Respiratory System NAD 200

Respiratory Function

Takes in oxygen Disposes of wastes

* Carbon dioxide * Excess water

The Respiratory System



The respiratory system works with the cardiovascular system to exchange gases between the air and blood (external respiration) and (external respiration) between blood and tissue fluids (internal (internal respiration). respiration).

Automatic Function- Normally we breathe to Functionremove CO2 from the body, NOT to get oxygen

Human Respiratory System

Figure 10.1

Respiration Processes
Breathing (ventilation): air into and out of lungs  External respiration: gas exchange between air and blood  Internal respiration: gas exchange between blood and tissues  Cellular respiration: oxygen use to produce ATP, carbon dioxide as waste


Pulmonary Ventilation
  

The physical movement of air into and out of the lungs A mechanical process that depends on volume changes in the thoracic cavity Volume changes lead to pressure changes, which lead to the flow of gases to equalize pressure

Figure 23.15

Goals of Respiration
Primary Goals Of The Respiration System Distribute air & blood flow for gas exchange Provide oxygen to cells in body tissues Remove carbon dioxide from body Maintain constant homeostasis for metabolic needs

   

Functions of Respiration

of pulmonary ventilation 2. Diffusion of O2 & CO2 between alveoli and blood 3. Transport of O2 & CO2 to and from tissues 4. Regulation of ventilation & respiration

1. Mechanics

External & Internal Respiration

External Respiration  Mechanics of breathing  The movement of gases into & out of body  Gas transfer from lungs to tissues of body  Maintain body & cellular homeostasis Internal Respiration  Intracellular oxygen metabolism  Cellular transformation  Krebs cycle aerobic ATP generation  Mitochondria & O2 utilization

Respiratory Mechanics
Factors required to alter lung volumes Respiratory muscles generate force to inflate & deflate the lungs  Tissue elastance & resistance impedes ventilation  Distribution of air movement within the lung, resistance within the airway  Overcoming surface tension within alveoli


The Breathing Cycle

Airflow requires a pressure gradient  Air flow from higher to lower pressures  During inspiration alveolar pressure is subsubatmospheric allowing airflow into lungs  Higher pressure in alveoli during expiration than atmosphere allows airflow out of lung  Changes in alveolar pressure are generated by changes in pleural pressure


Movement of Breathing Cycle

Lower respiratory tract disorders

The Respiratory Tract

 Air

is cleansed, warmed, and moistened cleansed, warmed, as it passes the cilia and mucus in the nostrils and nasal cavity. cavity.  In the nose, the hairs and the cilia act as a screening device.  In the trachea, the cilia beat upward, trachea, carrying dust and mucus into the pharynx.  Exhaled air carries out heat and moisture. moisture.

Respiratory System Functions

     

Gas exchange: Oxygen enters blood and carbon dioxide leaves Regulation of blood pH: Altered by changing blood carbon dioxide levels Carbonic acid Buffer system Sound production: Movement of air past vocal folds makes sound and speech Olfaction: Smell occurs when airborne molecules drawn into nasal cavity Thermoregulation: Thermoregulation: Heating and cooling of body Protection: Against microorganisms by preventing entry and removing them

Respiratory Physiology
  

Internal respiration - exchange of gases between interstitial fluid and cells External respiration - exchange of gases between interstitial fluid and the external environment The steps of external respiration include:
  

Pulmonary ventilation Gas diffusion Transport of oxygen and carbon dioxide

The path of air- Respiration airVentilation: Movement of air into and out of lungs External respiration: Gas exchange between air in lungs and blood Transport of oxygen and carbon dioxide in the blood Internal respiration: Gas exchange between the blood and tissues Cellular Respiration: The use of O2 to produce ATP via Glycolysis, TCA cycle, & ETS

The Trachea
trachea, supported by C-shaped trachea, Ccartilaginous rings, is lined by ciliated cells, which sweep impurities up toward the pharynx.  The trachea takes air to the bronchial tree.  Blockage of the trachea requires an operation called a tracheostomy to form an opening.
 The

The Lungs


Lungs are paired, cone-shaped organs that lie on coneeither side of the heart and within the thoracic cavity. The right lung has three lobes, and the left lung has two lobes, allowing for the space occupied by the heart. The lungs are bounded by the ribs and diaphragm.

The Bronchial Tree

The trachea divides into right and left primary bronchi which lead into the right and left lungs.  The right and left primary bronchi divide into ever smaller bronchioles to conduct air to the alveoli.  constriction causes wheezing.


The Alveoli
 Alveoli

are the tiny air sacs of the lungs made up of squamous epithelium and surrounded by blood capillaries.

 Alveoli

function in gas exchange, oxygen exchange, diffusing into the bloodstream and carbon dioxide diffusing out.

Respiration and Health

 The

presence of disease in the upper or lower respiratory tract means that homeostasis is threatened.
 Upper

Respiratory Tract Infections  These infections involve the nasal cavities, pharynx, or larynx.

Restrictive Pulmonary Disorders

 In

restrictive pulmonary disorders, vital disorders, capacity is reduced because the lungs have lost their elasticity due to inhaled particles such as silica, coal dust, or asbestos.

 Fibrous

connective tissue builds in the lungs in pulmonary fibrosis, caused by exposure to fibrosis, inhaled particles, including those of fiberglass.

Obstructive Pulmonary Disorders

 In

obstructive pulmonary disorders, air disorders, does not flow freely in the airways, and inhalation and exhalation are difficult. bronchitis with inflamed airways, emphysema where alveolar walls break down, and asthma with constricted bronchioles obstruct the airways and tend to get progressively worse or recur.

