Respiratory Care

Training Package for Nurses Version 1.1. March 2020.

#RisingToTheChallenge

Contents

1. Summary of training package

2. Competency document

3. Supportive materials: training cards

4. Oxygen titration tool

5. Staff information leaflet

Summary

As the COVID-19 situation develops we anticipate a large increase in patients requiring

respiratory care in our ward areas. Traditionally many of these patients would be cared for in a

respiratory ward area, however during the COVID-19 epidemic it is unlikely the traditional units

will be able to meet the demand.

This training package has been designed to re-familiarise and refresh our nursing teams

knowledge around caring for patient with respiratory conditions outside of the usual specialist

respiratory ward areas.

The ‘Respiratory Care Training Package for Nurses’ is intended to provide an agile training

platform suitable for bedside teaching, small groups and act as a resource that can be referred

to. The programme has been a collaborative effort involving the Acute Care Team, Education

Teams from Manchester Royal Infirmary and Wythenshawe Hospital, Corporate Nursing

Teams and Physiotherapy.

2. Competency document

1. Anatomy and Physiology

I can demonstrate through discussion:

Structure of respiratory system

Mechanism of breathing

Respiratory Failure

Type I respiratory failure

Type II respiratory failure

Signs and symptoms of respiratory failure

Effects of poor ventilation and oxygenation on other systems:

Cardiac

Renal

Gastrointestinal

Cerebral

Skin

2. Assessment and investigations

I can demonstrate through discussion:

Normal parameters for respiratory observations – need to observe for one full

minute. Look at rate, rhythm, depth, symmetry, accessory muscle use

Trends in observation charts

Respiratory Assessment

Look

Listen

Feel

Skin colour:

Peripheral cyanosis

Central cyanosis

Respiratory Competencies for Ward Based Staff

Cough Strength

Effective and ineffective

Ability to expectorate vs retention

Sputum assessment

Prescribed target oxygen ranges

Indications and methods for Oxygen therapy and titration

3. Management

I can demonstrate through discussion:

Oxygen therapy:

Non-rebreathe mask

Venturi

Humidified

Nasal cannula

Treatment

Nebulisation technique

Inhaler technique

Patient positioning:

Maximising ventilation

Postural draining positioning

Deep breathing exercises/ testing procedures:

Incentive spirometry

Secretion clearance/ oral suctioning

Provision of emotional reassurance and support for patient

Escalation for higher level of respiratory support

Recognition of level of care requirements

Escalation procedures

Self-assessment

Staff name/grade/ward area

Assessor sign and date

Please return to Yvon Poland to populate training database,

email. yvon.poland@mft.nhs.uk

3. Supportive material: training

cards

4. Oxygen titration tool

Oxygen titration

Venturi 24% 2-4l/min

Nasal cannula 4 l/min Venturi 35% 8-10 l/min

Venturi 28% 4-6 l/min Nasal cannula 2-3

l/min

Nasal cannula 1 l/min

Venturi 40% 10-12 l/min or simple face mask 5-6 l/min

Venturi 60% 12-15 l/min or simple face mask 7-10 l/min

Reservoir mask at 15 l/min oxygen flow

If Reservoir mask is required or ≥60%, seek senior medical input immediately

Patients in peri-arrest situation and critically ill patients should receive maximum oxygen via a reservoir mask or bag valve mask while help is being

summoned.

If patient requires

increasing oxygen

delivery or shows signs of

respiratory deterioration, seek medical

advice

5. Staff information sheet

Look

Count the respiration rate for one full minute

What is the rhythm of the breathing – is it irregular?

What is the depth of the breathing – is it shallow?

Is the chest moving equally/symmetrically?

Is the patient mouth breathing, pursing the lips on

expiration, using the abdominal muscles or flaring

the nostrils?

Are there any signs of bluish colouration in the skin,

fingertips or lips (cyanosis)?

Is there new confusion or agitation?

What are the oxygen saturations – are they within

the prescribed oxygen saturation requirements?

Check the position of the trachea: deviation to one

side indicates mediastinal shift (e.g. pneumothorax,

lung fibrosis or pleural fluid) – this an emergency

situation if new deviation

Listen Listen to the patient’s breath sounds a short

distance from his face: rattling airway noises

indicate the presence of airway secretions, usually

caused by the inability of the patient to cough

sufficiently or to take a deep breath. Stridor or

wheeze suggests partial, but significant, airway

obstruction

Feel Auscultate the chest if trained to: bronchial

breathing indicates lung consolidation with patent

airways; absent or reduced sounds suggest a

pneumothorax or pleural fluid or lung consolidation

caused by complete obstruction

Feel the chest for symmetry of movement

Information for Respiratory Assessment and Management of Respiratory Failure

Respiratory Assessment

A respiratory assessment is an external assessment of ventilation that includes observations of the rate, depth and pattern of respirations.

