J Borrero 2/08 NUR240

Respiratory Stressors II

Chest TraumaRespiratory FailureARDSVentilators

Chest Trauma

About 25% of all traumatic deaths result from chest injuries

- Pulmonary contusion - Rib fracture - Flail chest - Pneumothorax - Tension Pneumothorax - Hemothorax - Tracheobronchial trauma

Assessment

Assessment of overall condition and type of injury

Car accident-blunt trauma Assess for blood loss Assess for underlying structures Monitor for airway obstruction, tension

pneumothorax,open pneumothorax, flail chest with pulmonary contusion

Emergency Assessment

Maintain ABCs Obtain a quick hx What happened? What was the mechanism of

injury? How long ago did it happen? Where is the pain? What does it feel like? Pain scale? Does it radiate? Is there anything that makes the pain better or

worse? Medical hx?

Emergency 1 Minute Assessment

Shortness of breath and cyanosis VS, Heart sounds, skin color and temp Wound size and location Look and listen for sucking chest sounds Bilateral breath sounds, stridor, paradoxical chest

movement (flail chest), use of accessory muscles Tracheal deviation SQ emphysema Assess for bowel sounds in the chest-ruptured

diaphragm

Emergency Interventions

O2 therapy Prepare for chest tube insertion Start IV lines Prepare for STAT portable CXR Prepare for intubation for flail chest Monitor for arrhythmias

Pathophysiology

Hypoxia Hypovolemia Pulmonary ventilation/perfusion mismatch Changes in intrathoracic pressure

relationships Respiratory acidosis, Hypercarbia Metabolic acidosis

Flail Chest

Complication of blunt trauma, 2 or more ribs next to each other are broken in half

Inward movement of thorax during inspiration and outward during expiration

Fractured ribs Fractured sternum-blunt deceleration May occur after CPR

Flail Chest Assessment

Chest wall is unstable and leads to repiratory distress, dyspnea, anxiety

Breath sounds diminished and crackles may be heard

Hypoventilation and hypoxemia Hypotension/ inadequate tissue perfusion and

metabolic acidosis—shock Pain assessment

Management of Flail Chest

Depending on the amount of distressMild-moderate: Humidified O2 Pain management Promotion of lung expansion through DB and positioningSevere: Mechanical ventilation IV hydration Monitor ABGs, pulse ox, pain management Psychosocial support

Pulmonary Contusion

Due to blunt trauma-potentially lethal

Damage leading to lung tissue hemorrhage and local edema

Damage to the lung leads to leakage of serum proteins and plasma

Increased oncotic pressure pulls fluid into lungs…. Results in hypoxemia and CO2 retention

May not be evident for 12-24hrs

S&S of Pulmonary Contusion

MILD Tachypnea Tachycardia Pleuritic chest pain Hypoxemia Blood tinged sputum

SEVERE Tachypnea Tachycardia Severe hypoxemia Crackles Respiratory acidosis Mental changes

Management of Pulmonary Contusion CXR for diagnosis Insure adequate ventilation Maintain airway: O2,chest PT, postural drainage, suctioning, Intubation and mechanical ventilation with PEEP for severe

symptoms I&O adequate hydration and prevention of overload Pain management NG tube Antibiotics Extensive damage can lead to ARDS

Diaphragmatic Rupture

Herniation of the abdominal viscera into the chest

Most often occurs on left side

S&S Diaphragmatic Rupture

Dyspnea Cyanosis Dysphagia Sharp shoulder pain Bowel sounds in lower to middle chest Decreased breath sounds

Management

Maintain adequate oxygenation with endotracheal tube placement and mechanical ventilation

NGT Immediate surgical repair

Acute Respiratory Failure

Pressure of arterial oxygen < 60 mm Hg Pressure of arterial carbon dioxide > 50 mm

