5 Oropharyngeal Airway (cont.) Hard plastic deviceInserted through the mouth extending to the pharynxPrevents the tongue from occluding the airwayNursing careMonitor airway patencyListen to breath soundsSuction as needed*Never place an oropharyngeal airway in a conscious patient.
7 Nasopharyngeal Airway (cont.) Flexible tube inserted nasally and extends to the base of the tongueCan use in a conscious patientUseful when frequent nasotracheal suction is neededNursing careAssess the patient’s risk for epistaxisAssess coagulopathy
9 Endotracheal Tube (cont.) Semirigid tube inserted nasally or orally and extends into the tracheaProvides airway protectionUsed with mechanical ventilationInserted by personnel with advanced trainingPlacement confirmed by auscultation, end-tidal CO2 device, bilateral chest rise, chest x-ray
10 Endotracheal Tube (cont.) Nursing careConfirm equipment and suction are working properly.Preoxygenate the patient for intubation.Administer medications for intubation.Provide good oral hygiene.Reposition the tube from side to side.Suction when needed.Note markings on the tube to ensure proper position is maintained.
11 TracheostomyInserted directly into the trachea through a stoma in the neckImproves patient comfortImproved ability to communicateOral feeding is possible.Indicated if greater than 3 to 7 days on a ventilatorFacilitates weaning
12 Tracheostomy (cont.) Obturator and extra tracheostomy tube at bedside Accidental decannulation in the first 7 days may need reintubation before emergency tracheostomy can be done.After approximately 7 days, a tract is formed and tracheostomy tube can by reinserted into the stoma.Clean site every 8 to 12 hours.Replace inner cannula daily following facility policy.Change tracheal ties as needed.Suction as needed.
13 QuestionWhich type of artificial airway can never be used on a conscious person?A. TracheostomyB. Oropharyngeal airwayC. Nasopharyngeal airwayD. Endotracheal
14 Answer B. Oropharyngeal airway Rationale: An oropharyngeal airway stimulates the gag reflex and can cause vomiting and aspiration.
15 Indications for Suctioning Visualization of secretions in airwayCrackles, rhonchi, mucus plugs, or coughingIncrease in peak airway pressureDecrease in tidal volumeHypoxia
16 Suctioning Oral suctioning Removal of posterior oropharyngeal secretionsNasotracheal suctioningSterile procedure using flexible red rubber catheterPassed through nostril to nasopharynxEndotracheal and tracheostomy suctioningInline suction catheters*Instillation of normal saline to facilitate removal of thick secretions is not recommended.
17 Manual Ventilation Manual Ambu Bag, bag-valve-mask device Force of squeeze equals tidal volume.Number of squeezes per minute equals respiratory rateForce and rate equal the peak flow.Ensure complete exhalation between breaths.Observe chest rise.Monitor for abdominal distention.
18 QuestionWhen using a bag-valve-mask device, the nurse must do all of the following except:A. Time breaths to coincide with spontaneous breathsB. Allow time for complete exhalationC. Squeeze faster to get more air inD. Observe chest rise to ensure proper ventilations
19 Answer C. Squeeze faster to get more air in Rationale: Squeezing faster will cause hyperventilation and the patient will not receive air and will cause air trapping in the lungs, which can cause hypotension and lung injury.
20 Mechanical Ventilation Indicated for respiratory failurepH <7.25PaCO2 >50 mm HgPaO2 >50 mm HgMaintain alveolar ventilation.Correct hypoxemia.Correct respiratory acidosis.Rest ventilatory muscles.Maximize oxygen transport.
21 Modes of Positive-Pressure Ventilation Volume ventilationPreset volume of air delivered with each breathPressure ventilationPreset driving pressure is delivered and sustained throughout the inspiratory phase of ventilationHigh-frequency ventilationDelivers small volume of air at a very fast rate (panting)
23 QuestionWhich mode of ventilation delivers a preset volume of air with each breath?A. Pressure ventilationB. Volume ventilationC. CPAPD. High-frequency ventilation
24 Answer B. Volume ventilation Rationale: Volume ventilation—a preset volume of air delivered with each breath
25 Ventilator Settings Fraction of inspired oxygen (FiO2) Percentage of oxygen in the air delivered to the patient (room air is 21%.)Tidal volumeAmount of air delivered with each breath (5-8 mL/kg of body weight is recommended.)Respiratory rateNumber of breaths per minute
26 Ventilator Settings (cont.) Positive end-expiratory pressure (PEEP)Pressure maintained in the lungs at end expirationPeak flowVelocity of gas flow per unit of time expressed as liters per minuteInspiratory pressure limit (high pressure alarm)Highest pressure allowed in the ventilator circuit (coughing, secretions, kinked tubing can cause high inspiratory pressures)
27 Ventilator Settings (cont.) SensitivityControls the amount of patient effort to initiate a breathInspiratory:expiratory (I:E) ratioNormal is 1:2 or 1:3.Allows time for air to passively exitAn inverse I:E ratio improves oxygenation by allowing longer inspiratory times and more opportunity for gas exchange.
28 Ventilator Modes-Volume Modes Assist-control (A/C) modeRespiratory rate and tidal volume are preset.A preset tidal volume is delivered with each breath (preset and spontaneous breaths).Synchronized intermittent mandatory ventilation (SIMV) modeBreaths initiated above the preset rate are at the patient’s own spontaneous tidal volume.
29 Ventilator Modes-Pressure Modes Maximum peak inspiratory pressure is preset.Ventilator delivers breath until pressure limit is reached and then stops.Respiratory rate, inspiratory pressure limit, and I:E ratio are preset not tidal volume.Tidal volume varies with each breath.
30 Pressure Modes Pressure-controlled ventilation (PCV) Delivers breaths at a preset pressure limitPressure support ventilation (PSV)Assists spontaneous breaths with preset pressure levelInverse ratio ventilation (IRV)Inspiratory time is greater than/equal to expiratory time.Airway pressure release ventilation (APRV)High and low pressures are timed during the inspiration.
31 Pressure Modes (cont.) Volume-guaranteed pressure options (VGPO) Delivers a preset tidal volume by using pressure control modeContinuous positive airway pressure (CPAP)Provides pressure throughout respiratory cycleNoninvasive bilevel positive-pressure (BiPAP)Delivered through face mask, nasal prongs, or nasal maskProvides an inspiratory pressure and an expiratory (PEEP) pressure
32 Nursing Care Nasogastric or orogastric Maintain airway Monitor vital signs, arterial oxygenation saturation, mental status, respiratory status, and arterial blood gasesMonitor ventilator settings and alarmsSuction as neededPsychosocial supportNasogastric or orogastricCheck endotracheal tube cuff inflationHead of the bed elevated 30 degreesOral hygieneNutritional supportEye care
33 Question Is the following statement True or False? BiPAP, CPAP, and PCV are all volume modes of ventilation.
34 AnswerFalseRationale: BiPAP, CPAP, and PCV are all pressure modes of ventilation.
35 Weaning from Mechanical Ventilation Successful weaning:Multidisciplinary approachStandardized weaning protocolsCritical pathwaysWean in the morningMedicate for comfortRaise the head of the bedSupport and reassurance
36 Methods of Weaning T-piece trial (flow-by) Breaths through endotracheal tube without a ventilatorSIMVGradually decrease the number of delivered breathsCPAPDecreases the patient’s work of breathingPSVProgressively decrease the amount of pressure support