Nursing care in mechanical ventilation

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Nursing Care of the
Mechanically Ventilated Patient


Nursing Care of the
Mechanically Ventilated Patient
• Nursing care of patients who are being
mechanically ventilated requires some
special considerations.
• Some special considerations relate
specifically to the type of tube via which
the patient is being ventilated (i.e.
endotracheal or tracheostomy) and
others related to the patient, and the
ventilator itself.


Precaution & Care

• Tracheobronchial Hygiene:

• Placement of tube: Chest movement
Auscultation
Post intubation X-ray

• Cuff pressure: If insufficient- Leak
Displacement of the tube
Aspiration

If high pressure - Tracheal stenosis
Desired Pressure - 20-30cm water


Normal

Care of the Ventilator Patient
• Observe and document • Provide oral care prn
– Airway type, size, and • Reapply ETT tape
position q24h and prn
– Character of insertion
site
• Provide trach care
and replace inner
– Date airway inserted
cannula q12h and
– Pulmonary assessment
prn
• Inspection
• Palpation • Monitor for
• Percussion complications
• Auscultation • Suction as needed
• Wean and extubate


Nursing Care of the Mechanically
Ventilated Patient
• Pulmonary assessment is perhaps never as
important as it is in the mechanically ventilated
patient.
• These patients require frequent reassessments
on a schedule and on an “as needed” basis.
• Further assessments can be documented in
Protouch under “Reassessments”.


Nursing Assessment
Components: Breath Sounds
• Breath sounds should be assessed at least
every four hours, and more frequently as
needed.
• Both the anterior and the posterior chest
need to be auscultated bilaterally.
• Clearly document any adventitious breath
sounds that are heard, and report significant
alterations to the Physician.


Nursing Assessment Components:
Rate & Volume
• Make sure to assess and document the
patient’s spontaneous respiratory rate and
tidal volume. This information tells you a lot
about the patient’s respiratory functioning.
• Note any changes in this area, and report
significant findings to the patient’s Physician.


Anatomy


Nursing Assessment
Components:Pulse Oximetry
• Pulse oximetry is a useful monitoring tool, but
provides minimal indication of the patient’s
ventilatory or acid-base status.
• Readings can be affected by abnormal
hemoglobins, vascular dyes, and poor perfusion.
• Plus, the machine can’t distinguish between
normal and abnormal hemoglobins, so a patient
with carbon monoxide poisoning could have a
pulse ox reading of 100%.


• Monitoring:
Continuous and Periodic monitoring of

• Vital parameters such as temperature,SpO2, Pulse,
BP,ECG pattern, breath rate etc.

• Ventilator settings: All settings should be
recorded – as per the
doctors order

• Sensorium
• Intake and output
• Level of comfort
• Arterial blood gases – p r n or twice daily

Remember that
• PaO2 depends on FiO2 & PEEP
• PaCO2 depends on Tidal volume & Rate

In ICU, our primary aim is
• To get a PaO2 of 60-90 mmHg &
• PaCO2 of 30-50mmHg.
• Ensure that plateau inspiratory pressure
does not exceed 30cm of H2O ( risk of VALI –
Ventilator Associated Lung Injury)


ABG - Setting
• pH = 7.16 • A VT = 500
• PaCO2 = 81 mmHg • B RR = 12
• HCO3 = 28 mEq/L • C O2 = 50
• PaO2 = 36 mmHg • D PEEP = 5
• SaO2 = 69%


PH=7.49
PaCO2=30 ‫ﻣﯿﻠﯽ ﻣﺘﺮ ﺟﯿﻮه‬
BE= +0.5 ‫ﻣﯿﻠﯽ اﮐﯽ واﻻن در ﻟﯿﺘﺮ‬
HCO3 = 22.6 ‫ﻣﯿﻠﯽ اﮐﯽ واﻻن درﻟﯿﺘﺮ‬
PaO2= 72 ‫ﻣﯿﻠﯽ ﻣﺘﺮ ﺟﯿﻮه‬
Sao2=95.8%


