MSE 2 Respiratory therapy

Respiratory Therapies

Promoting Oxygenation

  • Hydration status monitoring

    • Important for keeping secretions thin, white, watery, and easily removable.

    • Excessive coughing to clear thick or tenacious secretions is fatiguing and energy depleting.

    • Fluid intake recommendation: 1500 to 2500 mL/day.

  • Teaching effective coughing and breathing techniques

    • Includes methods such as turning, coughing, and deep breathing.

    • Aids in getting secretions up and may involve suctioning the airway as needed (particularly for artificial airways).

  • Chest physiotherapy: Used to help mobilize secretions.

Maintenance and Promotion of Lung Expansion

  • Ambulation: Critical for preventing atelectasis and ventilator-associated pneumonia.

    • Studies show early ambulation improves lung expansion.

    • Patients should be dangled and stood if needed; get them out of bed as soon as possible, ideally the day of surgery.

  • Proper positioning: Essential for maximizing respiratory function.

    • Change patient positions frequently; 45-degree semi-Fowler’s position is most effective.

    • For unilateral disease, position the "good side" down.

Coughing and Deep Breathing

  • Diaphragmatic breathing: Technique that increases air to the lower lungs; abdomen moves out when breathing in and sinks back in when breathing out.

    • Deep breathing helps to loosen secretions.

  • Coughing schedule: Recommended every 2 hours while awake for patients with respiratory conditions and post-operative cases.

    • For patients with a large volume of secretions, cough every hour while awake and every 2-3 hours at night.

Pursed Lip Breathing

  • Technique description: Involves deep inspiration and prolonged expiration.

    • Aims to prevent alveolar collapse.

    • Patient should be in a sitting position; take a deep breath and exhale slowly through pursed lips as if blowing through a straw, where the exhalation phase is longer than the inspiration phase.

    • Especially beneficial for COPD patients to control shortness of breath and anxiety during panic episodes.

    • Promotes removal of CO₂.

Chest Physiotherapy

  • Purpose: Mobilizes and drains secretions from gravity-dependent areas of the lung.

  • Three components:

    • Chest Percussion: Technique used to dislodge secretions.

    • Vibration: Helps to aid in secretion clearance.

    • Postural Drainage: Uses gravity to facilitate drainage of secretions.

Suctioning

  • Indication: Necessary when patients are unable to clear secretions on their own.

  • Types of suctioning:

    • Oropharyngeal and nasopharyngeal: For patients who can cough but cannot expectorate clear secretions.

    • Orotracheal and nasotracheal: For patients unable to manage secretions by coughing.

    • Tracheal: Performed through an artificial airway such as endotracheal or tracheostomy tubes.

Types of Airways

  • Oral airway: Prevents tracheal obstruction by keeping the tongue displaced in the oropharynx.

  • Endotracheal and tracheal airways: Used for short-term ventilation, relieving upper airway obstruction, protecting against aspiration, and clearing secretions.

  • Tracheostomy: A long-term assistance method, involving a surgical incision made into the trachea.

Incentive Spirometer

  • Function: Encourages deep breathing by providing visual feedback.

  • Goals: Promotes deep breathing and prevents atelectasis.

  • Patient instructions: Encourages coughing, and teach patients how to splint the incision if post-operative.

  • Seal requirement: Ensure a firm seal around the mouthpiece.

Nebulizers

  • Function: Adds moisture or medications to the air.

  • Usage: Administer bronchodilators and mucolytic agents to enhance mucociliary clearance.

Oxygen Delivery

  • Non-invasive ventilation methods:

    • Continuous Positive Airway Pressure (CPAP): Used for sleep apnea or heart failure, maintains airway patency.

    • Bi-level Positive Airway Pressure (BiPAP): Provides distinct inspiratory and expiratory airway pressures; useful in preventing endotracheal intubation during respiratory failure, pulmonary edema, and COPD exacerbation.

  • Oxygen therapy methods include:

    • Room air

    • Simple face mask

    • Partial rebreather mask

    • Non-rebreather mask

    • Variable flow rate mask

    • Venturi mask

Oxygen Therapy for Hypoxemia

  • Requirement: Delivery of O₂ by some device in concentrations greater than room air (21%).

