NUR 317 Exam 2 - Supporting Ventilation

Respiratory physiotherapy

Using techniques to improve lung function, enhance breathing mechanics, and optimize respiratory health

Some common techniques and interventions used in respiratory physiotherapy include:

• Breathing exercises – diaphragmatic breathing, pursed lip breathing

• Airway clearance techniques – chest percussion, vibration, postural drainage

• Breathing aids and devices – incentive spirometer (IS)

Diaphragmatic breathing

• AKA abdominal breathing

• Focuses on using the diaphragm to breathe

• Improving lung function

  • Obstructive and restrictive disorders

  • Prevent post-op complications

    • Atelectasis

    • Pneumonia

    • Hypoxemia

  • Reducing anxiety and stress

Pursed lip breathing

• Prolongs expiration to prevent bronchiolar collapse and air trapping

  • Increases PEEP (positive end-expiratory pressure)

• Obstructive and restrictive disorders

• Supports post-op care and anxiety-related dyspnea

Pursed lip breathing method

• Inhale slowly and deeply through the nose

• Exhale slowly through pursed lips as if blowing out a candle

  • Be sure to relax facial muscles

• Exhale should be 2-3 times longer than inhalation

Airway clearance techniques

• Huff coughing

• Postural draining

• Percussion or vibration

• Airway clearance devices

Huff coughing

• Forced expiratory using small coughs

  • Clears excess mucus and secretions from the airway

  • Useful in pt with excessive mucus production

    • COPD

    • Bronchiectasis

    • Cystic fibrosis

    • Chronic bronchitis

    • Prevents atelectasis/pneumonia

    • Safer than forceful coughing in pts with abdominal incisions

Huff coughing method

• Position the patient and ensure they are breathing deeply from the diaphragm

• After holding the breath for a few seconds, the patient exhales with several small coughs, then rests for several breaths and repeats the cycle

Postural draining

• Uses gravity to drain secretions

• 5 min

Percussion or vibration

Breaks up thick fluids and promotes movement of secretions into the larger airways

Airway clearance devices

Combines high-frequency oscillations and PEEP to split the airway

Room air oxygen percentage

21% oxygen

Supplemental oxygen

Increases FiO₂ — ranges from 24% to 100% depending on device & flow rate

Oxygen therapy clinical indications

Used when room air is insufficient to maintain oxygen saturation (hypoxemia, pneumonia, PE, shock)

Oxygen target goals (not COPD patients)

SpO₂ > 92%

PaO₂ 80–100 mmHg

Prolonged high FiO₂ alert

↑ risk of oxygen toxicity (> 60% for > 24 hrs)

Oxygen “dose”

Delivered FiO₂, titrated to optimize oxygenation while minimizing toxicity

Oxygen therapy

• Improves survival in COPD patients, decreases WOB

• Used in management of:

  • Lower airway

  • Restrictive and obstructive disorders

  • Non-lung diseases heart failure or other cancers

• With all devices monitor for pressure injuries on face, nose, ears, neck

Nasal cannula

• Low oxygen flow

• For regular hospital and home care

• O2 flow: 1-6 L/min

• FiO2: 24-44%

Simple face mask

• Moderate oxygen flow

• For regular hospital and home care

• O2 flow: 6-12 L/min

• FiO2: 35-50%

Reservoir mask

• High oxygen flow

• For hospital care

• O2 flow: 10-15 L/min

• FiO2: 60-90%

Nasal high flow

• Very high oxygen flow

• Used in situations of respiratory failure

• O2 flow: up to 60 L/min

• FiO2: up to 60%

CPAP

• Specialized form of pressure positive ventilation

• Can be used for patients with apnea or to maintain an open airway

• O2 flow: 15 L/min

• FiO2: up to 100%

Ventilator

• Invasive form of pressure positive ventilation

• Required when a patient’s lungs are severely impaired

• O2 flow: PRN for life support

• FiO2: up to 100%

Venturi mask

• Mask with a multi-flow adapter with different colored jet ports

• Each adapter corresponds to a specific O2 concentration when connected to oxygen

