Thompson: Mosby's Clinical Nursing, 5th ed., Copyright 2002 Mosby, Inc.

AIRWAY MAINTENANCE
Interventions
Airway maintenance procedures include cough techniques; postural drainage; percussion and vibration; orotracheal, nasotracheal, or endotracheal suctioning; oropharyngeal or nasopharyngeal airways; endotracheal intubation; and tracheostomy.

Clinical Assessment General to Airway Maintenance Procedures

Restlessness, labored breathing Wheezing, stridor, noisy respirations Rhonchi over large airways, decreased breath sounds Retractions: Intercostal, suprasternal, supraclavicular Mouth breathing, nasal flaring Tachycardia Decreased oxygen saturation

Preprocedural Nursing Care General Teaching for Airway Maintenance Procedures

If the patient requires airway maintenance procedures in an emergency, teaching may be limited to a very simple and rapid explanation. Additional information can be provided after the airway is safely secured.

NONINVASIVE TECHNIQUES COUGH TECHNIQUES

Indications
Cough techniques are taught to improve cough effectiveness and maintain airway clearance. Many types of patients need assistance with cough: those who are postoperative, those with inability to take a deep breath (neuromuscular disease, pain), those who are unable to generate rapid expiratory flows (airways obstructive diseases).

Procedural Guidelines
Several cough techniques can be used, as follows: 1. In the normal cough the individual inhales to a large inspiratory volume and then performs several "coughs," each with less air in the lung (cascade cough). Patients should be instructed to cough in a similar manner. Have the patient inhale deeply, hold the breath for several seconds, and then perform several coughs before inhaling again. For the patient with easily collapsible airways, an open glottic technique is used. This type of cough has been called huff coughing or forced expiratory technique (FET) cough. The same maneuver is followed as described for normal cough. The difference is that the repeated expiratory maneuvers are performed without glottic closure/opening; therefore there is no cough noise. Again, several forced expiratory maneuvers should be done on the one deep breath before the patient inhales again. The huff cough may not result in expectoration, but it usually stimulates

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a natural cough; because secretions have been moved mouthward by the "huffing," the natural cough becomes effective. The huff cough is also effective in postoperative patients. A type of cough used in patients with bronchiectatic types of disease is the end-expiratory cough. The patient inhales deeply, does a short breath hold, and breathes out slowly through pursed lips. Just before the next inhalation, a short cough is done, exhaling the air remaining in the lung. The cough should be performed after most of the air has been exhaled. Several end-expiratory cough maneuvers will often move secretions to a point in the airway where they can be expectorated using a normal cough maneuver. The augmented cough is a modification of the Heimlich maneuver. This maneuver has several variations and is used in patients who are unable to produce sufficient expiratory force during a cough maneuver. Patients with chest wall pain/discomfort often attempt to refrain from coughing or cough with less force. Wrapping a towel around the chest and pulling it snugly during the forced expiratory maneuver often contributes to expiratory force and reduces pain. The abdominal thrust maneuver is used in patients with neuromuscular disease who are unable to generate sufficient abdominal pressure to produce an effective cough. (Examples are tetraplegics, paraplegics with loss of abdominal muscles, and those with amyotrophic lateral sclerosis or muscular dystrophy.) The patient is instructed to take a deep breath (in neuromuscular disease, positive pressure delivered by a self-inflating bag or mechanical device may be used to accomplish a deep breath; a technique of "breath stacking" is often usedseveral inhalations without exhaling in order to achieve a maximal inspiration); then as the patient attempts to cough, abruptly compress the abdomen with an in-and-up motion. (The caregiver's hand is placed on the abdominal wall throughout the inspiratory and expiratory maneuver so the action is one of compressing, not hitting.)

Mechanical Devices to Improve Cough Effectiveness

In those patients (usually those with neuromuscular disease) who are unable to generate sufficient inspiratory volumes and expiratory flows, mechanical devices have been used to assist in the expectoration of sputum. Some of these devices (IPV) are discussed as alternatives to postural drainage. One device specifically for cough is the "coughalator" (Inexsufflator). This device delivers air under positive pressure. Once the patient has taken a deep breath, the patient is switched (either automatically or manually) to exhalation and a negative pressure is applied to the airway. The larger pressure gradients on both inspiration and expiration result in a deeper breath and a more forceful expiration than the patient would be able to take unassisted. Inspiratory pressures used with the device are usually in the +25 to +30 cm H2O range and the expiratory pressures are -40 cm H2O. The patient uses the device for three or four breaths, coughs, and then relaxes. The procedure is then repeated. Care is taken not to hyperventilate the patient. In addition to assisting cough, many neuromuscular patients use this device at home to help them take periodic deep breaths.

POSTURAL DRAINAGE, PERCUSSION, AND VIBRATION

Postural drainage, percussion, and vibration are effective methods for loosening and moving secretions when patients are unable to maintain airway clearance. The techniques are most helpful for patients who raise copious amounts of sputum (>30 ml/day) and are frequently used in the chronic management of cystic fibrosis and bronchiectasis. These techniques may also be used in other patients when airway clearance is a problem, but the effectiveness must be evaluated individually. Postural drainage with percussion and vibration has also been demonstrated to be effective in reinflating atelectatic lung. Treatments are usually done after an aerosolized bronchodilator.

