OO2 2 RESPIRATORY RESPIRATORY

TO BREATHE OR NOT TO TO BREATHE OR NOT TO BREATHE, THAT IS OUR BREATHE, THAT IS OUR

QUESTION!QUESTION!

Hope Knight BSN, RNHope Knight BSN, RN

Fig 25-1 structures of respiratory tract

STRUCTURE OF LUNGSSTRUCTURE OF LUNGS

Upper Respiratory TractUpper Respiratory Tract

Lower Respiratory TractLower Respiratory Tract

Chest WallChest Wall

Structures of Lower AirwaysStructures of Lower Airways

Fig 25-3 structure of lower airway

Fig 25-5 total thickness is less than 1/5000 inch

Fig 25-7

ARTERIAL BLOOD GASESARTERIAL BLOOD GASES

Normal ValuesNormal Values PH 7.35 – 7.45PH 7.35 – 7.45 PaOPaO2 2 80-100mm Hg80-100mm Hg PaCOPaCO2 2 35-45 mm Hg35-45 mm Hg HCOHCO33 22-26 mEq/L 22-26 mEq/L SaOSaO2 2 >95%>95%

INTERPRETATION OF ABGINTERPRETATION OF ABG

ACID ACID BASEBASE

PhPh PaCOPaCO22 HCOHCO33

NORMALNORMAL 7.357.35 35-4535-45 22-2622-26RESP. RESP. ACIDOSISACIDOSIS

NORMALNORMAL

RESP.RESP.

ALKALOSISALKALOSISNORMALNORMAL

METABOLIC METABOLIC ACIDOSISACIDOSIS

NORMALNORMAL

METABOLIC METABOLIC ALKALOSISALKALOSIS

NORMALNORMAL

Table 25-2 S/S inadequate oxygenation

Swan Ganz catheter used to measure Pulmonary Swan Ganz catheter used to measure Pulmonary Artery Pressure. Elevation seen in Pulmonary Artery Pressure. Elevation seen in Pulmonary

disease, pulmonary embolism, pulmonary disease, pulmonary embolism, pulmonary hypertension, left ventricular failure, MI. Decrease hypertension, left ventricular failure, MI. Decrease

noted in hypovolemia.noted in hypovolemia.

GERENTOLIGIC DIFFERENCES GERENTOLIGIC DIFFERENCES IN ASSESSMENTIN ASSESSMENT

CUES TO RESPIRATORY PROBLEMS CUES TO RESPIRATORY PROBLEMS

Pulmonary Function Test measures lung Pulmonary Function Test measures lung volumes and air flow. volumes and air flow.

Obstructive Sleep Apnea fig 26-4Obstructive Sleep Apnea fig 26-4

Collaborative Management and Nursing Care Collaborative Management and Nursing Care for Obstructive Sleep Apneafor Obstructive Sleep Apnea

BIPAP/CPAP MACHINESBIPAP/CPAP MACHINES

CLINICAL APPLICATION FOR CLINICAL APPLICATION FOR BIPAPBIPAP

•BiPAP is essentially pressure BiPAP is essentially pressure support ventilation with CPAP. The support ventilation with CPAP. The flow of gas switches between a flow of gas switches between a high inspiratory positive airway high inspiratory positive airway pressure (IPAP) and a low expiratory pressure (IPAP) and a low expiratory positive airway pressure (EPAP). positive airway pressure (EPAP). The difference between IPAP and The difference between IPAP and EPAP is the pressure support level EPAP is the pressure support level and contributes to the total and contributes to the total ventilation.ventilation.

CONTRAINDICATIONS FOR CONTRAINDICATIONS FOR BIPAPBIPAP

Need for immediate intubation.Need for immediate intubation. Hemodynamic instability.Hemodynamic instability. Uncooperative patient.Uncooperative patient. Facial burns or trauma.Facial burns or trauma. Need for airway protection.Need for airway protection.

PULMONARY EMBOLIPULMONARY EMBOLI

Thrombi in venous Thrombi in venous circulation or right circulation or right side of the heart side of the heart occlude pulmonary occlude pulmonary arterial blood flow arterial blood flow to parts of lungto parts of lung

CLASSIFICATION OF CLASSIFICATION OF RESPIRATORY FAILURERESPIRATORY FAILURE

ACUTE RESPIRATORY ACUTE RESPIRATORY FAILUREFAILURE

Hypoxemic RespiratoryHypoxemic Respiratory Ventilation Perfusion (V/Q mismatch)Ventilation Perfusion (V/Q mismatch) ShuntShunt Diffusion LimitationDiffusion Limitation Alveolar HypoventilationAlveolar Hypoventilation

