Specific Methods of Respiratory Management

1
Specific Methods of Respiratory Management

• Respiratory Module

2
Deep Breathing Coughing

• Airway clearance
• Nrs Dx
• Ineffective airway clearance
• h fluids

3
Breathing Exercises

• Goal
• i work of breathing
• h efficiency
• Diaphragmatic breathing
• Pursed-lip breathing

4
Breathing Exercises

• Diaphragmatic breathing
• Gen info
• Diaphragm muscle
• Practice
• Procedure
• Place 1 hand on abdomen and other on chest
• Push out abd during I
• Chest move very little

5
Breathing Exercises

• Pursed-lip Breathing
• Gen info
• Used when SOB
• Keep airway open during E ? h CO2 excretion
• With diaphragmatic breathing
• Counting ? i anxiety

6
Breathing Exercises

• Pursed-lip Breathing
• Procedure
• I
• slowly through nose
• Count 2
• E
• Through pursed lips
• Count 4

7
Positioning

• Conserve energy
• Max lung expansion
• Pt specific
• Fowlers
• Chair
• leaning forward
• Good lung down

8
Oxygen therapy

• Goal
• Provide adequate transport of O2
• i work
• i stress to myocardium
• Need for O2 based on
• ABGs
• Clinical assessment

9
Oxygen therapy

• Cautions on O2 tx
• Med!
• Except in emergency need MD Rx
• Give O2 only to bring the pt back to baseline
• COPD
• WHY?

10
Oxygen therapy

• COPD O2
• Normal - CO2 indicator to breath
• COPD O2 indicator to breath
• d/t h CO2 levels burned medulla sensor for CO2
• Medulla uses O2 to initiate breath

11
COPD O2

• COPD h O2 ?
• i Resp ?
• h PaCO2 ?
• Carbon dioxide narcosis acidosis ?
• Deathmosis

12
Oxygen therapy

• Precautions
• Catalyst for combustion
• No smoking sign
• Tanks ? missiles
• No friction toys

13
Oxygen

• Side effects
• O2 ?
• Hyper or hypo ventilation?
• Hypoventilation ?
• Atelectasis

14
Oxygen toxicity

• O2 overdose
• h O2 concentration gt 48 hrs
• r/t the destruction and i of surfactant
• the formation of a hyaline membrane lining the
  lung
• and the development of pulmonary edema that is
  not cardiac in origin

15
Oxygen Toxicity

• SS
• Sub-sternal distress
• Chest pain
• Dry cough
• Paresthesia
• Dyspnea
• Progressive
• Restlessness
• PaO2 gt 100mmHg

16
Oxygen Toxicity

• Prevention
• i FiO2
• P.E.E.P.
• Positive, End, Expiratory, Pressure
• C.P.A.P.
• Continuous positive airway pressure

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Method of O2 Administration

• Nasal Cannula
• Flow rate
• 1-6 L/min
• FiO2
• 20-40
• Nrs
• Talk eat
• Comfort
• Nose breather

18
Method of O2 Administration

• Simple Mask
• Flow rate
• 6-10 L/min
• FiO2
• 40-60
• Nrs
• Higher flow rate

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Method of O2 Administration

• Partial Re-breather Mask (Reservoir)
• Flow rate
• 6-10 L/min
• FiO2
• 60-100
• Nrs
• Uses reservoir to capture some exhaled gas for
  rebreathing
• Vents allow room air to mix with O2

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Method of O2 Administration

• Non-rebreather Mask
• Flow rate
• 6-10 L/min
• FiO2
• 70-100

21
Method of O2 Administration

• Nrs
• Side vents closed
• Reservoir vent closed for I, open for E
• Reservoir bag stores O2 for I but does not allow
  E air in
• Reservoir never collapse to lt½

22
Method of O2 Administration

• Venturi
• Flow rate
• 4-8
• FiO2
• 20-40
• Nrs.
• Precise of O2
• i.e. COPD

23

• Which one of the following conditions could lead
  to an inaccurate pulse oximetry reading if the
  sensor is attached to the clients ear?
• Artificial nails
• Vasodilation
• Hypothermia
• Movement of the head

