Perform Respiratory Care
TERMINAL LEARNING OBJECTIVE Give the necessary medical equipment in a holding or ward setting. You are providing casualty care as part of an integrated team in a Minimal Care Ward.
INTRODUCTION: The respiratory system supplies oxygen to the bodyís cells. Adequate oxygenation is dependent upon several factors to include maintaining a patent airway. During this block of instruction you will learn techniques used to suction the airway, to include oral, endotracheal and tracheostomy suctioning. You will also learn to perform endotracheal tube and tracheostomy care and administer a nebulization treatment.
a. Respiration - breathing and exchange of oxygen and carbon dioxide within the body tissues
b. Inspiration - inhaling, breathing in or drawing air into the lungs (active phase)
c. Expiration - exhaling, breathing out or expelling air from the lungs (passive phase)
d. Ventilation - it is the process by which gases are moved into and out of the lungs. It can be normal breathing or with mechanical assistance.
e. Diffusion of gases - it is a natural process essential to respiration in which molecules of a gas pass from an area of greater concentration to one of lesser concentration (example: oxygen moving from inhaled air through capillaries into deoxygenated blood).
f. Thorax - it is the chest or the upper part of the trunk between the neck and the abdomen.
g. Mediastinum - the space between the lungs where the heart, great vessels (aorta and vena cava), esophagus, trachea, and major bronchi lie
h. Anoxia - an abnormal condition characterized by a lack of oxygen
i. Apnea - absence of spontaneous respiration
j. Aspiration - taking foreign matter into the lungs during inhalation (e.g., vomitus)
k. Bradypnea - an abnormally slow rate of breathing
l. Cheyne-Stokes respiration - an abnormal pattern of respiration, characterized by alternating periods of apnea (10-20 sec) and deep, rapid breathing
m. Dyspnea - shortness of breath or difficulty in breathing
n. Hyperpnea - deep, rapid, or labored respiration
o. Hyperventilation - a ventilation rate that is greater than that metabolically necessary for the exchange of respiratory gases
p. Hypoventilation - an abnormal condition of the respiratory system that is characterized by a reduced rate and depth of breathing
q. Hypoxia - inadequate supply of oxygen to body tissue and cells
r. Kussmaul breathing - abnormally deep and very rapid respiration characteristic of diabetic acidosis
s. Respiratory arrest - cessation of breathing
t. Respiratory failure - the inability of the cardiac and pulmonary systems to maintain an adequate exchange of oxygen and carbon dioxide in the lungs
u. Suffocation - a condition characterized by inadequate oxygen and excessive carbon dioxide in the blood
v. Tachypnea - an abnormally rapid rate of breathing
w. Adventitious sounds - abnormal lung sounds heard with auscultation
x. Rhonchi - abnormal lung sound heard on auscultation of the when the patientís airways are obstructed with thick secretions. Can usually be cleared with coughing
y. Rales (crackles) - abnormal lung sound heard on auscultation characterized by fine bubbling sounds during inspiration.
z. Wheezes (wheezing) - abnormal lung sounds caused by severely narrowed bronchus. Can be both inspiratory and expiratory. Common lung sound associated with asthma.
aa. Tracheostomy - opening through the neck into the trachea through which an indwelling tube may be inserted.
a. Suctioning is used to clear the airway of excessive secretions when the patient is unable to clear the respiratory tract with coughing.
b. Signs and symptoms of excess secretions
(1) Assess oral cavity: gurgling noise on inspiration or expiration, obvious oral secretions, drooling, gastric secretions or vomitus in mouth, and productive cough without expectorating secretions from the mouth.
(2) Assess for lower airway obstruction: coughing, secretions in the airway, labored breathing, restlessness or irritability, unilateral breath sounds, cyanosis, decreased oxygen saturations or level of consciousness, increased fatigue, dizziness, increased pulse rate, increased respiratory rate and/or elevated blood pressure.
c. Assess lung sounds by auscultating all lung fields for adventitious sounds such as rhonchi, rales or wheezing.
d. Assess the patientís understanding of the procedure to remove excess secretions by one of the primary suctioning techniques.
e. Three primary suctioning techniques
(1) Oropharyngeal suctioning-used when the patient is able to cough effectively but is unable to clear secretions by expectorating or swallowing.
