Week 4 - Complex Respiratory Health

General signs and symptoms of Respiratory Injuries 

S&S of resp duress 

• Shallow respirations​

• Dyspnea ​

• Increased/decreased RR​

• Altered SpO2​

• Pain with respiration

General Principles of Respiratory Management

Support respiratory function: ​

• High fowler’s ​

• Supplemental O2 ​

• Splinting during turning and repositioning and deep breathing and coughing

Diagnosis by chest x-ray

Pleurisy (Pleuritis)​

• Inflammation of both layers of the pleura ​

• Causes: Pneumonia, Tuberculosis, chesttrauma, PE, lung cancer, post thoracotomy, etc. ​

Pleurisy (Pleuritis)​ - S&S + Management

S&S​

• Sharp pain with respiration (worse on inspiration, deep breathing, coughing or sneezing)​

• Pain often absent when breath held ​

• Pleural friction rub on auscultation

Management ​

• What is the underlying case? —> treating this will treat the pain ​

• NSAIDs —> pain relief; less pain = better resps

Plural Effusion ​

• Abnormal collection of fluid in the pleural space​

• Causes: Pneumonia, Tuberculosis, heart failure, Pulmonary embolism, lung tumors, liver cirrhosis, nephrotic syndrome, etc.

Plural Effusion - ​S&S + Management

S&S (Symptom severity depends on size of effusion)​

• Chest pain, SOB, ↓ breath sounds over affected area, dull flat sounds with percussion ​​

General Management​

• What is the underlying case? —> treating this will treat the symptoms AND prevent re-accumulation of fluid ​

• Remove the effusion —> Thoracentesis (needle aspiration) or insert chest tube (more on chest tubes later!)

  • thoracentesis = one time use, removed after 

Pleural effusion - Transudative vs Exudative

Transudative: occurs due to increased hydrostatic pressure (out of vessels) or low plasma oncotic pressure (into vessels) = low in liver disease 

• CHF, cirrihosis, nephronic syndrom, PE, hypoalbuninemia 

Exudative: occurs due to inflammation and increased capillary permeability 

• pneumonia, cancer, TB, viral infection, PE 

Empyema​

• Abnormal collection of pus (thick & purulent) in the pleural space​

• Causes: Pneumonia, lung abscess, blunt trauma, iatrogenic (thoracentesisor thoracic surgery) etc. ​

• pleural effusion (exudative) 

Empyema​ - S&S + management

S&S​

• Chest pain, SOB, decrease breath sounds over affected area, febrile,tachycardia (acutely ill – infection)​

General Management​

• Remove the empyema ​

  • Thoracentesis (needle aspiration) ​

  • Insert chest tube and connect to drain ​

• Administer antibiotics ​

Rib Fracture​

• Most common chest wall injury, typically due to blunt trauma to chest ​

• Displaced rib can penetrate pleura and = hemo/pneumothorax​

• Flail chest can occur if multiple are fractured –paradoxical respirations(inward on inspiration, outward on expiration)

Rib Fracture​ - S&S + management

S&S​

• Sharp pain with respiration, shallow respirations ​

• Secondary implications --> can lead to pneumonia (not wanting to do DB+C)

Management​

• Resolve spontaneously ​

• Requires pain management

Hemothorax ​

• Abnormal collection of blood in the pleural space​

• Causes: Blunt chest trauma (MVA, falls, bike crashes, direct blow to the chest, etc.), iatrogenic (e.g., lung biopsy), etc.

Hemothorax - S&S + management

S&S​

• Chest pain, SOB, decrease breath sounds over affected area, dull flat sounds with percussion,(acutely ill – trauma) ​

General Management​

• Remove the blood​

• Thoracentesis (needle aspiration) ​

• Insert chest tube and connect to drain ​

• Treat the underlying cause (with trauma, this is very complex!)​

• Vascular loss —> S&S of Fluid volume deficit —> do they need a transfusion?

Pneumothorax

• Abnormal collection of air in the pleural space​

Remember!= Loss of negative pressure in chest cavity —> “collapsed lung”​

• Causes: Blunt chest trauma (MVA, falls, bike crashes, direct blow to thechest, etc.), iatrogenic, diffuse lung disease, etc.

