Advanced Advanced Nursing Nursing

Concepts Part 2Concepts Part 2Ventilatory AssistanceVentilatory Assistance

Sandra H. Lewis, ARNP-BC-ADMSandra H. Lewis, ARNP-BC-ADM

Review of Anatomy and Review of Anatomy and PhysiologyPhysiology

• Respiratory system is divided into:• The Upper Airway=nasal cavity, the

pharynx…it conducts, warms humidifies and filters.

• The Lower Airway= the larynx, trachea, and right and left main stem bronchi ( the bifurcation at the angle of Louis is at the level of the 5th thoracic vertebra and is called the carina)

Cont..Cont..The right bronchus is wider, straighter and shorter

(making it easier to accidentally intubate)The lungs consist of two lobes on the left and three

lobes on the right. Each lobe is further divided into lobules that are supplied by one bronchiole. The lungs are covered by the pleura. The visceral pleura covers the lung surfaces and the parietal pleura covers the internal surface of the thoracic cavity. Between the pleura there is a thin fluid layer that allows the sliding action as respiration occurs.

Human RespirationHuman Respiration

Respiratory System.url

Regulation of BreathingRegulation of Breathing• The rate, depth and rhythm of ventilation

are controlled by The respiratory centers in the medulla and the pons.

• When CO2 is HIGH or the O2 level is LOW, chemoreceptors in the respiratory center, the carotid arteries, and the aorta send messages to the medulla to stimulate respiration.

• Persons with NORMAL lung function are stimulated by HIGH levels of CO2

Continued..Continued..• In persons with COPD, the stimulus

to breathe is the LOWER level of O2….higher levels of CO2 are baseline…

• So what do you think is a major nursing consideration about O2 therapy for persons with COPD?

WOB (Work of Breathing)WOB (Work of Breathing)• Compliance= The measure of

stretchability of the lung and chest wall… is primarily determined by the elastic recoil that must be overcome before lung inflation can occur.

• EXAMPLES OF GREATER ELASTIC RECOIL: ARDS, pulmonary fibrosis, pulmonary edema…lungs are stiffer and difficult to distend Compliance is LOW…greater pressures are required to expand lungs.

WOB cont..WOB cont..• ARDS, X-RAY

• In emphysema, destruction of lung tissue and enlarged air spaces cause the lungs to lose their elasticity.

• The decrease in elastic recoil causes compliance to be high.

• Therefore lower pressures are need to expand the lungs.

Cont…Cont…• Emphysema…Notice the flattening of

diaphragms, Increased lung volumes, Diffuse hyperlucency

ResistanceResistance• The opposition to gas flow in the

airways.• Examples: mucous, edema,

bronchospasm• Remember…the smaller the internal

diameter of artificial airway increases resistance to air flow..

SpirometerSpirometer• Used to measure lung volumes.• Allows the practitioner to assess

baseline pulmonary function and to monitor changes.

Lung volumesLung volumes• Volumes and capacities are usually

stated for “healthy men”• Volumes for women are 20-25% less• Volumes decline with age. • Tidal Volume= Volume of normal

breath

Health HistoryHealth History• Tobacco use, type, amount, #years used…pack

years=packs cig a day x years smoked• Occupational…asbestos, coal mining, farming• Sputum• SOB, CP, dyspnea, cough, anorexia, weight loss• Respiratory med hx: inhaled, steroids,

bronchodilators• OTC Drugs• Allergies• Last CXR and TB screening

Physiological Changes with Physiological Changes with AgeAge

• Decreased alveolar surface• Decreased alveolar elasticity• Decreased chest wall distensibility• Decreased physiological

compensatory mechanisms: (resp, cardiac, renal, immune)

Physical ExamPhysical Exam

Respiratory AssessmentRespiratory Assessment• INSPECTION

– landmarks; scapula , vertebrae– Respiratory rate– Position and use of accessory

muscles– Colour – Breath sounds

PERCUSSIONPERCUSSION• Posteriorly

– upper and lower lobes• Start with apical areas, moving L to

R and then slowly moving down to 10 ICS.

