Common Laboratory and Diagnostic Tests

PHYSICAL ASSESSMENT Common Laboratory and Diagnostic Tests Pulmonary Function Studies Spirometry Measures the volume of air (liters) exhaled or inhaled by a patient over time Evaluates lung function and airway obstruction & promotes deep breathing Measures the degree of airway obstruction & elevates response to inhaled medications. EX: PT inhales deeply and exhales forcefully into spirometer instrument that measures lung volume and airflow. NOT THE SAME AS AN INCENTIVE SPIROMETER- (SIMPLE DEVICE FOR AT HOME & DOESN’T MEASURE BREATH VOLUME OR LUNG FUNCTION). Peak Expiratory Flow Rate (Point of Highest flow during forced expiration) Reflects changes in the size of pulmonary airway & measured using a peak flow meter . Used for moderate/severe asthma to measure the severity of the disease and degree management. PT sits/lays back as straight as possible, takes a deep breath with the peak flow meter in her mouth closing their lips. PT forcibly exhales into the peak flow meter and an indicator rises (maximum flow rate). Pulse Oximetry – Non-invasive; measures ARTERIAL OXYHEMOGLOBIN SATURATION (SpO2) of Arterial Blood. Ratio report, expressed as percentage, between actual oxygen content & potential maximum oxygen-carrying capacity of hemoglobin. 90% - 100% = NORMAL SpO2 Values <90% = LOW When administering supplemental oxygen to patients target saturation = 94% -98% Parameters for acceptable SpO2 saturation readings may differ for patients. Chronic lung disease 88% -92% considered within normal limits or may indicate need for oxygen therapy Be aware of PT hemoglobin levels before evaluating (test measures only oxygen being carried by hemoglobin). Capnography – Non-invasive; monitors respiratory function and ventilation Measures the carbon dioxide level in expired air (end-tidal CO2) Exhaled air pass through a sensor that measures amount of carbon dioxide exhaled w/ each breath. Capnometer (device displaying numeric measurements of CO2) 35 – 45 mm Hg = NORMAL Detects signs of abnormal ventilation (respiratory depression, hypoventilation ) earlier than pulse oximetry. Can confirm placement of endotracheal, tracheostomy, nasogastric tubes Thoracentesis – procedure of puncturing the chest wall and inserting a needle into the pleural space to aspirate pleural fluid or/and air. Obtain a diagnostic specimen, remove accumulated fluid/air, instill medication. Advance practice, Permit signature, surgical asepsis Procedure: Position – Ribs are lifted and separate to allow easier needle insertion Unable to sit up – lie on unaffected side with the hand of the affected side raised above the shoulder. Antimicrobial Agent, Needle inserted between the ribs through the intercostal muscles and fascia and into the pleura. Syringe or plastic catheter (“vacuum”) (reduces possible lung puncture). Catheter – threaded through the needle (tubing and bottle must be sterile). Maximum amount of fluid removed: 1,200 – 1,500 mL (reduces risk of cardiovascular collapse from rapid removal). After – needle/plastic catheter removes and sterile dressing placed over site. Nursing Responsibilities Collects Baseline data, monitor PT’s (color, pulse, oxygen saturation, respiratory rates). Prepare PT physically and emotionally Instruct PT not to cough or breath deeply during procedure and to remain still as possible. Administer analgesics Dress the wound with a sterile dressing Assess PT for complications (pneumothorax, pain, hypotension, pulmonary edema), vital signs (respirations, oxygen saturation), monitor lung sounds, assess for cough/dyspnea. IF BLOOD APPEARS IN SPUTUM OR PATIENT HAS SEVERE COUGHING, NOTIFY HEALTHCARE TEAM PROMPTLY!! Monitor puncture site; chest Radiograph DIAGNOSING ACTUAL OR POTENTIAL HEALTH PROBLEMS AND NEEDS OUTCOME IDENTIFICATION AND PLANNING THE PATIENT WILL: Demonstrate improved gas exchange in the lungs by an absence of cyanosis or chest pain and a pulse oximetry reading more than 95% Relate the causative factors, if known, and demonstrate a method of coping with these factors Preserve cardiopulmonary function by maintaining an optimal level of activity Demonstrate self-care behaviors that provide relief from symptoms and prevent further cardiopulmonary problems IMPLEMENTING PROMOTING OPTIMAL FUNCTION Healthy Lifestyle Choices Encourage a healthy diet Monitor cholesterol, triglyceride, high-density protein, low density protein; and blood pressure. Limit alcohol intake and stop smoking. Encourage patients to maintain a healthy weight Encourage a patient to participate in regular exercise in their daily activities (moderate, 2.5 – 5 hrs.). Vaccination Influenza (contagious, mild-severe