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Transcript of Respiratory Function
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Gas Exchange and
Respiratory FunctionPart One
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Review of Terms
Cyanosisinfluenced by polycythemia andanemia
Clubbing-Schamroth method
Hemoptysis
Perfusionactual blood flow through thecirculation
Ventilation----movement of gas into and out ofthe alveoli
Diffusionoxygen and CO2 exchanged from
environment>trachea>bronchi>bronchioles andalveoli
Compliance-measure of the elasticity,expandability, and distensibility of lungs,influenced by surfactant
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VentilationPerfusion Ratios
Normal lung is 1:1
Shunts: when perfusionexceeds
ventilation, a shunt exists. Blood
bypasses the alveoli w/o gasexchange occurring.
Pneumonia, atelectasis, tumors,
mucous plugs
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Ventilation-Perfusion Ratios cont.
High ventilation-perfusion ratio---Deadspace
Ventilation exceeds perfusion
Alveoli do not have adequate blood
supply for gas exchange to occur
Pulmonary emboli, pulmonary
infarction, cardiogenic shock
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Ventilation-Perfusion Ratios cont.
Silent unitabsence of ventilationand perfusion
Seen in pneumothorax and severe
ARDS
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Neurologic Control of Ventilation
Phrenic nerve
Respiratory center in medulla and
pons
Central chemoreceptors in medulla,influenced by chemical changes in csf
Peripheral chemoreceptors in aortic
arch and carotid arteries, respond firstto changes in PaO2, then PaCO2 and
pH
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Gerontologic Considerations
Decreased strength of respiratorymuscles
Decreased elasticity
Increased respiratory dead space
Decreased number of cilia
Decreased cough and gag reflex
Increased collagen of alveolar walls
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Respiratory Assessment
Health History Risk factors for respiratory disease-
genetics, smoking, allergens,occupational and recreational exposure
Dyspnea, orthopnea
Cough, ?productive
Chest pain
Cyanosis
Lung sounds
Clubbingindicates chronicity
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Diagnostic Evaluation
PFTs-assess respiratory function,screening, assess response to therapy
FVCvital capacity performed with amaximally forced expiratory effort
Forced expiratory volumeFEV1volume of air exhaled in the specifiedtime during the performance of forced
vital capacity. FEV1 is volume exhaled inone second.
FEV1/FVC%--ratio of timed forced exp.volume to forced vital capacity
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Diagnostic Evaluation--ABGs
1. pH
2. evaluate the PaCO2 and HCO3-
3. Look to see if compensation has
occurred. If CO2 is >40, respiratoryacidosis; If HCO3-
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ABGs continued
Can have two acid-base disturbances atsame time
This can be identified when the pH does
not explain one of the changes, e.g., pH 7.2
PaCO2 52
HCO3 13 Notice that oxygen level is not a
component in determining the acid-base
balance
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ABGs cont.
Normal values for arterial gases: 7.35-7.45, CO2 35-45 mm Hg, HCO3 22-26
mEq/L, O2 80-100 mm Hg, BE +/-2
mEq/Lsat >94%
Mixed Venous Blood: 7.33-7.41, CO2
41-51 mm Hg, HCO3 22-26 mEq/L,O2 35-40 mmHg, BE +/- 2mEq/L, sat
60-80%
See chapter 14 of text
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Acidosis
Results in decreased myocardialcontractility and a decreased vascular
response to catecholamines. May
interfere with metabolism of certainmedications
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Alkalosis
Can radically impair oxygen releasefrom RBCs. For this reason, use
bicarbonate infrequently in code
situations
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Other diagnostic studies
Pulse oximetrynot reliable in severeanemia, high CO levels, or in shock
CO2 monitoringtells us ventilation to lungsis occurring, that CO2 is being transported to
lungs, exp. CO2 indicates adequateventilation
Cultures
Imagingchest xray, CT, MRI, lung scans
(inject isotope, inhale radioactive gas), PET Bronchoscopy
Thoracentesis
others
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Sleep Apnea
Associated with frequent, loud snoringwith breathing cessation for 10
seconds or long, at least 5 episodes
per hour, followed by awakening by asnort when O2 levels drop
May be associated with obesity
Decreased pharyngeal tone (related toalcohol, sedatives, neuromuscular
disease)
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Sleep Apnea
Diagnosed by polysomnography(ECG, EEG, EMG, pulse oximetry)
More common in men
High risk for CAD, cerebrovasculardisease and premature death.