Pneumothorax - S&S + management 

S&S​

• Chest pain, SOB, decrease breath sounds over affected area,hyperresonance with percussion, (acutely ill —> S&S of respiratory distress) ​

General Management​

• Remove the air​

• Thoracentesis (needle aspiration) ​

• Insert chest tube and connect to drain ​

• Treat the underlying cause

Pneumothorax Types ​

Open: chest cavity exposed to outside air, penetrating trauma/impalement​

Closed: chest wall intact, spontaneous​ —> air leaks from lung into pleural space

Complication —> Tension: Air enters and gets trapped in pleural space = increased pressure causes compression of everything in chest cavity, mediastinum (heart, trachea, vessels) shifts to unaffected​

• tension can occur with both open + closed

Chest Tube (Thoracostomy)​

• Chest tubes drains air or fluid from the pleural space to return negative pressure to the chest cavity​

• Surgically placed by provider, placement confirmed with chest xray​

• System must be air-tight​ = otherwise pneumothorax can occur 

• Connected to drainage system ​

  • Passive (gravity)​

  • Suction (Usually, 80 mmHg at wall)​

• Uses​

  • Pneumothorax, Infections, LungCancer, Chest Surgery

"Wet" Chest Tube Suction​

• Fluid and air from client enters chamber “from patient”​

• Air moves into water seal (lets air escape from chest, cannot go back in)= intermittent bubbling 

  • continuous = air leak in system (bad) 

• System is connected to external suction to create pressure in system

• Suction control is through water chamber 

Cannot be knocked over to prevent air entering 

"Dry suction" 

• Set with regulator dial ​

• Air/fluid drains from pleural space → into drainage collection chamber.

• Air moves into the water seal chamber — creates a one-way valve so air can exit but not re-enter the chest.

• air leak indictor - minimal bubbling expected (no bubbling) 

Chest Tube - Management​

• Keep drainage system below level of chest at all times = let gravity do the work! ​

• Ensure all tubes are connected and check for patency​

  • NEVER clamp without an order!​ —> can cause tension pneumothorax

  • can be clamped for short time to change system 

• Check water level (min 2 cm) and for intermittent bubbling ​

• Monitor output into atrium ​

  • Document fluid balance​

  • Colour, consistency, amount​

  • Mark amount on collection chamber​

• Monitor dressing/ change dressing​

• Assess respiratory, pain, SpO2​

• Administer pain relief ​

Chest Tube - Management​ - Issues

Assess patient first!

ABC, check site, follow down the tubing (looking for patency, blockages along tube)

Chest Tube - Management​ - Signs of Issues

• Continuous bubbling in chambers =LEAK! ​

• Hear sucking noises at point of entry (pt) =LEAK!​

• > 70 – 100 mL/hour drainage, ordrainage becomes bright red =complication!​

• Sudden loss of draining = occlusion?​

• If tube becomes inadvertently dislodged, pinch skin together and cover with occlusive dressing, then notify provider

  • from thorax —> cover w occulsive dressing (3 sides) + notify 

    • inhale (flaps downs), exhale (air can escape), 4 sides = trap air become tension 

  • from drainage —> place end in sterile water (creates water seal = no air into system) 

The nurse is working on a medical-surgical unit and caring for a clientwith a chest tube to manage a hemothorax. Which of the followingfindings may indicate a complication? ​

​

A) There is a sudden reduction in the amount of drainage in the collection chamber​

B) The client reports that they are experiencing mild discomfort insertion site​

C) Water in the water seal chamber rises and falls when client breathes

D) Colour of drainage has changed from sanguineous to serosanguinous

A 

Gentle tidaling —> normal

A patient is admitted with a chest wound and experiencing extreme dyspnea, tachycardia, and hypoxia. The chest wound is located on the left mid-axillary area of the chest. On assessment, you note there is unequal rise and fall of the chest with absent breath sounds on the left side. You also note a “sucking” sound when the patient inhales and exhales. The nurse suspects this patient is experiencing a: ​

​

A. Closed pneumothorax​

B. Open pneumothorax​

C. Tension pneumothorax​

D. Hemothorax

B

Sucking sound --> open

Obstructive Sleep Apnea ​

• Apnea during sleep caused by compromised airway from tissue relaxation during sleep​

• Risks​

  • Excessive weight, narrowed airway, hypertension, smoking,diabetes, asthma, etc. ​

• Treatment​

  • CPAP & BiPAP

Non-Invasive Ventilation

​​Non-Invasive refers to the fact these are used without an invasive artificial airway, rather using orofacial or nasal mask

• CPAP + BiPAP 

CPAP = Continuous Positive Airway Pressure

• Delivers a set pressure continuously during inhale and exhale​

  • i.e., the client can be taking a breath, not taking a breath or breathing very fast or very slow and the machine will always push in air at the same level of pressure ​

