Gas Exchange

Front 1

Normal series of events in cough mechanism

Back 1

-Deep inhalation, closure of glottis, active contraction of expiratory muscles, and glottis opening

-Deep inhalation increases the lung volume and airway diameter, allowing air to pass thru partially obst' mucus plugs or other foreign matter

-Cont' of expiratory muscles against the closed glottis causes a high intrathoracic pressure to develop

-When the glottis opens, large flow of air is expelled at a high speed, providing momentum for mucus to move to the upper airways to be expectorated or swallowed

Front 2

Diaphragmatic/ belly breathing

Back 2

Technique that encourages deep breathing to increase air to the lower lungs.

-Belly moves out when inhaling and sinks when exhaling

* Opens the pores of Kohn btw alveoli to allow sharing of Oxygen between alveoli

-This is important if alveoli are plugged with mucus.

Front 3

Evaluating effectiveness of coughing by:

Back 3

-Sputum expectoration

-Pt's report of swallowed sputum

-Clearing of adventitious sounds by auscultation

Encourage pt w/ chronic pulmonary diseases, URT infections, LRT infections to deep breathe and cough q2h while awake

Pt w/ excessive sputum to cough q1h and wake to cough q2-3h during night

PostOP directed cough q 2-4h while pt awake to prevent accumulation of secretions (use splint)

Front 4

Cascade cough

Back 4

Pt takes a slow, deep breath and holds it for 2 seconds while contracting expiratory muscles

Then opens the mouth and performs a series of coughs throughout exhalation, coughs at progressively lowered lung volumes

* Promotes airway clearance and a patent airway in pt's with large volume of sputum

Front 5

huff cough

Back 5

Simulates a natural cough reflex and is generally effective only for clearing central airways

-While exhaling, pt opens glottis by saying the word huff

(w/ practice pt able to progress to cascade cough)

Front 6

Quad cough

Back 6

For pt without abdominal muscle control (SCI)

While pt breathes out with a maximal expiratory effort, the patient or nurse pushes inward and upward on the abdominal muscles toward the diaphragm, causing the cough

Front 7

Chest physiotherapy (CPT)

Back 7

-Group of therapies for mobilizing pulmonary secretions

Postural drainage, chest percussion, vibration

-Followed by productive coughing or suctioning of a pt who has decreased ability to cough

--Recommended for pt who produces greater than 30 mL of sputum per day, atelectasis, pneumonia

Front 8

Contraindications for CPT

Back 8

-Diuretics, antihypertensives decrease pt's tolerance to postural changes and postural drainage

-Long term use of steroid increases risk for rib fractures and contra to vibration

-Increased ICP, SCI, abd aneurysm resection contra to positional changes of postural drainage

-Thoracic trauma or surgery contra percussion + vibration

-Congenital / acquired cog limitations alter pt ability to learn and follow controlled coughing techniques

- Be aware of exercise tolerance since CPT is fatiguing

Front 9

Assessment before CPT

Back 9

- Respiratory assessment to confirm need for CPT ( sputum production, effectiveness of cough, hx of pulmonary probs successfully tx w/ CPT)

-abnormal lung sounds, documented conditions such as atelectasis, pneumonia, changes in o2 status

Front 10

Postural drainage

Back 10

Use of positioning techniques that drain secretions from specific segments of the lungs and bronchi into the trachea

Purpose of various positions in postural drainage is to drain each segment toward the larger airways

- Position maintained for about 5 minutes during p+v

- Schedule procedure to be completed 1 hour before meals or 3 hours after meals

Front 11

Contraindications for positions for postural drainage (trendelenburg)

Back 11

chest trauma

hemoptysis

heart disease

pulmonary embolus

head injury

Other conditions where pt's condition is not stable

Front 12

Percussion

Back 12

Rhythmically clapping on the chest wall over the area being drained to force secretions into larger airways for expectoration

- Position hand w/ fingers and thumb touching and hands cupped (cupping makes hand conform to chest wall while trapping air cushion to soften intensity of clapping)

- Procedure should sound hallow and not be painful

-Perform over single layer of clothing

Front 13

Contraindications for percussion

Back 13

Bleeding disorders

osteoporosis

fractured ribs

Avoid over burns, open wounds, infected skin of thorax

- Caution to percuss lung fields under the ribs and NOT over spine, breastbone, stomach, lower back b/c trauma to spleen, liver, and kidneys

Front 14

Vibration

Back 14

Shakes secretions to larger airways

--> Place flattened hand or 2 hands firmly on chest wall over the appropriate segment and tense muscles of the arm and provide a shaking motion.

