Interventions for

Critically Ill Patients

with Respiratory
Problems
Demuel Dee L. Berto, RN, MD

Disorders of the
Pulmonary Vasculature
Pulmonary
Embolism
an occlusion of a
portion of the
pulmonary blood
vessels by an
embolus

Virchows triad:
1. Venous stasis
2. Hypercoagulable state
3. Vessel injury
Etiology:
Sites of thrombus formation:
1. Iliofemoral venous system most common
2. Prostatic veins
3. Pelvic veins

D/O of the Pulmonary Vasculature

Pulmonary Embolism

Precipitating factors:
1. Exercise
2. Straining on defecation

Other sources of
emboli:
6. Amniotic fluid 80-90%
1. Tumors
mortality
2. Air
- 1 per 20,00-30,000
deliveries
3. Fat Fx of long bones
7. Septic emboli
4. Bone marrow
8. Vegetations on heart
5. IV catheter
valves

D/O of the Pulmonary Vasculature

Pulmonary Embolism

Risk factors:
1. Previous surgery on the pelvis / legs.
2. Trauma of long bones.
3. Immobility

early ambulation
leg exercises

4. Obesity

weight loss

5. DVT
Homans sign
area

dont massage calf

- avoid restrictive clothing on legs

D/O of the Pulmonary Vasculature

Pulmonary Embolism

DV
T

Pathophysiolog
y

Emboli
single or
multiple

IVC

RV

Pulmonary
artery

obstruction

Resistance
to blood
flow
Pulmonar
y HPN
RV
strain
RV failure
Lungs have 3 sources of O2:
pulmonary circulation

Release of
humoral
substances

V/Q Mismatch

Vasoconstricti
on
throughout
lungs
Pulmonar
y
infarction
lungs, bronchial circulation,

D/O of the Pulmonary Vasculature

Pulmonary Embolism

Clinical manifestations:
Symptoms
1. Dyspnea at rest
2. Syncope w/ CO
3. Pleuritic chest pain when pulmonary
infarction occurs, stabbing, sharp during
inspiration
4. Cough
5. Hemoptysis pulmonary infarction
6. Feeling of impending doom

 Signs
Tachypnea,

tachycardia

Crackles
Pleural

friction rub
Diaphoresis
Low grade fever
Distended neck veins

D/O of the Pulmonary Vasculature

Pulmonary Embolism

Diagnostics:
1. Chest X Ray - usually Normal
- wedge-shaped density
- pulmonary infarction
2. ECG
- diff. Between MI & PE
- sinus tachycardia: most common
- peaked P waves, ST segment
abnormalities, LAD or RAD
3. ABGs

- PO2 : hypoxia
- PCO2: hyperventilation

alk.

- PCO2 pH : mild acute resp.

4. Perfusion scanning - blood is labeled

w/ radioactive tracer
5. Xenon ventilation scan patient
inhales tracer
6. Pulmonary angiography gold
standard , definitive and specific

 7.

Blood Coagulation Tests

Prothrombin Time
Evaluates the effectiveness of coumadin
(Vit. K)
1.5 to 2 times the normal or control
11 to 16 seconds

Partial Thromboplastin Time

Best single screening test for disorders of
coagulation
Evaluates the effectiveness of Heparin
(Protamine Sulfate)
Normal range is 60 70 secs

 Activated

Time

Partial Thromboplastin

Most specific test to evaluate

effectiveness of heparin
2 to 2.5 times the normal
30 45 secs

Collaborative Management
Problem:

Hypoxemia
O2 Therapy
Nasal canula or mask, ABGs and Pulse
Oximetry
Monitoring

V/S, Lung sounds, increasing DOB, NVE,

dysrhythmias, pedal edema

 Anticoagulation

Heparin IVP/infusion monitored by the

aPTT at 2 to 2.5 times the normal
Oral anticoagulation (warfarin) at 3rd day
of heparin and continues up to 3-6 weeks
Bleeding precautions
Thrombolytics

