MECHANICAL VENTILATION The mechanical ventilator device functions as a substitute for the bellows action of the thoracic cage

and diaphragm. The mechanical ventilator can maintain ventilation automatically for prolonged periods. It is indicated when the patient is unable to maintain safe levels of oxygen or CO2 by spontaneous breathing even with the assistance of other oxygen delivery devices. Clinical Indications Mechanical Failure of Ventilation

Neuromuscular disease CNS disease CNS depression (drug intoxication, respiratory depressants, cardiac arrest) Inefficiency of thoracic cage in generating pressure gradients necessary for ventilation (chest injury, thoracic malformation) When ventilatory support is needed postoperatively

Disorders of Pulmonary Gas Exchange

Acute respiratory failure Chronic respiratory failure Left-sided heart failure Pulmonary diseases resulting in diffusion abnormality Pulmonary diseases resulting in V/Q mismatch Acute lung injury

Underlying Principles

Variables that control ventilation and oxygenation include: o Ventilator rateadjusted by rate setting. o VTvolume of gas required for one breath (ml/kg) o Fraction of inspired oxygen concentration (FiO2)set on ventilator and measured with an oxygen analyzer. o Ventilator dead spacecircuitry (tubing) common to inhalation and exhalation; tubing is calibrated. o PEEPset within the ventilator or with the use of external PEEP devices; measured at the proximal airway. CO2 elimination is controlled by VT, rate, and dead space. Oxygen tension is controlled by oxygen concentration and PEEP (also by rate and VT). In most cases, the duration of inspiration should not exceed exhalation. The inspired gas must be warmed and humidified to prevent thickening of secretions and decrease in body temperature. Sterile or distilled water is warmed and humidified by way of a heated humidifier.

Types of Ventilators Negative Pressure Ventilators

Applies negative pressure around the chest wall. This causes intra-airway pressure to become negative, thus drawing air into the lungs through the patient's nose and mouth. P.256

No artificial airway is necessary; patient must be able to control and protect own airway. Indicated for selected patients with respiratory neuromuscular problems, or as adjunct to weaning from positive pressure ventilation. Examples are the iron lung and cuirass (shell unit) ventilator.

Positive Pressure Ventilators During mechanical inspiration, air is actively delivered to the patient's lungs under positive pressure. Exhalation is passive. Requires use of a cuffed artificial airway.

Pressure cycled. o Delivers selected gas pressure during inspiratory phase. o Volume delivered depends on lung compliance and resistance. o Use of volume-based alarms is recommended because any obstruction between the machine and lungs that allows a buildup of pressure in the ventilator circuitry will cause the ventilator to cycle, but the patient will receive no volume. o Exhaled tidal volume is the variable to monitor closely. Volume limited. o Designated volume of air is delivered with each breath regardless of resistance and compliance. Usual starting volume is 6 to 8 ml/kg. o Delivers the predetermined volume regardless of changing lung compliance (although airway pressures will increase as compliance decreases). Airway pressures vary from patient to patient and from breath to breath. o Pressure-limiting valves, which prevent excessive pressure buildup within the patient-ventilator system, are used. Without this valve, pressure could increase indefinitely and pulmonary barotrauma could result. Usually equipped with a system that alarms when selected pressure limit is exceeded. Pressure-limited settings terminate inspiration when reached.

Modes of Operation Controlled Ventilation

Patient receives a set number and volume of breaths/minute. Provides a fixed level of ventilation, but will not cycle or have gas available in circuitry to respond to patient's own inspiratory efforts. This typically increases work of breathing for patients attempting to breathe spontaneously. Generally used for patients who are unable to initiate spontaneous breaths.

Assist/Control

Inspiratory cycle of ventilator is activated by the patient's voluntary inspiratory effort and delivers a preset full volume. Ventilator also cycles at a rate predetermined by the operator. Should the patient not initiate a spontaneous breath, or breathe so weakly that the ventilator cannot function as an assistor, this mandatory baseline rate will provide a minimum respiratory rate. Indicated for patients who are breathing spontaneously, but who have the potential to lose their respiratory drive or muscular control of ventilation. In this mode, the patient's work of breathing is greatly reduced.

Intermittent Mandatory Ventilation (IMV)

Allows patients to breathe at their own rate and volume spontaneously through ventilator circuitry. Periodically, at preselected rate and volume or pressure, cycles to give a mandated ventilator breath. Ensures that a predetermined number of breaths at a selected tidal volume are delivered each minute. Gas provided for spontaneous breaths usually flows continuously through the ventilator. Indicated for patients who are breathing spontaneously, but at a VT and/or rate less than adequate for their needs. Allows the patient to do some of the work of breathing.

Synchronized Intermittent Mandatory Ventilation (SIMV)

Allows patient to breathe at their own rate and volume spontaneously through the ventilator circuitry. Periodically, at a preselected time, a mandatory breath is delivered. The mandatory breaths are synchronized with the patient's inspiratory effort. Gas provided for spontaneous breathing flows continuously through the ventilator. Ensures that a predetermined number of breaths at a selected VT are delivered each minute. Indicated for patients who are breathing spontaneously, but at a VT and/or rate less than adequate for their needs. Allows the patient to do some of the work of breathing.

Pressure Support

Augments inspiration to a spontaneously breathing patient. Maintains a set positive pressure during spontaneous inspiration. The patient ventilates spontaneously, establishing own rate, VT, and inspiratory time. Pressure support may be used independently as a ventilatory mode or used in conjunction with CPAP or synchronized intermittent mandatory ventilation.

Positive Pressure Ventilation Techniques Positive End-Expiratory Pressure

Maneuver by which pressure during mechanical ventilation is maintained above atmospheric at end of exhalation, resulting in an increased functional residual capacity. Airway pressure is therefore positive throughout the entire ventilatory cycle. P.257

Purpose is to increase functional residual capacity (or the amount of air left in the lungs at the end of expiration). This aids in: o Increasing the surface area of gas exchange. o Preventing collapse of alveolar units and development of atelectasis. o Decreasing intrapulmonary shunt. o Improving lung compliance. o Improving oxygenation. o Recruiting alveolar units that are totally or partially collapsed. Benefits: o Because a greater surface area for diffusion is available and shunting is reduced, it is often possible to use a lower FiO2 than otherwise would be required to obtain adequate arterial oxygen levels. This reduces the risk of oxygen toxicity in conditions such as acute respiratory distress syndrome (ARDS). o Positive intra-airway pressure may be helpful in reducing the transudation of fluid from the pulmonary capillaries in situations where capillary pressure is increased (ie, left-sided heart failure). o Increased lung compliance resulting in decreased work of breathing. Hazards: o Because the intrathoracic pressure is increased by PEEP, venous return is impeded. This may result in:

decreased cardiac output and decreased oxygen delivery to the tissues (especially noted in hypovolemic patients) decreased renal perfusion ICP hepatic congestion. o The decreased venous return may cause antidiuretic hormone formation to be stimulated, resulting in decreased urine output. Precautions: o Monitor frequently for signs and symptoms of respiratory distressshortness of breath, dyspnea, tachycardia, chest pain. o Monitor frequently for signs and symptoms of pneumothorax (increased PAP, increased size of hemothorax, uneven chest wall movement, hyperresonant percussion, distant or absent breath sounds). o Monitor for signs of decreased venous return (decreased BP, decreased cardiac output, decreased urine output, peripheral edema). o Abrupt discontinuance of PEEP is not recommended. The patient should not be without PEEP for longer than 15 seconds. The manual resuscitation bag used for ventilation during suction procedure or patient transport should be equipped with a PEEP device. In-line suctioning may also be used so that PEEP can be maintained. o Intrapulmonary blood vessel pressure may increase with compression of the vessels by increased intra-airway pressure. Therefore, central venous pressure (CVP), PAP, and pulmonary capillary wedge pressure may be increased. The clinician must bear this in mind when determining the clinical significance of these pressures.

Continuous Positive Airway Pressure

Assists the spontaneously breathing patients to improve oxygenation by elevating the end-expiratory pressure in the lungs throughout the respiratory cycle. May be delivered through ventilator circuitry when ventilator rate is at 0 or may be delivered through a separate CPAP circuitry that does not require the ventilator. Indicated for patients who are capable of maintaining an adequate VT, but who have pathology preventing maintenance of adequate levels of tissue oxygenation or for sleep apnea. CPAP has the same benefits, hazards, and precautions noted with PEEP. Mean airway pressures may be lower because of lack of mechanical ventilation breaths. This results in less risk of barotrauma and impedance of venous return.

