PROCEDURE • Can maintain ventilation for prolonged periods

• Explain the procedure and need for of time.

intubation to significant others and/or to 25
patient if conscious and non-urgent INDICATIONS:
• Secure written consent for the Acute respiratory failure
procedure. For emergency and critical • In a patient with previously normal ABGs, the
situation wherein no one is available to ABG results will be as follows:
decide it is the attending physician - PaO2 < 50 mmHg with pH <7.25 accompanied
and/or resident in duty's responsibility to by confusion, anxiety, tachypnea, tachycardia
decide for the later. and diaphoresis.
• Gather and prepare/test equipment. - PaCO2 >50 mmHg accompanied by
Initiate cardiac monitoring, pulse hypertension, irritability, somnolence (late),
oximetry. cyanosis (late) and decrease LOC (late).
In summary...
• Do the appropriate universal precautions
Failure to oxygenate
apparel.
Failure to ventilate
• Connect the manual resuscitor and mask
to oxygen.
• Test the pilot balloon on the
endotracheal tube, insert the stylet, and
lubricate the tube.
• Test and tighten the laryngoscope
blades' bulb.
• Position the patient appropriately.
• Hyperoxygenate the patient with
resuscitation bag, mask and 100%
axygen
• Assist the physician as needed during
the intubation with suctioning, patient
repositioning, supplies, cricoids TYPES OF INTUBATIONS
pressure, and bag/mask ventilation.
1. ENDOTRACHEAL-maybe inserted through
• Monitor the oxygen saturation using the the nose or the mouth.
pulse oximeter and notify the physician a. OROTRACHEAL
If saturation falls below 90%. Assist Disadvantages:
with re-oxygenation. Increased oral secretions
• Once endotracheal tube is inserted. • Decreased patient comfort
Assure proper placement of the
• Difficulty with stabilization
endotracheal tube by observation of
• Inability of patient to use lip movement
chest expansion and auscultating the
as a communication means.
chest bilaterally for equal sounds and the
b. NASOTRACHEAL
abdomen for evidence of esophageal
Disadvantages:
intubation. Keep the head of bed
• Blind insertion is required
elevated at 30 degrees after intubation.
• Possible development of pressure
After good placement has been confirmed, note
the "cm" or level marking the tube at the necrosis of nasal airway
position of the lip or teeth, and secure the tube. • Sinusitis
The "cm" marking at the lip or teeth should be • Otitis media
documented. 2. TRACHEOSTOMY-inserted into the trachea
Document the following information via incision created at the level at the 2nd or 3rd
including: cartilage ring
1 Date and time of the procedure PREPARING PATIENT FOR INTUBATION
2 Endotracheal tube size (or tracheostomy tube 4. Chest X-ray
size) 5. Emotional support as needed/ensure safety
3. Endotracheal tube level at the position of the 6. Documentation
lip or teeth VENTILATOR SETTINGS
+ Position of tube and cuff pressure (if 2. RESPIRATORY RATE
applicable) • Just as we normally adjust our own
Mechanical ventilator settings as ordered by the respiratory rate to meet our body's
Physician needs, we are able to adjust the
Complications or adverse effects programmed respiratory rate that the
MECHANICAL VENTILATOR ventilator will deliver.
• Functions as a replacement for the bellows
action of the thoracic cage and diaphragm.
 • The programmed number represents the Advantages:
minimum number of breaths the patient • Patient can control their respiratory rate
will receive every minute. • Facilitates weaning
3. TIDAL VOLUME (VT) • There is a back up rate if the patient is apneic.
• It is the amount of gas inspired in one Disadvantages:
breath. • Patient may hypoventilate
• Volume that the ventilator attempts to • Patient may hyperventilate
push in during volume cycled • Asynchronous breathing may result.
ventilation or the maximum amount that C. INTERMITTENT MANDATORY
is pushed during pressured cycled VENTILATION (IMV)
ventilation. • The IMV mode is similar to A/C mode
• The normal values are dependent on in that the patient is given a certain
many factors, including patient size, number of mandatory breaths and is
with the normal range for tidal volume permitted to breathe spontaneously
being 5-10ml/kg. between them.
4. POSITIVE END EXPIRATORY PRESSURE • The difference lies in how the ventilator
(PEEP) handles the patient initiated breaths.
• PEEP is a constant pressure that the D. SYNCHRONIZED INTERMITTENT
ventilator exerts at the end of expiration. MANDATORY VENTILATION (SIMV)
• Goal of PEEP is to prevent alveolar • Identical in all features to IMV except
collapse that the ventilator will synchronize the
• In a non-intubated patient, physiologic mandatory breaths with the patient
or natural PEEP is present. initiated breaths
• Normal ratal PEEP settings are 3-5 • If the ventilator wants to deliver its
cmH20 mandatory breath, it will first determine
6. DEAD SPACE whether or not a spontaneous breath is
• With every breath, only some of the already in progress
inspired gas reaches the alveoli to • Can be used as an initial mode in
participate in gas exchange. The rest is patients who are spontaneously
termed "dead space" ventilation. breathing and can be used as a weaning
• Dead space is the area occupied by mode.
inspired gas that is trapped in the E. PRESSURE SUPPORT VENTILATION
trachea, bronchi and all parts of the (PSV)
airway that do not participate in gas • PSV differs significantly from the other
exchange. modes, in that there are no "mandatory
7. SENSITIVITY. breaths" that the ventilator is required to
• The sensitivity setting determines how give.
much negative pressure the patient must • The patient is solely responsible for
generate before the ventilator will initiating all breaths. This differs from
recognize it as an attempt at breathing. PEEP, in that this pressure is applied
• Range for sensitivity is between - • during inspiration.
0.5cmH2O and -2 cmH20. • Pressure support can be used in
MODES OF MECHANICAL conjunction with other modes to
VENTILATION maximize the spontaneous breaths of the
A. CONTROLLED MANDATORY patient. It can be used with SIMV but
VENTILATION (CMV) not with CMV and A/C.
F. CONTINUOUS POSITIVE AIRWAY
• With this mode, the ventilator is in
PRESSURE (CPAP)
complete and total control of all the
respiratory function. • CPAP is synonym for PEEP. It is
achieved by the application of PEEP to
• If the patient attempts to initiate a
spontaneous breathing.
breath, the ventilator simply ignores the
• Allows spontaneous breathing at set
attempt and does not respond.
B. ASSIST CONTROL (A/C) FiO2 and pressure levels.
• The A/C mode overcomes the • Allows easy monitoring of ventilatory
limitations on spontaneous breathing status.
imposed by the CMV mode. COMPLICATIONS OF MECHANICAL
• As the assist control name implies, the VENTILATION
ventilator still "controls" the breathing, 1. Associated with patient's response to
but will also "assist" the patient if they Mechanical Ventilation
attempt to breathe spontaneously. A. Decreased Cardiac Output
CAUSE
 • Venous return to the right atrium • Fluid overload evidenced by decreased
impeded by the dramatically increased urine specific gravity dilutional
intrathoracic pressures during hyponatremia, increased heart rate and
inspiration from positive pressure BP
ventilation • Decreasing Fluid Intake
• Also reduced sympatho-adrenal
stimulation leading to a decrease in
peripheral vascular resistance and
reduced blood pressure.
SYMPTOMS
• Increased heart rate, decreased blood
pressure and perfusion to vital organs,
decreased CVP and cool clammy skin.
TREATMENT
• Aimed at increasing preload (fluid
administration)
• Decrease the airway pressures exerted
during mechanical ventilation by
decreasing inspiratory flow rates and
tidal volume.
• Or using other methods to decrease
airway pressures (e.g. diff. modes of
ventilation)
C. Nosocomial Pneumonia
CAUSE
• Invasive device in critically ill patients
becomes colonized with pathological
bacteria within 24 hours in almost all
patients. 20-60% of these develop
nosocomial pneumonia

