• List the necessary equipment and critical steps for preparing a patient for Rapid Sequence Intubation (RSI).
• State the four crucial methods for confirming proper Endotracheal Tube (ETT) placement.
• Differentiate between the primary modes of mechanical ventilation (A/C, SIMV, PSV) and their clinical uses.
• Explain the significance of the four key critical ventilation parameters (VT, Rate, FiO2, PEEP).
• Apply the Ventilator-Associated Pneumonia (VAP) bundle to minimize patient risk.
• Perform assessment and troubleshooting of acute respiratory distress in the mechanically ventilated patient.

Endotracheal Intubation (ETI): Principles and Nursing Role

Endotracheal Intubation (ETI) is the process of placing a flexible tube into the trachea to maintain a patent airway and provide mechanical ventilation. For a nurse, ETI represents a critical moment in patient care, demanding preparation, rapid assessment, and precise intervention.

Indications and Goals of Intubation

The primary goal of ETI is to support the patient's oxygenation and ventilation until the underlying cause of respiratory failure is resolved.

• Airway Protection: Preventing aspiration in patients with decreased level of consciousness, such as from drug overdose, stroke, or trauma.
• Respiratory Failure: Inability to maintain adequate oxygenation (PaO2) or ventilation (PaCO2), often requiring positive pressure support.
• Apnea or Severe Respiratory Distress: Complete cessation of breathing or severe exhaustion that precedes failure, for example, during a severe asthma exacerbation.
• General Anesthesia: Used to protect the airway and facilitate ventilation during surgical procedures.

Nursing Role: Before Intubation

Preparation is crucial for a successful and rapid intubation, often referred to as Rapid Sequence Intubation (RSI).

• Gather Equipment: Ensure all equipment is organized and functional.
  • Suction: Test wall suction and have a Yankauer catheter and inline suction available.
  • Oxygen: Have a 100% oxygen delivery system (bag-valve mask or Ambu bag) ready and connected.
  • Airway Supplies: Laryngoscope (check light source), various endotracheal tube (ETT) sizes—typically 7.0-8.5 mm for adults—a stylet, and a syringe to inflate the cuff.
  • Securement: Have a commercially available ETT holder or tape prepared.
• Be prepared to administer pre-medication, induction agents, and paralytics. A common RSI sequence involves a sedative/hypnotic, such as propofol or midazolam, followed immediately by a paralytic like succinylcholine or rocuronium.
• Position the patient in the "sniffing position" (neck flexed, head extended) to align the oral, pharyngeal, and tracheal axes for optimal visualization of the vocal cords.

Nursing Role During Intubation

The nurse monitors the patient and assists the provider, ensuring proper tube placement is confirmed immediately.

• Monitor Vitals: Continuously monitor heart rate, blood pressure, and oxygen saturation. Brief periods of desaturation during the attempt are expected.
• Cricoid Pressure: Apply gentle pressure on the cricoid cartilage (known as the Sellick maneuver) to occlude the esophagus, reducing the risk of gastric inflation and aspiration.
• Confirmation of Placement: Once the ETT is placed and the cuff is inflated, the following steps must be performed simultaneously to confirm tracheal placement and rule out dangerous esophageal placement:
  1. Auscultation: Listen for bilateral breath sounds over the lung fields and absence of sounds over the stomach (epigastrium).
  2. Capnography: The most reliable method. Check for the presence of end-tidal CO2 (EtCO2) indicated by a gold color on a colorimetric device or a waveform on the monitor. Sustained CO2 detection confirms tracheal placement.
  3. Visualization: Observe for bilateral chest rise and fall.
  4. Condensation: Look for condensation (fogging) in the ETT during exhalation.

Nursing Role After Intubation

• Securement: Secure the ETT immediately with a commercial ETT holder or tape at the measured depth, for example, 23 cm at the lip.
• Chest X-ray: Obtain a stat chest X-ray to confirm the final position of the ETT tip, which should rest 2-4 cm above the carina.
• Documentation: Document the tube size, the depth of the tube at the lip or gumline, initial CO2 readings, and the patient's response.
• Begin Ventilation: Connect the patient to the mechanical ventilator and ensure initial prescribed settings are accurate.

Mechanical Ventilation (MV) is the process by which a machine (ventilator) assists or completely replaces spontaneous breathing.

Goals and Physiologic Effects

• Maintain Alveolar Ventilation: Ensure adequate PaCO2 and pH.
• Improve Oxygenation: Increase PaO2 and SaO2.
• Reduce Work of Breathing: Allow respiratory muscles to rest and recover.
• Physiologic Impact: MV, especially with Positive End-Expiratory Pressure (PEEP), increases intrathoracic pressure, which can decrease venous return to the heart, potentially leading to hypotension, a critical side effect.

Ventilator modes dictate the control the machine has over the patient's breathing.

• Assist-Control (A/C) or Continuous Mandatory Ventilation (CMV):
  • Function: The ventilator delivers a preset tidal volume (VT) or pressure and a preset rate. If the patient spontaneously breathes, the ventilator assists by delivering the full mandatory breath.
  • Use: Used for patients requiring full respiratory support (heavily sedated or paralyzed).
  • Risk: Hyperventilation and respiratory alkalosis if the patient triggers many breaths.
• Synchronized Intermittent Mandatory Ventilation (SIMV):
  • Function: The ventilator delivers a preset tidal volume (VT) or pressure at a preset rate. Mandatory breaths are synchronized with the patient's spontaneous effort. Spontaneous breaths taken between mandatory breaths are limited to the patient's own effort, receiving no machine assistance.
  • Use: Used for weaning; allows the patient to exercise respiratory muscles.
• Pressure Support Ventilation (PSV):
  • Function: All breaths are spontaneous. The ventilator applies a preset amount of positive pressure to the patient’s spontaneous inspiratory effort to overcome the resistance of the ETT and reduce the work of breathing.
  • Use: A comfort or weaning mode; the patient must have a reliable respiratory drive.

Critical Ventilation Parameters

• Tidal Volume (VT)
  • Definition: Volume of gas delivered with each breath.
  • Typical Range: 6-10 mL/kg (Ideal Body Weight)
  • Nursing Significance: Keep low (4-8 mL/kg) for ARDS to prevent barotrauma.
• Rate (f)
  • Definition: Number of breaths the ventilator delivers per minute.
  • Typical Range: 10-20 breaths/min
  • Nursing Significance: Affects PaCO2 (ventilation). Increasing the rate decreases CO2.
• FiO2
  • Definition: Fraction of inspired oxygen (concentration).
  • Typical Range: 0.21-1.0 (21% to 100%)
  • Nursing Significance: Use the lowest possible setting (<0.5 - 0.6) to maintain PaO2 to prevent oxygen toxicity.
• PEEP
  • Definition: Positive End-Expiratory Pressure. Pressure applied at the end of expiration.
  • Typical Range: 5-15 cm H2O
  • Nursing Significance: Prevents alveolar collapse. High PEEP can reduce cardiac output and cause hypotension.

This guide provides a comprehensive overview of the crucial nursing responsibilities related to endotracheal intubation (ETI) and the management of patients on mechanical ventilation (MV). These interventions are fundamental in critical care, often representing the difference between life and death for patients in acute respiratory failure. This resource is designed to solidify your knowledge of procedural preparation, continuous patient monitoring, interpretation of ventilator settings, and rapid troubleshooting, ensuring safe and effective care in the intensive care unit.