(2) Nasotracheal suctioning-necessary when the patient with pulmonary secretions is unable to cough and does not have an artificial airway.
(3) Tracheal suctioning-accomplished through an artificial airway. The artificial airway may be an endotracheal or nasotracheal tube or it may be a tracheostomy tube.
f. Preparation for all techniques/types of suctioning
(1) Verify MD/PA order as required for procedure.
(2) Explain the procedure to the patient and the reason that it is to be done. Explain how the procedure with help clear the airway and relieve breathing problems and that temporary coughing, sneezing, gagging, or shortness of breath is normal.
(3) Gather equipment necessary to correctly perform the procedure. Some facilities have commercially prepared suctioning kits. Check what is available in your facility or check procedural manuals for equipment lists.
(4) Don gloves (nonsterile) and use mask or face shield as per local policy
(5) Fill basin or cup with approximately 100 cc of water
(6) Connect one end of connecting tubing to suction machine. Check that equipment is functioning properly by suctioning a small amount of water from basin
(7) Turn on suction device. Set regulator to appropriate negative pressure: wall suction, 80-120 mm Hg; portable suction, 7-15 mm Hg for adults
NOTE: Elevated pressure settings increase risk of trauma to mucosa
g. Oropharyngeal suctioning
(1) Attach suction catheter to connecting tubing. Remove oxygen mask from patient if present. Nasal cannula or prongs may be left in place while performing this type of suctioning.
(2) Assist the patient to assume comfortable position for the procedure. Usually this will be a semi-Fowlerís position or sitting upright. Proper positioning reduces stimulation of the gag reflex, promotes patient comfort and aids in secretion drainage.
(3) Insert catheter into patientís mouth. With suction applied, move the catheter around the mouth, including the pharynx and the gum line until secretions are cleared. If the catheter does not have a suction control to apply intermittent suction, take care not to traumatize oral mucosal surfaces with continuous suctioning.
NOTE: Oropharyngeal suctioning is usually performed using a rigid plastic catheter with one large and several small eyelets that mucous enters when suction is applied. This type of catheter is called a Yankauer or tonsil suctioning device. Alert patients can be taught to use this device to control excess secretions in the mouth.
(4) Encourage the patient to cough. Coughing moves secretions from the lower and upper airway into the mouth where they can be easily suctioned.
(5) Repeat suctioning as needed until the mouth is clear of excess secretions.
(6) Replace the oxygen mask if removed earlier.
(7) Suction water from the basin through the catheter until the catheter is cleared of secretions. Clearing secretions from the catheter and the tubing before they dry reduces the possibility of transmission of microorganisms and insures delivery of accurate suction pressures.
(8) Place the catheter in a clean, dry area for reuse with the suction turned off. If the patient has been taught to use the suction catheter, leave the suction on and the catheter within reach of the patient.
(9) Dispose of water and clean the basin as per policy. Remove your gloves and dispose of per local policy.
h. Nasotracheal suctioning
(1) Open suction kit or catheter using aseptic technique. If sterile drape is available, place it across the patientís chest. Do not allow the suction catheter to touch any nonsterile surfaces
(2) Unwrap or open a sterile basin and place on the bedside table. Be careful not touch the inside of the sterile basin. Fill the basin with approximately 100 cc of sterile Normal Saline (NS).
(3) Apply one sterile glove to each hand, or apply nonsterile glove to nondominant hand and sterile glove to dominant hand. Attach nonsterile suction tubing to sterile catheter, keeping hand holding catheter sterile.
(4) Secure catheter to tubing aseptically. Coat distal 2-3 inches of catheter with water-soluble lubricant (K-Y Jelly/Lubricant).
