Transcript Types of Ventilation

Chapter 25:
Patient Management:
Respiratory System
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Goals of Bronchial Hygiene Therapies
• Promote removal of secretions
• Improve ventilation
• Improve gas exchange
• Decrease risk for pulmonary infection
• Decrease risk for atelectasis
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Indications for
Postural Drainage
• Difficulty clearing
secretions
Indications for
Percussion/Vibration
• Helps to loosen and
dislodge secretions
• Sputum production >
30 mL/day (cystic
fibrosis)
• Mucous plugs causing
atelectasis
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Question
When the nurse is positioning a client with an abscess in
the right lung for chest physiotherapy (CPT), which of
the following is correct?
A. Position the client with the diseased lung down.
B. Position the client with the diseased lung up.
C. Position the client in either direction.
D. The client should not have CPT.
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Answer
A. Position the client with the diseased lung down.
Rationale: When a client has an abscessed lung, the client
needs to be positioned with the diseased lung down to
keep the abscess from spreading to the opposite lung.
If the client had a lung disease other than an abscess,
then the client should be positioned with the diseased
lung up, because positioning the diseased lung down
would lead to increased hypoxemia.
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Goals of Oxygen Therapy
• Stabilize the arterial oxygen saturation (SaO2)
• Achieve normal respiratory rate and effort
• Decrease discomfort
• Improve myocardial oxygenation
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Assessing the Patient Receiving Oxygen
• Oxygen is administered at ordered rate and method
• Mentation
• Airway patency
• Breathing effort and rate
• Nail beds
• Pulse oximetry and ABG results
• Use of accessory or abdominal muscles
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Ways to Prevent Oxygen Complications
• Change strap position frequently and pad areas to
decrease skin breakdown.
• Provide oral hygiene and apply protective barriers to
nares and lips.
• Enforce no-smoking rule.
• Check tubing connections.
• Keep oxygen concentrations as low as possible.
• Monitor for CO2 narcosis in patients with COPD.
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Question
Which of the following statements about managing a
nasopharyngeal airway is correct?
A. Use the airway in an unconscious client only.
B. Measure for the correct airway length from the tip of the
nose to the earlobe.
C. Use the smallest outer diameter that fits the nostril.
D. Nasotracheal suctioning is a clean technique and the
catheter may be used for multiple sessions.
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Answer
B. Measure for the correct airway length from the tip of the
nose to the earlobe.
Rationale: The airway should be used in a conscious client
because it is more comfortable and does not elicit the
gag reflex. Use the largest outer diameter that fits the
nostril. Nasotracheal suctioning is a sterile technique, so
follow sterile suctioning guidelines.
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Comparison of Intubation Approaches
Orotracheal
Nasotracheal
• Allow direct
visualization of cords
• Blind intubation
• Quicker approach in
apneic patient
• Alternative approach in
awake, breathing
patient
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Complications of Intubation Approaches
Orotracheal
• Dental injury
Nasotracheal
• Nasal trauma
• Soft tissue trauma
• Posterior pharyngeal
wall perforation
• Aspiration
• Esophageal intubation
• Vocal cord injury
• Mainstem bronchus
intubation
• Aspiration
• Esophageal intubation
• Vocal cord injury
• Mainstem bronchus
intubation
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Causes of Iatrogenic Pneumothorax
• Central line placement
• Placement of internal pacemaker
• Lung biopsy
• Cardiopulmonary resuscitation
• Barotrauma
• Thoracentesis
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Comparison of Chest Tube Drainage
System Principles
• Collection chamber
• Water chamber
• Suction control chamber
– 2 cm of water
creates negative
pressure on pleural
space
– Suction is
determined by
water level in the
chamber and not
the amount on the
wall suction
– Vent
– Dry suction
– Tidaling
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Preventing Complications of Chest Tube
Drainage System Management
• Avoid dependent loops.
• Never raise a drainage system above the patient’s chest.
• Assess the patient and the integrity of the system and
drainage every hour.
