Treatments
Respiratory disorders interfere with airway clearance, breathing patterns, and gas exchange. If not corrected, these disorders can adversely affect many other body systems and can be life-threatening. Treatments for respiratory disorders include drug therapy, inhalation therapy, surgery, and other types of therapies.
DRUG THERAPY
Drugs are used for airway management in patients with such disorders as acute respiratory failure, acute respiratory distress syndrome, asthma, emphysema, chronic bronchitis, and chronic obstructive pulmonary disease (COPD).
Drug categories
Types of drugs used to improve respiratory function include:
aerosol anti-infectives
antitussives
beta2-adrenergic agonists
corticosteroids
decongestants
expectorants
leukotriene modifiers
mast cell stabilizers
mucus inhibitors
xanthines.
AEROSOL ANTI-INFECTIVES
Aerosol inhalation provides direct, targeted local airway delivery of anti-infectives with minimal systemic blood levels. Aerosol anti-infectives, especially antibiotics, should be given with high flow rate nebulizers that deliver flow rates of 10 to 12 L/minute. Four inhaled anti-infectives are available: pentamidine (Nebupent), ribavirin (Virazole), tobramycin (TOBI), and zanamivir (Relenza).
Pentamidine is an antiprotozoal recommended as a secondline drug for the prevention of Pneumocystis carinii pneumonia (PCP) in high-risk human immunodeficiency virus-infected patients who have a history of one or more episodes of PCP or a CD4+ lymphocyte count of less than or equal to 200/µl. This drug should be given in isolation and through an environmental containment system such as a negative-pressure room. The nebulizer system should have one-way valves and scavenging filters that prevent or reduce environmental contamination.
Ribavirin is an antiviral recommended for the treatment of respiratory syncytial virus (RSV) or in patients who are at risk for severe infection. RSV is a common seasonal respiratory infection that occurs in young infants and children. Adverse reactions include bronchospasm, skin rash, eyelid erythema, and conjunctivitis.
Tobramycin is used to treat Pseudomonas aeruginosa in patients with cystic fibrosis. This drug should be given after other cystic fibrosis therapies such as other inhaled drugs. It should be given under containment to prevent environmental saturation of the antibiotic into other hospital areas, which in turn helps prevent the development of resistant organisms. Possible adverse reactions include auditory and vestibular damage with the potential for deafness and nephrotoxicity. Women who are pregnant should avoid inhalant exposure because of fetal harm resulting from aminoglycosides.
Zanamivir is used to treat uncomplicated cases of influenza in adults and adolescents ages 12 and older who have had symptoms lasting no longer than 2 years. Adverse reactions include diarrhea, vomiting, bronchitis, cough, sinusitis, dizziness, and headaches.
Nursing considerations
Monitor the patient for bronchospasm and reduction of lung function, especially if the patient has asthma or COPD.
Make sure that the patient understands how to use the aerosol correctly.
Caution the patient to report adverse effects immediately.
Advise the patient taking inhaled tobramycin to report episodes of tinnitus, changes in hearing, or voice alteration.
ANTITUSSIVES
Antitussive drugs suppress or inhibit coughing. They are given orally as a liquid and are typically used to treat dry, nonproductive coughs. The major antitussives include:
benzonatate (Tessalon)
codeine
dextromethorphan hydrobromide (Robitussin)
hydrocodone (Vicodin).
The uses and actions of these drugs differ, but each is used to treat a nonproductive cough that interferes with a patient’s ability to rest or carry out activities of daily living.
Benzonatate acts by anesthetizing stretch receptors throughout the bronchi, alveoli, and pleura. Benzonatate relieves coughs caused by pneumonia, bronchitis, the common cold, and chronic pulmonary diseases such as emphysema. It can also be used during bronchial diagnostic tests, such as bronchoscopy, when the patient must avoid coughing.
Codeine, dextromethorphan, and hydrocodone suppress the cough reflex by direct action on the cough center in the medulla of the brain, thus lowering the cough threshold.
Nursing considerations
Obtain a history of the patient’s cough before giving the drug, and reassess the patient after giving the drug.
Look for adverse reactions and drug reactions.
Assess the patient’s and his family’s knowledge of drug therapy.