• Allows for precise and controlled oxygen therapy

• Adjustable by switching out the adapters

Venturi mask adapters

• Blue = 24%

• White = 28%

• Orange = 31%

• Yellow = 35%

• Red = 40%

• Green = 60%

Humidification

• High flow oxygen irritates the mucosa and dries the secretions

• Humidity with sterile distilled water can prevent these complications

• Supplied by bubble humidifier

Oxygen therapy monitoring

• SpO₂ (noninvasive, pulse oximetry → % of Hgb saturated with O₂)

• PaO2- pressure of oxygen dissolved in the arterial blood

• Normal range 80-100 mm Hg

• Reflects oxygen transfer from lungs to the blood

  • Green zone = normal (80–100)

  • Yellow zone = mild hypoxemia (60–79)

  • Red zone = severe hypoxemia (<60)

O2 therapy complications

• Combustion

  • No smoking or open flames while O₂ is in use

• Oxygen toxicity

  • Prolonged high FiO₂ ( >24 hrs) → damages alveolar-capillary membrane → pulmonary edema

• Clinical pearl: always use the lowest FiO₂ needed to keep SpO₂ > 92% and PaO₂ 80–100 mmHg

• Loss of hypoxic respiratory drive (CO₂ narcosis)

  • Seen in some COPD patients who rely on low O₂ levels to stimulate breathing

  • Too much O₂ → removes hypoxic drive → ↓ respiratory drive → worsening hypoventilation & ↑ CO₂

Non-invasive support

• CPAP

• BiPAP

CPAP (continuous positive airway pressure)

• One constant pressure is delivered during both inspiration and expiration (8-10 cmH2O)

• The main clinical role is to splint the upper airway open, preventing collapse (e.g., in obstructive sleep apnea)

• Because pressure is continuous, it helps improve oxygenation by increasing functional residual capacity (FRC) and preventing alveolar collapse — but it doesn’t actively help with ventilation (CO₂ removal)

• Think of CPAP as a “pneumatic stent” that keeps the airway and alveoli open all the time

BiPAP (bilevel positive airway pressure)

• Provides two different pressures:

  • IPAP (inspiratory positive airway pressure): higher pressure during inhalation → augments tidal volume and ventilation, helping blow off CO₂ (8–20 cm H₂O )

  • EPAP (expiratory positive airway pressure): lower pressure during exhalation → keeps alveoli open and improves oxygenation (4–10 cm H₂O)

• Because it assists with both inhalation and exhalation, BiPAP supports both upper airway patency and ventilation of the lower airways/lungs

• Useful in conditions like COPD exacerbations, hypercapnic respiratory failure, or acute pulmonary edema where patients need help with both

Complications of CPAP and BiPAP

• Injury to facial tissue

• Gastric distention

• Aspiration pneumonia

• Hypotension

• Pneumothorax

CPAP and BiPAP should not be used in patients with:

• Recent facial surgery

• Excessive secretions

• Inability to protect their airway

• Severe facial burns

• Facial or skull fractures

Invasive support

• Nasopharyngeal airway

• Oropharyngeal airway

• Mechanical ventilation: endotracheal tube, proning, alarms, VAP

• Tracheostomy

Nasopharyngeal airway

• Airway adjunct inserted through the nose into the posterior pharynx

• Maintains upper airway patency by bypassing obstruction from the tongue or secretions

Nasopharyngeal airway uses

• Useful when: intubation is not required, or the mouth cannot be opened

• Can be placed in conscious or unconscious patients (does not trigger gag reflex)

• Often used for patients needing frequent suctioning

• Can remain in place long-term (weeks to months) with proper care

Oropharyngeal airway

Temporary airway adjunct - minutes to an hour

Oropharyngeal airway uses

• Used to maintain or open the airway by stopping the tongue or secretions from covering the epiglottis

• Only used in unconscious patients

  • Stimulates the gag reflex

Mechanical ventilation

• A medical intervention that assists or replaces spontaneous breathing when patients cannot maintain adequate ventilation and oxygenation

  • Provides controlled or assisted breath, ensuring oxygen delivery to the lungs

  • Promotes effective CO2 elimination

• Endotracheal tube (most common form)

• Tracheostomy

Endotracheal tube (ETT)

• Tube inserted into the trachea

• Inserted between the vocal cords into the trachea; cuff inflated below cords

• Typically not used >14 days (consider tracheostomy if prolonged)

• Indications:

  • Mechanical ventilation

  • Severe respiratory failure

  • Airway protection (e.g., ↓ LOC, aspiration risk)