Hg pH < 7.30 O2 sats < 90% Ventilatory failure, oxygenation failure, or a

combination of both ventilatory and oxygenation failure

Mortality rate is 50-60%

Acute Respiratory FailureClassification

1.Ventilatory Failure-perfusion is normal but ventilation is inadequate

Causes: extrapulmonary

intrapulmonary

2.Oxygenation Failure

3. Combined Ventilatory and Oxygenation Failure

Ventilatory Failure Type of mismatch in which perfusion is

normal but ventilation is inadequate Thoracic pressure insufficiently changed

to permit air movement into and out of the lungs

Mechanical abnormality of the lungs or chest wall

Defect in the brain’s respiratory control center

Impaired ventilatory muscle function

Causes of Ventilatory Failure

Decreased respiratory drive

Brain disorders

Dysfunction of the chest wall

Oxygenation Failure

Thoracic pressure changes are normal, and air moves in and out without difficulty, but does not oxygenate the pulmonary blood sufficiently.

Ventilation is normal but lung perfusion is decreased.

Causes of Oxygenation Failure

Dysfunction of the lung parenchyma, conditions of the lung that interfere with ventilation by preventing expansion of the lung

Pain-restricting chest movement Ascites Upper airway obstruction

Combined Ventilatory and Oxygenation Failure Hypoventilation involves poor

respiratory movements. Gas exchange at the alveolar-capillary

membrane is inadequate—too little oxygen reaches the blood and carbon dioxide is retained.

Causes of Ventilation/Oxygenation Failure CAL Cardiac failure- can’t reverse hypoxia by

increasing CO

Dyspnea Encourage deep breathing exercises. Assess for:

Perceived difficulty breathingOrthopnea: client finds it easier to breathe

when in upright positionOxygenPosition of comfortEnergy-conserving measuresPulmonary drugs

Assessment of ARF

HYPOXEMIA Dyspnea Tachypnea Cyanosis Restlessness Apprehension Confusion Impaired judgement Tachycardia Dysrhythmias Hypertension

HYPERCAPNIA Dyspnea Respiratory depression Headache Pailedema Tachycardia Hypertension Drowsiness Coma Heart failure

Management of ARF

GOALS: treat the underlying cause and restore adequate gas exchange

Keep O2 >60% C&DB, respiratory tx Prevent complications of immobility Monitor ABGs and pulse Ox Maintain endotracheal intubation and mechanical

ventilation Relaxation techniques Energy conserving measures

ARDSAcute Respiratory Distress SyndromeOther names-wet lung, shock lungForm of acute respiratory failurePathophysiology is complex and not clearly understoodAcute respiratory failure occurs 1-96hrs after a pulmonary or non

pulmonary eventChemical mediators and endotoxins are released by the body

which cause increased capillary permeability and pansystemic microvascular injury

Alveoli fill with RBCs, neutrophils and protein-rich fluid which impairs perfusion and damages surfactant

Decreased surfactantBlood in capillaries pass damaged alveoli “shunting”Hypoxemia not responsive to O2 tx

Acute Respiratory Distress Syndrome Refractory Hypoxemia that persists even

when oxygen is administered at 100% Severe dyspnea, with air hunger, retractions

and cyanosis. Works at breathing Noncardiac-associated bilateral pulmonary

edema Dense pulmonary infiltrates seen on x-ray Decreased lung compliance (stiff lung)

Causes of Lung Injury in Acute Respiratory Distress Syndrome Systemic inflammatory response is the

common pathway. Intrinsically the alveolar-capillary membrane is

injured from conditions such as sepsis and shock.

Extrinsically the alveolar-capillary membrane is injured from conditions such as aspiration or inhalation injury.

“Leaky capillaries”- increased permeability leads to alveolar flooding and collapse

Common Causes Of ARDSDamage directly or indirectly to the Lung Shock, trauma Cardiopulmonary bypass Serious nerve injury Pancreatitis Fat and amniotic fluid emboli Pulmonary infections Sepsis and multi-system failure (30-40% mortality) Inhalation of toxic gases Pulmonary aspiration Drug ingestion (opioids, heroin, ASA) Hemolytic disorders Multiple transfusions Near drowning

Diagnostic Assessment

Severely impaired gas exchange Lower PaO2 value on arterial blood gas <60mm/Hg PaCo2 over 45mm/Hg Poor response to refractory hypoxemia Ground-glass appearance to chest x-ray No cardiac involvement on ECG Low to normal PCWP PFTs to determine decreased lung compliance Normal Swan-Ganz pressures

