respiratory Flashcards
During ABCDE - What do we look for in the airway?
is the airway
patient
blocked ?
can they speak? is there voice wet ?
is there cynosis ?
During ABCDE assessement what do we look for in breathing ?
Are they self ventilating? are they on 02? RR are they brady or tachy? is the pattern atipical ? is there symmetry, increased WOB? accessory muscle use? ausculation - check each lobe, percussion - dull - resonant ? do they have a cough?
ABCDE assesment what do we look for in circulation ?
HR, BP, capillary refill, temperature, colour (pale, flushed), fever or hypothermic, renal output? urine normal 0.5mls? check the fluid balance chart, any dialysis machnines ?
ABCDE - what does Disability mean?
GCS score, pupils, seizures, sedation, muscle tone, pain, posture, positioning.
ABCDE what does EXPOSURE/Everything else mean?
dignity and respect, trauma, bruising, bleeding, swellin, odema, antibiotics, chest strain, feeding tube etc.
normal Blood PH?
7.35 - 7.45
normal value of PaCO2
4.7 - 6.0 kPa
normal PaO2 (arterial partial pressure of oxyge)
11 - 14 kPa
Normal SpO2 (02 saturation)
95-98% pulse oximetry
BE normal range
-2 -+2
What does an objective assement look like?
CNS, Cardiovasuclar and Respiratory
AVPU, GCS, awake reposnding, do they know the date, prime minister ? (CNS), Temp, BP, HR, odema ?(cardiovascular system), and 02 sats, ascultation, blood gasses, cynosis.
What to look for during Breathing assessment
Breathing: Spontaneous breaths? Ventilation settings / mode? Breathing pattern & depth?, Respiratory rate (RR), Cyanosis / low SpO2? Expansion / symmetry / fremitus / resonance? Accessory muscles use? Auscultation? What about cough & sputum?
Circulation: patient’s colour, HR, BP, raised JVP, fluid charts
Disabilities: level of consciousness
Exposure: other considerations – trauma / fracture / fall risk – mobility
signs of respiratory distress?
Central cyanosis
Reduced SpO2 / ABGs (more about ABGs next session)
Sweating
Use of accessory muscle of respiration / abdominal breathing
Increased RR / SOB
Wheezing
Rattling noises
Hypoxemia is ……….?
Hypoxemia is a below-normal level of oxygen in your blood, specifically in the arteries
hypoxia is?
Hypoxia is a state in which oxygen is not available in sufficient amounts at the tissue level to maintain adequate homeostasis; this can result from inadequate oxygen delivery to the tissues either due to low blood supply or low oxygen content in the blood
when is oxygen used ?
A drug used to treat hypoxemia NOT for breathlessness
What is the indication for hypoxemia ?
Pa02 is less than 8Kpa or
Sp02 is less than 94% in acute ill adults and 88-92% is a risk of hypercapnea in COPD patients
casues of hypoxemia ?
exercise induced
post tracheal suction,
post operative
nocturnal hypoxemia
considerations for an 02 delivery system ?
duration of treatment, type of illness, C02 retention, age, tolerance, mouth breather, humidification, RR?
how many litres does a nasal cannulae provide ?
up to 5l
how many litres does a simple face mask provide ?
5-10l
How many litres does a high concentration (non-rebreath) mask hold?
10-15l
How to assess efficay of treatment ?
02 sats, ABG’s, cynosis, conscious level? increase in Pa02, improvement of RR, HR, WOB
cough assist contraindicatons
barotrauma, pnemothorax, bullous emphysema, Unstable CV system, uncontrolled asthma and bronchspasm, hypotension, heamoptosis,
relative contraindications to cough assist
nausa,raised intercranial pressure, osophegeal surgery, tumors, PE, lung abscessess, pneumothorax
reasons to stop the cough assist?
Patient request to do so
Signs of increased WOB
Signs of cyanosis
Drop in SpO2
Patient feels uncomfortable
Secretions needs to be cleared
Suspect patient is unstable
cough assist settings
start low +15 to+40 insufflation
exsufflation -20 to -50 (4-6 reps). Always end on insufflation
Why is manua hyperfinflation used?
Technique that uses a manual resuscitation circuit to provide a larger than baseline tidal volume to the lungs of a patient who is intubated
indictions (reasons to use) to manual hyperinflation
Atelectasis
To improve gas exchange
Mobilisation of secretions
To assess lung compliance
Improve respiratory mechanics (increase compliance, reduced resistance)
complications to manual hyperinflation
Haemodynamic instability
Increased barotrauma risk
Discomfort/anxiety
Reduced sats
Increase ICP
Manual hyperinflation contraindications
Extra-alveolar air (undrained pneumothorax/bullae /surgical emphysema)
Acute / Severe Bronchospasm
Gross cardiovascular instability
Acute head injury / Neurosurgery 0-72 hours
Increased levels of respiratory support (PEEP >10cmH20)
precautions of manual hyperinflation
Emphysematous bullae
Renal dialysis
Recent lung surgery
Patients at risk of barotrauma
Rib fracture (especially in the presence of flail segments)
Hypoxic driven COPD/ Acute exacerbation of COPD
Significant pain
Surgical emphysema/drained pneumothorax
Air leaks
ARDS
Haemoptysis
Broncho-pleural/broncho-oesophageal fistula
patient selection for manual hyperinflation
No arrhythmias compromising cardiovascular function,
Stable ETT, Tracheostomy position
FiO2 <0.75 provided SaO2 >95% and PaO2 >9.0
no fitting in the last 72 hours
<2 sedation scale
Manual Hyperinflation indications
Improve atelectasis
Increase lung volume and compliance
Mobilise secretions
Improve respiratory mechanics
Precautions for manual hyperinflation
Drained pneumothorax
Increased intracranial pressure
Rib fracture
Renal dialysis
Barotrauma
Heamoptosis (blood)
ARDS
Contraindications for manual hyperinflation
Untrained pnemonthorax
Unstable CV system
Severe broncospasm
Increased intracranial pressure
Indications for suction
Patients don’t have an effective cough (to stimulate a cough). Access secretions that can’t by any other means
Risks of suction?
