Beruflich Dokumente
Kultur Dokumente
Respiratory Function
Part One
By
Linda Self
Review of Terms
Cyanosisinfluenced
VentilationPerfusion
Ratios
Normal
lung is 1:1
Shunts: when perfusion exceeds
ventilation, a shunt exists. Blood
bypasses the alveoli w/o gas
exchange occurring.
Pneumonia, atelectasis, tumors,
mucous plugs
unitabsence of
ventilation and perfusion
Seen in pneumothorax and
severe ARDS
nerve
Respiratory center in medulla
and pons
Central chemoreceptors in
medulla, influenced by chemical
changes in csf
Peripheral chemoreceptors in
aortic arch and carotid arteries,
respond first to changes in PaO2,
then PaCO2 and pH
Gerontologic
Considerations
Decreased
strength of respiratory
muscles
Decreased elasticity
Increased respiratory dead space
Decreased number of cilia
Decreased cough and gag reflex
Increased collagen of alveolar
walls
Respiratory Assessment
Health
History
Risk factors for respiratory diseasegenetics, smoking, allergens,
occupational and recreational exposure
Dyspnea, orthopnea
Cough, ?productive
Chest pain
Cyanosis
Lung sounds
Clubbingindicates chronicity
Diagnostic Evaluation
PFTs-assess
respiratory function,
screening, assess response to therapy
FVCvital capacity performed with a
maximally forced expiratory effort
Forced expiratory volumeFEV1
volume of air exhaled in the specified
time during the performance of forced
vital capacity. FEV1 is volume exhaled in
one second.
FEV1/FVC%--ratio of timed forced exp.
volume to forced vital capacity
Diagnostic Evaluation-ABGs
1.
pH
2. evaluate the PaCO2 and HCO33. Look to see if compensation
has occurred. If CO2 is >40,
respiratory acidosis; If HCO3<24, metabolic acidosis; next
look at value other than primary
disorder, if moving in same
direction as primary value,
compensation is underway.
ABGs continued
Can
ABGs cont.
Normal
Acidosis
Results
in decreased myocardial
contractility and a decreased
vascular response to
catecholamines. May interfere
with metabolism of certain
medications
Alkalosis
Can
Sleep Apnea
Associated
Sleep Apnea
Diagnosed
by polysomnography
(ECG, EEG, EMG, pulse oximetry)
More common in men
High risk for CAD,
cerebrovascular disease and
premature death.
Results in hypoxia and
hypercapnia which trigger
sympathetic response. Can lead
to dysrhythmias and elevated BP
daytime sleepiness
Frequent nocturnal awakening
Insomnia
Loud snoring
Morning headaches
Personality changes
Systemic hypertension
Dysrhythmias
Pulmonary hypertension, cor pulmonale
polycythemia
Management
Nurse
educates patient
Avoid alcohol and sedatives
Weight loss
CPAP or BiPAPCPAP prevents airway
collapse, BiPAP makes breathing easier
and results in lower airway pressure
Uvulopalatopharyngoplasty
Tracheostomy
Provigil, Provera, Diamox, Triptil may
help
Laryngeal Cancer
Clinical
manifestations
1. Hoarseness of greater than two weeks duration
2. Persistent cough
3. Sore throat
4. Dysphagia
5. Dyspnea
6. Ulceration
7. Foul breath
8. Cervical adenopathy
9. Weight loss
10.Debilitation
with
biopsy/staging of disease
CT and MRI to assess adenopathy
and further stageing
Laryngeal CancerManagement
Depends
on staging of tumor
Options include surgery,
radiation and chemotherapy
Sometimes combination therapy
Ensure any dental problems
corrected, usually before other
treatments
Surgical Management
Laser
Post-operative Care
Usually
ICU postop
Monitor airway, VS,
hemodynamic status and comfort
level
Monitor for hemorrhage
Monitor for infection
Monitor tracheal stoma
Have extra trach at bedside (of
same size!)
