Interventions for Critically Ill Patients With Respiratory Problems Lecture

8/8/2019 Interventions for Critically Ill Patients With Respiratory Problems Lecture

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Interventions forInterventions forCritically Ill PatientsCritically Ill Patientswith Respiratorywith Respiratory

ProblemsProblems

Demuel Dee L. Berto, RN, MDDemuel Dee L. Berto, RN, MD


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Disorders of the PulmonaryDisorders of the Pulmonary

VasculatureVasculaturePulmonaryPulmonary

EmbolismEmbolism

an occlusion ofaan occlusion ofaportion of theportion of thepulmonary bloodpulmonary blood

vessels by anvessels by anembolusembolus


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Virchows triadVirchows triad::

1.1. Venous stasisVenous stasis

2.2. Hypercoagulable stateHypercoagulable state

3.3. Vessel injuryVessel injury

EtiologyEtiology::

Sites of thrombusSites of thrombus formation:formation:

1.1. Iliofemoral venous systemIliofemoral venous system most commonmost common2.2. Prostatic veinsProstatic veins

3.3. Pelvic veinsPelvic veins


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D/O of the Pulmonary Vasculature

Pulmonary Embolism

Precipitating factorsPrecipitating factors

::

1.1. ExerciseExercise

2.2. Straining on defecationStraining on defecation

Other sources of emboliOther sources of emboli::

1.1. TumorsTumors

2.2. Air Air

3.3. FatFat Fx of long bonesFx of long bones

4.4. Bone marrowBone marrow

5.5. IV catheterIV catheter

6. Amniotic fluid6. Amniotic fluid 8080--90%90%mortalitymortality

-- 1 per 20,001 per 20,00--30,00030,000deliveriesdeliveries

7. Septic emboli7. Septic emboli

8. Vegetations on heart8. Vegetations on heart

valvesvalves


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Pulmonary Embolism

Risk factorsRisk factors::

1.1. Previous surgery on the pelvis / legs.Previous surgery on the pelvis / legs.

2.2. Trauma of long bones.Trauma of long bones.

3.3. Immobility early ambulationImmobility early ambulationleg exercisesleg exercises

4.4. Obesity weight lossObesity weight loss

5.5. DVTDVTHomans sign dont massage calf areaHomans sign dont massage calf area

-- avoid restrictive clothing on legsavoid restrictive clothing on legs

-- prolonged standing / sittingprolonged standing / sitting


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Pulmonary Embolism

PathophysiologyPathophysiology

DVT Emboli singleor multiple

IVC RV Pulmonary artery

obstruction

o Resistance

to blood flowRelease of humoral

substancesV/Q Mismatch

Pulmonary

HPN Vasoconstriction

throughout lungs

Pulmonary

infarction

RV strain

RV failure

Lungs have 3 sources of O2: lungs, bronchial circulation, pulmonary circulationLungs have 3 sources of O2: lungs, bronchial circulation, pulmonary circulation


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Pulmonary Embolism

Clinical manifestations:Clinical manifestations:SymptomsSymptoms

1.1. Dyspnea at restDyspnea at rest

2.2. SyncopeSyncope w/w/ qq COCO

3.3. Pleuritic chest painPleuritic chest pain when pulmonarywhen pulmonaryinfarction occurs, stabbing, sharp duringinfarction occurs, stabbing, sharp during

inspirationinspiration4.4. CoughCough

5.5. HemoptysisHemoptysis pulmonary infarctionpulmonary infarction

6.6. Feeling of impending doomFeeling of impending doom


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SignsSigns

Tachypnea, tachycardiaTachypnea, tachycardia

CracklesCrackles Pleural friction rubPleural friction rub

DiaphoresisDiaphoresis

Low grade feverLow grade fever

Distended neck veinsDistended neck veins


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4. Perfusion scanning4. Perfusion scanning -- blood is labeledblood is labeledw/ radioactive tracerw/ radioactive tracer

