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Complex Care Exam 1 > Artificial Airways > Flashcards

Artificial Airways Flashcards

1
Q

Compliance

A
  • The ability of the lungs to stretch & expand
    > low compliance = stiff lungs
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2
Q

Resistance

A
  • The resistance of the resp tract to airflow during inhalation & exhalation
    > asthma & bronchospasm: narrows the airways
    > secretions: narrow the airway & makes it harder for air to be inhaled & exhaled
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3
Q

What meds affect resistance?

A
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4
Q

Endotracheal Tube (ETT)

A

A flexible plastic tube w/ a cuff on the end which sits inside the trachea & terminates 3-4 cm above the carina secured w/ a commercial tube holder

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5
Q

Endotracheal Tube (ETT) - Placement

A
  • Through the orotracheal route via direct laryngoscopy, video laryngoscopy, or nasotracheal route via blind nasal intubation
    > fully secures the airway: the gold standard of airway management
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6
Q

Endotracheal Tube (ETT) - Uses

A
  • Maintenance of airway patency
  • Protection of airway from aspiration
  • Application of positive-pressure ventilation
  • Facilitation of pulmonary hygiene
  • Use of high oxygen concentrations
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7
Q

ETT Complications - During Intubation

A
  • Nasal & oral trauma
  • Pharygneal & hypopharyngeal trauma
  • Vomiting w/ aspiration
  • Cardiac arrest
  • Hypoxemia & hypercapnia: bradycardia, tachycardia, dysrhythmias, HTN, & hypotension
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8
Q

ETT Complications - After Intubation

A
  • Nasal & oral inflammation & ulceration
  • Sinusitis & otitis
  • Laryngeal & tracheal injuries
  • Tube obstruction & displacement
  • Laryngeal & tracheal stenosis and a cricoid abscess
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9
Q

Tube Obstruction - Causes

A
  • Pt biting tube
  • Tube kinking during respositioning
  • Cuff herniation
  • Dried secretions, blood, or lubricant
  • Tissue from tumor
  • Trauma
  • Foreign body
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10
Q

Tube Obstruction - Prevention & Treatment

A
  • Prevention
    > place bite block
    > sedate pt PRN
    > suction PRN
    > humidify inspired gases
  • Treatment
    > replace tube
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11
Q

Tube Displacement - Causes

A
  • Movement of pt’s head
  • Movement of tube by pt’s tongue
  • Traction on tibe from ventilator tubing
  • Self-extubation
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12
Q

Tube Displacememt - Prevention & Treatment

A
  • Prevention
    > secure tube to upper lip
    > sedate pt PRN
    > ensure tht only 2 in of tube extend beyond lip
    > support vent tubing
  • Treatment
    > replace tube
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13
Q

Sinusitis & Nasal Injury - Causes

A
  • Obstruction of paranasal sinus drainage
  • Pressure necrosis of nares
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14
Q

Sinusitis & Nasal Injury - Prevention & Treatment

A
  • Prevention
    > avoid nasal intubation
    > cushion nares from tube & tape or ties
  • Treatment
    > remove all tubes from nasal passages
    > administer antibiotics
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15
Q

Tracheoesophageal Fistula - Causes

A

Pressure necrosis of posterior tracheal wall, resulting from overinflated cuff & rigid nasogastric tube

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16
Q

Tracheoesophageal Fistula - Prevention & Treatment

A
  • Prevention
    > inflate cuff w/ minimal amnt of air necessary
    > monitor cuff pressure q8
  • Treatment
    > position cuff of tube distal to fistula
    > place gastrostomy tube for enteral feedings
    > place esophageal tube for secretion clearance proximal to fistula
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17
Q

Mucosal Lesions - Causes

A

Pressure at tube & mucosal interface

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18
Q

Mucosal Lesions - Prevention & Treatment

A
  • Prevention
    > inflate cuff w/ minimal amnt of air necessary
    > monitor cuff pressures q8
    > use appropriate size tube
  • Treatment
    > may resolve spontaneously
    > peform surgical intervention
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19
Q

Laryngeal or Tracheal Stenosis - Causes

A

Injury to area from end of tube or cuff, resulting in scar tissue formation & narrowing of airway