illness/death) recommended for ages 6 months and older. Pneumococcal Disease (pneumococcus bacterial infection) recommend for 2 years and older; especially older adults 65 years and older. Pneumococcal Pneumonia, Meningitis, Otis Media COVID-19 (infection caused by a novel coronavirus [SARS-CoV-2] Vaccine are effective in protecting patients from getting COVID-19 and significantly decrease the risk of serious illness. Symptoms: mild-moderate respiratory illnesses (fever, dry cough, tiredness); severe illness (shortness of breath, chest pain/pressure, loss of speech or movement. TEACHING ABOUT POLLUTION-FREE ENVIRONMENTS Teach PT to assess the environment and make adjustments to factors that impair respiratory functioning (“triggers”). Including a job change, use of protective equipment, requesting enforcement of laws by government facilities, or subcontracting jobs. Explain to the patient that exposure to industrial or occupational hazards (e.g., paint, varnish, gaseous fumes, asbestos) must also be restricted. Monitor closely to Fine Pollutants (carbon monoxide, sulfur dioxide, total suspended particles, ozone, nitrogen dioxide). Significant elevations = morbidity and mortality rates among people with preexisting pulmonary disease are increased greatly. Alerts should be considered by people with altered respiratory function (reduce activities, stay indoors, air conditioner, electronic air cleaner/filter. Cigarette smoking is a major risk factor in cardiopulmonary diseases (increase airway resistance, reduce ciliary action, increase mucus production, alveolar-capillary membrane thickening, wall thickening and elasticity loss of bronchial). Encourage the decision to never start smoking or to stop smoking. Provide appropriate information, counseling, support, and resources to assist patients to be successful with smoking cessation. REDUCING ANXIETY Use effective listening skills and accurate observation to display a caring attitude. Attempt to understand the patient’s life experiences and habits without judging them. MAINTAINING GOOD NUTRITION Encourage eating patterns that include a variety of nutrient-dense floods and beverages (fruits/vegetables, low-fat dairy products, whole grains, protein-rich foods, reduced saturated fats/added sugars/sodium). Encourage use of small meals at frequent intervals Provide frequent oral hygiene + rest periods before eating ; improve PT intake. Encourage mealtime for 1-2 hours after breathing treatments and exercise COPD – high protein/high caloric intake Provide necessary oxygen needs (eating/digestion requires energy/oxygen) PROMOTING COMFORT Positioning Position allow ing free movement of the diaphragm & expansion of the chest wall Dyspnea and Orthopnea – high flower position (accessory muscles + respiration) Acutely Ill Pulmonary Diseases – prone position improves oxygenation Maintaining Adequate Fluid Intake Drink 1.5 – 2 L fluids daily = keeps secretions thin Sodium intake (2000 – 3000 mg) Increased fluids: elevated temperature, breathing through the mouth, coughing, thickened secretions , loss of excessive body fluids. Providing Humidified Air Inspiring dry air removes the normal moisture (protects against irritation, infection) and compromises ciliary function and mucous production. Humidifiers/Vaporizers add water vapor (moister) to the air Vaporizer Heats water and a dds steam/ w arm mist to the air Humidifier – release s a fine cool mist into the air water tank should be emptied, and all surfaces dried daily to help keep it clean. prevent mineral buildup and the growth of bacteria and mold Humidification supplemental oxygen therapy, and artificial airway and mechanical ventilation systems. PROMOTING PROPER BREATHING Deep Breathing Deep ventilations nasally and then expiring slowly through the mouth Used to overcome hypoventilation Each breath needs to be deep enough to move the bottom of the ribs Using Insensitive Spirometry Provides visual reinforcement for deep breathing Assists the patient to breathe slowly and deeply and to sustain maximal inspiration . D irect the patient’s inspiratory flow through a tube to lift one or more light balls or disks . Higher the ball is raised (higher inspiratory flow), Longer inspiratory flow maintained (larger volume) Visualization provides positive reinforcement Not recommended for routine use in postoperative PT, more benefit in higher risk populations. ENCOURAGES PATIENT TO MAXIMIZE LUNG INFLATION & PREVENT OR REDUCE RESPIRATORY COMPLICATIONS. Pursed-lip Breathing Reduces experience of dyspnea and feelings of panic Exhaling through pursed lips creates a smaller opening for air movement, effectively slowing and prolonging expiration. Avoid