Respiratory Modalities

RESPIRATORY MODALITIES

OBJECTIVE After the lecture, the learner will be able to: Have enhanced knowledge on selected respiratory diagnostic test and procedures (ie. Pulse Oximeter, ABG Analysis and Chest Tubes) Understand the implications of the test results Identify the nursing implications of the various procedures used for diagnostic evaluation of respiratory function. Provide optimal patient care before, during and after the test or procedure. Interpret arterial blood gas measurements. Explain the principles of chest drainage and the nursing responsibilities related to the care of the

ANATOMY & PHYSIOLOGY

PURPOSE OF THE RESPIRATORY SYSTEM The lungs, in conjunction with the circulatory system, deliver oxygen to and expel carbon dioxide from the cells of the body. The upper respiratory system warms and filters air. The lungs accomplish gas exchange.

STRUCTURES OF THE UPPER RESPIRATORY TRACT Nose Sinuses and nasal passages Pharynx Tonsils and adenoids Larynx: epiglottis, glottis, vocal cords, and cartilages Trachea

PARANASAL SINUSES

CROSS-SECTION OF NASAL CAVITY

UPPER RESPIRATORY SYSTEM

STRUCTURES OF THE LOWER RESPIRATORY SYSTEM Lungs Pleura Mediastinum Lobes of the lungs: Left: upper and lower Right: upper, middle, and lower Bronchi and bronchioles Alveoli

AVEOLI Where gas exchange takes place Alveolar-capillary membrane Types of alveolar cells Surfactant

LOWER RESPIRATORY SYSTEM

THE LOBES OF THE LUNGS AND BRONCHIOLE TREE

VENTILATION: THE MOVEMENT OF AIR IN AND OUT OF THE AIRWAYS. Thoracic cavity airtight chamber. Diaphragm

Floor

Inspiration contraction of the diaphragm (movement of this chamber floor downward) contraction of the external intercostal muscles increases the space in this chamber Lowered intrathoracic pressure

Expiration: with relaxation Diaphragm moves up and intrathoracic pressure increases Increased pressure pushes air out of the lungs. Expiration requires the elastic recoil of the lungs. Inspiration normally is 1/3 of the respiratory cycle and expiration is 2/3.

GAS EXCHANGE AND RESPIRATORY FUNCTION

VENTILATIONPERFUSION RATIOS: A- NORMAL RATIO B- SHUNTS C- DEAD SPACE D- SILENT UNIT

LIGHTER SIDE

HOW good is your clinical eye?

READ OUT LOUD THE TEXT INSIDE THE TRIANGLE BELOW.

MORE THAN LIKELY YOU SAID, "A BIRD IN THE BUSH." If this IS what YOU said, then you failed to see that the word THE is repeated twice!               Sorry, look again.

NEXT, LET'S PLAY WITH SOME WORDS.       WHAT DO YOU SEE?

WHAT DO YOU SEE?

PULSE OXIMETRY A noninvasive method to monitor the oxygen saturation of the blood (SaO2) Does not replace ABGs Normal level is 95-100%. May be unreliable cardiac arrest shock when dyes (ie, methylene blue) or vasoconstrictor medications severe anemia high carbon monoxide level.

SPO2 Oxygen saturation ratio of oxyhemoglobin (HbO2) to the total concentration of hemoglobin (HbO2 + deoxyhemoglobin)

Figure 2 660nm910nmHboHb20.110RedIRPhot odiode

PULSE OXIMETER

RECOMMENDED CONTINUOUSLY FOR critical or unstable airway post-operative clients conscious sedation for diagnostic procedure history with risk for significant desaturation known lung dysfunction morbidly obese/obstructive apneas with acute pain who received analgesics cardiopulmonary disorder transfers of critically ill clients during hemodialysis

INTERMITTENTLY on supplemental oxygen tracheotomy long term mechanical ventilator for stable, chronic respiratory failure

NOT RECOMMENDED during cardiopulmonary resuscitation hypovolemia assess of adequacy of ventilatory support detecting worsening lung function in patients on high concentration of oxygen

NURSING CONSIDERATIONS Be familiar with the manufacturer's recommendations for the device. Use the correct size to avoid skin complications and ensure accurate readings

NURSING CONSIDERATIONS Reevaluating the sensor site periodically. When using disposable sensors, assess the site every two to four hours and replace the sensor every 24 hours. When using a reusable sensor, the site should be checked every two hours and changed every four hours. Manufacturer's recommendations regarding cleaning agents should also be followed.

