Ch
.
28
Supporting Ventillation
:
Respiratory Physiotherapy
Breathing Therapy
Diaphragmatic breathing using diaphram instead of accessory muscles to inhale & Slow RR
·
:
benefits thoracic & abd.
-
-
·
not
beneficial for
COPD
Pursed-Lip Breathing
better control over
-
:
surgery pts
b/c it can ↑WOB
prolong exhalation
,
prevent bronchial collapse & air trapping
breathing during exercise & dyspnea
Slows RR
-
Airway Clearance Techniques (ACT) loosen secretions to be cleared by coughing
Huff coughing
·
-
·
-
COPD &
helpful for
Chest
forced expiration technique
consisting of several small coughs
:
emphysema
physical therapy (CPT)
Postural
Drainage
↳ best for
:
:
used for pts w/
excessive
bronchial secretions that are hard to clear
positions that help drain secretions
pts w/ atelectasis , COPD
↳ bronchodilators &
,
& Pneumonia
hydration before procedure
↳ contraindicated for Pts w/ <BI neck
,
injung , chest trauma , hemoptysis , heart disease , PE , & hemorrhage
-
-
Percussion
Vibration :
↳
:
done
wh appropriate postural drainage position ; promotes movement of mucus
may be done manually or wh devices
Airway Clearance Devices
·
Flutter
Acapella
TheraPEP Therapy System
↳
High Frequency
Chest Wall Oscillation
:
rest that vibrates Chest
w/airwaves
&
dislodges secretions
O2 Therapy
·
Absorption atelectasis
:
> alveolus
collapse
nitrogen is "washed out" & -
>
-
absorption atelectasis
-
·
O2 toxicity from
↳ can cause
monitor
prolonged use d/t inflammatory response damages alveolar capillary membrane
pulmonary edema , shunting
of blood
,
hypoxemia
O2
pts w/ high
therapy (X-ray
,
ABG , suctioning , lowest O2 (v1 )
)
Methods of Administration
deliver
Humidification
-
can
:
adding Sterile water (bubble
↑ risk for infection
-
through humidifier) to prevent breathing dry O2
fixed 82 concentrations
Artificial
Nasstracheal Tube
Airways
Nasopharyngeal Airway (NPA)
·
measure
·
when
oral intubation is not possible d/+ cervical spine injury
from tip of the nose to tip of the ear & choose nostril wh highest air flow
Oropharyngeal Airway COPA)
·
·
only done on unconscious pts
measure
from
corner
of mouth to the
angle of the jaw /earlobe
Endotracheal Tube
·
Indications
=
ARDS
,
apnea , upper
airway
obstruction , ineffective clearance of secretions , high risk for aspiration
,
dental abscess
epiglottitis
,
Support Ventilation
Procedures to
Chest Tubes
Please space
·
Sizes
-
-
-
Pleural Drainage
&
&
:
re-establish negative pressure , drain the
lung expansion
allow
Painful procedure done in
:
·
Large (36F-40F) drain blood
emergent settings
local anesthetic ; sutured in place & covered wh occlusive
dressing
(24F-36F) drain fluid
Medium
Small
-
(127-24f) drain air
-very small pigtail catheters (10F-14F) safer alternative for pneumothorax
·
Pleural
Drainage System
1.Collection
2
.
chamber
receives
Water-seal chamber :
↳
↳
Tiddling
:
↳
dry
:
:
pleural space-hold
burning in chest
=
reposition dlt possible kink
through water to prevent backflow of air
,
stop of tidaling
= occlusion
water
2000mLo
= check
during exhalation coughing & sneezing but should eventually stop (continuous bubbling
tubing)
up & down movement of water w/ pts breathing ; reflects
Suction control chamber :
↳ Wet
fluid & air from
receives air from collection chamber & bubbles
Intermittent bubbling
↳ sudden
.
