Chapter 43 Egans Flashcards
What is atelectasis?
Alveoli collapse
What causes atelectasis?
persistent ventilation with small tidal volumes or by resorption of gas distal to obstructed airways
What patients are at more risk for developing atelectasis?
Patients who have undergone upper abdominal or thoracic surgery
What are 3 signs of atelectasis?
-Rapid, shallow breathing
-Fine late inspiratory crackles
-abnormalities on chest radiograph
3 types of atelectasis
Gas absorption
Lobar
Compression
Gas absorption atelectasis
-Complete interruption of ventilation to a section of the lung
or
-Significant shift in V/Q
~ Elevated FiO2
Lobar atelectasis
Complete or partial collapse of the entire lung or area (lobe) of the lung
Compression atelectasis
When the transthoracic pressure exceeds the trans alveolar pressure
What is transthoracic pressure
Pressure difference between the body surface and the alveoli
What is trans alveolar pressure
The pressure difference between the alveoli and pleural space
Supine patients Vs. Paralized
Supine: Lower, dependent portion of the diaphragm performs most movement
Paralyzed: Upper portion of diaphragm performs most movement
Moderate atelectasis
Increased RR and consistently lower SpO2
Breathe sounds with crackles and possibly faint bronchial breath sounds
Severe atelectasis
Dyspnea, need more O2, absent breath sounds over affected area with distinct brachial sounds in surrounding area
Chest X-ray with atelectasis
increased opacity
Pal gradient
Difference between alveolar and pleural pressure pal= Palv-Ppl
How to increase Pal gradient
1) decreasing surrounding Ppl
2) Increasing Palv
3) Deep breath in
Goal of any lung expansion therapy
Implement a plan that provides an effective strategy in the most efficient manner
Two major issues related to efficiency
Staff time, equipment
4 parts of general assessment
1) Measuring vital signs
2) Assessing the patient’s appearance and sensorium
3) Assessing breathing patterns through chest auscultation
4) Patients level of motivation and their ability to follow instructions
Pulmonary complications of immobility
Development of atelectasis, pneumonia, and pulmonary emboli (PE)
Complications of prolonged bed rest
Cardiovascular, pulmonary, gastrointestinal, skin integrity issues
Purpose of IS (Incentive Spirometry)
- treat existing atelectasis
- Also helps coach the patient to take a sustained maximal inspiratory (SMI) effort resulting in a decrease in Pal and maintaining the patency of airways at risk for closure
Most common problem of IS?
Respiratory alkalosis
Volume oriented IS devices:
Measure and visually indicate the volume achieved by SMI
Flow oriented IS Devices:
Measure and indicate degree of inspiratory flow (Flow x time = volume)
Phases of IS application
Preliminary planning- identify needs/risks
Implementation- The patient should be instructed to inspire slowly and deeply to maximize the distribution of ventilation
~ Correct technique calls for diaphragmatic breathing at slow to moderate inspiratory flows
~ Goal is an intermittent, maximal inspiration
~ 5-10 SMI maneuvers each hour
Follow up- Assessing patients performance
NIV (Noninvasive Ventilation)
Provides breathing support to patients with inadequate ability to ventilate
IPPB
Proved machine-assisted deep breathes assisting the patient to breathe deeply and stimulate a cough
~ Lung volumes are increased because Palv>Ppl
~ Should provide the patient with augmented Vt, achieved with minimal effort
Gastric distention
Gas from IPPB device passes directly into the esophagus
CPAP
Provides distending pressure to reinflate the collapsed airways thus improving V/Q
~ Pressure maintained between 5cm H2O- 20cm H2O
~ Should be used continuously until patient recovers
~ Reduces venous return and cardiac filling pressures
HFNC (High flow nasal cannula)
Flow rate of 40-50L/min
~ Provide a more stable FiO2
~ Reduces anatomic dead space by approximately 1/3, reducing PCO2 by 3-5mm Hg and decreasing WOB
~ 1 cm H2O PEEP is established for every 10L/min flow through the HFNC
PAP therapy factors(PEP, Flutter, CPAP)
1) recruitment of collapsed alveoli through an increase in FRC
2) decreased WOB due to increased compliance or elimination of intrinsic bution of ventilation through collateral channels
4) Increase in the efficiency of secretion removal
Extra Facts
~ If the VC exceeds 15mL/kg of lean body weight or the IC is greater than 33% of predicted, IS is given
~ If either VC or the IC is less than these threshold levels, IPPB is initiated with the pressure gradually manipulated from the initial setting to deliver at least 15mL/kg
~ If excessive sputum production is a compounding factor, a trial of PEP therapy is substituted for IS
