Interpreting ABGs and the ODC - 11857 Health Across Lifespan - PDF

11857 Health Across Lifespan - High acuity care needs Mini Lecture 1 –Interpreting ABG’s and ODC Kate Steirn 11857 Health Across Lifespan - High Acuity Lecture Objectives Analysing health data by interpreting arterial blood gas samples Respiratory acidosis Respiratory alkalosis...

11857 Health Across Lifespan - High acuity care needs Mini Lecture 1 –Interpreting ABG’s and ODC Kate Steirn 11857 Health Across Lifespan - High Acuity Lecture Objectives Analysing health data by interpreting arterial blood gas samples Respiratory acidosis Respiratory alkalosis Metabolic acidosis Metabolic alkalosis Mixed acidosis and alkalosis Compensated and partially compensated gases Why does it matter if my patient is acidotic or alkalotic Oxyhaemoglobin dissociation curve ABG Interpretation Acid Normal Base pH < 7.35 7.35 – 7.45 > 7.45 PaO2 70 – 100mmHg PaCO2 (lungs – respiratory, Acid) > 45 35-45mmHg < 35 HCO3- (kidney – metabolic, Base) < 22 22-26mmol/L > 26 pH :7.23 Acid Normal Base PaO2: 55mmHg Respiratory Acidosis with pH HCO3- hypoxaemia PaCO2: 50mmHg PaCO2 HCO3-: 25mmol/L pH: 7.53 PaO2: 85mmHg Acid Normal Base Respiratory Alkalosis HCO3- pH pH PaCO2: 23mmHg PaCO2 PaCO2 HCO3- : 18mmol/L  ABG Interpretation Acid Normal Base pH < 7.35 7.35 – 7.45 > 7.45 PaO2 70 – 100mmHg PaCO2 (lungs – respiratory, Acid) > 45 35-45mmHg < 35 HCO3- (kidney – metabolic, Base) < 22 22-26mmol/L > 26 pH: 7.21 Acid Normal Base PaO2: 95mmHg pH PaCO2 Metabolic Acidosis PaCO2: 44mmHg HCO3- HCO3-: 18mmol/L pH 7.48 Acid Normal Base PaO2: 78mmHg PaCO2 pH Metabolic Alkalosis PaCO2: 42mmHg HCO3- HCO3-: 35mmol/L  Mixed ABGs Acid Normal Base pH < 7.35 7.35 – 7.45 > 7.45 PaO2 70 – 100mmHg PaCO2 (lungs – respiratory, Acid) > 45 35-45mmHg < 35 HCO3- (kidney – metabolic, Base) < 22 22-26mmol/L > 26 Acid Normal Base pH: 7.25 PaO2: 91mmHg pH Mixed respiratory and PaCO2 metabolic acidosis PaCO2: 65mmHg HCO3- HCO3-: 13mmol/L pH: 7.49 Acid Normal Base PaO2: 75mmHg pH Mixed respiratory and metabolic alkalosis PaCO2: 27mmHg PaCO2 HCO3-: 28mmol/L HCO3- Compensation No compensation pH remains abnormal and the value that is NOT the cause of the problem will remain normal or has not made an attempt to help normalise the pH Partial compensation pH is still abnormal, but the value that is NOT the cause of the problem is abnormal and has begun to help normalise the pH Full compensation pH is normal and the value that is NOT the cause of the problem is abnormal and has been successful in normalising the pH ABGs with/without Compensation Acid Normal Base pH < 7.35 7.35 – 7.45 > 7.45 PaO2 70 – 100mmHg PaCO2 (lungs – respiratory, Acid) > 45 35-45mmHg < 35 HCO3- (kidney – metabolic, Base) < 22 22-26mmol/L > 26 pH: 7.21 Acid Normal Base PaO2: 58mmHg Metabolic Acidosis without pH PaCO2 compensation and with PaCO2: 44mmHg hypoxaemia HCO3- HCO3-: 18mmol/L pH 7.23 Acid Normal Base Respiratory Acidosis with PaO2: 65mmHg pH HCO3- partial metabolic PaCO2: 50mmHg compensation and mild PaCO2 hypoxaemia HCO3-: 30mmol/L ABGs with/without Compensation Acid Normal Base pH < 7.35 7.35 – 7.45 > 7.45 PaO2 70 – 100mmHg PaCO2 (lungs – respiratory, Acid) > 45 35-45mmHg < 35 HCO3- (kidney – metabolic, Base) < 22 22-26mmol/L > 26 pH: 7.39 Acid Normal Base PaO2: 78mmHg Respiratory Acidosis with full PaCO2 pH metabolic compensation PaCO2: 55mmHg HCO3- without hypoxaemia HCO3-: 30mmol/L  Oxyhaemoglobin dissociation curve Why does it matter if my patient is acidotic or alkalotic  O2 affinity  O2 unloading to tissues  O2 affinity  O2 unloading to tissues References Aitken, L., Marshall, A., & Buckley, T. (2024). Critical Care Nursing (5th ed). Elsevier Craft, J.,A., Gordon, C. J., Huether, S.E., McCance, K.L., & Brashers, V.L. (2020). Understanding