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

10. Early & Late Responses in Asthma

11. Classification of Asthma Severity

12. Pathophysiology of Acute Asthma Attack

13. Stepwise Approach for Managing Asthma

14. Interferences with VentilationAsthma – Medication

15. Interferences with VentilationAsthma - Medication

16. Drug Therapy Asthma & COPD

17. Drug Therapy – Asthma & COPD

18. How to Use Metered-Dose Inhaler

19. 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 – body’s 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 - > 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 (cont’d): • Recurring respiratory tract infections • H. flu, Strep pneumoniae, Moraxella catarrhalis • Heredity – alpha 1 –Antitrypsin (ATT) deficiency • Accounts for <1% 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

29. Comparison of Emphysema & Chronic Bronchitis Alveolar Problem Airway Problem

30. COPDPulmonary Blebs & Bullae

31. COPD -- Interaction of Chronic Bronchitis & Emphysema

32. Pathophysiology of Chronic Bronchitis and Emphysema

33. 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 patient’s respiratory pattern • Venturi Mask – up to 50% • Low Flow — amount delivered varies with patient’s 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, N&V, 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 > 50% for > 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

44. Chest PercussionCupped Hand Technique

45. Chest Physiotherapy

46. Postural Drainage

47. 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; Referral—financial & 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 (ADL’s) / rest; avoidance of alcoholic beverages, caffeine products, & other stimulants before bedtime; include family; sexual activity—positions of comfort; psychosocial issues