5. Xenon ventilation scan5. Xenon ventilation scan patientpatient

inhales tracerinhales tracer

6. Pulmonary angiography6. Pulmonary angiography goldgold

standard , definitive and specificstandard , definitive and specific


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7. Blood Coagulation Tests7. Blood Coagulation Tests

Prothrombin TimeProthrombin Time Evaluates the effectiveness of coumadin (Vit. K)Evaluates the effectiveness of coumadin (Vit. K)

1.5 to 2 times the normal or control1.5 to 2 times the normal or control

11 to 16 seconds11 to 16 seconds

Partial Thromboplastin TimePartial Thromboplastin Time Best single screening test for disorders ofBest single screening test for disorders of

coagulationcoagulation

Evaluates the effectiveness of Heparin (ProtamineEvaluates the effectiveness of Heparin (Protamine

Sulfate)Sulfate) Normal range is 60Normal range is 60 70 secs70 secs


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Collaborative ManagementCollaborative Management

Problem: HypoxemiaProblem: Hypoxemia

O2 TherapyO2 Therapy

Nasal canula or mask, ABGs and PulseNasal canula or mask, ABGs and PulseOximetryOximetry

MonitoringMonitoring

V/S, Lung sounds, increasing DOB, NVE,V/S, Lung sounds, increasing DOB, NVE,dysrhythmias, pedal edemadysrhythmias, pedal edema


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Surgical ManagementSurgical Management

EmbolectomyEmbolectomy removal of the embolus orremoval of the embolus oremboli from the pulmonary arteriesemboli from the pulmonary arteries

Inferior VenaCaval InterruptionInferior VenaCaval Interruption vena cavalvena cavalfilterfilter


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Problem: Decreased Cardiac OutputProblem: Decreased Cardiac Output

IV FluidsIV Fluids crystalloidscrystalloids

Watch out for RSHFWatch out for RSHF DrugsDrugs

Positive inotropes (Dobutamine)Positive inotropes (Dobutamine)

Vasodilators (Nitroprusside)Vasodilators (Nitroprusside) MorphineMorphine for painfor pain


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Acute Respiratory FailureAcute Respiratory Failure

CriteriaCriteria

PaO2 < 60mmHgPaO2 < 60mmHg

SaO2 < 90%

SaO2 < 90%

PaCo2 > 50mmHgPaCo2 > 50mmHg

Acidemia ( pH


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ClassificationClassificationVentilatory FailureVentilatory Failure

Perfusion is normal but ventilation isPerfusion is normal but ventilation isinadequateinadequate

Occurs when the thoracic pressure cannot beOccurs when the thoracic pressure cannot bechanged sufficiently to permitappropriate airchanged sufficiently to permitappropriate airmovement into and out of the lungsmovement into and out of the lungs

CausesCauses

Mechanical abnormality in the lung or chest wallMechanical abnormality in the lung or chest wall Problem in the respiratory center in the brainProblem in the respiratory center in the brain

Impaired respiratory musclesImpaired respiratory muscles


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OxygenationFailureOxygenationFailure

Lungs are able to move air sufficiently butLungs are able to move air sufficiently butcannot oxygenate the pulmonary bloodcannot oxygenate the pulmonary bloodproperlyproperly

Ventilation is normal but perfusion isVentilation is normal but perfusion isdecreaseddecreased


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Combined Ventilatory and OxygenationCombined Ventilatory and OxygenationFailureFailure

Involves insufficient respiratory movementsInvolves insufficient respiratory movements

( hypoventilation)( hypoventilation)

Gas exchange at the alveolar capillaryGas exchange at the alveolar capillarymembrane is inadequate so that too littlemembrane is inadequate so that too little

oxygen reaches the blood and CO2 is retainedoxygen reaches the blood and CO2 is retained


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CausesCausesVentilatory FailureVentilatory Failure

MS, MG, GBS, Polio, stroke, SCI, increasedMS, MG, GBS, Polio, stroke, SCI, increasedICP, kyphosis, sleep apnea, PEICP, kyphosis, sleep apnea, PE