forcing air out on exhalation; encourage PT to breath slowly Prolonged Expiration = decreased airway during expiration and prevent the collapse of small airways. Improved air/gas exchange and decreased dyspnea. PT control over rate and depth of respirations, reducing feelings of dyspnea. Encourages relaxation Diaphragmatic Breathing (“Belly Breathing”) Helps to slow down the person’s breathing and help the “catch their breath” Better control of breathing and use less energy to breathe PT sits upright in a comfortable chair or lies back on a flat surface, with the knees bent and a pillow under the knees to support their legs. Place one hand on their stomach and the other on the middle of their chest. Breathe in slowly through the nose, letting their abdomen protrude out against their hand, the hand on the chest should remain still as possible. Then breath out through pursed lips while contracting the abdominal muscles, letting the stomach muscles fall inward and keeping the hand on their chest as still as possible. (4-3 times for 5-10 minutes) PROMOTING AND CONTROLLING COUGHING Nonproductive Cough: a cough that is dry. Productive Cough: a cough that produces respiratory secretions. Sputum: respiratory secretion expelled by coughing or clearing the throat. Congested: excessive fluids or secretions in an organ or body tissue. Phlegm: thick respiratory secretions. Voluntary Coughing : a cough that does not occur as a result of reflex stimulation of the cough-sensitive areas. More effective when combined with deep breathing Planned scheduling for coughing (after rising – removes secretion that accumulated over night ; before meals – improves the taste and oxygenation; bedtime – removes any buildup and improves sleep patterns). Assisted Cough: place 1 hand on top of each other below the diaphragm and above the naval. Apply firm pressure on the abdomen by pushing upward and under the rib cage, in rhythm with exhalation. Involuntary Coughing Accompanies respiratory tract infections and irritations Secretions are triggers Productive – helps clear the airway Nonproductive – fatiguing and irritating Observation of the patient’s breathing and coughing characteristics Using Cough Medication Expectorants Facilitates the removal of respiratory tract secretions by reducing the viscosity of the secretions. Used to THIN MUCOUS Guaifenesin is widely used as an expectorant in cold and cough medications. INCREASE FLUID TO HELP LOOSEN AND LIQUIFY SECRETIONS (2-3 QUARTS DAILY) Adequate fluid intake and air humidification act as effective expectorants . Cough Suppressants Depress a body function (cough reflex) Codeine is the preferred cough suppressant ingredient. Can be addictive and possible for abuse Drowsiness is a side effect Dextromethorphan (non -addictive) Appropriate treatment for irritating, nonproductive cough in people without congestion . Suppressing a cough can allow for secretions to retain... Can lead to a pulmonary infection Monitor for drowsiness Lozenges relieve mild, nonproductive coughs in people without congestion small, solid medication intended to be held in the mouth until it dissolves control coughs by the local anesthetic effect of benzocaine controls the primary irritation and inhibiting afferent and efferent impulses (acts on sensory and motor nerves). Teaching About Cough Medications A ppropriate choice of expectorants and suppressants A bout misuse of cough mixtures Preparations containing antihistamines have an anticholinergic action, which can cause serious problems for people with glaucoma or cause urinary retention in men with prostate enlargement. P rolonged use of self-prescribed cough preparations can conceal more serious health problems . Contact health provider for a cough that lasts more than 7 days Encourage an increase fluid intake if the secretions become too thick to expectorate. PERFORMING CHEST PHYSIOTHERAPY Conventional Chest Physiotherapy: percussion, vibration, and postural drainage and is usually performed by respiratory therapists and physical therapists, or nurses with specialized skills, in acute care environments for select patients. Helps loosen and mobilize secretions increasing mucous clearance. Has short-term effects in increasing mucus transport and expectoration. Suctioning The Airway Maintain a patent airway and to remove saliva, pulmonary secretions, blood, vomitus, or foreign material from the pharynx. Suctioning of the oropharynx or nasopharynx may be indicated if the patient is able to raise secretions from the airways but unable to clear from the mouth. If the patient is unable to raise secretions from the airways, tracheal suctioning may be indicated. Can cause Hypoxemia (insufficient oxygen in the blood) P reoxygenate the patient before suctioning. Apply or increas e supplemental oxygen and hav e the patient take several deep breaths before inserting the catheter. S uctioning provides comfort by relieving respiratory distress ; can increase anxiety and pain or respiratory arrest (incorrectly). Anticipate the administration of pharmacologic (analgesic medication) and use of nonpharmacologic interventions for the patient before suctioning. Wear gloves on both hands, goggles or a face shield, and a mask—and a gown, if necessary—for protection from microorganisms. Continuously monitor the patient’s color and heart rate and the color, amount, and consistency of secretions. Stop suctioning if cyanosis, slow/rapid heart rate, bloody secretions and administer oxygen. Notify healthcare team. Hypoxia and mucosa damage indication. Meeting Oxygenation Needs With Medications Inhaled Medication : open narrow airways (bronchodilators), to liquefy or loosen th ick secretions (mucolytic agents), or to reduce inflammation in airways (corticosteroids). Administered via nebulizer, metered-dose inhaler (MDI), or dry powder inhaler (DPI) Nebulizers utilize the force of high-glow oxygen or compressed air through a fluid medication to disperse fine particles of liquid medication into the deeper passages of the respiratory tract, where absorption occurs. MDI is a handheld inhaler that uses an aerosol spray or mist to deliver a controlled dose of medication with each compression of the canister that is then breathed in by the patient. Common Mistakes: Failing to shake the canister Holding the inhaler upside down Inhaling through the nose rather than the mouth Inhaling too rapidly Stopping the inhalation when the cold propellant is felt in the throat Failing to hold their breath after inhalation Inhaling two sprays with one breath P atient must activate the device while continuing to inhale P referred method of use is with a device called a valved holding chamber or spacer (reservoir) . Compressed the medication is deposited in the reservoir, and the patient then inhales the medication from the spacer device. DPI is a handheld inhaler ( diskus ) that uses a dry powder form of medication, either in a small capsule or disk inserted into the DPI, or in a compartment inside the DPI. A quick deep breath by the patient activates the flow of medication, eliminating the need to coordinate activating the inhaler (spraying the medicine) while inhaling the medicine at the same time. One disadvantage of DPIs is that the medication in DPIs will clump if exposed to humidity. Teaching Patients About Inhaled Medications Overuse may result in serious side effects and eventual ineffectiveness of the medication. Nebulizers require cleaning after use; thus, patients must understand how to do this correctly. Patients must understand that it is important to keep track of dosing with MDIs. Patients must understand the importance of keeping track of dosing to ensure that they are not using an empty canister. Patients should not exhale into the DPI, as they risk blowing out the medication. To ensure correct administration when a spacer is used, slow, deep inspirations are necessary. A spacer is also recommended for patients using inhaled corticosteroid agents because it reduces the risk of acquiring an oral fungal infection . Types PROVIDING SUPPLEMENTAL OXYGEN Oxygen therapy provides a higher concentration of oxygen than ambient air (supplemental oxygen) to increase the pressure difference to aid in the diffusion of gas across the membrane between the alveoli in the lungs and the pulmonary capillaries, with the resulting increased saturation of hemoglobin and delivery of oxygen via the blood to all cells. Indicated when hypoxemia is suspected Targeted Oxygen Saturation 94%-98% (Chronic Obstructive Pulmonary Disease – 88%-92%) Prescribed by Prescriber Sources of Oxygen Cylinder or Tank: Valve regulator is used to release oxygen at a desired rate 2 Gauges – 1 nearest to tank shows the pressure /amount of oxygen in the tank; 2 indicates the # of liters per minute of oxygen being released. Oxygen Concentrators: concentrate room air to provide the appropriate prescribed concentration of oxygen. Usually used in home situations. Cylinder Refill system + potable oxygen cylinder Portable Concentration: allows PT to leave home for extended periods of time. Oxygen-conserving Devices: conserve oxygen supply reducing consumption and enabling the use of either smaller and lighter systems or extending the length of time between cylinder refilling. Methods – Integrated reservoirs or intermittent flow Oxygen Flow Rate Determines the amount of