 Chronic

VENTILATION
Movement of air into and out of lungs via negative pressure pump mechanism Air moves from area of higher pressure outside the lung to area of lower pressure created in the thorax and lungs by diaphram

Pressure is inversely related to volume in that as pressure goes down lung volume goes up

NORMAL BREATHING CYCLE

Compliance


Measure of the ease with which lungs and thorax expand

greater the compliance, the easier it is for a change in pressure to cause expansion  A lower-than-normal compliance means the lower-thanlungs and thorax are harder to expand
 The
 Conditions


that decrease compliance

Pulmonary fibrosis  Pulmonary edema  Respiratory distress syndrome

Pulmonary Volumes


Tidal volume


Volume of air inspired or expired during a normal inspiration or expiration Amount of air inspired forcefully after inspiration of normal tidal volume Amount of air forcefully expired after expiration of normal tidal volume Volume of air remaining in respiratory passages and lungs after the most forceful expiration

Inspiratory reserve volume



Expiratory reserve volume



Residual volume


Physical Principles of Gas Exchange Diffusion of gases through the respiratory membrane


Depends on membrane s thickness, the diffusion coefficient of gas, surface areas of membrane, partial pressure of gases in alveoli and blood

Relationship between ventilation and pulmonary capillary flow

Increased ventilation or increased pulmonary capillary blood flow increases gas exchange  Physiologic shunt is deoxygenated blood returning from lungs


Oxygen and Carbon Dioxide Diffusion Gradients

Oxygen
Moves from alveoli into blood. Blood is almost completely saturated with oxygen when it leaves the capillary P02 in blood decreases because of mixing with deoxygenated blood Oxygen moves from tissue capillaries into the tissues

Carbon dioxide
Moves from tissues into tissue capillaries Moves from pulmonary capillaries into the alveoli

Hemoglobin and Oxygen Transport



Oxygen is transported by hemoglobin (98.5%) and is dissolved in plasma (1.5%) A shift of the curve to the left because of an increase in pH, a decrease in carbon dioxide, or a decrease in temperature results in an increase in the ability of hemoglobin to hold oxygen A shift of the curve to the right because of a decrease in pH, an increase in carbon dioxide, or an increase in temperature results in a decrease in the ability of hemoglobin to hold oxygen

Modification of Ventilation
Cerebral and limbic system  Respiration can be voluntarily controlled and modified by emotions  Chemical control  Carbon dioxide is major regulator  Increase or decrease in pH can stimulate chemochemosensitive area, causing a greater rate and depth of respiration  Oxygen levels in blood affect respiration when a 50% or greater decrease from normal levels exists

Effects of Aging
Vital capacity and maximum minute ventilation decrease  Residual volume and dead space increase  Ability to remove mucus from respiratory passageways decreases  Gas exchange across respiratory membrane is reduced


RESPIRATORY ASSESSMENT

Respiratory Assessment


Initial Assessment (A, B, C, D) Manage life threats Complete focused history and physical

Initial Assessment
 Airway
 Listen
 Noisy

to patient breathe, talk

breathing is obstructed breathing  But all obstructed breathing is not noisy  Snoring = Tongue blocking airway  Stridor = Tight upper airway from partial obstruction

Initial Assessment


Airway  Anticipate airway problems with

 Decreased

LOC  Head trauma  Maxillofacial trauma  Neck trauma  Chest trauma

Initial Assessment
 Breathing  Is patient moving air?  Is air moving adequately?  Is the patient s blood being oxygenated?

Initial Assessment


Breathing
 LOOK

of chest expansion  Increased respiratory effort  Changes in skin color

 LISTEN

 Symmetry

movement at mouth, nose  Air Movement in peripheral lung fields

 Air

Initial Assessment
 FEEL

movement at mouth, nose  Symmetry of chest expansion

 RATE
 Tachypnea  Bradypnea

 Air

 POSITIONING
 Orthopnea  Tripod

position

Initial Assessment


Breathing
 Signs

of respiratory distress

 Nasal

flaring  Tracheal tugging  Retractions  Neck, pectoral muscle use on inhalation  Abdominal muscle use on exhalation
 Skin

Color

 Pale,

cool moist skin (Early sign of hypoxia)  Cyanosis (Late, unreliable sign of hypoxia)

Initial Assessment


Breathing
 If

trauma patient has compromised breathing, bare chest, assess for:

 Open

pneumothorax  Flail chest  Tension pneumothorax

Respiratory Assessment


Circulation
 Is

heart beating?  Is there major external hemorrhage?  Is patient perfusing? perfusing?  Effects of hypoxia:
 Adults

(early): tachycardia  Adults (late): bradycardia  Children: bradycardia

Circulation
 Don t

let respiratory failure distract you from assessing for circulatory failure  Low oxygen or high carbon dioxide levels can depress cardiovascular function

Disability
 Restlessness,

anxiety, combativeness = hypoxia Until proven otherwise  Drowsiness, lethargy = hypercarbia Until proven otherwise
 Just

because they stop moving or fighting does not necessarily mean better

Initial Mangement


Patient Responsive/Breathing Adequate

Oxygen may be indicated  Oxygenate immediately if patient has:  Decreased level of consciousness  Possible shock  Possible severe hemorrhage  Chest pain  Chest trauma  Respiratory distress or dyspnea  History of any kind of hypoxia



IF YOU THINK OXYGEN THEN GIVE OXYGEN

Initial Management


Patient responsive, breathing inadequate

 Open/maintain

airway  Place nasopharyngeal airway  Assist ventilations

 Mouth

to Mask  2-person Bag-valve Mask Bag Manually Triggered Ventilator  1-person Bag-valve Mask Bag-

Golden Rules
 If  If

you think about giving O2, give it!!!

you can t tell whether a patient is breathing adequately, he isn t !

 If

you re thinking about assisting a patient s breathing, you probably should be!