OxygenationFailureOxygenationFailure Right to left shuntingRight to left shunting

Impaired diffusion of oxygenat the alveolarImpaired diffusion of oxygenat the alveolarlevelslevels

Abnormal hemoglobin levelsAbnormal hemoglobin levels

CombinationCombination

BA, Bronchitis, emphysema,BA, Bronchitis, emphysema,


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Adult RespiratoryAdult RespiratoryDistress SyndromeDistress Syndrome

(ARDS)(ARDS) Progressive form ofProgressive form of

respiratory failurerespiratory failure

characterized bycharacterized by severe dyspneasevere dyspnea

refractory hypoxemiarefractory hypoxemia

diffuse bilateral infiltratesdiffuse bilateral infiltrates NonNon--cardiogenic bilateralcardiogenic bilateral

pulmonary edemapulmonary edema

-- Decrease pul. complianceDecrease pul. compliance


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Etiologies and RiskEtiologies and Risk

factors:factors:1.1. AspirationAspiration

2.2. Drug ingestionandDrug ingestionand

overdoseoverdose3.3. HematologicHematologic

disorderdisorder

4.4. oxygen toxicityoxygen toxicity5.5. localized infectionlocalized infection

5.5. metabolicmetabolicdisordersdisorders

6.6. shockshock7.7. traumatrauma

8.8. major surgerymajor surgery

9.9. fat/air embolismfat/air embolism10.10. sepsissepsis


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Manifestations:Manifestations:

This stage involves dyspnea, esp onThis stage involves dyspnea, esp on

exertionexertion Respiratory and heart rates are normal toRespiratory and heart rates are normal to

highhigh

Auscultation may reveal diminished breath

Auscultation may reveal diminished breathsoundssounds

Management: O2 supportManagement: O2 support


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Tachypnea with use ofaccessoryTachypnea with use ofaccessorymusclemuscle

Restless and apprehensiveRestless and apprehensiveDry or frothy sputum, cracklesDry or frothy sputum, crackles

Elevated heart rateElevated heart rate

Cool and clammy skinCool and clammy skin

Treatment: ET intubation, MV andTreatment: ET intubation, MV andprevent complicationsprevent complications


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Goals of Med Mgt.:Goals of Med Mgt.:

1.1. Respiratory SupportRespiratory Support

Hook to mechanical ventilatorHook to mechanical ventilator Administer nitric oxide which dilates theAdminister nitric oxide which dilates the

capillary bed of the lungscapillary bed of the lungs

High concentrations of supplemental O2High concentrations of supplemental O2

Surfactant replacementSurfactant replacement Prone positioningProne positioning

2.2. Maintenance of hemodynamic stabilityMaintenance of hemodynamic stability

Administer diuretics

Administer diuretics Fluid restrictionFluid restriction if fluids are to be given,if fluids are to be given,

give crystalloidsgive crystalloids

Administer inotropic drugsAdminister inotropic drugs


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Artificial AirwayArtificial Airway

Endotracheal TubeEndotracheal Tube An endotracheal tube is a long,An endotracheal tube is a long,

slender, hollow tube, inserted intoslender, hollow tube, inserted into

the trachea via the mouth or nose. Itthe trachea via the mouth or nose. Itpasses through the vocal cords, andpasses through the vocal cords, andthe distal tip is positioned justabovethe distal tip is positioned justabove

the carinathe carina


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Major Indications for IntubationMajor Indications for Intubation

Airway protection when the client losesAirway protection when the client losesreflexes because ofanesthesia,reflexes because ofanesthesia,

medications, disease, or decreased LOCmedications, disease, or decreased LOC

To provide posiive pressure or highTo provide posiive pressure or highoxygen concentrationoxygen concentration

To bypass airway obstructionTo bypass airway obstruction Facilitating pulmonary hygieneFacilitating pulmonary hygiene


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Tube insertionTube insertion

Secure the tube firmly with tapeSecure the tube firmly with tape

A chestXA chestX--ray may be ordered toray may be ordered toconfirm tube placementconfirm tube placement


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ContinuationContinuation2.2. Monitoring the cuffMonitoring the cuff

Check pilot balloonand keep it inflated.Check pilot balloonand keep it inflated.

