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On-Call Training BookletSouthport & Ormskirk HospitalModified 2018Questions to ask when the phone ringsName and age of the patientWard number and hospitalPatients presenting diagnosis and current conditionReason for call-outFrom the following information, establish whether it really is an appropriate emergency call-out:Investigations done:CXRABG’sSaO2Respiratory Support:Self-ventilatingIntubated and VentilatedNon-invasive ventilation?Oxygen Therapy e.g FiO2, HumidificationMedication, Do they need of have they had:Analgesia – adequate?BronchodilatorAnti-emeticConscious level?Previous physiotherapy input? Have they been seen today already?Will the patient be available for Assessment when you arrive?Who is calling? Referrals should be made at least by the Senior Nurse in charge for ITU/Paeds/Spinals, Night nurse co-ordinator or Nurse Consultant.Checklist of major points for Pulmonary AssessmentPatient’s NotesHistory (past, present, family, social, drug)InvestigationsMedical/Surgical PlanCeiling of treatmentCPR statusChartsSp02, Respiratory Rate, Heart rate, BP, TemperatureArterial Blood GasesMedicationOxygen prescription and DeliveryPeak Flow Fluid BalanceSubjective AssessmentSymptomsFunctional Limitations/Baseline functionAttachmentsOxygen (Mask; fixed/variable, Nasal Specs, HFNC, CPAP, NIV, Vents)HumidificationPulse OximetryDripsChest Drains (Bubbling, swinging, static, on suction)Sputum (Colour, consistency, volume)ObservationPosture/PositionColourOedemaChest ShapeBreathing PatternPalpation Equal/ any expansionTactile FremitusPercussion NoteResonant, hyper-resonant, dullAuscultation Breath SoundsAdded SoundsVoice SoundsChest X-RayDate/TimePositionFocal ChangesRespiratory MedicationBronchodilators1. Beta two agonistsShort acting Beta 2 agonist (SABA)Stimulate predominately beta two receptorsUsed for rapid relief of mild to moderate symptoms of asthma and COPDMinimal effects on the cardiovascular systemSalbutamol – Salbulin, Airsalb, AsmaventTerbutaline – BricanylIndicationsReversible airway obstructionSymptomatic relief of breathlessness and wheeziness during an acute episode of bronchospasmAid mucociliary clearanceSide EffectsContraindication - severe pre-eclampsia Minimal side effects with therapeutic dosesHand tremor, palpitation, sweating, tachycardia with oral administration when taken in higher than normal doses. This is due to activation of beta two receptors in myocardial tissue and is common with COPD where higher doses are requiredMode of deliveryInhalation via powder, aerosol or nebulised solution. This delivers medication to the airways in smaller doses and with less side effects. Onset of action is 5-15 minutes, with peak action at 60 - 90 minutes and a duration of 4-6 hours.Oral via tablets or solution. This is less effective and should only be used for prolonged action (overnight)IV for treatment of severe bronchospasm.Mode of actionBeta two agonists bind to beta two receptors of bronchial smooth muscleStimulation of adenyl cyclase increases the production of cyclic AMPAMP inhibits protein kinase and stimulates the binding of calcium ions to the cell membraneMycoplasmal calcium concentration in the smooth muscle decreases causing relaxationEffectiveness related to pathologyBest response in asthmaticsOccasional response in CF patients, mainly in acute exacerbation Long acting Beta 2 agonist (LABA)Stimulate beta two receptors over a longer period of timeSalmeterol – Serevent, NeoventFormoterol – Foradil, Oxis, Atimos modulIteIndacterol – OnbrezOlodaterol- StriverdiIndicationsNocturnal asthmaExercise induced asthmaReversible airway obstruction in patients requiring long term regular bronchodilatorsTreatment of patients with COPDSide EffectsContraindication - olodaterol contraindicated in pregnancyOropharyngeal irritationTaste disturbanceNauseaDizzinessNasopharyngitisMode of deliveryInhalation via powder or aerosol. Onset of action is 5-30 minutes and a duration of 12-24 hours, depending on which LABAMode of actionDue to high lipid solubility rather than resistance to metabolismHigh lipid solubility permits them to dissolve in the smooth muscle cell membrane in high concentrationsSlow release- formoterol acts rapidly then has 12 hrs duration of actionEffectiveness related to pathologyUsed in asthmatics in conjuction with other medication (corticosteroids)2. AntimuscarinicsUse in conjunction with other bronchodilators (beta two agonists)Ipratropium bromide – Atrovent, Respontin (short-acting SAMA)Long-acting LAMATiotropium – Spiriva, BraltusAclinidium – EkliraGlycopyrronium- SeebriUmeclinidium -IncruseIndicationsShort – acting agent. Treatment of reversible bronchospasm associated with COPD and asthmaLong –acting agent. Maintenance bronchodilator treatment to relieve COPD symptomsContraindicationsKnown hypersensitivity to atropine or derivativesCautionsGlaucomaPregnancyBreastfeedingArrythmiasSide EffectsHypersensitivityDry mouthTachycardiaOropharyngeal candidiasisMode of deliveryShort-acting agent: Inhalation via aerosol, powder or nebulised solution. Onset of action is 3-10 minutes, with a peak action at 90 minutes and a duration of 4-6 hours Long-acting agent : Onset/ duration dependent on each particular agentMode of actionCompetitive inhibition of acetylcholine at cholinergic receptors on bronchial smooth muscleInhibit bronchoconstriction of smooth muscleEffectiveness related to pathologyMore effective with COPD were cholinergic tone is the only reversible componentEffective in the elderly were asthma may be complicated by a degree of COPDCombination LAMA / LABAIndicationMaintenance treatment of COPDAclinidium with formoterol – DuaklirGlycopyrronium with indacterol – Ultibro breezhalerTiotropium with olodaterol - Spiolto respimatUmeclidinium with vilanterol – Anoro ellipta3. TheophyllineOther therapeutic uses include reducing inflammation, increasing inspiratory muscle action, improving gaseous exchange, promoting mucociliary clearanceAminophylline is 80% theophylline and 20% ethylene diamine (improves solubility)Aminophylline preparations – PhyllocontinTheophylline preparations – Uniphyllin, Nuelin SA, Slo-phyllinIndicationsSevere reversible airway obstructionSide effectsNo contraindicationsHypersensitivityNauseaDiarrhoeaNervousnessHeadachesTachycardiaPalpitationsCNS stimulationHypokalaemiaArrhythmias following rapid iv injectionCautionsCardiac disease / cardiac arrhythmiasHyperthyroidismEpilepsyPregnancyBreast feedingPeptic ulcerMode of deliveryOral via tablets or solutionInjection IV infusionMode of actionNo known mechanismEffectiveness related to pathologyFor use with severe bronchoconstriction that does not respond to other bronchodilatorsCorticosteroidsSuppress inflammatory reactions that cause bronchospasm, oedema and mucus hypersecretionUsed prophylactically with increased dosage during infectionBeclometasone dipropionate – asmabec, qvar, ClenilBudesonide – pulmicort, Budelin novoliserFluticasone propionate – flixotide,Ciclenoside- AlvescoMometasone – AsmanexIndicationsProphylactic treatment of asthma Used orally for acute exacerbation of asthma/COPD. Occasionally used as oral maintenance treatmentAcute asthma where there is no improvement with bronchodilators or where symptoms worsen despite maintenance of bronchodilator therapyChronic asthma were response to other medication has been poorSide EffectsLess systemic side effects when inhaledHoarsenessCandidiasisOsteoporosisBruising/thining skinHyperglycaemiaMode of deliveryInhalation via aerosol or powderOralMode of actionSuppresses inflammatory reactions that cause bronchospasm, oedema and mucus hypersecretionImproves responsiveness to bronchodilatorsEffectiveness related to pathologyVery effective with asthmaticsCombination therapy with LABA:IndicationRegular treatment of asthmaSymptomatic treatment of patients with COPDFluticasone – Flutiform, Sirdupla, Seretide, RelvarBudesonide - Symbicort, DuorespTriple therapy with LABA/LAMA:IndicationsMaintenance treatment in adult patients with moderate to severe COPDFluticasone – TrelegyBeclomethasone - TrimbowMast Cell StabilisersPrevent inflammationOnly effective if taken prophylactically – regular inhalation can reduce incidence of asthma attacks and allows dosage reduction of bronchodilatorsSodium cromoglicate – intalNedocromil sodium – tiladeRofulimast -DaxasIndicationsProphylactic treatment in asthmaticsPrevention of exercise induce and allergic asthmaSide effectsCoughThroat irritationHypersensitivityDry mouthTight chestWheezeNauseaHeadacheMode of deliveryInhalation via aerosol, powder or nebulised solutionMode of actionUnclearReduces response to allergensInhibits release of histamine and leukotrienes Maintains membrane stabilityEffectiveness related to pathologyProphylactically in asthmaticsNo value in acute attacksDecrease dosage of bronchodilators and corticosteroidsMucolyticsAdjunct therapy to aid removal of secretionsCarbocisteine Dornase Alfa – pulmozymeErdosteine -ErdotinIndicationsSignificant airway obstruction due to secretionsAbnormal viscous secretionsContraindicationsHypersensitivityPregnancy – erdosteine, carbocysteine in first trimesterActive peptic ulcerationMode of deliveryOral via solution or tabletInhalation via jet nebuliser for Dornase alfaMode of actionSplitting of disulphide bondsEffectiveness related to pathologyCOPDCFLeukotriene inhibitorsInhibit inflammatory processMontelukast – singulairZafirlukast – accolateIndicationsProphylactic treatment of exercise induced asthmaWhen poor compliance with other medicationContraindications -zafirlukastBreastfeedingUnder 12 years oldHepatic impairment/cirrhosisCautionsPregnancyBreastfeedingSide effectsDry mouthThirstDizzinessRestlessnessHeadacheURTIAbdo pain, nauseaMode of deliveryOral via tabletsMode of actionBlocks the effects of cysteinyl leukotrienes in the airwaysReduces inflammatory processEffectiveness related to pathologyUse in asthmaSigns and SymptomsChest Infection/Infective ExacerbationPAINNot usuallyAUSCExpiratory Crackles, Occasional WheezeSPUTUMYellow/Green/Occasionally Brown. ↑Quantity compared to normalSOBNot particularly unless COPDSUBJECTIVEMay feel unwell, off foodCXRLocalised patchy shadowing↑TEMP ?Usually but not alwaysPneumoniaPAINPleuritic, ↑ on Inspiration and CoughingAUSCBronchial Breathing or Expiratpry crackles or NADSPUTUMVery little, classically BrownSOBPossibly but not particularlySUBJECTIVEUsually preceeded by a period of feeling unwell, off food, possibly a chest infectionCXRLocalised patchy shadowing, usually