ETT & Mechanical Ventilation

• What are the indications for endotracheal intubation?


  • Unresponsive client unable to maintain airway 
  • Need for mechanical ventilation 
  • Management of secretions ~ uncommon  
• How will a nurse assist during ETT insertion?

  • Have SOAPI ready! 
  • S: Suction --> yankeur, tubing canister; set up to ensure it is working 
  • O: Oxygen equipment --> bag-valve mask connected to O2, ventilator machine 
  • A: Airway equipment --> ETT, laryngoscope, stylet 
  • P: Pharmaceuticals  
  • If responsive = pre-medicate w/ sedative, analgesics, and paralytic to reduce risk of aspiration   
  • I: IV access 
  • If compensating --> obtain additional IV access for intubation and maintenance IV drips
• What are safety precautions when giving care to a client with mechanical ventilation?

  • Ventilator checks ~ assure settings are as ordered  
  • Maintain airway 
  • Assure ETT is well secured 
  • Check position @ teeth/gum line 
  • Have at least 2 ppl for repositioning pt and resecuring tube 
  • Protect devices  
  • Suction 
  • Safety equipment ~ wrist restraints to protect tube 
  • Always have ambu bag w/ mask @ bedside!  
  • Alarm Management  
• If you are unable to determine the cause of an alarm, what should you do as the nurse?

  TAKE PATIENT OFF VENTILATOR AND PROVIDE RESPIRATORY SUPPORT WITH BAG VALVE MASK (AMBU BAG)
• What do high-pressure alarms indicate on a ventilator?

  there is a blockage/obstruction
• What do low-pressure alarms indicate on a ventilator?

  The patient is not receiving enough oxygen and we need to address this quickly!
• What are examples of high-pressure alarms on the ventilator?

  • increased secretions 
  • Bronchospasm 
  • Patient biting  endotracheal tube (ETT) 
  • Kinked ventilator tubing 
  • Water in the ventilator tubing 
  • Patient fighting the ventilator (anxious)
  • Pneumothorax
• What are examples of low-pressure alarms on the ventilator?

  • cuff leak
  • disconnected tubing
  • unexplained extubation
  • patient stops breathing
• What are some nursing interventions to prevent hypotension when a patient is on the ventilator?

  • IV fluids 
  • adjustment to ventilator settings – is it too much support? 
  • assess sedation – is it too high? 
• what are interventions to prevent infection in a patient on a ventilator?

  • Elevate HOB 30 – 45 degrees;  
  • oral care 
  • proper suctioning equipment 
  • handwashing  
• What are nursing interventions for a patient experiencing barotrauma on a ventilator?

  • Notify HCP immediately!  
  • prepare for Chest tube insertion to remove trapped air  
  • Monitor Tidal Volume  
  • Vent Settings – is it too much pressure? 
• What are nursing interventions for a patient experiencing ventilator-associated pneumonia?

  • Elevate HOB 30-35 degrees (unless contraindicated) --> reduces risk for aspiration; also improves ventilation 
  • Daily sedation vacation of readiness to wean --> hold sedation to assess readiness to wean; too much sedation can decrease RR and effort  
  • Oral care q2-4h, chlorohexidine solution 2x daily 
  • VAP Bundle (sedations level, oral care, suctioning)  
  • Getting them off the vent ASAP  
• What interventions are needed for all ventilator patients in preventing complications?

  • Peptic ulcer disease (PUD) prophylaxis --> meds to decrease gastric acidity and prevent PUD & GI bleed 
  • H2 agonists (famotidine); PPIs 
  • DVT prophylaxis --> @ risk for DVT d/t immobilization; use of anticoagulants and/or SCDs 
  • I&O ~ maintain balance = affects their BP, thickness of secretions
• How will the nurse care for the ventilated client experiencing impaired gas exchange and ineffective airway clearance?

  • Impaired Gas Exchange: 
  • Assess respiratory effort: breathing with machine or against?; increase sedation? Monitor bilateral breath sounds, ABGs, VS, airway/pressure 
  • Ineffective Airway Clearance:  
  • Suction as needed based on assessment  
• How does suction affect a ventilated patient?

