treatment Flashcards
02 therapy
- Is a drug
- Should be prescribed with target sats
EXCEPT - In an emergency situation when someone is critically unwell
Aims of Treatment
- Sputum retention
- Reduced lung volume (asceticism / collapse)
- Increased work of breathing (WOB)
- Pain
- Fatigue
- Reduced exercise tolerance
Can lead to hypoxia (deficiency in oxygen reaching the tissues)and respiratory failure
Target Saturations
94-98% for most (Scale 1) (BTS)
88-92% for patients at risk of CO2 retention (Scale 2) (COPD)
92-96% for Covid positive patients
Titrating up and down
- Increase FiO2 if SpO2 is lower than target range
- Decrease FiO2 if SpO2 is higher than target range
Titrating up and down monitoring
3
- Monitor SpO2 for 5mins at every change
- If FiO2 is increased, medical assessment is needed
- Ensure any changes are documented
too much 02
4
- Absorption Atelectasis.
- High concentrations may impair the respiratory drive of hypercapnic COPD patients.
- Oxygen toxicity.
- Affects on the CV system.
too much 02- absorbsion atelectasis
when absorption of oxygen from alveoli exceeds replenishment of alveolar gas, so that the alveoli are no longer held open by a cushion of inert Nitrogen. “nitrogen wash out”
too much 02- increased co2
- Normally, rising CO2 levels drives respiration, however those patients with chronically raised CO2 have lost their sensitivity to it so rely on hypoxic drive
too much 02- Oxygen toxicity
Excess oxygen depletes protective anti-oxidants, causing oxygen toxicity
* inflammatory response of lung tissue, predominantly.
too much 02- CV system
increase systemic vascular resistance, affects post-MI
02 therapy In an emergency
- When a patient is critically unwell OR has SpO2 <85%
- Once stable, aim for SpO2 94-98% or patient-specific target range
02 sat scale 1
94-98% for most (BTS)
02 sat scale 2
88-92% for patients at risk of CO2 retention (BTS)
02 sat COVID
92-96%
6
O2 delivery methods
- Nasal Canula
- Face Tent
- Reservoir Face Mask
- Humidified Oxygen Device
- Venturi Mask
- Trachi Mark
blue vevnturi
- 24%
- 2-3 l/min
- OR nasal cannulae 1L
white venturi
- 28%
- 4-6 l/min
- OR nasal cannulae 2L
Yellow venturi
- 35%
- 8-12 l/min
- OR nasal cannulae 4L
Red venturi
- 40%
- 10-15 l/min
- OR nasal cannulae or simple face mask 5-6L/min
green venturi
- 60%
- 15 l/min
- OR simple face fask 7-10L/min
neubulisers
- Direct delivery of medication to the lungs - run at flow of 6-8l (oxygen) or air if don’t require high oxygen
- 0.9% or 7% - hypertonic (care needed though, not all patients require)
- Bronchodilators can reduce bronchoconstriction to aid air flow
saline nebulisers
- Saline can aid airway clearance by reducing the viscosity of sputum
- Saline 0.9% or 7% - hypertonic (care needed though)
Bronchodilators (nebulisers)
can reduce bronchoconstriction to aid air flow
nebulisers other medication
To consider from DH
* Mucolytics, parkinsons meds*
Pain management
* Need extra, encourage to use e.g. PCA*
Timing of these can be important
Think about treatment etc.
postural drainage
7
- Uses gravity to assist drainage of secretions
- Area to be drained positioned highest
- Most affected area drained first
- Ideally 10 mins in each position (position for every lobe)
- Max 3 positions per session
- Think about patients ability to get into positions
- Head down not used anymore (unsafe GERD / GORD / Injury or NGT)
postural drainage precautions/ contrindications
8
- Increased WOB (work of breathing)
- Head and neck pathology/Raised ICP
- Cardiovascular pathology
- Abdominal pathology
- Pregnancy
- Obesity
- Care with attachments
Reflux GERD/GORD or nausea
Positioning To Decrease WOB:
3
- Stabilise shoulder girdle/optimise thoracic cage movement
- Dome a flattened diaphragm
- Decrease energy consumption
- relaxed standing
- forward lean standing
- relaxed sitting
- forward lean sitting
Active Cycle of Breathing Technique (ACBT)
Has 3 stages repeated as a cycle:
1. Breathing control 20-30s
2. Thoracic expansion exercises (TEEs)
3. Forced expiratory technique (FET) or “huff”
- It is a flexible approach and can be adapted to the patient.
- Can be used by the patient without assistance.
Breathing Control:
- Tidal breathing
- Encourage:
○ Relaxation of upper chest
○ Diaphragmatic breathing - Use of proprioceptive facilitation can be helpful.
