Respiratory 1. Finnegan.pdf

Respiratory Day 1 MANAGEMENT OF PATIENTS WITH CHEST AND LOWER RESPIRATORY DISORDERS  Previous Material  A&P  Function of the respiratory system  Assessment of respiratory function  Acutely or critically ill patient  Diagnostic evaluation: PFT, Pulse...

Respiratory Day 1 MANAGEMENT OF PATIENTS WITH CHEST AND LOWER RESPIRATORY DISORDERS  Previous Material  A&P  Function of the respiratory system  Assessment of respiratory function  Acutely or critically ill patient  Diagnostic evaluation: PFT, Pulse oximetry *, CXR, Cat Scan, ABG’s *, Biopsy, bloodwork, EKG.  https://abg.ninja/abg Assessment of the pulmonary system  Assessment of the lung field (auscultation)  Anterior  Posterior  Work of breathing (visual inspection)  Rate and rhythm  Accessory musculature  Level of consciousness  Patients requiring artificial ventilation  *Common medications used for rest/agitation and decreased WOB. Intravenous Medications that are common in the ICU for sedation/pain artificial ventilation in place.  Propofol (Diprivan) sedative and amnesic.  Commonly used for sedation (Fast acting)  May cause hypotension and bradycardia  Oversedation (can stick around)  Metabolized in the liver. High fat emolument intravenous tubing changed every 12 hours  Precedex (Dexmedetomidine) *  Preferred by providers  Reverses faster  Decreased chance of delirium  Bradycardia and hypotension IV medications continued the Benzo’s  Valium (Diazepam)  Alcohol detoxification  Hypotension oversedation  Romazicon (Flumazenil)  Ativan (Lorazapam)  Seizure control  Hypotension, respiratory depression  Midazolam (Versed)  Short acting  Hypotension, respiratory depression Paralytics  Norcuron, Pavulon, Nimbex (more)  The client must be on a ventilator  Must be on continuous IV sedation  Initiated before and continued after until paralytic is cleared.  Monitored with Train of Four.  Provider ordered level of response follow your hospital policy  Usually two or one out of four. Documented every hour. Anatomy of the lungs  Upper respiratory tract: Filters impurities and warms the air.  Lower respiratory tract: Lungs Three lobes on the right, two on the left. Right lung is more likely to be intubated by mistake.  Pleura: Visceral: vital (closest to lung); parietal lines pleural cavity Function Overview GAS EXCHANGE AND OXYGEN TRANSPORT Respiration and Ventilation  What is the difference?  Respiration is the whole process of gas exchange between the atmosphere and the blood including the cellular exchange of O2 and CO2.  Ventilation is the movement of air in and out of the lungs. Inspiration is active, expiration is passive. Gas Exchange in Lungs Oxygen transport Ventilation and Perfusion Chapter 19 Management of Disorders  Chest Trauma  Pulmonary Embolus  Acute Respiratory Failure  Acute Respiratory Distress Syndrome (ARDS) Chest Trauma  Blunt vs. penetrating trauma  Life threatening injuries  Hypoxemia  Hypovolemia  Cardiac failure Types of Chest Trauma  Blunt trauma  Sternal/Rib fractures  Flail chest  Pulmonary contusion Types of chest trauma 2  Penetrating trauma  Gunshot/stab wounds  Pneumothorax  Cardiac tamponade  Subcutaneous emphysema Chest Trauma  Management  Assessment  Airway  Time is critical  Need for O2  Mechanism of injury  Reestablish fluid volume  Responsiveness  Reestablish negative pressure  Specific injuries  Drainage of intrapleural fluid/blood  Estimated blood loss  Recent alcohol use  Pre-hospital treatment  Diagnostics Fracture Hemothorax Crash Rib Fracture Fluid in Lungs  Pulmonary Embolism  Obstruction of the pulmonary