Module 3 : Altered Ventilatory Function

Acute/Chronic Obstructive Pulmonary Disease

• A disease characterized by airflow limitation that is not fully reversible.

Emphysema

Manifestation

• pink puffer

• Mild production of sputum

• barrel chest

• dyspnea

• cough may be present

Chronic bronchitis

Manifestation

• Blue bloater

• Productive Cough

• Thick, gelatinous sputum

• Wheezing might be present

• Notable dyspnea

Diagnostic Procedures

• Spirometry

• ABG levels

• Chest X-ray

• Alpha1-antitrypsin assay

Medical management

• Bronchodilators

• Inhaled and systemic corticosteroids

• Alpha1-antitrypsin augmentation therapy

• Antibiotic Agents

• Mucolytic agents

• Antitussive agents

• Vasodilators and

• Narcotics

Surgical management

• Bullectomy

• Lung Volume Reduction Surgery

Nursing Care Management

1. symptoms reductions

2. Pursed-lip breathing & diaphragmatic breathing

3. small frequent meals & hydration

4. administer low flow of oxygen

5. pulmonary rehabilitation

Acute Respiratory Distress Syndrome

• s a severe form of acute lung injury. This clinical syndrome is characterized by a sudden and progressive pulmonary edema, increasing bilateral infiltrates on chest x-ray, hypoxemia unresponsive to oxygen supplementation regardless of the amount of Patients often demonstrate reduced lung compliance

Manifestation

• develops over 4 to 48 hours

• severe dyspnea, severe hypoxemia

• Arterial hypoxemia

• chest x-ray are similar to those seen with cardiogenic pulmonary edema

• increased alveolar dead space

• Severe crackles and rhonchi heard on auscultation

• Labored breathing and tachypnea

Diagnostic Procedures

• Clinical presentation and history of findings

• Hypoxemia on ABG despite increasing inspired oxygen level

• Chest x-ray shows bilateral infiltrates

• Plasma Brain Natriuretic Peptide (BNP)

• Echocardiography

• Pulmonary Artery Catheterization

Management

• Treatment of the underlying condition

• Optimize oxygenation

• Intubation and mechanical ventilation

• Sedation may be required

• Paralytic agents may be necessary

• Antibiotics, as indicated

• PEEP usually improves oxygenation

Pneumonia

• Inflammation of the lung parenchyma

Manifestation

• Sudden onset, rapidly rising fever of 38.3° C to 40.5° C

• Cough productive of purulent sputum

• Pleuritic chest pain aggravated by deep respiration/coughing

• Dyspnea, tachypnea accompanied by respiratory grunting, nasal flaring, use of accessory muscles of respiration, fatigue

• Rapid, bounding pulse

• Orthopnea, Rusty, blood-tinged sputum

• Poor appetite & Diaphoresis

Diagnostic Procedures

• CXR for extent of pulmonary disease

• Gram Stain and culture for organism identity

• Blood culture detects bacteremia

Management

• Antibiotics, anti pneumococcal,

• Oxygen therapy

Nursing Interventions

• coughing and deep breathing

• semi-fowler position and monitor pulse oximeter

• hydration

• health teaching about antimicrobial therapy

Pneumothorax

• occurs when the parietal or visceral pleura is breached and the pleural space is exposed to\ positive atmospheric pressure

Manifestation

• Hyperresonance & Diminished breath sounds.

• Reduced mobility of affected half of thorax.

• Tracheal deviation

• Air hunger, agitation, hypotension, cyanosis and profuse diaphoresis

• Mild to moderate dyspnea and chest discomfort may be present with spontaneous

  pneumothorax

Kinds

• Spontaneous Pneumothorax

• Tension Pneumothorax

• Open Pneumothorax

Nursing Intervention

• Apply petroleum gauze to sucking chest wound

• position patient upright

• administer pain medications

• monitor oximetry and ABG levels

• provide oxygenation

SARS-COV 2/ COVID-19 Disease

• Newly discovered Corona Virus originated from Wuhan, China (December 2019). This serious disease attacks the respiratory system that may lead to imminent death.