basal↑TEMP ?Maybe but not alwaysPulmonary Oedema (CCF, LVF, ARF)PAINNot usuallyAUSCBilateral bi-basal crackles (fine or coarse)SPUTUMWhite of Pink FrothySOBVery usually gradual onset, OrthopnoeaSUBJECTIVENil elseCXRBilateral basal white fluffy appearance, ↑ hilar markings↑TEMP ?Not usuallyPleural EffusionPAINOccasionally but not usuallyAUSC↓ Breath Sounds except over fluid lineSPUTUMNone unless also have another problemSOBVery, ↑ with amount of fluideSUBJECTIVENil elseCXRAsymmetrical white out, Basal, sometimes with a fluid level↑TEMP ?Not usuallyPulmonary EmbolismPAINCentral Chest PainAUSCReduced Breath Sounds or NADSPUTUMNoneSOBVerySUBJECTIVESudden onset, may follow calf pain (DVT)CXRLocalised patchy shadowing due to localised shutdown of ventilation↑TEMP ?Not usuallyCardiac Chest PainPAINCentral, crushing, sometimes left sided (arm,face,jaw), relieved by GTNAUSCNADSPUTUMNoneSOBPossiblySUBJECTIVEMay be preceeded by exercise/exertionCXRNAD↑TEMP ?NoRoutine MonitoringClinicalCharts:Hourly observations available to give an overall picture of the patient throughout the shift.i.e. Vent SettingsTemp – rise indicating infectionsPulse, BP – CVS stabilityFluid balance/ U.O.Conscious level/Glasgow Come ScaleECGRate and Rhythm: Arrhythmias are common in sick patients and in ICU.e.g. Heart blockAF (with rate 140+ compromises ventricular filling and Cardiac Output)Ischaemia: 12 Lead ECG shows ischaemic changes (S.T. depression)B.PInvasive:radial trace via arterial line allows beat-to-beat measurement of BP with greater accuracy.Also easy access to arterial samples for blood gas analysis.C.V.P – Central Venous PressureMeasures pressure in the great veins and right atrium → synonymous with right atrial pressure.Gives information on:265747558420357187558420NB. Trends are more important than isolated measurements00NB. Trends are more important than isolated measurementsRight ventricular functionVenous tone25717503048000Venous returnIntrathoracic pressureRadio-opaque catheter is passed into the right superior vena cava usually via internal jugular vein or alternatively the subclavian vein. It is monitored continuously with a transducer. Normal Values (Measured at mid axillary line) 5 – 10 cm H2OComplications of insertion can include Pneumothorax, Haemothorax and Air Embolism (if patient not head down) so it is important to check CXR prior to Physio treatment.A low CVP: May indicate peripheral vasodilation (sepsis) hypovolaemiaA negative CVP indicates severe dehydrationA high CVP: Hypervolaemia↓heart contractility in presence of normal blood volume i.e. heart failure/cardiogenic shockPulmonary congestion/oedemaArterial Blood Gas AnalysisReasons for blood gas analysisDetermine whether the patient is well oxygenatedDetermine the acid-base status of the patient, identifying both the respiratory and metabolic componentsThese gas values are nearly always available on ITU as the samples are taken from the patient’s arterial line. It arterial access is not available the blood sample is obtained with an arterial stab, usually via the radial artery.Certain information is entered in the gas machine e.g. Temperature, FiO2, admission number/name. It is particularly important to note the concentration of oxygen that the patient is on, as this is necessary when analysing the gas reading.Normal ValuespH7.35 – 7.45If pH > 7.45If pH < 7.35Indicates H+ concentration and reflects acid/base balance. The pH of arterial blood is slightly alkaline.Patient is alkalotic [H+] lowPatient is acidotic [H+] highH+45 - 35The ratio of acid versus base. Determines the [H+] in the body.PaCO24.5 -6.0 KpaPartial pressure of CO2 in arterial blood. Indicated the respiratory status of the patient PaCO2 ↑ hypoventilation, ↓ hyperventilation.PaO210 – 14KpaPartial pressure of O2 in arterial blood. Plays no part in acid-base balance but important to work out O2 requiements.HCO3-22 - 27Standard bicarbonate. Indicated the acid base status of the blood once the respiratory component is removed i.e. renal involvementBE+ 2 to -2The amount of base needed to return pH to normal. BE ↑ = alkalosis BE ↓ = acidosis. Indicates the metabolic aspect.SaO296 to 98%The % haemoglobin attached to O2N.B pH <6.8 or >7.8 is incompatible with life.Acid/Base BalanceBody cells and chemical reactions are acutely sensitive to the acidity or alkalinity of their environment and any deviation from the ‘normal’ is fiercely resisted by several homeostatic mechanisms.Through dietary intake and cell metabolism there is a net surplus of acid i.e. H+ concentration and pH decrease. The fall is minimised through buffers, the most important one being the carbonic acid – bicarbonate system (Coleman & Houston 1998).H+ + HCO3 ? H2CO3 ? H2O + CO2As H+ concentration increases this is temporarily buffered by HCO3It is particularly significant because of its large quantity and the ability of the body (lungs and kidneys) to alter each component.Lungs - excretion of CO2Kidneys – excretion of H+ reabsorption of HCO3Hyper/hypoventilation can stabilise acid/base balance in minutes. Elimination via the kidneys takes longer, up to 4 hours. The is known as compensation and is never complete.N.B a buffer has the ability to resist changes in pH when and acid or base is added to it.InterpretationLook at PaO2 and FiO2 to assess the oxygenation ability of the lungsLook at the pH and determine the presence of an acidosis or alkalosisLook at the PaCO2 , HCO3- and BE to determine the respiratory and metabolic components.Respiratory disorders involve changes in the PaCO2Metabolic disorders involve changes in HCO3 and base excessThe primary abnormality is always that which explains the observed pH. Compensation is always incomplete and only moderates the effects of the primary abnormality.Signs and symptoms of the problems to be addressedDecreased lung volume - CXR, auscultation, Sa02, spirometry (FVC), thoracic expansion, percussion note.Sputum retention - CXR, auscultation, Sa02, cough, ABGs, WOB, palpation, vibs.Bronchospasm - Auscultation, Sa02, RR, PEFR, breathing pattern.Respiratory failure I Increased WOB - Type 1 / Type 2 - ABGsTreatments used to address the problemsDecreased lung volume: Mobilisation, MHl, positioning for increased FRC v/q matching, ACBT (inspiratory holds/sniffs), manual over-pressure, rib springing, IPPB, incentive spirometry.Sputum retention: NaCI nebs, saline instillation, increase H20, ACBT, autogenic drainage, manual techniques / assisted coughing, IPPB / Percussionaire / Cough Assist, suction, mobilisation.Bronchospasm: Breathing control, positioning, bronchodilators.Respiratory failure / increased WOB (address the above): IPPB, CPAP, maximize 02 requirements, breathing control, optimize medication.Active Cycle Of BreathingSit comfortablyWith your hand on your stomach take three slow relaxed breaths allowing your hand to rise gently visualizing air filling your stomach like a balloonTake four deep breaths keeping your shoulders relaxedTake three relaxed breaths (as above)Take three huffs, imagine you are steaming a mirrorRelaxed breathingRepeat this until secretions are ready to be coughed upManual TechniquesManual techniques (shaking and vibrations) are carried out in the direction of the normal movement of the ribs during expiration. The vibratory effect is transmitted through the chest using body weight. This increases expiratory flow and aids the removal of secretions. Shaking – is a coarse movement in which the chest in compressed.Vibrations – consist of a fine oscillation of the hands directed inwards against the chest.IndicationsSelf ventilating patients with acute on chronic respiratory disorders with large quantities of sputumTo aid clearance of secretions in ventilated patientsPrecautionsRib fracturesLoss of skin integrity (surgery, burns)CV instabilityClotting disordersOsteoporosisMetastatic depositsPostural DrainageIndicationsDefective secretion clearance mechanismPrecautionsDownward head tip in the following conditions: cardiac failure, severe hypertension, acute head injury, stroke, severe haemoptysis, headache, breathlessness, recent head or neck surgery.TechniqueAvoid before and after mealsBronchodilators 15 minutes beforeArea to be drained uppermostWorst area to be drained first10 minutes per positionMaximum of three positions per treatment (max 30 minute treatment)Discontinue if the patients complain of headaches, discomfort, dizziness, palpitations or breathlessnessPositions for Postural DrainageBreathlessnessBreathlessness is an awareness of the intensity of breathing.The following positions will assist relaxation of the upper chest while encouraging use of the lower chest.High side lying Forward leaning in sittingForward leaning in standingBreathing control while walkingThis is helpful when walking on stairs and slopes and it may be necessary when walking on the level. Try to relax the upper chest, shoulders and arms and use the controlled, lower chest breathing. The tendency is to hold the breath, which only increases the feeling of breathlessness. It is helpful to breathe rhythmically in time with steps taken e.g. breathe in for one step and out for two steps.MobilityMobilisation is the first line treatment for patients who are able to get out of bed.Patients that are unable to mobilize can use controlled activity by transferring bed to chair or sit to stand.Effects of mobilisation:Increases lung volumeIncrease thoracic expansionDecreases WOB with caudal displacement of the diaphragmMobilise secretionsStimulate spontaneous coughEncourages basal distributionNatural deep breathingThe level of activity is controlled so that the depth of breathing increases slightly.IPPBIPPB is assisted breathing with a pressure cycle ventilator, triggered into inspiration by the patient and allowing passive expiration.IndicationsIncrease lung volumeDecrease WOBMobilise secretionsContraindicationsBullous emphysemaUndrained pneumothoraxPneumomediastinumRecent barotraumaICP >15Recent facial/ oral/ oesophageal surgeriesSpinal InstabilityAcute pulmonary oedemaAcute lung injuryCardiovascular instabilityBronchial tumourAcute BronchospasmRecently fed (may cause vomiting/nausea) If PEG fed it is recommended to stop feed 1 hour pre-treatment when first triallingActive TBUndiagnosed haemoptysis Nausea and vomitingPrecautionsEmphysematous bullaeRecent lung resectionRestrictive lung diseaseCautionsIf a patient relies on hypoxic drive (i.e. COPD patients) then use BIRD on an air cylinder. Oxygen may be delivered via nasal spec if necessary (24-28%)Breath cannot be