lesson 4 airway management from american association of critical care nurses essentials of critical...
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Lesson 4 Airway ManagementFrom American Association of Critical Care NursesEssentials of Critical Care Orientation
PRESENTED BY:
KATY ZAHNER RN, BSN, CCRN
NURSE EDUCATOR STUDENT
GEORGETOWN UNIVERSITY
Objectives
Identify indications, complications, and management methods for artificial airways and oxygen delivery devices
Describe and discuss monitoring devices used to determine oxygenation
Identify indications, complications, and management methods for non-invasive pressure ventilation
Oxygen
Why do we administer oxygen? Delivery systems
High, low and reservoir systems
Administration Nursing Assessment
Complications O2 toxicity, absorption atelectasis, CO2 retention
(COPD)
Noninvasive positive pressure ventilation (NPPV)
Used to deliver PPV with or without o2 BiPAP – 2 levels of pressure = IPAP and EPAP Requires the patient to maintain spontaneous ventilation Use of face or nasal mask Chronic vs. acute use Patient populations
COPD
Hypoxemic respiratory failure – hemodynamically stable
Extubation failure
Cardiogenic pulmonary edema
AACN Practice Pearls
Room Air (RA) 21% SpO2 tells nothing about CO2 Change in LOC is a sensitive indicator for
hypoxemia Patients with Fio2 > 50% for longer than 24
hours are at high risk for complications related to o2 toxicity
Artificial Airways
Endotracheal tube
Requires endotracheal intubation
Indications
Anesthesia/Surgery
Protect airway
Removal of secretions
Respiratory failure
Characteristics
7.0 – 9.0mm diameter
Radiopaque line
Low pressure high-volume balloon with inflation port
Equipment Needed for Intubation
Intubation tray
Suction
Manual resuscitation bag with mask and O2
Water-soluble lubricant
10ml syringe for inflation of cuff
Tape or ETT device
Stethoscope
Monitoring equipment
Secondary confirmation device
Medications
Ventilator
Anesthetic spray
Intubation Procedure
https://www.youtube.com/watch?v=0VGiBwyfuNI
Nursing Interventions
Prevent skin breakdown around tube Evaluate for inflammation and ulceration of the nose
or mouth Implement treatment for sinus or ear infections Assess for airway injury and/or displacement of ETT
Tracheostomy
Placed when long-term mechanical ventilation is expected (>10-14 days)
Neuromuscular disease
Obstruction of upper airways
Facilitates airway maintenance
Increases patient comfort
**Research shows that early transition (<48 hours) of the patient from ETT to tracheostomy tube offers improved outcomes
Tracheostomy Tubes Characteristics
Sized by inner diameter Inner cannula Universal adapter Decannulation plug
Placing Tracheostomy Tube
Complications – Not the same as ETT
Either surgically or placed percutaneous at bedside
Complication –hemorrhage, wound infection, subcutaneous emphysema
Additional complications Displacement or obstruction
Tracheal stenosis
Tracheoesophageal fistula
Tracheoinonimate artery fistula
Tracheal malascia
Scarring after decannulation
Nursing Interventions
Monitor for tube positioning and patency Assess skin surrounding tracheostomy Evaluate secretions Cuff management Assess breath sounds Sterile suctioning Oral care
Lesson 6Thoracic Surgical Procedures
Objectives
Discuss the types of and indications for, and common complications of thoracic surgical procedures
Describe different systems and principles of management for chest tubes Discuss the indications for, common complications of and nursing
management of patients undergoing video-assisted thoracoscopy, thoracotomy, and pneumonectomy
Compare and contrast the different types of closed chest drainage systems
Describe the nursing management of patients with chest tubes
Thoracic Surgery
Why? Remove tumor and abscess
Surgically resect a segment, lobe or full lung
Repair esophagus or thoracic vessels
Types Pneumonectomy
Lobectomy
Segmental resection
Open lung biopsy
Lung volume reduction surgery
Decortication
Bullectomy
VATS
Drainage of empyema
Preoperative Conditions
Lung function Cardiac function Tumor removal Pain management
Clinical Approach
Incision usually posterolateral
Depends on location of operative area
ETT with double-lumen common
When full lung removed, evaluation of position of mediastinum and trachea before surgical site closed
Postoperative Complications
Hemorrhage
Acute respiratory failure
Pneumonia
Pain
Mediastinal shift Development of bronchopleural fistula, hemorrhage, and
cardiovascular compromise
Postoperative ComplicationsHemorrhage
Life threatening
Most likely to occur during immediate postoperative period
Potential causes: Dislodged suture or clip
Bleeding from intercostal or bronchial artery
Potential indicators: Fresh red blood
Sudden increase in drainage
Drainage volume exceeding 100ml/hr
Postoperative ComplicationsBronchopulmonary Fistula
Suture line does not hold Can be compromised by mechanical ventilation and high
airway pressures
Early weaning is a priority
Indicators: Shortness of breath, cough, hemoptysis
High postoperative mortality rate
Postoperative ComplicationsMediastinal Shift
Accumulation of fluid or an increase in pressure on the surgical side
Remove air or fluid on surgical side Chest tubes
Postoperative ComplicationsCardiovascular
Can occur as a result of large volume of lung tissue and pulmonary vascular bed is resected
Use of vasoactive medications may be indicated to optimize cardiac function
Postoperative Interventions
Goal: Maximize oxygen and ventilation and prevent complications
Interventions Patient positioning and pain management
Maintain chest tube system
Assist with progressive patient activity
Pain management
Pain Management
Indicators of pain Tachypnea
Tachycardia
Increased BP
Grimacing, splinting or moaning
Unwillingness to move and restlessness
Narcotic infusion through epidural of patient-controlled analgesia device may be indicated Medicate sufficiently to allow for deep inspiration
Insertion and Management of Chest Tubes
Why insert a chest tube?
