Respiratory System & Oxygen Delivery: Nasal Cannula

Main Components of the Respiratory System

• Ventilation involves air moving from the atmosphere to the alveoli
• Diffusion refers to the exchange of O2 and CO2 across the alveolar capillary membrane
• Perfusion is blood flow through the cardiopulmonary system into the alveolar capillaries
• FiO2 denotes the percentage of oxygen delivered or the fraction of inspired oxygen
• Supplemental oxygen causes patients to have higher FiO2 than atmospheric air

Oxygen Delivery: Nasal Cannula

• Nasal cannulas are low-flow oxygen delivery devices
• Advantages:
  • Safe, simple, and inexpensive
  • Comfortable and decreases the risk of claustrophobia
  • Facilitates eating and drinking, and prevents CO2 rebreathing
  • Delivers a FiO2 of 24-44% at flow rates of 1-6 L/min
  • Humidification is needed if the flow rate is 3 L/min or higher
• Disadvantages:
  • Can cause dermatitis and nasal irritation
  • Easily dislodged
  • Suitable for flow rates less than 4 L/min
  • Not recommended for clients with nasal obstructions such as polyps and mucosal edema
  • Flow settings and breathing patterns determine oxygen concentrations, so FiO2 varies
  • Compared to a Venturi mask, it is less accurate
• Nursing Actions:
  • Assess the patency of the nares
  • Ensure proper fit of the prongs
  • Application water-soluble gel prevents dry nares

Oxygen Delivery: Simple Face Mask

• A simple face mask is a low-flow oxygen delivery device
• Advantages
  • Inexpensive and can be used on mouth breathers
  • Delivers FiO2 of 35-60% at flow rates of 5-10 L/min
  • A minimum flow rate of 5 L/min ensures CO2 flushing
• Disadvantages
  • May cause claustrophobia and is not recommended for those with CO2 retention risk
  • Rebreathing CO2 can occur if the flow rate is less than 5 L/min
  • Monitor clients who complain of nausea/vomiting or are at risk for aspiration/airway obstruction
  • Moisture and pressure under the mask can cause skin breakdown
• Nursing
  • Assess proper fit, ensuring a secure seal over the nose and mouth
  • Ensure clients wear nasal cannula during meals

Oxygen Delivery: Partial Rebreather Mask

• Partial rebreather masks are low-flow devices
• Advantages:
  • Covers the nose and mouth
  • Delivers FiO2 of 60-90% at flow rates of 10-15 L/min
  • A reservoir bag with no valve allows clients to rebreathe one third of exhaled air with room air
• Disadvantages:
  • CO2 buildup can occur if the reservoir bag deflates during inspiration
  • The client’s breathing pattern affects the FiO2
  • Not well-tolerated by clients with anxiety or claustrophobia
  • Eating, drinking, and talking is impaired
  • Caution is needed for clients with high risk of aspiration or airway obstruction
• Nursing
  • Adjust the oxygen flow rate to keep the reservoir bag from deflating
  • Assess proper fit, ensuring a secure seal over the nose and mouth
  • Assess skin breakdown beneath the edges of the mask and bridge of the nose
  • Ensure the client uses a nasal cannula during meals

Oxygen Delivery: Non-Rebreather Mask

• Non-rebreather masks are low flow devices
• Advantages:
  • Covers the clients nose and mouth
  • Delivers a FiO2 of 80-95% at flow rates of 10-15 L/min, keeping the reservoir ⅔ full during inspiration and expiration
  • Delivers the highest O2 concentration without intubation
  • A one-way valve is situated between the mask and the reservoir for maximum O2 inhalation, while exhalation ports with flaps prevent room air from entering
• Disadvantages:
  • The valve and flap on the mask must be intact and functional during each breath
  • Can be poorly tolerated by clients due to anxiety or claustrophobia
  • Eating, drinking, and talking is impaired
  • Administer cautiously in clients with high risk of aspiration or airway obstruction
• Nursing
  • Perform hourly assessments of the valve and flap to ensure patency and proper function
  • Ensure a secure seal over the nose and mouth
  • Assess for skin breakdown over the nose and face
  • Supplemental nasal cannula is needed during meals