Maintain cuff pressure at minimum.Maintain cuff pressure at minimum.(Keep it below 20 mmHg)(Keep it below 20 mmHg)

Assess patients ability to talk.Assess patients ability to talk.

Auscultate for a slight hissing sound atAuscultate for a slight hissing sound atthe peak of inspirationthe peak of inspiration

Inspect for presence of food particlesInspect for presence of food particleswhen suctioningwhen suctioning


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3.3. SuctioningSuctioning

Assess for airway obstruction e.g.Assess for airway obstruction e.g.restlessness, increased pulse andrestlessness, increased pulse andrespiration, presence ofadventitiousrespiration, presence ofadventitious

breath sounds, visible mucus bubbling inbreath sounds, visible mucus bubbling inthe airway, cyanosisthe airway, cyanosis

Hyperoxygenate client by increasingHyperoxygenate client by increasing

flow rate; encourage deep breathingflow rate; encourage deep breathing Lubricate the suction catheter withLubricate the suction catheter with

sterile watersterile water


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ContinuationContinuation

If tracheal suction is being used, insertIf tracheal suction is being used, insert

catheter to the end of the tubecatheter to the end of the tube(approximately 4 inches);(approximately 4 inches);

Ifnasotracheal suction is being used, insertIfnasotracheal suction is being used, insertuntil the cough reflex is induceduntil the cough reflex is induced

APPLY NOSUCTION WHILE THEAPPLY NOSUCTION WHILE THECATHETER IS BEING INSERTEDCATHETER IS BEING INSERTED

Rotate and withdraw the catheter whileRotate and withdraw the catheter whilesuction is applied; DO NOT EXCEED 10suction is applied; DO NOT EXCEED 10--1515SECONDSSECONDS

Clear the catheter with sterile solutionandClear the catheter with sterile solutionand

encourage the client to breathe deeplyencourage the client to breathe deeply


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Give oxygen for a few breaths, thenGive oxygen for a few breaths, theninsertanew, sterile suction catheterinsertanew, sterile suction catheterinside the tubeinside the tube

Have the patient inhale. At peak ofHave the patient inhale. At peak ofinspiration remove the tubeinspiration remove the tube

Place on supplemental O2 therapyPlace on supplemental O2 therapy


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NOTE: Extubation is performed withNOTE: Extubation is performed with

physician

s ordersan

d carried outphysici

ans orders

and c

arried outby health team members capableby health team members capable

of reinserting the ET tube ifof reinserting the ET tube ifnecessary!necessary!


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Monitoring after extubation is essentialMonitoring after extubation is essential

Monitor VS every hour initially. WOF signsMonitor VS every hour initially. WOF signsof Respiratory distressof Respiratory distress

Early signs include: mild dyspnea, coughingEarly signs include: mild dyspnea, coughing

and inability to expectorate secretions,and inability to expectorate secretions,STRIDOR.STRIDOR.

Sore throatand hoarseness for a fewSore throatand hoarseness for a fewdays after extubationdays after extubation

Semi fowlers, deep breathing andSemi fowlers, deep breathing andincentive spirometryincentive spirometry


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Artificial AirwayArtificial Airway

TracheostomyTracheostomy

Definition:Definition:

TracheotomyTracheotomy

A surgical incisionA surgical incisioninto the tracheainto the tracheathrough overlyingthrough overlying

skinand muscles forskinand muscles forairway management.airway management.


