Responses to :

Alterations /Problems and

its Pathophysiologic Basis in
Life Threatening Conditions ,
Acutely ill / Multi – organ
Problems, High Acuity an
Emergency Situation
 L

NCM 118

Lesson 3:
Responses to
Altered Ventilatory Function

Prof. Dodie A. Dichoso

Altered respiratory function is associated
with increased metabolic risk, independently of
adiposity, fitness and physical activity.

Role of Respiratory System

 The respiratory system regulates blood pH
by controlling the amount
of carbon dioxide removed from the
blood.
 Near systemic cells , carbon dioxide forms
bicarbonate ions in the blood
H+ ions are also released , thereby
decreasing blood pH.
At the alveolar capillaries , bicarbonate
ions are converted back to carbon
dioxide gas which diffuses out into the
alveolus.
 Altered Ventilatory Function

People having trouble breathing often

show signs that they are having to work
harder to breathe or are not getting
enough oxygen, indicating respiratory
distress. Below is a list of some of the signs
that may indicate that a person is working
harder to breathe and may not be getting
enough oxygen. It is important to learn
the signs of respiratory distress to know how
to respond. Always see a healthcare
provider for a diagnosis:
Signs of Respiratory Distress
1. Breathing rate. An increase in the number of
breaths per minute may mean that a person is
having trouble breathing or not getting enough
oxygen.

2. Color changes. A bluish color seen around the

mouth, on the inside of the lips, or on the
fingernails may happen when a person is not
getting as much oxygen as needed. The color of
the skin may also appear pale or gray.

3. Grunting. A grunting sound can be heard each

time the person exhales. This grunting is the
body's way of trying to keep air in the lungs so
they will stay open.
Signs of Respiratory Distress
4. Nose flaring. The openings of the
nose spreading open while
breathing may mean that a person is
having to work harder to breathe.
5. Retractions. The chest appears to sink
in just below the neck or under the
breastbone with each breath or both. This
is one way of trying to bring more air into
the lungs, and can also be seen under the
rib cage or even in the muscles between
the ribs.
 Signs of Respiratory Distress

6. Sweating. There may be increased sweat on the

head, but the skin does not feel warm to the touch.
More often, the skin may feel cool or clammy. This
may happen when the breathing rate is very fast.
7. Wheezing. A tight, whistling or musical sound heard with each
breath can mean that the air passages may be smaller (tighter),
making it harder to breathe.

8. Body position. A person may spontaneously lean forward while

sitting to help take deeper breaths. This is a warning sign that he or
she is about to collapse.
 Assessment for Altered Ventilatory function

Patient History
A respiratory assessment must begin with a
detailed patienthistory. Ask about previous
respiratory illnesses, chronic respiratory conditions,
and cardiovascular health. If the patient has an
infection or is in respiratory distress, get as many
details as possible about the event preceding the
emergency. Ask about the patient’s vaccine history,
as well.
 Subjective Assessment

Collect data using interview questions, paying particular attention to what

the patient is reporting. The interview should include questions regarding
any current and past history of respiratory health conditions or illnesses,
medications, and reported symptoms. Consider the patient’s age,
gender, family history, race, culture, environmental factors, and current
health practices when gathering subjective data. The information
discovered during the interview process guides the physical exam and
subsequent patient education. See Table 10.3a for sample interview
questions to use during a focused respiratory assessment.
 Objective Assessment

A focused respiratory objective assessment includes interpretation of

vital signs; inspection of the patient’s breathing pattern, skin color, and
respiratory status; palpation to identify abnormalities; and auscultation of
lung sounds using a stethoscope. For more information regarding
interpreting vital signs, The nurse must have an understanding of what
is expected for the patient’s age, gender, development, race, culture,
environmental factors, and current health condition to determine the
meaning of the data that is being collected.
Observe the patient for
important respiratory clues:
1. Check the rate of respiration.
2. Look for abnormalities in the shape of the patient’s
chest.
3. Ask about shortness of breath and watch for signs of
labored breathing.
5. Check the patient’s pulse and blood pressure.
6. Assess oxygen saturation. If it is below 90 percent, the
patient likely needs oxygen.

In infants and newborns:

1.Check for flaring nostrils, which could indicate breathing
problems.
2. Look for retractions or bulging of the muscles between
the ribs, which suggest difficulty getting enough air.
 Lung auscultation is
a subjective method
used in clinical practice
for the evaluation and
detection of respiratory
system abnormalities.

Measuring respiratory
mechanics at the
bedside is an objective
method and helps to
guide clinical practice
Clubbing of the Fingers
Diagnostic Test used to evaluate respiratory
function
Spirometry. This is the simplest and most common
lung test. You breathe in and out as hard as you can
through a tube, and your doctor measures how
much air goes in and out of your lungs. It can help
diagnose conditions that affect how much air your
lungs can hold, like chronic obstructive pulmonary
disease (COPD).

Spirometry is used to diagnose asthma,

chronic obstructive pulmonary disease
(COPD) and other conditions that affect
breathing. Spirometry may also be used
periodically to monitor your lung condition and
check whether a treatment for a chronic lung
condition is helping you breathe better.
Shortness of Breath: Diagnostic tests may
include pulmonary function tests, chest X-ray,
EKG, echocardiogram, bronchoscopy, blood
tests or chest CT scan. Treatment for
shortness of breath depends on the underlying
cause and severity.

Pulse oximetry is a non-invasive method

used to measure blood-oxygen saturation,
similar to the technology commonly
employed in smart watches to monitor heart
rate.
Objective Data Assessment

1. Physical Assessment
2. Diagnostic Assessment
a. Non invasive
b. Invasive
1. ABG
2. Pulmonary Capillary wedge Pressure
3. Pleural Fluid Analysis
4. Pulmonary Angiography
5. Ventilation Perfusion (V/Q) Scan
6. Capnography
 1. An arterial blood gas
(ABG) test measures oxygen and carbon
dioxide levels in your blood. It also
measures your body's acid-base (pH) level,

2. Pulmonary
capillary wedge
pressure (PCWP)
is frequently used
to assess left
ventricular filling,
represent left
atrial pressure,
and assess mitral
valve function.
3. Pleural Fluid Analysis
The fluid is considered an exudate if any
of the following are present: The ratio of
pleural fluid to serum protein is greater than
0.5. The ratio of pleural fluid to serum LDH is
greater than 0.6. The pleural fluid LDH value is
greater than two-thirds of the upper limit of the
normal serum value.

Normal value of Pleural Fluid

In a healthy human, the pleural space
contains a small amount of fluid (about 10 to
20 mL), with a low protein concentration (less
than 1.5 g/dL).
 4. Pulmonary Angiography
Pulmonary Angiography is a medical
fluoroscopic procedure used to
visualize the pulmonary arteries and
much less frequently, the pulmonary
veins. It is a minimally invasive
procedure performed most frequently
by an interventional radiologist or
interventional cardiologist to visualise
the arteries of the lungs.
Pulmonary Angiogram is an
angiogram of the blood vessels of the
lungs. The procedure is done with a special
contrast dye injected into the body's blood
vessels. This is done in the groin or arm. The
dye shows up on X-rays. Fluoroscopy is
often used during this test
5. A V/Q scan consists of two imaging
tests that look for certain lung problems. The
tests are:
1. A ventilation scan, which measures how air moves in
and out of your lungs

2. A perfusion scan, which measures circulation (how

blood flows in the lungs)
The two scans may be done separately or together.
A V/Q scan uses a small amount of a radioactive
substance called a tracer that helps look for disease in
the body. The scans help diagnose different lung
conditions, including a pulmonary embolism (PE). A PE is
a life-threatening blockage in an artery in the lungs. It
usually happens when a blood clot in another part of the
body breaks loose and travels to the lungs.
Ventilation Perfusion (V/Q Scan)
The ventilation scan is used to see how well
air moves and blood flows through the lungs. The
perfusion scan measures the blood supply through
the lungs. A ventilation and perfusion scan is most often
done to detect a pulmonary embolus (blood clot in the
lungs).

You may need a V/Q scan if you have

symptoms of a pulmonary embolism (PE).
These include:
A.Trouble breathing
B. Chest pain
C. Coughing or coughing up blood
D. Rapid heartbeat
6. Capnography is a non-invasive measurement
during inspiration and expiration of the partial pressure of
CO2 from the airway. It provides physiologic
information on ventilation, perfusion, and metabolism,
which is important for airway management.

