● A tube is inserted through

● Mouth intubation is the

the client’s nose or mouth
easiest and quickest form of
into the trachea. This allows
INDICATIONS intubation and is often
for emergency
performed in the emergency
airway management of the
department.
client.

● Nasal intubation is
performed when the client
has facial or oral trauma. This
route is not used if the client
has a clotting problem.
PLACEMENT

● Intubation is typically performed by a nurse anesthetist, anesthesiologist, or

pulmonologist.

● A chest x‐ray verifies correct placement of the endotracheal (ET) tube.

● ET tubes can be cuffed or uncuffed. The cuff on the tracheal end of an ET tube is
inflated to ensure proper placement and the formation of a seal between the
cuff and the tracheal wall. This prevents air from leaking around the ET tube.

● The seal ensures that an adequate amount of tidal volume is delivered by the
mechanical ventilator when attached to the external end of the ET tube.

● The client is unable to talk when the cuff is inflated.

 ● Have resuscitation ● Ensure the intubation
equipment to include a attempts last no longer
NURSING ACTIONS manual resuscitation bag than 30 seconds and then
with a face mask at the reoxygenate before another
bedside at all times. attempt to intubate.

● Auscultate for breath

● Monitor vital signs, and ● Observe for symmetric
sounds bilaterally after
check tube placement. chest movement.
intubation.

● Stabilize the endotracheal ● Monitor for hypoxemia,

tube with a tube holding dysrhythmias, and
device or secure with tape. aspiration.
Mechanical ventilation

Mechanical ventilation provides

breathing support until lung function is
restored, delivering warm (body
temperature 37° C [98.6° F]), 100%
humidified oxygen at FiO2 levels
between 21% to 100%.
Mechanical Ventilator
a positive or negative-pressure breathing device that supports ventilation and
oxygenation for a prolonged period of time
Indications
- continuous decrease in oxygenation (PaO2) - <55mmhg
- increase in arterial CO2 levels - >50mmhg
- persistent acidosis (decreased pH) - < 7.32
- conditions that lead to respiratory failure
- apnea that is not readily reversible
• Types:
• Positive-Pressure
Ventilators
• inflate the lungs by
exerting positive pressure
on the airway, pushing air
in, similar to a bellows
mechanism, and forcing the
alveoli to expand
during inspiration​
• Noninvasive Positive-Pressure Ventilation (NIPPV)
• CPAP –Continuous Positive Airway Pressure
• BiPAP – Bilevel Positive Airway Pressure
• a method of positive-pressure ventilation that can be given via facemasks that cover the
nose and mouth, nasal masks, or other oral or nasal devices such as the nasal pillow (a
small nasal cannula that seals around the nares to maintain the prescribed pressure)
• it eliminates the need for endotracheal intubation or tracheostomy and decreases the
risk of nosocomial infections such as pneumonia
Indication:

acute or chronic respiratory failure

acute pulmonary edema

COPD

chronic heart failure

sleep-related breathing disorder e.g. OSA

Ventilator Modes:
refers to how breaths are delivered to the patient
A/C mode – Assist- control mode
Provides full ventilator support by delivering a preset tidal volume
and respiratory rate
SIMV – synchronized intermittent mandatory ventilation
delivers a preset tidal volume and number of breaths per minute
Between ventilator-delivered breaths, the patient can breathe
spontaneously with no assistance from the ventilator on those
extra breaths = Because the ventilator senses patient breathing
efforts and does not initiate a breath in opposition to the patient’s
efforts fighting the ventilator is reduced
Pressure support ventilation
applies a pressure plateau to the airway throughout the patient
triggered inspiration
• Ventilators setting:
• tidal volume (6-10ml/kg or 4-8ml/kg for patients with ARDS)
• Mode
• FIO2
• Rate
• PEEP if applicable
• Peak inspiratory pressure (PIP) – (Normal – 15-20cmH2O)
• Increased = increased airway resistanceor decrease compliance
 - 2 important b. interpretation
Nursing a. pulmonary
general nursing of ABG
Interventions: auscultation
interventions: measurements