  • Cardiac arrest

  • Post-op support (e.g., CABG)

  • Severe trauma (burns, facial trauma)

  • Neuromuscular disease (e.g., ALS)

Endotracheal tube and vented patients nursing considerations

• Confirm and secure placement:

  • Colorimetric capnometer

  • Auscultation

  • Chest x-ray to confirm depth (2-3 cm above the carina)

  • Mark and document tube depth at lips/teeth (e.g 22-24 cm for adults)

• Prevent accidental displacement

  • Secure with an ETT holder or tape

  • Monitor for tube displacement

• Prevent pressure injuries

  • Move the ETT to the other side of the mouth q12 hrs to prevent device-related PI

• Maintain airway patency

  • Suction as needed

  • Monitor for signs of mucous plugging (sudden respiratory distress, high airway pressure alarm)

• Monitor cuff pressure

  • Cuff pressure 20-30 cm H2O to prevent:

    • Aspiration (if too low)

    • Tracheal injury/ischemia (if too high)

    • Check with manometer once a shift

• Assess for complications

  • Airway trauma, ulcerations

Positive end-expiratory pressure (PEEP)

• Ventilator setting

  • The positive pressure applied and measured in the alveoli at the end-expiration

  • It helps reduce FiO₂ needs and prevents alveoli collapse

• Nurses must monitor oxygenation and watch for complications (e.g. ↓ cardiac output, barotrauma)

Low-pressure ventilator alarms

• Ventilator tube disconnection

• Airway cuff leak or displacement

• Total or partial extubation

High-pressure ventilator alarms

• Secretions

• Kinked or compressed tubing

• Bronchospasms

• Coughing

• Patient biting

Apnea ventilator alarms

• Loss of airway

• Over sedated

• Respiratory arrest

• Wrong vent setting

The Society of Critical Care Medicine’s ICU Liberation Bundle

Prone positioning

• Positioning patient on stomach with face down

• Improves lung recruitment

  • Gravity reverses effects of fluid in dependent parts of lungs

  • Heart rests on sternum, contributing to uniformity of pleural pressures

• Nurse-intensive therapy (5 or more staff)

• Requires increased sedation

• Effective for ARDS and COVID patients

• Monitor for pressure injuries

Ventilator associate pneumonia (VAP)

• 40% of MV patients develop ventilator-associated pneumonia

• Clinical manifestations - PNA that develops ≥ 48 hours after endotracheal intubation and initiation of mechanical ventilation

  • Fever

  • High WBC count

  • Purulent odorous sputum

  • Crackles or wheezes

  • Pulmonary infiltrates

• Organisms - bacteria are most common (viruses and fungi less common)

  • Pseudomonas aeruginosa: respiratory equipment, humidifiers, suction tubing

  • Klebsiella pneumonia & E. coli: part of normal gut flora, can colonize the oropharynx

  • Acinetobacter species: lives on the skin and hospital surfaces (bed rails, ventilators)

  • Staph aureus (including MRSA): found in nose, skin & oropharynx, can spread to respiratory equipment or airways

Ventilator associate pneumonia prevention

• Hand hygiene

• Early mobilization

• Suctioning the subglottic aspiration port

• Elevate HOB 30-45°

• Oral care q 2-4 hrs

• Chlorhexidine q 12 hrs – oral decontamination

• Early weaning protocols

• Daily sedation breaks

Tracheostomy

• Placed into the trachea via a surgical incision

• Used for long-term airway support

  • Permits long-term MV (over 10-14 days)

  • Facilitates weaning from MV

• Used for urgent airway needs when oral or nasal intubation is not possible

  • Bypasses upper airway obstruction

  • Facilitates secretion removal

Advantages of tracheostomy over endotracheal tube

• Cleaner; better oral and bronchial hygiene

• Patient comfort increased

• Less risk of damage to vocal cords

Tracheostomy post-op nursing management

• Airway patency and ventilation

  • Monitor airway patency and cuff pressure (20 to 25 cm H2O)

    • Over-inflating the cuff can cause tracheal ischemia and necrosis

  • Assess respiratory status

  • Provide humidified O2 – thins secretions & prevents mucus plugs

  • Be prepared to suction as needed

• Monitor for bleeding and obstruction

  • Infection prevention

  • Pain management

  • Stoma care

  • Communication

  • Tube security

• Complications: monitor for signs of air leaking into surrounding tissue, pneumothorax

