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What is the difference between a CPAP and BiPAP?

CPAP delivers continuous oxygen to the patient, increases work of breathing and used for OSA.
BiPAP has 2 functions: high inspiratory positive airway pressure and low expiratory positive airway pressure. It is used for COPD with HF, Acute Respiratory Failure, and sleep apnea


Endotracheal intubation (ET) indications

Only used for short period of time
Upper Airway obstruction
High risk of Aspiration
Ineffective secretion clearance
Respiratory distress


How do you set the patient up for intubation? Explain intubation process.

Obtain consent if not emergent
Have a self-inflated bag-valve-mask (BVM) attach to oxygen and suctioning nearby
Ensure patient has an IV access
Remove patient's dentures or partial plates
Place patient in sniffling position - supine with head extended and neck flexed
Preoxygenate patient with BVM for 3-5 minutes or give rapid-sequence intubation (RSI) if emergent
Monitor O2 status
Intubate patient and confirm placement
Inflate the cuff
Connect ET tube to ventilator and secure it.
Obtain chest x-ray
Obtain ABGs 15-30 minutes after


How does a BVM or Ambu bag work?

The slower the bag is deflated and inflated, higher O2 concentration


How do you confirm ET tube placement during the intubation process?

EtCO2 detector - how much CO2 is expelled from the lungs. Should be consistent after 5-6 exhalations
Auscultate lungs for bilateral breath sounds and epigastrium for absence of air sounds
X-ray location is 2-6cm above carina


What is an Rapid-sequence intubation (RSI)?

Combination of sedatives and paralytic to make the patient unconscious for intubation.


How can you detect CO2 with end tidal CO2 (EtCO2) detector?

The color or number changes with more exhaled oxygen


What are the nursing responsibilities for patients with artificial airways?

Maintain correct tube placement
Maintain proper cuff inflation
Monitoring oxygenation and ventilation
Maintaining tube patency
Providing oral care and maintaining skin integrity
Provide comfort and communication


How do you maintain correct tube placement?

Mark where the tube is after intubation process and ensure it is in the same place. (21 cm for women, 23 cm for men)
Observe for chest wall symmetry and auscultate for bilateral lung sounds


What do you do if the tube was misplaced?

Stay with patient and give oxygen via BVM and 100% O2
Call for help


How do you maintain cuff pressure?

20-25 cm H2O
Measure and record cuff pressure after intubation and on a routine basis (q8hrs).


How do you monitor for oxygenation and ventilation with ET?

Monitor ABGs, SpO2, ScvO2 or SVO2.
Assess for hypoxemia
Assess respiratory rate, depth, rhythm and use of accessory muscles
Monitor PaCO2 and PETCO2


Suctioning indications

When you can see secretions in the ET tube
Sudden onset of Respiratory distress
When you suspect patient is aspirating on their own secretions
Tachypnea or frequent coughing
SpO2 decreases
Peak airway pressure increases
Auscultated adventitious breath sounds


What is the difference between closed-suctioning technique (CST) or open-suctioning technique (OST)?

OST comes in a kit and requires a new single-use catheter every time.
CST is the most common choice and a catheter can be used multiple times within 24 hours. Additionally, oxygenation and ventilation are maintained during suctioning and decreases exposure to secretions.


What do you do when a patient can not tolerate suctioning?

Stop immediately


How do you prevent hypoxemia when suctioning?

Give patient a lot of oxygen before suctioning and after each suctioning pass.
Limit each pass to 10 seconds or less
Assess ECG and SpO2 before, during and after suctioning.


Tracheal damage signs and symptoms

Blood streaks or tissue shreds in secretions


How do you prevent tracheal damage?

Limit pressure to less than 120 mm Hg
Slow and adequate suctioning and catheter insertion
Assess secretions that are coming out
Notify HCP


How do you manage thick secretions?

Maintain adequate hydration and supplemental humidification
No saline instillation
Mobilize and turn patient every 2 hours
Antibiotics PRN


Why is oral care important?

The mouth is always open and dry.


What is RASS scale?

A medical scale to assess agitation and sedation in a patient.


Why is the RASS scale used for intubated patients?

They receive around the clock pain medications and you need to assess effectiveness.


What do you need to monitor in patients when giving sedatives?

Respiratory rate and oxygen saturation.


BiPAP contraindications

Patients with shock, altered mental status, increased airway secretions


What is the mechanism for negative pressure ventilation?

The ventilator pulls the chest wall outwards and reduces intrathoracic pressure. It allows for passive expiration.


What is the mechanism for positive pressure ventilation (PPV)?

It utilizes volume ventilation (Vt) and pressure ventilation.
Ventilator pushes air into lungs during inspiration. and raises intrathoracic pressure.


What is alarm fatigue and how do we prevent it?

Alarm fatigues are for the care team who got used to hearing unnecessary amount of alarms and causes them to delay their response.
Set alarms based on patient's specific needs


Positive End Expiratory Pressure (PEEP)

Positive pressure is applied during the expiration phase.
It increases lung volume, functional residual capacity (FRC) and oxygenation of the lungs.
FIO2 can be reduced
Pressure falls between 3-20 cm H2O.


Nitric Oxide (NO)

Gaseous molecule that increases vasodilation.
Diagnostic tool for pulmonary HTN and to improve oxygenation during mechanical ventilation


Prone Positioning

Repositioning patient onto their stomachs. face down.
Improves lung recruitment
Requires sedation
Used with severe ARDS