3
:
:
applies suction
controlled suction
controlled by a dial ;
; make sure it
usually
stays upright
20mmity
intrapleural pressure As during breathing (no more
means
& Pneumothorax
Nursing Management
Subcutaneus
·
:
Chest
emphysema
:
Drainage
air
leaking into tissue surrounding insertion site
that
feels like crackles"
Chest Tube
Removal
:
done when
lungs are
&
reexpanded
drainage is minimal
-may allow to drain wh gravity 24hrs before removal
-
-
-
Chest
·
Preop care
-
-
-
·
Surgery
:
collect needed labs
;
smoking Cessation
;
postop expectations
deep breathing exercises & incentive spirometry
splinting
;
ROM exercises
postop care
-
Care
↳
↳
priorities
:
Assessing respiratory function
=
Monitoring Chest tube function
↳ Pain
management
↳ Fever & other
signs of infection
↳
wound care
RR
=
,
effort , sounds & sputum /
drainage
amount &d type of
drainage
medicate 30-60 min before removal ;pt will either bare down or hold
their
breath
site is
covered
whairtight occlusive dressing
X-ray done 30-60 min after removal to assess for pneumothorax or fluid
Apnea :Fatigue nla , CAD /heart deprived)
,
Nusing Management
Noninvasive Ventilation
·
help ventilate pt
uses a mask
to
ideal for pts
needing higher(ul of ventilation (COPD
·
provides pressure delivered continuously
during
inspiration &
Common tx for sleep
appea ; used w/ caution
↑ WOB d/t
-
-
·
·
HF)
Airway Pressure ((PAP)
Continuous Positive
·
expiration
pts w/ HF
in
-
·
·
Airway Pressure for more acute problems
LOC
,
hemodynamic stability
mouth
,
nase ,
Help prevent
·
needing forceful exhale against CPAP
Bilevel Positive
Assessment
·
.
or
of Noninvasive Ventilation
,
WoB
eyes
skin breakdown
& ulceration
alleviate pressure from tight filting mask
Elevate HOB 30
-
450
Ensure pt can remove mask
independently
provides 2 levels of positive pressure
·
Inspiratory positive airway pressure : helps w/ removal of CO2
-
Expiratory positive airway pressure
-
pts must be awake
·
candidates :
·
COPD ,
alert
,
,
:
helps keep alveoli open at end expiration
and able to breathe
spontaneously ; high risk of aspiration ; must be hemodynamically stable
of HF
pneumonia
, exacerbation
& ArF
& after extubation
Mechanical Ventilation
·
Non-curative & meant to support pt until recovery of
·
Indications
ARF
:
,
inability to breathe/protect airway respirating muscle fatigue
apnea ,
,
of Ventilators
Types
Negative Pressure Ventilation
intermittent
·
iron
·
:
inspiration & passive expiration
passive expiration
(PPV)
:
pushes air into lungs w/
positive pressure during inspiration
↑ intrathoracic pressure
balloon !
predetermined tidal volume (vi) is delivered each inspiration
needed varies on lung compliance
VT is consistent
Pressure ventilation :
-
-
intrathoracic pressure produces
=
ventilation
pressure
-
·
like normal ventilation ;
lung
volume
-
:
> air rushes in
negative pressure pulls chest outward -
Positive Pressure Ventilation
·
independent breathing
Vi
varies
predetermined peak inspiratory pressure (PIP)
&
based on pressure
monitor exhaled V +
to
lung compliance
prevent hypoventilation
&
hypoxemia
Endotracheal Intubation Procedure
·
Equipment
self-inflating BvMwIO2-meds (propofol ; pancuronium)
-
suctioning
-
IV access
-
Gral intubation
·
sniff position : supine
-
·
·
head extended
,
neck
flexed
Nasal intubation
Spray nasal passages wl
-
·
,
Preoxygenate for
2 min
w/
local anesthetic & vasoconstrictor (lidocaine w/ epinephrine)
100 % 82
Rapid Sequence Induction/Intubation
-
-
↓ risk of
injury & aspiration
sedative
hypnotic
-
Confirming placement
·
-
-
-
-
amnesic
:
fast administration of sedative
,
:
chest wall movement
paralytic drugs during emergency intubation
(propofol etomidate) to sedate & rapid-onset opisid (fentany1) for pain ; followed by vocuronium to paralyze
auscultate lung sounds & epigastrium for abscence of air sounds
Et CO2 detector
&
symmetry
helps confirm placement by noting exhaled CO2
Watch for
·
Risks of Oral ET intubation
·
-
-
-
limited head & neck
teeth
·
mobility
watch for
hypo/hyperventilation
hypersecretions
damage ; challenging mouth care
↑ salivation
Ventilator
Settings
Positive
·
End-Expiratory Pressure (PEEP)
exhalation remains
ventilator
setting that applies positive pressure during exhalation
passive but airway pressure falls to PEEP level
a functional residual capacity &
·
·
:
Oxygenation by splinting open collapsed alveoli & preventing further collapse
Optimal PEEP : titrated to the point where oxygenation improves w/ compromising hemodynamics
glottic mechanism
·
Physiologic PEEP
·
Weaning improves gas exchange vital capacity & inspiratory force
=
ScMH2O PEEP
,
Modes of Volume Ventilation
; replaces
Artificial
1
.