Eliminate air or fluid that has accumulated resulting in compromised ling function
Placed in the pleural space – 4th or 5th intercostal space
Connects to drainage system
X-ray used for confirmation after placement
Average size 28Fr – 40Fr
https://www.youtube.com/watch?v=Hn0SHGuUVak
Chest Drainage Systems
Drainage chamber
Water seal chamber
Suction control chamber
Patient Care
Regularly assess pulmonary status
Measure and record output regularly
Institutional policies related to “milking the tube” Stripping entire length is contraindicated – results in transient HIGH
negative pressures in the pleural space and lung entrapment
Inspection Redness
Swelling
Pain
Purulent drainage
Emergent Response and Troubleshooting
Have sterile water and package of petroleum gauze available If air leak was present before accidental dislodgement of
chest tube, application of occlusive dressing may result in tension pneumothorax
Troubleshooting Chest tube dislodgement
Cessation of drainage
Collection chamber falls
Troubleshooting
Water Seal Chamber Problems present if fluctuation with
inspiration and expiration
Examine entire system beginning at insertion site of patient
Suction Control Chamber Problems present if bubbling absent
Address leaks in the system
Chest Tube Removal Preparation
Timing of removal
Explain procedure to patient
Done during deep breath by patient after cleaning site
Chest X-ray
Observe patient for signs of pneumothorax
Lesson 5Basic Ventilator management
Objectives
Describe endotracheal intubation and discuss nursing considerations
Discuss the management of patients with tracheostomy tube
Compare and contrast the indications, complications and nursing management considerations for commonly used ventilator modes including PPV, pressure controlled/inverse ratio ventilation and volume guaranteed pressure mode ventilation
Discuss nursing care of the mechanically ventilated patient
Describe the common pharmacologic interventions utilized to assist with managing patients
Discuss techniques for the prevention of ventilator acquired pneumonia
Discuss common problems encountered with mechanical ventilators and how to troubleshoot them
Identify key factors that impact ventilator weaning
Describe nursing management of patients who are being weaned from mechanical ventialtion
Mechanical Ventilation
Goal – support gas exchange Indications
Apnea
Acute impending respiratory failure
Severe hypoxemia
Respiratory muscle fatigue
Support during anesthesia or sedation
Mechanical ventilation
2 types Negative and positive pressure
Negative referred to as iron lung
No artificial airway
polio
Positive pressure
Most common
Used with artificial airway
Modes of Ventilation
Ventilator cycle functions Modes
Volume or pressure
Ventilator settings
Mechanical Ventilation ModesVolume
Set amount of volume (Vt) will be delivered to lungs
Common volume modes
Continuous mandatory ventilation (CMV)
Assist – controlled (AC)
IMV/SIMV – intermittent mandatory ventilation/synchronized
Settings
Rate (f)
Tidal volume (Vt)
FIO2
Sensitivity
Positive End Expiratory Pressure (PEEP)
Mechanical Ventilation ModesPressure
Desired pressure is set to achieve Vt
Used for lung protective strategies and noncompliant lungs
Modes include
Pressure Support Ventilation
Pressure Control
CPAP
Settings:
RR
FiO2
Inspiratory Pressure Level (IPL)
Inspiratory time
PEEP
Complications of Mechanical Ventilation
Changes in intrathoracic pressure
Cardiovascular complications
Barotrauma
Volutrauma
GI complications
Patient Ventilator Dysynchrony
Ventilator Associated Pneumonia
Nursing interventions
Troubleshooting Ventilators
1st – Respond to the alarm
2nd – Look at the patient!