Oxygen Delivery: Venturi Mask

• Venturi masks are high-flow devices
• Advantages:
  • Delivers a precise amount of O2
  • FiO2 ranges from 24-60% at flow rates of 10-15 L/min; adapters allow specific amounts of air to mix with oxygen
  • Venturi barrels exchanged to deliver various concentrations
  • Reduces rebreathing of exhaled air
  • It functions independently of client breathing factors and flow of oxygen
  • The oxygen concentration remains consistent even with changes in the flow rate
  • Delivers the most precise oxygen concentrations without intubation
  • Humidification is not required
  • Best for clients with chronic lung disease
• Disadvantages:
  • Can be expensive and noisy
  • May induce claustrophobia
  • Interferes with eating and drinking
• Nursing
  • Frequently assess the flow rate for accuracy
  • Ensure tubing isn't kinked
  • Routinely assess for skin breakdown, particularly around the nares
  • Supplemental nasal cannula is needed during meals

Oxygen Delivery: Aerosol Mask, Face Tent, Trach

• Aerosol masks, face tents, and trach masks are high-flow devices
• Face Tents
  • Fit loosely around the face and neck
• Trach Masks
  • Small mask covering a surgically created opening in the trachea
• Additional features
  • FiO2 24-100% at flow rates of at least 10 L/min
  • Offers high humidification along with oxygen delivery
• Advantages:
  • Useful for clients who don't tolerate masks well
  • Good for those with facial trauma, burns, or thick secretions
• Disadvantages:
  • Frequent monitoring is needed due to high humidification levels
• Nursing
  • Empty condensation from the tubing frequently
  • Ensure water is present in the humidification canister
  • Make sure aerosol mist exits from the vent port
  • Prevent the tubing from pulling of the trach

Acute Respiratory Failure (ARF)

• ARF is a sudden, life-threatening decline in gas exchange
• Hypoxemia management: Administer O2
• Hypercapnia considerations:
  • Address breathing issues and observe systemic/pulmonary blood vessel responses
  • Systemic blood vessels dilate, and pulmonary blood vessels constrict

Common Causes of ARF

• Ventilatory Failure: conditions such as COPD, pulmonary embolism, pneumothorax, flail chest, ARDS, neuro disorders( MS, GBS, spinal injuries, CVA, elevated ICP
• Oxygenation Failure: stems from pneumonia, hypoventilation, hypovolemic shock, pulmonary edema/embolism, low hemoglobin, low oxygen concentrations
• Combination Failure: results from a combination of ventilation and oxygenation issues
• Decreased Respiratory Drive: from TBI, CNS depressants, or metabolic disorders
• Chest Wall Dysfunction: due to trauma or neuromuscular/musculoskeletal disorders
• Dysfunction of Lung Parenchyma: from pleural effusion, hemo/pneumothorax, atelectasis, PNA, PE, COPD, ARDS
• Miscellaneous Causes: such as post-op hypoventilation from medications or pain

Impact of Diseased Lungs on ARF

• Diseased lungs trigger both ventilation and oxygenation issues
• Conditions including asthma, emphysema, and cystic fibrosis, affecting oxygenation and increasing the work of breathing
• Respiratory muscle fatigue leads to ventilatory failure
• Combined failure causes more profound hypoxemia
• ARF criteria based on ABG values

Clinical Manifestations and Nursing Care for ARF

• Early Signs: restlessness and fatigue, dyspnea, air hunger, mild tachycardia/tachypnea, increased BP
• Late Signs: confusion, lethargy, cyanosis, diaphoresis, respiratory arrest,
  • Central signs often indicate cardiac/pulmonary problems
  • Peripheral signs suggest circulation issues
• Implement a plan that includes assessments, lab testing, and diagnostics
• Assessments: physical, vital signs, monitoring SpO2, ABG interpretation
• Lab testing -ABGs to confirm and monitor -PaO2 less than 60 and Ox sats less than 90 on RA -PaCO2 greater than 50 and pH less than 7.35 (hypoxemia, hypercapnia)
• Diagnostics -Chest x ray --pulmonary edema, cardiomegaly -CT scan -Ecg to rule out cardiac involvement
• Maintain a patent airway and respiratory status hourly
• Track ECG alterations linked to hypoxemia
• Often requires mechanical ventilation with PEEP or CPAP; monitor for pneumothorax caused by high PEEP
• Administer oxygenation before suctioning; suction PRN
• Provide support required for intubation
• Communicate with the client and family