Streptokinase IV infusion
WOF for anaphylactic reaction and
bleeding

 Surgical

Management

Embolectomy removal of the embolus

or emboli from the pulmonary arteries
Inferior Vena Caval Interruption vena
caval filter

 Problem:

Decreased Cardiac Output

IV Fluids crystalloids
Watch out for RSHF
Drugs

Positive inotropes (Dobutamine)

Vasodilators (Nitroprusside)
Morphine for pain

Acute Respiratory Failure

Criteria

PaO2 < 60mmHg

SaO2 < 90%
PaCo2 > 50mmHg
Acidemia ( pH<7.30)

Classification
Ventilatory

Failure

Perfusion is normal but ventilation is

inadequate
Occurs when the thoracic pressure cannot
be changed sufficiently to permit
appropriate air movement into and out of
the lungs
Causes
Mechanical abnormality in the lung or chest
wall
Problem in the respiratory center in the brain
Impaired respiratory muscles

 Oxygenation

Failure

Lungs are able to move air sufficiently

but cannot oxygenate the pulmonary
blood properly
Ventilation is normal but perfusion is
decreased

 Combined

Ventilatory and
Oxygenation Failure
Involves insufficient respiratory
movements
( hypoventilation)
Gas exchange at the alveolar capillary
membrane is inadequate so that too
little oxygen reaches the blood and CO2
is retained

Causes

Ventilatory Failure

MS, MG, GBS, Polio, stroke, SCI, increased ICP,

kyphosis, sleep apnea, PE

Oxygenation Failure
Right to left shunting
Impaired diffusion of oxygen at the alveolar
levels
Abnormal hemoglobin levels

Combination
BA, Bronchitis, emphysema,

Adult Respiratory
Distress Syndrome
(ARDS)
Progressive form of
respiratory failure
characterized by
severe dyspnea,
refractory hypoxemia
diffuse bilateral infiltrates,
Non-cardiogenic bilateral
pulmonary edema
- Decrease pul. compliance

Etiologies and
Risk factors:
1. Aspiration
2. Drug ingestion
and overdose
3. Hematologic
disorder
4. oxygen toxicity
5. localized
infection

metabolic
disorders
6. shock
7. trauma
8. major surgery
9. fat/air embolism
10. sepsis
5.

Pathophysiology:
4 Phases
Phase 1- Initiation of ARDS
Macrophages and neutrophils adheres to the
capillary and alveolar walls and releases
chemical mediators, peptides, enzymes
Manifestations:
This stage involves dyspnea, esp on exertion
Respiratory and heart rates are normal to
high
Auscultation may reveal diminished breath
sounds
Management: O2 support

Phase II- Onset of Pulmonary Edema

Capillaries become permeable to
erythrocytes, proteins and plasma, thereby
increasing interstitial oncotic pressure
resulting to the movement of fluids to the
alveoli
Tachypnea with use of accessory muscle
Restless and apprehensive
Dry or frothy sputum, crackles
Elevated heart rate
Cool and clammy skin
Treatment: ET intubation, MV and
prevent complications

Phase III- Alveolar Collapse

Accumulated fluids inactivates surfactant
and damages type 2 cells causing
atelectasis
Days 2 to 10
involves obvious respiratory distress with
tachypnea
use of accessory muscle
tachycardia with arrythmias
cyanosis
diminished breath sound
crackles and ronchi
Maintain adequate O2 transport, prevent
complications

Phase IV End-stage ARDS

Fibrin and cells debris combine to form
hyaline membrane. Alveoli are less
compliant and no gas exchange occur
Day 10 onwards
decreasing respiratory and heart
rates
loss of consciousness
cyanosis
diminished to absent breath sounds
Treatment : preventing sepsis,
pneumonia, MODS