Results in hypoxia and hypercapnia
which trigger sympathetic response.Can lead to dysrhythmias and
elevated BP
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Sleep Apnea signs and
symptoms Excessive daytime sleepiness Frequent nocturnal awakening Insomnia Loud snoring Morning headaches Personality changes Systemic hypertension
Dysrhythmias Pulmonary hypertension, cor pulmonale polycythemia
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Management
Nurse educates patientAvoid alcohol and sedatives
Weight loss
CPAP or BiPAPCPAP preventsairway collapse, BiPAP makesbreathing easier and results in lowerairway pressure
Uvulopalatopharyngoplasty
Tracheostomy
Provigil, Provera, Diamox, Triptil may
help
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Cancer of the Larynx
Squamous cell most common95% Increasing in women
More common in African Americans
Most common in individuals between50-70 years of age
Carcinogenstobacco, alcohol,
exposure to asbestos, wood dust,cement dust, tar products, leather andmetals
Most often affects glottic area
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Laryngeal Cancer
Clinical manifestations1. Hoarseness of greater than two weeks
duration
2. Persistent cough
3. Sore throat4. Dysphagia
5. Dyspnea
6. Ulceration
7. Foul breath8. Cervical adenopathy
9. Weight loss
10. Debilitation
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Assessment and Diagnosis
H&P
Laryngoscopy with biopsy/staging of
disease
CT and MRI to assess adenopathyand further stageing
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Laryngeal Cancer
Management Depends on staging of tumor
Options include surgery, radiation and
chemotherapy
Sometimes combination therapy
Ensure any dental problems
corrected, usually before other
treatments
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Surgical Management
Laser surgery, supraglottic laryngectomy,hemilaryngectomy, total laryngectomy
In case of total laryngectomy, advancedcancer present
Laryngeal structures removed includingportion of trachea. Results in permanentloss of voice and permanenttracheostomy
Often will have radical neck dissectioninvolves removal of sternocleidomastoidmuscle, lymph nodes, jugular vein,surrounding soft tissue
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Post-operative Care
Usually ICU postop
Monitor airway, VS, hemodynamic
status and comfort level
Monitor for hemorrhage
Monitor for infection
Monitor tracheal stoma
Have extra trach at bedside (of same
size!)
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Post-operative Care
May be on ventilator initially Will have trach
Ensure humidityat all times
May have split thickness skin graft ortrapezius or pectoralis muscle graftsensureside of flap or graft not in dependent position
May have PCA
NG, G tube or jejunostomy tube may be inplacenutrition important
Speech rehab, esophageal speech,electrolarynges
Support group
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Patients with chronic obstructive
pulmonary disorders COPDnonreversible
Includes emphysema and chronic
bronchitis
Can co-exist with asthma
Present with s/s in middle life and
incidence increases with age
FVC and FEV1 decreased
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Chronic Bronchitis
Disease of airways
Increased mucous production,
decreased ciliary activity,
inflammation, reduced alveolarmacrophage function
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Emphysema
Lobulephysiologic unit of lungconsisting of bronchiole and its branches(alveolar ducts, sacs and alveoli)
Two typespanlobar and centrilobular
In Panlobartypedestruction ofbronchiole, alveolar duct and alveoli; littleinflammation, hyperexpanded chest,work on exhalation
Centrilobar typederangement of theV/Q ratios, chronic hypoxemia,hypercapnea, polycythemia and rightsided heart failure
See p. 688 for schematic
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Emphysema
Risk factors include:
1. Cigarette smoking
2. Occupational dusts, chemicals,
pollution
3. Deficiency of alpha1-antitrypsin,
protective enzyme that protects lung
parenchyma from injury---seen inCaucasians
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COPD clinical manifestations
Chronic cough, sputum production,and dyspnea on exertion (DOE)
Weight loss common
Increased number of respiratoryinfections
In primary emphysema, will have
barrel chest
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Diagnosis of COPD
Thorough H&P Spirometry to evaluate airflow
obstruction
FEV1/FVC will be less than 70% Reversibility will be tested
Chest xray
ABGs Screening for alpha1-antitrypsin
deficiency
Classified by five stages0 throughIV (see p. 690)
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Medical Management
Smoking cessation will slow progression May use Chantix, Wellbutrin,
nortriptyline, clonidine Bronchodilatorsbeta agonists,
anticholinergics, methyxanthines,combinations, nebulized medications,inhaled and systemic corticosteroids
Influenza and pneumococcal vaccines
Oxygen therapyusually started insevere COPD
High fat, low CHO diet
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Oxygen Therapy in COPD
Previously felt that high levels of O2affected hypoxic drive
Now thought that Haldane effect
relates to ability of hgb to carry O2and CO2. With increased levels of O2,
increased saturation, increased CO2
load w/o being able to expel it. So,increased hypercapnia.