Too little CO2 in the blood may indicate:

Addison's disease, another disorder of the adrenal
glands. In Addison's disease, the glands don't produce
enough of certain types of hormones, including
cortisol. The condition can cause a variety of
symptoms, including weakness, dizziness, weight
loss, and dehydration.
 Carbon dioxide

(CO2) is a gaseous waste product from metabolism. The blood

carries carbon dioxide to your lungs, where it is exhaled. More
than 90% of it in your blood exists in the form of bicarbonate
(HCO3). The rest of it is either dissolved carbon dioxide gas
(CO2) or carbonic acid (H2CO3). Your kidneys and lungs
balance the levels of carbon dioxide, bicarbonate, and carbonic
acid in the blood.
This test measures the level of bicarbonate in a sample of
blood from a vein. Bicarbonate is a chemical that acts as a
buffer. It keeps the pH of blood from becoming too acidic or too
basic.
 Nursing Diagnosis

1. Ineffective Airway Clearance related to

Excessive and Tenacious secretions.
2. Impaired Gas Exchange related to Activity
Intolerance
3. Anxiety related to Breathlessness related to
Feelings of Loss of Control
4. High Risk for Ineffective Therapeutic Regimen
Management related to Lack of Knowledge
 Nursing Diagnosis : Ineffective airway clearance related to
excessive and Tenacious secretions.

Signs and Symptoms

An ineffective airway clearance is characterized by the
following signs and symptoms:
Abnormal breath sounds (crackles, rhonchi, wheezes)
Abnormal respiratory rate, rhythm, and depth
Dyspnea
Excessive secretions
Hypoxemia/cyanosis
Inability to remove airway secretions
Ineffective or absent cough
Orthopnea
 Nursing Interventions for Ineffective Airway Clearance
The following are the therapeutic nursing interventions for ineffective airway
clearance:

Nursing Interventions Rationales

Teach the patient the proper The most convenient way to

ways of coughing and
breathing. (e.g., take a deep
breath, hold for 2 seconds,
and cough two or three times
in succession).
remove most secretions is
coughing. So it is necessary
to assist the patient during
this activity. Deep breathing,
on the other hand, promotes
oxygenation before
controlled coughing.
Nursing Interventions
Educate the patient in the
following:
• Optimal positioning (sitting
position)
•Use of pillow or hand splints
when coughing
•Use of abdominal muscles for
more forceful cough
•Use of quad and huff techniques
•Use of incentive spirometry
•Importance of ambulation and
frequent position changes
Rationales
The proper sitting position and
splinting of the abdomen promote
effective coughing by increasing
abdominal pressure and upward
diaphragmatic movement. Controlled
coughing methods help mobilize
secretions from smaller airways to
larger airways because the coughing
is done at varying times. Ambulation
promotes lung expansion, mobilizes
secretions, and lessens atelectasis.
Nursing Interventions
Position the patient upright if
tolerated. Regularly check the
patient’s position to prevent sliding
down in bed.
Perform nasotracheal
suctioning as necessary,
especially if cough is ineffective.
Rationales
Upright position limits
abdominal contents from
pushing upward and inhibiting
lung expansion. This position
promotes better lung
expansion and improved air
exchange.
Suctioning is needed when
patients are unable to cough
out secretions properly due
to weakness, thick mucus
plugs, or excessive or
tenacious mucus production.

Nursing Interventions
•Explain procedure to patient
•Use well-lubricated soft
catheters
•Instruct the patient to take several
deep breaths before and after
nasotracheal suctioning procedure
and use supplemental oxygen, as
appropriate.
Rationales
This procedure can also stimulate a
cough. Frequency of suctioning
should be based on patient’s present
condition, not on preset routine, such
as every 2 hours. Over suctioning
can cause hypoxia and injury to
bronchial and lung tissue.
Using well-lubricated catheters
reduces irritation and prevents
trauma to mucous membranes.
Hyperoxygenation before, during, and after
suctioning prevents hypoxia.
 Nursing Interventions
•Stop suctioning and provide
supplemental oxygen if the patient
experiences bradycardia, an
increase in ventricular ectopy,
and/or significant desaturation.
•Use universal precautions:
gloves, goggles, and mask, as
appropriate.
Rationales
Oxygen therapy is recommended
to improve oxygen saturation and
reduce possible complications.
As protection against the blood-
related modes of transmission,
health care workers should use
universal precautions when
coming in contact with the blood
of all patients, or bodily fluids
containing blood.
 Nursing Interventions
Instruct patient about the need
for adequate fluid intake even
after hospital discharge.
Consider verbalization of feelings.
Explain further the effects of
smoking, including secondhand
smoke.
Rationales
Instruct patient about the need for
adequate fluid intake even after
hospital discharge.
Recognize reality of
situation. Anxiety adds to oxygen
demand, and hypoxemia potentiates
respiratory distress or cardiac
symptoms, which in turn increases
anxiety.
Chemical irritants and allergens can
increase mucus production and
bronchospasm.
 Nursing Interventions Rationales

Refer to the pulmonary

Consultants may be helpful in
clinical nurse specialist, home
ensuring that proper treatments
health nurse, or respiratory
are met.
therapist as indicated.
 2. Impaired Gas Exchange related to Activity
Intolerance
Nursing Assessment
Ongoing assessment is essential in order to identify potential
problems that may have lead to Activity Intolerance as well as
identify any issues that may arise during nursing care. Monitoring
the individual’s responses to activity are cue points in performing an
assessment related to activity intolerance:

Activity intolerance is a common side effect of

heart failure and can be related to generalized weakness and
difficulty resting and sleeping. A contributing factor is often
tissue hypoxia caused by decreased cardiac output.
 Assessment
Assess the physical activity level and
mobility of the patient.
•Take the resting pulse, blood pressure,
and respirations.
•Consider the rate, rhythm, and quality of
the pulse.
•If the signs are normal, have the patient
perform the activity.
•Obtain the vital signs immediately after
activity
•Have the patient rest for 3 minutes and
then take the vital signs again
Rationales
Provides baseline information for
formulating nursing goals during goal
setting.
Discontinue the activity if the patient
responds with:
•chest pain, vertigo, and/or dizziness
•decreased pulse rate, systemic blood
pressure, respiratory response
Reduce the duration and intensity of
the activity if:
•Pulse takes longer than 3 to 4
minutes to return to within 6-7 beats of
the resting pulse.
•RR increase is excessive after the
activity.
 Assessment
Investigate the patient’s
perception of causes of
activity intolerance.
Observe and monitor the
patient’s sleep pattern and
the amount of sleep achieved over
the past few days.
Assess the need for
ambulation aids (e.g., cane,
walker) for ADLs.
Rationales
Causative factors may be temporary
or permanent as well as physical or
psychological. Determining the cause
can help guide the nurse during
the nursing intervention.
Sleep deprivation and difficulties during
sleep can affect the activity level of the
patient – these needs to be addressed
before successful activity progression can
be achieved.
Assistive devices enhance the
mobility of the patient by helping him
overcome limitations.
 Planning

Planning for Health Restoration and maintenance

 Client positioning
Preventing Desaturation
Promoting Secretion
Clearance
Patient Education
Optimizing Oxygenation and ventilation
Preventing Atelectasis
 Health Restoration Induction of a return to a previous state, as a
return to health or replacement of a part to normal position.

Health maintenance is a guiding principle in health care that

emphasizes health promotion and disease prevention rather than the
management of symptoms and illness.

Patients best Position in Respiratory Distress

Prone positioning is widely used to improve oxygenation of patients
with acute respiratory distress syndrome (ARDS).
During prone positioning, ventilation is improved due to
changes in pleural pressure (PPL) and the amount of lung
atelectasis present. PPL is the sum of all forces acting to
compress the alveolus and includes the weight of tissue above
the alveolus and the transmitted pressure across the diaphragm
from the abdomen.

Care of the Proned Patient

Close monitoring of the patient, especially for the first hour,
after turning prone is necessary. 1. Reposition arms and head
to reduce pressure as tolerated. Consider turning patient's
head to the side and reverse the positioning of the patient's
arms.
https://www.va.gov/covidtraining/docs/Prone-
ceilinglift-Seattle.pdf
Patients admitted to the ICU for acute respiratory
failure frequently required intubation and invasive
mechanical ventilation. In the early stage of
management the invasive mechanical ventilation is
commonly delivered in a semi-recumbent supine
position under sedation with or without
neuromuscular blockade. Changing position is
important to break through the routine monotonic
delivery of mechanical ventilation and to favor the
clearance of respiratory secretions, the prevention of
pressure sores and ventilator acquired pneumonia,
and the improvement in lung volume and
oxygenation. On top of that, in the acute respiratory
distress syndrome (ARDS), the early and prolonged
prone positioning has been found to increase survival
in selected patients
 Respiratory desaturation, known as
hypoxemia in medical terms,
is when you have low blood
oxygen saturation. Your blood
oxygen saturation is a measure of
how much oxygen is in your blood.
A normal blood oxygen reading is
generally considered to be 95 to
100 percent .

