ICU Respiratory Disorders

Pneumothorax

air enters the pleural space, causing lung collapse

What are two main reasons for a pneumothorax?

• invasive procedures (CVL insertion, thoracentesis)

• barotrauma (caused by a high PEEP)

Pneumothorax assessment findings

• unilaterally absent breath sounds

• increased WOB/SOB

• pleuritic chest pain

How is a pneumothorax treated?

chest tube

TRUE or FALSE: chest tubes can be inserted at the bedside.

true

What should you assess in a chest tube drainage unit?

• color and amount of drainage (and trends!)

• water tidaling → rises + falls w/ breathing

• intermittent bubbling (not continuous)

What does continuous bubbling in a water seal chamber mean?

an air leak

TRUE or FALSE: pain is an expected finding for a chest tube.

true

Chest tube - nursing responsibilities

• resp. assessment

• document output

• assess the dressing

• encourage turn, cough, deep breathe to prevent pneumonia

• monitor for complications

What should a chest tube dressing always look like?

sterile and occlusive on all sides

Where should a chest tube drainage unit be located?

taped to the floor, below the chest level

What is the purpose of turn, cough, deep breathe?

to prevent pneumonia

Chest tube complications

• infection at chest tube site

• subcutaneous emphysema

Subcutaneous emphysema - assessment findings

feeling + hearing snapping/popping

What should you do if you notice subcutaneous emphysema?

notify the provider (no nursing actions)

Which two things should you NOT do with a chest tube?

• strip or milk the tube

• clamp the tube

When is ti appropriate to clamp the chest tube?

with orders OR when changing the drainage unit

Why should you never strip or clamp a chest tube?

it increases chest pressure

Pleural effusion

fluid enters the pleural space faster than it can lead, resulting in a collapsed lung

What color should fluid in a pleural effusion be?

straw-colored

Pleural effusion - assessment findings

• pleuritic chest pain

• SOB/tachypnea

• hypoxia

• diminished breath sounds

How is a pleural effusion managed?

chest tube, thoracentesis, or pleurodesis

Thoracentesis

one-time aspiration of fluid from the pleural space (not continuous like a chest tube)

How should a patient be positioned for a thoracentesis?

sitting at EOB and leaning over a table or pillow, OR lying on the unaffected side w/ HOB at 30-45 degrees

Pleurodesis

surgical intervention for recurrent pleural effusions

Acute respiratory failure

rapid onset of inadequate gas exchange

Which three gas exchange issues occur with acute respiratory failure?

hypoxemia (low paO2), hypercapnia (high paCO2), acidosis

Hypoxemia

paO2 <60

Hypercapnia

paCO2 >50

What are some causes of acute respiratory failure?

COPD, pneumonia, ARDS, pulmonary embolism, etc.

S/s of acute respiratory failure

• dyspnea

• cyanosis

• restlessness or altered LOC

• crackles or wheezing

Which disorder might you hear wheezing in acute respiratory failure?

COPD

Which disorder might you hear crackles in for acute respiratory failure?

pneumonia or ARDS

How is acute respiratory failure treated?

managed with intubation + mechanical ventilation until the underlying cause can be reversed

Acute respiratory distress syndrome (ARDS)

widespread inflammation and damage in the alveoli (usually caused by some type of direct or indirect pulmonary injury)

Characteristics of ARDS

• increased lung edema

• impaired gas exchange

• changes to vascular tissue in the lungs

TRUE or FALSE: ARDS is a primary lung disease.

false

What must be ruled out before a diagnosis of ARDS?

cardiac cause of pulmonary edema

How does non-cardiogenic pulmonary edema occur (ARDS)?

1) trauma damages the capillary membranes of the alveoli

2) fluid shifts occur in the alveoli from the damaged capillaries

3) edema/fluid builds up in the alveoli

4) alveoli collapse, causing a lack of gas exchange

ARDS assessment findings

• rapid, shallow breathing

• tachycardia

• neurologic changes

• crackles

• refractory hypoxia

What are some neurologic changes that occur from ARDS?

restlessness + confusion (from lack of oxygen)

Which adventitious lung sounds are heard in ARDS and why?

crackles → non-cardiogenic edema in the alveoli

Refractory hypoxemia

ARDS doesn’t improve with increased oxygen

Which three symptoms must be present to diagnose a patient with ARDS?

non-cardiogenic pulmonary edema, refractory hypoxemia, and intrapulmonary shunting

Intrapulmonary shunting

ventilation without oxygenation

How is intrapulmonary shunting measured?

the percentage of CO that’s not oxygenated due to collapsed/fluid-filled alveoli

What percentage of pulmonary shunting is associated with ARDS?

15% or more (meaning that >15% of CO is unoxygenated)

Which other value indicates ARDS (other than 15%+ pulmonary shunting)?

P:F ratio of less than 300 (the paO2/fiO2)

What is the P:F ratio of a patient on 70% oxygen with a PaO2 of 75?

107 (75/.7=107)

What are the 6 P’s of managing ARDS?

• perfusion

• prone position

• protective lung ventilation

• protocol weaning (if not proned)

• pharmacologic treatment

TRUE or FALSE: it’s important for fluids to be given to ARDS patients to improve perfusion.

false

How is perfusion improved in ARDS?

vasopressors + strict I/Os (with possible diuretic use)

Why are patients with ARDS proned?

to keep all of the alveoli open (rather than just laying on the back all the time)

Who should always be at the bedside when proning an ARDS patient?

RN and RT

What should you be extremely careful of when proning a patient?

keeping the breathing tube in place

What does protective lung ventilation entail for ARDS patients?

low tidal volume + high PEEP (keeps the alveoli open without giving large breaths)

Which alternative treatment is used if the 6 P’s don’t work for ARDS?

ECMO