oxygen delivered to the PT ( in liters/minute) To regulate the oxygen percentage concentration accurately, samples of the air mixture the patient is actually inhaling may be analyzed every 4 hours. Humidification Recommended for PT experiencing discomfort (dry upper respiratory tract mucous) and when oxygen is delivered at higher flow rates (> 35%) . PT with tracheostomy or artificial airways and PT experiencing difficulties expectorating sputum. When moving patients receiving humidified oxygen, make sure that water from the humidifier does not enter the tubing through which the oxygen is flowing. Supplemental Oxygen Delivery System Nasal Cannula Low-flow /variable performance : based on PT’s own inspirator flow ( how deeply and fast the patient is breathing ) and the oxygen inhaled is composed of some of the supplemental oxygen mixed with inhalation of some air present in the room , reducing the accuracy of the concentration of oxygen that the PT is actually receiving (variable performance) . High-flow (HFNC): continuous delivery of an air/oxygen mixture through a heater/humidifier to a wide-bore nasal cannula. Delivers oxygen flow greater than 30 L/min-60 L/min + up to 100% humidified oxygen. Maintain a small amount of continuous positive pressure R educes patient discomfort and upper airway dryness, improves extubation outcomes and weaning , reduces the risk of intubation, and improves the management of respiratory secretions . Close monitoring of the patient’s status Pressure Injury Preventions (secure mask, frequent rotations, prophylactic cushioning ) Face Masks Fit mask to prevent leakage (comfortabl y snug but not tight) Pressure Injury Preventions (secure mask, frequent rotations, prophylactic cushioning) Types: Simple Face Mask (non-reservoir mask) : low-flow/variable performance device and is used when a higher oxygen level is needed than can be attained with a nasal cannula or when a cannula is not appropriate, such as with nasal obstruction . Flow rate – 5 to 10 L/min Vents allow room air to leak in at many places ( dilut e the source oxygen ) . The vents also allow exhaled carbon dioxide to escape. Less than 12 hours Partial Rebreather Mask: low-flow/variable performance device; equipped with a reservoir bag for the collection of the first part of the patient’s exhaled air. The remaining exhaled air exits through vents. Reservoir air is mixed with 100% oxygen and some room air inhaled through the mask ports for the next inhalation. Flow Rate – 10 to 15 L/min Advantage room air inhalation possible during interruptions . Disadvantage – eating/talking difficulties , skin breakdown Non-breather Mask: low-flow/variable-performance device, delivers the highest concentration of oxygen via a low-flow mask. incorporates valves between the bag and the mask and on at least one of the exhalation side ports on the mask . Supplemental oxygen is directed via tubing into the mask and into the reservoir bag. A one-way valve prevents exhaled gas from entering the reservoir and the entire exhaled volume exits the mask through the mask ports and between the patient’s face and mask, preventing the patient from rebreathing exhaled air . During exhalation, the reservoir bag refills with oxygen. At the beginning of inspiration, the mask exhalation port valves close, minimizing room air from being drawn in, and the reservoir valve opens, allowing the patient to inhale oxygen from the reservoir in addition to the oxygen flow. The oxygen flow rate must be set high when using this type of mask, not below 10 L/min. Monitor the reservoir bag carefully. It should not deflate with inspiration Disadvantage – eating/talking difficulties, skin breakdown Venturi Mask: high-flow /fixed performance device , allows the mask to deliver the most precise concentrations of oxygen. L arge tube with an oxygen inlet, a Venturi barrel, to control the oxygen concentration . O xygen passes through the narrow opening in the barrel, the pressure drops, causing a high velocity stream that draws a constant proportion of room air to be pulled in through the base of the mask . Be sure that the ports on the barrel are always open ( oxygen delivered might be at an unsafe (too high or too low) concentration ) Disadvantage: eating/talking difficulties, skin breakdown Monitoring of Patient’s Receiving Supplemental Oxygen Therapy M onitor the flow rate to verify oxygen deliver as prescribed, patient color (signs of cyanosis), respiratory rate (e.g., tachypnea), respiratory depth, increase work of breathing (use of accessory muscles), pulse oximetry measurements, and ABG results closely for changes . Oxygen therapy should be provide using minimal oxygen to maintain