Worse Case Scenario 2: Intubation

by Andria RN · 0 comments

in ICU,Podcast,Uncategorized

Download to learn more about respiratory failure, and what the nurse does before, during, and after intubation.

Causes of Respiratory Failure

Sepsis, Pneumonia (aspiration), COPD Exacerbation, Trauma, Pulmonary Embolism, Pneumothorax, and Pleural Effusion

What is a pleural effusion?

A pleural effusion is an abnormal collection of fluid in the pleural lining which disrupts oxygen exchange and can cause symptoms in a patient when fluid reaches 1500ml. It is caused by CHF, cirrhosis, nephrotic syndrome or an infectious process.
They are diagnosed and monitored by CXR, CT Scan and Ultrasound. Treat with diuresis, thoracentesis or pleurodesis.

What does an Intubated patient look like before they are intubated?

  1. The patient is already intubated. Respiratory sets up the ventilator- the nurse should have sedation ready if necessary. Let the patient settle in, especially if you transferred the patient from bed to stretcher. Check the ventilator settings and note when the next ABG should be drawn. If the patient has not had one, call provider and get an order.
  2. Patients in Respiratory Distress on the BiPap. Do not do a full assessment. Let the patient relax and get settled. You can still listen to lung sounds but don’t ask the patient to speak or to perform motor strength tests. Treat anxiety as needed. Make sure there has been a recent ABG and CXR taken.
  3. Sudden Respiratory Failure: This is the patient that was doing fine on small volumes of oxygen and suddenly decompensates. Have Respiratory ventilate patient with ambu bag if necessary or place venti mask at highest percentage. Get ABG, CXR and notify provider. Monitor for arrythmias, confusion and sleepiness.
  4. Decreased Glasgow Coma Scale Score: This is the patient with a worsening head issue, hepatic encephalopathy, increasing lethargy, etc. We are taught that ET intubation occurs with a GCS less than 8, but this is not ALWAYS the case. Think about intubating any Neuro or Trauma patient who is at risk for aspiration (poor cough and gag reflex) or respiratory decline (low RR, lethargy).
  5. Code Blue: A patient that is in VFib, Pulseless Vtach or PEA will likely be intubated in a code situation. Chest compressions are not performed during the actual intubation but are resumed after tube is in place. Patient is ventilated with 100% oxygen while continuous chest compressions are performed.

Notes about Positive Airway Pressure (CPAP and BiPAP)

Positive Airway Pressure only used with patients who are breathing spontaneously. PAP is often used with pulmonary edema and COPD exacerbation patients.

 

CPAP isn’t used for patients with CO2 retention. CPAP delivers one level of pressure (5-15cmHg) and there is no rate setting so this won’t be used for a patient who is retaining CO2- it helps keep alveoli open so is good for patients with low O2 sats who just need help oxygenation- not ventillating.

 

BiPAP has two settings, an inhaled pressure and an exhaled pressure (IPAP and EPAP). BiPAP ventilation helps recruit alveoli AND delivers a respiratory rate if necessary so it can be used for patients with high CO2.

What does the nurse do during an intubation?

If you call the ABG results to the provider and he/she tells you to prepare for intubation- grab the intubation tray (usually located on the code cart).

Get consent if patient is able to consent or family is present. If it is an emergency, have the MD sign the consent form after the intubation.

Ask provider which medications they would like to use. Know the difference between anesthetics, analgesics and paralytics. Listen to the audio version of this post for more information about specific drugs.

  • Anesthetic: Loss of feeling/awareness, do not treat pain→ Etomidate, Versed, Propofol
  • Analgesic: Treat pain → Fentanyl
  • Paralytic: Muscle Relaxers →Rocuronium* *must be given by qualified personnel!

Pre-oxygenate the patient for 2-3 minutes with 100% oxygen. This is usually done by Respiratory Therapy via the ambu bag.

During the intubation there are a lot of hands in the cookie jar and a lot of hustle and bustle. Make sure someone is recording medications (name, dose, time) and don’t forget to write this order in the chart and on the medication record. If the nurse is unable to give a certain medication- write that it was written by HCP.

How often do you need a blood pressure? Most monitors in the ICU have an option to record a blood pressure every 2-3 minutes. A patient that is coding should either have the stat blood pressure button pressed or the 1 minute option.

Set up suction cannisters if not already done.

No CPR during the actual intubation if the patient is coding. Resume compressions after airway is in place.

Provider may ask for cricoid pressure which is slight pressure to the cricoid airway to help the provider better visualize the airway.

Know which blade is which! The Miller Blade is straight (The LL in Miller is a straight letter) and the Macintosh Blade is curved (like a Macintosh Apple.)

Top: Macintosh Blade Bottom: Miller Blade

Continue to monitor O2 sats. If the HCP provider is taking a long time to intubate, perhaps the patient needs to be bag mask ventilated for another 2 minutes before the second attempt. If the airway is difficult, send for the difficult airway cart. At our facility- respiratory therapy brings this to the bedside.

While the provider is intubating, start setting up yoru sedation- ask provider which meds they would like to use. Take advantage of the extra help and ask for PCA pumps, extra tubing, etc.

What does the nurse do after the endotracheal tube is in place?

With your stethoscope, listen to the stomach FIRST to make sure the tube is not esophageal. Then assess symmetry of breath sounds in right and left lungs realizing that the ET tube has a tendency to end up on the right side of the lung because it’s bigger.

Use the CO2 detector to aid in placement determination.

RT will set up the ventilator to the ordered parameters (per physician- so if you don’t have orders, get some).

Get a CXR to confirm ET placement! The radiologist will call you quickly if the tube is not in place.

Verify with the provider, but usually the nurse or respiratory therapy will get a follow up ABG in 1-2 hours.

If your patient needs restraints, have HCP sign the order.

If your patient was taking PO meds before intubation, now they will likely need an
NGT/OGT or small bore feeding tube.

Often the HCP will want to place an arterial line and/or a central line as well.

And last but not least- don’t worry! This always sounds worse than it is and is frightening for a new nurse but it is really not that bad. When the chain of events start, you’ll have a lot of help and after your patient is intubated- they will likely be much more calm and comfortable.

Email me at host@newnurseblog.com if you have any questions or comments! Or sign in to make a comment below.

Links:

CPAP vs BiPAP
http://www.lakesidepress.com/CPAP/CPAP.htm

Difficult Airway
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1200729/

Video of Endotracheal Intubation

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