10 Mechanical Ventilation & Endotracheal Intubation Nursing Care Plans

Impaired Spontaneous Ventilation

In general, maintenance of spontaneous breathing in clients diagnosed with acute respiratory failure (ARF) under ventilatory support such as endotracheal intubation and/or tracheostomy has many positive effects such as improving oxygenation, preventing the mass loss and atrophy of the peripheral muscles, protecting against the diaphragm dysfunction, reducing the need for pharmacological sedation, and curbing the incidence of delirium. In clients diagnosed with acute respiratory distress syndrome (ARDS), the inspiratory effort might be affected by different stimuli not always subjected to ventilatory support. Different degrees of lung inflammation could influence the respiratory drive irrespective of gas exchange impairment. In clients diagnosed with COVID-19, the direct invasion of respiratory centers due to the virus may cause an alteration of the respiratory drive, thus affecting inspiratory effort (Tonelli et al., 2021). 

Nursing Diagnosis

• Impaired Spontaneous Ventilation

May be related to

• Acute respiratory failure
• Noncompliant lung tissue
• Respiratory muscle weakness or paralysis
• Altered O2/CO2 ratio

Possibly evidenced by

• Adventitious breath sounds
• Apnea
• Apprehension
• Arterial ph less than 7.35
• Decreased tidal volume
• Decreased oxygen saturation (Sao₂ <90%)
• Decreased Pao₂ level (>50 to 60 mm Hg)
• Diminished lung sounds
• Dyspnea
• Forced vital capacity less than 10 mL/kg
• Increased Paco₂ level (50 to 60 mm Hg or higher)
• Increased or decreased respiratory rate
• Inability to maintain airway (emesis, depressed gag, depressed cough).
• Restlessness

Desired Outcomes

• The client will maintain spontaneous gas exchange resulting in reduced dyspnea, normal oxygen saturation, and normal arterial blood gases (ABGs) within client parameters.
• The client will demonstrate an absence of complications from mechanical ventilation.
• The client will participate in efforts to wean within the individual ability as appropriate.
• The caregiver will demonstrate behaviors necessary to maintain the client’s respiratory function.

Nursing Assessment and Rationales

Prior intubation assessment:

1. Investigate the etiology of respiratory failure.
Understanding the underlying cause of the client’s particular ventilatory problem is essential to the care of the client, for example, decisions about future capabilities and ventilation needs and the most appropriate type of ventilatory support. The client should have a correctable underlying problem that can be resolved with the support of mechanical ventilation because there is no mode of mechanical ventilation that can cure a disease process (Jackson et al., 2020).

2. Observe changes in the level of consciousness.
Early signs of hypoxia include disorientation, irritability, and restlessness, while lethargy, stupor, and somnolence are considered as late signs. Mechanical ventilation is indicated for both hypercapnic respiratory failure and hypoxemic respiratory failure (Amitai & Mosenifar, 2020).

3. Assess the client’s respiratory rate, depth, and pattern, including the use of accessory muscles. 
Changes in the respiratory rate and rhythm are early signs of possible respiratory distress. As moving air in and out of the lungs becomes more difficult, the breathing pattern changes to include the use of accessory muscles to increase chest excursions. Mechanical ventilation is indicated when the client’s spontaneous ventilation is inadequate to sustain life. It is indicated as a measure to control ventilation in critically ill clients and as prophylaxis for the impending collapse of other physiologic functions such as respiratory or mechanical insufficiency and ineffective gas exchange (Jackson et al., 2020).

4. Assess the client’s heart rate and blood pressure.
Tachycardia may result from hypoxia. Increased blood pressure happens in the initial phases then followed by lowered blood pressure as the condition progresses. Sufficiently severe hypoxia can result in tachycardia to provide sufficient oxygen to the tissues (Bhutta et al., 2022).

5. Auscultate the lung for normal or adventitious breath sounds.
Adventitious breath sounds such as wheezes and crackles are an indication of respiratory difficulties. Quick assessment allows for early detection of deterioration or improvement. Bilateral basilar crackles may indicate pulmonary edema or volume overload, other signs of that includes jugular vein distention and lower limb edema. Wheezing and rhonchi can be found in obstructive lung disease. Absent unilateral air entry can be caused by either massive pleural effusion or pneumothorax. Clear lung fields in the presence of hypoxia should raise suspicion of pulmonary embolism, especially if the client is tachycardic and has evidence of DVT (Bhutta et al., 2022).

