Respiratory Modalities

Copyright 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
Chapter 25

Respiratory Care Modalities

Oxygen Therapy
Administration of oxygen at greater than 21% (the
concentration of oxygen in room air) to provide adequate
transport of oxygen in the blood, to decrease the work of
breathing, and to reduce stress on the myocardium.
Assess for signs and symptoms of hypoxia, arterial blood
gas results, and pulse oximetry.
Oxygen administration systems

Venturi Mask, Nonrebreathing Mask,
Partial Rebreathing Mask
Venturi Mask
Nonrebreathing
Mask
Partial
Rebreathing Mask
T-Piece and Tracheostomy Collar
Question
Is the following statement True or False?

The primary oxygen administration method for a patient
with COPD is a nasal cannula.
Answer
False

The primary oxygen administration method for a patient
with COPD is a Venturi mask, not a nasal cannula.
Venturi mask provides the most accurate method of
oxygen delivery.
The Venturi mask is used primarily for patients with COPD
because it can accurately provide an appropriate level of
supplemental oxygen, thus avoiding the risk of
suppressing the hypoxic drive. This type of mask is
constructed in a way that allows a constant flow of room
air blended with a fixed flow of oxygen.
Complications of Oxygen Therapy
Oxygen toxicity
Reduction of respiratory drive in patients with chronic low
oxygen tension
Fire
Oxygen Toxicity
Oxygen concentrations of greater than 50% for extended
periods of time (longer than 48 hours) can cause an
overproduction of free radicals which can severely
damage cells.
Symptoms include substernal discomfort, paresthesias,
dyspnea, restlessness, fatigue, malaise, progressive
respiratory difficulty, refractory hypoxemia, alveolar
atelectasis, and alveolar infiltrates on X-ray.
Prevention:
Use lowest effective concentrations of oxygen.
PEEP or CPAP prevent or reverse atelectasis and
allow lower oxygen percentages to be used.
Prevention of oxygen toxicity is achieved by using
oxygen only as prescribed. Often, positive end-expiratory
pressure (PEEP) or continuous positive airway pressure
(CPAP) is used with oxygen therapy to reverse or prevent
microatelectasis, thus allowing a lower percentage of
oxygen to be used. Oxygen is moistened by passing
through a humidification system. Changing the tubing on
the oxygen therapy equipment is the best technique for
controlling bacterial growth.
Question

A patient with hypoxemia will have an increase in the PaO2
level.
Answer
False

A patient with hypoxemia will have a decrease in the PaO2
level, not an increase in the PaO2 level.

Incentive Spirometer
Types: volume and flow
Device insures that a volume of air is inhaled and the
patient takes deep breathes.
Used to prevent or treat atelectasis.
Nursing care
Positioning of patient, teach and encourage use, set
realistic goals for the patient, and record the results.
Question

The patient should be encouraged to use an incentive
spirometer approximately ten breaths per hour between
treatments while awake.
Answer
True

The patient should be encouraged to use an incentive
spirometer approximately ten breaths per hour between
treatments while awake.

Intermittent Positive-Pressure Breathing
Indicated for patients who need to increase lung
expansion.
Rarely used.
Monitor for side effects, which may include
pneumothorax, increased intracranial pressure,
hemoptysis, gastric distention, psychological
dependency, hyperventilation, excessive oxygen
administration, and cardiovascular problems.
Mini-Nebulizer Therapy
A hand-held apparatus that disperses a moisturizing
agent or medication such as a bronchodilator into the
lungs. The device must make a visible mist.
Nursing care: instruct patient in use.
Patient is to breathe with slow, deep breathes
through mouth and hold a few seconds at the end of
inspiration.
Coughing exercises may be encouraged to mobilize
secretions after a treatment.
Assess patent before treatment and evaluate patient
response after treatment.

The nurse instructs the patient and family about the
purpose of the treatment, equipment setup, medication
additive, and proper cleaning and storage of the
equipment.
Chest Physiotherapy
Includes postural drainage, chest percussion and vibration, and
breathing retraining. Effective coughing is also an important
component.
Goals are removal of bronchial secretions, improved
ventilation, and increased efficiency of respiratory muscles.
Postural drainage uses specific positions to use gravity to assist
in the removal of secretions.
Vibration loosens thick secretions by percussion or vibration.
Breathing exercises and breathing retraining improve
ventilation and control of breathing and decrease the work of
breathing

