Care of the Respiratory Patient

1. Care of the Respiratory Patient Pneumonia Respiratory Failure

2. Function of the respiratory system • Exchange of gases between air and blood • Exchange of gases between blood and cells • Filter, warm, and humidify air • Speech • Sense of smell • Maintenance of homeostasis

3. Components of the respiratory system

4. Muscles required for breathing • Diaphragm • Intercostals • Abdominals • Neck, collarbone

5. Specific neck muscles involved

6. Control of respiration • Center at base of brain (medulla oblongata) • Baroreceptors (carotid and aorta) • Both detect O2 and CO2 levels and cause adjustment in breathing rate

7. Other important sensors • Sensors in airways detect irritants and can • provoke a cough or • spasm as in asthma • Sensors in alveoli detect fluid build up and trigger rapid, shallow breathing • Sensors in joints and muscles detect movement and respond with increased rate and depth

8. Pneumonia • Acute inflammation of the lungs • Cause is infection • Initial diagnosis is by chest xray:

9. Causes, symptoms, treatment… Vary depending upon:

10. Community acquired pneumonia • Occurs in people with little-no contact with medical settings • Over 100 microorganisms can cause CAP • Streptococcus pneumoniae • Hemophilusinfluenzae • Enteric gram negative bacteria • Viruses • Pseudomonas aerugenosa • Viruses • Atypical organisms

11. Signs, symptoms of CAP • Malaise • Cough, usually productive • Dyspnea • Chest pain is pleuritic, adjacent to infected area • Can manifest as upper abdominal pain if site is close to the diaphragm • Signs include: fever, tachycardia, tachypnea, crackles, bronchial breath sounds

12. Diagnosis of CAP • Chest xray shows some infiltrate, but sometimes not until after 24-48 hours • Pulmonary embolism often mistaken for CAP if no sputum production • CBC and Chem Panel • 2 sets of blood cultures • Pulse oximetry or ABG • Usually no attempt to identify organism unless patient is critical! • ICU care required if mechanical ventilation required or if patient is hypotensive

13. Treatment of CAP • Antibiotics according to likely pathogen (“empiric treatment”) • 90% of patients with CAP treated empirically improve • Failure to improve suggests drug resistance • Most viral pneumonias resolve without specific treatment • Adults should have follow-up xray 6 weeks after treatment

14. Hospital acquired pneumonia • Develops at least 48 hours after hospitalization • Common causes are : • Gram negative bacilli • E. coli • Salmonella • Klebsiella • Proteus

15. Risk factors for HAP • Mechanical ventilation • Previous antibiotic treatment • Cardiac, pulmonary, hepatic, and renal comorbidities • Age > 70 • Abdominal or thoracic surgery • Dependent functional status

16. Signs, symptoms HAP • Same as CAP for nonintubated patients • In critically ill, mechanically ventilated patients: • Fever • Increased respiratory rate • Increased heart rate • Increased purulent secretions • Worsening hypoxemia

17. Diagnosis of HAP • Suspected on basis of new infiltrate • No symptom, sign, or xray finding is specific for the diagnosis • Aggressive testing (bronchoscopy, Gram stain with C&S, etc.) are controversial—are they accurate? Are the results colonization?

18. Treatment of HAP • Empirically chosen antibiotics • May begin with broad-spectrum (e.g., ceftazidime, imipenem, pipericillin/cipro, or gentamycin if no MDR risk) • Replaced with most specific drug after culture results obtained

19. LTC Facility acquired pneumonia • Usually gram negative bacilli, Staphylococcus aureus, Streptococcus pneumoniae, Haemophilusinfluenzae, and influenza

20. Risk factors for LTCFAP • Poor functional status • Impaired mood • Mental status decline • Swallowing impairment • Presence of tracheostomy

21. Signs, symptoms LTCFAP • Symptoms likely to be more subtle • Altered mental status • Anorexia • Weakness • Restlessness, agitation • Falling • Incontinence • Signs: ↓responsiveness, fever, tachycardia, tachypnea, wheezes, crackles, “wet breathing”

22. Diagnosis of LTCFAP • Xrays may be difficult in nursing home • Transfer to hospital for evaluation may be necessary • May start treatment without xray confirmation • May not have an infiltrate due to dehydration due to febrile pneumonia!