- Promote - Promote
- Enhance Gas - Prevent Trauma
Effective Airway Optimal Level of
Exchange and Infection
Clearance Mobility

- Promote - Monitor and

- Promote Coping
Optimal Manage Potential
Ability
Communication Complications
• FiO2: Percentage of oxygen in the air
mixture that is delivered to the patient.
Flow: Speed in liters per minute at which
the ventilator delivers breaths.
• Frequency (Back Up Rate) • the number
of breaths per minute that is intended to
provide eucapneic ventilation (PaCO2 at
patient's normal) • The initial frequency is
usually set between 12 and 16/min. •
Frequencies of 20/min or higher are
associated with auto-PEEP and should be
avoided.
• Tidal volume is the amount of air that
moves in or out of the lungs with each
respiratory cycle. It measures around 500
mL in an average healthy adult male and
approximately 400 mL in a healthy female. It
is a vital clinical parameter that allows for
proper ventilation to take place
NEW FIO2=0.42XBW-103XFIO2
UPON ABG/
PO2 ON ABG
FORMULA FOR FIO2
 ● Positive-pressure ventilators
deliver air to the lungs under
pressure throughout inspiration
◯ Forced/enhanced lung
and/or expiration to keep the Benefits include the following.
expansion
alveoli open during inspiration and
to prevent alveolar collapse during
expiration.

◯ Improved gas exchange

◯ Decreased work of breathing
(oxygenation)
CONSIDERATIONS PREPARATION OF THE CLIENT

● Explain the procedure to the client.

● Establish a method for the client to communicate,

such as asking yes/no questions, providing writing
materials, using a dry-erase and/or picture
communication board, or lip reading.
ONGOING CARE

● Maintain a patent airway.

◯ Assess the position and placement of tube.

◯ Document tube placement in centimeters at the client’s

teeth or lips.
◯ Use two staff members for repositioning and to resecuring
the tube.
◯ Apply protective barriers (soft wrist restraints) according
to hospital protocol to prevent self-extubation.
◯ Use caution when moving the client.
◯ Suction oral and tracheal secretions to maintain tube
patency.

◯ Support ventilator tubing to prevent mucosal erosion and

displacement.

◯ Have a resuscitation bag with a face mask available at the

bedside at all times in case of ventilator malfunction or
accidental extubation.
● Assess respiratory status every 1 to 2 hr: breath
sounds equal bilaterally, presence of reduced or absent
breath sounds, respiratory effort, or spontaneous breaths.
● Suction the tracheal tube to clear secretions from the
airway.
● Monitor and document ventilator settings hourly.

◯ Rate, FiO2, and tidal volume

◯ Mode of ventilation

◯ Use of adjuncts (PEEP, CPAP)

◯ Plateau or peak inspiratory pressure (PIP)

◯ Alarm settings
Monitor ventilator alarms, which signal if the client is not receiving the
correct ventilation.

◯ Never turn off ventilator alarms.

◯ There are three types of ventilator alarms.

■ Volume (low pressure) alarms indicate a low exhaled volume due to a

disconnection, cuff leak, and/or tube displacement.

■ Pressure (high pressure) alarms indicate excess secretions, client biting

the tubing, kinks in the tubing, client coughing, pulmonary
edema, bronchospasm, or pneumothorax.
■ Apnea alarms indicate that the ventilator does not detect
spontaneous respiration in a preset time period.
● Maintain adequate (but not excessive) volume in
the cuff of the endotracheal tube.

◯ Assess the cuff pressure at least every 8 hr.

Maintain the cuff pressure below 20 mm Hg to
reduce the risk of tracheal necrosis.

◯ Assess for an air leak around the cuff (client

speaking, air hissing, or decreasing SaO2).
Inadequate cuff pressure can result in inadequate
oxygenation and/or accidental extubation.
Administer medications as
prescribed.

