1. Terminate the treatment

*HR increase 20 bpm, adverse reaction, dizziness

*Stop treatment and notify physician

2. Treatment Technique

a. IPPB (Indication)

1. Increase in work of breathing

2. Hypoventilation

3. Inadequate cough (get air behind secretions)

4. Stiff Lungs

5. Ate1ectasis- sedated post-op and patients recovering from abdominal surgery

6. Pulmonary edema

b. Incentive Breathing Techniques 1. Patient sitting upright

2. Twice the patient's tidal volume

3. Inspiratory Time should be 5-15 sec, with a 2-3 sec pause

4. Incentive Spirometry is an alternative to IPPB if patient is able to achieve a Vital Capacity of

more than 15 ml/kg of body weight

c. Aerosol Therapy

1. Take slow deep breaths

2. Heated nebs are the greatest source of delivery of contamination moisture to the patient

3. Keep water drained out of the tubing because this will increase the percent of the oxygen delivered to

the patient

d. Oxygen Therapy

1. Nasal Cannula

a. 24 to 44 % at flow rates 1 to 6 L/min

2. Simple Mask

a. 35 to 55 % at flow rates 5 to 12 L/min

3. Partial Rebreathing Mask

a. 35 to 60 % at flow rates 8 to 15 L/min

4. Non-rebreathing mask

a. 60 to 80 % at flow rates 8 to 15 L/min

5. Venturi mask

a. 24 to 50 %

6. Aerosol Mask

a. 21 to 100 % at flow rates of8 to 15 L/min

7. T-tube. Briggs adapter

a. 21 to 100 % at flow rates of 8 to 15 L/min

8. Trach Mask

a. 35 to 60 % at flow rates of 10 to 15 L/min

9. Oxygen Blender

a. Use 50 psig gas sources to mix or blend oxygen and compressed air to deliver 21 to 100% at flow

rates of 2 to 100 L/min

b. Provide a stable Fi02 as long as the outlet flow exceeds the patient's inspiratory flow demands

e. Specialty Gas Therapy

1. Helium/Oxygen Therapy (80/20) (70/30)

a. Second light gas; decrease total density of the gas this allows the gas to pass through

obstructions more easily

b. Must be delivered in a tightly closed system to prevent gas from leaking out

~Non-rebreather, endotracheal tube, tracheostomy tube

c. 80:20 multiply flowmeter reading by 1.8 to determine correct flow d. 70:30 multiply

flowmeter reading by 1.6 to determine correct flow

f. Bronchial Hygiene Therapy

1. CPT

a. Performed over each area for 2 to 5 min

b. Posterior basal segment of lower lobe -Prone, Trendelenberg

c. Lateral basal segment of the lower lobe -1/2 turn, Trendelenberg

d. Superior Segment of lower lobe -Prone, bed flat, pillow under hips

e. Anterior basal segment of lower lobe -1/2 turn, Trendelenberg

f. Lateral and medial segments of the right middle lobe -1/4 turn, Trendelenberg

g. Superior and inferior lingular segments of the left lung -1/4 turn, Trendelenberg

h. Apical segment of the upper lobe -Pt sitting upright

i. Anterior segment of the upper lobe -Supine, bed flat, pillow under knees

j. Posterior segment of the upper lobe -Sitting upright, leaning forward

2. PEP (RRT only)

a. Effective for preventing postoperative atelectasis by opening airways and improving gas

exchange

b. PEP levels of 10 to 20 cm H2O are used

c. Patient inhale a larger-than-normal volume, and then actively exhale: 'riot forcefully, with

expiration lasting 2-3 times longer than inspiration

d. Perform 10 to 20 of these breaths, remove mask and perform 2-3 huff

coughs

e. Repeat procedure 4-6 times per session

3. Flutter

a. Patient exhales to produce a PEP of between 10 and 35 cm H2O

b. Patient inhales slowly, just a bit more than a normal breath (not filling the lungs) and hold

breath for 2-3 seconds

c. Exhale reasonably fast, not forcefully

d. Oscillations are transmitted down the respiratory tract, creating vibrations that result in

mobilization of secretions

e. Should be cleaned every 2 days in a soap solution and disinfected at

regular intervals by soaking in a 1:3 solution of vinegar and water for 15 min, dried, and

reassembled for future use

g. Management of artificial airway

1. Changing a tracheostomy tube within 48 hours of the tracheotomy is not

advisable and only should be done by a surgeon~ tracheal rings may recede when the tube is