Tracheostomy nursing management

• Prevent dislodgement - care w/ turning, repositioning

• Accidental dislodgement

  • Assess the patient for signs of respiratory distress

  • Immediately call for help and activate response team

  • Maintain oxygenation with bag valve mask

  • Attempt to reinsert if appropriate

  • Monitor patient and prepare for reinsertion

Daily tracheostomy care - procedure for changing the inner cannula

1. Gather sterile supplies (cannula, gloves, saline, trach kit)

2. Wearing clean gloves, remove and inspect old inner cannula

3. Using sterile technique- insert new (or cleaned) inner cannula

4. Remove old gauze, perform hand hygiene

5. Clean stoma and under faceplate with saline

6. Replace trach dressing

7. Change trach ties if needed

Types of suctioning

• Open suction technique (sterile procedure)

• Closed-suction technique aka. in-line suction (clean procedure)

  • Reduces risk of infection and atelectasis

  • Maintains oxygenation and ventilation

  • Decreases exposure to secretions

  • More comfortable and faster

• With both techniques - only suction as needed

Open vs closed suction technique

Open - requires disconnecting a mechanically ventilated patient from their ventilator (sterile)

Closed - uses an inline catheter that keeps the patient connected, thus maintaining ventilation and positive end-expiratory pressure (clean)

Suctioning preparation

• Gather sterile suction kit, sterile saline, and PPE

• Explain procedure to patient, provide reassurance

• Position patient in semi-Fowler’s if tolerated

Suctioning hand hygiene and PPE

• Wash hands, apply mask/eye protection

• Don sterile gloves, maintain sterile field

Suctioning preoxygenation

Administer 100% O₂ via trach collar or manual resuscitation bag for 1–2 minutes to reduce risk of hypoxemia

Suctioning catheter insertion

• Connect catheter to suction tubing

• Insert catheter gently into tracheostomy without suction applied

Suctioning guidelines

• Apply suction intermittently by occluding the port and withdrawing catheter

• Limit suctioning to 10–15 seconds per pass

Suctioning recovery

• Provide supplemental O₂ and allow patient to rest 2–3 minutes between passes

• Repeat as needed until secretions are cleared

Suctioning post-procedure

• Reassess SpO₂, heart rate, lung sounds, and overall respiratory status

• Dispose of equipment, remove gloves, wash hands

• Document procedure

Potential complications of suctioning

• Hypoxemia, bronchospasm

• Increased ICP, dysrhythmias

• Bradycardia, hypotension

• Mucosal trauma, bleeding, pain, infection

Planned decannulation

• A patient progresses from ventilator → trach collar → cuff deflation → speaking valve/capping → decannulation

• Indications for decannulation:

  • Pt can breathe effectively through their upper airway

  • Pt has a strong cough to clear secretions

Decannulation steps

• Preoxygenate the patient before tube removal

• Deflate the cuff of the tracheostomy tube

• Remove the trach tube gently and quickly

• Apply a sterile occlusive dressing over the stoma

• Apply O2 via nasal cannula

• Monitor respiratory status closely

Stoma care

• Keep stoma covered with an occlusive dressing

• Change dressing PRN keep the site dry and promote healing

• Clean site w/ sterile NS

• Monitor for signs of infection

• Stoma should close within hours to days

Thoracentesis

• A less invasive way to remove pleural fluid

• Used to remove small to moderate amounts of fluid from pleural space that cause breathing difficulties, provides immediate relief of symptoms and aids in diagnosis

• Single one-time procedure

• Diagnostic - analysis of fluid guide to treatment

• Therapeutic - temporarily removes fluid and improves lung function (cirrhosis, cancer, heart failure)

Thoracentesis complications

• Infection

• Pneumothorax

• Hemorrhage

• Hypotension

Thoracentesis procedure

• Preparation

  • Position: sitting upright (leaning forward)

  • Cleanse and sterilize insertion site

  • Administer local anesthesia

• Insertion

  • Needle/catheter inserted into pleural space between ribs (lower chest)

  • Ultrasound often used for guidance

• Fluid removal

  • Withdraw fluid/air through needle or catheter

  • Volume removed depends on patient condition

• Post-procedure

  • Remove needle/catheter; apply dressing

  • Chest X-ray to confirm lung re-expansion and rule out complications

Chest tubes

• Placed in the pleural space to re-establish negative pressure, drain pleural fluid, allow for lung expansion

