NCLEX: Respiratory disorders

Respiratory disorders: Treatments

Focus topic: Respiratory disorders

Respiratory disorders interfere with airway clearance, breathing patterns, and gas exchange. If not corrected, they can adversely affect many other body systems and can be life-threatening. Treatments for respiratory disorders include drug therapy, surgery, inhalation therapy, and chest physiotherapy.

Respiratory disorders: Drug therapy

Focus topic: Respiratory disorders

Drugs are used for airway management in such disorders as bronchial asthma and chronic bronchitis and may include:
• xanthines (theophylline and derivatives) and adrenergics to dilate bronchial passages and reduce airway resistance, making it easier for the patient to breathe and allowing sufficient ventilation
• corticosteroids to reduce inflammation and make the airways more responsive to bronchodilators
• antihistamines, antitussives, and expectorants to help suppress coughing and mobilize secretions
• antimicrobials to reduce or eliminate infective organisms
• leukotrine receptor modifiers to help block the bronchoconstrictive effect of leukotrines
• antihistamines to block or reverse inflammation caused by sensitivity to allergens.

Respiratory disorders: Surgery

Focus topic: Respiratory disorders

If drugs or other therapeutic approaches fail to maintain airway patency and protect healthy tissues from disease, the patient may need surgical intervention. Respiratory surgeries include tracheotomy, chest tube insertion, and thoracotomy. Lung resection, lung reduction, pneumonectomy, or lung transplant surgery may also be indicated.

Tracheotomy
A tracheotomy provides an airway for an intubated patient who needs prolonged mechanical ventilation and helps remove lower tracheobronchial secretions in a patient who can’t clear them. It’s also performed in emergencies when endotracheal (ET) intubation isn’t possible, to prevent an unconscious or paralyzed patient from aspirating food or secretions, and to bypass upper airway obstruction due to trauma, burns, epiglottiditis, or a tumor.

After the doctor creates the surgical opening, he inserts a tracheostomy tube to permit access to the airway. He may select from several tube styles, depending on the patient’s condition.

Patient preparation
Before a tracheotomy, take these steps:
• For an emergency tracheotomy, briefly explain the procedure to the patient as time permits and quickly obtain supplies or a tracheotomy tray.
• For a scheduled tracheotomy, explain the procedure and the need for general anesthesia to the patient and his family. If possible, mention whether the tracheostomy will be temporary or permanent.
• Set up a communication system with the patient (letter board or flash cards), and practice it with him to ensure he’ll be able to communicate comfortably while his speech is limited.

A friend in need

Focus topic: Respiratory disorders

• Introduce a patient requiring a long-term or permanent tracheostomy to someone who has experienced the procedure and has adjusted well to tracheostomy care.
• Ensure that samples for ABG analysis and other diagnostic tests have been collected and that the patient or a responsible family member has signed a consent form.

Monitoring and aftercare
After a tracheotomy, take these steps:
• Auscultate breath sounds every 2 hours after the procedure. Note crackles, rhonchi, or diminished breath sounds.
• Observe for abnormal bleeding at the tracheostomy site. A small amount of bloody drainage is normal for the first 24 hours.
• Turn the patient every 2 hours to avoid pooling tracheal secretions. As ordered, provide chest physiotherapy to help mobilize secretions, and note their quantity, consistency, color, and odor.
• Replace humidity lost in bypassing the nose, mouth, and upper airway mucosa to reduce the drying effects of oxygen on mucous membranes. Humidification will also help to thin secretions. Oxygen administered through a T-piece or tracheostomy mask should be connected to a nebulizer or heated cascade humidifier.
• Monitor ABG results and compare them with baseline values to check adequacy of oxygenation and carbon dioxide removal. Also monitor the patient’s oximetry values as ordered.
• Suction the tracheostomy using sterile technique to remove excess secretions only when necessary. Avoid suctioning a patient for longer than 10 seconds at a time, and discontinue the procedure if the patient develops respiratory distress.

