RESPIRATORY CARE

MODALITIES

2
 LEARNING OBJECTIVES
On completion of this chapter, the learner will be able
to:
1. Describe the nursing management of patients
receiving oxygen therapy, incentive spirometry,
flutter valve therapy, small-volume nebulizer
therapy, chest physiotherapy, and breathing
retraining.
2. Discuss the patient education and transitions in
care considerations for patients receiving 3

oxygen therapy.
 LEARNING OBJECTIVES

3. Identify the nursing care of a patient with an

endotracheal tube and a patient with a
tracheostomy.

4. Use the nursing process as a framework

for care of patients who are mechanically
ventilated.
3
 LEARNING OBJECTIVES

5. Describe the process of weaning the

patient from mechanical ventilation.
6. Examine the significance of preoperative
nursing assessment and patient education
for the patient who is going to have
thoracic surgery.
 LEARNING OBJECTIVES

7. Explain the principles of chest

drainage and the nursing responsibilities
related to the care of the patient with a
chest drainage system.

8. Use the nursing process

 NONINVASIVE RESPIRATORY
THERAPIES
Oxygen Therapy
- is the administration of
oxygen at a concentration
greater than that found in
the environmental
atmosphere 7
 OXYGEN THERAPY INDICATIONS:

Hypoxemia
-decrease in the arterial oxygen tension in
the blood.

8
 HYPOXEMIA
Manifested by:
- changes in mental status, - changes in heartrate,
- dyspnea, - dysrhythmias,
- increase in blood - central cyanosis (late sign),
pressure, - diaphoresis,
- changes in heartrate, - cool extremities
- dysrhythmias, - cool extremities
- central cyanosis (late - diaphoresis,
sign), 7
HYPOXEMIA USUALLY LEADS TO HYPOXIA

Hypoxia
- decrease in oxygen supply to the
tissues and cells that can also be caused
by problems outside the respiratory
system.

1
0
 TYPES OF HYPOXIA

1. Hypoxemic Hypoxia
2. Circulatory Hypoxia
3. Anemic Hypoxia
4. Histotoxic Hypoxia
1
1
 1. HYPOXEMIC HYPOXIA
12
• is a decreased oxygen level in the blood resulting
in decreased oxygen diffusion into the tissues.
Caused by:
✓ hypoventilation,
✓ high altitudes,
✓ ventilation-perfusion mismatch
* It is corrected by increasing alveolar ventilation
or providing supplemental oxygen.
 2. CIRCULATORY HYPOXIA
• is hypoxia resulting from inadequate
capillary circulation.
Caused by:
✓ decreased cardiac output,
✓ local vascular obstruction,
✓low-flow states such as shock, or cardiac
arrest 11
 3. ANEMIC HYPOXIA
• is a result of decreased effective hemoglobin
concentration, which causes a decrease in the
oxygen-carrying capacityof the blood.
Caused by:
✓ decreased effective hemoglobin concentration
✓ carbon monoxide poisoning.
- it reduces the oxygen-carrying capacity of
hemoglobin 12
 4. HISTOTOXIC HYPOXIA

• occurs when a toxic substance, such as cyanide,

interferes with the ability of tissues to use
available oxygen.
•The defect in the use of oxygen leads to a
reduction in adenosine triphosphate (ATP)
production by the mitochondria.
13
 INTERVENTIONS
• Oxygen is a medication.
-to increase the partial pressure of oxygen (PaO2)
back to the patient’s normal baseline to 60 to 95 mm
Hg
• assess the patient frequently for:
- confusion,
- restlessness progressing tolethargy,
-diaphoresis, pallor, tachycardia, tachypnea,
and hypertension.
• Intermittent or continuous pulse oximetry is used to14

monitor oxygen levels.

COMPLICATIONS

15
 COMPLICATIONS
Oxygen Toxicity
o may occur when too high concentration of oxygen
(greater than 5 0 % ) is given for an extended period
(generally longer than 24 hours)
oIt is caused by overproduction of oxygen free
radicals, which are by-products of cell metabolism.
oClinical manifestations of oxygen toxicity causing
lung damage are similar to acute respiratory distress
syndrome (ARDS) 16
 OXYGEN TOXICITY
Signs and symptoms include: 19

✓ substernal discomfort, ✓progressive

✓ paresthesias, respiratory difficulty,
✓ dyspnea, ✓ refractory hypoxemia,
✓ restlessness, ✓alveolar atelectasis,
✓ fatigue, and alveolar infiltrates
evident on chest x-rays
✓ malaise,
 INTERVENTIONS
20

