ECMO patient care

Noninvasive Ventilation

• Breathing assistance is provided without artificial airways like endotracheal tubes or tracheostomy through a mask, such as a full-face mask, nasal mask, or nasal prongs (pillows).

Continuous Positive Airway Pressure (CPAP)

• CPAP delivers continuous pressure during spontaneous breathing, enhancing alveoli capacity and function.
• Primary use is for treating obstructive sleep apnea.
• CPAP increases the work of breathing, as the client must forcibly exhale against the pressure.
• Clients must independently remove the CPAP mask to avoid aspiration from vomiting.
• Clients must be able to maintain their airway.
• CPAP is not suitable for those with excessive secretions.
• It delivers a set pressure to increase oxygen levels, reduce work of breathing, and decrease cardiac workload.
• CPAP helps to prevent airway collapse.
• Pressure relief settings aid user tolerance during exhalation by reducing pressure.

Bilevel Positive Airway Pressure (BiPAP)

• BiPAP delivers positive pressure at two levels: a higher pressure during inspiration and a lower pressure during expiration.
• It is used for clients with COPD, heart failure, respiratory failure and sleep apnea.
• Clients must be able to spontaneously breathe and comply with ventilation.
• Not suitable for those with increased secretions due to risk of aspiration.
• Clients with decreased mental status are not candidates due to their inability to remove the mask if needed.
• BiPAP is beneficial for removing CO2.
• Makes breathing easier and results in lower average airway pressure
• Delivers different pressure during inhalation and exhalation.
• A specific rate is programmed into the device.
• This ensures programmed pressure delivery at the programmed rate, regardless of the client's breathing.

CPAP and BiPAP Similarities

• Both are noninvasive ventilation modes.
• Therapy involves wearing a snug-fitting face mask.

Invasive Mechanical Ventilation

• Required for clients unable to protect their airway or provide adequate respiratory effort.
• Uses an endotracheal tube (ETT), which is inserted by a provider.
• Supplies needed include:
  • Laryngoscope with Macintosh or Miller blades
  • ETT (size to be determined by provider)
  • 10 mL syringe
  • Sedation medications
• The team involved includes a respiratory therapist and possibly a CRNA.
• Immediately after placement, the cuff is inflated to allow breaths to enter the lungs without leakage.
• Ventilate with an ambu-bag.

Confirming ETT Placement

• Placement confirmed with an end-tidal CO2 detector.
• Color change indicates the presence of CO2.
• Auscultate breath sounds for equal bilateral air movement.
• Auscultate the epigastrium for the absence of air movement in the stomach.
• Observe the chest for equal and symmetrical wall movement.
• Note the SpO2, which should improve and stabilize.
• CXR (chest x-ray) is the final confirmation of correct ETT placement.
• Note the depth of the ETT using markings on the tube.
• Assess the ETT size and insertion depth relative to the client’s anatomy.
• The pilot balloon is where air is inserted to inflate the cuff.
• The cuff is at the end of the tube inside the trachea.

Tracheostomy Tubes

• The obturator is a smooth guide used for tube insertion.
• Once inserted, the obturator is removed and kept in case of dislodgement.
• Inserted into the neck, bypassing the mouth and nose.
• Similarities to ETT: pilot balloon and cuff to occlude the airway
• Tracheostomy tubes are shorter, with size selected by the provider.
• After insertion, inflate the cuff and auscultate breath sounds.
• Use end-tidal CO2 capnography to confirm placement via color change.
• Pass a suction tube through the trach, then remove the ETT.
• Secure the tube to prevent dislodgement, and obtain a chest x-ray.

Modes of Ventilation

• Full Support Mode: Assist Control (A/C)
  • Assists with each breath by providing volume or pressure.
  • If respiratory rates fall below a setting, the ventilator will control ventilation.
• Partial Support Mode: Synchronized Intermittent Mandatory Ventilation (SIMV)
  • Administers ventilation with the client’s inspiratory efforts.
  • A preset rate ensures delivery of a fixed number of breaths at a fixed tidal volume.
  • A patient can trigger a spontaneous breath with the volume determined by patient effort.
• Spontaneous Modes: Pressure Support Ventilation or CPAP
  • Respiratory rate, tidal volume, and inspiratory times are determined by the patient.
  • Requires that the patient can spontaneously initiate breaths.

