Human needs, exam 1 : supporting ventilation

breathing exercises

diaphragmatic breathing- “belly”

• diaphragm muscle instead of accessory

• not useful in COPD (increase WOB and dyspnea)

pursed lip breathing

• prolonged exhalation to prevent air trapping (decrease RR)

• purse lips like whistling (dont puff cheeks)

• make breathing out (exhal) 3x long than breathing in (inhal)

• good for COPD

airway clearance techniques (ACTS)

loosens mucus/ secretions so they can be cleared by coughing

• huff cough

• chest pT

• airway clearance devices

• high frequency chest ventilation

Chest Physiotherapy (CPT)

for patient having trouble clearing excessive bronchial secretions

• improper technique can result in fractured ribs, bruising of chest wall, hypoxemia, discomfort

percussion

• place thin towel over area for comfort

• place hands in “cup”-like position

• alternate hands rhythmically

• you’ll hear a “HOLLOW” sound if done correctly

• promotes movement of thick mucus

vibration

• promotes movement of secretions to largery airways

HUFF coughing

forced expiratory technique that consists of a series of smaller coughs

• benefits patients with copd emphysema

patient teaching:

• inhale slow and deep thru mouth , hold for 2-3 sec

• forcefully exhale quickly as if “fogging up the mirror” creating the “huff”

• repeat the huff 1-2x w/o having a regular cough

• rest for several breathes and repeat 3-5x

oxygen considerations

• giving high levels of oxygen to a mechanical ventilated patient leads to oxygen toxicity (blurred vision / coughing / chest pain / dyspnea / seizures)

• target levels are to keep SpO2=at least 95% (at rest/some pts may live low) and PaO2=60-100 (ASSES!!!)

  • modify for pts with chronic COPD maybe ain’t for SpO1 >88%

• start low and go slow when giving

management

• assess need with pulse ox (isn’t 100% accurate on colored skin) and/or ABGs

Oxygen Administration Complications

combustible

• teach pt (highly flammable)

• can burn

• no smoking

toxicity

• keep at lowest as possible (blurred vision/ cough/ dyspnea/ seizures)

Low flow Oxygen systems v High flow Oxygen System

Low Flow

• provide a mix of O2 and Room Air (exact O2 concentration is unknown)

• amount of oxygen inhaled depends on RA and patients breathing pattern

• nasal prongs/cannula & simple mask & non-rebreather mask

high flow

• delivered fixed O2 concentration Independent of patients respiratory rate or pattern

• have HIGHER oxygen requirements

• venturi mask / high flow nasal cannula

Nasal Cannula (low flow oxygen system)

add humidification if at 3 L or above

• can dry membranes and cause risk of nose bleeds

assess skin

simple face mask (low flow oxygen system)

(may need to switch to NC to eat)

**flow meter set to 6-10L/min and delivers 35-50% oxygen

• has to be at least 6L to wash exhaled gases out of mask— if not high enough, CO2 rebreathing is possible

!!watch for pressure ulcers/ skin at top of ears form straps with long term use

• wash and dry under mask q4h and PRN

Partial / Non-Rebreather

partial- rebreather

• valves stay open

• flow rate: 10-15mL/min

• provide 60-90% O2 concentration

NON- rebreather

• one way valves are closed

• provides 95% O2 with a flight seal

Nasal Cannula (high flow oxygen system)

reaches up to 100% O2 concentration

• flow rate= up to 60 L/min

!!heated humidiefer capable of 100% humidity

• constant

• can cause dripping from nose

venturi mask (high flow oxygen system)

delivers precise rates of o2

• helpful for giving low, constant O2 concentration to patients with COPD

Home O2 Use Education

• do not change rate without talking to HCP

• make sure you have extra oxygen for weekends and holiday

• wash hands before and after oxygen use

• wash NC prongs with liquid soap and rinse 1-2x/week

• replace NC every 2-4 weeks (if you have a cold - replace after symptoms pass

• keep oxygen tanks at least 5 feet from any source of heat (stoves/ fireplace)

