This document discusses airway and ventilation management. It covers indications for intubation and mechanical ventilation, different modes of ventilation including their advantages and disadvantages, complications of mechanical ventilation, nursing assessment and care of ventilated patients, and methods for weaning patients from ventilators. The roles of nurses in intubation and post-intubation care are described. Key aspects of ventilator settings, management of complications, nutrition, and criteria for determining readiness for weaning are also outlined.

1. Airway and Ventilation
Management

2. Learning outcomes
□ List indications for intubation
and mechanical ventilation
□ Differentiate between modes of ventilation
and advantages and disadvantages of
each
□ List complications of mechanical ventilation
□ Describe nursing assessment and care of
ventilated patient
□ Discuss methods used for weaning patients

3. Indications for intubation
1. Elective: for general anesthesia
2. Urgent:
A. Relive upper airway obstruction
B. Isolate/protect airway
C. For suctioning of tracheobronchial tree
D. For assisted ventilation

4. Routes for
intubation
□ Endotracheal
□ Nasotracheal
□ Tracheal
1. Tracheostomy-elective
2. Cricoidotomy-urgent

5. Role of nurse in endothacheal
intubation
1. Manage Airway
Obstructed Head tilt/chin lift
Jaw
thrust

6. Role of nurse in endothacheal
intubation
2. Ventilation : bag valve mask device
with self inflating bag
3. Oxygenation with 100% oxygen

7. Role of nurse in endothacheal
intubation
4. Removal of obstructing foreign
material using suction & Yankauer

8. Role of nurse in endothacheal
intubation
5. Insert nasal or oral pharyngeal airway
if necessary (oral airway used only in
unconscious patient because it can
stimulates gagging, vomiting,
laryngospasm if patient conscious)
Guedel oral airway Nasal airway

9. Role of nurse in endothacheal
intubation
6. Prepare equipment:
A. Face mask and oxygen supply
B. Airway
C. Suctioning equipment
D. Laryngoscope
E. Lubricant
F. Malleable wire guide or introducer
G. Magill forceps
H. End tidal CO2 detector

10. Role of nurse in endothacheal
intubation
7. Assist with procedure:
A. Ventilate and oxygenate (allow15-30
seconds for intubation)
B. Monitor vital signs
C. Suction when necessary
D. Provide cricoid pressure if requested
(press below Adams apple, will push
trachea back and collapse esophagus
making intubation easier)

11. Role of nurse in endothacheal
intubation
7. Auscultate over lung and air fields
8. Inflate cuff of ET or NT tube
A. Ensure cuff pressure does not exceed 20mmHg
—it can cause tissue death and fistula
formation if higher
B. If lower than 15mmHg increased risk of
aspiration.
7. Secure ET tube
8. Follow up Chest X ray
A. ET tube at front teeth between 19-23cm in adult
B. On X ray should be 2cm above carina

12. Position of ET
tube

13. Endotracheal tube position

14. Indications for Mechanical
Ventilation
A. Inability to maintain adequate ventilation
(ability to remove CO2)
-
-
-
- PaCO2 > 55mmHg and pH < 7.25 criterion for
mechanical ventilation
B. Inability to maintain adequate
oxygenation (hypoxemia)
Patient may have normal PaCO2 and low
PaO2
O2 supplement may help
PaO2 < 50mmHg on FiO2 > 0.5 criterion for
mechanical ventilation
C. Work of breathing greater than patient can
maintain

15. Types of
ventilation
1. Non-invasive positive pressure ventilation
– NIPSV
2. Mechanical ventilation

16. Ventilator
s

17. Ventilator tubing set up

18. Ventilatory modes
□ CMV—controlled mechanical ventilation

19. Disadvantages of CMV

20. IMV & SIMV
□ Mandatory breath at preset VT and
rate
□ Patient can breath above rate without
assistance from ventilator
□ Difference between IMV an SIMV…

21. IMV & SIMV

22. Advantages & disadvantages of SIMV

23. Pressure support ventilation-
PSV
□ A pressure assisted mechanical
ventilation helping patient with his own
efforts
□ Instead of selecting VT we select
positive airway pressure
□ May use for weaning or with SIMV

24. Advantage & disadvantages of PSV

25. Pressure controlled ventilation-
PCV
□ Mechanical inhalation phase is
pressure limited to prevent trauma to
lungs
□ Can have longer inspiration than
expiration (I : E ratio up to 4:1)

26. Advantages and disadvantages of PCV

27. Positive end expiratory
pressure PEEP
□ Airway pressure maintained in lungs
after end of exhalation
□ Keeps alveoli open increasing area of
gas exchange
□ May reduce cardiac output, increase
cerebral pressure, risk of
pneumothorax incresed