Contraindications/Cautions
1. Patients with significant hemoptysis

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Patients in whom a head-down position is contraindicated (e.g., those with head injury) Patients with bleeding disorders Patients with rib fractures, or predisposition to pathologic fractures Patients in whom the techniques cause increased dyspnea, wheezing

Procedural Guidelines
Postural drainage consists of specific positioning of the patient so that the different segments of the lung are drained by gravity. The postural drainage treatment may be done to drain all areas or may concentrate on one or two positions (e.g., to concentrate on a left lower lobe atelectasis). Each position is maintained for at least 5 minutes. (Postural drainage positions are depicted in Fig. 4-37 Fig. 4-37 ). The figure demonstrates all positions, but it is common that emphasis is placed on three or four lower lobe positions (those for the basal segments) and two upper lobe positions. After each position the patient should do several deep breaths with prolonged exhalation and end-expiratory cough, followed by a cascade cough. If positioning and coughing are not effective, percussion and vibration may be added. The percussion and vibrations are done over the areas being drained ( See Fig. 4-37 Fig. 4-37 ), these techniques should always be done over ribs, not over the sternum, over vertebral bodies, or below the ribs. To percuss, cup the hands and rhythmically strike the chest wall. The percussion is usually done over one thin layer of clothing. A hollow, deep sound indicates the technique is being performed correctly; there should not be a slapping sound. The area being drained is percussed for 1 to 3 minutes. In many settings, plastic cups are used instead of the hands. The purpose of the percussion is to transmit vibration through the chest wall; the percussion does not need to be forceful! Following the percussion, the hand is flattened and applied to the chest wall (same area that was percussed). Have the patient take a deep breath. As the patient does a prolonged exhalation, vibrate and compress the chest wall. Vibration is usually repeated for two to three breaths. If the vibration does not stimulate a productive cough, have the patient cough voluntarily. If necessary, repeat the percussion and vibration before moving to the next position.

ALTERNATIVES TO POSTURAL DRAINAGE WITH PERCUSSION AND VIBRATION

Various techniques have been developed as an alternative to postural drainage with percussion and vibration. Their purpose is to make therapy for patients easier, especially in the home setting, and to avoid some of the side effects of standard postural drainage with percussion and vibration. Some of those more commonly used are discussed here. Additional techniques that are used more extensively in CF populations are autogenic drainage (a combination of breathing techniques and FET coughing) and positive expiratory pressure therapy (similar to the flutter valve).

Flutter Valve
The flutter valve is a small handheld device. The patient takes a slow deep breath and then exhales through the flutter valve. The flutter creates a vibrating column of air in the airway, similar to the sensation as with percussion and vibration. When the patient is using the device correctly, a vibration should be felt inside the chest. After a few normal exhalations, the patient exhales more forcefully. The maneuver often stimulates a spontaneous cough. Studies have demonstrated that the technique is beneficial in CF, and it has also been used for patients with bronchiectasis. Many patients have been able to replace postural drainage with daily use of the flutter valve. When the technique is effective, patients appreciate the simplicity of treatments, the ability to use the technique while away from home, and the fact that they do not require assistance from others.

High-Frequency Chest Oscillation

The high-frequency chest oscillation technique has been used to replace postural drainage in patients with CF and bronchiectasis. The technique can be used in the hospital or at home. The procedure is carried out with the patient in a sitting position. A vest is put on the patient; the vest is attached to a device that creates high-frequency vibration of the chest wall. Several different frequencies are used to optimize airway clearance. Treatments require about 15 minutes (less time than full postural drainage). After each change in frequency, the patient is requested to cough.

Intrapulmonary Percussive Ventilation (IPV)

IPV is a mechanical device that has been used for patients with CF, bronchiectasis, atelectasis, and neuromuscular disease. The device generates an oscillating pressure. Air is delivered to the patient in short bursts (15 to 25/slow inhalation). Because the inspired oscillating gas flow is delivered under pressure, the results are a deep breath, enlargement of the airways, and vibration of the airways. The vibration tends to move secretions mouthward. The device is used with a mouthpiece or mask, or it can be attached directly to a tracheostomy tube or endotracheal tube. With this device the bronchodilator aerosol is delivered as part of the treatment rather than separately.

