INDICATIONS
● A tube is inserted through the client’s nose or mouth
into the trachea. This allows for emergency
airway management of the client.
● Mouth intubation is the easiest and quickest form of
intubation and is often performed in the emergency
department.
● Nasal intubation is performed when the client has
facial or oral trauma. This route is not used if the client
has a clotting problem.
PLACEMENT
● Intubation is typically performed by a nurse anesthetist, anesthesiologist, or
pulmonologist.
● A chest x‐ray verifies correct placement of the endotracheal (ET) tube.
● ET tubes can be cuffed or uncuffed. The cuff on the tracheal end of an ET tube is
inflated to ensure proper placement and the formation of a seal between the
cuff and the tracheal wall. This prevents air from leaking around the ET tube.
● The seal ensures that an adequate amount of tidal volume is delivered by the
mechanical ventilator when attached to the external end of the ET tube.
● The client is unable to talk when the cuff is inflated.
● Have resuscitation ● Ensure the intubation
equipment to include a attempts last no longer
NURSING ACTIONS manual resuscitation bag than 30 seconds and then
with a face mask at the reoxygenate before another
bedside at all times. attempt to intubate.
● Auscultate for breath
● Monitor vital signs, and ● Observe for symmetric
sounds bilaterally after
check tube placement. chest movement.
intubation.
● Stabilize the endotracheal ● Monitor for hypoxemia,
tube with a tube holding dysrhythmias, and
device or secure with tape. aspiration.
Mechanical ventilation
Mechanical ventilation provides
breathing support until lung function is
restored, delivering warm (body
temperature 37° C [98.6° F]), 100%
humidified oxygen at FiO2 levels
between 21% to 100%.
• FiO2: Percentage of oxygen in the air mixture that is delivered
to the patient. Flow: Speed in liters per minute at which the
ventilator delivers breaths.
• Frequency (Back Up Rate) • the number of breaths per minute
that is intended to provide eucapneic ventilation• The initial
frequency is usually set between 12 and 16/min. • Frequencies of
20/min or higher are associated with auto-PEEP and should be
avoided.
• Tidal volume is the amount of air that moves in or out of the
lungs with each respiratory cycle. It measures around 500 mL in
an average healthy adult male and approximately 400 mL in a
healthy female. It is a vital clinical parameter that allows for
proper ventilation to take place
● Positive-pressure ventilators
deliver air to the lungs under
pressure throughout inspiration
◯ Forced/enhanced lung
and/or expiration to keep the Benefits include the following.
expansion
alveoli open during inspiration and
to prevent alveolar collapse during
expiration.
◯ Improved gas exchange
◯ Decreased work of breathing
(oxygenation)
CONSIDERATIONS PREPARATION OF THE CLIENT
● Explain the procedure to the client.
● Establish a method for the client to communicate,
such as asking yes/no questions, providing writing
materials, using a dry-erase and/or picture
communication board, or lip reading.
ONGOING CARE
● Maintain a patent airway.
◯ Assess the position and placement of tube.
◯ Document tube placement in centimeters at the client’s
teeth or lips.
◯ Use two staff members for repositioning and to resecuring
the tube.
◯ Apply protective barriers (soft wrist restraints) according
to hospital protocol to prevent self-extubation.
◯ Use caution when moving the client.
◯ Suction oral and tracheal secretions to maintain tube
patency.
◯ Support ventilator tubing to prevent mucosal erosion and
displacement.
◯ Have a resuscitation bag with a face mask available at the
bedside at all times in case of ventilator malfunction or
accidental extubation.
● Assess respiratory status every 1 to 2 hr: breath
sounds equal bilaterally, presence of reduced or absent
breath sounds, respiratory effort, or spontaneous breaths.
● Suction the tracheal tube to clear secretions from the
airway.
● Monitor and document ventilator settings hourly.
◯ Rate, FiO2, and tidal volume
◯ Mode of ventilation
◯ Use of adjuncts (PEEP, CPAP)
◯ Plateau or peak inspiratory pressure (PIP)
◯ Alarm settings
Monitor ventilator alarms, which signal if the client is not receiving the
correct ventilation.
◯ Never turn off ventilator alarms.
◯ There are three types of ventilator alarms.
■ Volume (low pressure) alarms indicate a low exhaled volume due to a
disconnection, cuff leak, and/or tube displacement.
