Chapter 10 Airway Management and Ventilatory Support

Artificial Airways Establish an airway Protect the airway Facilitate airway clearance Facilitate mechanical ventilation

Types of Airways Oropharyngeal airway Nasopharyngeal airway Endotracheal tube Tracheostomy

Oropharyngeal Airway

Oropharyngeal Airway (cont.) Hard plastic device Inserted through the mouth extending to the pharynx Prevents the tongue from occluding the airway Nursing care Monitor airway patency Listen to breath sounds Suction as needed *Never place an oropharyngeal airway in a conscious patient.

Nasopharyngeal Airway

Nasopharyngeal Airway (cont.) Flexible tube inserted nasally and extends to the base of the tongue Can use in a conscious patient Useful when frequent nasotracheal suction is needed Nursing care Assess the patient’s risk for epistaxis Assess coagulopathy

Endotracheal Tube

Endotracheal Tube (cont.) Semirigid tube inserted nasally or orally and extends into the trachea Provides airway protection Used with mechanical ventilation Inserted by personnel with advanced training Placement confirmed by auscultation, end-tidal CO2 device, bilateral chest rise, chest x-ray

Endotracheal Tube (cont.) Nursing care Confirm 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.

Tracheostomy Inserted directly into the trachea through a stoma in the neck Improves patient comfort Improved ability to communicate Oral feeding is possible. Indicated if greater than 3 to 7 days on a ventilator Facilitates weaning

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.

Question Which type of artificial airway can never be used on a conscious person? A. Tracheostomy B. Oropharyngeal airway C. Nasopharyngeal airway D. Endotracheal

Answer B. Oropharyngeal airway Rationale: An oropharyngeal airway stimulates the gag reflex and can cause vomiting and aspiration.

Indications for Suctioning Visualization of secretions in airway Crackles, rhonchi, mucus plugs, or coughing Increase in peak airway pressure Decrease in tidal volume Hypoxia

Suctioning Oral suctioning Removal of posterior oropharyngeal secretions Nasotracheal suctioning Sterile procedure using flexible red rubber catheter Passed through nostril to nasopharynx Endotracheal and tracheostomy suctioning Inline suction catheters *Instillation of normal saline to facilitate removal of thick secretions is not recommended.

Manual Ventilation Manual Ambu Bag, bag-valve-mask device Force of squeeze equals tidal volume. Number of squeezes per minute equals respiratory rate Force and rate equal the peak flow. Ensure complete exhalation between breaths. Observe chest rise. Monitor for abdominal distention.

Question When using a bag-valve-mask device, the nurse must do all of the following except: A. Time breaths to coincide with spontaneous breaths B. Allow time for complete exhalation C. Squeeze faster to get more air in D. Observe chest rise to ensure proper ventilations

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.

Mechanical Ventilation Indicated for respiratory failure pH <7.25 PaCO2 >50 mm Hg PaO2 >50 mm Hg Maintain alveolar ventilation. Correct hypoxemia. Correct respiratory acidosis. Rest ventilatory muscles. Maximize oxygen transport.

Modes of Positive-Pressure Ventilation Volume ventilation Preset volume of air delivered with each breath Pressure ventilation Preset driving pressure is delivered and sustained throughout the inspiratory phase of ventilation High-frequency ventilation Delivers small volume of air at a very fast rate (panting)

Lung Injury Risk with Positive-Pressure Ventilation Barotrauma Volutrauma Atelectrauma Biotrauma Ventilator-associated lung injury (VALI) Ventilator-induced lung injury (VILI)

Question Which mode of ventilation delivers a preset volume of air with each breath? A. Pressure ventilation B. Volume ventilation C. CPAP D. High-frequency ventilation

Answer B. Volume ventilation Rationale: Volume ventilation—a preset volume of air delivered with each breath

Ventilator Settings Fraction of inspired oxygen (FiO2) Percentage of oxygen in the air delivered to the patient (room air is 21%.) Tidal volume Amount of air delivered with each breath (5-8 mL/kg of body weight is recommended.) Respiratory rate Number of breaths per minute

Ventilator Settings (cont.) Positive end-expiratory pressure (PEEP) Pressure maintained in the lungs at end expiration Peak flow Velocity of gas flow per unit of time expressed as liters per minute Inspiratory pressure limit (high pressure alarm) Highest pressure allowed in the ventilator circuit (coughing, secretions, kinked tubing can cause high inspiratory pressures)

Ventilator Settings (cont.) Sensitivity Controls the amount of patient effort to initiate a breath Inspiratory:expiratory (I:E) ratio Normal is 1:2 or 1:3. Allows time for air to passively exit An inverse I:E ratio improves oxygenation by allowing longer inspiratory times and more opportunity for gas exchange.

Ventilator Modes-Volume Modes Assist-control (A/C) mode Respiratory rate and tidal volume are preset. A preset tidal volume is delivered with each breath (preset and spontaneous breaths). Synchronized intermittent mandatory ventilation (SIMV) mode Breaths initiated above the preset rate are at the patient’s own spontaneous tidal volume.

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.

Pressure Modes Pressure-controlled ventilation (PCV) Delivers breaths at a preset pressure limit Pressure support ventilation (PSV) Assists spontaneous breaths with preset pressure level Inverse 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.

Pressure Modes (cont.) Volume-guaranteed pressure options (VGPO) Delivers a preset tidal volume by using pressure control mode Continuous positive airway pressure (CPAP) Provides pressure throughout respiratory cycle Noninvasive bilevel positive-pressure (BiPAP) Delivered through face mask, nasal prongs, or nasal mask Provides an inspiratory pressure and an expiratory (PEEP) pressure

Nursing Care Nasogastric or orogastric Maintain airway Monitor vital signs, arterial oxygenation saturation, mental status, respiratory status, and arterial blood gases Monitor ventilator settings and alarms Suction as needed Psychosocial support Nasogastric or orogastric Check endotracheal tube cuff inflation Head of the bed elevated 30 degrees Oral hygiene Nutritional support Eye care

Question Is the following statement True or False? BiPAP, CPAP, and PCV are all volume modes of ventilation.

Answer False Rationale: BiPAP, CPAP, and PCV are all pressure modes of ventilation.

Weaning from Mechanical Ventilation Successful weaning: Multidisciplinary approach Standardized weaning protocols Critical pathways Wean in the morning Medicate for comfort Raise the head of the bed Support and reassurance

Methods of Weaning T-piece trial (flow-by) Breaths through endotracheal tube without a ventilator SIMV Gradually decrease the number of delivered breaths CPAP Decreases the patient’s work of breathing PSV Progressively decrease the amount of pressure support