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20
Q

Laryngeal or Tracheal Stenosis - Prevention & Treatment

A
  • Prevention
    > inflate cuff w/ minimal amnt of air necessary
    > monitor cuff pressures q8
    > suction area above cuff frequently
  • Treatment
    > perform tracheostomy
    > place laryngeal stent
    > perform surgical repair
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21
Q

Tracheostomy Tube

A

Preferred method of airway maintenance in a pt who requires long-term intubation (>7 days)

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22
Q

Trach Complications - During Surgery

A
  • Misplacement of tracheal tube
  • Hemorrhage
  • Laryngeal nerve injury
  • Pneumothorax
  • Pneumomediastinum
  • Cardiac arrest
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23
Q

Trach Complications - After Surgery

A
  • Stomal infection
  • Bleeding/hemorrhage
    > bleeding may occur after surgery & traumatic suctioning
  • Tracheoesophageal fistula
  • Tube obstruction & displacement
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24
Q

Open Suctioning

A

The pt is disconnected from the vent & the suction catheter is introduced in the ETT/Trach

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25
Closed Suctioning
**A sterile, closed tracheal suction system (CTSS) allows the pt to remain on the vent when suctioned**
26
Subglottic Suctioning
- **Deep oropharyngeal suctioning at least q12 & *before deflating the cuff or moving the tube*** OR - **Continuous (-20 to -30 cm H2O) or intermittent suction using the aspiration lumen tht ends w/ an opening above the cuff**
27
Artificial Airway: Nursing Interventions
- **Provide humidification** - **Manage the cuff** (balloon) > cuff pressure are maintained w/in 20-30 cm H2O - **Establish a method of communication** - **Provide oral hygiene** > follow protocol
28
Suctioning Complications - Hypoxemia ## Footnote caused by prevented by
- **Caused by**: disconnected from vent, during suctioning - **Prevented by**: hyper-oxygenate 30-60 sec before & 60 sec after suctioning - hyper-oxygenate if pt is known to de-sat
29
Suctioning Complications - Atelectasis ## Footnote caused by prevented by
- **Caused by**: large suction cath greater than one half of diameter of ETT, causes excessive negative pressure, promoting collapse of distal airways - **Prevented by**: using appropriate size suction cath; less than one half of internal diameter of ETT
30
Suctioning Complications - Infection ## Footnote caused by prevented by
- **Caused by**: cross contamination, poor hand hygiene, pooling of sections in back of throat, poor sterile technique - **Prevented by**: aseptic technique
31
Suctioning Complications - Bronchospasm ## Footnote caused by prevented by
- **Caused by**: irritation/stimulation from plastic introduced - **Prevented by**: lower suctioning, limit duration, limit amnt of passes
32
Suctioning Complications - Airway Trauma ## Footnote caused by prevented by
- **Caused by**: cath bumps into airways, excessive negative pressure - **Prevented by**:
33
Suctioning Complications - Dysrhythmias ## Footnote caused by prevented by
- **Caused by**: particularly bradycardias, attributed to vagal stimulation - **Prevented by**:
34
Using 150 mmHg or less of suction dcr chances of...
- **Hypoxemia** - **Atelectasis** - **Airway trauma**
35
Limiting duration of each suction pass to 10-15 secs helps minimize...
- **Hypoxemia** - **Airway trauma** - **Cardiac dysrhythmias**
36
Normal Cuff Pressure
**15-20 mmHg**
37
Too much cuff pressure...
**Cause a pressure ulcer, fistula = infection**
38
Mechanical Ventilation: Indications
- **To facilitate the transport of oxygen & CO2 btwn the atmosphere and the alveoli for the purpose of enhancing pulmonary gas exchange**
39
Mechanical Ventilation: Physiologic Indications
- **Supporting cardiopulmonary gas exchange** > alveolar ventilation & arterial oxygenation - **Incring lung vol**
40
Mechanical Ventilation: Clinical Indications