  • Too much suction = bronchospasm; trauma to tracheal mucosa or bradycardia 
• How will a nurse reduce risk of infection in a ventilated client?

  • NO saline down ETT 
  • Use inline suctioning to prevent contamination 
  • OG tube placed to prevent aspiration and prevent sinusitis compared to NGT 
• How will a nurse manage decreased mobility in a ventilated client?

  OOB to chair ASAP = stimulates respirations & improves psychological status; ROM 
• What are nursing actions to manage impaired nutrition in a ventilated client?

  • Feed w/in 24H; need protein for healing & muscle strength 
  • Monitor GI function/BMs 
• What are nursing actions to manage acute confusion on ventilated clients?

  Reorientation, sedation vacation; OOB to chair/EARLY mobilization; wake/sleep cycle  
• What are examples of volume-cycled ventilator modes?

  • Controlled Mechanical Ventilation (CMV) 
  • Assist-Control Ventilation (AC) 
  • Synchronized Intermittent Mandatory Ventilation (SIMV) 
• What are examples of pressure-cycled ventilator modes?

  • Airway Pressure Release Ventilation (APRV) 
  • Pressure Support Ventilation (PSV) 
• Controlled Mechanical Ventilation (CMV):

  Delivers a preset rate and volume of breaths per min 

  *NO respiratory drive* pt sedated or deteriorated neuro status = pt is dependent on vent = TOTAL support  
• Assist-Control Ventilation (AC) 

  Delivers preset volume of breaths per min but pt sets rate 

  Pt initiates breath but receives set volume to decrease work of breathing; pt does a lil more work 
• Synchronized Intermittent Mandatory Ventilation (SIMV):

  If the pt does not initiate breath, the ventilator delivers a preset rate and volume  

  Pt can breathe spontaneously but vent is back up & synchronized to reduce competition 

  *can be used for weaning* 
• Airway Pressure Release Ventilation (APRV):

  Delivers a high level of pressure to recruit alveoli 

  Essentially bipap on the ventilator = forced alveoli to open and allows gas exchange 
• Pressure Support Ventilation (PSV):

  Patient breaths spontaneously with additional pressure during inspiration  

  Keeps alveoli from collapsing = work of breathing is easier  

  *used for weaning mode* 
• What is the weaning criteria for a ventilated patient?

  • Underlying cause of respiratory failure is reversed  
  • Patient can intiate adequate respiratory effort 
  • 10 > RR < 30; MV 6 – 10L/min; PaO2 > 60 on FiO2 < 50 %; PCO2 < 45; secretions controlled  
  • Adequate oxygenation 
  • Hemodynamic stability 
  • Ability to maintain pH of at least 7.25, PEEP </= 5 – 8, FiO2 40 – 50% or less  
  • Must have adequate nutrition for muscle strength 
  • Need to be able to hold head up off pillow 
  • Awake and following commands  
  • Psychological dependence: fear of weaning  
• What are some things the nurse might assess during weaning?

  *have ambu bag w/mask ready at bedside* 

  • RR and effort, SPO2 
  • HR and rhythm 
  • BP 
  • Mental status  
• What might an increase of HR/RR/BP during weaning mean?

  weaning is NOT tolerated; may see arrhythmias  
• What type of nursing care is provided during extubation?

  • Maintain high fowlers 
  • Alternative O2 delivery system -> NC, HFNC, vapotherm 
  • BVM bag and suction bedside 
  • Monitor Resp status 
  • Signs of airway obstruction; cardiac and resp status 
  • Monitor VS – continuous SPO2, cardiac and resp monitoring  
  • Hoareness and/or sore throat is common 
  • IS – cough and DB 
  • Monitor for stridor
• During extubation the nurse hears stridor, what should the nurse perform next?

  • NOTIFY HCP IMMEDIATELY! (respiratory and MD) 
  • Likely means for re-intubation