Predisposing Factors

1. Host

• Age (Older populations)

• Smokers

• Immunosuppressed individuals

• existing comorbidities

• family life and culture

• Lack of discipline and education

2. Environment

• population density

• high level exposure to wet market with wildlife animal trading

3. Agent

• SARS-COV-2

• attaching protein spikes in the lungs

• phases of attack

  1. Viral replication

  2. Hyperactivity of pulmonary system

  3. pulmonary destruction

Manifestation

• Cough, Sore Throat & Headache

• Diarrhea & Fever

• Loss of Smell & Loss of Taste

• Difficulty of Breathing & Shortness of Breath

• Haziness and tiny white spots in the X-ray Result

Diagnostic test

• SWAB TEST: rt-PCR (Real-Time Polymerase Chain Reaction)

Medications

• Tocilizumab

• Remdesivir \

• Baricitinib + Remdesivir

• Low dose Heparin or Enoxapin

Management

• Supportive Care

• Providing fluids

• Providing oxygen

• Ventilatory support (Mechanical Ventilator) if indicated

Acute Lung Failure

Symptoms

• Hypoxemia

• Hypercapnia

• Hypoxia (Hallmark sign)

Pathophysiology

• pulmonary system fails to maintain adequate gas exchange; another disorder alters normal pulmonary function to lower ventilatory drive, decreased muscle strength, decreased chest wall elasticity, decreased lung’s capacity for gas exchange, and increase resistance, or increased metabolic O2 requirements

Assessment and Diagnosis

• ABG analysis

  • Increased or decreased levels of PaCo2, PaO2, &pH

  • PaO2< 60 mmHg. if patient with hypercapnia, PaCo2 > 45 mm Hg

  • increased PaCo2, includes pH <7.35

• Bronchoscopy for airway surveillance or specimen retrieval

• chest radiography, thoracic ultrasound, Thoracic CT, lung function studies

Medical Management

• promote adequate gas exchange, correct acidosis, provide nutritional support, & prevent complications

• supplemental O2 for hypoventilation & V/Q mismatch, PEEP for increased gas exchange

Medications

• Beta2 agonist & anticholinergics - smooth muscle relaxation and bronchial dilation

• steroids - airway inflammation & enhance beta2 agonists

• sedation - comfort and decreased work of breathing

• Analgesics - pain control

Nursing Intervention

• positioning - HOB 30 -35, reposition Q2

• Prevent desaturation - hyper oxygenate before suctioning

• Minimize oxygen consumption - limit physical activity

• Education and Emotional support

Acute Respiratory Distress Syndrome

• occurs when capillary membrane that surrounds alveolar sac to leak fluids causing it to collapse

• fast onset for patients who are already hospitalized w/ another conditions

• develops due to systemic inflammation

Symptoms

• hypoxemia

Causes

• Indirect

  • source is not the lungs

    • Sepsis

    • burns

    • blood transfusion

    • inflammation pancreas

    • drug overdose

• Direct

  • source is the lungs

    • Pneumonia

    • Aspiration

    • Inhalation injury

    • near-drowning

    • embolism

Phases

1. Exudative

• 24 hrs. after injury, damage to capillary membrane

• fluid start to leak on the sac. protein rich fluid that draws more water to the sac causing pulmonary edema

• Diminished lung sounds and Crackles

• decreased surfactant causing decreased surface tension leading to atelectasis

• hyaline membrane making the lungs more stiff and decreased lung compliance causing VQ mismatch

• Hallmark sign : Refractory hypoxemia : increased RR, Low O2, Low CO2 leading to alkalosis

1. Proliferative

2. Fibrotic

Pulmonary Embolism (PE) 

• occurs when a clot or other material, such as fat, air, or amniotic fluid, blocks the pulmonary arteries, disrupting blood flow. 

• The most common source of thrombotic emboli is from the deep leg veins (e.g., iliac, femoral veins).

• Pathophysiology:

• In massive PE, blockage of a lobar artery can lead to ventilation without perfusion, hypoxemia, and respiratory acidosis.

• Hemodynamic consequences include pulmonary hypertension, right ventricular failure, and decreased cardiac output.

• Management:

• Prevention: Prophylactic anticoagulation (low-dose heparin or LMWH) and pneumatic compression devices for at-risk patients.

• Clot dissolution: Fibrinolytics like rt-PA or streptokinase are used in massive PE.

• Surgical options: Pulmonary embolectomy for severe cases.

Status Asthmaticus 

Definition:

• A severe asthma attack that is unresponsive to bronchodilators and can progress to acute lung failure.