sustained at the end of inspirationPressure cycled therefore if lung compliance is low then, little tidal volume is deliveredC02 retention may occur if inadequate tidal volume deliveredMay cause gastric distensionAir trapping may occur in CF and emphysemaIncreased WOB if used incorrectlyEquipment SettingsPowered by compressed oxygen or air.Air mix control - to entrain room airSensitivity - the amount of effort required to trigger the machine. The weaker the patient the higher the sensitivity required. If the aim is to reduce WOB, it is important to keep it high so that the machine is easily triggered.Flowrate - is how fast the breath is delivered. Intially adjust the flow rate to synchronise with the patient’s respiratory rate. Then aim for a decrease in flow rate as this decreases the turbulence in the airway, leading to more laminar flow and better ventilation. Pressure - reached in the patients chest at which stage the machine shuts off. Usually ranges between 0-30 cmH2O. Start off at 10-15 cmH2O and then increase depending on the patient size, ability to tolerate feeling, compliance of lung tissue and chest wall.Typical settings - Sensitivity 5 Flow Rate 10-15 Pressure 10-15 cmH2OPROGRESS BY REDUCING THE FLOW RATE AND INCREASING THE PRESSURENebulisation - Always instill 0.9% saline into the nebuliser unit. Bronchodilators may also be used.Breathing CircuitDisposable with mouth piece or face maskPatient PositionSitting uprightHigh side lyingSide lyingThe BIRD provides positive pressure and therefore the uppermost lung will be better ventilated in side lying, thus decreased lung upExplanation to the PatientCareful explanation to the patient – how it will feel (“a cool stream of air”), how it will help (“to open up the lungs and improve the breathing”). Reassure the patient not to fight the machine (“it will help you take a deeper breath more easily”)Ask him to put the mouthpiece between his teeth and over his tongue and make a tight seal around the mouthpiece with his lips.Ask him to slowly breath in and out through the machine. With his inspiratory effort the machine is triggered and then ask him to relax and let the machine take over. The machine gives a positive pressure during inspiration allowing the lungs to inflate and when the set pressure reached, the machine cuts itself off and expiration begins.Patient may be taught to look at the manometer. If you look at the pressure gauge, the needle which will have been resting at 0, makes a swift movement into negative, the machine is switched on when the negative pressure created is equivalent to the sensitivity setting. The needle then swings back to zero, and into the positive. The needle moves slowly at first, to indicate positive pressure developing in the lungs in the early part of the breath when the lungs accept volume with little change in pressure and then at the end of the breath rapidly to the set preset pressure, at which stage the machine switches off. The needle returns to zero with the patient breathing out through the exhalation mon Problems EncounteredThe machine keeps blowing and does not cut itself off. This is because the positive pressure is not building up in the lungs due to leakage of air. Check that the patient is having a tight seal and that there are no leaks. If patient unable to maintain a tight seal with the mouth piece or is confused then a face mask with the head strap can be used, checking for an adequate seal.Delay in increase in positive pressure. This can occur if the patient assists through inspiration even after the machine is triggered. This can be checked on the manometer if there is an increase in swing of needle into the negative indicating unnecessary effort by the patient. Explain to the patient that he need only inhale gently to trigger the machine, once triggered the patient should relax and allow the machine to fill his lungs passively.Machine switches itself off quickly. This happens if the patient is expiring actively. The machine shoots over preset pressure sharply and cuts into expiration.The patients breathe is not detected. The patient may be breathing through their nose or there may be a leak around the mouthpiece.The patient only accepts the breath into the mouth. The breath will be very short and the cheeks will be seen to bulge.Positive Expiratory Pressure (PEP)PEP is the application of positive pressure during expiration.Breathing out against resistance is thought to open up collateral airways, even the distribution of ventilation, mobilise secretions and splint floppy airways.Pressures between 12-15cmH2OMainly used with bronchiectasis and CF patients.PEP Devices Illustration of the oscillatory positive expiratory pressure (OPEP) devices and descriptions of their theory of operation. (Respiratory Care April 2017, 62 (4) 451-458; DOI: )Flutter & AcapellaThe Flutter and Acapella exploit the combined effects of PEP and oscillation via counterweighted lever and a magnet respectively.Oscillating PEP is designed to be used with a steady expiratory manoeuvre for at least 4 seconds.PEP can be increased by tilting the flutter upwards, or by turning the dial on the end of the Acapella towards the + sign (clockwise).PEP devices are used for 5 to 20 minutes depending on the patient, with 10 PEP breaths alternated with several relaxed breaths.Clinicians and patients generally prefer the Acapella because it is not gravity dependent and therefore can be used in any position; it can produce effective oscillations at a low flow rate, achieve higher pressures and can be attached to an oxygen supply.Mediflo-duoThe mediflo-duo can be used as both an incentive spirometer and as a PEP device depending on the position of the tubing.Turning the blue dial can increase/decrease PEP.Incentive SpirometerIncentive spirometry is designed to mimic natural sighing or yawning by encouraging the patient to take long, slow, deep breaths.This is accomplished by using a device that provides patients with visual or other positive feedback when they inhale at a predetermined flowrate or volume and sustain the inflation for a minimum of 3 seconds.The objectives of this procedure are to increase transpulmonary pressure and inspiratory volumes, improve inspiratory muscle performance, and re-establish or simulate the normal pattern of pulmonary hyperinflation. When the procedure is repeated on a regular basis, airway patency may be maintained and lung atelectasis prevented and reversed.Ultrasonic Nebuliser/Induced SputumA ultrasonic nebulizer is an electrical device that transmits vibrations through a liquid to atomize particles into a mist producing smaller particles than a regular nebulizer.The theory is that a more uniform, smaller particle size makes the mist penetrate more deeply into the lungs and therefore increase sputum yield.Disadvantages include limited evidence, risk of bronchospasm and risk of infection if the machine is not maintained properly.Due to the increased sputum yield ultrasonic nubulisation can be used to gain a diagnostic sputum sample for analysis in those struggling to expectorat e.g. TB, pneumocystis pneumonia (PCP), Lung Ca.PCP is a form of pneumonia caused by a fungus Pneumocystis Jirovecii. Pneumocystis is commonly found in the lungs of healthy people but can develop into an infection in people who are immuno-suppressed.Suspected TB samples are tested for alcohol acid-fast bacillus (AAFB) which is a physical property of the bacteria.N.B for procedure see Protocol on shared folder.CPAPAssistance to lung inflation and improved gas exchange can be given by pneumatically splinting open the airways with continuous positive pressure. CPAP can be described as positive airway pressure above atmospheric, which is maintained throughout inspiration and expiration in spontaneously breathing patients this can be delivered via a mask, a hood and in some patients a nasal mask or shield.IndicationsPrevention and treatment of post-operative atelectasisManagement of acute type I respiratory failurePulmonary contusion and flail chestAvoidance of intubation and conventional ventilationFacilitate weaning from conventional ventilationContraindicationsUn-drained pneumothoraxSubcutaneous emphysemaBullaeBronchopleural fistulaOesphageal and bronchial surgeryFacial traumaComplicationsIf using high oxygen concentrations, then removal of mask may cause rapid desaturationPressure sores on bridge of nose if not adequately protectedClaustrophobia and gas blowing into eyesC02 retention can occur if a hypercapnic COPD patient breaths with a small tidal volume against a high PEEPCPAP can cause gastric distention CPAPIPPBContinuous positive pressure during inspiration and expirationIncreases FRCDecreases WOBHelps with hypoxaemia by improving oxygenationIntermittent positive pressure during inspirationIncrease TVDecreases WOBHelps with hypercapnia by blowing off carbon dioxideManual Hyperinflation‘Bagging’ can be used as a technique to hand ventilate a patient or during physiotherapy. When hand ventilating normal tidal volumes are delivered. With physiotherapy treatment larger breaths (hyperinflation) are required.IndicationsTo aid removal of secretionsTo aid reinflation of atelectatic segmentsTo assess/improve lung complianceStimulate a coughContraindicationsUndrained pneumothoraxBullaeSevere bronchospasmCV instabilityUnexplained haemoptysisPEEP> 15, maximal ventilatory support, high pressuresCautionsBullaeRecent lung resectionHigh tidal volumes >800ARDSIncreased ICP/Acute head injuryComplicationsRespiratoryHypoventilation - due to inadequate ventilationReduced respiratory drive — reduced carbon dioxide levels during treatment may reduce a patients respiratory drive100% oxygenVolutrauma/barotraumasDecrease in saturations — due to sputum plug, bronchospasm or pneumothoraxCardiovascularDecrease in blood pressure — compromised venous return will reduce the stroke volume and drop a patients blood pressureIncrease in ICP -~ an increase in carbon dioxide in cerebral blood vessels may lead to vasodilation, resulting in an increase in blood flowTechniqueMonitor patients obsOne/two handed techniqueType of bagFlow rateSalinePEEPPosition of valveUse of adjunctsCoordinate with patientSlow deep inspirationRecruits collateral ventilation (thus mobilising secretions)Aids re-expansion of atelectatic segmentsImproves gaseous exchangeAssesses and potentially improves complianceInspiratory holdCollateral ventilationFast expiratory releaseMimics a forced expirationStimulates a coughHand held PEEPTo maintain the same level of PEEP