Respiratory Competencies By Paula Willmore

Origins of Competences Led initially by the DoH NICE “All staff should have competence in monitoring, measuring and interpreting vital signs” “Education and training should be provided to help staff competences and competence should be developed”

Should be used in conjunction with formal and informal teaching Develop and build on existing knowledge Increase confidence Develop clinical practice Create a platform to encourage ward based learning Improve patient care The Aim of the Competencies

Anatomy and Physiology Gross anatomy and physiology of the respiratory system

Anatomy and Physiology Mechanism of breathing

Anatomy and Physiology Transport of oxygen

Anatomy and Physiology Regulation of Ventilation Complex and not completely understood Regulated by; Controller Effectors Sensors

Controller Housed by the CNS Not located in one specific area Several areas work together to provide coordinate ventilation Brainstem regulates automatic ventilation Cerebral cortex allows voluntary ventilation Neurons housed in the spinal cord process information This information is then sent to the muscles of ventilation

Effectors The muscles of ventilation They function in a co-ordinated fashion Regulated by the CNS

Sensors Central and peripheral chemoreceptors Chemoreceptors respond to changes in chemical composition of blood or other fluid around them Other sensors have a smaller role Found in the lungs Irritant receptors, stretch receptors and the juxtacapillary (J) receptors

Respiratory Assessment 4 techniques are used in respiratory assessment; 1. Inspection 2. Palpation 3. Percussion 4. Auscultation

Inspection 3 areas focused on 1. Observation of the tongue and sublingual area 2. Assessment of the chest wall configuration 3. Evaluation of respiratory effort

Palpation Three areas of focus; 1. Confirmation of the position of the trachea 2. Assessment of thoracic expansion 3. Evaluation of fremitus

Percussion 2 areas of focus; 1. Underlying lung structure 2. Diaphragmatic excursion

Auscultation Focus on 3 different areas; 1. Evaluation of normal breath sounds 2. Identification of abnormal breath sounds 3. Assessment of voice sounds

Airway obstruction Partial or complete Partial obstruction often precedes complete Can occur at any level from the nose and mouth down to the bronchi

Causes of Partial Airway Obstruction Cerebral or pulmonary oedema Exhaustion Secondary apnoea Hypoxic brain injury Eventually cardiac arrest

Causes of Airway Obstruction CNS depression Blood Vomit Foreign body Direct trauma to face or throat Epiglottitis

Pharyngeal swelling Laryngospasm Bronchospasm Bronchial secretions

Recognition of Airway Obstruction. Look, Listen and Feel LOOK for chest and abdominal movement LISTEN and FEEL for airflow at the nose and mouth

Partial Airway Obstruction Creates Sounds Inspiratory stridor Expiratory wheeze Gurgling Snoring Crowing or stridor

Airway Management Unless an airway obstruction can be relieved within a few minutes to enable the patient to breath, injury to the brain and other vital organs and cardiac arrest will occur

Treatment for Airway Obstruction

Basic Techniques for Opening an Airway Head tilt Chin lift Jaw thrust

Adjuncts to Airway Techniques Oralpharyngeal airway Attempt insertion only in unconscious patients Need to maintain head tilt/chin lift or jaw thrust. Continue to check patency of airway

Adjuncts to Airway Techniques Nasopharangeal airway Used in patients that are not deeply unconscious Once in place use the look, listen and feel techniques to assess patency of airway Head tilt/chin lift may be required

Suction Oropharangeal suction Wide bore rigid suction (yankauer) To remove; Blood, saliva, gastric contents Caution... If the patient has a gag reflex it can provoke vomiting

Suction Suction via a nasopharangeal airway. The need for suctioning should be assessed Complications include hypoxemia, broncospasm, cardiac dysrhythmias and airway trauma

Recovery Position Refers to a side lying position The position allows the drainage of fluid from the patient nose and mouth Can be useful in a patient at risk of a partial airway obstruction The airway should be continually monitored for patency

Importance of Accurate Respiratory Observations Often first observation to change Look at the trend A high respiratory rate is a marker of illness and a warning that the patient may deteriorate suddenly

Oxygen Therapy Oxygen is a drug and as such most trusts now require it to be prescribed with a goal Spo2 Once oxygen therapy has begun the patients oxygenation status should be evaluated and reevaluated so that the lowest possible level of oxygen is administered

Methods of Delivery Low flow system Allows flows of less than or equal to 4L/min Inspired oxygen content varies Can deliver up to 36%

Methods of Delivery Variable flow meters Allows for a oxygen percentage to be delivered rather than L/min Can deliver up to 60%

Methods of Delivery Reservoir systems Stores oxygen in the reservoir Less mixing of room air Can deliver up to 70%

Humidification Oxygen use causes the mucosal layer of the upper respiratory tract to become dry External humidification prevent drying and irritation of the respiratory tract Prevent loss of body water Facilitate secretion removal

Complications of Oxygen Therapy Hyperoxia produces an overabundance of oxygen free radicals Free radicals damage alveolar- capillary membrane This lung damage can lead to acute lung injury

Carbon dioxide retention Absorption atelectasis

Oxygen Saturation A measure of the amount of oxygen bound to haemoglobin Cool peripheries prevent make pulse oximetry difficult and often produce inaccurate results Wave form measurements enable a more accurate assessment Does not measure Co2

Respiratory Distress Identified by; Increased respiratory rate Increased work of breathing Use of accessory muscles Difficulty speaking in full sentences Spo2 may be lowered

Causes of Respiratory Distress Shock- Especially septic shock Trauma- Lung contusion Infection- Pneumonia Inhalation injury- Smoke Haematological- Massive blood transfusion

Obstetric-Amniotic fluid embolism Drug overdose- Heroin Miscellaneous- Pancreatitis

Treatment Positioning Oxygen therapy Nebuliser therapy Secretion removal Physiotherapy Know when to ask for help

Respiratory Failure Divided into 2 categories Type I Type II

Type I Acute hypoxemia Common causes include; Pulmonary oedema Pneumonia Fibrosing alveolitis

Type II Ventilatory failure Common causes include; COPD Respiratory muscle weakness Depression of the respiratory centre Untreated type I respiratory failure

Monitoring in Respiratory Failure Respiratory assessment Pulse oximetry ABG

Management of Respiratory Failure Oxygen therapy Positioning Secretion removal Nebuliser therapy Physiotherapy Treatment of underlying cause Positive pressure may be required in type II

Nebuliser Therapy Considerations O2 vs Air Patient position Drugs effect

Embedding Competencies into Practice Measurable impact on staff performance Staff understand their contribution Measurable impact on patient outcome Consistency Evidence based care