2. O 2 RESPIRATORY TO BREATHE OR NOT TO BREATHE, THAT IS OUR QUESTION! Hope Knight BSN, RN

4. Fig 25-1 structures of respiratory tract

5. STRUCTURE OF LUNGS Upper Respiratory Tract Upper Respiratory Tract Lower Respiratory Tract Lower Respiratory Tract Chest Wall Chest Wall Structures of Lower Airways Structures of Lower Airways

6. Fig 25-3 structure of lower airway

7. Fig 25-5 total thickness is less than 1/5000 inch

8. Fig 25-7

9. ARTERIAL BLOOD GASES Normal Values Normal Values PH 7.35 – 7.45 PH 7.35 – 7.45 PaO 2 80-100mm Hg PaO 2 80-100mm Hg PaCO 2 35-45 mm Hg PaCO 2 35-45 mm Hg HCO 3 22-26 mEq/L HCO 3 22-26 mEq/L SaO 2 >95% SaO 2 >95%

10. INTERPRETATION OF ABG ACID BASE Ph PaCO 2 HCO 3 NORMAL7.3535-4522-26 RESP. ACIDOSIS NORMAL RESP.ALKALOSISNORMAL METABOLIC ACIDOSIS NORMAL METABOLIC ALKALOSIS NORMAL

11. Table 25-2 S/S inadequate oxygenation

12. Swan Ganz catheter used to measure Pulmonary Artery Pressure. Elevation seen in Pulmonary disease, pulmonary embolism, pulmonary hypertension, left ventricular failure, MI. Decrease noted in hypovolemia.

13. GERENTOLIGIC DIFFERENCES IN ASSESSMENT

14. CUES TO RESPIRATORY PROBLEMS

15. Pulmonary Function Test measures lung volumes and air flow.

16. Obstructive Sleep Apnea fig 26-4

17. Collaborative Management and Nursing Care for Obstructive Sleep Apnea

18. BIPAP/CPAP MACHINES

19. CLINICAL APPLICATION FOR BIPAP BiPAP is essentially pressure support ventilation with CPAP. The flow of gas switches between a high inspiratory positive airway pressure (IPAP) and a low expiratory positive airway pressure (EPAP). The difference between IPAP and EPAP is the pressure support level and contributes to the total ventilation. BiPAP is essentially pressure support ventilation with CPAP. The flow of gas switches between a high inspiratory positive airway pressure (IPAP) and a low expiratory positive airway pressure (EPAP). The difference between IPAP and EPAP is the pressure support level and contributes to the total ventilation.

20. CONTRAINDICATIONS FOR BIPAP Need for immediate intubation. Need for immediate intubation. Hemodynamic instability. Hemodynamic instability. Uncooperative patient. Uncooperative patient. Facial burns or trauma. Facial burns or trauma. Need for airway protection. Need for airway protection.

21. PULMONARY EMBOLI Thrombi in venous circulation or right side of the heart occlude pulmonary arterial blood flow to parts of lung Thrombi in venous circulation or right side of the heart occlude pulmonary arterial blood flow to parts of lung

23. CLASSIFICATION OF RESPIRATORY FAILURE

24. ACUTE RESPIRATORY FAILURE Hypoxemic Respiratory Hypoxemic Respiratory Ventilation Perfusion (V/Q mismatch) Ventilation Perfusion (V/Q mismatch) Shunt Shunt Diffusion Limitation Diffusion Limitation Alveolar Hypoventilation Alveolar Hypoventilation Hypercapnic Respiratory Failure Hypercapnic Respiratory Failure Airway and alveoli Airway and alveoli Central nervous system Central nervous system Chest Wall Chest Wall Neuromuscular Condition Neuromuscular Condition

25. VENTILATION TO PERSUSION RELATIONSHIPS (V/Q mismatch)

26. DIFFUSION LIMITATION

27. ACUTE RESPIRATORY FAILURE MANIFESTATIONS Develops suddenly or gradually Develops suddenly or gradually Compensatory mechanisms Compensatory mechanisms Mental status changes Mental status changes Tachycardia Tachycardia Mild hypertension Mild hypertension Severe morning headache Severe morning headache Cyanosis (late sign) Cyanosis (late sign)

28. NURSING AND COLLABORATIVE MANAGEMENT Respiratory therapy Respiratory therapy Nasal cannula, simple face mask, venturi mask, positive pressure ventilation, mechanical ventilation Nasal cannula, simple face mask, venturi mask, positive pressure ventilation, mechanical ventilation Mobilization of secretions Mobilization of secretions Positive Pressure Ventilation Positive Pressure Ventilation Nutrition Nutrition Diet – Drug interactions Diet – Drug interactions

30. ARDS Sudden and Progressive form of acute respiratory failure Sudden and Progressive form of acute respiratory failure Mortality is 50% Mortality is 50% Injury or Exudative phase Injury or Exudative phase Reparative or Proliferative Phase Reparative or Proliferative Phase Fibrotic Phase Fibrotic Phase Complications Complications

31. STAGES OF EDEMA FORMATION IN ARDS

32. PHYSIOLOGY OF ARDS

33. PREDISPOSING FACTORS OF ARDS

34. DIAGNOSTIC FINDINGS IN ARDS TABLE 66-8

36. MECHANICAL VENTILATORS Servo type ventilator 7200 type ventilator

37. Care Standards for the Ventilator Patient Normal Saline as a lavage is NOT used routinely during suctioning. Normal Saline as a lavage is NOT used routinely during suctioning. Perform vigorous oral care Q2 hours and PRN. Perform vigorous oral care Q2 hours and PRN. Position patient in a semi-upright position with head of bed elevated 30° to 45° to reduce the possibility of aspiration. Position patient in a semi-upright position with head of bed elevated 30° to 45° to reduce the possibility of aspiration. ALARMS!!! Check the patient! Bag the patient if Sats (Sa02) are low and then check the machine. Always remember, patient first!! ALARMS!!! Check the patient! Bag the patient if Sats (Sa02) are low and then check the machine. Always remember, patient first!!

