The nasal passages, pharynx, larynx, trachea, main bronchus
and bronchial tubes, and lungs make up this system. All these organs provide respiration, the
exchange of gas, or air, between the environment and the body and the process
of making it usable for the body. The
byproduct of respiration, carbon dioxide, is eliminated by exhaling. Inhaling provides oxygen; it is then
exchanged on a cellular level, via the alveoli, and transported to all cells
via the blood pumped by the heart. It is
the alveoli, the main functioning cellular pieces of the respiratory system,
along with the bronchial tubes and organs, which connect the inside of the body
to the outside environment – and perform gas exchange providing pulmonary
functionality.
A wide variety of
illnesses and disorders are accompanied by problems with breathing. Often the
need for respiratory intervention and assessment is what distinguishes patients
who need skilled nursing care at home from those who do not. Some of the various
respiratory systems conditions and care considerations are described below.
Chronic Obstructive Pulmonary Disease (COPD): is a long-term
(chronic), debilitating, irreversible, and progressive group of lung diseases
that results in air-flow resistance into and/or out of the lungs, noted
by increased expiration time along with an abnormal decreased elasticity of the
lungs further decreasing the air flow.
This group of pulmonary diseases includes chronic bronchitis and
emphysema. Asthma is also included in
this group but will be addressed separately.
Chronic Bronchitis is a widespread
inflammation and/or infection of the lungs causing narrowing and blockage of
the bronchial tubes due to increased mucous, and that is the hallmark of the
disease: airflow obstruction due to
mucous. While it can be acute, if
increased mucous and cough are present over a period and occurs over
consecutive years, it is classified as chronic bronchitis. It is characterized by airway resistance
affecting the smaller “limbs” or tubes of the bronchial tree. It does not directly affect the smallest
functioning units of the lungs, the alveoli – rather, it is mucous that blocks
the smaller tubes, hampering receipt of oxygen to the cellular level, as well
as blocking carbon dioxide exchange.
Because the airways are obstructed, oxygen transport to the body via the
arterial blood system is reduced.
Patients with this condition often show productive (phlegm-producing)
cough, cyanosis (blueness) of extremities due to decreased oxygenation, and
hypoventilation (breathing in an unusually slow and shallow fashion) due to
mucus production that blocks enough oxygen into airways.
Emphysema is very severe; it causes recurrent
damage at the cellular level (the alveoli) rather than affecting the bronchial
tubes. It is characterized by permanent
and abnormal gaps or spaces between alveoli due to alveolar wall
destruction. Without these walls, large
air spaces (bullae) result, creating an inability for gas exchange to occur:
the gaps are too large to permit efficient transport. Ultimately, pulmonary functioning cannot be
achieved. Carbon dioxide cannot be
released, and oxygen cannot be consumed and made useful. Airflow obstruction is not from mucous, as
is the case with chronic bronchitis, but from cellular tissue damage of the
lung. Patients with this condition show
long and slow exhalation to get rid of trapped carbon dioxide. They are often described as having
“barrel-chests,” and they tend to use respiratory and abdominal muscles to
force air out of their lungs. These
patients tend to hyperventilate (breathe especially deeply and rapidly) because
they have trapped carbon dioxide and tend to be hypoxic (low on oxygen).
Care Considerations for COPD (Chronic
Obstructive Pulmonary Disease):
1) Muscle fatigue
often occurs, due to trapped carbon dioxide that results in an inability to
inhale oxygen. This can result in “air
hunger.” To treat this condition,
promote exhalation and inhalation.
Monitor for nasal flaring and use of accessory muscles. Other signs are difficulty speaking and
trouble breathing (dyspnea) during exertion or at rest.
2) Position patient
to ease in breathing. Place in
“tripod” position, where patient rests forearms on a high table and lean
forward to expand chest. When in bed,
place head of bed to as upright a position as is tolerable, but ensure patient
has ability to expand both diaphragm and abdominal muscles essential for deep
breaths.
3) Monitor
respirations for rapid rate and shallowness, indicating
hyperventilation. Have patient perform
pursed lip breathing to expel carbon dioxide:
breathe in through nose and exhale very slowly through pursed lips (lips
drawn into a kissing position). Avoid
fatigue and faintness.
4) Provide
supplemental oxygen at the medically prescribed level only. Too much oxygen can cause oxygen toxicity and
resulting carbon dioxide toxicity.
(Oxygen is a drug to be maintained at prescribed levels.)
5) Monitor vital
signs, such as percentage oxygen saturation, heart rate, and respiration
rate. These should be within normal
range for your patient.
6) Monitor for loss
of appetite which could occur if mucous is being ingested and causing
nausea.
7) Promote fluids
intake to decrease mucous thickness (and viscosity) and promote expelling
mucous.