PH=7.46
BE=+13 ‫ﻣﯿﻠﯽ اﮐﯽ واﻻن در ﻟﯿﺘﺮ‬
-
HCO3 =40‫ﻣﯿﻠﯽ اﮐﯽ واﻻن درﻟﯿﺘﺮ‬
PaO2=58 ‫ﻣﯿﻠﯽ ﻣﺘﺮ ﺟﯿﻮه‬
Sao2=90.7%


PH=7.25
BE=-6.5 ‫ﻣﯿﻠﯽ اﮐﯽ واﻻن در ﻟﯿﺘﺮ‬
-
HCO3 =20.6‫ﻣﯿﻠﯽ اﮐﯽ واﻻن درﻟﯿﺘﺮ‬
PaO2=56 ‫ﻣﯿﻠﯽ ﻣﺘﺮ ﺟﯿﻮه‬
Sao2=83.4%


PH=7.٢٨
PaCO2=۶٩ ‫ﻣﯿﻠﯽ ﻣﺘﺮ ﺟﯿﻮه‬
BE=+٢.۵ ‫ﻣﯿﻠﯽ اﮐﯽ واﻻن در ﻟﯿﺘﺮ‬
HCO3 =٣٢‫ﻣﯿﻠﯽ اﮐﯽ واﻻن درﻟﯿﺘﺮ‬
PaO2= 49 ‫ﻣﯿﻠﯽ ﻣﺘﺮ ﺟﯿﻮه‬
Sao2=٧٨%


ABG - Setting
• pH = 7.4 • A VT = 400
• PaCO2 = 50 mmHg • B RR = 13
• HCO3 = 30 mEq/L • C O2 = 44
• PaO2 = 60 mmHg • D PEEP = 11
• SaO2 = 90%
• Pplat = 33 cmH2O


Nebulisation

• It is advisable to put all the patients on
bronchodilators on regular basis.

• Nebulise as per the doctor’s order


Pain related to Mechanical
ventilation & ET tube placement

• Positioning of the tube, pulling of
the circuits, in appropriate flow
rates, sensitivity setting that
requires patient’s greater efforts,
etc.
• Prevent all the above as much as
possible.


Eye & Mouth care
• For unconscious patients
eyes are kept closed by
taping.

• Goggles can also be used.

• Regular & proper mouth
care should be given.


Monitoring for infection
• Colour, consistency, and amount of the
sputum / secretions with each
suctioning should be observed.

• Fever and other parameters have to
closely observed for any other
infection. (central line, etc)


Nutrition:
• Enteral nutrition to support the
patient’s metabolic needs and defend
against infection.
• Avoid high carbohydrate diet during
weaning.

NG tube if necessary – relieves gastric
distension and prevents aspiration.


Nutritional support

Important :
Skeletal muscle weakness  Difficult weaning

Hypophosphatemia  Poor contractility
diaphragm that accompany with ARF & ARDS

Caloric in take  (Hyper alimentation)  CO2
Production   Necessitating VA 


Stress gastric ulcer
• Very common in critically ill patients
• Send stools for occult blood and
gastric juice for pH estimation
• Auscultate bowel movements
• Sedation and antacids adequately.


Positioning:

• Place the patient in low or semi
Fowler’s position to improve comfort
and facilitate respiration.


In the absence of medical contraindication(s).

CDC Guideline for Prevention of Healthcare Associated Pneumonias, 2003
Drakulovic et al, Lancet, 1999,354:1851


Signs and Symptoms of Acute
Hypoxia
• Tachycardia • Anxiety
• Tachypnea • Arrhythmias
• Dyspnea • Decreased PaO2
• Euphoria • HTN
• Stupor • Impaired judgment
• Tremors • Blurred Vision
• Hyperreactive • Coma/Death
reflexes


Oxygen Delivery Methods
Mechanical Ventilation
• Allows administration of 100% oxygen

• Controls breathing pattern for patients who are
unable to maintain adequate ventilation