as the ventilatorSuctioningIndicationsWhen the normal mechanism to prevent bronchial obstruction is impaired (sputum retention, ineffective cough, impaired mucociliary clearance) and the secretions are detrimental to the patient.Routes of entryNP-openOP-openET — open or closedTracheostomy tube — open or closedMinitracheostomy – openContraindicationsWhen it is not indicatedSF leak due to head injuryStridor - suction catheter will obstruct the airway furtherSevere bronchospasm - suction catheter will obstruct the airway furtherHigh bronchial tumourFrank haemoptysisNasal surgery/trauma - for NP suctionCautionsCV instabilityClotting disordersHigh anastomosisPulmonary oedemaAcute head injury — possibility of CSF leakRaised ICP — Tracheal stimulation and an increase in intrathoracic pressure causes a decrease in venous return during coughingComplicationsRespiratoryAtelectasis — negative pressure from suctioning can lead to airway collapseBronchoconstrictionHypoxia — connected to atelectasis. Airway collapse will lead to an increase in oxygen demandCardiovascularHypotensionHypertensionVaso-vagal stimulationCardiac arrythmias — direct tracheal stimulation can cause a vasovagal reflexOtherInfection — due to poor techniqueMucosal damage — due to poor technique (incorrect pressure and catheter) when passing a catheterPatient distress — due to poor communicationEquipmentGloves and gownSterile glovesCorrect size suction cathetersYankeurSuction unit (static or mobile) — check pressure. Should be 60-l50mmIIg or 11-20 kPa. Use the lowest effective pressure.Airways (if appropriate)Lubricating jellyWaterTechnique:Position patient appropriately — if you extend the neck you are less likely to enter the oesophagusPreoxygenateAttach suction catheter to the suction tubingSterile glove on dominant handHold the suction catheter with the sterile handInform patient of what you are about to doIntroduce the catheter slowly on inspiration until resistance is felt or a cough is stimulatedWithdraw the catheter by 1cm to limit mucosal damageApply suction continuously not intermittently (unless there is a sticky plug)Withdraw the suction catheter slowly (max. 15-20seconds)Replace oxygen or catheter mountRepeat as indicatedClosed suction V Open suctionClosed suction can be used without disconnecting a patient from the ventilator.IndicationsInfectious patientsHigh PEEPAdvantagesDecreased risk of infectionNo loss of PEEP or oxygenationDisadvantagesExpenseLoss of sensitivityOver suctioningMore trauma due to rigid suction catheters and repeated suctioningAirwaysIndicationsAssist clearance of secretionsNaso-pharyngeal airwayInsertion can cause bleeding from nose or nasopharnyx, if tube is too long can cause vomitingCan lead to laryngeal spasm, vagal nerve stimulation leading to cardiac arrhythmia’sContraindicated in head injuries with basal skull fracture due to potential CSF leak and risk of infectionSized in mm - use same size as diameter of patients little fingerInsertion - check patency of right nostril. Place a safety pin through flange to prevent inhalation of the airway. Insert lubricated airway, bevefled end first, vertically along the floor of the nose with a twisting action. The tip should lie in the pharynx. Oropharyngeal airwayCurved plastic tube that fits between the tongue and the hard palateInappropriate for conscious patients because stimulation of gag reflex may cause vomiting and aspirationEstimate of size - select airway that corresponds in length to distance between corner of mouth and angle of jaw. Most common sizes are 2,3,4 for s,m,l adults. Inserted with the tip directed to the roof of the mouth and then rotated. Can be distressing.TracheostomiesWhat is a tracheostomy?A tracheostomy is a surgical opening in the anterior wall of the trachea to facilitate ventilation. The tube enables airflow to enter the trachea and lungs directly, reducing the upper airway anatomical dead space (bypassing the nose, pharynx and larynx).This benefits the patient by reducing the effort required for breathing when compared with normal breathing or endotracheal airway management. As the tracheostomy tube bypasses the upper airway, the humidification and filtering of air does not occur naturally.Indications for a tracheostomyFacilitate removal of bronchial secretions Protection of airway to minimise aspiration in the absence of laryngeal reflexes To facilitate weaning from positive pressure ventilation (decreases ventilation and airway resistance compared with endotracheal tube)Prolonged or long term ventilatory supportProphylactically if undergoing head or neck surgery To obtain an airway in a patient with head or neck injuries Secure an airway in actual or impending upper respiratory tract obstructions when prevented from placing an endotracheal tubeFacilitate oral intake Improve communicationPatient comfortWhy use a tracheostomy tube over an ETT?Each patient has to be reviewed on an individual basis and the potential risks and benefits weighed up carefully. The literature states that a tracheostomy tube is favoured over an endotracheal tube when a patient has been ventilated for seven days and were he is to be ventilated for a further seven days.Prolonged ventilation >1/52WeaningImproves tolerance to intubationDecreased risk of accidental extubation (more secure)Improve patient comfortEasier clearance of secretions by suctionFacilitation of communication (cuff deflated and speaking valve in situ)Allows oral intakeImproves oral hygieneTypes of tracheostomyThere are three types of tracheostomy:Cricothyroidotomy (mini-tracheostomy)PercutaneousSurgicalAll Percutaneous and surgical tracheostomy tubes are sited between the second and fourth tracheal rings. The higher the level of the tracheostomy tube, the greater the risk of laryngeal/tracheal stenosis. The lower the level of the tracheostomy tube, the greater the risk of haemorrhage from the major vessels of the thoracic outlet.Mini-tracheostomyA small non-cuffed tube sited through the cricothyroid membraneIndicationsSputum retention (can’t use > 10 suction catheter)Emergency procedure for life threatening airway obstruction and delivery of oxygenThe advantages of a mini-tracheostomy include preservation of the glottis function (coughing, speaking, swallowing) and natural humidification.ContraindicationsPatients who do not have a gag, swallow or cough reflexPatients with thick secretionsMini-tracheostomies are not for long-term use and have a maximum life 30 days.PercutaneousThere are two types of percutaneous insertion techniques, one involves inserting the tracheostomy tube between the first and second tracheal rings while the second involves the second and third tracheal rings. One procedure involves forceps to dilate the trachea, whilst the other increases the diameter of the stoma gradually.IndicationsRequiring long term positive pressure ventilation or airway managementFacilitate weaning from positive pressure ventilation or airway supportSputum retentionThe advantages of a percutaneous tracheostomy are that it can be performed on ICU with a smaller incision site (lower incidence of wound infection) and no tracheal resection.ContraindicationsAbnormal coagulationAbnormal anatomyDisadvantages of a percutaneous tracheostomy include an increased risk of surgical emphysema (risk of air leaks from the trachea accumulating within the surrounding tissues) and pneumothorax.SurgicalA surgical tracheostomy is sited between the second and third tracheal rings and is four to five centimetres in length. They sometimes involve a flap of skin with sutures or a slit incision.IndicationsAs with percutaneous (Long term positive pressure ventilation or airway management, facilitate weaning from positive pressure ventilation or airway support, sputum retention)Elective proceduresAbnormal anatomyAbnormal blood clottingThe advantages of a surgical tracheostomy include improved visualisation and decreased risk of incorrect placement.ContraindicationTransference of unstable patient to theatreDisadvantages of a surgical tracheostomy include increased incidence of infection due to greater trauma and more post-op complications.Tracheostomy tubesCuffed tracheostomy tubeThe two main purposes of a cuff are:to allow application of positive pressure ventilation without loss of tidal volume and to prevent air/oxygen mix leaking backwards past the outside of the tracheostomy tubeto prevent or decrease the risk of aspiration of oral or gastric secretions (but may make swallowing difficult by pressing on the oesophagus)Air leaks may occur because of the cuff itself or around the cuff due of the position. The disadvantage of a cuffed tracheostomy tube is trauma by over-inflation of the cuff (keep to MOV).Double cannula tracheostomy tubeSecretions may adhere to the internal lumen of the tracheostomy tube, reducing the internal diameter, therefore, increasing the patients work of breathing. A tracheostomy tube with an inner cannula allows the inner cannula to be removed to facilitate cleaning without removing the entire tracheostomy tube. This minimises trauma and discomfort.Some tracheostomy tubes require the inner tube to be in place to be able to connect to the ventilator therefore a spare inner tube is required at the patients bedside. When suctioning, ensure the inner cannula is non fenestrated to allow the suction catheter to pass easily.Uncuffed tracheostomy tubeAn uncuffed tracheostomy tube is more suitable for long term use in patients who have competent glottic function and in whom aspiration is not a problem.This type of tube also allows the patient to speak. In the event of the tube becoming blocked the patient can breathe around the tube. An uncuffed tracheostomy tube is unsuitable for patients who require artificial ventilation.Fenestrated tracheostomy tubeA fenestrated tracheostomy tube has one or more holes in the upper third posterior portion of the outer cannula. When the inner cannula is removed the tube assists to direct airflow out of the holes and up through the vocal cords so phonation can occur. Patients who are at risk of aspirating or who are on positive pressure ventilation should not have a fenestrated tracheostomy tube unless a non-fenestrated inner cannula is used. A non-fenestrated inner cannula should also be used for suctioning.Tracheostomy tube with adjustable flange A tracheostomy tube with an adjustable flange is specially designed for patients who have deep-set tracheas. The adjustable flange means the tracheostomy tube can be adjusted to the desired