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Interventions 2 (RESP 319) > Mod 9 Bronchopulmonary Hygiene > Flashcards

Mod 9 Bronchopulmonary Hygiene Flashcards

1
Q

How are neonatal Endotracheal Tubes different from pediatric and adult endotracheal tubes?

A
  1. Primarily uncuffed to eliminate cuff related problems
  2. Tubes are small and easily kinked or obstructed
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2
Q

What is a common risk factor of endotracheal tubes?

  • How is it managed?
A

Increased risk of aspiration and increased mucus production (hypersecretion)

  • Suctioning helps minimize aspiration and prevents tube occlusion.
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3
Q

Why do endotracheal tubes increase risk of aspiration?

A

Improper cuff pressure or ETT placement can redirect secretions into 3rd spaces. I.E lower airways if in fowlers or supine.

  • secretions may also be retained in unintended areas.
  • Problematic if the Pt. can’t clear their airway
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4
Q

What is the snowball affect that can be caused by Retained secretions?

A

Leads to:

  • Increased airway resistance
  • Increased WOB
  • Can cause hypoxemia, hypercapnia, atelectasis, and infection.
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5
Q

Why might a patient have difficulty clearing secretions?

A
  • Thickness or amount of secretions
  • Ineffective cough
  • Lung pathologies
  • Loss of airway control
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6
Q

What does the prescence of the Endotracheal tube have in the trachea?

A
  • Increased mucus secretions
  • Prevents closure of the glottis which impairs compression phase of cough
  • Tube cuff mechanically blocks the mucociliary escalator
  • Tube tip can erode the tracheal mucosa which impairs mucociliary clearance
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7
Q

Why is Suctioning a problem for intubated patients?

A

Suction can also damage airway mucosa and impair mucociliary transport

  • Can cause bradycardias
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8
Q

What are the steps of suctioning for a Pt w/a endotracheal tube

A
  1. Assess the Pt. for indications
  2. Assemble and check equipment
  3. Maintain adequate oxygenation and ventilation
  4. Insert the catheter
  5. Suction
  6. Maintain adequate oxygenation and ventilation
  7. Monitor
  8. Repeat if needed
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9
Q

What indications would lead you to suction a patient?

A

Suspected aspiration of gastric or upper airway secretions.

  • Increased WOB
  • Increased PIP on volume control
  • Decreased Vt on pressure control
  • Changes in oxygenation
  • Patency check
  • DOPE
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10
Q

How do you observe changes in oxygenation?

A
  • Pt colour
  • Saturation (pulse oximetry)
  • ABG
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11
Q

What can be done with ETT aspirates?

A

samples can be taken to lab to identify what antimicrobials will kill it

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12
Q

Add slides 12-14

A
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13
Q

What are complications of having suction catheter that is too large?

A
  1. Can obstruct the ETT
  2. Negative pressure can evacuate lung volume and cause atelectasis and hypoxemia
  3. Never suction a Pt with a catheter whose outer diameter is greater than 1/2 of the internal diameter of the artificial airway
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14
Q

What are indications for closed system catheters?

A
  • Hemodynamics instability
  • High vent requirements
  • On isolation
  • Receiving inhaled agents
  • Frequent Sun
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15
Q

What is Hemodynamics instability associated with?

A

Ventilator disconnection

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16
Q

According to Egans, what is considered as high ventilator requirements?

A
  • PEEP > 10
  • MAP > 20
  • Ti > 1.5 seconds
  • Fraction of inspired O2 > 0.6
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17
Q

What are pediatric suction catheter sizes for 6 month old?

A

6-8F

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18
Q

What are pediatric suction catheter sizes for 18 month old?

A

8f

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19
Q

What are pediatric suction catheter sizes for 2-5 Yr old?

A

use 10F

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20
Q

What are pediatric suction catheter sizes for 8-16 Yr old?

A

10-12F

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21
Q

What are pediatric suction catheter sizes for 16+ Yrs old?

A

12-14F (adult)

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22
Q

What are newborn suction catheter sizes for a baby that weighs < 1Kg?

A

5-6F

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23
Q

What are newborn suction catheter sizes for a baby that weighs >3Kg?