6. Assess the skin color and examine the lips and nailbeds for cyanosis.
Bluish discoloration of the skin (cyanosis) indicates an excessive concentration of deoxygenated blood and that breathing pattern is ineffective to maintain adequate tissue oxygenation. Cyanosis might indicate severe hypoxia (Bhutta et al., 2022).

7. Monitor oxygen saturation using pulse oximetry.
Pulse oximetry is useful in detecting early changes in oxygen. Oxygen saturation levels should be between 92% and 98% for an adult without any respiratory difficulties. Resting arterial oxygen saturation (SaO2) less than or equal to 95% or exercise desaturation greater than or equal to 5% is considered abnormal. However, clinical correlation is always necessary as the exact cut-off below which tissue hypoxia ensues has not been defined (Bhutta et al., 2022).

8. Monitor arterial blood gases (ABGs) as indicated.
Increasing PaCo2 and decreasing PaO2 indicate respiratory failure. If the client’s condition begins to fail, the respiratory rate and depth decrease, and PaCo2 begins to rise. PaCO2 is an indirect measure of the exchange of CO2 with the air via the alveoli, its level is related to minute ventilation (Bhutta et al., 2022).

After intubation assessment:

9. Assess for correct endotracheal (ET) tube placement through observation of a symmetrical rise of both chest sides, auscultation of bilateral breath sounds, and X-ray confirmation.
Correct ET tube placement is important for effective mechanical ventilation. Changes in chest symmetry may indicate improper placement of the ET tube or the development of barotrauma. Frequent crackles or rhonchi that do not clear with coughing or suctioning may indicate developing complications, such as atelectasis, pneumonia, acute bronchospasm, and pulmonary edema.

10. Assess for the client’s comfort and the ability to cooperate while on mechanical ventilation.
Client discomfort may be secondary to incorrect ventilator settings that result in insufficient oxygenation. Once intubated and breathing on the mechanical ventilator, the client should be breathing easily and not “fighting or bucking” the ventilator.

11. Assess the ventilator settings and alarm system every hour.
The assessment ensures that settings are accurate and alarms are functional. Controls and settings are adjusted according to the client’s primary disease and results of diagnostic testing to maintain parameters within appropriate limits. Do not turn off alarms, even for suctioning. Ventilators have a series of visual and audible alarms, such as oxygen, low volume or apnea, high pressure, and inspiratory/expiratory (I:E) ratio. Turning off or failing to reset alarms places the client at risk for unobserved ventilator failure or respiratory distress or arrest.

12. Count the client’s respirations for 1 full minute and compare with desired respirations and ventilator set rate.
Respirations may vary depending on the problem requiring ventilatory assistance; for example, the client may be totally ventilator dependent or be able to take breaths on their own between ventilator-delivered breaths. Rapid client respirations can produce respiratory alkalosis and prevent the desired volume from being delivered by the ventilator. Slow client respirations and hypoventilation increases PaCO2 levels and may cause acidosis.

Nursing Interventions and Rationales

1. Maintain the client’s airway. Use the oral or nasal airway as needed.
An artificial airway is used to prevent the tongue from occluding the oropharynx. Different-sized oral appliances are available and measured from the lip to the angle of the jaw. These are useful for clients with spontaneous respirations who need help to keep their airways open (Avva et al., 2022).

2. Maintain client in a High-Fowler’s position as tolerated. Frequently check the position.
This position promotes oxygenation via maximum chest expansion and is implemented during events of respiratory distress. Do not let the client slide down; this causes the abdomen to compress the diaphragm, which could cause respiratory change.

Preparation for endotracheal intubation:

3. Notify the respiratory therapist to bring a mechanical ventilator.
Mechanical ventilators are classified according to the method by which they support ventilation. The two types are negative-pressure and positive-pressure ventilators (used most frequently). Volume-cycled ventilation is the most common form of ventilator cycling used in adult medicine because it provides a consistent breath-to-breath tidal volume (Jackson et al., 2020).

