Common therapeutic measures
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Deep breathing & coughing
Pursed-lip breathing
Tripod breathing
Accessory muscle use
Chest physiotherapy
Suctioning
Oxygen therapy
Mechanical ventilation
Airway obstruction
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May be complete (medical emergency) or partial
Causes:
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Aspiration
Laryngeal edema
Laryngeal or tracheal stenosis - narrowing of the upper airway between the larynx and the
trachea
CNS depression – poor ventilation = collapse
Allergic reaction/ anaphylaxis
Pneumonia – too many secretions
Broncho/tracheal spasm
Symptoms:
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Stridor
Use of accessory muscles
Suprasternal and intercostal retractions
Wheezing
Tachycardia
Cyanosis
Tracheostomy
Tracheotomy - Surgical incision into the trachea for the purpose of establishing an airway
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Tracheostomy is inserted into the tracheal cartilage
Indications
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To bypass an upper airway obstruction
To facilitate removal of secretions
To permit long-term mechanical ventilation
To permit oral intake and speech in the patient requiring long- term mechanical ventilation
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Cancer
Trauma (attempted hanging)
Long term ventilation – permitting oral intake and speech
Pneumonia
Quadriplegics
Head and neck surgery
Complications
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NO filtering
NO warmth & moisture = more lung infections
NO control of when sputum/mucus comes out
NO vocalization WHEN CUFF IS INFLATED
Cuffed tracheostomy – for patients who require positive pressure ventilation and airway protection
Uncuffed tracheostomy – used when patient no longer needs positive pressure ventilation and has no
significant aspiration risk
Nutrition
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Thickened fluids, enteral feeds, Parenteral nutrition
Suctioning effects
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Hypoxia
Tissue trauma
Infection
Vagal stimulation – can cause pulse to drop = syncope
Bronchospasm
When can the trach be removed (Decannulation)
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When the patient is stable and able to breathe on their own
When the patient is able to expectorate secretions
When the patient’s gag reflex has returned
Asthma
- Chronic Inflammatory disorder of the airways; reactive airway disease
 Triggers of asthma attacks: allergens, exercise, respiratory infections, nose and sinus problems,
drugs and food additives
 Signs and Symptoms:
o Dyspnea
o Productive cough, accessory muscle use, audible wheezes
o Tachycardia, tachypnea
o Air trapping as a result of bronchospasm
o Edema and mucous in bronchioles
 Nursing Assessments
o Hx of exposure to triggers/ allergens
o Hx of Asthma
o RR and O2 Sat
o Accessory muscle use, audible and auscultated wheezing, auscultated deep breathing
o Peak flow – maximum speed of expiration; measures airflow through the bronchi and
therefore the degree of obstruction to the airways
o Assess for severity
o Peak Expiratory Flow Rate (PEFR)
 Interventions:
o Administer SAGA; 1 puff every 30 to 60 seconds -> up to 20 puffs
o Reassess Q20 Q30 Q60 minutes
o Take ABG if severe and not improving
 Medications
o Ipratropium Bromide (Atrovent) – prevents bronchoconstriction
o Oral corticosteroids (Prednisone) – Anti-inflammatory
o Epinephrine (Ventolin) – Bronchodilator; Increases Heart rate
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Anti-inflammatory drugs: corticosteroids, antileukotrienes, Anti IgE
Bronchodilators: B-agonists (Short and long acting)
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 Ventolin; short-acting B Agonist – rescue drug
Anticholinergic drugs
Methylxanthines
Chronic Obstructive Pulmonary Disease (COPD)
- Characterized by progressive, partially reversible airflow obstruction, systemic manifestations,
and increasing frequency and severity of exacerbations
 Signs and Symptoms
o Dyspnea, difficulty breathing, SOB, limitations in activity
o Chronic bronchitis and emphysema
o Lungs are struggling to expand and contract
 Causes
o Cigarette smoking
o Chemicals and dust
o Infection
o Heredity
o Aging
 Complications
o Cor pulmonale
o Acute exacerbations of COPD
o Acute respiratory failure
 Management of COPD
o Goals: symptom relief and slowing down of disease progression, improve activity
tolerance
o Smoking cessation
o Influenza vaccine
o Drug therapy: Bronchodilators, steroid inhalers (Anti-inflammatory)
o Pulmonary rehabilitation
o Oxygen Therapy
Pulmonary Embolism
 Occlusions can be caused by:
o Blood clot
o Air embolism (from iv therapy)
o Fat embolism
o Bacterial Clumps
o Amniotic fluid
 Risk factors
o Surgery of pelvis or lower extremities (Dislodging of clots from DVT)
o Immobility
o Obesity
o Estrogen therapy – estrogen increases plasma concentration of clotting factors = more
clotting
o Clotting abnormalities
 Signs and Symptoms
o Sudden onset difficulty breathing
o Chest pain (pleuritic) on INSPIRATION
o Palpitations
o Tachypnea and tachycardia
o Low BP, O2 Sats
o Collapse and sudden death
 Diagnostics
o D-dimer – tells us about the presence of a blood clot by detecting fribrinogen
o ABG- decreased PaO2 (Partial pressure of oxygen in the blood) due to blocked
pulmonary vessels
o ECG, CXR, CT
o Pulmonary Angiogram
 Management
o Oxygen therapy
o Thrombolysis
o Anticoagulation
o Embolectomy
 Patient teaching
o Maintain and follow medication routine
o Maintain health through nutrition and exercise
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Smoking cessation
No birth control – why though? In some women, the estrogen in combination hormonal
birth control methods increases the risk of a blood clot in a leg (deep vein thrombosis,
or DVT) or a blood clot in a lung (pulmonary embolism, or PE).