pathophysiology (4th ed). Elsevier Dorman Wagner, K., Hardin-Pierce, M., Welsh, D., & Johnson, K. (2015) High acuity Nursing Global Edition (6th ed). Pearson  The University of Canberra acknowledges the Ngunnawal people, traditional custodians of the lands where Bruce Campus is situated. We wish to acknowledge and respect their continuing culture and the contribution they make to the life of Canberra and the region. We also acknowledge all other First Nations Peoples on whose lands we gather. The University of Canberra acknowledges the Ngunnawal people, traditional custodians of the lands where Bruce Campus is situated. We wish to acknowledge and respect their continuing culture and the contribution they make to the life of Canberra and the region. We also acknowledge all other First Nations Peoples on whose lands we gather. 11857 Health Across Lifespan - High acuity care needs Mini Lecture – HFNP, CPAP, BiPAP(NIV) and Invasive Mechanical Ventilation Kate Steirn 11857 Health Across Lifespan - High Acuity Lecture Objectives High flow assist devices High flow nasal prongs (HFNP) Ventilator terminology Non-invasive Ventilation Continuous positive airway pressure (CPAP) Bi-level positive airway pressure (BiPAP) Nursing management Invasive ventilation Basics Nursing management High flow nasal cannulae (HFNP) Have larger prongs to facilitate oxygen flow of up to 60L/min Generate low levels of PEEP (explain further) And can therefore reduce tachypnoea and WOB. Prevents CO2 rebreathing and therefore decreases PaCO2 Well tolerated Must be used with humidification Comparison Flow and FiO2 Flow (L/min) FiO2 Comfort Mouth or nose breathing Nasal cannula 1- 6 24-40% Yes Nose Face mask 6-10 35-60% Mod Mouth Venturi mask 2-15 24-50% Mod Mouth Non-rebreather 10-15 50-90% No Mouth High flow nasal 15-60 30-100% Mod Nose cannula Ventilator Terminology FiO2 – fraction of inspired oxygen or O2 concentration 30-100% Respiratory Rate (RR) – no of breaths per minute Tidal Volume (Vt) - is the volume of gas moved into or out of the lung in a single normal inspiration and expiration. Minute Volume (Ve) - is the volume of gas moved in and out of the lungs in one minute. i.e. Vt x RR. Positive End Expiratory Pressure (PEEP) or End expiratory positive airway pressure (EPAP) – the amount of pressure still in the lungs/alveoli at the end of expiration. Pressure Support (PS) - push of air to help Patient with spontaneous breath Peak inspiratory pressure (PIP) – maximum amount of pressure during inspiration Non-invasive ventilation (NIV) CPAP and BiPAP are 2 different versions of NIV or non-invasive positive pressure ventilation (NPPV) Both CPAP and BiPAP requires patient to trigger breathing (patent airway and adequate level of consciousness) Both CPAP and BiPAP preserves the patient’s ability to speak, swallow, cough and clear secretions and decreases risks associated with endotracheal intubation May have increased FiO2 or may just have pressure controls CPAP BiPAP Continuous Positive Airway Pressure (CPAP) Indications ARDS, cardiac pulmonary oedema (HF), bilateral, diffuse pneumonia, Type 1 respiratory failure (PaO2 60mmHg), Obesity hypoventilation Benefits: Same benefits as CPAP as we are still applying EPAP in this mode as well but has added benefit of pressure support on inspiration which significantly decreasing the work of breathing required. avoidance of inspiratory muscle fatigue through the addition of inspiratory positive pressure thus reducing dyspnoea increases tidal volume which increases the elimination of CO2 and reverses acidaemia BiPAP / PS ventilation PEEP (EPAP) = 5cm H2O PS (IPAP) = 7cm H2 Peak inspiratory pressure (PIP) PEEP + IPAP 5 + 7 = 12cmH2O Nursing monitoring requirements Patient education – outlining benefits/rationale for intervention Ensure mask fits face and provides good seal and monitor for presence of air leaks Full MEWS and NIV observations are completed, on both the NIV and MEWS charts, half hourly for the first four hours, then hourly for the first 24 hours recording the following: Patient monitored for respiratory and haemodynamic stability (Oxygen saturation + cardiovascular observations) Flow rate of supplemental oxygen if required NIV settings Time on and time off machine Nursing Monitoring requirements cont.. Patient comfort (Claustrophobia leading to agitation) and accessory muscle use Coordination of respiratory effort with the ventilator Fluid balance chart Skin integrity – check at all pressure points i.e. bridge of nose, tips of ears Ensure all equipment used on the patient is cleaned in the correct manner as per the manufactures instructions. Nasal congestion or nasal dryness Invasive ventilation - intubated Patients Synchronised intermittent mandatory ventilation. Pressure regulated volume control (SIMV-PRVC) Set: RR, FiO2, PEEP, Vt, PS + other settings Synchronised with patients own intrinsic breathing Patient triggered breath Pressure supported – same as biPAP Mandatory ventilation only when required if patient doesn’t initiate breath Volume control – controls volume of mandatory breaths only Pressure regulated – pressure is regulated to prevent barotrauma. (Usually set to 35cm H2O) as an alarm that pressure is high and will cut off a breath if pressure too high (usually 40cmH2O). Invasive ventilation - intubated Patients Pressure support ventilation (PSV) – Weaning mode Set: FiO2, PEEP, PS No RR is set - Patient must trigger every breath. Ventilator delivers a pressure boost to patient own breath Exactly the same as BiPAP only not via a mask is via a ETT or trachy. Nursing monitoring requirements Assessing and maintaining airway. (ETT or Tracheostomy) Suctioning equipment Always have emergency adjunctive airways and BVM at bedside Check circuit - Humidified circuits Ventilator settings and alarms Coordination of respiratory effort with the ventilator Monitor waveforms and capnography Patient monitored for respiratory and haemodynamic stability (Oxygen saturation + cardiovascular observations) Skin integrity – check at all pressure points i.e. ETT in mouth a lips and tapes around face/neck etc. References ACT Health (2021) Non-invasive ventilation management for adult patients outside the ICU HDU Retrieved from: https://www.canberrahealthservices.act.gov.au/about-us/policies-and- guidelines?result_1981007_result_page=16 Aitken, L., Marshall, A., & Buckley, T. (2024). Critical Care Nursing (5 th ed). Elsevier Craft, J.C., Gordon,C.J., Huether,S.E., McCance,K.L., & Brashers, V.L. (2020) Understanding pathophysiology (4th ed.). Elsevier. Dorman Wagner. K., & Hardin-Pierce, M. G. (2015). High-Acuity Nursing, Global Edition (6th ed). Pearson Margutti, E.M., Brambilla, A.M., Maraffi, T., & Cosentini, R. (2017) Non-invasive ventilation in acute respiratory failure: the key “w” questions. Internal and Emergency Medicine Vol 12, pp1307-1311. Yartsev, A (2023) Effects of positive pressure ventilation on pulmonary physiology. Retrieved from: https://derangedphysiology.com/main/cicm-primary-exam/required-reading/respiratory- system/Chapter%20522/effects-positive-pressure-ventilation-pulmonary-physiology  The University of Canberra acknowledges the Ngunnawal people, traditional custodians of the lands where Bruce Campus is situated. We wish to acknowledge and respect their continuing culture and the contribution they make to the life of Canberra and the region. We also acknowledge all other First Nations Peoples on whose lands we gather. The University of Canberra acknowledges the Ngunnawal people, traditional custodians of the lands where Bruce Campus is situated. We wish to acknowledge and respect their continuing culture and the contribution they make to the life of Canberra and the region. We also acknowledge all other First Nations Peoples on whose lands we gather. 