Week 3 Respiratory Disorders B

Introduction

• This week's focus: restrictive respiratory disorders, including pleural effusion and pneumothorax.
• Topics include pathophysiology, management, intercostal catheters (ICCs), underwater sealed drainage (UWSD), and tracheostomy tube management.
• Learning Outcomes:
  • Explain pathophysiological concepts and clinical manifestations of pleural effusion and pneumothorax.
  • Apply systematic, person-centered approach to patient assessment and management.
  • Identify patient needs, and plan/implement appropriate nursing care.
  • Critically reflect on decisions for patient-centered care.
  • Identify interprofessional team members for collaboration.
  • Discuss/demonstrate indications, assessment, nursing management, and potential complications of tracheostomy (suction, oxygenation, humidification).
  • Discuss/demonstrate indications, assessment, nursing management, and potential complications of ICCs and UWSD systems.

Resources

• Reading
  • Brown, D. & Edwards, H. (2023). Lewis's Medical-Surgical Nursing (6th edition). Elsevier.
    • Chapter 26: Nursing Management: Upper respiratory problems. p. 594-608
    • Chapter 27: Nursing Management: Lower respiratory problems. p. 639- 645; p. 648-649
  • Craft, J. & Gordon, C. (2022). Understanding Pathophysiology: ANZ edition (4th edition). Elsevier.
    • Pneumothorax: p. 756-757
    • Pleural effusion: p. 757

Restrictive Respiratory Disorders Overview

• Pleural effusions and pneumothoraces are restrictive respiratory disorders.
• Restrictive disorders impair chest wall and diaphragm movement during respiration.
• Understanding thoracic cavity anatomy and breathing physiology is crucial.
• Key principles for caring for patients with pleural effusion or pneumothorax:
  • Chest movement during inspiration and expiration.
  • Pressure changes within the lungs during inspiration and expiration.
  • Role of the pleural space and linings in the breathing process.
• Focus on pleural effusion and pneumothorax.

Pleural Effusion

• Definition: Abnormal collection of fluid in the pleural space.
• Normal pleural space contains 5-15ml of fluid (pleural fluid) for lubrication.
• Pleural effusion is a result of other disease processes.
• Fluid movement governed by hydrostatic pressure, oncotic pressure, and membrane permeability.
• Classification:
  • Transudative: Fluids pass through a membrane, few cells or proteins; result from conditions impacting fluid flow (congestive heart failure, liver disease, renal disorders).
  • Exudative: Fluid leaks from blood vessels, higher concentration of cells/proteins; result from infections, cancer, autoimmune conditions.
  • Empyema: Collection of purulent fluid (pus) caused by pneumonia, TB, lung abscess.
  • Chylothorax: Collection of lymphatic fluid due to trauma or malignancy.
• Fluid build-up results from:
  • Increased capillary pressure (hydrostatic pressure).
  • Decreased oncotic pressure.
  • Increased pleural membrane permeability.
  • Obstruction of lymphatic flow.
• Clinical Manifestations
  • Dyspnoea
  • Cough
  • Sharp, non-radiating chest pain, worse on inspiration
  • Decreased chest movement on affected side
  • Dullness to percussion
  • Diminished breath sounds over affected area
  • Empyema: fever, night sweats, weight loss
  • Chest X-ray and/or CT inform the size and location of the effusion.
• Nursing Assessment
  • Health history assessment (subjective/objective data)
  • Primary assessment
  • Secondary assessment (detailed pain assessment)
  • Focused assessment
  • Adopt a 'head-to-toe' approach, also see Respiratory A Own-Time eBook, chapter 5
• Treatment
  • Maximize breathing capability
    • High Fowler's position or sitting out of bed
    • Allowing patient to tripod
    • Breaks/rest between activities
    • Respiratory hygiene (deep breathing and coughing)
    • Oxygenation when indicated
• Medical management
  • Depends on effusion size; untreated fluid can cause severe shortness of breath.
  • Small effusion due to infection: conservative management, treatment of infection.
  • Larger effusion: fluid drainage needed.
    • Thoracentesis: aspiration of intrapleural fluid for diagnostic or therapeutic purposes, may only be sufficient for pathological examination, or may draw off as much fluid as possible.
    • Drain tube (pigtail drain or intercostal catheter) insertion for larger effusions (>50-100ml), attached to sterile drainage bag.
• Nursing Management Post Thoracentesis
  • Monitor for pneumothorax, bleeding, and infection.
  • Support patient and monitor vital signs.
    • Vital signs monitoring per facility guidelines (e.g., 15 minutely for the first hour, then as guided by the facility and the patient's condition.) – BP, HR, RR, O_2 sats, temperature, pain, conscious state.
    • Visual inspection of respiratory effort.
    • Visual inspection of thoracentesis site or drain tube (drainage color and volume).
    • Encourage deep breathing and coughing post-procedure if pain is managed.

