RESPIRATORY MODALITIES

OBJECTIVE
After the lecture, the learners 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

Diaphragm
Floor

airtight chamber.

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 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 660nm910nmHboHb20.110RedIRPhotodiode

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

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 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.

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 Allens test

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

Allens Test
Used to test blood supply to the hand, specifically, the patency of the radial and ulnar arteries.

The hand is elevated and the patient/person is asked to make a fist for about 30 seconds. Pressure is applied over the ulnar and the radial arteries so as to occlude both of them. Still elevated, the hand is then opened. It should appear blanched (pallour can be observed at the finger nails). Ulnar pressure is released and the colour should return in 7 seconds. Inference: Ulnar artery supply to the hand is sufficient and it is safe to cannulate/prick the radial If color does not return or returns after 710 seconds, the test is considered positive and the ulnar artery supply to the hand is not sufficient. The radial artery therefore cannot be safely pricked/cannulated.

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
on a specified FiO2

O2 saturation

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 7.41/39/88/32 O2 7.21/75/41/20 7.32/50/98/22 air

97% O2 saturation on 100% O2 95% O2 saturation on 100% on room air 99% O2 saturation on room

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 longterm 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

L ET S EXERCISE !
pH

PaCO2
mmHg

HCO3
mEq/L

PaO2
mmHg

SaO2
%

Remarks

7.27
7.52

53
29

24
23

50
100

79
98

7.18
7.60

44
37

16
35

92
92

95
98

7.30

30

14

68

92

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. To re-establish an adequate ventilationperfusion 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

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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 units pressure level causes slow but steady bubbling in the suction control chamber.

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 dont, the system may not be patent or working properly, or the patients 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 cant 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 thats 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.

DONT
Dont let the drainage tubing kink, loop, or
interfere with the patients movement. Dont clamp a chest tube, except momentarily when replacing the CDU, assessing for an air leak, or assessing the patients tolerance of chest tube removal, and during chest tube removal. Dont aggressively manipulate the chest tube; dont 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!