CH 9, 10, 38, 55: Caring for the Client with Upper Airway Conditions Flashcards
Obstruction of the larynx leads to:
life-threatening hypoxia or suffocation
causes of laryngeal obstruction
Edema of the glottis
Acute laryngitis
Anaphylaxis
Laryngospasm
Aspiration
risk factors for laryngeal obstruction
hx of allergies
inhalation/ingestion of foreign body (chemicals)
tumor
family history of airway problems
ACE inhibitors
throat pain/fever
throat surgery
previous trach
clinical manifestations of laryngeal obstruction
-difficulty breathing, labored breathing
-hoarseness** emergency!!
-stridor** emergency!!
-croupy cough
-expectoration of blood/mucous
-decreased 02 sat - pH will decreases - resp. acidosis
-use of accessory muscles
-dx made based on s/s and x-ray
medical and nursing management of laryngeal obstruction
ABCs
Heimlich maneuver
–Five quick, sharp abdominal thrusts below xiphoid process; turn on side
Finger sweep in mouth - only if visibly seen and reached
Bag and Mask resus
Immediate trach (last resort)
Treat underlying cause
Ventilation or perfusion in the lungs is impaired
Life-threatening
Are hypoxemic and/or hypercapnic
Can be combined and have multiple causes
Chronic can develop to:
acute respiratory failure
causes of ventilation or perfusion of lungs being impaired
Due to decreased 02 delivery to alveoli
Inability of alveoli to remove C02
Damage to alveoli
Perfusion is adequate, but impaired ventilation
Ventilation is adequate, but impaired perfusion
too little 02 reaches tissues
Hypoxemic/Oxygenation respiratory failure
too little 02 is exchanged for C02
Hypercapnic/Ventilatory respiratory failure
causes of Hypoxemic/Oxygenation respiratory failure (too little 02 reaches tissues)
Due to lack of perfusion to capillary bed or conditions that alter gas exchange
-Anemia
-Hemorrhage
-Intracardiac shunts
-ARDS
-Pulmonary edema
causes of Hypercapnic/Ventilatory respiratory failure (too little 02 is exchanged for C02)
Due to mechanical abnormality of lungs/chest wall, impaired muscle function, malfunction of respiratory control center in the brain
–Airway obstruction (chronic bronchitis, cystic fibrosis)
–Weakness of breathing (effects of anesthetics, pain, obesity, drugs)
–Muscular weakness (cervical SCI, GBS, ALS, chest wall trauma, muscular dystrophy)
–Lung disease (pulmonary edema, pneumonia, PE, COPD, ARDS)
–Chest wall abnormalities (kyphosis, scoliosis)
early clinical manifestations of ARF
Restlessness
Fatigue
Headache
Dyspnea
Air hunger
Mild tachycardia, tachypnea
clinical manifestations after ARF
Confusion, lethargy - AMS
Tachycardia and tachypnea
Central cyanosis
Diaphoresis
Use of accessory muscles
Decreased breath sounds and Sp02
Respiratory arrest
Labs/Diagnostics (on room air) with ARF
Pa02 < 60 (hypoxemic failure) OR PaC02 > 45 (hypercapnic/ventilatory failure) AND pH <7.35
Sp02 <90%
Chest x-ray
goal for ARF and how to achieve
correct underlying cause & restore oxygenation and ventilation
Mechanical ventilation
Management in ICU
Nursing assessment
Similar interventions for ARDS
patho of Acute Respiratory Distress Syndrome (ARDS)
A sudden systemic inflammatory response injures the alveolar-capillary membrane
increased permeability to large molecules lung space to fill with fluid and blood
Alveoli can’t stay open b/c of infiltrates, blood, fluid, and lack of surfactant
so they collapse
consequences of ARDS
-Leads to decreased gas exchange and fluid collection
-Sudden, progressive pulmonary edema, increasing bilateral infiltrates on chest x-ray, hypoxemia resistant to supplemental 02, and reduced lung compliance (stiff lungs) due to surfactant dysfunction
-High mortality (50-60%)
risk factors for ARDS
Direct Injury to lungs-Source is in the lungs
-Smoke inhalation
-Near drowning
-Aspiration
-PE
-Pneumonia and other resp. infections
-Fat emboli
Indirect injury to lungs-Source is not in the lungs
-Septic shock most common
-Massive fluid resus
-Multiple blood products
-DIC
-Burns
-Pancreatitis
-Substance use/overdose
-Trauma
clinical manifestation of ARDS
-Rapid onset of dyspnea 12-48 hours after event
