Evidence of retained secretions in the airway
-Increased density in the lungs on x-ray, bronchial breath sounds, dullness to percussion, sometimes inspiratory crackles, low oxygen saturation, an increase in heart rate and breathing rate
Improvement in condition of patient
- Lungs less dense to percussion, breath sounds will change from bronchial to vesicular, heart rate and breathing rate will improve, oxygen saturation would increase, increased sputum production
Flutter and Acapella
- Requires patient cooperation, ability to generate large cough
Direct coughing
- Patient needs to have spontaneous cough and needs to cough effectively, needs to be alert and cooperative, ability to close glottis, adequate pain control, hard to teach to children, maintenance therapy-not ideal for acutely ill patient
IPV
- Atelectasis caused by airway obstruction from retained secretions, can perform independently
- Contraindications- pneumothorax
PEP
-Maintenance therapy for persons with chronic secretions problems, may improve delivery of bronchodilators
-May cause: baratrauma, increased ICP, increased WOB
Vest
-Frequency and amplitude can be adjusted, does not require another person
When choosing therapy for patient
-Want simplest, least costly method, what therapy that is best for patient
situation, consider limitations of patient, look at
effectiveness of each method, consider compliance of patient, age of patient,
if second person is available to perform therapy on patient
*Flutter, PEP, vest, IPV- patient can sit upright
Therapeutic uses
-Sleep induction, relief of anxiety, voluntary muscle relaxant, anesthesia, protect patient from self injury
Complications
-Confusion, dizziness, drowsiness, fainting, decrease in BP/CO, ventilatory muscle weakness
Consider when weaning pt from ventilator
-Spontaneous breathing, good urinary output, ABGs, chest x-ray, pain
management, WOB, good CO/BP, color of patient, weaning parameters, breath
sounds, nutritional status, initial problem reversed, FiO2 requirements, drug
therapy, psychology of pt
Values for weaning
-BR less than 25, VC 10-15 ml/kg, Vt at least 250-300 ml
Weaning techniques
-SIMV- decrease rate until reach CPAP
-T-piece trials-alternate time on vent and t-piece and increase time on t-piece
-PS- adjust to achieve desired tidal volume and continue to decrease that PS level
-SIMV/PS- Turn down SIMV rate and then wean the PS level or turn down PS level and then decrease the SIMV rate
-MMV as patient improves they will get less mechanical breaths
-RSBI- measures spontaneous rate and divide by spontaneous tidal volume in Liters, want value to be less than 100 to be determined weanable
MIP- measures strength of inspiratory muscles by expire maximally: want value to be at least 20
MVV- patient breathes rapidly and deeply for 12-15 seconds: want value to
be 2
Acceptable conditions for weaning
-SIMV rate less than 4, low CPAP/PS level, spontaneous breaths on MMV, on t-piece for long periods of time, ABG`s are normal for patient, vital signs are stable, clear chest x-ray, normal weaning parameters, minimal secretions
Complications of being on ventilator for long periods of time
-Sinusitis, vocal cord injury, laryngeal injury, laryngeal stenosis, tracheal injury, hemoptysis, pulmonary infection
Uses
- Hyaline membranes in the immature lung and the onset of respiratory distress syndrome (RDS)
- Preventive treatment in which surfactant is administered at the time of birth or shortly after to infants who are at high risk for developing RDS and for rescue or therapeutic treatment in which surfactant is administered after the initiation of mechanical ventilation in infants with clinically confirmed RDS
o Confirmed RDS- chest radiograph, mean airway pressure greater than 7 cm H2O to maintain adequate PaO2, SaO2
Contraindications
- Respiratory distress in infants with laboratory evidence of lung maturity
- Presence of congenital anomalies incompatible with life beyond the neonatal period
Complications
-Plugging of ET tube, hemoglobin desaturation and increased need for O2, bradycardia, tachycardia, surfactant only in one lung, apnea, mucus plugs, increase risk of ROP, barotraumas
Equipment
-Syringe containing surfactant warmed to room temperature, endotracheal tube connector with delivery port, mechanical ventilator or manual ventilator, airway manometer, blended O2 source, sxn equipment, radiant warmer. Pulse oximeter, transcutanous monitor
Monitor
-Placement/position, ventilator settings, reflux of surfactant, position of pt, chest wall movement, O2 saturation, HR, BR, color, chest radiograph, breath sounds, BP
*Given at 6-12 hr intervals
Use
-Increase rate of urine formation
-Pulmonary edema, CHF, chronic or acute renal failure, systemic fluid overload
Effects
-Increase Na+ excretion, increase in loss of K+, most are not affected by acid-base imbalances, administered in tablet form
Uses
-Relief of severe pain and provide sedation; usually not used in acutely ill patients
-Cough control, pulmonary edema, and control of patients on ventilators
Effects
-Decrease in BR, Vt, MV seen in large doses
Uses
-Loss of consciousness, voluntary muscle relaxants
Effects
-Impaired judgment and loss of self-control, relief of anxiety, sleep, anesthesia, depression of respiratory system, drowsiness
Mucomyst
-Concentrations- 10 and 20%
-Indications- thick/retained secretions
-Contraindications- hypersensitivity
-Side effects- bronchospasm, nausea, increase amount of dried, retained secretions
