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Acute Respiratory Concepts

Overview

  • Speaker: Nancy Findley MSN, RN
  • Topics Covered:
    • Acute Respiratory Distress and Failure
    • Nursing Interventions
    • Introduction to Ventilator Modes and Nursing Interventions
  • Review Topics:
    • Oxygen Modalities
    • Other Airway Knowledge
    • Patient Assessment
    • Arterial Blood Gases (ABG)

Case Studies

  • Case Study 1:
    • Patient Details: 49-year-old client with asthma, admitted for exacerbation.
    • Symptoms: Complaining of shortness of breath.
    • Vital Signs (VS): 144/80, RR 35, Pulse oximetry (SpO2) 91%, Temp 97.4
    • Key Questions:
    • What assessment are you going to do?
    • Do you need an order for Oxygen?
    • What medications do you anticipate will be ordered?
Assessments For Dyspnea
  • Evaluate patient’s vital signs, respiratory rate, SpO2 levels, work of breathing, and comfort level after interventions.

Alveolar Ventilation (V)

  • Concepts:
    • V (Ventilation) and Q (Perfusion) management.
    • Air (L/min) and Pulmonary Blood Flow (L/min)

Causes of Impaired Ventilation and Perfusion

  • Ventilation Causes:
    • Altered tidal volume: airway obstruction, atelectasis.
    • Perfusion Causes:
    • Pulmonary embolism, shock/poor tissue perfusion, altered hemoglobin, cardiac pump failure.

Oxygen Delivery Devices

  • Nasal Cannula:
    • Flow Rate: 1-6L/min
    • FiO2: 24-44%
    • Humidify above 6L
  • Simple Face Mask:
    • Flow Rate: 5-8L/min
    • FiO2: 40-60%
  • Venturi Mask:
    • Flow Rate: 4-10L/min
    • FiO2: 24-40%
  • High Flow Nasal Cannula:
    • Flow Rate: 30-60L/min
    • FiO2: 65-90%
    • Delivers Positive End-Expiratory Pressure (PEEP)
  • Non-Rebreather Mask:
    • Flow Rate: 10-15L/min
    • FiO2: 85%

Case Study 2: Nursing Interventions

  • Post-Nasal Cannula Treatment:
    • Initial saturation and comfort improved briefly; reassessment needed.
    • Current VS: 110/60, RR 41, SpO2 91%, Temp 97.4
  • RRT Activation:
    • Patient had a pulse oximetry reading of 83% on a simple face mask; consider further interventions and communication with the physician.

Types of Respiratory Failure

Hypoxemic Respiratory Failure
  • Criteria:
    • PaO2 ≤ 60 mm Hg on ≥ 60% oxygen.
  • Common Conditions:
    • COPD, pneumonia, asthma, pulmonary embolism, and pulmonary fibrosis.
Hypercapnic Respiratory Failure
  • Criteria:
    • PaCO2 > 50 mm Hg and pH < 7.35
  • Associated Causes:
    • Ventilatory failure, heart failure, fluid overload, CNS conditions.

Clinical Manifestations & Patient Assessment

  • Early Signs of Impaired Oxygenation:
    • Restlessness, fatigue, headache, dyspnea, increased respiratory rate, tachycardia, elevated blood pressure.
  • Late Signs of Impaired Oxygenation:
    • Confusion, lethargy, central cyanosis, diaphoresis, respiratory arrest.

Nursing Interventions for Respiratory Issues

  • Positioning: High Fowler’s for optimal lung expansion.
  • Supportive Care:
    • Pain control, anxiety management, medication administration like bronchodilators, and oxygen management.
  • Pre-Intubation Preparation:
    • Ensure the room is equipped with suction and oxygen, and prepare for intubation when necessary.

Medical Management of Acute Respiratory Conditions

  • Goals of Care:
    • Ensure patent airway, optimize oxygen delivery, treat underlying causes, and prevent complications.
  • ET Tube Management:
    • Employ intubation for severe respiratory failure and ventilatory needs.
  • Utilize medications such as antibiotics for pneumonia, diuretics for pulmonary edema, and bronchodilators/steroids for asthma.

Ventilator Management Overview

Ventilator Modes
  • Controlled Mechanical Ventilation:
    • Used for apneic clients; preset tidal volume and respiratory rate.
  • Assist Control (AC):
    • Provides full support; can result in respiratory alkalosis due to over-breathing.
  • Synchronized Intermittent Mandatory Ventilation (SIMV):
    • Allows for spontaneous breaths between mandatory ventilator breaths.
  • Pressure Support Ventilation (PSV):
    • Reduces workload on patient’s breathing by providing additional pressure during spontaneous breaths.
  • Positive End-Expiratory Pressure (PEEP):
    • Keeps alveoli open at the end of expiration; risk for barotrauma or decreased cardiac output at high levels.

Alarms and Complications

Common Alarms and Their Causes
  • High-Pressure Alarms:
    • Causes include kinked tubing, secretions, coughing, and high lung pressure.
    • Treatment involves addressing the cause or manually ventilating the patient if unresolved.
  • Low-Pressure Alarms:
    • Disconnected tubing or accidental extubation.
    • Require prompt response to restore ventilation.
  • Apnea Alarms:
    • Indication of patient not breathing on CPAP or BiPAP; necessitates assessment and possible manual ventilation.

Prevention of Ventilator-Associated Complications

  • Use protocols to prevent infections (e.g., VAP bundle), monitor for tracheal injury, and maintain optimal cuff pressures.
  • Address psychosocial factors affecting ventilated patients, including stress and anxiety.

Extubation Considerations

Planned Extubation
  • Criteria:
    • Stabilized medical condition, normal ABG, ability to manage secretions, ideal RASS, and positive air leak test.
Unplanned Extubation
  • Assess the patient's stability, apply oxygen if necessary, and prepare for potential reintubation if unstable.

Weaning Process

Criteria for Weaning
  • Reversal of respiratory failure cause, ability to maintain certain pH levels and oxygen parameters, hemodynamic stability, and adequate spontaneous effort.
Monitoring During We