adequate SpO2 in the patient’s target range to avoid complications . Assess and monitor the patient’s comfort with the delivery device Assess and monitor the oral and nasal mucous membranes, the lips and nose, and face and ears Monitor fluid status and maintain hydration through adequate fluid intake Provide routine oral hygiene Oxygen Therapy in the Home Liquid Oxygen : kept inside a small container that can be refilled from a larger storage tank kept in the home. Oxygen Concentrator removes nitrogen from the air and concentrates the oxygen left in the air. Power Source – electrical outlet, battery pack, charger Portable, cost-effective, easy use Transtracheal Oxygen Delivery : small catheter is inserted unto the trachea under local anesthesia and then attached to an oxygen source. delivers oxygen throughout the respiratory cycle reduced amount of oxygen flow needed at rest and exercise, reduced symptoms of shortness of breath, improved patient mobility, and increased patient adherence with therapy . improved mobility, comfort, and appearance, and lower cost Oxygen-conserving Devices (OCD ) Reservoir Cannulas a reservoir space stores oxygen during exhalation. On subsequent inhalation, the patient receives that stored oxygen ( Bolus Volume ). Intermittent-flow devices turn oxygen delivery on during some portion of inhalation and off for the balance of the breathing cycle . exhaled oxygen is conserved, allowing a supply of oxygen to last two to four times as long as if it was delivered continuously Educate about long-term oxygen use and associated equipment to improve patient adherence and implementation of safety precautions Positive Airway Pressure Noninvasive positive airway pressure (PAP) therapy uses mild air pressure to keep airways open delivered via a mask. maintain better carbon dioxide and oxygen levels in the blood Continuous positive airway pressure (CPAP) provides continuous mild air pressure to keep airways open. Bilevel positive airway pressure (BiPAP) changes the air pressure while the patient breathes in and out. Autotitrating (adjustable) positive airway pressure (APAP) changes pressure throughout the therapy, based on the patient’s breathing patterns A ssist patients by reinforcing accurate information about treatment; encourage patients to ease into use of the device . Become accustom to how the equipment feels, they should shift to using the device every time they sleep—at night and during naps. Provide support and encouragement so that the patient persists with the therapy ensuring correct use by the patient, and assessment of respiratory status Managing Chest Tubes A chest tube is a plastic tube with drainage holes in the proximal end that is inserted in the pleural space. S ecured with a suture at the insertion site, covered with a dressing, secured with tape a few inches below the insertion site, and attached to a drainage system that may or may not be attached to suction . Closed water-seal (drainage system) prevents air from reentering the chest once it has escaped and a suction control chamber that prevents excess suction pressure from being applied to the pleural cavity. Suction Chamber – Water-filled: regulated by the amount of water in the chamber Dry Chamber : a one-way mechanical valve system that allows air to leave the chest and prevents air from moving back into the chest and is automatically regulated to changes in the patient’s pleural pressure. portable drainage systems that utilize gravity for drainage Chest tubes are indicated when negative pressure in the pleural space is disrupted fluid (pleural effusion), blood (hemothorax), or air (pneumothorax) in the pleural space require a chest tube to drain these substances, restore the negative intrathoracic pressure, and allow the compressed lung to reexpand . Examples: M ediastinal chest tube may be placed after cardiac surgery to drain blood from around the heart . T unneled pleural catheter (tunneled under the skin before entering the pleural space) may be used to improve quality of life in patients with recurrent pleural effusions . When air is to be drained , the tube is placed higher in the chest. If fluid needs to be drained, the tube is inserted lower in the lung because fluids settle at the base of the lung . Monitor respiratory status & vital signs Check dressing Maintain the latency & integrity of the drainage system Assist w/ insertion & removal of chest tube PRECAUTIONS FOR OXYGEN X-ray is used to evaluate the amount of air or fluid removed Administer analgesics prior to the tube removal Provide emotional support for the patient Using Artificial Airways – used to preserve a functioning airway in PT’s who are unable