• post “NO smoking” - oxygen in use” warning signs on front and back doors

oral/nasal airways

• can be used to maintain patent airway during use of BMV (bag mask valve) but provides NO protection

oropharyngeal (OP)- unconscious pt

Bag Mask Valve (BMV)

ambu bag- “bag the pt”

• used to preoxygenate a patient before intubation and is part of emergency equipment thats on crash carts or kept in room if patient is unstable

Chest Tube (patho/purpose/insertion)

• sterile tube with several drainage hole inserted into the pleural space (not lung tissue)

• may require drainage unit anytime negative pressure in cavity is disrupted

pleural effusion / pneumothorax / hemothorax / cardiac tamponade

• drains the pleural space and reestablishes negative pressure

!!inserted mid-axillary : HOB elev 30-69, arm above head, local anesthetic (lidocain)

• chest x-ray to confirm placement

• advocate for pain meds!

• consent for insertion

assessments for patient with Chest Tube

• lung sounds / pain / drainage amount / assess site

• report >200mL/hr in 1st hour and 100 mL/hr after (risk of repulmonary edema if too much fluid is removed rapidly causing hypotension)

• do not clamp chest tube unless quick to change CDU, do not compress/ milk / strip tube

• keep CDU below chest, pt will need assist with ambulation

• avoid over turning unit

• if system breaks, place distal end in sterile water - mimics negative pressure

subcutaneous emphysema: small amounts of air leaking into SQ at insertion site

• feels like “crackling” when palpating

• large amounts around Head and neck can cause swelling and airway compromise

Teaching for patients with Chest tubes

encourage deep breathing / incentive spirometry / coughing

• decrease risk of atelectasis

ROM exercises

• prevents shoulder stiffness

removal of chest tubes

pre medicate 30-60 min prior

• valsalve maneuvar (increase intrathoracic pressure so air does NOT rush in the patient)

…..OR

• Trendelenburg / holding breath

!occlusive dressing (petroleum gauze)

compartments names of CDU

(a) suction control regulator

(b) water seal chamber

(c ) air leak monitor

(d) collection chamber

(e ) suction monitor bellow

function of each compartments of CDU

(A) suction control dial: controls amount of suction

(B) water seal chamber: look for tidaling

• acts as one way valve with 2cm of water

• air goes in , bubbles up, but doesn’t go back in patient (bubbles are normal with cough/sneeze and then stops)

(C) Air Leak Monitor: look for bubbling

• allows for visual of possible air leaks or connection problems

(D) Collection Chamber: monitor I/O

• fluid stays in and air vents to 2nd compartment

• allows to measure output

(E) how you see its working!

suction control.

dry suction= most common

• wall suction is used to create negative pressure

• excess suction is vented to atmosphere so it doesnt matter how high wall suction is set

• usual pressure = 20 cm H2O]water seal chamber and air leak detector still present

tidaling

normal up down fluctuation of water d/t pressure changes with breathing (look in compartment b- water seal chamber )

• reflects intra-pleural pressure changes during breathing

• gradually disappears as lungs re-expand (normal)

• occluded chest tube can cause sudden stop and needs immediate attention

bubbling

• brisk bubbling at first often occurs as pneumothorax evacuates (look in compartment b- water seal chamber)

• brisk bubbling disappears as lungs re-expand

• intermittent with exhalation, coughing, sneezing (normal)

• if bubbling stops than increases again, suspect a leak (continuous bubbling indicates an air leak)

Chest surgery: pre-op

• assess baseline

• post op teaching (better to do preop)

  • oxygen/ IV/ possible intubation/ blood administration / purpose and function of chest tubes / pain management

• educate on use of ROM exercises/ deep breathing. IS/ splinting

chest surgery: post-op

1. pain meds— ABC

care priorities:

• assessing respiratory functions

• monitory chest tube function

tracheostomy

surgically created stoma (opening) to:

• establish airway / bypass an upper airway obstruction

• facilitate secretion removal

• permit long term mechanical ventilation

• facilitate weaning from mechanical ventilation

EARLY TRACH!!