BETA2-ADRENERGIC AGONISTS
Beta2-adrenergic agonists are used to treat symptoms associated with asthma and COPD. These drugs increase levels of cyclic
adenosine monophosphate through the stimulation of the beta2-adrenergic receptors in the smooth muscle, resulting in bronchodilation. Inhaled beta2-adrenergic agonists are preferred because they act locally in the lung, resulting in fewer adverse reactions than systemic drugs.
adenosine monophosphate through the stimulation of the beta2-adrenergic receptors in the smooth muscle, resulting in bronchodilation. Inhaled beta2-adrenergic agonists are preferred because they act locally in the lung, resulting in fewer adverse reactions than systemic drugs.
Drugs in this class may be short or long acting. A short-acting inhaled beta2-adrenergic agonist, such as albuterol (Proventil) or pirbuterol (Maxair), is used to quickly relieve symptoms in patients with asthma or COPD. Some COPD patients may use these drugs around-the-clock on a specified schedule.
A long-acting beta2-adrenergic agonist is best used in combination with anti-inflammatories—namely, the inhaled corticosteroids—to provide maintenance therapy to control asthma. Salmeterol (Serevent) is the only long-acting beta2-adrenergic agonist currently approved in the United States. Because of its prolonged onset, it must be given on a scheduled basis.
Nursing considerations
Caution the patient about possible adverse reactions, which may include tremors, nervousness, dizziness, headache, nausea, tachycardia, palpitations, electrocardiogram (ECG) changes, bronchospasm, and cough.
Make sure that the patient taking a long-acting beta2-adrenergic agonist knows that he can’t use this drug to treat acute symptoms because the onset isn’t quick enough.
Excessive use of a short-acting beta2-adrenergic agonist may indicate poor asthma control, requiring reassessment of the patient’s therapeutic regimen.
CORTICOSTEROIDS
Corticosteroids are anti-inflammatory drugs that are available in inhaled and systemic forms for the short- and long-term control of asthma symptoms. Many different products are available and have various potencies. (See Understanding corticosteroids.)
Corticosteroids are the most effective drugs available for the long-term treatment of patients with reversible airflow obstruction. They work to prevent asthma exacerbations by suppressing immune responses and reducing inflammation.
Systemic corticosteroids are commonly reserved for moderate to severe acute exacerbations but are also used for severe
asthma that’s refractory to other measures. Systemic corticosteroids, such as dexamethasone (Decadron), methylprednisolone (Medrol), and prednisone, are given to manage an acute respiratory event, such as acute respiratory failure or exacerbations of COPD. These drugs should be used at the lowest effective dose and for the shortest period possible to avoid adverse reactions. These drugs are initially given I.V. and, when the patient stabilizes, the dosage is tapered and an oral form may be substituted.
asthma that’s refractory to other measures. Systemic corticosteroids, such as dexamethasone (Decadron), methylprednisolone (Medrol), and prednisone, are given to manage an acute respiratory event, such as acute respiratory failure or exacerbations of COPD. These drugs should be used at the lowest effective dose and for the shortest period possible to avoid adverse reactions. These drugs are initially given I.V. and, when the patient stabilizes, the dosage is tapered and an oral form may be substituted.
UNDERSTANDING CORTICOSTEROIDS
Use this table to learn about the indications, adverse reactions, and practice pointers associated with corticosteroids.
DRUG | INDICATIONS | ADVERSE | PRACTICE |
|---|---|---|---|
SYSTEMIC CORTICOSTEROIDS • Dexamethasone (Decadron) • Methylprednisolone (Medrol) • Prednisone (Prednisone) | • Anti-inflammatory in acute respiratory failure, acute respiratory distress syndrome, and chronic obstructive pulmonary disease • Anti-inflammatory and immunosuppressor in asthma | • Heart failure, cardiac arrhythmias, edema, circulatory collapse, thromboembolism, pancreatitis, peptic ulcer | • Use cautiously in patients with recent myocardial infarction, hypertension, renal disease, and GI ulcer. • Monitor blood pressure and blood glucose levels. |
INHALED CORTICOSTEROIDS • Beclomethasone (Qvar) • Budesonide (Pulmicort) • Flunisolide (Aerobid) • Fluticasone (Flonase) • Triamcinolone (Azmacort) | • Long-term asthma control | • Hoarseness, dry mouth, wheezing, bronchospasm, oral candidiasis | • Don’t use to treat an acute asthma attack. • Use a spacer to reduce adverse effects. • Rinse mouth after use to prevent oral fungal infection. |
Inhaled corticosteroids remain the mainstay of therapy to prevent flare-ups in those with mild to severe asthma. Patients commonly use beclomethasone (Qvar), budesonide (Pulmicort Turbuhaler), flunisolide (AeroBid), fluticasone (Flovent), and triamcinolone (Azmacort). Use of these drugs reduces the need for systemic steroids in many patients, thus reducing the risk of serious long-term adverse effects.
