in oxygen supply to the tissues and cells. can be caused by problems outside the respiratory system - ruptured hematoma in leg
86
oxygen therapy: high flow
- humidified with a special flow system up to 40 L/min
- pt is more comfortable and can get up 60%-90% O2 concentration (higher (O2) than non-rebreather)
87
high flow: venturi mask
each orifice will give a specific FiO2 corresponding to the numbers
- FiO2 = fraction of inspired oxygen; the concentration of oxygen in the gas mixture
88
oxygen toxicity
too high a concentrated of O2 (>50%) is administered for an extended period (longer than 48 hrs)
89
oxygen toxicity if untreated
free radicals severely damage cells - respiratory failure, pulmonary edema, cell death
90
s/s of oxygen toxicity
substernal discomfort, paresthesia, dyspnea, restlessness, fatiguem malaise, progressive respiratory difficulty, refractory hypoxemia, alveolar atelectasis, alveolar infiltrates evident on chest x-rays
91
prevention of oxygen toxicity
- use lowest effective concentrations of O2
- PEEP or CPAP prevent/reverse atelectasis + lower oxygen percentages to be used
92
low flow systems
- cannula
- nasal catheter
- mask, simple
- mask, partial rebreathing
- mask nonrebreathing
93
cannula suggested flow rate (L/min)
1-2
3-5
6
94
nasal catheter suggested flow rate (L/min)
1-6
95
mask simple suggested flow rate (L/min)
5-8
96
mask, partial rebreathing suggested flow rate (L/min)
8-11
97
mask, nonrebreathing suggested flow rate (L/min)
10-15
98
cannula O2 percentage setting
24-28
32-40
44
99
transtracheal catheter suggested flow rate (L/min)
1/4 - 4
100
mask, venturi suggested flow rate (L/min)
4-6
6-8
101
mask, aerosol suggested flow rate (L/min)
8-10
102
tracheostomy collar suggested flow rate (L/min)
8-10
103
t-piece suggested flow rate (L/min)
8-10
104
face tent suggested flow rate (L/min)
8-10
105
pulse dose suggested flow rate (mL/breath)
10-40
106
nasal catheter O2 percentage setting
22-44
107
mask, simple O2 percentage setting
40-60
108
mask, partial rebreathing O2 percentage setting
50-75
109
mask, nonrebreathing O2 percentage setting
80-95
110
high flow systems
- transtracheal catheter
- mask, venturi
- mask, aerosol
- tracheostomy collar
- t-piece
- face tent
111
oxygen conserving devices
pulse dose (or demand)
112
transtracheal catheter O2 percentage setting
60-100
113
mask, venturi O2 percentage setting
24, 26, 28
30, 35, 40
114
mask, aerosol O2 percentage setting
30-100
115
tracheostomy collar O2 percentage setting
30-100
116
t-piece O2 percentage setting
30-100
117
face tent O2 percentage setting
30-100
118
cannula advantages
lightweight, comfortable, inexpensive, continuous use with meals and activity
119
nasal catheter advantages
inexpensive, does not require a tracheostomy
120
mask, simple advantages
simple to use, inexpensive
121
mask, partial rebreathing advantages
moderate O2 concentration
122
mask, nonrebreathing advantages
high O2 concentration
123
transtracheal catheter advantages
more comfortable, concealed by clothing, less oxygen liters per minute needed than nasal cannula
124
mask, venturi advantages
provides low levels of supplemental O2
precise FiO2, additional humidity available
125
mask, aerosol advantages
good humidity, accurate FiO2
126
tracheostomy collar advantages
good humidity, comfortable, fairly accurate FiO2
127
t-piece advantages
same as tracheostomy; good humidity, comfortable, fairly accurate FiO2
128
face tent advantages
good humidity, fairly accurate FiO2
129
pulse dose (or demand) advantages
deliver O2 only on inspiration, conserve 50-75% of O2 used
130
cannula disadvantages
easily dislodged, from nares, skin breakdown over ears or nares, nasal mucosal drying, variable FiO2
131
nasal catheter disadvantages
nasal mucosa irritation; catheter should be changed frequently to alternate nostril
132
mask, simple disadvantages
poor fitting, variable FiO2, must remove to eat
133
mask, partial rebreathing disadvantages
warm, poorly fitting, must remove to eat
134
mask nonrebreathing disadvantages
poorly fitting, must remove to eat
135
transtracheal catheter disadvantages
requires frequent and regular cleaning, requires surgical intervention, with associated risk for surgical complications
136
mask, venturi disadvantages
must remove to eat
137
mask, aerosol disadvantages
uncomfortable for some
138
t-piece disadvantages
heavy with tubing
139
face tent disadvantages
bulky and cumbersome
140
pulse dose (or demand) disadvantages
must carefully evaluate function individually
141
attempt to open the airway
- head-tilt/chin lift maneuver= pulls tongue away from back of pharynx
142
attempt to clear the airway
- observe chest + listen/feel for movement of air
- use a cross-finger technique to open the mouth and observe for obvious obstructions
- if no passage of air is detected = CPR
143
bag and mask resuscitation
- apply mask to pt's face and create a seal by pressing thumb of the non dominant hand on bridge of the nose and index finger on chin
- using rest of the fingers on the hand, pull on the chin and the angle of the mandible to maintain the head in extension
- use dominant hand to inflate the lungs by squeezing the bag to its full volume