A

8F

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24
Q

What inflation pressures and RR should be taken into consideration before suctioning?

A
  • Adults should be preoxygenated to 100% FiO2
  • Neonates should be left at the same FiO2 as the vent settings or 10% above for suction
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25
Q

How deep do you insert the suction catheter in adults?

A

Until you meet resistance

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26
Q

How deep do you insert suction catheters for neonates and paediatrics?

A

Use the markers!

  • Suction catheter should only go as far as the ned of the ETT, not beyond
  • Match the marking from the ETT to the markings on the suction catheter
  • A piece of tape is cut to the desired insertion depth and placed at the head of the warmer/isolate once determined
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27
Q

What suction pressures are used for adults on a closed or open system?

A
  • Open 80-120 mmHg
  • Closed less than or equal to 160
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28
Q

What suction pressures are used for kids on a closed or open system?

A

80-100 mmHg on both open and closed

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29
Q

How long should it take to withdraw a catheter with suctioning?

A

Adults = 15-20 seconds

Kids = 10-15 seconds

Infants = 5 seconds

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30
Q

How long should the suction procedure take (disconnect to reconnect)?

A
  • Adults = 30 seconds
  • Children = 25 seconds
  • Infants < 20 seconds
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31
Q

What are 3 artificial cough devices?

A
  1. Chet Vest Oscillator
  2. Cough Assist
  3. Flutter valves
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32
Q

What is a Chest Vest Oscillator?

A

A high frequency chest wall oscillation (HFCWO) device used primarily for Pts with CF.

  • Works by rapidly oscillating air volumes within the vest to rapidly compress and vibrate the chest of the patient
  • Effective chest PT is more efficient
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33
Q

What are Cough Assist device used for and how do they work?

A

Improves secretions clearance by gradually applying positive pressure to the airway and then rapidly shifts to negative pressure.

  • Rapid shift in pressure produces a high expiatory flow from the lungs, stimulating a cough.
34
Q

What population would benefit the most from the use of a Cough Assist device?

A

Patients with neuromuscular disease and a weak cough

35
Q

How do flutter valves work?

A

HFOA uses expiratory pressures and high frequency oscillation through the valve.

  • on exhalation, the expiatory pressure created ranges from 10-25 cmH2O and oscillations (15hz) create are transmitted into the chest wall.
  • Oscillation PEP
36
Q

Which population group would benefit the most from Flutter Valves?

A

Patients with CF and CB in cycles of 10-20 breaths at a time

37
Q

What suction should not be performed while the patient is awake with a gag reflex?

A

Oropharyngeal suctioning

38
Q

What suction method is preferred routine method for a awake non-intubated patient?

A

Nasopharyngeal suction

  • flexible suction catheter inserted through external nares or in adults, through a nasopharyngeal airway (NPA)
39
Q

What suction devices can you use through nasal pathways?

A

Flexible catheter or bulb

40
Q

What suction devices can you use through the mouth?

A

Rigid (Yankauer, bulb, or flexible)

  • Rigids aren’t used on infants
41
Q

What suction devices can you use through naso/oropharyngeal pathways?

A

Flexible.

  • Nasopharyngeal route is preferred in an awake non intubated Pt.
  • For adults you can use NPA to facilitate this
42
Q

What suction devices can you use through Lower Airway pathways?

  • aka trachea and bronchi
A

Flexible

  • Single use (open)
  • Multi use (inline, aka closed)
43
Q

What should you do if your patient can’t mobilize their secretions?

A
  • Bland Aerosol/sputum induction
  • Chest PT
44
Q

What is Bland Aerosol Administration?

A

Delivery of:

  • Hypotonic saline
  • Isotonic (normal) saline
  • Hypertonic saline
  • Sterile/distilled water
  • May be given w/O2 admin
45
Q

What are indications for bland aerosol? (3)

A
  • Minimizing humidity deficit when upper airway has been bypassed
  • Use of cool, bland aerosol therapy is primarily indicated for upper airway edema
  • Sputum induction/secretion mobilization
46
Q

What should your pre sputum induction procedure entail?

