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This document discusses various factors that can affect a person's respiration and oxygenation. It describes several conditions that can affect the airway such as allergies, asthma, common colds, and bronchitis. It also discusses factors that can affect the movement of airways like dyspnea and conditions like tachypnea and bradypnea. Further, it covers conditions that can affect gas diffusion like pulmonary edema and COPD. Various methods of oxygen administration are outlined including nasal cannulas, oxygen masks, venturi masks, and T-pieces. Potential complications of long-term oxygen therapy like oxygen toxicity are also mentioned.

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Oxygenation Needs Mr. Ramprasad S M.Sc (N), SCEM Associate Professor Medical Surgical Nursing, Neurosciences Nursing Trainer In Skills Lab, FRT, ENLS, BLS, TCLS, GFATM, Research Guide, Reviewer (IJMR/IJNR/IJOGN), (Member TNAI/NTAI/IPA/NSS/IRS) 14-03-2024 1
Factors affecting Respiration • The following factors affects the normal respiration of the individual. They are, a. Internal factors b. External factors 14-03-2024 2
Conditions that affecting the AIRWAY 14-03-2024 3
1. Allergies A condition that occur when immune system respond to foreign particles, such as pollens, dust, certain food, chemicals, etc. Allergies are characterized by rashes, cough, sneeze, running nose, chest congestion, wheezing etc. 14-03-2024 4
2. Bronchial Asthma A condition characterized by inflammation, bronchospasm, and edema airway. Characterized by, cyanosis, rapid pulse, cough, shortness of breath. 14-03-2024 5
3. Common Cold Infection of the upper respiratory tract results in narrowing of the airway. Common characteristics are, Cough, running nose, fever, congestion, nose block 14-03-2024 6
4. Bronchitis It is an inflammatory condition of the bronchial tube. Common signs are Production of the mucus, chest tightness, low grade fever, 14-03-2024 7
Conditions that affecting the Movement of the Airway 14-03-2024 8
1. Dyspnea/Shortness of breath It is defined as the sensation of breathlessness or decrease breathing. Tight feeling in chest, caused by asthma, heart failure, and lung disease. 14-03-2024 9
Grading Grade 1 :occurs when strenuous activity Grade 2 : person cant climb the stairs Grade 3 : occurs in usual activities Grade 4 : requires assistance during ADL Grade 5 : occurs at rest 14-03-2024 10
Causes Anemia/ Asthma Heart and lung disease Obesity/rib injury/ poisoning 14-03-2024 11
2. Tachypnea Condition that occurs when respiratory rate more than 20 per minute 14-03-2024 12
Causes Exercise Increased physical activity Allergy Pneumonia / TB 14-03-2024 13
Symptoms Shortness of breath LOC Confusion Sweating 14-03-2024 14
3. Bradypnea A condition where heart rate less than 16 per minute Caused by, Opiods , smoking, alcoholism, sleep apnea, neuro muscular disorder 14-03-2024 15
Symptoms, Itching , dry skin, hair loss, dizziness, cyanosis, coma 14-03-2024 16
Conditions Affecting Diffusion 14-03-2024 17
1. Pulmonary Edema Abnormal accumulation and collection of fluid in the lung tissue or in the alveolar space. 14-03-2024 18
Causes are, Severe HTN, MI, cardiomyopathy, kidney failure 14-03-2024 19
Clinical Features are Central cyanosis (lips /nails) Blood mixed secretions Dyspnea Respiratory distress 14-03-2024 20
Grunting and wheezing sound Pale skin Rapid heart rate 14-03-2024 21
Causes Cardiogenic causes artherosclerosis, HTN, MI, cardiomyopathy Non cardiogenic causes pneumonectomy , renal failure, toxic inhalation 14-03-2024 22
2. COPD Condition where airflow is obstructed due to emphysema chronic bronchitis, or both 14-03-2024 23
Causes are, Chronic smoking, infections , obesity , asthma, air pollution , occupation exposure 14-03-2024 24
Features are, Chronic cough, sputum, chest pain, dyspnea, hemoptysis, weakness,fatigue 14-03-2024 25
A condition characterized by collapse of the lungs, may be acute or chronic. Atelectasis 14-03-2024 26
Caused due to blockage in the air passages or pressure on the lungs by outside. The other risk factors are, Anesthesia, foreign object in the airway, lung disease, tumor 14-03-2024 27
Factors affecting Oxygen Transport 14-03-2024 28
It is an inability of the heart to pump adequate blood to the parts of the body. The primary causes are CHD, HTN, VHD,Cardiomyopathies, Arrythmias 1. Heart Failure 14-03-2024 29
Other causes, Pulmonary embolism, anemia, anesthesia, increase sodium intake. 14-03-2024 30
Nursing Interventions To Promote Oxygenation 14-03-2024 31
Oxygen Administration 14-03-2024 32
it is to treat the deficiency in oxygen among the individual but not to treat the underlying causes. This is important to keep the healthy level of tissue oxygen. Introduction 14-03-2024 33
To reduce the effect of anoxemia To maintain healthy tissue level oxygen Purposes 14-03-2024 34
Basics of Anantomy 14-03-2024 35
Low Flow System High Flow System Nasal cannula Venturi mask Simple mask T-Piece NRVM/NRBM Partial Rebreather mask Methods of oxygen administration 14-03-2024 36
Basic Oxygen Delivery Methods Nasal cannula and face mask are noninvasive interventions. Useful to deliver O2 if the patient is breathing on their own Nasal Cannula (nasal prongs) Simple face mask Face Mask with Reservoir bag Bag-Valve-Mask (BVM / AMBU bag) Page 7 14-03-2024 37
1. Nasal cannula 2. Nasal prongs 3. Oxygen mask 4. Oxygen tent 5. Venturi mask 6. Oxygen hood Methods of oxygen administration 14-03-2024 38
A plastic tube that used to administer oxygen which connected to the oxygen cylinder. The maximum flow of the oxygen will be upto 4L/Min Nasal cannula 14-03-2024 39
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It is a disposable. plastic devise with two protruding prongs for insertion into the nostrils, connected to an oxygen source. Used for low-medium concentrations of Oxygen (24-44%). 14-03-2024 41
Disadvantages Advantages Priority Nursing Interventions Amount Delivered F1o2 (Fraction Inspired Oxygen) Method may cause irritation to the nasal and pharyngeal mucosa if oxygen flow rates are above 6 liters/minute Variable FIO2  Client able to talk and eat with oxygen in place Easily used in home setting Check frequently that both prongs are in clients nares Never deliver more than 2-3 Lmin to client with chronic lung disease Low flow 24-44 % 1 Lmin=24% 2 Lmin=28% 3 Lmin=32% 4 Lmin=36% 5 Lmin=40% 6 Lmin=44% Nasal Cannula 14-03-2024 42
The types of face mask are The Simple Oxygen Mask The Partial Rebreather Mask: The Non Rebreather Mask: The Venturi Mask: Face mask 14-03-2024 43
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The simple Oxygen mask Simple mask is made of clear, flexible , plastic or rubber that can be molded to fit the face. 14-03-2024 45
The simple Oxygen mask It delivers 35% to 60% oxygen . A flow rate of 6 to 10 liters per minute. Often it is used when an increased delivery of oxygen is needed for short periods (i.e., less than 12 hours). 14-03-2024 46
Disadvantages Advantages Priority Nursing Interventions Amount Delivered F1o2 (Fraction Inspired Oxygen) Method Tight seal required to deliver higher concentration Difficult to keep mask in position over nose and mouth Potential for skin breakdown (pressure, moisture) Wasting Uncomfortable for pt while eating or talking Expensive with nasal tube Can provide increased delivery of oxygen for short period of time Monitor client frequently to check placement of the mask. Support client if claustrophobia is concern Secure physician's order to replace mask with nasal cannula during meal time Low Flow 6-10 Lmin 35%-60% Simple mask 14-03-2024 47
The partial rebreather mask The mask is have with a reservoir bag must inflated during both inspiration & expiration  It collection of the first parts of the patients' exhaled air. It is used to deliver oxygen concentrations up to 80%. 14-03-2024 48
The partial rebreather mask The oxygen flow rate must be maintained at a minimum of 6 L/min to ensure that the patient does not rebreathe large amounts of exhaled air. The remaining exhaled air exits through vents. 14-03-2024 49
The non rebreather mask  This mask provides the highest concentration of oxygen (95-100%) at a flow rate6-15 L/min. It is similar to the partial rebreather mask except two one-way valves prevent conservation of exhaled air. The bag is an oxygen reservoir 14-03-2024 50
Disadvantages Advantages Priority Nursing Interventions Amount Delivered F1o2 (Fraction Inspired Oxygen) Method Requires tight seal (eating and talking difficult, uncomfortable Not as drying to mucous membranes PT can inhale room air through openings in mask if oxygens supply is briefly interrupted Set flow rate so mask remains tow- thirds full during inspiration Keep reservoir bag free of twists or kinks Low Flow 6 Lmin 75%-80% oxygen Partial Rebreather Mask 14-03-2024 51