Newer Modes of Ventilation Inverse Ratio Ventilation

I:E ratio is greater than 1, in which inspiration is longer than expiration. Potentially used in patients who are in acute severe hypoxemic respiratory failure. Oxygenation is thought to be improved. Very uncomfortable for patients; need to be heavily sedated. Pressure-controlled inverse ratio ventilationused in ARDS and acute lung injury. Pressure-regulated volume control ventilator mode is a volume-targeted mode used in acute respiratory failure that combines the advantages of the decelerating inspiratory flow pattern of a pressure-control mode with the ease of use of a volume-control (VC) mode.

Airway Pressure Release Ventilation

Ventilator cycles between two different levels of CPAP. The baseline airway pressure is the upper CPAP level and the pressure is intermittently released. Uses a short expiratory time. Used in severe ARDS/acute lung injury.

Non-invasive Positive Pressure Ventilation

Uses a nasal or face mask, or nasal pillows. Delivers air through a volume or pressure controlled ventilator. Used primarily in the past for patients with chronic respiratory failure associated with neuromuscular disease. Now is being used successfully during acute exacerbations. Some patients are able to avoid invasive intubation. Other indications include acute or chronic respiratory distress, acute pulmonary edema, pneumonia, COPD exacerbation, weaning, and postextubation respiratory decompensation. P.258

Can be used in the home setting. Equipment is portable and relatively easy to use. Eliminates the need for intubation, preserves normal swallowing, speech, and the cough mechanism. May include BiPAP, which is essentially pressure support with CPAP. The system has a rate setting as well as inspiratory and expiratory pressure setting.

High-Frequency Ventilation

Uses very small VT (dead space ventilation) and high frequency (rates greater than 100/minute).

Gas exchange occurs through various mechanisms, not the same as conventional ventilation (convection). Types include: o High-frequency oscillatory ventilation. o High-frequency jet ventilation. Theory is that there is decreased barotrauma by having small VT and that oxygenation is improved by constant flow of gases. Successful with infant respiratory distress syndrome, much less successful with adult pulmonary complications.

Nursing Assessment and Interventions

Monitor for complications: o Airway aspiration, decreased clearance of secretions, ventilator-acquired pneumonia, tracheal damage, laryngeal edema o Impaired gas exchange o Ineffective breathing pattern o ET tube kinking, cuff failure, mainstem intubation o Sinusitis o Pulmonary infection o Barotrauma (pneumothorax, tension pneumothorax, subcutaneous emphysema, pneumomediastinum) o Decreased cardiac output o Atelectasis o Alteration in GI function (stress ulcers, gastric distention, paralytic ileus) o Alteration in renal function o Alteration in cognitive-perceptual status Suction the patient as indicated. o When secretions can be seen or sounds resulting from secretions are heard with or without the use of a stethoscope o After chest physiotherapy o After bronchodilator treatments o Increased peak airway pressure in mechanically ventilated patients that is not due to the artificial airway or ventilator tube kinking, the patient biting the tube, the patient coughing or struggling against the ventilator, or a pneumothorax. Provide routine care for patient on mechanical ventilator (see Procedure Guidelines 1019). Provide regular oral care to prevent ventilator-associated pneumonia. Provide humidity and repositioning to mobilize secretions. Assist with the weaning process, when indicated (patient gradually assumes responsibility for regulating and performing own ventilations; see Procedure Guidelines 10-20, pages 263 to 265).

Patient must have acceptable ABG values, no evidence of acute pulmonary pathology, and must be hemodynamically stable. o Obtain serial ABGs and/or oximetry readings, as indicated. o Monitor very closely for change in pulse and BP, anxiety, and increased rate of respirations. o The patient is awake and cooperative and displays optimal respiratory drive. Once weaning is successful, extubate and provide alternate means of oxygen (see Procedure Guidelines 10-21, pages 265 to 267). Extubation will be considered when the pulmonary function parameters of VT, VC, and negative inspiratory pressure are adequate, indicating strong respiratory muscle function.

Community and Home Care Considerations Patients may require mechanical ventilation at home to replace or assist normal breathing. Ventilator support in the home is used to keep patient clinically stable and to maintain life.

Candidates for home ventilation are those patients who are unable to wean from mechanical ventilation, and/or have disease progression requiring ventilator support. Candidates for home mechanical ventilator support: o Have a secure artificial airway (tracheostomy tube). o Have FiO2 requirement 40%. o Are medically stable. o Are able to maintain adequate ventilation on standard ventilator settings. Patients may choose not to receive home ventilation. Examples of inappropriate candidates for home ventilation include patients who: o Have a FiO2 40%. o Use PEEP > 10 cm H2O. o Require continuous invasive monitoring. o Lack a mature tracheostomy. o Lack able, willing, appropriate caregivers, and/or caregiver respite. o Lack adequate financial resources for care in home. o Lack adequate physical facilities: Inadequate heat, electricity, sanitation. Presence of fire, health, or safety hazards. For patients on mechanical ventilation in the home, a contract and relationship with a home medical equipment company must be developed to provide: o Care of ventilator-dependent patient. o Provision and maintenance of equipment. o Timely provision of disposable supplies. o Ongoing monitoring of patient and equipment. o Training of patient, caregivers, and clinical staff on proper management of ventilated patient and use and troubleshooting of equipment.

Equipment required: o Appropriate ventilator with alarms (disconnect and high pressure). o Power source. o Humidification system. o Manual resuscitation bag with tracheostomy adapter. o Replacement tracheostomy tubes. o Supplemental oxygen, as medically indicated. o Communication method for patient. o Backup charged battery to run ventilator during power failures. Lay caregiver training and return demonstration must include: o Proper setup, use, troubleshooting, maintenance, and cleaning and infection control of equipment and supplies. o Appropriate patient assessment and management of abnormalities, including cardiopulmonary resuscitation, response to emergencies, power and equipment failure. Potential complications include: o Patient deterioration, need for emergency services. o Equipment failure, malfunction. o Psychosocial complications, including depression, anxiety, and/or loss of resources (caregiver, financial, detrimental change in family structure or coping capacity). Communication is essential with local emergency medical services (fire, police, rescue) and utility (telephone, electric) companies from whom the patient would need immediate and additional assistance in event of emergency (eg, power failure, fire).

P.259

PROCEDURE GUIDELINES 10-19 Managing the Patient Requiring Mechanical Ventilation EQUIPMENT

Artificial airway (endotracheal ET tube or tracheostomy) Manual self-inflating resuscitation bag Pulse oximetry Suction equipment Mechanical ventilator Ventilation circuitry Humidifier

See manufacturer's directions for specific machine

PROCEDURE Nursing Action Preparatory phase 1. Obtain baseline samples for blood gas determinations (pH, PaO2, PaCO2, HCO3-) and chest X-ray. Performance phase 1. Give a brief explanation to the patient and family.

Rationale 1. Baseline measurements serve as a guide in determining progress of therapy.

1. Emphasize that mechanical ventilation is a temporary measure. The patient should be prepared psychologically for weaning at the time the ventilator is first used. 2. Premedicate as needed. 2. To promote cooperation through mild sedation. 3. Establish the airway by means of a cuffed ET 3. A closed system between the ventilator and or tracheostomy tube (see pages 216-222). patient's lower airway is necessary for positive pressure ventilation. 4. Prepare the ventilator. (Respiratory therapist 4. To have all equipment and settings in place does this in many facilities.) before applying to patient. a. Set up desired circuitry. b.Connect oxygen and compressed air source. c. Turn on power. d.Set VT (usually 6 to 8 mL/kg body weight d.Adjusted according to pH and PaCO2. Morton). e. Set oxygen concentration. f. Set ventilator sensitivity. e. Adjusted according to PaO2. g.Set rate at 12 to 14 breaths/minute (variable). g.This setting approximates normal ventilation. These machines' settings are subject to change according to the patient's condition and response, and the ventilator type being used. h.Set inspiratory-expiratory (I:E) times h.The slower the flow, the lower the peak (varies depending on the ventilator). Adjust airway pressure will result from set volume flow rate (velocity of gas flow during delivery. This results in lower intrathoracic inspiration). Usually set at 40 to 60 pressure and less impedance of venous L/minute. Depends on rate and VT. return. However, a flow that is too low for the rate selected may result in inverse I:E ratios.