(have pt exhale slowly during vibration)

- increases velocity and turbulence of exhaled air, helps remove secretions, increases exhalation of trapped air, shakes mucous loose, and induces a cough

- Tolerated better than percussion and can be used in sitch where percussion is contraindicated

Front 15

Cuff inflation pressure

Back 15

16 - 20 mmHg or < 25 cm H20

Should not exceed to allow adequate tracheal capillary perfusion

(add or remove air to the pilot tubing using a syringe and stopcock.)

-Verify cuff pressure with manometer

- High pressure predisposes to tracheal necrosis

- Cuff can be deflated when pt no longer at risk for aspiration

-Suction trach tube then mouth before deflating to prevent aspiration during deflation

- Deflate during exhalation, inflate during inhalation

Front 16

Obturator

Back 16

-Used when inserting the tube

- When inserting place obturator inside the outer cannula with rounded tip protruding from the end of the tube to ease insertion

-TAKE OUT IMMEDIATELY so air can flow through the tube

-Keep at bedside for use in case of accidental decantation

Front 17

Non disposable inner cannula ?

Back 17

Clean every 8 hours

Front 18

Suction catheter size

Back 18

- no more than half the size of the lumen of the tracheostomy tube

Front 19

Suction pressure set at

Back 19

-120 to -150 mmHg

Front 20

Preoxygenate for

Back 20

minimum of 30 seconds by:

1) adjusting ventilator to deliver 100% oxygen

2) using MRB connected to 100% oxygen

3) asking pt to take 5-6 deep breaths while administering oxygen

Front 21

Insert suction catheter

Back 21

WITHOUT SUCTION to minimize amount of O2 removed from lungs

To point where pt coughs or resistance is met OR

0.5- 1.0 cm beyond length of artificial airway

then,

withdraw catheter 0.5 - 1.0 cm before applying suction to prevent trauma to carina

Front 22

Limit suction time to

Back 22

10 seconds

Front 23

D/C suctioning if :

Back 23

HR decreases from baseline by 20 beats/min

HR increases from baseline by 40 beats/min

A dysrhythmia occurs

SpO2 decreases to less than 90%

Front 24

After each suction pass:

Back 24

Oxygenate for at least 30 seconds with 5-6 breaths by MRB

Front 25

Tracheostomy care provided

Back 25

every 8 hours

Front 26

Oropharyngeal and nasopharyngeal suctioning

Back 26

- Used when pt is able to cough effectively but unable to clear secretions by expectorating

-Apply suction after pt has coughed

-Once the pulmonary secretions decrease and a patient is less fatigued, he is then able to expectorate or swallow mucus, and suctioning no longer necessary

Front 27

orotracheal and nasotracheal suctioning

Back 27

Necessary when pt w/ pulmonary secretions is unable to manage secretions by coughing and doesn't have artificial airway

-Pass sterile catheter the mouth or nose into the trachea (nose preferred to reduce gag reflex)

-Advance catheter tip farther into the pt's trachea

-Allow pt to rest bwt passes of the catheter

Front 28

Tracheal suctioning

Back 28

Performed thru an artificial airway such as an endotracheal or tracheotomy tube

-Catheter size should be as small as possible, but large enough to remove secretions

- Half the internal diameter of the ET tube is size recommendation

-never apply suction pressure while inserting the catheter to avoid traumatizing the lung mucosa

-Once insert catheter to necessary distance, maintain pressure bwt 120 and 150 mmHG as you withdraw

Apply suction intermittently ONLY while withdrawing the catheter

Front 29

Open VS closed suctioning

Back 29

Open suctioning involves using a new sterile catheter for each suction session

Closed suctioning involves using a reusable sterile suction catheter that is encased in a plastic sheet to protect it btw suction sessions

(used most often on pt who require mechanical ventilation to support resp status b/c it permits continuous delivery of 02 while suction is performed & reduces risk of o2 desaturation

Sterile gloves not required

Front 30

Oral airway

Back 30

-Prevents obstruction of the trachea by displacement of the tongue into the oropharynx

