Respiratory Care: Airway Management & Gas Exchange

• Respiratory patients often require frequent suctioning to maintain a clear airway, especially those on ventilators in the ICU.

Maintaining a Patent Airway

• Registered Nurses (RNs) and Respiratory Therapists handle suctioning.
• Respiratory therapists typically perform deeper suctioning.
• Secretions must be removed via frequent suctioning to ensure a clear airway.
• Deep suctioning is needed to clear secretions from the lower respiratory tract.

Promoting Gas Exchange

• Frequent position changes improve gas exchange.
• Proning (placing the patient on their stomach) can benefit some respiratory patients.
• A quiet environment promotes rest and reduces stress, improving gas exchange.
• Regularly monitor breath sounds to assess lung function and detect changes.
• Frequent oral care prevents infections and maintains a healthy airway.

Monitoring Vital Signs

• Cardiac monitors are often used to track heart rhythm in respiratory patients.
• Positive End-Expiratory Pressure (PEEP) is a mechanical ventilation method that keeps alveoli open during expiration.
• Closely monitor condition; even small changes can be significant.
• Any signs of deterioration should be reported immediately.

Chronic Obstructive Pulmonary Disease (COPD)

• COPD is a progressive and irreversible lung disease causing airflow limitation.
• COPD encompasses both emphysema and chronic bronchitis.
• COPD is characterized by a chronic limitation of airflow in the bronchioles.
• It is a progressive disease that worsens over time and cannot be reversed.
• COPD results in decreased inspiratory and expiratory lung capacity.
• COPD obstructs airflow to and from the bronchioles.

Emphysema

• Emphysema is a COPD type involving alveoli destruction, leading to air trapping and decreased lung function.
• Patients with emphysema are often called "pink puffers" due to their reddish skin color from increased CO2 retention.
• Emphysema patients often have tachycardia (rapid heart rate) and tachypnea (rapid breathing).
• As emphysema progresses, patients may produce copious mucus.
• Patients with emphysema often find it easier to breathe in an orthopnic (upright) position.
• Pursed-lip breathing helps patients with emphysema exhale more effectively.
• Emphysema is characterized by permanent alveolar enlargement, trapping air during expiration.
• Alveolar rupture and scarring can occur, further reducing lung function.
• Emphysema leads to decreased oxygen and increased carbon dioxide levels in the blood.
• Smoking is a major cause of emphysema and worsens the condition.
• Significant weight loss may occur due to the increased work of breathing.
• Expiration is prolonged as patients struggle to push air out of their lungs.
• As emphysema progresses, patients may have dyspnea (shortness of breath) even at rest.

Clinical Manifestations of Emphysema

• Patients may develop a barrel chest due to air trapping.
• Exertional dyspnea (shortness of breath with exertion) is a common symptom.
• Patients are easily fatigued due to the increased work of breathing.
• Anxiety is common due to breathing difficulty.
• Accessory muscles may be used to help breathe.
• Clubbing (widening of fingertips) can occur due to chronic hypoxia.
• Cor pulmonale is a complication involving right ventricle hypertrophy due to high pulmonary circulation pressure.
• Edema may develop in lower extremities, sacral area, and perineum in patients with cor pulmonale.
• Distended neck veins are another sign of cor pulmonale.
• An enlarged liver can occur in patients with cor pulmonale.
• Ascites (fluid buildup in the abdomen) can also develop.

Diagnosing Emphysema

• Pulmonary function tests measure lung capacity and airflow.
• Pulmonary function tests show decreased lung capacity.
• Patients have increased residual volume, indicating trapped air.
• Arterial Blood Gases (ABGs) measure oxygen and carbon dioxide levels.
• ABGs show respiratory acidosis due to elevated CO2 levels.
• A chest x-ray can show hyperinflation of the lungs.
• A Complete Blood Count (CBC) may show elevated red blood cell count and hematocrit due to polycythemia.
• Polycythemia is an increase in red blood cells, occurring as a compensatory mechanism for chronic hypoxia.

Managing Emphysema

• Smoking cessation is crucial.
• Patients may require home oxygen therapy.
• Deep breathing exercises and incentive spirometry improve lung function.
• Bronchodilators help open airways.
• Controlled breathing and coughing techniques help clear airways.
• Pursed-lip breathing helps exhale air more effectively.
• Chest physiotherapy helps loosen and remove mucus.
• Corticosteroids reduce inflammation during COPD exacerbations.
• Antibiotics treat infections during COPD exacerbations.
• Diuretics may reduce fluid buildup in patients with cor pulmonale.
• Elevating the head of the bed helps improve breathing.
• Mechanical ventilation may be required for severe exacerbations.
• Steroids should be tapered off gradually to prevent withdrawal symptoms.
• Steroid side effects include GI bleed, increased appetite, decreased immunity, and bone loss.
• Mucolytics and expectorants help thin and loosen mucus.
• Bronchodilator side effects include tachycardia, nervousness, and tremors.
• Oxygen flow rate should be limited to 1-2 liters per minute for COPD patients.
• High oxygen flow rates can suppress the respiratory drive in COPD patients.
• Respiratory depressants, such as opioids, should never be used.
• Daily exercise is important for maintaining lung function.