i. Select mode of ventilation. j. Check machine functionmeasure VT, j. Ensures safe function. rate, I:E ratio, analyze oxygen, check all alarms. 5. Couple the patient's airway to the ventilator. 5. Make sure all connections are secure. Prevent ventilator tubing from pulling on artificial airway, possibly resulting in tube dislodgement or tracheal damage. 6. Assess patient for adequate chest movement 6. Ensures proper function of equipment. and rate. Note peak airway pressure and PEEP. 7. Set airway pressure alarms according to 7. patient's baseline: a. High pressure alarm a. High airway pressure is set at 10 to 15 cm H2O above peak inspiratory pressure. An alarm sounds if airway pressure selected is exceeded. Alarm activation indicates decreased lung compliance (worsening pulmonary disease); decreased lung volume (such as pneumothorax, tension pneumothorax, hemothorax, pleural effusion); increased airway resistance (secretions, coughing, bronchospasm, breathing out of phase with the ventilator); loss of patency of airway (mucus plug, airway spasm, biting or kinking of tube). b.Low pressure alarm b.Low airway pressure alarm set at 5 to 10 cm H2O below peak inspiratory pressure. Alarm activation indicates inability to build up airway pressure because of disconnection or leak, and changing compliance and resistance. 8. Assess frequently for change in respiratory status by evaluation of ABGs, pulse oximetry, spontaneous rate, use of accessory muscles, breath sounds, and vital signs. Other means of assessing are through the use of exhaled carbon dioxide (see Capnography, page 215, or oxygen saturation monitoring, page 213). If change

is noted, notify appropriate personnel. 9. Monitor and troubleshoot alarm conditions. 9. Priority is ventilation and oxygenation of the Ensure appropriate ventilation at all times. patient. In alarm conditions that cannot be immediately corrected, disconnect the patient from mechanical ventilation and manually ventilate with resuscitation bag. 10.Check for secure stabilization of artificial 10.Reduces risk of inadvertent extubation. airway. 11.Positioning: 11. a. Turn patient from side to side every 2 a. For patients on long-term ventilation, this hours, or more frequently if possible. may result in sleep deprivation. Follow a Consider kinetic therapy as early turning schedule best suited to a particular intervention to improve outcome. patient's condition. Repositioning may improve secretion clearance and reduce atelectasis. b.Lateral turns are desirable; from right semiprone to left semiprone. c. Sit the patient upright at regular intervals if c. Upright posture increases lung compliance. possible. d.Consider prone positioning to improve d.Proning has been shown to have some oxygenation. beneficial effects or the improvement of oxygenation in certain populations, such as patients with ARDS. 12.Carry out passive range-of-motion exercises 12.To prevent contractures. of all extremities for patients unable to do so. 13.Assess for need of suctioning at least every 2 13.Patients with artificial airways on hours. mechanical ventilation are unable to clear secretions on their own. Suctioning may help to clear secretions and stimulate the cough reflex. 14.Assess breath sounds every 2 hours: 14. a. Listen with stethoscope to the chest in all a. Auscultation of the chest is a means of lobes bilaterally. assessing airway patency and ventilatory distribution. It also confirms the proper placement of the ET or tracheostomy tube. 14.b.Determine whether breath sounds are present or absent, normal or abnormal, and whether a change has occurred. c. Observe the patient's diaphragmatic excursions and use of accessory muscles of

respiration. 15.Humidification.

15.Humidity may improve secretion mobilization. a. Check the water level in the humidification a. Water condensing in the inspiratory tubing reservoir to ensure that the patient is never may cause increased resistance to gas flow. ventilated with dry gas. Empty the water This may result in increased peak airway that condenses in the delivery and pressures. Warm, moist tubing is a perfect exhalation tubing into a separate breeding area for bacteria. If this water is receptacle, not into the humidifier. Always allowed to enter the humidifier, bacteria wash hands before and after emptying fluid may be aerosolized into the lungs. from ventilator circuitry. Humidification Emptying the tubing also prevents may also be achieved using a moisture introduction of water into the patient's enhancer. airways. 16.Assess airway pressures at frequent intervals. 16.Monitor for changes in compliance, or onset of conditions that may cause airway pressure to increase or decrease. 17.Measure delivered VT and analyze oxygen 17.To ensure that patient is receiving the concentration every 4 hours or more appropriate ventilatory assistance. frequently if indicated. (Respiratory therapist performs this in most facilities.) 18.Monitor cardiovascular function. Assess for 18. abnormalities. a. Monitor pulse rate and arterial BP; intraa. Arterial catheterization for intra-arterial arterial pressure monitoring may be carried pressure monitoring also provides access out. for ABG samples. b.Use pulmonary artery catheter to monitor b.Intermittent and continuous positive pulmonary capillary wedge pressure pressure ventilation may increase the PAP (PCWP), mixed venous oxygen saturation and decrease cardiac output. (SvO2), and cardiac output (CO). 19.Provide mouth care every 1-4 hours and 19. assess for development of pressure areas from ET tubes. a. Monitor for systemic signs and symptoms a. For comfort and reduced risk of infection. of pulmonary infection (pulmonary physical examination findings, increased heart rate, increased temperature, increased count). 20.Evaluate need for sedation or muscle 20.Sedatives may be prescribed to decrease relaxants. anxiety, or to relax the patient to prevent competing with the ventilator. At times,

pharmacologically induced paralysis may be necessary to permit mechanical ventilation. 21.Use ventilator bundle protocol, as directed, 21.To reduce the risk of aspiration, peptic ulcer, to prevent ventilator-associated and deep vein prophylaxis; and to reduce complications. sedation that may interfere with assessment. a. Elevate the head of the bed to between 30 and 45 degrees. b.Daily sedative interruption and daily assessment of readiness to extubate. c. Peptic ulcer disease prophylaxis. d.Deep vein thrombosis prophylaxis (unless contraindicated). 22.Report intake and output precisely and obtain 22.Positive fluid balance resulting in increase in an accurate daily weight to monitor fluid body weight and interstitial pulmonary balance. edema is a frequent problem in patients requiring mechanical ventilation. Prevention requires early recognition of fluid accumulation. An average adult who is dependent on parenteral nutrition can be expected to lose 12 lb (0.25 kg) per day; therefore, constant body weight indicates positive fluid balance. 23.Monitor nutritional status. 23.Patients on mechanical ventilation require inflation of artificial airway cuffs at all times. Patients with tracheostomy tubes may eat, if capable, or may require enteral feeding tubes or parenteral nourishment. Patients with ET tubes are to receive nothing by mouth (the tube splints the epiglottis open) and must be entirely tube fed or parenterally nourished. 24.Monitor GI function. 24.Mechanically ventilated patients are at risk for development of stress ulcers. a. Test all stools and gastric drainage for a. Stress may cause some patients requiring occult blood (if part of facility protocol). mechanical ventilation to develop GI bleeding. 25.Provide for care and communication needs of patient with an artificial airway. 26.Provide psychological support. 26.Mechanical ventilation may result in sleep deprivation and loss of touch with surroundings and reality.

a. Assist with communication. b.Orient to environment and function of mechanical ventilator. c. Ensure that the patient has adequate rest and sleep. Follow-up phase 1. Maintain a flow sheet to record ventilation 1. Establishes means of assessing effectiveness patterns, ABGs, venous chemical and progress of treatment. determinations, hemoglobin and hematocrit, status of fluid balance, weight, and assessment of the patient's condition. Notify appropriate personnel of changes in the patient's condition. 2. Change ventilator circuitry per facility 2. Prevents contamination of lower airways. protocol; assess ventilator's function every 4 hours or more frequently if problem occurs. NURSING ALERT For patients in severe compromised respiratory state or who are unstable hemodynamically, consider use of specialty bed with kinetic therapy. DRUG ALERT Never administer paralyzing agents until the patient is intubated and on mechanical ventilation. Sedatives should be prescribed in conjunction with paralyzing agents, because the patient may not be able to move but can still have awareness of his surroundings and inability to move. Evidence Base Chulay, M., and Burns, S. (2006). AACN essentials of critical care nursing. New York: McGraw-Hill. Morton, P., et al. (2005). Critical care nursing: A holistic approach (8th ed). Philadelphia: Lippincott Williams & Wilkins. P.263

PROCEDURE GUIDELINES 10-20 Weaning the Patient from Mechanical Ventilation EQUIPMENT

Varies according to technique used Briggs T-piece (see page 243) Intermittent mandatory ventilation (IMV) or synchronized intermittent mandatory ventilation (SIMV) (set up in addition to ventilator or incorporated inventilator and circuitry) Pressure support

PROCEDURE P.264

Nursing Action Preparatory phase 1.For weaning to be successful, the patient must be physiologically capable of maintaining spontaneous respirations. Assessments must ensure that:

Rationale 1.Provides baseline; ensures that patient is capable of having adequate neuromuscular control to provide adequate ventilation.