NURSING CONSIDERATIONS Check that the right type of sensor is being used. To exclude motion artifact caused by shivering, patients should be kept warm. To avoid potential interference from ambient light, the sensor can be covered with the patient's linens. Nail polish or artificial nails should be

NURSING CONSIDERATIONS Nurses should explain why pulse oximetry is being used, how it works, and what the readings indicate in language the patient and family can comprehend.

HOW GOOD IS YOUR CLINICAL EYE?

ARTERIAL BLOOD GASES Measurement of arterial oxygenation and carbon dioxide levels. Used to assess the adequacy of alveolar ventilation and the ability of the lungs to provide oxygen and remove carbon dioxide. Also assesses acid-base

ABG ANALYSIS Pre-test: Secure equipmentsheparinized syringe, needle, container with ice Choose site carefully, perform the Allen’s test

Intra-test: Obtain a 5 mL specimen from the artery (brachial, femoral and radial), no air on the syringe

Post-test: Apply firm pressure for 5 minutes or 15 minutes with patients on anticuagulants, Label specimen correctly noting oxygenation and amount or room air if applicable, Place in the container with ice Assess for swelling, bruising, numbness, tingling, and pain

pH/PaCO2/PaO2/HCO3       O2 saturation on a specified FiO2 pH  =  arterial blood pH PaCO2 (or PCO2)  =  arterial pressure of CO2, in mm Hg PaO2 (or PO2)  =  arterial pressure of O2, in mm Hg HCO3  =  serum bicarb. conc., in mEq/liter O2 saturation  =  % hemoglobin saturated with O2

7.49/42/88/32       97% O2 saturation on 100% O2 7.41/39/88/32       95% O2 saturation on 100% O2 7.21/75/41/20 7.32/50/98/22      on room air

on room air 99% O2 saturation

ABG ANALYSIS ABG normal values pH

7.35- 7.45

PaCO2

35-45 mmHg

HCO3

22- 26 mEq/L

PaO2

80-100 mmHg

O2 Sat

95-99%

THE 6 EASY STEPS TO ABG ANALYSIS: 1.

Is the pH normal?

2. Is the CO2 normal? 3. Is the HCO3 normal? 4. Match the CO2 or the HCO3 with the pH 5. Does the CO2 or the HCO3 go the opposite direction of the pH? 6. Are the PaO2 and the SaO2

METABOLIC ACIDOSIS Due to renal failure Manifestations: headache, confusion, drowsiness, increased respiratory rate and depth, decreased blood pressure, decreased cardiac output, dysrhythmias, shock; if decrease is slow, patient may be asymptomatic until bicarbonate is 15 mEq/L or less Correct the underlying problem and correct the imbalance; bicarbonate may be administered

With acidosis, hyperkalemia may occur as potassium shifts out of the cell As acidosis is corrected, potassium shifts back into the cell and potassium levels decrease Monitor potassium levels Serum calcium levels may be low with chronic metabolic acidosis

METABOLIC ALKALOSIS Most commonly due to vomiting or gastric suction; may also be caused by medications, especially long-term diuretic use Hypokalemia will produce alkalosis Manifestations: symptoms related to decreased calcium, respiratory depression, tachycardia, and symptoms of hypokalemia Correct underlying disorder, supply chloride to allow excretion of excess bicarbonate, and restore fluid volume

RESPIRATORY ACIDOSIS Always due to a respiratory problem with inadequate excretion of CO2 With chronic respiratory acidosis, the body may compensate and may be asymptomatic; symptoms may include a suddenly increased pulse, respiratory rate, and BP; mental changes; feeling of fullness in the head Potential increased intracranial pressure Treatment is aimed at improving ventilation

