PE – 4 questions / ARDS – 7 questions
Components of Respiratory Assessment
Airway
Respirations
Rate
Depth
Use of accessory muscles or nasal flaring
Clubbing—esp seen with ppl that have COPD
Breath Sounds—chart what you hear!
Changes can be subtle---status can change quickly and it can be as subtle as “shallow respirations.”
Cardiac
- Rhythm
- Tachy, Brady, PVCs, Asystole, PEA (pulseless electrical activity)
- Chest Pain—can be pleuritic (lung)related and/or cardiac related
Neuro
LOC—hypoxia can cause changes in LOC. Decreased O2 = personality or LOC change or agitation
Anxiety
Restlessness
Confusion
Extremity color – cyanotic?
Renal: urine output
Causes of Hypoxia
Acidosis (hypoventilation)
- Tx: Increase RR;Vt (Tidal volume); Minute volume etc to combat hypoxia
Decreased alveolar Ventilation
- Tx: Increase PEEP to keep alveoli open (recruit alveoli); Increase pressure support to help people overcome resistance of breathing through a tube
Diffusion Defects (injury to alveoli or capillary membrane)
- Asbestos, sarcadosis, CA, Scleroderma, Lupus
- Tx: Increase FIO2
Oxygen delivery
NC (nasal cannula)
- 2L=23-28%
- 6L=44%
- Up to 6 L with nasal cannula after that some other type of O2 delivery
Ventimask
vapotherm
NRB (non-rebreather masks)
Bipap—used if cannot saturate
- Used for OSA
- Carbon retainers
Ventilators
- Noninvasive
- Invasive
Oxygen demands in ICU
Increases O2 demand- Fever, Hyperthyroidism
- Agitation, Anxiety
- Increased work of breathing
- Infection
- Sepsis
- Shivering
- Seizing, Muscular Activity
- Burns
- Dressing changes
- Visitors
- Turning
- Assessing
- Hypothermia
- Morphine
- Anesthetic
- Paralytics
- Sedation
- Hypothyroidism
Respiratory Failure
Non Invasive ventilation—first try non-invasive ventilation. Progress to intubation if non-invasive measure do not work.
Intubation
- lab values K+; Must check K+ meds because some of the meds used for intubation can affect K+ levels
- intubation cart
- ventilator
- suction equipment
- supine position/ towel under shoulder blades
Meds
- Etomidate
- Succinylcholine
Establish correct placement: Establish placement and verify where the tube was initially placed!
Documentation
- size of ETT
- Placement—verify against original placement and if the tube has been moved since.
- holder
Modes of Ventilation
Volume Control
- A/C—most dependent, every breath is mechanical.
- SIMV – responds to and allows pt to breathe giving mechanical breaths only as needed.
- PSV/CPAP—least dependent, decreases workload of breathing by decreasing the force needed to overcome the pressure in the chest.
Pressure Control
- PCV(generic)
- BILEVEL – bipap is external.
Pulmonary Embolism - **This is a code situation
Predisposing Factors: major operations, emboli
Ortho surgery = increased risk of PEs, especially with hip replacements
Lack of ambulation
Peripheral vascular disease
PEA—pulseless electrical activity predisposes
Assessment
Pain (pleuritic)
Dyspnea, tachypnea
Tachycardia
Anxiety
Even hypotension, MI, PEA; crackles may be heard
PE Diagnostics
ABG-resp alkalosis, ↓ PaO2, PaCO2
CXR atelectasis; decreased breath sounds
EKG
D-Dimer to R/O
SpiralCT or
**VQ scan- best diagnostic test because it is noninvasive.
PE Treatment
Airway Management—Airway!!! Raise HOB!!!
Oxygen - NC
Weight based heparin protocol/Therapeutic Lovenox (aPTT 46-70) – cornerstone treatment
Treat symptoms—pain, anxiety, dyspnea, fluids to treat hypotension
Thrombolytics (especially in code)—TPA for example.
IVC filter—Inferior vena cava filter as a prophylactic measure
Pneumothorax
Predisposing Factors
Causes: blunt trauma, surgical trauma, chest wound, extreme coughing; May be tension or open.
Assessment
Pain
Cough with hemptysis
Tachycardia &Tachypnea (hypoxia)
Decreased breath sounds on affected side
Unsymmetrical chest expansion
Tracheal deviation to the unaffected side
Also may see PMI shift either laterally or medially
Pneumothorax
Diagnosis
- CXR:
Treatment
- Airway
- Oxygen—increase O2
- Chest tube Insertion
- **airway support; Increase O2 and insert chest tube
- Chest tube may be used to convert tension pneumothorax (more serious) to open pneumothorax (less serious).