a. The underlying disease process is significantly reversed, as evidenced by pulmonary examination, ABGs, chest X-ray. b.The patient can mechanically perform ventilation. Should be able to generate a negative inspiratory pressure less than -20 cm H2O; have a vital capacity 10 to 15 mL/kg; have a resting minute ventilation less than 10 L/minute; and be able to double this; have a spontaneous respiratory rate of less than 25 breaths/minute; without significant tachycardia; be normotensive; have optimal hemoglobin for condition; have adequate nutritional status. 2.Assess for other factors that may cause respiratory 2.Weaning is difficult when these insufficiency. conditions are present. a. Acid-base abnormality b.Nutritional depletion c. Electrolyte abnormality d.Fever e. Abnormal fluid balance f. Hyperglycemia g.Infection h.Pain i. Sleep deprivation j. Decreased LOC 3.Assess psychological readiness for weaning. 3.Patient must be physically and psychologically ready for weaning. Performance phase 1.Ensure psychological preparation. Explain procedure 1.Explaining procedure to patient will and that weaning is not always successful on the initial decrease patient anxiety and attempt. promote cooperation. The patient

should not be discouraged if weaning is unsuccessful on the first attempt. 2.Prepare appropriate equipment. 3.Position the patient in sitting or semi-Fowler's position. 3.Increases lung compliance, decreases work of breathing. 4.Pick optimal time of day, preferably early morning. 4.The patient should be rested. 5.Perform bronchial hygiene necessary to ensure that the 5.The patient should be in best patient is in best condition (postural drainage, pulmonary condition for weaning to suctioning) before weaning attempt. be successful. T-Piece This system provides oxygen enrichment and humidity to a patient with an ET or tracheostomy tube while allowing completely spontaneous respirations (for setup and function see oxygen delivery section). 1.Discontinue mechanical ventilation and apply T-piece 1.Stay with the patient during weaning adapter. time to decrease patient anxiety and monitor for tolerance of procedure. 2.Monitor the patient for factors indicating need for 2.Indicates intolerance of weaning reinstitution of mechanical ventilation. procedure. a. BP increase or decrease greater than 20 mm Hg systolic or 10 mm Hg diacstolic b.Heart rate increase of 20 beats/minute or greater than 110 c. Respiratory rate increase greater than 10 breaths/minute or rate greater than 30 d.VT less than 250 to 300 mL (in adults) e. Appearance of new cardiac ectopy or increase in baseline ectopy f. PaO2 less than 60, PaCO2 greater than 55, or pH less than 7.35 (may accept lower PaO2 and pH, and higher PaCO2 in patients with COPD) 3.Increase time off ventilator with each weaning attempt 3.The patient will progress as he as the patient's condition indicates. Evaluate for becomes mentally and physically toleration before moving to the next increment. able to perform adequate spontaneous ventilation. 4.Institute other techniques helpful in encouraging 4.Provides motivation and positive weaning. feedback. a. Mental stimulation b.Biofeedback

c. Participation in care d.Provision of rewards e. Contact with successfully weaned patients 5.When patient tolerates 40 to 60 minutes of continuous weaning, weaning increments can increase rapidly. 6.When the patient can maintain spontaneous ventilation throughout day, begin night weaning. CPAP weaning 1.The principles and techniques for continuous positive 1.This weaning technique is preferred airway pressure (CPAP) weaning are the same as for T- for patients prone to atelectasis when piece weaning. placed on a T-piece. 2.The patient breathes with CPAP at low level (2.5 to 5 cm H2O), rather than with the T-piece, for periods that increase in length. IMV or SIMV weaning 1.Set ventilator to IMV or SIMV mode. 2.Set rate interval. 2.This determines the time interval between machinedelivered breaths, during which the patient will breathe on his own. 3.If the patient is on continuous flow IMV circuitry, 3.The gas flow rate into the bag must observe reservoir bag to be sure that it remains mostly be adequate to prevent the bag from inflated during all phases of ventilation. collapsing during inspiration. Flow rates of 6 to 10 L/minute are usually adequate. 4.If gas for the patient's spontaneous breath is delivered 4.Aids in decreasing work of via a demand valve regulator, ensure that machine breathing necessary to open demand sensitivity is at maximum setting. valve. 5.Evaluate for tolerance of procedure. Monitor for factors 5.If the patient does not tolerate the indicating need for increase or decrease of mandatory procedure, the PaCO2 will rise and respiratory rate (see step 3 of T-piece adapter section pH will fall. above). In rapid weaning, changes may be made approximately every 20 to 30 minutes. 6.If PaCO2 and pH levels remain stable, then continue to 6.May be done as frequently as every decrease mandatory rate as patient tolerates. 20 to 30 minutes with ABG monitoring, pulse oximetry, documentation of successful weaning. Pressure support 1.May be beneficial adjunct to IMV or SIMV weaning.

2.The amount of pressure support (cm H2O) provided to the airway is progressively decreased over time, allowing the patient to increase role in supporting own spontaneous ventilation. Follow-up phase 1.Record at each weaning interval: heart rate, BP, 1.Provides record of procedure and respiratory rate, FiO2, ABG, pulse oximetry value, assessment of progress. respiratory and ventilator rate (if IMV or SIMV), or length of time off ventilator (if T-piece weaning).

Note: It is not within the scope of this manual to establish criteria for the use of one weaning modality as opposed to another. Evidence Base AARC. (2002). Clinical practice guidelines: Evidence-based guidelines for weaning and discontinuing ventilatory support. Respiratory Care 47(1):69-90. P.265

PROCEDURE GUIDELINES 10-21 Extubation EQUIPMENT

Tonsil suction (surgical suction instrument) 10 mL syringe Resuscitation bag and mask with oxygen flow Face mask connected to large-bore tubing, humidifier, and oxygen source Suction catheter Suction source Gloves Face shield

PROCEDURE P.266

Nursing Action

Rationale

Preparatory phrase 1. Monitor heart rate, lung expansion, and breath 1. VT, VC, and NIF are measured to assess sounds before extubation. Record tidal volume respiratory muscle function and adequacy (VT), vital capacity (VC), negative inspiratory of ventilation. pressure (NIP). 2. Assess the patient for other signs of adequate 2. Adequate muscle strength is necessary to muscle strength. ensure muscle strength for spontaneous breathing and coughing. a. Instruct the patient to tightly squeeze the index and middle fingers of your hand. Resistance to removal of your fingers from the patient's grasp must be demonstrated. b. Ask the patient to lift head from the pillow and hold for 2 to 3 seconds. Performance phase 1. Obtain orders for extubation and 1. Do not attempt extubation until postextubation oxygen therapy. postextubation oxygen therapy is available and functioning at the bedside. 2. Explain the procedure to the patient: 2. Increases patient cooperation. a. Artificial airway will be removed. b. Suctioning will occur before extubation. c. Deep breath should be taken on command. d. Instruction will be given to cough after extubation. 3. Prepare necessary equipment. Have ready for use tonsil suction, suction catheter, 10-mL syringe, bag-mask unit, and oxygen by way of face mask. 4. Place the patient in sitting or semi-Fowler's 4. Increases lung compliance and decreases position (unless contraindicated). work of breathing. Facilitates coughing. 5. Put on face shield. 5. Spraying of airway secretions may occur. 6. Put on gloves. Loosen tape or ET tube-securing device. 7. Suction ET tube. 8. Suction oropharyngeal airway above the ET 8. Secretions not cleared from above the cuff cuff as thoroughly as possible. will be aspirated when the cuff is deflated. 9. Extubate the patient: 9. a. Ask the patient to take as deep a breath as a. At peak inspiration, the trachea and possible (if the patient is not following vocal cords will dilate, allowing a less commands, give a deep breath with the traumatic tube removal.

resuscitation bag). b. At peak inspiration, deflate the cuff completely and pull the tube out in the direction of the curve (out and downward). 10.Once the tube is fully removed, ask the patient 10.Frequently, old blood is seen in the to cough or exhale forcefully to remove secretions of newly extubated patients. secretions. Then suction the back of the Monitor for the appearance of bright red patient's airway with the tonsil suction. blood due to trauma occurring during extubation. 11.Apply oxygen therapy as ordered. 12.Evaluate immediately for any signs of airway 12.Immediate complications: obstruction, stridor, or difficult breathing. If the a. Laryngospasm may develop, causing patient develops any of these problems, attempt obstruction of the airway. to ventilate the patient with the resuscitation b. Edema may develop at the cuff site. bag and mask and prepare for reintubation. Signs of narrowing airway lumen are (Nebulized treatments may be ordered to avoid high-pitched crowing sounds, decreased having to reintubate the patient.) air movement, and respiratory distress. Follow-up phase 1. Note patient tolerance of procedure, upper and 1. Establishes a baseline to assess lower airway sounds postextubation, improvement/development of description of secretions. complications. 2. Observe the patient closely postextubation for 2. Tracheal or laryngeal edema develops any signs and symptoms of airway obstruction postextubation (a possibility for up to 24 or respiratory insufficiency. hours). Signs and symptoms include highpitched, crowing upper airway sounds and respiratory distress. 3. Observe character of voice and signs of blood 3. Hoarseness is a common postextubation in sputum. complaint. Observe for worsening hoarseness or vocal cord paralysis.

