1. Care of Critically Ill Patients with Respiratory Problems
Chapter 34
Care of Critically Ill Patients with Respiratory Problems
Display signals, alarms, and control panel of a typical volume-cycled ventilator.

2. Pulmonary Embolism
Collection of particulate matter—solids, liquids, air—that enters venous circulation and lodges in pulmonary vessels
Usually occurs when blood clot from a VTE in leg or pelvic vein breaks off; travels through vena cava into right side of heart

3. Pulmonary Embolus
Pulmonary embolism with infarction.

4. Risk Factors Prolonged immobilization Central venous catheters Surgery
Obesity
Advancing age
Conditions that increase blood clotting
History of thromboembolism

5. Health Promotion & Illness Prevention
Smoking cessation
Weight reduction
Increased physical activity
If traveling or sitting for long periods, get up frequently and drink plenty of fluids
Refrain from massaging/compressing leg muscles

6. Clinical Manifestations
Respiratory
Dyspnea, tachypnea, tachycardia, pleuritic chest pain, dry cough, hemoptysis
Cardiac
Distended neck veins, syncope, cyanosis, systemic hypotension, abnormal heart sounds, abnormal ECG
Low grade fever, petechiae, flu-like symptoms

7. Laboratory Assessment
ABGs
Pao2 – Fio2 ratio falls
Pulse oximetry
Imaging assessment

8. Nonsurgical Management
Oxygen therapy (nasal cannula, mask)
Continuous patient monitoring
Obtain adequate venous access
Continuous monitoring of pulse oximetry
Drug therapy
Anticoagulants
Fibrinolytics

9. Interventions
Ensure appropriate antidotes are present on the nursing unit!
Assess for bleeding every 2 hr
Examine all stool, urine, drainage, vomitus for gross blood; test for occult blood
Measure abdominal girth every 8 hr
Monitor laboratory values

10. Surgical Management
Embolectomy
Inferior vena cava filtration

11. Community-Based Care Home care management Teaching for self-management
Health care resources

12. Acute Respiratory Failure
ABG value of Pao2 <60 mm Hg, Sao2; <90%; or Paco2 >50 mm Hg with pH <7.30
Ventilatory/oxygenation failure
Patient is always hypoxemic

13. Ventilatory Failure Physical problem of lungs or chest wall
Defect in respiratory control center in brain
Poor function of respiratory muscles, especially diaphragm
Extrapulmonary causes
Intrapulmonary causes

14. Oxygenation Failure
Insufficient oxygenation of pulmonary blood at alveolar level
Ventilation normal, lung perfusion decreased
Right to left shunting of blood
V/Q mismatch
Low partial pressure of O2
Abnormal hemoglobin

15. Combined Ventilatory/Oxygenation Failure
Often occurs in patients with abnormal lungs (e.g., chronic bronchitis, emphysema, asthma attack)
Diseased bronchioles and alveoli cause oxygenation failure; work of breathing increases; respiratory muscles unable to function effectively

16. Dyspnea Interventions
Oxygen therapy
Position of comfort
Relaxation, diversion, guided imagery
Energy-conserving measures
Drugs

17. Acute Respiratory Distress Syndrome (ARDS)
Persisting hypoxia
Decreased pulmonary compliance
Dyspnea
Noncardiac-associated bilateral pulmonary edema
Dense pulmonary infiltrates seen on x-ray

18. Causes of Lung Injury in ARDS
Systemic inflammatory response is common pathway
Alveolar-capillary membrane injured
Intrinsic causes—sepsis, shock
Extrinsic causes—aspiration, inhalation injury

19. Diagnostic Assessment
Lower Pao2 value on ABG
Refractory hypoxemia
“Whited-out” (ground glass) appearance to chest x-ray
No cardiac involvement on ECG
Low-to-normal PCWP

20. Interventions
ET intubation, conventional mechanical ventilation with PEEP or CPAP
Drug and fluid therapy
Nutrition therapy
Case management
Phase 1
Phase 2
Phase 3
Phase 4

21. Endotracheal Tube
A, Endotracheal tubes. B, Correct placement of an oral endotracheal tube.

22. Verifying Tube Placement
End-tidal carbon dioxide levels
Chest x-ray
Assess for breath sounds bilaterally, symmetrical chest movement, air emerging from ET tube

23. Stabilizing the Tube
Do not tape the tube too tightly to the nose or skin breakdown will occur on the naris.

24. Endotracheal Tubes: Nursing Care
Assess tube placement, minimal cuff leak, breath sounds, chest wall movement
Prevent movement of tube by patient
Check pilot balloon
Soft wrist restraints
Mechanical sedation

25. Mechanical Ventilation
Ventilator types:
Negative-pressure
Positive-pressure
Pressure-cycled
Time-cycled
Volume-cycled

26. Modes of Ventilation Assist-control ventilation (AC)
Synchronized intermittent mandatory ventilation (SIMV)
Bi-level positive airway pressure (BiPAP)
Others

27. Ventilator Controls and Settings
Tidal volume (Vt)
Rate—breaths/min
Fraction of inspired oxygen (Fio2)
PIP
CPAP
PEEP
Flow and other settings

28. Nursing Management Always assess patient first, ventilator second
Monitor patient response
Manage ventilator system
Prevent complications!

