Respiratory Care Modalities

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 NonrebreathingMask

Partial Rebreathing Mask

T-Piece and Tracheostomy Collar

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.

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.

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.

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- Lower Lobes, Anterior Basal Segment

Postural Drainage- Upper Lobes, Anterior SegmentsPostural Drainage- Upper Lobes, Anterior Segments

Postural Drainage- Lower Lobes, Lateral basal segmentsPostural Drainage- Lower Lobes, Lateral basal segments

Postural Drainage- Upper Lobes, Apical SegmentsPostural Drainage- Upper Lobes, Apical Segments

Postural Drainage- Lower Lobes, Superior SegmentsPostural Drainage- Lower Lobes, Superior Segments

Postural Drainage- Upper Lobes, Posterior SegmentsPostural Drainage- Upper Lobes, Posterior Segments

Percussion and Vibration

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 • Patient assessment• Risk for injury/airway compromise related to tube

removal• Patient and family teaching

Endotracheal Tube

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

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

Noninvasive Positive–Pressure 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)

Positive Pressure Ventilator

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

Weaning

• Process of withdrawal of dependence upon the ventilator

• Successful weaning is a collaborative process • Criteria for weaning• Patient preparation• Methods of weaning

Patients Undergoing Thoracic Surgery

• Preoperative assessment• Preoperative preparation• Patient teaching• Reduction of anxiety• Postoperative expectations• Strategies to reduce postoperative

complications: atelectasis and infection

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

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