38. MODES OF VENTILATION - CMV Volume Control Ventilation (CMV, A/C, VC) The clinician sets the tidal volume (Vt) to be delivered at a preset minimum rate. The clinician sets the tidal volume (Vt) to be delivered at a preset minimum rate. Each time the patient initiates a breath with a negative inspiratory effort or flow reaching or exceeding a set threshold, the ventilator delivers an additional breath at the preset Vt. Each time the patient initiates a breath with a negative inspiratory effort or flow reaching or exceeding a set threshold, the ventilator delivers an additional breath at the preset Vt. The patient can increase the ventilator rate, and therefore ventilatory support, on demand. The patient can increase the ventilator rate, and therefore ventilatory support, on demand.

39. MODES OF VENTILATION SIMV Synchronized Intermittent Mandatory Ventilation (SIMV) The clinician sets a Vt for a preset number of breaths each minute. The clinician sets a Vt for a preset number of breaths each minute. Additional breaths initiated by the patient are spontaneous; patient controls Vt and RR. Additional breaths initiated by the patient are spontaneous; patient controls Vt and RR. The synchronization allows the ventilator to deliver the preset machine breaths between the patient’s spontaneous inspiratory efforts. The synchronization allows the ventilator to deliver the preset machine breaths between the patient’s spontaneous inspiratory efforts.

40. Modes of ventilation -- SIMV with PS (Pressure Support) Pressure Support is added to the spontaneous breaths in order to “boost” the patient’s Vt. Pressure Support is added to the spontaneous breaths in order to “boost” the patient’s Vt. Advantages: Advantages: Allows the patient to assume a portion of their ventilatory requirement. Allows the patient to assume a portion of their ventilatory requirement. The negative inspiratory pressure generated by spontaneous breathing leads to increased venous return to the right side of the heart, which may improve cardiac output and cardiovascular function. The negative inspiratory pressure generated by spontaneous breathing leads to increased venous return to the right side of the heart, which may improve cardiac output and cardiovascular function.

41. MODES OF VENTILATION - PCV Pressure Control Ventilation (PCV): Pressure Control Ventilation (PCV): PCV is a time-cycled mode of ventilation that allows limitation of peak inspiratory pressures (PIP). PCV is a time-cycled mode of ventilation that allows limitation of peak inspiratory pressures (PIP). The PIP is set by the clinician and the Vt (tidal volume) and V E (minute ventilation) are a result of changes in the lung compliance or airway resistance. The PIP is set by the clinician and the Vt (tidal volume) and V E (minute ventilation) are a result of changes in the lung compliance or airway resistance.

42. MODES OF VENTILATION – P/S Spontaneous - Pressure Support (PSV or PS) This mode is completely patient controlled -- Patient controls/sets their own respiratory rate, duration of inspiration, gas flow rate, and Vt. This mode is completely patient controlled -- Patient controls/sets their own respiratory rate, duration of inspiration, gas flow rate, and Vt. The machine delivers a preset pressure -- Vt will vary depending on the patient’s lung compliance. The machine delivers a preset pressure -- Vt will vary depending on the patient’s lung compliance. The inspiratory assist is used to overcome the increased resistance and WOB imposed by the disease process, the endotracheal tube (ET), inspiratory valves, and other mechanical aspects of ventilatory support. The inspiratory assist is used to overcome the increased resistance and WOB imposed by the disease process, the endotracheal tube (ET), inspiratory valves, and other mechanical aspects of ventilatory support.

43. MODES OF VENTILATION P/S CONT. Spontaneous - Pressure Support continued The delivered Vt is affected by pulmonary compliance and resistance. The delivered Vt is affected by pulmonary compliance and resistance. The amount of pressure support set during mechanical ventilation is titrated according to the RR and the Vt of the patient. The amount of pressure support set during mechanical ventilation is titrated according to the RR and the Vt of the patient. Advantage: comfort and tolerance the mode offers patients. Reducing the WOB. Advantage: comfort and tolerance the mode offers patients. Reducing the WOB.

44. MODES OF VENTILATION - CPAP CPAP (Continuous Positive Airway Pressure) All breaths are controlled by the patient. All breaths are controlled by the patient. This mode simply delivers FiO 2 and a variable flow with or without a preset inspiratory and/or expiratory pressure. This mode simply delivers FiO 2 and a variable flow with or without a preset inspiratory and/or expiratory pressure.

45. MODES OF VENTILATION - PEEP Positive End Expiratory Pressure- the application and maintenance of pressure above atmospheric at the airway throughout the expiratory phase of positive pressure mechanical ventilation. Positive End Expiratory Pressure- the application and maintenance of pressure above atmospheric at the airway throughout the expiratory phase of positive pressure mechanical ventilation.

46. Physiologic Effects of CPAP & PEEP PEEP/CPAP will reduce sub-atmospheric intrathoracic pressure seen at end- expiration or even change it to positive values. PEEP/CPAP will reduce sub-atmospheric intrathoracic pressure seen at end- expiration or even change it to positive values. This may exert profound effects on the circulation by increasing CVP and decreasing venous return to the heart (preload), thereby decreasing cardiac output. This may exert profound effects on the circulation by increasing CVP and decreasing venous return to the heart (preload), thereby decreasing cardiac output.

47. Weaning from Mechanical Ventilation Assessing for weaning readiness Assessing for weaning readiness Weaning techniques Weaning techniques Causes of weaning failure Causes of weaning failure Weaning protocols Weaning protocols