to maintain a PT airway without assistance. Oropharyngeal and Nasopharyngeal Airways – semicircular tube inserted into the pharynx through the mouth or nose in a PT with spontaneous breathing patterns . Oropharyngeal – keeps the tongue clear of the airway. Incorrect sizing can hinder airway maintenance ( too big will obstruct the airway, and one that is too small will not aid in opening the airway ) Removed once patient regains consciousness Nasopharyngeal – inserted through the naris and protrudes into the back of the pharynx. Allows for frequent nasotracheal suctioning without trauma. may be left in place, without much discomfort, in the patient who is alert and conscious Endotracheal Tube a polyvinyl chloride airway that is inserted through the nose or mouth into the trachea, using a laryngoscope as a guide. Administers oxygen by mechanical ventilator, to suction secretions easily, or to bypass upper airway obstruction orotracheal insertion is often the method of choice (less trauma, lesser infection rates , accommodates a larger diameter tube). M ore difficult and requires the use of a narrower tube . Cuffed Endotracheal (most common) prevents air leakage and bronchial aspiration of foreign material while allowing more precise control of oxygen and mechanical ventilation. M onitoring of cuff pressure (20-30 cm H2O) is necessary . S ecured via tape, twill tape, or a commercial device Placement of an endotracheal tube results in the inability to speak, which can be frightening and frustrating for the patient and may contribute to ineffective responses to patient concerns and needs. Assess the patient’s ability to use alternative methods of communication. Plan for and provide alternative methods of communication. Establishing a rapport with the patient through eye contact and careful attention to nonverbal cues and communication is important. Patients with endotracheal tubes often require suctioning via the endotracheal tube to remove secretions from the airway. Routine oral suctioning to aspirate secretions that accumulate above the cuff of the tube is also necessary to reduce the risk of pneumonia and provide patient comfort. Providing diligent oral hygiene can limit the growth of pathogens in the oropharyngeal secretions . TRACHEOSTOMY TUBE Tracheostomy : an artificial opening made into the trachea, usually at the level of the second or third cartilaginous ring . Tracheostomy Tube : A curved tube inserted through the opening. Inserted under sterile conditions using local anesthesia and can be temporary or permanent. Replace endotracheal tube to provide a method for mechanical ventilation of the patient, to bypass an upper airway obstruction, in conditions in which endotracheal tube intubation is not possible , or to remove tracheobronchial secretions . The most commonly used tubes are made from PVC, silicone or polyurethane . O bturator : guides the direction of the outer cannula, is inserted into the tube during placement and removed once the outer cannula of the tube is in place. The outer cannula remains in place in the trachea, and the inner cannula is removed for cleaning or replaced with a new one . Periodic cleaning or replacement of the inner cannula prevents airway obstruction from secretions . Cuffed VS Cuffless Cuff – seals the opening around the tube creating a seal in the trachea. Prevents air leakage and aspiration and permits mechanical ventilation. Low pressure . Cuffless – does not require invasive respiratory support and have an effective gage and cough reflex. Fenestrated tracheostomy: one large or several small openings or windows on its outer curve, has an inner cannula, and can be cuffed or cuffless. When the patient is being mechanically ventilated, the inner cannula is in place, blocking the small openings. S hould be considered only for patients with normal upper airway reflexes . Held in place for 7 days with sutures and then removed; then can be held in place by twill tapes or a commercially available tube holder . Regularly check cuff pressure A dminister heated, humidified oxygen to prevent secretions from becoming dry . Keep the tracheostomy tube free from foreign objects and nonsterile materials . Routine oral suctioning to aspirate secretions that accumulate above the cuff of the tube and frequent oral hygiene . Placement of tracheostomy tube may result in the inability to speak Replace a disposable inner cannula or cleaning a nondisposable one at least once per 8 hours . R egularly change any dressings and ties. Use gauze dressings that are not filled with cotton to prevent aspiration of foreign bodie s. TRACHEAL SUCTIONING maintain a patent airway and remove pulmonary