• within 10-14 days

• reduces number of ventilatory dependent days/ length of hospital stay/ pain

• improves communication when the need for an artificial airway is expected to be prolonged

• can be done emergently (crico), surgically or at bedside

advantages of a tracheostomy v a endotracheal tube

pts can learn to speak/ eat/ drink with trach’s

• easier to keep clean

• better oral and bronchial hygiene

• patient comfort increased (no tube in mouth)

• easy to do breathing test

• great for ventilator weaning

• less risk of long term damage to vocal cords

  • usually pt can have ETT in for about 2 weeks for HCP recommend a trach to prevent vocal cord damage

tracheostomy components

OBTURATOR

• placed in outer cannula when replacing a trach, allows for easy passage into tracheostomy stoma, its removed after trach placement

• needs to be kept in the room

• part of the safety check for pts with trache’s

• want to keep an extra one a size smaller incase pt has swelling

trach collar

attaches to the neck with a strap and can deliver humidity and oxygen

• some oxygen conc is lost into atmosphere bc collar does not fit tightly

• can use venturi mask

• 2 person assist clean/ change of ties

• remove and clean q4h and PRN to prevent aspiration/infection

cuffed vs uncuffed trachestomy tube

cuffed

• pt requires ventilator needs cuffed

• cuff “balloon” blocks air from moving around the tube

• monitor cuff pressure q8h * PRN - use least amount of air as possible (20-30 cmH2O)

  • too high pressures can result in tracheal necrosis / erosion — not enough / low pressure air leaks out

• uncuffed

  • allows air to pass and apes thru voice box and allows pt to speak

  • more comfortable

  • pt who dont need mechanical ventilation

  • used when a risk of aspiration decreases

fenestrated tracheostomy tube

• has an opening on dorsal surface of the tube that helps promote spontaneous breathing

• breathing spontaneously and speaking with a trach is possible when a fenestrated cuffless / deflated cuff is used (when cuff reflates air cant pass thru the vocal cords)(

• must not be at risk for aspiration !!

Tracheostomy Preop care

• emergency equipment available (trach comes out with ambu bag)

• assess bedside suction

• position patient supine

• CPR with trach

Tracheostomy Post op care

• after using obturator to place trach and removing after placed (KEEP OBTURATOR IN ROOM ALWAYS)

• cuff (balloon) is inflated)

confirm placement:

• auscultate for air entry , end tidal CO2 capnography, passage of suction catheter

• chest x ray!

Principles of suctioning

• assess need for suctioning hourly

• suction only when needed (PRN) not routinely

complications of Suctioning

• increase ICP

• HTN or hypotension

• hypoxemia

  • closely assess pt before, during. after suctioning

  • if pt doesnt tolerate it, stop at once

  • resume after patient achieves stability

  • prevent hypoxemia during suctioning by hyperoxygenating before and after — limit each pass to 10 sec or less (max 3 passes)

• dysrhythmias

  • caused by vagal stimulation from tracheal irritation

• mucosal damage

  • prevent by limitiing suction pressures to less than 120 mn

  • avoid overly viogorous catheter insertion

  • note blood streaks or tissue shreds (talk to doctor)

tracheostomy care

• cleaning the trach

• changing the ties (tapes)

  • 2 ppl assist: 1 stabilizes trach and 1 changes tapes

  • tie tapes securely with room for 2 fingers between ties and skin

• changing the inner cannula

prevent dislodgment

• watch when turning and repositioning

• keep replacement tube of equal and one small size and an obturator at bed side

accidental dislodgement of tracheostomy

medical emergency- call for help

quickly assess LOC , ability to breathe, respir distress

place patient in semi fowlers

• attempt to re insert using spare trach (if policy allows)

if you can not reinsert:

• cover stoma with steril dresing

• ventilate patient with BVM over nose and mouth

Speech with a Tracheostomy

• get with speech therapist to assess for swallowing and aspiration risk

• provide patient with wiriting tools if speaking devices are not used

• establish routines- this is distressing on pt

• fenestrated cuffless/ deflated cuff tubes allow for speech

decannulation

removal of trach

• epithelial tissue forms in 24 - 48 hours , opening closes in 4-5 days

• we SLOWLY step down

criteria:

• hemodynamic stability

• respir drive stable intact

• adequare air exchange

• independently expectorates

opening usually closes in 4-5 days