-Extends from the teeth to the oropharynx, maintaining the tongue in the normal position

Use correct size airway: measure the distance from the corner of the mouth to the angle of the jaw just below the ear to the distance from the flange of the airway to the tip

(airway too small, tongue doesn't stay in place)

(airway too large, forces tongue toward the epiglottis and obstructs the airway)

-Insert airway by turning the cure of airway toward the cheek and placing it over the tongue

-When airway is in oropharynx, turn it so the opening points downward

Correct placement: airway moves the tongue forward away from the oropharynx, and the flange (flat portion of the airway) rests agains pt's teeth

Front 31

Endotracheal and tracheal airway

Back 31

ET is a short term artificial airway to admin mechanical ventilation, relieve upper airway obst, protect against aspiration, clear secretions

-Tube is passed thru the pt's mouth passed the pharynx, and into the trachea

-Usually removed w/n 14 days, can be used longer

Front 32

Tracheostomy

Back 32

Long term assistance artificial airway

(incision made into trachea, a short artificial airway the tracheostomy tube is inserted)

MC complication is partial or total airway obstruction caused by buildup of respiratory secretions

-Humidification from air humidifiers or humidified oxygen tracheostomy collars can help prevent drying secretions that cause occlusion

Front 33

Nursing interventions to maintain or promote lung expansion

Back 33

Noninvasive: ambulation, positioning, incentive spirometry, noninvasive ventilation

Invasive: chest tube insertion and management assist in restoring lung expansion

Front 34

Noninvasive positive pressure ventilation

Back 34

-Used to prevent using invasive artificial airways in pt w/ acute respiratory failure, cariogenic pulmonary edema, or exacerbation of COPD, after ET tube extubation

-Purpose: maintain positive airway pressure and improve alveolar ventilation

-Prevents/ treats atelectasis by inflating the alveoli, reducing pulmonary edema by forcing fluid out of lungs back into circulation

TypesL CPAP, BiPAP (bilevel)

Front 35

Chest tubes

Back 35

-A catheter inserted thru the thorax to remove air and fluids from the pleural space or to reestablish normal intrapleural and intrapulmonic pressures

Common after chest surgery and chest trauma and used for tx of hemothorax, pneumothorax to promote lung reexpansion

Front 36

Chest tube sizes

Back 36

small bore chest tube (12-20 Fr) used to remove a small amount of air

Large bore chest tube to remove large amounts of fluid or blood and large amounts of air

Front 37

S/S of upper and lower airway obstruction (requiring suctioning)

Back 37

- abnormal RR

-adventitious sounds on inspiration + expiration

-nasal secretions

-Gurgling

-drooling

-restlessness

-gastric secretions/ vomit in mouth

-Coughing without clearing secretions from airway

Front 38

s/s associated w/ hypoxia and hypercapnia

Back 38

-Decreased Sp02

-Increased pulse and BP

-Increased RR

-apprehension

-anxiety

-decreased ability to concentrate

-lethargy

-Decreased LOC

-fatigue, dizziness, irritability

-dysrhythmias, pallor, cyanosis

Front 39

RF for upper or lower airway obstruction

Back 39

COPD

Pulmonary infection

Fluid imbalance

Lack of humidity

Impaired mobility

Decreased LOC

Decreased gag or cough reflex

Dysphagia

Presence of feeding tube

Front 40

Contraindications to nasotracheal suctioning

Back 40

occluded nasal passages

nasal bleeding

epiglottitis

croup

acute head, facial, neck injury

Coagulopathy or bleeding disorder

Irritable airway

laryngospasm / bronchospasm

gastric surgery w/ high anastomosis

MI

Front 41

Tracheostomy tube with an inflated cuff

Back 41

-Used if pt is at risk for aspiration or needs mechanical ventilation

-Cuff exerts pressure on tracheal mucosa

-Cuff inflation pressure should not exceed 20 mmHg or 25 cm H2o (higher pressures may compress tracheal capillaries, limit blood flow, predispose pt to tracheal necrosis

-MLT (minimal leak technique) and MOV (minimal occlusion volume) methods used to inflate cuff

Front 42

Deflating cuff

Back 42

-Done when pt no loner risk for aspiration

-Before deflation, have pt cough up secretions and suction the tracheostomy tube then the mouth (prevents aspiration of secretions)

