Interferences with Ventilation Objectives

1
Interferences with VentilationObjectives

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

2
Interferences with VentilationRestrictive /
Obstructive Airway Disease

• Restrictive Disorders
• Decreased compliance of the lungs or chest wall
  or both
• Extrapulmonary CNS, Neuromuscular, Chest Wall
• Intrapulmonary Pleural, Parenchymal
• Obstructive Disorders
• Increased resistance to airflow
• Asthma, Emphysema, Chronic Bronchitis, COPD

3
Obstructive Sleep Apnea (OSA)
4
Obstructive Sleep Apnea (OSA)

• 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 nCPAP / BiPAP
• nCPAP continuous airway pressure 5-15 cm
  H2O pressure
• BiPAP bilevel airway pressure delivers
  higher pressure during inspiration lower
  pressure during expiration
• Surgery

5
Pathophysiology of Chronic Airflow Limitation
6
Interferences with VentilationAsthma

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

7
Respiratory System DrugsAsthma

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

8
Interferences with VentilationAsthma

• Triggers of Asthma Attacks
• Allergens
• Exercise
• Respiratory Infections
• Nose sinus problems
• Drugs and food additives
• Gastroesophageal reflux disease (GERD)
• Emotional Stress

9
Interferences with VentilationAsthma -
Pathophysiology

• Hallmarks of Asthma
• Airway inflammation nonspecific
  hyperirritability
• Early phase
• Characterized by bronchospasm
• Induces inflammatory sequelae of the late phase
  response
• Allergen or irritant cross-links IgE receptors on
  mast cells beneath the basement membrane of the
  bronchial wall
• OR
• Hyperresponsiveness of the tracheobronchial tree
• Caused by bronchoconstriction in response to
  physical, chemical and pharmacological agents

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Early Late Responses in Asthma
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Classification of Asthma Severity
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Pathophysiology of Acute Asthma Attack
13
Stepwise Approach for Managing Asthma
14
Interferences with VentilationAsthma Medication
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Interferences with VentilationAsthma - Medication
16
Drug Therapy Asthma COPD
17
Drug Therapy Asthma COPD
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How to Use Metered-Dose Inhaler
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Metered-Dose Inhaler
20
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?  
• A. Tachycardia and nervousness
• B. Nasal congestion and dry mouth
• C. Sedation and lethargy
• D. Joint pain and unstable gait

21
Pair Share

• When exercising, a client with asthma should be
  taught to monitor for which of the following
  problems?
• 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?

22
Status Asthmaticus

• Severe, life-threatening asthma attack
• 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

23
Status Asthmaticus

• Clinical Manifestations
• Wheezing, forced exhalation, neck vein
  distention, HTN, sinus tachycardia, ventricular
  dysrhythmias
• Initial hypoxemia hypocapnia
• Late hypoxemia hypercapnia
• Medical Management
• Medications Corticosteroids, B2-adrenergic
  agonists via MDI, IV Aminophylline
• Hydration
• Oxygen Humidified Intubation/Mechanical
  Ventilation 10 of the time

24
Chronic Obstructive Lung Disease Chronic
Bronchitis

• 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
• Hx of cigarette smoking for many years
• Hypoxemia Hypercapnia result from
  hypoventilation
• Bluish-red color of skin
• Polycythemia bodys attempt to compensate for
  chronic hypoxemia by increasing production of red
  blood cells

25
Chronic Obstructive Lung Disease Chronic
Bronchitis

• 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

26
Chronic Obstructive Lung Disease Chronic
Bronchitis

• 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 PaCO2, and
  increased
• PaO2
• 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

27
Chronic Obstructive Lung Disease Emphysema

• Abnormal permanent enlargement of the airspaces
  distal to the terminal bronchioles, accompanied
  by destruction of their walls and without obvious
  fibrosis
• Risk Factors
• Cigarette Smoking
• Irritation - gt 4,000 chemicals inhaled
• Hyperplasia reduces airway diameter
• Abnormal dilatation of distal airspaces
• Destruction of alveolar walls

28
Chronic Obstructive Lung Disease Emphysema

• Risk Factors (contd)
• Recurring respiratory tract infections
• H. flu, Strep pneumoniae, Moraxella catarrhalis
• Heredity alpha 1 Antitrypsin (ATT) deficiency
• Accounts for lt1 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
• Gradual loss of elastic recoil thin alveolar
  wall thoracic cage changes from osteoporosis
  calcification

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Comparison of Emphysema Chronic Bronchitis
Alveolar Problem
Airway Problem
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COPDPulmonary Blebs Bullae
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COPD -- Interaction of Chronic Bronchitis
Emphysema
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Pathophysiology of Chronic Bronchitis and
Emphysema
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Interferences with VentilationMedical Management
Goals