Nursing considerations
To reduce the risk of adverse effects occurring with inhaled drugs, use the lowest possible doses to maintain control.
Advise the patient to rinse his mouth with water after each dose to prevent oropharyngeal fungal infections.
Caution the patient that inhaled corticosteroids may cause hoarseness, throat and nose irritation, dry mouth, and headache or dizziness.
Monitor the patient for serious adverse effects, which may include dyspnea, wheezing, or bronchospasm.
DECONGESTANTS
Decongestants may be classified as systemic or topical. Both types of decongestants are used to relieve the symptoms of swollen nasal membranes resulting from hay fever, allergic rhinitis, vasomotor rhinitis, acute coryza, sinusitis, and the common cold.
Systemic decongestants activate the sympathetic division of the autonomic nervous system to reduce swelling of the respiratory tract’s vascular network. Topical decongestants are powerful vasoconstrictors that provide immediate relief from nasal congestion and swollen mucous membranes when applied directly to the nasal mucosa. Absorption of the topical form of the drug is negligible.
Nursing considerations
Discourage the use of over-the-counter decongestants in a patient who’s hypersensitive to other sympathomimetic amines. Such a patient may also be hypersensitive to decongestants.
Monitor the patient’s blood pressure, pulse, and ECG, as instructed, particularly noting hypertension and an irregular heartbeat or tachycardia.
Maintain seizure precautions during decongestant therapy.
Note if the patient uses drugs that alter urine pH because alkaline urine increases renal tubular reabsorption of sympathomimetic amines.
Don’t give a monoamine oxidase inhibitor, a beta-adrenergic blocker, methyldopa (Aldomet), reserpine (Hiserpia), or guanethidine (Ismelin) at the same time as a topical decongestant.
Warn the patient that transient burning and stinging of the nasal mucosa may occur during administration of the topical decongestant.
Monitor the patient receiving a topical decongestant for signs of rebound nasal congestion such as red, swollen, boggy nasal mucosa. If rebound nasal congestion occurs, withhold the drug and notify the prescriber.
Encourage the patient taking a decongestant to report difficulty urinating, which is especially common in the patient with prostatic hypertrophy.
EXPECTORANTS
By increasing production of respiratory tract fluids, expectorants reduce the viscosity, thickness, adhesiveness, and surface tension of mucus, making it easier to clear from the airways. Expectorants also soothe mucous membranes of the respiratory tract and result in a more productive cough. The most commonly used oral expectorant is guaifenesin (Robitussin).
Nursing considerations
Caution the patient that the drug may produce vomiting if taken in doses larger than necessary for the expectorant action. Administer with a full glass of water.
Monitor the patient for dyspnea or ineffective cough. Instruct him to cough effectively.
Teach the patient about the prescribed drug.
Monitor the patient for adverse effects, such as diarrhea, drowsiness, nausea, vomiting, and abdominal pain.
LEUKOTRIENE MODIFIERS
The leukotriene modifiers (zafirlukast [Accolate] and montelukast [Singulair]) are primarily used for the prevention and
long-term control of mild asthma. They may also be used as steroid-sparing drugs in some patients.
long-term control of mild asthma. They may also be used as steroid-sparing drugs in some patients.
Leukotrienes are substances released from mast cells, eosinophils, and basophils. They can result in smooth muscle contraction of the airways, increased permeability of the vasculature, increased secretions, and activation of other inflammatory mediators.
The leukotriene receptor antagonists (zafirlukast, montelukast) are competitive inhibitors of the leukotriene receptors, inhibiting leukotriene from interacting with its receptor, thereby blocking its action.
Nursing considerations
Zafirlukast’s absorption is decreased by food (especially highfat or high-protein meals); therefore, give the dose 1 hour before or 2 hours after meals.
