Respiratory Care Procedures

1
Respiratory Care Procedures

• Chapter 6

2
Airway Clearance

• Relies on effective mucociliary clearance
• Traditional treatment is CPT
• Goals
• Mobilize secretions
• Improve ventilation
• Preemies are especially prone to atelectasis
  because of surfactant deficiency

3
Indications

• Retained secretions
• Excessive secretions
• Aspiration
• prophylaxis

4
Classic Procedure

• Auscultation
• Listen to breath sounds
• Try to determine if the problem is atelectasis or
  excess secretions
• What will the BS be in each situation?
• Postural drainage
• Uses gravity to enhance secretion movement
• Should drain each segment 2-5 mindepends on the
  segments to be drained how long you spend on
  each
• Total time should not exceed 20 min

5
Classic Procedure, cont

• Percussion
• Clapping of the chest wall to mobilize secretions
• Most babies too small for you to use your hands
  need an infant percussor (or you can make one of
  your own)
• Vibration
• Rapidly shaking the chest wall during exhalation
• A bit tricky on babies due to the high RR

6
Removal of Secretions

• Older peds patients can be encouraged to
  coughmake a game out of it and you are more
  likely to get cooperation. Like, cough and see
  if you can get this paper to move
• Infants and neonates may need to be suctioned if
  they dont have a spontaneous coughuse -50 to
  -80 for infants and -80 to -100 for small children

7
PEP

• Positive expiratory pressure (10-20 cm H2O)
  dilates the airways, allowing air to get behind
  secretions to the alveoli distal
• Improves oxygenation and ventilation because it
  opens collapsed alveoli
• Improves secretion mobilization because there is
  now air behind the secretion to move it with
• Patient should to about 10 PEP breaths, then stop
  and huff cough (FET)they repeat this cycle for
  about 10-15 minutes if they have the stamina

8
Active Cycle Breathing

• Combines postural drainage with FET
• Developed in the UK and much more popular in
  Europe than the US

9
Autogenic Drainage

• A multiphase breathing exercise that allows
  clearance of the lungs from the bottom up
• Phase 1 from low lung volumes the person does a
  forced exhalation to move secretions from
  peripheral airways to larger ones
• Phase 2 from mid lung volumes the person does a
  forced exhalation to move secretions from midsize
  airways to larger airways
• Phase 3 from high lung volumes the person does
  a forced exhalation to move secretions from the
  large to the mainstem/tracheal area to be coughed
  out

10
Flutter Valve

• The original flutter was a heavy plastic cone
  with a steel ball that moved up and down during
  exhalation to produce vibrations that transmitted
  back to the airwaysnow we use a disposable one
  the Acapella
• The airway oscillations shake secretions loose
  from the inside
• Green is for adultsblue is for peds (and adults
  with very low air flow)
• These devices provide both oscillation and PEP

11
The Vest

• Uses high frequency chest wall oscillations to
  vibrate secretions loose
• Improves gas distribution and mobilizes
  secretions
• Procedure
• Fit the vest properly
• Start with low frequency for a few minutes, then
  turn to mid for a few minutes, then high
• Total time is about 15-30 min, depending on
  patient tolerance

12
Contraindications to airway clearance techniques

• Need to dramatically increase FiO2 during therapy
• Feeding within the last hour
• Reflux
• Very young preemies (lt32 wks)
• History of intraventricular hemorrhage

13
Hazards to airway clearance techniques

• HYPOXEMIA!!!
• Emesis
• Aspiration
• Injuries from percussion (too hard on delicate
  skinpercussing the wrong tissue)

14
Aerosolized Drug Therapy

• Can be delivered one of 3 ways
• Small volume nebulizer can be used on all ages
  and on uncooperative patients
• MDI can be used even on infants, but best
  results with kids who are a bit older and can
  cooperate
• DPI can be used on children who are
  cooperative, but usually not lt3 yrs old