4. Provide supplemental oxygen using face mask. NURSING ALERT Keep in mind that patient's underlying problems must be improved or resolved before extubation is considered. Patient should also be free from infection and malnutrition. Evidence Base AARC. (2002). Clinical practice guidelines: Removal of endotracheal tube. Available: www.rcjournal.com/cpgs/. P.267

THORACIC SURGERIES Evidence Base Allibone, L. (2006). Assessment and management of patient with pleural effusions. Nursing Standard 20(220):55-64. Lewis, S., et al. (2007). Medical surgical nursing (7th ed.). St. Louis: Mo. Elsevier. Thoracic surgeries (see Table 10-2, page 268) are operative procedures performed to aid in the diagnosis and treatment of certain pulmonary conditions and when performing surgery that compromises the integrity of the thoracic cavity. Procedures include thoracotomy, video-assisted thoracoscopy, decortication, lung volume reduction surgery, lobectomy (see Figure 10-6, page 269), pneumonectomy, segmental resection, and wedge resection. These procedures may or may not require chest drainage immediately after surgery. NURSING ALERT Meticulous attention must be given to the preoperative and postoperative care of patients undergoing thoracic surgery. These operations are wide in scope and represent a major stress on the cardiorespiratory system. Preoperative Management Goal is to maximize respiratory function to improve the outcome postoperatively and reduce risk of complications.

Encourage the patient to stop smoking to restore bronchial ciliary action and to reduce the amount of sputum, and likelihood of postoperative atelectasis, by decreasing secretions and increasing oxygen saturation. Teach an effective coughing technique. o Sit upright with knees flexed and body bending slightly forward (or lie on side with hips and knees flexed if unable to sit up). o Splint the incision with hands or folded towel. o Take three short breaths, followed by a deep inspiration, inhaling slowly and evenly through the nose. o Contract abdominal muscles and cough twice forcefully with mouth open and tongue out. o Alternate techniquehuffing and coughingis less painful. Take a deep diaphragmatic breath and exhale forcefully against hand; exhale in a quick distinct pant, or huff. Humidify the air to loosen secretions. Administer bronchodilators to reduce bronchospasm. Administer antimicrobials for infection. Encourage deep breathing with the use of incentive spirometer (see Procedure Guidelines 10-22, pages 270 to 271) to prevent atelectasis postoperatively. Teach diaphragmatic breathing.

Carry out chest physical therapy and postural drainage to reduce pooling of lung secretions (see page 236). Evaluate cardiovascular status for risk and prevention of complication. Encourage activity to improve exercise tolerance. Administer medications and limit sodium and fluid to improve heart failure, if indicated. Correct anemia, dehydration, and hypoproteinemia with I.V. infusions, tube feedings, and blood transfusions as indicated. Give prophylactic anticoagulant, as prescribed, to reduce perioperative incidence of deep vein thrombosis and pulmonary embolism. Provide teaching and counseling. o Orient the patient to events that will occur in the postoperative periodcoughing and deep breathing, suctioning, chest tube and drainage system, oxygen therapy, ventilator therapy, pain control, leg exercises and range-of-motion (ROM) exercises for affected shoulder. Make sure that patient fully understands surgery and is emotionally prepared for it; verify that informed consent has been obtained.

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TABLE 10-2 Thoracic Surgery Types TYPES DESCRIPTION Exploratory Internal view of lung thoracotomy Usually posterolateral parascapular but could be anterior incision Chest tubes after procedure Lobectomy Lobe removal Thoracotomy incision at site of lobe removal Chest tubes after procedure

INDICATIONS May be used to confirm carcinoma or for chest trauma (to detect source of bleeding)

Pneumonectomy

Segmentectomy

Used when pathology is limited to one area of lung: bronchogenic carcinoma, giant emphysematous blebs or bullae, benign tumors, metastatic malignant tumors, bronchiectasis and fungal infections Removal of an entire lung Performed chiefly for carcinoma, but Posterolateral or anterolateral may be used for lung abscesses, thoracotomy incision bronchiectasis, or extensive Sometimes there is a rib resection tuberculosis Normally no chest drains or tubes Note: Right lung is more vascular because fluid accumulation in empty than left; may cause more physiologic space is desirable problems if removed Only certain segment of lung removed Used when pathology is localized

 Segments function as individual units (such as in bronchiectasis) and when the patient has preexisting cardiopulmonary compromise Wedge resection Small localized section of lung tissue Performed for random lung biopsy removedusually pie-shaped and small peripheral nodules Incision made without regard to Considered when less invasive tests segments have failed to establish a diagnosis Chest tubes after procedure May be used as a therapeutic procedure Thoracoscopy Direct visualization of pleura with VATS may be used for lung biopsy, thorascope via an intercostal incision lobectomy, resection of nodules, repair of fistulas Medical under sedation or local anesthesia; allows for visualization and biopsy Video assisted thorascopic surgery (VATS) under general anesthesia; multiple puncture sites and video screen allow for visualization and manipulation of the pleura, mediastinum, and lung parenchyma Decortication Removal or stripping of thick fibrous Empyema unresponsive to membrane from visceral pleura conservative management Use of chest tube drainage system postoperatively Thoracotomy not Incision into the thoracic cavity for Used for hiatal hernia repair, open involving lungs surgical procedures on other structures heart surgery, esophageal surgery, tracheal resection, aortic aneurysm repair Lung volume Involves reducing lung volume by Performed in advanced bullous reduction surgery multiple wedge excisions or VATS emphysema, 1-antitrypsin (LVRS) emphysema P.269 (segmental resection)

FIGURE 10-6 Operative procedures. (A) Lobectomy. (B) Pneumonectomy. Postoperative Management

Use mechanical ventilator and/or supplemental oxygen until respiratory function and cardiovascular status stabilize. Assist with weaning and extubation.

Auscultate chest, monitor vital signs, monitor ECG, and assess respiratory rate and depth frequently. Arterial line, CVP, and pulmonary artery catheter are usually used. Monitor ABG values and/or SaO2 frequently. Monitor and manage chest drainage system to drain fluid, blood, clots, and air from the pleura after surgery (see page 272). Chest drainage is usually not used after pneumonectomy because it is desirable that the pleural space fills with an effusion, which eventually obliterates the space.

Complications

Hypoxiaassess for restlessness, tachycardia, tachypnea, and elevated BP. Postoperative bleedingmonitor for restlessness, anxiety, pallor, tachycardia, and hypotension. Pneumonia; atelectasismonitor for fever, chest pain, dyspnea, changes in lung sounds on auscultation. Bronchopleural fistula from disruption of a bronchial suture or staple; bronchial stump leak. o Observe for sudden onset of respiratory distress or cough productive of serosanguineous fluid. o Position with the operative side down. o Prepare for immediate chest tube insertion and/or surgical intervention. Cardiac dysrhythmias (usually occurring third to fourth postoperative day); MI or heart failure.

Nursing Diagnoses

Ineffective Breathing Pattern related to wound closures Risk for Deficient Fluid Volume related to chest drainage and blood loss Acute Pain related to wound closure and presence of drainage tubes in the chest Impaired Physical Mobility of affected shoulder and arm related to wound closure and the presence of drainage tubes in the chest

Nursing Interventions Maintaining Adequate Breathing Pattern

Monitor rate, rhythm, depth, and effort of respirations. Auscultate chest for adequacy of air movement to detect bronchospasm, consolidation. Monitor pulse oximetry and obtain ABG analysis and pulmonary function measurements as ordered. Monitor LOC and inspiratory effort closely to begin weaning from ventilator as soon as possible.

Suction, as needed, using meticulous aseptic technique. Elevate the head of the bed 30 to 40 degrees when patient is oriented and BP is stabilized to improve movement of diaphragm and alleviate dyspnea. Encourage coughing and deep-breathing exercises and use of an incentive spirometer to prevent bronchospasm, retained secretions, atelectasis, and pneumonia. Provide optimal pain relief to promote deep breathing, turning, and coughing.