4 criteria:
1. Sudden onset
2. PaO2 / FiO2 ratio < 200
3. PCWP < 18 mmHg or no clinical
evidence of LHD
4. Bilateral pulmonary infiltrates

Diagnostic Tests:
1. ABG: hypoxemia and alkalosis
2. CXR: diffuse haziness, white
out appearance (ground glass)
3. Low PaO2 levels
4. Swan Ganz Catheter monitoring
decreased PCWP (<15mmHg)

Goals of Med Mgt.:

1. Respiratory Support
Hook to mechanical ventilators
Administer nitric oxide which dilates the
capillary bed of the lungs
High concentrations of supplemental O2
Surfactant replacement
Prone positioning
2. Maintenance of hemodynamic stability
Administer diuretics
Fluid restriction if fluids are to be
given, give crystalloids
Administer inotropic drugs

Treatment of underlying causes

3.

4.

Antibiotics
Steroids

Nutrition Therapy
- TPN or tube feedings as soon as possible

5.

Prevention of complications
Cardiac dysrhythmia due to
hypoxemia
Oxygen toxicity
Renal failure

Artificial Airway

Endotracheal Tube
An endotracheal tube is a long,
slender, hollow tube, inserted
into the trachea via the mouth
or nose. It passes through the
vocal cords, and the distal tip is
positioned just above the carina

Endotracheal tube

Major Indications for

Intubation

Airway protection when the client loses

reflexes because of anesthesia,
medications, disease, or decreased
LOC
To provide posiive pressure or high
oxygen concentration
To bypass airway obstruction
Facilitating pulmonary hygiene

Nursing Responsibilities:
1. Tube insertion
Explain procedure to the client and his
family and obtain informed consent.
Obtain the correct size for an oral ET
tube. (typical size is 7.5 mm for
women and 8 mm for man)
Administer medications as ordered to
decrease respiratory secretions,
induce analgesia, and help calm and
relax the conscious patient

Tube insertion
Remove dentures, if present
Auscultate breath sounds and
watch for chest movement to
ensure correct placement and
full lung ventilation.

Tube insertion

Secure

the tube firmly with

tape
A chest X-ray may be ordered
to confirm tube placement

Continuation
2.

Monitoring the cuff

Check pilot balloon and keep it
inflated.
Maintain cuff pressure at minimum.
(Keep it below 20 mmHg)
Assess patients ability to talk.
Auscultate for a slight hissing sound
at the peak of inspiration
Inspect for presence of food particles
when suctioning

3.

Suctioning
Assess for airway obstruction e.g.
restlessness, increased pulse and
respiration, presence of adventitious
breath sounds, visible mucus
bubbling in the airway, cyanosis
Hyperoxygenate client by increasing
flow rate; encourage deep breathing
Lubricate the suction catheter with
sterile water

Continuation

If tracheal suction is being used,

insert catheter to the end of the tube
(approximately 4 inches);

If nasotracheal suction is being used,

insert until the cough reflex is induced

APPLY NO SUCTION WHILE THE

CATHETER IS BEING INSERTED

Rotate and withdraw the catheter

while suction is applied; DO NOT
EXCEED 10-15 SECONDS

Clear the catheter with sterile solution

and encourage the client to breathe

Continuation
4.

Extubation (removal of endotracheal

tube)
Removed when client demonstrate
adequate blood oxygen levels, tidal
volume and spontaneous breathing
Have self-inflating bag and mask ready
in case ventilatory assistance is
required immediately after extubation.
Suction the tracheobronchial tree and
oropharynx, remove tape, then deflate
the cuff

Continuation
Give

oxygen for a few breaths,

then insert a new, sterile suction
catheter inside the tube
Have the patient inhale. At peak
of inspiration remove the tube
Place on supplemental O2
therapy

NOTE: Extubation is performed

with physicians orders and
carried out by health team
members capable of
reinserting the ET tube if
necessary!