• Is a temporary support that “buys time” for
correcting the primary pathologic process


Hazards of Oxygen Therapy
• Oxygen induced hypoventilation with the
following risk criteria:
– Pts baseline PaCO2 > 50 mmHg
– Baseline O2 saturation < 90%
– With supplemental O2, PaO2 doesn’t exceed 60
mmHg
• Absorption atelectasis with the following risk
criteria:
– FiO2 > 50%
– Decreasing alveolar volumes
– Airway obstruction


Signs of Oxygen Toxicity
• Substernal pain • Decreased
• Cough compliance
• Dyspnea • Pulmonary edema
• Anxiety • Atelectasis
• Paresthesia • Decreased vital
• Fatigue capacity
• Pulmonary • Increased shunting
infiltrates (V/Q mismatching)
• Decreased PaO2

Oxygen toxicity

• Try and maintain a SpO2 of > 90% and
PaO2 of 60 – 90 mmHg with minimum
possible FiO2 to prevent O2 toxicity.

• Especially for COPD patients :
Maintain SpO2 of 85 – 90% and PaO2
of 55 – 70 mmHg.


Suction
• Should be done on PRN basis
• Ascultate and assess
• View the chest X-ray
• Determine the need and for effective
suctioning
• Hyperoxygenation & ventilation –
ambu/normal
• Keep strict vigil on the cardiac monitor pulse
oximeter during and soon after suctioning
• If necessary carry out effective chest physio


Nursing Care of the Patient with an
Tracheostomy Tube
• Trach care should be performed at least every shift,
and as needed as ordered by the patient’s Physician.
• The patient should always be pre-oxygenated with
100% oxygen prior to suctioning.
• Saline should not be routinely instilled into the airway.
Saline installation has been shown to increase
infection rates and to cause decreased oxygen levels
for longer periods of time than suctioning without it.


Closed suction systems


Albert, NEJM 1981; Preston, AJM 1981; Tablan, 1994


Oral Cavity
• Suction the oral cavity
• Swab the oral cavity every 4 hours and
PRN to cleanse and maintain oral
mucosal integrity

• Moisturize oral cavity every 4 hours


Oropharyngeal Suctioning

• Suction every 12 hours to remove
secretions from the oropharyngeal
area above the vocal cords.


Brush Teeth
• Brush teeth 2 times per day to remove
dental plaque


Communication:
• If conscious, explain the environment,
procedures, co-operation expected etc.
• Use verbal & non verbal methods
• Use paper & pen if necessary
• Provide calling bell if necessary
• Reassurance and support the patient
during the period of anxiety, frustration
and hopelessness
• Document patient’s emotional
response and any signs of psychosis
• Include family in the care


Teach……
• Co-operation with medical and nursing
interventions
• Certain breathing techniques
• The patient to recognize the importance
of breathing techniques.
• Frequent assessment of consciousness
level, adequate rest etc. are necessary.


Nursing Care of the Ventilator
• Record and document • NEVER use the top of
the following settings per the ventilator as a
unit standards
desk
– Rate (mech and spont)
– FiO2 • NEVER sit liquids on
– Tidal volume (mech & or near the ventilator
spont)
– PS/PEEP/CPAP
• NEVER make
– Peak pressure (PIP) changes to ventilator
– SpO2 settings
• Refer to RT, MD, or
Charge Nurse as
needed


47


Injury during Mechanical Ventilation

• Possibility of ventilator associated lung
injury, baro-trauma, tracheal necrosis
etc have to be detected in time and take
appropriate action.

• Use soft restrainers whenever
necessary.


