Pulmonary disorders

1
Pulmonary disorders
2
Acute Respiratory Failure

• Medical Management
• Non-Invasive Ventilation
• CPAP or BI-PAP (Face or Nasal Mask)
• Invasive Mechanical Ventilation
• Endotracheal tube, nasotracheal tube, or
  tracheostomy
• Initial ventilator settings individualized for
• patient size and severity of respiratory failure

3
Acute Respiratory Failure

• Nursing Management
• Positioning
• Position patient to best match ventilation /
  perfusion

4
Acute Respiratory Failure

• Nursing Management
• Preventing Desaturation
• Procedures only when needed
• Hyperoxygenate before suction
• Provide rest and recovery time
• Minimize oxygen consumption
• Sedation to control anxiety
• Control fever
• Continuous pulse oximetry monitoring

5
Acute Respiratory Failure

• Nursing Management
• Promoting Secretion Clearance
• Systemic hydration
• Humidifying supplemental oxygen
• Suctioning
• Postural drainage, turn at least every 2 hours
• When extubated coughing to remove secretions
• Chest auscultation and assessment

6
Acute RespiratoryDistress Syndrome (ARDS)

• Description
• Acute in onset
• Ratio of PaO2 / FIO2 equal to or below 200 mm Hg
• Example
• PaO2 of 80 mm Hg receiving 70 (0.7) O2
• 80 divided by 0.7 114 mm Hg
• Bilateral infiltrates on chest x-ray
• PAWP less or equal to 18 mm Hg

7
Acute Respiratory Distress Syndrome (ARDS)

• Etiology
• Direct Injury
• Indirect Injury

Box 21-3 on page 556
8
Acute Respiratory Distress Syndrome (ARDS)

• Pathophysiology
• Exudative Phase
• 24 hours after onset
• Increased capillary membrane permeability
• Leaking protein-rich fluid into pulmonary
  interstitium
• Pulmonary lymphatics are overwhelmed
• Fluid now forced into alveoli
• Alveolar edema

Figure 21-1 on page 557
9
Acute Respiratory Distress Syndrome (ARDS)

• Pathophysiology
• Proliferative Phase
• 7 to 10 days after onset (may last for up to a
  month)
• Disordered healing in the lungs
• Impaired surfactant production and alveolar
  collapse
• Hypoxemia from intra-pulmonary shunting
• Decreased functional residual capacity (FRC)
• Increased work of breathing and fatigue
• Increased alveolar dead space

10
Acute Respiratory Distress Syndrome (ARDS)

• Pathophysiology
• Fibrotic Phase
• 2 to 3 weeks later
• Pulmonary fibrosis develops
• Structural changes in alveoli and vessels
• Survival from ARDS is directly related to absence
  of other organ complications and sepsis

Table 21-3 on page 558
11
Acute Respiratory Distress Syndrome (ARDS)

• Medical Management
• Oxygen Therapy
• Lowest level possible to maintain saturation gt
  90
• FIO2 preferably lt 65 (0.65)
• Positive End-Expiratory Pressure (PEEP)
• Purpose is to open alveoli and decrease FIO2
  levels
• Generally PEEP 10 - 15 cm H2O
• If PEEP too high it over-distends alveoli
• If PEEP too low alveoli collapse during expiration

12
Acute Respiratory Distress Syndrome (ARDS)

• Medical Management
• Ventilation
• Assist Control or SIMV (traditional methods)
• Permissive Hypercapnia
• Smaller tidal volumes (5 - 8 ml/kg)

13
Acute Respiratory Distress Syndrome (ARDS)

• Nursing Management
• Optimizing oxygenation and ventilation
• Providing comfort and emotional support
• Awareness of potential complications
• Airway clearance
• Positioning Prone and other positions

Nursing Diagnoses Box 21-4 on page 560
14
Pulmonary Embolism (PE)

• Description
• Clot (thrombotic emboli) or other embolic matter
  (fat or other material) lodges in the pulmonary
  artery or pulmonary arterioles and disrupts
  blood flow to a region of lungs.