Respiratory disorders

A secure feeling

Focus topic: Respiratory disorders

  • Make sure the tracheostomy ties are secure but not too tight. To prevent accidental tube dislodgment or expulsion, avoid changing the ties until the stoma track is stable. Report any tube pulsation to the practitioner; this may indicate the tube is close to the innominate artery, which predisposes the patient to hemorrhage.
  • Change the tracheostomy dressing when soiled or once per shift using sterile technique, and check the color, odor, amount, and type of drainage. Also check for swelling, crepitus, erythema, and bleeding at the site and report excessive bleeding or unusual drainage immediately. Wear goggles, gloves, and a mask when changing tracheostomy tubes.
  • Keep a sterile tracheostomy tube (with obturator) at the patient’s bedside and be prepared to replace an expelled or contaminated tube. Also keep available a sterile tracheostomy tube (with obturator) that’s one size smaller than the tube currently being used. You may need the smaller tube if the trachea begins to close after tube expulsion, making insertion of the same size tube difficult.

Home care instructions
Take these steps to help the patient and his family prepare for returning home:
• Tell the patient or his family to notify the practitioner of breathing problems, chest or stoma pain, or a change in the amount or color of his secretions.
• Make sure that the patient or his family can care for the stoma and tracheostomy tube effectively.
• Tell the patient to place a foam filter over his stoma in winter to warm the inspired air and to wear a bib over the filter.
• Teach the patient to bend at the waist during coughing to help expel secretions. Tell him to keep a tissue handy to catch expelled secretions.
• Instruct the patient and his family to keep an extra sterile tracheostomy tube available; make sure all family members know where it’s located.

Chest tube insertion
A chest tube may be required to help treat pneumothorax, hemothorax, empyema, pleural effusion, or chylothorax. Inserted into the pleural space, the tube allows blood, fluid, pus, or air to drain and allows the lungs to reinflate.

Water tight

Focus topic: Respiratory disorders

In pneumothorax, the tube restores negative pressure to the pleural space through an underwater-seal drainage system. The water in the system prevents air from being sucked back into the pleural space during inspiration. If a leak occurs through the bronchi and can’t be sealed, suction applied to the underwater-seal system removes air from the pleural space faster than it can collect.

Patient preparation
Before the procedure, take these steps:
• If time permits, the doctor will obtain a signed consent form after explaining the procedure. Reassure the patient that chest tube insertion will help him breathe more easily.
• Obtain baseline vital signs and administer a sedative as ordered.
• If the patient requires an underwater-seal drainage system, collect necessary equipment, including a thoracotomy tray and an underwater-seal drainage system. Prepare lidocaine (Xylocaine) for local anesthesia as directed. The doctor will clean the insertion site with antimicrobial solution. Set up the drainage system according to the manufacturer’s instructions and place it at the bedside, below the patient’s chest level. Stabilize the unit to avoid knocking it over.

Respiratory disorders

Monitoring and aftercare
After tube insertion, take these steps:
• When the patient’s chest tube is stabilized, instruct him to take several deep breaths to inflate his lungs fully and help push pleural air out through the tube.
• Obtain vital signs immediately after tube insertion and every 15 minutes thereafter, according to facility policy (usually for 1 hour).
• Routinely assess chest tube function. Describe and record the amount of drainage on the intake and output sheet.
• Monitor the suction chamber to make sure it has a consistent water level. You may need to add water if any is lost through evaporation.
• After most of the air has been removed, the drainage system should bubble only during forced expiration unless the patient has a bronchopleural fistula. Constant bubbling in the system may indicate that a connection is loose or that the tube has advanced slightly out of the patient’s chest. Promptly correct any loose connections to prevent complications.
• Change the dressing daily (or according to facility policy) to clean the site and remove drainage.
• If the chest tube becomes dislodged, cover the opening immediately with petroleum gauze and apply pressure to prevent negative inspiratory pressure from sucking air into the chest. Call the practitioner and have an assistant collect equipment for tube reinsertion while you keep the opening closed. Reassure the patient, and monitor him closely for signs of tension pneumothorax.
• The practitioner will remove the patient’s chest tube after the lung has fully re-expanded. As soon as the tube is removed, apply an airtight, sterile petroleum dressing.