Manually ventilate patient if needed
DOPE
Ensure alarms are set within safe parameters
Common alarms include:
High peak inspiratory pressure (PIP)
Low Vt
Apnea
Nursing Assessment
Assess for effectiveness of mechanical ventilation
Monitor for changes that would indicate a presence of infection
Monitor ventilator function according to unit policy
Assess airway position and suction requirements
Position patient to provide the best opportunity for ventilation-perfusion
Ensure that ventilator alarms are set and functioning and that ventilator connections are intact
Evaluate for adequate hydration and nutritional support
Evaluate for anxiety and ventilator synchrony
Managing the Ventilated Patient
Sedation – Balance
Too much vs. Too little
Consequences of pain and anxiety
Stress response vasoconstriction increased HR, BP, RR release of aldosterone by adrenal cortex increased reabsorption of Na+ and Cl-
But Before Sedation …
Consider nonpharmacological interventions Establishing nonverbal communication
Calm voice and gentle touch
Frequent repositioning
Use of distraction
Noise or light reduction
Improving sleep
Guided imagery or massage therapy
Sedation
Goal of sedation Patient comfort
Control physiologic effects of anxiety
Patient management
Ordering of sedatives Collaborative decision
No single agent is adequate in critical care setting
Assessment of Sedation
Continuous vs. Bolus administration Use sedation “holidays”
Dependent on institution
Several scales are available RASS
Pitfalls of Over/Undersedation
Liver failure Can result in over or undersedation
Oversedation Respiratory depression, hypotension, bradycardia and potential
thromboembolism
Undersedation Patient aware of situation, decreased comfort and increased
agitation and combativeness
Attempt to pull out tubes and lines
Neuromuscular Blockade Agents (NMBA)
May be necessary WITH sedatives and analgesics
ARDS
Increased intracranial pressure (ICP)
Use Train of Four (TOF) for patients receiving NMBA
NMBA associated with prolonged neuropathies and myopathies and increased patient morbidity
Paralytic agents may ONLY be used in patients who are mechanically ventilated
No sedative or analgesic properties
Weaning from Mechanical Ventilation
Starts when patient intubated and mechanical ventilated Underlying illness is improved
Patient must be hemodynamically stable
Helped by having correct size ETT Evaluation of mechanics of ventilation and muscle
strength CPAP, PSV, T-piece
Nutritional support
Weaning
Use standardized protocols
Reconditioning the muscles of ventilation
Especially if patient has been on mechanical ventilator for long period of time
Specific patient prerequisites ABG WNL – FiO2 < 0.50, minute ventilation < 10L/min, PEEP < 5cmH20
Negative inspiratory pressure at least -20cmH2O
Spontaneous Vt > 5ml/kg
Vital Capacity > 10ml/kg
RR < 30 breaths/min
Rapid shallow-breathing index < 100-105 (RR/Vt)
Weaning Methods/Modes
Spontaneous Breathing Trials (SBT): Humidified O2 30-120 minutes
SIMV: Gradually reduce the number of ventilator induced breaths
Pressure Support Ventilation (PSV) – Gradually reduce PSV level
Facilitating Weaning Process
Explain process to patient and family
Optimal positioning
Decrease sedation
Analgesia as indicated
Remain with patient
Avoid physical exertion or painful procedures during this time
Optimize environment
Assess breath sounds and secretions
VS
Trend O2 saturation
Evaluate WOB
Weaning Intolerance
Need to return to vent to “rest” Dyspnea
Increased RR, HR, BP
Shallow breaths or decrease in Vt
Accessory muscle use
Anxiety
Deterioration in SpO2 or ETCO2
Weaning Long-term Ventilator Patients
Can take up to weeks or months Weaning is goal since long-term mechanical
ventilation is associated with high morbidity and mortality
Use of protocols helpful Collaborative approach Specialized units Clear decisions with patient and family required
ReviewQuiz
Review Questions
When the nurse monitors the chamber with the water seal, which finding suggests that the system is functioning correctly?
a) The fluid rises and falls with respirations
b) The fluid level is lower than when first filled
c) The fluid bubbles continuously
d) The fluid looks frothy white
Answer = a
Review Question
Nursing interventions related to care of the tracheostomy include which of the following? (Select all that apply)
a) Suction Q1 hour
b) Pre-oxygenate and suction using sterile technique
c) Oral care
d) Perform tracheostomy change Every 72 hours
e) Suction patient with catheter until resistance is met and patient coughs
f) Assess skin surrounding tracheostomy
Answer – b, c, f
Review Question
True or False: Tracheal deviation to non-surgical side is a normal finding post pneumonectomy
Answer - False
Review Question
The nurse is caring for a patient in the emergency room who has been intubated and placed on mechanical ventilator. An ABG is obtained with the following results: pH – 7.32, PaCO2 – 60, PaO2 – 126, HCO3 – 28. Based on these results, which ventilator settings would be appropriate to be adjusted? Select all that apply.
a) FiO2
b) Rate
c) VT
d) PEEP
e) PIP
Answer – b, c
Modes commonly used when weaning from mechanical ventilation include which of the following? Select all that apply.
a) PSV
b) CPAP
c) Pressure control
d) Spontaneous breathing trial
e) Assist/control
Answer – a, b, d