Headache is the most common adverse reaction experienced with these drugs. Asthenia, dizziness, dyspepsia, gastroenteritis, and fever may also occur.
The drug isn’t used to treat acute bronchospasm.
The drug is used in conjunction with corticosteroids and other antiasthmatics.
Patients with liver impairment may require a dosage adjustment if taking zafirlukast. Monitor the patient closely for adverse reactions. Monitor liver enzyme levels in the patient taking zafirlukast because the drug may cause an increase in these levels.
MAST CELL STABILIZERS
Mast cell stabilizers are used to prevent asthma attacks, especially in pediatric patients and those with mild disease. They’re given in inhalation or intranasal form. Some examples are nedocromil (Alocril) and cromolyn (Intal).
The mechanism of these drugs is poorly understood, but they inhibit the release of inflammatory mediators by stabilizing the mast cell membrane, possibly through the inhibition of chloride channels.
These drugs are used for the prevention and long-term control of asthma symptoms by controlling the inflammatory
process. They’re also useful for the prevention of exerciseinduced asthma.
process. They’re also useful for the prevention of exerciseinduced asthma.
Adverse reactions may include throat irritation, bad taste in the mouth, cough, and nausea. Severe reactions, such as wheezing or bronchospasm after inhalation of powder, may also occur.
Nursing considerations
Mast cell stabilizers shouldn’t be used for an acute asthmatic attack.
These drugs are used in combination with an inhaled beta2-adrenergic agonist or inhaled corticosteroid.
Reduce dosage gradually to the lowest effective dosage.
Discontinue the drug if eosinophilic pneumonia or pulmonary infiltrates with eosinophilia occur.
Instruct the patient to follow his practitioner’s and the manufacturer’s directions closely.
MUCUS INHIBITORS
Mucus inhibitors, or mucolytics, act directly on mucus, breaking down thick, tenacious secretions so they’re more easily eliminated. The most commonly used mucolytic is acetylcysteine (Mucomyst). Mucus-controlling drugs are given by inhalation.
Another type of mucolytic, called dornase alpha (Pulmozyme), is a genetically engineered clone of natural human pancreatic DNase enzyme. It’s a proteolytic enzyme that can break down the deoxyribonucleic acid material found in purulent secretions. For that reason, it’s more effective than acetylcysteine in reducing the viscosity of infected mucus in cystic fibrosis.
Acetylcysteine decreases the thickness of respiratory tract secretions by altering the molecular composition of mucus and irritates the mucosa to stimulate clearance.
Mucolytics are used with other therapies to treat patients with abnormal or thick mucus secretions and may benefit patients with bronchitis, pulmonary complications related to cystic fibrosis, and atelectasis caused by mucus obstruction, as may occur in pneumonia, bronchiectasis, or chronic bronchitis.
Mucolytics may also be used to prepare patients for bronchial studies.
Nursing considerations
Warn the patient about the drug’s “rotten egg” smell, which may cause nausea.
Give acetylcysteine via nebulizer. Because acetylcysteine reacts with iron, copper, and rubber, frequently monitor the patient’s nebulizer equipment for reactive effects. The drug doesn’t react with glass, plastic, aluminum, or stainless steel.
Be ready to give a beta2-adrenergic agonist by aerosol, as prescribed, if the patient experiences bronchospasm.
Use 10% and 20% acetylcysteine solutions undiluted, as prescribed. If further dilution is needed, use normal saline solution or sterile water for injection.
Avoid contamination of the solution, and refrigerate an opened vial. Discard opened vials after 96 hours.
Assess the patient’s respiratory status before and after each dose, particularly noting any breathing difficulty, unproductive cough, wheezing, or dyspnea. Follow acetylcysteine administration with chest physiotherapy and postural drainage, as prescribed, and encourage coughing and deep breathing to facilitate removal of respiratory secretions. Suction the patient as needed.
Have the patient gargle after administration to relieve the unpleasant odor and dryness; wash the patient’s face to eliminate stickiness caused by the drug.
Monitor the patient closely for signs of stomatitis, such as swollen, tender gums that bleed easily, papulovesicular ulcers in the mouth and throat, malaise, irritability, and fever.