(5) Remove oxygen delivery device, if present, with nondominant hand. Without applying suction and using the dominant thumb and forefinger, gently, but quickly insert the sterile catheter into either nare during inhalation with a slight downward slant. Do not force the catheter. Try the other nare if insertion meets resistance or is difficult to insert.
NOTE: Never apply suction during insertion. Application of suction pressure while introducing the catheter into the trachea increases risk of damage to the mucosa and increases the risk of hypoxia because the removal of oxygen present in the airway. Remember that the epiglottis is open during inspiration and facilitates insertion of the catheter into the trachea.
(6) Insert the catheter approximately 16-20 cm (6 Ĺ-8 inches) in the adult patient. One method of measuring the correct length of catheter to insert is to use the distance from the patientís nose to the base of the earlobe as a guide.
(7) Apply intermittent suction by placing and releasing nondominant thumb over the vent of catheter. Slowly withdraw the catheter while rotating it back and forth with suction on for as long as 10-15 seconds.
(8) Assess the need to repeat suctioning procedure. Allow adequate time between suction passes for ventilation and oxygenation. Ask the patient to deep breathe and cough. Keep oxygen readily available in case the patient exhibits signs of hypoxia. Administer oxygen to the patient between suctioning attempts
(9) When the pharynx and trachea are cleared of secretions, perform oral suctioning to clear the mouth of secretions. Do not suction the nose or trachea after suctioning the mouth.
(10) Rinse the catheter and connecting tubing by suctioning NS from the basin until the tubing is clear. Dispose of equipment as per facility policy. Turn off suction device
i. Endotracheal or tracheostomy tube suctioning
(1) Performed through an artificial airway (endotracheal/nasotracheal or tracheostomy). Artificial airways are indicated for patients with deceased level of consciousness, airway obstruction, mechanical ventilation and for removal of tracheal bronchial secretions. Artificial airways allow easy access to the patientís trachea for deep tracheal suctioning.
(2) Prepare suction equipment, suction catheter using sterile technique and don sterile gloves as previously described for nasotracheal suctioning
(3) Hyperoxygenate the patient before suctioning, using manual resuscitation Ambu-bag connected to an oxygen source.
(4) Open swivel adapter or if necessary remove the oxygen delivery device (ventilator tubing) with your nondominant hand.
(5) Without applying suction, gently, but quickly insert the sterile catheter using the dominant thumb and forefinger into the artificial airway until resistance is met, or the patient coughs and them pull back the catheter approximately Ĺ inch.
(6) Apply intermittent suction by placing and releasing nondominant thumb over the vent of the catheter while rotating it back and forth between the dominant thumb and forefinger. Encourage the patient to cough, if possible. Observe continuously for respiratory distress.
NOTE: If the patent develops respiratory distress during the suctioning procedure, immediately withdraw the catheter and administer additional oxygen and breaths as needed.
(7) Close the swivel adapter, or replace the oxygen delivery device (ventilator tubing).
(8) Rinse catheter and tubing with NS
(9) Assess for secretion clearance. Repeat suctioning procedure 1-2 times more to clear secretions if necessary. Allow adequate time between suction passes (at least one full minute) for ventilation and oxygenation.
(10) Perform oropharyngeal suctioning as needed. Catheter is now contaminated. Do not reinsert into the artificial airway.
(11) Dispose of suctioning equipment per policy. Turn off suction device
(12) Reposition the patient as indicated by condition
j. Record the amount, consistency, color and any odor of secretions and the patientís response to the procedure. Document the patientís pre- and post suctioning respiratory status.
k. Continue to monitor patientís vital signs to include pulse oximetry if available.
a. Artificial airways place the patient at high risk for infection and make the patient more susceptible to airway injury.
b. Endotracheal (ET) tubes are used as short-term artificial airways and are used to administer mechanical ventilation, relieve upper airway obstruction, and protect the patient from aspiration or clear excessive secretions. ET tubes may be placed either nasally or orally. They are generally removed within 14 days.
