Respiratory Respiratory CompetenciesCompetencies

By Paula Willmore 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 Should be used in conjunction with formal and informal teachingand informal teaching

Develop and build on existing knowledgeDevelop and build on existing knowledge

Increase confidenceIncrease confidence

Develop clinical practice Develop clinical practice

Create a platform to encourage ward Create a platform to encourage ward based learningbased learning

Improve patient careImprove patient care

Improve patient careImprove patient care

The Aim of the The Aim of the CompetenciesCompetencies

Anatomy and Anatomy and PhysiologyPhysiology

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

ControllerHoused 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

Inspection3 areas focused on

1. Observation of the tongue and sublingual area

2. Assessment of the chest wall configuration

3. Evaluation of respiratory effort

PalpationThree 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 ObstructionCerebral 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 Recognition of Airway Obstruction.Obstruction.

Look, Listen and FeelLook, Listen and Feel

LOOKLOOK for chest and for chest and abdominal movementabdominal movement

LISTENLISTEN and and FEEL FEEL for for airflow at the nose and airflow at the nose and mouthmouth

Partial Airway Obstruction Creates

SoundsInspiratory 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

SuctionSuction 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 changeOften first observation to change

Look at the trendLook at the trend

A high respiratory rate is a marker of A high respiratory rate is a marker of illness and a warning that the patient may illness and a warning that the patient may deteriorate suddenlydeteriorate 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 FailureOxygen 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

PracticeMeasurable impact on staff performance

Staff understand their contribution

Measurable impact on patient outcome

Consistency

Evidence based care