28. Continuous Positive Airway Pressure—
CPAP
□ Patient breathes independently through
ventilator circuit, or with CPAP mask
□ No VT is present
□ Only FIO2 and gas pressure at end-
exhalation are controlled
□ Term CPAP used when the patient breathing
spontaneously
□ Used most often with patients
requiring intubation but not
ventilatory support
□ May also be used as last stage of weaning in
select patients
□ CPAP and non-invasive positive airway

29. Complications of mechanical
ventilation
1. Complications from ET/NT tube
□ Lip, tongue, nasal, pharyngeal, tracheal or
laryngeal pressure ulcers
□ Mucous plugs impairing ventilation
□ Obstruction by biting tube
□ Sinusitis and otitis with NT tube
□ Tracheal-esophageal fistula
□ Infection

30. Complications of mechanical
ventilation
2. Complications from ventilator
□ Auto-PEEP – unintended air trapping can cause
hypotension, reduce cardiac output-- mostly
seen in patients with asthma, obstructive lung
disease
□ Hemodynamic instability from positive pressure
ventilation
□ ADH secretion positive H2O balance
□ Infection
□ GI bleeding due to stress ulcer
□ Barotrauma
□ Oxygen toxicity—when on settings greater than
0.5-0.6 FiO2 in adults for long time

31. How to determine ventilator settings
□ Tidal volume (VT) 8-12 ml/kg adults
□ Respiratory rate
□ RR X VT = VE (minute volume)--the
higher the VE the lower the PaCO2
□ FiO2 set to maintain and SaO2 > 90%
□ PEEP 5-15 cmH2O (useful
in pnenumonia and ARDS)

32. Nursing Management
1. Observe for S&S of inadequate ventilation
□ Rising PaCO2/falling PaO2
□ Shallow respirations
□ Irregular respirations/chest-abdominal
dyssynchrony
□ Dyspnea, tachypnea, bradypnea, apnea
□ Headache, restlessness, confusion, lethargy
□ Rising BP (early sign), or falling BP (late sign)
□ Tachycardia, arrhythmeas
□ Cyanosis
□ Agitation, anxiety

33. Normal
ABGs
□ pH 7.4 +/- 0.05
□ PaO2 90 +/- 10
□ PaCO2 40 +/- 5
□ HCO3 24 +/- 2
□ SaO2 97 +/- 3
pH
Oxygenation
Respiratory Mechanism
Metabolic Mechanism
Oxygenation

34. Nursing Management
2. Observe for pneumothorax/tension
pneumothorax
□ Increased anxiety
□ Dyspnea, Tachycardia, Hypotension
□ Unequal breath sounds
□ Sudden CVS collapse
2. Guard against dislodgment of ET tube

35. Nursing Management
•
4. Help patient to cope
Remove airway secretions by suctioning
when:
i. Audible airway noise
ii. Coughing
•
iii. Respiratory distress
iv.Assess and improve airway patency
Allow for different method of
communication
• Remove accumulated water in tubing
• Comforting measures/sedation

36. Suction technique
□ Sterile technique
□ Catheter Size
□ Suction pressure –not lower than -120cmH2O for
adults and -60-80 pediatric
□ Preoxygenation (100%), hyperventilation
□ Don’t suction when inserting catheter
□ Suction time no longer than 15 seconds
□ Hyperoxygenate and hyperventilate between suction
passes
□ Saline should not be used—infection and reduce O2
saturation
□ Use closed ET suction system with preoxygenation

37. Nursing management
5. Troubleshoot ventilator
□ Check against incorrect ventilator settings
□ Ventilator disconnect is common
□ High pressure alarm may be due to:
□
□
□
□
Suction needed
Biting tube
Displaced tube
Compliance decreased
□
□ Barotrauma
If problem not found disconnect patient and
manually ventilate with 100% O2 until
problem corrected

38. Nutritionvery important
Malnourishment will cause:

39. Weaning from ventilator
□ Adequate PaO2, pH and PaCO2
□ FIO2 is .4 to .5
□ Very low or no PEEP
□ Reasonable respiratory rate

40. Prepare patient for weaning

41. Weaning techniques
□T-tube
□SIMV
□PSV

42. Nursing Responsibilities in
Weaning

43. Weaning Failure
□ When two or more:
□ BP deviation of 20mmHG or more
□ Alteration in heart rate of 20bpm or more
□ Cardiac dysrhythmeas deviating from
patient’s baseline
□ Change in level of consciousness
□ Or when RR greater than 35 bpm

44. Learning outcomes
□ List indications for intubation
and mechanical ventilation
□ Differentiate between modes of ventilation
and advantages and disadvantages of
each
□ List complications of mechanical ventilation
□ Describe nursing assessment and care of
ventilated patient
□ Discuss methods used for weaning patients