- **Reversing hypoxemia & acute resp acidosis** - **Relieving resp distress** - **Preventing or reversing atelectasis & resp muscl fatigue** - **Permitting sedation & neuromuscular blockade** - **Dcring oxygen consumption** - **Reduce intracranial pressure** - **Stabilizing chest wall**
41
Positive Pressure Ventilation
- **Invasive** > mechanical ventilator - **Non-invasive** > CPAP: constant pressure > BiPAP: need a tight fitting mask
42
Common Complications of CPAP or BiPAP
- **Pressure ulcers on face** - **Bloody noses** > too dry/no humidification
43
Ventilator Settings: Respiratory Rate
- **Number of breaths the ventilator delivers per minute** - **Typical settings**: 6-20 bpm
44
Ventilator Settings: Tidal Volume (Vt)
- **Volume of gas delivered to a pt during each ventilator breath** - **Typical settings**: 6-10 mL/kg (500mL in an average healthy adult male & approx 400mL in healthy female) - Too much air = pneumo - Not enough air = atelectasis
45
Ventilator Settings: Fraction of Inspired Oxygen (FiO2)
- **Oxygen concentration delivered to pt** - **Typical settings**: may be set btwn 21-100%; adjusted to maintain PaO2 lvl > 60mHg or SpO2 lvl > 92%
46
Ventilator Settings: (I)nspiration:(E)xpiration Ratio
- **Ratio of the duration of inspiration to the duration of expiration** - **Typical settings**: 1:2 to 1:1.5 unless inverse ratio ventilation is desired
47
Ventilator Settings: PEEP
- **Positive pressure applied at end of expiration of ventilator breaths** > this is pressure tht remains in alveoli at end of expiration > assists in keeping alveoli open: improves oxygenation > **not a mode of mech vent** > added to other modes of ventilation - **Typical settings**: 3-5 cm H2O > can go higher
48
Modes of Ventilation
- **Mode refers to how the machine ventilates the pt** - **The mode of ventilation determines how much the pt participates in their own ventilatory pattern** - **The mode depends on the pt's situation & goals of treatment**
49
Modes of Ventilators: Pressure-Cycled
**Vent delivers a breath until a preset pressure is reached w/in the pt's airways**
50
Modes of Ventilators: Time-Cycled
**Vent delivers a breath over a preset time interval**
51
Modes of Ventilators: Volume-Cycled
**Vent is designed to deliver a breatth until a preset vol is delivered**
52
Modes of Mech Vent: Continuous Mandatory (vol or pressure) Ventilation (CMV) ## Footnote this one on test
- aka Assist/Control (AC) ventilation - **Delivers gas at *preset tidal volume or pressure* in response to pt's inspiratory efforts & initiates breath if the pt fails to do so w/in a preset time** > *preset minimum (guaranteed) RR* > vent-initiated breaths are at set tidal vol > pt's initiated respirs are delivered at vent's set tidal vol *(gauranteed tidal vol)* - **Clinical application** > primary mode of ventilation
53
Can CMV be used in a weaning trial?
No
54
CMV: Settings Used
- **FiO2** - **Tidal volume (TV)** - **Rate** - **PEEP** > optional based on pt condition
55
CMV: Nursing Implications
- **Hyperventilation can occur in pts w/ incrd resp rates** - **These pts require sedation** - **Monitor for complications** > high lvls of PEEP: pneumo > high lvls of FiO2: oxygen toxicity
56
Major Factors tht Affect the Pt's Ability to Wean
- **The ability of the lungs to participate in ventilation & respiration** - **Secretions** - **Cardiovascular performance** - **Psychological readiness**
57
Weaning Methods
- **IM V** (SIM V) > guaranteed rate & tidal vol - **Spontaneous Breathing Trials** > CPAP > T-tube, T-piece; pt does all the work > Pressure support ventilator (PSV)
58
T-Tube/T-Piece
- **Pt initiates breaths & tidal vol** - **Ventilator is turned off, pt is placed on a T-Piece thts attached to wall O2**
59
Pressure Support
- **No set respiratory rate or tidal vol** - **Pt's breaths are supplemented w/ positive pressure tht overcomes the impedance of the endotacheal tube**
60
CPAP
- **The pt initiates breaths & tidal vol** - **Low lvls of CPAP (5 cm H2O) while the pt breathes spontaneously** - **PaCO2 & respiratory effort are monitored for s/s of fatigue**
