Interferences with Ventilation Objectives n Describe causes pathophysiology

Interferences with Ventilation Objectives n Describe causes, pathophysiology, clinical manifestations, therapeutic interventions, & nursing management of patients with restrictive & obstructive pulmonary disease of the upper and lower airway n n Sleep apnea, asthma in child & adult, emphysema, chronic bronchitis, COPD Describe the nursing process for patients who experiences accidental interferences to ventilation n Chest trauma

Interferences with Ventilation Restrictive / Obstructive Airway Disease n Restrictive Disorders: n Decreased compliance of the lungs or chest wall or both Extrapulmonary – CNS, Neuromuscular, Chest Wall n Intrapulmonary – Pleural, Parenchymal n n Obstructive Disorders: n Increased resistance to airflow n Asthma, Emphysema, Chronic Bronchitis, COPD

Obstructive Sleep Apnea (OSA)

Obstructive Sleep Apnea (OSA) n n n Clinical Manifestations: insomnia, daytime sleepiness; witnessed apneic episodes; snoring; morning headaches; impaired concentration & memory Dx: Polysomnography (sleep study) – multiple episodes of apnea or hypopnea (airflow diminished 30 -50% with respiratory effort) TX: Avoid sedatives & alcohol 2 -4 hrs prior to sleep; compliance with n. CPAP / Bi. PAP n n. CPAP – continuous + airway pressure + 5 -15 cm H 2 O pressure Bi. PAP – bilevel + airway pressure – delivers higher pressure during inspiration & lower pressure during expiration Surgery

Pathophysiology of Chronic Airflow Limitation

Interferences with Ventilation Asthma n Chronic inflammatory disorder of the airways n Causes varying degrees of obstruction in the airways Recurrent episodes of wheezing, breathlessness, chest tightness, and cough, particularly at night and in early morning n Associated with hyperresponsiveness to a variety of stimuli n Affects 1 in 20 Americans n 10 millions absences per year n 5, 000 deaths per year n

Respiratory System Drugs Asthma n n Recurrent and reversible shortness of breath Airways become narrow as a result of: n Bronchospasm n Inflammation & Edema of the bronchial mucosa n Production of viscid mucus Alveolar ducts/alveoli remain open, but airflow to them is obstructed Symptoms n n Wheezing Difficulty breathing

Interferences with Ventilation Asthma n Triggers of Asthma Attacks n n n n Allergens Exercise Respiratory Infections Nose & sinus problems Drugs and food additives Gastroesophageal reflux disease (GERD) Emotional Stress

Interferences with Ventilation Asthma - Pathophysiology n Hallmarks of Asthma: Airway inflammation & nonspecific hyperirritability n Early phase n n Characterized by bronchospasm Induces inflammatory sequelae of the late phase response Allergen or irritant cross-links Ig. E receptors on mast cells beneath the basement membrane of the bronchial wall OR Hyperresponsiveness of the tracheobronchial tree n Caused by bronchoconstriction in response to physical, chemical and pharmacological agents

Early & Late Responses in Asthma

Classification of Asthma Severity

Pathophysiology of Acute Asthma Attack

Stepwise Approach for Managing Asthma

Interferences with Ventilation Asthma – Medication

Interferences with Ventilation Asthma - Medication

Drug Therapy Asthma & COPD

Drug Therapy – Asthma & COPD

How to Use Metered-Dose Inhaler

Metered-Dose Inhaler

Pair Share n When exercising, a client with asthma should be taught to monitor for which of the following problems? n n n A. Increased peak expiratory flow rates B. Wheezing from bronchospasm C. Wheezing from atelectasis D. Dyspnea from pulmonary hypertension What would the nurse recommend to prevent future episodes of this problem?

Pair Share A client who has been newly diagnosed with asthma is admitted to the acute care unit for evaluation. The nurse provides the client with an Albuterol (Proventil, Ventolin) metered-dose inhaler. The nurse will plan to monitor the client very closely for which of the following side effects of Albuterol? n n A. Tachycardia and nervousness B. Nasal congestion and dry mouth C. Sedation and lethargy D. Joint pain and unstable gait

Status Asthmaticus n Severe, life-threatening asthma attack n Refractory to the usual treatment “The longer it lasts, the worse it gets, and the worse it gets, the longer it lasts” Causes: viral illnesses, ASA or NSAID ingestion, allergen exposure, abrupt discontinuation of therapy, B-adrenergic blocker ingestion, poorly controlled asthma Results: increased airway resistance – edema, mucous plugging, bronchospasm

Status Asthmaticus n Clinical Manifestations: n Wheezing, forced exhalation, neck vein distention, HTN, sinus tachycardia, ventricular dysrhythmias Initial hypoxemia & hypocapnia n Late – hypoxemia & hypercapnia n n Medical Management: Medications: Corticosteroids, B 2 -adrenergic agonists via MDI, IV Aminophylline n Hydration n Oxygen – Humidified; Intubation/Mechanical Ventilation 10% of the time n