Monitoring after extubation is essential

Monitor VS every hour initially. WOF
signs of Respiratory distress

Early signs include: mild dyspnea,

coughing and inability to expectorate
secretions, STRIDOR.

Sore throat and hoarseness for a few

days after extubation
Semi fowlers, deep breathing ans
incentive spirometry

Artificial Airway
Tracheostomy
Definition:
Tracheotomy
A surgical incision into
the trachea through
overlyng skin and
muscles for airway
management.

Definition
Tracheostomy
A surgical creation
of an opening or
stoma, into the
trachea through
which an indwelling
tube is inserted
Best route for longterm airway
maintenance

Indication for tracheostomy:

Relief of acute or chronic upper
airway obstruction
Access for continuous mechanical
ventilation
Prevention of aspiration
Promotion of pulmonary hygiene
Bilateral vocal cord paralysis
Prolonged endotracheal tube
insertion resulting in erosion or pain

Potential Complications:
Tracheal wall necrosis
Tracheal dilation
Tracheal stenosis
Airway obstruction
Infection
Accidental decannulation
Subcutaneous emphysema

Nursing Responsibilities:
1.
2.
3.
4.
5.
6.

Assess for adequate gas exchange

Monitor patency of airway
Monitor cuff of tube
Provide tracheostomy care
Perform suctioning
Provide adequate hydration

Continuation
7.

8.

9.
10.
11.

Secure tube
properly
Prevent or
assess for infection
Prevent aspiration
Avoid constipation
Provide alternative means of
communication

Mechanical Ventilation
Mechanical ventilation is use of a
mechanical device to instill a
mixture of air and oxygen into the
lungs

Indications:
Low PaO2 levels
Individuals incapable of spontaneous
breathing
Individuals with inadequate ventilation
Individuals with difficulty of expelling
CO2
Individuals with persistently high
blood pH

Goals of mechanical ventilation:

Maintain adequate ventilation
Deliver precise concentrations of
FiO2
Deliver adequate tidal volumes to
obtain an adequate oxygenation
Lessen the work of breathing in
clients who can not sustain
adequate ventilation on their own.

Modes of Mechanical Ventilation

Continuous Mechanical Ventilation

(CMV)
Ventilators deliver preset volume of
air during inspiration (tidal volume)
Takes full control of respiration
Does not allow spontaneous
breathing

Modes of Mechanical Ventilation

Assist / Control Ventilation (A/C)

Pt starts ventilation but ventilator
completes it
Ventilator delivers preset volume of air
during inspiration when client initiates it.
Respiratory rate is controlled by the clients
ability to initiate breathing
Has a back up mechanism. If the client does
not initiate breathing or inspiratory effort is
less than a preset number in a minute, the
ventilator takes charge of breathing until
the ability to initiate breath returns

Modes of Mechanical Ventilation

Intermittent Mandatory Ventilation

(IMV)
Ventilator delivers preset tidal
volume and respiratory rate
Allows spontaneous unassisted
between the preset breath
Commonly use in respiratory
weaning

Modes of Mechanical Ventilation

Positive End-Expiratory Pressure

(PEEP)
Preset amount of pressure stays in
the lungs at the end of exhalation
which keeps the alveoli open
Use in combination with CMV, A/C,
and IMV

Modes of Mechanical Ventilation

Continuous Positive Airway Pressure

(CPAP)
Similar to PEEP. Preset amount of
pressure stays in the lungs at the end of
exhalation which keeps the alveoli open
Use in clients who can breathe on their
own

Nursing Management
Monitoring patients response
Monitor VS
Auscultate BS every 30 to 60 minutes
initially
Observe secretions and suction promptly
Assess area around ET tube or
tracheostomy site q 4 hours for color,
tenderness , skin irritation and drainage
Psychological support

Continuation
Observe for signs of respiratory
insufficiency, such as tachypnea, cyanosis,
and changes in sensorium
Ascertain blood gases as ordered to
determine effectiveness of ventilation
Establish a means of communication
because client will be unable to speak
while on a ventilator
Evaluate clients response to procedure;
revise plan as necessary