■ Pressure (high pressure) alarms indicate excess secretions, client biting
the tubing, kinks in the tubing, client coughing, pulmonary
edema, bronchospasm, or pneumothorax.
■ Apnea alarms indicate that the ventilator does not detect
spontaneous respiration in a preset time period.
● Maintain adequate (but not excessive) volume in
the cuff of the endotracheal tube.
◯ Assess the cuff pressure at least every 8 hr.
Maintain the cuff pressure below 20 mm Hg to
reduce the risk of tracheal necrosis.
◯ Assess for an air leak around the cuff (client
speaking, air hissing, or decreasing SaO2).
Inadequate cuff pressure can result in inadequate
oxygenation and/or accidental extubation.
Administer medications as
prescribed.
◯ Analgesics: morphine and
fentanyl
◯ Sedatives: propofol, diazepam,
lorazepam, midazolam, and
haloperidol
◯ Ulcer-preventing
agents: famotidine
or lansoprazole
◯ Antibiotics for
established infections
● Reposition the oral endotracheal tube every 24 hr or
according to protocol. Assess for skin breakdown.
◯ Older adult clients have fragile skin and are
more prone to skin and mucous membrane breakdown.
Older adult clients have decreased oral secretions.
They require frequent, gentle skin and oral care.
● Provide adequate nutrition.
◯ Assess gastrointestinal
functioning every 8 hr.
◯ Monitor bowel habits.
◯ Administer enteral or
parenteral feedings as prescribed.
● Continually monitor the client during the weaning process and
watch for signs of weaning intolerance.
◯ Respirations greater than 30/min or less than 8/min
◯ Blood pressure or heart rate changes more than 20% of
baseline
◯ SaO2 less than 90%
◯ Dysrhythmias, elevated ST segment
◯ Significant decrease in tidal volume
◯ Labored respirations, increased use of accessory muscles, and
diaphoresis
◯ Restlessness, anxiety, and decreased level of consciousness
● Have a manual resuscitation bag with a face mask and oxygen
readily available at the client’s bedside.
● Have reintubation equipment at bedside.
● Suction the oropharynx and trachea.
● Deflate the cuff on the endotracheal tube, and remove the tube
during peak inspiration.
● Following extubation, monitor for signs of respiratory distress or
airway obstruction, such as ineffective cough, dyspnea, and stridor.
● Assess SpO2 and vital signs every 5 min.
● Encourage coughing, deep breathing, and use of the incentive
spirometer.
● Reposition the client to promote mobility of
secretions.
● Older adult clients have decreased respiratory
muscle strength and chest wall compliance, which
makes them more susceptible to aspiration,
atelectasis, and pulmonary infections. Older adult
clients require more frequent position changes to
promote mobility of secretions.
COMPLICATIONS
Trauma
Barotrauma (damage to the lungs by positive
pressure) can occur due to a pneumothorax,
subcutaneous emphysema or pneumomediastinum.
Volutrauma (damage to the lungs by volume
delivered from one lung to the other).
Fluid retention
Fluid retention in clients who are receiving
mechanical ventilation is due to decreased cardiac
output, activation of renin-angiotensin-aldosterone
system, and/or ventilator humidification.
NURSING ACTIONS: Monitor intake and output,
weight, breath sounds, and endotracheal secretions.
Oxygen toxicity
Oxygen toxicity can result from high concentrations
of oxygen (typically greater than 50%), long durations
of oxygen therapy (typically more than 24 to 48 hr),
and/or the client’s degree of lung disease.
NURSING ACTIONS: Monitor for fatigue, restlessness,
severe dyspnea, tachycardia, tachypnea, crackles,
and cyanosis.
Hemodynamic compromise
Mechanical ventilation has a risk of increased thoracic
pressure (positive pressure), which can result in
decreased venous return.
NURSING ACTIONS: Monitor for tachycardia,
hypotension, urine output less than or equal to 30
mL/hr, cool, clammy extremities, decreased peripheral
pulses, and a decreased level of consciousness.
Aspiration
Keep the head of the bed elevated 30° at
all times to decrease the risk of aspiration.
NURSING ACTIONS: Check residuals every 4
hr if the client is receiving enteral feedings
to decrease the risk of aspiration.
Gastrointestinal ulceration (stress ulcer)
Gastric ulcers can be evident in clients
receiving mechanical ventilation.
NURSING ACTIONS
● Monitor gastrointestinal drainage and
stools for occult blood.
● Administer ulcer prevention medications
(sucralfate and histamine2 blockers).