8) Perform chest
physiotherapy, including “cupping” of back to loosen secretions.
9) Ensure
medications are taken as prescribed; these may include bronchodilators,
inhalation therapy, diuretics, antibiotics, or steroids. Compliance with instructions is
essential.
10) Reassure the
patient, who may mourn the difficulty in breathing and feel he can no
longer participate in life, becoming hopeless.
To prevent the experiencing of a loss of self, encourage interaction
with others.
11) Obtain portable
oxygen, if it’s needed all the time, to encourage leaving the home and
combat isolation.
12) Provide assistance with care while
promoting self-care as much as possible.
13) Do activities in
short bouts to decrease fatigue and allow periods of rest in between
them. Learn the signs of weariness and
exhaustion.
Asthma: is a form of chronic
obstructive pulmonary disease (COPD) but is often discussed separately from
chronic bronchitis and emphysema because episodic symptoms often result from
triggers or environmental stimuli and the patient may be asymptomatic between
episodes. Airway obstruction can be
caused in three different ways, acting separately or collectively: bronchospasms, mucus secretion, and mucosal
edema.
Bronchospasms are the narrowing of the
bronchial tubes due to contractions of the muscles, causing coughing and
wheezing.
Increased mucus production is the result of
inflammatory responses to allergic reactions due to outside allergens, causing
the release of histamine (extrinsic reaction) or due to effects of non-allergic
causes such as emotions or cold weather (intrinsic reaction).
The thick
over-production of mucus, along with edema (swelling due to fluid build-up) of the
bronchial tube lining further constricts the opening of the bronchial
tubes. When the patient inhales, the
bronchial lumen (space within the tube) is only partially open. However, due to pressures within the body,
the lumen closes when the patient exhales, trapping carbon dioxide, and gas exchange
at the alveolar level is impaired.
Asthma triggers may include anything that causes an allergic reaction,
such as dust, pollen, food allergies, as well as conditions including stress,
fatigue, exercise, and temperature changes.
Care Considerations for Asthma:
1) Learn the
triggers of the asthma attacks and limit the triggers as much as is
possible. While it is difficult to
eliminate extrinsic triggers such as cold weather, minimizing contact, using
scarves, or entering warm cars may discourage attacks.
2) Proper use of
medications, whether daily or for attacks, is essential. Bronchodilators help to decrease the
bronchial constriction and edema while promoting ventilation. Corticosteroids act like bronchodilators but
also help to decrease the inflammatory and immune response to the
allergen.
3) During attacks,
supplemental oxygen may be necessary if the patient has difficulty
breathing (dyspnea) or shows signs of insufficient oxygen intake with increased
respiratory rate and depth. Be sure to
use proper amount of oxygen, as too much can be as detrimental as too
little. Beware of carbon dioxide air
trapping.
4) Pursue effective
relaxation techniques, which could prove vital during an exacerbation. Imagery, yoga, or focused breathing may help
to calm patient and decrease anxiety and fear during an attack when he is
unable to breathe.
5) Promote fluids,
especially after an attack, to help thin secretions and help expel them.
6) During an attack,
position patient to assist in breathing.
He should sit upright and lean forward to promote chest expansion.
7) Because attacks can
be episodic, fear may be constant, especially if triggers are unknown or
unable to be avoided. Teach and
reinforce that medications will assist.
As the time the patient has been enduring the disease increases, so will
his ability to understand and recognize the early signs of an asthma
attack.
Sleep Apnea: This is defined as temporary absence of
breathing during sleep, absences that may last more than 10 seconds and occur
thirty times or more in a seven-hour sleep period. When breathing stops for a prolonged period,
oxygenation decreases, and carbon dioxide levels increase. Sleep is fragmented, and the patient often
wakes many times a night. In the morning,
he feels he had unsatisfying sleep, may feel drowsy and fatigued, or suffer a
morning headache. It is a common
condition, and partners are often the first to observe the situation. There are three distinct types of sleep
apnea:
Obstructive sleep apnea is caused by an
inability to keep the upper airway open (patent); the structures in and around
the mouth and pharynx collapse or become obstructed. This is usually accompanied by snoring, as
the airways start to close, and snorting, which then opens them up.
Central sleep apnea does not have sounds
associated with it, because it is not due to obstruction but rather is from
lack of nervous system communication.
This type of apnea strictly involves the part of the brain center that
controls respiration and the respiratory muscles that perform the work of
breathing. Proper signals are not sent
by the brain and thus not directing the muscles to act. Simply stated, the brain has not told the
muscles to breathe for the body. This
results in no breathing, no movement of the chest, and no breath sounds. This
is further marked by excessive daytime sleepiness, such as falling asleep
during meetings or while driving, as the body has been deprived of oxygen
during these episodes.
