NG-006 took you up the oxygen ladder as
far as a non-rebreather and high-flow nasal cannula. This page starts where that one stops. When
oxygen alone can no longer keep the numbers up — or when the problem is CO₂ that will not come out —
the next step is positive pressure: first non-invasively through a mask (CPAP, BiPAP), and if that
fails, invasively through a tube in the trachea. Two ideas carry the whole page: BiPAP gives TWO pressures
and CPAP gives ONE, and a patient who cannot protect their own airway must not be strapped into a mask.
🚨 NO MASK IF…Decreased LOC · can't protect the airway ·
vomiting · facial trauma · apnea. Those patients get a tube, not a mask.
📈 CONFIRM THE TUBEWaveform capnography + bilateral
breath sounds + chest X-ray. Auscultation alone is NOT confirmation.
🪜
PART 1 · WHERE THIS PAGE STARTS
ESCALATION
The handoff from NG-006 — and the two kinds of respiratory failure that decide what comes next.
Everything below the gold line is on
NG-006. Everything above it is on this page. Escalation is
always stepwise — you do not jump to a tube because a cannula isn't working.
➡️ Picking up where NG-006 left off
NG-006 covers flow rates, FiO₂ percentages, the non-rebreather bag rule and the COPD oxygen
caution. None of that is repeated here.
What this page adds is the answer to one question: what do you do when the highest-FiO₂ mask is on
and the patient is still failing?
Drowsy, confused, headache, flushed, flapping tremor — sleepy is the dangerous sign
First-line support
Oxygen · consider CPAP or high-flow
BiPAP — it is the pressure difference that moves the CO₂
🧠 HyperCAP → give BiPAP. High CO₂ (over 45) is the BiPAP patient.
🚨 The drowsy hypercapnic patient
A rising CO₂ makes people sleepy, not agitated. A COPD patient who has "settled down and is finally
resting" after a bad night can be a patient whose CO₂ is climbing.
Never interpret sudden calm in a struggling respiratory patient as improvement without
checking the numbers.
🧠 Restless = low O₂. Sleepy = high CO₂. Both are emergencies.
🧠 What "positive pressure" actually buys you
It holds airways and alveoli open that would otherwise collapse — more surface for gas exchange.
It pushes fluid out of the alveoli back into the circulation — which is why CPAP works so well
in cardiogenic pulmonary edema.
It does some of the work of breathing for exhausted respiratory muscles.
With two levels, it moves air — and moving air is what clears CO₂.
🧠 Pressure props the lung open. A pressure DIFFERENCE moves the air.
😷
PART 2 · CPAP & BiPAP
NON-INVASIVE
Non-invasive ventilation — a mask, not a tube. It buys time, and sometimes it avoids the tube entirely.
If you remember only one thing about these two machines,
remember the shape of the two traces. One flat line vs a square wave that steps up and down.
⚖️ CPAP vs BiPAP — side by side
CPAP
BiPAP
Name
Continuous Positive Airway Pressure
Bilevel Positive Airway Pressure
Pressures
ONE — the same throughout the breath
TWO — IPAP (higher, inspiratory) and EPAP (lower, expiratory)
What it does
Splints airways and alveoli open. The patient does all the
breathing.
Splints open AND gives inspiratory support — it helps move air, so it clears CO₂.
COPD exacerbation with high CO₂ · acute hypercapnic failure · neuromuscular weakness ·
some pulmonary edema
Effect on CO₂
Limited
This is its main job
Patient must…
…be awake enough to protect their own airway and breathe
on their own. That is true of both.
🧠 C = Continuous = ONE. Bi = TWO. Count the letters, count the pressures.
🫧 Why BiPAP is the classic COPD answer
In a COPD exacerbation the problem is trapped air and retained CO₂, not just low oxygen. Extra
oxygen alone does not fix a CO₂ of 70.
BiPAP's higher inspiratory pressure pushes a breath in and the lower expiratory pressure lets it out —
that tidal movement is what washes CO₂ out. It is frequently the last step before intubation,
and used early it often prevents one.
🚨 Contraindications — who must NOT be put on a mask
Decreased level of consciousnessThey cannot protect their airway. If they
vomit, it goes into the lungs.
Cannot protect the airway / absent gagSame reason. This is the single biggest
one.
Active vomiting or high aspiration riskA strapped-on mask over a vomiting
patient is a catastrophe.
Facial trauma, burns or recent facial surgeryNo seal — and pressure on injured
tissue.