length. When in situ the flange can be moved to help clean around the plications of a tracheostomyNOTE: Complications more frequent after emergency tracheostomy for airway obstructionImmediate <24 hoursHaemorrhageMisplacement – pretracheal tissue, main bronchus, posterior tracheal wall perforationTension pneumothorax (result of attempting to ventilate the patient through a misplaced tube, resulting in air tracking down into the mediastinum and pleural cavities)Occlusion of tube by cuff herniationSurgical emphysema (common – but unless accompanied by a pneumothorax is unimportant)Hypoxia linked to misplacementLoss of airway due to misplacement of tracheostomy tubeDelayed >24 hoursBlocked tube with secretions (need adequate humidification)Infection of stoma site and bronchial treeTracheal dilation (due to overinflated cuff causing distention) → ulceration → necrosisMucosal ulceration (due to asymmetrical inflation of the cuff, excessive cuff pressures or tube migration)Tracheo-oesophageal fistula formationRisk of occlusion of tracheostomy tube in obese patientsLate >6/12Tracheal dilationTracheal stenosis at the cuff siteScar formationSpeaking valvesVoice production may be achieved in patients with tracheostomy tubes by using a speaking valve. Speaking valves allow air to be entrained via the tube opening on inspiration. At the end of inspiration the valve closes so that on expiration air is forced back down the tube and up into the larynx. A speaking valve must never be placed on a non-fenestrated tube when the cuff is inflated as the patient will not be able to exhaleContraindicationsInability to tolerate cuff deflationAirway obstructionMedically unstableSevere anxietyExcessive secretionsCough AssistIndicationsPatients who are unable to clear secretions easily and effectively with assisted cough.ContraindicationsBullous emphysemaUndrained pneumothoraxPneumomediastinumRecent barotraumaICP >15Recent facial/ oral/ oesophageal surgeriesSpinal InstabilityAcute pulmonary oedemaAcute lung injuryCardiovascular instabilityAcute BronchospasmRecently fed (may cause vomiting/nausea) If PEG fed it is recommended to stop feed 1 hour pre-treatment when first triallingActive TBUndiagnosed haemoptysisParametersManualAuto-Inhale time-Exhale time-Pause5439410-6350PressureInhale FlowInhale PressureManual/AutoThe machine can be set to operate in manual or auto cycling. Depends on patient preference in auto mode inhale and exhale and pause and pause times must be set.Recommended TimesLow inhaled flowHigh inhaled flowInhale time (secs)3-41.5-2.5Exhale time (secs)1-21-2Pause1-21-2In manual mode the manual control lever is used to cycle the machine into inhalation or exhalation.Pressure SettingThe inhale and exhale pressure must be CHECKED BEFORE EACH TREATMENT AND SET.On initial treatment 10 - 20 cm H2O inhale/exhale pressures can be used, as patient becomes acclimatised, and to increase effectiveness of treatment, exhale pressure may need to be 40 - 45 cm H2O. Inhale pressure can be set between 50 - 100% of exhale pressure.To set pressure:Ensure in manual modeCover and seal end of patient hosePush manual control lever to exhale and holdObserve pressure readingAlter pressure as appropriate using pressure knobPush manual control lever to inhale and holdSet inhale pressure to appropriate setting using inhale pressure knobChange to auto to confirm readings on pressure gauge (Patient hose sealed)The inhale flow can be adjusted between low and high flow depending on the desired speed of inhalation. Inhale and exhale times are adjusted accordingly.Patient InterfaceFacemask or mouthpiecePatient CircuitMask or mouthpieceConnector36” smooth bore tubingAntibacterial viral filterTreatment Duration4 - 5 inhale/exhale cycles, rest period of about 30 seconds. This sequence can be repeated as tolerated (aim for 4 - 6).Instructions to PatientsThe machine will blow air into the lungs then suck it out to help clear secretions.The patient must time breathing with the machine.The patient may experience ‘sore muscle’ ache post treatment due to increased thoracic expansion.Clearway cough assistIndicationsPatients who are unable to clear secretions easily and effectively with assisted coughIncrease lung volume (can use 02 within clearway circuit)Contraindications/cautions Bullous emphsemaUndrained pneumothoraxPneumomediastinumRecent barotraumaICP >15Recent facial/ oral/ oesophageal surgeriesSpinal InstabilityAcute pulmonary oedemaAcute lung injuryCardiovascular instabilityAcute BronchospasmRecently fed (may cause vomiting/nausea) If PEG fed it is recommended to stop feed 1 hour pre-treatment when first triallingActive TBUndiagnosed haemoptysis Equipment requiredMask, mouth piece or tracheostomy catheter mountClearway circuit with filter included Recommended Times:Inhale time (secs)2.8Exhale time (secs)3.0Pause2.5Pressure SettingThe inhale and exhale pressure should be locked in when initially set and relocked following any adjustments needed from treatment to treatment.On initial treatment 10-20cm H2O inhale/exhale pressures can be used, as the patient becomes acclimatised, aim to increase the exhale pressures to increase effectiveness. Exhale pressures may need to be 40-45com H2O. Inhale pressure can be between 50-100% of exhale pressure.Treatment Duration:4-5 inhale/exhale cycles, with a rest period of approx. 30 secs. This sequence can be repeated as tolerated. (Aim for 4-6). Apply adequate pressure during insufflation period to ad mask seal and reduce leak potential.Instructions to patient:The machine will blow air into the lungs then suck it out to help clear secretions.The patient must try to time breathing with the machineThe patient may experience ‘sore muscle’ ache post treatment due to increase thoracic expansionCommon problems that can be encountered:Asynchrony of breaths between the patient and machine, try and incorporate a deep breath just prior to starting the cycle on the clearway cough assist to identify with the patients breathing pattern to aid synchronyAsynchrony can also occur when the timed breaths are too long/short in seconds in the insufflation and exsufflation individual phase or in the ‘pause’ element, watch the patient closely in the first cycle to see whether to increase/decrease these times to suit the patients natural deep breathing patternWhen using a mask, ensure the pressure is sufficiently applied to the face to ensure treatment is optimal, if there is any leak, slightly adjusting the mask/applying more pressure may aid a better sealStarting with lower pressures will most probably not ensure optimal treatment from the beginning, but it may assist with getting the patient on board with the treatment hence increase the chance of success of treatment overall, explaining each step of the process will also help with this.Non Invasive Ventilation (NIV)This may also be known as ‘bipap’ (even though this term is a trade name) which effectively is ventilation with two pressures (hence the ‘bi’). This is a nurse led service at SDGH and can be commenced on A&E with the only suitable ward for continued care designated as 14B. It is not expected that physiotherapists in this trust will set up/titrate or advise on NIV use, this information is merely to aid knowledge and understanding of NIV use. IndicationsType 2 Respiratory Failure (T2RF) also known as Acute Hypercapnic Respiratory failure (AHRF). This is indicated when the ABG’s present an acidotic picture (pH<7.35) alongside high pCO2 (in excess of 6.5) and low pO2 (under approx. 10). NIV is used once a specific medical plan has been followed and has not achieved the desired improvements in ABG’s.Patient groups that NIV is advised for with T2RF consist of patients with COPD, OSA/OHS and MSK issues such as kyphoscoliosis. This links in with guidance from the British Thoracic Society (BTS) in 2016 for ventilatory management of AHRF in adults.Contraindications/CautionsPneumothorax- if present on CXR and undrained at presentrecent upper gastrointestinal/Oesophageal and bronchial surgeryFacial trauma copious respiratory secretions confusion/agitation Acute bowel obstructionSubcutaneous emphysemaBullaeBronchopleural fistulaStarting pressures and anticipated management plan according to guidelines:Inspiratory Positive Airway Pressure (IPAP): 15cm H20Expiratory Positive Airway Pressure (EPAP): 3-4cm H20 Rise time (RT, the rate of time to reach the selected airway pressure): 1-3Back up breath rate (BPM, mandatory breath rate if the patient was to become more reliant on the ventilator): 16-20 (even though this may be as low as 12 in practice)Supplemental O2 as required to achieve SaO2 of 88-92% (higher Sa02 aim if COPD not present), initially starting with O2 that has been given during course of medical management, titrating down accordingly. This will be alongside optimising ventilatory pressures to meet the individual patients needs.Maximise NIV use in first 24 hours then wean to night time only over next 2-3 days until able to wean offCommon problems that can be encountered:The patient is reluctant to engage in the treatment, hence the advice given to closely monitor the patient and encourage as much use as possible.Leak from the mask can be problematic so the right size and position is important to optimise treatment and aid with patient comfort increasing their likelihood of complianceIf worn for long periods, risk of a bridge of nose pressure sore can be increased, nursing staff should be aware of this and act accordinglyClaustrophobia with the level of pressure used alongside the mask size- reassurance is required‘Air swallowing’ can occur causing gastric retention- to be monitored and medically managed as this can reduce compliance AuscultationTechniqueUnderlying lobes should be visualised.Patient should breathe normally through the mouth and not hyperventilateEach lung area should be compared on alternate sidesBest position for assessment is high sitting (or if possible standing)Surface markings of the lungs and pleuraBreath SoundsIntensity relates to extent of ventilation in the underlying lung or to factors that affect transmission of these sounds.They are generated by turbulent airflow in the proximal airways. Airflow becomes less turbulent in the narrower airways creating less noise due to the large cross sectional area of the peripheral zones.Normal: Muffled tone due to transmission through lung tissue, Faint Expiration, No pause between inspiration and expirationAbnormal: Bronchial Breathing – hollow tone, loud expiration, inspiratory