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Chapter 10
Airway Management and
Ventilatory Support
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Artificial Airways
• Establish an airway
• Protect the airway
• Facilitate airway clearance
• Facilitate mechanical ventilation
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Types of Airways
• Oropharyngeal airway
• Nasopharyngeal airway
• Endotracheal tube
• Tracheostomy
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Oropharyngeal Airway
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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.
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Nasopharyngeal Airway
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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
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Endotracheal Tube
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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
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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.
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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
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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.
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Question
• Which type of artificial airway can never be used on a
conscious person?
– A. Tracheostomy
– B. Oropharyngeal airway
– C. Nasopharyngeal airway
– D. Endotracheal
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Answer
• B. Oropharyngeal airway
• Rationale: An oropharyngeal airway stimulates the gag
reflex and can cause vomiting and aspiration.
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Indications for Suctioning
• Visualization of secretions in airway
• Crackles, rhonchi, mucus plugs, or coughing
• Increase in peak airway pressure
• Decrease in tidal volume
• Hypoxia
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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.
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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.
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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
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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.
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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.
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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)
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Lung Injury Risk with Positive-Pressure
Ventilation
• Barotrauma
• Volutrauma
• Atelectrauma
• Biotrauma
• Ventilator-associated lung injury (VALI)
• Ventilator-induced lung injury (VILI)
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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
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Answer
• B. Volume ventilation
• Rationale: Volume ventilation—a preset volume of air
delivered with each breath
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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
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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)
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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.
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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
– Respiratory rate and tidal volume are preset.
– Breaths initiated above the preset rate are at the
patient’s own spontaneous tidal volume.
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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.
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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.
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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
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Nursing Care
• Maintain airway
• Nasogastric or orogastric
• Monitor vital signs,
arterial oxygenation
saturation, mental status,
respiratory status, and
arterial blood gases
• Check endotracheal tube
cuff inflation
• Monitor ventilator settings
and alarms
• Oral hygiene
• Suction as needed
• Eye care
• Head of the bed elevated
30 degrees
• Nutritional support
• Psychosocial support
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Question
• Is the following statement True or False?
• BiPAP, CPAP, and PCV are all volume modes of
ventilation.
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Answer
• False
• Rationale: BiPAP, CPAP, and PCV are all pressure modes
of ventilation.
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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
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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
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