Postural drainage
Postural drainage is usually performed two to four times
per day. The patient uses gravity to facilitate postural
draining, which may require the use of pillows.
Postural Drainage- Lower Lobes, Anterior
Basal Segment

Postural Drainage- Upper Lobes, Anterior
Segments

Postural Drainage- Lower Lobes, Lateral
basal segments

Postural Drainage- Upper Lobes, Apical
Segments

Postural Drainage- Lower Lobes, Superior
Segments

Postural Drainage- Upper Lobes, Posterior
Segments
Percussion and Vibration
High Frequency Chest Wall Oscillation
Vest
Refer to fig. 25-5
Patient Teaching: Home Oxygen-
Safety considerations
Flow rate and flow adjustment
Maintenance of equipment
Identification of malfunction
Humidification
Ordering of supplies and oxygen
Signs and symptoms to report
Diet and activity, travel
Electrical outlets
Endotracheal Intubation:
Placement of a tube to provide a patent airway for
mechanical ventilation and for removal of secretions
Purpose and complications related to the tube cuff
Assessment of cuff pressure Complications can occur
from pressure exerted by the cuff on the tracheal wall.
Cuff pressures should be maintained between 15 and 20
mm Hg.
Patient assessment
Risk for injury/airway compromise related to tube
removal
Patient and family teaching
Endotracheal Tube
disadvantages of an endotracheal tube.
suppression of the patient's cough reflex,
thickening of secretions, and
depressed swallowing reflexes.
Endotracheal intubation may be used for no longer than 3
weeks, by which time a tracheostomy must be
considered to decrease irritation of and trauma to the
tracheal lining, to reduce the incidence of vocal cord
paralysis (secondary to laryngeal nerve damage), and to
decrease the work of breathing.
It is usually necessary to suction the patient's secretions
because of the decreased effectiveness of the cough
mechanism. Tracheal suctioning is performed when
adventitious breath sounds are detected or whenever
secretions are present.
Assessment data indicate the need for suctioning and
allow the nurse to monitor the effect of suction on the
patient's level of oxygenation. Explaining the procedure
would be the second step; performing hand hygiene is
the third step, and turning on the suction source is the
fourth step.
Tracheostomy
Bypasses the upper airway to bypass an obstruction,
allow removal of secretions, permit long-term mechanical
ventilation, prevent aspirations of secretions, or to
replace an endotracheal tube.
Complications include bleeding, pneumothorax,
aspiration, subcutaneous or mediastinal emphysema,
laryngeal nerve damage, posterior tracheal wall
penetration.
Long-term complications include airway obstruction,
infection, rupture of the innominate artery, dysphagia,
fistula formation, tracheal dilatation, and tracheal
ischemia and necrosis.
Tracheostomy Tubes
A tracheostomy permits long-term use of mechanical
ventilation to prevent aspiration of oral and gastric
secretions in the unconscious or paralyzed patient.
Nursing Diagnoses: Patients with
Endotracheal Intubation or Tracheostomy
Communication
Anxiety
Knowledge deficit
Ineffective airway clearance
Potential for infection
Mechanical Ventilation
Positive or negative pressure breathing device to
maintain ventilation or oxygenation.
Indications

Negative-pressure
Iron lung, chest cuirass
Positive-pressure
Pressure-cycled
Timed-cycled
Volume-cycled

Ventilators
Refer to fig. 25-8
Noninvasive PositivePressure Ventilation
Use of mask or other device to maintain a seal and
permit ventilation.
Indications
Continuous Positive Airway Pressure (CPAP)
Bi-level Positive Airway Pressure (bi-PAP)
Ventilator Modes
Nursing Process: The Care of Patients who
are Mechanically Ventilated Infections-
Assessment
Assessment of the patient
Systematic assessment include all body systems
In-depth respiratory assessment including all
indicators of oxygenation status
Comfort
Coping, emotional needs
Communication
Assessment of the equipment

Nursing Process- The Care of Patients
who are Mechanically Ventilated
Infections- Diagnoses
Impaired gas exchange
Ineffective airway clearance
Risk for trauma
Impaired physical mobility
Impaired verbal communication
Defensive coping
Powerlessness
Collaborative Problems
Alterations in cardiac function
Barotrauma
Pulmonary infection
Sepsis
Nursing Process: The Care of Patients who
are Mechanically Ventilated Infections-
Planning
Goals include achievement of optimal gas exchange,
maintenance of patent airway, attainment of optimal
mobility, absence of trauma or infection, adjustment to
nonverbal methods communication, acquisition of
successful coping measures, and the absence of
complications.
Enhancing Gas Exchange
Monitor ABGs and other indicators of hypoxia. Note
trends.
Auscultate lung sounds frequently
Judicious use of analgesics
Monitor fluid balance
A complex diagnosis that requires a collaborative
approach.
Promoting Effective Airway Clearance
Assess lung sounds at least every 2-4 hours.
Measures to clear airway: suctioning, CPT, position
changes, promote mobility
Humidification
Medications