Disadvantages Advantages Priority Nursing Interventions Amount Delivered F1o2 Method Impractical for long term Therapy Malfunction can cause CO2 buildup suffocation Expensive Feeling of suffocation Uncomfortable Costly Delivers the highest possible oxygen concentration Suitable for pt breathing spontaneous with sever hypoxemia Maintain flow rate so reservoir bag collapses only slightly during inspiration Check that valves and rubber flaps are function properly (open during expiration ) Monitor SaO2 with pulse oximeter Low Flow 6-15 L min 80%- 100% Non rebreather MASK 14-03-2024 52
Venturi mask  It is high flow concentration of oxygen. Oxygen from 40 - 50% At liters flow of 4 to 15 L/min. 14-03-2024 53
Disadvantages Advantages Priority Nursing Interventions Amount Delivered F1o2 Method uncomfortable Risk for skin irritation produce respiratory depression in COPD patient with high oxygen concentration 50% Delivers most precise oxygen concentration Doesn’t dry mucous membranes (humidity Requires careful monitoring to verify F1O2 at flow rate ordered Check that air intake valves are not blocked Oxygen from 40-- 50% of 4 to 15 L/min. Venturi Mask 14-03-2024 54
T-piece Used on end of ET tube when weaning from ventilator Provides accurate FIO2 Provides good humidity 14-03-2024 55
Side effect & complication of oxygen therapy Oxygen toxicity Retrolental fibroplasia Absorption atelectasis 14-03-2024 56
oxygen toxicity It is a condition in which ventilator failure occurs due to inspiration of a high concentration of oxygen for aprolonged period of time. Oxygen concentration greater than 50% over 24 to 48 hours can cause pathological changes in the lungs. 14-03-2024 57
Signs and symptoms of oxygen toxicity Non-productive cough. • Nausea and vomiting. • Sub sternal chest pain. • Fatigue. • Nasal stuffiness. 14-03-2024 58
Sore throat. • Hypoventilation. . Nasal congestion. . Dyspnea. . Inspiration pain 14-03-2024 59
Evaluation Breathing pattern regular and at normal rate.  pink color in nail beds, lips, conjunctiva of eyes.  No confusion, disorientation, difficulty with cognition. Arterial oxygen concentration or hemoglobin  Oxygen saturation within normal limits. 14-03-2024 60
Documentation Date and time oxygen started. Method of delivery. Oxygen concentration and flow rate. Patient observation. Add oro nasal care to the nursing care plan 14-03-2024 61
Oxygen Delivery and Maintaining the Airway Page 9 Delivery Method O2 lpm O2 % Skill level Airway Patency BASIC Nasal Cannula 1-4 24 - 36 Minimal Conscious patient with patent airway, If the patient is breathing spontaneously Simple Mask 5-10 40 - 60 Minimal Non-Rebreather Mask 10-15 60 - 90 Minimal Bag Valve Mask (BVM) / AMBU bag >15 20 - 95 Basic Reduced consciousness (or unconscious) Consider insertion of nasal or oral airway Manual positive pressure ventilation (PPV) ADVANCED LMA, ETT and Crico- thyroidotomy >15 21 - 100 Advanced Unconscious (if not, needs sedation) and airway not protected Start with manual PPV with bag valve. Connect to ventilator when available 14-03-2024 62
Summary Oxygen Administration can be done under the following ways. Invasive and Non Invasive Supraglotic and Infra Glottis Slow flow rate and High flow rate 14-03-2024 63
Maintaining The Airway Methods of Maintaining Airway Patency 14-03-2024 64
The following methods are used to maintain the airway, 1. Positioning 2. Manoeuvres a. Head Tilt and Chin lift b. Jaw Thrust 3. Suction 4. Use of airway adjuncts a. Nasopharyngeal Airway b. Oropharyngeal Airway 14-03-2024 65
5. Advanced Airway Methods a. Laryngeal Mask Airway (LMA) b. Endotracheal Intubation (ETT) c. Cricothyroidotomy 14-03-2024 66
• Patient positioning: • Manual airway maneuvers • Towel support under shoulders • Suctioning • Supplemental oxygen • Airway adjuncts • Advanced airway placement 67 14-03-2024 67
Airway Management Techniques • Airway Maneuvers: Chin lift / jaw thrust (most basic) • Airway adjuncts: Oral, nasal • Bag-Valve-Mask (BVM) • Supraglottic Airways • Endotracheal intubation • Cricothyrotomy (most advanced) 68 14-03-2024 68
Airway Management – The Basics The tongue is the commonest cause of airway obstruction. 69 14-03-2024 69
Jaw thrust head tilt chin lift Head Tilt + Chin Lift Or Jaw Thrust Head tilt and chin lift contraindicated in: - Trauma - History of neck surgery or cervical spine pathology Only jaw thrust Airway Management – Open the Airway! 14-03-2024 70
Airway Adjuncts Airway adjuncts should be used as early as possible when needed Nasopharyngeal Airway (NPA) Oropharyngeal Airway (OPA) • In conscious and unconscious patients • Only in unconscious patients • DON’T use if gag reflex is intact 14-03-2024 71
Nasopharyngeal Airway 1. Can be used both conscious and unconscious patients 2. Used easily and effectively 3. Check the appropriate size of the NPA 4. Position the airway accurately 5. Contraindicated in nasal fractures 14-03-2024 72
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Adult 6 to 9 cm. small adult 6 to 7 medium size adult 7 to 8 cm large adult 8 to 9 cm NPA airway sizes 14-03-2024 74
Oropharyngeal Airway 1. Can be used only in unconscious patients 2. Avoid using when the Gag reflex in intact 3. Avoid in oral trauma/spasm of mouth muscles 4. Check the appropriate size of the OPA 5. Position the airway accurately 6. Contraindicated in conscious patient 14-03-2024 75
OPA airway sizes 14-03-2024 76
Neonatal 00 Infant 0 Child 1 Small adult 2 Adult 3 Large adult 4 5 6 14-03-2024 77
Endotracheal Intubation https://www.youtube.com/watch?v=70fhNvE6aGQ 14-03-2024 78
ENDOTRACHEAL INTUBATION Endotracheal Intubation is placement of special tube in trachea. Endotracheal intubation is employed to relieve upper airway obstruction, maintain a patent airway or treat impending or actual respiratory failure from any cause. 14-03-2024 79
Indications/Purposes To secure airway To supply oxygen For general anesthesia For cardiopulmonary resuscitation For ventilator therapy in ICU 14-03-2024 80
Articles Endotracheal tubes Laryngoscope blades Oral airway Suction devices: catheters and tonsil tip Intravascular catheters, spinal needle, or bone marrow needle. Oro gastric tube 14-03-2024 81
Laryngoscope handles and blades Scissors ,Gloves, Syringes, Needles, 14-03-2024 82
Pre-Procedure I. Assess current respiratory status and history including Reason for intubation. Response to intubation. II. Auscultate breath sound bilaterally III. Evaluate respiratory effort Respiratory rate Respiratory pattern 14-03-2024 83
V. Auscultate breath sound bilaterally. VI. Evaluate respiratory effort. Respiratory rate, Respiratory pattern, Chest expansion: equal and bilateral 14-03-2024 84
VIII. Observe colour and tissue perfusion. IX. Assess heart rate. Assess activity and alertness, irritability, confusion, fatigue, lethargy, inappropriate behavior and coma. Assess child and family's understanding of need, purpose and functioning of intubation. 14-03-2024 85
Procedure 1. Confirm availability of all equipment 2. Wear PPE 3. Perform hand washing 4. Don gloves 5. Take laryngoscope and place inside the throat to visualize the glottis 6. Take appropriate sized ET tube and put bougie into it 7. Inflate the ET tube and check its efficacy 8. Bend the ET tube and insert into the mouth upto trachea 14-03-2024 86
Procedure (Contd…) 9. Once the ET tube is placed remove the styllet or bougie and inflate the tube with 5-7 ml of air. 10. Secure the ET Tube with the adhesive plaster and confirm its placemat by auscultation. 11. Check the inflation by using AMBU (chest should expand) 12. Do 5 point auscultation including epigastrium (sound will be absent at epigastrium) 14-03-2024 87
CHEST PHYSIOTHERAPY 14-03-2024 88
Definition Chest physiotherapy (CPT) is a therapeutic intervention applied to help natural airway clearance mechanisms (cough and ciliary cleansing mechanisms) reduce or prevent blockage of airways by thick, tenacious mucus 14-03-2024 89
Purposes/Indication • Assist in coughing • Reeducate breathing muscles • Improve ventilation of the lungs 14-03-2024 90
Contraindications • Increased ICP • Unstable head or neck injury • Active haemorrhage or heamoptysis • Recent spinal injury • Rib fracture • Uncontrolled hypertension • Thoracic surgeries 14-03-2024 91
Articles Needed Tilt bed and/or pillows Towels or thick pad Sputum cup/tissue Stethoscope 14-03-2024 92
Types of CPT The procedure of chest physiotherapy includes the following types, 1. Percussion 2. Chest Vibration 3. Deep breathing Exercises 4. Postural drainage 5. Coughing 14-03-2024 93
Preprocedure care • Identify physical indications for CPT. • Identify possible contraindications for CPT. • Determine child's age, developmental level, ability to understand procedure, and ability to cooperate. • Assess diversional activities child might enjoy during CPT. • Determine parent's under-standing of and ability to perform CPT at home. • Assess ability of older child to do self-physiotherapy 14-03-2024 94
Percussion/tapotment/clapping/cupping • Therapist and parents should wash hands before treatment. • Administer bronchodilators as ordered before CPT. • Select areas of lungs to be percussed. • Treatments may be split up into sections and performed at various times throughout the day 14-03-2024 95