• ResonanceResonance - long, low pitch sound, heard over most lung fields

• Hyperresonance - low sounds (abnormal) heard when emphysema

• Flatness/dullnessFlatness/dullness - pneumonia and atelectasis.

PALPATIONPALPATION– breathing excursionbreathing excursion

•position palms of hands on patients back between 8th and 10th ribs. Thumbs are ‘free floating’. Ask patient to take a breath. Each hand should move the same distance (3-5 cms)

– tactile Fremitustactile Fremitus•Using the ball of your hand , place

them on the posterior wall of the chest, starting in the apical lobe area, ask your patient to say ‘99’. You should feel vibrations. In pneumonia, there is increased intensity of the vibrations and with pneumothorax, reduced intensity.

AUSCULTATIONAUSCULTATION

• Follow same pattern as used when percussing.

• Observe for expected breath sounds in the region assessing – BronchialBronchial– BronchovesicularBronchovesicular– vesicularvesicular

• Listen for Crackles & Wheezes• Pleural rub

DOCUMENTATIONDOCUMENTATION• Respiration rate, skin colour, physical

position and respiration sounds -INSPECTION

• Tactile fremitus, and respiratory excursion - PALPATION

• Breath sounds, describe and compare from lung apex to base as well as from LR

• Presence of crackles and/or wheezes; state their location - AUSCULTATION

Signs and Symptoms of Signs and Symptoms of HypoxemiaHypoxemia

• Integument: Pallor, cool, dry, diaphoresis, cyanosis

• Respiratory: Dyspnea, tachypnea, accessory muscle use

• Cardiovascular: Tachycardia, dysrhythmias, CP, HTN with increased heart rate, hypotension with decreased heart rate.

• CNS: Anxiety, restlessness, combativeness, fatigue, confusion, coma

Common Acid-Base Common Acid-Base AbnormalitiesAbnormalities

• See Box 8-2 page 172• Resp. Acidosis (CO2 retention):

COPD,CNS Depression, restrictive lung disease

• Resp. Alkalosis (hyperventilation): Anxiety, pain, stimulants, pneumonia CHF, pulmonary edema

Cont..Cont..• Metabolic Acidosis (increased acids): Renal

failure, DKA, Lactic acidosis, drug OD… Methanol, salicilates, ethylene glycol (loss of base)..diarrhea

• Metabolic Alkalosis ( gain of base): excess antacids, or sodium bicarb…. or (loss of acids), vomiting, NG suction, Low K+ or CL, diuretics, increased aldosterone level

ABG’sABG’s• Blood Gas Analysis Handout• Pages172-173.Critical Care Nursing

Pulse OximetryPulse Oximetry

• Measures SpO2, reflects: SaO2 (arterial saturation)

• A light emitting diode measures pulsatile flow and light absorption of the hemoglobin.

• Accurate readings require a warm, well perfused area.

• Patient motion and edema at the site adversely effect results…nail polish, sunlight and florescent light also interfere

Oxygen AdministrationOxygen Administration

IF YOUR PATIENT ISIF YOUR PATIENT IS

BLUEBLUE….….......TRY SOMETRY SOME

OO22

HeadTilt/ChinLiftProcedureHeadTilt/ChinLiftProcedure• Tongue, the most

common cause of airway obstruction

• One hand on patient’s forehead, fingers of opposite hand under bony part of the chin

• Lift the chin forward and support the jaw, helping to tilt the head back

Modified Jaw ThrustModified Jaw Thrust• Used when

possibility of C-spine injury exists

• Grasp the angles of the patient’s lower jaw and lift with both hands, displacing the mandible forward

• If the lips close, retreat the lower lip with thumb

Oral AirwaysOral Airways• are designed to keep

the tongue from falling back and blocking the upper airway

• easily available in six to nine sizes

• are only used in unresponsive patients without a gag reflex

• do not eliminate the need to monitor airway for patency

Oral Airway SizingOral Airway Sizing

• To choose the proper size, hold the airway against the side of the patient’s face. It should extend from the corner of the patient’s mouth to the angle of the jaw.