 Managing the Ventilator System

Maintain ventilator settings TV, FiO2,
mode of ventilation etc.
Check water temperature and humification
Interventions for various causes of
ventilator alarms
Suctioning

Presence of secretions
Increased peak airway pressure
Presence of rhonchi and wheezes
Decreased breath sounds

 Preventing Complications
Cardiac hypotension and fluid retention
Avoid valsalva, adequate humidification, monitor
I and O, weight hydration and signs of
hypovolemia

Lungs barotrauma (due to positive

pressure) and volutrauma (due to excess
volume delivered to one lung over the
other) and AB abnormalities
Adjust ventilation settings, monitor response of
patient to MV, adjust fluids and correct
electrolyte imbalances

 GI and Nutritional Complications

stress ulcers antacids, PPIs , H2 receptor
blockers, TPN,
Low Carbohydrate and High fat diet
especially for COPD patients
Electrolyte replacement K, Ca, Mg, phos

Infection
Strict handwashing
Oral care and pulmonary hygiene
Chest physiotherapy and postural drainage

Muscular Complications
Due to immobility
Passive ROM while on ventilation

 Ventilator Dependence
Can be psychological or physiologic
The longer on ventilator the move difficult it
is to wean because the respiratory muscle
fatigue and cannot assume breathing
Techniques
Synchronus Intermittent Mandatory Ventilation
T Piece Technique
Pressure Support Ventilation

CHEST TRAUMA
Pneumothorax
life threatening situation wherein air
enters the pleural cavity causing a
lung to collapse partially or
completely on the affected side,
resulting in a reduction in tidal
volume and gas

Types:
1. Spontaneous
most common type of closed
pneumothorax
Air accumulates within the pleural
space without an obvious cause.
Rupture of a small bleb on the
visceral pleura most frequently
produces this type of pneumothorax

2.

Traumatic
Open Pneumothorax: Laceration
in the parietal pleura that allows
atmospheric air to enter inside.
Closed Pneumothorax- Laceration
in the visceral that allows air in
the lung to enter the pleural
space.

Assessment Findings
Diminished

breath sounds on
auscultation
Hyperresonance on percussion
Prominence of the involved side of the
chest, which moves poorly with
respirations
Deviation of the trachea away from
(closed) or toward (open) the affected
side

 Pleuritic

chest pain
Tachypnea
Subcutaneous emphysema

3.

Tension Air enters the

pleural space with
each inspiration but
cannot escape
Causes increased
intrathoracic pressure
and shifting of the
mediastinal contents
to the unaffected side
(mediastinal shift)

Assessment
Asymmetry

of the thorax
Tracheal deviation to the unaffected
side
Respiratory distress
Absence of breath sounds on one side
Distended neck veins
Cyanosis
Hypertympanic sound on percussion
over the effected side

Etiology/ Classification:
1. Penetrating common cause of
open pneumothorax
2. Blunt chest trauma- common cause
of close pneumothorax
3. Rupture of alveoli
4. Medical procedure

Lab. And Dx. Test:

Chest x-ray
Med. Mgt.
Closed Chest Drainage
Insertion of large bore needle at the
2nd ICS MCL of the affected side

Chest Tube
Use of tubes and suction to return negative
pressure to the intrapleural space and to
drain air from the intrapleural space,
To maintain negative pressure, the chest
tube is placed in the second or third
intercostal space
To drain blood or fluid, the catheter would
be placed at a lower site, usually the eighth
or ninth intercostal space
Also called closed thoracotomy tube (CTT),
chest tube drainage

Types of drainage:

One-chamber
system
one bottle serves
both as a water
seal and drainage
bottle

Types of drainage:

Two-chamber
system
1st bottle is
for drainage
2nd bottle is a
water seal

Types of drainage:

