Respiratory assessment FCCNC 2018

1. Respiratory assessmentFCCNC 2018 Catherine Jones Practice Educator GICU

2. Plan for session • 1. Why bother with Respiratory Assessment? • 2. Patient Assessment • History • Look, Listen, Feel • 3. Patient Monitoring • Pulse Oximetry • Capnography • Vent Graphics

3. Why do we assess? • To ensure safety • To have a baseline that we can build our goals and management (identify issues) • To prevent or identify problems • Respiratory system is responsible for external and internal respiration (gas exchange) • To administer most appropriate treatment • To evaluate treatment’s response

4. Components of respiratory assessment 1. Initial quick assessment 2. History • PMH, medication, allergies 3. Patient Assessment • Look • Listen • Feel 4. Patient Monitoring • Pulse Oximetry (SpO2) • End Tidal Co2 Monitoring (EtCO2) • Ventilator Graphics • Arterial blood gas analysis (session tomorrow) • Chest XRay 5. Documentation

5. 1. Initial Assessment AKA ‘End of bed ogram..’ • Patient Responsive or Unresponsive? • Unresponsive?  BLS

6. 2. History

7. 3. Patient assessment FEEL LISTEN LOOK

8. LOOK Colour Position Chest Shape & Scars Ability to speak Respiratory Rate, depth & Pattern Accessory Muscles Chest Movement Sputum – quantity, viscosity, colour

9. COLOUR

10. position

11. Chest shape

12. Chest

13. Normal Adults:12-20/min Tachypnea Rapid, shallow breathing Hyperypnea Rapid, deep breathing Hyperventilation Kussmaul breathing Bradypnea Breathing Patterns • Rate, Depth, Regularity Ataxic breathing Biot’s breathing Irregularly irregular Cheyne-Stokes breathing Regular rate, irregular depth MAY be normal Sighs Hyperventilation syndrome 1 sigh per 200 breaths

15. Clubbing

16. Accessory muscles

17. 21 secs clipflail chest & paradoxical breathing https://www.youtube.com/watch?v=mJ_FYwUqzsM Usually associated with chest trauma flails & #ribs or extreme fatigue 2ndry acute respiratory failure

19. LISTEN • Speech • Noisy respirations - Stridor, wheeze, rattly chest, gurgling, snoring

20. Stridor • High pitched wheezing sound caused by obstruction to airflow. • Usually blockage to larynx, trachea (anaphylaxis, tumour, swelling..) • BAD SIGN – If new onset – GET HELP!!

21. Ability to speak

22. Chest Auscultation • Movement of air in & out of airways • Flow and airway size dependent • Normal sounds / Added abnormal sounds • Interpretation  Practice!

23. Chest ausculation

24. The lungs and lobes

25. The lungs and lobes / Where to listen?

26. Where to auscultate?

27. CLASSIFICATION OF BREATH SOUNDS: normal • Vesicular • Quiet breath sounds heard over most lung fields. • Bronchial • Loud, hollow, high pitched breath sounds heard over bronchus. • NB this is an ABNORMAL sound if heard elsewhere – indicative of consolidation. • Bronchiovesicular • Normal breath sounds heard over lung tissue between bronchus & peripheries

28. CLASSIFICATION OF BREATH SOUNDS: Abnormal • Diminished / Absent? • Obesity •  tidal volumes • Pleural effusion • Occluded airway + collapse • Pneumothorax

29. CLASSIFICATION OF BREATH SOUNDS: Abnormal • Added sounds • Wheeze • Crackles • Stridor (NB Don’t need auscultation to hear) • Pleural Rub www.wilkes.med.ucla.edu/intro.html: normal; wheeze & crackles

30. CHEST X-RAY - NORMAL • Name & date • Technical quality Exposure AP / PA Orientation / Rotation Degree of inspiration • Methodically review film

32. FEEL Tracheal Deviation Surgical emphysema - presence of air in s/c tissue Equality of chest expansion/excursion Tactile fremitus Technique – Pt says ‘99’ resulting in a palpable vibration Decreased transmission = pleural effusion, pneumothorax Increased transmission = pneumonia, consolidation MV – fremitus can be found when there are secretions in airways

33. 4. Patient monitoring PULSE OXIMETRY VENTILATOR WAVEFORMS CAPNOGRAPHY

34. PULSE OXIMETRY • SpO2 is an indirect measurement of peripheral arterial oxygen saturation • Red & Infrared Light are emitted from a diode through pulsatile blood flow to a photodector. • Oxygenated (Bright Red) blood differs from deoxygenated (Blue Tinge) blood in light absorption & the oximeter measures the amount of light absorbed over 5 pulses to calculate the oxygen saturation.

35. Limitations of pulse oximetry • Doesn’t give any info about adequacy of ventilation • Dependent on adequate peripheral perfusion • Cardiac Arythmias • Motion artefact – pt movement or shivering • Nail varnish – equivocal evidence – blue, black, green • Dyshaemoglobins – carboxyhaemoglobin & methaemoglobin – can’t distinguish from oxyhaemoglobin so false high. • Skin pigment - jaundice

36. Pulse oximetry waveforms

37. Capnography MAINSTREAM SAMPLING SIDE STREAM SAMPLING

38. ETCO2 DETERMINED BY:

39. Why Measure ETCO2? • Monitor adequacy of ventilation • Detect correct placement of ETT • Detect apnoea • Indication of acid base balance • Indication of cardiac output • Indication of metabolic state • Monitor pulmonary perfusion in CPR • Diagnosis of PE • Safety in transporting critical care patient

40. Measurement of CO2 at the very end of expiration • Correlates with PaCO2 in ‘normal lungs’ <1kpa difference • EtCO2 can be significantly lower than PaCO2 (with poor lungs or poor perfusion)

43. Ventilator graphics

44. General info • Ventilator Waveforms depend on • Mode of ventilation • Ventilator properties & settings • Patient lung characteristics • 2 Types of Waveform: • Scalar (aka Curve) Pressure/Time; Volume/Time; Flow/Time • Loops Pressure/Volume; Volume/Flow; Flow/Pressure

45. Things to look out for..

46. Spontaneous effort

47. asynchrony

48. Airtrapping/autopeep/intrinsic peep…

49. Final thoughts • Respiratory data can be sought from multiple sources • ‘Old fashioned’ hands on assessment complements ‘New fashioned’ hands off assessment

50. references • Coombs et al (2013) ‘Assessment, monitoring & interventions for the respiratory system’, in Mallet et al (Eds) Critical Care Manual of Clinical Procedures & Competencies (Wiley Blackwell, London) Pgs. 63-166) • Corley A. & Ringdal M. (2012) ‘Respiratory Assessment & Monitoring’, in Elliott et al (Eds) ACCCN’s Critical Care Nursing 2nd ed (Mosby Elsevier, London) Pgs 325-351) • Moore T. Respiratory Assessment in Moore T. & Woodrow P. (2004) High Dependency Nursing Care (Routledge, London) P.124-133. • Smith J. & Rushton M. (2015) How to perform respiratory assessment Nursing Standard 30,7. P.34-36.