4. Prepare the following equipment: ET tubes of different sizes; blades, laryngoscope, and stylet; syringe, benzoin, and waterproof tape or other securing materials; and local anesthetic agent (e.g., Xylocaine spray or jelly, benzocaine spray, cocaine, lidocaine, and cotton-tipped applicators.
Endotracheal tubes come in various sizes and shapes. Adult sizes range from 7 to 9 mm. Selection is based on the client’s size. Blades and scopes facilitate the opening of the upper airway and visualization of the vocal cords for the placement of oral ET tubes. A stylet makes the ET tube firmer and gives additional support to direction during intubation. A syringe is used to inflate the balloon (cuff) after the ET tube is in position. Tape and benzoin are used to secure the ET tube. These anesthetic agents suppress the gag reflex and promote general comfort.

Administer sedation as ordered.

5. Sedation facilitates comfort and ease of intubation. Pretreatment agents may be used to mitigate the physiologic response to laryngoscopy and induction and paralysis, which may be undesirable in certain clinical situations. Pretreatment medications are typically administered two to three minutes prior to induction and paralysis. These medications can be remembered by using the mnemonic LOAD (Lidocaine, Opioid analgesic, Atropine, Defasciculating agents) (Lafferty & Soo, 2020).

Assist with intubation:

6. Place the client in a supine position, hyperextending the neck unless contraindicated, and align the client’s oropharynx, posterior oropharynx, and trachea.
This position is necessary to promote the visualization of landmarks for accurate tube insertion. In the neutral position, the oral, pharyngeal, and laryngeal axes are not aligned to permit adequate visualization of the glottic opening. Place the client in the sniffing position for adequate visualization; flex the neck and extend the head. Studies have shown that simple head extension alone was as effective as the sniffing position in facilitating endotracheal intubation (Lafferty & Soo, 2020).

7. Apply cricoid pressure (Sellick maneuver) as directed by the healthcare provider.
Use of cricoid pressure to prevent passive regurgitation during rapid sequence intubation. It may also prevent passive regurgitation of gastric and oesophageal contents. This maneuver may lack supporting literature and may impede the laryngeal view, it is still initiated to prevent the regurgitation of gastric contents. Initiate this maneuver upon observing the beginning of unconsciousness. Maintain pressure throughout the intubation sequence until the position of the ET tube is verified (Lafferty & Soo, 2020).

8. Preoxygenate the client as indicated.
Administer 100% oxygen via a nonrebreather mask for three minutes for nitrogen washout. This is done without positive pressure ventilation using a tight seal. Assist ventilation with a bag-valve-mask (BVM) system only if needed to obtain an oxygen saturation equal to 90%. The client must be adequately pre-oxygenated to prevent desaturation during the apnea after the paralytic agent has been administered.

9. Assist with the verification of correct ET tube placement. Use an end-tidal carbon dioxide detector as indicated.
Correct placement is needed for effective mechanical ventilation to prevent complications associated with malpositioning such as vomiting, hypoxia, gastric distention, and lung trauma. The current criterion standard is end-tidal carbon dioxide detection, using either a calorimetric capnometer that changes color from purple to yellow with CO2 exposure or a quantitative capnometer that measures CO2 levels and can display a waveform. The yellow color change should occur rapidly within one to two breaths (Lafferty & Soo, 2020). Other capnography devices that provide numerical measurements of end-tidal carbon dioxide (normal value is 35 to 45 mm Hg) and Capnograms may also be used.

10. Continue with manual Ambu bag ventilation until the ET tube is stabilized. Assist in securing the ET tube once tube placement is confirmed.
Stabilization is necessary before initiating mechanical ventilation. Blow-by high-flow oxygen via a nonrebreather mask is usually used, but for clients who are noted to desaturate beyond 90%, breaths delivered via 100% oxygen BVM may be required. A client who is hypoxemic during attempts at intubation should undergo positive pressure ventilation with a BVM to raise PaO2 levels (Lafferty & Soo, 2020).

