Respiratory Care Modalities

Rachel Joy R. Rosale, RN, RM, MAN

Oxygen Therapy
Indicated for clients with hypoxemia O2 concentration is more important than L/min Observe safety precautions and complications Medical intervention prescribed by the physician Nurse may initiate therapy

Complications
O2-induced hypoventilation
RR Supply of O2 sensed by the brain RR O2 Hypoventilation CO2 retention Respiratory acidosis

O2 toxicity
Prolonged O2 admin, client might develop toxicity then become blind Retrolental fibroplasia

Absorption atelectasis

Drying of mucus membrane

Infection

Oxygen Delivery System

Low-Flow Delivery Systems
Gas delivered via small bore tubing at a rate shown on the flowmeter Room air is inhaled with O2

Used for clients with RR below 25 and a regular and consistent rate
Contraindicated to clients who require carefully monitored concentrations of oxygen Ex: Nasal cannula, simple face mask, partial rebreather mask

Oxygen Delivery System

High-Flow Delivery Systems
Supply all of the gas required during ventilation in precise amounts regardless of the clients respiratory status The ratio of room air to oxygen is regulated and does not vary with the clients respiration Precise and consistent in O2 delivered

Ex: Venturi mask, face tent, T-tube/T-piece, transtracheal delivery and tracheostomy collar

Transtracheal Oxygen Delivery

Incentive Spirometry

Endotracheal Intubation
Use of an endotracheal tube through the mouth or nose into the trachea with the use of laryngoscope Once inserted, cuff is inflated Maintain cuff pressure between 15-20 mmHg
High: Bleeding, ischemia, necrosis Low: Risk of aspiration pneumonia
612

Unit 5

G EXC AS HANG AND R PIR R FUNC N E ES ATO Y TIO

A su Afte prop the t twee chan T arou place vent

Com FIG E25-5 UR

Endotracheal tube in place. Tube has been inserted using the oral route. The cuff has been inated to maintain the tubes position and minimize the risk for aspiration.

Com cheo the t ing,

Tracheostomy
Indications:
Bypass an obstruction

Tracheotomy is an opening made into the trachea;

Removal of secretions

Permit long term use of mechanical ventilator

Prevent aspiration of oral/gastric secretions in an unconscious Replace ET tube

replace with a new disposable inner cannula. tracheostomy instruction 2. Provide patient and family tube. 10. Remove soiled twill tape with clean tape, after the new tape is in This taping technique provi cheostomy care, beginning with how t place. Place clean twill tape in position to secure the tracheostomy the neck, moisture or dra cheostomy dressing forwhich is needed tube by inserting one end of the tape through the side opening of dislodged 3. Perform hand hygiene. by movement o the outer cannula. Take the tape around the back of the patients A dislodged tracheostomy 4. Explain procedure to patient and fami neck and thread it through the opposite opening of the outer cantory distress may occur. D nula. Bring both ends around so that they meet on one side of the clean medicalremove and discar 5. Put on gloves; emergency. neck. Tighten the tape until only two ngers can be comfortably biohazard container. inserted under it. Secure with a knot. For a new tracheostomy, 6. Prepare sterile supplies, including hydr two people should assist with tape changes. saline solution or sterile water, cotton11. Remove old tapes and discard in a biohazard container. Tapes with dressing, and tape. old secretions m 12. Althoug s h omelong rm tra os -te che tomie with he le s 7.smaon sterile gloves. (Some physicians s a d toma Put y Healed tracheostomies with not re quireadre s , othe tra os s ing r che tomie do. In s ca e , uslong-term tracheostomythat will sh s uch s s e ing. Dressings patients in for as riletra os te che tomy dre s , tting it s cure unde thetwill s ing e ly r because of the risk that pi ta sa a eof tra os pe nd ng che tomy tubes tha theincis is Cleanse the wound and the plate of th o t ion 8. into the tube, and eventu cove d, a s re s hown be low. tion or applicators moiste sterile cotton-tippedabscess formation. tendency to shred are use peroxide. Rinse with sterile saline solut 9. Soak inner cannula in peroxide and rin replace with a new disposable inner ca 10. Remove soiled twill tape with clean tap place. Place clean twill tape in position (A) tube by inserting one end of the tape th sm the outer cannula. Take the tape aroun tha neck and thread it through the opposite nula. Bring both ends around so thatcap th (B) neck. Tighten the tape until only two pad inserted under it. Secure with a knot. F shr two people should assist with tape chan rat 11. Remove old tapes and discard in a bioh 12. Althoug s h omelong rm tra os (C -te che tom not re quireadre s , othe tra os s ing r che thr to tom as riletra os te che tomy dre s , tting i s ing of ta sa a eof tra os pe nd ng che tomy tubes A B C cove d, a s on re s hown be low.