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DefinitionDefinition

TracheostomyTracheostomy A surgical creation ofA surgical creation ofan opening or stoma,an opening or stoma,into the tracheainto the trachea

through which anthrough which anindwelling tube isindwelling tube isinsertedinserted

Best route for longBest route for long--term airwayterm airwaymaintenancemaintenance


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Indication for tracheostomy:Indication for tracheostomy:

Relief ofacute or chronic upper airwayRelief ofacute or chronic upper airwayobstructionobstruction

Access for continuous mechanicalAccess for continuous mechanical

ventilationventilation Prevention ofaspirationPrevention ofaspiration

Promotion of pulmonary hygienePromotion of pulmonary hygiene

Bilateral vocal cord paralysisBilateral vocal cord paralysis Prolonged endotracheal tube insertionProlonged endotracheal tube insertion

resulting in erosion or painresulting in erosion or pain


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Potential ComplicationsPotential Complications::

Tracheal wall necrosisTracheal wall necrosis

Tracheal dilationTracheal dilation

Tracheal stenosisTracheal stenosis

Airway obstructionAirway obstruction

InfectionInfection

Accidental decannulation

Accidental decannulation

SubcutaneousSubcutaneousemphysemaemphysema


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Nursing Responsibilities:Nursing Responsibilities:

1.1. Assess for adequate gas exchangeAssess for adequate gas exchange

2.2. Monitor patency ofairwayMonitor patency ofairway

3.3. Monitor cuff of tubeMonitor cuff of tube4.4. Provide tracheostomy careProvide tracheostomy care

5.5. Perform suctioningPerform suctioning

6.6. Provide adequate hydrationProvide adequate hydration


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7.7. Secure tubeSecure tube

properlyproperly

8.8. Prevent orPrevent or

assess for infectionassess for infection

9.9. Prevent aspirationPrevent aspiration

10.10. Avoid constipationAvoid constipation

11.11. Provide alternative means ofProvide alternative means ofcommunicationcommunication


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Mechanical Ventilation

Mechanical ventilation is use of a

mechanical device to instill amixture of air and oxygen into the

lungs


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Indications:

Low PaO2 levels Individuals incapable of

spontaneous breathing

Individuals with inadequate

ventilation

Individuals with difficulty of

expelling CO2

Individuals with persistently high

blood pH


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Goals of mechanical ventilation:

Maintain adequate ventilation

Deliver precise concentrations of

FiO2 Deliver adequate tidal volumes to

obtain an adequate oxygenation

Lessen the work of breathing inclients who can not sustain

adequate ventilation on their own.

Modes of Mechanical Ventilation


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Continuous Mechanical Ventilation(CMV)

Ventilators deliver preset volume of

air during inspiration (tidal volume) Takes full control of respiration

Does not allow spontaneous

breathing



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Assist / Control Ventilation (A/C)

Pt starts ventilation but ventilatorcompletes it

Ventilator delivers preset volume of airduring inspiration when client initiates it.

Respiratory rate is controlled by theclients ability to initiate breathing

Has a back up mechanism. If the client

does not initiate breathing or inspiratoryeffort is less than a preset number in aminute, the ventilator takes charge ofbreathing until the ability to initiate breath

returns



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Intermittent Mandatory Ventilation

(IMV)

Ventilator delivers preset tidal

volume and respiratory rate Allows spontaneous unassisted

breathing between the preset

breath

Commonly use in respiratory

weaning



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Positive End-Expiratory Pressure

(PEEP)

Preset amount of pressure stays in

the lungs at the end of exhalation

which keeps the alveoli open

Use in combination with CMV, A/C,

and IMV



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Continuous Positive Airway Pressure(CPAP)

Similar to PEEP. Preset amount of

pressure stays in the lungs at the endof exhalation which keeps the alveoli

open

Use in clients who can breathe on theirown

Nursing Management


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Nursing Management

Monitoring patients response

Monitor VS Auscultate BS every 30 to 60 minutes

initially

Observe secretions and suction promptly

Assess area around ET tube or

tracheostomy site q 4 hours for color,

tenderness , skin irritation and drainage

Psychological support

Continuation


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Observe for signs of respiratory

insufficiency, such as tachypnea,cyanosis, and changes in sensorium

Ascertain blood gases as ordered to

determine effectiveness of

ventilation

Establish a means of

communication because client will

be unable to speak while on aventilator

Evaluate clients response to

procedure; revise plan as necessary


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Managing the VentilatorSystem

Maintain ventilator settings TV, FiO2,mode of ventilation etc.

