pulmonary assessment and challenges for the new icu nurse · • increased in tidal volume...
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Pulmonary Assessment and Challenges for the New ICU Nurse
Michael Nanney – BSN, RN, RRT, CPAN, CCRN
November 7, 2018 | 3:20 PM
Faculty Disclosure:No Conflicts of Interest.
No Sponsorship or Commercial Support.
Michael NanneyBSN, RN, RRT, CPAN, CCRN
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• Oxygenation:– Process of adding oxygen to the body
– Occurs at the cellular level
– Alveoli/capillary bed
– Oxygen binds to hemoglobin -> dissolves in the plasma -> body
• Ventilation:– A separate physiological process
– Air simply moves in and out of the lungs.
– Can be spontaneous or artificial
– Ventilation occupies from the nose/mouth -> alveoli.
– Active vs. passive phase of breathing
The Process
Perfusion – Cardiopulmonary System
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• Obesity
• Restrictive lung diseases
• Obstructive lung diseases
• Air, blood, fluid in the pleural space
• Decreased surfactant production
• Cardiac issues
• Surgery
• CNS issues
Conditions that Alter Oxygen/Ventilation
• Good air entry + good blood flow = V/Q matching
Ventilation/Perfusion
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Pulmonary Shunt
• A decreased amount of oxygenation in the tissues, secondary to hypoxemia
• Causes: anemia, carbon dioxide poisoning, pneumonia, atelectasis, hypoventilation
• S/S: tachycardia, tachypnea, anxious, restlessness, cyanosis, altered mental status
Hypoxia
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• Tachypnea and tachycardia initially occur
• Central and peripheral chemoreceptors activate– Central chemoreceptors located in the medulla
– Peripheral chemoreceptors located in the carotids and aorta
– Respond to changes in PaCO2 (ventilation) more sensitive to the changes in pH
The Body’s Response System
So How Do We Assess Our Patients?
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• Pulse Oximetry– Noninvasive
– Easy to set up, use and read -> rapid results
– Assessment of oxygenation status only
– Evaluate therapy
– Evaluate effectiveness of medications
– Diagnostic tool
– * Only reflects oxygenation.
– *Changes in ventilation may not be detected.
– *Not indicated to monitor ventilation
– *Patients are often on oxygen device -> misleading.
Assessment Tools
• A true measurement of ventilation
• Alternate to obtaining an ABG to evaluate PaCO2
• Gradient between PaCO2 and ETCO2 is 2-5mm Hg.
• National standard for moderate sedation
• Indications for ETCO2:– Monitor for oversedation
– Airway patency
– ETT placement
– Provides an accurate respiratory rate
– Assessment of ventilation issues
– TJC advisory
Capnography
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• Less than 35 mm Hg
• Tachypnea
• Increased in tidal volume
• Anxiety
• Pain
• Decreased cardiac output
• The patient is hyperventilating.
Low ETCO2 Readings
• Greater than 45 mm Hg
• Low tidal volumes
• Low respiratory rate
• Sedation issues
• Splinting
• Overdose
• The patient is hypoventilating.
High ETCO2 Readings
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• Continuous positive airway pressure
• The patient has spontaneous breaths.
• Requires an adequate respiratory drive
• Adequate spontaneous tidal volumes
• Recruits alveoli
• One setting on the device (cm H20)
• For improving OXYGENATION
CPAP
• Noninvasive positive pressure ventilation
• Bilevel positive airway pressure (BiPAP)
• Two settings: inspiratory and expiratory
• Decreases the work of breathing
• Aids in the active phase of the respiratory cycle
• Primary for correcting VENTILATION issues but will aid with oxygenation
NIPPV
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• Before and after mechanical ventilation
• Neuromuscular respiratory failure
• Decompensated obstructive sleep apnea
• Obesity hypoventilation syndrome
Indications for NIPPV
• Noncompliant patient
• Coma (low GCS)
• Respiratory arrest
• Severe bradypnea
• Unstable airway
• Hemodynamic instability
• Upper GI bleed
• Excessive secretions
• Vomiting
• Head/facial trauma
Contraindications for NIPPV
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• Indications:
– Respiratory rate > 30/min or < 6/min sustained
– pH less than 7.25
– Altered LOC -> airway compromise, loss of reflexes
– PaO2 <45 mm Hg on supplemental oxygen
– Hemodynamic instability
– Spontaneous tidal volume less than 5mL/kg
– Accessory muscle use
– Respiratory Failure Type I or Type II
Intubation & Mechanical Ventilation
• Improve oxygenation
• Improve ventilation
• Correction of respiratory acidosis
• Decrease the work of breathing
• Protect from further insult
• Promote comfort
• Providing artificial ventilation to assist or replace spontaneous ventilation
Goals of Mechanical Ventilation
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• Mode of ventilation: how the mechanical breaths are being delivered
• Tidal volume: Vt or TV, approx. 6 mL/kg of ideal body wt.