expiratory pause, heard over consolidation as sound is transmitted through solid tissue, a similar sound can also be heard at the upper level of an effusion. (Simulation of bronchial breathing can be heard over the trachea)Diminished: If patient in poor position, not breathing deeply, no air entry to generate sound, air entry but insufficient turbulence to generate sounds e.g. hyperinflated lungs. Air entry but sound transmission hindered by acoustic barrier e.g. pneumothorax or pleural effusion.If Localised? atelectasisIf in dependent regions? Pleural effusionIf unilaterally? pneumothoraxIf generally? hyperinflationIf bibasally? poor position or reduced tidal volumeAdded sounds: Can mask breath sounds. If louder on one side than the other may be due to increased added sounds on the same side or reduced breath sounds on the other side. Beware of transmitted sounds from the abdomen, voice, upper airway and tubing.Crackles: short interrupted sounds, produced by abrupt opening of airways, can be due to sputum, pulmonary oedema or parenchymal disorder.Early InspirationIn large airways, COPDMid inspirationCharacteristic of bronchiectasisLate inspirationOriginate in peripheral airways as they open at end of inspiration e.g. pulmonary oedemaExpiratoryWhen many secretions are presentWheeze: generated by air rushing through airways that are narrowed to point of closure causing oscillation of airway walls. Commonly associated with bronchoconstriction, but also produced by pulmonary oedema, sputum, tumour and foreign bodies.ExpiratoryUsually BronchospasmInspiratory & ExpiratoryCan be phlegmPleural rub: Inflammation with roughening of the pleural space produces sound like crunching snow. Identical on inspiration and expiration. Tends to be localised.Oxygen Therapy and Modes of DeliveryMonitoringO2 therapy should always be monitored. Pulse oximetry will confirm an adequate O2 flow rate but will not exclude dangerous hypercapnia. Arterial blood gases are an accurate way of measuring oxygen levels.Assessment should also in clue RR, HR, cyanosis, subjective assessment of breathlessness.Regular assessment of the need for continued high concentration is required to avoid oxygen toxicity and/or lung collapse developing.Delivery SystemsFixed Delivery Systems – Venturi (coloured connectors)Delivers fixed concentrations of 24, 28, 35, 40, 60% of oxygenIdeal when accurate percentages of oxygen are requiredThe flow rate indicated on the venturi valve is the minimum oxygen flow rate setting needed to give the percentage required.Valves: Blue24%White28%Yellow35%Red40%Green60% With fixed performance masks it is possible to achieve an unvarying mixture of gases and a known concentration of oxygen using the high air flow oxygen enrichment principle. These masks derive their name from the Venturi barrel in which a relatively low flow rate of oxygen is forced through a narrow jet. There are side holes in the barrel and this jet causes the air to be drawn in at a high rate. As the mixture of gas created is at a flow rate above that of inspiration, the mixture will be constant. Fixed oxygen therapy can be delivered either by simple mask plus coloured valve (dry, variable oxygen flow from the walled flow meter) or via a humidification system (where the valve is attached to the bubble through humidifier).Documentation should be as a percentage of oxygen e.g. 60% dry via face mask rather than the flow rate from the flow meter.Variable Delivery System – medium concentration (white connector)Delivers unpredictable concentrations that vary with flow rate and respiratory pattern and rate. Can deliver between 35 – 60%.Needs a minimum flow rate of 5 litres/min, or rebreathing can occur.Simple semi-rigid plastic masks are low-flow masks which entrain the air from the atmosphere and therefore are able to deliver a variable oxygen percentage (anything from 21 to 60%). Large discrepancies between the delivered fractional inspired oxygen (FiO2) and the actual amount received by the patient will occur, dependent on the patient’s rate and depth of breathing.This simple mask is connected directly to the walled flow meter, therefore document as a flow rate e.g. 4L/min via simple mask.High concentrations – (Non re-breathe bag or reservoir)Delivers high concentrations of oxygen. Can deliver between 60-80%+ of oxygen.Rarely needed except in patients with severe hypoxia not corrected by use of a standard oxygen maskThe reservoir bag must be fully inflated prior to the application to the patient. Flow rates must be sufficient to keep the bag partially inflated at the end of inspiration.Oxygen delivery of greater than 80% can be achieved. The semi-rigid mask has the addition of a reservoir bag with a one-way valve between the reservoir bag and mask, preventing accumulation of expired gases in the reservoir bag and retention of carbon dioxide.Nasal CannulaDelivers unpredictable oxygen concentrations between 22-35% that vary with flow rate and respiratory pattern.Flow rates of 2-4litre/min and normally used.Can be used in patients with stable Type II respiratory failure.Nasal cannulae consist of two prongs that are inserted inside the anterior nares and supported on a light frame. Advantages to the patient are that they have access to their face and are able to eat, drink and communicate. Nasal cannulae catheters provide an alternative to a mask, but there are great discrepancies between the delivered FiO2 and the actual oxygen percentage received by the patient. When used at low flow rates, for example 2 Litre/minute, they are well tolerated and afford the patient more freedom than a mask. At high flow rates, above 8 litres/minute, they may cause discomfort and dryness of the nasal mucosa leading to crusting of secretions and epistaxis. Nasal cannulae cannot be attached satisfactorily to and external humidification device.Nasal cannulae are connected directly to the walled flow meter therefore document as a flow rate e.g. 4L/min via nasal cannulae.Summary of methods of artificial HumidificationHumidity is the amount of water vapour present in a gas. The terms used to define humidity are absolute humidity, maximum capacity and relative humidity. Absolute humidity is the mass of water vapour that a given volume of gas can carry at a set temperature. When a gas is at its maximum capacity it is said to be fully saturated. Relative humidity is the ratio of the absolute humidity to the maximum capacity.The warmer the gas, the more vapour it can hold but if the temperature of the gas falls, water held as vapour will condense out of the gas into the surrounding atmosphere.In normal health the nasal passages and upper airways are able to warm, moisten and filter the inspired gases very effectively, The process of humidification is necessary to compensate for the normal loss of water from the respiratory tract which, under resting conditions, is about 250ml per day. This can increase in patients who are unwell.Normal room air has an approximate temperature of 22oC with a relative humidity of 50% and a water content of 10mg H2O. For effective gas exchange to occur in the lungs, the air would need to be at a temperature of 37oC with 100% humidity and a water content of 44mg H20 per litre by the time it reaches the bifurcation in the trachea, which is referred to as the isothermic point.When the temperature falls below 37oC and humidity falls below 100% several changes take place in the airways. The respiratory tract is lined with ciliated epithelial cells that secrete mucus. Each cell has about 200 hair-like structures known as cilia, whose role is to remove unwanted mucus and secretions. With a drop in temperature and humidity, the mucus that collects in the airways thickens and movement of the cilia is reduced. If there is no improvement the mucus will become thicker and immobile; the cilia will also lose their mobility so clearance of all secretions will stop and infection can set in.If there is a continuing lack of humidity further damage occurs. The cilia can break off, causing damage to the mucosal lining of the respiratory tract. The isothermic point of saturation moves further from the bifurcation of the trachea to a lower point in the lungs, resulting in further damage which can lead to collapse of the alveoli, decrease in lung function and hypoxaemia.Inhalation of oxygen, which is a dry gas can cause evaporation of water from the respiratory tract and lead to the consequences above if humidification is not provided.In patients who are intubated or have a tracheostomy the natural pathway of humidification is bypassed.Systemic HydrationIt is essential that oral and IV fluids are monitored to ensure satisfactory hydration/ Dehydration may lead to an increased viscosity of sputum. Over-hydration may result in peripheral/pulmonary oedema.Heated HumidificationOperates actively by increasing the heat and water vapour content of inspired gas, so that gas is delivered fully saturated at core temperature.With these devices, inspired gas is forced over or through a heated reservoir of water. To achieve an adequate humidity for the patient, the water bath must reach a set temperature. The gas will then cool as it moves down the breathing circuit to the patient, and a relative humidity of 100% will be reached. Hot water bath humidifies are therefore very efficient and useful in the care of the immobile patient, particularly to humidify when the patient is receiving mechanical ventilation.Cold HumidificationBubbles gas through cold water, but only delivers a relative humidity of 50% at ambient temperature. This device delivers partially humidified oxygen that is about 50% relative humidity. Gas is forced across or bubbled through water at room temperature.Saline NebulisationThe nebuliser unit converts saline into a supersaturated aerosol of liquid droplets, which penetrate the lung moistening the airways.Heat Moisture Exchange UnitOperates passively by storing heat and moisture obtained from condensation during expiration. In this situation an HME performs the function of the nose and pharynx in conditioning the inspired air. It retains heat and moisture in the expired air and returns them to the patient in the next inspired breath. Many HMEs contain a bacterial filter.Optiflow (Nasal Highflow)Optimal humidity is fundamental to Optiflow, as it makes it possible to comfortably deliver a wide range of flows directly into the nostrils. ?Emulating the natural balance of temperature and humidity that occurs in healthy adult lungs (37 °C, 44 mg/L) promotes