XANTHINES
Xanthines, also called methylxanthines (theophylline [Theo-Dur] and derivatives), are adrenergics that dilate bronchial passages and reduce airway resistance, making it easier for the patient to breathe. They can be given orally or inhaled.
Xanthines decrease airway reactivity and relieve bronchospasm by relaxing bronchial smooth muscle. Theophylline relaxes smooth muscle in addition to decreasing inflammatory mediators (such as mast cells, T cells, and eosinophils), possibly through the inhibition of phosphodiesterase.
In nonreversible obstructive airway disease (chronic bronchitis, emphysema, and apnea), xanthines appear to increase the
sensitivity of the brain’s respiratory center to carbon dioxide and to stimulate the respiratory drive.
sensitivity of the brain’s respiratory center to carbon dioxide and to stimulate the respiratory drive.
In chronic bronchitis and emphysema, these drugs decrease fatigue of the diaphragm, the respiratory muscle that separates the abdomen from the thoracic cavity. They also improve ventricular function and, therefore, the heart’s pumping action.
Theophylline is used as a second- or third-line drug for the long-term control and prevention of symptoms related to:
asthma
chronic bronchitis
emphysema.
Theophylline levels need to be monitored to evaluate efficacy and avoid toxicity. Levels need to be assessed when a dose is started or changed and when drugs are added or removed from the patient’s regimen.
Especially high serum levels of theophylline may cause nausea, vomiting, diarrhea, and central nervous system effects, such as irritability, insomnia, anxiety, headache and, with very high levels, seizures. Adverse effects may also include abdominal cramping, epigastric pain, anorexia, and diarrhea.
Nursing considerations
Instruct the patient that smoking cigarettes or marijuana increases theophylline elimination, decreasing its serum level and effectiveness.
Advise the patient that taking adrenergic stimulants or drinking caffeinated beverages may result in additive adverse effects to theophylline or signs and symptoms of xanthine toxicity.
Instruct the patient about possible adverse effects, including cardiovascular effects, such as tachycardia and palpitations, and to notify the physician if they occur.
Monitor the patient’s theophylline level during treatment.
AGE AWAREWhen theophylline is given to a neonate, monitor serum theophylline and caffeine levels because theophylline metabolizes to caffeine in the neonate.
DELIVERY METHODS
AEROSOL TREATMENTS
Aerosol treatment can be delivered through handheld nebulizers or MDIs. These devices deliver topical medications to the respiratory tract, producing local and systemic effects. The mucosal lining of the respiratory tract absorbs the inhalant almost immediately.
Common inhalants are bronchodilators, used to improve airway patency and facilitate mucus drainage; mucolytics, to achieve a high local concentration to liquefy tenacious bronchial secretions; and corticosteroids, to decrease inflammation.
MDIs are handheld inhalers that use air under pressure to produce a mist containing medication. Drugs delivered in this form, such as bronchodilators and mucolytics, can travel deep into the lungs. MDIs are portable, compact, and relatively easy to use. (See Types of handheld inhalers.)
The pressurized MDI canisters contain a micronized powder form of medication. The drug is dissolved or suspended in one or more liquid propellants along with oily, viscous substances called surfactants, which are used to keep the drug suspended in the propellants. The surfactant also lubricates the valve mechanism of the MDI. Hand-breath coordination is needed to successfully deliver the aerosol during the patient’s inhalation.
Newer devices called flow-triggered MDIs eliminate the need for hand-breath coordination. They automatically trigger the medication in response to the patient’s inspiratory effort.
Inhalers with a special attachment called a spacer provide greater therapeutic benefits for children and patients with poor coordination. The spacer attachment, an extension to the inhaler’s mouthpiece, provides more dead-air space for mixing medication.
Turbo-inhalers deliver dry powder medication without the use of propellants and don’t require hand-breath coordination. Used to dispense terbutaline (Brethine) or budesonide (Pulmicort), the inhaler contains 200 doses of medication.
The patient holds the turbo-inhaler in the upright position and twists the lower ring to load the medication. He then exhales
and places his mouth over the dispenser and inhales the medication. The dispenser has a dose counter so that the patient knows when he has 20 doses remaining.
and places his mouth over the dispenser and inhales the medication. The dispenser has a dose counter so that the patient knows when he has 20 doses remaining.