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Surgical Management
Bullectomyhave blebs or enlargedairspaces that do not contribute to
ventilation
Lung volume reduction surgerymayimprove quality of life but not life
expectancy
Lung transplantation
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Nursing Management
Key is education Breathing exercises Inspiratory muscle trainingbreathe
against a set resistanceActivity pacing Self-care activities Physical conditioning Oxygen tx Nutritional therapy Coping measures
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Bronchiectasis
Chronic, irreversible dilation of thebronchi and bronchioles
Caused by: inflammation d/t recurrentinfections damaging bronchial walls,
thick sputum and decreased mucociliaryclearance; genetic disorders like CF,idiopathic causes
Results in atelectasis, fibrosis, VQ
mismatch R/O TB or other pathology Tx-chest PT, smoking cessation,
continuous abx tx, possible surgical
resection of affected areas
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Asthma
Chronic inflammatory disease
characterized by mucosal edema,
airway hyperreactivity, and mucous
production
Largely reversible
Allergy is strongest predisposing
factor
Poorly controlled asthma can result in
remodeling. Bronchial muscles and
mucous glands enlarge, alveoli
hyperinflate and subbasement fibrosis.
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Asthma
Cells that play role in inflammation ofasthma include: leukotrienes,bradykinins, prostaglandins, mastcells, neutrophils, eosinophils
Beta receptor stimulation results indecrease of chemical mediators andcauses bronchodilation
Three most common symptoms ofasthma are cough, dyspnea andwheezing
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Asthma
Family, environmental andoccupational history is necessary
Comorbid conditions like GERD, drug-
induced asthma and allergicbronchopulmonary aspergillosis may
be present
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Asthma
Triggers Complicationsstatus asthmaticus
Rescue and maintenance medications
Peak flow monitoringmeasure
highest airflow during a forced
expiration. See asthma action plan on
p. 715. Height, age and sex arevariables to consider in personal best
determination.
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Status Asthmaticus
Severe and persistent asthma that does notrespond to conventional therapy. Can beprecipitated by infection, irritants, ASA orothers
Severe bronchospasm with mucous plugging
leading to asphyxia Labored breathing, engorged neck veins,
cough, wheezing
ABGs indicated
O2, IV fluids, burst of steroids, short actingcorticosteroids, possibly magnesium sulfate
Nurse monitors, administers fluids and meds,ensures no irritants in environment
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Atelectasis
Closure of collapse of alveoli Often occurs in postoperative setting
and in those who are immobilized
Can result from any obstruction thatblocks air to and from alveoli
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Atelectasis
Clinical manifestationscough,sputum, low grade fever. In severe
cases, tachycardia, tachypnea, central
cyanosis Chest xray may reveal patchy
infiltrates, crackles will be heard over
affected area, O2 saturation may belower than 90%
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Atelectasis
Preventionturning, mobilizingpatient, deep breathing maneuvers,
incentive spirometry, secretion
management such as suctioning,nebulizers, chest PT
ManagementIPPB, chest PT,
nebulizer tx, bronchoscopy, possibleventilator support, thoracentesis
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Pneumonia
Is an inflammation of the lungparenchyma caused by
microorganisms
Community acquiredusually causedby: Strep pneumo, Hemophilus
influenza, Legionella, Mycoplasma
pneumoniae, Chlamydia, viral Hospital acquiredPseudomonas,
Staph aureus, Klebsiella
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Pneumonia
Pneumonia in theimmunocompromised patient
Aspergillus, Pneumocystis,
Mycobacterium tuberculosisAspiration pneumonia
Is the most infectious disease causing
death in the United States
P th h i l f
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Pathophysiology of
pneumoniaArises when normal flora has been
aspirated, when host defenses are
down or from bloodborne organisms
that enter the pulmonary circulationAffects ventilation and diffusionwill
have adequate perfusion but not
ventilation
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Risk factors for Pneumonia
Conditions resulting in mucousobstruction (cancer, smoking, COPD)
Immunosuppression
Prolonged immobility Depressed cough
NPO, ETT, NG or OG tubes
Alcohol intoxicationAdvanced age
Medications that depress respirations
Cli i l M if t ti f
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Clinical Manifestations of
Pneumonia Not possible to diagnose a certain
type by manifestations alone
May be sudden in onset with fever,
chills and pleuritic pain as seen inpneumococcal pneumonia
May be gradual in onset with low
grade fever, HA, pleuritic pain,myalgias and pharyngitis
Orthopnea
Purulent sputum
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Diagnosis of Pneumonia
History Physical exam
Sputum cultures
Blood cultures
Chest xray
Possible bronchoscopy depending on
severity
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Medical Management
Antibiotic depending on Gram stain Often treat empirically, intervene
promptly
CAP-tx with Zithromax, Biaxin, doxy,or fluoroquinolone. With comorbidities,
may use Augmentin, Vantin, Ceftin,
and a macrolide or doxy. Symmetrelfor Flu A, Tamiflu for Flu A/B. Bactrim
for PCP.