• Assist person in assuming proper positioning, placing pillows for comfort, support and to maintain position. • Perform percussion using cupped hands. Clap rhythmically over specific area to be drained. Mold hands side by side. 14-03-2024 96
Alternate hands while clapping. Clapping should be vigorous, not painful. Percuss 1 minute over lung segment to be drained. 14-03-2024 97
Procedure 1. Check the right patient 2. Explain the procedure to the patient 3. Check the last meal that he has consume 4. Wash hands and dry 5. Inform the patient to perform diaphragmatic breathing 6. Position the patient 14-03-2024 98
Percussion 1. clap with cupped hands over the chest wall for over 1-2 min in each lung area 2. the percussion should be from lower ribs to shoulder on the back and from lower ribs to top of the chest in the front 3. Avoid percussion on spine, liver , kidney, spleen, breast and clavicle. 14-03-2024 99
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Vibration 1. place hand /palm down on chest area to be drained with one hand over the other or fingers together. 2. Patient should inhale and exhale slowly through pursed lips 3. Vibrate for 5 exhalations in each lungs after 3-4 vibrations encourage patient to cough and clear the secretion 14-03-2024 102
Post Procedure 1. Allow patient to rest 2. Auscultate and check the breath sound 3. Repeat cycle for 10-15 minutes based on patient condition 4. Wash hands 5. Comfort the patient 14-03-2024 103
Special Considerations 1. CPT should be perform 1 hour before meals and 1-3 hours after meal 2. Administer bronchodilator and MDI 15 minutes earlier 3. Check breathing pattern and cyanosis in him 4. Administer pain killers 15-20 minutes before 5. Stop procedure if there is tachycardia/fall in BP/chest pain 14-03-2024 104
Postural Drainage Also called as bronchial drainage, an intervention for airway clearance by mobilizing secretions in one or more lung segments to the central airway by placing the patient in various positions. 14-03-2024 105
Indications 1. Cystic fibrosis 2. Bronchiectasis 3. Pulmonary diseases 4. Patient with artificial airway 14-03-2024 106
Contraindications 1. Severe hemoptysis 2. Cardiac arrhythmias 3. Neurosurgery patients 4. Unstable angina 14-03-2024 107
5. Plural effusion 6. Pneumothorax 7. Pulmonary embolism 14-03-2024 108
Preparations 1. Check the clinical findings and indications for PD 2. Tilt the patient to drain the secretions 3. Lower lobes requires the PD than upper lobe 14-03-2024 109
4. Provide bronchodilators or Nebulizer 5. The PD can be scheduled 3-4 times a day based on degree of lung congesion 6. Time is before breakfast/lunch and bed time 14-03-2024 110
Care of Chest Drainage 14-03-2024 111
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14-03-2024 113 • Parietal pleura: Inside membrane of the rib cage • Pulmonary or visceral pleura: Outside membrane of the lungs • The two membranes are separated by a lubricating fluid (pleural fluid) which enables them to slide against each other. Lung can expand and contract • Vacuum or “negative pressure” in the pleural space keeps the two pleurae together. If fluid or air enters the pleural space, lungs cannot fully expand during each respiratory cycle
Chest TUBE Placement
Normal Breathing Mechanics Diaphragm contracts down & draws air into the trachea, bronchi, bronchioles, and alveoli. Negative pressure between the pleurae is approximately -8cmH2O Diaphragm relaxes, rises, and pushes air & CO2 back out the same route. Negative pressure between the pleurae is approximately - 4cmH2O INHALATION EXHALATION
14-03-2024 116 • Pneumothorax: Air in the pleural space (trauma, lung disease, procedure complications) • Hemothorax: blood in the pleural space (blunt or penetrating trauma) • Hemopneumothorax: air & Blood in the pleural space • Tension pneumothorax: occurs when injured tissue forms a one way valve or flap allowing air to enter but preventing it from escaping naturally, (emergent situation)
Indications For Chest Tube Insertion •Pleural effusion: excessive fluid in pleural space •Empyema: collection of pus d/t infection •Chylothorax: lymphatic fluid accumulation in the pleural space (trauma, expanding tumor, surg in the mediastinum) – milky white pleural fluid 14-03-2024 117
Insertion Site Superior Tube Placement: Removal of Air (ie. Pneumothorax) Inferior Tube Placement: Removal of Fluids (ie. Hemothorax, Empyema) Posterior Tube Placement: Loculated (confined pocket) fluid or air
Insertion Site “Safe Triangle” Tube placed in the midaxillary line btw 4th and 5th Ribs should successfully drain fluid or vent air
CHEST TUBE SYSTEM
3 Bottle System Patient Suction Collection Bottle Water Seal Suction Control
Collection Bottle and Water Seal Collection Chamber: Collects drainage Water Seal: Maintained at 2cm, One way valve; Prevents air or fluid from returning to the chest Patient SUCTION
Nursing Assessments and Interventions
Assessment USE THE ACRONYM S = Site T = Tubing O = Output P = Patency
STOP S = Site Check Site: • Ensure tube is in place, • No S&S of infection • Dressing CDI, change q48h & PRN wet or soiled. Sterile technique, occlusive dressing  Subcutaneous emphysema
Subcutaneous Emphysema (Air Underneath the Skin) Subcutaneous emphysema (air trapped under skin) a. Palpate – Crepitis (Rice Krispies) b. Notify MD c. Continuous Monitoring
Check the Dressing & Site
sTOP T = Tubing  Connections are secured  No dependent loops, kinks  Straighten periodically  Keep the drainage system below patient’s level
STOP O = Output  Document amount, type and color  Check the level regularly  Document in Epic – LDA  Use the white write-on column on the drainage chamber to mark drainage include date & time (Check with your unit to see how often)
STOP P = Patency (A: water seal)  Assess the water seal with the suction off  If water seal level is too high, it will be more difficult for air to leave the chest (aspirate water via grommet)  If the water seal level is too low, it leaves the water seal chamber at risk for exposure to air and can cause a pneumothorax (add sterile water via grommet)
STOP P = Patency (B: Bubbling) Bubbling means there is a leak in the system unless the patient has a pneumothorax. • Intermittent bubbling may indicate air leak from pleural space, will resolve when lung re-expands • Continuous bubbling suspect a leak in the system
STOP P = Patency (C: fluctuations)  Normal:  Inspiration the water seal level will reach -10cm  Expiration the water seal level will reach -4cm of negative pressure normally  If fluctuations stop, the tubing may be obstructed (kinks, pt lying on tubing, stuck in railing, etc.)  If more than 2cm of water the drainage will decrease  If less than 2cm of water there is risk of pneumothorax
Assess pulmonary status • Respiration Rate • Work of Breathing • Breath Sounds • Continuous SpO2 Monitoring
At the bedside • Always keep drain BELOW the chest for gravity drainage • Creates a pressure gradient with relatively higher pressure in the chest • Fluid moves from an area of higher pressure to an area of lower pressure
At the bedside – Emergency actions Dislodged tube from pt. • Cover open insertion site with Vaseline gauze at peak inspiration • Cover with 4x4’s gauze & tape three sides only • Notify M.D. STAT • chart event Dislodged from collection device • place the end of the tube into bottle of sterile water to create a one way valve. • Prepare new drainage device and connect to pt tubing
Items to be kept at bedside • 2 clamps • Vaseline gauze • 4x4 gauze dressing • Non-porous tape • Sterile water bottle or NS
Clamping Clamp Only When  Changing the device (the drainage system)  Checking for an air leak  Tubing is disconnected and sterile water is out of reach  Checking lung re-expansion prior to chest tube removal DO NOT Clamp  Ambulating Patient (will increase risk of tension pneumothorax)  Transport – Disconnect suction tubing at Suction Control Stop cock, leave open
Chest Tube removal INDICATIONS: • Improved respiratory status • Symmetrical rise and fall of chest • Bilateral Breath Sounds • Decreased chest tube drainage • Absence of bubbling in the water seal chamber during inspiration • Improved CXR findings
Chest Tube removal Process: • Premedicate to relieve pain • Teach valsalva maneuver (preformed before tube removal to prevent air from reentering pleural space) • Supplies: sterile gloves, goggles, gown, mask, dressing supplies, sterile suture removal kit, wide occlusive tape.
• Semi-Fowlers position • Practitioner clamps chest tube, pt peforms Valsalva maneuver, chest tube removed • Occlusive dressing applied • Post CT removal CXR – ensure lung remains fully inflated 14-03-2024 140
Pulse Oximetry Pulse Oximeter is used to measure the level of oxygen saturation in the body that shows the amount of oxygen that hemoglobin is carrying in the blood 14-03-2024 141
Normal oxygen saturation in adult is 95%-100% 14-03-2024 142
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Working Principles 14-03-2024 144