144
endotracheal intubation
- placement of tube (with the aid of a laryngoscope) through the nose or mouth into the trachea
- oral route is preferred: less trauma and infections
- secure tube to prevent accidental extubation
145
sniffing position
- head even with shoulders, instead of with bed, using a folded blanket
- will help facilitate endotracheal intubation
146
purpose of endotracheal intubation
- provide patent airway for mechanical ventilation, removal of secretions, pts w/ upper airway obstruction
147
equipment needed for endotracheal intubation
- stylet, endotracheal tube, 10 mL syringe for cuff inflation, laryngoscope (curved or straight blade depending on pt's anatomy), lubricant, CO2 detector (capnography), tape to secure, yankauer, forceps to help with movement/guiding, chlorhexidine to clear out airway
148
lecture note about intubation
you will know if you intubate the right mainstream bronchus because you will not have chest rise on the left side
149
how to prevent air leaking and minimize aspiration (endotracheal tube) ?
tube cuff inflated to prevent air from leaking around the outer parts of the tube to minimize the possibility of aspiration + secure the tube
150
verify positioning of endotracheal tube
- checking end-tidal carbon dioxide levels + confirmed with chest x-ray
151
pressure that cuff pressures should be maintained at
20-25 mmHg
152
complication of high cuff pressure
tracheal bleeding, ischemia, and pressure necrosis
153
complication of low cuff pressure
increases the risk of aspiration pneumonia
154
what should always be introduced through the endotracheal tube
warm, humidified oxygen
155
max of how long it can be used for
no longer than 14-21 days, by which time a tracheostomy must be considered to decrease irritation of and trauma to the tracheal lining, to reduce the incidence of vocal cord paralysis (secondary to laryngeal nerve damage), + to decrease the work of breathing
156
disadvantages of endotracheal intubation
- depressed cough reflex, thicker secretions, depressed swallow reflexes, increased risk of aspiration and ventilator-associated pneumonia, ulcerations/stricture of the larynx/trachea, inability of pt to communicate needs
157
to improve pts tolerance of tube
comfort measures, opioid analgesia and sedation
158
what can inadvertent removal of the tube cause
laryngeal swelling, hypoxemia, bradycardia, hypotension, and even death
159
PEEP
not a specific mode, but it is an adjunct to any of the vent modes
- the amount of pressure remaining in the lung at the END of the expiratory phase
- utilized to keep otherwise collapsing lung units open while improving oxygenation
160
collaborative practice interventions to prevent ventilator-associated pneumonia (5 key elements)
1) elevation of HOB (30-45 degrees
2) daily "sedation vacations" + assessment of readiness to extubate
3) peptic ulcer disease prophylaxis
4) DVT prophylaxis
5) daily oral care w/ chlorhexidine (0.12% oral rinses)
161
care of the patient with an endotracheal tube: immediate after intubation
1) check symmetry of chest expansion
2) auscultate breath sounds of anterior and lateral chest bilaterally
3) obtain capnography or end-tidal CO2 as indicated
4) ensure chest x-ray obtained to verify proper tube placement
5) check cuff pressure every 6-8 hrs
6) monitor for signs and symptoms of aspiration
7) ensure high humidity; a visible mist should appear in the T-piece or ventilator tubing
8) administer oxygen concentration as prescribed by the primary provider
9) secure the tube to the patient's face with tape, and mark the proximal end for position maintenance
9a) cut proximal end of tube if its longer than 7.5 cm (3 in) to prevent kinking
9b) insert an oral airway or mouth device of orally intubated to prevent atelectasis and to optimize lung expansion
10) use sterile suction technique and airway care to prevent iatrogenic contamination and infection
11) continue to reposition patient every 2 hours and as needed to prevent atelectasis and to optimize lung expansion
12) provide oral hygiene and suction the oropharynx whenever necessary
162
care of the patient with an endotracheal tube: extubation (removal of endotracheal tube)
1) explain the procedure
2) half self-inflating bag and mask ready in case ventilatory assistance is required immediately after extubation
3) suction the tracheobronchial tree and oropharynx, remove tape, and then deflate the cuff
4) give 100% oxygen for a few breaths, then insert a new, sterile suction catheter inside tube
5) have the patient inhale. At peak inspiration, remove the tube, suctioning the airway through the tube as it is pulled out
163
care of the patient with an endotracheal tube: care of the patient following extubation
1) give heated humidity and oxygen by facemask and maintain the patient in a sitting or high fowler's position
2) monitor respiratory rate and quality of chest excursions. Note stridor, color change, and change in mental alertness or behavior
3) monitor the patient's oxygen level using a pulse oximeter
4) keep patient NPO, or only give ice chips for the next few hours
5) provide mouth care
