Mechanical Ventilation

• O2 is increased by: conditions, procedures, and medications
• Oropharyngeal Airway (OPA)

  • comes in multiple sizes: small, medium, large
  • Select correct size: measure from edge of mouth to ear lobe
  • Insertion: rotate upon insertion
• Nasopharyngeal Airway (NPA)

  • Soft rubber catheter with tube opening for clint to breath through
  • Sizes based on internal diameter (ID): measure from tip of nose to the ear lobe
  • Insertion: water soluble lubricant, insert back and down, and may have a slightly rotate back and forth
• Nasal Cannula

  • Delivers between 24-44% or 0.24-0.44 fiO2 oxygen
  • Flow meter rate 1.6 L/min unless high flow
  • 1 L/min increases oxygen by approximately 3-4% : room air 21% so 1L = 24%, 2L = 28%, 3L = 32%
  • High flow systems available (longer/noncompliant tubing): HF delivers 60-90% (0.60-0.90% fiO2) or 15-40 L/min oxygen
• Simple Face Mask

  • Delivers between 30-60% oxygen or 0.30-0.60 fiO2
  • Flow meter rate 5-12 L/min
• Non-Rebreather Mask

  • Meter flow rate 15 L/min (to the top)
  • Delivers 60-80% or 0.60-0.80 fiO2
  • Reservoir bag allows: inspiration O2 flows into mask and bag, One-way valves on expiration ensuring highest O2 delivery.
• Bag Valve Mask

  • AKA the Ambu Bag or Bag Valve Mask
  • 15 L/min = 100% O2 or 1.00 FiO2
• O2 Delivery Device FiO2:

  • Fraction of delivered O2 (FiO2)
  • Room Air 21% or 0.21 FiO2
  • Nasal Cannula = 0.24 - 0.44 FiO2
  • High-Flow Cannula = 0.60 - 0.90 FiO2
  • Simple Face Mask = 0.30 - 0.60 FiO2
  • Nonrebreather = 0.60 - 0.80 FiO2
• Endotracheal Intubation

  • Isolate and protect airway
  • Facilitate suctioning of tracheobronchial tree
  • Facilitate assisted ventilation
  • Oxygenation failure!! : Correct impaired gas exchange, and correct impaired tissue perfusion
• Common Causes of O2 failure with need for mechanical ventilation:

  • Pulmonary edema
  • ARDS
  • Aspiration
  • Atelectasis
  • Pneumothorax
  • Pneumonia
  • Pulmonary embolism
  • Asthma/obstruction lung disease
• Three indications for Mechanical Ventilation:

  1. Support Oxygen
  2. Support CO2 clearance
  3. Reduce work or breathing (WOB)
• Intubation Routes: Airway

  • Endotracheal 'oral intubation'
  • Nasotracheal
  • Tracheal
• Endotracheal 'oral intubation' :

  • Visualize cords
  • Route of choice
• Nasotracheal:

  • 'Blind approach' cannot visualize larynx
  • Requires a smaller ETT, thus increasing airway resistance & WOB
  • Associated with sinus infections
  • Independent risk factors for VAP
• Tracheal:

  • Tracheotomy 'surgical procedure'
• Oropharyngeal Airway (OPA)

  
• Nasopharyngeal Airway (NPA)

  
• Nasal Cannula

  
• Simple Face Mask

  
• Non-Rebreather Mask

  
• Bag Valve Mask or Ambu Bag

  
• Endotracheal Tube (ETT)

  
• Preparation for Intubation:

  • Can be elective or emergent
  • Informed consent; unless emergent
  • Educate: client and family
  • Assemble equipment
  • Prepare client: sedation and positioning
  • Appropriate healthcare team members
• Considered medications for intubation:

  • Versed
  • Fentanyl
  • Atropine
  • Propofol
  • RSI: etomidate
  • Succinylcholine
  • Vecuronium
• Client positioning for intubation:

  • 'Sniffing position'
• Intubation process:

  1. educate patient and family
  2. sedation, pain meds, paralytics
  3. Ventilate with BVM
  4. Sniffing position
  5. Pt intubated -inflate cuff
  6. ETCO2 (end -tidal CO2 indicator), O2 sats
  7. Listen over lung fields & stomach
  8. Confirm placement
  9. Secure tube-note exit position (21-23 cm)
  10. ABGS
• Immediate Considerations:

  • Ventilation with BVM
  • Assess oxygenate by SpO2
  • Suction when necessary
  • Watch the clock with intubation attempts!
  • Preliminary assessment of eETT placement
  • Secure the tube & identify 'cm' placement
  • Inflate the cuff via pilot balloon
• Preliminary assessment of eETT placement:

  • observe chest for symmetrical rise and fall
  • Auscultate lungs bilaterally
  • Auscultate over the stomach
  • CO2 detector
• Secure the ET tube:

  • A variety of products exist to secure the ETT
  • KEY is maintaining a secure & stable airway!
  • ASSESS!!
• Confirm Placement:

  • Stat CXR after intubation (tip of ETT should be 3-4 cm above carina for adults
  • Assess daily CXR on ventilated clients for ETT position
  • Document size of ETT
  • Document placement (depth of ETT) by confirming cm at lip
  • Document ventilator settings
  • Time for an ABG?
• Proper Cuff inflation:

  • Just enough to create a seal: prevent air leak, decrease risk of pulmonary aspiration
  • Maintain pressure at 25 - 30 cm H2O: excessive pressure can cause tracheal ischemia, necrosis (erosion of surrounding tissue) and cuff rupture
  • Check policy. Who measures & how often?