Evaluation
Evaluation of all the noninvasive home devices/techniques used to improve airway clearance is similar. The chest should be auscultated and the patient assessed immediately after the technique and again within an hour. Often the techniques "move" secretions, but they are not expectorated until 30 to 60 minutes after treatment. Other goals are as follows: Improvement in adventitial breath sounds Sputum is produced Breathing patterns are effective without dyspnea; respiratory rate and rhythm are adequate Gas exchange is adequate; ABGs are within acceptable range Therapy does not overly tire the patient

INVASIVE TECHNIQUES OROTRACHEAL, NASOTRACHEAL, OR ENDOTRACHEAL SUCTIONING

Indications
Signs of respiratory distress Noisy, wet breathing Auscultated rhonchi Ineffective cough effort

Contraindications
Tight wheeze with bronchospasm or croup

Procedural Guidelines
1. 2. 3. 4. 5. If possible, position patient in semi-Fowler's position. Use sterile, gloved technique. Use smallest catheter size possible to remove secretions. Monitor baseline SpO2 and heart rate. Hyperoxygenate patient and hyperinflate before suctioning procedure, or ask the patient to breathe deeply. If orotracheal or nasotracheal suction approach is used, maintain oxygen cannula or mask on during procedure.

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Lubricate catheter tip with sterile saline solution or water before procedure. Use water-soluble gel lubricant only for nasotracheal approach. Do not apply suction while catheter is being inserted. Insert and advance catheter. If resistance is met, withdraw catheter 0.5 cm. Apply suction for 5 to 10 seconds interval while gently rotating and withdrawing catheter. Administer oxygen and hyperinflate between suctioning passes. Monitor SpO2 and heart rate for changes after each pass. Allow patient to recover to baseline or SpO2 >90% before making another suction pass. Note and record amount and character of sputum. Note and record patient's response to suctioning procedure. Discard catheter after each treatment. Change vacuum container and tubing every day.

Closed Suction Systems

Closed, in-line suction catheter systems are available for use with endotracheal or tracheostomy tubes. Advantages include the ability to maintain positive pressures and hyperoxygenate via a mechanical ventilator during suctioning, as well as elimination of the nurse's exposure to sputum.

Potential Complications
Wheezing or stridor during or after procedure indicating bronchospasm or laryngospasm (if noted, administer oxygen and contact physician) Traumatic airway ulceration with hemorrhage Infection Hypoxemia Cardiac dysrhythmias

OROPHARYNGEAL OR NASOPHARYNGEAL AIRWAYS

Indications
Potential or actual upper airway obstruction owing to altered levels of consciousness, resulting in relaxation of the tongue against the hypopharynx Trauma-induced upper airway obstruction

Procedural Guidelines
1. Determine type of airway according to individual patient needs. a. Oropharyngeal airway (poorly tolerated in awake patients, causes gagging): Length should be from front teeth to the mandibular angle of jaw. b. Nasopharyngeal airway: May be indicated if patient has associated mouth injury; the width should be slightly narrower than the nares' diameter. Insertion techniques a. Oropharyngeal airway: Approaching from the side of the mouth, insert airway upside

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down (with distal end pointing up), then rotate the airway over the tongue 180 degrees; the flange of the airway should be securely positioned outside the teeth. b. Nasopharyngeal airway: Elevating the tip of the nose, the airway should be inserted in anatomic line with the nasal passage. Use water-soluble gel as a lubricant. Position patient on side to facilitate drainage. Remove and clean oral airway at least every 6 to 8 hours; observe for ulcerations of mucous membranes. Remove and clean nasal airway every 12 to 24 hours; rotate to other nare; observe for ulcerations of mucous membranes. Carefully observe position of airway at least every hour; suction if needed via the airway. Provide mouth and nose care at least every 2 hours. Airway removal: Observe patient's level of consciousness and presence of gag and swallow reflexes; when patient is awake, instruct him or her to push oral airway out with tongue; carefully observe patient for adequate airway maintenance after removal.

Potential Complications
Aspiration of secretions not prevented; suction must be available May cause awake patient to gag May become clogged or dislodged, so that the tube becomes an obstruction Bleeding or infection secondary to trauma of insertion Ulceration of nares or pharynx after prolonged insertion

ENDOTRACHEAL INTUBATION
Indications
Airway obstruction not resolved with use of a simple oral or nasal airway Prevention of pulmonary aspiration in an unconscious patient Access to remove tracheobronchial secretions Route to provide mechanical ventilation

Procedural Guidelines
1. 2. 3. 4. 5. 6. 7. Assemble all equipment before attempting intubation procedure. Check the cuff on endotracheal tube for leakage. Assist to position patient in the sniffing position; this should bring the mouth, larynx, and trachea in line. Before intubation, explain the procedure and ensure that any dentures or mouth appliances have been removed. Before intubation, hyperventilate patient using self-inflating bag with supplemental 100% oxygen. If intubation attempt is prolonged, interrupt the procedure and oxygenate the patient. Monitor SpO2 and ECG throughout intubation procedure. Once the endotracheal tube is in place, assist to determine proper endotracheal tube placement; this is done by considering the following: a. Correct placement: Bilateral lung inflation, breath sounds heard equally throughout all

