Pierce, L. Louis, MO: Saunders Elsevier. Ventilatory assistance. Sole, D. Mosel Eds. Sole, M. Introduction to critical care nursing 6th ed. Even though mechanical ventilation can be a life-saving intervention, there are many essential elements that must be monitored in patients receiving this treatment.
Caring for patients who require mechanical ventilation is a core competency to acquire and develop for all registered nurses working in critical care areas. This chapter provides a detailed approach to nursing care required at the bedside for monitoring a mechanically ventilated patient, includ- ing assessment, arterial blood gas ABG step-by-step analysis, hemo- dynamic monitoring related to mechanical ventilation, basic chest x-ray interpretation, and documentation requirements.
These foun- dational skills use the systematic approach of inspection, auscultation, and palpation to assist the critical care nurse in formulating an indi- vidualized plan of care for the patient.
History The first step in a comprehensive respiratory assessment is to obtain the subjective data. Through a tailored approach, the nurse is able to obtain the necessary information without overtaxing the critically ill patient. Management at the Bedside To acquire the necessary data, carefully formulated exercises and ques- tions contribute to a thorough assessment.
Note: In certain cases, the patient will not be able to answer some or all of the questions posed. Physical Assessment Following a systematic approach, much information can be obtained through the clinical exam using inspection, auscultation, and palpa- tion.
Inspection is the foundation of the respiratory assessment. A thor- ough inspection will mobilize emergency interventions if required, as well as yield important physiological data to formulate a plan of care.
In the initial general assessment, survey the environment for patient safety. Ensure all alarms on the monitor and ventilator are activated.
Have equipment at the bedside such as a bag-valve mask and oropharyngeal airway in the event of an emergency Lian, Management at the Bedside Table 4. After the general survey, a close inspection of the thorax follows. Assessment of the respiratory rate, depth, and rhythm, including use of accessory muscles, will alert the practitioner to institute immediate interventions as required.
Ventilatory effort should be observed in both the ventilated and nonventilated patients. Observe the shape of the chest and the slope of the ribs. Following inspection of the thorax, auscultation of the anterior and posterior chest is completed. Expertise in listening to the chest will provide valuable data regarding the status of the lungs and pleural space.
Auscultate for the presence of adventitious sounds that indicate an underlying pathology, such as congestive heart failure, atelectasis, or inflammation. When auscultating, compare side to side starting at the top of the thorax and move toward the lower chest. Listening in all three lobes of the right lung field and both lobes of the left lung field, as well as over the right and left bronchi and trachea, will ensure a thorough assessment.
The practitioner then palpates the chest to assess for any bulges, tenderness, or depressions in the chest wall. Assess midline position of the trachea using the sternal notch as central reference, slip index finger to either side of trachea.
Palpate, noting any areas of tenderness, instability of chest wall, or crepitus such as that found with subcutaneous emphysema. Data obtained from these tests assist in classifying the underlying condition, provide a baseline for the patient experiencing pulmonary disease, as well as for preoperative assessments Alspach, The bedside tests are divided into two categories, each with four assessments.
The most important tests for assessing adequacy of ventilation are reserve volume, tidal vol- ume, and functional residual capacity Diepenbrock, Other influences on ventilation are compliance and resistance. Compliance refers to the dispensability of pulmonary tissue. Management at the Bedside deformities. Resistance is the measurement of the opposing force. Nar- rowing of the air passages due to a mucous plug will obstruct airflow, increasing resistance.
Factors affecting resistance are categorized as patient-related or ventilator-related causes. Patient factors, such as bronchoconstriction, whereas ventilator factors, such as kinked venti- lator tubing, will resist air flow Pierce, Physical Assessment Care of patients requiring airway adjuncts is a key priority for nurses for both invasive and noninvasive airway management. Patients may have an endotracheal tube ETT placed to facilitate ventilation or a tight- fitting mask for short-term noninvasive ventilation.
Protective skin dressings over potential areas of breakdown can prevent complications and create a tight seal. This tight-fitting mask can cause abrasions to the face, especially over the bridge of the nose. Take measures to prevent skin breakdown by beginning with assessment of the skin under the facemask every 1 to 2 hours.
Avoid over-tightening the head and chin straps to maintain the tight seal, as this will increase patient discomfort. Common tube placement is approximately 21 cm to 23 cm using the teeth as the reference point. Securing the ETT is of prime importance to prevent accidental dislodge- ment of the tube. Various methods such as manufactured devices, twill tape, or adhesive tape can be used according to institutional policy. To prevent dislodging several tubes, secure each tube as a single unit.