Respiratory arrest / apneaThese machines assist breathing. They do not
replace it.
Hemodynamic instability, untreated pneumothorax, upper-airway obstruction,
excessive secretionsEscalate rather than mask.
If the patient cannot protect their own airway, the answer is a
tube — not a tighter mask.
🧠 Awake, breathing, and able to say your name. If not, the mask is the wrong tool.
Pressure injury under an NIV mask is one of the most common
and most preventable harms on a medical ward — and the nasal bridge is where it happens first.
✅ Mask fit — the nursing job
Size it with the manufacturer's gauge; a too-big mask leaks and a too-small one digs in.
Two fingers should slide under the strap. Tighter is not better.
Fix a leak by re-seating and re-sizing first, not by cranking the straps down.
Protect the nasal bridge with a hydrocolloid or foam dressing before problems start.
Inspect the skin under the mask at least every shift, and release the mask periodically as
the patient's condition allows.
A leak jetting upward dries and irritates the eyes — check for that too.
🧠 Two fingers under the strap. A dressing on the bridge.
⭐ The rest of the NIV nursing care
Head of the bed up — semi-Fowler's or higher. Reduces aspiration and improves the mechanics.
Stay with the patient when it goes on. It feels frightening. Coaching beats sedating.
Watch the abdomen — swallowed air causes gastric distension, which raises aspiration risk.
A nasogastric tube may be ordered.
Humidify; give frequent oral care and eye care for dryness.
Have suction and a bag-valve-mask at the bedside, always.
Monitor respiratory rate, effort, SpO₂, level of consciousness and blood gases — a repeat gas
after 1–2 hours tells you whether it is working.
Plan for eating, drinking and talking — the mask has to come off, and that has to be safe.
🧠 Never restrain someone to a mask. Fighting the mask is information, not misbehavior.
🚨 When to say "this isn't working"
CO₂ still climbing, or pH still falling, on the repeat blood gas.
Level of consciousness dropping.
Respiratory rate and work of breathing not improving after a reasonable trial.
Hemodynamic instability, or the patient cannot tolerate the mask at all.
Secretions the patient can no longer clear.
Escalate early. A planned intubation is far safer than a crash one.
🧠 NIV is a trial with a deadline, not a destination.
🫁
PART 3 · INTUBATION
INVASIVE
A tube through the vocal cords into the trachea — the definitive airway.
Airway obstruction or the threat of it — facial/inhalation burns, angiedema, trauma.
Apnea or respiratory arrest.
To allow deep sedation or general anesthesia.
🧠 Protect · Oxygenate · Ventilate. Fail any one of the three and the tube goes in.
🎒 Before the procedure — what you set up
1
Consent / emergency documentation and, where possible,
an explanation to the patient and family.
2
Equipment: laryngoscope with working light, correctly
sized endotracheal tubes plus one size smaller, stylet, 10 mL syringe for the cuff, water-soluble
lubricant, tube holder or tape, oral airway, bite block.
3
Suction connected, tested and within reach — rigid
catheter ready.
4
Bag-valve-mask connected to oxygen, and
pre-oxygenate the patient.
5
Capnography ready to attach, continuous monitoring on:
ECG, SpO₂, blood pressure.
6
IV access patent; sedation and (if used) paralytic drawn
up by the prescriber's order. Emergency drugs available.
7
Position the patient, remove dentures, and plan who does
what.
Learn three things off this drawing: the tube goes
through the cords, the cuff seals the trachea, and the tip sits above the carina. Every
complication on this page is one of those three going wrong.
🧩 The parts of an endotracheal tube
The tube itself, with centimeter markings printed along it.
The cuff — inflated after insertion to seal the trachea, so gas goes to the lungs and
secretions do not go past it.
The pilot balloon — the little balloon outside; feel it to check the cuff is inflated.
The connector at the end that joins the ventilator circuit.
🧠 Tube · cuff · pilot · connector. Four parts, four things to check.
Read the red box carefully. Every item in it is something
students routinely offer as "confirmation" — and none of them is.
🚨 Confirming placement — in order of authority
1
Waveform capnography (end-tidal CO₂) — a
continuous square waveform with every breath. This is the most reliable bedside confirmation.
No waveform = assume it is not in the trachea.
↓
2
Auscultate — bilateral, equal breath sounds
and listen over the epigastrium. Gurgling in the stomach = esophageal placement.
↓
3
Chest X-ray — confirms the depth, with
the tip sitting above the carina. This is the definitive check of position.