Oral Airway InsertionOral Airway Insertion• Open mouth with cross

finger technique. Insert airway with tip pointing up to avoid pushing tongue backward.

• Rotate airway tip slowly downward until its curve matches the curve of the tongue.

• The flange of the airway should rest against the patient’s lips.

Nasopharyngeal AirwaysNasopharyngeal Airways• Curved, flexible rubber or plastic

tubes inserted into the patient’s nostril

• Use on responsive patients who need an airway assist

Nasopharyngeal Airway Nasopharyngeal Airway SizingSizing

• Measure length from tip of patient’s nose to earlobe

• Diameter of airway should fit patient’s nostril without excessive tightness

Oxygen Tanks and Oxygen Tanks and RegulatorsRegulators

• Always green-designates O2

• Various tank sizes– D, E, M

• Yoke vs. Threaded outlet• Tank pressure-2000 lbs. per sq. in.• Common regulators

– fixed orifice, bourdon gauge

Delivery DevicesDelivery Devices

• Nasal cannula– Flow rate 2-6 lpm

• Non-Rebreather mask– Flow rate 10-15 lpm

• Two rescuer Bag Valve Mask (BVM)– Flow rate 15 lpm

Set up of Tank/RegulatorSet up of Tank/Regulator

• Step 1-open tank to blow out dust• Step 2-Attach regulator (o-ring)• Step 3-Open tank, check pressure• Step 4-Attach proper delivery device• Step 5-Open flow to proper lpm for

device• Step 6-Place delivery device on

patient

Break down of Break down of Tank/RegulatorTank/Regulator

• Step 1-Turn off flow• Step 2-Remove mask/cannula , turn

off tank• Step 3-Open flow meter to

relieve/bleed pressure-close when complete

• Step 4-Remove regulator

Safety ConsiderationsSafety Considerations

• Position/placement of tank• Properly fitting regulator• Close all valves when not in use• O2 fuels fire-not a flammable gas• Do not roll tanks on side or bottom• Inspect valve seats and o-rings• Store tanks in cool, well ventilated area• Have tanks tested on regular basis

Oral Vs Nasotracheal Oral Vs Nasotracheal IntubationIntubation

• Box 8-6 on page 181 in Critical Care Nursing

Look carefully at advantages and disadvantages.

Equipment for IntubationEquipment for Intubation• See Figure 8-19 page 182• Be able to set up for an intubation

and discuss choosing ET size and rationale for nasal or tracheal intubation.

ET & More infoET & More info• How quickly should the ET be placed? 30 seconds• Where should the tip end? 3-4 cm above the carina• What is the role of rapid sequence intubation? Emergency airway

management, while decreasing the risk of aspiration, combativeness and injury to the patient.

• HOW is RSI achieved? Neuromuscular blocking agent (Succinylcholine) + potent sedative (fentanyl or other).

• What is Sellecks maneuver? Pressure on the cricoid is applied.• Why is it used? To decrease risk of vomiting and therefore

aspiration• When can blind intubation be done? Only if the patient is capable

of spontaneous respirations.• How long can a ET tube generally be left in place? 3-4 weeks.• Where is the incision made for a tracheostomy? At the level of the

cricoid or between the 1st and second tracheal ring.

Suctioning the Intubated Suctioning the Intubated PatientPatient

• See box 8-9 page 188 Critical Care Nursing

• Discuss proper suctioning technique

Negative Pressure Negative Pressure VentilationVentilation

• Used for sleep apnea, neuromuscular problems and when Chronic Respiratory Failure patients need short periods of ventilation.