11. Document the ET tube position, noting the centimeter reference marking on the ET tube.
Documentation provides a reference for determining possible tube displacement, usually 21 cm for women and 23 cm at the lips for men. Traditionally, an endotracheal tube size 7.0 is used for women, while an 8.0 is used for men. Variations in size depend on the client’s height and whether they will require bronchoscopy (Alvarado & Panakos, 2022).

12. Institute mechanical ventilation with prescribed settings.
Modes for ventilating (assist/control, synchronized intermittent mandatory ventilation), tidal volume, rate per minute, a fraction of oxygen in inspired gas (F_IO2), pressure support, positive end-expiratory pressure, and the like must be preset and carefully evaluated for response. In most circumstances, the initial mode of ventilation should be AC mode. The client can affect the frequency and timing of the breaths. If the client makes an inspiratory effort, the ventilator senses a decrease in the circuit pressure and delivers the preset tidal volume. This way, the client can dictate a comfortable respiratory pattern (Jackson et al., 2020).

13. Anticipate the need for nasogastric and/or oral gastric suction.
Abdominal distention may indicate gastric intubation and can also occur after cardiopulmonary resuscitation when the air is inadvertently blown or bagged into the esophagus, as well as the trachea. Suction prevents abdominal distention. Oral gastric suctioning may also reduce the risk of sinusitis.

14. Administer muscle-paralyzing agents, sedatives, and opioid analgesics as ordered:

14.1 Induction agents
Induction agents provide a rapid loss of consciousness that facilitates ease of intubation and avoids psychic harm to the client. Etomidate has a rapid onset, short duration, is cerebroprotective, and is not associated with a significant drop in blood pressure. It is hemodynamically neutral compared with other agents, such as sodium thiopental. Ketamine produces a “dissociative” state, has analgesic properties, is a bronchodilator, and may decrease rather than increase intracranial pressure (Lafferty & Soo, 2020).

14.2 Paralyzing agents
These agents provide neuromuscular blockade and are administered immediately after the induction agent. The neuromuscular blockade does not provide sedation, analgesia, or amnesia; thus, administering a potent induction agent is important. Succinylcholine has a rapid onset (45 to 60 seconds) and the shortest duration of action (8 to 10 minutes). Rocuronium has a slightly longer onset of action (60 to 75 seconds) and a longer duration of action (30 to 60 minutes) (Lafferty & Soo, 2020).

15. Examine the cuff volume by checking whether the client can talk or make sounds around the tube or whether exhaled volumes are significantly less than the volumes delivered. To correct this, slowly reinflate the cuff with air until no leak is detected. Notify the respiratory therapist to check cuff pressure.
Cuff pressure should be maintained at 20 to 30 mm Hg. Maintenance of low-pressure cuffs prevents many tracheal complications formerly associated with ET tubes. Notify the healthcare provider if the leak persists. The ET tube cuff may be defective, requiring the HCP to change the tube.

16. Position the client by elevating the head of the bed if possible.
Elevating the client’s head and helping the client get out of bed while still on the ventilator is both physically- helps decrease the risk of aspiration- and psychologically beneficial. All clients on mechanical ventilation should have the head of the bed elevated to at least 30 degrees. According to a Cochrane review on ventilator-associated pneumonia, “ a semi-recumbent position reduced clinically suspected VAP by 25.7% when compared to a supine position” (Hickey & Giwa, 2022).

17. Inflate the endotracheal tube cuff properly. Check cuff inflation every 4 to 8 hours.
The cuff must be properly inflated to ensure adequate ventilation and delivery of desired tidal volume and to decrease the risk of aspiration. Endotracheal cuff pressures should be monitored initially after intubation and every 4 hours thereafter, with goal pressures of 20 to 30 cm water, as an increased risk of pneumonia has been associated with cuff pressures less than 20 cm water (Amitai & Mosenifar, 2020).

18. Note inspired humidity and temperature; use a heat moisture exchanger (HME), as indicated.
The usual warming and humidifying function of the nasopharynx are bypassed with intubation. Dehydration can dry up normal pulmonary fluids, cause secretions to thicken, and increase the risk of infection. The temperature should be maintained at about body temperature to reduce the risk of damage to cilia and hyperthermia reactions. The introduction of a heated wire circuit to the traditional system significantly reduces the problem of “rainout” or condensation in the tubing.