Check water temperature and

humidification

Interventions for various causes of

ventilator alarms

Suctioning

Presence of secretions Increased peak airway pressure

Presence of rhonchi and wheezes

Decreased breath sounds


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Preventing Complications

Cardiac hypotension and fluid retention Avoid valsalva, adequate humidification,

monitorI and O, weight hydration and signs of

hypovolemia

Lungs barotrauma (due to positivepressure) and volutrauma (due to excess

volume delivered to one lung over the

other) and AB abnormalities

Adjust ventilator settings as ordered, monitorresponse of patient to MV, adjust fluids and

correct electrolyte imbalances


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GI and Nutritional Complications

stress ulcers antacids, PPIs , H2 receptorblockers, TPN,

Low Carbohydrate and High fat diet

especially for COPD patients

Electrolyte replacement K, Ca, Mg, phos

Infection

Strict handwashing

Oral care and pulmonary hygiene

Chest physiotherapy and postural drainage Muscular Complications

Due to immobility

Passive ROM while on ventilation


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Ventilator Dependence

Can be psychological or physiologic The longer on ventilator the move difficult it

is to wean because the respiratory muscle

fatigue and cannot assume breathing

Techniques

Synchronus Intermittent Mandatory Ventilation

T Piece Technique

Pressure Support Ventilation


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CHEST TRAUMACHEST TRAUMA

PneumothoraxPneumothorax life threatening situation whereinairlife threatening situation whereinair

enters the pleural cavity causing a lung toenters the pleural cavity causing a lung tocollapse partially or completely on thecollapse partially or completely on theaffected side, resulting ina reduction inaffected side, resulting ina reduction intidal volume and gastidal volume and gas

Types:Types:


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Types:Types:

1.1. SpontaneousSpontaneous

most common type of closedmost common type of closedpneumothoraxpneumothorax

Air accumulates within the pleural spaceAir accumulates within the pleural space

withoutan obvious cause.withoutan obvious cause. Rupture ofa small bleb on the visceralRupture ofa small bleb on the visceral

pleura most frequently produces this typepleura most frequently produces this type

of pneumothoraxof pneumothorax


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2.2. TraumaticTraumatic

Open Pneumothorax: Laceration in theOpen Pneumothorax: Laceration in theparietal pleura thatallows atmosphericparietal pleura thatallows atmosphericair to enter inside.air to enter inside.

Closed PneumothoraxClosed Pneumothorax-- Laceration inLaceration inthe visceral thatallows air in the lungthe visceral thatallows air in the lungto enter the pleural space.to enter the pleural space.


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AssessmentFindingsAssessmentFindings

Diminished breath sounds onauscultationDiminished breath sounds onauscultation

Hyperresonance on percussionHyperresonance on percussion

Prominence of the involved side of theProminence of the involved side of thechest, which moves poorly withchest, which moves poorly withrespirationsrespirations

Deviation of the tracheaaway fromDeviation of the tracheaaway from(closed) or toward (open) the affected(closed) or toward (open) the affectedsideside


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Pleuritic chest painPleuritic chest pain

TachypneaTachypnea

Subcutaneous emphysema

Subcutaneous emphysema


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3.3. TensionTension--

Air enters the pleuralAir enters the pleuralspace with eachspace with eachinspiration but cannotinspiration but cannotescapeescape

Causes increasedCauses increasedintrathoracic pressureintrathoracic pressureand shifting of theand shifting of themediastinal contentsmediastinal contentsto the unaffected sideto the unaffected side(mediastinal shift)(mediastinal shift)