Pneumothorax

• Definition: Accumulation of air or gas in the pleural cavity (Brown et al., 2023 p. 639).
  • Rupture in visceral or parietal pleura and chest wall.
• Normal lung: negative pressure between visceral and parietal pleura allows lung filling during chest wall expansion.
• Air in pleural space changes negative pressure, causing lung collapse.
• Suspect pneumothorax with chest wall trauma.
• Classification:
  • Closed: air does not enter through external wound.
  • Open: air enters through an external wound.
• Complication: Tension pneumothorax (life-threatening).
• If there is trauma/injury to the thoracic cavity from an assault, penetrating chest injury or blunt trauma, then bleeding from ruptured blood vessels will result in a haemothorax.
• Types of Pneumothorax
  • Spontaneous: Rupture of small blebs on lung apex (tall, thin males) or due to lung disease (COPD, asthma, cystic fibrosis, pneumonia); closed pneumothorax; may become tension pneumothorax.
  • Iatrogenic: Laceration/puncture during medical procedures (transthoracic needle aspiration, subclavian catheter insertion, pleural biopsy, transbronchial lung biopsy, excessive ventilatory pressure); present as closed pneumothorax.
  • Traumatic:
    • Penetrating chest wounds (stabbing, gunshot): air enters through chest wall; sucking chest wound requires semi-occlusive dressing (three sides covered, one open).
    • Blunt trauma: fractured ribs lacerate lungs; flail chest results in opposite movement of rib section; management includes pain control and chest splinting.
  • Tension: Air enters pleural space but cannot exit; lung collapses, mediastinal shift occurs, compromising oxygenation, venous return, and cardiac output; requires decompression.
  • Haemothorax: Blood accumulation in pleural space due to injury; when with pneumothorax, called haemopneumothorax; requires drain tube attached to UWSD system.
  • Chylothorax: Lymphatic fluid collects in pleural space due to abnormal lymphatic circulation; management depends on cause, may require chest drain.
• Diagnosis: Based on presentation, clinical manifestations, and patient assessment; definitive diagnosis with chest x-ray (CXR).
• Clinical Manifestations:
  • Dyspnoea
  • Tachypnoea
  • Tachycardia
  • Chest pain
  • Hypoxia
  • Reduced/absent breath sounds over affected area
  • Tension pneumothorax: severe hypoxaemia, marked tachycardia, neck vein distension, cyanosis, diaphoresis, tracheal deviation (mediastinal shift), hypotension (reduced cardiac output)
• Nursing Assessment:
  • Health history assessment (subjective/objective data)
  • Primary assessment
  • Secondary assessment (detailed pain assessment)
  • Focused assessment (trachea position assessment)
  • Subcutaneous emphysema: air escapes into subcutaneous tissue, causing crepitus.
  • Adopt a 'head-to-toe' approach, also see Respiratory A Own-Time eBook, chapter 5
• Treatment:
  • Depends on severity and cause.
  • Minimal air/fluid: may resolve spontaneously.
  • Larger pneumothoraxes: Intercostal Catheter (ICC) with UWSD.
• ICC with UWSD
  • Drains pleural space of air/fluid, re-establishes negative pressure.
  • May be short term (up to four hours) or long term (days or weeks).
  • Placement depends on air, fluid, or both.
  • Prevents re-entry of air/fluid with air seal (UWSD or Heimlich valve).
• Different Systems
  • HEIMLICH VALVE- these valves maintain the negative pressure of the pleural space by allowing air to escape but not to re-enter on inspiration. These may be used for patients with a simple, spontaneous pneumothorax
  • UWSD SINGLE COLLECTION SYSTEM - this is a chamber system which incorporates the air seal, suction attachment and collection chambers all in one. There are a number of different versions of these.
  • THREE BOTTLE SYSTEM - whilst these are not common any longer, you may still see them in some healthcare facilities. These systems utilise three collection bottles when using suction

