Airway and

Ventilation
Management

Learning outcomes
List indications for intubation and
mechanical ventilation
Differentiate between modes of ventilation
and advantages and disadvantages of each
List complications of mechanical
ventilation
Describe nursing assessment and care of
ventilated patient
Discuss methods used for weaning
patients

Indications for intubation

1. Elective: for general anesthesia
2. Urgent:
A. Relive upper airway obstruction
B. Isolate/protect airway
C. For suctioning of tracheobronchial
tree
D. For assisted ventilation

Routes for intubation

Endotracheal
Nasotracheal
Tracheal
1.Tracheostomy-elective
2.Cricoidotomy-urgent

Role of nurse in
endothacheal intubation

1. Manage Airway

Obstructed
lift

Head tilt/chin

Jaw thrust

Role of nurse in
endothacheal intubation
2. Ventilation : bag valve mask
device with self inflating bag

3. Oxygenation with 100% oxygen

Role of nurse in
endothacheal intubation
4. Removal of obstructing foreign
material using suction &
Yankauer

Role of nurse in
endothacheal intubation
5. Insert nasal or oral pharyngeal
airway if necessary (oral airway
used only in unconscious patient
because it can stimulates gagging,
vomiting, laryngospasm if patient
conscious)

Guedel oral airway

Nasal

Role of nurse in
endothacheal intubation
6. Prepare equipment:
A. Face mask and oxygen supply
B. Airway
C. Suctioning equipment
D. Laryngoscope
E. Lubricant
F. Malleable wire guide or
introducer
G. Magill forceps

Role of nurse in
endothacheal intubation
7. Assist with procedure:
A. Ventilate and oxygenate (allow1530 seconds for intubation)
B. Monitor vital signs
C. Suction when necessary
D. Provide cricoid pressure if
requested (press below Adams apple,
will push trachea back and collapse
esophagus making intubation easier)

Role of nurse in
endothacheal intubation

7. Auscultate over lung and air fields

8. Inflate cuff of ET or NT tube

A. Ensure cuff pressure does not exceed

20mmHgit can cause tissue death and
fistula formation if higher
B. If lower than 15mmHg increased risk of
aspiration.

9. Secure ET tube
10.Follow up Chest X ray
A. ET tube at front teeth between 19-23cm in
adult
B. On X ray should be 2cm above carina

Position of ET tube

Endotracheal tube
position

Indications for Mechanical

Ventilation
A. Inability to maintain adequate
ventilation (ability to remove CO2)
-

PaCO2 > 55mmHg and pH < 7.25

criterion for mechanical ventilation

B. Inability to maintain adequate

oxygenation (hypoxemia)
-

Patient may have normal PaCO2 and low

PaPO2
O2 supplement may help
PaO2 < 50mmHg on FiO2 > 0.5 criterion
for mechanical ventilation

C. Work of breathing greater than

patient can maintain

Types of ventilation
1. Non-invasive positive pressure
ventilation NIPSV

2. Mechanical ventilation

Ventilators

Ventilator tubing set up

Ventilatory modes
CMVcontrolled mechanical
ventilation

Disadvantages of CMV

IMV & SIMV

Mandatory breath at preset VT
and rate
Patient can breath above rate
without assistance from
ventilator
Difference between IMV an
SIMV

IMV & SIMV

Advantages & disadvantages of

SIMV

Pressure support ventilationPSV

A pressure assisted mechanical
ventilation helping patient with
his own efforts
Instead of selecting VT we select
positive airway pressure
May use for weaning or with
SIMV

Advantage & disadvantages of

PSV

Pressure controlled
ventilation- PCV
Mechanical inhalation phase is
pressure limited to prevent
trauma to lungs
Can have longer inspiration than
expiration (I : E ratio up to 4:1)

Advantages and disadvantages of

PCV

Positive end expiratory

pressure PEEP
Airway pressure maintained in
lungs after end of exhalation
Keeps alveoli open increasing
area of gas exchange
May reduce cardiac output,
increase cerebral pressure, risk
of pneumothorax incresed

