Mechanical Ventilation

1. Mechanical Ventilation Nursing 2904 Spring 2006 Carol Isaac MacKusick, MSN, RN, CNN

2. Ventilation • Methods of delivering oxygen • Low-flow systems • Gives < 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

3. 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 client’s ventilatory pattern • Venturi mask, aerosol mask, face tent, tracheostomy collar, t-piece

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

5. Artificial Airways • Intubation required for all mechanical ventilation • Short term – Pharyngeal, Endotracheal • Long term - Tracheostomy • > 2 weeks

6. Indications for Intubation • Airway protection • Provision of positive pressure or high oxygen concentration • Bypass airway obstruction • Facilitate pulmonary hygiene

7. Goals of Intubation • Maintain patent airway • Provide ventilation and oxygen • Provide a means to remove secretions

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

9. 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

10. 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

11. 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

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

13. 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

14. Positive Pressure Ventilators • Pressure-cycled ventilation • Volume-cycled • Time-cycled • Flow-cycled • Microprocessor ventilators

15. Modes of Ventilation • Assist mode • Control mode • Assist / Control mode • SIMV • PSV • High frequency ventilation • Inverse ratio ventilation

16. 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

17. Ventilator Settings • Rate • Tidal Volume • FIO2 • I:E ratio • Flow • Sensitivity • Pressure limit • Peak Inspiratory Pressure • Sigh

18. 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

19. 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

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

21. 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

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

23. 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

24. Nursing Diagnosis and Care • Most common / most important: • Ineffective Airway Clearance • Impaired Gas Exchange • Ineffective Breathing Patterns • Remember ABCs!!

25. 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

26. 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

27. 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

28. 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

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

30. 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

31. The End! • Questions / Concerns? • Next class: compensated acid / base balance • Exam One: • ICU environment, Trauma, OB emergencies, respiratory • 2/7/06