Home care instructions
Typically, a patient is discharged with a chest tube only if it’s used to drain a loculated empyema, which doesn’t require an under water seal drainage system. Teach this patient how to care for his tube, perform wound care and dressing changes, and dispose of soiled dressings.
Teach the patient with a recently removed chest tube how to clean the wound site and change dressings. Tell him to report any signs of infection.

Thoracotomy
A thoracotomy is the surgical removal of all or part of a lung; it aims to spare healthy lung tissue from disease. Lung excision may involve a pneumonectomy, lobectomy, segmental resection, or wedge resection.

Respiratory disorders

The whole shebang

Focus topic: Respiratory disorders

A pneumonectomy is the excision of an entire lung; it’s usually performed to treat bronchogenic carcinoma but may also be used to treat TB, bronchiectasis, or a lung abscess. It’s used only when a less radical approach can’t remove all diseased tissue. Chest cavity pressures stabilize after a pneumonectomy and, over time, fluid enters the cavity where lung tissue was removed, preventing significant mediastinal shift.

One out, four remaining

Focus topic: Respiratory disorders

A lobectomy is the removal of one of the five lung lobes; it’s used to treat bronchogenic carcinoma, TB, a lung abscess, emphysematous blebs or bullae, benign tumors, and localized fungal infections. After this surgery, the remaining lobes expand to fill the entire pleural cavity.

Bits and pieces

Focus topic: Respiratory disorders

A segmental resection is the removal of one or more lung segments; it preserves more functional tissue than lobectomy and is commonly used to treat bronchiectasis. A wedge resection is the removal of a small portion of the lung without regard to segments;it preserves the most functional tissue of all the surgeries but can treat only a small, well-circumscribed lesion. Remaining lung tissue must be re-expanded after both types of resection.

Patient preparation
Take these steps to help prepare the patient:
• Explain the anticipated surgery to the patient and inform him that he’ll receive a general anesthetic.
• Tell the patient that postoperatively he may have chest tubes in place and may receive oxygen.
• Teach him deep-breathing techniques, and explain that he’ll perform these after surgery to promote lung re-expansion. Also teach him to use an incentive spirometer; record the volumes he achieves to provide a baseline.

Monitoring and aftercare
After surgery, take these steps:
• After a pneumonectomy, make sure the patient lies only on the operative side or on his back until stabilized. This prevents fluid from draining into the unaffected lung if the sutured bronchus opens.
• Make sure the chest tube is functioning, if present, and observe for signs of tension pneumothorax.
• Provide analgesics as ordered.
• Have the patient begin coughing and deep-breathing exercises as soon as his condition is stable. Auscultate his lungs, place him in semi-Fowler’s position, and have him splint his incision to promote coughing and deep breathing.
• Perform passive range-of-motion (ROM) exercises the evening of surgery and two or three times daily thereafter. Progress to active ROM exercises.

Home care instructions
Before discharge, teach the patient to:
• continue his coughing and deep-breathing exercises to prevent complications and report changes in sputum characteristics to his practitioner
• continue performing ROM exercises to maintain mobility of his shoulder and chest wall
• avoid contact with people who have an upper respiratory tract infection
• refrain from smoking
• care for his wound and change the dressing as necessary.

Respiratory disorders: Inhalation therapy

Focus topic: Respiratory disorders

Inhalation therapy uses carefully controlled ventilation techniques to help the patient maintain optimal ventilation in the event of respiratory failure. Techniques include mechanical ventilation, continuous positive airway pressure (CPAP), and oxygen therapy.