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PROCEDURE GUIDELINES 10-22 Assisting the Patient Using an Incentive Spirometer EQUIPMENT According to the type of device used PROCEDURE Nursing Action Rationale Preparatory phase 1. Measure the patient's normal tidal volume 1. The patient's baseline is established. (VT) and auscultate the chest, preferably preprocedure/treatment and/or preoperatively. Performance phase 1. Explain the procedure and its purpose to the 1. Optimal results are achieved when the patient. patient is given pretreatment or preoperative instruction. The device provides measurement and feedback related to breathing effectiveness and mimics the natural sigh and yawn thus keeping the lungs clear. 2. Place the patient in a comfortable sitting, 2. Diaphragmatic excursion is greater in this semi-Fowler's, or upright position. position; however, if the patient is medically unable to be in this position, the exercise may be done in any position. 3. For the postoperative patient, try as much as 3. Incentive spirometry is most successful possible to avoid discomfort. Try to when pain is controlled. coordinate treatment with administration of pain-relief medications. Instruct and assist the patient with splinting of incision. 4. Set the incentive spirometer VT indicator at 4. The initial VT may be prescribed, but the the desired goal the patient is to reach or purpose of the device is to establish a exceed (500 mL is often used to start). The baseline VT and provide incentive to achieve

VT is set according to the manufacturer's instructions. 5. Demonstrate the technique to the patient. 6. Instruct the patient to exhale fully. 7. Tell the patient to take in a slow, easy, deep breath from the mouthpiece.

greater volumes progressively.

7. Noseclips are sometimes used if the patient has difficulty breathing only through mouth. This will ensure full credit for each breath measured. 8. When the desired goal is reached (lungs fully 8. Sustaining the inspiratory effort helps to inflated), ask the patient to continue the open closed alveoli. For the postoperative inspiratory effort for 3 seconds, even though patient, hypoventilation can result in the patient may not actually be drawing in atelectasis within the first hour. more air. 9. Instruct the patient to remove the mouthpiece, 9. Usually one incentive breath per minute relax, and passively exhale; patient should minimizes patient fatigue. No more than take several normal breaths before attempting four to five maneuvers should be performed another one with the incentive spirometer. per minute to minimize hypocarbia. 10.Continue to monitor the patient's spirometer breaths, periodically increasing the VT as the patient tolerates. 11.At the conclusion of the treatment, encourage 11.The deep lung inflation may loosen the patient to cough after a deep breath. secretions and enable the patient to expectorate them. 12.Instruct the patient to take 10 sustained 12.A total of 10 sustained maximal inspiratory maximal inspiratory maneuvers per hour and maneuvers per hour during waking hours is note the volume on the spirometer. a typical order. A counter on the incentive spirometer indicates the number of breaths the patient has taken.

Flow incentive spirometer. Patients are instructed to inhale briskly to elevate the balls and to keep them floating as long as possible. The volume inhaled is estimated and variable. Follow-up phase 1. Auscultate the chest. Chart any improvement 1. Notes the effectiveness and patient tolerance or variation, the volume attained, of the treatment for continuity of care. effectiveness of cough, description of any secretions expectorated. 2. Record effectiveness and frequency in use of incentive spirometer every 2 hours.

Evidence Base Cleveland Clinic. (reviewed last 2005). How to use an incentive spirometer. Available: www.clevelandclinic.org/health/health-info/docs/0200-0239asp?index=430z&scrc=news. P.271

NURSING ALERT Tracheobronchial secretions are present in excessive amounts in postthoracotomy patients because of trauma to the tracheobronchial tree during operation, diminished lung ventilation, and diminished cough reflex. NURSING ALERT Look for changes in color and consistency of suctioned sputum. Colorless, fluid sputum is not unusual; opacification or coloring of sputum may mean dehydration or infection. Stabilizing Hemodynamic Status

Take BP, pulse, and respiration every 15 minutes or more frequently as indicated; extend the time intervals according to the patient's clinical status. Monitor heart rate and rhythm by way of auscultation and continuous ECG because dysrhythmias are frequently seen following thoracic surgery. Monitor CVP for prompt recognition of hypovolemia and for effectiveness of fluid replacement. Monitor cardiac output and pulmonary artery systolic, diastolic, and wedge pressures. Watch for subtle changes, especially in the patient with underlying cardiovascular disease. Assess chest tube drainage for amount and character of fluid. P.272

Chest drainage should progressively decrease after first 12 hours. o Prepare for blood replacement and possible reoperation to achieve hemostasis if bleeding persists. o Chest tube drainage in excess of 1,000 to 1,200 cc per 24-hour period should be reported to the physician for follow-up. Maintain intake and output record, including chest tube drainage. Monitor infusions of blood and parenteral fluids closely because the patient is at risk for fluid overload if portion of pulmonary vascular system has been reduced.

Achieving Adequate Pain Control

Perform comprehensive pain assessment including onset, location, duration, characteristics, precipitating factors, and response to interventions. Provide appropriate pain reliefpain limits chest excursions, thereby decreasing ventilation. Severity of pain varies with type of incision and with the patient's reaction to and ability to cope with pain. Usually a posterolateral incision is the most painful. Give opioids (usually by continuous I.V. infusion or by epidural catheter by way of patient-controlled analgesia pump) for pain relief, as prescribed, to permit patient to breathe more deeply and cough more effectively. To avoid respiratory and CNS depression, do not give too much opioid; patient should be alert enough to cough. Assist with intercostal nerve block or cryoanalgesia (intercostal nerve freezing) for pain control as ordered. (see page 325). Position for comfort and optimal ventilation (head of bed elevated 15 to 30 degrees); this also helps residual air to rise in upper portion of pleural space where it can be removed by the chest tube. o Patients with limited respiratory reserve may not be able to turn on unoperated side because this may limit ventilation of the operated side. o Vary the position from horizontal to semierect to prevent retention of secretions in the dependent portion of the lungs. Encourage splinting of incision with pillow, folded towel, or hands, while turning, changing position, or coughing. Teach relaxation (nonpharmacologic) techniques, such as progressive muscle relaxation and imagery, to help reduce pain.

NURSING ALERT Evaluate for signs of hypoxia thoroughly when anxiety, restlessness, and agitation of new onset are noted, before administering as-needed sedatives. Increasing Mobility of Affected Shoulder

Begin ROM exercise of arm and shoulder on affected side immediately to prevent ankylosis of the shoulder (frozen shoulder). Perform exercises at time of maximal pain relief. Encourage patient to actively perform exercises three to four times per day, taking care not to disrupt chest tube or invasive lines (ie, I.V.).

Patient Education and Health Maintenance

Advise that there will be some intercostal pain for several weeks, which can be relieved by local heat and oral analgesia. Many patients experience intercostal pain up to 1 year following surgery. Advise that weakness and fatigability are common during the first 3 weeks after a thoracotomy, but exercise tolerance will improve with conditioning.

Suggest alternating walking and other activities with frequent short rest periods. Walk at a moderate pace and gradually extend walking time and distance. Encourage continuing deep-breathing exercises for several weeks after surgery to attain full expansion of residual lung tissue. Instruct on maintaining good body alignment to ensure full lung expansion. Advise that chest muscles may be weaker than normal for 3 to 6 months after surgery. Patient must avoid lifting more than 20 lb (9 kg) until complete healing has taken place. Any activity that causes undue fatigue, increased shortness of breath, or chest pain should be stopped immediately. Because all or part of one lung has been removed, warn patient to avoid respiratory irritants (smoke, fumes, high level of air pollution). o Avoid irritants that may cause coughing spasms. o Sit in nonsmoking areas in public places. Encourage patient to receive an annual influenza vaccine and obtain a pneumococcal pneumonia vaccine. Encourage patient to keep follow-up visits. Instruct patient to prevent respiratory infections by frequent hand washing and avoiding others with respiratory infections.