Treatment Goals

Prompt recognition and tx Optimize gas exchange Maintain tissue perfusion and cardiac

output Manage underlying pathology Adequate fluid and nutrional support

Medical Management

Endotracheal intubation and mechanical ventilation (PEEP, CPAP)

Monitor for complications of PEEP Neuromuscular blocking drugs Sedation Corticosteroids Antibiotics Fluid volume Induced diuresis TPN or enteral feedings Prone position prn Surfactant and nitrous oxide NSAIDS

Phase I

Dyspnea and Tachypnea

Tx Support

Provide O2

Phase II Interventions Increasing Pulmonary Edema Endotracheal intubation and

mechanical ventilation with positive end-expiratory pressure or continuous positive airway pressure

Drug therapy Nutrition therapy; fluid therapy

Phase III

Occurs over 2-10 days Progressive hypoxemia not responsive to

high levels O2 Support failing lung until it can heal

Phase IV

Occurs after 10 days Pulmonary fibrosis- irreversible Late or chronic ARDS Goals: To prevent sepsis, PN, MODS May require long term ventilation

Mechanical VentilationIndications Airway protection when the pt loses reflexes To provide positive pressure or high O2

concentration To bypass airway obstruction Facilitating pulmonary hygiene and

suctioning of secretions when the client can’t handle secretions

Mechanical Ventilation Requires Endotracheal Intubation

“Artificial Airway”

Components of the endotracheal tube Preparation for intubation Verifying tube placement Stabilizing the tube Nursing care

Mechanical Ventilation

Types of ventilators:Negative-pressure ventilatorsPositive-pressure ventilators

1.Pressure-cycled ventilators 2.Time-cycled ventilators

3.Microprocessor ventilators

4.Volume-cycled (most common)

Modes of Ventilation

How the machine will ventilate the patient in relation to the pts own repiratory efforts

The ways in which the client receives breath from the ventilator include: Assist-control ventilation (AC) Synchronized intermittent mandatory ventilation

(SIMV) Bi-level positive airway pressure (BiPAP), CPAP

and others

Ventilator Settings

Settings are adjusted towards pt needs and include:

Mode of ventilation Tidal Volume- Normal 7-10ml/kg FiO2- 21%-100% Rate- breaths per minute Sighs- increases air 1.5-2x Specialized delivery modes: CPAP or PEEP PEEP is used if FiO2 is>50%

Nursing Management

First concern is for the client; second for the ventilator.

Monitor and evaluate response to the ventilator.

Manage the ventilator system safely. Prevent complications.

Nursing Management:

Monitor/evaluate response to ventilation

Monitor respiratory patterns and lung sounds Does pt assist/buck vent Assess airway tubes frequently, minimal leak

technique BP and HR CXR, observe for SQ emphysema ABGs/Pulse ox Plan methods for communication Sedation/anti-anxiety meds as needed Observe for ICU psychosis

Nursing Management:

Manage the ventilator system safely

Monitor ventilator settings Suction prn- preoxygenate, when?/ Provide humidification Check alarms-always have alarms

activiated Remove condensation in tubing

Nursing Management:

PreventComplications Complications can include:

PulmonaryCardiacGastrointestinal and nutritional

Infection Muscular complications Ventilator dependence Inadvertant Extubation

Complications

Ventilator associated PN: Elevation of HOB 30-45 degrees Daily sedation “vacation” and

assessment for readiness to wean Peptic ulcer prophylaxis DVT prophylaxis

ComplicationsMalnutrition is major reason why pts cannot be

weaned Nutrition: daily weights maintain TF or TPN

GI Bleed- stress ulcer preventionNose, lip, trachea problemsDecreased saliva and mouth ulcersBarotrauma-hypoxemia,crepitus,no breath soundsPneumothoraxVentilator dependence

