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
Virchow’s 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:

1. Tumors 6. Amniotic fluid – 80-90%
mortality
2. Air
- 1 per 20,00-30,000 deliverie
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
Homan’s sign don’t massage calf area
- avoid restrictive clothing on legs
- prolonged standing / sitting
D/O of the Pulmonary Vasculature
Pulmonary Embolism

Pathophysiology
DVT Emboli single or IVC RV Pulmonary artery
multiple

obstruction

 Resistance to Release of humoral

V/Q Mismatch
blood flow substances

Pulmonary
HPN Vasoconstriction
throughout lungs
RV strain

Pulmonary
RV failure infarction

Lungs have 3 sources of O2: lungs, bronchial circulation, pulmonary 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
-  PCO2 pH : mild acute resp. alk.
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 Partial Thromboplastin Time
– 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, ABG’s 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 5. metabolic
2. Drug ingestion and disorders
overdose 6. shock
3. Hematologic 7. trauma
disorder 8. major surgery
4. oxygen toxicity 9. fat/air embolism
5. localized infection 10. sepsis
 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
 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
 Days 2 to 10
– involves obvious respiratory distress
with tachypnea
– use of accessory muscle
– tachycardia with arrhythmias
– cyanosis
– diminished breath sound
– crackles and rhonchi
– Maintain adequate O2 transport,
prevent complications
 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 ventilator
– 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
3. Treatment of underlying causes
- Antibiotics
- Steroids
4. 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 patient’s 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 deeply
 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 and
incentive spirometry
 Artificial Airway
Tracheostomy
Definition:
Tracheotomy
 A surgical incision into the
trachea through overlying
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 long-

term 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. Assess for adequate gas exchange
2. Monitor patency of airway
3. Monitor cuff of tube
4. Provide tracheostomy care
5. Perform suctioning
6. Provide adequate hydration
 Continuation…

7. Secure tube
properly

8. Prevent or
assess for infection
9. Prevent aspiration
10. Avoid constipation
11. 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 client’s
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
breathing 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 client’s who can breathe on their
own
Nursing Management
• Monitoring patient’s 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 client’s response to procedure;
revise plan as necessary
• Managing the Ventilator System
– Maintain ventilator settings – TV, FiO2,
mode of ventilation etc.
– Check water temperature and
humidification
– 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 ventilator settings as ordered, monitor
response of patient to MV, adjust fluids and
correct electrolyte imbalances
– GI and Nutritional Complications
• stress ulcers – antacids, PPI’s , 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 2 nd
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 not working properly or
if the lung has re-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