Periwinkle is a lovely color. A soft, subtle blue, it looks best as Helen Hunt’s eyeshadow in 1995 or on an Easter egg. It looks worst on your patient’s skin. While waiting for the respiratory therapist to come bail you out, understanding some common sense and troubleshooting will keep your patient pink, or in my case, healthy brown instead of sickly green. Let’s talk about some tips for new nurses working with ventilators. And, please remind me in the comments to seek professional help about my troubling childhood, because this is not the first time I’ve compared cyanosis to eyeshadow.
Top Tips for New Nurses Working With Ventilators
The Patient’s Condition
Moving on, the patient’s condition will help prioritize your response to various alarms, whistles, and catcalls from the ventilator.
- Do they have ARDS and need every possible molecule of oxygen stuffed into those stubborn alveoli?
- Is this a patient the intensivist didn’t feel like extubating at shift change so we’ll wean them in the morning?
- Has there been in a change in patient behavior or vent settings?
- How much time does it normally take to recruit competent help if you need it?
I’m talking real life, not some ideal job where you drop everything to deal with each alarm rather than blissfully ignore irrelevant ones if you’re busy. Alarm fatigue is a completely different discussion and one I’m the wrong person to lead because I’m evil and would set my alarm limits to narrow ranges to see how many times during a shift a meticulous coworker of mine would come over and cancel my alarms for me. Remember to prioritize by what an alarm means, not how annoying it sounds. Otherwise, an Alaris pump going off would mean “I will eat your patient’s soul if you do not flick the air bubble out of this IV line” while sudden onset atrial fibrillation in a patient with an already weak heart is a “meh” moment.
Vitals With Ventilators
Once you know why a patient has a plastic tube forcing air between their vocal cords, you can better predict what will happen to their vital signs because of the alarm or message on the ventilator. This is how I practice anesthesia–I always care much more about where the oxygen saturation will be in 30 seconds than what’s currently on the screen. Especially on a sick patient, the data from a good looking pleth (and please look at the oximetry waveform every time you look at the number) is much more delayed than the instant electrical impulse from an EKG, and it’s not that accurate below 75% anyway. Am I saying that the saturation could dip below normal and your patient could be perfectly fine?! Yes, just like you can float underwater much longer than you can flail and blow bubbles. Overreacting is almost as holy as “critical thinking” in nursing culture, but even as a new nurse, having a general idea of what you can handle and what requires a few phone calls serves your patients well.
Are You Touching My Tube?
As a self-proclaimed nurse hobo, I probably worked in 50 different ICUs before anesthesia school. In most of them, the rule from RT was, “Don’t touch the tube or my vent, unless it’s the 100% O2 button so the sat will look better despite the patient coughing.” In some cases, my valuable information above isn’t enough and you’ll need to mess with the tube anyway, since we all know the only unbreakable rule is, “Do what’s best for the patient.” And maybe, “If there’s unattended food on the table in the break room, anyone can eat it.” Always follow the endotracheal tube from where it exits the mouth, between 21-24 centimeters, and the eventual attachment of inhalation and exhalation connections to the ventilator. For adequate ventilation, pressure and CO2 tracings should look like squares, not shark fins or the spiky part of an EKG–er, R wave. A tube pushed down too far only ventilates one lung and results in much higher pressures and usually lower saturation. A patient who suddenly extubates themselves might need an ambu bag (preferably with an oral airway and jaw thrust), CPAP via mask, or a non-rebreather mask whether or not the plan is to reintubate them. The combination of a tube that is no longer between the vocal cords blowing air around and one of the above looks silly and doesn’t work. Shut the vent off. This is not the time to worry about giving the patient too much oxygen, but please remember that 100% oxygen doesn’t help someone who isn’t breathing. In fact, if a partially or completely paralyzed patient gets extubated, you should push the code button, because there isn’t much time to decide whether to reintubate immediately, push sugammadex to reverse paralysis from rocuronium or vecuronium, or continue down the airway algorithm.
How Ventilators Work
The above .gif of mind-blown Dr. Phil is pretty much what a partially paralyzed patient looks like, minus his vibrant pink hue. Listen, we’ve already established that I’m a terrible person–let’s finish with a quick review of how ventilators work. Yeah, I know, maybe we should have started with this, but I think of Dr. Phil as more of a closer than Helen Hunt. Normally, we inhale because of negative pressure caused by pressure differences between the lungs and the chest wall. This is why you should avoid being stabbed in the lung. Ventilators deliver a consistent volume of air and oxygen into the lungs without exceeding set pressures or allowing alveoli to deflate in the complete absence of pressure. The various acronyms for types of ventilation simply tell us whether each attempt to inflate the lungs is more focused on reaching a particular volume or pressure. Some modes, such as SIMV, are more accommodating when the patient tries to breathe on their own. If the patient’s coughing is continually setting off alarms, it may be time to consider one of those modes, start the weaning process, or increase sedation with infusions of propofol and/or fentanyl, Precedex, or, if your hospital is really poor, morphine and Versed. The important alarms relate to high pressure or low volume. Often this is because laminar flow becomes turbulent. The smooth, golden stream moving through catheter tubing after you insert a Foley into a patient who really needs it is an example of laminar flow. Turbulent flow is what makes whitewater rafting fun but positive pressure ventilation ineffective. Coughing, mucus, or narrowed airways all cause air to slow down and change directions, like cars braking and shifting lanes in heavy traffic. The whole goal of ventilation is to have a ratio of inspiration to expiration that allows air to inflate alveoli and trade oxygen for CO2 from capillaries, but exit the lungs before the next breath. Otherwise, breaths stack together and pressure continues to build. I can go into greater detail about these topics in the comments, or you can contact me via social media and buy my book.
Nick Angelis, CRNA, MSN, is the author of How to Succeed in Anesthesia School (And Nursing, PA, or Med School) and regularly writes or presents continuing education articles on a variety of dry and dreary topics, just like this one. He also has a thing for satire such as The Twerk Vaccine. Nick works as a nurse anesthetist in NW Florida and NE Ohio and enjoys playing several sports poorly. You can connect with him on Twitter or Instagram.
More Resources:
- All Things Respiratory
- What Do ICU Nurses Do?
- Vent Alarms from Nursing.com
- Unveiling the Mysteries of Mechanical Ventilation from Nicole Kupchik
Ventilator Modes Made Easy: An Easy Reference for RRT’s, RN’s, and Medical Residents
The Ventilator Book: Second EditionVentilator BluesVentilator Modes Made Easy: The Complete Guide For Registered Nurse, Respiratory Therapist, And Medical Resident!UNDERSTANDING RESPIRATORY CARE
Entertaining and educational post, thanks!
Something that has helped me with managing the ventilator is to ask my respiratory therapist to teach me about the vent, the different settings, and how to trouble shoot the alarms. RT’s deal with the vent all the time and if you are willing to humble yourself, I have found people are more than happy to share their knowledge with you. It is ok, you may already know some of what they share but you will learn from the vent pro and begin to build rapport with your RT. And I always let the RT know if I do something major with the vent as a professional courtesy.
Good points David. I made an RT mad the other day when I came to collect my patient for surgery and played with all their settings. Plus, I wasn’t sure where the ventilator “off” switch was, so when I disconnected the patient to use an ambu bag, air blew everywhere sounding like Darth Vader having a panic attack. When I returned with the patient, I made sure to listen to my own advice and me much more collaborative.