• Use the lowest amount of oxygen needed to

maintain an acceptable PaO2 level
• treating the underlying condition aids in the
prevention of oxygen toxicity.
• If high concentrations of oxygen are necessary,
it is important to minimize the duration of
administration and reduce its concentration as
soon as possible.
 INTERVENTIONS
21

• PEEP is applied at the end of expiration of

ventilator breaths or CPAP.
- to reverse/prevent microatelectasis which
will allow a lower percentage of oxygen to be
used.
YOUTUBE LINK FOR PEEP LECTURE:
•https://youtu.be/ROlqR5_DvEI
 ABSORPTION ATELECTASIS
23
• An additional adverse effect of the
administration of high concentrations of
oxygen (greater than 5 0 % ) to patients who are
sedated and breathing small tidal volumes of air.
 ABSORPTION ATELECTASIS
Nitrogen, in addition to other gases,
During inhalation fills the alveoli and helps keep the
alveoli open

With the administration of high

With the administration of high
concentrations of oxygen,
nitrogen is diluted and replaced
with oxygen.
The alveoli collapse,
concentrations of oxygen, nitrogen is
diluted and replaced with oxygen.
Oxygen in the alveoli is absorbed
quickly into the bloodstream and
not replaced rapidly enough in the
alveoli to maintain patency.
21

causing atelectasis
 SUPPRESSION OF VENTILATION

• it was assumed the stimulus for respiration

in patients with COPD.
• normally, is a decrease in blood oxygen
rather than an elevation in carbon dioxide
levels, commonly referred to as the
H Y P O X I C DRIVE.
22
SUPPRESSION OF VENTILATION
The hypoxic drive theory posited that the
administration of a high concentration of oxygen.

removes the respiratory drive that has

been created largely by the patient’s
chronic low oxygen tension.
decrease in alveolar
ventilation would then
cause a progressive
in rare cases, lead to
increase in partial acute respiratory failure
pressure of arterial secondary to carbon
carbon dioxide (PaCO2) dioxide narcosis, 23

acidosis, and death.

 SUPPRESSION OF VENTILATION

• The hypoxic drive is a real phenomenon;

however, research reports it accounts for only
10% of the stimulus to breathe.
• it is important to closely monitor the
respiratory rate and the oxygen saturation.
to maintain an oxygen saturation
between 9 0 % and 9 3 % on the lowest liter flow
24

of oxygen.
 OTHER COMPLICATIONS

• there is always a danger of fire when it is used

(Because oxygen supports combustion)
• Oxygen therapy equipment is also a potential
source of bacterial contamination.
- the nurse or respiratory therapist changes
the tubing according to infection prevention
policy.
25
 METHODS OF OXYGEN ADMINISTRATION
✓Oxygen is dispensed from a cylinder or a piped-in
system.
✓a flow meter regulates the flow of oxygen in liters
per minute (L/min).
✓When oxygen is used at high flow rates, it should be
moistened by passing it through a humidification
system.
to prevent it from drying the mucous
membranes of the respiratorytract. 26
OXYGEN DELIVERY SYSTEMS CLASSIFICATION

1. Low-flow delivery system

(variable performance)

2. High-flow delivery system

(fixed performance)
27
OXYGEN DELIVERY SYSTEMS CLASSIFICATION

1. Low-flow delivery system

(variable performance)
▪ contributepartially to the
inspired gas the patient
breathes, which means that the
patient breathes some room air
along with the oxygen. 28
32
OXYGEN DELIVERY SYSTEMS CLASSIFICATION
33

2. High-flow delivery system

(fixed performance)
▪are indicated for patients who require
a constant and precise amount of
oxygen.
34
TYPES OF OXYGEN MASKS
T-pieces and tracheostomy collars are devices used when weaning
33

patients from mechanical ventilation.

