Kim Fuzzard Clinical Educator Postgraduate Critical Care Nursing Course
Overview of fundamental safety for the intubated, mechanically ventilated adult patient in the Emergency Department. Launch new BH iLearn module Advanced Life Support for Adults ‘Airway & Breathing’
Endotracheal Intubation ◦ plan and prepare ◦ procedure ◦ tube safety Mechanical Ventilation ◦ settings ◦ attachment ◦ surveillance & monitoring ◦ issues for ED clinicians Photo: S. Makepeace
Characteristics of patients receiving invasive mechanical ventilation in Aust ED’s: Altered mental state 59% Cardiac arrest 14% Intrapulmonary respiratory failure10% Other (sepsis, trauma, heart failure) 14% Airway compromise 3% Ref: Rose & Gerdtz (2009) Sites in study included Bendigo, Alfred, Angliss, Bairnsdale, Ballarat, Box Hill, East Wimmera, Goulburn V, Mildura, Northern, RMH, StV’s and hosps in other states also
Endotracheal intubation and invasive mechanical ventilation are required for the resuscitation of a range of patient presentations, however Rose & Gerdtz (2007) Care requires specialist expertise to avoid significant risks and ensure patient safety. CENA (2013)
Ref: RTIC Severn Emergency induction checklist. Available:
Airway and Breathing
Creates a seal Cuff does not hold the ETT insitu!
Regular observation of length at lip 1:1 care CENA (2013) Photos: Fuzzard, K. (2004)
Hollister TM Anchor Fast Oral Endotracheal Tube Holder
Meticulous preparation for insertion Safe insertion Confirm placement in airway- clinical & CXR Monitor end-tidal CO2 Monitor & maintain lip level Keep the ETT secure Provide constant1:1 care
Settings must be based on current scientific principles Individualised for the patient’s pathophysiology Photo: Drager Medical
The following are commonly used in Australian ED’s and may be initially suitable for a large proportion of patients, prior to reassessment, review and potential alteration of settings. Mode: SIMV (Volume Control) Breath rate: 12-14bpm Tidal volume: 6-8mL/kg Pressure support: 10cmH2O PEEP: 5cmH2O FiO2: 1.0= 100% Ref: Rose & Gerdtz (2009)
ETT Closed suction device HME ◦ (heat/moisture exchanger/filter) Continuous capnography Ventilator circuit
◦ ETT length at lip & security ◦ Respiratory Observations of ventilator Observations of patient Incl. ETCO2 ◦ Cardiovascular ◦ Neurological ◦ Comprehensive patient assessment ◦ Vigilant observation ◦ Photo: S. Evans
Patient re/assessment Vent alarm setting & troubleshooting CXR analysis ABG analysis Titration of ventilation Careful positioning Mouth, eye, pressure care Psychological support pt & family Weaning of ventilation Extubation
There is minimal use of pressure controlled modes despite potential advantages particularly for patients with intrapulmonary disease: ◦ eg. Reduction in peak airway pressures
Evidence – ED nurses have active involvement in decision-making & high levels of responsibility & autonomy Rose & Gerdtz (2009) Minimum standard- an evidence based competency education program BUT Optimum- relevant postgrad qualification CENA (2013) ◦ (Bendigo Health) Potential issue: ◦ Lack of consistent exposure to ventilated pts Rose & Gerdtz (2009)
ED is not designed to provide ongoing care of the mechanically ventilated pt Marshall & Hodge (2011) Rose & Gerdtz (2009) Transfer out to ICU asap when safe to do so CENA (2013), Marshall & Hodge (2011) Rose & Gerdtz (2009) Transporting pts exposes them to additional risks & requires highly trained & skilled clinicians ACEM (2013)
Ventilation modes & parameters Alarm setting Sedation Ongoing care & weaning Ventilation of special pt populations ◦ eg. raised ICP, lung disease Advanced ventilation strategies Patient transport And much more….
“Mechanical ventilation is a complex and invasive intervention, which can have serious implications if not properly applied or resourced.” CENA (2013)
Rose & Gerdtz (2009) Use of invasive mechanical ventilation in Australian emergency departments. EMA 21, Rose & Gerdtz (2009) Mechanical Ventilation in Australian emergency departments: Survey of workforce profile, nursing role responsibility and education. AENJ 12:38-43 Rose & Gerdtz (2007) Invasive ventilation in the emergency department. Part 1: What nurses need to know. AENJ 10:21-25 Rose & Gerdtz (2007) Invasive ventilation in the emergency department. Part 2: Implications for patient safety. AENJ 10:26-29 CENA (2013) Position Statement: Mechanical ventilation [Accessed online 14/08/ pdf] CENA (2013) Position Statement: Mechanical ventilation [Accessed online 14/08/ pdf RTIC Severn Emergency induction checklist. Available: Bendigo Health (2014) ‘Airway & Breathing’ ALS e-learning module. Marshall & Hodge (2011) ‘Respiratory emergencies’ in Emergency & trauma care for nurses & paramedics. Eds: Curtis & Ramsden. Mosby: Sydney. ACEM (2013) Guidelines for transport of critically ill patients. [Accessed online 14/08/ f194c3/P03-Guidelines-for-Transport-of-Critically-Ill-Pat.aspx ACEM (2013) Guidelines for transport of critically ill patients. [Accessed online 14/08/ f194c3/P03-Guidelines-for-Transport-of-Critically-Ill-Pat.aspx