• Secure the system to the floor.
• Secure all connections with tape.
• Keep padded hemostats, sterile water, occlusive dressing
supplies at bedside.
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Question
What will happen if the nurse fills the water seal in a chest
tube drainage system above the 2-cm level?
A. The patient will have increased difficulty breathing
because there is a longer column of fluid to move when
breathing.
B. There will be no effect on the client, but it will make
drainage more difficult.
C. It will have no effect on the client because 2 cm is the
minimum.
D. It will get rid of an air leak more quickly.
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Answer
A. The client will have increased difficulty breathing
because there is a longer column of fluid to move when
breathing.
Rationale: Increasing the fluid above 2 cm in the water
seal exerts an increased negative pressure on the
pleural space and can prevent the air leak from getting
better. The higher the water column is, the harder it is
for the client to breathe because the client has to move
the column of water during breathing. The level at 2 cm
is recommended because physiologically it is the best
level to act as a one-way valve to close the drainage
system to outside air.
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Role of the Nurse in Determining the
Cause of Agitation
• Consider the effects of medications on the older
adult.
• Consider any new medications added or drug
interactions.
• Consider physiological causes.
• Consider pain.
• Consider alcohol or illicit drug withdrawal, if the
patient has a history of using illicit drugs or alcohol.
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Definition of Respiratory Failure
The respiratory system is unable to perform adequate gas
exchange, as evidenced by a PaO2 < 60 mm Hg and a
PaCO2 > 50 mm Hg.
• Classified as acute or chronic
• Hypoxemic respiratory failure (type I)
• Hypercapnic respiratory failure (type II)
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Types of Ventilation
Negative-Pressure
Ventilation
Positive-Pressure
Ventilation
• Thoracic cage is pulled
outward to cause
inspiration
• Air is forced into the lung at
a certain rate, time, and
volume or pressure
• Exhalation is passive
• Exhalation is passive
• Types of ventilators
• Types of ventilators
– Iron lung
– Volume
– Portable external vents
worn over the thorax
like a turtle shell
– Pressure
– High-frequency
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Types of Ventilation (cont.)
Volume Ventilators
• Certain volume of air
is delivered with each
breath
• Pressure to deliver
breath depends on
lung compliance and
other issues
Pressure Ventilators
• Certain amount of gas
pressure is delivered in
early inspiration and is
kept until the
inspiratory cycle is
done
• Volume of gas not
consistent
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Ventilator Modes
• Assist-control ventilation (A/C)
– Patient can initiate (trigger) a breath
– Volume and rate are preset by ventilator
• Used for a client with weak respiratory muscles
• Watch the patient, because the patient may be
breathing too many breaths between the breaths
delivered by the ventilator and may hyperventilate.
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Ventilator Modes (cont.)
• Synchronized intermittent mandatory ventilation
(SIMV)
– Preset volume and rate
– Patient can have independent breaths between
ventilator-delivered breaths
• Used for weaning
• Examine the minute volume to ensure that the client
is being adequately ventilated.
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Ventilator Modes (cont.)
• Pressure support ventilation (PSV)
• Augments a spontaneous inspiration to overcome
the work of breathing.
• Use cautiously in patients with restrictive airways.
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Ventilator Modes (cont.)
• Pressure-controlled ventilation (PCV)
• Used to control plateau pressures when compliance is
decreased and risk for barotrauma exists
• Patient/ventilator asynchrony results in large decrease in
SaO2
• Mean airway and intrathoracic pressures increase
– Results in decrease in cardiac output and O2 delivery
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Adverse Effects of PEEP
• Decreased venous return
• Decreased cardiac output
• Increased risk for barotrauma
• Increased intracranial pressure (ICP)
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Advantages and Disadvantages of
Tracheostomy
Advantages
Disadvantages
• Decreased dead space,
quicker weaning
• Infection
• Communication
• Comfort
• Oral feeding
• Hemorrhage
• Risks of operation
• Pneumothorax
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