• 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

34
Interferences with VentilationMedical Treatment

• Patients are treated primarily as outpatients
• Hospitalizations
• Acute exacerbations
• Complications
• Respiratory failure, pneumonia, congestive heart
  failure

35
Interferences with VentilationCOPD

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

36
Interferences with VentilationCOPD

• 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

37
Interferences with VentilationMedical Management

• Smoking cessation
• Treatment of respiratory infections
• Bronchodilator therapy
• Beta2-adrenergic agonists
• Anticholinergic agents
• Long-acting theophylline
• Corticosteroids
• PEFR monitoring (peak expiratory flow rate)
• Chest physiotherapy / Breathing exercises
  retraining
• Hydration 3L/day (unless contraindicated)
• Rest - Progressive plan of exercise
• Patient family education
• Influenza / Pneumovax immunization
• Low flow oxygen rate (if indicated)
• Pulmonary rehabilitation program

38
Interference with VentilationOxygen Therapy

• Indications
• Treat Respiratory CV CNS disturbances
• Oxygen Administration High or low flow systems
• High Flow delivers fixed concentrations
  independent of the patients respiratory pattern
• Venturi Mask up to 50
• Low Flow amount delivered varies with patients
  respiratory pattern
• Nasal cannula 2L/min 28 oxygen
• Face tent or trach collar Increased humidity
• Non-re-breathing mask delivers 60-90
• Humidity
• 1-4L low flow use of bubble-through
  controversial
• Nebulized

39
Interferences with VentilationOxygen Therapy-
Complications

• CO2 Narcosis
• two chemoreceptors O2 CO2
• CO2 accumulation major stimulus
• COPD patient
• Develops tolerance to high CO2
• Respiratory Center loses sensitivity to elevated
  CO2
• O2 Drive Hypoxemia
• Concern about administering O2 to COPD patients
  ??
• Bigger Concern not providing adequate O2
• Goal Titrate O2 to the lowest effective dose
  based on arterial blood gas monitoring

40
Interferences with VentilationOxygen Therapy-
Complications

• O2 Toxicity
• Prolonged exposure to high level O2
• Determined by patient tolerance, exposure time,
  and effective dose
• High level Manifestations
• Initial -- Inactivate surfactant and lead to ARDS
  reduced vital capacity, cough, substernal
  chest pain, NV, paresthesia, nasal stuffiness,
  sore throat, malaise
• Later affects alveolar-capillary gas exchange
  pulmonary edema with copious sputum
• End Stage lung fibrosis
• O2 Administration Goal enough O2 to maintain
  PaO2 within normal or acceptable limit
• O2 administration gt 50 for gt 24 hours
  potentially toxic

41
Chronic Obstructive Lung Disease Complications
42
Pair Share

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

43
Nursing Care ManagementIneffective airway
clearance

• Assess Normal breath sounds effective coughing
• Nsg Action Elevate head of bed sitting up
  hydration 2-3L/d chest physiotherapy Meds
  inhaled bronchodilators
• Pt Education Effective breathing coughing
  techniques Medications administration

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Chest PercussionCupped Hand Technique
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Chest Physiotherapy
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Postural Drainage
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Nursing Care ManagementImpaired Gas Exchange

• Assess Mental status VS with Pulse oximetry
  ABGs
• Nsg Action Position Tripod-supported
  extremities Administer O2 to effective level
• Pt Education Pursed-lip breathing signs,
  symptoms consequences of hypercapnia avoidance
  of CNS depressants Medication action smoking
  cessation

48
Orthopnea Positions to Decrease the Work of
Breathing
49
Nursing Care ManagementImbalanced Nutrition

• Assess
• 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
• Nsg Action
• Hi PRO, HI Calorie foods liquid supplements
  small frequent feedings periods of rest after
  food intake Referralfinancial nutritional
  support (Meals-on-wheels food stamps)
• Pt Education
• Referrals / Importance of rest / digestion / high
  protein calorie foods menu planning

50
Nursing Care ManagementDisturbed Sleep Pattern

• Assess
• Identify usual patterns explore reasons for
  discomfort, wakefulness, or difficulty sleeping
  sleep apnea
• Nsg Action
• Identify pt-specific relaxation methods
  environment conducive to rest
• Pt Education
• Balance activity (ADLs) / rest avoidance of
  alcoholic beverages, caffeine products, other
  stimulants before bedtime include family sexual
  activitypositions of comfort psychosocial issues

51
Nursing Care ManagementRisk for Infection

• Assess
• 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
• Nsg Action
• Humidification specimen collection medication
  administration
• Pt Education
• Hand-washing avoid contact with infected
  individuals care cleaning of home respiratory
  equipment when to seek medical attention
  steroid use medication use

52
Breathing Exercises
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Pair Share

• 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 clients 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