1. Complex Respiratory Disorders N464- Fall 2014

2. Ventilator-Associated Pneumonia (VAP) Aspiration of bacteria from oropharynx or gastrointestinal tract Many potential causes Controversies about best way to diagnose—no “gold standard”

3. VAP Bundle Elevate head of bed 30 to 45 degrees Awaken daily and assess readiness to wean and extubate Stress ulcer disease prophylaxis Venous thromboembolism (VTE) prophylaxis Oral care in some bundles—the role of the nurse

4. Prevention of VAP Handwashing and standard precautions Aseptic suctioning of endotracheal tube (ET) tube Oral and nasal care Maintain ET tube cuff pressure Elevate head of bed Assess gastric residual volumes Turn and reposition frequently

5. What “therapeutic medications may result in hypoventilation?

6. What ventilator modes contribute to hypoventilation?

7. What nursing interventions may prevent hypoventilation?

8. How does hemoglobin affect oxygenation?

9. Why would a low cardiac output result in hypoxia?

10. What nursing interventions assist in reducing oxygen demands?

11. ARDS Noncardiogenic pulmonary edema Diagnostic criteria Acute lung injury scoring

12. ARDS Pathophysiology – Insult—systemic inflammatory response syndrome (SIRS) – Release of inflammatory mediators – Damage to alveolar-capillary membrane – Increased capillary permeability – Pulmonary edema (noncardiogenic)

13. ARDS Pathophysiology continued… – Microatelectasis – Decreased compliance (stiff lungs) – Decreased surfactant (damage to type II pneumocytes) – Impaired gas exchange – V/Q mismatch

14. What patients would you identify as having a high risk of developing ARDS?

15. ARDS Symptoms – What would you anticipate seeing in a patient who is progressing to ARDS?

16. Why is hyperventilation an early sign seen in patients developing ARDS? What related ABG abnormality will be seen?

17. ARDS Treatment – Treat the cause – Oxygenation and ventilation – What are complications associated with PEEP?

18. ARDS Treatment: – Comfort – Decrease O2 consumption – Positioning Prone positioning shows good results Continuous lateral rotation therapy

19. ARDS Treatment: – Fluid and electrolyte balance – Adequate nutrition – Psychosocial support

20. ARDS Other therapies: – Inhaled nitric oxide – Liquid ventilation – Extracorporeal lung assist – Surfactant – Corticosteroids – Vasodilators – Anticoagulation mediators

21. ARDS Be alert for complications: – Multiple-organ dysfunction syndrome – Renal failure – Disseminated intravascular coagulation – Long-term pulmonary effects associated with high oxygen and other therapies

22. Pleural Effusion Accumulation of fluid in space between the visceral and parietal pleurae that lines the lungs and interior chest wall Symptoms

23. Pleural Effusion Diagnostic Studies Management – Thoracentesis – Chest tube placement

24. Pneumothorax Occurs if air enters the pleural space between the visceral and parietal pleurae, producing partial or complete lung collapse Two Types

25. Pneumothorax Assessment – History and Physical findings – Diagnostic Studies Management

26. Pulmonary Embolism (PE) Virchow’s triad Embolus results in a lack of perfusion to ventilated alveoli (V/Q mismatch)

27. PE Assessment – What would you anticipate on an assessment of a patient with a PE?

28. PE Diagnosis – Clinical signs and symptoms – Chest x-ray (nonspecific) – V/Q scan with high probability of PE – Pulmonary angiogram—definitive

29. PE Complications Prevention

30. PE Treatment: – ABCs; oxygen – Thrombolytics (dissolve the clots) – Heparin – Surgical procedures Embolectomy Vena cava umbrella (prevention)

31. Acute Respiratory Failure (ARF) Altered gas exchange (room air) – Pao2 < 60 mm Hg – Pao2 > 50 mm Hg – pH ≤ 7.30

32. ARF Etiology – Failure of oxygenation – Failure of ventilation – Both of the above

33. ARF Failure of Oxygenation – Hypoventilation – Intrapulmonary shunting – Ventilation-perfusion mismatch – Diffusion defects – Low cardiac output – Low hemoglobin level – Tissue hypoxia

34. Assessment of ARF Neurologic—shows earliest signs of hypoxemia and hypercapnia Respiratory Cardiovascular Nutrition Psychosocial Chest x-ray Pulmonary function tests Arterial blood gases (ABGs) Pulse oximetry and end tidal CO2

35. ARF Interventions: – Maintain a patent airway – Optimize O2 delivery – Minimize O2 demand – Treat the cause of ARF – Prevent complications