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In this document
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Introduction to oxygenation needs and the qualifications of the presenter.

Exploration of internal and external factors that impact normal respiration.

Discusses various conditions affecting the airway: allergies, bronchial asthma, common cold, and bronchitis.

Focus on conditions affecting airway movement, including dyspnea, tachypnea, bradypnea, and their causes.

Details pulmonary edema, COPD, and atelectasis, including causes and associated symptoms.

Describes heart failure impacts on oxygen transport and its primary causes.

Strategies for nursing interventions, including purposes of oxygen administration.

Overview of low flow and high flow systems for oxygen delivery and their methods.

Details on different types of face masks: simple, partial rebreather, non-rebreather, and Venturi.

Explains side effects and complications of oxygen therapy, including oxygen toxicity.

Criteria for evaluating oxygen therapy effectiveness and documentation practices.

Summary of invasive and non-invasive oxygen delivery methods, including flow rates.

Methods for maintaining airway patency, including positioning and suction techniques.

Basic and advanced airway management techniques including adjuncts and maneuvers.

Processes and purposes of endotracheal intubation and its medical equipment.

Introduction to chest physiotherapy (CPT) for airway clearance and indications.

Methods of CPT, including percussion, postural drainage, and techniques for assisting breathing.

Explains indications, preparations, and contraindications for postural drainage.

An overview of chest tube placement, management, assessments, interventions and potential complications.

Indications and procedures for chest tube removal, ensuring safety and patient comfort.

Explains the purpose of pulse oximetry and provides information on normal oxygen saturation levels.

oxygenation needs.pptx, vital component to understand the basics of oxygenation needs.