TYPES OF HANDHELD INHALERS
Handheld inhalers use air under pressure to produce a mist containing tiny droplets of medication. Drugs delivered in this form (such as mucolytics and bronchodilators) can travel deep into the lungs.
Metered-dose inhaler | Inhaler with built-in spacer |
|
|
Turbo-inhaler | Diskus dry powder inhaler |
|
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Another device, such as the Advair or Serevent metered inhaler incorporates a disk that contains 60 sealed pockets on an aluminum foil strip within the disk. A lever that the patient activates advances the strip. As the drug pocket reaches the mouthpiece, the cover is peeled away and the medication is dispensed and ready for inhalation.
Patient preparation
Instruct the patient how to use the device, and encourage him to practice before actually using it to develop hand-breath coordination.
Inform the patient of possible adverse reactions to each drug.
Instruct the patient to rinse his mouth after drug administration to prevent stomatitis.
If the patient is using a steroid inhaler along with a bronchodilator, instruct him to use the bronchodilator first, wait 5 minutes, and then use the steroid inhaler.
Instruct the patient to exhale completely before using the inhaler. This increases his inspiratory effort, giving him better drug administration and distribution.
Monitoring and aftercare
Monitor the effectiveness of the medication.
Because proper drug dosage depends on the correct use of the equipment, assess the patient’s ability to perform the medication administration.
Assess the patient’s breath sounds before and after inhaler use.
NEBULIZER THERAPY
An established component of respiratory care, nebulizer therapy helps bronchial hygiene by restoring and maintaining the continuity of the mucosal lining; hydrating dried, retained secretions; promoting expectoration of secretions; humidifying inspired oxygen; and delivering medications. Treatment may be given through nebulizers that have a large or small volume, are ultrasonic, or are placed inside ventilator tubing.
Large-volume nebulizers are used to provide humidity for an artificial airway, such as a tracheostomy, and small-volume nebulizers are used to deliver medications such as bronchodilators. Ultrasonic nebulizers are electrically driven and use high-frequency vibrations to break up surface water into particles. The resultant dense mist can penetrate smaller airways and is useful for hydrating secretions and inducing a cough. In-line nebulizers are used to deliver medications to patients who are being mechanically ventilated. In this case, the nebulizer is placed in the inspiratory side of the ventilatory circuit as close to the endotracheal tube as possible. (See Comparing nebulizers, page 124.)
Patient preparation
Explain the procedure to the patient.
Take the patient’s vital signs and auscultate his lung fields to establish a baseline. If possible, place the patient in a sitting or high Fowler’s position to encourage full lung expansion and promote aerosol dispersion. Encourage the patient to take slow, even breaths during the treatment.
Before using an ultrasonic nebulizer, give an inhaled bronchodilator (MDI or small-volume nebulizer) to prevent bronchospasm.
Monitoring and aftercare
Check the patient frequently during the procedure to observe for adverse reactions. Watch for labored respirations because ultrasonic nebulizer therapy may hydrate retained secretions and obstruct airways. Monitor the patient’s vital signs and auscultate his lung fields for adventitious breath sounds and effectiveness of therapy.
Encourage the patient to cough and expectorate, or suction as needed.
Check the water level in a large-volume nebulizer at frequent intervals and refill or replace as indicated. When refilling a reusable container, discard the old water to prevent infection from bacterial or fungal growth, and refill the container to the indicator line with sterile distilled water.
Change the nebulizer unit and tubing according to your facility’s policy to prevent bacterial contamination.
If the nebulizer is heated, tell the patient to report warmth, discomfort, or hot tubing because these may indicate a heater malfunction.
Be especially careful when using ultrasonic nebulization in children. Monitor the child’s weight and note any changes. (See Nebulizer therapy in children.)
Nebulized particles can irritate the mucosa in some patients and result in bronchospasm and dyspnea. Other complications include airway burns (when heating elements are used), infection from contaminated equipment (although rare), and adverse reactions from medications.