c. Patients who require artificial airway assistance for longer than 14 days usually require a tracheostomy. This procedure involves a surgical incision to be made into the trachea and a short, artificial airway (trach tube) is inserted. This procedure is normally accomplished in the operating room under sterile conditions.
d. Endotracheal (ET) tube care
(1) Verify MD/PA order as required by facility
(2) Explain the procedure to the patient and reason it is being done in terms the patient understands
(3) Gather equipment necessary to perform the procedure
(4) Initiate and perform endotracheal suctioning prior to the procedure. This allows for the removal of secretion and diminishes the patientís need to cough during the procedure.
(5) Connect oral suction catheter (Yankauer) suction to suction device
(6) Prepare tape. Cut piece of tape long enough to go completely around the patientís head from nare to nare (nasal ET tube) or from edge of mouth to edge of mouth (for oral ET tube) plus approximately 6 inches. Lay adhesive side up on table and cut and lay approximately 6 inches of tape, adhesive side down, in the center of the long strip. This will prevent the longer piece of tape from sticking to the patientís skin and hair on the back of the head/neck.
(7) Carefully remove tape from the ET tube and the patientís face. An assistant may be required to help hold the ET tube in place so that the tube does not move. This is especially important in an uncooperative patient.
(8) Remove excess adhesive from the face with adhesive remover if necessary.
(9) Remove bite block or oral airway if present
(10) Clean mouth, gums and teeth with NS or mouthwash solution and a 4 X 4 gauze, sponge tipped applicator or saline swabs. Brush teeth if necessary and suction oral cavity with Yankauer suction.
(11) Clean face and neck with soap and water. Shave the make client as necessary.
(12) Apply tincture of benzoin to the upper lip (oral ET tube) or across nose (nasal ET tube) and cheeks to ears. Allow to dry completely.
(13) Slip tape under the patientís head and neck, adhesive side down. Do not twist tape or catch hair. Do not allow tape to stick to itself. Center tape so that the double-faced tape extends around the back of the neck from ear to ear.
(14) On one side of the face, secure tape from ear to nares (nasal ET tube) or edge of mouth (oral ET tube). Tear remaining tape in half, length wise, forming two pieces that are Ĺ to ĺ inch wide. secure bottom half of tape across upper lip (oral ET tube) or across tope of nose (nasal ET tube). Wrap top half around the ET tube.
(15) Gently pull other side of tape firmly to pick up slack and secure to remaining side of face.
(16) Clean oral airway in warm soapy water and rinse well. Hydrogen peroxide can aid in the removal of crusty secretions.
(17) Reinsert oral airway being careful not to push the tongue into the oropharnyx
e. Tracheostomy Care
(1) Suction trach. Suctioning prior to the procedure removes secretions so that they do not occlude the outer cannula while the inner cannula is removed. Reduces the need for the patient to cough during the procedure.
(2) Open sterile trach care kit (commercially available). Open three 4 X 4 sterile gauze packages using aseptic technique and pour NS on one package and hydrogen peroxide on another. Leave the third package dry.
(3) Open two packages of cotton tipped swabs and pour NS on one package and hydrogen peroxide on the other.
(4) Open sterile trach package. Unwrap sterile basin and pour about 1 inch of hydrogen peroxide into it. Open small sterile brush package and place aseptically into the basin.
(5) Measure and cut twill trach tape long enough to around the patientís neck two times (approximately 24-30 inches. Cut ends on a diagonal. Lay aside in a dry area.
(6) Don sterile gloves. Keep dominant hand sterile throughout the procedure.
(7) Remove oxygen source/ventilator tubing.
(8) Remove inner cannula of trach with a slight twisting motion with the nondominant hand and drop the cannula into the hydrogen peroxide basin
(9) Place oxygen source over or near the outer cannula. Oxygen delivery tubing cannot be attached to all outer cannulas when the inner cannula is removed.