61
Weaning
- **Weaning is the withdrawal of the mechanical ventilator & the resstablishment of spontaneous breathing** - Conside the length of time on the vent, sleep deprivation, & nutritional status
62
Pt is Ready for a Spontaneous Breathing Trial if the Following Criteria are Met
- **Awake, cooperative, & follows commands** - **Good gag reflex** - **Strong cough** - **Minimal secretions** - **Hemodynamically stable off vasopressors** - **Underlying disease leading to intubation has resolved** - **Hgb greater than, equal to 8 g/dL** - **Spontaneously breathing on PEEP < 5-8** - **PaO2/FiO2 ratio greater than, equal to 150-200** (or SaO2 greater than, equal to 90% w/ FiO2 less than, equal to 0.4) - **Systemic pH greter than, equal to 7.25** - **Minute ventilation < 15 L/minute** - **Rapid shallow breath index < 105**
63
Weaning Trial Prep
- **Position pt upright to facilitate breathing & suctioned to ensure airway patency** - **Explain the process to the pt, reassure, & provide diversional activities as needed** - **Assess pt immediately before thestrat of & frequently during the weaning period for signs of weaning intolerance** - **Draw ABG before & 30 mins after trial begins**
64
Successful Weaning Trial
- **RR greater than, equal to 35** - **HR < 120-140/minute** - **SBP > 90 & < 180 mmHg** - **SaO2 greater than, equal to 90% or PaO2 greater than, equal to 55 mmHg on FiO2 less than, equal to 0.4** - **Vt greater than, equal to 4 mL/kg predicted body weight or greater than, equal to 325 mL**(in adults) - **PaCO2 incr < 10 mmHg** - **Absence of agitation, diaphoresis, or incrd work of breathing**
65
Weaning Tolerance Indicators
- **Dcr in LOC** - **SBP incrd or dcrd by 20 mmHg** - **DBP greater than 100 mmHg** - **HR incrd by 20 beats/min** - **Premature ventricular contractions greater than 6/min, couplets, or runs of ventricular tachycardia** - **Changes in ST segment** (usually elevation) - **RR greater than 30 breaths/min or less than 10 breaths/min** - **RR incrd by 10 breaths/min** - **Spontaneous tidal vol less than 250mL** - **PaCO2 incrd by 5-8 mmHg and/or pH less than 7.30** - **SpO2 less than 90%** - **Use of accessory muscles of ventilation** - **Complaints of dyspnea, fatigue, or pain** - **Paradoxical chest wall motion or chest abdominal asynchrony** - **Diaphoresis** - **Severe agitation or anxiety unrelieved by reassurance**
66
Nursing Management
- **Pt Assessment**: focused pulm assessment > resp rate, effort, secretions > ABGs > pulse ox & EtCO2 > subcutaneous emphysema > ETT/trach placement - **Symptom Management** > manage anxiety, pain, SOA, confusion, & agitation - **Maintain adequate sedation** - **Sedation vacation**
67
Big Valve Mask (BVM)
**Connected to oxygen at bedside**
68
Mechanical Ventilation: Patient Safety
- **Big valve mask (BVM) connected to oxygen at bedside** - **Vent is free of** > water > kinks > obstructions (secretions) > disconnections - **Change tubing per hosp policy** - **Monitor temp of inspired air** - **Vent malfunctions** > pt is removed from vent -> BVM > vent malfunction -> BVM - **Review alarms**
69
Low Pressure Alarm
- **Unattached tubing/leak around ETT** - **ETT displaced into pharynx or esophagus** - **Pneumothorax** - **Tracheoesophageal fistula** - **Poor cuff inflation or leak** - **Dcrd airway resistance** > barotrauma, pneumo - **Low Vt**
70
High Pressure Alarm
- **Coughing** - **ETT in right mainstem bronchus or against carina** - **Kinked tubing** - **Incr airway resistance** > pt trying to speak - **Dcr lung compliance** > ARDS, pneumonia, abd distention
71
Points to Remember
- **Treat the pt** > not the machine - **Vent care is supportive care** > not a cure - **Vent delivers oxygen to lungs** > gas exchange must occur w/in alveoli - **Called a vent, not respirator** - **If machine malfunctions take pt off vent & ventilate them by hand** > do not leave them

Complex Care Exam 1 (6 decks)

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