Auscultation alone is not confirmation. Neither is chest rise,
condensation in the tube, or a normal pulse oximeter reading.
🧠 Wave · Listen · Film. In that order, every single time.
🚨 The three placement errors
Esophageal — no CO₂ waveform, gurgling over the stomach, the abdomen distends, sats fall.
Remove it and ventilate with a bag-valve-mask.
Right main-stem (too deep) — the right bronchus is straighter, so a tube pushed too far goes
down it. Breath sounds present on the right, absent on the left. The tube is withdrawn to the
correct depth on the order of the provider.
Too shallow / dislodged — a cuff sitting at the cords, an audible leak, the patient suddenly
able to make sounds, and the cm marking has changed.
🧠 Silent on the LEFT = too deep on the RIGHT.
✅ Securing, documenting and cuff care
Secure with a commercial tube holder or tape, and check that it is still secure every shift.
Document the cm marking at the teeth or lip once placement is confirmed — then check it every
shift, after every turn, after transport, and any time the patient coughs hard or the alarms change.
A changed number means the tube has moved.
Cuff pressure is measured with a manometer per protocol. Too high injures the tracheal mucosa;
too low lets secretions past. Report a persistent leak.
Reposition the tube side to side per policy to prevent lip and mouth breakdown.
Never leave an intubated patient without suction and a bag-valve-mask at the bedside.
🧠 The cm number is a vital sign. Chart it like one.
Notice rule 1. Routine, scheduled suctioning is no longer
standard practice — it causes trauma, hypoxia and dysrhythmias for no benefit. Suction because you found a
reason to.
⭐ Suctioning — the principles
Only when indicated — visible or audible secretions, coarse crackles, rising airway pressures,
falling SpO₂, the patient coughing or distressed.
Hyperoxygenate before and after each pass with 100% oxygen.
Apply suction only on the way OUT, not on the way in.
Keep each pass short — commonly around 10–15 seconds — and limit the
number of passes, letting the patient recover in between.
Sterile technique for open suctioning; closed in-line systems reduce interruption and exposure.
Stop for dysrhythmia, a significant desaturation, bradycardia (vagal stimulation) or new
bleeding.
Do not instil saline down the tube as a routine — evidence does not support it.
Exact durations, pressures and technique vary between facilities — follow your unit's policy.
🧠 Reason · oxygen · short · out only.
🔔
PART 4 · THE VENTILATOR & VAP
ONGOING CARE
Two things you will be expected to handle: an alarm going off, and stopping the pneumonia that ventilators cause.
You do not need to know ventilator modes to answer alarm
questions safely. You need this one branch — and the rule that if you cannot fix it fast, you disconnect and bag.
🚨 HIGH-pressure alarm = something in the WAY
The ventilator is meeting resistance delivering the breath.
Secretions in the tube → assess, then suction.
Biting the tube → bite block, review sedation.
Kinked tubing, or the patient lying on the circuit.
Water pooled in the circuit → drain away from the patient.
Coughing or fighting the ventilator.
Bronchospasm → bronchodilator as ordered.
Pneumothorax — sudden, severe, with falling BP and tracheal deviation. Emergency.
🧠 HIGH = something is in the way.
📉 LOW-pressure alarm = something is MISSING
Air is escaping — a leak or a disconnection.
Disconnection anywhere in the circuit → trace it end to end, patient to machine.
Cuff leak or an under-inflated cuff → check the pilot balloon.
The tube has moved or come out → check the cm marking, listen, look at the patient.
A loose or cracked connector.
A leak around a chest tube or the airway itself.
🧠 LOW = something is missing.
🚨 The rule that beats every alarm
Look at the patient before you look at the machine.
Assess color, chest rise, level of consciousness, SpO₂ and the capnography trace first. Then read
what the alarm actually says.
If you cannot immediately identify and fix the problem — disconnect the patient from the
ventilator and manually ventilate with a bag-valve device on 100% oxygen while you call for help.
Never silence an alarm you have not explained, and never leave the patient to go and troubleshoot.
🧠 Patient first · bag if in doubt · never silence and walk away.
Every element of this bundle is a nursing action. VAP
prevention is almost entirely nursing work, which is exactly why it is examined so heavily.
🦠 What VAP is, and why it matters
Ventilator-associated pneumonia is a lung infection that develops in a patient who has been on
mechanical ventilation. The tube holds the airway open — which means it also holds the airway's normal
defenses open.