6) educate the patient about how ti perform coughing and deep-breathing exercises
164
care of the patient with an endotracheal tube: preventing complications associated with endotracheal tubes
- administer adequate warmed humidity
- maintain cuff pressure at appropriate levels
- suction as needed per assessment findings
- maintain skin integrity. change tape and dressing as needed or per protocol
- auscultate lung sounds
- monitor for s/s of infection, including temperature and WBC
- administer prescribed oxygen and monitor oxygen saturation
- monitor for cyanosis
- maintain adequate hydration of the patient
- use sterile techniques when suctioning and performing tracheostomy care
165
tracheostomy
- surgical procedures in which an opening is made in the trachea btw the 2nd and 3rd tracheal rings
- bypasses the upper airway to bypass of an obstruction, allows removal of secretions, permits long-term mechanical ventilation, prevents aspirations of secretions, or replaces an endotracheal tube
166
cuffed tracheostomy tube of an appropriate size is inserted
- an inflatable attachment to the tracheostomy tube that is designed to occlude the space between the tracheal walls and the tube, to permit mechanical ventilation, and to minimize the risk of aspiration
167
complications of tracheostomy
bleeding, pneumothorax, aspiration, subcutaneous/mediastinal emphysema, laryngeal nerve damage, posterior tracheal wall penetration
168
long term complications of tracheostomy
airway obstruction, infection, rupture of the innominate artery, dysphagia, tracheoesophageal fistula formation tracheal dilatation, tracheal ischemia and necrosis
169
fenestrated t-tube
allows pt to talk
170
double cuffed tube
inflating the two cuffs alternately can help prevent tracheal damage
171
nursing management for tracheostomy
- continuous monitoring
- when VS are stable place pt in semi-fowler's position to facilitate ventilation, promote drainage, minimize edema, and prevent strain on the suture lines
- suction PRN; when adventitious breath sounds are detected or whenever secretions are obviously present
- maintain cuff pressure at appropriate level
- auscultate lung sounds
- maintain skin integrity - change tape and dressing PRN or per protocol
- maintain adequate hydration of the pt
- monitor for cyanosis
- administer prescribed oxygen and monitor oxygen saturation
- use sterile technique when performing tracheostomy care
- analgesia and sedative agents must be given w/ caution b/c of risk of suppressing the cough reflex
172
what can unnecessary suctioning do
initiate bronchospasm + cause mechanical trauma to tracheal mucosa
173
how often should cuff pressure be monitored by
at least q8h
174
mechanical ventilation
positive or negative pressure breathing device to maintain ventilation or oxygenation for a prolonged period
175
spontaneous respiration
negative inspiratory force - air enters the lungs
176
mechanical respiration
positive inspiratory pressure - air pushed into the lungs
177
indications for mechanical ventilation
- PaO2 <55 mmHg - continuous decreases in O2
- PaCO2 > 50 mmHg and pH <7.32 - persistent acidosis
- vital capacity <10 mL/kg
- negative inspiratory force <25 cm H2O
- FEV1 <10 mL/kg
- thoracic/abdominal surgery, drug overdose , neuromuscular disorders, inhalation injury, COPD, multiple trauma, shock, multiple trauma, shock, multisystem failure, and coma
178
negative-pressure ventilators
"iron lung", chest cuirass, rarely used today
179
positive-pressure ventilators
inflate lungs by exerting positive pressure on airway, pushing air in, and forcing the alveoli to expand during inspiration; expiration occurs passively; intubation or tracheostomy is usually necessary
180
pressure-cycled
delivers a flow of air (inspiration) until it reaches a preset pressure, and then cycles off, and expiration occurs
181
pressure-cycled limitation
volume of air or oxygen can vary as the pt's airway resistance or compliance changes - tidal volume delivered may be inconsistent
182
high-frequency oscillatory support ventilators
- deliver very high respiratory rates (180 to 900 breaths/min) that are accompanied by very low tidal volumes and high airway pressures through small pulses of oxygen enriched air
- used to open alveoli in situations and high airways (atelectasis + ARDS) and to protect the lungs from pressure injury
183
RTZ
delivers very small tidal volumes at extremely fast rate which minimizes changes of a lung injury; ventilation increased by increasing amplitude or decreasing frequency; oxygenation increased by increasing the MAP or increasing the FiO2; indicated for neonates (pulmonary hypoplasia)
184
volume-cycled
deliver a preset, relatively constant volume of air with each inspiration
185
disadvantage of volume cycled
pts may experience barotrauma because of the pressures required to deliver the breaths may be excessive; causes damage to alveolar capillary membrane and air to leak into the surrounding tissues
186
noninvasive positive pressure ventilation
- use of facemask or other device to maintain a seal + permit ventilation
- eliminates need for endotracheal intubation/tracheostomy + decreases risk of nosocomial infections