-Usually given with bronchodilator
RhDNAse (pulmozyme)
- Used for treatment of secretions in CF patients to reduce respiratory infections-reduces viscosity of sputum
- 2.5 mg given usually with Pari neb
- Side effects- chest pain, voice alteration, laryngitis, cough, dyspnea, pneumo
Corticosteriods
-Reduce mucosal edema
Corticosteriod for asthma patients
-Used when usual bronchodilators have not worked for 4-6 hours
Leukotriene modifiers
-Good for tx of exercise-induced asthma, allergy induced asthma
-Few side effects
-Not indicated for acute relief or rescue therapy
-Not recommended for persistent asthma
Cromolyn sodium
-Longer administration time
-Not used in acute bronchoconspasm: may take 2-4 weeks for improvement in patient’s symptoms
-Alternative of to use of inhaled corticosteriods
Short acting Bronchodilators
- Levalbuterol, albuterol, pirbuterol, terbutaline, salmeterol
- Increase expiratory airflow
Indications
- Reversible airway obstruction , improve flow rates in asthma patients
Adverse effects
- Dizziness, nausea, worsening ventilation/perfusion ratio, bronchospasm
Assessment of therapy
-Monitor flow rates, ABG, BP, HR
Flexible
- Can enter right or left main stem bronchus
Complications
-Most often due to medications administered rather than procedure,
-Bleeding, pneumothorax, pneumonias
Equipment needed
-Sxn, O2 source, defibrillator, electrocardiograph, drugs (usually use versed and Demerol)
Contraindications
-Recent myocardial infarction, unstable severe asthma, renal failure, lung abscess, severe hypoxia, hypercapnia
Respiratory Therapist’s Role
- Monitor patient’s vital signs including BP, HR, Br, temp, initial SaO2 before procedure
- Cardiac status and SaO2 are monitored continuously
- Supplemental O2 is administered at a rate to keep patient in safe range
Minute ventilation
-1/10 L per kg (most adults 6-10 L/min)
Want inspiratory time long enough to achieve plateau effect so that inspiratory flow decreases to 0 before end of inspiration
FiO2/PEEP/CPAP
-Usually decrease FiO2 first if above 0.5: if under 0.5 decrease PEEP/CPAP pressures
-PEEP/CPAP- more gas participation in gas exchange/opens alveoli
Change mean airway pressure
-Increase TI/PIP, pause hold
Patient with fairly normal lungs have 10-12ml/kg of body weight
ARDS
-6-7 ml/kg-permissive hypercapnia
-14-20 breaths per minute
Dead space- increases CO2 in body
Rate- Increase will blow off CO2
Inverse I:E ratio
-keeps alveoli open for extended periods of time
-May reduce dead space
Mode-
pressure control PEEP-
4 cmH2O
Rate- 20 I:E
ratio- 4:1 or 3:1
PIP- 40 cmH2O FiO2- 1.00
and lower
Increasing TI
- Increases Paw without increasing PIP, PEEP, changing tidal volume
- Auto-PEEP may occur due to shortened TE
- Increased Paw- increases oxygenation
Auto-PEEP
-Caused by airflow limitations or insufficient expiratory times
-Not measured in ventilator circuit
-Occurs if exhalation is passive and rates exceed 20 bpm
-Increases WOB compresses before gas can enter lungs
Plateau Pressure
-Affected by- elasticity of lungs and any pressure exerted by the volume in the ventilator circuit
Bigger difference in expiratory and inspiratory pressures gives bigger Vt
EPAP
like PEEP / CPAP, IPAP like PIP
Used when
-Patient shows hypotension, decreased consciousness, pulmonary congestion, and chest pain
Used for
- V-Tach, A-Fib, and Atrial Flutter
Energy levels generally 200, may start lower
Procedure
-Local anesthetic is used, ET not removed until just prior to insertion of tracheostomy tube, incision on second or third tracheal ring, insertion of guidewire until stoma is big enough for the trach tube, insertion of tube, inflation of cuff, securing of tube
Tube size
-Must occupy between 2/3 and ¾ of internal diameter of trachea
When to intubate
-Patient’s PCO2 is more than 60 mm Hg
-pH is less than 7.25
- PaO2 is less than 70 mm Hg with an FiO2 of more 0.60
- Breath sounds are absent, patient is lethargic, apneic episodes
Want tube 2-3 cm above the carina
Select ventilator equipment and settings when patient’s cardiovascular status is stabilized
Monitor
-Color improvement, if chest is moving, listen for breath sounds, pulse ox, lack of stomach distention
Equipment
-Manual resuscitation bag and mask, stethoscope, syringe, tape, stylet, manometer, nipple adapter, sxn, ABG kit, magill forceps, gloves, laryngoscope, yankauer
Indications
-Facilitate positive pressure ventilation/sxn, maintain airway patency, protect airway from aspiration
Flexible
- Can enter right or left main stem bronchus
Complications
-Most often due to medications administered rather than procedure,
-Bleeding, pneumothorax, pneumonias
Equipment needed
-Sxn, O2 source, defibrillator, electrocardiograph, drugs (usually use versed and Demerol)
Contraindications
-Recent myocardial infarction, unstable severe asthma, renal failure, lung abscess, severe hypoxia, hypercapnia
Respiratory Therapist’s Role
- Monitor patient’s vital signs including BP, HR, Br, temp, initial SaO2 before procedure
- Cardiac status and SaO2 are monitored continuously
- Supplemental O2 is administered at a rate to keep patient in safe range
Must trigger breath by creating negative pressure in the circuit
Hard for patients with COPD and other patients with weak inspiratory efforts to trigger
Set sensitivity
- Want sensitivity set when it’s easiest to trigger without self-cycling, pressure 0.5-2 cmH2O, flow about 40-60
- Flow trigger may be changed to 2-3 L/min: check for auto-triggering and ability to trigger