• Contributing factors include upper respiratory infections, allergen exposure, and lack of treatment adherence

  Pathophysiology:

• Exposure to triggers causes bronchospasm, increased mucus production, and airway narrowing leading to airflow obstruction and systemic effects on pulmonary and cardiovascular systems.

  Management:

• Use inhaled β₂-agonists, anticholinergics, magnesium sulfate for refractory cases, and systemic corticosteroids to reduce inflammation.

• Oxygen therapy and mechanical ventilation if needed.

COVID-19 Critical Care Management 

Etiology & Transmission:

• Caused by SARS-CoV-2, a novel coronavirus. Transmission occurs through respiratory droplets, aerosols, and contaminated surfaces.

• Incubation period: 5–6 days, but can be as long as 14 days.

  Management:

• Oxygen therapy escalation, use of mechanical ventilation with low tidal volume for ARDS, and prone positioning to improve oxygenation.

• Anticoagulation and corticosteroids (e.g., dexamethasone) help in severe cases.

  Nursing Considerations:

• Strict infection control measures and emotional support for isolated patients and their families. Monitoring for signs of worsening hypoxia and hemodynamic instability is essential.

Oxygen

• is considered a medication, and its use needs to be carefully managed to avoid both hypoxia (low oxygen) and oxygen toxicity (excessive oxygen). 

• It is vital to ensure that oxygen therapy improves tissue oxygenation and perfusion without causing damage due to prolonged exposure to high levels of oxygen.

• PaO₂ should be maintained above 60 mm Hg and SaO₂ (oxygen saturation) should be kept above 90% during rest and with exercise.

• FiO₂ (Fraction of Inspired Oxygen): Oxygen therapy should aim for the lowest FiO₂ that can achieve the target oxygen saturation, ideally < 0.50 (50%) to prevent oxygen toxicity.

• High levels of FiO₂ can cause oxygen toxicity, which increases the risk of lung injury, especially in critically ill patients.

Low-Flow Systems:

1. Nasal Cannula

2. Simple Face Mask

Nasal Cannula

Delivers up to 6 L/min of oxygen, providing around 24-44% FiO₂ depending on the patient's respiratory pattern.

Simple Face Mask

Provides between 35-55% FiO₂ at 6-10 L/min; often used for patients who need a higher concentration of oxygen than a nasal cannula can provide.

Reservoir Systems

1. Partial Rebreather Mask

2. Non-Rebreather Mask (NRM)

Partial Rebreather Mask

Delivers higher FiO₂ compared to simple face masks, as it stores oxygen in the bag between breaths.

Non-Rebreather Mask (NRM)

: Provides 60-100% FiO₂ at 10-15 L/min; has a one-way valve that prevents exhaled air from entering the bag. This is used in emergency situations to deliver high oxygen concentrations.

High-Flow Nasal Cannula (HFNC)

• Delivers warmed, humidified oxygen with flow rates typically between 30-60 L/min, which improves oxygenation and reduces the work of breathing. It is more comfortable and better tolerated by patients than traditional oxygen delivery methods.

• These systems ensure the patient receives 100% of their inspiratory volume, regardless of breathing pattern, and maintain consistent FiO₂ regardless of the patient’s respiratory rate or pattern.

Positive End-Expiratory Pressure (PEEP)

• is a technique used in mechanical ventilation to maintain positive pressure in the lungs at the end of exhalation. It helps keep the alveoli open, preventing collapse and improving oxygenation.

• improves functional residual capacity (FRC), reduces intrapulmonary shunting, and increases lung compliance in critically ill patients. 

• The typical level for _____ in ARDS is between 10-15 cm H₂O. Higher _____ levels may cause complications such as barotrauma (injury caused by excessive pressure) or decreased cardiac output.

Low Tidal Volume Ventilation

• (6 mL/kg) is used to minimize barotrauma and volutrauma (damage from excessive volume). The goal is to keep the plateau pressure < 30 cm H₂O and maintain normal CO₂ elimination using higher respiratory rates

Permissive Hypercapnia

• In certain cases (e.g., ARDS), a higher PaCO₂ is allowed to reduce ventilator-induced lung injury. This method tolerates higher CO₂ levels, generally accepting a rise of ≤ 10 mm Hg/hour.

• This is contraindicated in patients with increased intracranial pressure or pulmonary hypertension.