- most comfortable mode for the pt = pressure-controlled ventilation with pressure support
- eases the work of breathing and enhances gas exchange
187
indications for noninvasive positive pressure ventilation
acute or chronic respiratory failure, acute pulmonary edema, COPD, chronic heart failure, or a sleep-related breathing disorder
188
contraindications for noninvasive positive pressure ventilation
respiratory arrest, serious dysrhythmias, cognitive impairment, or head/facial trauma
189
CPAP ; continuous positive airway pressure
- provides positive pressure to the airways throughout the respiratory cycle; can be used as an adjunct to mechanical ventilation with a cuffed endotracheal tube or tracheostomy tube to open the alveoli or used with a leak-proof mask to keep alveoli open to prevent respiratory failure
190
what is CPAP effective for
OSA, positive pressure acts as splint, keeping upper airway+ trachea open during sleep
191
patient needs to be_______ for CPAP
breathing independently/spontaneously - no mandatory breaths are given
192
RTZ for CPAP
continuous pressure that is above atmospheric pressure is delivered and maintained throughout entire breathing cycle; useful mode for weaning
193
Bi-level positive pressure airway pressure
(BiPAP) delivers two levels of positive airway pressure provided via a nasal/oral mask, nasal pillow, or mouthpiece with a tight seal and a portable ventilator each inspiration can be initiated either by the pt or by the machine if it is programmed with a backup rate (ensures the pt receives a set number of breaths per minute)
194
controlled mechanical ventilation mode
- provides full ventilator support by delivering preset tidal volume + respiratory rate
- indicated for pts who are apneic
195
continuous mandatory ventilation (CMV)/ assist control ventilation (A/C) modes
- delivers a preset tidal volume or pressure at a preset rate of respirations, regardless of whether the breath is initiated by the pt or the ventilator
- Pt triggers additional spontaneous breaths in btw whatever the ventilator is set at; when they initiate the breath by exerting the negative inspiratory pressure, vent is going to deliver volume of assisted breath constantly (whether they do or don't take a breath) - not good for pts w/ COPD because they have a longer expiratory phase so we would be giving them a breath as they are trying to breathe out
196
CMV and A/V disadvantages
in pts w/ respiratory alkalosis: pt hyperventilates due to anxiety/pain; treated w/ sedation/anti-anxiety med or changing it to SIMV
197
CMV and A/C RTZ
minimum number of breaths delivered by the ventilator but the ventilator the pt can also trigger assisted breaths; pt makes effort to breathe and ventilator assists in delivering the breath, breaths are NOT spontaneous (pt triggered but still delivered by ventilator); sensitivity control can be adjusted to make it easier or harder for the pt to initiate a breath; indicated when mechanical ventilation is first initiated; provides full ventilatory support; major complication = hyperventilation - respiratory alkalosis (result of too many breaths being given to pt)
198
intermittent mandatory ventilation (IMV) mode
- combination of mechanically assisted breaths + spontaneous breaths
- mechanical breaths delivered at preset intervals + preselected tidal volume, regardless of the it's effort
- allows pts to use their own muscles for ventilation to prevent atrophy
- spontaneous breaths are limited to the tidal volume generated by pt
- lowers mean airway pressure
- "fighting the ventilator" may be increased - trying to exhale when ventilator is delivering a breath
- set # of breaths from ventilator + btw those, pt can spontaneously breathe
- IMV does not recognize spontaneous breaths (allows pt to be breathing at the same time as the vent) - DO NOT use on it who breathes spontaneously
199
synchronized intermittent mandatory ventilation (SIMV) mode
- delivers preset tidal volume + number of breaths per minute
- senses pt breathing efforts and does not initiate a breath in opposition to pt's efforts - fighting the ventilator is reduced + prevent stacking breaths (machine will not breathe on top of the pt)
- when pt's ability to breathe spontaneously increases, preset number of ventilator breaths is decreased + the pt does more work of breathing
200
RTZ SIMV
- delivers preset mandatory number of breaths but also allows the pt to initiate spontaneous breaths in between the mandatory breaths; allows operator to set with a controlled pressure or controlled volume; primary indication is partial ventilatory support; used for weaning; helps maintain pt's respiratory strength; distributes tidal volumes evenly throughout lung fields reducing the V/Q mismatching; helps to decrease pt's mean airway pressure
201
pressure support ventilation (PSV) mode
- pt is triggered, pressure limited, and flow cycled
- applies a pressure plateau to the airway throughout the pt-triggered inspiration to decrease resistance within the tracheal tube and ventilator tubing
- pressure support is reduced gradually as the pt's strength increases