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Nebulizer Mist Treatment

• Deliver Moisture OR medication directly into the
  lungs
• Topical i systemic S/E
• Indications
• Must be able to deep breath

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Nebulizer Mist Treatment

• Meds
• Bronchodilators
• Albuteral (ventolin)
• Corticosteroids
• Mucolytic agents
• Acetylcysteine
• Antibiotics

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Metered Dose Inhaler

• Admin. Topical meds directly into the lungs
• i systemic S/E
• Meds
• Corticosteroids
• Bronchodilators
• Mast cell inhibitors

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Metered Dose Inhaler

• Procedure
• Canister into unit correctly
• Shake gently
• Hold inhaler breath out slowly (not into
  inhaler)

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Metered Dose Inhaler

• Place mouthpiece into your mouth
• Close lips around it
• Tilt head back
• Keep tongue out of way
• Press top of the canister firmly breath in
  through your mouth

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Metered Dose Inhaler

• Remove inhaler from mouth
• Hold breath for several seconds
• Breath out slowly

30
Metered Dose Inhaler

• Rinse your mouth afterward to help reduce
  unwanted side effects

31
Incentive Spirometry

• Device enc. Deep breath
• Prevent tx Atelectasis
• Procedure
• Inhale!

32
Chest physiotherapy

• Goal
• Remove bronchial secretions
• h ventilation
• h efficiency of respiration

33
Chest physiotherapy

• Postural drainage
• Help move secretion deep w/in lungs
• Used when pt has weak or ineffective cough (
  retaining secretions)
• Client is placed in various positions to drain
  lungs
• 15 min each position

34
Chest physiotherapy

• Nrs. Management
• Auscultate /a /p
• Pt comfort
• Assess for
• h pain
• SOB
• Weakness
• Lightheadedness
• Hemoptysis

35
Chest physiotherapy

• Percussion
• Cupped hands strike the chest repeatedly
• ? sound waves loosen secretions
• Vibration
• Vibrations using hands or vibratos to loosen
  secretions

36
Chest physiotherapy

• Percussion vibration
• X after meals
• X over
• Chest tubes
• Sternum
• Spine
• Kidneys
• Spleen
• Breasts
• Caution with elderly

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Chest Drainage Tubes

• Continuous chest drainage
• Insertion of one or more chest tube by MD
• Into the pleural space
• Drain fluid or air

38
Chest Drainage Tubes

• Indications
• Air in pleural space
• Pneumothorax
• Pleural effusion
• Penetrating chest injury
• Chest surgery

39
Chest Drainage Tubes

• Upper, anterior chest (2nd 4th intercostal
  space)?
• Remove air
• Lower lateral chest (8th or 9th intercostal
  space)?
• Remove fluid

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Chest Drainage Tubes

• MD inserts
• Nrs connects system and secures all connections
• Vaseline gauze and sterile occlusive dressing at
  insertion site to prevent leakage

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Chest Drainage Tubes

• 2 padded clamps at bedside
• Clamps only used if
• Chest system accidentally disconnected
• Changing drainage system
• Trial period before removal

42
Chest Drainage Tubes

• Tubes never clamped for more than few min ?
• Prevents air from escaping ?
• Buildup of air in pleural space ?
• Pneumothorax

43
Chest Drainage Tubes

• 3-bottle system
• Water seal bottle
• Suction bottle
• Drainage bottle

44
Chest Drainage Tubes

• Water seal
• When pt E ?
• Air trapped in the pleural space travels through
  chest tube to the water seal bottle ?
• Bubble up and out of the bottle

45
Chest Drainage Tubes

• Water seal
• Water acts as a seal allows air to escape,
  prevents air from getting back in
• Bubbles with E
• Normal
• Constant bubbling
• Abnormal leak
• Check for leaks

