Airway & Ventilatory Management1

AIRWAY MANAGEMENT ENDOTRACHEAL INTUBATION 3 ROUTES: 1. TRACHEOTOMY- an ET tube may be inserted through a tracheotomy when the upper airway is obstructed or when the physical characteristics of the neck make nasal or oral placement impossible. 2. NASOTRACHEAL INTUBATION- a nasotracheal tube is often more comfortable for conscious patients than an oral tracheal tube, time consuming to insert and its diameter is limited by upper airway anatomy. 3. ORAL TRACHEAL INTUBATION- is generally preferred as the quickest & least traumatic means of emergency airway placement. EQUIPMENTS: • Topical anesthesia • Suction machine • Suction catheter/s • Sterile glove • Sterile NSS • Laryngoscope • ET tube • Xylocaine spray • Metal stylet / Guide wire • Bite block / Oral pharyngeal airway • Adshesive Tape • Stethoscope METHODS: 1. Check tube cuff, laryngoscope, batteries & bulbs to ensure properly functioning equipment. 2. Insert the stylet into the selected tube;lubricate & shape to desired curve for insertion to decrease mucosal trauma & makes insertion easier. 3. Remove headboard from bed to provide access to the head of the patient, prepare the patient by removing dentures, suctioning airway & hyperventilating the patient with 100% oxygen. 4. Open patient’s jaw widely using cross finger technique with right hand to decrease gagging & discomfort & spray pharynx with topical anesthesia. 5. Hold laryngoscope in non-dominant hand & introduce blade along right side of the mouth then advance blade & move centrally to displace tongue to left to expose epiglottis. 6. Insert ET tube with cuff deflated & concavity oriented laterally into larynx until cuff disappears beyond vocal cords. 7. Remove stylet, inflate cuff and if necessary, suction tube using sterile technique; then insert pharyngeal airway or bite block. 8. Ventilate the patient with 100% oxygen & auscultate chest to check tube placement, obtain chest x-ray to ascertain exact tube position, tube should be at least 3 cm above carina. 9. Cleanse patient’s cheeks & mark tube at the level of mouth. 10. Connect patient to humidified oxygen source or mechanical ventilator. 11. Recheck cuff volume to ascertain that minimum amount of air necessary to protect airway & permit ventilation is used. 12. Observe for signs of esophageal intubations, abdominal distention, absent breath sounds across the lung fields & eructation with manual ventilation. 13. Insert a NGT to avoid gastric distention & aspiration, it may be used for feedings and medication administration.

MECHANICAL VENTILATION

TYPES: 1. Pressure-cycled ventilator  Pushes air into the lungs until an airway pressure is reached.  Used for short periods as in the post-anesthesia care unit & for respiratory therapy. 2. Time-cycled ventilator  Pushes air into the lungs until a preset time has elapsed.  Primarily used in the pediatric or neonatal client. 3. Volume cycled ventilator  Pushes air into the lungs until a preset volume is delivered.  A constant tidal volume is delivered regardless of the changing compliance of the lungs and chest wall or the airway resistance in the client or ventilator. 4. Microprocessor ventilator  A computer or microprocessor is built into the ventilator to allow continuous monitoring of ventilatory functions, alarms & client parameters.  Is more responsive to clients who have severe lung disease or require prolonged weaning. MODES OF VENTILATION: 1. Controlled  The client receives a set tidal volume at a set rate.  Used for clients who cannot initiate respiratory effort.  The least used mode; if the client attempts to initiate breath, the efforts are blocked by the ventilator. 2. Assist-control (AC)  Most commonly used mode.  Tidal volume & ventilatory rate are preset on the ventilator.  The ventilator takes over the work of breathing for the client.  The ventilator is programmed to respond to client’s inspiratory effort if the client does initiate a breath.  The ventilator delivers the preset tidal volume when the client initiates a breath, while allowing the client to control the rate of breathing.  If the client’s spontaneous ventilatory rate increases, the ventilator continues to deliver a preset tidal volume with each breath, which may cause hyperventilation & respiratory alkalosis. 3. Synchronized intermittent mandatory ventilation (SIMV)  Similar to AC in that the tidal volume & ventilatory rate are preset on the ventilator.  Allows the client to breath spontaneously at his or her own rate and tidal volume between the ventilator breaths.  Can be used as a primary ventilatory mode or as a weaning mode.  When used as a weaning mode, the number of SIMV breaths is gradually decreased & the client gradually resumes spontaneous breathing. VENTILATOR CONTROL & SETTINGS 1. Tidal volume  The volume of air that the client receives with each breath. 2. Rate  Number of ventilator breaths delivered per minute. 3. Fraction of inspired oxygen (FiO2)  The oxygen concentration delivered to the client, which is determined to the client, which is determined by the client’s condition & the arterial blood gases.