Chronic Bronchitis

• Chronic bronchitis is a COPD type characterized by inflammation and excessive mucus production in the bronchi.
• It involves chronic inflammation of the bronchi.
• Patients produce excessive mucus, leading to coughing and difficulty breathing.
• Patients are often called "blue bloaters" due to cyanotic appearance and fluid retention.

Emphysema - Continued

Positioning & Lifestyle

• Encourage patients to sit upright and lean forward with their head slightly elevated.
• Promote independence as much as possible.
• Avoid gas-forming foods in their diet.
• Provide small, frequent, high-calorie, high-protein meals.
• The rationale is patients with emphysema lose weight due to the effort required to breathe.
• Encourage patients to rest for at least 30 minutes before meals.
• Encourage forced fluids as tolerated, aiming for 2-3 liters per day.
• Drink fluids between meals to decrease gastric distension and pressure on the diaphragm.
• Frequent oral hygiene is essential.
• Minimize anxiety, as it can increase respiratory rate.
• Use a humidifier to provide moist, warm air.
• Encourage patients to perform deep breathing exercises at least every two hours.
• Suction as needed.
• Administer respiratory treatments as prescribed.
• Annual flu shot is recommended and the pneumococcal vaccine every 5 years.
• Assist with chest physiotherapy, including percussion, vibration, and postural drainage to loosen secretions.
• Organize care to allow for uninterrupted rest periods of at least 90 minutes.
• Encourage active range of motion exercises to increase stamina and prevent complications.
• Educate patients on the importance of avoiding excessive oxygen use, as it can be harmful.
• Teach patients to avoid crowds and people who are ill to prevent infection.

Chronic Bronchitis - Continued

• Chronic bronchitis is one component of COPD.
• Patients are often referred to as "blue bloaters" due to their cyanotic appearance.
• The cilia, hair-like projections that move mucus and secretions, are not functioning properly.
• The mucous glands hypertrophy and increase secretion, leading to excessive sputum production.
• Excess mucus gets trapped in the airways, obstructing airflow.
• Inflamed bronchi can scar, which is irreversible.
• Trapped mucus can become infected, leading to bronchospasm, hypoxia, and hypercapnia.
• Hypercapnia leads to acidosis.
• Pulmonary hypertension causes right heart hypertrophy.
• Cyanosis develops due to chronic hypoxia.
• Chronic hypoxia stimulates red blood cell production, leading to polycythemia (thick blood).
• Patients may experience dependent edema.
• A recurrent or chronic cough lasting more than three months per year for at least two years is a common symptom.
• Cigarette smoking and occupational exposure to lung irritants are major risk factors.
• Clinical manifestations: dusky to cyanotic color, recurrent cough with sputum production, hypoxia, hypercapnia, acidosis, edema, tachypnea, exertional dyspnea, increased incidence of smoking, cardiac enlargement, accessory muscle movement, cor pulmonale, and wheezing.
• Diagnosis: Chest x-ray, EKG, CBC (showing polycythemia and elevated hemoglobin), ABGs (showing respiratory acidosis), pulmonary function tests, and pulse oximetry.
• Patients often have a reddish-blue hue due to cyanosis.
• Poor ventilation and perfusion lead to hypoxia and cyanosis.
• Chronic hypoxia can cause clubbing of the fingers.
• Treatment: Bronchodilators, corticosteroids, mucolytics, and antibiotics (if infection is present).
• Encourage healthy lifestyle adaptations, including avoiding exposure to respiratory infections, dust, and other irritants, staying indoors during cold or wet weather, and avoiding strenuous activity.
• Low-flow oxygen therapy may be used to maintain oxygen saturation above 90%.
• Smoking cessation is crucial.
• Encourage forced fluids.
• Suction as needed.
• Good oral hygiene is essential.
• Provide periods of rest.
• Nutritional needs are similar to those of patients with emphysema.

Asthma

• Characterized by intermittent airway obstruction of sudden onset.
• Asthma attack triggers: allergens, (feathers, animal dander, foods, pollen, dust), physical fatigue, GERD, exercise, respiratory infections, altered immune response, stress, and emotional upset.
• Asthma attacks are often worse at night or in the early morning.
• Mild asthma: Dyspnea on exertion and wheezing that is controlled with medication.
• Acute asthma attack: Expiratory wheezes, acute respiratory distress, tachypnea, tachycardia, diaphoresis, nasal flaring, use of accessory muscles for breathing, anxiety, chest tightness, productive cough with copious thick mucus, and a hunched forward position.
• Diagnosis: Pulmonary function tests (spirometry, peak flow testing), ABGs, pulse oximetry, sputum culture, CBC (showing increased eosinophils), and Theophylline levels (if patient is on Theophylline).
• Treatment: Maintenance therapy and acute asthma attack therapy.
• Maintenance therapy: Leukotriene modifiers (Singulair), bronchodilators (Serevent, Foradil), inhaled steroids (Fluticasone), and Theophylline.
• Acute asthma attack therapy: Bronchodilators (Serevent, Foradil), inhaled steroids (Fluticasone), and Mast Cell stabilizers (Intal, Cromolyn).

Learn about airway management for respiratory patients, including suctioning techniques used by RNs and respiratory therapists. Discover how position changes, proning, and a quiet environment promote gas exchange. Understand the importance of monitoring vital signs and providing regular oral care.