Intercostal Catheter (ICC) and Under Water Seal Drainage (UWSD) System

• ICCs are drain tubes inserted between ribs to remove air, fluid, pus, or blood from pleural space.
• Fluid/air build-up after surgery, inflammation, infection, or traumatic injury.
• Chest x-ray confirms air/fluid presence; ultrasound/CT scan evaluates fluid.
• UWSD collects drained fluid/air and restores respiratory function.

Nursing Management

• Focus on ICC with UWSD for pleural effusion or pneumothorax management.
• Patient requires close support and monitoring.
• Nursing roles:
  • Set-up and insertion
  • Drainage system management
  • Monitoring patient's clinical status
  • Monitoring the chest drainage system
• Set-up and insertion
  • Nurse's role: ensure patient awareness, support doctor with insertion.
  • Consider pain relief.
  • Gather equipment as per facility procedure.
  • Prepare UWSD system (add sterile water).
  • Position and support patient.
  • Monitor patient condition (oxygen saturations, respiratory rate, haemodynamic status).
• Patient Assessment/Clinical Status
  • Primary/start of shift assessment - DRSABCDE
  • Emergency bedside equipment check - two (2), surgical tubing clamps.
    • NOTE: Clamps should never be used for transportation of the patient as they can be accidentally left on resulting in a tension pneumothorax.
  • Monitoring of vital signs as per hospital policy (an example may be: 15 minutely for 2 hours post insertion, 1 hourly after that) – HR, BP, SpO_2, RR, respiratory effort, temperature, pain assessment, level of consciousness.
  • Focused respiratory assessment (chest auscultation, ICC insertion site inspection, surgical emphysema palpation).
  • Ongoing patient education (tube and UWSD system care, deep breathing and coughing, pain management).
  • Pain management: chest tubes are painful; regular analgesia needed.
• Drainage System
  • Connected to drainage system to collect fluid and prevent air re-entry.
  • Keep tubing loosely coiled below chest level.
  • Tubing should have no dependent loops - Dependent loops prevent drainage of fluid into the collection chamber increasing the backward pressure in the tubing and impacting effective drainage of both fluid and air from the pleural space.
  • Keep the tubing above the level of the insertion point on the UWSD system and below the level of entry into the chest.
  • Ensure tubing is not compressed underneath the patient, or against bedside rails, the mattress, bed wheels, or other equipment at the bedside. Compressed tubing prevents air and fluid escaping resulting in increasing positive pressure in the pleural space potentially resulting in re-collapse of the lung and possibly tension pneumothorax.
  • Ensure tight connections between ICC and UWSD system.
  • Secure tubing to patient's chest to prevent pulling.
  • Keep collection chamber upright to maintain water seal.
  • Keep collection chamber below patient's chest level to prevent backflow.
  • Take care when patient moves around the bed so that they do not accidentally pull on the tubing.
• Monitoring and documentation of the UWSD system
  • Occurs at the same time as vital signs are undertaken.
  • There will normally be a separate document where these assessments should be entered.
  • Swinging (tidally, air fluctuation) of the fluid within the water-seal chamber - pressure changes within the pleural space (increase in negative pressure with inspi9raton and increase in positive pressure with expiration) which causes the fluid in the underwater chamber to move up and down. This is a normal expectation. It the UWSD is attached to suction, this fluid movement will not be visible.
    • Sudden cessation of swinging may indicate occlusion in tubing or kinks.
  • Bubbling (movement of air through the fluid): air escapes through the tubing and chamber and moves through the water seal. This eventually decreases, occurring on deep breathing, coughing or sneezing until the leak seals.
    • Increase in bubbling may indicate an air leak in the ICC and/or UWSD system or a leak at the ICC insertion site.
  • Suction: if attached to the system, the suction strength must be checked to ensure the correct prescribed level is set. This is normally set by the surgeon/physician at -20mmHg and is adjusted either at the system suction control or by the water level, depending on the system used.
    • Depending on the healthcare organisation policy/procedure, the suction may be disconnected to assess for swinging and bubbling.
  • Drainage: volume and color should be documented with each set of vital signs.
    • The level of the fluid will be marked at least once per day, but may require more measurements depending on the amount of drainage. The level is marked on the drainage chamber usually with a pen/permanent marker.