11857 Health Across Lifespan - High acuity care needs Mini Lecture – Intubation and assessing an artificial airway Kate Steirn 11857 Health Across Lifespan - High acuity care needs Lecture Objectives Intubation (ETT and Tracheostomy) indications for Risks of checking correct placement Assessment of artificial airways (ETT and Trachy) Documenting an artificial airway Nursing responsibilities Emergency equipment check Airway suctioning When to intubate Impending cardiorespiratory arrest – MET call Vomiting or haematemesis Multi -organ failure requiring extensive Recent facial/ENT/Upper GI or neurological monitoring surgery, trauma, or deformity Haemodynamic instability with hypotension or Acute burn with possible airway involvement unstable cardiac arrhythmia Barotrauma Untreated pneumothorax Allergic reaction to materials of the face/nose Pneumonia in immunocompromised patients mask Reduced level of consciousness and inability to protect airways Confusion requiring sedative medications or physical restraints to apply NIV Induction Medications Sedative (Midazolam, propofol) – induction and infusion Paralytic (Succinycholine, Vecuronium, Rocuronium) - induction and possibly infusion thereafter depending on patient condition Analgesic (Fentanyl, morphine) – induction and infusion Intubation- Endotracheal Tube (ETT) 2 routes: Orotracheal Nasotracheal 1. Size (internal diameter in mms) 2.0-12.0 (0.5 increments) 2. Length 3. Radiopaque line (shows on CXR) 4. Inflated cuff and Pilot tube 5. Connector (standard 15mm) 6. Subglottic suction Risks of intubation - ETT Infection – pneumonia or Ventilator Acquired Pneumonia (VAP) Tooth dislodgement Bleeding Perforation oropharynx Oesophageal placement – immediate removal and re-placement in trachea Vocal cord damage – prolonged use, extubation without deflating balloon Tracheal mucosa ischaemia- increased cuff inflation pressures Indicators for a tracheostomy There are several reasons why a patient may have a tracheostomy tube: To bypass upper airway obstruction – subglottic, glottic, supraglottic (e.g. tumours, foreign bodies, vocal cord paralysis and following head and neck surgery.) Uncontrolled aspiration e.g. decreased conscious state, inability to manage secretions Prolonged intubation To facilitate long term ventilator support/airway management To facilitate weaning from ventilator support Assessing an Artificial Airway Type of artificial airway (ETT, NTT or Tracheostomy) Size - diameter (both) Length at teeth (ETT only) Cuff pressure (both) Assess securing device (tapes, anchorfast, sutures) – is it adequate, not too tight or too loose (2 fingers space) Suctioning - frequency and description of secretions, cough reflex present? +/- Dressing (trachy) other cares (oral/mouth care both) Pressure area assessment (lips, mouth, neck, face) NB: ventilator settings and circuit/system set up assessment is a function of Breathing NOT airway. (covered in next lecture) Assessing an Artificial Airway Checking correct placement Auscultate - bilateral breath sounds; Bilat rise and fall of chest Auscultate epigastric (on insertion) End tidal CO2 is gold standard, method for confirming ETT placement (on insertion) Capnography is even more reliable and a requirement for continuous monitoring as per anaesthesia and resuscitative guidelines CXR (daily) 2cm above carina or above biofication of bronchus Documenting Artificial Airway Nursing: Assumed care of patient at 0700hrs. Airway: Patient