Pulmonary Assessment and Challenges for the New ICU Nurse · • Increased in tidal volume •Anxiety •Pain • Decreased cardiac output • The patient is hyperventilating. Low

Pulmonary Assessment and Challenges for the New ICU Nurse

Michael Nanney – BSN, RN, RRT, CPAN, CCRN

November 7, 2018 | 3:20 PM

Faculty Disclosure:No Conflicts of Interest.

No Sponsorship or Commercial Support.

Michael NanneyBSN, RN, RRT, CPAN, CCRN

MED-ED, Inc. | 800-763-3332 | www.MedEdSeminars.net | www.CurrentsConference.com 1911 Charlotte Dr., Charlotte, NC 28203 | 2018 © MED-ED, Inc., All Rights Reserved

• Oxygenation:– Process of adding oxygen to the body

– Occurs at the cellular level

– Alveoli/capillary bed

– Oxygen binds to hemoglobin -> dissolves in the plasma -> body

• Ventilation:– A separate physiological process

– Air simply moves in and out of the lungs.

– Can be spontaneous or artificial

– Ventilation occupies from the nose/mouth -> alveoli.

– Active vs. passive phase of breathing

The Process

Perfusion – Cardiopulmonary System


• Obesity

• Restrictive lung diseases

• Obstructive lung diseases

• Air, blood, fluid in the pleural space

• Decreased surfactant production

• Cardiac issues

• Surgery

• CNS issues

Conditions that Alter Oxygen/Ventilation

• Good air entry + good blood flow = V/Q matching

Ventilation/Perfusion


Pulmonary Shunt

• A decreased amount of oxygenation in the tissues, secondary to hypoxemia

• Causes: anemia, carbon dioxide poisoning, pneumonia, atelectasis, hypoventilation

• S/S: tachycardia, tachypnea, anxious, restlessness, cyanosis, altered mental status

Hypoxia


• Tachypnea and tachycardia initially occur

• Central and peripheral chemoreceptors activate– Central chemoreceptors located in the medulla

– Peripheral chemoreceptors located in the carotids and aorta

– Respond to changes in PaCO2 (ventilation) more sensitive to the changes in pH

The Body’s Response System

So How Do We Assess Our Patients?


• Pulse Oximetry– Noninvasive

– Easy to set up, use and read -> rapid results

– Assessment of oxygenation status only

– Evaluate therapy

– Evaluate effectiveness of medications

– Diagnostic tool

– * Only reflects oxygenation.

– *Changes in ventilation may not be detected.

– *Not indicated to monitor ventilation

– *Patients are often on oxygen device -> misleading.

Assessment Tools

• A true measurement of ventilation

• Alternate to obtaining an ABG to evaluate PaCO2

• Gradient between PaCO2 and ETCO2 is 2-5mm Hg.

• National standard for moderate sedation

• Indications for ETCO2:– Monitor for oversedation

– Airway patency

– ETT placement

– Provides an accurate respiratory rate

– Assessment of ventilation issues

– TJC advisory

Capnography



• Less than 35 mm Hg

• Tachypnea

• Increased in tidal volume

• Anxiety

• Pain

• Decreased cardiac output

• The patient is hyperventilating.

Low ETCO2 Readings

• Greater than 45 mm Hg

• Low tidal volumes

• Low respiratory rate

• Sedation issues

• Splinting

• Overdose

• The patient is hypoventilating.

High ETCO2 Readings


• Continuous positive airway pressure

• The patient has spontaneous breaths.

• Requires an adequate respiratory drive

• Adequate spontaneous tidal volumes

• Recruits alveoli

• One setting on the device (cm H20)

• For improving OXYGENATION

CPAP

• Noninvasive positive pressure ventilation

• Bilevel positive airway pressure (BiPAP)

• Two settings: inspiratory and expiratory

• Decreases the work of breathing

• Aids in the active phase of the respiratory cycle

• Primary for correcting VENTILATION issues but will aid with oxygenation

NIPPV


• Before and after mechanical ventilation

• Neuromuscular respiratory failure

• Decompensated obstructive sleep apnea

• Obesity hypoventilation syndrome

Indications for NIPPV

• Noncompliant patient

• Coma (low GCS)

• Respiratory arrest

• Severe bradypnea

• Unstable airway

• Hemodynamic instability

• Upper GI bleed

• Excessive secretions

• Vomiting

• Head/facial trauma

Contraindications for NIPPV


• Indications:

– Respiratory rate > 30/min or < 6/min sustained

– pH less than 7.25

– Altered LOC -> airway compromise, loss of reflexes

– PaO2 <45 mm Hg on supplemental oxygen

– Hemodynamic instability

– Spontaneous tidal volume less than 5mL/kg

– Accessory muscle use

– Respiratory Failure Type I or Type II

Intubation & Mechanical Ventilation

• Improve oxygenation

• Improve ventilation

• Correction of respiratory acidosis

• Decrease the work of breathing

• Protect from further insult

• Promote comfort

• Providing artificial ventilation to assist or replace spontaneous ventilation

Goals of Mechanical Ventilation


• Mode of ventilation: how the mechanical breaths are being delivered

• Tidal volume: Vt or TV, approx. 6 mL/kg of ideal body wt.