23. Treatment of LTCFAP • Should be hospitalized if 2 or more unstable vital signs • One dose of broad spectrum antibiotic before transfer

24. Pneumonia in the immunocompromised patient • Often caused by unusual pathogen • Diagnosis requires blood cultures, bronchoscopy, and chest xray • Overall mortality can be up to 20%

25. Nursing care of the patient with pneumonia

26. Preventative measures • Smoking prevention • Flu shot annually • Pneumonia vaccine (when?) • General health maintenance habits

27. Case finding • Be alert to signs and symptoms, particularly in the elderly • Perform through physical assessment • Provide patient education on CAP • Refer high risk patients to community follow up resources

28. Direct care • Monitor vital signs with SaO2 every 2 to 4 hours as indicated (may be hourly or more) • Monitor lung sounds as appropriate • TCDB • Antibiotics as prescribed • Maintain appropriate hydration • Maintain airway patency • Pain medication as indicated • Prevent additional sources of infection • Support patient’s mental and emotional status

29. Respiratory failure A syndrome in which the respiratory system fails in one or both of its gas exchange functions:

30. Acute vs chronic respiratory failure • Acute develops over minutes to hours • Chronic develops over days or longer, allowing time for renal compensation • pH decreased in acute, slightly decreased in chronic

31. Causes of respiratory failure

32. Pathophysiology • Breathing is the process of moving air in and out of the lungs • Respiration involves three processes: • Transfer of oxygen across the alveolus • Transport of oxygen to the tissues • Removal of CO2 from the blood→ alveolus→ environment • Respiratory failure occurs from malfunctioning of any of these processes

33. Signs and symptoms • Dyspnea • Use of accessory muscles • Tachypnea • Tachycardia • Diaphoresis • Cyanosis • Altered consciousness • Eventual obtundation

34. Treatment respiratory failure • Acute failure requires ICU care • Correction of underlying cause • Supplemental oxygen • Control of secretions • Ventilatory support if necessary

35. Normal ventilation

36. Mechanical ventilation • Required when the patient cannot maintain these volumes independently • If volumes are not maintained, oxygenation and dispelling of CO2 is compromised • Mechanical ventilation performs the functions that the lungs cannot, either temporarily or permanently

37. Ventilators • Wide range of ventilator sizes and complexities • Selection of ventilator depends on: • Desired result • Availability

38. Types of ventilators

39. And, of course…

40. Patients in iron lungs

41. What the ventilator provides… • There are many features, all of which cannot be covered here! • MAJOR components are:

42. Basic format of mechanical ventilation

43. Common ventilator modes:Assist control (AC) • Ventilator delivers a breath every time the patient initiates a breath • Ventilator breath will have either a preset tidal volume or preset peak pressure • There is usually a back-up breath rate that is set in the event the patient fails to breathe enough • Benefit: requires little work on the part of the patient

44. Common ventilator modes: Controlled mechanical (CMV) • Ventilator delivers breaths based on a preset rate regardless of the patient’s efforts • Not used if the patient is very alert and responsive

45. Synchronized intermittent mandatory ventilation (SIMV) • A preset breath based on pressure or volume is delivered regularly within so many seconds • Represents a “normal” respiratory rate for that patient • If patient initiates another spontaneous breath within that cycle, the ventilator will not deliver another mechanical breath so that the patient is not hyperventilated • Used when decreasing patient’s dependence on ventilator (“weaning”)

46. Continuous positive airway pressure (CPAP) • The patient initiates all breaths • The ventilator maintains a continuous level of pressure throughout the airways • Promotes oxygenation and decreases the workload of the heart and lungs

47. Positive end expiratory pressure (PEEP) • Similar to CPAP • Here the ventilator maintains a higher pressure in the lungs during the exhalation phase of breathing

48. Nursing responsibilities: mechanical ventilation • Validate accuracy of settings • Monitor patient response to O2 therapy • Collaborate with RT, MD, for appropriate delivery (mode, volume, O2 percent) • Maintain airway patency • Promote patient comfort • Monitor ABGs, SaO2 , and appropriate labs • Actively promote patient’s decreased dependence on mechanical ventilation if feasible