○ Get hands on! - Continue until patient is ready to progress
Diaphragmatic (tidal) breathing
- One hand on stomach and one hand on chest, breathe in through your nose.
- You’ll feel your stomach expand against your hand and your chest should barely move
- Breath out through your mouth and you’ll feel your stomach sink back down.
Can be used to help manage increased WOB
Thoracic Expansion Exercises
6
- Simply - deep breathing exercises (DBEs)
- Encouraging lateral chest expansion
○ Hands on for proprioceptive feedback - Can add a 3’s hold and a ‘sniff’
- Increases collateral ventilation
- Monitor - patients can become lightheaded, 3-5 +/- breaths
thoracic expansion - hold
- Hold has been shown to decrease collapsed lung tissue and may be good for those with lung pathology as air will first fill in the unobstructed area and the hold may give time for ventilation of collateral pathways.
- especially helpful for where reduced lung volume is reversible (eg. surgery)
thoracic expansison mechanics
4
- Air travels in direction of least resistance – like electricity
- Air will go in to region of least resistance, incomplete equilibrium. Add a pause or insp hold, allows air to move into more regions and recreating equilibrium
- Think of how you blow up a balloon.
- Consequently this component is useful for increasing lung volume and also mobilising sputum
Forced Expiratory Technique (FET)
8
- Forcefully expelling air through an open throat and mouth
- “fogging up a mirror”
- Also known as a “huff”
- Helps move sputum from small to larger airways
○ Medium and high volume - Don’t do too many – can cause bronchospasm
- May initiate a cough
- Can be challenging with surgical pain – + supported
FET mechanics
- Medium moves from more peripheral airways – normal breath in and long huff out
- High moves from more central airways – deep breath, short sharp huff out
FET physiology EPP
- EPP – point at which pressure inside the airway is equal to the pressure outside (intrapleural pressure)
FET location
- Where in the airway this begins depends on where in the airway the pressure is equal to that outside the airway aka the ‘equal pressure point’ (EPP).
- The EPP depends on the volume of inspired air.
- Forces generated by this manoeuvre cause airway compression and collapse towards the mouth.
- Less exhausting than coughing and as effective for moving distal secretions if not more (coughing increases plural pressure and the collapse/compression is more severe potentially inhibiting clearance)
breathing control use
can reduce work of breathing
thoracic expansion exercises use
hold and sniff can help improve lung volume
forced expiration technique use
- high and low voulmes to aid sputum clearance
- can also be taught prophylactically
bronchospasm precaution
care with forceed exhilation technique, may have brochodilators prior to maximise effects
manual tecniques
- percussion
- shakes
- vibrations
Percussion:
- Rhythmical patting of the chest with a cupped hand
- Performed during normal tidal breathing
- Loosens the sputum from the walls of the airways
shakes
- Application of large oscillatory movements to the chest wall
- Usually performed on expiration
Mobilize secretions along the airways
vibrations
- Fine oscillatory movements to the chest wall
- Usually performed on expiration
- Mobilize secretions along the airways
contraindications of manual techniques
- fractures - rib
- surgical wounds
- frank heamoptysis - alot of blood in sputum
- severe osteoporosis
- severe hypoxia
precautions of manual techniques
- bronchospasm
- pain
- osteoporosis
- bone metastases
- near chest drains
mobilisation and exercise Risk Assessment - TILEO
- Think about what you plan to do
- How will you manage that safely?
- Incorporates aspects of A-E- CV stability
- Oxygen requirement
- Attachments
- Any weight bearing restrictions?
- Any investigations outstanding?
mobilisation- Can be to:
- The edge of the bed
- A chair
- Walking from A to B
- Achieving functional level to return home
- May require aids to assist:
- For support and safety
- To reduce the load and WOB
exercise can be to
- To maintain ROM and muscle strength
- To improve exercise tolerance
- To increase lung volumes
- To aid sputum clearance
- Prescription – what type and to what level, rep and sets.
- Patients can be independent with exercises
reduced exercise tolerance
- feel breathless
- avoid activitys that make you breathless
- you do less
- muscles become weaker and less efficient
- you get more breathless
- Some patients need supplemental oxygen to be able to mobilise
- Walking aids might help
- Operate pacing and breathlessness management techniques.
Monitoring Exercise Tolerance:
- BORG - self-assessment of perceived exertion (often used in pulmonary rehab)
- RPE - rate of perceived exertion
Pulmonary Rehabilitation (PR)
- 6-12 week programme
- Education & Exercise (cardio & strengthening)
- Usually run in groups
- Should involve the MDT
- Aims to improve patient’s physical fitness and ability to manage their own condition
education and advice
- Long term secretion management
- Hydration and diet
- Medication
- Pacing and activities
- Exercise/ Pulmonary rehabilitation
- Smoking cessation
- Signs of infection