15
Small Volume Nebulizer

• Advantages
• Doesnt really require cooperation
• Can adjust dosage
• Can use any liquid drug
• Effective even if there is no breath hold
• Disadvantages
• Expensive
• Less easily transported
• Bacterial medium
• Requires cleaning
• Not very efficient
• Dose delivered varies according to breathing
  pattern

16
MDI

• Advantages
• Portable
• Efficient drug delivery
• No prep required
• Disadvantages
• Have to coordinate breathing with delivery
• Limited drug choice
• Limited to dosage in MDI
• Propellants may cause a reaction
• Aspiration of foreign body (eg-gum)

17
DPI

• Advantages
• All of those for MDIs
• Easier to coordinate
• No propellants to react to
• Disadvantages
• Very few drugs available
• Airway irritation
• Requires high flow rate for best results
• Available DPIs are mainly maintenance drugs, not
  rescue drugs

18
Indications for aerosols

• Bronchodilators
• Presence of bronchoconstriction
• Decreased chest expansion
• Wheezing
• Retractions, flaring, grunting
• Tachypnea
• Decreased air movement
• Increased FiO2 needs
• Mucolytics
• Presence of thick secretions
• Steroids
• inflammation
• History of BPD or asthma

19
Equipment needed

• SVN
• Need a nebulizer and an interface
• Blow-by is commonly used for infants
• Servo makes its own USN to use with their
  ventilators
• MDI
• For younger children, use the spacer/mask
• Can also bag in an MDI on an infant
• DPI
• Need capsule for some of them
• Special canister to deliver the med

20
Hazards of Aerosol Therapy

• Infection
• Medication side effects
• Drug reconcentration
• Ventilator malfunction
• Excessive noise

21
SPAG

• Used to deliver ribavirin (Virazole) to patients
  with RSV
• Delivers molecular ribavirin
• Not used much anymore b/c ribavirin is really
  expensive
• Attaches to a ventilator, hood, croup tent, or
  aerosol maskusually used on the sickest of the
  sick, so generally through a ventilator
• Use 12-18 hrs/day for 3-7 days

22
Pentamidine

• Need a special nebulizer that filters expiratory
  gasRespiragard II
• Used for prophylaxis against Pneumocystis carinii
  pneumonia
• Not approved for use in infants/children

23
Suctioning

• Indications
• Remove secretions
• Maintain patency of ETT
• Obtain a sample for lab analysis
• When you suctioning depends on when the patient
  needs itgo by BS and clinical condition (drop in
  sat, increased distress, after CPT)

24
Procedure to suction an intubated infant

• You could just feed the catheter down the tube
  until you hit the carina and stimulate a
  coughbut this causes airway breakdown and babies
  are more susceptible to this than adults
• So, what you do is add 4 to the cm marking at the
  adapter of the ETTthis corrects for the length
  of the adapter so the sx catheter will just be at
  the tip of the tube and not impacting the airway
• To lavage, use a few drops of saline, not the
  entire vial
• Preoxyenate, postoxygenate with each pass of the
  catheter babies will desaturate much more
  quickly than adults

25
Hazards to Suctioning

• Bradycardia vagal response as well as hypoxemia
  response
• Hypoxemia keep sx time/P at recommended levels
• Mucosal damage measure from adapter
• Atelectasis/lung collapse watch sx T/P
• Airway contamination sterile technique
• Accidental extubation uncuffed tubes come out
  easily!!