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lobes. Obtain a chest roentgenogram after insertion to ascertain exact positioning of tube. b. Incorrect placement: 1. Esophagus: Absence of breath sounds, respiratory distress, cyanosis; if these are noted, the endotracheal tube should be removed and reinserted. 2. Right mainstem bronchus or carina: The endotracheal tube has been inserted too far; clinical signs include unilateral breath sounds on the right and coughing; if this is noted and confirmed by radiographic examination, the endotracheal tube should be retracted slightly and resecured; reassessment should indicate proper placement. Once the endotracheal tube is in correct position, tape it securely to avoid movement. If patient cannot cooperate with maintaining tube placement, use soft wrist restraints to prevent self-extubation with potential laryngeal injury. Monitor tube placement and patency at least every hour; this assessment should include the following: a. Tube position b. Tube patency c. Lung inflation d. Respiratory distress, need for suctioning Provide ongoing care for patients with endotracheal tube in place: a. Provide mouth care every 2 hours. b. Clean nares and around endotracheal tube at least every 6 to 8 hours. c. Reposition and retape oral endotracheal tube at least daily. If tube has cuff, use minimal occlusive volume technique to maintain the airway seal; record the amount of air inserted to inflate the cuff; monitor cuff pressures each shift; attempt to maintain pressures <20 mm Hg to avoid tracheal pressure injury. Use bite block or oral airway if the patient bites the endotracheal tube. While intubated, patient should receive oxygen (100% humidification). If patient is awake, provide writing materials for communication or agree on use of sign language/communication board. Remind patient that ability to speak returns after tube removal. Extubation: Should be attempted only in a controlled environment, with staff available who can reintubate, if necessary. a. Assess patient's ability to breathe on own and protect airway before extubation. b. Determine that patient is able to maintain spontaneous respiratory rate and tidal volume sufficient to maintain stable blood gas values. c. Carefully suction endotracheal tube and pharynx above endotracheal cuff before deflating cuff for extubation. d. Immediately after extubation, assess for signs of respiratory distress or laryngeal spasm, such as dyspnea, noisy breathing, use of abdominal or accessory muscles, restlessness, irritability, tachycardia, tachypnea, decreased PaO2, or increased PaCO2; if these are noted, consult physician immediately and prepare for reinsertion of endotracheal tube. e. Teach patient that throat discomfort from the endotracheal tube generally resolves in 24 to 48 hours.

Potential Complications
Delay of oxygenation or ventilation during intubation procedure Placement of endotracheal tube into right mainstem bronchus, resulting in unilateral aeration with potential for pneumothorax on right side, atelectasis on left side Ulceration of trachea or tracheoesophageal fistula Mucous plugs or other blockage of endotracheal tube may lead to hypoxia and respiratory distress Unplanned extubation by combative patient or secondary to poorly secured tube requires immediate airway and ventilatory assessment by the nurse, as well as potential need for oral airway, patient positioning, and ventilation by Ambubag with supplemental oxygen Pulmonary aspiration of secretions secondary to poorly inflated cuff, inadequate suctioning before cuff deflation, or too small noncuffed endotracheal tube used

Potential laryngospasm or laryngeal edema after intubation or extubation

NURSING CARE NURSING ASSESSMENT

Ability to maintain patent airway Chest auscultation: Bilaterally equal breath sounds, presence of adventitial sounds, ease of respiration Gas exchange: Oximetry, ABGs Sputum production, ease of expectoration

POTENTIAL COMPLICATION
Increased shortness of breath, increased wheeze Airway trauma (varies with technique used) Hypoxemia Dysrhythmias

PATIENT PROBLEMS/NURSING DIAGNOSES & INTERVENTIONS

RESPIRATORY MANAGEMENT

Ineffective airway clearance related to increased tracheobronchial secretions, decreased cough effectiveness, foreign body, or decreased level of consciousness Impaired gas exchange Risk for aspiration related to excessive oral secretions and presence of tube in airway Maintain oxygenation during airway care procedure. Select appropriate airway technique to maintain airway patency; must consider risk/benefit ratio for individual (see procedures for specific techniques). Encourage frequent position changes. Using sterile technique, suction as needed to maintain airway. If patient has oral endotracheal tube in place, teach him or her to avoid biting the tube. If necessary, provide oropharyngeal airway or bite block to prevent biting on the endotracheal tube. If swallowing reflex is diminished, elevate head of bed when performing mouth care. Avoid triggering gag mechanism when performing mouth care. Avoid scheduled airway care measures after meals. Ensure adequate humidification and fluid intake. For patients with reduced level of consciousness, ensure head of bed is elevated to prevent gastric regurgitation and aspiration, unless contraindicated. Position patients with reduced level of consciousness laterally to allow drainage of oral secretions out of mouth, unless position is contraindicated.

COMMUNICATION ENHANCEMENT

Impaired verbal communication related to dyspnea or presence of artificial airway Teach family how to support patient and use an alternative means, if necessary, of communication, such as letter board, pencil and paper, signing, or mouthing words. Provide frequent information about procedures before the patient is surprised or becomes anxious. Provide emotional support for the difficulty of communication and frustration that can occur for patient, family, and health-care providers. Teach patient/family how to participate in airway care techniques.