Mechanical ventilation
Mechanical ventilation corrects profoundly impaired ventilation, evidenced by hypercapnia, hypoxia, and signs of respiratory distress (such as nostril flaring, intercostal retractions, decreased blood pressure, and diaphoresis). Typically requiring an ET or tracheostomy tube, it delivers up to 100% room air under positive pressure or oxygenenriched air in concentrations up to 100%.

Pressure’s on

Focus topic: Respiratory disorders

Major types of mechanical ventilation systems include positive-pressure, negative-pressure, and high-frequency ventilation (HFV). Positive-pressure systems, the most commonly used, can be volume-cycled or pressure-cycled. During a cycled breath, inspiration ceases when a preset pressure or volume is met.

Pressure’s off

Focus topic: Respiratory disorders

Negative-pressure systems provide ventilation for patients who can’t generate adequate inspiratory pressures. HFV systems provide high ventilation rates with low peak airway pressures, synchronized to the patient’s own inspiratory efforts.

Who’s in control

Focus topic: Respiratory disorders

Mechanical ventilators can be programmed to assist, control, or assist-control. In assist mode, the patient initiates inspiration and receives a preset tidal volume from the machine, which augments his ventilatory effort while letting him determine his own rate. In control mode, a ventilator delivers a set tidal volume at a prescribed rate, using predetermined inspiratory and expiratory times. This mode can fully regulate ventilation in a patient with paralysis or respiratory arrest. In assist-control mode, the patient initiates breathing and a backup control delivers a preset number of breaths at a set volume.

Synchronicity

Focus topic: Respiratory disorders

In synchronized intermittent mandatory ventilation (SIMV), the ventilator delivers a set number of specific-volume breaths. The patient may breathe spontaneously between the SIMV breaths at volumes that differ from those on the machine, however. Commonly used as a weaning tool, SIMV may also be used for ventilation and helps to condition respiratory muscles.

Patient preparation
Before mechanical ventilation begins, take these steps:
• Describe to the patient what mechanical ventilation system will be used, including its benefits and what he may experience.
• If he’s not already intubated or doesn’t have a tracheostomy tube in place, describe the intubation process.
• Set up a communication system with the patient (such as a letter board), and reassure him that a nurse will always be nearby. Keep in mind that an apprehensive patient may fight the machine, defeating its purpose.
• If possible, place the patient in semi-Fowler’s position to promote lung expansion. Obtain baseline vital signs and ABG readings.

Monitoring and aftercare
The patient must be intubated to establish an artificial airway. A bite block is commonly used with an oral ET tube to prevent the patient from biting the tube. After the patient is intubated, arrange for a chest X-ray to evaluate tube placement. Secure the tube to the patient’s face and mark the proximal end to identify position. Make sure he has a communication device and a call bell within reach, and continuously monitor his pulse oximetry level. For all patients, check ABG levels as ordered. Over ventilation may cause respiratory alkalosis from decreased carbon dioxide levels. Inadequate alveolar ventilation or atelectasis from an inappropriate tidal volume may cause respiratory acidosis. Perform the following steps every 1 to 2 hours and as needed:
• Check all connections between the ventilator and the patient. Make sure critical alarms are turned on, such as the low-pressure alarm that indicates a disconnection in the system and is set at not less than 3 cm H2O and the high-pressure alarm that prevents excessive airway pressures. The high-pressure alarm should be set 20 to 30 cm H2O greater than the patient’s peak airway pressure. Volume alarms should also be used if available. Make sure the patient can reach his call bell.
• Verify that ventilator settings are correct and that the ventilator is operating at those settings; compare the patient’s respiratory rate with the setting and, for a volume-cycled machine, watch that the spirometer reaches the correct volume. For a pressure- cycled machine, use a respirometer to check exhaled tidal volume.