• See figure 8-24• Examples: iron lung, tank ventilator

Noninvasive positive Noninvasive positive pressure ventilationpressure ventilation

• See figure 8-25 page 189 Critical Care Nursing

• Face Mask covers mouth and nose.• Used in those requiring ventalatory

support post intubation to resolve hypercapnia and short term…pulmonary edema, or for patient who refuses intubation

Controlled VentilationControlled Ventilation• Rarely used because of the

superiority of Assist/Control (causes less anxiety, less hemodynamic instability).

• Locks out patients attempts at respiration

• Indicated for high c-spine injuries, patients with NO respiratory effort, chemically paralyzed patients

Assist ControlAssist Control• Helps preserve muscle tone, reduces

dyssynchrony (fighting the vent)• Potential complication of A/C=resp

alkalosis (patients own resp rate too high triggering the vent…this can be adjusted by adjusting the sensitivity, sedating the patient if needed, or using IMV)

SIMVSIMVSynchronized Intermittent Synchronized Intermittent

Mandatory VentilationMandatory Ventilation• Delivers a preset Vt at a preset rate and

allows the patients own breaths at his own rate and depth between the ventilator breaths.

• Guarantees at set number of breaths• Helps prevent muscle weakness and

hyperventilation.• Can increase muscle fatigue associated

with patient efforts

PEEPPEEPPositive End Expiratory Positive End Expiratory

PressurePressure

• Higher that atmospheric pressure at the end of expiration

• Increases oxygenation by preventing the collapse of small airways and maximizing the number of alveoli available for gas exchange.

• Often ordered to reduce the FiO2 needed for optimal oxygenation

PEEP cont…PEEP cont…• “physiologic peep” = 3-5 cm H2O• Usual peep range 3-20 cm H2O• Can decrease cardiac output (secondary to

decreased venous return.)• Increases risk of volutrauma• Increased ICP from decreased venous

return to the head• Can cause alterations in renal function

secondary to reduced renal blood flow.

CPAPCPAPContinuous Positive Airway Continuous Positive Airway

PressurePressure• The concept of peep is used to

augment the patients residual functional capacity and oxygenation during spontaneous breathing

• Administered through nasal of face mask or through artificial airway

• Often used in obstructive sleep apnea

Some Ventilator Some Ventilator TerminologyTerminology

• Tidal Volume- amount of air delivered with each preset breath, usually 10-15 ml/kg, however, recent research indicates lower Vt=less volutrauma…this could not be used in head injured patients because of the resultant hypercapnia…increases intercranial pressure because of vasodilation from CO2

Cont.Cont.• Respiratory Rate- Frequency of

breaths delivered• FiO2- The percentage of inspired

oxygen 21-100%, after emergency intubation 50-100%...adjustments made based on ABG’s

• Sigh-A mechanically set breath with greater Vt. (volume), used to prevent atelectasis.

Complications of Mechanical Complications of Mechanical VentilationVentilation

• Volutrauma• Intubation of Right main stem bronchus• ET out of place or unplanned extubation• Tracheal Damage• Oral or Nasal mucosa damage• Problems associated with O2 administration• Resp Acidosis or Alkalosis• Aspiration• Infection• Inability to wean• Communication

Care of the Patient with Care of the Patient with Mechanical VentilationMechanical Ventilation

• Medications• Nutritional Support

Trouble shooting the VentTrouble shooting the Vent• Never Shut off alarms• Manually ventilate the patient if you cannot

trouble shoot the problem or suspect mechanical failure.

• Volume alarms-low=patient not receiving preset Vt.

• Pressure Alarms-High= pressure exceeding preset limit, Look at patient factors..coughing , biting tube, excess secretions, pulmonary edema,bronchospasm, pneumo or hemothorax….also kinks in the ventilator tubing

Cont…Cont…• Apnea Alarms- Ventilator does not

detect spontaneous respiration within the preset interval…especially important when patient has low set rate.