Mechanical Ventilation

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Mechanical Ventilation

• Nursing 2904
• Spring 2006
• Carol Isaac MacKusick, MSN, RN, CNN

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Ventilation

• Methods of delivering oxygen
• Low-flow systems
• Gives lt 8 L/min
• Variable FIO2 as oxygen is mixed with room air
  and ventilatory pattern changes
• Nasal cannula
• Reservoir systems
• Less mixing of inspired oxygen with room air so
  can deliver a higher FIO2
• Simple face masks, partial rebreathers,
  nonrebreathing masks

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Ventilation

• Methods of delivery
• High-flow systems
• Oxygen flows out of device into airways in
  amounts sufficient to meet all inspiratory volume
  requirements
• Not affected by clients ventilatory pattern
• Venturi mask, aerosol mask, face tent,
  tracheostomy collar, t-piece

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Ventilation

• Complications of oxygen therapy
• Oxygen toxicity
• Carbon dioxide retention
• Absorption atelectasis

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Artificial Airways

• Intubation required for all mechanical
  ventilation
• Short term Pharyngeal, Endotracheal
• Long term - Tracheostomy
• gt 2 weeks

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Indications for Intubation

• Airway protection
• Provision of positive pressure or high oxygen
  concentration
• Bypass airway obstruction
• Facilitate pulmonary hygiene

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Goals of Intubation

• Maintain patent airway
• Provide ventilation and oxygen
• Provide a means to remove secretions

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Nursing Interventions

• Humidification
• Hydration
• Cuff inflation and monitoring
• Suctioning
• Skin and trachea care
• Lung sounds
• Safety and sterility
• Improve communication

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Artificial Airways

• Pharyngeal oral or nasal
• Both used to maintain airway patency
• Keeps tongue from obstructing upper airway
• Used until intubation occurs
• Oropharyngeal
• Size determined by holding airway against side of
  face and making sure it extends from corner of
  mouth to angle of jaw
• Used in unconscious client with absent or
  diminished gag reflex
• Nasopharyngeal
• Hold to side of face extends from tip of nose to
  earlobe

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Artificial Airways

• Endotracheal Tubes
• Most commonly used airway for short-term
  management
• May be oral or nasal tracheal
• Tip should be 2-4 cm above carina with head in
  neutral position
• Note level of insertion at the teeth or nares
• Verification of placement
• Tube should be stabilized

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Artificial Airways

• Tracheostomy tubes
• Preferred method of airway maintenance requiring
  long-term intubation
• Generally done at two weeks time frame
• Complications
• Tube obstruction
• Tube dislodgment
• Pneumothorax
• Subcutaneous emphysema
• Bleeding
• Infection

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Mechanical Ventilation

• Respiration versus ventilation
• Refers to how the machine ventilates the client
• Choice depends on situation and goals of treatment

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Mechanical Ventilation

• Types of ventilators
• Positive pressure
• Use a mechanical drive mechanism to force air
  into lungs
• Requires artificial airway
• Several different types
• Negative pressure
• Generally not used in critical care area
• Body or trunk encased in tank

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Positive Pressure Ventilators

• Pressure-cycled ventilation
• Volume-cycled
• Time-cycled
• Flow-cycled
• Microprocessor ventilators

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Modes of Ventilation

• Assist mode
• Control mode
• Assist / Control mode
• SIMV
• PSV
• High frequency ventilation
• Inverse ratio ventilation

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Modes

• PEEP (Positive End Expiratory Pressure)
• Provide alveoli with constant amount of positive
  pressure at end of each expiration
• Used in those who have part of all of work of
  breathing supplied by mechanical ventilator
  variety of modes (assist/control and IMV)
• CPAP (Continuous Positive Airway Pressure)
• Used when pts spontaneously breathing
• Increases functional residual capacity

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Ventilator Settings

• Rate
• Tidal Volume
• FIO2
• IE ratio
• Flow
• Sensitivity
• Pressure limit
• Peak Inspiratory Pressure
• Sigh