Respiratory desaturation is when the amount of oxygen bound to your hemoglobin

drops below the normal level. Any condition that disrupts your body’s ability to
deliver adequate oxygen to your blood can cause respiratory desaturation. This
can vary from mild to life-threatening depending on how low your levels drop.
Respiratory Desaturation (Low Blood Oxygen) - Healthline
https://www.healthline.com › health › respiratory-desat...
 Normal Ranges of ABG Values

Value Description Normal Range

pH Acid-base balance of blood 7.35-7.45
PaO2 Partial pressure of oxygen 80-100 mmHg

PaCO2 Partial pressure of carbon dioxide 35-45 mmHg

HCO3 Bicarbonate level 22-26 mEq/L

SaO2 Calculated oxygen saturation 95-100%

Hypoxia and Hypercapnia

is defined as a reduced level of tissue oxygenation. Hypoxia has many causes,
ranging from respiratory and cardiac conditions to anemia. is a specific type of hypoxia
that is defined as decreased partial pressure of oxygen in the blood (PaO2), measured
by an arterial blood gas (ABG).
Atelectasis (at-uh-LEK-tuh-sis) is a complete or partial collapse of the entire lung or
area (lobe) of the lung. It occurs when the tiny air sacs (alveoli) within the lung
become deflated or possibly filled with alveolar fluid.
Atelectasis is one of the most common breathing (respiratory) complications after
surgery. It's also a possible complication of other respiratory problems, including
cystic fibrosis, lung tumors, chest injuries, fluid in the lung and respiratory weakness.
You may develop atelectasis if you breathe in a foreign object.

common cause of atelectasis

Atelectasis occurs from a blocked airway (obstructive) or pressure
from outside the lung (nonobstructive). General anesthesia is a
common cause of atelectasis. It changes your regular pattern of
breathing and affects the exchange of lung gases, which can cause the
air sacs (alveoli) to deflate.
 Alteration in Ventilation
 1. Acute and Chronic
 2. Obstructive Pulmonary Disease
 3. Pulmonary embolism
 4. Acute Respiratory Distress
syndrome
 5. Acute Lung injury
 6. Respiratory Failure
 7.Pneumonia
 8. Community acquired
 9. Ventilator Acquired
 10. Respiratory Pandemics
 11. pulmonary Hypertentson
 Alteration in Ventilation
 1. AECOPD An
acute exacerbation of
chronic obstructive
pulmonary disease
(AECOPD) is a clinical
diagnosis made when a
patient with COPD
experiences a sustained
(e.g., 24–48 h) increase in
cough, sputum
production, and/or
dyspnea. AECOPD has
clinical consequences
ranging from a self-
limited illness to
progressive respiratory
failure.
Symptoms
COPD symptoms often don't appear until significant
lung damage has occurred, and they usually worsen
over time, particularly if smoking exposure continues.
Signs and symptoms of COPD may include:
•Shortness of breath, especially during physical
activities
•Wheezing
•Chest tightness
•A chronic cough that may produce mucus (sputum)
that may be clear, white, yellow or greenish
•Frequent respiratory infections
•Lack of energy
•Unintended weight loss (in later stages)
•Swelling in ankles, feet or legs
Alteration in Ventilation
2. Chronic Obstructive Pulmonary Disease
Chronic Obstructive Pulmonary Disease, or COPD, refers to a
group of diseases that cause airflow blockage and
breathing-related problems. It includes emphysema and
chronic bronchitis.

Common symptoms of COPD include:

•increasing breathlessness – this may only
happen when exercising at first, and you may
sometimes wake up at night feeling breathless.
•a persistent chesty cough with phlegm that
does not go away.
•frequent chest infections.
•persistent wheezing.
https://www.nhs.uk › conditions › symptoms
Alteration in Ventilation
 Pulmonary embolism (PE) occurs when a blood clot gets stuck in
an artery in the lung, blocking blood flow to part of the lung. Blood clots
most often start in the legs and travel up through the right side of the
heart and into the lungs. This is called deep vein thrombosis .
Sign and symptoms of a Pulmonary
Embolism
•Sudden shortness of breath (most common)
•Chest pain (usually worse with breathing)
•A feeling of anxiety.
•A feeling of dizziness, lightheadedness, or
fainting.
•Irregular heartbeat.
•Palpitations (heart racing)
•Coughing and/or coughing up blood.
•Sweating.
https://www.hopkinsmedicine.org › conditions-and-
diseases
Alteration in Ventilation
 Acute respiratory distress syndrome (ARDS) is a serious lung
condition that causes low blood oxygen. People who
develop ARDS are usually ill due to another disease or a major
injury. In ARDS, fluid builds up inside the tiny air sacs of the
lungs, and surfactant breaks down.
https://www.nhlbi.nih.gov › health › ards
The signs and symptoms of ARDS can
vary in intensity, depending on its
cause and severity, as well as the
presence of underlying heart or lung
disease. They include:
•Severe shortness of breath
•Labored and unusually rapid breathing
•Low blood pressure
•Confusion and extreme tiredness
Alteration in Ventilation


Acute lung injury is a disorder of acute inflammation that causes

disruption of the lung endothelial and epithelial barriers. The alveolar–
capillary membrane is comprised of the microvascular endothelium,
interstitium, and alveolar epithelium.
https://www.ncbi.nlm.nih.gov › articles › PMC3133560
Alteration in Ventilation
Acute lung injury

Among the causes of epithelial injury are infections,

inflammation, toxic compounds, and trauma.

symptoms of a lung injury?

•Bluish coloring around nails and
lips. This means there's a lack of
oxygen in the blood.
•Chest pain, often when you inhale.
•Cough.
•Fever.
•Fast heart rate.
•Shortness of breath.
Alteration in Ventilation
Respiratory Failure
Respiratory failure is a serious condition that makes it difficult to
breathe on your own. Respiratory failure develops when the
lungs can't get enough oxygen into the blood. We breathe
oxygen from the air into our lungs, and we breathe out carbon
dioxide, which is a waste gas made in the body's cells.
https://www.nhlbi.nih.gov › health › respiratory-failure

4 TYPES Respiratory Failure:

•Type 1 (Hypoxemic ) - PO2 < 50 mmHg on room air. Usually seen in patients
with acute pulmonary edema or acute lung injury. ...
•Type 2 (Hypercapnic/ Ventilatory ) - PCO2 > 50 mmHg (if not a chronic
CO2 retainer). ...
•Type 3 (Peri-operative). ...
•Type 4 (Shock) - secondary to cardiovascular instability.

https://www.mcgill.ca › teaching › teaching-files › acute-r..

Symptoms include:
1. shortness of breath or feeling like you can't get enough air, 2. extreme
tiredness, 3. An inability to exercise as you did before, and sleepiness.
https://www.nhlbi.nih.gov › health › respiratory-failure
Alteration in Ventilation
Pneumonia
Pneumonia is an infection that inflames the air sacs in one or
both lungs. The air sacs may fill with fluid or pus (purulent
material), causing cough with phlegm or pus, fever, chills, and
difficulty breathing. A variety of organisms, including bacteria,
viruses and fungi, can cause pneumonia.
https://www.mayoclinic.org › pneumonia › syc-20354204

Common Causes of Pneumonia

Viruses, bacteria, and fungi can all cause pneumonia. In the United States,
common causes of viral pneumonia are influenza, respiratory syncytial virus (RSV),
and SARS-CoV-2 (the virus that causes COVID-19). A common cause of bacterial
pneumonia is Streptococcus pneumoniae (pneumococcus).
https://www.cdc.gov › pneumonia › causes
Alteration in Ventilation Pneumonia

Sign and Symptoms of

pneumonia
•a cough – which may be dry, or produce
thick yellow, green, brown or blood-
stained mucus (phlegm)
•difficulty breathing – your breathing may
be rapid and shallow, and you may feel
breathless, even when resting.
•rapid heartbeat.
•high temperature.
•feeling generally unwell.
•sweating and shivering.
https://www.nhs.uk › conditions ›
pneumonia
Alteration in Ventilation
Community-acquired pneumonia
Is lung infection that develops in people outside a
hospital. Many bacteria, viruses, and fungi can cause
pneumonia. The most common symptom of pneumonia is a
cough that produces sputum, but chest pain, chills, fever,
and shortness of breath are also common.
https://www.msdmanuals.com › ... › Pneumonia