greater patient comfort and improves tolerance to treatment while optimizing mucociliary clearance.Mucocilary ClearanceOptimal Humidity delivery achieves the balance of temperature and humidity that occurs in healthy lungs, maintaining mucociliary clearance. This can be particularly important for patients with secretion problems. This reduces drying of the airway, which maintains the function of the mucociliary transport system – clearing secretions more effectively and reducing the risk of complications such as respiratory infection.Accurate Oxygen DeliveryA key aspect of Optiflow is the flexibility to deliver a blend of air and oxygen over a wide range of flows from low though to high flow.A fundamental issue associated with traditional oxygen therapy is uncertainty around the levels of oxygen patients are receiving. With Optiflow, the aim is to meet or exceed the patient’s normal peak inspiratory demand, which creates minimal air dilution, even when breathing orally. Optiflow can more accurately deliver prescribed oxygen concentrations at high flows, providing both versatility and continuity of care.This greater degree of flexibility eliminates the need to switch between oxygen therapy delivery systems as patients wean or if their condition declines.Washout of Anatomical DeadspaceWith the delivery of high flows directly into the nostrils, a flushing effect occurs in the nasopharynx. The anatomical dead space of the upper airway is flushed by the high incoming gas flows. This creates a reservoir of fresh gas available for each and every breath, while minimising re-breathing of CO2.Therefore if deadspace is reduced alveolar ventilation will be a greater fraction of minute ventilation.Low Level PressuresClinical evidence collected by Fisher & Paykal suggests that with the delivery of Optiflow, low levels of positive airway pressure are generated. Mean airway pressure during the respiratory cycle has been shown to be elevated with the delivery of Optiflow.The degree of pressure is likely to be dependent on a number of variables including flow rate, geometry of the upper airway, breathing method through the nose or mouth) and size of the cannula relative to the nostrils. Pressure appears higher if mouth is closed throughout the breathing cycle.EquipmentOptiflow circuitHigh Flow stand with humidifierSmall length green O2 tubingBag of sterile waterPack with nasal cannule (appropriate size: S,M,L) Small bacterial filterO2 and Air ports reachableSet upConnect AC supply and oxygen and air linesConnect green tubing from flow meter to top of pressure manifoldInsert humidifier and connect inspiratory tubing to humidifier as per manufacturer’s instructionsDo not use extra unheated blue extension tube routinely. Add nasal cannula, of appropriate size, and connector to blue tubingAttach bag of sterile water for inhalationSet flow to desired flow (usually 10-60lpm), according to medical guideline or Consultant instructionOngoing care Ensure prongs are clean and patent at all timesConsider careful positioning, if necessary, to reduce the work of breathing e.g. high sittingWeaningThe flow and oxygen will be used for weaning purposes, as dictated by medical staff, wean oxygen as per prescribed titration targets, aim to reduce FiO2 before weaning down flow unless the patient in unable to tolerate the flow.CleaningChange entire circuit every 7 days.Clean humidifier and blender as per unit protocolConsiderationsUse flow to match or exceed work of breathing and RR, (those patients with high RR will need more flow)Higher flows will produce higher mean airway pressure (PEEP)Oxygen instillation should be for target saturations and should be weaned down accordinglyChest X-RaysThere are 2 types of X-rays, departmental and portable.DepartmentalThe standard projection of a departmental X-ray is postero-anterior (PA). It is taken at full inspiration with the X-ray focal spot behind the subject whose anterior chest wall is pressed against the X-ray plate. The patient is in an erect position with arms internally rotated and no scapula shadows are visible on X-ray. A standard exposure is used and films are comparable.PortablePortable X-rays taken on the ward will be taken antero-posteriorly (AP), the patient lying on or propped against the plate. Scapula shadows are visible on the film. The heart may appear enlarged on AP x-rays due to the divergence of the x-rays.Different exposures may be used and films may be over or under exposed.Examination of X-raysX-rays must be examined in an orderly manner so that no area is missed.Note : ET tubes, Chest drains, ECG Leads, Central Lines, NG Tubes etcBoney Structure: Scapulae – are edges visible in lung fields i.e PA/AP Clavicles – are they equidistant from vertebral bodies, any fractures? Ribs – All present? Fractures? Note shape/angle, Bone density (evidence of osteoporosis?)Mediastinum: The space between the two pleural cavities which contains the heart, great vessels, trachea, oesophagus, pulmonary vessels. It is a mobile area and can be displaced.Heart – Approx. 1/3 of the width of the diaphragm, 2/3 to the left and 1/3 to the right.Trachea – Lies centrally with a slight deviation to the right in the lower 1/3. Left and right main bronchi may be seen.Hilar regions – Traingular in shape composed of pulmonary vessels.Lung Fields: Compare the translucency of both lung fieldsDo lung markings extend to the peripheryAre hemidiaphragms clear, left lies approx 2.5cm lower than rightAre costophrenic and cardiophrenic angles clear and acuteCheck for presence of lung fissuresArea under diaphragm: Note presence of air under hemidiaphragm etcSoft Tissues Abnormalities Seen on Chest X-RayChronic Chest Patients: Bony structures may have a decrease in density due to long term steroid useRibs may appear horizontalFlattened hemidiaphragms Total Homogenous shadow of one lung: 1. Collapse/Displacement of structures on same side2. Consolidation, No displacement of structures3. Pleural effusion, Displacement of structures to opposite sideHomogenous shadows occupying part of one lung field:1. Lobar Colapse2. Lobar/segmental consolidation3. Small/moderate pleural effusionCollapse : Tracheal/heart deviated to same sideDisplacement of fissures towards area of collapseHemidiaphragm raisedIncreased translucency of remaining lung fieldLobar consolidation: Air in lobe is replaced by fluid/cellsA homogenous shadow occupying the normal anatomical position of a lobe without a fissure or mediastinal displacement.An air bronchogram may be seenSegmental consolidation: Triangular or pyramidal shadows which roughly corresponds to a segmentSmall Pleural Effusion: Haziness of the costophrenic angleModerate Pleural effusion: May casue collapse of the underlying lung, causing displacement of structures to the same side. If the patient is in an erect position a fluid level may be visible which tends to track up the pleura giving an upward going line. Pneumothorax: Occurs when air occupies the pleura. The edge is often seen as a faint line running vaguely parallel internally to the chest wall. There is loss of lung markins peripherally.Pulmonary Oedema: Fluid may be lost into the lung as a result of heart failure, renal failure, fluid overload, inflammation etc, giving a bilateral fluffy appearance. Alveolar Oedema is usually seen as small nodular opacities in the peripheral regions and is associated with an acute cardiac episode. Interstitial Oedema causes linear opacities extending towards the periphery.Adult Respiratory Distress Syndrome: A diffuse bilateral shadowing is seen similar to interstitial oedema, but has a finer “ground glass” appearanceLarge Circular or Oval Shadows: Bronchial Ca/secondary deposits Benign growths (fibroma) Fluid contaning cyst Lung abscess T.B. Focus Fungus infection e.g. aspergillomaSpinal Respiratory PhysiotherapyEffect of spinal injury on respiratory systemMain muscle of inspiration is the diaphragm which is supplied by C3-5.Above C3 patients only have accessory muscles for inspiration.Expiration T1-12 intercostal muscles.Expiration T7-12 abdominals.Importance of positioning of spinally injured patient-1047756286500Different to the “normal“ patient you would treat for respiratory. Vital capacity often worse sitting up. In lying you a patients abdominal contents dome the diaphragm. Abdominal binders can help maintain Vital Capacity (Goldman et al, 1986)?. When treating you would position as you normally would for drainage. May find that a patient can change drastically when turned side to side.How to measure vital capacity using wrights spirometerVital capacity is the greatest volume of air expelled after inhaling the deepest possible breathMonitor vital capacity regularly for a trend- wouldn’t expect normal values e.g. for a male 3000-4000ml. More looking for a trend which will be documented in end of bed notes. Peak cough flowUsed for measuring how effective a cough is. Use a peak flow (like used for people who suffer from asthma). Encourage patients with a tight seal to cough into mouthpiece. 