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Alarms

• Never shut alarms off!!
• Manually ventilate the client if you are not able
  to troubleshoot alarms quickly or you suspect
  equipment failure
• Most common alarms
• Low exhaled volume
• High pressure

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Noninvasive Ventilation

• Negative pressure ventilation
• Client placed in a device that applies negative
  pressure to the trunk or body which pulls the
  chest wall outward and causes inspiration to
  occur
• Example is the iron lung

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Noninvasive Ventilation

• Negative pressure
• Noninvasive Intermittent Positive Pressure
  Ventilation (NIPPV)
• Continuous Positive Airway Pressure (CPAP)
• Bilevel Positive Airway Pressure (BiPAP)

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Complications of Mechanical Ventilation

• Pulmonary System
• Barotrauma
• Intubation of right mainstem bronchus
• ETT displacement or extubation
• Tracheal damage
• Oxygen toxicity
• Acid-Base Disturbances
• Aspiration
• Infection
• Ventilator Dependence

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Complications

• Cardiovascular
• Decreased cardiac output
• Hypotension
• Fluid retention
• Neurovascular
• Increased ICP
• Decreased cerebral perfusion pressure
• Renal
• Decreased urinary output
• Fluid retention
• ATN

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Complications

• GI system
• Stress ulcers and GI bleeding in about 25 of
  clients on mechanical ventilation
• May develop paralytic ileus
• Inadequate nutrition common
• Constipation
• Sensory
• Conjunctivitis
• Impaired communication

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Nursing Diagnosis and Care

• Most common / most important
• Ineffective Airway Clearance
• Impaired Gas Exchange
• Ineffective Breathing Patterns
• Remember ABCs!!

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Nursing Care

• Medications
• Analgesics Opioid analgesics provide pain
  relief and sedation in hemodynamically stable
  clients
• Sedatives Benzodiazepines (Valium, Ativan,
  Versed), Neuroleptics (Haldol), and Diprivan
• Neuromuscular blocking agents
• Monitor the depth of paralysis through peripheral
  stimulation or through monitoring efforts to
  initiate a spontaneous breath
• Pavulon, Norcuron, Tracrium
• Require sedation and meticulous skin and eye care

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Nursing Diagnosis and Care

• Protection of the Airway
• Adequately secure tube
• Maintain sufficient slack on tubing to minimize
  tension on airway during movement
• Disconnect ventilator and bag when moving in and
  out of bed
• Soft wrist restraints and sedation for client who
  is not fully oriented or is uncooperative
• Used as a last resort

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Nursing Diagnosis and Care

• Alteration in Cardiac Output
• Alteration in Nutrition
• Alteration in oral mucous membranes
• Risk for pulmonary infection
• Risk for injury
• Risk for FVE / FVD
• Anxiety
• Sleep pattern disturbance
• Altered communication
• Family support

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Weaning

• Procedure should be explained to the patient and
  family
• Patient should be adequately rested and
  positioned comfortably
• Baseline parameters obtained
• Observe for tolerance of procedure
• Most hospitals have policies / procedures
  regarding weaning

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Weaning

• Methods of weaning
• Intermittent Mandatory Ventilation/Synchronized
  IMV
• Pressure support
• Continuous Positive Airway Pressure
• T-piece
• Extubation after complete weaning process

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Causes of impaired weaning

• Increased oxygen demands
• Anemia, fever, pain
• Decreased lung function
• Malnutrition, overuse of sedatives, sleep
  deprivation
• Psychological
• Apprehension and fear, helplessness, depression
• Equipment and technique problems
• Time of day, inadequate weaning periods,
  inability to tolerate technique

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The End!

• Questions / Concerns?
• Next class compensated acid / base balance
• Exam One
• ICU environment, Trauma, OB emergencies,
  respiratory
• 2/7/06