Common causes — Streptococcus pneumoniae

(pneumococcus) and respiratory viruses are the most frequently
detected pathogens in patients with CAP.
https://www.uptodate.com › contents › overview-of-co...
 Alteration in Ventilation

Sign and Symptoms of

Community-Acquired
Pneumonia

•Shortness of breath.
•Coughing.
•Heavy sputum.
•Fever and chills.
•Chest pain that is worse when you
breathe or cough.
•Upper belly (abdomen) pain with
nausea, vomiting, or diarrhea.
https://www.cedars-sinai.org › diseases-
and-conditions
Alteration in Ventilation
Most Common Etiology of CAP by site of Care
Patient Type Etiology
Outpatient Streptococcus pneumonia,
Mycoplasma pneumonia,
Hemophilic influenza,
Chlamydia Pneumonia.
respiratory virus.
Inpatient (non ICU) S pneumonia, M pneumonia ,
C Pneumonia , H influenza ,
Legionella species ,aspiration ,
respiratory virus.
Inpatient (ICU) S pneumonia , Staphylococcus aureus ,
Legionella species , gram negative bacilli ,
H influenza .
Alteration in Ventilation
Ventilator Acquired Pneumonia
Ventilator-associated pneumonia is a lung infection that
develops in a person who is on a ventilator. A ventilator is a
machine that is used to help a patient breathe by giving oxygen
through a tube placed in a patient's mouth or nose, or through a
hole in the front of the neck. https://www.cdc.gov › hai › vap › vap

Common to get pneumonia on a ventilator

Ventilator-associated pneumonia (VAP) continues to be a major
problem in the care of intensive care unit (ICU) patients. The incidence
of VAP in mechanically ventilated patients is high, ranging from 10
to 30%.
https://erj.ersjournals.com › content
Alteration in Ventilation Sign and Symptoms of (VAP)

Ventilator-associated
pneumonia (VAP) occurs in
patients that have been on
mechanical ventilation for
more than 48 hours. It presents
with clinical signs that
include purulent tracheal
discharge, fevers, and
respiratory distress in the
presence of microorganisms.
https://www.ncbi.nlm.nih.gov ›
books › NBK507711
Alteration in Ventilation
Alteration in Ventilation

Ventilator Acquired Pneumonia

Alteration in Ventilation
Respiratory Pandemics

What are the known coronaviruses that

can infect people?
 Human coronaviruses are
capable of causing illnesses
ranging from the common cold
to more severe diseases such as
Middle East respiratory syndrome
(MERS, fatality rate ~34%). SARS-
CoV-2 is the seventh known
coronavirus to infect people, after
229E, NL63, OC43, HKU1, MERS-
CoV, and the original SARS-CoV.
https://en.wikipedia.org › wiki ›
Severe_acute_respiratory...
Alteration in Ventilation

Respiratory Pandemics
Philadelphia 1918: The Flu 1918 pandemic’s impact in
Pandemic Hits Home Central Texas was swift, deadly
Alteration in Ventilation
Respiratory Pandemics
What is the novel coronavirus?
The novel coronavirus is a new strain of coronavirus that has not been
previously identified in humans. The novel coronavirus has caused severe
pneumonia in several cases in China and has been exported to a range of countries
and cities.
Last February 12, 2020, the World Health Organization (WHO) announced that the
novel disease is officially called Coronavirus Disease 19 or COVID-19, and the virus
infecting it is referred to as COVID-19 virus.
https://doh.gov.ph › COVID-19 › FAQ

The lungs are the organs most affected by COVID‐19

COVID-19
https://en.wikipedia.org › wiki › Coronavirus_disease_2019
Alteration in Ventilation

Respiratory Pandemics

Where were first COVID-19 infections discovered?

The first known infections from SARS‐CoV‐2 were discovered in Wuhan,
China. The original source of viral transmission to humans remains unclear, as
does whether the virus became pathogenic before or after the spillover event.
SARS-CoV-2
https://en.wikipedia.org › wiki › Severe_acute_respiratory..
Alteration in Ventilation
Respiratory Pandemics
Watch for Symptoms
People with COVID-19 have had a wide range of symptoms reported – ranging from mild
symptoms to severe illness. Symptoms may appear 2-14 days after exposure to the virus. Anyone can
have mild to severe symptoms. People with these symptoms may have COVID-19:
•Fever or chills
•Cough
•Shortness of breath or difficulty breathing
•Fatigue
•Muscle or body aches
•Headache
•New loss of taste or smell
•Sore throat
•Congestion or runny nose
•Nausea or vomiting
•Diarrhea
This list does not include all possible symptoms. CDC will continue to update this list as we learn more
about COVID-19. Older adults and people who have severe underlying medical conditions like heart or
lung disease or diabetes seem to be at higher risk for developing more serious complications from
COVID-19 illness.
Alteration in Ventilation
Pulmonary hypertension
 Pulmonary hypertension is high blood pressure in the blood vessels that
supply the lungs (pulmonary arteries). It's a serious condition that can damage the
right side of the heart. The walls of the pulmonary arteries become thick and stiff,
and cannot expand as well to allow blood through.
Pulmonary hypertension - NHS
https://www.nhs.uk › conditions › pulmonary-hypertension

Some common underlying causes of pulmonary hypertension include high blood

pressure in the lungs' arteries due to some types of congenital heart disease,
connective tissue disease, coronary artery disease, high blood pressure, liver disease
(cirrhosis), blood clots to the lungs, and chronic lung diseases like emphysema .

Pulmonary Hypertension | cdc.gov

https://www.cdc.gov › heartdisease › pulmonary_hyper...
Alteration in Ventilation Pulmonary hypertension
Pulmonary hypertension cannot
be cured, but treatments can reduce
your symptoms and help you
manage your condition. If the cause
is identified and treated early, it may
be possible to prevent permanent
damage to your pulmonary arteries,
which are the blood vessels that
supply your lungs.

Treatment pulmonary hypertension. -

NHS
https://www.nhs.uk › conditions ›
treatment
Alteration in Ventilation
Pulmonary hypertension
Symptoms of pulmonary hypertension include:
•shortness of breath
•tiredness
•feeling faint or dizzy
•chest pain (angina)
•a racing heartbeat (palpitations)
•swelling (oedema) in the legs, ankles, feet or tummy
(abdomen)
The symptoms often get worse during exercise,
which can limit your ability to take part in physical
activities.
If you have a type of pulmonary hypertension known
as pulmonary arterial hypertension (PAH), you may
not have any symptoms until the condition is quite
advanced.
Alteration in Ventilation
Pneumothorax
A Pneumothorax is a
collapsed lung. A pneumothorax
occurs when air leaks into the space
between your lung and chest wall.
This air pushes on the outside of your
lung and makes it collapse. A
pneumothorax can be a complete
lung collapse or a collapse of only a
portion of the lung.
A Pneumothorax can be
caused by a blunt or penetrating
chest injury, certain medical
procedures, or damage from
underlying lung disease. Or it may
occur for no obvious reason.
Symptoms usually include sudden
chest pain and shortness of breath.
On some occasions, a collapsed lung
can be a life-threatening event.

Treatment for a pneumothorax usually involves inserting a needle or chest

tube between the ribs to remove the excess air. However, a small
pneumothorax may heal on its own.
Alteration in Ventilation
Pneumothorax

Collapsed and normal lung

In a collapsed lung, air from the lung leaks into the chest cavity.
The example shown is a complete left pneumothorax.
Alteration in Ventilation
Pneumothorax
Symptoms normally come on almost
immediately and commonly begin with chest
pain. Other signals that the problem may be
a collapsed lung are:
•Sharp, stabbing chest pain that worsens
when trying to breath in
•Shortness of breath
•Bluish skin caused by a lack of oxygen
•Fatigue
•Rapid breathing and heartbeat
•A dry, hacking cough
Symptoms, Diagnosis and Treating Pneumothorax
https://www.lung.org › lung-disease-lookup › symptoms-...
 Implementation
A. Medical / Surgical Management C. Nutritional and Diet
Therapy
1. Mobilization of Secretion 1. Tube Feeding
2. Artificial Airway Management 2. Fluid therapy
3. Administering Oxygen Therapy 3. High CHON , High Calorie
4. Mechanical Ventilation Supplements
5. Thoracic Surgeries
6. Lung Transplantation

