1. Chapter 10 Airway Management and Ventilatory Support

2. Artificial Airways Establish an airway Protect the airway
Facilitate airway clearance
Facilitate mechanical ventilation

3. Types of Airways Oropharyngeal airway Nasopharyngeal airway
Endotracheal tube
Tracheostomy

4. Oropharyngeal Airway

5. Oropharyngeal Airway (cont.)
Hard plastic device
Inserted through the mouth extending to the pharynx
Prevents the tongue from occluding the airway
Nursing care
Monitor airway patency
Listen to breath sounds
Suction as needed
*Never place an oropharyngeal airway in a conscious patient.

6. Nasopharyngeal Airway

7. Nasopharyngeal Airway (cont.)
Flexible tube inserted nasally and extends to the base of the tongue
Can use in a conscious patient
Useful when frequent nasotracheal suction is needed
Nursing care
Assess the patient’s risk for epistaxis
Assess coagulopathy

8. Endotracheal Tube

9. Endotracheal Tube (cont.)
Semirigid tube inserted nasally or orally and extends into the trachea
Provides airway protection
Used with mechanical ventilation
Inserted by personnel with advanced training
Placement confirmed by auscultation, end-tidal CO2 device, bilateral chest rise, chest x-ray

10. Endotracheal Tube (cont.)
Nursing care
Confirm equipment and suction are working properly.
Preoxygenate the patient for intubation.
Administer medications for intubation.
Provide good oral hygiene.
Reposition the tube from side to side.
Suction when needed.
Note markings on the tube to ensure proper position is maintained.

11. Tracheostomy
Inserted directly into the trachea through a stoma in the neck
Improves patient comfort
Improved ability to communicate
Oral feeding is possible.
Indicated if greater than 3 to 7 days on a ventilator
Facilitates weaning

12. Tracheostomy (cont.) Obturator and extra tracheostomy tube at bedside
Accidental decannulation in the first 7 days may need reintubation before emergency tracheostomy can be done.
After approximately 7 days, a tract is formed and tracheostomy tube can by reinserted into the stoma.
Clean site every 8 to 12 hours.
Replace inner cannula daily following facility policy.
Change tracheal ties as needed.
Suction as needed.

13. Question
Which type of artificial airway can never be used on a conscious person?
A. Tracheostomy
B. Oropharyngeal airway
C. Nasopharyngeal airway
D. Endotracheal

14. Answer B. Oropharyngeal airway
Rationale: An oropharyngeal airway stimulates the gag reflex and can cause vomiting and aspiration.

15. Indications for Suctioning
Visualization of secretions in airway
Crackles, rhonchi, mucus plugs, or coughing
Increase in peak airway pressure
Decrease in tidal volume
Hypoxia

16. Suctioning Oral suctioning
Removal of posterior oropharyngeal secretions
Nasotracheal suctioning
Sterile procedure using flexible red rubber catheter
Passed through nostril to nasopharynx
Endotracheal and tracheostomy suctioning
Inline suction catheters
*Instillation of normal saline to facilitate removal of thick secretions is not recommended.

17. Manual Ventilation Manual Ambu Bag, bag-valve-mask device
Force of squeeze equals tidal volume.
Number of squeezes per minute equals respiratory rate
Force and rate equal the peak flow.
Ensure complete exhalation between breaths.
Observe chest rise.
Monitor for abdominal distention.

18. Question
When using a bag-valve-mask device, the nurse must do all of the following except:
A. Time breaths to coincide with spontaneous breaths
B. Allow time for complete exhalation
C. Squeeze faster to get more air in
D. Observe chest rise to ensure proper ventilations

19. Answer C. Squeeze faster to get more air in
Rationale: Squeezing faster will cause hyperventilation and the patient will not receive air and will cause air trapping in the lungs, which can cause hypotension and lung injury.

20. Mechanical Ventilation
Indicated for respiratory failure
pH <7.25
PaCO2 >50 mm Hg
PaO2 >50 mm Hg
Maintain alveolar ventilation.
Correct hypoxemia.
Correct respiratory acidosis.
Rest ventilatory muscles.
Maximize oxygen transport.