The last type is mixed
apnea, the combination of the two types.
Care Considerations for Sleep Apnea:
1) Diagnosis is made
in a formal sleep study lab.
Encourage participation. Fear of
positive diagnosis or embarrassment may prevent patient from undergoing
study.
2) If apnea is due
to obstruction, surgical remedy may be available. Help patient understand the ramifications of
surgery, the potential benefits or curative possibility (whether partial or
complete). Learn post-surgical complications
and healing actions. Provide honest
feedback of results.
3) Many sleep apnea
patients are obese, causing or increasing the incidents of the apnea. Encourage weight loss. Promote healthy foods, increased non-caloric
fluids, and exercise. In addition,
changes in some underlying conditions, such as type-2 diabetes or hypertension
may occur. Prior to initiating, discuss with physician.
4) After confirming
diagnosis and weight loss does not remedy the condition, treatment may be
obtained using a continuous positive airway pressure (CPAP) machine. Used at night, this machine, with a device
that covers the nose and/or mouth, provides a constant mild stream of air that
forces the airway to remain open. Ensure
that face apparatus fits properly and comfortably, has ample tubing, is set correctly,
and functions optimally.
5) If patient is
using a CPAP machine, he may be uncomfortable initially. Provide support but do not pressure
usage. Encourage use by noting positive
benefits such as increased energy in morning and during the day, as well as enhanced
mood and disposition due to getting a restful night’s sleep.
Respiratory Treatments and Therapies: Effective respiration occurs at the cellular
level when carbon dioxide and other wastes are exchanged for oxygen via the
blood. For this to happen, inhaled
oxygen from the environment proceeds within the lung structure comprised of
increasingly smaller tubes (the bronchial tree) to the smallest functional unit
in the lungs (the alveolus), where gas exchange takes place and transported via
the venous system. If there is an
inadequate amount of oxygen available in the blood (hypoxemia), then there will
be insufficient oxygen to meet the needs of tissues and cells (hypoxia). Any blockage or obstruction, such as mucus,
inflammation or infection, prohibits this from happening, and, therefore,
decreases pulmonary function. Forms of
treatments and therapies to promote respiration include suctioning, eliminating
mucus plugs, lavage, chest percussion, and controlled coughing and positioning.
Suctioning is used to eliminate
excess secretions from a part of the respiratory system to maintain an open
airway. Secretions that could cause
obstruction may be thin and watery or thick and tenacious. This will vary dependent on location and
underlying disease and ventilation assistance that the patient may have. All types of suctioning require attachment to
a suction machine via long tubing.
Oropharyngeal suctioning uses a rigid plastic
catheter with openings, often called a Yankauer suction catheter, to remove
oral secretions. It is inserted into the
mouth to remove excess liquid; it is often required for patients who have
inefficient gag reflexes and an inability to swallow these secretions. Yankauer suctioning removes saliva and mucus
that could enter the lungs. Depending on
the awareness of the patient, this suction can be done directly by him, as it
is much like handling a toothbrush.
Nasotracheal suctioning is used to clear
secretions from the trachea and lower airways when a patient cannot do so
himself. It requires a sterile technique
even though the airway access is obtained from the nose. Secretions can range from as thin as saliva
to being much thicker in nature.
Endotracheal and tracheostomy suctioning is used when there is
a direct access to the lower airways, either by intubation or permanent
placement of a tracheostomy tube, respectively.
This type of ventilation and suction completely bypasses the respiratory
system above the trachea. Strict sterile
technique is necessary, and often a closed suction tubing suctioning system is
used to promote sterility, as well as not requiring the patient be disconnected
from a ventilator.
Care Considerations for Suctioning:
1) Sterile technique
is essential for all suctioning, except oropharyngeal, as the area below the
pharynx is a sterile area. Patients
requiring suctioning usually have compromised pulmonary systems and are at risk
for respiratory infections.
2) Ensure proper
technique is used. Insert catheter
into airway until resistance is felt or the patient coughs. Pull back slightly and then apply
intermittent suction until the catheter is removed. Never apply suction while inserting the
catheter.
3) Patient should be
well oxygenated prior to suctioning, especially if a closed suction system
is not used.
Mucus Plugs are merely accumulations of mucus,
tissues, cells, and dirt that block or obstruct an airway or tube. Patients with artificial airways are more
susceptible, because the tubes can stimulate or cause stasis of secretions. In
addition, air bypasses the usual defenses, filtration, and humidification of
normal airways. However, replacing
equipment, such as an inner cannula, or carrying out lower airway suction,
often relieves the obstruction. Removing
plugs in patients with natural airways are difficult and requires strong
forceful coughing, abdominal thrusts, and suctioning. Regardless of the type of airway, mucus plugs
must be removed.