EVALUATION/PATIENT OUTCOMES
Respiratory Management: Airway is patent. Breath sounds are clear and bilaterally equal. Rhonchi are decreased. Breathing is easy. Blood gas values are within normal limits for patient. Pulmonary aspiration did not occur. Temperature and respiratory rate are within normal limits. Lung fields are clear on chest radiograph. Communication Enhancement: Patient is able to communicate needs and concerns to staff and family. Family interacts with patient using a method acceptable to both patient and family. Patient/family understands use of selected technique.

CHEST TUBES AND CHEST DRAINAGE SYSTEMS

Description and Rationale
Chest tubes, with attached drainage systems, are placed in the pleural cavity to drain fluid, blood, or air from the pleural cavity and to reestablish a negative pressure that will facilitate expansion of the lung. Chest tubes may be inserted postoperatively, as an emergency procedure after chest trauma, or therapeutically as a disease treatment modality. Chest tubes are also used to drain the mediastinum after cardiac surgery. Following are chest tube insertion sites for different pleural collections: Pneumothorax: Usually in second and third intercostal spaces (anterior or lateral) Hemothorax: Usually in seventh, eighth, or ninth intercostal space (posterolateral) Thoracotomy: One tube generally inserted in second or third intercostal space (anterior) and another in lower posterior axillary line Mediastinal: Generally two tubes, inserted below xiphoid process Chest tubes are removed when radiographic examination determines that the lung is reexpanded and the drainage is minimal.

Cautions
Chest tubes are inserted by a physician and sutured into place. Cautions specific to chest tubes and drainage systems include the following: Sterility must be maintained so as not to introduce infection into the pleural cavity. The system must remain patent: The tubing must not become blocked; if this occurs, a tension pneumothorax may result. If the drainage tubing becomes dislodged from the patient chest tube or a drainage bottle breaks, reestablish drainage with a sterile system immediately. If the chest tube becomes dislodged from the patient's chest, the patient should exhale forcefully, and the chest wall incision should be quickly covered with a petrolatum jelly gauze (see Pneumothorax, p. 167 .)

Preprocedural Nursing Care

Carefully assess patient's preprocedural condition, including respiratory rate and quality. Note evidence of dyspnea, labored breathing, tachypnea, tachycardia, quality and distribution of breath sounds, mediastinal shift, subcutaneous emphysema, and crepitus. Teach the patient the purpose and goal of chest drainage. Set up drainage equipment appropriately for the type of system being used, most commonly disposable three-chamber units (Fig. 4-38) or three-bottle systems. Some systems provide access to collected blood for autotransfusion back to the patient, either with or without additional processing of the collected blood.

Removal of Chest Tubes

Chest tubes may be removed after the lung has been reinflated. Indications for removal are usually confirmed by chest radiographic examination. Removal of either pleural or mediastinal chest tubes is associated with significant discomfort. Analgesics should be administered before tube removal. Removal procedures include the following: 1. 2. 3. 4. 5. Place patient in semi-Fowler's position or on side. Physician instructs patient to take a deep breath and hold it. The chest tube suture is clipped, and the tube is quickly removed. An occlusive dressing or petrolatum jelly gauze is placed over the chest wall wound. Patient is instructed to breathe normally, and the dressing is taped securely.

NURSING CARE NURSING ASSESSMENT

Accumulation of air in the pleural space (can occur before tube inserted, after tube in place, or after tube removal): Dyspnea, tachypnea, tachycardia, anxiety, and restlessness; decreased or absent breath sounds on affected side; tracheal shift; increased subcutaneous emphysema; decreased oxygen saturation Drainage system function: Water in the water seal chamber should fluctuate slightly with respirations; indicates that tube is patent Continuous bubbling in the water seal chamber suggests an air leak in the drainage system (or a massive pleural air leak) Intermittent bubbling in the water seal chamber is expected until the pleural air leak is resolved Note drainage volume, color, consistency

POTENTIAL COMPLICATION
Infection, elevated WBC count, increased temperature, evidence of purulent drainage through chest tube or around site

PATIENT PROBLEMS, NURSING DIAGNOSES & INTERVENTIONS

RESPIRATORY MANAGEMENT Impaired gas exchange related to decreased lung expansion from pleural accumulation

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Maintain patency of chest tubes by keeping a continuous drainage path without kinks or dependent loops. Always keep chest tube drainage system lower than the patient's chest. Ensure that all tubing connections are securely attached and taped. Assist patient to cough, deep breathe, and change position at least every 2 hours to promote drainage of accumulated fluid. Observe special positioning if indicated because of special technique or surgery.

PHYSICAL COMFORT PROMOTION Acute pain related to chest tube placement and surgical incision Assist patient to splint areas of chest tube insertion and incision with a pillow or folded towel. Provide analgesia as needed to promote effective ventilation.

EVALUATION/PATIENT OUTCOMES
Respiratory Management: Breath sounds are clear bilaterally. Roentgenograms confirm lung reexpansion. Blood gases are within normal limits for patient. Physical Comfort Promotion: Patient is able to breathe deeply without pain.