Hypercapnic Respiratory FailureHypercapnic Respiratory Failure Airway and alveoliAirway and alveoli Central nervous systemCentral nervous system Chest WallChest Wall Neuromuscular ConditionNeuromuscular Condition

VENTILATION TO PERSUSION VENTILATION TO PERSUSION RELATIONSHIPS (V/Q RELATIONSHIPS (V/Q

mismatch)mismatch)

DIFFUSION LIMITATIONDIFFUSION LIMITATION

ACUTE RESPIRATORY FAILURE ACUTE RESPIRATORY FAILURE MANIFESTATIONSMANIFESTATIONS

Develops suddenly or graduallyDevelops suddenly or gradually Compensatory mechanismsCompensatory mechanisms Mental status changesMental status changes TachycardiaTachycardia Mild hypertensionMild hypertension Severe morning headacheSevere morning headache Cyanosis (late sign)Cyanosis (late sign)

NURSING AND NURSING AND COLLABORATIVE COLLABORATIVE MANAGEMENTMANAGEMENT

Respiratory therapyRespiratory therapy Nasal cannula, simple face mask, venturi mask, Nasal cannula, simple face mask, venturi mask,

positive pressure ventilation, mechanical ventilationpositive pressure ventilation, mechanical ventilation

Mobilization of secretionsMobilization of secretions Positive Pressure VentilationPositive Pressure Ventilation Nutrition Nutrition Diet – Drug interactionsDiet – Drug interactions

ARDSARDS

Sudden and Progressive form of Sudden and Progressive form of acute respiratory failureacute respiratory failure

Mortality is 50%Mortality is 50% Injury or Exudative phaseInjury or Exudative phase Reparative or Proliferative PhaseReparative or Proliferative Phase Fibrotic PhaseFibrotic Phase ComplicationsComplications

STAGES OF EDEMA STAGES OF EDEMA FORMATION FORMATION

IN ARDSIN ARDS

PHYSIOLOGY OF ARDSPHYSIOLOGY OF ARDS

PREDISPOSING FACTORS OF PREDISPOSING FACTORS OF ARDSARDS

DIAGNOSTIC FINDINGS IN DIAGNOSTIC FINDINGS IN ARDSARDS

TABLE 66-8

MECHANICAL VENTILATORSMECHANICAL VENTILATORS

Servo type ventilator7200 type ventilator

Care Standards for the Care Standards for the Ventilator PatientVentilator Patient

Normal Saline as a lavage is Normal Saline as a lavage is NOTNOT used used routinely during suctioning.routinely during suctioning.

Perform vigorous oral care Q2 hours and PRN.Perform vigorous oral care Q2 hours and PRN. Position patient in a semi-upright position with Position patient in a semi-upright position with

head of bed elevated 30° to 45° to reduce the head of bed elevated 30° to 45° to reduce the possibility of aspiration.possibility of aspiration.

ALARMS!!! Check the patient! Bag the patient ALARMS!!! Check the patient! Bag the patient if Sats (Sa02) are low and then check the if Sats (Sa02) are low and then check the machine. Always remember, patient first!!machine. Always remember, patient first!!

MODES OF VENTILATION - MODES OF VENTILATION - CMVCMV

Volume Control Ventilation (CMV, Volume Control Ventilation (CMV, A/C, VC)A/C, VC)

The clinician sets the The clinician sets the tidal volumetidal volume (Vt) to (Vt) to be delivered at a preset be delivered at a preset minimumminimum rate. rate.

Each time the patient initiates a breath with Each time the patient initiates a breath with a negative inspiratory effort or flow a negative inspiratory effort or flow reaching or exceeding a set threshold, the reaching or exceeding a set threshold, the ventilator delivers an additional breath at ventilator delivers an additional breath at the the preset Vtpreset Vt..

The The patient can increase the ventilator patient can increase the ventilator raterate, and therefore ventilatory support, on , and therefore ventilatory support, on demand. demand.

MODES OF VENTILATION SIMV MODES OF VENTILATION SIMV

Synchronized Intermittent Mandatory Synchronized Intermittent Mandatory Ventilation (SIMV) Ventilation (SIMV)

The clinician The clinician sets a Vt for a preset number sets a Vt for a preset number of breaths each minute.of breaths each minute.

Additional breaths initiated by the patient are Additional breaths initiated by the patient are spontaneous; patient controls Vt and RR.spontaneous; patient controls Vt and RR.

The synchronization allows the ventilator to The synchronization allows the ventilator to deliver the preset machine breaths between deliver the preset machine breaths between the patient’s spontaneous inspiratory efforts.the patient’s spontaneous inspiratory efforts.