Extracorporeal Membrane Oxygenation (ECMO) 

Purpose:

• ECMO is a last-resort therapy used when conventional treatments (e.g., ventilation) fail. ECMO allows the lungs to rest by taking over the role of gas exchange, much like a heart-lung bypass machine used in open-heart surgery.

  Techniques:

• ECMO (Extracorporeal Membrane Oxygenation) involves the removal of blood from the body, passing it through a membrane oxygenator, and returning oxygenated blood to the patient.

• ECCO₂R (Extracorporeal CO₂ Removal) focuses specifically on removing CO₂, allowing patients to have their lungs “rest” while improving gas exchange.

  Risks:

• Major complications include bleeding (due to anticoagulation therapy), infection, and vascular complications.

Prone Positioning in ARDS 

• Prone positioning (placing patients on their stomach) can significantly improve oxygenation in ARDS patients by improving V/Q matching, enhancing perfusion to the nondependent areas of the lungs, and reducing shunting.

• Duration:

• Studies show that 12-16 hours of prone positioning per day improves outcomes, particularly in patients with severe ARDS.

  Nursing Considerations:

• Continuous monitoring for changes in vital signs and oxygenation is essential. Care must be taken to prevent pressure injuries and aspiration during positioning.

• Sedation and neuromuscular blockade may be required for safe proning and to reduce discomfort during the procedure.

Endotracheal tube

• Medical procedure in which a tube is placed into the windpipe (trachea) through the mouth or nose. In most emergency situations, it is placed through the mouth.

• Maintains an open airway and helps prevent suffocation, a flexible plastic tube is placed into the trachea through the mouth to help patient to breathe.

Indications:

1. Respiratory Failure: ex. Hypoxia, Hypercapnia, tachypnea, or Apnea (Asthma, ARDS, Pulmonary edema, infection, COPD, exacerbation, severe hypoxemia)

2. Inability to ventilate unconscious patients

3. Maintenance or protection of an intact airway -

4. hemodynamic instability – facilitate mechanical ventilator, such as Shock, Cardiac Arrest

5. Medication Administration

6. Airway obstruction – maintain airway patency ex. Laryngeal edema, burns, tumor, trauma

7. For supporting ventilation during general anesthesia

Benefits:

1. Necessary if the patient requires mechanical ventilation

2. To protect the lungs from aspiration

3. To get enough oxygen into the blood stream

4. To remove secretions.

RISKS:

1. Injury to teeth, or dental work

2. Injury to the throat.

3. A buildup too much fluid in organs or tissues.

4. Bleeding

5. Lung complications or injury.

6. Aspiration (stomach contents and acids that end up in the lungs)

7. Lacerated lips or tongue from forceful pressure between laryngoscope blade and the tongue or cheek

8. Injury to the vocal cords.

9. Brain damage or death – wrong placement of ET tube

Note: Skilled healthcare provider must perform this procedure provided he/she meet the following criteria:

1. Personnel are well trained

2. Personnel perform intubation frequently

3. Personnel receive frequent refresher training skill, continuous quality improvement to detect frequent and minimize complications.

Mechanical Ventilation

• is the use of a machine called a ventilator or respirator to improve the exchange of air between the lungs and the atmosphere.

• is an automatic machine designed to provide all or part of the work the body must produce to move gas into and out of the lungs. The act of moving air into and out of the lungs is called breathing, or, more formally, ventilation.

• is the use of a machine to take over active breathing for a patient.

• It is used when a patient can no longer breathe due to injury, illness, or general anesthesia during surgery.

Purposes

• The patient does not have to work as hard to breathe – their respiratory muscles rest

• Helps the patient get adequate oxygen and clears carbon dioxide

• Preserves a stable airway and preventing injury from aspiration

• Air is delivered in patients with compromised ventilation

• Oxygenate the different organs of the body

• Expel the carbon dioxide in the lungs

• Provide comfortable breathing pattern to patients experiencing shortness of breath

• To breathe for patients who are seriously compromised ventilation such as in comatose, brain damaged, or patients with spinal cord injuries.