- may need to adjust the pressure support to avoid tachypnea or large tidal volumes
- backup rate may be given (adding SIMV)
202
PSV RTZ
pt's spontaneous breaths are sup[ported by the ventilator during the inspiratory phase of breathing; as the pt trigger a breath, the ventilator assists by adding pressure to make breathing easier; level of pressure is preset by operator so have control over how much support you give the pt; the higher the level of pressure support that is set - the easier it will be for the pt to take a breath; breaths are time-cycled and pressured-limited; often used to help the pt overcome the airway resistance that is caused by the endotracheal tube (if tube is too small)
203
pressure regulated/volume controlled (PRVC) mode
- preset tidal volume at a set rate with lowest possible pressure
- similar to assist control
- breaths can be vent initiated (controlled) or patient initiated (assisted)
- vent makes adjustments breath to breath
204
PRVC RTZ
- provides volume controlled breaths with the lowest pressure possible by altering the flow and inspiratory time, used to keep peak airway pressure at the lowest possible level; volume-cycled; can be pt triggered or time triggered
205
airway pressure release ventilation (APRV) mode
- time triggered, pressure-limited mode of mechanical ventilation that allows unrestricted, spontaneous breathing throughout the ventilatory cycle
- allows alveolar gas to be expelled through the lungs' natural recoil
- associated with less ventilator-induced lung injury, fewer adverse effects on cardiocirculatory function, and lower need for sedation/neuromuscular blockade
206
APRV RTZ
two levels of CPAP are applied with an intermittent release phase for spontaneous breaths; set high pressure/low pressure/high time/low time; recommended to improve oxygenation and treat refractory hypoxemia; good for pts with ARDS, acute lung injury, atelectasis
207
proportional assits ventilation (PAV) mode
- provides partial ventilatory support in which the ventilator generates pressure in proportion to the pt's inspiratory efforts
- the more inspiratory pressure the pt generates, the more pressure the ventilator generates
208
PAV RTZ
machine uses variable pressure to provide pressure support for a pt's spontaneous breaths; level of pressure support is adjusted depending on the pt's work of breathing; wither pressure triggered or flow-triggered and breathing cycle ends once the pt's volume or flow demands are met; if pt's lungs show rapid improvement - over distention or barotrauma could occur because too much pressure would be delivered
209
PEEP
positive pressure applied at end of expiration to keep alveoli open and avoid hypoxemia
- set from 5-20 cm H2O
210
high PEEP
- common in its with long term vents and ARDS
- increases intrathoracic pressure
- can result in decreased CO d/t decreased venous return + increased ICP
- caution for barotrauma
- have a chest tube on hand
211
adjusting the ventilator purpose
- pt is comfortable and breaths synchronously with the machine
- if the volume ventilator is adjusted appropriately, the pt's ABG values will be satisfactory and there will be little or no cardiovascular compromise
212
monitoring the equipment
- controlling mode (A/C ventilation and SIMV)
- tidal volume and rate settings (tidal volume is usually set at 6-10 mL/kg [ideal body weight[ or 4-8mL/kg for the patient with ARDS [ideal body weight]; rate is usually set at 12-16 breaths per minute
- FiO2 setting may be set btw 21-100% to maintain optimal PaO2 (>60 mmHg) or SpO2 level >92%
- peak inspiratory pressure (PIP) (Normal is 15-20 cm H2O; increases w/ increased airway resistance or decreased compliance
- sensitivity (A 2-cm H2O inspiratory force should trigger the ventilator)
- inspiratory-to-expiratory ratio (usually 1:2 [1 sec of inspiration to 2 sec of expiration] unless inverse ratio is ordered)
- sigh settings (usually set at 1.5x the tidal volume and raging from 1-3/hr), if applicable
- water in the tubing, disconnection or kinking of the tubing
- humidification (humidifier filled with water) and temperature
- alarms (turned on and functioning properly at all times per the Joint Commission Alarm Safety Goal)
- PEEP and pressure support level if applicable
213
ventilator problems
- increase in peak airway pressure or decrease in pressure or loss of volume
214
alterations in cardiac function
- position intrathoracic pressure during inspiration compresses the heart and great vessels which reduces venous return, cardiac output, tissue perfusion, and oxygenation
- assess for s/s of hypoxia
- assess cardiac output, cardiac index, hemodynamic values if pulmonary artery catheter is in place
215
barotrauma
trauma to the trachea or alveoli secondary to positive pressure
216
pulmonary infection and sepsis
- report fever or change in color/odor of sputum
- subglottic secretions may increase the pts' risk for the development of VAP
217
GI complications from ventilators
- stress ulcers and GI bleeding
- start enteral feeding as soon as possible + give ulcer prophylaxis
- monitor for occult blood + aspirate from GI system
218
alveolar injury or rupture as a result of...