Preventing Trauma and Infection
Infection control measures
Tube care
Cuff management
Oral care
Elevation of HOB
Other Interventions
ROM and mobility; get out of bed
Communication methods
Stress reduction techniques
Interventions to promote coping
Include in care: family teaching, and the emotional and
coping support of the family.
Home ventilator care
It is important to perform tracheostomy care at least
every 8 hours because of the risk of infection. The use of
antacids can contribute to nosocomial infections. The
patient should be encouraged to ambulate, if possible.
The cuff pressure should be monitored every 8 hours.
Weaning
Process of withdrawal of dependence upon the ventilator
Successful weaning is a collaborative process Stable vital
signs and arterial blood gases are important predictors of
successful weaning.
Before weaning a patient from mechanical ventilation, it
is most important to have baseline ABG levels. During
the weaning process, ABG levels will be checked to
assess how the patient is tolerating the procedure.
The process of withdrawing the patient from dependence
on the ventilator takes place in three stages: the patient
is gradually removed from the ventilator, then from the
tube, and, finally, oxygen.
Assess patient for weaning criteria: vital capacity should
be 10 to 15 mL/kg, maximum inspiratory pressure (MIP)
should be at least 20 cm H
2
O, tidal volume should be 7
to 9 mL/kg, minute ventilation should be 6 L per minute,
rapid/shallow breathing index should be below 100
breaths per minute per liter, and PaO
2
should be greater
than 60 mm Hg with FiO
2
less than 40%.
Patients Undergoing Thoracic Surgery
Preoperative assessment
Preoperative preparation
Patient teaching
Reduction of anxiety
Postoperative expectations
Strategies to reduce postoperative complications:
atelectasis and infection The nurse emphasizes the
importance of progressively increased activity. The nurse
also instructs the patient on the importance of
performing should exercise five times daily. The patient
should ambulate with limits and realize that the return of
strength will likely be gradual
The objectives of preoperative care for the patient
undergoing thoracic surgery are to ascertain the patient's
functional reserve, to determine whether the patient is
likely to survive and recover from the surgery, and to
ensure that the patient is in optimal condition for
surgery.
The recovery process may take longer than the patient
had expected, and providing support to the patient is an
important task for the home care nurse.
Chest Drainage
Used to treat spontaneous and traumatic pneumothorax
Used postoperatively to reexpand the lung and remove excess
air, fluid, and blood.
Types of drainage systems

Traditional water seal
Dry suction water seal
Dry suction
Management

Prevention of cardiopulmonary complications

Constant bubbling in the chamber indicates an air leak
and requires immediate intervention. The patient with a
pneumothorax will have intermittent bubbling in the
water-seal chamber. Patients without a pneumothorax
should have no evidence of bubbling in the chamber. If
the tube is obstructed, the nurse should notice that the
fluid has stopped fluctuating in the water-seal chamber.
Chest Tube Drainage System
Refer to fig. 25-10
Heimlich Valve
Patient Teaching and Home Care
Considerations
Breathing and coughing techniques
Positioning
Addressing pain and discomfort
Promoting mobility and arm and shoulder exercises
Diet
Prevention of infection
Signs and symptoms to report

Technique for Supporting Incision While a
Patient Coughs
Preoperative teaching for a patient who will undergo a
thoracotomy includes the use of incentive spirometry,
turning, coughing, deep breathing, and splinting the
incision.
The amount of suction is determined by the water level.
It is usually set at 20 cm H
2
O; adding more fluid results
in more suction.
Respiratory care and other treatment modalities (oxygen,
incentive spirometry, CPT, and oral, inhaled, or IV
medications) may be continued at home. Therefore, the
nurse needs to instruct the patient and family in their
correct and safe use.
Another technique, huffing, may be helpful for the
patient with diminished expiratory flow rates or for the
patient who refuses to cough because of severe pain.
Huffing is the expulsion of air through an open glottis.
Instruction in the use of incentive spirometry begins
before surgery to familiarize the patient with its correct
use.

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