Upper Airway Obstruction

• Importance of considering upper airway conditions that may impact respiration.
• Some conditions may require a tracheostomy.
• Good assessment skills and understanding of disorders affecting the upper airway are essential.
• Information provides an overview of conditions that may obstruct the upper airway.
• Upper airway obstructions affect the trachea, larynx, pharynx (nasopharynx and oropharynx) and can result from inflammation, trauma, loss of muscle tone, or growths (whether benign or malignant).
• Partial obstructions affect work of breathing; complete obstruction is a medical emergency.
• The nose, sinuses, pharynx, epiglottis, and larynx are all susceptible to inflammation.
• Nose & Sinus
  • The nose and sinuses are often inflamed due to hay fever or the common cold.
  • Whilst these are annoying and can be painful, they do not generally result in complete airway obstruction.
• Significant inflammation of the oropharynx, epiglottis, larynx and trachea can result in complete obstruction of the airway.
• Pharynx
  • Pharyngitis (sore throat) may be viral or bacterial with symptoms ranging from 'scratchy throat' to severe pain restricting swallowing, fever, and cervical lymph adenopathy (enlarged lymph glands).
  • Occasionally, a peritonsillar abscess (quinsy) can develop as a complication. Severe quinsy can result in airway obstruction.
  • Nursing management goals include infection control, symptom relief and prevention of secondary infections. Bacterial pharyngitis is managed with oral antibiotics, normally penicillin-based.
• Epiglottis
  • The epiglottis is a 'lid' of fibrocartilage that closes over the larynx during swallowing. Viral infections may result in inflammation and swelling of the epiglottis
  • When the swelling starts to obstruct the larynx, breathing will be impaired making this a medical emergency. Clinical manifestations include high fever, sore throat, inability to control secretions (drooling), tripod positioning, difficulty breathing and irritability. Intubation will be required to maintain a patent airway.
  • Occasionally, the patient with epiglottitis may need the insertion of a tracheostomy as the epiglottis may be so swollen that it is not possible to insert a endo-tracheal tube.
• Larynx
  • Laryngitis is the inflammation of the larynx resulting in a hoarse voice, difficulty speaking, sore throat, mild fever and an irritating cough.
  • Clinical manifestations of laryngeal oedema, post operatively, will be an expiratory stridor (barking like a seal on expiration). Your patient will be distressed so you will need to remain with them whilst calling for assistance.
  • People may be diagnosed with laryngeal cancer requiring the surgical removal of the larynx. This then also removes the passageway to the upper airway.
• Upper Airway Trauma
  • Maxillofacial trauma can result in life-threatening airway and haemorrhage problems leading to obstruction of the airway.
    • burns (heat or chemical) that cause swelling to the epiglottis and mucous membranes around the larynx
    • gunshots, knife wounds or blunt trauma wounds that collapse portions of the airway or cause continuous bleeding or vomiting that obstructs the airway
  • If the injuries are likely to take a long time to heal and ongoing airway obstruction is likely, they may require insertion of a tracheostomy tube.
• Foreign Objects and Growths
  • Airway obstruction resulting from foreign bodies require emergency management.
• Loss of Muscle Tone
  • Loss of muscle tone within the upper airway will result in the inability to protect the airway and may be a result of loss of consciousness due to cardiac arrest, head trauma or other medical condition, or some neurological conditions including some high spinal cord injuries.
  • If the loss of muscle tone is expected to take more than 10 days to 2 weeks to resolve, then patients will often require a tracheostomy to protect the larynx.