• Respiratory rate: RR or f, the frequency the breaths are being delivered
• Oxygen: FiO2, titrated based on oxygen needs
• PEEP: recruits alveoli, aids in oxygenation
• Pressure support: PSV, assists w/the insp. phase of the resp cycle, decreases the work of breathing and often used in weaning mode
Ventilator Settings
• PaCO2:– Rate adjustment
– Vt changes
– Adding or removing PSV
– Changing the mode of ventilation
• PaO2:– Increasing or decreasing FiO2
– Increasing or decreasing PEEP levels
Adjusting Ventilator Settings
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• Low-Pressure Alarm:– Loose tubing
– ETT problem
– Leak in the system
– Disconnect issue
• High-Pressure Alarm:– Obstruction
– Secretions
– Bronchospasms
– Dyssynchrony
– Agitation
Ventilator Alarms
• Call for help.
• Notify respiratory staff.
• Manually ventilate the patient.
• Assess the patient. (ABCs priority.)
• Identify the problem utilizing “DOPE” mnemonic.
What to Do?
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• Reduction in anxiety
• Amnesia effect
• Decreases the level of stress hormones
• Compliance with mechanical ventilation
• Decrease in oxygen demand
• Aids in achieving stabilization of hemodynamics
• Tolerance of the airway itself
• Tolerance of the mode of ventilation
Sedation & Mechanical Ventilation
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• Vital signs
• Breath sounds
• ABG, POX, ETCO2 readings & waveforms
• Secretions
• Ventilator settings/NIPPV settings
• Cardiac assessment
• Assessment of the ETT
• Chest X-ray
• Patient comfort
• Skin care/mouth care
Patient Care & Assessment
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• CPOT score indicates pain presence, not so much on severity of the pain.
• A score of 3 or > indicates pain.
• Therefore goal of 2 or <.
• A change or decrease by 2 -> successful intervention of pain control.
Key Points about CPOT
• Can become dislodged
• Displacement
• Right main intubation
• Cuff leak
• Unplanned extubation
• Intolerance of the ETT
• Skin issues
• Nasal intubation can lead to sinusitis, otitis media.
Endotracheal Tube Issues
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• As the process of assisting the patient to breathe on their own or the transition from mechanical ventilation support to adequate spontaneous breathing.
• Weaning and extubation are two separate processes.
• Weaning should only be considered once the underlying issue requiring mechanical ventilation has been resolved.
Weaning and Extubation
• Lung issue is stable or resolved.
• Medical condition is stable or resolved.
• Hemodynamically stable
• Able to initiate spontaneous breaths
• Good neuromuscular function
• Low FiO2 settings
• Low PEEP settings
General Requirements for Weaning
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• Why did the patient require mechanical ventilation?
• Assessment of sedation score
• What is the Glasgow Coma Scale?
• NMBA utilized
• Sedation score/gtt’s required
• BIS monitor readings
Additional Considerations
• CIWA score
• Seizure activity?
• GCS?
• No agitation
• No paralytics on board
• No myocardial ischemia indications
• Normal ICP readings
Wake-Up Assessment Screening
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• Communication between respiratory, nursing and physicians occur
• Patients now only require intermittent sedation.
• Document the ability to follow commands, RASS and ventilator tolerance
• RASS goal is -1 to +1
The Wake-Up Assessment
• Anxiety
• RR > 35/min
• SpO2 <90%
• Obvious respiratory distress
• New onset of cardiac dysrhythmias
• HR > 140/min or a change >20% of baseline
• SBP > 180 mm Hg or a change of >20% of baseline
Wake-Up Assessment Failure
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• Ventilator providing minimal support
• Assessment of the patients own / spontaneous breaths
• Monitor …
– Respiratory rate
– Spont TV
– Minute ventilation
– VS
– Cardiac status
– ETCO2/POX values
Spontaneous Breathing Trials
• Respiratory rate <25/min
• Negative inspiratory force > -20 cm H20 pressure
• Spontaneous Vt 5 mL/kg
• Vital capacity 10-15 mL/Kg
• Minute ventilation 5-10 liters/min
• Ventilator settings/mode of ventilation
• PaO2 >60 mm Hg with FiO2 0.40 or less
Weaning Parameters - RT
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• Infection issues
• Sleep deprivation
• Pain
• Abdominal distention
• Poor nutritional status
• Continued for sedatives
• Mental status
Factors that can Impair Weaning
• RR <8 or >30/min
• Labored respirations
• Spontaneous Vt < 5 mL/kg
• Use of accessory muscles
• Abnormal breathing pattern
• POX constantly <90%
• HR increases by 20%
• Ectopy
• ST segment changes
• Agitation, anxiety, panic
Criteria to Stop Weaning
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• Aspiration risk not present
• Airway edema not noted
• Control of fluids/secretions
• Cough present
• Intact gag reflex
• Sedation level acceptable
• Adequate oxygenation
• Adequate ventilation
Criteria to Extubate
• Team approach
• A proper assessment
• Try to involve the patient.
• Share/communicate plan of care.
• Weaning protocols & criteria should be RT/RN friendly.
• If failure occurs -> WHY?
So Remember …
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