Focused History & Physical

Chief Complaint
Dyspnea Subjective sensation that breathing is excessive, difficult, or uncomfortable Respiratory Distress Objective observations that indicate breathing is difficult or inadequate

Focused History and Physical



History of Present Illness (OPQRST)

     

Gradual or sudden onset? What aggravates or alleviates? How long has dyspnea been present? Coughing? Productive cough? What does sputum look/smell like? Pain present? What does pain feel like? How bad? Does it radiate? Where?

Focused History and Physical



Past History
If
Hypertension, MI, Diabetes Edema Chronic Cough , Smoking, Recurrent Flu Allergies, Acute Episodes of SOB Lower Extremity Trauma, Recent Surgery, Immobilization COPD

Then???
CHF with Pulmonary

Asthma Pulmonary Embolism

Focused History and Physical

 Medications

If
Breathing Pills, Inhalers
Albuterol Aminophylline Ipratropium Terbutaline Salbumatol Zafirlukast Montelukast Oxtriphylline Cromolyn Prednisone

Then???
Asthma or COPD

Focused History and Physical



Medications
If
Lasix, hydrodiuril, digitalis Coumadin, BCP s embolism

Then???
CHF Pulmonary

Focused History and Physical Exam



Crackles (Rales)
 

Stridor
 

Fine, crackling Fluid in smaller airways, alveoli Coarse, rumbling Fluid, mucus in larger airways

High pitched, crowing Upper airway restriction Whistling Usually more pronounced on exhalation Generalized: narrowing, spasm of the smaller airways Localized: foreign body aspiration

Wheezing
  

Rhonchi
 

54

Temple College EMS Program

Diagnostic Studies
START HERE

Arterial Blood Gases

Purpose of ABG


Assess degree to which lungs are able to provide adequate oxygen and remove CO2 and degree to which the kidneys are able to reabsorb or excrete HCO3

Must know What is Normal to be Able to Know What is Abnormal

pH = 7.35 to 7.45  PaCO2 = 34 to 45 mm Hg  PaO2 = 80 to 100 mm Hg  HCO3 = 22 -26 mEq/L mEq/L


What Do You Have to Look at to Interpret ABGs



Look at Your pH Look at your PaCO2 Now Look at Your HCO3

Are they normal? Are they high? Are they low?

Examples
pH=7.36  pH = 7.23  pH = 7.47


A high pH indicates alkalosis  A low pH indicates acidosis



Look at your PaCO2



This is the respiratory component

An abnormality in the PaCO2 will indicate a respiratory problem

Examples
PaCO2 = 50 mm Hg  PaCO2 = 23 mm Hg


A high PaCO2 indicates acidity  A low PaCO2 indicates alkalosis



PaCO2


Lungs will increase or decrease ventilation to remove the appropriate amount of CO2 Lung compensations begins quickly

Now Look at Your HCO3



This is the metabolic component An abnormality in the HCO3 indicates a metabolic problem

The kidneys excrete Hydrogen (acid) & retain bicarbonate (base) to help maintain pH Renal compensation is slow

Examples
HCO3 = 28 mEq/L mEq/L  HCO3 = 19 mEq/L mEq/L  Missing one here


A low HCO3 indicates acidity HCO3  A high HCO3 indicates alkalosis



Metabolic Acidosis
ABG  Low pH (below 7.35)  Decreased HCO3 (below 22)  PaCo2 will be normal
 

Remember both the pH and HCO3 will be low

Metabolic Acidosis
Caused by too much acid in the body or loss of bicarbonate  Diarrhea (loss of HCO3)  Diabetic ketoacidosis  Renal failure


Respiratory Acidosis
ABG  Low pH (below 7.35)  Increased PaCO2 (above 45)  HCO3 will be normal
 

Remember the pH will be low & PaCO2 will be elevated (opposite)

Respiratory Acidosis
Caused by acid buildup due to lungs not eliminating CO2  Anything that decreased respirations can cause respiratory acidosis  Chronic respiratory disease  CNS depression


Alkalosis
Develops when  Excess accumulation of bicarbonate  Loss of acid


Metabolic Alkalosis
ABG  Increase in PH (greater than 7.45)  Increased HCO3 (greater than 26)  PaCO2 will be normal
 

Remember both the PH & the HCO3 2ill be elevated

Metabolic Alkalosis
Loss of acid or increase in HCO3  Vomiting or NG drainage (loss of Hydrogen)  Excessive use of antacids


Respiratory Alkalosis
ABG  Increase in PH (greater than 7/45)  Decrease in PaCO2 (less than 35)  HCO3 will be normal
 

Remember the pH will be high & PaCO2 will be low (opposite)

Respiratory Alkalosis
Caused by too much CO2 being excreted by the lungs  Hyperventilation


Interpreting ABGs

Step 1: Look at pH
Is it normal (7.35-7.45) (7.35 Does it reflect acidosis (less than 7.35)  Does it reflect alkalosis (greater than 7.45)
 

Label accordingly

Step 2: Look at PaCO2

This is the respiratory component  Is it normal  Does it reflect alkalosis (less than 35)  Does it reflect acidosis (greater than 45)
 

Label accordingly

Step 3: Look at the HCO3

This is the metabolic component  Is it normal  Does it reflect acidosis (less than 22)  Does it reflect alkalosis (greater than 26)
 

Label accordingly

Let s Put It All Together

  

pH of 7.33 PaCO2 of 40 mm Hg HCO3 of 20 mEq/L mEq/L What does it indicate pH = acidosis PaCO2 = normal Break it down HCO3 = acidosis
An abnormal HCO3 indicates a metabolic problem Indicates: METABOLIC ACIDOSIS

 

