specific methods of respiratory management

Specific Methods of Respiratory Management

Respiratory Module

Deep Breathing & Coughing

• Airway clearance– Nrs Dx

• Ineffective airway clearance

– fluids

Breathing Exercises

• Goal– work of breathing – efficiency

• Diaphragmatic breathing

• Pursed-lip breathing

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

Breathing Exercises

• Pursed-lip Breathing– Gen info

• Used when SOB• Keep airway open during

E CO2 excretion• With diaphragmatic

breathing• Counting anxiety

Breathing Exercises

• Pursed-lip Breathing– Procedure

• I – slowly through nose– Count 2

• E– Through pursed lips– Count 4

Positioning

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

• Good lung down

Oxygen therapy

• Goal– Provide adequate

transport of O2– work– stress to myocardium

• Need for O2 based on– ABG’s– Clinical assessment

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?

Oxygen therapy

• COPD & O2– Normal - CO2 indicator to breath– COPD – O2 indicator to breath• d/t CO2 levels “burned” medulla sensor for CO2

– Medulla uses O2 to initiate breath

COPD & O2

• COPD + O2 • Resp • PaCO2 • Carbon dioxide narcosis & acidosis • Deathmosis

Oxygen therapy

• Precautions– Catalyst for combustion– “No smoking” sign– Tanks missiles– No friction toys

Oxygen

Side effects• O2 • Hyper or hypo

ventilation?– Hypoventilation – Atelectasis

Oxygen toxicity

• O2 overdose• O2 concentration > 48 hrs• “r/t the destruction and of surfactant• “the formation of a hyaline membrane lining

the lung • “and the development of pulmonary edema

that is not cardiac in origin”

Oxygen Toxicity

S&S• Sub-sternal distress• Chest pain• Dry cough• Paresthesia• Dyspnea

– Progressive

• Restlessness• * PaO2 > 100mmHg

Oxygen Toxicity

Prevention• FiO2• P.E.E.P.– Positive, End,

Expiratory, Pressure

• C.P.A.P.– Continuous positive

airway pressure

Method of O2 Administration

Nasal Cannula• Flow rate– 1-6 L/min

• FiO2– 20-40%

• Nrs– Talk & eat– Comfort– Nose breather


Simple Mask• Flow rate– 6-10 L/min

• FiO2– 40-60%

• Nrs– Higher flow rate


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


Non-rebreather Mask• Flow rate– 6-10 L/min

• FiO2– 70-100%


• 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 <½


Venturi • Flow rate– 4-8 %

• FiO2– 20-40%

• Nrs.– Precise % of O2– i.e. COPD

• Which one of the following conditions could lead to an inaccurate pulse oximetry reading if the sensor is attached to the clients ear?A. Artificial nailsB. VasodilationC. HypothermiaD. Movement of the head

Nebulizer Mist Treatment

• Deliver Moisture OR medication directly into the lungs

• Topical – systemic S/E

• Indications:– Must be able to deep

breath

Nebulizer Mist Treatment

Meds:• Bronchodilators– Albuteral (ventolin)

• Corticosteroids• Mucolytic agents– Acetylcysteine

• Antibiotics

Metered Dose Inhaler

• Admin. Topical meds directly into the lungs

• systemic S/E• Meds:– Corticosteroids– Bronchodilators– Mast cell inhibitors


Procedure• Canister into unit

correctly• Shake gently• Hold inhaler – breath

out slowly (not into 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


• Remove inhaler from mouth

• Hold breath for several seconds

• Breath out slowly


Rinse your mouth afterward to help reduce unwanted side effects

Incentive Spirometry

• Device enc. Deep breath

• Prevent & tx Atelectasis

• Procedure– Inhale!

Chest physiotherapy

• Goal– Remove bronchial

secretions– ventilation– efficiency of

respiration

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

Chest physiotherapy

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

Chest physiotherapy

Percussion• Cupped hands strike

the chest repeatedly• sound waves

loosen secretionsVibration• Vibrations using hands

or vibratos to loosen secretions

Chest physiotherapy

Percussion& vibration• after meals• over:

– Chest tubes– Sternum– Spine– Kidneys– Spleen– Breasts

• Caution with elderly

Chest Drainage Tubes

• Continuous chest drainage

• Insertion of one or more chest tube by MD

• Into the pleural space• Drain fluid or air


Indications• Air in pleural space• Pneumothorax• Pleural effusion• Penetrating chest

injury• Chest surgery


• Upper, anterior chest (2nd & 4th intercostal space)– Remove air

• Lower lateral chest (8th

or 9th intercostal space)– Remove fluid

•


• MD inserts• Nrs connects system

and secures all connections

• Vaseline gauze and sterile occlusive dressing at insertion site to prevent leakage