46
Chest Drainage Tubes

• Water Seal
• Water level fluctuates
• h I
• i E
• Tidaling
• Normal
• When lung is reinflated ?
• Tidaling stops
• If tidaling stops
• Lung reinflated
• Tubing kinked
• Tubing occluded

47
Chest Drainage Tubes

• Suction Bottle
• Suction sometimes used to speed up lung
  reinflation
• Amt of suction is dependent of the level of H2O
  in the bottle, not the amt of suction set on the
  machine

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Chest Drainage Tubes

• Suction Bottle
• Suction level order by MD
• -20cm Water
• Turn suction machine on enough to cause gentle
  bubbling
• Normal

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Chest Drainage Tubes

• Suction bottle
• Vigorous bubbling ?
• water evaporation ?
• change amt of suction
• Turn down suction
• No bubbling
• Kink in system
• Suction disconnected

50
Chest Drainage Tubes

• Drainage bottle
• Collect fluid from pleural space
• Fluid d/t
• Pleural effusion
• Chest trauma
• Surgery

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Chest Drainage Tubes

• Drainage bottle
• Fluid is not emptied to measure
• Mark line q shift
• Date
• Time
• Amt.
• Add to IO
• Sudden h in fluid, or very bloody ?
• Notify MD

52
Chest Drainage Tubes

• Nrs. Care
• Must always be kept upright
• Always below level of chest
• Notify MD if
• h Dyspnea
• Drainage chamber full

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Chest Drainage Tubes

• Transporting
• Transport w/ pt
• Ask MD if suction Ok to be off while transporting
• Leave open to air
• Do not clamp to transport

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Chest Drainage Tubes

• Nrs management
• P rate, effort, SOB, symmetry, pain
• Auscultate lung sounds
• Absent/decreased ? normal as inflate
• P Drsg intact, drainage
• Palpate insertion site for crepitus
• P tubing for kinks, connections

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Chest Drainage Tubes

• No depended loops
• System below level of chest
• P system for cracks or leaks
• P water seal for
• H2O level
• Tidaling
• Bubbling w/ E

56
Chest Drainage Tubes

• P suction control bottle
• Gentle bubbling
• H2O level
• P and mark amount of drainage

57
Chest Drainage Tubes

• Stripping
• Slide fingers down the tube
• Milking
• Gently squeezing tube w/out sliding
• MD order only!

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Chest Drainage Tubes

• Accidental removal
• Drainage tube disconnected from system
• Clamp immediately
• Reconnect system
• Unclamp
• Drainage tube pulled out of patient
• Cover site with Vaseline gauze/ occlusive drsg
• Notify MD

59
Chest Drainage Tubes

• Removal of tube
• MD removes
• Place Vaseline gauze sterile occlusive dressing
  over site
• Assess
• Crepitus
• Resp status
• Dressing site

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Question?

• You notice that the water seal on a pt chest tube
  rises and falls with each breath. What does this
  mean?
• There is a leak in the system
• Tubing is kinked
• Too much suction
• Too little suction
• Lung reinflated
• Normal occurrence

61
Question?

• You notice constant bubbling in the water seal
  bottle of a chest tube drainage system. What
  does this mean?
• There is a leak in the system
• Tubing is kinked
• Too much suction
• Too little suction
• Lung reinflated
• Normal occurrence

62
Question?

• You notice vigorous bubbling in the suction
  bottle of a chest tube drainage system. What
  does this mean?
• There is a leak in the system
• Tubing is kinked
• Too much suction
• Too little suction
• Lung reinflated
• Normal occurrence

63
Question?

• You notice constant bubbling in the suction
  bottle of a chest tube drainage system. What
  does this mean?
• There is a leak in the system
• Tubing is kinked
• Too much suction
• Too little suction
• Lung reinflated
• Normal occurrence

64
Question?

• You notice no bubbling in the suction bottle of a
  chest tube drainage system. What does this mean?
• There is a leak in the system
• Tubing is kinked
• Too much suction
• Too little suction
• Lung reinflated
• Normal occurrence

