ETT Intubation

 

What advanced airway adjuncts have you used in your nursing experience?

I have an experience of using an endotracheal tube in my unit. 

 

What are the indications of ETT insertion?

ETT allows us to control patients' airways. It ensures an open airway, control ventilation and oxygenation. Also it protects from aspiration. 

It can be used in respiratory failure, decreased mental status (GCS less than 8), medical procedure (sedation/Anesthesia), Airway issues (injury, edema), and apnea. 

 

What are some complications of ETT insertion? How can you minimize complications (your nursing management and interventions)

The complications are bleeding, infection (pneumonia or VAP (ventilator associated pneumonia), perforation of the oropharynx, hoarseness (vocal cord injury), damage to teeth and lips or esophageal placement. 

 

How can you tell that your patients are hypoxemic? (remember to organize your answers in order of priority)

If the patients complain about dyspnea/ tachypnea, altered mental status, chest pain/tachycardia, abdominal discomfort (nausea, vomiting), and cyanosis,  we can suspect that they might undergo hypoxemic circumstances. 

 

• Mechanical Ventilation 

Have you managed patients who were on mechanical ventilators? 

Yes I have experience of using ventilators.

 

What ventilator modes have you used in your experience?

AC mode: assisted controlled

SIMV: synchronized ventilation

PSV: pressure support ventilation

 

Why did your patients require mechanical ventilation? What are the indications of mechanical ventilators?

The patient can’t breathe and altered mental status. Also, there was a high risk of aspiration, so we applied a ventilator. 

 

What are some complications associated with mechanical ventilators?

Infections (VAP: pneumonia), Barotrauma (alveolar rupture due to elevated transalveolar pressure), and lung injury. 

 

What ventilator alarms are you familiar with (state at least 3), and explain how you will troubleshoot. 

High pressure alarm, low pressure alarm, low volume alarm. high or low rate (apnea)

High pressure: can lead to alveolar overdistension. overdistension can reduce blood flow to the alveoli, rupture weakened alveoli and cause dangerous inflammatory changes in lung tissue. ⇒ check the patient coughing, “fighting” with the ventilator?(patient-ventilator dyssynchrony)=>  suctioned and if not probable needs more sedation.  check there is a kink in the tubing and water in the line. 

Low exhaled tidal volume: air loss btw the breath delivered by the ventilator and the air that is returned to the ventilator with exhalation. => check equipment: break in the tubing of the circuit?, disconnection of the endotracheal tube because of the patient movement, cuff on the airway tube underinflated?

 

High respiratory rate: self-explanatory- the patient is breathing too fast. ⇒ check the patient anxious or in pain, medicate, coughing or gagging (laughing), water in line

 

What are some causes of the ventilator alarms? (Explain using the mnemonic-DOPES), how will your troubleshoot for each of the causes (explain using the mnemonic DOTTS)

D: displaced ET tube/ ET tube cuff not inflated or has a leak

O: obstruction of ET tube

P: pneumothorax

E: equipment malfunction (disconnection of the ventilator, incorrect vent setting, etc. 

S: stacking (breath stacking/ Auto-PEEP)

 Fix the problem with DOTTS

D: disconnect: disconnect patient from the ventilator

O: oxygen: oxygenate patient with a BVM (bag valve mask) and feel for resistance as you bag

T: tube position/ function: did the ET tube migrate? Is it kinked or is there a mucus plug?

T: tweak the vent: is the setting correct for this patient?

S: sonogram(ultrasound): sonogram to look for pneumothorax, mainstem intubation, etc. 

 

• VAP Bundle

What is VAP? What are the causes of VAP

VAP is a hospital acquired pneumonia that occurs more than 48 hours after mechanical ventilation . Early-onset VAP:  onset within 4-5 days/ Late-onset VAP: onset after 5 days. Risk factors are elderly, malnutrition, underlying lung disease, artificial airway/NG tube, colonization of dental plaque with respiratory pathogens, bacterial colonization of the oropharyngeal area, aspiration of subglottic secretions, head of bed less than 30 degrees or surgery.

How can you prevent VAP in the hospital (explain using the VAP Bundle)

VAP bundle is a set of evidence-based interventions related to disease processes that when executed together result in better outcomes, than when implemented individually. 

• hand hygiene, used gloves appropriated
• semi-recumbent positioning (30-45 degree)
• oral hygiene with 0.2% chlorhexidine
• peptic ulcer disease prophylaxis
• DVT prophylaxis
• sedation vacation and spontaneous breathing trial. 
• Aspiration of subglottic secretions
• ET cuff pressure monitoring (22~32cmH2O)
• Aseptic suction
• eliminate routine saline bronchial lavage
• drain condensation in ventilator tubing down and away from the patient.