Medications - ARF

• Benzodiazepines
  • reduce anxiety, resistance to ventilation, and oxygen consumption
  • Nursing: Monitor respirations, blood pressure, SpO2, opioid conjunction
• Propofol
  • induces anesthesia and sedation
  • Nursing: --CI if hyperlipidemia or egg allergy --Slow drip to assess neuro status --Monitor for hypotension --Titrate to desired sedation, no analgesia
• Corticosteroids
  • reduce WBC migration and inflammation
    • Nursing: --decrease med gradually, administer antiulcer to prevent peptic ulcer --monitor weight/BP, glucose/electrolytes, take with food and don't stop suddenly
• Neuromuscular blocking agents
  • promotes ventilation and reduce oxygen consumption
  • used with painful vents
    • Nursing: --administer only to clients who are intubated and vented, --monitor ecg/bp/muscle strength

Acute Respiratory Distress Syndrome (ARDS)

• ARDS is a sudden and progressive pulmonary edema (non-cardiac)
• Increasing bilateral infiltrates on CXR
• Refractory hypoxemia
• Reduced lung compliance
• High mortality rates, which leads to multisystem organ failure
• ARDS is caused by tissue injury
  • Direct: injury to the lung parenchyma
  • Indirect:systematic injury that causes an inflammatory response, pancreatitis, sepsis, DIC, aspiration, pulmonary emboli, pna/pulmonary infections, CNS damage, smoke inhalation, drug ingestion, COVID

Initial Injury and Phases of ARDS

• Direct and indirect injuries trigger inflammatory-immune responses, leading to activation of neutrophils, macrophages, and platelets
• Chemical mediators damage the alveolo-capillary membrane
• Exudative Phase
  • Chemical mediators increase pulmonary capillary permeability, microthrombi, and pulmonary arterial pressure
  • Fluid (protein, blood cells, fibrin, mediators) leak into the pulmonary interstitium which leads to decreased diffusion
  • Fluid is forced from interstitial space into alveoli
  • Alveolar edema and damage to type 1 alveolar cells decrease surfactant production
  • Collapse of alveoli
  • Decreased lung compliance and refractory Hypoxemia

Additional Phases and Diagnosis of ARDS

• Proliferative Phase
  • Decreased surfactant and lung compliance causes pulmonary shunting/hypoxemia, increasing airway resistance and work of breathing.
  • Hypoventilation, increased alveolar dead space, worsening hypoxemia, pulmonary HTN, increased right ventricular afterload as well as RHF with decreased CO result
• Fibrotic Phase
  • Cellular granulation and collagen deposition within alveolo-capillary membrane pulmonary fibrosis which leads to structural and vascular remodeling
  • Increase in Pulmonary HTN
  • Worsening hypoxemia resulting in MODS
• Diagnostic:
  • Based on berlin criteria: occurs within seven days; imaging shows indication of lung infiltrates, abnormal oxygenation
  • Mild 200-300 PaO2, Moderate 100-199PaO2, Severe less than 100 PaO2

Management and Nursing Care of ARDS

• Patients appear normal with initially clear breath sounds
• Progress with dyspnea, pulmonary edema, reduced lungs, dense patchy bilateral pulmonary infiltrates, cyanosis, pallor
• Exudative Phase: with an increase in WOB & RR
• Fibrotic: leads to respiratory failure, right-sided heart failure, coarse crackles, hypoxemia, shunting
• Controlled Ventilation Support: lowest possible to allow low tidal volumes
• Nursing Care: High PEEP, monitor o2 stats, fluid and diuretics

Pulmonary Embolism

• Definition: Obstruction of pulmonary artery or it’s branches
• Often linked to states that are often associated with trauma, Ortho surgeries, hyper-coagulating states
• Risk Factors: Immobility, oral contraceptives, pregnancy, trauma
• What to look for: sudden chest pains that increase with breath, coughing blood when coughing
• Nursing: Assess for Tachypnea, low 02, coughing blood, increased HR
• Treatment: High Fowlers, Oxygen and anxiety -Use CTPA scans and pulmonary angiogram to visualize
• Anticoagulants: Heparin, Lovenox What to watch out for: Spontaneous bleeding

Chest Trauma Types

• Blunt Chest Trauma: MVC, crushing injury, bike accident
• Penetrating Trauma: Gunshot, stab wound
• Complications:
  • Tension Pneumothorax: Lung collapses -Nursing: High flow, Oxygen, semi-fowler's Benzo
• Hemothorax: Thoracic cavity contains blood, which causes little to no pain
• Flail Chest: Rib fractures from blunt trauma, which can also cause unequal chest expansion, paradoxical movement, anxiety