65
Question?

• While tuning a patient, the chest tube
  accidentally is pulled out of the patients chest.
  What should you do first?
• Clamp the tube
• Open the site with stoma openers
• Cover the site with occlusive dressing
• Re insert the tube
• Call the MD

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Tracheostomy

• Tracheotomy
• Surgical opening through the base of the neck
  into the trachea
• Tracheostomy
• Permanent and has a tube inserted into the
  opening to maintain patency

67
Tracheostomy

• Reasons for Trach
• Laryngeal CA
• Airway obstruction
• Trauma
• Tumor
• Difficulty clearing airway
• Prolonged mechanical Ventilation

68
Tracheostomy

• Pt breaths through this opening, bypassing the
  upper airways
• Semi-fowler position post-op
• Cuff management
• Usually 20-25mmHg

69
Tracheostomy

• If trach pulled out
• Tracheal dilator to keep stoma open until MD
  arrives and reinsert tube

70
Suctioning

• General Info
• Frightening uncomfortable
• Leads to Hypoxia
• Leads to Vagal stim ?
• Bradycardia ?
• Cardiac arrest ?

71
Suctioning

• Not do PRN
• Enc cough
• Hold own breath

72
Suctioning

• Oropharyngeal (clean) or nasopharyngeal (sterile)
  suctioning procedure
• Gather equipment
• Explain
• Connect cath to suction tubing, keep cath. inside
  sterile sleeve
• Turn on suction to level specified by facility
  (80-120 mmHg)

73
Suctioning

• Pour saline into sterile container
• Put on sterile gloves
• Suction small amt of saline into catheter to
  rinse and test suction
• Have pt take several breaths

74
Suctioning

• With thumb control uncovered, insert cath.
  through mouth/nose into pharynx until resistance
  is met or pt coughs
• Slowly withdraw cath, suction intermittently
  while rotating
• lt 15 sec

75
Suctioning

• Allow pt to rest
• Repeat 2 more time if needed
• If trach DO NOT instill sterile saline into
  trach
• If trach hyperventilate before suctioning

76
Intubation

• Endotracheal tube (ET)
• Mouth - trachea
• Most also mech ventilated
• Damages vocal cords surrounding tissue
• Only short term
• Long term ?
• Tracheostomy

77
Mechanical Ventilators

• General Info
• Provide ventilation to pt unable to breath
  effectively on own
• Use pressure to push O2 air in via ET or Trach
  tube

78
Mechanical Ventilators

• Indication for use
• Cont. i in PaO2
• Cont. h PaCo2
• Persistent Acidosis

79
Mechanical Ventilators

• Nrs Management
• Advance directives
• Assess/monitor pt
• Setting per order
• Respond to alarms
• Tubing free of water
• Airway clear
• Manual resuscitation bag at bedside

80
Mechanical Ventilators

• Ventilator modes
• FiO2
• Fraction of inspired oxygen
• Concentration of O2
• Tidal Volume
• Amt of air delivered with ea. Breath

81
Mechanical Ventilators

• Rate
• Frequency of breaths
• IE
• Inspiration to expiration ratio
• 13
• I-1 sec
• E-3 sec

82
Mechanical Ventilators

• AC
• Assist control mode
• Delivers breath ea time pt begins to inhale
• If pt X breath, delivers preset minimum of
  breaths

83
Mechanical Ventilators

• SIMV
• Synchronized Intermittent mandatory ventilation
• Pt breaths on own, but delivers minimum breaths

84
Mechanical Ventilators

• Pressure support (PS)
• Provided pressure on I to i work of breathing

85
Mechanical Ventilators

• Continuous positive airway pressure (CPAP)
• pressure on I E to i work of breathing in
  spontaneously breathing pt

86
Mechanical Ventilators

• Positive End Expiratory Pressure (PEEP)
• Provides pressure on E to keep small airways
  open
• Prevent Atelectasis
• If too high ?
• pneumothorax