• ↑O2, ↓ work of breathing and ↑intrathoracic pressure (↓preload)​

• Used for sleep apnea, heart failure, and COPD exacerbations ​

• keeps alveoli open

BiPAP = Bilevel Positive Airway Pressure

• Delivers two pressures, depending on if the client is breathing in or out​

• IPAP – Inspiratory Positive Airway Pressure ​

• EPAP – Expiratory Positive Airway Pressure ​

• IPAP – EPAP = Pressure Support ​

  • positive pressure —> additional added into space 

• Can respond to changes in breathing, appropriate for respiratory failure(esp.hypercapnic - too much co2) 

• oxygenation and co2 removal 

CPAP + BiPAP Similaries

• Non-invasive ventilation techniques​

• Use nasal mask or prong masks to deliver air +/- O2​

• Require monitoring of resp status and response to treatment​

• Can be used in hospital or at home

CPAP + BiPAP Differences

• BiPAP = 2 pressure levels,CPAP = 1 pressure level​

• BiPAP can be used to treat more severe resp distress.Can improve oxygenation inpatients with hypoxemia or hypercapnia ​

  • improves oxygen and co2

• CPAP often used for sleep apnea/less severe resp distress​​

  • keeps airways open for better gas exchange

(Non) + Invasive Airways General Principles

• Monitor: ​

  • Airway – patent?​

  • Respiratory Status​

    • ABGs, SpO2, Auscultate bilateral BS​

  • Neuro status (non-invasive) – able to keep airway patent? If no -> invasive​

• Prevent aspiration – HOB minimum 30 degrees​

• Keep emergency kit at bedside (AMBU bag, replacement tubes)​

• Provide oral care!

Invasive Airways - Sunctioning

Suctioning: keep patent! ​

• Suction – as needed. How would you know?

  • Gurgling sounds, visually see secretions, stats dropping (obstruction)​

• Verify agency policy! ​

• Don appropriate PPE​

• Sterility to reduce infection​

• Most will recommend; administer 100% O2 for 1 minute prior to suctioning​

• Typically suction with 100-120 mmHg​

• Insert sterile catheter into tube​

• Only suction on removal, rotate with withdrawal​

• Move smooth and with pace​

• AVOID prolonged suctioning > 10 seconds

Endotracheal Intubation ​

• Placement of a tube through nose or mouth into the trachea​

  • Patent airway (i.e. coma, obstruction)​

  • Respiratory distress (mechanical ventilation)​

• Cuff is inflated to reduce risk of aspiration,prevent air leaking, and decrease tube movement​

• Confirm placement with CO2 test and chestxray​

**short term management (EMERG) 

Tracheostomy​

• Tracheostomy tube is an indwelling tube inserted into the trachea(permanent or temporary)​

  • long term needs

• Allows bypassing of upper airway obstruction, removal of tracheobronchial secretions, long-term use of mechanical ventilation​

  • inflammation, tumors, burns, etcs.

Tracheostomy: Nurse Management ​

• Suction (PRN!)​

• Maintain skin integrity*​

• Maintain humidity​

• Maintain hydration (dehydration —> thickens secretions)​

• Verify cuff inflation per policy/orders (max 20-25cm of H2O)​

• Monitor for complications ​

  • Pneumonia, inadequate ventilation (cyanosis) ​

  • Abdominal distension = dislodgement ​

Tracheostomy: Nurse Management ​- Skin intergrity

• Maintain skin integrity*​

  • Around stoma: dressing dry and intact, use dressing type appropriate for amount of drainage from unique patient​

    • Clean site, allow to DRY​

• Around ties:​

  • Tip: should be tight enough to prevent dislodgement, but not so tight to cause skin breakdown, 1finger should slide underneath​

  • Changing ties is 2 person task, 1 to hold, 1 to change!​

Unintended Trach Removal: Emergency ​

• New (<7 days)​

  • Cover stoma with sterile occlusive dressing and bag client using mask(Ambu)​

  • Contact provider​

• Healed (>7days)​

• Reinsert using obturator, if able​

• If tube cannot be replaced, cover stoma with sterile occlusive dressing and bag client using mask(Ambu)​

Mechanical Ventilation: The BASICS ​

• Artificial breathing, where a machine is used to assist with or completely replace spontaneous breathing​

​Indications:​

• During surgery ​

• When the drive to breath has been removed (injury or meds)​

• Ventilation efforts are inadequate related to oxygenation or carbon dioxide (respiratory failure) ​