Alarms
• Never keep alarm system muted
• Never ignore even when you know the
cause for the alarm and may not be
fatal


Weaning
• Assess for readiness to wean.
• Follow a clear cut protocol
• Provide emotional support and decrease the
patient’s fear and anxiety
• Never try weaning at night
• If weaning once failed ( fatigue, sweating,
dyspneic etc..) do not attempt for the next 24-
48 hours.
• Once weaning is successful, switch over to T
piece
• Before extubation, do a leak test and cough
test .
• if the above tests are positive -extubate by
following proper protocol


Methods of Weaning
1- T-piece trial,

2- Continuous Positive Airway Pressure
(CPAP) weaning,

3- Synchronized Intermittent Mandatory
Ventilation (SIMV) weaning,

4- Pressure Support Ventilation (PSV) weaning.


1- T-Piece trial
• It consists of removing the patient from the
ventilator and having him / her breathe
spontaneously on a T-tube connected to
oxygen source.

• During T-piece weaning, periods of ventilator
support are alternated with spontaneous
breathing.

• The goal is to progressively increase the
time spent off the ventilator.


2-Synchronized Intermittent Mandatory
Ventilation ( SIMV) Weaning

• SIMV is the most common method of
weaning.

• It consists of gradually decreasing the
number of breaths delivered by the ventilator
to allow the patient to increase number of
spontaneous breaths


3-Continuous Positive Airway Pressure (
CPAP) Weaning

• When placed on CPAP, the patient does all
the work of breathing without the aid of a
back up rate or tidal volume.

• No mandatory (ventilator-initiated) breaths
are delivered in this mode i.e. all ventilation
is spontaneously initiated by the patient.

• Weaning by gradual decrease in pressure
value


4- Pressure Support Ventilation (PSV)
Weaning
• The patient must initiate all pressure support
breaths.

• During weaning using the PSV mode the level of
pressure support is gradually decreased based on
the patient maintaining an adequate tidal volume (8
to 12 mL/kg) and a respiratory rate of less than 25
breaths/minute.

• PSV weaning is indicated for :-

- Difficult to wean patients
- Small spontaneous tidal volume.


Ventilator Weaning
• Vital Capacity at least 10 – 15 ml/kg
• Tidal Volume > 5 ml/kg
• Resting minute volume <10 L per minute
• ABG’s adequate on < 40% FiO2
• Stable vital signs
• Intact airway protective reflexes (strong cough)
• Absence of dyspnea, neuromuscular fatigue,
pain, diaphoresis, restlessness, use of
accessory muscles


Predictions of the outcome
of weaning
Variables used to predict weaning
success: Gas exchange
• PaO2 of > 60 mmHg with FiO2 of < 0.35
• PaO2/FiO2 ratio of > 200


Weaning success prediction
• Tidal volume > 325 ml
• Tidal volume/BW > 4 ml/kg
• Dynamic Compliance > 22 ml/cmH2O
• Static compliance > 33 ml/cmH2O
• Rapid shallow breathing index < 105
breaths/min/L


Rapid Shallow Breathing Index(RSBI)

RSBI<105

In spontaneous breathing
or CPAP mod PSV=5-7cmH2o

Respiratory(f)/Tidal volume(VT)


Extubation Procedure
• Explain procedure to patient
• RT must be at bedside
• Wash your hands
• Suction airway and oropharynx for pooled
secretions (prevents aspiration of secretions
atop balloon)
• Place a towel on patient’s chest
• Assure new oxygen setup is ready to use
• Deflate cuff and remove tube instructing
patient to cough as tube is removed
• Apply supplemental oxygen
• Monitor pt for distress (stridor, coughing,
anxiety)


Complications of Mechanical
Ventilation
• One of the reasons for such a frequent and
thorough assessment of the pulmonary
system while patients are being mechanically
ventilated is due to the many complications
that can occur with the use of mechanical
ventilation.
• Thorough assessments can lead to the early
discovery of potential complications, heading
off more serious complications later.


Complications of Mechanical
Ventilation
• Positive Pressure Ventilation:
 can cause:
hypotension
decreased venous return
decreased cardiac output
 Other complications:
pneumothorax
subcutaneous emphysema
air embolus
localized pulmonary hyperinflation
nosocomial infections
increased intracranial pressure (cerebral edema)


Nursing care in mechanical ventilation

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