◯ Analgesics: morphine and

fentanyl

◯ Sedatives: propofol, diazepam,

lorazepam, midazolam, and
haloperidol
◯ Ulcer-preventing
agents: famotidine
or lansoprazole​​
◯ Antibiotics for
established infections​​
● Reposition the oral endotracheal tube every 24 hr or
according to protocol. Assess for skin breakdown.

◯ Older adult clients have fragile skin and are

more prone to skin and mucous membrane breakdown.

Older adult clients have decreased oral secretions.

They require frequent, gentle skin and oral care.

● Provide adequate nutrition.

◯ Assess gastrointestinal
functioning every 8 hr.
◯ Monitor bowel habits.

◯ Administer enteral or
parenteral feedings as prescribed.
● Continually monitor the client during the weaning process and
watch for signs of weaning intolerance.
◯ Respirations greater than 30/min or less than 8/min

◯ Blood pressure or heart rate changes more than 20% of

baseline
◯ SaO2 less than 90%

◯ Dysrhythmias, elevated ST segment

◯ Significant decrease in tidal volume

◯ Labored respirations, increased use of accessory muscles, and

diaphoresis
◯ Restlessness, anxiety, and decreased level of consciousness
● Have a manual resuscitation bag with a face mask and oxygen
readily available at the client’s bedside.

● Have reintubation equipment at bedside.

● Suction the oropharynx and trachea.

● Deflate the cuff on the endotracheal tube, and remove the tube
during peak inspiration.

● Following extubation, monitor for signs of respiratory distress or

airway obstruction, such as ineffective cough, dyspnea, and stridor.

● Assess SpO2 and vital signs every 5 min.

● Encourage coughing, deep breathing, and use of the incentive

spirometer.
● Reposition the client to promote mobility of
secretions.

● Older adult clients have decreased respiratory

muscle strength and chest wall compliance, which
makes them more susceptible to aspiration,
atelectasis, and pulmonary infections. Older adult
clients require more frequent position changes to
promote mobility of secretions.
COMPLICATIONS

Trauma

Barotrauma (damage to the lungs by positive

pressure) can occur due to a pneumothorax,
subcutaneous emphysema or pneumomediastinum.

Volutrauma (damage to the lungs by volume

delivered from one lung to the other).
Fluid retention

Fluid retention in clients who are receiving

mechanical ventilation is due to decreased cardiac
output, activation of renin-angiotensin-aldosterone
system, and/or ventilator humidification.

NURSING ACTIONS: Monitor intake and output,

weight, breath sounds, and endotracheal secretions.
Oxygen toxicity

Oxygen toxicity can result from high concentrations

of oxygen (typically greater than 50%), long durations
of oxygen therapy (typically more than 24 to 48 hr),
and/or the client’s degree of lung disease.

NURSING ACTIONS: Monitor for fatigue, restlessness,

severe dyspnea, tachycardia, tachypnea, crackles,
and cyanosis.
Hemodynamic compromise

Mechanical ventilation has a risk of increased thoracic

pressure (positive pressure), which can result in
decreased venous return.

NURSING ACTIONS: Monitor for tachycardia,

hypotension, urine output less than or equal to 30
mL/hr, cool, clammy extremities, decreased peripheral
pulses, and a decreased level of consciousness.
Aspiration

Keep the head of the bed elevated 30° at

all times to decrease the risk of aspiration.

NURSING ACTIONS: Check residuals every 4

hr if the client is receiving enteral feedings
to decrease the risk of aspiration.
Gastrointestinal ulceration (stress ulcer)

Gastric ulcers can be evident in clients

receiving mechanical ventilation.
NURSING ACTIONS

● Monitor gastrointestinal drainage and

stools foroccult blood.
● Administer ulcer prevention medications
(sucralfate and histamine2 blockers).