30 Questions
What is the typical respiratory rate for an adult patient on a mechanical ventilator?
10-20 breaths per minute
What is the purpose of PEEP in mechanical ventilation?
To prevent collapse of small airways and alveoli
What is the mode of ventilation used for weaning from the ventilator?
Synchronized Intermittent Mandatory (SIMV)
What should be done when an alarm sounds during mechanical ventilation?
Look at the patient and assess for distress
What is the purpose of pressure support mode in mechanical ventilation?
To assist patient breathing with a preset amount of inspiratory pressure
Why is it important to monitor cuff pressure during mechanical ventilation?
To prevent tracheal necrosis
What is the purpose of the Ventilator Bundle of Care?
To improve patient outcomes
What is the purpose of inverse inspiratory to expiratory ratio in mechanical ventilation?
To improve oxygenation in patients with non-compliant lungs
What should be done when a patient is disconnected from the ventilator circuit?
Manually ventilate the patient with a bag-valve device
What is the purpose of the SIMV mode in mechanical ventilation?
To provide assistance with adequate ventilation
What is the primary purpose of the device attached to the end of the ETT?
To detect the presence of CO2
How is the aspiration device used to verify the placement of the ETT?
It is compressed, deflated, and attached to the ETT to detect CO2
What should the tip of the ETT be positioned at during intubation?
3-4 cm above the carina
Why is the ETT secured with tape or a commercial device?
To prevent the tube from being dislodged
What is the preferred method of securing the ETT?
Using adhesive tape
What is the purpose of the tracheostomy tube?
All of the above
What is the advantage of using a tracheostomy tube over an ETT?
All of the above
What should be done with the condensate in the ventilator tubing?
Drain it into the collection trap and empty
How often should the ventilator tubing and equipment be changed or cleaned?
Every 48-72 hours
Why should the patient be turned from side to side every 1-2 hours?
To promote circulation and prevent complications
What is the purpose of inflating the cuff of the endotracheal tube?
To facilitate ventilation of the patient by sealing the trachea
What is the purpose of the pilot balloon on the endotracheal tube?
To inflate and deflate the cuff of the endotracheal tube
What is the purpose of the laryngoscope in oral endotracheal intubation?
To facilitate the passage of the endotracheal tube through the oropharynx
Why is the patient positioned with their head extended and neck flexed during oral endotracheal intubation?
To improve visualization of the glottis
What should be done to the outside of the endotracheal tube before insertion?
It should be lubricated with a water-soluble lubricant
What is the purpose of using a stylet during oral endotracheal intubation?
To facilitate the passage of the endotracheal tube
What is the purpose of verifying the placement of the endotracheal tube?
To verify that the tube is in the trachea, not the esophagus
What is the purpose of the radiopaque line on the endotracheal tube?
To verify the placement of the tube on an x-ray
Why is it important to check the cuff of the endotracheal tube for leaks?
To ensure a proper seal is maintained
What is the purpose of using a minimal leak technique when inflating the cuff of the endotracheal tube?
To ensure a proper seal is maintained while allowing a minimal amount of air to pass
Study Notes
Mechanical Ventilation
- Inspiratory to Expiratory (I:E) Ratio:
- In spontaneous ventilation, inspiration is shorter than expiration
- In mechanical ventilation, I:E ratio is usually set at 1:2 to mimic this pattern
- Inverse I:E ratio (e.g. 2:1, 3:1) is used to improve oxygenation in patients with non-compliant lungs, such as ARDS
- Positive End-Expiratory Pressure (PEEP):
- Addition of positive pressure into the airways at the end of expiration
- Measured in cm of H2O (typical setting: 5-20 cmH2O)
- Increases oxygenation by preventing collapse of small airways and maintaining the number of alveoli available for gas exchange
- Total Respiratory Rate:
- Equals the number of breaths delivered by the ventilator (set rate) plus the number of breaths initiated by the patient
- Provides data regarding the patient's contribution to the work of breathing and whether the ventilator is performing all of the work
Modes of Mechanical Ventilation
- Volume Controlled Modes:
- Volume Assist/Control (V-A/C): delivers a preset respiratory rate of a preset tidal volume
- Volume Intermittent Mandatory Ventilation (V-IMV): delivers a preset number of breaths of a preset tidal volume, with patient-initiated spontaneous breaths in between
- Pressure Controlled Modes:
- Continuous Positive Airway Pressure (CPAP): a non-invasive form of PEEP, delivers positive pressure throughout the respiratory cycle
- Bilevel Positive Airway Pressure (BiPAP): provides positive airway pressure during both inspiration and expiration
- Pressure Support (PS): a weaning mode, in which the patient's spontaneous respiratory activity is augmented by the delivery of a preset amount of inspiratory positive pressure
- Pressure Assist/Control (P-A/C): a mode in which there is a set RR and every breath is augmented by a set amount of inspiratory pressure
Alarm Systems
- Two important rules:
- NEVER shut off alarms