Post-operative Care
May
be on ventilator initially
Will have trach
Ensure humidity at all times
May have split thickness skin graft or trapezius
or pectoralis muscle graftsensure side of flap
or graft not in dependent position
May have PCA
NG, G tube or jejunostomy tube may be in
placenutrition important
Speech rehab, esophageal speech,
electrolarynges
Support group
Chronic Bronchitis
Disease
of airways
Increased mucous production,
decreased ciliary activity,
inflammation, reduced alveolar
macrophage function
Emphysema
Lobulephysiologic
Emphysema
Risk
factors include:
1. Cigarette smoking
2. Occupational dusts, chemicals,
pollution
3. Deficiency of alpha1-antitrypsin,
protective enzyme that protects
lung parenchyma from injury--seen in Caucasians
COPD clinical
manifestations
Chronic
cough, sputum
production, and dyspnea on
exertion (DOE)
Weight loss common
Increased number of respiratory
infections
In primary emphysema, will have
barrel chest
Diagnosis of COPD
Thorough
H&P
Spirometry to evaluate airflow
obstruction
FEV1/FVC will be less than 70%
Reversibility will be tested
Chest xray
ABGs
Screening for alpha1-antitrypsin
deficiency
Classified by five stages0 through
IV (see p. 690)
Medical Management
Smoking
Surgical Management
Bullectomyhave
blebs or
enlarged airspaces that do not
contribute to ventilation
Lung volume reduction surgery
may improve quality of life but
not life expectancy
Lung transplantation
Nursing Management
Key
is education
Breathing exercises
Inspiratory muscle trainingbreathe
against a set resistance
Activity pacing
Self-care activities
Physical conditioning
Oxygen tx
Nutritional therapy
Coping measures
Bronchiectasis
Chronic,
Asthma
Chronic
inflammatory disease
characterized by mucosal edema,
airway hyperreactivity, and
mucous production
Largely reversible
Allergy is strongest predisposing
factor
Poorly controlled asthma can
result in remodeling. Bronchial
muscles and mucous glands
enlarge, alveoli hyperinflate and
Asthma
Cells
Asthma
Family,
environmental and
occupational history is necessary
Comorbid conditions like GERD,
drug-induced asthma and allergic
bronchopulmonary aspergillosis
may be present
Asthma
Triggers
Complicationsstatus
asthmaticus
Rescue and maintenance
medications
Peak flow monitoringmeasure
highest airflow during a forced
expiration. See asthma action
plan on p. 715. Height, age and
sex are variables to consider in
Status Asthmaticus
Severe
Atelectasis
Closure
of collapse of alveoli
Often occurs in postoperative
setting and in those who are
immobilized
Can result from any obstruction
that blocks air to and from alveoli
Atelectasis
Clinical
manifestationscough,
sputum, low grade fever. In
severe cases, tachycardia,
tachypnea, central cyanosis
Chest xray may reveal patchy
infiltrates, crackles will be heard
over affected area, O2 saturation
may be lower than 90%
Atelectasis
Preventionturning,
mobilizing
patient, deep breathing
maneuvers, incentive spirometry,
secretion management such as
suctioning, nebulizers, chest PT
ManagementIPPB, chest PT,
nebulizer tx, bronchoscopy,
possible ventilator support,
thoracentesis
Pneumonia
Is
Pneumonia
Pneumonia
in the
immunocompromised patient
Aspergillus, Pneumocystis,
Mycobacterium tuberculosis
Aspiration pneumonia
Is the most infectious disease
causing death in the United
States
Pathophysiology of pneumonia
Arises
Clinical Manifestations of
Pneumonia
Not
possible to diagnose a
certain type by manifestations
alone
May be sudden in onset with
fever, chills and pleuritic pain as
seen in pneumococcal
pneumonia
May be gradual in onset with low
grade fever, HA, pleuritic pain,
myalgias and pharyngitis
Diagnosis of Pneumonia
History
Physical
exam
Sputum cultures
Blood cultures
Chest xray
Possible bronchoscopy depending
on severity
Medical Management
Antibiotic
depending on Gram
stain
Often treat empirically, intervene
promptly
CAP-tx with Zithromax, Biaxin,
doxy, or fluoroquinolone. With
comorbidities, may use
Augmentin, Vantin, Ceftin, and a
macrolide or doxy. Symmetrel for
Flu A, Tamiflu for Flu A/B. Bactrim
Medical Management
cont.
Hospital
acquiredIV antibiotics
such as second generation
cephalosporins, carbapenems,
fluoroquinolones. If MRSA, use
vancomycin, Zyvox. For
Pseudomonas, use Timentin,
Unasyn, and an aminoglycoside.
Viral pneumonia is supportive
care only.