airway maintained via size 7.5 ETT/ Patient intubated with size 7.5 ETT. [choose either], ETT 22cm at teeth, cuff pressure 24cm H2O, ETT secured with anchorfast/tapes [choose], suctioned 2nd hourly with mod amounts thick creamy secretions. Minimal cough reflex during suctioning. Oral cares attended to 2nd hourly APP. Oral mucosa, pink, clean, nil Pressure areas to lips. Breathing: Nursing: Assumed care of patient at 0700hrs. Airway: Patient airway maintain via size 7.0 portex trachy/ Patient intubated with size 7.0 portex trachy [choose either], cuff pressure 24cmH2O, trachy secured with ribbon tapes/ trachy secured with sutures and ribbon tapes [choose]. Suctioned prn with minimal clear secretions. Patient has strong spontaneous cough. Trachy dressing clean and intact.[if dressing present] Breathing: Bedside Emergency Equipment Check All different size ETT or tachy’s should have one of each size available Bag valve mask (BVM) without face mask attached Face masks for BVM available Cuff monitor device (manometer) and 10ml syringe Trachy dressing equipment Securing devices (spare tapes or anchorfast depending on type of airway) Tracheal dilators (for tracheostomy patients) Suctioning equipment – circuit + Catheters + Yanker sucker (oral cares) Sterile N/Saline for suctioning /gloves Oral care equipment: Lip cream/tooth brush, tooth paste/ mouth swabs Nursing responsibilities Tracheostomy dressings and strappits are not changed for 24 hours postoperatively. This is due to the risk of accidental dislodgement before there is a fully formed tract. A second nurse is required to assist during the procedure in order to stabilise the airway (ETT or Trachy) when moving patient for pressure area cares and other cares (incl: trachy dressing changes). Provide daily care of the patient including tracheostomy/respiratory needs (e.g. suctioning, dressings, stoma care, respiratory monitoring, monitoring ventilation parameters and liaising with team as required). ACT Health policy Suctioning via ETT or Tracheostomy Indication of suction - need to remove Audible upper respiratory tract noises accumulated pulmonary secretions as evidenced Deterioration of ABGs or SpO2 by one or more of the following: Suspected aspiration Coarse breath sounds on auscultation Clinically apparent increased work of breathing Tactile fremitus (palpable secretions in chest) CXR changes consistent with sputum retention Inability to generate an effective spontaneous The need to obtain a sputum specimen cough Reversible increased peak inspiratory pressures As part of a respiratory assessment during volume controlled ventilation or The need to maintain patency and integrity of decreased tidal volume on pressure controlled the artificial airway. ventilation Visible secretions in the tracheostomy References ACT Health (2023) Tracheostomy Management Adult patients. Retrieved from https://www.canberrahealthservices.act.gov.au/about-us/policies-and-guidelines Aitken, L., Marshall, A., & Buckley, T. (2024). Critical Care Nursing (5th ed). Elsevier Al-metwalli, R.R., Fallatah, S.M., & Alghamdi, T.M. (2021). Endotracheal tube cuff pressure: An overlooked risk. Anaesth. pain intensive care. Vol 25, Iss, 1. pp, 88-97. Dorman Wagner, K., & Hardin-Pierce, (2015). High-Acuity Nursing Global Edition, (6th ed.). Pearson Knights, K., Darroch, S., Rowland, A., & Bushell, M. (2023). Pharmacology for health professionals (6th ed) Elsevier  The University of Canberra acknowledges the Ngunnawal people, traditional custodians of the lands where Bruce Campus is situated. We wish to acknowledge and respect their continuing culture and the contribution they make to the life of Canberra and the region. We also acknowledge all other First Nations Peoples on whose lands we gather.