• 2 padded clamps at bedside

• Clamps only used if:– Chest system

accidentally disconnected

– Changing drainage system

– Trial period before removal


• Tubes never clamped for more than few min

• Prevents air from escaping

• Buildup of air in pleural space

• Pneumothorax


• 3-bottle system1. Water seal bottle2. Suction bottle3. Drainage bottle


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


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


Water Seal• Water level fluctuates

– I – E

• Tidaling– Normal

• When lung is reinflated – Tidaling stops

• If tidaling stops:– Lung reinflated– Tubing kinked – Tubing occluded


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


Suction Bottle• Suction level order by

MD– -20cm Water

• Turn suction machine on enough to cause gentle bubbling – Normal


Suction bottle• Vigorous bubbling • water evaporation • change amt of suction

– Turn down suction

• No bubbling– Kink in system– Suction disconnected


Drainage bottle• Collect fluid from

pleural space• Fluid d/t– Pleural effusion– Chest trauma– Surgery


Drainage bottle• Fluid is not emptied to

measure– Mark line q shift

• Date• Time• Amt.

– Add to I&O• Sudden in fluid, or very

bloody – Notify MD


Nrs. Care• Must always be kept

upright• Always below level of

chest• Notify MD if:– Dyspnea – Drainage chamber full


Transporting• Transport w/ pt• Ask MD if suction Ok

to be off while transporting– Leave open to air

• Do not clamp to transport


Nrs management• rate, effort, SOB,

symmetry, pain• Auscultate lung sounds

– Absent/decreased normal as inflate

• Drsg intact, drainage• Palpate insertion site for

crepitus• tubing for kinks,

connections


• No depended loops• System below level of

chest• system for cracks or

leaks• water seal for– H2O level– Tidaling– Bubbling w/ E


• suction control bottle– Gentle bubbling– H2O level

• and mark amount of drainage


Stripping • Slide fingers down the

tubeMilking• Gently squeezing tube

w/out sliding• MD order only!


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


Removal of tube• MD removes• Place Vaseline gauze &

sterile occlusive dressing over site

• Assess:– Crepitus– Resp status– Dressing site

Question?

• You notice that the water seal on a pt chest tube rises and falls with each breath. What does this mean?

A. There is a leak in the systemB. Tubing is kinkedC. Too much suctionD. Too little suctionE. Lung reinflatedF. Normal occurrence

Question?

• You notice constant bubbling in the water seal bottle of a chest tube drainage system. What does this mean?


Question?

• You notice vigorous bubbling in the suction bottle of a chest tube drainage system. What does this mean?


Question?

• You notice constant bubbling in the suction bottle of a chest tube drainage system. What does this mean?


Question?

• You notice no bubbling in the suction bottle of a chest tube drainage system. What does this mean?


Question?

• While tuning a patient, the chest tube accidentally is pulled out of the patients chest. What should you do first?

A. Clamp the tubeB. Open the site with stoma openersC. Cover the site with occlusive dressingD. Re insert the tubeE. Call the MD

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

Tracheostomy

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

Ventilation

Tracheostomy

• Pt breaths through this opening, bypassing the upper airways

• Semi-fowler position post-op

• Cuff management– Usually 20-25mmHg

Tracheostomy

• If trach pulled out– Tracheal dilator to

keep stoma open until MD arrives and reinsert tube

Suctioning

General Info:• Frightening &

uncomfortable• Leads to Hypoxia• Leads to Vagal stim – Bradycardia – Cardiac arrest

Suctioning

• Not do PRN• Enc cough• Hold own breath

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)

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

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 • < 15 sec

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

Intubation

• Endotracheal tube (ET) – Mouth - trachea

• Most also mech ventilated• Damages vocal cords &

surrounding tissue– Only short term

• Long term – Tracheostomy

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


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


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

at bedside


Ventilator modes• FiO2– Fraction of inspired

oxygen– Concentration of O2

• Tidal Volume– Amt of air delivered

with ea. Breath


• Rate– Frequency of breaths

• I:E– Inspiration to

expiration ratio– 1:3

• I-1 sec• E-3 sec


• AC– Assist control mode– Delivers breath ea time

pt begins to inhale– If pt breath, delivers

preset minimum # of breaths


• SIMV– Synchronized

Intermittent mandatory ventilation

– Pt breaths on own, but delivers minimum # breaths


• Pressure support (PS)– Provided + pressure on

I to work of breathing


• Continuous positive airway pressure (CPAP)– + pressure on I & E to

work of breathing in spontaneously breathing pt


• Positive End Expiratory Pressure (PEEP)– Provides + pressure on

E to keep small airways open

– Prevent Atelectasis– If too high

• pneumothorax

specific methods of respiratory management

Documents

o2 txmed

breathcopd o2 indicator

breathcopd o2copd h

ereservoir bag stores

emergency need md rxgive

breathdt h co2 levels

e air inreservoir

sobkeep airway