Hydration is important in all
Other treatments
Antihistamines
Nasal
decongestants
Antipyretics
Monitoring O2 saturation,
possibly ABGs
Serial xrays
Gerontologic
Considerations
In
assessmentnight
sweats, fever, chills, cough, lung
sounds
Encourage hydration as
hydration thins and loosens
secretions
Humidification w/or w/o oxygen
Encourage cough, chest
physiotherapy
Promote rest
Respiratory Care
Modalities
Nasal
Respiratory Care
Modalities
Oxygen
Hypoxemiadecrease
in arterial oxygen
tension in blood
Hypoxiadecrease on oxygen supply to
tissues
Oxygen toxicitycan occur if delivering
>50% for longer than 48h. Caused by free
radical production.
Signs/symptoms of oxygen toxicity
paresthesias, fatigue, refractory hypoxemia,
alveolar atelectasis, alveolar infiltrates
Consider
Tracheostomy
Surgical
Complications of tracheostomy
Bleeding,
pneumothorax, air
embolism, aspiration,
subcutaneous or mediastinal
emphysema, recurrent laryngeal
nerve damage
Airway obstruction from
accumulation of secretions
,tracheoesophageal fistula,
tracheal ischemia
semi-fowlers position to
facilitate ventilation, promote
drainage, minimize edema, and
prevent strain on the sutures
Allow method of communication
Ensure humidity to trach
Suction secretions as needed
Manage cuffusually keep
pressure less than 25 mm Hg but
more than 15 mm Hg to prevent
Endotracheal Intubation
Pass
Mechanical Ventilation
Used
to control patients
respirations, to oxygenate when
patients ventilatory efforts are
inadequate, to rest respiratory
muscles
Can be positive pressure or
negative pressure
Key for the nurse is assess
patientnot the ventilator
Classification of Ventilators
Negative Pressure
Used
Ventilatorspositive
pressure
Inflate
Positive Pressure
Ventilators
Pressure
cycled ventilators
delivers air until reaches a preset
pressure, then cycles off, then
passive expiration
Can vary as patients airway
resistance or compliance changes
Volume delivered thus will vary
and may compromise ventilation
Positive Pressure
Ventilators
Time cycled rarely seen in adults
(used in newborns and infants)
Volume cycledmost common.
Delivers a preset volume usually
8-10ml per kg
Noninvasive positive pressure
ventilationCPAP and BiPAP.
CPAP indicated for sleep apnea,
BiPAP esp. useful to avoid
intubating patients and in those
with neuromuscular disorders,
Ventilator Modes
Assist
control
Intermittent mandatory control
Synchronized intermittent
mandatory ventilation
Pressure supportassists SIMV,
applies pressure plateau to spont.
resp. during inspiratory phase
New modes incl. computerized
systems
volume
Lowest concentration of oxygen
to maintain PaO2 80-100 mm Hg
Peak inspiratory pressure
ModeAC or SIMV, possibly PEEP
Sensitivity so that patient can
trigger the vent. With minimal
effort
Check ABGs after being on vent.
for 20-30 minutes
Remember..
If
in cardiac function
Barotrauma and volutrauma
resulting in pneumothorax
Vagal stimulation
Pulmonary infectionsuse
chlorhexidine gluconate in oral
care
capacityamount of air
expired after maximum
inspiration. Should be 1015mL/kg.
Maximum inspiratory pressureused to assess the patients
respiratory muscle strength
should be at least -20cm H20
Tidal volumevolume of air that
is inhaled or exhaled during
ventilationequals resp
rate times tidal volume. Normal is
6 L/min.
PaO2 greater than 60 mm Hg
with FiO2 <50%, stable vital
signs, adequate nutritional status
Would refrain from sedating
patient during weaning
Thoracic Surgeries
Pneumonectomy
Lobectomy
Segmental
resection
Lung volume reduction
others
obesity, poor
nutritional status, smoking,
preexisting lung disease,
comorbid states
Intraoperativethoracic incision,
prolonged anesthesia
Postopimmobile, supine,
inadequate pain management,
prolonged intubation/ventilator,
airway clearance
Positioning-lobectomy turn either
side,pneumonectomy turn on
affected side, segmental
resection varies per doctor
Chest tube drainage/care
Relieve pain
Promote mobility
Maintain fluid volume and
nutrition
Monitor
respiratory status
Vitals
For
dysrhythmias
For bleeding, atelectasis and
infection
Monitor chest tube drainage, for
leaks, for tube kinks, for
excessive drainage