21. Modes of Positive-Pressure Ventilation
Volume ventilation
Preset volume of air delivered with each breath
Pressure ventilation
Preset driving pressure is delivered and sustained throughout the inspiratory phase of ventilation
High-frequency ventilation
Delivers small volume of air at a very fast rate (panting)

22. Lung Injury Risk with Positive-Pressure Ventilation
Barotrauma
Volutrauma
Atelectrauma
Biotrauma
Ventilator-associated lung injury (VALI)
Ventilator-induced lung injury (VILI)

23. Question
Which mode of ventilation delivers a preset volume of air with each breath?
A. Pressure ventilation
B. Volume ventilation
C. CPAP
D. High-frequency ventilation

24. Answer B. Volume ventilation
Rationale: Volume ventilation—a preset volume of air delivered with each breath

25. Ventilator Settings Fraction of inspired oxygen (FiO2)
Percentage of oxygen in the air delivered to the patient (room air is 21%.)
Tidal volume
Amount of air delivered with each breath (5-8 mL/kg of body weight is recommended.)
Respiratory rate
Number of breaths per minute

26. Ventilator Settings (cont.)
Positive end-expiratory pressure (PEEP)
Pressure maintained in the lungs at end expiration
Peak flow
Velocity of gas flow per unit of time expressed as liters per minute
Inspiratory pressure limit (high pressure alarm)
Highest pressure allowed in the ventilator circuit (coughing, secretions, kinked tubing can cause high inspiratory pressures)

27. Ventilator Settings (cont.)
Sensitivity
Controls the amount of patient effort to initiate a breath
Inspiratory:expiratory (I:E) ratio
Normal is 1:2 or 1:3.
Allows time for air to passively exit
An inverse I:E ratio improves oxygenation by allowing longer inspiratory times and more opportunity for gas exchange.

28. Ventilator Modes-Volume Modes
Assist-control (A/C) mode
Respiratory rate and tidal volume are preset.
A preset tidal volume is delivered with each breath (preset and spontaneous breaths).
Synchronized intermittent mandatory ventilation (SIMV) mode
Breaths initiated above the preset rate are at the patient’s own spontaneous tidal volume.

29. Ventilator Modes-Pressure Modes
Maximum peak inspiratory pressure is preset.
Ventilator delivers breath until pressure limit is reached and then stops.
Respiratory rate, inspiratory pressure limit, and I:E ratio are preset not tidal volume.
Tidal volume varies with each breath.

30. Pressure Modes Pressure-controlled ventilation (PCV)
Delivers breaths at a preset pressure limit
Pressure support ventilation (PSV)
Assists spontaneous breaths with preset pressure level
Inverse ratio ventilation (IRV)
Inspiratory time is greater than/equal to expiratory time.
Airway pressure release ventilation (APRV)
High and low pressures are timed during the inspiration.

31. Pressure Modes (cont.) Volume-guaranteed pressure options (VGPO)
Delivers a preset tidal volume by using pressure control mode
Continuous positive airway pressure (CPAP)
Provides pressure throughout respiratory cycle
Noninvasive bilevel positive-pressure (BiPAP)
Delivered through face mask, nasal prongs, or nasal mask
Provides an inspiratory pressure and an expiratory (PEEP) pressure

32. Nursing Care Nasogastric or orogastric Maintain airway
Monitor vital signs, arterial oxygenation saturation, mental status, respiratory status, and arterial blood gases
Monitor ventilator settings and alarms
Suction as needed
Psychosocial support
Nasogastric or orogastric
Check endotracheal tube cuff inflation
Head of the bed elevated 30 degrees
Oral hygiene
Nutritional support
Eye care

33. Question Is the following statement True or False?
BiPAP, CPAP, and PCV are all volume modes of ventilation.

34. Answer
False
Rationale: BiPAP, CPAP, and PCV are all pressure modes of ventilation.

35. Weaning from Mechanical Ventilation
Successful weaning:
Multidisciplinary approach
Standardized weaning protocols
Critical pathways
Wean in the morning
Medicate for comfort
Raise the head of the bed
Support and reassurance

36. Methods of Weaning T-piece trial (flow-by)
Breaths through endotracheal tube without a ventilator
SIMV
Gradually decrease the number of delivered breaths
CPAP
Decreases the patient’s work of breathing
PSV
Progressively decrease the amount of pressure support