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 patient with a chest drainage system.

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 causes air to

enter through the airways and inflate the lungs.

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

VENTILATION-PERFUSION RATIOS:A- NORMAL RATIOB- SHUNTS C- DEAD SPACED- SILENT UNIT

LIGHTER SIDE

HOW good is HOW good is your clinical your clinical eye?eye?

READ OUT LOUD THE TEXT READ OUT LOUD THE TEXT INSIDE THE TRIANGLE BELOW.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 NEXT, LET'S PLAY WITH SOME WORDS.SOME WORDS.

      WHAT DO YOU SEE?      WHAT DO YOU SEE?

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 660nm910nmHboHb20.110RedIRPhotodiode

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

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 removed.

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.

NURSING CONSIDERATIONS

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 balance

ABG ANALYSIS

Pre-test: Secure equipments- heparinized

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

FiO2 = fraction of inhaled gas that is 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 on room air

7.32/50/98/22 99% O2 saturation on room air

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 saturation normal?

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 and must be corrected before treating the 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 with sodium chloride solutions

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 hyperventilation

O2 SATURATION VS. ABG

MEMORIZE THESE 4 SETS OF NUMBERS:

mm Hg O2 sat.

27 50% - 50% saturation.

40 75% -PvO2

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

100 98% -PaO2

GAS EXCHANGE AND RESPIRATORY FUNCTION

pHPaCO2

mmHg

HCO3

mEq/L

PaO2

mmHg

SaO2

%

Remarks

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

LET’S EXERCISE!

Lighter SideLighter Side

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CAN YOU READ THIS?

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.

To re-establish an adequate ventilation-perfusion ratio.

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, maybe from CHF, sometimes from a tumor process, will collect between the pleura

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67

69

CLOSED-CHEST DRAINAGE SYSTEM

76

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 steady bubbling in the suction control chamber.

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 water-seal chamber, which indicates leaks in the drainage system. Identify and correct external leaks. Notify the health care provider immediately if you can’t identify an external leak or correct it.

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, cloudy, or unexpectedly bloody.

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.

DO

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.”

-Goethe

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

- Fisher

THANK YOU!

QUIZ TIME!