 HYPERBARIC OXYGEN THERAPY
37
• is the administration of 1 0 0 % oxygen, either
intermittently or continuously, at pressures
greater than atmospheric pressure.
38
 39

Emergency Management
of Upper Airway
Obstruction
CAUSES:
• food particles,
• vomitus,
• blood clots, or anything that obstructs the larynx or

trachea
• enlargement of tissue in the wall of the airway:
✓ epiglottitis,
✓ obstructive sleep apnea,
✓ laryngeal edema,
✓laryngeal carcinoma, or peritonsillar abscess, or
37

from thick secretions

RAPID OBSERVATIONS TO ASSESS FOR SIGNS AND SYMPTOMS OF
UPPER AIRWAY OBSTRUCTION:
Inspection:
✓ Is the patient conscious?
✓ Is there any inspiratory effort?
✓ Does the chest rise symmetrically?
✓ Is there use or retraction of accessory muscles?
✓ What is the skin color?
✓Are there any obvious signs of deformity or
obstruction (trauma, food, teeth, vomitus)?
✓ Is the trachea midline?
38
RAPID OBSERVATIONS TO ASSESS FOR SIGNS AND SYMPTOMS OF
UPPER AIRWAY OBSTRUCTION: 42

Palpation:
✓Do both sides of the chest rise equally with
inspiration?
✓Are there any specific areas of tenderness,
fracture, or subcutaneous emphysema
(crepitus)?
RAPID OBSERVATIONS TO ASSESS FOR SIGNS AND SYMPTOMS OF
UPPER AIRWAY OBSTRUCTION: 43

Auscultation:

✓Is there any audible air movement, stridor

(inspiratory sound), or wheezing (expiratory
sound)?
✓Are breath sounds present over the lower
trachea and all lobes?
EMERGENCY MEASURES FOR UPPER AIRWAY
OBSTRUCTION: 44
EMERGENCY MEASURES FOR UPPER AIRWAY
OBSTRUCTION: 45
Endotracheal tube
in place.
43
 Video on Intubation: 47

YOUTUBE LINK

https://youtu.be
/XeQIivOFwTw
48
49
50
51
 ET TUBE
• ET Tube Complications can occur from pressure
exerted by the cuff on the tracheal wall.
High cuff pressure can cause:
✓ tracheal bleeding,
✓ ischemia,
✓ pressure necrosis
Low cuff pressure can:
49

✓ increase the risk of aspiration pneumonia.

To prevent risk of aspiration Pneumonia and hypoxia:

✓ avoid routine deflation of the cuff.

- can increase the risk of aspiration pneumonia
✓ suction tracheobronchial secretions.
✓ administer a warmed, humidified oxygen.
✓Endotracheal intubation may be used for no longer
than 14 to 21 days, by which time a tracheostomy must
be considered to decrease irritation of and trauma to
the tracheal lining
50
TRACHEOSTOMY
54
• is a surgical

procedure in which
an opening is made
into the trachea.
• indwelling tube
inserted into the
trachea is called a
tracheostomy tube
PURPOSES OF TRACHEOSTOMY:
55
• to bypass an upper airway obstruction.
• to allow removal of tracheobronchial secretions
• to permit the long-term use of mechanical

ventilation
• to prevent aspiration of oral or gastric secretions
in the unconscious or paralyzed patient (by
closing off the trachea from the esophagus),
• to replace an endotrachealtube.
 COMPLICATIONS:
Early complications: 56

✓ tube dislodgement,
✓ accidental decannulation,
✓ bleeding,
✓ pneumothorax,
✓ air embolism,
✓ aspiration,
✓ subcutaneous or mediastinal emphysema,
✓ recurrent laryngeal nerve damage,
✓ posterior tracheal wall penetration
 COMPLICATIONS:
Late complications:
✓ airway obstruction from accumulation of secretions or
protrusion of the cuff over the opening of the tube
✓ infection,
✓ rupture of the innominate artery
✓ dysphagia
✓ tracheoesophageal fistula
✓ tracheal dilation
✓ tracheal ischemia 54

✓ necrosis.
 58
•
 MECHANICAL VENTILATOR
59
• is a positive- or negative-pressure breathing
device that can maintain ventilation and oxygen
delivery for a prolonged period.
INDICATIONS
• compromised airway or respiratory failure
“an increase in arterial carbon dioxide levels (PaCO2), and a persistent
acidosis (decreased pH)”
Conditions that may lead to respiratory failure:
✓ thoracic or abdominal surgery
✓ drug overdose
✓ neuromuscular disorders
✓ inhalation injury
✓ COPD
✓ multiple trauma
✓ shock, multisystem failure
✓ coma
57
 61
•
TWO GENERAL CATEGORIES
62
Positive-Pressure Ventilators
• inflate the lungs by exerting positive pressure on the
airway, pushing air in, similar to a bellows mechanism,
and forcing the alveoli to expand during inspiration.
Negative-pressure ventilators
• are older modes of ventilatory support that are
rarely utilized today. (e.g., “iron lungs,” chest
cuirass)