upper respiratory part 2

chest trauma (blunt)

shearing and compression injuries of chest structures

external appear minor (skin may not break)

examples: Falls, MVA

chest trauma (penetrating)

foreign object impales or passes through body tissues creating OPEN WOUND

• can cause pneumo thorax

Examples: GSW, Stab wounds, Arrow

signs of respiratory distress

dyspnea (shortness of breath)

cough w/ or w/o hempotysis (coughing up blood)

cyanosis

tracheal deviation = collapsed lung, tension pneumothorax

decreased O2 sat

frothy secretions = pulmonary edema

assess for signs of cardiocascualr compromise

rapid, thready pulse

decreased BP w/ narrowed pulse pressure or asymmetric readings

distended neck veins

muffled heart sounds

chest pain, dysrhythmias

cover sucking chest wound w/

nonporous dressing taped on 3 sides, allows air to exit but not enter, WOULD BE USED W/ PENETRATING WOUNDS

inspiration: pulls dressing against wound so air cannot enter

expiration: dressing pushes out & air escapes

•If impaled object in place, stabilize it with a bulky dressing but do not pull it out

initial interventions w/ chest trauma

ABC’s

Apply O2 to keep it >90%

IV access w/ 2 large-bore catheters and fluid resuscitation as appropriate. Stabilize impaled objects

place patient in semi-Fowler’s or injured side (after ruling out cervical spine injury)

prepare for emergency needle decompression

ongoing monitoring for chest trauma

vital signs

level of consciousness

oxygen saturation

cardiac rhythm

respiratory status

urine output

(Potential intubation)

cardiac temponade

Key finding: muffled heart sounds

s/s: distant heart sounds, hypotension, neck vein distention, ↑ central venous pressure

def: blood fills up the pericardium of the heart

w/o treatment heart collapse and go into arrest

intervention for cardiac tamponade

Medical emergency: Pericardiocentesis with surgical repair as appropriate.

BECKS Triad for Cardiac tamponade

Hypotension/ narrowing pulse pressure

jugular vein distention

muffled heart sounds

flail chest

key finding: Paradoxical movements (occur if 3 or more ribs fracture or sternum fracture), rapid shallow breathing)

increase risk of atelectasis & pneumonia

treatment: O2, analgesia, ventilation

• goal is to promote lung expansion and ensure adequate oxygenation

open pneumothorax

air enters through an opening in the chest wall and parietal (outler lining of the pleura. cl

closed pneumothorax

when the visceral (inner) lining of the pleura is disrupted, allowing air to enter the pleural space from the lung.

• there is no external wound

pneumo vs hemo

pneumo: hyperressonance

hemo: dullness when percussed

• ways to differ them is lung assessment t

tension pneumothroax

think: air hunger, extreme agitation, hyperresonance, tracheal/ mediastinal shift (late sign)

• air enters & cannot escape

• may result from either an open or a closed pneumothorax.

• chest tubes are clamped or become blocked in a patient with a pneumothorax

May be fatal if pressure in pleural space not relieved.

manifestations of tension pneumothorax

Manifestations include Severe dyspnea, tachycardia, tracheal deviation, decreased or absent breath sounds on affected side, neck vein distention, cyanosis, diaphoresis.

Decreased or absent breath sounds will be present on the affected side.

Patient describes an intense air hunger (know this!!)

spontaneous pneumothorax

rupture of small bleds

• COPD, asthma, CF, and pneumonia

  • AT RISK are SMOKERS, TALL THIN MALES, family hxt, previous spontaneous

latrogeni pneumothorax (know this)

laceration that occurs during a procedure (transthoracic needle aspiration, subclavian catheter insertion, pleural biopsy, and transbronchial lung biopsy)

chylothorax pneumothorax

lymphatic fluid thoracic duct leaks in pleural space

• trauma/injury, CANCER or TB infections

treatment for pneumothorax

• needle decompression/needle ostomy to allow trapped air to escape, this is temporary life saving intervention.