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AssessmentAssessment

Asymmetry of the thoraxAsymmetry of the thorax

Tracheal deviation to the unaffected sideTracheal deviation to the unaffected side

Respiratory distressRespiratory distress

Absence of breath sounds on one sideAbsence of breath sounds on one side

Distended neck veinsDistended neck veins

CyanosisCyanosis

Hypertympanic sound on percussion overHypertympanic sound on percussion overthe effected sidethe effected side


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Etiology/ Classification:Etiology/ Classification:

1.1. PenetratingPenetrating common cause of opencommon cause of openpneumothoraxpneumothorax

2.2. Blunt chest traumaBlunt chest trauma-- common cause ofcommon cause of

close pneumothoraxclose pneumothorax3.3. Rupture ofalveoliRupture ofalveoli

4.4. Medical procedureMedical procedure


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Lab. And Dx. Test:Lab. And Dx. Test:

Chest xChest x--rayray

Med. Mgt.Med. Mgt.

Closed Chest DrainageClosed Chest Drainage

Insertion of large bore needle at the 2Insertion of large bore needle at the 2ndnd

ICS MCL of the affected sideICS MCL of the affected side

Chest Tube


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Use of tubes and suction to return

negative pressure to the intrapleuralspace and to drain air from theintrapleural space,

To maintain negative pressure, the chest

tube is placed in the second or thirdintercostal space

To drain blood or fluid, the catheter

would be placed at a lower site, usuallythe eighth or ninth intercostal space

Also called closed thoracotomy tube(CTT), chest tube drainage


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Types of drainage:

One-chambersystem

one bottle serves

both as a waterseal and drainage

bottle

Types of drainage:


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Two-chamber

system

1st bottle isfor drainage

2nd bottle is a

water seal

Types of drainage:


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Three-chamber system

1st bottle is for drainage

2nd bottle is a water seal

3rd bottle is for suction


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Types of drainage:


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Commerciallyprepared plastic

unit

e.g. Pleur-Evac

Combines the

features of the

other systems

and may or maynot be attached

to suction

Nursing Responsibilities:


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Collection chamber

Monitor drainage, report if greater than100ml per hour or if bright red or

increases suddenly

Mark chest tube drainage at 1-4 hour

intervals using a tape

Water seal

Monitor for fluctuation of the fluid level

in the water seal chamber Fluctuation stops in obstruction,

looping, suction not working properly or

if the lung has re-expanded


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In pneumothorax patients intermittent

bubbling in the water seal chamber isexpected but continuous bubbling

indicates an air leak in the system

Assess respiratory status and lung

sounds

Keep drainage below the level of the

chest and the tubes free of kinks or

obstructions


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Encourage coughing and deep

breathing Do not strip or milk a chest tube

unless directed by a physician

Keep a clamp and sterile occlusivedressing at bedside at all times

Never clamp a chest tube without

written orders from the physician


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If the drainage system cracks or

breaks, insert the chest tube into abottle of sterile water, remove the

cracked or broken system and

replace it

If the chest tube is pulled out

accidentally pinch the skin opening

together, apply an occlusive sterile

dressing, cover the dressing withoverlapping pieces of tape and call

the physician


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When the chest tube is removed , the

client is asked to take a deep breathand hold it and the tube is removed; a

dry sterile dressing, petroleum gauze

dressing is taped in place

During removal of tube, deep breath ,

exhale and bear down


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Pulmonary ContusionPulmonary Contusion

Frequently follows injuries caused by rapidFrequently follows injuries caused by rapiddeceleration during vehicular accidentsdeceleration during vehicular accidents

Most common manifestation of blunt chestMost common manifestation of blunt chesttraumatrauma

Interstitial hemorrhage accompaniesInterstitial hemorrhage accompaniespulmonary contusion which results inpulmonary contusion which results in

pulmonary edema that would lead topulmonary edema that would lead todecreased lung compliance and gasdecreased lung compliance and gasexchangeexchange