• Rest respiratory muscles (working towards weaning)​

IMPORTANT: If an alarm is going off; assess patient first, then ventilator!​

The nurse is caring for a client who has recently undergone endotracheal intubation. Based on their knowledge of ET tubes,the nurse identifies that the client is at risk of aspiration. Which of the following interventions to prevent this complication would be inappropriate? ​

A) Maintain the head of the bed at 30 degrees​

B) Suction the client frequently ​

C) Monitor for and prevent vomiting​

D) Inflate the ET cuff as required

B - only suction when necessary

cuff prevent secretions from leaking into lungs

The nurse is caring for a client with a tracheostomy tube which was surgically placed 10 days ago. The nurse asks another nurse to assist them with turning the client. While turning, the tube becomes suddenly dislodged. Which of the following is the next most appropriate action for the nurse to take? ​

A) Call the provider to notify them of the dislodgement​

B) Place the client in semi-fowler’s position​

C) Attempt to replace the dislodged cannula​

D) Close the stoma and use the bag value mask

C

Pulmonary Embolism ​

• Obstruction of the pulmonary artery or one of it’s branches ​

• Clot —>  vessel construction, and increases pressure in pulmonary system

Types of Blockage ​

• Thrombus —> i.e., VTE (deep veins), move from R. side of heart ​to pulmonary

• Air —> i.e., central line, scuba diving ​

• Fat —> i.e., open traumatic bone fracture ​

• Amniotic fluid —> i.e., birth complication ​

Pulmonary Embolism: Focused Nursing Assessments​

Sudden Onset ​

Respiratory ​

• Acute hypoxemia (Desaturation —> ↓ SpO2)​

• Dyspnea, tachypnea​

• Pleurisy (sharp chest pain)​

• Hemoptysis (coughing up blood)​

Cardiac​

• Tachycardia, hypotension​

Neuro ​

• Apprehension, anxiety, syncope​

Pulmonary Embolism: Diagnosis ​

• Fatal outcome can occur very rapidly; earlyrecognition is key!​

• Rule out other causes (i.e., MI)​

  • ECG (expect sinus tachycardia) ​

• Chest X-Ray​

• Labs​

  • ABGs (expect hypoxemia and hypocapnia)​

  • D-dimer​

• CT​

PE Lab values

D-Dimer ​

• Product of fibrin degradation ​= body tries to break clot (cannot keep up) 

• Uses​

• Investigate DVT, PE and DIC​

• Monitor thrombolytic therapy (how well is the clot breaking down?)​

• Interpretation​

• <500 ug/L —> “negative D-dimer” —> low probability of thrombosis ​

  • with regular blood clotting w injuries, very little + short lived (liver clears) 

• >500 ug/L —> “positive D-dimer” —>  high probability of thrombosis BUT not diagnostic

  • inside blood vessels where it shouldn’t, large amts of fibrin formed + broken down

CT scan done after

Pulmonary Embolism – Nurse Management ​Upstream

Upstream: Health Promotion​

• Routine respiratory assessment, notice changes​

• Minimize the risk of PE development ​

  • Identify high risk populations ​

  • Use thrombosis prophylaxis (prevention) where appropriate (think dalteparin in post op populations)​

  • Mobilization to prevent complications of immobility, using compression devices to promote venous return​

Pulmonary Embolism – Nurse Management ​ Downstream

Downstream: Reduce morbidity and mortality​

• Assess for S&S of PE (early recognition!)​

• Provide oxygen therapy ​

• Establish & maintain IV access ​

• Blood draw to determine labs ​

• Apply 12-lead ECG ​

• Administer pharmacological therapy ​

  • Analgesia, anticoagulation therapy, thrombolytic therapy ​

• Monitor for complications

  • Hemodynamic instability, shock

Pulmonary Hypertension​

• secondary to R. CHF 

• High pressure in pulmonary circulation ​

• Due to pathological changes in vasculature including vasoconstriction, muscle atrophy in vessel walls, tissue changes in vessel walls which restrict flow and increase pressure​

• Results in R side of heart working ++ hard to push flow into pulmonary circulation (pulmonary arteries)​ (in RCHF = back up) 

• WHO? COPD (most common), hepatic portal hypertension (we will talk about this when we talk about liver dysfunction), congenital heart diseases, idiopathic (no known cause)