Continuous Positive Airway Pressure

CPAP
Patient breathes independently through
ventilator circuit, or with CPAP mask
No VT is present
Only FIO2 and gas pressure at endexhalation are controlled
Term CPAP used when the patient
breathing spontaneously
Used most often with patients requiring
intubation but not ventilatory support
May also be used as last stage of
weaning in select patients
CPAP and non-invasive positive airway
pressure masks used for sleep apnea Rx

Complications of mechanical
ventilation
1. Complications from ET/NT tube
Lip, tongue, nasal, pharyngeal,
tracheal or laryngeal pressure
ulcers
Mucous plugs impairing ventilation
Obstruction by biting tube
Sinusitis and otitis with NT tube
Tracheal-esophageal fistula
Infection

Complications of mechanical
ventilation
2. Complications from ventilator
Auto-PEEP unintended air trapping can
cause hypotension, reduce cardiac
output-- mostly seen in patients with
asthma, obstructive lung disease
Hemodynamic instability from positive
pressure ventilation
ADH secretion positive H2O balance
Infection
GI bleeding due to stress ulcer
Barotrauma
Oxygen toxicitywhen on settings
greater than 0.5-0.6 FiO2 in adults for
long time

How to determine ventilator

settings
Tidal volume (VT) 8-12 ml/kg adults
Respiratory rate
RR X VT = VE (minute volume)--the
higher the VE the lower the PaCO2
FiO2 set to maintain and SaO2 >
90%
PEEP 5-15 cmH2O (useful in
pnenumonia and ARDS)

Nursing Management
1. Observe for S&S of inadequate
ventilation
Rising PaCO2/falling PaO2
Shallow respirations
Irregular respirations/chest-abdominal
dyssynchrony
Dyspnea, tachypnea, bradypnea, apnea
Headache, restlessness, confusion, lethargy
Rising BP (early sign), or falling BP (late sign)
Tachycardia, arrhythmeas
Cyanosis
Agitation, anxiety

Normal ABGs
pH7.4 +/- 0.05
PaO290 +/- 10
PaCO240 +/- 5

pH
Oxygenation

Respiratory Mechanism

HCO324 +/- 2
Metabolic Mechanism

SaO297 +/- 3 Oxygenation

Nursing Management
2. Observe for
pneumothorax/tension
pneumothorax

Increased anxiety
Dyspnea, Tachycardia, Hypotension
Unequal breath sounds
Sudden CVS collapse

3. Guard against dislodgment of ET

tube

Nursing Management
4. Help patient to cope
Remove airway secretions by
suctioning when:

i.
ii.
iii.
iv.

Audible airway noise

Coughing
Respiratory distress
Assess and improve airway patency

Allow for different method of

communication
Remove accumulated water in tubing
Comforting measures/sedation

Suction technique
Sterile technique
Catheter Size
Suction pressure not lower than -120cmH2O for
adults and -60-80 pediatric
Preoxygenation (100%), hyperventilation
Dont suction when inserting catheter
Suction time no longer than 15 seconds
Hyperoxygenate and hyperventilate between
suction passes
Saline should not be usedinfection and reduce
O2 saturation
Use closed ET suction system with preoxygenation

Nursing management
5. Troubleshoot ventilator
Check against incorrect ventilator
settings
Ventilator disconnect is common
High pressure alarm may be due to:

Suction needed
Biting tube
Displaced tube
Compliance decreased
Barotrauma

If problem not found disconnect patient

and manually ventilate with 100% O2
until problem corrected

Nutrition very important

Malnourishment will cause:

Weaning from ventilator

Adequate PaO2, pH and PaCO2
FIO2 is .4 to .5
Very low or no PEEP
Reasonable respiratory rate

Prepare patient for weaning

Weaning techniques
T-tube
SIMV
PSV

Nursing Responsibilities in
Weaning

Weaning Failure
When two or more:
BP deviation of 20mmHG or more
Alteration in heart rate of 20bpm or
more
Cardiac dysrhythmeas deviating
from patients baseline
Change in level of consciousness

Or when RR greater than 35 bpm

Learning outcomes
List indications for intubation and
mechanical ventilation
Differentiate between modes of ventilation
and advantages and disadvantages of each
List complications of mechanical
ventilation
Describe nursing assessment and care of
ventilated patient
Discuss methods used for weaning
patients