excessive pressure: subcutaneous emphysema or pneumomediastinum
- s/s = high peak inspiratory pressure, decreased breath sounds, tracheal deviation to unaffected side, crepitus, air leak in chest drainage systems, signs of hypoxemia
219
troubleshooting problems with mechanical ventilation
- high pressure - high blockage
- low pressure - loss of connection, leak
220
ventilator problems
- increase in peak airway pressure
- decrease in pressure or loss of volume
221
cause of increase in peak airway pressure
- coughing or plugged airway tube
- patient "fighting" ventilator
- decreasing lung compliance
- tubing kinked
- pneumothorax
- atelectasis or bronchospasm
222
cause of decrease in pressure or loss of volume
- increase in compliance
- leak in ventilator or tubing; cuff on tube/humidifier not tight
223
patient problems
- cardiovascular compromise
- barotrauma/pneumothorax
- pulmonary infection
224
cardiovascular compromise cause
decrease in venous return due to application of positive pressure to lungs
225
barotrauma/pneumothorax cause
application of positive pressure to lungs; high mean airway pressures lead to alveolar rupture
226
pulmonary infection cause
bypass of normal defense mechanisms, frequent breaks in ventilator circuit; decreased mobility; impaired cough reflex
227
the ABCDE bundle
the awakening and breathing, coordination, delirium monitoring and management, early mobility bundle
228
awakening and spontaneous breathing trials
- the nurse determines if it safe to stop sedation
- if determined safe, the nurse will determine if patient tolerated the sedation interruption
- if the patient tolerated the interruption, the respiratory therapist will determine if the patient is a candidate for a breathing trial
229
monitoring and management of delirium
the patient will be assessed at least every 2-4 hrs using a sedation assessment scale (e.g. the CAM-ICU)
230
early mobility
- the patient is able to respond to verbal stimuli
- the patient is receiving less than 60% FiO2 and less than 10 cm of PEEP
- the patient has no circulatory or central catheters or injuries that may contraindicate mobility
231
nursing interventions: enhancing gas exchange
- monitor ABGs and other indicators of hypoxia - not trends
- auscultate lung sounds frequently
- judicious use of analgesics to relieve pain w/o suppressing the respiratory drive
- monitor fluid balance: I&O + daily weights
- frequent repositioning to diminish the pulmonary effects of immobility
232
nursing interventions: promoting effective airway clearance
- assess lung sounds + presence of secretions at least every 2-4 hrs
- measures to clear airway: suctioning, CPT, position changes, promote mobility
- periodic sighs to prevent atelectasis
- at least 1-3 sighs per hour at 1.5 x the tidal volume if the pt is receiving A/C ventilation
- in SIMV mode, mandatory ventilations act as sighs b/c they are greater volume than the pt's spontaneous breaths
- humidification of airway to liquefy secretions so that they are more easily removed
233
medications to promote effective airway clearance
- adrenergic bronchodilators
- anticholinergic bronchodialtors
- mucolytic agents (acetylcysteine)
234
adrenergic bronchodilators
most inhaled + work by stimulating the beta-receptor sites to mimix the effects of epinephrine - result in smooth muscle relaxation + dilation of constricted bronchial tubes
235
anticholinergic bronchodilators
produce airway relaxation by blocking cholinergic-induced bronchoconstricton
- monitor for dizziness, nausea, decreased oxygen saturation, hypokalemia, increased HR, + urine retention
236
mucolytic agents
- acetylcysteine
- liquefy secretions so that they are more easily mobilized
- monitor for adequate cough reflex, sputum characteristics nausea, vomiting, bronchospasm, stomatitis, urticaria, + rhinorrhea
237
preventing trauma and infection
- infection control measures
- tube care: position the tubing so that there is minimal pulling or distortion of the tube in the trachea. replace ventilator circuit tubing and in-line suction tubing periodically
- tracheostomy care performed q8h or more frequently
- cuff pressure monitored q8h
- oral care - oral cavity is a primary source of contamination of the lungs
- elevation for increased temp or increased WBC count