How it announces itself:fever · new or increased purulent secretions with a
positive sputum culture · new infiltrates on the chest X-ray · rising white cell count ·
worsening oxygenation · new crackles.
🧠 Fever · pus · film. Three signs, and they are the ones the source infographic lists.
✅ The VAP prevention bundle
Head of bed elevated 30–45° unless contraindicated.
Oral care with chlorhexidine per protocol — commonly every 2 hours, plus scheduled antiseptic
care. The mouth is the reservoir.
Daily sedation vacation and a daily assessment of readiness to wean/extubate — fewer
ventilator days means less VAP.
DVT prophylaxis — anticoagulant and/or sequential compression devices as ordered.
Peptic ulcer prophylaxis — PPI or H₂ blocker as ordered.
Reposition side to side every 2 hours; subglottic suctioning if the tube has that port.
Hand hygiene and keeping the circuit closed and free of pooled condensate.
🧠 Up · clean · wake · clot · ulcer · turn. Six actions, all yours.
🎯 The exam questions this page produces
A client with a COPD exacerbation has a PaCO₂ of 68 mmHg, pH 7.28, and is drowsy but
rousable and protecting their airway. Which intervention should the nurse anticipate?
1
Increase the nasal cannula to 6 L/min. — More oxygen
does not remove CO₂, and in this patient it is not the problem being asked about.
2
BiPAP ✅ — hypercapnic respiratory failure in
COPD is the textbook BiPAP indication. Two pressures move air and clear CO₂.
3
A non-rebreather mask. — Delivers a high FiO₂ but
provides no ventilatory support.
4
Immediate intubation. — Possible later, but the
patient is still rousable and protecting the airway, so a trial of non-invasive support comes first.
The discriminator is the CO₂. Read the gas: a high CO₂ with a low pH is a
ventilation problem. Oxygen devices treat oxygenation. BiPAP treats ventilation.
Immediately after intubation, which finding best confirms correct tube placement?
1
Symmetrical chest rise. — An esophageal tube can
still produce apparent chest movement.
2
Bilateral breath sounds. — Supportive, but sounds
transmit; not confirmation alone.
3
A continuous square waveform on capnography ✅ —
the most reliable bedside confirmation.
4
SpO₂ of 98%. — Lags by minutes and can look fine
immediately after pre-oxygenation, whatever the tube is doing.
Note the word "best". Several options are things you genuinely do — the question is
asking which one settles it. Capnography at the bedside, chest X-ray for depth.
A high-pressure alarm sounds on a ventilated client. Which action should the nurse take
first?
1
Suction the client. — May well be needed, but not
before you have assessed.
2
Assess the client — color, chest rise, level of
consciousness, SpO₂ and the tubing ✅. Look at the patient, then the machine.
3
Silence the alarm. — Never silence an alarm you have
not explained.
4
Call respiratory therapy and wait. — You do call for
help, but you do not wait at the bedside doing nothing.
"First" questions are assessment questions unless the stem describes an immediate
life threat. And if assessment shows a problem you cannot fix at once — disconnect and bag.
🧠 Airway support is a ladder: more oxygen → pressure through a mask → a tube.
🔢 CPAP=1 · BiPAP=2One continuous pressure vs IPAP (in) and
EPAP (out). The difference between the two is what moves air and clears CO₂.
🫧 HyperCAP → BiPAPPaCO₂ > 45 with
a falling pH — classically COPD. Drowsy, not agitated. Oxygen alone won't fix it.
🚨 MASK CONTRAINDICATIONS↓LOC · can't protect the airway ·
vomiting · facial trauma · apnea · instability. Those patients need a tube.
📈 CONFIRM: WAVE · LISTEN · FILMWaveform capnography, then
bilateral breath sounds + epigastrium, then chest X-ray for depth.
Auscultation alone is not confirmation.
📏 CHART THE cm MARKINGAt the lip, every shift and after every
move. A changed number = the tube has moved. Silent on the LEFT = too deep on the RIGHT.
🔔 HIGH vs LOWHIGH = something in the WAY (secretions, biting,
kink, water). LOW = something MISSING (disconnect, cuff leak). Can't fix it fast? Disconnect and BAG.
🦠 VAP BUNDLEHOB 30–45° · oral care
with chlorhexidine · sedation vacation + daily wean assessment · DVT and ulcer prophylaxis · turn q2h.
💨 SUCTION SMARTOnly when indicated · hyperoxygenate first ·
suction on the way OUT only · short passes · stop for dysrhythmia or desaturation.