Ventilator Settings

• FiO2: Percentage of oxygen in the air provided to the client.
• PEEP: Positive end-expiratory pressure is the amount of pressure remaining in the lungs upon expiration.
• PS (Pressure Support): Preset pressure to ease breathing when the client initiates a breath.
• Rate: Minimum respiratory rate before ventilation support begins.
• Tidal Volume: Amount of air moved into or out of the lungs with each breath.

Positive End-Expiratory Pressure (PEEP)

• Pressure is applied to the airways at the end of expiration to prevent atelectasis by keeping alveoli open.

Ventilator Alarms

• When an alarm sounds, immediately check the client and the equipment.
• If the issue is unclear, disconnect the client from the ventilator.
• Provide manual breaths with an ambu bag and call for help.
• High Pressure:
  • Caused by increased circuit pressure.
  • Causes include coughing, asynchronous breathing, condensation in tubing, kinked tubing, bronchospasms, or decreased lung compliance like pulmonary edema, ARDS, atelectasis, or tension pneumothorax.
• Low Pressure:
  • Caused by decreased circuit pressure.
  • Causes include disconnection of tubing or accidental extubation.
  • Ensure tubing connections are tight.
• Apnea:
  • Sounds when no breathing is sensed.
  • Can occur in modes without a set rate.
  • May indicate respiratory arrest or over-sedation.
  • May require changing the ventilator setting or titrating sedation.
• High Vt or RR:
  • Generally indicates the client is breathing too fast.
  • Can be caused by pain, anxiety, infection, fever, hypoxia, or hypercapnia.
  • Treat the underlying condition; verbal coaching can help with anxiety.
• Low Vt:
  • Similar to low pressure but senses volume.
  • Caused by disconnected tubing, leaks in the circuit, or cuff leaks in the ETT or tracheostomy tube.
  • Reconnect tubing or consult with respiratory therapist to resolve air leaks.

Alarm Fatigue

• Tuning out frequent alarms can endanger clients.

Mechanical Ventilation Complications

• Cardiovascular:
  • Increased intrathoracic pressure can decrease cardiac output and venous return.
• Pulmonary:
  • Barotrauma: Rupture of the lungs due to added pressure.
  • Volutrauma: Lung rupture due to high air volume.
  • Atelectasis: Can result from insufficient volume or PEEP.
  • Ventilator-Associated Pneumonia (VAP): Risk for all ventilated clients.
  • Oxygen Toxicity: Can occur with FiO2 over 50% for more than 24-48 hours, causing fatigue, restlessness, nausea, vomiting, coughing, dyspnea, and hypoxia.
    • Avoid this by using the lowest amount of oxygen to keep SpO2 > 90%.
    • Never compromise oxygenation due to risk of oxygen toxicity.

Preventing Ventilator-Associated Pneumonia (VAP)

• The most effective way to prevent its is to remove the ventilator.
• Minimize sedation based on CPOT and RASS assessments.
• Nursing Interventions:
  • Elevate the head of the bed.
  • Perform range of motion exercises.
  • Provide oral care.
  • Assess and clean the skin frequently.
  • Administer medications for peptic ulcer prophylaxis.
  • Ensure nutritional needs are met via tube feeds or TPN.
• Daily spontaneous breathing trials and sedation vacations are implemented to assess readiness for ETT removal.
• A weaning process is used and determined by meeting pre-established criteria.

Extracorporeal Membrane Oxygenation (ECMO)

• Cardiopulmonary support delivered in the ICU.
• Blood is removed from the body, oxygenated and has carbon dioxide removed mechanically, then reinfused.
• Nurses Role: assessment, preventive care, and timely communication.
• Monitor for:
  • Bleeding
  • Thrombus formation
  • Heparin-induced thrombocytopenia (HIT)
  • Internal hemorrhaging
  • Neurological changes
  • Renal failure, oliguria
  • Sepsis
• Prophylactic care:
  • Suction secretions every 4 to 6 hr.
  • Perform frequent position changes.
  • Manage blood transfusions if hemoglobin levels drop below 8 g/dL.
  • Provide total parenteral nutrition (TPN) to assist with maintaining nutrition, as well as fluid and electrolyte levels.

Medications used in Ventilation

This quiz focuses on the critical aspects of nursing care for patients undergoing Extracorporeal Membrane Oxygenation (ECMO). It covers potential complications like kidney dysfunction and sepsis, medication management, and patient selection for respiratory therapies. This helps nurses manage ECMO patients effectively.