removed, making reintubation difficult

2. Indication for suctioning

a. Remove retained secretions that patient cannot mobilize

b. Maintain patency of artificial airway

c. To obtain sputum culture and sensitivity testing

3. Inflate and/or deflate the cuff

a. Minimal leak technique

~ With stethoscope beside the larynx, listen for airflow as the cuff is inflated

-Inflate until no airflow is heard, then withdraw air slowly until a slight leak is heard

b. Minimal occluding volume :-,

~Same technique, except the cuff is slowly inflated just to the point where no leak is heard

h. Suctioning

1. Frequency and duration

a. Suction when needed

2. Size of catheter

a. Divide the inner diameter by 2 and multiply by 3

b. Yankauer

-Used to suction oropharynx

3. Negative Pressures

a. Adults --80 to -120 mm Hg

b. Children --80 to -100 mm Hg c. Infants --60 to -80 mm Hg

4. Lavage

a. 3 to 5 ml of normal saline to help thin secretions b. 0.3 to 0.5 ml ~infants

i. Mechanical Ventilation

1. Sensitivity

a. Set so the patient generates -0.5 to -2.0 cm H2O b. If it take more increase sensitivity

2. Oxygenation

a. Once 60 % Fi02 is reached, Peep should be added or increased

b. Peep used to maintain positive pressure in the airway after a vent. Breath

3. Adjust I:E settings

a. Increase tidal volume, increase inspiratory time b. Increase flow, decrease inspiratory time

c. Increase respiratory rate, decrease expiratory time d. Total cycle time = 60/Rate I time =

TCT/parts

4. Modify Ventilator Technigues

a. Pressure Support

-spontaneous breathing more comfortable by overcoming the high resistance and increase

inspiratory work caused by the ET tube

-may be used for patients who are ventilating well but are intubated to protect their airway

of for patients on CP AP with oxygenation deficiencies

b. Pressure Control

-used for patients with ARDS in which Peep has not improved ventilation or oxygenation -

Initial settings

*Fi021.0

*Pip of about 50 % of that on a volume ventilator

*Tidal volume 6 to 10 ml/kg of ideal body weight

*Peep > 15 cm H2O

*I:E 1:2

-Can be uncomfortable, so patient should be sedated

5. Adjust noninvasive Positive Pressure ventilation

a. make sure mask is tight so there is no leak

b. IPAP – EPAP determines Vt in relation so compliance of lung and airways resistance

EPAP affects PaO₂

6. Monitor and adjust alarm settings

a. Low pressure alarm

-activated by leaks in the ventilator circuit or by patient disconnection

b. High pressure alarm

-activated by decrease in lung compliance

-increasing airway resistance caused by

*airway secretions

* bronchospasm

*water in the ventilator tubing

*kink in the ventilator tubing

*patient coughing

c. Low PEEP/CPAP alarm

-Activated by leaks in the ventilator circuit or by patie~t disconnection d. Apnea alarm

-set according to the patient's respiratory rate

-Activated after a preset time passes with no inspiratory flow through the tubing

7. Adjust ventilator settings based on ventilator graphics

a. Flow curve

-Flow remains constant throughout inspiration

-Change in airway resistance and compliance won't change the flow pattern

b. Leak

-Volume does not return to baseline, around the ETT or cuff -Auto-Peep or patient may be

coughing or agitated

c. Obstructive

-Causes the tracing to be flat during exhalation as a result of decreased expiratory flows

8. Change mechanical deadsl2ace

a. Mechanical dead space may be added to the circuit between the ventilator wye adapter and

the ET tube adapter to increase PaCo2 levels

b. For every 100 ml of dead space, PaCo2 increases approximately 5 mm Hg c. Added to the

circuits of patients on control or assist/control modes only d. Never add dead space if the

patient is on SIMV, IMV, or CP AP

j Procedures for weaning

1. Criteria for weaning

a. Tidal volume = 3x body weight in kg

b. Vital Capacity> 15 ml/kg

c. MIP of at least -20 cm H2O

d. V d/Vt of less than 0.60

e. P (A-a) 02 less than 350 mm Hg on 100 % 02

f. Respiratory rate < 22

g. Patient alert and can follow commands

h. Patient should be off medications that hinder spontaneous ventilation

i. Shock or hypotension should not be present

j. Anemia, fever, or electrolyte imbalances should not be present

k. Reason patient was put on the vent should be reversed

2. Weaning Technigues

a. Patient should be on 40 % 02 or less

b. SIMV or IMV rate of 4/min of less

c. Post-op patients may be weaned after they begin to wake up

~ Normal acid/base balance blood gas levels