Maintain skin integrity around the lips, tongue, and oral cavity by repositioning the ETT. This may be done once every 24 hours just prior to the daily x-ray. The use of an ETT with a port to suction subglottic secretions will help prevent ventilator-acquired pneumonia. Assess size and type of tracheostomy tube and keep a spare in case of accidental decanulation. Special equipment such as an obturator should be kept at the bedside in case of accidental dislodgement.
Note any drainage on the dressing under the tracheostomy tube, as well as the condition of the skin around the tracheostomy. When instituting mechanical ventilation, monitoring of all parameters related to circulation is required. Heart rate, blood pressure, pulmonary artery systolic pressure, pulmonary vascular resistance, and cardiac output can change depending on ventilator pressures.
When documenting mechanical ventilation, make note of the relationship between the baseline vital signs and those after initiation of mechanical ventilation. Observe the trend of these val- ues as there is no need to perform additional calculations due to the addition of positive end expiratory pressure PEEP Pierce, Positive pressure ventilation causes increased intrathoracic pressures, impeding right ventricular preload.
Th is results in decreased cardiac output and decreased blood pressure. The addition of PEEP further increases airway pressures reducing venous return. The influence of auto-PEEP may occur when there is obstruction to flow in patient conditions such as wheezing or in a patient with cardiopulmonary disease or with a high respiratory rate. A tension pneumothorax, a serious complication of mechanical ventilation, causes increased intrathoracic pressure. As a result, compression of the heart and adja- cent blood vessels occurs, leading to cardiac decompensation and ultimately to cardiac arrest.
Cardiac arrhythmias may result from hypoxemia during intubation or periods of suctioning Grossbach, Suctioning may precipitate a vasovagal reaction resulting in profound bradycardia and hypotension. Always pre-oxygenate prior to suctioning, as well as observe the cardiac monitor during the pro- cedure for tachycardia, bradycardia, or heart blocks AACN, Aseptic technique must be used while suctioning. Alteration in renal function can occur in the mechanical-ventilation patient, as positive pressure ventilation can cause sodium and water retention, as well as fluid absorption from the humidification system.
Frequently this leads to peripheral edema, pulmonary edema, and alterations in fluid and electrolytes Alspach, A number of these points are expanded on later in the chapter. A summary of these comfort measures is listed below.
Ventilator Alarms 65 Table 4. It is critical that alarms are always on while caring for patients to prevent life-threatening condi- tions from being missed. In order to provide safe, high-quality care to the critically ill patient, it is essential that causes of these alarms are diagnosed and treated in a timely manner.
Some alarms on the Table 4. Management at the Bedside mechanical ventilator are activated by high pressure, whereas others are activated by low pressure. If the cause of the alarm is not quickly determined, the patient should be removed from the ventilator and ven- tilated with a manual resuscitation bag until the cause is discovered.
Table 4. While the ETT is in place the patient will not be able to verbal- ize because the ETT is inserted through the vocal cords; therefore, it is important to find alternative ways for the patient to communicate. The first is to establish a communication-friendly environment. In order to do this, the nurse should reduce other extraneous noise as much as possible, face the patient while trying to be at eye level, ensure adequate lighting, and speak directly to the patient rather than from the side or from behind.
Management at the Bedside The second step is to assess functional skills that affect communi- cation. Functional skills refers to vision e. Update as needed. Source: Grossbach, Stranberg, and Chlan Reprinted with permission. The fourth step would be to facilitate lip reading wherever possible. To enable this stand where the patient can see you preferably at eye level close to the bedside and ensure adequate lighting. The fifth step is to consider using alternative and augmentative communication devices to facilitate communication when the patient is ventilated.
Strategies can include having a clipboard with pencil and paper at the bedside, encouraging the patient to nod his or her head up or down or use his or her hand or facial gestures, writing down com- mon needs e. Management at the Bedside will exist for the patient to communicate. Settings to document include the set tidal volume Vt , the mode of ventilation, level of oxygen delivered FiO2 , set rate, peak airway pres- sure, and adjuncts such as PEEP or pressure support.
Each time mouth care or suction is provided to the patient, it should be recorded. Typically, hourly ventilator checks and documentation are performed in the critical care unit.