A
  • Standard precautions for PPE (n95) and negative pressure room
  • AM samples x3
  • Equipment
  • Introduction and identifcation
  • Explain procedure for deep cough
  • Provide sterile container
47
Q

Can sputum induction be performed for asthmatics?

A

You bet. think eosinophils?

48
Q

What does the Sputum Induction Procedure entail?

A
  1. Have Pt rinse mouth and pretreat w/bronchodilator aerosol if needed.
  2. Place solution in neb
  3. Have Pt breath from neb
  4. Slow inspiration and breath hold
  5. Cont’d until either acceptable sputum specimen collected or pt unable to tolerate procedure.
49
Q

During the sputum induction procedure, when the pt is breathing from a neb, when should they breath inhale or exhale through their nose and mouth?

A
  • On inspiration, Pt inhales via mouth.
  • On expiration, Pt exhales via nose
50
Q

What is the core purpose of Chest Physical Therapy?

A

combination of lung expansion techniques and bronchial hygiene used to prevent or correct atelectasis and prevent secretion accumulation

51
Q

What are methods of Chest Physical Therapy (CPT)?

A
  • Cough Techniques
  • Postural drainage
  • Percussion
  • Vibration
  • Incentive spirometry and adjuncts
  • Breathing techniques
52
Q

What is bronchial hygiene dependent on?

A

A effective cough

  • some diseases inhibit/blunt the cough reflex making it ineffective
53
Q

What are the most commonly taught cough techniques?

A

Directed cough and forced expiratory technique

54
Q

What is a directed cough?

  • How is it performed?
A
  1. Position the patient sitting up.
  2. Have Pt take a slow big breath via the nose using diaphragmatic breathing.
  3. Have the Pt bear down against the glottis (valsalva), may need to be in short bursts. (multiple huffs)
  4. Bearing down mimics a spontaneous cough
55
Q

How should directed coughs be modified for COPD’ers?

A

Have them breath in only moderately and breath out via pursed lip breathing while bending forward slightly.

  • Forward flexion should help mimic a cough
56
Q

Why would expiratory bearing down have to be altered to short bursts?

A

To decrease fatigue and increase effectiveness for some patients

57
Q
  1. What are Assisted Coughs?
  2. What population group would benefit from Assisted coughs?
A

Useful for Pts with restrictive or paralytic disorders that impair lung excursions and increase the risk of secretion clearance failure.

58
Q

How are Assisted Coughs performed?

A
  • Have the Pt take 3 breaths in and force out a cough
  • During the cough phase, the practitioner applies force 2 inches below the xiphoid and pushes up towards the head of the patient.
59
Q

What is Forced Expiratory Technique (FET)

A

A modified directed cough (a huff cough)

  • Consists of 2 forced exhalation w/o closing the glottis followed by relaxation and diaphragmatic breathing

-Verbal huffing during exhalation keeps glottis open

60
Q

How is Forced Expiratory Technique (FET) used in relation to Active Cycles of breathing (ACBT)

A

The final stage of a gradual breathing techniques to direct a cough at the end of exhalation

  1. Breathing control: relaxed diaphragmatic breathing
  2. Thoracic expansion: deep inspirations X3 with passive exhalation
  3. FET’s X2 followed by relaxed breathing (hopefully secretions and need to clear w/cough occur here)
  • Each are done in cycles of 2 to 4 times
61
Q

What is postural drainage?

A

Involves positioning the patient using gravity to drain secretions from lung segments into the central airways for expulsion by coughing or suctioning

  • Also referred to as Autogenic drainage
62
Q

What are key principles for Postural Drainage that need to be kept in mind before initiating?

A
  • Need doctor order before initiating
  • Chest pain control has been initiated for the comfort of the pt
  • Chest recent CxRs and O2 requirements
  • Explain the procedure to Pt
  • Check Pt vital signs and breath sounds
63
Q

What is the purpose of proning?

A

Improve V/Q by shifting blood from shunt areas.

  • Used extensively in Pts with refractory hypoxemia
64
Q

What procedures and techniques should be followed for Postural drainage?