29. Complications
Cardiac:
Hypotension
Fluid retention
Valsalva maneuver

30. Complications (cont’d)GI
Nutritional
Infections—ventilator-associated pneumonia (VAP)
Muscle deconditioning
Ventilator dependence

31. Complications (cont’d)
Respiratory:
Barotrauma
Volutrauma
Barotrauma (note air in the neck, arrow) as a consequence of ARDS in a patient receiving positive-pressure ventilation (PPV).

32. Weaning
Process of going from ventilator dependence to spontaneous breathing

33. Extubation Hyperoxygenate patient
Thoroughly suction ET and oral cavity
Rapidly deflate ET cuff
Remove tube at peak inspiration
Instruct patient to cough
Monitor patient every 5 min; assess ventilatory pattern for respiratory distress

34. Chest Trauma About 25% of traumatic deaths result from chest injuries
Pulmonary contusion
Rib fracture
Flail chest
Pneumothorax
Tension pneumothorax
Hemothorax
Tracheobronchial trauma

35. Pulmonary Contusion Potentially lethal injury
May be asymptomatic at first, later develop respiratory failure
Bloody sputum, decreased breath sounds, crackles, wheezes
Treatment—maintenance of ventilation and oxygenation

36. Rib Fracture Chest usually not splinted by tape or other materials
Main focus—decrease pain so adequate ventilation is maintained

37. Flail Chest
Paradoxical chest movement—“sucking inward” of loose chest area during inspiration, “puffing out” of same area during expiration
Flail chest. Normal respiration: A, Inspiration; B, Expiration. Paradoxic motion: C, Inspiration—area of the lung underlying unstable chest wall sucks in on inspiration; D, Expiration—unstable area balloons out. Note movement of mediastinum toward opposite lung during inspiration.

38. Tension Pneumothorax Left: Pneumothorax.
Right: Tension pneumothorax on the left with mediastinal shift to the right.

39. Tension Pneumothorax (cont’d)
Assessment findings:
Asymmetry of thorax
Tracheal movement away from midline toward unaffected side
Respiratory distress
Absence of breath sounds on one side
Distended neck veins
Cyanosis
Hypertympanic sound to percussion

40. Hemothorax
Left: Hemothorax. The amount of blood that can accumulate in the thoracic cavity (leading to hypovolemia) is a much more severe condition than the amount of lung compressed by this blood loss.
Right: Right hemothorax.

41. Tracheobronchial Trauma
Caused by blunt trauma, rapid deceleration
Tracheal lacerations
Upper airway obstruction
Cricothyroidotomy, tracheotomy

42. A 65-year-old woman is brought to the ED by her husband with new onset shortness of breath. She had an abdominal hysterectomy 5 days ago. Her husband states that she stayed in bed since she was discharged from her surgery 48 hours ago, because she feels very short of breath when she gets up. What risk factors are present for DVT?
Prolonged immobility; advancing age; recent surgery.

43. (cont’d)
During triage, the following vital signs and assessments are noted:
Temp – 99.6° F BP – 80/44 mm Hg
P – 126 (sinus tachycardia) R – 28 and labored
O2 saturation – 84% (room air) Crackles bilaterally
Petechiae across chest and in axillae
Based on these findings, what do you suspect might be happening with the patient?
The patient may have a pulmonary embolism. She could also have pneumonia based on her recent surgery and immobility. Further assessment should be performed to ascertain the specifics of her symptoms.

44. (cont’d)
When the ED physician is notified of the patient’s manifestations, she is moved immediately to a treatment room. The physician writes the following orders:
O2 at 2 L per nasal cannula
Stat CBC, BMP, d-dimer, aPTT, INR
Stat CT of the chest
Start a saline lock
Which order takes priority at this time?
Based on the patient’s pulse oximetry reading, the priority order is the administration of oxygen. Next, the saline lock should be started. Once the vein is accessed, blood can also be obtained for the CBC, BMP, d-dimer, PTT, and INR. After the laboratory specimens are sent, the radiology department can be notified to perform the stat CT of the chest.