Maintaining correct to be placement
-
-
-
-
.
2
-
.
4
.
note exit
point at mouth or nares
assess
integrity of tape or securement device
Observe
symmetric chest wall movement
ausculate for bilateral breath sounds
Maintain proper cuff inflation
-
3
Airway Management
minimal
occluding volume technique
manometer to confirm
Maintain tube
cuff pressure
patently w/ suctioning
Maintaining alarm systems
=
:
stethoscope over tracked d inflate cuff
20-30 cm
H28
& add air until
no
air
is
hear at PFP
(end of ventilator inspiration)
·
·
encourage pt to breathe wi vent
talking to pt while they are intubated
Preventing delirium
·
A :
B
C
·
ABCDEF
:
Assessment
Breathing trials(x/day
:
correct choice
:
of
analgesia & Sedation
prevention/management
D :
Delirum
Z :
Early mobility
F :
Family engagement
Rescue
-
-
:
alleviate hypoxemia in pts unable
mechanical ventilation , high FSO2
d +
-
therapies
,
&
to
maintain oxygenation
PEEP
pulmonary vasodilators
Prone
positioning
ECMO
Complications of Mechanical Ventilation
·
·
Aspiration
d/t
:
inability to clear
Sodium & water imbalance
kidneys
:
I saliva
airway ; intubation
fluid retention dit ↓ Co-d blood flow to
renin released
>
own
angiotensin & aldosterone t e sodium &
water retention
↑ stress
·
Adverse
hemodynamic effects
vessels
>
-
↓ venous
Alveolar ventilation
·
↳ suction & turn
·
Barotrauma
↑
-
-
·
·
Pneumothorax + PPV
alveolar rupture
can
=
=
life
↑ risk
;
to
changes
compresses thoracic
heart , preload , systolic BP , MAP & CO
alveolar
:
hypo/hyperventilation
& can rupture fragile alveoli/blebs
mediastinal shift
threatening
↑ intrathoracic pressure
·
,
hypotension
,
JVD
PEEP possible to avoid trauma
lowest
to wh chest tube
large volume of Vy used to ventilate noncompliant lungs
:
& movement of fluids & proteins
Auto-PEEP : caused
-
·
airway pressure distands lungs
lung inflation pressure
Volutrauma
-
↑
:
return
:
into alveolar spaces
by inadequate exhalation time
1/1 ↑ WOB barotrauma & hemodynamic instability
,
,
Alterations in Gastric Mobility
·
Ventilator Disconnection & Malfunction
·
Ventilator
-
-
Associated Pneumonia
24hr after
intubation
usually caused by gram-negative bacteria (E Coli
.
-
·
S/S : Fever
,
↑WBL
,
As
in
sputum amount & color ,
,
streptococcus Pneumonial from
crackles/wheezes
,
Chest
G5)
X-ray shows
infiltrates
oral care , clear tubes of secretions/humidification , assess for extubation
*
Vent
settings
RR
=
Tidal Vol
-82
PEEP
·
Unplanned Extubation
Bagging pt until help arrives
=
=
12
=
30
-
-
20
keep low
4-5mL/kg
100 %
ScmH28
to
- prevent barotrauma
low =
if low give more
Sedation & bronchodilator
↑ O2in small increments
ord sedation
Weaning from PPV
watch their trends & ABG
sometimes ordered
to test
pts own breathing
Tracheostomy
·
Early intervention
-
reduces number of ventilator dependent
Nursing Management of Tracheostomy
day length of hospitalization pain & improves communication
,
,