Hypoxemia that does not respond to supplemental 02 (refractory)
-Intercostal retractions
-Crackles (not related to left HF)
-Tachypnea
-Cyanosis
-Restlessness, confusion, or lethargy
-Tachycardia
-Reduced lung compliance (stiff lung) waveform and high pressure alarm
diagnostics for ARDS
Chest x-ray B/L infiltrates
Chest CT B/L patchy infiltrates with consolidation
ABG
–Pa02 < 60 and 02 sats <90% on RA
–PaC02 >45
–pH <7.35
–**Indicates hypoxemia and hypercarbia
Pa02/Fi02 ratio >300
diagnosis of ARDS is based on:
-History of systemic/pulmonary risk factors
-Acute onset of resp. distress
-B/L pulmonary infiltrates
-Clinical absence of left HF
-Pa02/Fi02 ratio <300
medical management of ARDS
-Identification and treatment of underlying causative condition
-Intubation and mechanical ventilation
-Adequate fluid volume
-Supplemental 02
-Positive End-Expiratory Pressure
-Pharmacologic Therapy
-Nutritional Therapy
use for positive end-expiratory pressure
Helps to keep the alveoli expanded
Increases oxygenation and improve lung expansion
5-10 mm
goal for positive end-expiratory pressure
Pa02 >60 OR 02 sats >90% at lowest possible Fi02
Need higher levels of PEEP for moderate/severe ARDS
–10-20 mm H20
Done with ventilators; may require sedation
complications of Positive End-Expiratory Pressure
Increased thoracic pressure
-Puts pressure on the heart; Decreases preload on heart decreased cardiac output and hypotension
—Give inotropics or vasopressors, IV crystalloids or colloids
—Monitor pulmonary wedge pressures
-Barotrauma hyperinflation of the lung pneumothorax or SQ emphysema
—Monitor high pressure alarms; chest tube
Pharmacological Therapy for ARDS
SEDATE AND THEN PARALYZE
Sedatives (benzos)
–To calm anxiety and agitation
–Use with caution
Neuromuscular blocking agents
–Paralyzes client to facilitate ventilation and decrease oxygen consumption; Doesn’t sedate or relieve pain!
–ONLY given to clients on mechanical ventilation
DVT and GI prophylaxis
Corticosteroids
Antibiotics
nutritional therapy for ARDS
Enteral nutrition
–Aspiration precautions
–Confirm placement
Daily weights (1-2 LBS concerning)
I&Os
nursing management of ARDS
Turns frequently
Prone position
–Improves oxygenation; mobilizes secretions; improves ventilation and perfusion (last resort)
Explain all procedures
Prevent infection and complications from immobility
Vent care
Suction PRN
Provide emotional support
Collaboration with interdisciplinary team
Provides adequate ventilation; can be used in conjunction with mechanical ventilation
artificial airways
types of artificial airways
Temporary or permanent
-Endotracheal
-Tracheostomy
artificial airways can cause:
-Discomfort
-Thicker secretions
-Ulceration
-Inability to communicate
-Decreased swallowing reflexes increases risk of aspiration
Endotracheal Intubation (ETT) - temporary airway
Used if ventilatory support required is < 10 days
Method of choice in an emergency
Cuff is inflated to prevent air leak, prevent movement, and prevent aspiration
–Low cuff pressure increased aspiration
–High cuff pressure tracheal bleeding, ischemia, pressure necrosis
Cuff must be deflated before ETT is removed
Chest x-ray to verify placement; auscultate B/L lung sounds
Unintentional or intentional removal is life-threatening
intubation that can be temporary or permanent
Tracheostomy Tube
indications for Tracheostomy Tube
bypass upper airway obstruction, allows removal of tracheobronchial secretions, long-term use of mechanical ventilation, prevent aspiration, replace ETT
procedure of a tracheostomy tube
Obturator guides insertion of cuffed trach; removed immediately after placement
–ALWAYS HAVE OBTURATOR AND SPARE CUFFED TRACH (SAME SIZE) AT BEDSIDE
Held in place by trach tie
Type of Tracheostomy TubeRequired for mechanical ventilation
Cuffed trach
Types of Tracheostomy Tube that Allows for vocalization with hole in tube
fenestrated
Types of Tracheostomy Tube that is NOT used for mechanical ventilation, patient covers end of tube to talk
uncuffed
complications of artificial airways
Bleeding
Pneumothorax
Air embolism
SQ or mediastinal emphysema
Laryngeal nerve damage
Posterior tracheal wall penetration