artery or one of it’s branches by a Pulmonar thrombus  Originate in the venous system y  DVT Embolism  DVT + PE = VTE Associated with:  Trauma  Surgery  Pregnancy  Heart failure  Age ( > 50)  Hypercoagulable states  Prolonged immobility  Atrial fibrillation Pulmonary Embolism Pathophysiology Blood Clot:  Complete of partial obstruction of a PA Gas exchange impairment/absent:  Alveolar dead space is increased  no blood flow  Ventilation is continued Pulmonary vasoconstriction: Increased pulmonary vascular resistance:  Increased right ventricular work Size: Degrees of hemodynamic instability Pulmonary Embolism 2  Clinical manifestations  Size dependent  Dyspnea, tachypnea (*most common side effect)  Chest pain  Cough, hemoptysis (secondary to cell death)  Anxiety, apprehension  Fever, tachycardia, diaphoresis Pulmonary Embolism 3  Assessment and Diagnosis  CXR, ECG, pulse ox, ABG (refractory hypoxemia)  V/Q scan  Minimally invasive, use of a contrast agent  Pulmonary angiogram * (best test if time/condition allows)  Pulmonary spiral CT scan/ D-dimer (blood test)  Medical Management  Emergency management  Lyse the existing emboli (TPA)  Prevent new one from forming*  Treatment  Improve respiratory and cardiovascular status  Anticoagulation therapy  Thrombolytic therapy  Surgical intervention V/Q scan: Ventilation Perfusion Pulmonary Embolism  Prevention  DVT/VTE  AVOID VENOUS STASIS  Activity/leg exercises  Early mobilization  Anti-embolic stockings  Sequential compression devices  Anticoagulant therapy Breathe Patient in ER Acute Respiratory Failure  Sudden and life threatening  Decline in gas exchange  Failure to provide oxygenation  pH < 7.35  PaO2 < 60mmHg (hypoxemia)  PaCO2 >50mmHg (hypercapnia)  Acute v. Chronic ? Acute vs Chronic  Chronic  Deterioration in the gas exchange function  Hypoxemia and hypercapnia develops gradually and is harmful  Persisted for a long period of time after an episode of acute respiratory failure  Absence of acute symptoms  COPD and neuromuscular disease  Acute Causes of Respiratory Failure FAILURE TO OXYGENATE Diffusion abnormalities FAILURE TO MAINTAIN Dead space AIRWAY FAILURE TO VENTILATE Shunting Obstruction Neurological Chest injury Muscular Abdominal compression ARF Acute Respiratory Failure 2 Pulmonary Edema Acute Respiratory Failure 3  Assessment Early:  Management  Restlessness, fatigue, HA,  Correct underlying dyspnea, tachycardia, cause hypertension, hypoxemia  Restore gas exchange Progression: in the lung  Confusion, lethargy,  Intubation/Mechanical tachycardia, tachypnea, Ventilation central cyanosis, diaphoresis, respiratory arrest  ABG  SaO2  VS  ICU care The arterial blood gas  Normal PH: 7.35-7.45  Normal PCO2: 35-45  Normal PAO2: 80-100  Normal Bicarbonate: 22-26.  The lungs work much faster than the kidney  Oxygenation is not part of the blood gas PH analysis but is just as important  You need both Metabolic acid-base abnormalities  Metabolic Alkalosis  Ph over 7.45 with a bicarbonate over 26.  Causes: Vomiting, excessive antacid use, contraction alkalosis  Metabolic acidosis  PH below 7.35 with a HCO3 below 22.  Causes: Any condition that causes a reduction in bicarbonate or in which the body’s metabolic processes outpace bicarbonate production.  Kidney Disease, DKA, Sepsis, lactic acidosis, Aspirin overdose Respiratory acid-base abnormalities  Respiratory alkalosis  PH over 7.45 with a PCO2 below 35  Causes: Hyperventilation  Respiratory Acidosis  PH below 7.35 with a PCO2 above 45.  Causes: Respiratory failure, hypoventilation syndrome. Blood gas interpretation  Abg.ninja  Normal, compensated, uncompensated, partial compensation, full compensation.  