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HemoptysisHemoptysis

Decreased breath soundsDecreased breath sounds

Crackles

Crackles

WheezesWheezes

Hazy opacity in the lobes or parenchymaHazy opacity in the lobes or parenchyma

I iI i


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InterventionsInterventions

Monitor CVPMonitor CVP

Monitor I and OMonitor I and O

Mechanical ventilation with PEEP ( inflateMechanical ventilation with PEEP ( inflatethe lungs)the lungs)

WOFARDSWOFARDS

Rib F tRib F t


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Rib FractureRib Fracture

Result from direct blunt trauma to theResult from direct blunt trauma to thechest usually with involvement of the fifthchest usually with involvement of the fifththrough ninth ribsthrough ninth ribs

Fractured ribs can drive the bone endsFractured ribs can drive the bone endsinto the thorax leading to pneumothoraxinto the thorax leading to pneumothorax


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T t tT t t


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TreatmentTreatment

For uncomplicated rib fractures no specificFor uncomplicated rib fractures no specifictreatment because the fractured ribs unitetreatment because the fractured ribs unitespontaneouslyspontaneously

No splinting should be doneNo splinting should be done Pain medsPain meds most important so thatmost important so thatadequate ventilation is maintainedadequate ventilation is maintained

Intercostal nerve bloack for severe painIntercostal nerve bloack for severe pain Avoid analgesics that depress theAvoid analgesics that depress the

respiratory system ( morphine)respiratory system ( morphine)

Fl il Ch tFl il Ch t


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Flail ChestFlail Chest

Paradoxical respirationParadoxical respiration

Inward movement of the thorax duringInward movement of the thorax duringinspiration, with outward movementinspiration, with outward movement

during expirationduring expiration

Usually involves one hemithorax andUsually involves one hemithorax andresults from multiple ribs fracturesresults from multiple ribs fractures

Occurs during high speed vehicularOccurs during high speed vehicularaccidents and CPRaccidents and CPR

A tA t


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Paradoxic chest movementParadoxic chest movement

DyspneaDyspnea

CyanosisCyanosis

TachycardiaTachycardia

HypotensionHypotension

PainPain

I t tiI t ti


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Humidified O2Humidified O2

AnalgesicsAnalgesics

Deep breathingDeep breathing

PositioningPositioning Secretion clearance by coughing and trachealSecretion clearance by coughing and trachealaspirationaspiration

MV for respiratory failureMV for respiratory failure

Positive pressure ventilationPositive pressure ventilation SurgerySurgery


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Monitor VSMonitor VS

Fluid and electrolytesFluid and electrolytes

Monitor I and Oand s/sx of shockMonitor I and Oand s/sx of shock

Psychological supportPsychological support

H thH th


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HemothoraxHemothorax

SimpleSimple blood loss of less than 1500 mlblood loss of less than 1500 mlinto the thoracic cavityinto the thoracic cavity

MassiveMassive more than 1500 mlmore than 1500 ml

Due to traumaDue to trauma



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If smallIf small asymptomaticasymptomatic

If largeIf large respiratory distressrespiratory distress

Decreased breath soundsDecreased breath sounds

Dull upon percussionDull upon percussion

CXRCXR

ThoracentesisThoracentesis


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Insertion if chest tubesInsertion if chest tubes

If initial drainage is 1500ml to 200ml ofIf initial drainage is 1500ml to 200ml ofbloo then open thoracotomy or persistentbloo then open thoracotomy or persistent

bleeding at the rate of 200ml/hr over 3bleeding at the rate of 200ml/hr over 3hourshours

Monitor VS, blood loss, I and OMonitor VS, blood loss, I and O

Monitor chest tubes and drainageMonitor chest tubes and drainage

IVF , blood transfusion (autotranfusion)IVF , blood transfusion (autotranfusion)


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THE ENDTHE END

Documents

Interventions for Critically Ill Patients With Respiratory Problems Lecture