- pallor and increased pulse may indicate internal hemorrhage
238
criteria for successful home ventilator care: patient criteria
- the pt has a chronic underlying pulmonary or neuromuscular disorder
- the pt clinical pulmonary status is stable
- the pt is willing to go home on mechanical ventilation
239
criteria for successful home ventilator care: home criteria
- the home environment is conducive to care of the pt
- the electrical facilities are adequate to operate all equipment safely
- the home environment is controlled, without drafts in cold weather and with proper ventilation in warm weather
- space is available for cleaning and storing ventilator equipment
240
criteria for successful home ventilator care: family criteria
- family members are competent, dependable, and willing to spend the time required for proper training as primary caregivers
- family members understand the diagnosis and prognosis
- family has sufficient financial and supportive resources and can obtain professional support if necessary
241
three stages of weaning
- pt is gradually removed from the ventilator
- pt is removed from the endotracheal/tracheostomy tube
- pt is removed from oxygen
242
criteria for initiation of weaning
physiologically and hemodynamically stable, demonstrates spontaneous breathing capability, recovering from acute stage of medical/surgical problems, + when cause of respiratory failure is sufficiently reversed
243
pt preparation for weaning
psychological preparation + assessing factors that impair the delivery of oxygen, increase oxygen demand (sepsis, seizures, and thyroid imbalances), or decreased the pt's strength (inadequate nutrition and neuromuscular disease)
244
methods of weaning
- CPAP
- SIMV
- T-piece trials
245
CPAP methods of weaning
allows pt to breathe spontaneously while applying positive pressure throughout the respiratory cycle to keep the alveoli open and promote oxygenation
246
SIMV methods of weaning
rate is slowly decreased by 1-3 breaths per minute until pt is fully breathing on their own
247
T-piece trials methods of weaning
normally conducted with pt disconnected from ventilator, receiving humidified oxygen only, and performing all work of breathing - pts do not have to overcome the resistance of the ventilator
- if pt appears to be tolerating T-piece/tracheostomy mask trial, a second set of ABGs is drawn 20 minutes after pt has been on spontaneous ventilation at a constant FiO2 PSV
- alveolar-arterial equilibrium takes 15-20 minutes to occur
248
when is pt placed back on the ventilator
- each time signs of fatigue or deterioration develops
- signs of exhaustion and hypoxia correlated with deterioration in the blood gas measurements indicate the need for ventilatory support
249
if clinically stable, pt usually extubated within ......
2-3 hrs after weaning and allowed spontaneous ventilation by means of a mask with humidified oxygen
250
pts who have hd prolonged ventilatory assistance usually require more gradual weaning...
may take days or even weeks, primarily weaned during the day and placed back on the ventilator at night
251
successful weaning supplemented by intensive pulmonary care
oxygen therapy, ABG evaluation, pulse oximetry, bronchodilator therapy, CPT, adequate nutrition/hydration, adequate humidification, BP measurements, + incentive spirometry
252
sedation vacation
if pt receiving IV sedatives (propofol and midazolam), current guidelines recommend that pt's sedative dose be decreased by 25-50% prior to weaning
253
removal of tracheostomy tube considered when...
pt can breathe spontaneously, maintain adequate airway by effectively coughing up secretion, swallow, + move the jaw
254
trial period of mouth breathing or nose breathing
- once pt can clear secretions adequately
255
methods of trial period of mouth breathing or nose breathing
changing to a smaller size tube to increase the resistance to airflow or plugging the tracheostomy tube, changing to a fenestrated tube, switching to a smaller tracheostomy/stoma button that helps keep the windpipe open after the larger tracheostomy tube has been removed
- when tube is removed, occlusive dressing is placed over stoma, which heals in several days-weeks
256
successful weaning requires...