  

pH of 7.59 PaCO2 of 29 mm Hg HCO3 of 24 mEq/L mEq/L What does this indicate

pH = alkalosis PaCO2 = alkalosis HCO3 = normal An abnormal PaCO2 indicates a respiratory problem RESPIRATORY ALKALOSIS

pH of 7.25  PaCO2 of 61 mm Hg  HCO3 of 26 mEq/L mEq/L

 

What does this indicate

pH = acidosis PaCO2 = acidosis HCO3 = normal An abnormal PaCO2 indicates a respiratory problem RESPIRATORY ACIDOSIS

pH of 7.51  PaCO2 of 44 mm Hg  HCO3 of 56

 

What does this indicate

pH = alkalosis PaCO2 = normal HCO3 = alkalosis An abnormal HCO3 indicates a metabolic problem METABOLIC ALKALOSIS

Compensation
    

What can the lungs do? How will this impact the pH? pH? What can the kidneys do? How will this impact the pH? pH? Who compensates more quickly?

Compensation
Occurs as the body begins to correct the acid base imbalance  pH will be normal or near normal if total compensation  pH will be abnormal if partial compensation


Compensation
Both the PaCO2 & HCO3 will be abnormal  Respiratory imbalances are compensated for by the renal system  Metabolic imbalances are compensated for by the respiratory system


Compensation
Balance and Buffers


The body s ability of counteracting disturbances in the balance between CO2 and HCO3 Partial vs. Full Compensation

Example
  

pH of 7.27 PaCO2 of 27 mm Hg HCO3 of 10 mEq/L mEq/L Note both the PaCO2 & the HCO3 are low
Low pH = acidosis Low PaCO2 = alkalosis Low HCO3 = acidosis HCO3 corresponds with the pH This a metabolic problem Metabolic acidosis with partial compensation

pH of 7.52  PaCO2 of 47 mm Hg  HCO3 of 36 mEq/L mEq/L



What does this indicate  Break it down



pH alkalosis PaCO2 = acidosis HCO3 = alkalosis PH and HCO3 go together Metabolic Alkalosis with partial compensation

Ph of 7.45  PaCO2 of 50 mm Hg  HCO3 of 33 mEq/L mEq/L



What does this indicate  Break it down



pH = normal PaCO2 = acidosis HCO3 = alkalosis Your pH leans toward the alkalosis side This is Fully Compensated Metabolic Alkalosis

THORACENTESIS

Diagnosis
Look at medical history  Physical Exam  Assessment  Test results


  

Thoracentesis is a procedure to remove excess fluid in the space between the lungs and chest wall (pleural space) Normally only @ 4 teaspoons there If more fluid builds up = pleural effusion presses on lungs .hard to breathe Done to find cause of pleural effusion and ease breathing (fluid, heart failure, lung cancer, tumors, embolism, etc) etc)

Prior to
Bleeding problems  Allergies (meds/latex)  Explain procedure


Procedure/Risks
  

Inserts needle or plastic tube fluid Send fluid for testing Risks pneumothorax shock Bleeding Infection

draws out excess

During
      

Sit on side of bed, chair, etc. Lean forward and rest arms on table, etc. Instruct not to move, cough, or breathe deeply once procedure started Area is cleanssed Needle inserted between ribs into pleural space May feel stinging, discomfort, pressure Monitor for shock

After
Position side lying with unaffected side down for at least an hour  May have chest x-ray x Report fever, chills, redness, swelling, bleeding or drainage at site, difficulty breathing


Lung Biopsy

Types


Bronchoscopic biopsy .Done using thin, flexible bronchoscope/or rigid. Takes @ 1 hr.. Chest xxray after Local anesthetic in mouth or nose tastes bitter, mouth dry for several hours, sore throat suck on lozengers or gargle. Avoid eating or drinking for @ 1 hour. May have slight fever for 24 hours

Needle Biopsy Use CT scan, ultrasound, or fluroscopey to guide needle Hold breathe while needle is inserted into lung and avoid coughing. Feel burning when numbing site. Needle inserted into chest may feel sharp pain for few seconds. Lie on side @ 1 hr. to allow needle site to seal. X-ray usually taken afterwards X-

Open biopsy and video assisted thoracoscopic surgery (VATS) Open chest. ET tube and vent assistance. Thoroscope through incision in chest. Will insert drain tube (chest tube) close incision with sutures. To help re-expand lung. reChest x-ray, chest tube set up..Tired for 1-2 x1days due to anesthesia general muscle aches, mild sore throat, some discomfort at site. Monitor for bleeding, some may be expected (small amount)

Risks of Lung Biopsy

Collapsed lung (pneumothorax)  Hemorrhage  Infection  Spasms of bronchial tubes  Arrhythmias  Rare death from complications


Monitor and Report

Severe chest pain  Lightheadedness  Difficulty breathing  Excessive bleeding  Coughed up more than TBSP. of blood  Fever


Lung Biopsy


Normal..Tissue normal, no infection, inflammation or cancer Abnormal..Abnormal cells and tissue..may be due to infection, lung diseases, cancer If cancer results can determine treatment options (surgery, radiation, chemotherapy)

LUNG BIOPSY.

Exhalation

Similar technique is used under fluoroscopic guidance

 

 

Usually 4-5 specimens are 4obtained Lung parenchyma is obtained by tearing the respiratory bronchioles Forceps to distal may cause pneumothorax Forceps too proximal may cause bleeding

Indications for fluoroscopy

To localize abnormalities  TO help prevent pneumothorax  TO extract foreign bodies  TO perform biopsy or brushing of solitary pulmonary nodules  To improve diagnostic yield  To detect pneumothorax

113 BI

Preventing bleeds after TBLB

 Avoid excessive suction after biopsy. Instead, use gentle brief suction to assess degree of bleeding.