  • 1.
    Oxygenation Needs Mr. RamprasadS M.Sc (N), SCEM Associate Professor Medical Surgical Nursing, Neurosciences Nursing Trainer In Skills Lab, FRT, ENLS, BLS, TCLS, GFATM, Research Guide, Reviewer (IJMR/IJNR/IJOGN), (Member TNAI/NTAI/IPA/NSS/IRS) 14-03-2024 1
  • 2.
    Factors affecting Respiration •The following factors affects the normal respiration of the individual. They are, a. Internal factors b. External factors 14-03-2024 2
  • 3.
    Conditions that affectingthe AIRWAY 14-03-2024 3
  • 4.
    1. Allergies A conditionthat occur when immune system respond to foreign particles, such as pollens, dust, certain food, chemicals, etc. Allergies are characterized by rashes, cough, sneeze, running nose, chest congestion, wheezing etc. 14-03-2024 4
  • 5.
    2. Bronchial Asthma Acondition characterized by inflammation, bronchospasm, and edema airway. Characterized by, cyanosis, rapid pulse, cough, shortness of breath. 14-03-2024 5
  • 6.
    3. Common Cold Infectionof the upper respiratory tract results in narrowing of the airway. Common characteristics are, Cough, running nose, fever, congestion, nose block 14-03-2024 6
  • 7.
    4. Bronchitis It isan inflammatory condition of the bronchial tube. Common signs are Production of the mucus, chest tightness, low grade fever, 14-03-2024 7
  • 8.
    Conditions that affectingthe Movement of the Airway 14-03-2024 8
  • 9.
    1. Dyspnea/Shortness ofbreath It is defined as the sensation of breathlessness or decrease breathing. Tight feeling in chest, caused by asthma, heart failure, and lung disease. 14-03-2024 9
  • 10.
    Grading Grade 1 :occurswhen strenuous activity Grade 2 : person cant climb the stairs Grade 3 : occurs in usual activities Grade 4 : requires assistance during ADL Grade 5 : occurs at rest 14-03-2024 10
  • 11.
    Causes Anemia/ Asthma Heart and lungdisease Obesity/rib injury/ poisoning 14-03-2024 11
  • 12.
    2. Tachypnea Condition thatoccurs when respiratory rate more than 20 per minute 14-03-2024 12
  • 13.
  • 14.
  • 15.
    3. Bradypnea A conditionwhere heart rate less than 16 per minute Caused by, Opiods , smoking, alcoholism, sleep apnea, neuro muscular disorder 14-03-2024 15
  • 16.
    Symptoms, Itching , dryskin, hair loss, dizziness, cyanosis, coma 14-03-2024 16
  • 17.
  • 18.
    1. Pulmonary Edema Abnormalaccumulation and collection of fluid in the lung tissue or in the alveolar space. 14-03-2024 18
  • 19.
    Causes are, Severe HTN,MI, cardiomyopathy, kidney failure 14-03-2024 19
  • 20.
    Clinical Features are Centralcyanosis (lips /nails) Blood mixed secretions Dyspnea Respiratory distress 14-03-2024 20
  • 21.
    Grunting and wheezingsound Pale skin Rapid heart rate 14-03-2024 21
  • 22.
    Causes Cardiogenic causes artherosclerosis, HTN,MI, cardiomyopathy Non cardiogenic causes pneumonectomy , renal failure, toxic inhalation 14-03-2024 22
  • 23.
    2. COPD Condition whereairflow is obstructed due to emphysema chronic bronchitis, or both 14-03-2024 23
  • 24.
    Causes are, Chronic smoking,infections , obesity , asthma, air pollution , occupation exposure 14-03-2024 24
  • 25.
    Features are, Chronic cough,sputum, chest pain, dyspnea, hemoptysis, weakness,fatigue 14-03-2024 25
  • 26.
    A condition characterizedby collapse of the lungs, may be acute or chronic. Atelectasis 14-03-2024 26
  • 27.
    Caused due toblockage in the air passages or pressure on the lungs by outside. The other risk factors are, Anesthesia, foreign object in the airway, lung disease, tumor 14-03-2024 27
  • 28.
    Factors affecting OxygenTransport 14-03-2024 28
  • 29.
    It is aninability of the heart to pump adequate blood to the parts of the body. The primary causes are CHD, HTN, VHD,Cardiomyopathies, Arrythmias 1. Heart Failure 14-03-2024 29
  • 30.
    Other causes, Pulmonary embolism,anemia, anesthesia, increase sodium intake. 14-03-2024 30
  • 31.
    Nursing Interventions ToPromote Oxygenation 14-03-2024 31
  • 32.
  • 33.
    it is totreat the deficiency in oxygen among the individual but not to treat the underlying causes. This is important to keep the healthy level of tissue oxygen. Introduction 14-03-2024 33
  • 34.
    To reduce theeffect of anoxemia To maintain healthy tissue level oxygen Purposes 14-03-2024 34
  • 35.
  • 36.
    Low Flow SystemHigh Flow System Nasal cannula Venturi mask Simple mask T-Piece NRVM/NRBM Partial Rebreather mask Methods of oxygen administration 14-03-2024 36
  • 37.
    Basic Oxygen DeliveryMethods Nasal cannula and face mask are noninvasive interventions. Useful to deliver O2 if the patient is breathing on their own Nasal Cannula (nasal prongs) Simple face mask Face Mask with Reservoir bag Bag-Valve-Mask (BVM / AMBU bag) Page 7 14-03-2024 37
  • 38.
    1. Nasal cannula 2.Nasal prongs 3. Oxygen mask 4. Oxygen tent 5. Venturi mask 6. Oxygen hood Methods of oxygen administration 14-03-2024 38
  • 39.
    A plastic tubethat used to administer oxygen which connected to the oxygen cylinder. The maximum flow of the oxygen will be upto 4L/Min Nasal cannula 14-03-2024 39
  • 40.
  • 41.
    It is adisposable. plastic devise with two protruding prongs for insertion into the nostrils, connected to an oxygen source. Used for low-medium concentrations of Oxygen (24-44%). 14-03-2024 41
  • 42.
    Disadvantages Advantages Priority Nursing Interventions Amount Delivered F1o2(Fraction Inspired Oxygen) Method may cause irritation to the nasal and pharyngeal mucosa if oxygen flow rates are above 6 liters/minute Variable FIO2  Client able to talk and eat with oxygen in place Easily used in home setting Check frequently that both prongs are in clients nares Never deliver more than 2-3 Lmin to client with chronic lung disease Low flow 24-44 % 1 Lmin=24% 2 Lmin=28% 3 Lmin=32% 4 Lmin=36% 5 Lmin=40% 6 Lmin=44% Nasal Cannula 14-03-2024 42
  • 43.
    The types offace mask are The Simple Oxygen Mask The Partial Rebreather Mask: The Non Rebreather Mask: The Venturi Mask: Face mask 14-03-2024 43
  • 44.
  • 45.
    The simple Oxygenmask Simple mask is made of clear, flexible , plastic or rubber that can be molded to fit the face. 14-03-2024 45
  • 46.
    The simple Oxygenmask It delivers 35% to 60% oxygen . A flow rate of 6 to 10 liters per minute. Often it is used when an increased delivery of oxygen is needed for short periods (i.e., less than 12 hours). 14-03-2024 46
  • 47.
    Disadvantages Advantages Priority Nursing Interventions Amount Delivered F1o2 (Fraction InspiredOxygen) Method Tight seal required to deliver higher concentration Difficult to keep mask in position over nose and mouth Potential for skin breakdown (pressure, moisture) Wasting Uncomfortable for pt while eating or talking Expensive with nasal tube Can provide increased delivery of oxygen for short period of time Monitor client frequently to check placement of the mask. Support client if claustrophobia is concern Secure physician's order to replace mask with nasal cannula during meal time Low Flow 6-10 Lmin 35%-60% Simple mask 14-03-2024 47
  • 48.
