Chapter 26: Respiratory Emergencies

Describe Pulmonary Embolus?

- this is a collection of particulate matter (solids, liquids, air) that enters venous circulation

- lodges in pulmonary vessel

- obstructs blood flow in pulmonary vessel

What can cause Pulmonary Embolus?

caused by:

- VTE/DVT (BLOOD CLOT = MOST COMMON)

- fatty embolus

- air embolus

- injected particles

- foreign body such as a sheared or broken venous catheter

- Immobility after surgery, smoking, diabetes, obesity, history of DVT

**** ANY SUBSTANCE CAN CAUSE EMBOLISM

Risk factors of Pulmonary Embolus?

- prolonged immobility (if can't ROM)

- Central Venous Catheter

- Surgery

- Pregnancy

- Obesity

- Advanced age

- General and genetic conditions that INCREASE blood clotting

- History of thromboembolism

- COVID-19

- Infection

What are the top 3 signs of Pulmonary Embolus?

- DYSPNEA

- HEMOPTYSIS (blood in spit)

- CHEST PAIN

*** these signs are classic BUT ONLY IN 20% of the cases

S/S of Pulmonary Embolus?

- DYSPNEA

- HEMOPTYSIS

- CHEST PAIN

- BLOODY SPUTUM

- SHORTNESS OF BREATH

- Pleuritic chest pain (worse on inspiration)

- Cough

- Lightheaded

- Tachypnea/Tachycardia

- Hypotension

- Low grade fever

- Anxiety

- Crackles/wheezes

- Hypoxemia, DECREASED SPo2

Describe Lifestyle changes of Pulmonary Embolus?

- Smoking cessation

- reduce weight

- become more physically active

- compression socks/shoes

- EARLY ambulation

- No restrictive clothing

- stool softeners!!

Describe lifestyle change for a person traveling with Pulmonary Embolus?

- drink plenty of fluids

- change positions often

- avoid crossing legs

- get up from sitting position 5 minutes of each hour

Describe Physical Assessment for Pulmonary Embolus?

- look at respiratory (stabbing pain) and cardiac systems!!!

Describe Psychosocial Assessment for Pulmonary Embolus?

- assess anxiety!

Describe Laboratory assessment for Pulmonary Embolus?

- LOW PaCO2 on ABG

- General metabolic panel

- INCREASED TROPONIN

- BNP

- INCREASED D-DIMER = blood clot

Describe imagining assessment for Pulmonary Embolus?

- CTPA

- this is to see if they see a clot

What are the PRIORITY PROBLEMS for Pulmonary Embolus?

- Hypoxemia

- Hypotension

- Potential for excessive bleeding

Describe Hypoxemia relating to Pulmonary Embolus?

- apply oxygen with oxygen saturation 90% or less

- elevated HOB

- recognize signs of PE

- alert rapid response

Describe Hypotension relating to Pulmonary Embolus?

- relates to IV fluid therapy

- and drug therapy

Describe how Pulmonary Embolus is at a potential for excessive bleeding?

- the pt is probably on a blood thinner

- bruising may appear

- look for any sings of blood output

- drug therapy

Describe Treatment for Pulmonary Embolus?

- PREVENTION = BEST TREATMENT

Describe Nonpharmacological treatments for Pulmonary Embolus?

- ROM excercises

- Ambulate ASAP

- Elevate the limb 20 degrees ABOVE the heart to promote venous blood return

- DO NOT CROSS LEGS IN BED

Anticoagulants are used for:

- to prevent embolus enlargement and further clotting

List Anticoagulants relating to Pulmonary Embolus?

- Heparin sodium

- LMWH - Enoxaparin

- Warfarin

- Rivaroxaban

Describe Heparin relating to Pulmonary Embolus?

- warfarin may be started SIMULTANEOUSLY

**** this med won't let the clot get any larger but it does NOT dissolve it so -> fibrinolytic is needed!! (CAN PREVENT FORMATION)

- Monitor with PTT = will be ELEVATED = expected (if in normal range, med is not strong enough)

*** Patient care/ SAFETY BLEEDING PRECAUTIONS (use soft toothbrush)!!

Antidote for Heparin:

Protamine sulfate

What to do for 5-10 days of Heparin?

- short life

- start warfarin after 1 day

- this takes a while to work

- can STOP heparin after warfarin is where it needs to be

Describe Heparin induced thrombocytopenia (HIT)?

- if you give with low platelet count there will be a bleeding risk!!

*** Monitor PTT, Factor anti-Xa, Platelet count

Describe LMWH- Enoxaparin relating to Pulmonary Embolus?

- this is a PREVENTATIVE MED

- aka LOVENOX

- Labs are not usually monitored...