 If bleeding is excessive: gently instill 5-10 ml iced-saline through FFB, wait for 30 sec, then suction gently.

114

BI

115

BI

TBLB in Renal Failure

Check INR & platelet count Bleeding time can be misleading Correct INR and platelet count if necessary (<1.5, >50,000) Risk of bleeding is about 8%

116

BI

Other antiplatelet agents and Anticoagulants

     

Aspirin (1) , Ticlopidine need not be discontinued Warfarin (Coumadin) should be discontinued until INR <1.5
(or INR corrected using Fresh Frozen Plasma or Vitamin K)

I.V. Heparin should be stopped 2-6 hrs prior 2to biopsy. Check PTT. Low molecular weight heparin should be held 12 hrs (hold previous dose). S.Q. Heparin is safe and can be continued. Follow recommendations for all other newer antianti-coagulants and other agents.
BI

117

OXYGEN THERAPY

Artificial Airways
Nasopharyngeal  Oropharyngeal  Endotracheal  Nasotracheal  Tracheostomy  Cricoidthyroidotomy


Transtracheal Oxygen

Transtracheal Oxygen Delivery



Used for long-term delivery longof oxygen directly into the lungs Avoids the irritation that nasal prongs cause and is more comfortable Flow rate prescribed for rest and for activity

The transtracheal catheter is the flexible little tube that passes from the lower neck into the trachea (or windpipe) and delivers oxygen directly to the lungs. The tube is kept in place by a safety flange and a bead chain necklace. Catheters are made of a flexible plastic, and should be replaced every 90 days (3 months) or if they start to become brittle, yellowed, or kinked. The hoses that connect the catheter to the oxygen source come in many different sizes, and feature a safety clip. This safety clip attaches to the pants, skirt, shorts or dress waistband and helps to absorb any accidental pulls on the hose. The SCOOP hose is designed to be worn on the right hip

Benefits
Improved Comfort and Convenience  Improved Self Image  Lower Oxygen requirements  Increased mobility  Greater Exercise Capacity


Physiological Benefits
Reduced Red Blood Cell Count  Improv ed Blood Flow through the lungs  Improved oxygen during sleep  Decreased work of breathing  Decrease in # of hospitilizations


Risks
Coughing that will subside  Infection if not taken care of correctly  Subcutaneous emphysema  Keloids @ tract sometimes


Endotracheal Tubes

Endotracheal Tubes


Chosen initially as a means of providing an airway When there is an obstruction @ the level of the epiglottis or below To deliver an accurate O2 concentrations & unable to clear secretions To institute mechanical ventilation

Mouth Method of choice, easier procedure, larger diameter tube. The larger the tube .reduces the work of breathing (WOB) (WOB) However ..

Uncomfortable for the pt .movement .laryngeal .laryngeal damage .may bite on tube & cause airway occlusion

Types of Tubes CuffedShort distance from tip. Balloon & circular. Most common used. Epiglottislarynx.trachea When inflated, seal formed, allows mechanical control of pts. respirations & precise concentrations of O2 to alveoli

FenestratedHas openings which are in contact with the mucosa

Checking Tube Placement Auscultate both sides of chest while manually ventilating pt. Why??....To assure sufficient amt. of air exchange in lungs Heard bilaterally & unable to speak Phonation requires airwith an adequate seal. Now unable to direct air flow thru vocal cords, so, unable to speak!

Checking Tube Placement Placement confirmed by CXR

Must be 1-2 cm above the carina

Intubated approx. 10-14 days.MD to decide whether to trach & peg

Documentation Amt of air in cuff Level of the tube: measured in cm Breath Sounds Tolerance of procedure Completion of CXR & ABGs

Minimal Leak Technique



MOV Minimal Occlusive Volume: Careful monitoring & management of tube cuff pressures. This pressures. minimizes complications Smallest amt. of air needed to achieve a seal should be used An adequate seal is achieved if during maximal mechanical ventilation a slight air leak can be heard over the trachea (with stethoscope) stethoscope) Check daily, 15-20 mm Hg cuff pressure, Above 20..tube too small 15-

Cares


Ambu, Ambu, ET tube of same size @ bedside Humidification must drain water out of tube Communication method

Oropharngeal/Nasopharngeal Oropharngeal/ Airways

Oropharyngeal airways
Keep the tongue from blocking the upper airway Allow for easier suctioning of the airway Used in conjunction with BVM device Used on unconscious patients without a gag reflex

Inserting an oropharyngeal airway Select the proper size airway. Open the patient s mouth. Hold the airway upside down and insert it in the patient s mouth. Rotate the airway 180 until the flange rests 180 on the patient s lips.

Nasopharyngeal airways
Conscious patients who cannot maintain airway Can be used with intact gag reflex Should not be used with head injuries or nosebleeds

Inserting a nasopharyngeal airway

1. Select the proper size airway. 2. Lubricate the airway. 3. Gently push the nostril open. 4. With the bevel turned toward the septum, insert the airway.