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Medical Management cont.
Hospital acquiredIV antibiotics suchas second generation cephalosporins,
carbapenems, fluoroquinolones. If
MRSA, use vancomycin, Zyvox. ForPseudomonas, use Timentin, Unasyn,
and an aminoglycoside.
Viral pneumonia is supportive careonly.
Hydration is important in all types.
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Other treatments
Antihistamines Nasal decongestants
Antipyretics
Monitoring O2 saturation, possiblyABGs
Serial xrays
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Gerontologic Considerations
In elderly the classic s/s of cough,chest pain, sputum production and
fever may be absent
May be difficult to distinguish heartfailure from pneumonia
Xrays particularly helpful in this
population
Nursing the patient with
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Nursing the patient with
pneumonia
Frequent assessmentnight sweats,fever, chills, cough, lung sounds
Encourage hydration as hydration
thins and loosens secretions Humidification w/or w/o oxygen
Encourage cough, chest
physiotherapy Promote rest
Maintain nutrition
Promote patient education
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Respiratory Care Modalities
Nasal cannulaup to 6L/min. Deliversup to 42% oxygen Simple maskflow rate 6-8L/min.
Delivers 40-60% oxygen.
Partial rebreather maskflow rate is 8-11L/min. Delivers 50-75% oxygen. Nonrebreather maskflow at 12 L/min.
Delivers 80-100% oxygen.
Venturi mask4-6 L/min, 6-8 L/min.Deliver respective oxygen concentrationof 24, 26, 28 or 30, 35, 40% oxygen.Most accurate delivery.
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Respiratory Care Modalities
Oxygen Hypoxemiadecrease in arterial oxygen
tension in blood Hypoxiadecrease on oxygen supply to
tissues Oxygen toxicitycan occur if delivering
>50% for longer than 48h. Caused byfree radical production.
Signs/symptoms of oxygen toxicityparesthesias, fatigue, refractoryhypoxemia, alveolar atelectasis, alveolarinfiltrates
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Consider alveolar collapse with highlevels of oxygen
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Tracheostomy
Surgical procedure in which an openingis made into the trachea
Tracheostomy tube
Temporary or permanent
Used to bypass an upper airwayobstruction, allow removal oftracheobronchial secretions, permit long
term use of mechanical ventilation, toprevent aspiration in unconsciouspatient or to replace endotracheal tube
Complications of
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Complications of
tracheostomy Bleeding, pneumothorax, air
embolism, aspiration, subcutaneous or
mediastinal emphysema, recurrent
laryngeal nerve damageAirway obstruction from accumulation
of secretions ,tracheoesophageal
fistula, tracheal ischemia
Nursing Care of the Patient with
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Nursing Care of the Patient with
Tracheostomy Initially, semi-fowlers position to
facilitate ventilation, promote drainage,
minimize edema, and prevent strain
on the suturesAllow method of communication
Ensure humidity to trach
Suction secretions as needed Manage cuffusually keep pressure
less than 25 mm Hg but more than 15
mm Hg to prevent aspiration
E d h l I b i
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Endotracheal Intubation Pass ETT via nose or mouth into
trachea
Method of choice in emergency
situation
Passed with aid of a laryngoscope
ETT generally has a cuff, ensure that
cuff pressure is between 15-20 mm
Hg. Use warmed, humidified oxygen
Should not be used for more than 3
week
P ti C li ti A i t d ith
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Preventing Complications Associated with
Endotracheal and Tracheostomy Tubes
Administer adequate warmed humidity Maintain cuff pressure at appropriate level
Suction as needed
Maintain skin integrity
Auscultate lung soundsETT can lodge inright mainstem bronchus
Monitor for s/s of infection
Monitor for cyanosis
Maintain hydration of patient Use sterile technique when suctioning and
performing trach care
Monitor O2 sat
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Mechanical Ventilation
Used to control patients respirations,to oxygenate when patients
ventilatory efforts are inadequate, to
rest respiratory muscles Can be positive pressure or negative
pressure
Key for the nurse is assess patientnot the ventilator
Indications for Mechanical
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Indications for Mechanical
Ventilation
PaO2 0.60 PaO2 >50 mm Hg with pH 35 bpm
( *vital capacity is dependent on age,gender, weight and body build. Usually
is twice tidal volume. If < 10mL/kg,
will need respiratory assist)
Classification of Ventilators
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Classification of Ventilators
Negative Pressure
Used for patients with polio, musculardystrophy, ALS, myasthenia gravis
Examples include the iron lung
chamber, pneumo wrap and tortoiseshell (portable devices with rigid shell
to create a negative pressure)
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Ventilatorspositive pressure
Inflate lungs by exerting positivepressure on the airway
Usually requires trach or ETT
Used in home setting as well Pressure cycled, time cycled and
volume cycled
Noninvasive positive pressureventilation is an option, does not
require ETT
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Positive Pressure Ventilators
Pressure cycled ventilatorsdeliversair until reaches a preset pressure,
then cycles off, then passive
expiration Can vary as patients airway
resistance or compliance changes
Volume delivered thus will vary andmay compromise ventilation
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Positive Pressure Ventilators Time cycled rarely seen in adults
(used in newborns and infants)
Volume cycledmost common.