Evaluation: Expected Outcomes

Respirations with normal range, adequate depth; lungs clear; ABG values and SaO2 within normal limits BP, CVP, and pulse within normal limits for individual. Coughs and turns independently; reports relief of pain Performs active ROM of affected arm and shoulder; reports improved exercise tolerance

CHEST DRAINAGE Evidence Base Coughline, A., and Parchinsky, C. (2006). Go with the flow of chest tube therapy. Nursing 36(3):36-41. Lewis, S., et al. (2007). Medical surgical nursing (7th ed). St. Louis Mo.: Elsevier. Chest drainage is the insertion of a tube into the pleural space to evacuate air or fluid, and/or help regain negative pressure. Whenever the chest is opened, there is loss of negative pressure in the pleural space, which can result in collapse of P.273 the lung. The collection of air, fluid, or other substances in the thoracic cavity can compromise cardiopulmonary function and cause collapse of the lung. TABLE 10-3 Indications for Chest Tube Use INDICATION ACCUMULATING SUBSTANCE Pneumothorax Air

Hemothorax Blood Pleural effusionFluid Chylothorax Lymphatic fluid Empyema Pus It is necessary to keep the pleural space evacuated postoperatively and to maintain negative pressure within this potential space. Therefore, during or immediately after thoracic surgery, chest tubes/catheters are positioned strategically in the pleural space, sutured to the skin, and connected to a drainage apparatus to remove the residual air and fluid from the pleural or mediastinal space. This assists in the reexpansion of remaining lung tissue. FIGURE 10-7 Chest drainage systems. (A) Strategic placement of a chest catheter in the pleural space. (B) Three types of mechanical drainage systems. (C) A Pleur-evac operating system: (1) the collection chamber, (2) the water-seal chamber, and (3) the suction control chamber. The Pleurevac is a single unit with all three bottles identified as chambers. Chest drainage can also be used to treat spontaneous pneumothorax or hemothorax/pneumothorax caused by trauma (see Table 10-3). Sites for chest tube placement are:

For pneumothorax (air)second or third interspace along midclavicular or anterior axillary line. For hemothorax (fluid)sixth or seventh lateral interspace in the midaxillary line.

Principles of Chest Drainage

Many types of commercial chest drainage systems are in use, most of which use the water-seal principle. The chest tube/catheter and collecting tubing is attached to a chest drainage system using a one-way valve principle. Water acts as a seal and permits air and fluid to drain from the chest. However, air cannot reenter the chest cavity. Chest drainage can be categorized into three types of mechanical systems (see Figure 107). There are numerous types of chest drainage units available.

P.274

One-Bottle Water-Seal System

The end of the collecting tube is covered by a layer of water, which permits drainage of air and fluid from the pleural space, but does not allow air to move back into the chest. Functionally, drainage depends on gravity, on the mechanics of respiration and, if desired, on suction by the addition of controlled vacuum. The tube from the patient extends approximately 1 inch (2.5 cm) below the level of the water in the container. There is a vent for the escape of any air that may be leaking from

the lung. The water level fluctuates as the patient breathes; it goes up when the patient inhales and down when the patient exhales. At the end of the drainage tube, bubbling may or may not be visible. Bubbling can mean either persistent leakage of air from the lung or other tissues or a leak in the system.

Two-Bottle Water-Seal System

The two-bottle system consists of the same water-seal chamber, plus a fluid-collection bottle. Drainage is similar to that of a single unit, except that when pleural fluid drains, the underwater-seal system is not affected by the volume of the drainage. Effective drainage depends on gravity or on the amount of suction added to the system. When vacuum (suction) is added to the system from a vacuum source, such as wall suction, the connection is made at the vent stem of the underwater-seal bottle. The amount of suction applied to the system is regulated by the wall gauge.

Three-Bottle Water-Seal System

The three-bottle system is similar in all respects to the two-bottle system, except for the addition of a third bottle to control the amount of suction applied. Recent research has shown that suction may actually prolong an air leak by pulling air through the opening that would otherwise heal on its own. The amount of suction is determined by the depth to which the tip of the venting glass tube is submerged in the water and level of water in the suction chamber or setting of a dialdepending on the system in use. In the three-bottle system (as in the other two systems), drainage depends on gravity or the amount of suction applied. The mechanical suction motor or wall suction creates and maintains a negative pressure throughout the entire closed drainage system. The manometer bottle regulates the amount of negative pressure transmitted back to the patient from the suction/vacuum device. This is accomplished through the use of a water or dry system that downregulates the suction/vacuum applied. In the commercially available systems, the three bottles are contained in one unit and identified as chambers (see Figure 10-7C). The principles remain the same for the commercially available products as they do for the glass bottle system. First chamber acts as the collection chamber and receives fluid and air from the chest cavity through the collecting tube attached to the chest tube. Second chamber acts as the water-seal chamber with 2 cm of water acting as a one-way valve, allowing drainage out but preventing backflow of air or fluid into the patient. Third chamber applies controlled suction. The amount of suction is regulated by the volume of water (usually 20 cm) in the chamber not the amount of suction or bubbling with a water system. In a dry suction control system no water is used, no bubbling occurs,

and a restrictive device or regulator is used to dial the desired negative pressure (up to 40 cm suction). NURSING ALERT When the motor or the wall vacuum is turned off, the drainage system should be open to the atmosphere so that intrapleural air can escape from the system. This can be done by detaching the tubing from the suction port to provide a vent. Nursing and Patient Care Considerations

Assist with chest tube insertion (see Procedure Guidelines 10-23, pages 275 to 277). Assess patient's pain at insertion site and give medication appropriately. If patient is in pain, chest excursion and lung inflation will be hampered. Maintain chest tubes to provide drainage and enhance lung reinflation (see Procedure Guidelines 10-24, pages 277 to 279). Maintain integrity of insertion site, observing for drainage, redness, impaired healing, and subcutaneous emphysema.

NURSING ALERT Milking and stripping of chest tubes to maintain patency is no longer recommended. This practice has been found to cause significant increases in intrapleural pressures and damage to the pleural tissue. New chest tubes contain a nonthrombogenic coating, thus decreasing the potential for clotting. If it is necessary to help the drainage move through the tubing, apply a gentle squeezeand-release motion to small segments of the chest tube between your fingers. NURSING ALERT Clamping of chest tubes is no longer recommended due to the increased danger of tension pneumothorax from rapid accumulation of air in the pleural space. Clamp only momentarily to change the drainage system. Check for leaks to assess the patient's tolerance for removal of the chest tube (perhaps up to 24 hours). P.275

PROCEDURE GUIDELINES 10-23 Assisting with Chest Tube Insertion EQUIPMENT

Tube thoracostomy tray Syringes Needles/trocar Basins/skin germicide Sponges Scalpel, sterile drape, and gloves

Two large clamps Suture material Local anesthetic Chest tube (appropriate size); connector Cap, mask, gloves, gown, drapes Chest drainage system-connecting tubes and tubing, collection bottles or commercial system, vacuum pump (if required) Sterile water

PROCEDURE P.276

Nursing Action Rationale Preparatory phase 1.Assess patient for pneumothorax, hemothorax, presence of respiratory distress. 2.Obtain a chest X-ray. Other means of localization 2.To evaluate extent of lung collapse or of pleural fluid include ultrasound or fluoroscopic amount of bleeding in pleural space. localization. 3.Obtain informed consent. 4.Verify right patient and right location/procedure. 5.Premedicate if indicated. 6.Assemble drainage system. 7.Reassure the patient and explain the steps of the 7.The patient can cope by remaining procedure. Tell the patient to expect a needle immobile and doing relaxed breathing prick and a sensation of slight pressure during during tube insertion. infiltration anesthesia. 8.Position the patient as for an intercostal nerve 8.The tube insertion site depends on the block or according to physician preference. substance to be drained, the patient's mobility, and the presence of coexisting conditions. Performance phase Needle or intracath technique 1.Using universal precautions, the skin is prepared, 1.The area is anesthetized to make tube anesthetized, and draped, using local anesthetic insertion and manipulation relatively with a short 25G needle and using aspetic painless. Use of universal precautions and technique. A larger needle is used to infiltrate the aseptic technique prevent contamination of subcutaneous tissue, intercostal muscles, and chest tube. Patient may feel pressure while parietal pleura. tube is inserted.

2.An exploratory needle is inserted.

2.To puncture the pleura and determine the presence of air or blood in the pleural cavity.

3.The IntraCath catheter is inserted through the needle into the pleural space. The needle is removed, and the catheter is pushed several centimeters into the pleural space. 4.The catheter is taped to the skin; may be sutured 4.To prevent it from being dislodged out of to the chest wall and covered with a dressing. the chest during patient movement or lung expansion. The chest tube clamp is removed once the chest tube is attached to the system. 5.The catheter is attached to a connector/tubing and 5.All connections are taped to prevent attached to a drainage system (underwater-seal or disconnection. commercial system) and all connections taped. Trocar technique for chest tube insertion Using universal precautions and aseptic technique, a trocar catheter is used for the insertion of a largebore tube for removal of a moderate to large amount of air leak or for the evacuation of serous effusion. 1.A small incision is made over the prepared, 1.To admit the diameter of the chest tube. anesthetized site. Blunt dissection (with a hemostat) through the muscle planes in the interspace to the parietal pleura is performed. 2.The trocar is directed into the pleural space, the 2.There is a trocar catheter available cannula is removed, and a chest tube is inserted equipped with an indwelling pointed rod into the pleural space and connected to a drainage for ease of insertion. system. Hemostat technique using a large-bore chest tube Using universal precautions and aseptic technique, a large bore chest tube is used to drain blood or thick effusions from the pleural space. 1.Using universal precautions, aseptic technique, 1.The skin incision is usually made one and after skin preparation and anesthetic interspace below proposed site of infiltration, an incision is made through the skin penetration of the intercostal muscles and and subcutaneous tissue. pleura. 2.A curved hemostat is inserted into the pleural 2.To make a tissue tract for the chest tube. cavity and the tissue is spread with the clamp. 3.The tract is explored with an examining finger. 3.Digital examination helps confirm the

presence of the tract and penetration of the pleural cavity. 4.The tube is held by the hemostat and directed through the opening up over the ribs and into the pleural cavity. 5.The clamp is withdrawn and the chest tube is 5.The chest tube has multiple openings at the connected to a chest drainage system. proximal end for drainage of air or blood. 6.The tube is sutured in place and covered with a 6.Prevents dislodgment. sterile dressing. 7.Catheter is attached to a connector/tube and to the 7.Clamps are removed from the chest tube system. All connections are taped. once connected to the drainage system. Chest tubes open to air at the time of insertion will result in a pneumothorax.