Tracheostomy Tubes

Tracheostomy: Purposes & Advantages

1. To maintain an artificial airway 2. Used to relieve upper airway obstructions in the respiratory tract 3. Provides an alternate route to remove secretions from trachea & bronchi 4. Provides a route for mechanical ventilation ..?? What type of trach needed 5. Prevents aspiration of food or vomitus from the pharynx into lower respiratory tract

Tracheostomy: Disadvantages


Normal protective coughing mechanisms is impaired because of the inability to close epiglottis tightly. Prevents necessary inc. intrathoracic pressure

Inspired air bypasses upper airway structures of nose & pharynx, thus, removing the filtering, warming, warming, humidification of inspired air

Lose ability to speak normally. Because trach lies below the pharynx & there is inadequate air pressure with in larynx to permit vocal cords to function

Inc. risk of infections versus ETT

New Tracheostomy


Do not manipulate, inc. cuff deflation for 24 hrs. hrs. Check for bleeding & crepitus Change dressings PRN; wash with N/S

Cuff Deflation


Sometimes is needed to decrease the pressure on tracheal mucosa RN must know: 1. Type of cuff, 2. MD order for inflation & deflation, 3. Amt. of air required Inject 1-6 cc SLOWLY

Air inflates cuff & you can test balloon  Clamp distal to balloon  Deflation of balloon means the cuff is deflated


Heat & Humidification

      

Bypasses the natural process O2 should be body temperature How?...thru a nebulizer Nebulizer attached to humidifier containing sterile water With ventilator these 2 pieces are part of machine Prevents encrustations & obstruction of airways Less likely to develop infections

Discharge
  

Cover neck with scarf Room humidifier in home Keep trach inner tube dry

Mechanical Ventilation

Mechanical Ventilation
Types are classified accordint to how the inspiration phase is terminated  Volume Cycled  Pressure Cycled  Time - Cycled


Volume Cycled Ventilators

Used in COPD pts. The changes in lung compliance & resistance from COPD will affect the pressure it takes to provideadequate ventilation Most commonly used vent in critical care because of constancy of Vt & O2 delivered End inspiration after delivering a preset volume of oxygen

Pressure Cycled Ventilators

Respirations end when a pre-set pressure preis reached  Variable & depends on airway pressure & Compliance  IPPB devices are examples of pressure cycledventilators  Pressure assisted ventilators are used as an adjunct to the weaning process


Time Cycled Ventilators



Tidal volume (Vt) may not always be (Vt) constant due to changes in airway resistance & compliance The flow of gas into the patient ends when a pre set time has elapsed after the start of inspiration

Vent settings to improve <oxygenation>

PEEP and FiO2 are adjusted in tandem

FIO2
Simplest maneuver to quickly increase PaO2 Long-term toxicity at >60% Free radical damage

Inadequate oxygenation despite 100% FiO2 usually due to pulmonary shunting

Collapse Atelectasis Pus-filled alveoli Pneumonia Water/Protein ARDS Water CHF Blood - Hemorrhage

Vent settings to improve <ventilation>

Respiratory rate
Max RR at 35 breaths/min Efficiency of ventilation decreases with increasing RR Decreased time for alveolar emptying

I:E ratio (IRV)

Increasing inspiration time will increase TV, but may lead to auto-PEEP

PIP
Elevated PIP suggests need for switch from volume-cycled to pressure-cycled mode Maintained at <45cm H2O to minimize barotrauma

TV
Goal of 10 ml/kg Risk of volutrauma

Permissive hypercapnea
Preferable to dangerously high RR and TV, as long as pH > 7.15

Plateau pressures
Pressure measured at the end of inspiratory phase Maintained at <30-35cm H2O to minimize barotrauma

Indications for extubation

No weaning parameter completely accurate when used alone

Clinical parameters Resolution/Stabilization of disease process Hemodynamically stable Intact cough/gag reflex Spontaneous respirations Acceptable vent settings FiO2< 50%, PEEP < 8, PaO2 > 75, pH > 7.25 General approaches SIMV Weaning Pressure Support Ventilation (PSV) Weaning Spontaneous breathing trials Demonstrated to be superior

Ventilator Settings
  

FIO2: Fraction of inspired oxygen concentration Increased FI02 = increased PO2 Decreased FIO2 = decreased PO2 FIO2 varies: 0.21 (21%) to 1.0 (100%) Usually set @ 0.40 (40%) Settings are dependent on ABG results Tidal Volume: Amount of oxygen delivered by each ventilator contolled breath Increased Tv = Decreased PCO2 Decreased Tv = Increased PCO2

  

   

Ventilator Settings



The number of ventilator controlled breaths the machine delivers in one minute

Increase the rate = decrease in PCO2  Decrease the rate = increase the PCO2
    

SIMV: SIMV: Synchronized intermittent ventilator ventilation Allows pt. to breath on own between breaths delivered by ventilator breaths Can wean with SIMV SIMV gives respiratory muscles time to recondition For example: SIMV of 5; 20 breaths on own=respiratory rate

Ventilator Settings
Assist Control: The mechanical ventilator delivers enough breaths to meet the pts. needs  If pt. takes spontaneous breath positive, the ventilator responds by delivering a breath as soon as pt. breaths  Preset # of pressure breaths @ a preset Vt


Ventilator Settings
   

PEEP: PEEP: Amount of positive pressure applied @ end of inspiration Increased PEEP = Increased PO2 Positive End Expiratory Pressure Inc. Inc. the resistance to expiration; inc. in amt. of O2 that remains in the lungs during expiratory phase .prevents alveolar collapse
In a pt. that does breath spontaneously, the epiglottis provides 5 cm of PEEP normally

Ventilator Settings


CPAP vs PEEP Continuous positive airway pressure Both improve oxygenation by inc the pts functional residual capacity (FRC) the volume of air in the lungs @ end of expiration CPAP can be provided using a specific CPAP device or a mask & may not require using a ventilator! ventilator! CPAP used during weaning to reduce the amt of energy the pt expends to pull O2 thru ventilator

Nursing Care
        

Assess respiratory Bilateral breath sounds Crackles or rhonchi: need to suction Position & security of tubes Skin @ tubes Cuff pressure Comfort level/anxiety Aerosol Therapy Hydration/Nutrition

Nursing Care
     

Never shut alarms off Major alarms: High Pressure: too much resistance .suction? Low pressure..not meeting expected breath Alarm initiated: CHECK PT. FIRST Gasping, Cyanotic, etc. Get help and ambu pt.