secretions, blood, vomitus, or foreign material from the airway . passing a sterile catheter through a tracheostomy or endotracheal tube ;s uctioning to remove secretions is performed using the sterile technique . audible and/or visible secretions reduced oxygen saturation presence of coarse crackles over the trachea deterioration of arterial blood gas values reduced breath sounds inability to generate an effective spontaneous cough acute respiratory distress, or suspected aspiration of secretions Anticipate the administration of pharmacologic (analgesic medication) and use of nonpharmacologic interventions for the patient before suctioning . Risks include hypoxia, infection, tracheal tissue damage, cardiac dysrhythmias , bronchospasm, and atelectasis . Sterile technique is used for tracheal suctioning hyperoxygenate the patient before and after suctioning for a minimum of 30 seconds and limit the application of suction to no more than 10 to 15 seconds . Monitor the patient’s pulse frequently to detect potential effects of hypoxia and stimulation of the vagus nerve. Using an appropriate suction pressure (no more than 150 mm Hg for adults) will help prevent atelectasis related to the use of high negative pressure . The open suctioning system requires disconnection of the endotracheal or tracheostomy tube from the ventilator or oxygen therapy source and insertion of a suction catheter each time the patient requires suctioning . A closed suctioning system makes use of an in-line suction catheter device that remains attached to the ventilator or oxygen source circuit. ASSISTING VENTILATION – Mechanical ventilators are used to assist or completely control ventilation. improves oxygenation and ventilation and supports the patient’s breathing function during emergency or acute care episodes as well as long-term situations addre ss the physical and psychological concerns of the patient and family/caregivers key interventions include evaluating the patient’s response to ventilation therapy, using safe practices and techniques, and monitoring the patient carefully for complications forces deeper inspiration by positive pressure inhalation and then permits passive exhalation . Use of IPPB may be indicated for patients with atelectasis, reduced pulmonary function resulting in an effective cough, neuromuscular disorders, fatigue or muscle weakness with impending respiratory failure, acute severe bronchospasm, and in COPD exacerbations that fail to respond to other therapy . C learing an Obstructed Airway Foreign-body obstruction of the airway often occurs during eating. mild airway obstruction with good air exchange, the patient can cough forcefully. partial airway obstruction, good air exchange can progress to poor air exchange. Poor air exchange may be indicated by a weak, ineffective cough, high-pitched noises while inhaling, increased breathing difficulties, and cyanosis. severe airway obstruction, the victim is unable to speak, cry or cough and may demonstrate poor or no air exchange; weak, ineffective cough or no cough; a high-pitched noise while inhaling or no noise at all; increased respiratory difficulty; and/or the universal choking sign (clutching the throat with both hands ). Choking relief in a responsive adult or child includes the use of abdominal thrusts to relieve choking . If severe airway obstruction continues and the victim becomes unresponsive, start CPR . Administering Cardiopulmonary Resuscitation Elements of this emergency care include cardiopulmonary resuscitation (CPR), which is the combination of chest compressions that circulate blood; mouth-to-mouth breathing, which supplies oxygen to the lungs; and defibrillation, which interrupts or stops an abnormal heart rhythm using controlled electrical shocks. The brain is very sensitive to hypoxia, and damage to the brain begins to occur within minutes without oxygen; after 5 minutes; permanent anoxic brain injury can occur . The faster emergency cardiovascular care (CPR) is initiated, the greater the chance of survival . Basic Life Support Provider Manual for further information and details for the other Chains of Survival : A utomated E xternal D efibrillator (AED) has proved effective in reducing deaths attributed to cardiac arrest. computer-based device is designed to deliver a shock (defibrillation) to the heart muscle quickly to interrupt shockable rhythms that resets the heart’s electrical system so a normal (organized) heart rhythm can return . ability to analyze the heart’s rhythm, direct the operator to deliver a shock when appropriate or deliver one automatically, and then reanalyze the rhythm to determine whether it has returned to normal . EVALUATING