• Respiratory rate: RR or f, the frequency the breaths are being delivered

• Oxygen: FiO2, titrated based on oxygen needs

• PEEP: recruits alveoli, aids in oxygenation

• Pressure support: PSV, assists w/the insp. phase of the resp cycle, decreases the work of breathing and often used in weaning mode

Ventilator Settings

• PaCO2:– Rate adjustment

– Vt changes

– Adding or removing PSV

– Changing the mode of ventilation

• PaO2:– Increasing or decreasing FiO2

– Increasing or decreasing PEEP levels

Adjusting Ventilator Settings


• Low-Pressure Alarm:– Loose tubing

– ETT problem

– Leak in the system

– Disconnect issue

• High-Pressure Alarm:– Obstruction

– Secretions

– Bronchospasms

– Dyssynchrony

– Agitation

Ventilator Alarms

• Call for help.

• Notify respiratory staff.

• Manually ventilate the patient.

• Assess the patient. (ABCs priority.)

• Identify the problem utilizing “DOPE” mnemonic.

What to Do?


• Reduction in anxiety

• Amnesia effect

• Decreases the level of stress hormones

• Compliance with mechanical ventilation

• Decrease in oxygen demand

• Aids in achieving stabilization of hemodynamics

• Tolerance of the airway itself

• Tolerance of the mode of ventilation

Sedation & Mechanical Ventilation


• Vital signs

• Breath sounds

• ABG, POX, ETCO2 readings & waveforms

• Secretions

• Ventilator settings/NIPPV settings

• Cardiac assessment

• Assessment of the ETT

• Chest X-ray

• Patient comfort

• Skin care/mouth care

Patient Care & Assessment


• CPOT score indicates pain presence, not so much on severity of the pain.

• A score of 3 or > indicates pain.

• Therefore goal of 2 or <.

• A change or decrease by 2 -> successful intervention of pain control.

Key Points about CPOT

• Can become dislodged

• Displacement

• Right main intubation

• Cuff leak

• Unplanned extubation

• Intolerance of the ETT

• Skin issues

• Nasal intubation can lead to sinusitis, otitis media.

Endotracheal Tube Issues


• As the process of assisting the patient to breathe on their own or the transition from mechanical ventilation support to adequate spontaneous breathing.

• Weaning and extubation are two separate processes.

• Weaning should only be considered once the underlying issue requiring mechanical ventilation has been resolved.

Weaning and Extubation

• Lung issue is stable or resolved.

• Medical condition is stable or resolved.

• Hemodynamically stable

• Able to initiate spontaneous breaths

• Good neuromuscular function

• Low FiO2 settings

• Low PEEP settings

General Requirements for Weaning


• Why did the patient require mechanical ventilation?

• Assessment of sedation score

• What is the Glasgow Coma Scale?

• NMBA utilized

• Sedation score/gtt’s required

• BIS monitor readings

Additional Considerations

• CIWA score

• Seizure activity?

• GCS?

• No agitation

• No paralytics on board

• No myocardial ischemia indications

• Normal ICP readings

Wake-Up Assessment Screening


• Communication between respiratory, nursing and physicians occur

• Patients now only require intermittent sedation.

• Document the ability to follow commands, RASS and ventilator tolerance

• RASS goal is -1 to +1

The Wake-Up Assessment

• Anxiety

• RR > 35/min

• SpO2 <90%

• Obvious respiratory distress

• New onset of cardiac dysrhythmias

• HR > 140/min or a change >20% of baseline

• SBP > 180 mm Hg or a change of >20% of baseline

Wake-Up Assessment Failure


• Ventilator providing minimal support

• Assessment of the patients own / spontaneous breaths

• Monitor …

– Respiratory rate

– Spont TV

– Minute ventilation

– VS

– Cardiac status

– ETCO2/POX values

Spontaneous Breathing Trials

• Respiratory rate <25/min

• Negative inspiratory force > -20 cm H20 pressure

• Spontaneous Vt 5 mL/kg

• Vital capacity 10-15 mL/Kg

• Minute ventilation 5-10 liters/min

• Ventilator settings/mode of ventilation

• PaO2 >60 mm Hg with FiO2 0.40 or less

Weaning Parameters - RT


• Infection issues

• Sleep deprivation

• Pain

• Abdominal distention

• Poor nutritional status

• Continued for sedatives

• Mental status

Factors that can Impair Weaning

• RR <8 or >30/min

• Labored respirations

• Spontaneous Vt < 5 mL/kg

• Use of accessory muscles

• Abnormal breathing pattern

• POX constantly <90%

• HR increases by 20%

• Ectopy

• ST segment changes

• Agitation, anxiety, panic

Criteria to Stop Weaning


• Aspiration risk not present

• Airway edema not noted

• Control of fluids/secretions

• Cough present

• Intact gag reflex

• Sedation level acceptable

• Adequate oxygenation

• Adequate ventilation

Criteria to Extubate

• Team approach

• A proper assessment

• Try to involve the patient.

• Share/communicate plan of care.

• Weaning protocols & criteria should be RT/RN friendly.

• If failure occurs -> WHY?

So Remember …



Pulmonary Assessment and Challenges for the New ICU Nurse · • Increased in tidal volume •Anxiety •Pain • Decreased cardiac output • The patient is hyperventilating. Low

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