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Lecture

Complications of Positive Pressure Ventilation.docx

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Department
Nursing
Course
NURS 201
Professor
Marywyatt Sindlinger
Semester
Winter

Description
Complications of Positive Pressure Ventilation Cardiovascular System  PPV can affect circulation because of the transmission of increased mean airway pressure to the thoracic cavity.  With increased intrathoracic pressure, thoracic vessels are compressed resulting in decreased venous return to the heart, decreased left ventricular end-diastolic volume (preload), decreased CO, and hypotension. Mean airway pressure is further increased if titrating PEEP (>5 cm H 2) to improve oxygenation. Pulmonary System  As lung inflation pressures increase, risk of barotrauma increases. o Patients with compliant lungs (e.g., COPD) are at greater risk for barotraumas. o Air can escape into the pleural space from alveoli or interstitium, accumulate, and become trapped causing a pneumothorax. o For some patients, chest tubes may be placed prophylactically.  Pneumomediastinum usually begins with rupture of alveoli into the lung interstitium; progressive air movement then occurs into the mediastinum and subcutaneous neck tissue. This is commonly followed by pneumothorax.  Volutrauma in PPV relates to the lung injury that occurs when large tidal volumes are used to ventilate noncompliant lungs (e.g., ARDS). o Volutrauma results in alveolar fractures and movement of fluids and proteins into the alveolar spaces.  Hypoventilation can be caused by inappropriate ventilator settings, leakage of air from the ventilator tubing or around the ET tube or tracheostomy cuff, lung secretions or obstruction, and low ventilation/perfusion ratio. o Interventions include turning the patient every 1 to 2 hours, providing chest physical therapy to lung areas with increased secretions, encouraging deep breathing and coughing, and suctioning as needed.  Respiratory alkalosis can occur if the respiratory rate orTV is set too high (mechanical overventilation) or if the patient receiving assisted ventilation is hyperventilating. o If hyperventilation is spontaneous, it is important to determine the cause (e.g., hypoxemia, pain, fear, anxiety, or compensation for metabolic acidosis) and treat it.  Ventilator-associated pneumonia (VAP) is defined as a pneumonia that occurs 48 hours or more after endotracheal intubation and occurs in 9% to 27% of all intubated patients with 50% of the occurrences developing within the first 4 days of mechanical ventilation. o Clinical evidence suggesting VAP includes fever, elevated white blood cell count, purulent sputum, odorous sputum, crackles or rhonchi on auscultation, and pulmonary infiltrates noted on chest x-ray. o Evidenced - based guidelines on VAP prevention include (1) HOB elevation at a minimum of 30 degrees to 45 degrees unless medically contraindicated, (2) no routine changes of the patient’s ventilator circuit tubing, and (3) the use of an ET with a dorsal lumen above the cuff to allow continuous suctioning of secretions in the subglottic area. Condensation that collects in the ventilator tubing should be drained away from the patient as it collects.  Progressive fluid retention often occurs after 48 to 72 hours of PPV especially PPV with PEEP. It is associated with decreased urinary output and increased sodium retention. o Fluid balance changes may be due to decreased CO. o Results include diminished renal perfusion, the release of renin with subsequent production of angiotensin and aldosterone resulting in sodium and water retention. o Pressure changes within the thorax are associated with decreased release of atrial natriuretic peptide, also causing sodium retention. o As a part of the stress response, release of antidiuretic hormone (ADH) and cortisol may be increased, contributing to sodium and water retention. Neurologic System  In patients with head injury, PPV, especially with PEEP, can impair cerebral blood flow.  Elevating the head of th
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