B. Pharmacologic Management Complementary and Alternative

medicines
1. Echinacea
2. Goldenseal
3. Zinc
 Medical / Surgical Management
What is ventilation
management?
 Proper management of mechanical
ventilation also requires an
understanding of lung pressures and
lung compliance. Normal lung
compliance is around 100 ml/cmH20.
This means that in a normal lung the
administration of 500 ml of air via
positive pressure ventilation will
increase the alveolar pressure by 5
cm H2O.
Ventilator Management - PubMed
 https://pubmed.ncbi.nlm.nih.gov › .
What is ventilation surgery ?
 A mechanical ventilator is a
machine that helps a patient
breathe (ventilate) when they are
having surgery or cannot breathe
on their own due to a critical
illness. The patient is connected to
the ventilator with a hollow tube
(artificial airway) that goes in their
mouth and down into their main
airway or trachea.
 Mechanical Ventilation -
Cleveland Clinic
 https://my.clevelandclinic.org ›
health › articles › 15368-..
Implementation
The two main types
of mechanical
ventilation include

1. Positive pressure
ventilation where air
is pushed into the
lungs through the
airways.
2. Negative pressure
ventilation where air
is pulled into the
lungs
Implementation

Positive vs. Negative Pressure Breathing

Air moves from high to low pressure

Positive Pressure Negative Pressure

 Normally, the pressure  If one Changes palm
gradient is produced by
Ex: bag , cpr , mouth to
changing.
mouth
 In terms of the Pressure
Gradient Force the
gradient is the change in
pressure from areas of
higher pressure into areas
of lower pressure.
Implementation

Positive pressure ventilation Negative pressure ventilation

Describes the process of either Is mechanical ventilation in which

using a mask or, more negative pressure is generated on
commonly, a ventilator to deliver the outside of the chest and
breaths and to decrease the work of transmitted to the interior to expand
breathing in a critically ill patient. the lungs and allow air to flow in.

Positive Pressure Ventilation - StatPearls - NCBI Negative Pressure Ventilation - an overview |

Bookshelf ScienceDirect Topics
https://www.ncbi.nlm.nih.gov › books › NBK560916 https://www.sciencedirect.com › medicine-and-dentistry

Higher air pressures are positive, and lower air

pressures are negative.
Implementation
Mobilization of secretions

Mucus in the lungs is known as phlegm or sputum.

It is a common symptom in chronic lung diseases such
as COPD (including chronic
bronchitis and emphysema), cystic
fibrosis, bronchiectasis, NTM lung disease or asthma.

Too much mucus in the lungs:

More than just an unpleasant nuisance, mucus that collects in your airways can
make breathing more difficult and increase your risk of infection, which can
further damage your lungs. Living with a chronic lung disease means you are likely
experiencing an excess of this thick and sticky fluid in your lungs.
Understanding Mucus in Your Lungs | American Lung Association
https://www.lung.org › blog › lungs-mucus
Implementation Mobilization of secretions

How do you mobilize secretions?

 Frequent repositioning, deep breathing and coughing, chest
physiotherapy, postural drainage, oral and parenteral hydration,
and supplemental humidification all help to thin and mobilize
secretions. Tubing from an external moisture source accumulates
moisture and will need frequent draining.
Nursing Care: Mobilizing Secretions - RN.com
https://lms.rn.com › courses › page357

Excessive Pulmonary mucus causes a lifetime of pulmonary inflammation,

impaired breathing, and lung infections. To maintain lung function and avoid potentially
fatal infections, patients must undergo a rigorous daily regimen to remove pulmonary
secretions.

Clearing away pulmonary secretions : Nursing2022 - Lippincott

https://journals.lww.com › nursing › fulltext › clearing_a..
Implementation
Mobilization of secretions
Implementation
Mobilization of secretions
Implementation
Artificial Air Management

Management of the Artificial Airway includes securing the tube

to prevent dislodgement or migration as well as removal of
secretions. Preventive measures include adequate humidification
and appropriate airway suctioning. Monitoring airway patency and
removing obstruction are potentially life-saving components of
airway management. Cuff pressure management is important for
preventing aspiration and mucosal damage as well as assuring
adequate ventilation. A number of new monitoring techniques have
been introduced, and automated cuff pressure control is becoming
more common. The respiratory therapist should be adept with all
these devices and understand the appropriate application and
management.
Management of the Artificial Airway - Respiratory
Carehttps://rc.rcjournal.com › content
Implementation
Artificial Air Management

Management of the artificial airway is one of the core competencies

of the bedside respiratory therapist. Airway management includes securing
the tracheal tube, monitoring tube position, maintaining patency,
and appropriate regulation of cuff pressure. There are a number of
methods for securing tubes from simple adhesive tape to more complex
devices that combine bite block, a method for moving the tube to prevent
skin breakdown and mucosal ulceration, and a fixation system.
Implementation
Artificial Air Management
Maintaining airway patency includes routine treatments, such
as humidification of inspired gases and suctioning, as well as
techniques to reduce biofilm or clear obstruction. Monitoring cuff
pressure is a time-honored activity to maintain a balance between
adequate lower airway protection from silent aspiration and
minimizing mucosal damage. Automated cuff pressure management
is a new method to achieve this result that is gaining popularity.
Implementation Artificial Air Management
Securing the Airway
Following placement of an artificial airway,
securing the tube to prevent accidental
removal or unintended migration is
recommended.2 Both unplanned
extubation and right main bronchus
intubation have severe consequences,
including barotrauma, aspiration, airway
injury, and death.3 As a result, early
homemade securing techniques included
adhesive tape and occasionally sutures in
an effort to assure placement.
Commercially available devices now use
Velcro, adjustable straps, bite blocks,
barrier materials to protect skin, and
adjustable tube-positioning devices.
Implementation Administering Oxygen Therapy
Oxygen administration may be
initiated for a variety of reasons. Increased
metabolic demand, maintenance of
oxygenation while providing anesthesia,
supplementation during treatment of lung
illnesses that affect oxygen exchange,
treatment of headaches, carbon monoxide
exposure are a few examples for its
initiation. Oxygen is necessary for basic
metabolic demand in the body, and it is an
important part of resuscitation in many
acute illnesses, as well as maintenance of
chronic hypoxemic diseases.
Oxygen Administration - StatPearls - NCBI Bookshelf
https://www.ncbi.nlm.nih.gov › books › NBK551617
Implementation Administering Oxygen Therapy
The goal of oxygen delivery is to maintain targeted SpO2 levels in children
through the provision of supplemental oxygen in a safe and effective way which is
tolerated by infants and children to:
•Relieve hypoxaemia and maintain adequate oxygenation of tissues and vital
organs, as assessed by SpO2 /SaO2 monitoring and clinical signs.

1. Give oxygen therapy in a way which prevents excessive CO2 accumulation - i.e.
selection of the appropriate flow rate and delivery device.

2. Reduce the work of breathing.

3. Ensure adequate clearance of secretions and limit the adverse events of

hypothermia and insensible water loss by use of optimal humidification (dependent
on mode of oxygen delivery).

4.Maintain efficient and economical use of oxygen.

Implementation Administering Oxygen Therapy

Definition of terms
1. FiO2: Fraction of inspired oxygen (%).
2. PaCO2: The partial pressure of CO2 in arterial blood. It is used to assess the adequacy
of ventilation.

3. PaO2: The partial pressure of oxygen in arterial blood. It is used to assess the adequacy
of oxygenation.

4. SaO2: Arterial oxygen saturation measured from blood specimen.

5. SpO2: Arterial oxygen saturation measured via pulse oximetry.
6. Heat Moisture Exchange (HME) product: are devices that retain heat and moisture
minimizing moisture loss to the patient airway.
7. High flow: High flow systems are specific devices that deliver the patient's entire
ventilatory demand, meeting, or exceeding the patients Peak Inspiratory Flow Rate
(PIFR), thereby providing an accurate FiO2. Where the total flow delivered to the patient
meets or exceeds their Peak Inspiratory Flow Rate the FiO2 delivered to the patient will be
accurate.
Implementation Administering Oxygen Therapy
Definition of terms
8. Humidification is the addition of heat and moisture to a gas. The amount of water
vapour that a gas can carry increases with temperature.
9. Hypercapnea : Increased amounts of carbon dioxide in the blood.
10. Hypoxaemia : Low arterial oxygen tension (in the blood.)
11. Hypoxia: Low oxygen level at the tissues.
12. Low flow: Low flow systems are specific devices that do not provide the patient's
entire ventilatory requirements, room air is entrained with the oxygen, diluting the
FiO2.
13. Minute ventilation: The total amount of gas moving into and out of the lungs per
minute. The minute ventilation (volume) is calculated by multiplying the tidal volume
by the respiration rate, measured in litres per minute.
14. Peak Inspiratory Flow Rate (PIFR): The fastest flow rate of air during inspiration,
measured in litres per second.
15. Tidal Volume: The amount of gas that moves in, and out, of the lungs with each
breath, measured in millilitres (6-10 ml/kg).
16. Ventilation - Perfusion (VQ) mismatch: An imbalance between alveolar ventilation
and pulmonary capillary blood flow.
Implementation Nurse initiated oxygen
OXYGEN THERAPY – STANDING MEDICAL
Administering Oxygen Therapy ORDERS FOR NURSES

•Both hypoxaemia and hyperoxaemia are harmful.