Chest Tube
Pneumothorax:
- Placement of chest tube: 4th ICS mid-clavicle (because air rises—tube has to be relatively higher for air to escape as compared with a hemothorax related chest tube)
Hemothorax or Pleural Effusion
- Placement of chest tube: 6th ICS Mid-axillary—to drain fluid
Check coagulation studies prior to insertion and after placement.
Airleak: indicated by continuous bubbling. Intermittent bubbling is expected, continuous is not.
Tidaling: fluid moves back and forth in the tube with respirations.
Water Seal/ Suction?
- One way valve so that air or fluids can drain but not return.
- Low level suction, 10-20 cm water.
Pulmonary Edema
Predisposing Factors
- CHF
- Renal Failure
- Aspiration, Barotrauma
Assessment
- Frothy, pink sputum. Can be pink, white or yellow (yellow= infection)
- Tachycardic/ Tachypneic
- Labored breathing
- Fine crackles
- Low spo2 (85%)
- Hypertension
Diagnosis
- CXR: will see “white out” where fluid has replaced air-filled lung tissue.
Treatment
- O2 and or ventilation; ↑ FiO2, CPAP
- Position the client with legs in dependent position to decrease venous return and improve stress on LV.
- Diuretics—especially with CHF, promote fluid excretion
- Morphine(cardiac): decreases SNS response and morphine reduces preload.
- Treat HTN crisis
- Inotropes
- Dialysis—CVVHD or regular dialysis, peritoneal
Acute Respiratory Distress (ARDS)
Definition: Acute lung injury characterized by:
alveolar capillary leak,
refractory hypoxia,
diffuse bilateral infiltrates,
pulmonary edema,
decreased compliance,increased work of breathing.
Mortality rates 40-70%
Assessment:
Severe dyspnea
Hypoxemia (<60%)
Diagnosis
CXR: Diffuse bilateral infiltrates.
Pulmonary edema with PCWP < 18
- (Pulmonary capillary wedge pressure)(non cardiogenic)
PaO2/FiO2 <200 (ex. 60/.6)
Pathophysiology
Two paths due to inflammatory responses due to chemical mediators:
- Atelectasis or alveolar damage
Pulmonary shunting, impaired gas exchange, decreased compliance—shunting = cannot get O2 to areas of lungs that can exchange O2
- Injury to pulmonary capillary or endothelial damage
Capillary leakage, decreased diffusion of O2, CXR turns “white”
ARDS: Treatment
Oxygenation usually 100% FIO2
Increased perfusion
- Recruit alveoli
Use high peep—10, 15-25
Prone positioning—helps the lungs expand!! Place in prone position if possible!
Minimize barotrauma
- PCV or Bilevel
PCV—pressure control vent; Bilevel (alternating levels of higher and lower PEEP settings)
Not trying to get a specific volume of FIO2, but trying to get a specific pressure into the lungs. The lungs are stiff, noncompliant and resistant secondary to the inflammatory process
Systemic steroids
- Decreases systemic responses and slows cascade of chemical mediators
Nitric oxide – causes vasodilation.
Helium
Precipitating Factors
- Direct Lung Injury
Pneumonia
Near Drowning
Inhalation of toxic substances /
- Indirect Lung Injury
Trauma(nonthoracic)
Massive transfusions
DIC, OD--overdoses
Fat Emboli
FLOLAN for Primary Pulmonary Hypertension: (this was not in the slides, but was discussed at length in class)
Flolan is a drug that is a potent pulmonary artery vasodilator
Link to transplant—the people on Flolan are on it for life or until they obtain a transplant
Never shut the pump off (not even in a code)!!!!
Never use the IV that is designated for Flolan unless it is an emergency as Flolan is not compatible with almost any other drugs
Multiple intricacies of administration: The drug itself (the bag it’s in) is packed in ice as it is administered. Abrupt withdrawal of the medication can quickly kill the client as the pulmonary arteries will vasoconstrict and the medical team cannot get them to dilate again. Can only disconnect Flolan for 3-5 minutes if absolutely necessary.
Speaker told of the time he was with a student in the ICU who he had specifically instructed not to touch the Flolan, the IV, pump, etc. She drew the curtain on the pt’s room to give the pt a bedbath and came out some time later asking him to help her turn the Flolan back on. {Guess she failed that clinical day? By the way, he made sure to point out that it was not a TWU student who had done this!}
Extra notes:
Will sometimes see Viagra used on pts in ICU as it vasodilates
Solution for primary pulmonary hypertension? = transplant
- S&S of PPH? SOB!
Decreased hemoglobin = can lead to hypoxia
Why can’t we use volume control ventilation setting on pt with non-compliant lungs? B/c of resulting barotraumas.