-Deflated during exhalation to help propel secretions to mouth

- Deflating cuff asap reduces swallowing dysfunction that the cuff causes

Front 43

Complications of tracheostomy

Back 43

Front 44

Fenestrated tube

Back 44

- Has openings on the surface of the outer cannula that permit air from the lungs to flow over the vocal cords

-Allows pt to breath spontaneously thru larynx, speak, cough up secretions while tracheostomy tube remains in place

-Only pt who can swallow without risk of aspiration can use this tube

-Also used when pt needs to be mechanically ventilated

Front 45

If there is no aspiration

Back 45

1) remove inner cannula (if nonfenenstrated)

2) deflated the cuff

3) place the decantation cap in the tube

Severe respiratory distress may result if tube is capped before removing the inner cannula and deflating the cuff

Front 46

Disadvantage of fenestrated tube

Back 46

Potential for developing tracheal polyps from tracheal tissue granulating into the fenestrated openings

Front 47

Speaking tracheostomy tube

Back 47

- Has 2 pigtail tubings (one connects to the cuff and is for cuff inflation, second connects to an opening just above the cuff)

-When the second tubing is connected to a low flow (4-6 L/minute) air source allows air to move up over vocal cords and permit speech

-Allows pt w at risk for aspiration to speak w/ cuff inflated

Front 48

Decannulation

Back 48

- Tracheostomy tube can be removed when the patient can adequately exchange air and expectorate secretions

- Close stoma with tape strips and cover it with occlusive dressing

- Epithelial tissue begins to form in 24 - 48 hrs

- Opening closes within 4 -5 days

- Splint stoma when coughing, swallowing, speak

-SURGICAL INTERVENTION NOT REQUIRED

Front 49

Pneumothorax

Back 49

Air in pleural space

-Dyspnea, decreased mvmc of chest wall, diminished or absent breath sounds on affected side, hyperresonance to percussion

Intervention: chest tube insertion with flutter valve or chest drainage system

Front 50

Hemothorax

Back 50

Blood in the pleural space, may/may nit occur in conjunction with pneumothorax

- Dyspnea, diminished or absent breath sounds, dullness to percussion, decreased hgb, shock depending on blood volume lost

Intervention: chest tube insertion w/ chest drainage system. Autotransfusion of collected blood, tx of hypovolemia as necessary

Front 51

Tension pneumothorax

Back 51

Air in pleural space that doesn't escape. Increased air in pleural space shifts organs and increases intrathoracic pressure

- Cyanosis, air hunger, violent agitation, tracheal dev away from affected side, subcutaneous emphysema, neck vein distention, hyperresonance to percussion

Intervention: needle decompression followed by chest tube insertion w/ chest drainage system

Front 52

Flail chest

Back 52

Fracture of two or more adjacent ribs in two or more places with loss of chest wall stability

- paradoxic mvmt of chest wall, respiratory distress. May be associated with hemothorax, pneumothorax, pulmonary contusion

Intervention: O2 as needed to maintain o2 sat, analgesia, CPAP, BiPAP (positive pressure ventilation), mechanical ventilation

Front 53

Cardiac tamponade

Back 53

Blood rapidly collects in pericardial sac, compresses myocardium because the pericardium doesn't stretch and prevents ventricles from filling

- Muffled, distant heart sounds, hypotension, neck vein distention, increased central venous pressure

Intervention: Surgery, medical emergency, pericardiocentesis

Front 54

Spontaneous pneumothorax

Back 54

Occurs due to the rupture of small blebs on apex of lungs

Primary: bleb occurs in healthy young individual

Secondary: as result of lung disease (COPD, asthma, CF, pneumonia)

- Smoking increases risk for bleb formation

- RF: being tall and thin, male gender, family hx, previous spontaneous pneumothorax

Front 55

Iatrogenic pneumothorax

Back 55

Due to laceration or puncture of lung during medical procedures

-Transthoracic needle aspiration is leading cause

Others: subclavian catheter insertion, thoracentisis, pleural biopsy, transbronchial lung biopsy

-Barotrauma from excessive ventilatory pressure during manual or mechanical ventilation