Modes of ventilation -- Modes of ventilation --

SIMV with PS (Pressure Support) SIMV with PS (Pressure Support) Pressure Support is added to the Pressure Support is added to the

spontaneous breaths in order to spontaneous breaths in order to “boost” the patient’s Vt.“boost” the patient’s Vt.

Advantages: Advantages: Allows the patient to assume a portion of Allows the patient to assume a portion of

their ventilatory requirement.their ventilatory requirement. The negative inspiratory pressure The negative inspiratory pressure

generated by spontaneous breathing generated by spontaneous breathing leads to increased venous return to the leads to increased venous return to the right side of the heart, which may right side of the heart, which may improve cardiac output and improve cardiac output and cardiovascular function.cardiovascular function.

MODES OF VENTILATION - MODES OF VENTILATION - PCVPCV

Pressure Control Ventilation (PCV):Pressure Control Ventilation (PCV): PCV is a time-cycled mode of ventilation PCV is a time-cycled mode of ventilation

that allows limitation of peak inspiratory that allows limitation of peak inspiratory pressures (PIP).pressures (PIP).

The The PIP is set by the clinicianPIP is set by the clinician and the and the Vt (tidal volume) and VVt (tidal volume) and VEE (minute (minute ventilation) are a result of changes in ventilation) are a result of changes in the lung compliance or airway the lung compliance or airway resistance.resistance.

MODES OF VENTILATION – P/S MODES OF VENTILATION – P/S

Spontaneous - Pressure Spontaneous - Pressure Support (PSV or PS)Support (PSV or PS)

This mode is completely patient controlled This mode is completely patient controlled -- -- Patient controls/sets their own Patient controls/sets their own respiratory rate, duration of respiratory rate, duration of inspiration, gas flow rate, and Vt.inspiration, gas flow rate, and Vt.

The The machine delivers a preset machine delivers a preset pressurepressure -- Vt will vary depending on the -- Vt will vary depending on the patient’s lung compliance.patient’s lung compliance.

The inspiratory assist is used to overcome The inspiratory assist is used to overcome the increased resistance and WOB the increased resistance and WOB imposed by the disease process, the imposed by the disease process, the endotracheal tube (ET), inspiratory valves, endotracheal tube (ET), inspiratory valves, and other mechanical aspects of and other mechanical aspects of ventilatory support.ventilatory support.

MODES OF VENTILATION P/S MODES OF VENTILATION P/S CONT. CONT.

Spontaneous - Pressure Support continuedSpontaneous - Pressure Support continued The delivered Vt is affected by The delivered Vt is affected by

pulmonary compliance and resistance.pulmonary compliance and resistance. The amount of pressure support set The amount of pressure support set

during mechanical ventilation is titrated during mechanical ventilation is titrated according to the according to the RRRR and the Vt of the and the Vt of the patient.patient.

Advantage: comfort and tolerance the Advantage: comfort and tolerance the mode offers patients. Reducing the mode offers patients. Reducing the WOB.WOB.

MODES OF VENTILATION - MODES OF VENTILATION - CPAPCPAP

CPAP (Continuous Positive Airway CPAP (Continuous Positive Airway Pressure)Pressure)• All breaths are controlled by the All breaths are controlled by the

patient. patient. • This mode simply delivers FiOThis mode simply delivers FiO22 and a and a

variable flow with or without a preset variable flow with or without a preset inspiratory and/or expiratory pressure.inspiratory and/or expiratory pressure.

MODES OF VENTILATION - PEEPMODES OF VENTILATION - PEEP

Positive End Expiratory Pressure- the Positive End Expiratory Pressure- the application and maintenance of application and maintenance of pressure above atmospheric at the pressure above atmospheric at the airway throughout the expiratory airway throughout the expiratory phase of positive pressure phase of positive pressure mechanical ventilation.mechanical ventilation.

Physiologic Effects of CPAP & Physiologic Effects of CPAP & PEEPPEEP

PEEP/CPAP will reduce sub-PEEP/CPAP will reduce sub-atmospheric intrathoracic pressure atmospheric intrathoracic pressure seen at end-expiration or even seen at end-expiration or even change it to positive values.change it to positive values. This may exert profound effects on the This may exert profound effects on the

circulation by increasing CVP and circulation by increasing CVP and decreasing venous return to the heart decreasing venous return to the heart (preload), thereby decreasing cardiac (preload), thereby decreasing cardiac output.output.

Weaning from Mechanical Weaning from Mechanical VentilationVentilation

Assessing for weaning readinessAssessing for weaning readiness Weaning techniquesWeaning techniques Causes of weaning failureCauses of weaning failure Weaning protocolsWeaning protocols