• chest tube and water seal drainage

• partial pleurectomy, stapling, pleurodesis

• chest tube to treat it

absent unilateral breath sounds, JVD, severe dyspnea, tracheal deviation think what

tension pneumothorax - do treatment first, diagnose later

chest tubes and pleural drainage

chest tubes: drains pleural space and reestablish negative pressure

allow the lung to expand:

• 20inches long

• 12 to 40 F

• Small: air / Medium: fluid / Large: blood

Pigtail tubes (10 to 14 F)

chest tube insertion

•May be placed in ED, OR, or at bedside

•Standard insertion site: midaxillary

•HOB elevate 30 to 60 degrees; arm raised above head

•Antiseptic cleanse; local anesthetic

•Small incision over rib, chest tube inserted

•Sutured in place; occlusive dressing

•Connect pleural drainage system

•Chest x-ray to confirm placement

notes from video

want gentle steady or continuous bubbling (NOT VIGOROUS BUBBLING)

Tidaling - rise and fall good (it slows your lung as not expanded)

Bright red blood over 100mL after 1st hr placement = active hemorrhage

Dark blood drainage = normal

Diminished breath sounds !priority!

subcutaneous emphysema

rice crackle pop sound, will see little bubbles under the skin and it feels like bubble wrap under the skin

chest tube gets disconnected

tell patient to cough and exhale immediately, then apply most occlusive dressing on 3 sides

bubbling in water seal chamber

brisk at first, eventually disappears as lung expants

intermittent w/ exhalation, coughing, or sneezing

tidaling in water seal chamber

fluctuation of water w/ pressure changes during respiration

disappears as lung re-expands

stop suddenly, check for an occulsion

suction control chamber (wet suction)

monitor: water levels, gentle bubbling.

• amount of water in chamber (20cm) controls suction

• excress suction from source vented

• usual suction order = -20 cm H2O

• adjust suction until gentle bubbling in third chamber

suction control chamber: dry suction

no water - less noise

dial regulator to pressure; visual alert (floats or bellows) shows when suction is working properly

turn dial to ordered amount

if decrease suction; depress high-negativity vent and check water level in water-seal chamber

nursing management chest drainage

consent/aware of procedure

gather & set up equipment as per order

• keep tubing loosely colied, connects tight, taped

  • observe: tidaling, ubbling, air leak, fluid levels

chest tube dressings

change according to agency policy and procedure

keep petroleum gauze by bed

• maintain aseptic technique, monitor for infection, document.

clamping chest tubes

may clamp briefly to change drainage unit.

not advocated during transport or disconnection due to risk of tension pneumothorax.

complications to monitor for chest tubes

reexpansion pulmonary edema - fluid buildup in the lungs that can occur rapidly after a collapsed lung.

hypotension

severe subcutaneous emphysema - large amount of air escapes into the deepest layer of the skin, chest wall, or neck

removal of chest tubes

Lungs re-expanded & drainage minimal. Premedicate prior to removal w/ analgesics

vasalva maneuver during removal

apply occlusive dressing

chest x ray

monitor for respiratory distress

pulmonary edema

abnormal accumulation of fluid in alveoli and interstitial spaces

complication of heart disease and lung disease

most common cause: Left side HF

A-FIB MAJOR CONTRIBUTOR

frothy sputum - blood tinged & lower lobes mostly affected.

monitor in pulmonary edema

vital signs, work of breathing, breath sounds, urine output, and response to treatment

pulmonary embolism

arise from deep vein thrombosis (DVT)

DVT to VTE is called venous thromboembolism

risk factors of pulmonary embolism

immobility or reduced mobility (truck drivers), surgery within the last 3 months especially pelvic & lower extremity

VTE, cancer, obesity, oral contraceptives, hormone therapy, smoking, prolonged air travel, HF, pregnancy, and clotting disorders

orgination of VTE

deep veins of legs, femoral or illac veins, right side of heart (A-FIB), and pelvic veins

others: central venous catheters or arterial lines (fat emboli) air emboli, vegetation on heart valves, amoniotic fluid, cancer tissue

saddle embolus

large thrombus at arterial bifurcation where the artery splits

complications of pulmonary embolism

Pulmonary infarction- occlusion of medium or large vessels, lack blood flow; preexisting lung disease. (death of lung tissue)

Pulmonary hypertension- hypoxemia or from involvement of a large surface area of the pulmonary bed

pulmonary HTN causes right vent. hypertrophy

diagnostic studies for PE

D-dimer: elevated w/ any clot degradation, false negatives w/ small PE

Spiral (helical) CT scan/CT angiography or CTA:

• most common, requires IV contrast media, 3D pic of pulmonary vasculature.