Front 56

Traumatic pneumothorax

Back 56

Can occur from penetrating (open) or non penetrating (closed) chest trauma

-Penetrating trauma allows air to enter pleural space thru an opening in chest wall

Ex: stab or gunshot wounds, surgical thoracotomy

Emergency tx is covering wound with an occlusive dressing secured on three sides (vent dressing)

Front 57

Tension pneumothorax

Back 57

Air enters pleural space but cannot escape

- Accumulation of air in pleural space causes increased intrapleural pressures = compression of lung on affected side and pressure of the heart and great vessels, pushing them away from affected side

Mediastinum shift towards unaffected side (compressing good lung), which further compromises oxygenation

As pressure increases, venous return is decreased and CO falls

--> Results from open or closed pneumothorax, mechanical ventilation, resuscitative efforts, chest tubes are clamped or become blocked

Front 58

Tension pneumothorax manifestations

Back 58

Dyspnea, tachycardia, tracheal deviation, decreaed or absent breath sounds on affected side, neck vein distension, cyanosis, diaphoresis

MEDICAL EMERGENCY: if tension in pleural space isn't relieved, pt likely to die from inadequate CO or severe hypoxemia

Front 59

Hemothorax

Back 59

Accumulation of blood in pleural space resulting from injury to chest wall, diaphragm, lung, blood vessels, or mediastinum.

- Occurs w/ pneumothorax is called a hemopneumothorax

- Pt requires immediate insertion of a chest tube for evacuation of the blood, which can ne recovered and reinserted for a short time after injury

Front 60

Chylothorax

Back 60

- Lymph fluid in pleural space

- Thoracic duct is disrupted traumatically or from a malignancy

- Normal lymph flow thru thoracic duct is 1500- 2500 mL/day. This amount can increase up to tenfold after ingestion of fats

- 50% of cases heal w/ conservative tx ( chest drainage, bowel rest, parenteral nutrition)

- Octreotide used to reduce the flow of lymph fluid

- Pleurodesis is artificial production of adhesions between the parietal and visceral pleura, usually done with chem sclerosing agent (talc or doxycycline)

Front 61

Fractured Ribs

Back 61

Most common type of chest injury resulting from blunt trauma

- Ribs 5-9 most frequently fractured because they are least protected by chest muscles

-Fractured rib is splintered or displaced, it may damage the pleura and lungs

-> pain at site of injury during inspiration and coughing, patient splints area and takes shallow breaths to decrease the pain

- Ateletasis and pneumonia develop because of decreased ventilation and retained secretions

- NSAID, opioids, nerve blocks, deep breathing, coughing, incentive spirometry

Front 62

Flail chest

Back 62

- Fracture of several consecutive ribs, in 2 or more separate places, causing an unstable segment.

- Instability of chest wall causes paradoxic mvmt during breathing

- Paradoxic chest mvmt prevents adequate ventilation aof lung in the injured area and increases the work of breathing

Front 63

Flail chest manifestations

Back 63

- rapid, shallow respirations and tachycardia

Diagnosed by ABGs, chest xray, palpitation of abnormal respiratory mvmt, evaluation for crepitus near rib fractures

Front 64

flutter of heimlich valve

Back 64

Used to evacuate air from the pleural space. (prevents reentry of air into pleural space)

-Consists of a one way rubber valve within a rigid plastic tube. It's attached to the external end of chest tube

- Valve opens when pressure in chest is greater than atmospheric pressure (during expiration) and closes when intrathoracic pressure is less than atmospheric pressure (during inspiration)

-Used in place of a chest drainage unit for small uncomplicated pneumothorax w/ little or no drainage and no need for suction

Front 65

Oropharyngeal (oral) airways (OPAs)

Back 65

Inserted into the mouth and used only on unconscious, unresponsive victims with no gag reflex

Contra: victim suffered oral trauma, such as broken teeth, recently undergone oral surgery

Front 66

Nasopharyngea (nasal) airways

Back 66

Inserted into the nose and may be used on a conscious, responsive victim or an unconscious victim

-Doesn't cause gag reflex

Contra: victims w/ suspected head trauma or skull fracture

Front 67

Inserting OPA

Back 67

1) measure OPA from earlobe to corner of the mouth

2) Use cross finger technique to open the victim's mouth

3) Grasp lower jaw and tongue and lift upward

4) Insert OPA w/ curved end along roof of mouth

5) as tip approaches back of mouth, rotate it 180 degrees

6) slide OPA into back of throat

--> Flange should rest on victim's lips

Front 68

Inserting NPA

Back 68

1) Measure from earlobe to tip of nostril. Ensure diameter of NPA is not larger than nostril