SYMPTOMS
• Increased foul- smelling sputum
production and cough, localized or
diffuse wheezing dyspnea, consolidation
in chest x-ray films, hypoxemia,
elevated WBC fever
TREATMENT
• Avoid cross-contamination by frequent
handwasing
• Decrease risk of (cuff occlusion of
trachea, pastoring use of small bare NG
tubes)
• Suction only when clinically indicated,
using sterile technique
• Maintain closed system set-up on
ventilator circuity and avoid posting of
condensation in the tubing
• Ensure adequate nutrition
• Avoid neutralization of gastric contents
with antacids and H2blockers
D Positive Water Balance
• Syndrome Of Inappropriate Antidiuretic
Hormone (SIADH) due to vagal stretch
receptors in right atrium sensing a
decrease in venous return
• Decrease of normal insensible water loss
due to closed ventilator circuit
preventing water loss from lungs
• Hypovolemia leading to a release of
ADH from the PPG and retention of
sodium and water
FOCUS OF CARE • Clear any oral secretions.
• Asses the patient's status • Apply face mask oxygen.
• Functioning of the ventilator • Follow the 02 saturation by pulse
• Airway maintenance oximetry and obtain ABG measurement
• Adequate oxygen and carbon dioxide removal in 30 minutes.
Comfort measures • Patient must be carefully observed for
• Relief of anxiety 10-15 mins after extubation.
• Assistance with communication • Maintain on NPO status for at least 6
• Client and family education hours post extubation.
CARE OF INTUBATED PATIENT CONCLUSION
• Be prepared SOAPCO Principle • Mechanical ventilation is a vital piece of the
Suction puzzle in caring for the acutely or chronically ill
Oxygen patient who for some reason cannot meet their
Airway skills and adjuncts body's ventilatory needs. As a nurse, it is
Pharmacology and intravenous fluids important to understand this option.
Cardiac monitor • It is also important to understand what modes
Others and parameters are available to support the
• Follow universal precautions patient.
• Inspect the tube and size • Finally, the nurse is responsible for monitoring
• Check tube placement the patient on mechanical ventilation for
• Ascertain ability to ventilate intolerance,
• Inspect anchorage changes in condition; need for sedation or pain
Suction the tube medication and adequacy of the ventilator
• Maintain oral and nasal hygiene support.
• Watch out for complications
CRITERIA FOR WEANING
• Disease process has been managed.
• Psychological preparedness of pt (assess
the patient's readiness to wean).
• Adequate. strength and nutritional status
• ABGS within acceptable values.
• Hemodynamically stable- i.e vital signs,
hematocrit
• Conscious/awake
• Presence of spontaneous breathing
• Clear or improved chest x-ray results.
FAILURE TO WEAN
F Fluid overload-diuresis if indicated
A Airway resistance-check ET tube, is it
obstructed or too small
I Infection-treat as indicated
L Lying down, bad V/Q mismatch elevate head
of bed
T Thyroid, toxicity of drugs-check Thyroid
Function Test, check medication list
O Oxygen-Increase FiO2 as patient is taken off
ventilator
W Wheezing-treat with neb
E Electrolytes, eating correct K/Mg/Ca: provide
adequate nutrition
A Anti-inflammatory needed? -consider steroids
in asthma/COPD
N Neuromuscular disease, neuro status
compromised think of Myasthenia Gravis,
Steroid/Paralytic neuropathy, etc; assure that
patient is in fact awake and alert.
EXTUBATION PROCESS
• Deflate the ET cuff and remove the tube
with positive pressure on the breathing
bag, producing food expiration to clear
the residual secretions.