Can a patient be acidotic both metabolically and respiratory: Absolutely  Ph: 7.30 PCO2: 50 HCO3: 20 Interpretation  Six steps  Analyze the PH  Look at the PCO2  Look at the HCO3  Match them to the PH  Look and see if the opposing system is trying to balance the PH if so there is compensation  Check for hypoxemia. NOT part of PH but equally important. Maybe even more so. Nursing Management of ARF  Assist with intubation  Maintain mechanical ventilation  Assess respiratory status:  LOC, ABG, VS, respiratory system  Care of the vented patient:  T&P, mouth care  Prevent complications  Communication and education Acute Respiratory Distress Syndrome (ARDS) ARDS  Spectrum of disease Acute Pulmonary Lung ARDS Edema Injury  Severity Pulmonary Fibrosis Damage of the alveolar membrane Vascular destruction MODS  Stages of ARDS  The acute exudative phase (about one week)  Injury  Proteinaceous flooding nullifies surfactant  Decreased gas exchange  Proliferative phase  Up to three weeks  Resolution of phase one/ may recover or move on the next phase.  Normal lung tissue changes into fibrotic tissue  Ventilator dependent/death is common. ARDS Continued  Severe form of acute lung injury  Severe inflammatory process  Sudden and progressive pulmonary edema  Bilateral infiltrates on chest x-ray  Hypoxemia unresponsive to oxygen  Regardless the amount of PEEP  Reduced lung compliance  Death from non pulmonary multi-system organ failure, with sepsis Factors Commonly Associated with the Development of ARDS Direct Lung Injury Indirect Lung Injury Pneumonia Sepsis Aspiration of gastric contents Severe trauma Pulmonary contusion Multiple bone fractures Near-drowning Flail chest Toxic inhalation injury Head trauma Burns Multiple transfusions 40% Drug overdose mortality Pancreatitis Post-cardiopulmonary bypass rate  ARDS Pathophysiology  Inflammation  Injury to the alveolar capillary membrane  Severe ventilation-perfusion mismatch occurs  Alveolar collapse  Lung compliance decreased (the ability the lung can stretch)  Loss of surfactant Alveolus Clinical Manifestations  Resembles severe pulmonary edema  Rapid onset dyspnea  Less than 72 hours after the precipitating event  Arterial hypoxemia  Visible bilateral infiltrates  Alveoli: Good ventilation, poor perfusion  Decreased pulmonary compliance: stiff  Recovery: oxygenation and CXR improve, better lung compliance  ARDS Assessment & Management  Assessmenet  Management  Develops over 48-72 hours  Intubate/Mechanical Ventilation  Crackles  PEEP to improve oxygenation  Rapid onset dyspnea  Low Tidal volumes  Arterial hypoxemia: refractory to  Vasopressor therapy oxygen therapy  Fluid volume  White patches on CXR  Nutrition  Pulmonary Edema or ARDS  Pharmacology  Brain natriuretic peptide (BNP)  Sedatives, analgesics, neuromuscular blockade, inhaled nitric oxide heliox  Specialty bed / Pronation Roto Prone  Clinical research has shown the effectiveness of prone therapy in improving oxygenation in ARDS patients. 2 Alveolra Recruitung ECMO Therapy  Used in severe cases of ARDS/ COVID 19/ Sepsis  Open heart surgery  VV mode (venous system)  VA mode (Arterial system and venous)  Multiple additional sub settings  Gas exchange machine  Decannulation  Clots  Infection  Fluid compromise/ must have anticoagulation Pulmonary Rehabilitation  Improves physical and psychological health  Increased exercise capacity  Reduced perceived breathlessness  Patients are taught breathing exercises and retraining exercises  + for COPD patients.