  • Benefits: Reduces workload of heart/lungs and protects from tissue hypoxia.

  • Safety Considerations:

    • Oxygen use regulations: Must adhere to government regulations and be administered according to the rights of medication administration.

    • Risk of oxygen toxicity: Must be monitored, including checking meters and connections.

    • Combustibility: Ensure secure storage of oxygen cylinders and check tanks prior to use.

Nasal Cannula

  • Delivery method: Oxygen is delivered through plastic cannulas via nares (24-40%).

    • Cannula prongs should face downward.

    • Flow meter should be adjusted correctly before placing on the patient (1-6 L/min).

    • Assess and prevent breakdown over ears.

Simple Face Mask

  • Mechanism: Oxygen enters through entry port at the bottom and exits through large holes on the sides.

    • Typically delivers 35-50% oxygen with a flow rate of 5-8 L/min.

    • Use nasal cannula during meals.

    • Partial non-rebreather mask: Contains a reservoir bag that collects first part of the client’s exhaled air, mixed with oxygen for the next breath; delivers 40-70% oxygen at 6-10 L/min.

  • Non-Rebreather Mask: Delivers the highest possible oxygen concentrations for spontaneously breathing clients (60-80% at 10 L/min).

Venturi Mask

  • Purpose: Only mask that provides specific concentrations of oxygen:

    • 4 L/min: 24%-28%

    • 8 L/min: 35%-40%

    • 12 L/min: 50%-60%

  • Offers the most accurate concentration for COPD clients.

Humidification

  • Definition: Process of adding water to gas.

  • Importance: Keeps airways moist, eases mobilization of secretions and prevents dry nasal passages and associated nosebleeds.

  • Conditions for use: May need humidification in a dry environment and typically administered over 24 hours using sterile distilled water.

Complications of Oxygen Therapy

  • Possible complications include:

    • Drying effects on respiratory mucosa.

    • Oxygen toxicity.

    • Supports combustion.

    • Skin breakdown from tank or tubing.

  • Hypoxic Drive:

    • Most individuals breathe primarily due to elevated CO₂ levels.

    • Some COPD patients are CO₂ retainers, relying on low oxygen levels for their drive to breathe. Excessive oxygen administration may lead to respiratory cessation in these patients.

Evaluation of Interventions

  • To assess efficacy of interventions, evaluate:

    • Degree of breathlessness.

    • Walking distance and fatigue improvement.

    • Rate and frequency of cough and sputum production.

  • Monitoring methods:

    • Respiratory rate observations before, during, and after activities.

    • Assess sputum quality and quantity.

    • Auscultate lung sounds for improvement.

Advanced Therapeutics

Pleural Effusion

  • Definition: Presence of fluid in the pleural cavity.

  • Diagnosis: Confirmed through chest X-ray (CXR).

  • Common causes:

    • Congestive heart failure (CHF).

    • Hypoalbuminemia.

    • Pulmonary malignancies or infections.

  • Clinical manifestations:

    • If large (> 250 mL), evident on CXR; if small (< 250 mL), may note decreased breath sounds on the affected side, which can be bilateral.

    • Other signs may include hypoxemia.

  • Types of Pleural Effusions:

    • Hemothorax: Blood in pleural space causing lung collapse (causes include chest trauma, tuberculosis, blood clotting disorders).

    • Empyema: Infection present in the pleural space.

    • Chylothorax: Presence of lymphatic fluid in pleural space.

Pleurodesis

  • Indication: Treatment for pleural effusions.

  • Procedure: Injection of a chemical irritant (commonly talc) into the pleural cavity.

    • Purpose: Create inflammation that tacks the two pleura together.

    • Result: No space for fluid accumulation from pleural effusion.

Thoracentesis: Nursing Care

  • During the Procedure:

    • Support the client verbally and describe procedure steps as required.

    • Monitor vital signs.

    • Patient may require supplemental oxygen.

    • Observe for signs of distress (dyspnea, pallor, coughing).

    • Positioning: Patient should be in a sitting position (arms raised on overbed table) or in a side-lying position on the unaffected side when unable to sit.