    The partial rebreathermask The mask is have with a reservoir bag must inflated during both inspiration & expiration  It collection of the first parts of the patients' exhaled air. It is used to deliver oxygen concentrations up to 80%. 14-03-2024 48
  • 49.
    The partial rebreathermask The oxygen flow rate must be maintained at a minimum of 6 L/min to ensure that the patient does not rebreathe large amounts of exhaled air. The remaining exhaled air exits through vents. 14-03-2024 49
  • 50.
    The non rebreathermask  This mask provides the highest concentration of oxygen (95-100%) at a flow rate6-15 L/min. It is similar to the partial rebreather mask except two one-way valves prevent conservation of exhaled air. The bag is an oxygen reservoir 14-03-2024 50
  • 51.
    Disadvantages Advantages Priority Nursing Interventions Amount Delivered F1o2(Fraction Inspired Oxygen) Method Requires tight seal (eating and talking difficult, uncomfortable Not as drying to mucous membranes PT can inhale room air through openings in mask if oxygens supply is briefly interrupted Set flow rate so mask remains tow- thirds full during inspiration Keep reservoir bag free of twists or kinks Low Flow 6 Lmin 75%-80% oxygen Partial Rebreather Mask 14-03-2024 51
  • 52.
    Disadvantages Advantages Priority Nursing Interventions Amount Delivered F1o2 Method Impractical forlong term Therapy Malfunction can cause CO2 buildup suffocation Expensive Feeling of suffocation Uncomfortable Costly Delivers the highest possible oxygen concentration Suitable for pt breathing spontaneous with sever hypoxemia Maintain flow rate so reservoir bag collapses only slightly during inspiration Check that valves and rubber flaps are function properly (open during expiration ) Monitor SaO2 with pulse oximeter Low Flow 6-15 L min 80%- 100% Non rebreather MASK 14-03-2024 52
  • 53.
    Venturi mask  Itis high flow concentration of oxygen. Oxygen from 40 - 50% At liters flow of 4 to 15 L/min. 14-03-2024 53
  • 54.
    Disadvantages Advantages Priority Nursing Interventions Amount Delivered F1o2 Method uncomfortable Risk for skin irritation producerespiratory depression in COPD patient with high oxygen concentration 50% Delivers most precise oxygen concentration Doesn’t dry mucous membranes (humidity Requires careful monitoring to verify F1O2 at flow rate ordered Check that air intake valves are not blocked Oxygen from 40-- 50% of 4 to 15 L/min. Venturi Mask 14-03-2024 54
  • 55.
    T-piece Used on endof ET tube when weaning from ventilator Provides accurate FIO2 Provides good humidity 14-03-2024 55
  • 56.
    Side effect &complication of oxygen therapy Oxygen toxicity Retrolental fibroplasia Absorption atelectasis 14-03-2024 56
  • 57.
    oxygen toxicity It isa condition in which ventilator failure occurs due to inspiration of a high concentration of oxygen for aprolonged period of time. Oxygen concentration greater than 50% over 24 to 48 hours can cause pathological changes in the lungs. 14-03-2024 57
  • 58.
    Signs and symptomsof oxygen toxicity Non-productive cough. • Nausea and vomiting. • Sub sternal chest pain. • Fatigue. • Nasal stuffiness. 14-03-2024 58
  • 59.
    Sore throat. • Hypoventilation. .Nasal congestion. . Dyspnea. . Inspiration pain 14-03-2024 59
  • 60.
    Evaluation Breathing pattern regularand at normal rate.  pink color in nail beds, lips, conjunctiva of eyes.  No confusion, disorientation, difficulty with cognition. Arterial oxygen concentration or hemoglobin  Oxygen saturation within normal limits. 14-03-2024 60
  • 61.
    Documentation Date and timeoxygen started. Method of delivery. Oxygen concentration and flow rate. Patient observation. Add oro nasal care to the nursing care plan 14-03-2024 61
  • 62.
    Oxygen Delivery andMaintaining the Airway Page 9 Delivery Method O2 lpm O2 % Skill level Airway Patency BASIC Nasal Cannula 1-4 24 - 36 Minimal Conscious patient with patent airway, If the patient is breathing spontaneously Simple Mask 5-10 40 - 60 Minimal Non-Rebreather Mask 10-15 60 - 90 Minimal Bag Valve Mask (BVM) / AMBU bag >15 20 - 95 Basic Reduced consciousness (or unconscious) Consider insertion of nasal or oral airway Manual positive pressure ventilation (PPV) ADVANCED LMA, ETT and Crico- thyroidotomy >15 21 - 100 Advanced Unconscious (if not, needs sedation) and airway not protected Start with manual PPV with bag valve. Connect to ventilator when available 14-03-2024 62
  • 63.
    Summary Oxygen Administration canbe done under the following ways. Invasive and Non Invasive Supraglotic and Infra Glottis Slow flow rate and High flow rate 14-03-2024 63
  • 64.
    Maintaining The Airway Methodsof Maintaining Airway Patency 14-03-2024 64
  • 65.
    The following methodsare used to maintain the airway, 1. Positioning 2. Manoeuvres a. Head Tilt and Chin lift b. Jaw Thrust 3. Suction 4. Use of airway adjuncts a. Nasopharyngeal Airway b. Oropharyngeal Airway 14-03-2024 65
  • 66.
    5. Advanced AirwayMethods a. Laryngeal Mask Airway (LMA) b. Endotracheal Intubation (ETT) c. Cricothyroidotomy 14-03-2024 66
  • 67.
    • Patient positioning: •Manual airway maneuvers • Towel support under shoulders • Suctioning • Supplemental oxygen • Airway adjuncts • Advanced airway placement 67 14-03-2024 67
  • 68.
    Airway Management Techniques •Airway Maneuvers: Chin lift / jaw thrust (most basic) • Airway adjuncts: Oral, nasal • Bag-Valve-Mask (BVM) • Supraglottic Airways • Endotracheal intubation • Cricothyrotomy (most advanced) 68 14-03-2024 68
  • 69.
    Airway Management –The Basics The tongue is the commonest cause of airway obstruction. 69 14-03-2024 69
  • 70.
    Jaw thrust head tilt chinlift Head Tilt + Chin Lift Or Jaw Thrust Head tilt and chin lift contraindicated in: - Trauma - History of neck surgery or cervical spine pathology Only jaw thrust Airway Management – Open the Airway! 14-03-2024 70
  • 71.
    Airway Adjuncts Airway adjunctsshould be used as early as possible when needed Nasopharyngeal Airway (NPA) Oropharyngeal Airway (OPA) • In conscious and unconscious patients • Only in unconscious patients • DON’T use if gag reflex is intact 14-03-2024 71
  • 72.
    Nasopharyngeal Airway 1. Canbe used both conscious and unconscious patients 2. Used easily and effectively 3. Check the appropriate size of the NPA 4. Position the airway accurately 5. Contraindicated in nasal fractures 14-03-2024 72
  • 73.
  • 74.
    Adult 6 to9 cm. small adult 6 to 7 medium size adult 7 to 8 cm large adult 8 to 9 cm NPA airway sizes 14-03-2024 74
  • 75.
    Oropharyngeal Airway 1. Canbe used only in unconscious patients 2. Avoid using when the Gag reflex in intact 3. Avoid in oral trauma/spasm of mouth muscles 4. Check the appropriate size of the OPA 5. Position the airway accurately 6. Contraindicated in conscious patient 14-03-2024 75
  • 76.
  • 77.
    Neonatal 00 Infant 0 Child1 Small adult 2 Adult 3 Large adult 4 5 6 14-03-2024 77
  • 78.
  • 79.
    ENDOTRACHEAL INTUBATION Endotracheal Intubationis placement of special tube in trachea. Endotracheal intubation is employed to relieve upper airway obstruction, maintain a patent airway or treat impending or actual respiratory failure from any cause. 14-03-2024 79