Chronic Obstructive Lung Disease Chronic Bronchitis n Presence of chronic productive cough for 3 months in 2 successive years in a patient in whom other causes of chronic cough have been excluded Frequent respiratory infections n Hx of cigarette smoking for many years n Hypoxemia & Hypercapnia result from hypoventilation n Bluish-red color of skin n n Polycythemia – body’s attempt to compensate for chronic hypoxemia by increasing production of red blood cells

Chronic Obstructive Lung Disease Chronic Bronchitis n n n A client with chronic bronchitis often shows signs of hypoxia. The nurrse would observe for which of the following clinical manifestations of this problem? A. Increased capillary refill B. Clubbing of fingers C. Pink mucous membranes D. Overall pale appearance

Chronic Obstructive Lung Disease Chronic Bronchitis n n n n n In chronic bronchitis, impaired gas exchange occurs as a result of which of the following? A. Chronic inflammation, thin secretions, and chronic infection B. Respiratory alkalosis, decreased Pa. CO 2, and increased Pa. O 2 C. Chronic inflammation and decreased surfactant in the alveoli and atelectasis D. Thickening of the bronchial walls, large amounts of thick secretions, and repeated infections

Chronic Obstructive Lung Disease Emphysema n n Abnormal permanent enlargement of the airspaces distal to the terminal bronchioles, accompanied by destruction of their walls and without obvious fibrosis Risk Factors: n Cigarette Smoking Irritation - > 4, 000 chemicals inhaled n Hyperplasia – reduces airway diameter n Abnormal dilatation of distal airspaces n n Destruction of alveolar walls

Chronic Obstructive Lung Disease Emphysema n Risk Factors (cont’d): n Recurring respiratory tract infections n n Heredity – alpha 1 –Antitrypsin (ATT) deficiency n n H. flu, Strep pneumoniae, Moraxella catarrhalis Accounts for <1% of COPD in US AAT is a serum protein produced by the liver and normally found in the lungs IV or nebulized AAT (Prolastin) slows COPD progression Aging – Changes in lung structure n Gradual loss of elastic recoil – thin alveolar wall – thoracic cage changes from osteoporosis & calcification

Comparison of Emphysema & Chronic Bronchitis Alveolar Problem Airway Problem

COPD Pulmonary Blebs & Bullae

COPD -- Interaction of Chronic Bronchitis & Emphysema

Pathophysiology of Chronic Bronchitis and Emphysema

Interferences with Ventilation Medical Management Goals n n n Improve ventilation Promote removal of secretions Prevent complications & progression of symptoms Promote patient comfort & participation in care Improve quality of life as much as possible

Interferences with Ventilation Medical Treatment n n Patients are treated primarily as outpatients Hospitalizations Acute exacerbations n Complications n n Respiratory failure, pneumonia, congestive heart failure

Interferences with Ventilation COPD A high-liter flow of oxygen is contraindicated in the client with COPD because of which of the following? n A. The client depends often on a hypercapnic drive to breathe n B. The client depends on a hypoxic drive to breathe n C. Receiving too much oxygen over a short time results in a headache n D. Response to high doses needed later will be ineffective

Interferences with Ventilation COPD n When teaching a client to use aerosol treatments, the following is the correct sequence for administering aerosol tx? A. Steroid should be given immediately after the bronchodilator B. Steroid should be given 5 to 10 minutes after the bronchodilator C. Bronchodilator should be given immediately after the steroid D. Bronchodilator should be given 5 to 10 minutes after the steroid

Interferences with Ventilation Medical Management n n n Smoking cessation Treatment of respiratory infections Bronchodilator therapy n Beta 2 -adrenergic agonists n Anticholinergic agents n Long-acting theophylline Corticosteroids PEFR monitoring (peak expiratory flow rate) Chest physiotherapy / Breathing exercises & retraining Hydration 3 L/day (unless contraindicated) Rest - Progressive plan of exercise Patient & family education Influenza / Pneumovax immunization Low flow oxygen rate (if indicated) Pulmonary rehabilitation program

Interference with Ventilation Oxygen Therapy n Indications: n Treat: Respiratory; CV; CNS disturbances n Oxygen Administration: High or low flow systems n High Flow — delivers fixed concentrations independent of the patient’s respiratory pattern n Venturi Mask – up to 50% n Low Flow — amount delivered varies with patient’s respiratory pattern n Nasal cannula 2 L/min = 28% oxygen n Face tent or trach collar – Increased humidity n Non-re-breathing mask – delivers 60 -90% n Humidity: n 1 -4 L low flow – use of “bubble-through” controversial n Nebulized