RESPIRATORY ALKALOSIS Always due to hyperventilation Manifestations: lightheadedness, inability to concentrate, numbness and tingling, and sometimes loss of consciousness Correct cause of

O2 SATURATION VS. ABG

MEMORIZE THESE 4 SETS OF NUMBERS: mm Hg O2 sat.       27   40

50%   - 50% saturation. 75%    -PvO2

60 90%    - Sats < 90% are entering the steep 100  

98%    -PaO2

GAS EXCHANGE AND RESPIRATORY FUNCTION

LET’S EXERCISE! pH

P S HCO3 PaO2 aCO2 aO2 mEq/L

mmHg

mmHg

%

7.27

53

24

50

79

7.52

29

23

100

98

7.18

44

16

92

95

7.60

37

35

92

98

7.30

30

14

68

92

Remarks

Lighter Side

CAN YOU READ THIS? I cdnuolt blveiee taht I cluod aulaclty uesdnatnrd waht I was rdanieg. The phaonmneal pweor of the hmuan mnid, aoccdrnig to a rscheearch at Cmabrigde Uinervtisy, it deosn't mttaer in waht oredr the ltteers in a wrod are, the olny iprmoatnt tihng is taht the frist and lsat ltteer be in the rghit pclae. The rset can be a taotl mses and you can sitll raed it wouthit a porbelm. Tihs is bcuseae the huamn mnid deos not raed ervey lteter by istlef, but the wrod as a wlohe. Amzanig huh? yaeh and I awlyas tghuhot slpeling was ipmorantt!

CHEST DRAINAGE Used to treat spontaneous and traumatic pneumothorax Used postop to re-expand the lung & remove excess air, fluid, blood by restoring negative intrapleural pressure.

To assess and measure drainage from the intrapleural space.

CHEST TUBES long, semi-stiff, clear plastic tubes that are inserted into the chest, so that they can drain collections of fluids or air from the space between the pleura

INDICATION Pneumothorax: a collection of air in the pleural space. Closed Open Tension

Hemothorax: a collection of blood in the pleural space, maybe from surgery, maybe from a traumatic injury. Empyema: Pus can collect in the pleural space Pleural effusion: Fluid, usually serous,

64

67

69

76

CLOSED-CHEST DRAINAGE SYSTEM

CHEST TUBE DRAINAGE SYSTEM

DO Keep the system closed and below chest level.

Make sure all connections are taped and the chest tube is secured to the chest wall.

Ensure that the suction control chamber is filled with sterile water to the 20-cm level or as prescribed. If using suction, make sure the suction unit’s pressure level causes slow but

DO Make sure the water-seal chamber is filled with sterile water to the level specified by the manufacturer. You should see fluctuation (tidaling) of the fluid level in the water-seal chamber; if you don’t, the system may not be patent or working properly, or the patient’s lung may have reexpanded. Look for constant bubbling in the waterseal chamber, which indicates leaks in the drainage system. Identify and correct external leaks. Notify the health care provider immediately if you can’t

DO Assess the amount, color, and consistency of drainage in the drainage tubing and in the collection chamber.

Mark the drainage level on the outside of the collection chamber (with date, time, and initials) every 8 hours or more frequently if indicated.

Report drainage that’s excessive,

DO Encourage the patient to perform

deep breathing, coughing, and incentive spirometry. Assist with repositioning or ambulation as ordered. Provide adequate analgesia.

Assess vital signs, breath sounds,

SpO2, and insertion site for subcutaneous emphysema as ordered. When the chest tube is removed, immediately apply a sterile occlusive petroleum gauze dressing over the site to prevent air from entering the pleural space.

DON’T •

Don’t let the drainage tubing kink, loop, or interfere with the patient’s movement.

• Don’t clamp a chest tube, except momentarily when replacing the CDU, assessing for an air leak, or assessing the patient’s tolerance of chest tube removal, and during chest tube removal. • Don’t aggressively manipulate the chest tube; don’t strip or milk it.

“Knowing is not enough; we must apply. Willing is not enough; we must do.” -

Knowledge is a process of piling up facts; wisdom lies in their

THANK YOU! QUIZ TIME!