4. Sighs  Volumes of air that are 1.5 to 2 times the set tidal volume, delivered 6 to 10 times per hour; maybe used to prevent atelectasis. 5. Peak airway inspiratory pressure (PIP)  Pressure needed by the ventilator to deliver a set tidal volume at a given compliance.  Monitoring PIP reflects changes in compliance of the lungs & resistance in the ventilator or client. 6. Continuous positive airway pressure (CPAP)  Application of positive airway pressure throughout the entire respiratory cycle for spontaneously breathing clients.  Keeps the alveoli open during inspiration & prevents alveolar collapse.  Used primarily as a weaning modality.  During CPAP, no ventilator breaths are delivered but the ventilator delivers oxygen & provides monitoring & an alarm system. 7. Positive end-expiratory pressure (PEEP)  Positive pressure exerted during the expiratory phase of ventilation.  Improves oxygenation by enhancing gas exchange & preventing atelectasis.  The need for PEEP indicates indicates a severe gas exchange disturbance. NURSING CONSIDERATIONS 1. Assess the client first & the ventilator second. 2. Assess vital signs, lung sounds, respiratory status & breathing patterns. 3. Monitor skin color, particularly in the lips & nail beds. 4. Monitor chest for bilateral expansion. 5. Obtain pulse oximetry readings. 6. Monitor ABG results. 7. Assess the need for suctioning & observe the type, color & amount of secretions. 8. Assess ventilator settings & maintain as ordered. 9. Assess level of water in humidifier & temperature of the humidification system because extremes in temperature can cause damage to the mucosa airway. 10. Ensure that the alarms are set. 11. If a cause for an alarm cannot be determined, ventilate the client manually with a resuscitation bag until the problem is corrected, have the resuscitation bag at bedside. 12. Turn the client at least every 2 hours or get the client out of bed, as prescribed to prevent complication of immobility. COMPLICATIONS 1. Hypotension caused by the application of positive pressure which increases intrathoracic pressure & inhibits blood return to the heart. 2. Respiratory complications such as pneumothorax or subcutaneous emphysema as a result of positive pressure. 3. Gastrointestinal alterations such as stress ulcers. 4. Malnutrition if nutrition is not maintained. 5. Infections 6. Muscular deconditioning. 7. Ventilator dependence or inability to wean. WEANING 3 WAYS: 1. SIMV  The client breathes between the ventilator’s preset breaths / minute rate.

