Airway and
Ventilation
Management
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
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
Routes for intubation
Endotracheal
Nasotracheal
Tracheal
1.Tracheostomy-elective
2.Cricoidotomy-urgent
Role of nurse in
endothacheal intubation
1. Manage Airway
Obstructed
lift
Head tilt/chin
Jaw thrust
Role of nurse in
endothacheal intubation
2. Ventilation : bag valve mask
device with self inflating bag
3. Oxygenation with 100% oxygen
Role of nurse in
endothacheal intubation
4. Removal of obstructing foreign
material using suction &
Yankauer
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
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
Role of nurse in
endothacheal intubation
7. Assist with procedure:
A. Ventilate and oxygenate (allow1530 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)
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
20mmHgit can cause tissue death and
fistula formation if higher
B. If lower than 15mmHg increased risk of
aspiration.
9. Secure ET tube
10.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
Position of ET tube
Endotracheal tube
position
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
Types of ventilation
1. Non-invasive positive pressure
ventilation NIPSV
2. Mechanical ventilation
Ventilators
Ventilator tubing set up
Ventilatory modes
CMVcontrolled mechanical
ventilation
Disadvantages of CMV
IMV & SIMV
Mandatory breath at preset VT
and rate
Patient can breath above rate
without assistance from
ventilator
Difference between IMV an
SIMV
IMV & SIMV
Advantages & disadvantages of
SIMV
Pressure support ventilationPSV
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
Advantage & disadvantages of
PSV
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)
Advantages and disadvantages of
PCV
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
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 endexhalation 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
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
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 toxicitywhen on settings
greater than 0.5-0.6 FiO2 in adults for
long time
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)
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
Normal ABGs
pH7.4 +/- 0.05
PaO290 +/- 10
PaCO240 +/- 5
pH
Oxygenation
Respiratory Mechanism
HCO324 +/- 2
Metabolic Mechanism
SaO297 +/- 3 Oxygenation
Nursing Management
2. Observe for
pneumothorax/tension
pneumothorax
Increased anxiety
Dyspnea, Tachycardia, Hypotension
Unequal breath sounds
Sudden CVS collapse
3. Guard against dislodgment of ET
tube
Nursing Management
4. Help patient to cope
Remove airway secretions by
suctioning when:
i.
ii.
iii.
iv.
Audible airway noise
Coughing
Respiratory distress
Assess and improve airway patency
Allow for different method of
communication
Remove accumulated water in tubing
Comforting measures/sedation
Suction technique
Sterile technique
Catheter Size
Suction pressure not lower than -120cmH2O for
adults and -60-80 pediatric
Preoxygenation (100%), hyperventilation
Dont suction when inserting catheter
Suction time no longer than 15 seconds
Hyperoxygenate and hyperventilate between
suction passes
Saline should not be usedinfection and reduce
O2 saturation
Use closed ET suction system with preoxygenation
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
Nutrition very important
Malnourishment will cause:
Weaning from ventilator
Adequate PaO2, pH and PaCO2
FIO2 is .4 to .5
Very low or no PEEP
Reasonable respiratory rate
Prepare patient for weaning
Weaning techniques
T-tube
SIMV
PSV
Nursing Responsibilities in
Weaning
Weaning Failure
When two or more:
BP deviation of 20mmHG or more
Alteration in heart rate of 20bpm or
more
Cardiac dysrhythmeas deviating
from patients baseline
Change in level of consciousness
Or when RR greater than 35 bpm
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