•Oxygen treatment should be commenced or

increased to avoid hypoxaemia and should be
reduced or ceased to avoid hyperoxaemia

•For children receiving oxygen therapy

SpO2 targets will vary according to the age of the
child, clinical condition and trajectory of illness.

Oxygen treatment is usually not necessary

unless the SpO2 is less than 92%.
That is, do not give oxygen if the SpO2 is ≥
92%.
Clinical Guidelines (Nursing) : Oxygen delivery
https://www.rch.org.au › rchcpg › Oxygen_delivery
Implementation
Mechanical Ventilation

 Mechanical Ventilation is a method to mechanically assist or

replace spontaneous breathing.
 A Ventilator is a device used to provide assisted respiration and
positive-pressure breathing .
 Mechanical Ventilation is the use of mechanical device (machine)
to inflate and deflate the lungs.

Care Essentials for Patients on Mechanical Ventilation

1. Maintain a patent airway. ...
2.Assess oxygen saturation, bilateral breath sounds for adequate air
movement, and respiratory rate per policy.
3.Check vital signs per policy, particularly blood pressure after a ventilator
setting is changed.
Implementation Mechanical Ventilation
Mechanical ventilation can partially or fully replace spontaneous
breathing. Its main purpose is to improved gas exchange and decreased work of
breathing by delivering preset concentrations of oxygen at an adequate tidal
volume. An artificial airway (endotracheal tube) or tracheostomy is needed to a
client requiring mechanical ventilation. This therapy is used most often in clients
with hypoxemia and alveolar hypoventilation. Although the mechanical ventilator
will facilitate movement of gases into and out of the pulmonary system, it cannot
guarantee gas exchange at the pulmonary and tissue levels. Caring for a client on
mechanical ventilation has become an indispensable part of nursing care in critical
care or general medical-surgical units, rehabilitation facilities, and the home care
settings. Ventilator-associated pneumonia (VAP) is a significant nosocomial
infection that is associated with endotracheal intubation and mechanical
ventilation.
Implementation Mechanical Ventilation
The major goals for a client receiving mechanical
ventilation include improvement of gas exchange,
maintenance of a patent airway, prevention of trauma,
promoting optimal communication, minimizing anxiety, and
absence of cardiac and pulmonary complications.

Mechanical Ventilation used to:

1. Improve oxygenation
2. Improve ventilation (CO2 removal )
3. Unload respiratory muscles

A support until patients conditions improves

Implementation

Thoracic Surgeries

Thoracic surgery refers to operations on organs in the

chest, including the heart, lungs and esophagus. Examples
of thoracic surgery include coronary artery bypass surgery,
heart transplant, lung transplant and removal of parts of
the lung affected by cancer. Specialized thoracic surgeons
treat lung and esophageal cancer, while specialized
cardiac surgeons treat the heart.

Types of Thoracic Surgeries for Cancer | CTCA

https://www.cancercenter.com › ... › Surgery
Implementation
Thoracic Surgeries

Most common thoracic surgery

The most frequent thoracic
surgeries are performed for the
treatment of primary lung cancer and
pleural mesothelioma. For lung cancer,
the standard procedures
are pneumonectomy and lobectomy
with associated mediastinal
lymphadenectomy.
[Thoracic surgery: the major surgical procedures] -
PubMed
https://pubmed.ncbi.nlm.nih.gov › ...
Implementation
Thoracic Surgeries

cardiac surgery and

thoracic surgery
Cardiac surgeons concentrate
on heart problems only, while
cardiothoracic surgeons perform a
wide range of surgeries on different
organs in the thorax. Cardiac
surgeons often follow up with their
patients for longer periods to provide
post-operative care and monitor the
condition of their patients.
Implementation
Thoracic Surgeries
A thoracotomy is when a surgeon goes between your ribs to get to
your heart, lungs, or esophagus to diagnose or treat an illness.
It's a major operation, and doctors usually don’t use it if something simpler
will work just as well. Your doctor might recommend a thoracotomy to:
•Take out part or all of a lung or a growth on a lung
•Reinflate a collapsed lung
•Take out a blood clot, tumor, or lymph node
•Repair your heart
•Remove a cyst in your chest
•Repair your diaphragm
•Remove part of your chest wall
In the emergency room, medical teams sometimes need to do a
thoracotomy if someone has a punctured heart.
Implementation Lung Transplantation
A lung transplant is an operation to remove and replace
a diseased lung with a healthy human lung from a donor. A
donor is usually a person who's died, but in rare cases a section
of lung can be taken from a living donor. .
Lung transplant - NHS
https://www.nhs.uk › conditions › lung-transplant

Lung transplantation, or pulmonary transplantation, is a

surgical procedure in which one or both lungs are replaced by
lungs from a donor. Donor lungs can be retrieved from a living
or deceased donor. A living donor can only donate one lung
lobe.
Implementation
Lung Transplantation
Biggest problem with lung transplants

Infection. The risk of infection for people

who have received a lung transplant is
higher than average for a number of
reasons, including: immunosuppressants
weaken the immune system, which
means an infection is more likely to take
hold and a minor infection is more likely
to progress to a major infection.
Lung transplant - Risks - NHS
https://www.nhs.uk › conditions › lung-transplant › risks
Implementation
Lung Transplantation
After a lung transplant
It usually takes at least 3 to 6
months to fully recover from
transplant surgery. For the first
6 weeks after surgery, avoid
pushing, pulling or lifting
anything heavy. You'll be
encouraged to take part in a
rehabilitation programme
involving exercises to build up
your strength.
Implementation Lung Transplantation
Some complications from lung
transplantation may include, but are not
limited to, the following:

•Bleeding.
•Infection.
•Blockage of the blood vessels to the
new lung(s)
•Blockage of the airways.
•Severe pulmonary edema (fluid in the
lung)
•Blood clots.
Lung Transplantation Risks | Stanford Health Care
https://stanfordhealthcare.org › complications
Implementation
Pharmacologic Management Complementary and
Alternative Medicines

Echinacea
Goldenseal
Zinc

Nutritional and Diet Therapy

Tube feedings
Fluid therapy
High CHON , High Calorie Supplements
Implementation
Pharmacologic Management Complementary
and Alternative Medicines

Complementary and alternative medicine are medicines and

health practices that are not usually used by doctors to treat
cancer.
1. Complementary medicine is used in addition to standard treatments.
2. Alternative medicine is used instead of standard treatments.
Complementary and Alternative Medicine - CDC
https://www.cdc.gov › cancer › survivors › patients › com
Implementation
Pharmacologic Management Complementary
and Alternative Medicines

Examples of complementary and alternative medicine include—

•Acupuncture.
•Tai chi, yoga, and other mind-body therapies.
•Vitamins, herbs, and other nutritional therapies.
•American Indian and Alaska Native traditional healing practices.
Talk to your doctor before you start any kind of complementary
or alternative medicine, even for managing side effects from
standard treatment. Complementary and alternative medicines
may make standard cancer treatments not work as well.
Implementation Pharmacologic Management
Complementary and Alternative Medicines
Implementation Pharmacologic Management Complementary
and Alternative Medicines
Medicinal uses of echinacea
Today, people use echinacea
to shorten the duration of
the common cold and flu,
and reduce symptoms, such
as sore throat (pharyngitis),
cough, and fever. Many
herbalists also recommend
echinacea to help boost the
immune system and help the
body fight infections.