 The SIMV rate is gradually decreased until the client is breathing on his own without the use of ventilator. 2. T- Piece  The client is taken off the ventilator & the ventilator is replaced with a T-piece or CPAP, which delivers humidified oxygen.  The client is taken off the ventilator for short periods initially & allowed to breathe spontaneously.  The client is taken off the ventilator for short periods initially & allowed to breathe spontaneously. 3. Pressure support (PS)  A predetermined pressure on the ventilator assists the client in his or her respiratory effort.  As weaning continues, the amount of pressure is gradually decreased.  With PS, pressure may be maintained while the ventilator’s preset breaths per minute are gradually decreased. INCENTIVE SPIROMETRY  Is a method of deep breathing that provides visual feedback to help the patient inhale slowly & deeply to maximize lung inflation & prevent or reduce atelectasis.  Is used after surgery, especially thoracic & abdominal surgery, to promote the expansion of the alveoli & to prevent or treat atelectasis. 2 TYPES: 1. Volume type  The tidal volume of the spirometer is set according to the manufacturer’s instructions.  Purpose is to ensure that the volume of air inhaled is incresed gradually as the patient takes deeper & deeper breaths. 2. Flow type  Has the same purpose as a volume spirometer but the volume is not preset.  The spirometer contains a number of movable balls that are pushed up by the force of the breath & held suspended in the air while the patient inhales; the amount of air inhaled & the flow of the air are estimated by how long & how high the balls are suspended. METHODS: 1. Explain the reason & objective for the therapy, the inspired air helps to inflate the lungs. The ball or weight in the spirometer will rise in response to the intensity of the intake of air. The higher the ball rises, the deeper the breath. 2. Assess the patient’s level of pain & administer pain medication if prescribed. 3. Position the patient in semi-Fowler’s position or in an upright position. 4. Demonstrate how to use diaphragmatic breathing. 5. Instruct the patient to place the mouthpiece of the spirometer firmly in the mouth, to breathe air in (inspire) and to hold the breath at the end of inspiration for about 3 seconds. The patient then exhales slowly. 6. Encourage approximately 10 breaths per hour with the spirometer during waking hours. 7. Set a reasonable volume & repetition goal (to provide encouragement & give the patient a sense of accomplishment). 8. Encourage coughing during and after each session. 9. Assist the patient to splint the incision when coughing postoperatively. 10. Place the spirometer within easy reach of the patient. 11. For the post operative patient, begin the therapy immediately. (If the patient begins to hypoventilate, atelectasis can start to occur within an hour)

12. Record how effectively the patient performs the therapy and the number of breaths achieved with the spirometer every 2 hours. PRE-PROCEDURE:  Determine if an analgesic that may depress the respiratory function is being administered.  Consult the physician regarding holding bronchodilators prior to testing.  Instruct the client to void prior to procedure & to wear loose clothing.  Remove dentures.  Instruct the client to refrain from smoking or eating a heavy meal for 4 to 6 hours prior to the test. POST-PROCEDURE:  Resume normal diet & any bronchodilators & respiratory treatments that were held prior to the procedure. ARTERIAL BLOOD GASES  Measure the dissolved oxygen & carbon dioxide in the arterial blood and reveal the acid-base state and how well the oxygen is being carried to the body. PRE-PROCEDURE  Perform Allen’s test prior to drawing radial artery specimens.  Have the client rest for 30 minutes prior to specimen collection.  Avoid suctioning prior to drawing ABG’s.  Do not turn off oxygen unless  The ABG’s are ordered to be drawn at room air. POST-PROCEDURE:  Place the specimen on ice.  Note the client’s temperature on laboratory form.  Note the oxygen & type of ventilation that the client is receiving on the laboratory form.  Apply pressure to the puncture site for 5 to 10 minutes and longer if the client is on Anticoagulant therapy or has bleeding disorder.  Transport the specimen to the laboratory within 15 minutes. PULSE OXIMETRY  A noninvasive test that registers the oxygen saturation of the client’s hemoglobin.  This arterial oxygen saturation (SaO2) is recorded as a percentage.  The normal value is 95% to 100%.  After a hypoxic client uses up the readily available oxygen (measured as the arterial oxygen pressure, PaO2, on arterial blood gas testing), the reserve oxygen, that oxygen attached to the hemoglobin (SaO2) is drawn on to provide oxygen to the tissues. PROCEDURE: 1. A sensor is placed on the client’s finger, toe, nose, earlobe or forehead to measure oxygen saturation which is then displayed on a monitor. 2. Maintain the transducer at heart level. 3. Do not select an extremity with an impediment to blood flow. 4. Results lower than 91% necessitate immediate treatment. 5. If the SaO2 is below 85% the body’s tissues have difficult time becoming oxygenated, an SaO2 of less than 70% is life threatening.

Mark AlvinAlisasis, RN