Weaning
 

SIMV used for patients that are difficult to wean Pt remains connected to vent & # of mandatory breaths delivered by the machine is gradually reduced allowing pt. to take increasing # of breaths on own PSV = Pressure support ventilation. All breaths initiated by pt. & supplement with positive pressure. PSV augments pt. Provides reg. exercise for pulmonary muscles

Nursing Care - Ventilation

Goal is to reduce respiratory rate until pt. takes on breathing on own  If pt. can talk then the cuff is leaking if it is supposed to be cuffed trach  Vent manually while you try to figure out a problem if you can t fix immediately or if it is low pressure meaning the pt. is not getting enough oxygen


CHEST TRAUMA
Thoracic Injury

Pneumothorax
Air between the pleurae is a pneumothorax Occurs when there is an opening on the surface of the lung or in the airways, in the chest wall or both Can be from internal Or external injury Open = sucking chest wound

Open pneumothorax
Opening in the chest wall (with or without lung puncture)  Allows atmospheric air to enter the pleural space  Penetrating trauma: stab, gunshot, impalement  Surgery


An open pneumothorax is also called a sucking chest wound  With the pressure changes in the chest that normally occur with breathing, air moves in and out of the chest through the opening in the chest wall  Looks bad and sounds worse, but the opening acts as a vent so pressure from trapped air cannot build up in the chest


Closed pneumothorax
Chest wall is intact  Rupture of the lung and visceral pleura (or airway) allows air into the pleural space


In a closed pneumothorax, a patient who pneumothorax, is breathing spontaneously can have an equilibration of pressures across the collapsed lung  The patient will have symptoms, but this is not life-threatening life

Tension pneumothorax occurs when a closed pneumothorax creates positive pressure in the pleural space that continues to build  That pressure is then transmitted to the mediastinum (heart and great vessels)


A tension pneumothorax can kill  Chest wall is intact  Air enters the pleural space from the lung or airway, and it has no way to leave  There is no vent to the atmosphere as there is in an open pneumothorax  Most dangerous when patient is receiving positive pressure ventilation in which air is forced into the chest under pressure


Mediastinal shift occurs when the pressure gets so high that it pushes the heart and great vessels into the unaffected side of the chest  These structures are compressed from external pressure and cannot expand to accept blood flow


Mediastinal shift can quickly lead to cardiovascular collapse  The vena cava and the right side of the heart cannot accept venous return  With no venous return, there is no cardiac output  No cardiac output = not able to sustain life


When the pressure is external, CPR will not help the heart will still not accept venous return  Immediate, live-saving treatment is liveplacing a needle to relieve pressure followed by chest tube


Blood in the pleural space is a hemothorax

Hemothorax occurs after thoracic surgery and many traumatic injuries As with pneumothorax, the negative pressure between the pleurae is disrupted, and the lung will collapse to some degree, depending on the amount of blood The risk of mediastinal shift is insignificant, as the amount of blood needed to cause the shift would result in a lifelife-threatening intravascular loss

Hemothorax is best seen in an upright chest radiograph Any accumulation of fluid that hides the costophrenic angle on an upright CXR is enough to require drainage
Note air/fluid meniscus

Transudate or exudate in the pleural space is a pleural effusion

Fluid in the pleural space is pleural effusion

 Transudate

is a clear fluid that collects in the pleural space when there are fluid shifts in the body from conditions such as CHF, malnutrition, renal and liver failure

 Exudate

is a cloudy fluid with cells and proteins that collects when the pleurae are affected by malignancy or diseases such as tuberculosis and pneumonia

Treatment for pleural conditions

Remove fluid & air as promptly as possible Prevent drained air & fluid from returning to the pleural space Restore negative pressure in the pleural space to re-expand the lung re-

Thoracostomy creates an opening in the chest wall through which a chest tube (also called thoracic catheter) is placed, which allows air and fluid to flow out of the chest

Remove Air and Fluid

Choose Site

Explore with finger

Place tube with clamp

Suture tube to chest

Thoracic Catheters

At the end of the procedure, the surgeon makes a stab wound in the chest wall through which the chest tube is placed into the pleural space

Prevent air & fluid from returning to pleural space

Chest tube is attached to a drainage device
 Allows

air and fluid to leave the chest  Contains a one-way valve to prevent air & onefluid returning to the chest  Designed so that the device is below the level of the chest tube for gravity drainage

How does a chest drainage system work?

Its all about bottles and straws

 

Most basic concept Straw attached to chest tube from patient is placed under 2cm of fluid (water seal) Just like a straw in a drink, air can push through the straw, but air can t be drawn back up the straw
Tube from patient

Tube open to atmosphere vents air

This system works if only air is leaving the chest If fluid is draining, it will add to the fluid in the water seal, and increase the depth As the depth increases, it becomes harder for the air to push through a higher level of water, and could result in air staying in the chest

For drainage, a second bottle was added  The first bottle collects the drainage  The second bottle is the water seal  With an extra bottle for drainage, the water seal will then remain at 2cm

Tube open to atmosph ere vents air
Tube from patient

Fluid drainage

The two-bottle system is the key for chest twodrainage

A

place for drainage to collect  A one-way valve that prevents air or fluid onefrom returning to the chest

Tube open to

Tube to vacuum source

atmosphere vents air

Tube from patient

Fluid drainage

The straw submerged in the suction control bottle (typically to 20cmH2O) limits the amount of negative pressure that can be applied to the pleural space in this case -20cmH2O The submerged straw is open at the top As the vacuum source is increased, once bubbling begins in this bottle, it means atmospheric pressure is being drawn in to limit the suction level

 