Echinacea Information | Mount Sinai -

New York
https://www.mountsinai.org › health-
library › herb › echi.
Implementation Pharmacologic Management Complementary
and Alternative Medicines
Can echinacea be taken with other medications?
No significant herb-drug interactions with echinacea have been
reported; adverse effects reported generally have been uncommon
and minor, including abdominal upset, nausea, and dizziness.
Echinacea - AAFP
https://www.aafp.org › pubs › afp › issues

It is commonly used for colds or sore throats caused by

cold viruses. However, there is limited evidence that echinacea
helps colds or similar illnesses. The FDA has not approved
this herb for any medical use.
Implementation
Pharmacologic Management Complementary
and Alternative Medicines
What is goldenseal used for in medicine?
It is commonly used to treat several skin, eye, and mucous membrane
problems, such as sinusitis, pink eye, and urinary tract infections. It is also
available in mouthwashes for sore throats and canker sores. Not many
scientific studies have looked at goldenseal.
Goldenseal Information | Mount Sinai - New York
https://www.mountsinai.org › health-library › herb › gold
Implementation Pharmacologic Management Complementary
and Alternative Medicines

Who should not take goldenseal?

Do not use this product without medical advice if you are pregnant.
Goldenseal is considered likely unsafe to use if you are nursing a baby.
Goldenseal should not be given to a newborn baby because it may cause
brain damage. Do not give any herbal/health supplement to a child without
medical advice.
Goldenseal Uses, Side Effects & Warnings - Drugs.com
https://www.drugs.com › mtm › goldenseal

Side effects of goldenseal include irritation of the mouth and

throat, nausea, increased nervousness, and digestive problems,
however, side effects are rare. The liquid forms of goldenseal are
yellow-orange and can stain.
Goldenseal: Benefits, Side Effects, Dosage, and Interactions
https://www.verywellhealth.com › goldenseal-what-should..
Implementation Pharmacologic Management
Complementary and Alternative
Medicines
What is zinc used for in medication?
It's needed for immune
function, wound healing, blood
clotting, thyroid function, and much
more. It also plays a key role in
maintaining vision and might have
effects against viruses. People
commonly use zinc for zinc
deficiency, diarrhea, and Wilson
disease.
ZINC: Overview, Uses, Side Effects, Precautions,
Interactions ... - WebMD
https://www.webmd.com › vitamins › ingredientmono-982
Implementation Pharmacologic Management
Complementary and Alternative Medicines
Zinc
Zinc is an essential trace mineral, so you get it through the
foods you eat. Next to iron, zinc is the most common
mineral in the body and is found in every cell. It has been
used since ancient times to help heal wounds and plays an
important role in the immune system, reproduction, growth,
taste, vision, and smell, blood clotting, and proper insulin
and thyroid function.

Your body doesn't need a large amount of

zinc. The recommended daily allowance for
adults is 8 - 11 mg. common to have slightly
low levels of zinc, but taking a multivitamin,
plus eating a healthy diet, should give you all
the zinc you need.
Implementation Pharmacologic Management
Complementary and Alternative Medicines
It's rare for people in industrialized
countries to be seriously deficient in zinc. Low
zinc levels are sometimes seen in the elderly,
alcoholics, people with anorexia, and people on
very restricted diets. People who have
malabsorption syndromes, such as Crohn's
disease or celiac disease, may also be deficient
in zinc.
Symptoms of zinc deficiency include loss of
appetite; poor growth; weight loss; lack of taste
or smell; poor wound healing; skin problems
such as acne, atopic dermatitis and psoriasis;
hair loss; lack of menstrual period; night
blindness; white spots on the fingernails; and
depression.
Implementation
Nutritional and Diet Therapy
(Tube Feeding)
How do ventilated patients
get nutrition?
Mechanically ventilated
patients are unable to take food
orally and therefore are dependent
on enteral nutrition for provision of
both energy and protein
requirements. Enteral nutrition is
supportive therapy and may impact
patient outcomes in the intensive
care unit.
Enteral Nutrition in the Mechanically Ventilated
Patient - PubMed
https://pubmed.ncbi.nlm.nih.gov › .
Implementation Nutritional and Diet Therapy
(Tube Feeding)
The nutrients within the tube feed are
similar to what you would get from normal
food, and are also digested in the same
way. Tube feeds contain all the nutrients
you need on a daily basis,
including carbohydrates, protein, fat,
vitamins, minerals, and water.
Prior to accessing a NGT/OGT for any
reason nursing staff members must ensure
that the tube is located in the stomach.
Coughing, vomiting and movement can move
the tube out of the correct position. The
position of the tube must be checked: Prior to
each feed.
Enteral feeding and medication administration
https://www.rch.org.au › rchcpg › Enteral_feeding_and...
Implementation Nutritional and Diet Therapy
(Tube feeding)
Correlations between nutritional status and respiratory function,
effects of nutritional substrates on respiration, and optimal nutritional support during
respiratory failure are reviewed. Somatic protein depletion is common in
patients with either acute respiratory failure or chronic obstructive pulmonary
disease. The etiology of the malnutrition includes decreased nutrient intake,
increased work of breathing, and increased metabolic rate caused by infections.
Excessive administration of glucose or protein can have detrimental effects on
respiratory status. Weaning patients from ventilators may be prolonged or even
impossible secondary to increased carbon dioxide production in patients receiving
high caloric loads of glucose. Excessive protein administration stimulates ventilatory
drive and can be detrimental in patients who cannot increase their minute ventilation.
Fat is the preferred substrate for energy in selected mechanically ventilated patients
requiring total parenteral nutrition because it is oxidized at a lower respiratory
quotient than glucose. Measurements of respiratory quotient, oxygen consumption,
and carbon dioxide production can be useful in providing optimal nutritional support
to the patient with respiratory compromise.
Implementation Nutritional and Diet Therapy
(Fluid Therapy)

Fluids & Nutrition

Encouraging a balanced healthy diet and fluid intake can influence
general health, the ability to recover from an illness and resistance to disease. Poor
diet and fluid intake are recognised as major contributory risk factors for ill health
and premature death.
Fluids & Nutrition - The Access Group
https://www.theaccessgroup.com › elearning-courses › flu.

Fluid Therapy is the administration of fluids to a patient as a

treatment or preventative measure. It can be administered via an
intravenous, intraperitoneal, intraosseous, subcutaneous and oral
routes. 60% of total bodyweight is accounted for by the total body water.
Implementation Nutritional and Diet Therapy
(Fluid Therapy)

Signs and symptoms Signs and

of malnutrition include symptoms
: of dehydration in
•Unintentional weight loss clude:
•Decreased muscle mass
•Lightheadedness and 1. Thirst
dizziness 2. Dry skin
•Inability to keep warm 3. Fatigue
•Constipation or diarrhea 4. Sluggishness
•Difficulty swallowing 5. Dizziness
•Sore mouth or swollen and 6. Confusion
bleeding gums 7. Nausea
•Recurrent infections
•Fatigue or weakness
•Bloated abdomen
Implementation Nutritional and Diet Therapy
(High Calorie Supplements)

High in Protein and Calories

1. Meat, fish, and poultry.
2. Milk and milk products. Add
powdered milk to other foods (such
as pudding or soups) to boost the
protein.
3. Eggs.
4. Cooked beans and legumes.
5. Peanut butter, nuts, and seeds.
6. Tofu.
7. Cheeses.
8. Protein bars.
Implementation Nutritional and Diet Therapy
(High Calorie Supplements)
High calorie diet used for:
It is a meal plan with extra calories and protein. You may need this diet if you
have certain health conditions that increase your body's need for protein
and calories. Some of these health conditions include cancer, HIV, AIDS,
wounds (such as pressure injuries and burns), and malnutrition.
High Protein / High Calorie Diet - What You Need to Know
https://www.drugs.com › high-protein-high-calorie-die
 Implementation Nutritional and Diet Therapy
(High Calorie Supplements)
Importance of nutrition in Malnutrition is common in patients who
ventilated patients are mechanically ventilated. Poor
nutritional status contributes to impaired
Inadequate nutrition has been respiratory muscle function, lung structure,
associated with impaired immune ventilatory response, and resistance to
response, increased susceptibility infection. By detecting malnutrition in its
to infection, poor wound healing, early stages, carefully calculating energy
and neuromuscular impairment. needs, determining appropriate nutrition
These factors lead to prolonged support, and avoiding nutrition support
dependence on ventilators, protracted complications, medical-surgical nurses can
length of stay, and increased morbidity provide effective nutrition care to
and mortality. mechanically ventilated patients. Improved
Improving Nutrition in Mechanically Ventilated nutritional status is associated with better
Patients - CEConnection
http://nursing.ceconnection.com › ovidfiles
pulmonary function and greater ease in
weaning from mechanical ventilation.
 Client Education

Continuing Education Activity

 Often changes to mechanical ventilator settings are performed
by health care providers that have limited training in specific functions
of the ventilator in use.
Mechanical ventilators are sophisticated and require training to ensure
positive outcomes and limit harm. Inappropriate setting changes, failure to
change alarms, changing settings without appropriate orders, and failure
to communicate changes to the medical team can result in poor patient
outcomes.
This activity is intended to guide health professionals to ensure that all
personnel trained are trained to set up, install, and make appropriate
adjustments to mechanical ventilation.
An interprofessional approach with communication between all members
of the interprofessional team will result in the safest delivery of care and
produce the best outcomes.
 Client Education
For safety, certain key features of mechanical ventilation are vital.
These include the following actions:
1. Communicate: Patients on mechanical ventilators are usually looked after by an
interprofessional group of healthcare professionals that may include an intensivist,
critical care nurse, nutritionist, infectious disease consult, respiratory therapist, primary
care physician, and a pulmonologist. For the patient to receive optimal care,
communication between each other is vital.