Three-chamber system
1st bottle is for drainage
2nd bottle is a water seal
3rd bottle is for suction

Types of drainage:

Commercially
prepared plastic
unit
e.g. Pleur-Evac
Combines the
features of the
other systems
and may or may
not be attached
to suction

Nursing Responsibilities:

Collection chamber
Monitor drainage, report if greater than
100ml per hour or if bright red or
increases suddenly
Mark chest tube drainage at 1-4 hour
intervals using a tape

Water seal
Monitor for fluctuation of the fluid level
in the water seal chamber
Fluctuation stops in obstruction,
looping, suction no working properly or
if the lung has not expanded

 In pneumothorax patients
intermittent bubbling in the water
seal chamber is expected but
continuous bubbling indicates an air
leak in the system
Assess respiratory status and lung
sounds
Keep drainage below the level of the
chest and the tubes free of kinks or
obstructions

 Encourage coughing and deep

breathing
Do not strip or milk a chest tube
unless directed by a physician
Keep a clamp and sterile occlusive
dressing at bedside at all times
Never clamp a chest tube without
written orders from the physician

 If the drainage system cracks or

breaks, insert the chest tube into a
bottle of sterile water, remove the
cracked or broken system and
replace it
If the chest tube is pulled out
accidentally pinch the skin opening
together, apply an occlusive sterile
dressing, cover the dressing with
overlapping pieces of tape and call
the physician

 When the chest tube is removed , the

client is asked to take a deep breath
and hold it and the tube is removed;
a dry sterile dressing, petroleum
gauze dressing is taped in place
During removal of tube, deep breath ,
exhale and bear down

Pulmonary Contusion
Frequently

follows injuries caused by rapid

deceleration during vehicular accidents
Most common manifestation of blunt chest
trauma
Interstitial hemorrhage accompanies
pulmonary contusion which results in
pulmonary edema that would lead to
decreased lung compliance and gas
exchange

Assessment
Hemoptysis
Decreased

breath sounds

Crackles
Wheezes
Hazy

opacity in the lobes or

parenchyma

Interventions
Monitor

CVP
Monitor I and O
Mechanical ventilation with PEEP
( inflate the lungs)
WOF ARDS

Rib Fracture
Result

from direct blunt trauma to

the chest usually with involvement of
the fifth through ninth ribs
Fractured ribs can drive the bone
ends into the thorax leading to
pneumothorax

Treatment
For

uncomplicated rib fractures no

specific treatment because the fractured
ribs unite spontaneously
No splinting should be done
Pain meds most important so that
adequate ventilation is maintained
Intercostal nerve bloack for severe pain
Avoid analgesics that depress the
respiratory system ( morphine)

Flail Chest
Paradoxical

respiration
Inward movement of the thorax
during inspiration, with outward
movement during expiration
Usually involves one hemithorax and
results from multiple ribs fractures
Occurs during high speed vehicular
accidents and CPR

Assessment
Paradoxic

chest movement

Dyspnea
Cyanosis
Tachycardia
Hypotension
Pain

Interventions

Humidified O2
Analgesics
Deep breathing
Positioning
Secretion clearance by coughing and
tracheal aspiration
MV for respiratory failure
Positive pressure ventilation
Surgery

 Monitor

VS
Fluid and electrolytes
Monitor I and O and s/sx of shock
Psychological support

Hemothorax
Simple

blood loss of less than 1500

ml into the thoracic cavity
Massive more than 1500 ml
Due to trauma

Assessment
If

small asymptomatic
If large respiratory distress
Decreased breath sounds
Dull upon percussion
CXR
Thoracentesis

Interventions
Insertion

if chest tubes
If initial drainage is 1500ml to 200ml of
bloo then open thoracotomy or
persistent bleeding at the rate of
200ml/hr over 3 hours
Monitor VS, blood loss, I and O
Monitor chest tubes and drainage
IVF , blood transfusion (autotranfusion)

THE END