(10) Quickly clean the inner cannula with the brush to remove secretions inside and outside the cannula. Rinse with NS, using the nondominant hand to pour.
(11) Replace the inner cannula and secure the locking mechanism with a slight twisting motion.Reapply the oxygen/ventilator source.
(12) Using hydrogen peroxide prepared cotton-tipped swabs and 4 X 4 gauze, clean the outer cannula surfaces and stoma under the faceplate of the trach tube, extending 2-4 inches in all directions from the stoma. Clean in a circular motion from stoma site outward. Always remember to use the dominant hand to handle sterile supplies
(13) Using NS prepared cotton-tipped swabs and 4 X 4 gauze, rinse hydrogen peroxide from the trach tube and skin.
(14) Using dry 4 X 4 gauze, pat dry the outer cannula and skin surfaces.
(15) Replace trach tie. If assistant available, have them hold the trach in place while old tie is cut and removed and new tie is applied. If no assistant is available, apply new tie before removing the old one.
(16) To replace the trach tie, insert one end of the tie through faceplate eyelet and pull ends even
(17) Slide both ends of behind the head and around the neck to the other eyelet and insert one tie through the second eyelet.
(18) Pull snug
(19) Tie ends securely in a double square knot, allowing space for only one finger in tie
(20) Insert fresh trach dressing under clean ties and faceplate.
(21) Assist patient to position of comfort and assess respiratory status.
f. Record respiratory assessments before and after care.
g. Record ET tube care to include frequency and extent of care, patient response to care and any abnormal findings to include skin breakdown/irritation.
h. Record tracheostomy care. Note size of trach tube, frequency and extent of care, patient tolerance of care and any abnormal findings to include signs of an infected stoma (increased redness, purulent drainage), skin breakdown/irritation.
i. Continue to monitor patientís vital signs to include pulse oximetry, if available.
a. Nebulization is process of adding moisture or medications to inspired air by mixing particles of varying size using compressed air or oxygen.
b. A nebulizer uses the aerosol principle to suspend a maximum number of water drops or particles of the desired size in inspired air.
c. Nebulization is often used for the administration of bronchodilators in the treatment of asthma
d. Administer a nebulization treatment
(1) Verify MD/PA order for treatment
(2) Verify patientís allergies to medications
(3) Prepare medication. Usually administer a bronchodilator such as albuterol, 0.2-0.3 ml in 3cc normal saline (NS). This medication is often available in unit dose packages. Check with facility for what is available.
(4) Assemble nebulizer as directed. Nebulizers are now pre-packaged, disposable systems for individual patient use.
(5) Place medication and NS into receptacle and screw lid onto medication receptacle. Attach the mouthpiece to the receptacle and attach the reservoir tubing to the other end.
(6) Connect the nebulizer to the compressed air or oxygen source. Oxygen is usually used to administer a nebulization treatment to a patient having an acute asthmatic attack.
(7) Turn on the compressed air/oxygen until you observe a fine mist coming from the mouthpiece of the nebulizer. This usually requires at least 10-12 LPM of the compressed air/oxygen.
(8) Have the patient place the mouthpiece in their mouth and close their lips around the mouthpiece.
(9) Patient should inhale the medication as deeply as possible and exhale through the nebulizer. The patient does not need to remove the nebulizer from their mouth to exhale. Make sure the patient does not hyperventilate nor hold his breath.
(10) The treatment should last 5-10 minutes.
(11) Upon completion of the treatment, turn off the compressed air/oxygen.
(12) Assess the respiratory status of the patient by auscultating the lungs
(13) Monitor vital signs to include pulse oximetry if available
(14) Document the treatment to include time, medication, deliver system and patientís response to treatment.
Respiratory integrity is the foundation for maintenance of health and well being. Your ability to accurately evaluate respiratory disorders will depend on your knowledge of respiratory physiology. Only by knowing what is normal, can you identify when alterations occur that may threaten the life of your patient and determine what interventions are required.