2. Check ventilator settings: When first entering the room of a patient on a

ventilator, check their vital signs, including pulse oximetry and the last arterial blood gas.
Auscultate the chest and determine if there are any significant changes from the previous
nursing shift. Assess the patient for comfort, distress, pain, and hemodynamic stability.
 Client Education
3. Ventilator management and respiratory therapist: The individual who
is best suited to manage, adjust, and document the ventilator is the respiratory therapist.
Secondly, to provide safe care to ventilated patients, the number of healthcare
professionals who are allowed to make adjustments to the ventilator should be limited

4. Alarms: All ventilators have alarm hush sounds when there is any change in ventilation.
A ventilator alarm should never be ignored or silenced without first checking the problem. It
is vital to know what to do when an alarm sounds on the ventilator.
 Client Education
5. Bag valve and mask: Every patient on a ventilator must have a bag valve
and mask located on the wall. This bag must be checked every day to make sure it
is in working order. When an alarm sounds on the ventilator, if the patient self-
extubates, when there is patient-ventilator dyssynchrony preventing the patient
from getting effective ventilation and oxygenation, when the endotracheal tube is
dislodged, a bag valve mask is required to oxygenate the patient manually until he
or she is reintubated.
 Client Education
6. Ventilator settings: The latest ventilators are sophisticated machines, and
each one has a slightly different setup, but medical professionals still have to
know some basic details about the equipment.

7. Modes of ventilation: The mode of ventilation will usually depend on many

patient variables.
8. Carbon dioxide detectors: The use of CO2 monitors has become routine
in most intensive care units.There are several types of monitors. The most basic
is the colorimetric monitors work by indicating a color change of the device
when CO2 is present. This is often used in emergency settings to verify ETT
placement as they are small portable devices.
 Client Education
9. Ventilator initiation: All manufacturers of ventilators highly recommend a
pre-operational check prior to the use of the ventilator on a patient. This precheck is
designed to check the integrity of the ventilator circuit, confirm the functioning of
the components, the humidifier system, and tubing.

10. Suctioning of ventilated patients: In general, all ventilated patients need regular
suctioning. Since these patients are not able to expectorate their secretions which
often collect in the airways, become viscous, and lead to respiratory distress. When
suctioning patients on a ventilator, look at the patient, and listen to the chest.

11. Check the position of the endotracheal tube: During the initial survey
of the intubated patient, the position of the endotracheal tube must be checked to
ensure that it has not slipped into the right mainstem bronchus. In some cases, the
endotracheal tube may be pulled up. The chest should be auscultated for equal
breath sounds, and then the length of the endotracheal tube inserted should be
checked.
 Client Education
Sedation: Having an endotracheal tube is very uncomfortable, and most
patients require some sedation. Thus, the patient should be assessed for pain and
anxiety. The sedation level of the patient can be assessed by the Ramsay sedation
and the Richmond agitation sedation scales. When an intubated patient is
agitated, the risk of self-extubation is very high. Therefore, it is best to sedate the
patient if the individual is not ready to be weaned.

13. Infection prevention: One problem with mechanical ventilation is the development
of pneumonia. Ventilator-associated pneumonia is not uncommon, and it adds significant
morbidity to the patient.

14. Hemodynamic stability: Patients on a ventilator need their respiratory and

cardiac status monitored closely. Most intensive care units monitor continuous pulse
oximetry and blood pressure. By maintaining stable hemodynamics, this also increases
tissue perfusion and enables early extubation. To maintain stable hemodynamics, some
patients may need continuous intravenous fluids, and others may require the use of
 Client Education
Hemodynamic stability: One of the key reasons
for admission into the ICU is hemodynamic
instability. Mechanical ventilation can alter
cardiac output and blood pressure. Potential
effects of mechanical ventilation include
increased pulmonary vascular resistance,
ventricular interdependence, and altered
autonomic responses . It is important to be able
to predict, anticipate, and proactively plan for
hemodynamic instability in the ventilated or
potentially future ventilated patients. • Monitor
cardiac and respiratory status closely, using
continuous pulse oximetry and blood pressure
(Williams & Sharma, 2020). • Determine need for
continuous intravenous fluids or pressor drugs
(i.e. norepinephrine)
 Client Education
15. Check the cuff pressure: Increased cuff pressure can lead to necrosis and stricture
formation of the trachea. Thus all hospitals have a policy on how much cuff pressure should be
used. The endotracheal tube cuff pressure must be in a range that ensures the delivery of
prescribed tidal volume and decreases the risk for aspiration of upper airway secretions that
accumulate above the cuff without compromising perfusion of the trachea. A cuff pressure of 20
to 30 cmH2O is recommended for the prevention of ventilator-associated pneumonia and
aspiration.
 Client Education
The cuff is inflated to seal the airway to deliver
mechanical ventilation. A cuff pressure between 20
and 30 cm H2O is recommended to provide an
adequate seal and reduce the risk of complications.
Lower cuff pressure may predispose the patient to
aspiration of oropharyngeal secretions and the
development of ventilator-associated pneumonia. Cuff
pressure should be measured at least once per shift to
maintain the pressure in the safe range to avoid
injury to the trachea and minimize the risk of
aspiration.
The cuff is designed to provide a seal with the airway,
allowing airflow through the ETT but preventing passage
 Client Education

16. Nutritional needs: Most patients on a mechanical ventilator are rapidly

extubated, and nutrition is generally started within 24 to 48 hours after intubation.
If the patient cannot be weaned off from the ventilator in 14 to 18 days and
requires a tracheostomy tube for prolonged ventilatory support, a percutaneous
gastrostomy tube (PEG) should be inserted at the same time for meeting the
nutritional goals

17. Weaning: At some point, the patient's ability to come off the ventilator
should be assessed. This can only be done if the patient is hemodynamically
stable, not having active MI, not going through delirium tremens, his or her
arterial blood gas is near normal limits, and the patient is tolerating 50% and
below FIO2 and positive end-expiratory pressure of 8 and below.
 Client Education

18. Ventilator failure: Every healthcare institution and long-term nursing home
which uses ventilators must have a backup plan for ventilation in case of a power
failure. In the event of a natural disaster, the institution may also require a generator to
power the machine. If the ventilator itself fails, a backup must be available.

19. Documentation: With the introduction of electronic health reporting (EHR), patient
information may be shared across the continuum of care both at the bedside and through
remote access. Thus, all ventilatory parameters should be entered in EHR with the time
and date. Some ventilators are electronically integrated with EHR, the pharmacy, and
medication delivery systems.
 Client Education
20. Guidelines and
Protocols: A committee with
the medical director and
respiratory therapist should help
set up the protocols and
guidelines for treatment. No
matter what protocol is
established, interprofessional
communication is vital when
looking after a ventilated patient.
Even the Joint Commission
mandates having standards
regarding the care coordination
of ventilated patients.
21. The patient's family: For most
families, it is frightening when a patient is
on a ventilator. Most people think that when
a patient is on a ventilator, it is a terminal
event. Thus, education is needed to teach the
family why ventilation is required and
emphasize the fact that most patients are
weaned off within a few days. Reinforce the
need for multiple assessments like chest X-
ray and arterial blood gases. Let the family
passively participate in the patient's care by
massaging the extremities, holding hands, or
speaking to the patient.
 Client Education
22. Competency and education: Mechanical ventilation of patients is a complex
endeavor. Because there are several types of machines and models, it is important to
regularly educate all the relevant personnel on the basic features of the machines. All
staff who care for ventilated patients must demonstrate competency; their knowledge
and skills must be Documented on a variety of ventilator settings. Almost all
respiratory and pulmonary boards recommend regular competency evaluations of all
providers of this invasive technique.
Ventilator Safety - StatPearls - NCBI Bookshelf
https://www.ncbi.nlm.nih.gov › books › NBK526044