Immobility/stasis – risk for clot formation
Chest Trauma
Rib Fractures
- Most common with 5th to 9th ribs -> subclavian artery rupture
- Manifestations include: pain, tenderness, muscle spasm, bruising
 Management
o Pain control
o Promote chest expansion
o Nerve Blocks (anesthesia)
o DBC
o Anti-inflammatory drugs
Flail Chest
- When two or more adjacent ribs are fractured at 2 or more sites resulting in a free-floating rib
(flail) segment
- Instability of chest wall
 Manifestations
o Paradoxical Chest movement – when chest wall moves in on inspiration and moves out
on expiration; reverse of normal action
o Rapid shallow respirations and tachycardia
o Lung contusion – lung bruising due to chest trauma
o Atelectasis – complete or partial collapse of the entire lung or area of the lung
 Management
o Intubation and sedation (induced coma)
o Mechanical ventilation
o Humidified O2
o Crystalloid IV fluids
o Diuretics for pulmonary contusion (bruising causes an increase in fluid which may lead
to pulmonary edema)
o Serial CXR, abg, pulse oximetry
Hemothorax
- Blood in the pleural cavity
- Collection of greater than 25mL of blood greatly reduces expansion of lung
 Manifestations
o Chest pain, SOB, Tachycardia, Anxiety, restlessness
o Decreased or absent breath sounds of affected side
o Asymmetric chest wall movement
 Management
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Objective: stabilize patient, stop bleeding, remove blood from pleural space, and
monitor for increased blood loss
CXR then Thoracentesis (withdrawal of fluid from test tube)
Pain control
Check hemoglobin levels (most likely will drop)
Pneumothorax
- A collection of air in the pleural space
 Types
o Closed – spontaneous, no external wound (intubation, rib puncture, blebs?)
o Tension – caused by open or closed pneumothorax ?? huh
o Open – chest trauma (gun shot/ knife wounds)
 Manifestations
o Similar to hemothorax
o Air expansion on unaffected side only
o Asymmetrical chest movement
o Absent breath sounds on affected side
 Signs and symptoms
o Chest pain, SOB, tachycardia, anxiety, restlessness
 Management
o Thoracentesis followed by chest tube
o Pain control
o Pigtail CT with Heimlich valve – a device that may be used with a chest tube to help
remove air from spaces around the lungs; a one way valve sensitive to pressure
changes; pushes open to remove air from chest and then closes to prevent air from reentering
Tension Pneumothorax
- When rapid accumulation of air enter but does not leave the pleural space
- Causes severe intrapleural high-pressure tension
- Leads to a collapsed lung
- Requires immediate needle decompression
 Manifestations
o Same as pneumothorax
o Obstructive shock (decreased BP, increased pulse and resp)
o Mediastinal shift
o Subcutaneous emphysema (rice krispy feeling)
o Tracheal deviation
 Management
o Immediate thoracentesis (needle decompression)
 2nd intercostal space mid clavicular through to pleural space
o Immediate chest tube (pleuravac)
o Pain control and surgery
Open Pneumothorax
- Results from chest wound that allows air to move in and out FREELY (life threatening)
 Manifestations
o Same as pneumothorax
o Shock-like symptoms
o Mediastinal Flutter
 Management
o Requires IMMEDIATE treatment
o 1 way valve device
 Sterile non permeable package of tegaderm attached with tape on 3 sidesallows air out but not back in
o Chest tube
o Pain control and surgery
Pulmonary Contusion
- Damage to lung tissues resulting in hemorrhage from capillary damage and localized edema
- Causes fluid build up in lungs – interferes with gas exchange
 Manifestations
o SOB, chest pain, hypoxemia, sang-tinged secretions, crackles, wheezing
Subcutaneous Emphysema
- The presence of gas within the tissue beneath the skin
 Management – high concentrations of oxygen may help promote REABSORPTION of SC air
Chest Tube
- Drains inserted into the pleural space to drain air or fluid
- Re-establish negative pressure, allowing the lung to fully expand
 Indications
o Trauma
o Thoracic surgery (cardiac and lung)
o Pleural effusion
o Pneumothorax and hemothorax
 Nursing Roles pre-insertion
o Patient teaching
o Gather supplies
o Baseline VS, H-T assessment
o Position patient, semi-fowlers beside table or supine with arms raised
 Patient sits at side of bed with arms on the table
 Nursing roles post-insertion
o Set and connect to suction
o Position and secure drainage system
o Apply dressing
o Observe amount, color, consistency of dressing
 Important things to note
o Chest tubes use gravity and/ or suction to restore negative pressure and remove air,
fluid, or blood from the pleural space
o Never irrigate/ never milk
Three bottle system
 1st Compartment
o Collects drainage
o If full, replace whole pleuravac system
o Vents air to the second compartment
 2nd Compartment
o H2O seal
o Prevents air from re-entering a patient’s pleural space
o One way valve
o Rises and falls with inspiration and expiration (tidaling)
 Continuous bubbles – may indicate possible air leak in tubing
o Tube is submerged under 2cm of water
o Air leaves and then enters 3rd compartment
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Tidaling corresponds with respiration; labored breathing causes more tidaling
o No tidaling = tubing may be occluded by a clot or kink, or the. lung may be fully reexpanded
Bubbling slight with expiration if pneumothorax or if coughing/sneezing
o Intermittent bubbling – pleural space is leaking air – means air is being expelled
o Continuous bubbling – indicate air leak in tubing
 Start at patient
 3rd compartment
o Tube depth determines suction
o Wet suction?