15
Pulmonary Embolism (PE)

• Etiology
• Hypercoagulability
• Venous stasis
• Injury to vascular endothelium
• Collectively known as Virchows triad

16
Pulmonary Embolism (PE)

• Pathophysiology
• Massive PE
• Greater than 40 pulmonary vascular bed occluded
• Increased Dead Space
• Area of lung receives ventilation without
  perfusion
• -- Shunting
• Unaffected areas of pulmonary arterial
  circulation receive entire cardiac output, cant
  oxygenate all

17
Pulmonary Embolism (PE)

• Pathophysiology
• Bronchoconstriction
• Multifactorial
• Hemodynamic Consequences
• Pulmonary vascular hypertension
• Pulmonary vascular constriction
• Increased right ventricular workload
• Decreased left ventricular output, decreased BP,
  shock

18
Pulmonary Embolism (PE)

• Assessment and Diagnosis
• Clinical presentation and symptoms
• V/Q scan
• -- CT scan
• Pulmonary angiogram
• Lower extremity DVT studies
• Arterial blood gases (ABG)

19
Pulmonary Embolism (PE)

• Medical Management
• Prevention Strategies
• Prophylactic anticoagulation
• Graduated compression stockings
• Intermittent pneumatic compression

20
Pulmonary Embolism (PE)

• Medical Management
• Treatment Strategies
• Filter
• Thrombolytic therapy
• Anticoagulation
• Heparin
• Warfarin (Coumadin)
• Coagulation studies
• PTT to monitor heparin
• INR to monitor warfarin (Coumadin)

21
Pulmonary Embolism (PE)

• PE Question
• What is the difference between anticoagulants
  and thrombolytics?

22
Pulmonary Embolism (PE)

• PE Question
• What is the difference between anticoagulants
  and thrombolytics?
• PE Answer
• Anticoagulants stop blood from clotting. They do
  not dissolve existing blood clots.
• Thrombolytics dissolve existing blood clots.

23
Pulmonary Embolism (PE)

• Nursing Management
• Prevention of PE - always in focus
• Recognition of at risk patients for DVT and PE
• Anti-embolic stockings
• Intermittent pneumatic compression devices
• Range of motion
• Adequate hydration
• Monitor coagulation profile, anticoagulants,
  bleeding
• Patient education

Box 21-11 on page 568
24
Air Leak Disorders

• Description
• Conditions that result in extra-alveolar air
  accumulation
• Pneumothorax
• Air in the pleural space
• Volutrauma
• Air in the lung interstitial space

25
Air Leak Disorders

• Etiology
• Disruption of the parietal or visceral pleura
• Formation of gas within the pleural space as a
  result of an infectious process
• Rupture of alveoli allowing air to escape into
  the pleural space

26
Air Leak Disorders

• Medical Management
• Pneumothorax lt 15
• No interventions are needed
• Pneumothorax gt 15
• Requires evacuation of air from pleural space
• Decompression with a needle
• Heimlich valve
• Chest tube

27
Air Leak Disorders

• Emergency Medical Management
• Tension Pneumothorax
• Chest tube insertion

28
Air Leak Disorders

• Nursing Management
• Optimize oxygenation and ventilation
• Managing the chest tube system
• Monitor suction applied to system
• Avoid kinks
• Avoid long loops of tubing
• Evaluate for air leak and if present, determine
  if air leak is from patient or from a break in
  the system

Figure 21-4 on page 573
29
Air Leak Disorders

• Emergency Nursing Management
• If the chest tube tubing becomes disconnected
• Place tube from patient into a few centimeters of
  sterile water (creates underwater seal
  protection)
• If the chest tube falls out of the chest
• Apply sterile petroleum gauze to opening and
  monitor patients respiratory status