45. (cont’d)
While in the treatment room, the patient says she needs to use the bathroom. The nursing assistant is delegated this task.
What is the best approach for the nursing assistant to take?
Place the patient on a bedpan and stay with her until she is finished.
Ambulate her into the hall bathroom on room air and stand outside the door until she is done.
Ask the provider for an indwelling catheter because of her shortness of breath when she ambulates.
Tell her to try to wait until the shortness of breath subsides.
ANS: A
The nursing assistant should place the patient on a bedpan and stay with her. She is too short of breath to ambulate to the bathroom and she should remain on the oxygen at all times. The nursing assistant should not ask the provider about an indwelling catheter because this would only increase the possibility of a UTI. The patient should never be told to try to wait, because this could also increase the risk for UTI.

46. (cont’d)
Two hours later, the patient is admitted to the medical unit where she is started on a continuous IV heparin weight-based protocol.
Which finding indicates that the heparin infusion is therapeutic?
INR is less than 1
INR is between 2 and 3
aPTT is the same as the control
aPTT is 1.5 to 2.5 times the control
ANS: D
When a patient is started on continuous heparin, the aPTT is drawn before therapy is started and then every 4 hours until a therapeutic range of 1.5 to 2.5 times the control is reached. Thereafter, the aPTT is checked daily.

47. (cont’d)
Three days later, the provider prepares to discharge the patient on warfarin (Coumadin).
Which teaching points do you include about this therapy? (Select all that apply.)
“Be sure to have follow-up INR laboratory tests done.”
“Report any bruising or bleeding to your provider.”
“Consume lots of foods that are rich in vitamin K, such as green leafy vegetables.”
“Use a soft toothbrush to brush your teeth and an electric razor to shave your legs.”
“A skin rash is expected while you are taking this drug.”
ANS: A, B, D
It will be important for the patient to have follow-up INR laboratory tests done, reporting any bruising or bleeding, and use a soft toothbrush and electric razor while on warfarin therapy. Vitamin K is the antidote for warfarin, so patients should not consume a great deal of foods that are high in this vitamin. A skin rash is a sign of an adverse drug reaction and should be reported to the provider immediately.

48. Audience Response System Questions
Chapter 34
Audience Response System Questions 48

49. Question 1
Which patient is at greatest risk of developing acute respiratory distress syndrome (ARDS)?
24-year-old male admitted with blunt chest trauma and aspiration at the scene
56-year-old male with a history of alcohol abuse and chronic pancreatitis
72-year-old male post heart valve surgery receiving 1 unit of packed red blood cells
82-year-old female on antibiotics for pneumonia
Answer: A
Rationale: All patient scenarios create a risk for ARDS. However, the trauma patient with direct chest injury and known aspiration is at greatest risk. ARDS risk factors include direct lung injury (most commonly aspiration of gastric contents), systemic illnesses, and injuries. The most common risk factor for ARDS is sepsis. Other risk factors include bacteremia, trauma with or without pulmonary contusion, multiple fractures, burns, massive transfusion, near drowning, post-perfusion injury after cardiopulmonary bypass surgery, pancreatitis, and fat embolism.
(Source: Accessed August 2, 2011, from

50. Question 2
A patient is going home on warfarin (Coumadin) therapy to manage an acute pulmonary embolism. Which patient response indicates further discharge teaching is needed?
“I should make a doctor’s appointment for weekly blood draws.”
“I should take the medication at the same time every day.”
“I should eat more green leafy vegetables like spinach.”
“I should limit my alcohol consumption.”
Answer: C
Rationale: Patients who experience a venothromboembolism/pulmonary embolism are frequently discharged on anticoagulant therapy (e.g., warfarin [Coumadin]). The patient should be educated to understand the risks and monitoring of this drug to include weekly monitoring for therapeutic levels, consistency in dosing regimens, and foods to avoid (e.g., leafy green vegetables, green tea, alcohol, cranberry juice, etc.).
(Source: Accessed August 2, 2011, from

51. Question 3
A patient in acute respiratory failure is classified as having ventilatory failure. A potential cause of ventilatory failure is:
Opioid analgesic overdose
Pulmonary embolus
Hypovolemic shock
Pulmonary edema
Answer: A
Rationale: Acute ventilatory failure is the type of problem in oxygen intake and carbon dioxide removal (ventilation) and blood delivery (perfusion) that causes a ventilation-perfusion (V/Q) mismatch in which perfusion is normal but ventilation is inadequate. It occurs when chest pressure does not change enough to permit air movement into and out of the lungs. As a result, too little oxygen reaches the alveoli and carbon dioxide is retained. Opioid analgesic overdose is a possible cause of ventilatory failure. The others listed are related to oxygenation failure.