MECHANICAL VENTILATION
Description and Rationale
Mechanical support of ventilation is indicated for patients who are unable to maintain adequate ventilation on their own. The following description of ventilatory devices is a brief overview of those that are used outside the setting of the intensive care unit. For more information on these devices or a discussion of the ventilatory techniques used for critically ill patients, the reader is referred to specialty texts for more information. The terminology of ventilatory devices is presented in Table 4-13 .

Table 4-13 -- Ventilator Terminology Term Definition/Description MAJOR CATEGORIES OF VENTILATION Positive pressure is applied to the inspired air. The device is connected to the airway Positive pressure via a mouthpiece, mask, tracheal tube. Air is essentially "pushed" into the lung. Most ventilation of the devices used today to assist ventilation are of the positive pressure type. Negative pressure is applied around the thorax during inspiration. The negative Negative pressure pressure pulls the chest wall outward and air flows into the lung. There is nothing ventilation connected to the airway. The iron lung is a negative pressure device. TERMS USED IN POSITIVE PRESSURE VENTILATION Intermittent Positive pressure applied during inspiration; expiration is passive positive pressure

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Term

Definition/Description

Positive endPositive pressure is applied at end expiration instead of allowing the airway pressure expiratory to fall to atmospheric pressure pressure (PEEP) A continuous pressure is applied over the airway during spontaneous breathing. Continuous Instead of inspiration and expiration varying over and under a baseline of "0" positive airway pressure, they now vary over and under a preset positive pressure (see text for pressure (CPAP) further discussion) TYPES OF POSITIVE PRESSURE VENTILATORS USED IN THE NON-ICU SETTING Volume cycled ventilator Pressure cycled ventilator The equipment allows the delivery of a specific tidal volume to the patient. The amount of pressure required may vary from breath to breath. Small volume ventilators with internal battery packs are available for home use. A predetermined inspiratory pressure is set. The ventilator delivers gas to the patient until that pressure is met. The volume actually delivered with each breath may vary.

Differing amounts of positive pressure are applied to the airway during inspiration (inspiratory pressure) and expiration (expiratory pressure or PEEP); a greater amount Bilevel ventilation of airway pressure is applied during inspiration with little or no pressure applied during expiration; the bilevel device uses "pressure support," a type of pressure cycling.

Patient-machine interfaces are presented in Table 4-14 .

Table 4-14 -- Patient-Machine Interfaces: Home Setting Tracheostomy tube Nasal mask, nasal pillows Usually reserved for those who require continuous ventilation or who are completely unable to protect the airway. See p. 210 P. 211 on care of patient with artificial airway. Used with both bilevel and volume ventilator; appropriate size must be determined; patients often have two different styles to alternate, relieve pressure areas. Addition of heated humidification often improves tolerance. Different types of headgear, used to keep mask in place, are also available. Used when adequate seal/ventilation not possible with one of the nasal masks or pillows; used with both bilevel and volume ventilator. Use mask with special emergency disconnect devices and safety valve so that patient can breathe if power failure to ventilatory device occurs.

Full face mask

Patient populations who may require non-intensive care unit (ICU) mechanical ventilatory assistance are as follows: Patients who require a prolonged weaning period after mechanical ventilation for acute respiratory failure. These patients are often transferred to non-ICU settings that specialize in chronic ventilation and weaning. Patient is usually tracheotomized. Usual ventilator is a volume ventilator or bilevel device. Patients with chronic obstructive lung disease with an acute exacerbation that causes acute CO2 retention. Noninvasive ventilation with bilevel or volume device may be instituted to avoid the need for intubation. Patients in this category require very close assessment and care to avoid intubation. Selected patients who have severe chronic respiratory disease with significant chronic CO2 retention. Institution of ventilatory assistance during sleep may stabilize the CO2 level, decrease fatigue, and improve daytime function. This type of assistance may be used for long periods in the home setting. A noninvasive approach (mask) is used; the usual device is bilevel assistance,

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although a volume ventilator may also be used. Patients with neuromuscular disease who have absent/significantly impaired inspiratory muscle strength. Some require only nighttime ventilation, while others may require continuous assistance. The device is usually bilevel or a volume ventilator. The patient/machine interface may be via a mask or via tracheostomy tube. Patients with obstructive sleep apnea (see p. 194) . CPAP device is used during sleep. If the patient requires high pressures, a bilevel device may improve tolerance.

Preprocedural Nursing Care

1. Review with physician/chart reason patient requires ventilatory assistance: Obstructive sleep apnea, inspiratory muscle weakness, chronic CO2 retention, acute CO2 retention in patient with chronic lung disease (remember this list does not include problems usually found in the ICU). Is ventilation to be continuous or nighttime? Nighttime Spo2 or ABGs; daytime Spo2 or ABGs. Does patient/family understand reason for instituting ventilatory assistance? Review the type of device ordered for the patient.

2. 3. 4. 5.