In addi- tion, any patient and family education should be documented. First, consider normal values. The normal range for pH is 7. Values under 7. For PCO2, the normal value is 35 to 45 mmHg. Values over 45 are considered acidic and values under 35 are considered alkalotic. PCO2 is primarily regulated by the respiratory system. Normal pH Scale 7. Values less than 22 indicate acidity and levels greater than 26 indicate alkalinity because bicarbonate is a base.
HCO3 is largely regulated by the kidneys. The level of oxygenation can be assessed by analyzing PO2. Nor- mal range is between 80 and mmHg. Lower levels of PO2 indicate hypoxemia.
Is the pH normal, acidic, or alkalotic? In the example in Figure 4. Step 2: Which Number Matches the pH? Note that in Figure 4. Because they are both acidic, this indicates that it is a respiratory distur- bance. Management at the Bedside pH 7. Therefore, if the pH matches the PCO2 the results can be analyzed as a respiratory prob- lem i.
In the event that both the PCO2 and the HCO3 match the pH, this is considered a mixed acidosis or mixed alkalosis, meaning that both the respiratory and the metabolic sys- tems are involved.
Step 3: Is There Compensation Present? Once the nature of the disturbance is determined e. If the patient is in respiratory acidosis, the kidneys may try to compensate by adding more base HCO3 ; if this is the case, the HCO3 levels will rise above the normal range. If the patient is in a respiratory alkalosis, the kidneys may compensate by decreasing levels of bicarbonate and the results would be an HCO3 level lower than the normal range.
Diagnostics 75 There are three levels of compensation: full, partial, and none. In full compensation, the respiratory system compensates for the meta- bolic system or vice versa and the pH returns to normal. In partial compensation, the numbers begin to show improvement but the pH has not yet returned to normal. When there is no level of compensa- tion the systems metabolic for respiratory and vice versa do not show compensation and the pH remains abnormal see Figure 4. Example 1: No Absent Compensation pH 7.
Example 2: Partial Compensation pH 7. Example 3: Full Compensation pH 7. Figure 4. Management at the Bedside Example 1: Hypoxemia pH 7. Step 4: Level of Hypoxemia In order to analyze the level of hypoxemia, the PO2 levels must be assessed.
Determine whether there is mild, moderate, or severe hypoxemia. Putting It All Together In order to complete the analysis, we must put all four steps together. See the practice examples and the accompanying full analysis below. Note that each ABG analyzed has three parts to interpretation: the disturbance, the compensation level, and the level of hypoxemia, if any. When reading x-rays may be outside the scope of practice for the bedside nurse, a basic understanding of normal structures and correct line placement will be helpful when advocating for a timely intervention.
First, a good-quality portable chest x-ray is taken by the technician using an anterior—posterior approach. To assist with this, the bedside nurse can place electrocardiogram leads out of the field of the x-ray beam. Other medical devices such as ventilator tubing or pulse generators may require repositioning as they can also obscure the view.
Example 2 pH 7. Example 3 pH 7. The developed x-ray film will vary from white to black depending on how easily the underlying structures are penetrated with the x-ray beam. Areas easily penetrated will appear black, whereas areas that are difficult to penetrate, such as pacemaker implants, will appear white, whereas structures such as the heart will appear gray Ku, Follow a systematic approach to chest x-ray interpretation Ku, : 1.
Identify the patient using two identifiers. Ensure interpretation of correct film. Management at the Bedside 3. Confirm the quality of the x-ray by visualizing vertebral bodies.
If visible, the x-ray penetration is satisfactory. Determine whether the patient is rotated by examining the sym- metry of the medial end of the clavicle to the spinous process. Confirm the trachea is in the midline position, which will appear as a gray shadow, with the mediastinum appearing whiter on the film. Inspect the bony structures for symmetry.
Identify nine to ten pairs of ribs seen posteriorly. Clavicle, ribs, scapulae, and spine are examined for any fractures. Assess interspaces for any widening. Review the size and shape of the heart. Evaluate the diaphragm, including sharp costophrenic angles. A gastric stomach bubble may be visible. Examine all lung and chest wall borders, as well as the subcutaneous tissues, for air or fluid accumulation.
Look for any abnormalities in den- sity for each of the lung fields, mediastinum, and surrounding tissues. Identify tubes, lines, wires, and catheters that may be present. Compare current x-ray with previous films. Rapid interpretation with clinical findings will prompt early interventions. The probe emits two light sources through the arte- rial vascular bed to a receptor on the other side of the probe.