  • 80.
    Indications/Purposes To secure airway Tosupply oxygen For general anesthesia For cardiopulmonary resuscitation For ventilator therapy in ICU 14-03-2024 80
  • 81.
    Articles Endotracheal tubes Laryngoscope blades Oralairway Suction devices: catheters and tonsil tip Intravascular catheters, spinal needle, or bone marrow needle. Oro gastric tube 14-03-2024 81
  • 82.
    Laryngoscope handles andblades Scissors ,Gloves, Syringes, Needles, 14-03-2024 82
  • 83.
    Pre-Procedure I. Assess currentrespiratory status and history including Reason for intubation. Response to intubation. II. Auscultate breath sound bilaterally III. Evaluate respiratory effort Respiratory rate Respiratory pattern 14-03-2024 83
  • 84.
    V. Auscultate breathsound bilaterally. VI. Evaluate respiratory effort. Respiratory rate, Respiratory pattern, Chest expansion: equal and bilateral 14-03-2024 84
  • 85.
    VIII. Observe colourand tissue perfusion. IX. Assess heart rate. Assess activity and alertness, irritability, confusion, fatigue, lethargy, inappropriate behavior and coma. Assess child and family's understanding of need, purpose and functioning of intubation. 14-03-2024 85
  • 86.
    Procedure 1. Confirm availabilityof all equipment 2. Wear PPE 3. Perform hand washing 4. Don gloves 5. Take laryngoscope and place inside the throat to visualize the glottis 6. Take appropriate sized ET tube and put bougie into it 7. Inflate the ET tube and check its efficacy 8. Bend the ET tube and insert into the mouth upto trachea 14-03-2024 86
  • 87.
    Procedure (Contd…) 9. Oncethe ET tube is placed remove the styllet or bougie and inflate the tube with 5-7 ml of air. 10. Secure the ET Tube with the adhesive plaster and confirm its placemat by auscultation. 11. Check the inflation by using AMBU (chest should expand) 12. Do 5 point auscultation including epigastrium (sound will be absent at epigastrium) 14-03-2024 87
  • 88.
  • 89.
    Definition Chest physiotherapy (CPT)is a therapeutic intervention applied to help natural airway clearance mechanisms (cough and ciliary cleansing mechanisms) reduce or prevent blockage of airways by thick, tenacious mucus 14-03-2024 89
  • 90.
    Purposes/Indication • Assist incoughing • Reeducate breathing muscles • Improve ventilation of the lungs 14-03-2024 90
  • 91.
    Contraindications • Increased ICP •Unstable head or neck injury • Active haemorrhage or heamoptysis • Recent spinal injury • Rib fracture • Uncontrolled hypertension • Thoracic surgeries 14-03-2024 91
  • 92.
    Articles Needed Tilt bedand/or pillows Towels or thick pad Sputum cup/tissue Stethoscope 14-03-2024 92
  • 93.
    Types of CPT Theprocedure of chest physiotherapy includes the following types, 1. Percussion 2. Chest Vibration 3. Deep breathing Exercises 4. Postural drainage 5. Coughing 14-03-2024 93
  • 94.
    Preprocedure care • Identifyphysical indications for CPT. • Identify possible contraindications for CPT. • Determine child's age, developmental level, ability to understand procedure, and ability to cooperate. • Assess diversional activities child might enjoy during CPT. • Determine parent's under-standing of and ability to perform CPT at home. • Assess ability of older child to do self-physiotherapy 14-03-2024 94
  • 95.
    Percussion/tapotment/clapping/cupping • Therapist andparents should wash hands before treatment. • Administer bronchodilators as ordered before CPT. • Select areas of lungs to be percussed. • Treatments may be split up into sections and performed at various times throughout the day 14-03-2024 95
  • 96.
    • Assist personin assuming proper positioning, placing pillows for comfort, support and to maintain position. • Perform percussion using cupped hands. Clap rhythmically over specific area to be drained. Mold hands side by side. 14-03-2024 96
  • 97.
    Alternate hands whileclapping. Clapping should be vigorous, not painful. Percuss 1 minute over lung segment to be drained. 14-03-2024 97
  • 98.
    Procedure 1. Check theright patient 2. Explain the procedure to the patient 3. Check the last meal that he has consume 4. Wash hands and dry 5. Inform the patient to perform diaphragmatic breathing 6. Position the patient 14-03-2024 98
  • 99.
    Percussion 1. clap withcupped hands over the chest wall for over 1-2 min in each lung area 2. the percussion should be from lower ribs to shoulder on the back and from lower ribs to top of the chest in the front 3. Avoid percussion on spine, liver , kidney, spleen, breast and clavicle. 14-03-2024 99
  • 100.
  • 101.
  • 102.
    Vibration 1. place hand/palm down on chest area to be drained with one hand over the other or fingers together. 2. Patient should inhale and exhale slowly through pursed lips 3. Vibrate for 5 exhalations in each lungs after 3-4 vibrations encourage patient to cough and clear the secretion 14-03-2024 102
  • 103.
    Post Procedure 1. Allowpatient to rest 2. Auscultate and check the breath sound 3. Repeat cycle for 10-15 minutes based on patient condition 4. Wash hands 5. Comfort the patient 14-03-2024 103
  • 104.
    Special Considerations 1. CPTshould be perform 1 hour before meals and 1-3 hours after meal 2. Administer bronchodilator and MDI 15 minutes earlier 3. Check breathing pattern and cyanosis in him 4. Administer pain killers 15-20 minutes before 5. Stop procedure if there is tachycardia/fall in BP/chest pain 14-03-2024 104
  • 105.
    Postural Drainage Also calledas bronchial drainage, an intervention for airway clearance by mobilizing secretions in one or more lung segments to the central airway by placing the patient in various positions. 14-03-2024 105
  • 106.
    Indications 1. Cystic fibrosis 2.Bronchiectasis 3. Pulmonary diseases 4. Patient with artificial airway 14-03-2024 106
  • 107.
    Contraindications 1. Severe hemoptysis 2.Cardiac arrhythmias 3. Neurosurgery patients 4. Unstable angina 14-03-2024 107
  • 108.
    5. Plural effusion 6.Pneumothorax 7. Pulmonary embolism 14-03-2024 108
  • 109.
    Preparations 1. Check theclinical findings and indications for PD 2. Tilt the patient to drain the secretions 3. Lower lobes requires the PD than upper lobe 14-03-2024 109
  • 110.
    4. Provide bronchodilatorsor Nebulizer 5. The PD can be scheduled 3-4 times a day based on degree of lung congesion 6. Time is before breakfast/lunch and bed time 14-03-2024 110
  • 111.
    Care of ChestDrainage 14-03-2024 111
  • 112.
  • 113.
    14-03-2024 113 • Parietalpleura: Inside membrane of the rib cage • Pulmonary or visceral pleura: Outside membrane of the lungs • The two membranes are separated by a lubricating fluid (pleural fluid) which enables them to slide against each other. Lung can expand and contract • Vacuum or “negative pressure” in the pleural space keeps the two pleurae together. If fluid or air enters the pleural space, lungs cannot fully expand during each respiratory cycle
  • 114.
  • 115.