early and aggressive nutritional support due to respiratory muscle atrophy
- compensation for inadequate nutrition must be undertaken with care- excessive intake can increase the production of carbon dioxide and the demand for oxygen and lead to prolonged ventilator dependence and difficulty weaning
- adequate protein intake
257
adequate protein intake
25% or total daily kilocalories, or 1.2 to 1.5 g/kg/day
258
pulmonary artery catheter (PAC)
procedure in which an intravascular catheter is inserted through a central vein (femoral, jugular, antecubital, brachial) to connect the right side of the heart and advance towards the pulmonary artery
259
what is PAC utilized for
access right sided chamber filling pressures, estimation of cardiac output, intracardiac shunt evaluation, valvular studies, and valvular resistance
260
what is PAC an excellent tool for
assessment if pts with pulmonary hypertension, cardiogenic shock, and unexplained dyspnea
261
indications for PAC
- evaluation or diagnosis of pulmonary hypertension
- distinguishing etiology of shock based on mixed venous oxygen saturation (SvO2) measurement such as septic or cardiogenic shock
- assessment of volume status in severe shock
- evaluation of pericardial illness such as cardiac tamponade or constrictive pericarditis
- assessment of right sided valvular disease, congenital heart disease, cardiac shunts - when surgical repair is planned
- ATI - critical illness, HF, post CABG, ARDS, AKI, burn injury, trauma injury
262
contraindications to PAC
- insertion of the catheter through a site where there is an active infection
- presence of a right sided ventricular assist device
263
placement of PAC
- insertion of catheter from one of main central veins - superior or inferior vena cava - right atrium- tricuspid valve- right ventricle- pulmonary valve- pulmonary artery
- tip of catheter lies in main pulmonary artery where balloon measures pressure
- inflation can measure pulmonary capillary wedge (occlusive pressure = indirect assessment of left sided filling pressure
- pressure waveform can be seen on monitor b/c of transducer in catheter
- each section of heart has distinct pattern that helps determine where tip of catheter is
- done under fluoroscopy (most common) or at the bedside w/ use of US and echocardiography
264
swan-ganz/right heart catheter
- quadruple lumen catheter w/ theromodilution sensor that is attached to a pressure transducer outside of body (60-110 cm in length; 4F-8F in caliber)
265
blue lumen
- CVP port; right atrial lumen
- 30 cm from tip and rests within right atrium
- proximal port used for infusion
- can assess CVP and RA pressure
266
white/clear lumen
- terminates close to prior lumen
- rests within the right atrium
- used for infusion
267
yellow lumen
- PA distal; pulmonary artery lumen
- distal port
- measure PAP
- can be used for mixed venous draws
268
red/white connector
- (thermistor)
- temperature sensitive wire that terminated 4 cm proximal to tip of catheter
- rests in a ain pulmonary artery
- connection of thermistor port to CO monitor allows determination of CO using thermodilution
269
red lumen
- balloon port
- helps place the tip of catheter in the pulmonary artery
270
complications of PAC
- infection of insertion site
- pneumothorax when placed in subclavian vein
- air embolism: entrapment of air from infusion ports
- atrial.ventricular arrhythmias due to irritation of contact of catheter w/ cardiac walls
- calve rupture or cardiac wall perforation
- vessel rupture at moment of balloon inflation
- pulmonary infarction can occur when balloon is inflated for long period/migration of catheter to distal branches
- thromboembolism secondary to inflammation or infection
271
PAWP - pulmonary artery wedge pressure
- measurement obtained during momentary balloon inflation of a pulmonary catheter
- reflective of left ventricular end-diastolic pressure
- normally ranges between 4-12 mmHg
272
decreased PAWP
hypovolemia or afterload reduction
273
increased PAWP
hypervolemia, left ventricular failure, mitral regurgitation, intracardiac shunt
274
arterial lines
- needed for continuous BP monitoring + blood specimens for ABGs
- common insertion sites: radial artery (most common), brachial artery, femoral artery
275
alien's test
- performed to verify patent radial and ulnar circulation
- pt['s hand is elevated + pt makes a fist for 30 seconds
- nurse compresses the radial and ulnar arteries simultaneously, causing the hand to blanch
- pt opens fist and nurse releases the pressure on the ulnar artery
- if blood flow is restored (hand turns pink) in 6 seconds, circulation to hand may be adequate enough to tolerate placement of radial artery catheter
276
assessing - arterial waveforms ; overdamped
complaint tubing; loose connections, blot clot in cannula tip kinked cannula
277
assessing - arterial waveforms ; underdamped
long stiff tubing, too many stop cocks, defective transducer
278
assessing blood pressure accuracy of arterial lines
compare arterial line reading with NIBP reading
279
neurovascular assessment 5 p's
pain, pulses, paresthesia, pallor, paralysis
280
setting up arterial lines; equipment
sterile gloves, ART-line kit, pressure tubing, 500 cc NS, pressure bag, IV pole, chloraprep, A-line needle, dressing/tape, transducer kit, cable to connect transducer to monitor
281
prevent nerve damage from arterial lines
- pt should have arm board on hand to prevent nerve damage if the wrist is bent + pressure on radial nerve from the catheter
282
zero calibrate line
tells transducer to ignore pressure from atmosphere
- every 4 hrs, after blood is taken, + as needed
283
arterial lines - pt should be...
flat
284
phlebostatic axis
- place transducer at level of right atrium
- alter level of transducer when pt changes position
285
how to get baseline data for arterial lines
square wave test
286
when removing arterial line....
hold pressure on site for 10 minutes and applying dressing to site
- do not apply BP cuffs to arm + do not infuse any IV fluids via arterial line
287
complications for arterial lines
- rapid extreme blood loss
- flat waveform or extremely low pressure reading - check STAT
- phlebitis + infection
- if a-line does not flush, do not force the flush b/c pt could have a thrombosis
471
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