Pulse oximetry has a high degree of accuracy; however, in certain states, such as low-flow states, accuracy diminishes. End-tidal carbon dioxide PETCO2 monitoring is used for assessing effectiveness of mechanical venti- lation, monitoring of CO2 production, determining placement of the endotracheal tube, and establishing the relationship between arterial carbon dioxide and expired carbon dioxide. Arterial car- bon dioxide is approximately 5 mmHg higher than expired carbon dioxide.
Conditions that result in a decreased blood flow to the lungs e. Increased PETCO2 can occur in conditions that cause a decrease in minute ventilation, retained secretions, or increased production of CO2 e. Values under indicate worsening lung function. Mixed venous blood gases obtained from the pulmonary artery catheter SvO2 are slightly lower than the sample obtained from the fiber-optic catheter centrally placed in the superior vena cava ScvO2.
This calculation represents the difference between the calculated alveolar oxygen and the measured arterial oxygen. This value is useful when determining the cause of hypoventilation. A nor- mal value on room air is considered 10 to 15 mmHg, although it is influenced by age, supplemental oxygen, and barometric pressure.
From Diepenbrock Summary 81 SUMMARY The care of the patient requiring mechanical ventilation is complex and requires the critical care nurse to have a broad range of skills in order to safely care for these patients. The critical care nurse must have knowledge of many elements of practice that may fall under the role of other members of the interprofessional team. It is prudent for the critical care nurse to follow institutional policy and regulatory guidelines when caring for the ventilated patient.
Analyze the following ABG result: pH 7. What strategies would you consider to promote communi- cation with a ventilated patient when using a clipboard and pencil? Why must the head of the bed be elevated 30 to 45 degrees at all times when caring for a mechanically ventilated patient?
What are the potential causes of high pressure alarms? List a minimum of five measures used to promote comfort in the ventilated patient.
A patient in the ICU has a centrally placed fiber-optic cath- eter to monitor the mixed venous oxygen saturation. What is occurring? Case Study Mr.
Samuel Geldhart, 72 years old, was admitted to the critical care unit after a left pneumonectomy for cancer of the lung. He has a 25 pack-year history of smoking and has type 2 diabetes. His initial vital signs are stable. The patient is placed on a mechanical ventilator with the following settings: pressure control of 34, respiratory rate of 20 bpm, 5 cm of PEEP, and FiO2 of 0. Core curriculum for critical care nursing 6th ed. Philadelphia, PA: Saunders Elsevier.
Diepenbrock, N. Quick reference to critical care. Geiger-Bronsky, M. Respiratory nursing: A core curriculum. Promoting effective communication for patients receiving mechanical ventilation. Critical Care Nurse, 31 3 , 46— A fresh look at chest x rays. Nursing Critical Care, 7 6 , 23— Lian, J.
Know the facts of mechanical ventilation. Nursing Critical Care, 3 5 , 43— Massey, D. Respiratory assessment 1: Why do it and how to do it. British Journal of Cardiac Nursing, 5 11 , — References 83 Massey, D. Respiratory assessment 2: More key skills to im- prove care. British Journal of Cardiac Nursing, 6 2 , 63— Critical care nursing: A holistic approach 9th ed. Tracy, M. Nonpharmacological interventions to manage com- mon symptoms in patients receiving mechanical ventilation.
Critical Care Nurse, 31 3 , 19— Louis, MO: Mosby Elsevier. AACN procedure manual of critical care 6th ed. Winkelman, C. Manual turns in patients receiving mechanical ventilation. Critical Care Nurse, 30 4 , 36— Once the under- lying disease process has been resolved the patient will require discon- tinuation or weaning from the ventilator.
This chapter describes the assessment required, as well as techniques and challenges in order to liberate the patient from the mechanical ventilator. Including the patient and family in the weaning process will decrease anxiety and prepare the patient for the weaning experience Burns, The approach to weaning is determined by the length of time the patient has required mechanical ventilation.
Patients requiring me- chanical ventilation for 3 days or less would be considered short-term ventilation and those requiring mechanical ventilation for longer than 3 days are considered long-term ventilation. To successfully wean a patient from the mechanical ventilator, an individualized plan of care based on standardized protocols is required. Weaning has required mechanical ventilation must be given.
There is a strong correlation between the amount of sedation used and liberation from the ventilator Burns, In addition, regimens to prevent ventilator-associated pneumonia, deep vein thrombosis, peptic ulcer disease, and other prophylaxis should be maintained. The underlying cause necessitating mechanical ventilation should be resolved. Figure 5. Absence of adventitious breath sounds? Secretions thin and minimal? Cough and swallow reflexes adequate? METHOD There are several weaning methods that are effective in liberating the patient from the ventilator, with no one method proving to be supe- rior.