Procedural Guidelines
1. 2. 3. In noninvasive techniques, assist with application of patient-machine interface. If invasive (tracheostomy), a cuffed tube is usually used; inflate cuff when patient on ventilator (see sections on tracheostomy, suctioning). Pressure/volume (volume ventilator would not be used for sleep apnea) must be appropriate for goals. If obstructive sleep apnea, need enough pressure to abolish significant apneas and hypopneas. If for chronic disease with inadequate ventilation, need enough pressure difference/volume to allow adequate tidal ventilation. Observe for good chest expansion, in synchrony with the ventilator. Observe that snoring is abolished. Observe that paradoxical respirations and use of accessory muscles on inspiration are abolished. Observe that apneas are abolished; automatic rate may be required if there is central apnea or respiratory muscle paralysis. Measure ABGs and or Spo2 during ventilation to demonstrate improvement. Make sure equipment is functioning properly: rise and fall in pressure; cycling between inspiration and expiration; no kinks in the tubing.

4. 5. 6. 7. 8. 9.

HINTS FOR APPLYING NASAL MASKS IN NONEMERGENCY SITUATIONS 1. 2. 3. 4. 5. 6. Be sure patient was measured for appropriate mask size. Allow patient to hold mask and breathe through it before it is connected to machine. While patient is holding mask, connect to ventilatory device; may start at lower pressures than goal for initial session. When patient is comfortable, attach to headgear; remember with bilevel device, a small leak will be tolerated. As patient relaxes, is comfortable; pressure is increased to level desired. Patient may tolerate better with humidification.

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EVALUATION/PATIENT OUTCOMES
Gas exchange improved/stabilized (ABGs, oximetry) Improvement in daytime energy level Decreased fatigue Decreased dyspnea

THORACIC SURGERY
Thoracotomy
Thoracotomy refers to a surgical incision of the chest wall. An exploratory thoracotomy may be performed to obtain a biopsy specimen or locate a source of bleeding. During the procedure the ribs are spread and the pleura is opened. Closed chest drainage is generally required postoperatively.

Pneumonectomy
Pneumonectomy refers to surgical removal of an entire lung. The surgeon severs and sutures off the main arteries, veins, and the mainstem bronchus at the bifurcation. The major indication for pneumonectomy is removal of lung cancer that has not spread beyond a single lung. Closed chest drainage is not used postoperatively, so that the thoracic cavity on the affected side will fill with serous exudates and eventually consolidate. The phrenic nerve on the affected side may be severed to elevate the diaphragm, which also assists to fill the empty thoracic space.

Lobectomy, Segmental Resection, and Wedge Resection

When less than an entire lung is removed, the procedure name refers to the amount of tissue removed. For example, a lobectomy refers to removal of a single lung lobe. Indications for these procedures include isolated tumor or injury or unresponsive cyst, tuberculosis, or abscess. A wedge resection may also be done for diagnostic biopsy. Closed chest drainage is used after partial lung removal. The remaining lung tissue on the operative side expands to fill the chest cavity, so breath sounds will be heard over the area where tissue was removed.

Decortication
Decortication refers to the stripping off of a thick fibrous membrane that may develop over the visceral pleura secondary to empyema or the prolonged presence of blood or fluid in the pleural space. Closed chest drainage is required postoperatively.

Lung Reduction
Lung reduction surgery is a therapeutic intervention in a highly select group of patients with emphysema. The principles are that a reduction of lung volume will (1) decrease the tension of the respiratory muscles and therefore decrease dyspnea and (2) allow normal lung that was previously compressed to expand and thus improve gas exchange. Two approaches are used. In one, a midline sternotomy is performed and both lungs "trimmed." Strips of bovine pericardium are usually used to help seal the cut surface of the lung and prevent large postoperative air leaks. In the other procedure a laser beam is used to trim the lung, usually through multiple thorascopic incisions.