  • After the Procedure:

    • Observe for changes in cough, sputum, respiratory depth, and breath sounds; note any complaints of chest pain.

    • Position the patient in a side-lying position with the unaffected side down for at least an hour.

    • Transport specimens for lab analysis.

    • Monitor the dressing over puncture site for bleeding or drainage, and monitor vital signs until stable.

Chest Tubes

  • Definition: Chest tubes are catheters inserted through the thorax to remove air and fluids from the pleural space and to restore normal intrapleural pressures.

Reasons for Chest Tube Insertion

  • Common indications:

    • Cardiovascular surgery.

    • Pneumothorax.

    • Hemothorax.

    • Chylothorax.

    • Empyema.

Nursing Care of Chest Tubes

  • Patient Assessment:

    • Note lung sounds, respiratory rate, any dyspnea indicating worsening pneumothorax or hemothorax.

    • Check skin around insertion site for subcutaneous crepitus (a crackling sensation detectable on palpation).

    • Encourage mobility through turning, coughing, and deep breathing.

Nursing Management of Chest Tubes

  • Drainage System: Keep below patient’s chest; ensure tubing is free from kinks and draining appropriately.

  • Drainage Collection Chamber: Monitor drainage (color and amount) – should drain no more than 100 cc/hr.

  • Water Seal Chamber: Provides an underwater seal to allow air removal while preventing outside air entry.

    • Water level fluctuates with respiration: increases during inspiration and decreases during expiration.

    • Intermittent bubbling may be normal; indicates air draining from the pleural space, especially in pneumothorax treatment.

Troubleshooting Chest Tubes

  • Dislodgment: Cover with a sterile dressing, taping on three sides to allow air escape; notify physician/APP immediately.

  • System breakage: Insert tube into sterile water/saline; obtain new system.

  • Milking/Stripping: Not recommended due to risk of negative pressure; follow hospital policy.

  • Clamping tubing: Increases risk of tension pneumothorax; do not clamp without an order.

  • Output > 100-200 cc/hr: Assess vital signs and assess for hemorrhage; notify medical team.

Caring for the Patient with a Tracheostomy

  • Indications for Tracheostomy:

    • Establishing a patent airway.

    • Bypassing upper airway obstruction.

    • Facilitating secretion removal.

    • Permitting long-term mechanical ventilation.

Tracheostomy Components

  • Key parts:

    • Cuffed trach (Shiley and Jackson versions).

    • Purpose of cuff: Creates snug fit to prevent aspiration and support stronger ventilator breaths.

Tracheostomy Cuff Management

  • General Protocol: Cuffs are typically deflated unless patient is mechanically ventilated or instructed by physician/APP to inflate during meals. Initial assessment should confirm cuff status.

  • Passy-Muir Speaking Valve: Allows air passage during expiration through vocal cords for non-ventilated patients post cuff deflation; used to support speech.

Tube Dislodgement & Accidental Decannulation

  • Procedure: Keep obturator taped at bedside for emergencies.

  • Insert obturator into outer cannula, extend neck and insert the outer cannula; remove obturator immediately and check breath sounds.

  • Secure the tracheostomy in place.

Bronchoscopy

  • Purpose: Visualization of bronchi for diagnostic procedures (e.g., biopsy or monitoring treatment).

  • Pre-Procedure Nursing Care:

    • Secure informed consent, obtain medical history (look for allergies and current medications).

    • Ensure NPO status for 6-12 hours before to reduce aspiration risk.

    • Monitor vital signs and provide oral hygiene to the patient.

    • Administer preoperative medications, including possible sedatives (e.g., Propofol) or topical anesthetics (e.g., Lidocaine).

    • Prepare for emergency resuscitation due to potential respiratory distress.

  • Intra-Procedure Nursing Care:

    • Position in sitting/supine position and provide supplemental oxygen.

    • Assist in tissue collection and perform other necessary procedures.

  • Post-Procedure Nursing Care:

    • Assess sputum for bleeding; mild blood is normal for a few hours.

    • Monitor respiratory status for complications, including bronchospasm and hypoxemia.

    • Maintain NPO status until anesthesia effects wear off; encourage pulmonary toilet and incentive spirometry post-operation.

    • Provide anxiety relief and comfort measures.