When the patient is able to main- tain spontaneous respiratory effort and is considered stable for 90 to minutes, the patient has passed the SBT. Depending on many factors, such as the length of time the patient has required mechanical ventilation, underlying disease process, and comorbidities, this may be a lengthy process taking days to weeks to accomplish. Prior to initiat- ing a weaning trial, the patient must pass the weaning screen test see Table 5.
The patient is said to have successfully completed the wean screen when he or she demonstrates hemodynamic stability, FiO2 is less than 0. Prede- termined criteria regarding the length of the trial should be established by the interprofessional team. To initiate weaning using this mode, the PS begins at a level that provides a normal respiratory rate and tidal volume. Gradually reduce the PS by 2 to 5 cm H2O as the patient tolerates. Some protocols stipulate reduction of PS by 2 cm H2O daily or twice daily.
This circuit does not rely on the ventilator; therefore, there are no alarms such as apnea, respiratory rate, or tidal volume to alert the critical care nurse of a deteriorating patient condition see Figure 5. With this method, the ventilator alarms will alert the critical care nurse to situations such as apnea, high respiratory rate, or low tidal volumes. Once the patient tolerates the SBT for 90 to minutes, the pa- tient is rested on the ventilator by adding additional PS or ventilator breaths to achieve a respiratory rate less than 20 breaths per minute.
After a minimum of 2 hours rest, the weaning process may be repeated, gradually increasing the SBT until the patient is performing the major- ity of the work of breathing. The patient may need to have prolonged periods of rest e.
The patient is considered to be successfully weaned when he or she does not need ventilator support for 24 hours. Table 5. Depending on the length of time the patient is intubated, this process can occur concurrently. Especially for short-term ventilation, the patient may be extubated when assessment criteria are met see section on Assessment at the beginning of this chapter.
If the patient requires the mechanical ventilator for prolonged periods of time, a tracheostomy would be the most appropriate airway approach Burns, The patient may then be liberated from the ventilator, and then decannulated once the patient is able to protect the airway see Chapter 1 for tracheostomy management. Extubation is considered when the patient is liberated from the ventilator and it is determined that the patient is capable of maintain- ing his or her own airway.
If the patient has a strong gag and cough reflex and is able to clear secretions, a cuff-leak test is performed. Th is test is performed after suctioning the oropharynx, removing the air from the cuff, and briefly occluding the ETT. Absence of a leak around the cuff may indicate tracheal edema, which is treated with a short course of corticosteroids or racemic epinephrine prior to extubation. The patient is then extubated under close observation.
If the patient develops stridor, racemic epinephrine via inhalation is administered. Assess respiratory status 2. Ensure that qualified personnel are available should reintubation be required 3. Discontinue feeding tubes 4 to 6 hours prior to extubation 4.
Hyperoxygenate and suction ETT and the pharynx 5. Remove securing device or tapes 6. Deflate cuff and instruct the patient to take a deep breath 7. Remove the ETT at peak inspiration 8. Encourage patient to breathe deeply and cough 9. Apply supplemental oxygen Monitor respiratory status, oxygen saturation, vital signs, presence of stridor or hoarseness, presence of larngospasm, and arterial blood gases Be prepared to institute invasive or noninvasive ventilation Source: Burns ; Pierce ; Pilbeam and Cairo Often these protocols are complex and perceived as difficult to implement at the bedside Burns, In order to integrate evidence-based practice, effective education strategies must be implemented for the health care team.
To evaluate effectiveness of implementation of evidence-based protocols, an audit of compliancy and feedback to the team are required Burns, Each institution should determine the best protocol to use in its intensive care units. Expertise of the critical care nurse is vital to the weaning process. Weaning protocols have been helpful in decreasing the number of days on a ventilator for patients with severe sepsis Dellinger et al. Once the patient has met the criteria for the wean screen arousable, hemodynamically stable, FiO2 at levels that could be maintained by a face mask or nasal prongs, and minimal ventilator support , an SBT should be initiated.
If the patient is successful, extubation should then be considered. Failure to wean is related to many factors, such as patient anxiety, premature weaning attempts, and sleep deprivation.
Clinician experience plays a role in weaning the patient from the mechanical ventilator Grossbach, If the patient fails the SBT, it is impor- tant to rest the patient overnight and attempt the SBT only once every 24 hours. Treating the reversible causes, such as pain, excessive sedation, fluid imbalance, and other organ dysfunction e. To manage the care of a patient requiring mechanical ventilation, the critical care nurse requires edu- cational support so that he or she is knowledgeable in evidence-based practice.