Water, water, everywhere

Focus topic: Respiratory disorders

  • Check the humidifier and refill it if necessary. Check the corrugated tubing for condensation; drain collected water into a container and discard. Don’t drain condensation — which may be contaminated with bacteria — into the humidifier, and be careful not to drain condensation into the patient’s airway.
  • If ordered, give the patient several deep breaths (usually two or three) each hour by setting the sigh mechanism on the ventilator or by using a handheld resuscitation bag.
  • Check oxygen concentration every 8 hours and ABG values whenever ventilator settings are changed. Assess respiratory status at least every 2 hours in the acute patient and every 4 hours in the stable chronic patient to detect the need for suctioning and to evaluate the response to treatment. Suction the patient as necessary, noting the amount, color, odor, and consistency of secretions. Auscultate for decreased breath sounds on the left side — an indication of tube slippage into the right main stem bronchus.
    Also perform the following:
  • Monitor the patient’s fluid intake and output and his electrolyte balance. Weigh him as ordered.
  • Using sterile technique, change the humidifier, nebulizer, and ventilator tubing according to facility protocol.
  • Reposition the patient frequently, and perform chest physiotherapy as necessary.
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No more heartburn

Focus topic: Respiratory disorders

  • Provide emotional support to reduce stress, and give antacids and other medications as ordered to reduce gastric acid production and to help prevent GI complications.
  • Monitor for decreased bowel sounds and abdominal distention, which may indicate paralytic ileus.
  • Check nasogastric (NG) aspirate and stools for blood; stress ulcers are a common complication of mechanical ventilation.
  • If the patient is receiving high-pressure ventilation, assess for signs and symptoms of a pneumothorax (absent or diminished breath sounds on the affected side, acute chest pain and, possibly, tracheal deviation or subcutaneous or mediastinal emphysema).
  • If the patient is receiving a high oxygen concentration, watch for signs and symptoms of toxicity (substernal chest pain, increased coughing, tachypnea, decreased lung compliance and vital capacity, and decreased PaCO2 without a change in oxygen concentration).
  • If the patient resists mechanical ventilation and ineffective ventilation results, give him a sedative, an antianxiety agent, a neuromuscular blocking agent, or a short-acting anesthetic, as ordered, and observe him closely.

Home care instructions
If the patient requires a ventilator at home, teach him and a family member:
• how to check the device and its settings for accuracy and the nebulizer and oxygen equipment for proper functioning at least once per day
• to refill his humidifier as necessary
• that his ABG levels will be measured periodically to evaluate his therapy
• how to count his pulse rate and to report changes in rate or\ rhythm as well as chest pain, fever, dyspnea, or swollen extremities
• to call his practitioner or respiratory therapist if he has questions or problems.

CPAP
As its name suggests, CPAP ventilation maintains positive pressure in the airways throughout the patient’s respiratory cycle. Originally delivered only with a ventilator, CPAP may now be delivered to intubated or nonintubated patients through an artificial airway, a mask, or nasal prongs by means of a ventilator or a separate high-flow generating system.

Goes with the flows

Focus topic: Respiratory disorders

CPAP is available as a continuous-flow system and a demand system. In the continuous-flow system, an air-oxygen blend flows through a humidifier and a reservoir bag into a T-piece. In the demand system, a valve opens in response to the patient’s inspiratory flow.

Other talents

Focus topic: Respiratory disorders

CPAP not only treats respiratory distress syndrome, it has also successfully treated pulmonary edema, pulmonary emboli, bronchiolitis, fat emboli, pneumonitis, viral pneumonia, postoperative atelectasis, and sleep apnea. In mild to moderate cases of these disorders, CPAP provides an alternative to intubation and mechanical ventilation. It increases the functional residual capacity by distending collapsed alveoli, which improves PaO2 and decreases intrapulmonary shunting and oxygen consumption. It also reduces the work of breathing. CPAP can also be used to wean a patient from mechanical ventilation.

Respiratory disorders

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