Incision is made between 2nd and 3rd tracheal ring

Mini-Nebulizer Therapy
Hand-held apparatus used to administer moisturizing agent or medication, such as bronchodilator or mucolytic agent, into microscopic particles into the lungs as the patient inhales Clears secretions; often used by COPD patients at home on a long term basis Instruct the client to breathe slowly through the mouth, then hold breath for a few seconds

Intermittent Positive-Pressure Breathing

Also called IPPV Compressed gas is delivered under positive pressure into a persons airways until a preset pressure is reached. Passive exhalation is allowed through a valve, and the cycle begins again as the flow of gas is triggered by inhalation Exhaled tidal volume goal of 10-15 mL/kg of body weight

Chest Physiotherapy
Percussion and vibration over the thorax to loosen secretions in the affected area of the lungs Consists of postural drainage, chest percussion, and vibration and breathing retraining Aims to remove bronchial secretions, improve ventilation and increase respiratory muscles efficiency C/I: Rib fracture, chest incisions

Chest Physiotherapy: Postural Drainage

Uses gravity to drain secretions from segments of the lungs

Combined with CPT

Best time: 1 hr before meals, 2-3 hrs after meals

Mechanical Ventilation
Classification
Negative pressure ventilations Positive pressure ventilations

Modes
Assist-control Intermittent-Mandatory Ventilation Synchronized

Mechanical Ventilation
Interventions:
Assess client first, then, ventilator Assess VS, lung sounds, respiratory status, and breathing patterns Monitor skin color Monitor chest for bilateral lung expansion Obtain SpO2 Monitor ABG Assess the need for suctioning and record Assess ventilator settings Assess level of water in humidifier and temperature of humidification system Ensure that the alarms are set If a cause for alarm is undetermined, BAG the patient Empty the tubing when moisture is present Turn the client q 2hours, prevent immobility complications Have resuscitation equipment @ bedside

Mechanical Ventilation
Causes of Alarms:
High Pressure Increased secretions in the airway Wheezing or bronchospasm Endotracheal tube is displaced ET is obstructed as a result of kinks Client coughs, gags, or bites ET

Low Pressure
Disconnection or lea Client stops spontaneous breathing

Mechanical Ventilation
Ventilation Control and Settings Tidal Volume vol. of air client receives with each breath

Rate number of vent. Breath delivered/minute

Fraction of inspired O2 (FiO2) O2 conc. delivered to the client Sighs vol. of air 1.5-2x the set tidal volume, deliverd 6-10x/hour Peak Airway Inspiratory Pressure pressure needed by the vent. To deliver a set tidal volume at a given compliance Continuous Positive Airway Pressure application of positive airway pressure throughout the cycle for spontaneous breathing clients; for weaning Positive End Expiratory Pressure (PEEP) exerted during expiration

Pressure Support application of positive pressure on inspiration; used in combi with PEEP for weaning

Mechanical Ventilation
Weaning the process of going from ventilator dependence to spontaneous breathing SIMV T piece Pressure support

The Patient Undergoing Thoracic Surgery

PRE-OPERATIVE:
Lobectomy - w/ tubes in place; Unaffected Pneumonectomy w/o tubes; Affected Segmentectomy Wedge resection Decortication stripping off lung lining Thoracoplasty ribs

***Chest Tube to allow expansion of affected lung

The Patient Undergoing Thoracic Surgery

POST-OPERATIVE:
VS O2 Positioning Meds Coughing, splinting

Closed Chest Drainage

Purposes:
Remove fluid and/or air from pleural space Re-establish normal negative pressure in the pleural space

Promote re-expansion of the lung

Prevent reflux of air/fluid into the pleural space form the drainage apparatus

Closed Chest Drainage

One Bottle System

Water seal and drainage in same bottle Observe for intermittent bubblingand fluctuation of fluid with each respiration

IND: emphysema

Closed Chest Drainage

Two Bottle System

Water seal and drainage in same bottle Observe for intermittent bubblingand fluctuation of fluid with each respiration IND: emphysema

Closed Chest Drainage

Three Bottle System

Closed Chest Drainage

Be sure CXR is done to assess placement. Check for bubbling/fluctuation that is constant, continuous and gentle TTS; ask the client to cough, deep breathe

Mark the amount of drainage at the beginning of each shift

Note character of drainage Be sure the tubing is without kinks, coiled on bed Keep bottles below level of the heart (2-3 feet) DONT CLAMP NOR MILK the tubing Maintain dry, occlusive dressing

Closed Chest Drainage

Removal of Chest Tubes: done by MD Equipment: suture removal kit, sterile gauze, petroleum gauze, adhesive tape. Semi-Fowlers or high-Fowlers position

Removal of tubes during expiration or at the end of full inspiration and do VALSALVA MANEUVER
Apply occlusive dressing

CXR
Assess complications: subcutaneous emphysema, respiratory distress.