A self-assured critical care nurse fosters trust and patient confidence, which in turn advances the weaning process. Having a consistent staff that can provide support and encouragement will also positively influence patient outcomes. Sometimes, however, a patient is unable to wean from the ventilator despite multiple attempts and will require placement in a long-term ventilation unit.
It is important that the family understands that the patient may die as soon as the ventilator is withdrawn or the patient may not succumb for several days. Reassure the family that the patient will be made comfort- able during this process with the use of sedation and analgesia.
There are two primary methods of withdrawing mechanical venti- lator support from the patient. One method is a gradual terminal wean- ing; the other is immediate withdrawal of ventilator support Stacey, To begin the process, the room should be made comfortable for the family by dimming the lights, removing any unnecessary equip- ment, and by keeping the environment quiet and respectful.
Remove unnecessary monitoring devices to avoid alarm situations. Discontinue any life-saving interventions such as intropes or other devices. To initi- ate terminal weaning, the ventilator rate is slowly turned down over a specified period of time in addition to reducing the FiO2 to 0.
It is important to provide analgesic and sedation, as well as bronchodilators to ensure patient comfort. The other method of withdrawing mechani- cal ventilation is immediate withdrawal by disconnecting the patient from the ventilator and extubating the patient.
Immediately after extu- bation, the patient may exhibit transitory signs of respiratory distress, which are managed by repositioning the airway, and sedation. In providing holistic care during this process, the critical care nurse should offer spiritual support to the patient and the family.
To illuminate meaning of this experience, encourage the family to recount stories about the life of the patient. Allow unrestricted access to the patient during this time. Encourage the family to touch and talk to the patient. Support for the family at this time is crucial.
As death is imminent, prepare the family for the physical manifestations that may be encountered, such as changes to skin color, skin temperature, respiratory pattern, or reflexes. Respirations may become noisy as the lungs fill with fluid.
Once death has occurred, the critical care nurse provides bereavement care based on the unique needs of the family. It may be necessary to provide a referral to counseling services for further bereavement support. Providing end-of-life care is a stressful time for health care provid- ers and may lead to compassion fatigue.
It is important for the criti- cal care nurse to arrange and participate in a formal debriefing with members of the interprofessional team soon after death occurs. This mutual support will assist the team members in providing quality end-of-life care. The first step in the process is to assess the patient using a hospital-specific screening tool or a reliable and valid tool such as the BWAP tool. Optimize conditions by ensuring that the patient is well rested, fluid status is addressed, cardiorespiratory stability is es- tablished, and oxygenation is within an acceptable range.
An SBT is attempted once every 24 hours to maintain conditioning of respira- tory muscles. Periods of rest alternating with prolongation of periods of spontaneous respiration are gradually increased. If the long-term ven- tilated patient is able to breathe spontaneously for 24 hours, then the patient may be extubated. Compare and contrast short-term ventilation and long-term ven- tilation. Describe the different weaning techniques and the advantages of each technique.
Provide a documentation note for the patient just extubated. Weaning Case Study Mr. Brian Snider, a year-old male, underwent a double valve replacement 6 days ago as a result of endocarditis. He received two biosynthetic valves to replace his mitral and tricuspid valves. Past health includes a pack-year history of cigarette smoking, mild chronic obstructive pulmonary disease, and hypertension. Snider required a prolonged period of time to stabilize due to postoperative bleeding.
He returned to the operating room for exploration of his chest cavity for the source of bleeding. When Mr. Snider returned from the operating room, he required the use of intropes to stabilize his blood pressure. On postoperative day 5, the inotropes were successfully weaned. For the past 3 days Mr. Today, postoperative day 6, Mr. Snider successfully passed the SBT and returned to the ventilator to be rested.
Show less. About the Authors. Download Links. You may also like. Airway Management Chapters. Bag-valve-mask ventilation. Endotracheal intubation. Cuff leaks. The Difficult Airway. Emergent Cricothyroidotomy. Ventilator Mechanics. Ventilator Modes. Assessing Lung Physiology. Mechanical Ventilation in Restrictive Lung Disease. Mechanical Ventilation in Obstructive Lung Disease.
Ancillary Methods to Mechanical Ventilation. Patient Outcomes post Mechanical Ventilation. Readiness testing and predictors.
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