Pulmonary HTN - pathology 

1. COPD + lung disease = damage lungs

2. Low oxygen or hypoxia —> hypoxic pulmonary vasoconstriction = limits blood flow to hypoxic alveoli 

3. vascular remodelling 

4. increased pulmonary arterial pressure 

5. increase RV afterload leading to RV dysfunction + failure 

Pulmonary Hypertension​ - S&S + Nurse’s role

S&S: SOB with exertion, weakness,fatigue, syncope, S&S of R. sided HF***(blood can’t get into the lungs, so the whole right side is going to back up)​

Nurse’s Role: ​

• Respiratory support: Supplemental O2, planning activity to reduce SOB ​

• Administer diuretics to reduce FVO ​

• Prevent clots (any backing up =pooling = clot risk!)​

​

Cor Pulmonale ​

• Complication of pulmonary hypertension​

• ↑ work of R. side of heart to pump against resistant pulmonary vasculature, caused by respiratory disease (ex.COPD) —>  enlargement of R. side of heart (thickening) —> atrophy (RV becomes dilated + weak) —> R sided HF (specific type)

Cor Pulmonale - S&S + Nurse’s role

S&S​

• R Sided Heart Failure symptoms that we discussed in week 3(remember that there is likely, in real life, overlap with some S/S of Lsided failure)​

Nurses Role ​

• Interventions for heart failure we discussed, with a specific additional focus on managing the respiratory disease that underpinned this condition (ex. COPD origin) ​

Pulmonary Edema​

• Abnormal accumulation of fluid in lung tissue, alveolar space, or both​

Types​

• Non-Cardiogenic​

  • cause = damage to pulmonary capillary lining (e.g., direct injury like chesttrauma or smoke inhalation, OR hematogenous (started/carried by thru blood) injury, like sepsis or multiple transfusions) ​

• Cardiogenic ​

  • Cause = heart failure (HF, left sided) —> resistance to LV filling —>  blood backs upinto pulmonary circulation​

  • Fluid volume overload, renal failure, liver failure ​

  • Slow or fast (flash pulmonary edema) ​

Pulmonary Edema​ S&S

• Early = neuro symptoms such as restlessness, anxiety, feeling like they “can’t breath” (sense of suffocation) ​

• Respiratory Presentation: ​

  • Frothy-pink blood-tinges sputum (fluid in alveoli mix with air and make bubbles)​

  • Impaired gas exchange —> hypoxemia ​

  • SOB, tachypnea​

  • Respiratory crackles on auscultation —> noisy bubbly breathing,constant “wet” cough ​

• Cardiac Presentation: weak, tachycardia, distended neck veins ​

• Late = neurological decompensation such as stupor (state of near-unconsciousness), lethargy, coma, and progression to central cyanosis​

Pulmonary Edema​ Nurse Role

• Monitor VS​

• Apply O2 (usually non-rebreather since they are in respiratory distress —> may need BiPAP or intubation)​

• Elevate HOB​

• Place client on cardiac monitor, initiate IV access​

• Administer medications [e.g. morphine - helps w dyspnea, diuretics (Lasix), inotropic medications (IV cardiac meds in critically care)] ​

• Interpret lab values (ABGs, electrolytes, labs r/t kidney or liver function)​

• Chest x-ray (assess extent of pulmonary edema)

Remember: The Lungs and Heart are CONNECTED! ​

• Problems in the lungs can cause heart problems​

  • Example; Pulmonary HTN —>  R. ventricular enlargement because the heart is having to work harder than usually to move blood into the pulmonary arteries —> R. sided HF (corpulmonale) ​

• Problems in the heart can cause lung problems ​

  • Example; L. HF results in blood backing up into the blood vessels of the lungs —>  fluid moves to the interstitial space —> pulmonary edema ​

The nurse is caring for a client who is 2 days post-op from an internal fixation surgery for a fractured femur. The client is complaining of chest pain and experiencing small amounts of hemoptysis. Vital signs are P 121 bpm, RR 31 rpm with accessory muscle use, and Sp02: 90%on room air, BP; 94/61 mmHg. ​

Which of the following interventions should the nurse prioritize? ​

A) Provide oxygen via face mask​

B) Administer intravenous morphine per order ​

C) Have the client perform incentive spirometry​

D) Begin IV fluids to increase fluid volume ​

​

A =The client’s main problem is hypoxia (SpO₂ 90%).

• The priority is to improve oxygenation immediately.

morphine can depress respirations and worsen hypoxia. May be used later to relieve anxiety/pain after oxygenation is stabilized.