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Lung Transplant
Lung transplantation originally required a heart-lung transplantation. Today, lung transplantation without transplanting the heart is possible. Depending on the recipient's underlying pulmonary pathology, a heart-lung, single-lung, or double-lung transplantation can be done. Heart-lung transplantations are done for patients with primary pulmonary hypertension and for cardiac defects associated with pulmonary hypertension (Eisenmenger's syndrome). Heart-lung transplantations are done via a midline sternotomy incision. Double-lung and double single-lung transplantation (in other words, a right and left lung are transplanted; the trachea is native to the recipient) is the procedure done in patients with CF. Because of the risk of infection if one native lung were left, single-lung transplantation is avoided. The doublelung transplantation is usually the procedure of choice in younger candidates. The double-lung transplantation is usually done via a clam shell incision (anteriorly, from side to side at the lower thoracic border). Some surgeons also prefer the double-lung transplantation for patients with emphysema. The single-lung transplantation is done for patients with interstitial fibrosis. Some surgeons also use this approach for patients with emphysema. This procedure allows more persons to receive a transplant, a consideration when donors are not always available. A lateral thoracotomy incision is usually used. In single-lung transplantation, one must always remember that the native lung with its disease is still present. The aim is for the native lung to essentially shut down, with blood flow and ventilation going to the new lung (Fig. 4-39) . Whenever a lung is transplanted, consideration is given not only to blood type and HLA typing but also to the size of the donor and recipient. (If the lung is too small, it may not fill the thorax; if the transplanted lung is too large, it may be difficult to fully inflate it.) Lung transplantation patients receive immunosuppressive medication, as do other transplantation patients. Another specific consideration in lung transplantation involves problems with airway clearance. The donor lung has no cough reflex (the lung is denervated), and the bronchial arteries are not attached to the recipient's systemic circulation. Mucus tends to be more tenacious, and mucociliary clearance is often impaired; coupling this finding with loss of the cough reflex means that nursing care and patient teaching regarding airway clearance are of prime importance. Patients are taught to voluntarily cough several times a day, and most are taught to do postural drainage every day. Impaired bronchial circulation after lung transplant may allow strictures to develop at the bronchial anastamosis. Strictures are treated with bronchial stent placement via fiberoptic bronchoscopy. Both acute and chronic rejection can be more difficult to diagnose in lung transplantation than in heart transplantations. It is often difficult to differentiate a pulmonary infection because of immunosuppression from rejection. The patient may be unaware of subtle changes in lung function. Thus patients do daily monitoring of spirometry (FEV1 and FVC); a fall in FEV1 or FVC is a signal to contact their caregivers. Bronchoscopy with biopsy may identify the cause of the fall in function, but patients are often treated for both infection (antibiotics) and rejection (corticosteroids) simultaneously. Chronic rejection in lung transplantation results in bronchiolitis obliterans with severe airways obstruction.

Contraindications/Cautions
The following are potential complications of thoracic surgery: Respiratory insufficiency Tension pneumothorax Atelectasis Bronchopleural fistula Pulmonary edema Subcutaneous emphysema Diaphragm paralysis

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Infection

Preprocedural Nursing Care

Carefully determine preoperative status of patient, including the following: Baseline pulmonary function studies ECG ABGs Electrolytes Other existing health problems Current respiratory status: Amount and extent of dyspnea, cough, sputum production, and respiratory distress General nutrition and hydration state

Provide preoperative teaching to include the following: Need to stop smoking preoperatively Coughing and deep breathing techniques Overview of equipment and procedures that will most likely occur postoperatively Listen preoperatively to patient and family questions and concerns; provide information and clarification when indicated. Assure patient that pain medication will be available postoperatively to assist with discomfort. Teach patient the need for postoperative ROM and leg exercises, early ambulation.

NURSING CARE POSTOPERATIVE NURSING ASSESSMENT

Respiratory status: Dyspnea, tachypnea, restlessness, inadequate chest expansion, stridor, shallow respirations, crackles, rhonchi, decreased tidal volume, cough effectiveness, sputum characteristics, mediastinal shift, paradoxical motion, SpO2, ABG results Chest tube drainage: Characteristics of drainage, function of closed drainage system, presence of air leak Pain: Pain with activities of turning, coughing, deep breathing, and ROM Fluid and electrolyte balance: Vital signs, electrolytes, adequate urinary output

POTENTIAL COMPLICATIONS
Infection: Increased WBC count, fever, purulent drainage or sputum, redness around incision area, decreased breath sounds, crackles, rhonchi Hemorrhage: Tachycardia, hypotension, decreased or absent breath sounds, dullness to percussion, hemoptysis, increased sanguinous drainage with clots from chest tubes

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PATIENT PROBLEMS/NURSING DIAGNOSES & INTERVENTIONS

RESPIRATORY MANAGEMENT

Ineffective airway clearance related to increased tracheobronchial secretions, muscle weakness, pain Impaired gas exchange related to pleural fluid accumulation, hypoventilation Maintain patent airway by suctioning and positioning; if patient has endotracheal tube, see p. 208 for additional strategies. See closed-chest drainage system, p. 210 , for additional strategies. Encourage coughing and deep breathing and use of incentive spirometry on a regular basis until patient is able to maintain procedure by self; observe and record response. Facilitate patient rest between activities. IMMOBILITY MANAGEMENT Impaired physical mobility related to incisional pain and chest tubes Place a call button for the patient to reach conveniently without straining. The patient is at risk for developing stiffness and ankylosis of the shoulder on the side with the chest tubes; encourage and assist ROM activities for that shoulder on a regular schedule. Encourage passive and active ROM of the legs to decrease the potential for thrombosis. Administer analgesics as ordered to manage pain and promote mobility. Ambulate patient as soon as possible and in accordance with patient's ability to tolerate ambulation.

EVALUATION/PATIENT OUTCOMES
Evaluation criteria are based on the individual procedure performed and the underlying disease state. Respiratory Management: Airways are patent. Breath sounds are clear. ABGs are within acceptable range. Immobility Management: ROM of the affected shoulder is maintained. Breathing pattern is effective without severe pain. Patient is able to increase activity.

Copyright 2008 Elsevier Inc. All rights reserved.

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