Care Considerations for Treating Mucus Plugs:
1) Maintenance of
and compliance to scheduled equipment usage is vital to optimal
functioning, filtering, and minimizing buildup of secretions.
2) Increased
hydration and humidification may assist in keeping mucus from
hardening. Use caution to prevent fluid
overload.
3) Suctioning, as
prescribed, eliminates the stasis (pooling) of secretions, which minimizes
the formation of a mucus plug.
4) Lavage may (or
may not) help to loosen secretions.
(Strictly follow physician’s and/or pulmonologist’s guidelines.)
Lavage (washing out) is a treatment that is not
universally recommended and not definitely a commonplace, accepted practice.
During lavage, a small amount of normal saline is instilled to stimulate a
cough. Once the fluid is delivered, the
patient is suctioned. The thought behind
lavage is that instilling a small amount of sterile, normal saline into the
bronchial tubes will loosen secretions, thereby making them easier to suction
and prevent mucus plugs. However,
research has not indicated whether this is true. Some theories suggest that instilling fluid,
while loosening secretions, may disperse bacteria throughout the lung. Alternatively, more humidification and
hydration may relieve the mucous plug condition.
Care Considerations for Lavage:
Consult your medical
professionals and follow their guidelines.
Inquire about humidification and hydration for the patient. Follow recommendations concerning care of the
equipment.
Chest Percussion, also known as Chest
Physiotherapy is done to loosen and help remove secretions that accumulate in
the lungs especially in the bases. It
involves using numerous techniques.
Clapping, or percussion, is performed by
thumping the hands, held in a cup-like position, against the patient’s
back. After clapping, postural drainage
is then utilized. To achieve this, the
patient’s body is tilted so his head is lower than his lungs. This aids in the drainage of secretions due
to gravity. If a patient is unable to be
tilted, suctioning would then be performed.
Care Considerations for Chest Percussion:
1) When cupping,
ensure clapping is not too forceful.
The thumping should be strong but should not cause pain or
discomfort. Massaging the back with
lotion in an upward motion after cupping also aids in movement of secretion as
well as provides comfort after the procedure.
2) Use caution when
placing a patient in a head-first downward angle. Depending on quality of his oxygen status,
the patient may be at risk for dizziness and fainting. The angle of the body does not need to be
great for adequate postural drainage.
Controlled Coughing and Positioning: Correct positioning helps to keep airways
clear by promoting ability to expand chest, breathe deeply, and use
muscles. While the patient is sitting,
the head of the bed should be at a 45- to 60-degree angle (semi-Fowlers) to a
90-degree angle (high Fowler’s position).
This enables chest expansion, full use of the diaphragm muscle and other
respiratory and abdominal muscles. If
the patient is standing, and having difficulty breathing, support his body
against a wall. This will provide safety
as well as support for his back to promote chest expansion. If the patient is lying in bed on his back
(supine position), use two or more pillows or raise the head of the bed to a
30-degree angle to promote deep breathing.
This is often a better position for patients who have a large abdominal
girth.
Controlled coughing is an exercise and
technique to clear secretions and maximize the coughing effort. Coughing that does not expel secretions is
not effective, causing additional coughing ultimately leading to discomfort and
fatigue. Position the patient in a
Fowler’s position. Often it is more
comfortable for the patient to support his abdomen with a pillow. He then takes two slow, deep breaths in
through the nose and exhaled through the mouth.
At the third breath, inhale through the nose and hold the breath, count
to three, then without inhaling between, cough deeply two or three times
pushing the air out of the lungs.
Care Considerations for Controlled Coughing and
Positioning:
1) Ensure patient
safety at times. If the patient is
not mobile, ensure turning and positioning is done every two hours to decrease
risk of pressure sores.
2) Be mindful of
patient comfort. When in discomfort,
less effective breathing is performed and is exhibited by shallow breaths,
increased or decreased rate, and ultimately a decrease in oxygen
saturation.
3) Monitor oxygen
saturation to provide actual verification of the effectiveness of the
position.
4) Encourage
ingestion of fluids to thin secretions for ease in their expulsion.
5) Practice controlled
coughing exercises. Count the repetitions and advise patient on
steps to perform technique. Support and
encourage practice, even if immediate results are not seen.
6) Observe for
correct use of incentive spirometer.
The goal is to maximize exhalation – not inhalation. Patient should take a deep breath in through
the nose, and then exhale though the mouth of the machine to make the device’s
indicator rise. The higher rise of the
indicator demonstrates that a deeper exhalation was accomplished.
###
Contact information:
Diane R. Beggin, RN
40 Sycamore Drive
Montgomery, NY 12549
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