Specific Methods of Respiratory
Management
Respiratory Module
Deep Breathing & Coughing
• Airway clearance
– Nrs Dx
• Ineffective airway
clearance
– h fluids
Breathing Exercises
• Goal
– i work of breathing
– h 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  h CO2 excretion
• With diaphragmatic
breathing
• Counting  i 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
– i work
– i 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 h CO2 levels “burned” medulla sensor for CO2
– Medulla uses O2 to initiate breath
COPD & O2
•
•
•
•
•
COPD + h O2 
i Resp 
h 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
h O2 concentration > 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”
Oxygen Toxicity
S&S
• Sub-sternal distress
• Chest pain
• Dry cough
• Paresthesia
• Dyspnea
– Progressive
• Restlessness
• * PaO2 > 100mmHg
Oxygen Toxicity
Prevention
• i 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
Method of O2 Administration
Simple Mask
• Flow rate
– 6-10 L/min
• FiO2
– 40-60%
• Nrs
– Higher flow rate
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
Method of O2 Administration
Non-rebreather Mask
• Flow rate
– 6-10 L/min
• FiO2
– 70-100%
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 <½
Method of O2 Administration
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.
B.
C.
D.
Artificial nails
Vasodilation
Hypothermia
Movement of the head
Nebulizer Mist Treatment
• Deliver Moisture OR
medication directly
into the lungs
• Topical – i 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
• i systemic S/E
• Meds:
– Corticosteroids
– Bronchodilators
– Mast cell inhibitors
Metered Dose Inhaler
Procedure
• Canister into unit
correctly
• Shake gently
• Hold inhaler – breath
out slowly (not into
inhaler)
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
Metered Dose Inhaler
• Remove inhaler from
mouth
• Hold breath for
several seconds
• Breath out slowly
Metered Dose Inhaler
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
– h ventilation
– h 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:
–
–
–
–
–
h pain
SOB
Weakness
Lightheadedness
Hemoptysis
Chest physiotherapy
Percussion
• Cupped hands strike
the chest repeatedly
•  sound waves
loosen secretions
Vibration
• Vibrations using hands
or vibratos to loosen
secretions
Chest physiotherapy
Percussion& vibration
• X after meals
• X 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
Chest Drainage Tubes
Indications
• Air in pleural space
• Pneumothorax
• Pleural effusion
• Penetrating chest
injury
• Chest surgery
Chest Drainage Tubes
• Upper, anterior chest
(2nd & 4th intercostal space)
– Remove air
• Lower lateral chest (8th
or 9th intercostal space)
– Remove fluid
•
Chest Drainage Tubes
• MD inserts
• Nrs connects system
and secures all
connections
• Vaseline gauze and
sterile occlusive
dressing at insertion
site to prevent leakage
Chest Drainage Tubes
• 2 padded clamps at
bedside
• Clamps only used if:
– Chest system
accidentally
disconnected
– Changing drainage
system
– Trial period before
removal
Chest Drainage Tubes
• Tubes never clamped
for more than few min

• Prevents air from
escaping 
• Buildup of air in
pleural space 
• Pneumothorax
Chest Drainage Tubes
•
1.
2.
3.
3-bottle system
Water seal bottle
Suction bottle
Drainage bottle
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
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
Chest Drainage Tubes
Water Seal
• Water level fluctuates
– hI
– iE
• Tidaling
– Normal
• When lung is reinflated 
– Tidaling stops
• If tidaling stops:
– Lung reinflated
– Tubing kinked
– Tubing occluded
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
Chest Drainage Tubes
Suction Bottle
• Suction level order by
MD
– -20cm Water
• Turn suction machine
on enough to cause
gentle bubbling
– Normal
Chest Drainage Tubes
Suction bottle
• Vigorous bubbling 
• water evaporation 
• change amt of suction
– Turn down suction
• No bubbling
– Kink in system
– Suction disconnected
Chest Drainage Tubes
Drainage bottle
• Collect fluid from
pleural space
• Fluid d/t
– Pleural effusion
– Chest trauma
– Surgery
Chest Drainage Tubes
Drainage bottle
• Fluid is not emptied to
measure
– Mark line q shift
• Date
• Time
• Amt.
– Add to I&O
• Sudden h in fluid, or very
bloody 
– Notify MD
Chest Drainage Tubes
Nrs. Care
• Must always be kept
upright
• Always below level of
chest
• Notify MD if:
– h Dyspnea
– Drainage chamber full
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
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
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
Chest Drainage Tubes
• P suction control
bottle
– Gentle bubbling
– H2O level
• P and mark amount
of drainage
Chest Drainage Tubes
Stripping
• Slide fingers down the
tube
Milking
• Gently squeezing tube
w/out sliding
• MD order only!
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
Chest Drainage Tubes
Removal of tube
• MD removes
• Place Vaseline gauze &
sterile occlusive
dressing over site
• Assess:
– Crepitus
– Resp status
– Dressing site
Question?
•
A.
B.
C.
D.
E.
F.
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
Question?
•
A.
B.
C.
D.
E.
F.
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
Question?
•
A.
B.
C.
D.
E.
F.
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
Question?
•
A.
B.
C.
D.
E.
F.
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
Question?
•
A.
B.
C.
D.
E.
F.
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
Question?
•
A.
B.
C.
D.
E.
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
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
Mechanical Ventilators
Indication for use
• Cont. i in PaO2
• Cont. h PaCo2
• Persistent Acidosis
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
Mechanical Ventilators
Ventilator modes
• FiO2
– Fraction of inspired
oxygen
– Concentration of O2
• Tidal Volume
– Amt of air delivered
with ea. Breath
Mechanical Ventilators
• Rate
– Frequency of breaths
• I:E
– Inspiration to
expiration ratio
– 1:3
• I-1 sec
• E-3 sec
Mechanical Ventilators
• AC
– Assist control mode
– Delivers breath ea time
pt begins to inhale
– If pt X breath, delivers
preset minimum # of
breaths
Mechanical Ventilators
• SIMV
– Synchronized
Intermittent
mandatory ventilation
– Pt breaths on own, but
delivers minimum #
breaths
Mechanical Ventilators
• Pressure support (PS)
– Provided + pressure on
I to i work of
breathing
Mechanical Ventilators
• Continuous positive
airway pressure
(CPAP)
– + pressure on I & E to
i work of breathing in
spontaneously
breathing pt
Mechanical Ventilators
• Positive End
Expiratory Pressure
(PEEP)
– Provides + pressure on
E to keep small airways
open
– Prevent Atelectasis
– If too high 
• pneumothorax