160 is the target and often referenced as a marker for successful decannulation and extubation. Autonomic DysreflexiaWhat is Autonomic Dysreflexia?It is a potentially life threatening response to a noxious stimulation below the level of injury.Most commonly affect those with spinal cord lesions at or above T6.The more complete the injury, the greater the severity of A.D.Why does Autonomic Dysreflexia occur?Occurs as a result of a disconnection of the sympathetic neurons from the brain.If a noxious stimulus occurs below the level of lesion, the stimulus sends nerve impulses to the spinal cord, where they travel upward until they are blocked by the lesion. Because the impulses are unable to reach the brain, a reflex is activated that increases the activity of the sympathetic portion of autonomic nervous system. This leads to vasoconstriction of the blood vessels below the level of injury, which causes a rise in the blood pressure.Also stimulation of the vagus nerve causes bradycardia in an attempt to control the rise in blood pressure.Vasodilation also occurs above the level of injury in response to the raised blood pressure.It is potentially life threatening and is a medical emergencyManual assisted coughAll those with a spinal cord injury above T12 have a weaker cough.The higher the injury the weaker the cough.The more complete the injury the weaker the cough.Cautions (not exclusive – use clinical reasoning)Paralytic ileusGastric ulcer bleedAbdominal surgery/trauma/drainsThoracic trauma/cardiac or phrenic pacersPain/hypersensitivitySpasmsRigid chestCare if patient has just eatenUnstable fractureConsiderationsTo have a technique for manual assisted coughs for both lying and sitting.To ensure the wheelchair is stabilised when completing a manual assisted cough so the wheelchair doesn’t tip. To decide how many people are required for an effective manual assisted cough. If more than one person is involved ensure all involved are agreed and happy with the technique being used.Consider manual handling risks e.g. height of bed, the position you perform the manual assisted cough in. Avoid hand placement over the stomach if there are problems in that area e.g. bowel problems, stomach ulcers, surgery, or if the patient has just finished eating. Also avoid hand placement over the ribs if there are problems here such as surgery or fractures. This list is not exhaustive, ask a G.P. if you are unsure and explain to them what the technique of a manual assisted cough involves.Examples of manual assisted cough techniquesOne person manual assisted cough502348518034000307149511557000-4667257239000386143520637500-135255166370005848357810500Two person manual assisted cough737235266700027051004953000-447675311150042424352540000SIRS, Sepsis and MODSSIRS – the systemic activation of the innate immune response, regardless of cause. The body’s response to a variety of sever clinical insults, e.g. burns, pancreatitis.Sepsis – defined as SIRS in response to infection whether it be bacterial , viral, fungal or parasitic.Severe sepsis – associated with at least one acute organ dysfunction, hypoperfusion or hypotension.Septic Shock – sepsis-induced hypotension persists despite adequate fluid resuscitation.MODS- presence of altered function of two or more organs in an acutely ill patient.Who is most at risk of becoming septic?All critically ill patientsIntra-abdominal surgeryMeningitisChronic diseases (including Diabetes, heart failure, chronic renal failure)Compromised immune statusCellulitisUTISIRS/Sepsis is characterised by the presence of two or more of the following features:Temperature >38oC or <36oCHeart rate >90bpmRespiratory rate >20/min or PaCO2 <4.3kPaWhite Cell Count >12 x 109L Severe sepsis can be characterised by the following:Organ dysfunction – such that normal physiology cannot be maintained without supportHypotension – systolic BP <90mmHg, a reduction of >40mmHg from the patients normal, MAP <70mmHg in the absence of other causes of an hypoperfusion – revealed by signs such as lactic acidosis, oliguria, acute alteration of mental state.Shock occurs when the reserve capacity of tissue respiration is exhausted. Once oxygen delivery (DO2) can no longer satisfy oxygen consumption (VO2), a cascade of damaging events ensues.Shock follows a characteristic sequence:Inadequate tissue perfusionAnaerobic metabolismLactic acidosisMetabolic acidosisCellular damageOrgan FailureSeptic shock occurs when sepsis-induced hypotension is unresponsive to fluid resuscitation. Sepsis causes a fever resetting the hypothalmic thermostat which leads to peripheral vasodilation in an attempt to lose heat, thus depleating perfusion to the viscera. Endotoxins stimulate excess nitric oxide production which augments uncontrolled vasodilation and in effect reduces circulating blood volume. High cardiac output therefore cannot sustain an adequate BP.Disseminated Intravascular Coagulation (DIC)The normal response to tissue damage is a contained explosion of thrombin to initiate coagulation and limit blood loss. This can become uncontained after severe damage such as burns, brian or spinal cord injury, any form of shock, and sometimes the drug ecstasy. This leads to DIC, in which the liberated thromboplastin activates uncontrolled coagulation and blocks vessels with clumps of platelets and fibrin causing ischaemia and organ damage. When clotting factors and platelets have been depleted, bleeding can occur from the slightest trauma including suction.DIC can occur as a result of sepsis due to the inhibition of Activated Protein C (APC). APC has anticoagulant, anti-inflammatory and fibrinolytic properties. In sepsis, the inflammatory cytokines damage thrombomodulin and thus prevent the activation of protein C. In addition protein C levels decrease in sepsis due to increased consumption and to an increase in alpha one antitrypsin (an inhibitor or APC).Multiple Organ FailureCirculatory failureCriteria for diagnosisBradycardia (heart rate <50bpm)Hypotension (mean arterial pressure <50 mmHg)Ventricular tachycardia or fibrillationMetabolic acidosis (pH <7.2)ManagementOptimise cardiac preloadMaximise cardiac contractility with inotropesMaximise perfusion pressures with vasopressorsCorrect AnaemiaTreat arrythmiaRespiratory FailureCriteria for diagnosisRespiratory Rate <5 or >40 breaths per minuteHypercapnia (PaCO2 >6.7 kPa)HypoxaemiaManagementOxygenMechanical VentilationPEEP or CPAPExtra or Intracorporeal gas exchangeAcute Renal FailureCriteria for diagnosisUrine Output <400ml per 24 hoursSerum creatinine >150mmol/l ManagementConservative measuresFluid and potassium restrictionDrug dose adjustmentHeamofiltration DialysisHaematological failure Criteria for diagnosisLeucopenia (WCC <100 cell/mm3)Thrombocytopenia (platelet <20,000 / mm3)Evidence of disseminated intravascular coagulationManagementRed cell and platelet transfusionFresh frozen plasmaCorrect antithrombin III deficiencyHepatic failure Criteria for diagnosisCoagulation defectRising hepatic enzymesManagementFresh frozen plasmaNutritional SupportCorrect hypoalbuninaemiaGastrointestinal failure Criteria for diagnosisIleusGastroparesisHaemorrhageManagementParenteral nutritionStress ulcer prophylaxisSelective gastrointestinal decontaminationNeurological failure Criteria for diagnosisDepressed level of conciousness (Glasgow Coma Score < 6)FitsManagementOxygenationControl SeizuresAcute Respiratory Distress Syndrome and Acute Lung InjuryARDS and ALI are heterogenous lung injuries characterised by hypoxaemia, non-cardiogenic pulmonary oedema, low lung compliance and widespread capillary leakage.ARDS and ALI are caused by any stimulus of local or systemic inflammation, principally sepsis.ARDS and ALI are defined as:Bilateral pulmonary infiltrated on chest x-rayPulmonary Capillary Wedge Pressure <18mmHg (this is a measure of the left atrial filling pressurePaO2/FiO2 = ALIPaO2/FiO2 = ARDS (ratio of arterial oxygen tension to fraction of inspired oxygen (PaO?/FiO?)when PaO2 is measured in mmHG)PathologySepsis results in an increase in alveolar and pulmonary capillary permeability.Protein–rich fluid engulfs the alveolus, activated neutrophils and macrophages follow, and an inflammatory cascade is initiated involving the release of inflammatory mediators and tumor necrosis factor.Neutrophils release oxidancts and variopus proteases leading to massive cell damage and sloughing of cell debris into the lumen of the alveolus.Alveolar surfactant is inactivated.(Meanwhile in the pulmonary capillary endothelial cells swell, causing platelets to gather, which can in some cases result in small-vessel thrombosis)Surfactant depletion, alveolar flooding, cellular debris within the alveolus and increased airway resistance all contribute to an increase work of breathing.Surfactant loss leads to alveolar collapse, which decreased lung volume and serves to decrease lung compliance.The interstitial lung space between the alveolus and the vascular endothelium is widened, resulting in slow diffusions of gases. This results in a decrease in arterial partial pressures of oxygen, and possible retention of carbon dioxide.As the respiratory muscles are then supplied with relatively deoxygenated blood (due to the low PaO2), they quickly fatigue; the body is then unable to maintain such sustained work of breathing and respiratory failure ensues.(In addition, hypoxia, hypercapnia, and small vessel thrombosis combine to elevate the pulmonary artery pressures, leading to increased ventricular work, increased right ventricular filling and, ultimately a septal shift towards the left ventricle. This leads to a decreased cardiac output, which results in further reduction in oxygen delivery to the tissues.)Prolonged inflammation within the lung results in fibroblastic proliferation, leading to lung fibrosis.Clinical Features of ARDS and ALITachyponea is an early sign as pulmonary oedema develops. Pulmonary compliance decreases, tidal volume decreases, and thus, WOB increases.Cyanosis may occur with increasing hypoxaemiaFever may reflect the underlying process casuing the ARDS or ALICrackles may be evident throughout the lung fields, signifying pulmonary oedema.Hypercarbia develops with worsening disease, reflecting the increase in dead spaceHypoxaemia may be evident. The extent of which will depend on the extent of the oxygen supplementation.TreatmentNo treatment for ARDS is definitiveAim to treat the underlying cause if possibleVentilation is the cornerstone of management of patients with ARDS. Aiming to maintain a reasonable PaO2 without casuing injury to the lungs with excessive O2 or Volutrauma.The ventilators should be set to low tidal volumes and the PEEP should be set high enough so as to prevent alveolar closure on expiration. Protective ventilation of 4 – 6 ml per Kg using Ideal Body Weight.Respiratory Problems and Intervention Options Intubated PatientLoss of VolumeSigns and SymptomsTreatment OptionsSecretion RetentionSigns and SymptomsTreatment Options↑Work of BreatingSigns and SymptomsTreatment OptionsRespiratory Problems and Intervention Options Self ventilating PatientLoss of VolumeSigns and SymptomsTreatment OptionsSecretion RetentionSigns and SymptomsTreatment Options↑Work of BreatingSigns and SymptomsTreatment OptionsClinical SkillsSuctionWhat are 3 different ways of suctioning a patient?1.2.3.When would suctioning a patient be appropriate?In what situations would you be cautious about suctioning, or would not suction a patient?Describe the technique you would use for open suction:IPPBWhat are the indications for using IPPB?What situations would require care with IPPB?What are some of the side effects of IPPB?Describe what equipment you need to set up the system and where would you get it from?Manual HyperinflationWhat are the indications for manual ventilation?1.2.3.4.In what situations would you be cautious about bagging a patient?What potential side effects may occur with manual hyperinflation? ................
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