• Chest tube sizes range from 12F to 40F

  • Large sizes used to drain blood (40F)

  • Medium sizes used to drain fluid or pus (24F)

  • Small sizes used to drain air (12F)

Inseration of tube toracostomy (chest tube)

• Patient positioning

  • Arm raised above the head on the affected side

  • Elevate HOB 45º when possible - this lowers the diaphragm and reduces risk for injury

  • A small incision (1-2 cm) between the ribs into the pleural space

• Post procedure

  • Provider will suture in place and close incision

  • Connect to pleura drainage system

  • Cover wound with petroleum occlusive dressing

  • Obtain x-ray confirmation

  • Monitor patient and manage pain

Chest tube nursing management

• Assess vital signs, lung sounds, pain, drainage amount, site infection, and SQ emphysema (cracking or popping sensation)

• Encourage deep breathing, IS, and shoulder ROM exercises

• Chest drainage – keep below chest, avoid overturning, measure output, replace unit when full

• If unit breaks, insert distal end of tube in 2cm sterile water (this creates a water seal)

• Never milking or stripping chest tubes of clots

• After removal - apply an occlusive petroleum gauze dressing; CXR; monitor for respiratory distress

Chest tube unplanned dislodgement

• Stay calm and immediately cover the open insertion site with a gloved hand

• Call for assistance and ask a colleague to immediately notify the provider and obtain petroleum gauze, dry gauze, and tape to cover the site

• Monitor for signs of respiratory distress

• If the patient develops respiratory distress or sudden change in vital signs, call the rapid response team

• Tape the occlusive dressing on 3 sides, allowing air to escape on the fourth side to reduce the risk of tension pneumothorax

• Prepare for possible needle decompression

• Prepare for reinsertion of a chest tube

Pleural drainage systems

• Use a catheter inserted into the pleural space to remove fluid or air, which helps the lungs expand and alleviates symptoms like shortness of breath

• Represents thoraic pressure

• Bubbles will appear if there is an air leak or air is being pullled from the patient

Pleural drainage system compartments

1. Collection chamber- air or fluid from pleural space; fluid stays in first chamber, and the air is expelled into second

2. Water seal chamber - contains 2 cm of water and acts as a 1-way valve; incoming air enters and bubbles up; the water prevents backflow of air into the patient

3. Suction control chamber - applies dry or wet suction to the drainage system

Wet suction bubbling

• Brisk bubbling of air occurs in the 2nd chamber when a pneumothorax is first evacuated

• Intermittent bubbling occurs during exhalation, coughing, or sneezing until the air has been removed from the pleural space

• Bubbling should cease once pneumothorax is resolved

• Continuous bubbling indicates an air leak

  • Assess the patient for respiratory distress – could indicate dislodgement or worsening of pneumothorax

  • Loose connections & malfunctioning chest tube

Wet suction tidaling

• Normal rise and fall of fluid levels in the water seal chamber with respirations

• Indicated normal lung expansion and contraction

• If tidaling stops, assess the chest tube may be occluded

Pleural drainage system key points

• Keep the drainage system below the level of the patient’s chest

• No dependent loops in the tubing

• Never allow the drainage system to be knocked over - replace if this happens

• Never clamp a chest tube without a provider order

• A sudden cessation of drainage with no fluctuation in the water seal chamber suggests an obstruction → air/fluid buildup → cause tension pneumothorax

• Replace the collection chamber when full

Flutter valve chest drainage

• Rigid plastic tube, one-way rubber valve inside

• Small to moderate pneumothorax

• Inlet nozzle allows air to pass into valve through chest tube

• Outlet nozzle air passes into collection device during expiration

• Increased mobility

• Can go home with flutter valve

Types of chest surgery

• Thoracotomy

• VATS (Video assisted toracoscopic surgery)

Thoracotomy

• A thoracotomy is a surgical procedure that involves making an incision between the ribs to access the chest

• The most common reason for a thoracotomy is to treat lung cancer

VATS

Video-assisted thoracoscopic surgery (VATS) is a minimally invasive procedure that allows doctors to perform surgery on the lungs and other structures in the chest cavity