Dysphagia
Tracheal dilation, ischemia, and necrosis
Infection
Accumulation of secretions
prevention of complications of artificial airways
Warmed humidified 02
Maintain cuff pressure
Skin, lung assessment
Maintain adequate hydration & skin integrity
Prevention of VAP
Sterile technique with care
nursing care of artificial airways
Semi-fowler’s
Prevent infection
Trach care
Provide effective means of communication
–Passy-Muir Valve: positive-closure, one-way speaking valve; allows client to talk with exhalation
Tracheal suction
–Sterile procedure
–Can use in-line suctioning
Managing the cuff
–Keep inflated; monitor every 8 hours
–Must be < 25 mm H20
purposes of temporary/permanent intubation and mechanical ventilation
Airway protection
Helps with airway clearance for those who can’t manage secretions
Management of respiratory function during surgery
Rest for muscular fatigue
Increased Fi02 for hypoxic client
Increased flow and pressure to ensure adequate ventilation
types of ventilators
Cycled based on time, volume, and pressure
job of time-cycled ventilators
Stop inspiration at a preset time; time regulates the amount of air delivered
–respiratory rate
job of volume-cycled ventilators
-Volume of air delivery is preset and relatively consistent
-Once air is delivered, vent cycles off and allows for passive exhalation
how much flow into the lungs
pt has abnormal ABG values after bing ventilated - what settings do we change?
time, volume, pressure
changes to vent settings based on alkalosis vs acidosis
- acidosis = increase rate and volume
- alkalosis = decrease rate and volume
job of pressure-cycled ventilators
-Deliver flow of air on inspiration at preset pressure to allow for passive exhalation
-Volume of air varies and inconsistent
Number of breathes machine delivers in a minute (normal 12-20)
rate
Oxygen concentration (35-100%)
Goal is to provide adequate Pa02 without high 02 percentages
fraction of inspired air (Fi02)
Amount of air given in each breathe (5-7 ml/kg; generally 500-800 mL)
tidal volume
Keeps alveoli open with positive pressure at end of expiration to improve gas exchange and air in lungs
–Keeps 02 in and C02 out
Usually 5 cm H20
Can cause barotrauma (damage to lungs by too much intrathoracic pressure) and lead to pneumo
Positive end expiratory pressure
Pushes air to help with spontaneous breathing; decreases work of breathing
pressure support
nursing management of the client with intubation/mechanical ventilation
-Continually assess respiratory status (Q1-2 hr) - end tidal,
-Administer meds: sedation, analgesics, GI and DVT prophylaxis, - not paralyzed
-Adequate suctioning
-Meticulous oral and skin care
-Turn and repositioning Q2
-Early mobility (ROM)
-Document ETT placement at the teeth/lips - using measurements
-Provide adequate nutrition
-Soft wrist restraints per protocol
-Develop alternative methods of communications
-Coping interventions and stress reduction techniques
nursing management of the equipment with intubation/mechanical ventilation
-Assess the ventilator frequently
-Have AMBU bag, obturator, and spare tube at bedside ALWAYS
-Assess cuff pressure
-Be aware of alarms
-Don’t just rely on the monitor, always assess the client!
causes of low pressure alarms
Low exhaled volume = leak
Causes: disconnection from the machine/tubing, low cuff pressure, tube displacement
causes of high pressure alarm
Resistance or obstruction so pressure increases
Causes: kink in the tubing, pneumo, bronchospasm, coughing, pulmonary edema, client biting the tube, excessive secretions
complications of Intubation and Mechanical Ventilation
-ventilator associated pneumonia
-increased ICP
-venous thromboembolism
-barotrauma
-GI bleeding
-decreased cardiac output
-tube dislodgement - loss of airway
weaning process with intubation and ventilation
Process of removing mechanical ventilation
Various criteria for weaning
Suction
Deflate the cuff before removing
–Remove tube during peak inspiration - breath in
Assess VS Q5 minutes
Encourage coughing, deep breathing, and IS
ABG values
pH = 7.35-7.45
PaCO2 = 35-45
PaO2 = 80-100
HCO3 = 22-26