26
Oxygen Therapy

• Indications
• Hypoxemia (lt50 for a preemie/neonatelt80 for a
  child)
• Signs and symptoms of hypoxia
• Hazards
• ROP only takes about 20 min for this to start
  usually shoot for PaO2 50-70 in babies
• O2 toxicity leads to BPD (baby COPD)
• Cerebral vasoconstriction reduces brain
  perfusion
• Fire hazard

27
Blenders

• Connect to 50 psi source
• Mixes air and O2 to the concentration you set on
  it
• Can do 21-100
• Blended gas is delivered by flowmeter or a 50 psi
  DISS threaded connection
• Can power respiratory equipment

28
Flowmeters

• Bourdon gauge
• Measures pressure really
• Can be used in any position
• Backpressure increases reading while decreasing
  flow to the patient
• Thorpe tube
• Uses a ball or pin to measure flow
• Must be upright to be accurate
• Compensated ones are calibrated to 50psi and are
  still accurate as long as the back pressure to
  them is lt50 psi
• Uncompensated ones read lower than actual flow
  with back pressure
• There are special flowmeters for peds and infants

29
Analyzers

• Monitor O2 percent
• Calibrate to room air and 100 prior to use
• Measure as close to the baby as possible

30
Humidifiers

• Add molecular water to dry gas
• Bubble humidifiers are used with low flow oxygen
  systems
• Passover humidifiers are used with high flow and
  ventilator systems (eg-Fischer Paykel)
• Jet nebulizers also add humidity

31
Oxyhood

• Clear plastic hood that fits over the head
• Generally used for FiO2 lt 0.50
• Need to use at least 7 lpm to prevent CO2 buildup
  in the hood
• Make sure its not too tight around the neck
• Air is heatedcold air blowing on a babys head
  causes increased heat loss (what type??)

32
Cannulas

• Dont use flows gt4 lpm in neonatesthe usual is 1
  lpm or less
• FiO2 depends on Vt and RR
• Approximate FiO2s for cannulas
• 0.25 lpm 24-27
• 0.50 lpm 26-32
• 1.00 lpm 30-35
• Can cut off the prongs of a cannula for babys
  whose nares are too smallposition the holes
  under the nares
• Must tape to the face to keep in placethey make
  special tape you can use or use paper tape

33
Masks

• Masks are not well tolerated by infants and
  children
• For neonates, simple masks will deliver
• 60-80 at 5 lpm if tight to the face
• 40 at 5 lpm if loosely held to the face
• For children
• Simple maskss deliver 35-45 at 6-8 lpm depending
  on respiratory pattern and size of the child
• NRB can provide 70-100 at 6-15 lpm
• Peds sized venturi masks are also available
• Hazards to masks
• Aspiration
• Skin necrosis
• CO2 retention

34
Oxygen Tents

• Plastic enclosures that cover the entire crib
• Provide a cool mist
• Used for croup, bronchiolitis, airway swelling
• Usually cooled to 5-10 degrees below room temp,
  but can get quite cold if the baby is very small
• Monitor the FiO2 near the face at mattress level
  b/c oxygen layering occurs inside the tent
• Hard to get much more than 35 in the tent
• Hazards
• High mist output obscures the patient
• Fire dangerno metal toys at all!!
• Overhydration of infants
• Lose FiO2 when tent is opened for care giving
• Toddlers can asphyxiate on the tent itself

35
Incubators/Isolettes

• Provide a temperature controlled environment
• Also can use the incubator for oxygen delivery,
  although its far more common to use a different
  O2 device inside the isolette and just use it for
  temp control
• Red flag up means FiO2 gt40...O2 attachment is on
  the back side
• Hazards
• Must open for care, losing FiO2 and temp control
  each time

36
Resuscitation Bags

• Self-Inflating
• Reinflate automatically following compression
• Reinflation entrains air/O2 into the bag
• Can achieve 80-100 with a reservoir
  attachedalso can attach to the flowmeter of a
  blender to deliver a specific FiO2 to the bag
• Most bags you will use will be this type
• Flow-Inflating
• Whatever is used to power the bag is the FiO2 of
  the bag
• Adjust flow rate so the bag reinflates between
  breathsthe faster the rate, the more flow needed
• Use a pressure manometer to monitor ventilation
  pressures when baggingonly use enough pressure
  to see chest movement