- Partially reversed with Protamine....

** MONITOR BP and PULSE

Describe Warfarin relating to Pulmonary Embolus?

- VIT K = antidote

- Monitor with PT/INR when pt is on maintenance at home ( does not tell anything about heparin)

*** PT/INR will be elevated = expected = if it gets HIGH, hold warfarin, notify provider!!

Describe Fibrinolytics/Thrombolytics relating to Pulmonary Embolus?

- breaks up existing clots!

- this is indicated for PE with HYPOTENSION in the absence of high risk bleeding

- Ex: Alteplase (Activase, tPA)

Describe Alteplase?

- MONITOR pt closely

- Pt will be in ICU setting

- Assess hourly, or more frequently, for internal and external bleeding

- Q1HR = while administering

- 8HR after = hemorrhage

Antidote for Alteplase?

- Amino-Caproic Acid = fresh frozen plasma

If PT and INR values are elevated this means:

- this indicates being at a serious risk for BLEEDING

- Alert provider!!

Describe Rivaroxaban relating to Pulmonary Embolus?

- used as a PREVENTATIVE!!

- aka " Factor XA" inhibitor

- this is a direct thrombin inhibitor = ORAL ANTICOAGULANTS

- Ex: NOACs, DOACs, TSOACSs

Describe Surgical stuff relating to Pulmonary Embolus?

- Embolectomy (surgical removal of the embolus)

- Inferior vena cava (IVC) filter: used as a PREVENTATIVE. This is the placement of a retrievable vena cava filter to prevent further emboli from reaching lungs

Describe Management of Pulmonary Embolus?

- INCREASING gas exchange

- Improving perfusion

- REDUCING risk for further clot formation

- preventing complications

- Apply Supp. O2 with cannula or mask if oxygen less than 90%

- Cardiac assessment

- Manage HYPOTENSION with vasopressor

What position do you place pts with Pulmonary Embolus?

High Fowlers Position

Describe Nonsurgical Treatment for Pulmonary Embolus?

- Anticoagulant Therapy

- Fibrinolyitcs/Thrombolytics

- Monitor PTT, INR and Platelets

- Manage HYPOTENSION

- IVF therapy to restore plasma volume and prevent shock

- USE VASOPRESSORS when hypotension does NOT respond to IVF (norephinephrine, dopamine)

Describe Acute Respiratory Failure (ARF)?

- this is the inability of the lungs to provide oxygenation

- and/or remove CO2 from the body

*** WILL HAVE ALTERED ABGs!!

What is Acute Respiratory Failure caused by?

- caused by oxygenation and ventilatory failure

- can be ACUTE or CHRONIC (COPD)

*** these pts are at an INCREASED RISK

Describe S/S of Acute Respiratory Failure?

- DYSPNEA (hallmark sign!!!)

- Hypoxia

- Orthopnea

- Hypercarbia (HIGH CO2 in blood) = LOW BP & bradycardia

- Respiratory acidosis

- AGITATED & IRRITABLE/ restless

- Hypercapnia

- Tachycardia/Tachypnea

- Cyanotic

Describe O2 and PaCO2 in Acute Respiratory Failure?

O2: < 60

PaCO2: > 45

- Arterial oxygen saturation = < 90%

What to assess for in Acute Respiratory Failure?

- Assess rate, pattern, lung sounds

- Monitor LOC

- Monitor ABGs

- Monitor SpO2 and SpCO2

- Use of accessory muscles?

Describe interventions for Acute Respiratory Failure?

- give oxygen therapy

( CO2 < 45)

- drug therapy

- position of comfort

For acute respiratory failure, describe drug therapy used:

- Steroid = inflammation

- Diuretic = fluids

- Antibiotics = infection

What position do you place a pt with acute respiratory failure?

- sit upright & prone position

- this is to help expand the lungs

Describe Pharmacological treatment for acute respiratory failure?

- nebulizer

- steroid

- sedation

- antibiotics if needed

Describe Acute Respiratory Distress Syndrome (ARDS)?

- this is the most severe form of acute respiratory failure!!

Describe hallmark sign of Acute Respiratory Distress Syndrome?

- no matter how much oxygen they are on, they are still NOT IMPROVING = HYPOXEMIA!!

- this persists even when 100% oxygen is given

Describe assessment of Acute Respiratory Distress?

- HYPOXEMIA

- Decreased pulmonary compliance

- Dyspnea

- Noncardiac-associated bilateral PULMONARY EDEA

- dense pulmonary infiltrates on x-ray

Acute Respiratory Distress Syndrome often occurs after an Acute Lung Injury (ALI) because of:

- SEPSIS

- Multiple organ shutdown

- shock

- trauma

- fire exposure

- denied blood transfusions

S/S of Acute Respiratory Distress Syndrome?

