WORKPLACE NURSES LLC
Critical Care Tips
Airway & Respiratory Distress
Early signs and symptoms:
Tachycardia Tachypnea Hypertension Use of Accessory Muscles
Decreased Levels of Consciousness Decreased Oxyhemoglobin Saturation (SPO2)
Circum-oral Cyanosis Paleness to nailbeds Complaint of Shortness of Breath
Late signs and symptoms:
Loss of respiration
Airway Management Techniques
Canula - effectively delivers up to 55% oxygen. Maximum flow rate is 6 Liters per
FIO2 calculation: FIO2 =( Flow Rate (in LPM) * 4
) + 21%
Mask - similar to Nasal canula
Mask - flow rate and FIO2 determined by venturi device inserted in Oxygen supply line.
Mask – delivers up to 100% oxygen based upon reservoir
in supply line.
ADVANCED AIRWAY DEVICES
Tube (Intubation ) - Airway of Choice in unconscious patients without a gag reflex.
Provides easy access for mechanical ventilation and management of airway secretions.
Disadvantage is that advanced training is required to place ET tubes.
Mask Airway – provides indirect airway management, protects airway from oral
secretions. Is easily used in pre-hospital situations.
Esophageal Combitube – provides airway management and the ability to manage airway secretions.
VENTILATOR WEANING PARAMETERS
- Assess level of sedation and medications administered over the last 6 hours prior to weaning attempt.
- Assess for signs and symptoms of adequate ventilation.
Stable PCO2, symmetrical
chest movement, absence of dyspnea, headache, crackles or rales, stable level of consciousness and orientation, stable blood
pressure & hemodynamics, cardiac rate & rhythm.
- Assess for signs and symptoms of adequate oxygenation within desired limits for patient.
PO2, respiratory rate within normal limits (generally <24), stable level of consciousness and orientation, absence of dyspnea
or central cyanosis, stable blood pressure, stable heart rate and rhythm.
- Assess the patient’s breathing pattern. An abnormal breathing
pattern may indicate that the patient is not ready to be weaned.
for absence of accessory muscle use, tracheal tug, respiratory alternans and respiratory muscle paradox.
5. Assess arterial blood gases on an FIO2 of 40% or less.
for pH >7.30 or <7.50, PO2 >60 and PCO2 >30 & <50
6. Assess chest x-ray for proper tube placement, absence of atelectasis, pneumonia or pulmonary edema.
Assess for end of ET tube on CXR 2 cm above carina
7. Note current ventilator settings and compare with MD orders.
8. Measure Respiratory parameters
Vital Capacity (VC)
Vital Capacity is the patient’s ability to take deep breaths and cough. Must be at least 10cc/kg
of body weight
Negative Inspiratory Force (NIF) 4 times
NIF evaluates the patient’’s ability to generate sufficient intrathoracic pressures for deep breathing
and airway clearance. Must be > -20 cm H2O.
Minute Volume (Ve) Measure for one full minute
Minute volume is a proxy indicator of the work of breathing. If minute volume is high, the work of breathing is
excessive and the patient will fatigue with spontaneous breathing.
Must be >10 L/min.
Tidal Volume (Vt)
Tidal Volume is a good indicator of the patient’s strength. Patient should also be able to lift head up
off of the bed or pillow for 5 seconds. Divide the minute volume by the respiratory rate
to determine the average spontaneous tidal volume.
Vt should be > 5ml/kg.
SIMV – Spontaneous Intermittent Mandatory Ventilation
Spontaneous breaths + preset number of machine breaths.
CMV – Continuous Mandatory Ventilation
Use when patient’s
respiratory rate is greater than 20 breaths per minute.
CMV rate must be higher
than mastery rate if patient is on a rate of 8 or less
Ventilator cannot lock patient’s
spontaneous breaths out.
Can not have pressure support
in this mode. It automatically converts to PEEP
MMV – Minimal Minute Volume or Mandatory Minute Volume Ventilator monitors the patient’s minute
volume and gives support only when the preset volume level is not attained.
Post-op patients can wean
Set rate and tidal volume
Set reasonable high rate
alarm (except when patient has a high rate and low volume)
There is usually a delay
when initiating this mode due to ventilator’s need to sense the patient’s intrinsic respiratory rate.
May have Pressure Support
CPAP – Constant Positive Airway Pressure – a residual pressure greater than atmospheric pressure at
the end of expiration on spontaneous breaths. Increases PO2 with a lower FIO2.
PEEP – POSITIVE END EXPIRATORY PRESSURE
remaining in ventilator circuit to hold alveoli open between breaths. Generally
initiated in 5mmHg
PRESSURE SUPPORT –
Usually start at 10
Functional with every spontaneous
Decreases work of breathing
Pressure support is set
as sum of PEEP and Pressure support
TROUBLE SHOOTING VENTILATOR -
D = Displacement- dislodgement of tube, check for tube placement
O = Obstruction – mucus plugs, kinked tubing, mechanical obstructions
P = Pneumothorax – check breath sounds and chest x-rays
E = Equipment Failure – disconnect from ventilator and manually with bag-mask
valve. If able to easily ventilate patient, suspect equipment failure and replace ventilator.
Weaning is successful if:
remain within acceptable range. PCO2 <50, PO2
> 65,pH >7.32,
status is stable.
Awake and alert, able to understand and follow commands.
is adequate to maintain respiration independently for no less than 30 minutes. Strength equals Vt > 5ml/kg, Ve < 10
l/min, VC >10 – 15 ml/kg, NIF > -20 cm H20 able to lift head > 5 seconds, respiratory rate < 25 breaths/min.
remains free of signs of respiratory distress as follow:
Increased respiratory rate
Poor quality of voice and ineffective
Decreased level of consciousness
Unstable vital signs
Ineffective airway clearance
Signs of laryngeal edema or spasm
DEFINING CHARACTERISTICS OF DYSFUNCTIONAL VENTILATORY WEANING RESPONSE
· Slight increase in respiratory rate from baseline
· Expressed feelings of increased oxygen need, breathing discomfort,
· Inquiries about possible machine dysfunction
· Increased focus or concentration on breathing
MODERATE: The last 6 digits together
may indicate a failure to wean.
Slight increase in blood pressure
<= 20 mmHg over baseline
Slight increase in heart rate <
=20 beats per minute over baseline
Increase in respiratory rate <=
to 5 beats per minute over baseline
Wide-eyed look (eyewidening)
ü Decreased air entry heard on auscultation
ü Slight respiratory accessory muscle use
ü Skin color changes: pale, slight cyanosis
ü Inability to respond to coaching
ü Inability to cooperate
ü These items together may indicate failure to wean and
may require a return to previous settings or a reintubation of a previously extubated
patient. After one hour reevaluate the patient to determine if settings need tobe changed. Consult a physician to determine
SEVERE: ABORT any attempt to wean patient! Immediately call a physician for
Ø Significant deterioration in ABGs from patient’s
Ø Increase in blood pressure > 20 mmHg from baseline
Ø Increase in heart rate > 20 beats per minute from baseline
Ø Significant increase in respiratory rate from baseline
Ø Shallow, gasping breaths
Ø Adventitious breath sounds
Ø Full respiratory accessory muscle use
Ø Paradoxical abdominal breathing
Ø Uncoordinated breathing with the ventilator
Ø Profuse diaphoresis
Ø Decreased level of consciousness