Hypotension
Increased ICP
Reduce O2 sats
Bradycardia/hypoxia
Introduce infection
Trauma to the airway
Vomiting
Contraindications of suction?
Severe bronchospasm
Surgery Gastro/throat
Stridor
Unexplained heamoptysis
Precautions of suction
Recent acute head injury
Clotting abnormality
Anticoagulants
Unstable CV system
Risks of suction
Increase intracranial pressure
Hypoxia
Vomiting
Hypotension
Bradycardia
Introduce infection
Vasovagel reflex
What is sepsis?
Multi organ failure
Signs of Sepsis
SPEECH
Extreme Pain
Passing no urine
Severe breathlessness
It feels like you’re dying
Skin discoloured
Nice Guideline for REHAB after traumatic injury ?
[NG211] MDT social workers, specialist nurses, pain management, Education, Rehab passport. Early weight bearing, maintain Joint ROM, splinting and orthotics, cognitive rehab, pain management, positioning, special referral, bladder and bowel, SALT
Oxygen therapy is used for?
Hypoxaemia not breathlessness
Hypoxaemia clinically is <8KPa but what’re the signs?
Increased WOB, Tachycardia, peripheral vasoconstriction, cyanosis, Tachypnoea
Signs of respiratory deterioration?
Increased HR, RR, drowsiness, headache, C02 retention, nasal flaring, accessory muscle use, stridor, sweating
Benefits of early mobilisation? Short term goals?
CG83 - reduces LRTI (infection), DVT, PE, reduce immobility in delirium
Day 1: transfer to chair (optimise lung volume)
Day2: take a few steps
Day3: mobilise and work towards baseline
Affects of General Anaesthetic?
Reduced tone in respiratory, lung volume, swelling, reduced tidal volume, reduced FRC, ATELECTASIS, RESPIRATORY DEPRESSION.
Before mobilisation what should you check?
BP and BM (blood sugar) Lying and standing BP to reduce the risk of a fall, have thy had a blood transfusion?
During C - what does finger clubbing indicate?
C02 retention - type 2 respiratory failure ?
If people are in respiratory distress what education will help?
Positions of ease - accessory muscles in a contracted position to reduce use of 02.
What to do if a patient has a bronchospasm?
Bronchodilators - open the airway - Beta 2 agonist - asthma and COPD
Corticosteroids - reduce inflammation
Treatment of exacerbation of asthma ? Increase RR driving up C02 ?
Intervention: breathing control & hold and sniff (improve collateral ventilation).
Education around using the inhaler and position to ease work of breathing
Head injury patients Treatment goals?
72 hours ? Wait until medically stable?
Maintain ROM - active/passive - splinting and casting
W/chair tilt in space chair
Positioning - spasticity management
SALT - Education - hobbies - job? Psychologist?
Nice Guidelines Traumatic Injury NG211 - Limb, nerve, chest and spine
Discuss with MDT rehab Ax and rehab potential and REHAB PASSPORT, Social sort, Skin bladder and bowel, education, wheelchair, psychologist, social sort, funding, exercise, equipment, manual therapy, ROM, BP? (Vasovagal?), vocational support, work adjustment, strength & aerobic exercise, splints, Orthotics, gait re-education? Bed exercise?
Head injury Short term goals?
CT scan, improve 02 sats, active/passive ROM, positioning V/Q & lung volume, splinting, casting, Neuro Ax, wean 02, sitting balance? Respiratory function management ? Postural drainage, collateral ventilation, maximise cough? Mobilise ASAP
Evidence for early mobilisation ?
Tazeean et al., (2022) Early mobilisation on ITU - reduce surgery complications - SOEOB, sitting balance (be aware of BMs and postural drop), DAY 1: chair transfer, DAY 2: then mobilise a few steps. DAY 3: mobile to baseline then D/C (OT home Ax and Stair Ax too)
Head injury Medium term goals ?
Neuro Assessment, Wien 02, REHAB passport, Early mobilisation, Gait retraining, ADLs, equipment, education, strength and aerobic training to reduce muscle atrophy, Transfer to Neuro rehab? Gait retraining, ADLs?, SALT, Skin management, bladder and bowel management, social sort.