- HYPOXEMIA despite 100% O2

- Dyspnea

- Tachypnea

- INCREASED work of breathing

- HYPERVENTILATION

(early resp. alkalosis -> then develops acidosis)

- Change in loss of consciousness

- Hypernea, noisy respirations, cyanosis, pallor, retraction intercostally or substernally

Describe Labs related to Acute Respiratory Distress Syndrome?

- LOW BP

- HIGH HR

- Dysrthythmias

- LOW partial pressure of arterial oxygen

- P/F ratio

What diagnostics are needed for Acute Respiratory Distress Syndrome?

- Sputum cultures

- Chest x-ray

- ECG

What are the 3 phases of Acute Respiratory Distress Syndrome?

- Exudative

- Fibroproliferative

- Resolution

Define Exudative phase for Acute Respiratory Distress Syndrome?

- this is when fluid moves into the alveoli (Atelectasis)

Define Fibroproliferative phase for Acute Respiratory Distress Syndrome?

- this is when there is INCREASED lung injury, pulmonary hypertension, and multiorgan disfunction syndrome

Define Resolution phase for Acute Respiratory Distress Syndrome

- this begins after 2 weeks, permanent lung damage may occur if patient survives

Describe Interventions for Acute Respiratory Distress Syndrome?

- Oxygenation and Ventilation

- Mechanical ventilation

For Acute Respiratory Distress Syndrome, describe oxygen and ventilation intervention?

- this is a non-invasive positive pressure ventilation (NPPV)

- CPAP or BiPAP

*** IF this does NOT work, pt will end up on VENTILATOR

For Acute Respiratory Distress Syndrome, describe Mechanical Ventilation intervention?

doing drug ad fluid therapy (conservative)

- Mucolytics = to excrete mucus

- Diuretics = avoid fluid overload

- Nutrition therapy

- Positioning

- Early Mobility

Describe Endotracheal Intubation (ETT)?

- most common artificial airway for SHORT-TERM basis

- CAUTION = Cervical spine Injury!!!

- requires complete cerebral spine immobilization

A tracheostomy needs to be considered instead of and Endotracheal Intubation (ETT) IF:

> 10-14 days

Describe ETT tube placement?

- Assess tube placement, minimal cuff leak, breath sounds, chest wall movement

- Prevent movement of tube by patient

- Check pilot balloon (one way valve)

*** Pressure within the cuff should be maintained between 20-30 cmH2O

Describe ETT nursing care?

- soft nursing restraint

- adequate sedation and pain control

- oral care!!

- prevent skin breakdown

- prevent aspiration secretions

Describe ETT complications?

- cardiac problems

- lung problems

- GI problems

- Infection

- Muscle deconditioning

- Ventilator dependence

Define Tracheotomy?

- this is the surgical incision into the trachea for the purpose of establishing an airway

Define Tracheostomy?

- this is the STOMA (opening) that results from tracheotomy

- can be temporary or permanent

List possible complications of a tracheostomy?

- Pneumothorax

- Subcutaneous emphysema (tear in tube)

- Bleeding

- Infection

- Tube obstruction

- Tube dislodgement

Describe what a tracheostomy looks like?

- disposable or reusable

- cuffed tube or tube without cuff for airway maintenance

- inner cannula disposable or reusable

- fenestrated tube

Describe Tracheostomy Care?

- Assess pt

- Secure tubes (tab around neck) in place -> need precut gauze

- prevent accidental decannulation

- Prevent tissue injury

- ensure nutrition

- communication

- weaning

- suctioning box

Describe Bronchial and Oral Hygiene for Tracheostomy?

- Turn every 1-2 hours

- support out of bed activities

- early ambulation

- coughing and deep breathing

- chest percussion, vibration, postural drainage

- promote pulmonary hygiene

- USE sponge tooth cleaner/soft brush moistened in water

*** AVOID glycerin swabs and mouthwash containing alcohol for oral care!!!

Describe Tracheostomy teaching for pt?

- tube care

- shower shield

- cover loosely with small cotton cloth during day

- INCREASE home humidity

- Wear medical alert bracelet

- follow up

Describe Air warming and humidification for Tracheostomy?

- this tube bypasses the nose and mouth which normally humidify, warm and filter air

- air MUST be humified

- maintain proper technique

- ensure adequate hydration

Describe Nutrition for Tracheostomy?

- swallowing can be a major problem for these patients!!