Steps of a respiratory assessment

Type 1 respiratory failure

(Hypoxemic respiratory failure)

Type 2 respiratory failure

(Hypercapnic respiratory failure)

Hypoxemic respiratory failure means

that you don’t have enough oxygen in

your blood, but your levels of carbon

dioxide are close to normal

A common cause of hypoxemic

respiratory failure is an abnormality of

the lung tissue, such as acute

respiratory distress syndrome, severe

pneumonia, excess fluid in the lungs

(for example, caused by heart failure or

kidney failure). Such abnormalities

disrupt the usual ability of the lung

tissues to take in oxygen from the air

Hypercapnic respiratory failure means that

there’s too much carbon dioxide in your

blood, and near normal or not enough

oxygen in your blood

With hypercapnic respiratory failure, the

level of carbon dioxide is usually too high

because something prevents the person

from breathing normally. Blockage or

narrowing of the airways, weakness of

muscles that normally inflate the lungs,

and an overdose of opioids or alcohol all

decrease the unconscious reflex that drives

people to breathe. Blockage or narrowing

of the airways can result from disorders

(such as asthma and chronic obstructive

pulmonary disease) as well as inhaled

foreign objects

Respiratory failure

Respiratory failure is a condition in which your blood doesn't have enough oxygen or has too much carbon dioxide.

In COVID-19 we are tending to see patients with acute Type 1 respiratory failure

Signs of respiratory failure

• Cyanosis – bluish colouration in the skin, fingertips or lips • Shortness of breath - rapid and shallow breathing • Use of accessory muscles/abdominal breathing • Added breathing sounds – e.g. wheezing, stridor, grunting • Restlessness/anxiety • New confusion/agitation • Reduced oxygen saturations • Tachycardia/ arrhythmias

If your patient is showing signs of respiratory failure, apply 15 litres of oxygen

via a non-rebreathe mask and escalate to the medical team immediately. If your

patient is losing consciousness or goes in to a peri-arrest state ring 2222

immediately and commence BLS as required

Treatment of respiratory failure

To manage respiratory failure we need to look at three steps

Oxygen delivery Treat cause Mechanical ventilation

Oxygen delivery Patients with Type 1 respiratory failure require oxygen immediately. Cardiac arrest can occur with a lack of sufficient oxygenation in as little as 4 minutes, so immediate application of oxygen is required. In the acute phase of respiratory failure you should apply 15 litres of oxygen via a non-rebreathe mask until the patient has received a medical review.

Types of oxygen delivery systems

Non-rebreathe mask Advantages: With a good fit, the mask can deliver between 60% and 80% FiO2 (fraction of inspired oxygen). The flow meter should be set to deliver O2 at 10 to 15 L/min. Flow rate must be high enough to ensure that the reservoir bag remains partially inflated during inspiration. Disadvantages: These masks have a risk of suffocation if the gas flow is interrupted. The bag should never totally deflate. The patient should never be left alone and should be monitored continuously. The mask also requires a tight seal and may be hot and confining for the patient.

Humidified oxygen Advantages: Able to provide humidification prevent the oxygen therapy from drying out the mucous membranes and reduces secretions becoming tenacious. Can provide 28-60% O2 at 4-10 L/min. Disadvantages: Can feel cold against the face and can be noisy

Venturi masks Advantages: The system can provide 24% to 60% O2 at 4 to 12 L/min. delivers a more precise level of oxygen by controlling the specific amounts of oxygen delivered. The port on the corrugated tubing (base of the mask) sets the oxygen concentration. Disadvantages: The mask may be hot and confining for some patients, and it interferes with talking and eating. Need a properly fitting mask.

Nasal cannula - It is used for short- or long-term therapy and is best used with stable patients who require low amounts of oxygen. Advantages: Can provide 24% to 36% O2 (1 to 4 litres per minute).It is convenient as patient can talk and eat while receiving oxygen. Limitations: Easily dislodged, not as effective is a patient is a mouth breather or has blocked nostrils.

If your patient requires oxygen to maintain saturations – the patient is not stable

and should have their observations taken by a qualified staff member. Oxygen is a

drug and should be prescribed and signed for on medication rounds.

If you commence oxygen therapy or are having to increase the flow of oxygen to

maintain saturations, you must escalate to the medical team immediately.

Treat cause

The treatment of the cause of the respiratory failure will be set out by the medical

team. This may include the COVID-19 treatment, or other drugs such as antibiotics

or steroids depending on the diagnosis

Patients will require other tests such as chest x-ray, sputum samples and peak flow.

Any treatments that are aerosol producing such as suction, physio and

nebulisation, you must wear PPE equipment as per trust policy.

Mechanical Ventilation

A number of patients will have respiratory failure that is so severe that they will require help with their breathing. Invasive mechanical ventilation may be required and the patient will be taken to an intensive care setting for this. Some patients may not need invasive ventilation bit may require non-invasive ventilation, such as CPAP (continuous positive airway pressure), which may be given in some ward areas. Further training will be given to ward staff if required.

Escalation

Continue to escalate your patients according to the Early Warning Score Policy

Make sure you familiarise yourself with specific hospital escalation for COVID-

19 positive patients