Interferences with Ventilation Oxygen Therapy- Complications n CO 2 Narcosis – n n n two chemoreceptors – O 2 CO 2 accumulation – major stimulus COPD patient – n Develops tolerance to high CO 2 n n n Respiratory Center loses sensitivity to elevated CO 2 Drive “Hypoxemia” Concern about administering O 2 to COPD patients ? ? Bigger Concern: not providing adequate O 2 Goal: Titrate O 2 to the lowest effective dose based on arterial blood gas monitoring

Interferences with Ventilation Oxygen Therapy- Complications n O 2 Toxicity n n n Prolonged exposure to high level O 2 Determined by patient tolerance, exposure time, and effective dose High level Manifestations – n n Initial -- Inactivate surfactant and lead to ARDS : reduced vital capacity, cough, substernal chest pain, N&V, paresthesia, nasal stuffiness, sore throat, malaise Later – affects alveolar-capillary gas exchange: pulmonary edema with copious sputum End Stage – lung fibrosis O 2 Administration Goal: enough O 2 to maintain Pa. O 2 within normal or acceptable limit n O 2 administration > 50% for > 24 hours potentially toxic

Chronic Obstructive Lung Disease Complications

Pair Share The nurse should report what unexpected findings in a client with emphysema? n n A. Decreased breath sounds and dyspnea on exertion n B. Sputum with gram negative rods an periods of apnea n C. Vesicular breath sounds and decreased thoracic expansion n D. Increased anteroposterior chest measurement n

Nursing Care Management Ineffective airway clearance n n n Assess: Normal breath sounds; effective coughing Nsg Action: Elevate head of bed; sitting up; hydration 2 -3 L/d; chest physiotherapy; Meds: inhaled bronchodilators Pt Education: Effective breathing & coughing techniques; Medications & administration

Chest Percussion Cupped Hand Technique

Chest Physiotherapy

Postural Drainage

Nursing Care Management Impaired Gas Exchange n n n Assess: Mental status; VS with Pulse oximetry; ABGs Nsg Action: Position – Tripod-supported extremities; Administer O 2 to effective level; Pt Education: Pursed-lip breathing; signs, symptoms & consequences of hypercapnia; avoidance of CNS depressants; Medication action; smoking cessation

Orthopnea Positions to Decrease the Work of Breathing

Nursing Care Management Imbalanced Nutrition n Assess: n n Nsg Action: n n Weight within normal range for height and age; appetite; caloric intact; energy level; gastric distention; sputum production; affect; lack of interest in foods; serum albumin level Hi PRO, HI Calorie foods & liquid supplements; small frequent feedings; periods of rest after food intake; Referral—financial & nutritional support (Meals-on-wheels; food stamps) Pt Education: n Referrals / Importance of rest / digestion / high protein & calorie foods – menu planning

Nursing Care Management Disturbed Sleep Pattern n Assess: n n Nsg Action: n n Identify usual patterns; explore reasons for discomfort, wakefulness, or difficulty sleeping; sleep apnea Identify pt-specific relaxation methods; environment conducive to rest Pt Education: n Balance activity (ADL’s) / rest; avoidance of alcoholic beverages, caffeine products, & other stimulants before bedtime; include family; sexual activity— positions of comfort; psychosocial issues

Nursing Care Management Risk for Infection n Assess: n n Nsg Action: n n Change in color, consistency, quantity, odor & viscosity of sputum; difficulty mobilizing secretions; foul oral odor; increased dyspnea; fever; chills; diaphoresis; changes in respiratory rate & quality; breath sounds; hypoxemia; hypercapnia – VS & pulse oximetry Humidification; specimen collection; medication administration Pt Education: n Hand-washing; avoid contact with infected individuals; care & cleaning of home respiratory equipment; when to seek medical attention; steroid use; medication use

Breathing Exercises

Pair Share n n n The client with chronic obstructive pulmonary disease (COPD) has been hospitalized in the respiratory intensive care unit due to an acute exacerbation of COPD. The client’s arterial blood gas analysis of 3 samples earlier in the day are demonstrating a trending of increasing hypoxemia and hypercapnia. The nurse will observe the client closely for a sign which would indicate impending respiratory failure, which would be A. increased expectoration of sputum B. decreased heart rate C. increased respiratory rate D. decreased level of consciousness

Chest Trauma n Blunt steering wheel injury to chest n n Shoulder harness seat belt injury to chest n n Fractured clavicle, dislocated shoulder, rib fractures, pulmonary contusion, cardiac tamponade Crush injury to thorax n n Rib fractures, flail chest, pneumothorax, hemopneumothorax, pulmonary contusion, cardiac tamponade, tear of great vessels Pneumothorax, hemopneumothorax, great vessel tears and rupture Penetrating Trauma n Gunshot wound or stabbing n Open pneumothorax, tension pneumothorax, hemopneumothorax, tear of great vessels, damaged trachea, cardiac tamponade, esophageal damage

Chest Trauma Emergency Treatment

Chest Trauma Emergency Treatment

Disorders of the Pleura

Chest Tube Placement

Water Seal Drainage