Expiratory positive pressure from the patient helps push air and fluid out of the chest (cough, Valsalva) Valsalva) Gravity helps fluid drainage as long as the chest drainage system is below the level of the chest Suction can improve the speed at which air and fluid are pulled from the chest

The bottle system worked, but it was bulky at the bedside and with 16 pieces and 17 connections, it was difficult to set up correctly while maintaining sterility of all of the parts In 1967, a one-piece, disposable plastic onebox was introduced The box did everything the bottles did and more

To suction

From patient

Suction control bottle

Water seal bottle

Collection bottle

NOTICE THERE IS LOTS OF BUBBLING IN THE SUCTION CHAMBER BUT VERY LITTLE IN WATER SEAL CHAMBER

Suction control chamber

Water seal chamber

Collection chamber

Collection chamber
 Fluids

drain directly into chamber, calibrated in mL fluid, write-on surface to note level and writetime

Water seal
 One

way valve, U-tube design, can monitor Uair leaks & changes in intrathoracic pressure

Suction control chamber

 U-tube,

narrow arm is the atmospheric vent, large arm is the fluid reservoir, system is regulated, easy to control negative pressure

Keep drain below the chest for gravity drainage  This will cause a pressure gradient with relatively higher pressure in the chest  Fluid, like air, moves from an area of higher pressure to an area of lower pressure  Same principle as raising an IV bottle to increase flow rate


Each time client exhales=air is trapped in pleural space and it travels down the chest tube to water seal bottle/chamber under water and then bubbles up and out of the bottle! The water acts as a seal allowing air to escape from pleural space but preventing air from getting back into the lungs via negative pressure of inspiration!

Monitoring intrathoracic pressure

The water seal chamber and suction control chamber provide intrathoracic pressure monitoring  Gravity drainage without suction: Level of water in the suction: water seal chamber = intrathoracic pressure (chamber is


more negative pressure in pleural space and signals healing  Goal is to return to -8cmH20  With suction: Level of water in suction control + level of suction: water in water seal chamber = intrathoracic pressure

calibrated manometer)  Slow, gradual rise in water level over time means

Monitoring Air Leak

Water seal is a window into the pleural space  Not only for pressure  If air is leaving the chest, bubbling will be seen here  Air leak meter (1-5) provides a way to (1measure the leak and monitor over time getting better or worse?


Setting up the system



 

Follow the manufacturer s instructions for adding water to the 2cm level in the water seal chamber, and to the 20cm level in the suction control chamber (unless a different level is ordered) Connect 6' patient tube to thoracic catheter Connect the drain to vacuum, and slowly increase vacuum until gentle bubbling appears in the suction control chamber

CHEST TUBE MANAGEMENT

At the bedside: Always keep 2 padded clamps- may be clampsneeded if the chest tubes accidentally become dislodged/disconnected from the tubing. PleurPleur-Evac system is the new modern closed drainage system that has evolved from older 3-bottle 3system ..works on same principle:

1=drainage collection bottle ( fluid/blood)  2= water seal bottle***** most important  3=suction bottle ( only if you need suction) otherwise suction chamber is left open or vented to allow air escape.


. Make sure all connections are secure (use adhesive tape to prevent a break in the system) and sterile petroleum- jelly petroleumbased occlusive gauze/ dressing are applied over insertion site to prevent air leaks!

Water seal bottle/chamber



The water level in the water seal bottle/chamber will fluctuate gently up and down with each inspiration/expiration. This is called tidaling Only time tidaling should stop is 1.= when the lung is rere-inflated and no longer requires a chest tube or 2.= if a problem occurs with the tubing (kinked, occlusion, breaks in the system) and should be checked ASAP! 3.=If constant or vigorous bubbling occur please check for a leak something is wrong

Suction bottle/chamber (bottle #3) used to speedily rereinflate the lungs. Water is added to the bottle/chamber. Suction is applied. (the force of suction is solely (the dependent on amount of water in bottle not the amount of suction set on suction machine. If water machine. evaporates=add evaporates=add more water to prescribed level of water. See gentle bubbling in suction bottle If vigorous bubbling=suction will not be maintained; did the water evaporate? Add prescribed amount. (DO NOT CONFUSE THIS BUBBLING WITH THAT IN THE WATER SEAL CHAMBER) If suction not used: chamber is then left open to allow air to escape.

 

 

Drainage/Collection bottle/chamber (#1) Only used if drain fluid/blood pleural space. (pleural effusion, chest trauma, surgery). Drainage chamber is not emptied but just marked amount every shift on the bottle/chamber. Report any marked increases in bloody drainage/fluid. Recorded as Output

Often when chamber is full; RN/M.D. will change out the closed chest drainage system (Pleur-Evac) with a new (Pleur-Evac) one.

  

General guidelines: Check system for any breaks,cracks, kinks in tubing, or breaks,cracks, broken connections Auscultate lung sounds, any sudden SOB, dyspnea, pain, hear any crepitous sounds= think SQ emphysema? hear & palpate for leakage of air into SQ tissue Tight occlusive dressing intact? Clamps at bedside? No dependent loops tubing? Is the drainage system below chest level? Check water seal chamber and or suction chamber for the correct amount of water in chambers? Any vigorous bubbling? leaks? Record drainage as output

  

If client must be transported: suction is usually off and air is vented out. Tubing is not clamped for transport! If a tube accidentally pulls out=quickly place a tight occlusive dressing over the insertion site on the chest to prevent air from re-entering follow hospital policy reProcess of Milking and Stripping tubes is controversial follow hospital policy If time to D/C d the Chest tube/closed drainage system= D/C M.D. pulls tube out and tight occlusive petroleum-jelly petroleumbased gauze is applied over insertion site: CXR done (check for pneumothorax d/t a puncture lung?), Monitor respirations & for crepitous? crepitous?