Chest tube (tube thoracostomy) inserted via hemostat technique. Follow-up phase 1.Observe the drainage system for blood and air. 1.If a hemothorax is draining through a Observe for fluctuation in the tube on respiration. thoracostomy tube into a bottle containing (See page 274.) sterile normal saline, the blood is available for autotransfusion. 2.Secure a follow-up chest X-ray. 2.To confirm correct chest tube placement and reexpansion of the lung. 3.Assess for bleeding, infection, leakage of air and 3.With too rapid removal of fluid, a fluid around the tube. vasovagal response may occur with resulting hypotension. Continued use of petroleum gauzes or ointment can irritate the skin. 4.Maintain integrity of the chest drainage system. 4.Chest tube malposition is the most common complication. P.277

PROCEDURE GUIDELINES 10-24 Managing the Patient with Water-Seal Chest Drainage EQUIPMENT

Closed chest drainage system Holder for drainage system (if needed) connector for emergency use Vacuum motor

Sterile connector for emergency use (ie, sterile water)

PROCEDURE P.278

Nursing Action Rationale Performance phase 1. Attach the chest tube from the pleural space 1. Water-seal drainage provides for the escape of (the patient) to the collecting/drainage air and fluid into a drainage bottle. The water tubing and water-seal drainage system. Add acts as a seal and keeps the air from being sterile water to water-seal chambers as drawn back into the pleural space. Vigorous needed. Adjust suction until bubbling is bubbling is not indicated. seen or set gauge as directed. Keep drainage system below level of chest. 2. Check the tube connections periodically. 2. Tube connections are checked to ensure tight Tape if necessary. fit, patency of the tubes, and to prevent a. The tube should be as straight as possible backflow of drainage or air. and coiled below level of chest without dependent loops. b. Do not let the patient lie on collecting/tubing drainage. 3. Mark the original fluid level with tape on 3. This marking will show the amount of fluid the outside of the drainage system. Mark loss and how fast fluid is collecting in the hourly and daily increments (date and time) drainage bottle. It serves as a basis for blood at the drainage level. replacement, if the fluid is blood. Grossly bloody drainage will appear in the bottle in the immediate postoperative period and, if excessive, may necessitate reoperation. Drainage usually declines progressively after the first 24 hours. 4. Assess patient's clinical status at least once 4. Removal of 1,000 to 1,200 mL of pleural fluid per shift. Observe and report immediately at one time can result in hypotension and signs of rapid, shallow breathing, cyanosis, rebound pleural effusion. Report to physician pressure in the chest, subcutaneous immediately. More frequent monitoring is emphysema, or symptoms of hemorrhage. required at the initiation of therapy and when warranted by patient's condition. Many clinical conditions may cause these signs and symptoms, including tension pneumothorax, mediastinal shift, hemorrhage, severe

incisional pain, pulmonary embolus, and cardiac tamponade. Surgical intervention may be necessary. 5. Make sure the tubing does not loop or 5. Fluid collecting in the dependent segment of interfere with the movements of the patient. the tubing will decrease the negative pressure applied to the catheter. Kinking, looping, or pressure on the drainage tubing can produce back pressure, thus possibly forcing drainage back into the pleural space or impeding drainage from the pleural space. 6. Encourage the patient to assume a position 6. The patient's position should be changed of comfort. Encourage good body frequently to promote drainage and body kept alignment. When the patient is in a lateral in good alignment to prevent postural position, place a rolled towel under the deformity and contractures. Proper positioning tubing to protect it from the weight of the helps breathing and promotes better air patient's body. Encourage the patient to exchange. Pain medication may be indicated change position frequently. to enhance comfort and deep breathing. 7. Put the arm and shoulder of the affected 7. Exercise helps to avoid ankylosis of the side through ROM exercises several times shoulder and assists in lessening postoperative daily. Some pain medication may be pain and discomfort. necessary. 8. Make sure there is fluctuation (tidaling) 8. Fluctuation of the water level in the tube of the fluid level in the drainage system. shows that there is effective communication between the pleural space and the drainage system; provides a valuable indication of the patency of the drainage system, and is a gauge of intrapleural pressure. 9. Fluctuations of fluid in the tubing will stop when: a. the lung has reexpanded. b. the tubing is obstructed by blood clots or fibrin. c. a dependent loop develops. 10.Watch for leaks of air in the drainage 10.Leaking and trapping of air in the pleural system as indicated by constant bubbling in space can result in tension pneumothorax. the water-seal bottle. a. Report excessive bubbling in the waterseal change immediately. 11.Encourage the patient to breathe deeply and 11.Deep breathing and coughing help to raise the cough at frequent intervals. If there are intrapleural pressure, which allows emptying

of any accumulation in the pleural space and removes secretions from the tracheobronchial tree so the lung expands. 12.If the patient has to be transported to 12.The drainage apparatus must be kept at a level another area, place the drainage system lower than the patient's chest to prevent below the chest level (as close to the floor backflow of fluid into the pleural space. as possible). 13.If the tube becomes disconnected, cut off the contaminated tips of the chest tube and tubing, insert a sterile connector in the chest tube and tubing, and reattach to the drainage system. Otherwise, do not clamp the chest tube during transport. 14.When assisting with removal of the tube: 14.The chest tube is removed as directed when a. Administer pain medication 30 minutes the lung is reexpanded (usually 24 hours to before removal of chest tube. several days). Signs of reinflation include little b. Instruct the patient to perform a gentle or no drainage, absence of air leak, no noted Valsalva maneuver or to breathe quietly. respiratory distress, no fluctuations in fluid in c. The chest tube is clamped and removed. water-seal chamber, no residual air or fluid in d. Simultaneously, a small bandage is chest X-ray. During the tube removal, avoid a applied and made airtight with petroleum large sudden inspiratory effort, which may gauze covered by a 4 4 gauze and produce a pneumothorax. thoroughly covered and sealed with tape. Follow-up phase

signs of incisional pain, adequate pain medication is indicated.

1. Monitor the patient's pulmonary status for 1. Patient could have reformation of signs and symptoms of decompensation. pneumothorax after removal as well as Observe insertion site for signs of infection infection at injection site. and changes in drainage. Evidence Base Coughlin, A., and Parchinsky, C. (2006). Go with the flow of chest tube therapy. Nursing 36(3):36-41. Halm, M. (2007). To strip or not to strip? Physiological effects of chest tube manipulation. American Journal of Critical Care 16(6):609-612. P.279

TABLE 10-4 Chest Drainage Units (CDU) TYPES DESCRIPTION INDICATIONS FOR USE Standard CDUDrainage of pleural cavity for air or any Following surgery that impacts on the type of fluid with or without the use continuity of suction of the thoracic Up to 2,000 ml capacity cavity (eg, thoracic, cardiac, esophageal surgery) Replaced when full Pneumothorax Hemothorax Pleural effusion Pleurodesis Smaller Drainage without use of suction For ambulatory patients Portable CDU Dry seal system that prevents air leaks Home care No lung reexpansion occurs Chronic conditions 500 ml maximum drainage Emptied when used in home Indwelling Small size chest tube or pigtail catheter Pneumothorax Pleural (smaller than standard 14F) Chronic drainage of fluid Catheter Can be irrigated if occluded by health Not for trauma or blood care provider Can be used for pleurodesis Less traumatic Heimlich One-way flutter valve Evacuates air from the pleural space Valve Removes air as patient exhales Used for emergency transport, home care, Valve opens when pleural space and long-term care units pressure is greater than atmospheric pressure and closes when the reverse occurs P.280