Treatment with Inadequate Ventilation

• Chest Tube: Used to alleviate Air, create a seal and allow fluid out and prevent air from entering the lungs -Can have a wet or dry system and Bubbles can indicate a leak in airway What to watch out for over 70mL of discharge
• Ventilation: CPAP and BIPAP deliver air but both do the same thing

Insertion, Complications and Management of ET Tubes

• Nursing: You will administer sedatives and neuromuscular blockers to relieve the patient
• Nursing Role In Inbation: You can administer neuromuscular blockers per doctors request
• Complications: Can cause infections or aspiration if suction is not performed correctly -Infection: Prevent infection by using proper hygiene, suctioning, oral care -Swallowing Suppressed: Require oral suctions
• Check lung positioning while moving

Medical Ventilation

• Positive Pressure: Is used to Keep Lungs Open and prevents alveoli from collapsing

• AC: Person is not breathing, ventilator forces air in, increasing RR

• SIMV: Same as AC, allows for spontaneous breaths

• Contraindications: ARF, COPD, Pulmonary disorders, Neuro disorders

• Management: Oxygenation, Ventilation, ABG Complications: Mucus, PNA

Ventilator Associated PNA

• Hospital environment from mechanical Ventilation
• Occurs within 48 hours of treatments Management: Mouth Care, HOV 30 Degrees

Tracheostomy Placement

• Rationale: To Bypass the upper airway from Long term ventilation that can cause Oral GI or gastric aspiration The ventilator will supply the lung with more CM 5 to 15

Shock

• Is a Deadly state when the body does not meet basic needs, such are oxygen intake -Can cause tissue damage and even tissue death

Stages Overview:

• Initial stage: Basic functions don’t work
• Compensated or PreShock: The body restores tissue profusion and oxygenation Nursing action: Make sure clients are above 92% oxygenation

Types of Shock

• Cardiogenic Shock → Caused by the heart
• Pump Failure → MI and CHF.
• Obstructive → Caused Lung problems from the lungs that cannot be returned.
• Hypovolemic Shock → Low Fluid volume
• Distributive → Infection or allergic reaction
• Hypothermia → Low body temperature Nursing → Provide family and information

Anaphylactic Schock

• Nursing Provide O2 ,Vent beta2 Agonist
• T6 or higher
• High heart due to Sympathetic nervous system and low due to nervous system

Burns

• Damage from the body by skin by fire, radiation or chemical exposure
• Superficial: Damage to the skin that heals itself and can cause minor pain -Partial thickness Burn: damage to the skin that forms partial thickness where the patient is in pain and needs Grafting

Types of Burns

• Dry: burns from fire that can cause explosion
• Moist Burns: Scalded skin, which is common amongst the young and old
• Contact Burn: Grease exposure or hard surface exposure Chemical exposure: A burn from Cleaners Electrical Burn: damage to the body electrical wire exposure and damage of body functions by the body Burn Management: High Fowler, Give O2 from mouth injuries caused by Smoke exposure

Immediate Actions

• Stop Fire or any burns
• Remove any clothes that may be containing and burning the skin
• Wound care, cleaning, bandaging

Extent of Burn Injury

• Burn is determined by amount of Tissue and surface that has been burned over 60%
• The Cardiovascular from Burn Shock: Where Body will not be stable with fluid and Sodium protein

Common Causes of Burn

-Systematic can cause Compartment pressure because scarred Skin is unable to stretch Pulmonary: Upper Airways causing fluid in Airway passages

Blood Carboxyhemoglobin Less than 15%-HA, dizzy, occasional confusion 20-40-Disorientation, visual impairment 40-60-Agitation, combativeness, hallucinations, coma, shock 60 Death

Wound Care with Burns

• Debridement: where dead tissue is removed and grafting happens if the wounds cannot restore and causes the body hyperthermia a year after surgery
• What to watch out for over 1500 volume of IV and is Aba Formula over first 24 hours to correct Burns The best type volume or rate to make the patient's body stable depends on how much electrical and skin damage
• Shock Phases: - General Dehydration
• Massive cellular trauma and excess k+ release from burn

Shock Phases from Burns

• Hypovolemic shock
• Potassium increase by shock
• TBSA volume percentage should be at 4 ml

Disorders linked Skin that cause potentially deadly reactions like burns SJS: Prevented by balancing fluids and electrolytes after a deadly reaction caused by meds or food

Topical Epidermal Necrolysis and SJS = infections by high level meds