Troubleshooting the VentCHECK PT FIRSTDO NOT IGNORE ALARMS

HIGH PRESSURE ALARM

1.pt needs to be suctioned

2.pt bucking/fighting the vent

3.displacement of ET tube

4.pt coughing when machine gives breath

5.water in the tubing

Troubleshooting

LOW PRESSURE ALARM

1. Leak-in the system

2. Disconnected tubing

Weaning From A VentilatorGOAL: SPONTANEOUS BREATHING

Factors related to weaning: 1. Pre-existing lung condition 2. Duration of mechanical ventilation 3. Pt physical and psychological condition

Short term vs long term

Weaning From A Ventilator

Ability to sustain spontaneous ventilation Monitor for respiratory distress Position to facilitate breathing Energy conservation-assist with care Avoid sedatives and respiratory

depressant meds

The Big Moment Has ArrivedEXTUBATION TIME Explain procedure Have O2 available Suction ET/oral Deflate cuff Have pt cough while tube is pulled Assess for respiratory fatigue and

obstruction Assess voice/sore throat

ABG Interpretation

What is acidosis??? What is alkalosis???Let’s look at: pH acidotic or alkalotic? PaO2 PaCO2 HCO3 O2 Saturation Remember ROME !

ABG Normal Ranges

pH 7.35-7.45

PaCO2 35-45 mm Hg

PaO2 80-100 mm Hg

SaO2 95%-100%

HCO3 22-26 mEq/L

Acid/Base MnemonicRemember ROME

R Respiratory O Opposite

pH up PCO2 down = Alkalosis pH down PCO2 up = Acidosis

M Metabolic E Equal

pH up HCO3 up = Alkalosis pH down HCO3 down = Acidosis

NCLEX Time

Of the following clients, which would be appropriate to assign to an LPN?

A.A 20-year-old man on a ventilator with a history of tension pneumothorax and currently awaiting transport to another hospital

B.A 59-year-old postoperative woman with a history of pulmonary embolism who is receiving subcutaneous heparin

C.A 65-year-old woman with acute respiratory distress syndrome who is on a ventilator and has a history of gastrointestinal bleeding

D.An 80-year-old man with a history of cancer of the larynx who is receiving CPAP ventilation through his tracheostomy

NCLEX Time

Of the following orders which would the nurse do first on a client who was intubated 30 minutes ago for acute respiratory distress syndrome?

A.Hang Levaquin 500 mg IV and D5 ½ normal saline.B.Obtain aerobic and anaerobic sputum culture.C.Increase ventilator rate as needed to keep between

16 and 20 breaths/min.D.Obtain arterial blood gases (ABGs) and pulmonary

wedge pressure via the arterial line.

NCLEX Time

Of the following tasks, which is appropriate to delegate to a new graduate nurse working with you?

A.Assessing respiratory system on a ventilated client with a history of barotrauma

B.Telephoning the cardiologist regarding a client you have just assessed who is complaining of shortness of breath and has noted ST depression

C.Administering Plavix to a client with a pulmonary embolism and paraplegia secondary to a spinal cord injury

D.Stripping the chest tube on a client with a left hemothorax from a motor vehicle collision sustained 12 hours earlier

NCLEX Time

Which of the following patients need immediate attention?

A.The 89-year-old male ventilated patient intermittently coughing

B.The 74-year-old female ventilated patient with noted tracheal deviation

C.The 57-year-old male patient recently extubated and complaining of a sore throat

D.The 40-year-old woman on BiPAP for asthma and with increased anxiety

NCLEX Time

Which of the following clients should the medical-surgical nurse consider transferring to the intensive care unit?

A.The 75-year-old client with a diagnosed pulmonary embolism who is receiving heparin and who currently is experiencing hemoptysis

B.The 63-year-old client with deep vein thrombosis receiving low–molecular-weight heparin and who has no calf pain

C.The 59-year-old client with a right pneumothorax currently being treated with a chest tube and oximetry of 96% on room air

D.The 30-year-old client with a history of being intubated 3 days ago and is currently on nasal cannula oxygen with clear lung sounds bilaterally

NCLEX Time

After starting oxygen 40% by face mask to a client with respiratory failure, an arterial blood gas is obtained. Which change would require immediate attention?

A.pH changes from 7.37 to 7.32

B.PaO2 increases from 56 to 60

C.PaCO2 increases from 47 to 55

D.O2 Sat remains at 88%