    Normal Breathing Mechanics Diaphragm contractsdown & draws air into the trachea, bronchi, bronchioles, and alveoli. Negative pressure between the pleurae is approximately -8cmH2O Diaphragm relaxes, rises, and pushes air & CO2 back out the same route. Negative pressure between the pleurae is approximately - 4cmH2O INHALATION EXHALATION
  • 116.
    14-03-2024 116 • Pneumothorax:Air in the pleural space (trauma, lung disease, procedure complications) • Hemothorax: blood in the pleural space (blunt or penetrating trauma) • Hemopneumothorax: air & Blood in the pleural space • Tension pneumothorax: occurs when injured tissue forms a one way valve or flap allowing air to enter but preventing it from escaping naturally, (emergent situation)
  • 117.
    Indications For ChestTube Insertion •Pleural effusion: excessive fluid in pleural space •Empyema: collection of pus d/t infection •Chylothorax: lymphatic fluid accumulation in the pleural space (trauma, expanding tumor, surg in the mediastinum) – milky white pleural fluid 14-03-2024 117
  • 118.
    Insertion Site Superior TubePlacement: Removal of Air (ie. Pneumothorax) Inferior Tube Placement: Removal of Fluids (ie. Hemothorax, Empyema) Posterior Tube Placement: Loculated (confined pocket) fluid or air
  • 119.
    Insertion Site “Safe Triangle” Tubeplaced in the midaxillary line btw 4th and 5th Ribs should successfully drain fluid or vent air
  • 120.
  • 121.
  • 122.
    Collection Bottle andWater Seal Collection Chamber: Collects drainage Water Seal: Maintained at 2cm, One way valve; Prevents air or fluid from returning to the chest Patient SUCTION
  • 123.
  • 124.
    Assessment USE THE ACRONYM S= Site T = Tubing O = Output P = Patency
  • 125.
    STOP S = Site CheckSite: • Ensure tube is in place, • No S&S of infection • Dressing CDI, change q48h & PRN wet or soiled. Sterile technique, occlusive dressing  Subcutaneous emphysema
  • 126.
    Subcutaneous Emphysema (Air Underneaththe Skin) Subcutaneous emphysema (air trapped under skin) a. Palpate – Crepitis (Rice Krispies) b. Notify MD c. Continuous Monitoring
  • 127.
  • 128.
    sTOP T = Tubing Connections are secured  No dependent loops, kinks  Straighten periodically  Keep the drainage system below patient’s level
  • 129.
    STOP O = Output Document amount, type and color  Check the level regularly  Document in Epic – LDA  Use the white write-on column on the drainage chamber to mark drainage include date & time (Check with your unit to see how often)
  • 130.
    STOP P = Patency(A: water seal)  Assess the water seal with the suction off  If water seal level is too high, it will be more difficult for air to leave the chest (aspirate water via grommet)  If the water seal level is too low, it leaves the water seal chamber at risk for exposure to air and can cause a pneumothorax (add sterile water via grommet)
  • 131.
    STOP P = Patency(B: Bubbling) Bubbling means there is a leak in the system unless the patient has a pneumothorax. • Intermittent bubbling may indicate air leak from pleural space, will resolve when lung re-expands • Continuous bubbling suspect a leak in the system
  • 132.
    STOP P = Patency(C: fluctuations)  Normal:  Inspiration the water seal level will reach -10cm  Expiration the water seal level will reach -4cm of negative pressure normally  If fluctuations stop, the tubing may be obstructed (kinks, pt lying on tubing, stuck in railing, etc.)  If more than 2cm of water the drainage will decrease  If less than 2cm of water there is risk of pneumothorax
  • 133.
    Assess pulmonary status •Respiration Rate • Work of Breathing • Breath Sounds • Continuous SpO2 Monitoring
  • 134.
    At the bedside •Always keep drain BELOW the chest for gravity drainage • Creates a pressure gradient with relatively higher pressure in the chest • Fluid moves from an area of higher pressure to an area of lower pressure
  • 135.
    At the bedside– Emergency actions Dislodged tube from pt. • Cover open insertion site with Vaseline gauze at peak inspiration • Cover with 4x4’s gauze & tape three sides only • Notify M.D. STAT • chart event Dislodged from collection device • place the end of the tube into bottle of sterile water to create a one way valve. • Prepare new drainage device and connect to pt tubing
  • 136.
    Items to bekept at bedside • 2 clamps • Vaseline gauze • 4x4 gauze dressing • Non-porous tape • Sterile water bottle or NS
  • 137.
    Clamping Clamp Only When Changing the device (the drainage system)  Checking for an air leak  Tubing is disconnected and sterile water is out of reach  Checking lung re-expansion prior to chest tube removal DO NOT Clamp  Ambulating Patient (will increase risk of tension pneumothorax)  Transport – Disconnect suction tubing at Suction Control Stop cock, leave open
  • 138.
    Chest Tube removal INDICATIONS: •Improved respiratory status • Symmetrical rise and fall of chest • Bilateral Breath Sounds • Decreased chest tube drainage • Absence of bubbling in the water seal chamber during inspiration • Improved CXR findings
  • 139.
    Chest Tube removal Process: •Premedicate to relieve pain • Teach valsalva maneuver (preformed before tube removal to prevent air from reentering pleural space) • Supplies: sterile gloves, goggles, gown, mask, dressing supplies, sterile suture removal kit, wide occlusive tape.
  • 140.
    • Semi-Fowlers position •Practitioner clamps chest tube, pt peforms Valsalva maneuver, chest tube removed • Occlusive dressing applied • Post CT removal CXR – ensure lung remains fully inflated 14-03-2024 140
  • 141.
    Pulse Oximetry Pulse Oximeteris used to measure the level of oxygen saturation in the body that shows the amount of oxygen that hemoglobin is carrying in the blood 14-03-2024 141
  • 142.
    Normal oxygen saturationin adult is 95%-100% 14-03-2024 142
  • 143.
  • 144.

Editor's Notes

  • #115 In short, The chest tube is placed in the Pleural space between lungs and chest wall.
  • #116 Under Normal Conditions the pleural space has Negative pressure to allow the lungs to expand and contract. When a condition arises in which there is positive pressure in the peural space, a chest drain may be required.
  • #119 So, when you think gravity, the heavier things are going to be found on the bottom where as air will have a tendency to float upwards.
  • #120 Safe Triangle: an area lateral to the nipple line bordered by the latissimus dorsi, the lateral border of the pectoralis major, and the apex of the triangle below the axilla
  • #122 The concept of the 3 bottle system is what brought about the water seal chest drain system that we currently use today.
  • #127 Subcutaneous Emphysema: arises as pleural space air leaks into subcutaneous tissue, when this happens tissues of the neck, face, and chest wall swell. Notify MD because tube placement or suction level may be evaluated.
  • #128 Check the dressing, Change every 48 hours and when needed if soiled or coming loose. At the site, check for s/s of infection (redness, drainage from the site)
  • #140 Post CT removal: Monitor- Resp status, vital signs, Site for drainage, pt’s comfort level