Tracheostomy

• A tracheostomy is a procedure where an artificial opening is established in the trachea, bypassing the patient's existing airway (nose and mouth).
• Indications:
  • Bypass an upper airway obstruction.
  • Facilitate removal of secretions.
  • Permit long term mechanical ventilation or facilitate weaning from mechanical ventilation
  • Protect the airway of patients with a reduced ability to swallow saliva
• Tracheostomies come in all different shapes and sizes, and the selection of the correct tracheostomy tube will be dependent on the patient's individual care needs and functional requirements.
• Benefits include freedom of movement, less vocal cord damage, increased comfort, ability to eat/drink, and potential to speak.
• Physical impact:
  • Bypassing upper airway means inspired air is colder and drier.
  • Bypassing larynx means patient cannot speak (impacts communication).
  • May affect sense of smell and taste.
  • Reduces work of breathing (less airway resistance).
  • Permanent tracheostomy impacts body image.
• Types of Tracheostomy Tubes
  • Cuffed: seal the airway, patient breathes entirely through tube, used for mechanical ventilation or inability to protect airway.
  • Uncuffed: no cuff, allows air to pass around the tube and through the upper airway
  • Fenestrated: holes in tube to enable air to escape via the pharynx and mouth potentially enabling speech).
• Percutaneous tracheostomies are created by making a small incision through which a guidewire is passed followed by larger dilators to expand the tract to enable the insertion of the tracheostomy tube.
• Securing the Tube
  • Tracheostomy tubes are initially secured in place with sutures that may be removed after 7-10 days, however they are also kept stable with the use of tapes
• Tracheostomy Complications:
  • Airway leak
  • Airway obstruction
  • Altered body image
  • Aspiration
  • Bleeding
  • Fistula formation - tracheo-oesophageal or tracheo-innominate artery
  • Impaired cough - inability to close epiglottis to generate force for a cough
  • Infection - wound or respiratory tract
  • Subcutaneous emphysema - go back to the chapter on pneumothorax to review what this is
  • Tracheal stenosis
  • Tracheal necrosis
  • Tube displacement
  • Cuff-related complications: under-inflation leads to air leak and tube displacement; monitor cuff volumes and pressures.
  • High volume, low pressure tubes have a larger surface area that is in contact with the tracheal wall which lowers the incidence of damaging the tracheal mucosa (less risk of tracheal necrosis or fistula formation).