Indications for _____ Use

• Continuous decrease in oxygenation

• Increase arterial carbon dioxide

• Persistent acidosis

• Respiratory failure:

• Apnea / respiratory arrest

• Inadequate ventilation(acute vs chronic)

• Inadequate oxygenation

• Chronic respiratory insufficiency with FTT

• Compromised airway patency

• Cardiac insufficiency

• Eliminate the work of breathing

• To reduce the oxygen consumption

• Neurologic dysfunction

• Central hypoventilation and frequent apnea

• Comatose patient with GCS < 8

• Inability to protect the airway

• ABG Results

• If the patient is under the following conditions:

• Multiple trauma

• Shock

• Multi-organ failure

• Drug overdose

• Thoracic or abdominal surgery

• Neuromuscular disorders

• Inhalation injury

• COPD

Complications in Long-Term Use

• Infections– A foreign object such as the endotracheal tube in the trachea makes the patient more susceptible to bacteria entering the lungs. This is treated with the use of antibiotics.

• Pneumothorax –This is the condition when the lung/s collapses. It is a complication when the lungs are damaged because of gets over-expansion. If this happened, a chest tube is inserted on the collapsed lung to allow it to re-expand and seal the leak.

• Lung damage – The air forced in the lungs can increase the risk for injury.

• Side Effects of medications– Intubated patients are most of the time given sedatives to allow easier ventilation of the machine. These medications keep the patient calm and sleepy.

• Maintenance of Life– The ventilator sometimes serves as the only reason why the patient is alive. Organs fail because the body is dying, this includes the lungs.

Tidal Volume (TV)

• Air that the client receives per breathing. Percentage in the mechanical ventilator is adjusted depending on client’s needs (40-100%). The normal value of tidal volume is ½ L or 500 ml.

Fraction of inspired oxygen (FiO2)

• the oxygen concentration delivered to the client. ABG is usually determined before adjusting FiO2 levels. It is adjusted from 40%-100%.

Peak Flow Rate (PFR)

• The peak flow rate is the maximum flow delivered by the ventilator during inspiration. Peak flow rates of 60 L per minute may be sufficient, although higher rates are frequently necessary.

Back-up Rate (BUR)

• for spontaneous or time mode ventilator, back-up rate is set so that the client may receive a minimum number of breaths per minutes if the client fail to breath. If the client’s breathing rate is slower, it will cycle inhale / exhale pressure at the set rate. The usual setting for BUR ranges from 12-22 breaths per minute, depending on the physician’s order.

Pressure end-expiratory pressure (PEEP)

• is exerted during the expiration phase of ventilation, which improves oxygenation by enhancing gas exchange and preventing atelectasis. Not all clients with mechanical ventilator is attached to PEEP. A typical initial applied PEEP is 5 cmH2O. However, up to 20 cmH2O may be used in patients undergoing low tidal volume ventilation for acute respiratory distress syndrome (ARDS)

Continuous positive airway pressure (CPAP)

• used for spontaneously breathing clients. Positive airway pressure is introduced during the respiratory cycle.

Sensitivity

• used to describe the ventilator’s responsiveness to the patient’s breathing effort. Sensitivity adjusts the level of negative pressure required to trigger the ventilator. With assisted ventilation, the sensitivity typically is set at -1 to -2 cm H2 O.

Low Pressure alarm

• may indicate leak in the patient’s tube, disconnection of the tube, or the patient stops to breath.

What are your interventions for _________?

• Check the tube connections.

• Reconnect patient to the ventilator.

• Replace leaking tubes by manually ventilating the patient.

• Auscultate patient’s lung fields for bilateral lung sounds.

• Monitor respiratory rate and breathing patterns.

• Evaluate cuff pressure. Reinflate if needed.

High Pressure alarm

• may indicate displacement of the ET tube, increased secretions, obstruction in the tube, bronchospasms, or the patient is coughing or biting the tube.

• Assess your patient.

• Auscultate lung fields for secretions. This should be done at least every 2 hours or more.

• Suction secretions as needed. Oxygenate patient manually before suctioning.

• If patient is biting the tube, provide bite block.

• Sedate patient if necessary especially when patient is fighting the vent. Make sure this is ordered by the attending physician or hospitalist on duty.

• Monitor pulse oximeter continuously if cardiac monitor and pulse oximeter devices are present.

Bundles of care to avoid Ventilator-associated Pneumonia (VAP)

1. Strict hand washing

2. Oral Hygiene

3. Initiate Close suction system

4. Avoid pressure ulcers

5. Elevate head of bed

6. Assess patient daily for extubating readiness

7. daily interruption of sedation