A
  • Ensure clothing, IV lines, and O2 tubing will be moveable when re-positioned
  • Position the Pt in the prescribed position, and check that the Pt is tolerating the position level w/o adverse side effects. Head 25 degree down 45 degree up
  • Maintain the position for 3-15 mins, depending on policy and pt tolerance
  • Restore the pt to their pre-treatment position and monitor their vital signs and breath sounds.
  • Encourage the Pt to cough after postural drainage
65
Q

Where is percussion and vibration performed?

A

Above the lung segment to be drained (at skin level)

66
Q

How does Percussion encourage secretion clearance?

A

Jars retained secretions loose from the tracheobronchial tree so they can be removed by coughing or suctioning

67
Q

How does vibration encourage secretion clearance?

A

Exhalation moves secretions into the larger airways during exhalation for removal by cough or suction

68
Q

Indications for percussion or vibration for secretion clearance?

A

To be used an adjunct to postural drainage and coughing when these alone cannot provide adequate secretion clearance

69
Q

What are contraindications for percussion or vibration for secretion clearance?

A
  • Subcutaneous emphysema, any lung or skin injury/surgery
  • Recent epidural or spinal anesthesia
  • New subcutaneous or transvenous pacers
  • TB
  • Bronchospasm
  • Osteomyelitis or osteoporosis
  • Bleeding disorders
  • Chest wall pain
70
Q

What are hazards of Percussion and vibrations for secretion clearance?

A
  • Pain and discomfort to Pt
  • SOB
  • Hypoxia
  • Rib fractures
71
Q

What are precautions of Percussion and vibrations for secretion clearance?

A
  • Never percuss directly over breast or bone
  • Same precautions w/postural drainage
72
Q

What does Incentive Spirometry work (IS)?

A

Increases transpulmonary P gradients by decreasing pleural pressures (Ppl).

  • Big inspirations cause a drop in Ppl due to expansion of the thorax. This drop transmits to the alveoli, negative Palv allows for more gas flow to the alveoli and lung expansion
73
Q

What are indications for Incentive Spirometry (IS)

A
  • Documented atelectasis
  • Impending atelectasis: thoracic/abdominal/cardiac surgery, post-op
  • Restrictive diseases/movement
74
Q

Contraindications for Incentive Spirometry (IS)?

A
  • Uncooperative or unable to perform procedure
  • Unable to understand instructions
  • Too weak or sick
  • VC less than 10 ml/kg
75
Q

Hazards of Incentive Spirometry (IS)

A
  • Hyperventilation and respiratory alkalosis
  • Discomfort due to poor pain control
  • Barotrauma
  • Hypoxemia if O2 has to be removed
  • Bronchospasm
  • Fatigue
  • Vagal stimulation
76
Q

Generally, how should incentive spirometry be performed by the Pt?

A

Should be done in 5-10 maneuvers/hour post surgery as the pt can tolerate

77
Q

How do you know if Incentive Spirometry works?

A
  • Subjective Pt Improvement: Decreased RR, Remission of fever, normal pulse, and improved breath sounds.
  • Improvement of atelectasis on CxR
78
Q

What should RT’s do when observing Incentive Spirometry (IS)?

  • Follow up monitor?
A
  • Observation of patient’s technique
    Additional instruction if needed
  • Making sure the device is within the patient’s reach and that they are using it on their own
  • Setting new and increased inspiratory goals every day if improving
  • Vital signs and breath sound assessment
79
Q

When is Lung Volume Recruitment (LVR) performed?

A

For Pts w/paralytic disorders, that have high risks of atelectasis and secretion clearance failure (like ALS)

80
Q

How is lung volume recruitment (LVR) performed?

A

Uses a resuscitation bag to stack breaths to achieve maximum insufflation and promote alveolar recruitment (stretch) and allow for a strong cough on exhalation if required.

  • Often followed by assisted cough maneuvers to promote secretion clearance.
81
Q

What are breathing techniques that can be used to help Pts breath more effectively?

A
  • Encourage more use of diaphragm and less use of accessory inspiratory muscles
  • Decrease the tendency to use gasping resps
  • Teach Pts to cope w/dyspnea
  • Decrease muscle inefficiency
  • Coordinate breathing w/motion and daily acitivies
  • Relieve exertional dyspnea
  • Improve cardiopulmonary fitness and exercise tolerance

Interventions 2 (RESP 319) (25 decks)

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