Nursing Management

• Ensure patent airway at all times.
• Assessment includes all requirements covered in Modules 1 and 2. It is important that we remember here, that in our start of shift or primary assessment, we start with A for airway. The tracheostomy is this patient's airway so must be included as part of your initial assessment for your patient.
• Safety: basic care keeps patients safe.
• PPE: goggles, masks, gloves (sterile or clean), apron.
• Safe environment:
  • Ensure completion of all safety and equipment checks
  • Humidification equipment (Maintains cilial and mucosal function, to help secretions move through airways, Warms and moistens inspired air, Decreases secretion viscosity and facilitates airway clearance, Decreases airway trauma due to dry airways, May reduce sputum plugging and risk of tracheostomy tube obstruction, May reduce risk of secretion retention and pulmonary infection)
  • Functioning suction equipment and suction catheters
  • Bottle of sterile water for cleaning suction tubing.
  • Cuff pressure checking devices (cuff manometer and 10ml syringe).
  • Spare tracheostomy tubes - one the same size - one a size smaller, also inner cannulas if indicated - two should be available - one in and one for changes. Spare cannula to be stored in a clean, covered container by the bedside.
  • Bag-valve-mask device (e.g. Air Viva with corrugated flex tube (liquorice stick) and face mask).
  • Tracheostomy dressing and tapes.
  • Sterile gloves.
• Humidification: supplemental humidification maintains cilial and mucosal function, warms and moistens inspired air, decreases secretion viscosity, decreases airway trauma, reduces sputum plugging and risk of tracheostomy tube obstruction, reduces risk of secretion retention and pulmonary infection
  • Devices: active heated humidifiers (heats water to 37^\circC), passive humidification (heat moisture exchange (HME) devices that collect the patient's expired heat and moisture and return it during the following inspiration).
  • Nebulisation therapy with 0.9% sodium chloride, bronchodilators or mucolytic medication may be required.
• Suctioning: essential for removing excessive secretions and maintaining patency of the tracheostomy tube
  • Volume and consistency can be affected:
    • Loss of normal humidification from the upper airway
    • Post surgical inflammation (the body's normal response to trauma or injury)
    • The presence of the tracheostomy tube paralyses the cilia in contact with it
    • The loss of a normal cough through bypassing the larynx and epiglottis
  • This results in secretions collecting at the lower end of the tracheostomy tube.
  • Proper suctioning technique must be used as there are a number of complications that can occur as a result of suctioning. These include:
    • Bronchospasm/laryngospasm - irritation of the mucosal lining from the suction tube
    • Transient hypoxia (on suctioning, you remove the oxygen as well as the secretions
    • Tracheal trauma or bleeding - friable mucous membrane and/or poor suctioning technique
    • Excessive coughing - over vigorous suctioning or inserting suction tubing too far down the trachea, stimulating the carina
    • Cardiac arrhythmias or hypotension
    • Pain and/or anxiety
    • Nosocomial pneumonia - poor suctioning technique
    • Increased intracranial pressure - taking too long to complete the suction process, too vigorous technique
    • Increased mean arterial pressure - noxious stimulation causing distress
  • Frequency: depends on patient, location, and health service policy. At a minimum, the patient's tracheostomy tube should be suctioned at the start of every shift but it depends on the patient's ability to independently clear secretions.
  • Signs indicating need for suctioning: noisy airway secretions, increased respiratory effort, restlessness, reduced oxygen saturation level, increased or ineffective coughing, increased use of accessory muscles, patient request, hypoxia or cardiovascular change
• Inner Cannula:
  • Removable inner tube decreases blockage risk.
  • Cleaned/changed every 8-hour shift or more often if needed.
• Tracheostomy Stoma Care:
  • Stoma is an open wound requiring regular cleaning with normal saline and kept dry.
  • Dressing should be intact for 24 hours post-creation.
  • Assesment/Inspection include TRAMS identifies the following points of inspection when assessing your patient's tracheostomy site and surrounding skin
    • Tracheostomy tube midline with tapes secure
    • Monitor for any signs of new or excessive bleeding
    • Monitor skin for any signs of breakdown
    • Infection (purulent discharge, local pain, odour, abscess formation, cellulitis or discolouration)
    • Increase in stoma size
    • Appearance of stoma edges
    • Hypergranulation (increased granulation at wound surface) tissue formation
    • Allergic reaction to dressing products (erythema)
    • Any signs of pulsation
    • Any pressure related injuries There are a number of different dressings that are used for tracheostomies. Two common ones are shown below.
• Securing the Tube
  • Essential at all times.
  • Newly created secured with sutures.
  • Long term secured by the cuff (if present) and ties around patient's neck.
  • If the tube is dislodged and the stoma has not yet established, the stoma may close over resulting in the patient having no airway - a medical emergency.
• Speaking Valves
  • When placed on the hub of the tracheostomy tube, or in-line with the ventilator circuit, the Passy Muir Valve redirects air flow through the vocal folds, mouth and nose, thus enabling vocal sounds, and improved communication.
  • Years of evidence-based research has shown that the Passy Muir Valve offers patients numerous clinical benefits beyond communication, including improvements in:
    • Voice/speech production
    • Swallowing
    • Secretion management
    • Oxygenation
    • Restoration of positive airway pressure
    • In-line ventilator use and interchangeability
    • Weaning
    • Decannulation
    • Olfaction
    • Infection control
    • Paediatric speech/language development
    • Quality of life

Interprofessional Collaboration

• Management of restrictive respiratory disorders requires interprofessional collaboration.
• Pharmacists: for analgesia and medication advice.
• Dieticians: for nutritional problems; dietary guidelines.
• Social Workers: for home assistance and support groups.
• Physiotherapists: for pulmonary hygiene, breathing exercises, and splinting techniques to prevent chest infection.
• Occupational Therapists: for home supports (rails, shower chairs) and communication equipment.
• Speech Pathologists: for swallowing difficulties and communication support.
• Respiratory Physician/ Specialist: guides care in hospital and monitors progress post-discharge.
• General Practitioner: monitors ongoing progress post-discharge and further investigations.