indication foe intubation ,routes of intubation , the role of nurse in intubation ,indication of mechanical ventilation ,ventilators ,ventalotory modes and its advantages and disadvantages , complication of mechanical ventilation , nursing Management for patients on ventilator ,suction technique and weaning process

1. Airway and VentilationAirway and Ventilation
ManagementManagement

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
PaPO2
- 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. Ventilators

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
pressure masks used for sleep apnea Rx

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 pH
□ PaO2 90 +/- 10 Oxygenation
□ PaCO2 40 +/- 5 Respiratory Mechanism
□ HCO3 24 +/- 2 Metabolic Mechanism
□ SaO2 97 +/- 3 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. Nutrition very 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