2) Use water soluble lubricant on NPA prior to insertion

3) With bevel toward septum (center of the nose), advance NPA gently, straight in, following the floor of the nose

4) Flange should rest on victim's nostril

Front 69

Take care not to dislodge tracheostomy during first 5-7 days when stoma is not mature

Precautions to prevent early tube replacement

Back 69

- Keep a replacement tube both smaller or bigger and equal size at bedside

-Do not change tracheostomy tapes for at least 24 hours after insertion procedure

- Physician performs first tube change no sooner than 7 days after tracheostomy

Front 70

What do you do in an accidental tube dislodgment?

Back 70

- Immediately attempt to replace it

- Grab retention sutures or use a hemostat to spread the opening to facilitate replacing tube

-Insert obturator in the replacement tube (lube with saline poured over tip)

-Insert tube into stoma at a 45 degree angle to the neck (remove obturator)

Front 71

what do you do if the tube cannot be replaced?

Back 71

-Assess level of respiratory distress

-Cover stoma with a sterile dressing and ventilate pt with bag mask ventilation over the nose and mouth until help arrives

Front 72

Flutter / heimich valve

Back 72

Used to evacuate air from the pleural space

- Consists of a one way rubber valve within a rigid plastic tube attached to external end of CT

- Valve opens when pressure in chest is greater than atmospheric pressure (during expiration) and closes when intrathoracic pressure is less than atmospheric pressure (inhalation)

-Used for small to moderate sized pneumothorax, blebs

Front 73

Collection chamber

Back 73

Receives fluid (drainage) and air from the pleural or mediastinal space.

The drained fluid stays in this chamber while the air vents to the water seal chamber

Front 74

Water seal chamber

Back 74

contains 2 cm of water, which acts as a one way valve.

-Incoming air enters from the collection chamber and bubbles up through the water

-Water prevents back flow of air into the patient from the system

-Intermittent bubbling as long as their is air in pleural space

-Normal fluctuation (tidaling) movement of water with respiration reflects intrapleural pressure changes during inspiration and expiration

-Sudden cessation of tidaling = occluded tube

Front 75

Suction control chamber

Back 75

Applies suction to the chest drainage system

(wet and dry suction control)

- Water: uses column of water with top end vented to the atmosphere to control the amount of suction from the wall regulator

-The amount of suction is regulated by the amount of water in the chamber

-Filled with 20 cm of water

- Suction pressure usually -20 cm H20

-Should see gentle bubbling

Front 76

If a chest tube becomes disconnected

Back 76

- Immediately reestablish the water seal system and attach a new drainage system asap

-immerse in sterile water (2 cm) until system can be reestablished

Front 77

Appearance of a new air leak

Back 77

-Assess drainage system to id where leak is coming from (patient or system)

- Chest tube may be momentarily clamped to change drainage apparatus or check for air leaks

Front 78

Complications associated w/ chest tube placement and drainage

Back 78

-Volumes of 1 - 1.5 L of pleural fluid are removed rapidly, reexpansion pulmonary edema or a vasovagal response with symptomatic hypotension may occur

- SubQ emphysema can occur from air leaking into the tissue surrounding the chest tube insertion site

-Severe subQ emphysema can cause drastic swelling of the head and neck with potential airway compromise

Front 79

Minimal occluding volume technique

Back 79

1) for the mechanically ventilated pt, place stethescope over trachea and inflate the cuff to MOV by adding air until no air leak is heard at peal inspiratory pressure (end of ventilator inspiration)

2) Spontaneously breathing: inflate until no sound is heard after a deep breath or after inhalation w/ a BVM

3) use a manometer to verify cuff pressure is between 20 -25 cm H20

(if cuff pressure cannot be maintained or larger volumes of air are needed to keep it inflated, could be a leak or tracheal dilation at the cuff site) Notify MD to reposition or change ET tube

Front 80

Minimal leak technique

Back 80

Procedure is same as MOV

- Remove a small amount of air from he cuff winter a slight air leak is auscultated at peak inflation