PE diagnostic studies/ ventilation perfusion (VQ Scan)

used if patients cant have contrast

perfusion scanning- radioisotope injection, images pulmon circulat.

ventilation scanning- radioactive gas inhaled, distrub of gas in lungs

• Option for people w/ kidney issues

interprofessional care for PE

Support cardiopulmonary status

oxygen - intubation/mech. ventilation

pulmonary hygiene (prevents atelectasis)

shock: fluids, vasopressors

HF - diuretics to pull off fluids

pain: opioids

drug therapy (anticoagulation) for PE (LWMWH), unfract heparin, warfarin

LMWH- is the recommended treatment for patients with acute PE

unfraction IV Heparin- hard to titrate to therapeutic levels

drug therapy - fibrinolytic agents (dissolve PE clot)

tissue plasminogen activator (tPA) AND Alteplase (activase)

• help dissolve the PE and the source of the thrombus in the pelvis or deep leg vein

Surgical therapy for PE

pulmonary embolectomy for massive PE

• hemodynamically unstable patients & thrombolytic therapy contradicated

Percutaneous catheter embolectomy or endovascular ultrasound delivered thrombolysis

Inferior vena caca (IVC) filter

• prevents migration of clots in pulmon. system

• prevents clots from coming through & will put it in vena cava

pulmonary HTN (might be primary or secondary complication)

elevated pulmonary artery pressure due to increase resistance to blood flow through pulmonary circulation

•Normal 12 to16 mm Hg

•Greater than 25 mm Hg at rest

•Greater than 30 mm Hg with exercises

pulmonary HTN 5 classes

•Group 1: medication, specific disease, genetic link or idiopathic

•Group 2: left-sided heart failure

•Group 3: lungs and hypoxemia

•Group 4: CV system and thromboembolic occlusion

•Group 5: Multifactorial: hematologic or metabolic involvement

pulmonary HTN manfestations

dyspnea on exertion (early signs), and fatigue

other: exertional chest pain, dizziness, syncope, abnromal heart sounds

progressio: dyspnea at rest, right ventricular hypertrophy

pulmonary HTN diagnostic

ECG, Chest x-ray, PFTS, echo, CT Scan

right sides heart catheterization

nursing & interprofessional management of PE

Early recognition - stop progression

report unexplained SOB, syncope, chest discomfort, and reverse remodeling

drug therapy for PE

pulmonary vasodilation, reduced RT ventricular overload, and reverse remodeling,

manage edema

prevent thrombi

prevent hypoxia

endrothelin receptor antagonists (ERAs) for PAH

Drugs: bosenstan, ambrisentam, macitentan

action; blocks endothelin-1 receptors causing vasodilation and less vascular remodeling

keypoints: teratogenic, monitor liver funct., can cause peripheral edema, anemia

phosphodiesterate 5 inhibitors for PAH

drugs: sildenafil, tadalafil

action: blocks PDE-5 raising cGMP and nitric oxide effects, causing pulmonary vasodilation

keypoints: contraindicated w/ nitrates (severe hypotension)

side effects: headache, flushing, hypotension, vision changes

prostacyclin medications for PAH

• Drugs: epoprostenol, treprostinil, iloprost, selexipag

• Action: Mimic prostacyclin, causing vasodilation and inhibiting platelet aggregation

• Key points: IV/SC forms must never be abruptly stopped (rebound pulmonary hypertension); side effects are jaw pain, headache, flushing, diarrhea, infusion site pain; bleeding risk

Cor pulmonale

enlarged right ventricle secondary to disorder of respiratory system; COPD.

• pulmonary HTN preexisit, HF

major complication of COPD (start off as a chronic respiratory disease, htn of the lungs, the right ventricle have to work harder)

manifestations of cor pulmonale

excertional dyspnea, tachypnea, cough, fatigue, RV hypertrophy (ECG), increased intensity in S2 heart sounds, polycythemia

HF: peripheral edema, weight gain, distended neck veins, full bounding pulses, enlarged liver.

DX and TX of cor pulmonale

DX- chest x ray will show RVH, BNP- elevated HF, CBC- H&H= 16.5/ 48% women 18.5/49% men polycythemia– ruddy complexion

Epoietin- low

TX: ID early, O2 therapy, low sodium diet

progression work of cor pulmonale

works in resp failure, COPD later develops into pulmonary HTN to Cor pulmonale, then becomes right sides heart failure.

Drug Therapy (Depending on the Primary Cause) for Cor pulmonale

• Bronchodilators

• Diuretics (use with caution)

• Pulmonary vasodilators

• Calcium channel blockers

• Inotropic agents

• Digitalis

• Anticoagulation therapy