Delivers a preset volume usually 8-
10ml per kg
Noninvasive positive pressure
ventilationCPAP and BiPAP. CPAP
indicated for sleep apnea, BiPAP esp.useful to avoid intubating patients and
in those with neuromuscular disorders,
other conditions.
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Ventilator Modes
Assist control Intermittent mandatory control
Synchronized intermittent mandatory
ventilation Pressure supportassists SIMV,
applies pressure plateau to spont.
resp. during inspiratory phase New modes incl. computerized
systems
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Initial Ventilator Settings
Tidal volume Lowest concentration of oxygen to
maintain PaO2 80-100 mm Hg
Peak inspiratory pressure ModeAC or SIMV, possibly PEEP
Sensitivity so that patient can trigger
the vent. With minimal effort Check ABGs after being on vent. for
20-30 minutes
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Remember..
If patient becomes agitated, confused,tachycardic, blood pressure increases
for some unexplained reason, assess
for hypoxia and manually ventilate on100%.
If patients heart rate slows and BP
drops during suctioning, possiblevagal stimulation. Stop suctioning and
give 100% O2.
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Bucking the ventilator
Occurs when the patients inspirationand expiration are out of synch with
the ventilator
Anxiety, hypoxia, increasedsecretions, hypercapnia, others
Sedatives, muscle relaxants,
paralytics may be necessary
Monitoring and Managing
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Monitoring and Managing
Potential Complications
associated with the ventilator See handout
Alterations in cardiac function Barotrauma and volutrauma resulting
in pneumothorax
Vagal stimulation Pulmonary infectionsuse
chlorhexidine gluconate in oral care
Weaning from the Ventilator
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Weaning from the Ventilator
criteria for weaning
Vital capacityamount of air expiredafter maximum inspiration. Should be
10-15mL/kg.
Maximum inspiratory pressure-used toassess the patients respiratory
muscle strengthshould be at least -
20cm H20 Tidal volumevolume of air that is
inhaled or exhaled during effortless
breath.
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Weaning criteria cont.
Minute ventilationequals resp ratetimes tidal volume. Normal is 6 L/min.
PaO2 greater than 60 mm Hg with
FiO2
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Thoracic Surgeries
Pneumonectomy Lobectomy
Segmental resection
Lung volume reduction
others
Risk factors for thoracic surgery
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g y
related atelectasis and
pneumonia Preopage, obesity, poor nutritional
status, smoking, preexisting lung
disease, comorbid states Intraoperativethoracic incision,
prolonged anesthesia
Postopimmobile, supine, inadequatepain management, prolonged
intubation/ventilator, presence of NG
tube, LOC, lack of education
Care of Patient after
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Care of Patient after
Thoracotomy
Maintain airway clearance Positioning-lobectomy turn either
side,pneumonectomy turn on affected
side, segmental resection varies perdoctor
Chest tube drainage/care
Relieve pain Promote mobility
Maintain fluid volume and nutrition
Care of Patient afterTh t it d
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Thoracotomymonitor and
manage potential complications
Monitor respiratory status
Vitals
For dysrhythmias For bleeding, atelectasis and infection
Monitor chest tube drainage, for leaks,
for tube kinks, for excessive drainage
Ch t t b d i t
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Chest tube drainage system
Based on three bottle system Drainage chamber
Water seal
Wet or dry suction Monitor water seal for bubbling
Check for subq emphysema
Gently milk tube
Occlusive dressing
M it d i