- Manually ventilate the patient with a bag-valve device if unable to troubleshoot alarms quickly or if equipment failure is suspected
- When an alarm sounds:
- Look at the patient and assess their condition
- Take immediate action if the patient is in acute distress
- Use a bag-valve device to manually ventilate the patient if necessary
- Alarms:
- Apnea alarm: no spontaneous breath within a preset time period
- Low-pressure alarm: indication of low exhaled volume
- High-pressure alarm: indication of high pressure
Nursing Interventions
- Establish a means of communication with the patient
- Ensure ETT is secured
- Prevent accidental extubation
- Suction oral and tracheal secretions as indicated
- Use caution when moving or turning the patient
- Have a manual bag-valve resuscitation device readily available
- Administer medications as prescribed
- Assess respiratory status and document findings
- Monitor ventilator alarms and adjust settings as necessary
Ventilator Bundle of Care
- Should be implemented on all patients who receive mechanical ventilation to improve outcomes
- Includes:
- Maintaining HOB at 30-45 degrees
- Interrupting sedation at least daily to assess readiness to wean from ventilator and extubated
- Providing prophylaxis for DVT and peptic ulcer disease
- Providing daily oral care with chlorhexidine
Verification of Endotracheal Tube Placement
- Use of esophageal intubation detector
- Aspiration device
- Confirming the position of the ETT tip at 3-4 cm above the carina
- Recording the centimeter depth marking at the teeth and gums
- Ensuring the ETT remains in proper position during each assessment
Securing the Endotracheal Tube
- Methods:
- Adhesive tape
- Harness device
- Importance of securing the ETT to prevent migration to an unsafe position
Tracheostomy
- A tracheostomy tube provides an airway directly into the anterior portion of the neck
- Indications:
- Long-term mechanical ventilation
- Long-term secretion management
- Protecting the airway from aspiration
- Bypassing an upper airway obstruction
- Reducing the work of breathing associated with an ETT
- Advantages:
- Better tolerated than the ETT
- Allows for oral intake and improved communication
- Allows for easier oral hygiene and careHere are the study notes in markdown format:
Gas Exchange
- Work of Breathing (WOB): the amount of effort required for the maintenance of a given level of ventilation
- Compliance: the measure of the stretchability of the lung and chest wall
- Resistance: refers to the opposition to the flow of gases in the airways
Acute Respiratory Failure
- Definition: an inability of the respiratory system to provide oxygenation and/or remove carbon dioxide from the body
- Classified into:
- Oxygenation (Hypoxemic) Failure: PaO2 < 60 mm Hg with a normal or low PaCO2
- Ventilatory (Hypercapnic) Failure: PaCO2 > 50 mm Hg and pH < 7.35
- Goals for treatment:
- Maintaining a patent airway
- Optimizing O2 delivery
- Minimizing O2 demand
- Treating the cause of ARF
- Preventing complications
ARDS (Acute Respiratory Distress Syndrome)
- Definition: acute respiratory failure with features:
- Acute onset of less than 7 days
- Hypoxemia that persists when 100% oxygen is provided
- Decreased pulmonary compliance
- Dyspnea
- Pulmonary edema without a cardiac origin
- Dense pulmonary infiltrates on chest x-ray
- Etiology:
- Sepsis
- Pulmonary infections
- Shock
- Cardiopulmonary bypass
- Inhalation of toxic gases/smoke inhalation
- Pulmonary aspiration, especially of stomach contents
- Trauma
- Drug/alcohol overdose
- Pathophysiology:
- Systemic inflammatory response
- Alveolar-capillary membrane injury
- Surfactant production reduced
- Lung fluid accumulation
- Clinical manifestations:
- Severe shortness of breath with labored and unusually rapid breathing
- Hypotension
- Tachycardia
- Dysrhythmias
- Confusion
- Extreme fatigue
- Cyanosis/pallor
- Diaphoresis
- Diagnostic studies:
- Arterial blood gases
- CBC panel
- Blood culture
- Urine culture
- Sputum cultures obtained by bronchoscopy or tracheal aspiration
Collaborative Care for ARDS
- Goals:
- Achieving adequate oxygenation
- Supporting ventilation
- Maintaining fluid balance
- Preventing complications
- Measures:
- Non-invasive positive pressure ventilation (NPPV)
- Mechanical ventilation
- Fluid restriction
- Sedatives
- Electrolyte and acid-base imbalances correction
- Vasopressors
- Nutritional support
- Alternative means of communication
- Monitoring vital signs and mechanical ventilator settings
Bronchopulmonary Dysplasia (BPD)
- Definition: a chronic obstructive pulmonary disease that occurs in newborns who require oxygen and mechanical ventilation
- Etiology:
- Premature birth
- Respiratory infection
- Oxygen supplementation
- Mechanical ventilation
- Pathophysiology:
- Lung immaturity
- Pressure of mechanical ventilation damages bronchial epithelium
- Thickening of alveolar walls
- Cystic and atelectic areas develop in the lungs
- Clinical manifestations:
- Tachycardia/tachypnea
- Pallor/cyanosis
- Weight loss/poor weight gain
- Restlessness/irritability
- Pursing of the mouth with flaring of the nares
- Diagnostic studies:
- Chest x-ray
- Collaborative care:
- Weaning oxygen as tolerated
- Maintaining adequate oxygenation
- Preventing further lung disease
- Promoting healing of damaged lungs
Test your knowledge on mechanical ventilation, including respiratory rates, PEEP, weaning modes, alarm responses, pressure support, and cuff pressure monitoring.
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