- if balloon is inflated = can interfere with passage of food through throat

*** Elevate HOB for at least 30 minutes after eating to prevent aspiration

Describe Prevention of tissue damage for tracheostomy:

- cuff pressure can cause mucosal ischemia

- use minimal leak and occlusive techniques

- check cuff pressure often

- prevent tube friction and movement

- prevent/ treat malnutrition, hemodynamic instability, hypoxia

Describe causes of hypoxia in the tracheostomy?

- ineffective oxygenation before, during, and after suctioning

- use of catheter that is too large for the artificial airway

- prolonged suctioning time

- excessive suctioning pressure

- too frequent suctioning

Describe Suctioning?

- this should be as indicated/as needed by assessment, NOT routine

What are indications for suctioning?

- visible secretions, coughing, Rhonchi, DECREASE in SpO2

- HIGH PIP on ventilator can indicate secretions

Closed suctioning has a:

DECREASED risk of infection

Conventional/Open suctioning has a:

HIGHER risk of infection due to the circuit being opened!

What kind of procedure is suctioning?

STERILE PROCEDURE!!

Describe Catheter Suctioning insertion?

- this should be no more than half the diameter of the artificial airway

For shallow suctioning, you need to suction at:

80-120 mm Hg

*** side note: NO benefit to deep suctioning...

BEFORE suctioning, BETWEEN passes and AFTER suctioning, we need to:

- HYPEROXYGENATE with 100% O2

- for 30 seconds

Intermittent suction should be:

- on WITHDRAWL of catheter ONLY

- NO LONGER THAN 10-15 seconds

Things to remember about suctioning:

*** AVOID normal saline instillation to thin secretions

- Keep patient hydrated to thin secretions

- meds (mucolytics), cough, position to thin secretions

- Do NOT apply suction while inserting the catheter!!

Describe aspiration prevention/precaution for tracheostomy's?

- Assess SWALLOWING ability

- Maintain appropriate positioning

- Maintain airway

- Suction secretions when indicated

- Provide oral hygiene

- Follow swallowing precautions

- Monitor for respiratory changes during/after eating

- Ensure nutrition safely

Describe positioning for tracheostomy?

- raise head of bed to 30-45 degrees (semi-fowlers) for rest.

- raise it higher 45-90 degrees (high-Fowlers) during suctioning and eating

Describe Flail Chest cause?

- this is when two or more adjacent ribs fractured in more than one location

- loose segment moves

IN during inspiration and OUT during expiration.

*** FREE FLOATING segment of the rib cage

What key assessment is part of Flail chest?

- Paradoxical chest-wall movement

- poor ventilation

- oxygen problem

S/S of Flail chest?

- increased work of breathing

- Tachypnea

- Hypoxemia

Describe management of Flail chest?

- intubation

- mechanical ventilation

- pain management

- position to improve ventilation/oxygenation

- frequent pulmonary care

Describe Pneumothorax?

- this is air in the pleural space

- occurs when air escapes from the injured lung into the pleural space (can be partial or complete collapse)

S/S of Pneumothorax?

- respiratory distress

- tachypnea

- tachycardia

- DECREASED or ABSENT breath sounds

Treatment of Pneumothorax?

- O2 and Chest tube placement

- HIGHER than hemothorax

Describe Hemothorax?

- this is a collection of blood in the pleural space

- caused by injuries to heart, vessels or pulmonary parenchyma

S/S of Hemothorax?

- DECREASED breath sounds

- dullness to percussion on affected side

- hypotension and respiratory distress

Describe chest tube insertion for Hemothorax?

- inserted in base of the lung to remove the blood from pleural space

- make sure body/ orders are compensating for lost blood

Describe Tension Pneumothorax?

- MEDICAL EMERGENCY!!!

- this is the injury to the chest allows air to enter the pleural cavity WITHOUT A ROUTE FOR ESCAPE

S/S of Tension Pneumothorax?

- distended neck veins and mediastinal shift

- each inspiration allows additional air to enter the pleural space causing increased intrapleural and intrathoracic pressures which can then cause compression of heart and great vessels to shift toward the unaffected side

Describe Cardiovascular collapse for Tension Pneumothorax?

- DECREASED cardiac output and alteration in gas exchange

- pt experiences anxiety, severe respiratory distress, absence of BS on affected side, hypotension

- tracheal deviation (shift from midline toward unaffected side)

- CYANOSIS = late manifestation

*** Diagnosis is made on clinical presentation; symptoms are not delayed for x-ray...

What is needed for Tension Pneumothorax?

- emergent treatment with NEEDLE THORACOSTOMY!!!

- chest tube inserted AFTER needle decompression

Pneumothorax and Acute Respiratory Disease Syndrome require:

x-ray!!!!