COMPARING NEBULIZERS
NEBULIZER | CHARACTERISTICS |
|---|---|
ULTRASONIC | Uses high-frequency sound waves to create an aerosol mist Advantages
Disadvantages
|
LARGE VOLUME (VENTURI JET)
| Works by passing air through a Venturi opening, drawing liquid up through feeding tubes, and nebulizing the solution Advantages
Disadvantages
|
SMALL VOLUME (MINI-NEBULIZER, MAXI-MIST)
| Handheld device that disperses a moisturizing agent into microscopic droplets and delivers it to the lungs with inhalation Advantages
Disadvantages
|
NEBULIZER THERAPY IN CHILDREN
When using high-output nebulizers, such as an ultrasonic nebulizer, on pediatric patients or patients with a delicate fluid balance, be alert for signs of overhydration (exhibited by unexplained weight gain occurring over several days after the beginning of therapy), pulmonary edema, crackles, and electrolyte imbalance.
Young children may be frightened by the mask used to deliver the medication and may become fatigued from fighting. Because of this, they may appear worse after the medication has been dispensed. Allow the child time to calm down before assessing his breath sounds after the treatment.
INHALATION THERAPY
Inhalation therapy uses carefully controlled ventilation techniques to help the patient maintain optimal oxygenation in the event of respiratory failure. Techniques include continuous positive airway pressure (CPAP), endotracheal (ET) intubation, mechanical ventilation, and oxygen therapy.
Continuous positive airway pressure
As its name suggests, CPAP ventilation maintains positive pressure in the airways throughout the patient’s respiratory cycle. Originally delivered only with a ventilator, CPAP may now be delivered to intubated or nonintubated patients through an artificial
airway, a mask, or nasal prongs by means of a ventilator or a separate high-flow generating system. (See Using nasal CPAP.)
airway, a mask, or nasal prongs by means of a ventilator or a separate high-flow generating system. (See Using nasal CPAP.)
CPAP is available as a continuous-flow and as a demand system. In the continuous-flow system, an air-oxygen blend flows through a humidifier and a reservoir bag into a T-piece. In the demand system, a valve opens in response to the patient’s inspiratory flow.
In addition to treating acute respiratory distress syndrome (ARDS), CPAP has been used successfully in pulmonary edema, pulmonary embolism, bronchiolitis, fat embolism, pneumonitis, viral pneumonia, and postoperative atelectasis. In mild to moderate cases of these disorders, CPAP provides an alternative to intubation and mechanical ventilation. It increases the functional residual capacity by distending collapsed alveoli, which improves partial pressure of arterial oxygen and decreases intrapulmonary shunting and oxygen consumption. It reduces the work of breathing. CPAP can also be used to help wean a patient from mechanical ventilation.
Nasal CPAP has proved successful for the long-term treatment of obstructive sleep apnea. In this type of CPAP, high-flow compressed air is directed into a mask that covers only the patient’s nose. The pressure supplied through the mask serves as a back-pressure splint, preventing the unstable upper airway from collapsing during inspiration.
CPAP may cause gastric distress if the patient swallows air during the treatment (most common when CPAP is delivered without intubation). He may also feel claustrophobic because of the mask. Because mask CPAP can cause nausea and vomiting, it shouldn’t be used in an unresponsive patient or in a patient at risk for vomiting and aspiration. Rarely does CPAP cause barotrauma or lower cardiac output.
PATIENT PREPARATION
If the patient is intubated or has a tracheostomy, you can accomplish CPAP with a mechanical ventilator by adjusting the settings. Assess his vital signs, oxygen saturation, and breath sounds during CPAP.
If CPAP is delivered through a mask, a respiratory therapist usually sets up the system and fits the mask. The mask should be transparent and lightweight, with a soft, pliable seal. A tight seal isn’t required as long as pressure can be maintained. Measure arterial blood gas (ABG) analysis and bedside pulmonary function studies to establish a baseline.
MONITORING AND AFTERCARE
Check for decreased cardiac output, which may result from increased intrathoracic pressure associated with CPAP.
Watch closely for changes in respiratory rate, rhythm, and effort. Uncoordinated breathing patterns may indicate severe respiratory muscle fatigue that can’t be helped by CPAP. Report this to the physician; the patient may need mechanical ventilation.
Check the CPAP system for pressure fluctuations, which may affect oxygenation.
Keep in mind that high airway pressures increase the risk of pneumothorax; monitor the patient for chest pain and decreased breath sounds.
Use oximetry, if possible, to monitor oxygen saturation, especially when the CPAP mask is removed to provide routine care.
If the patient is stable, remove his mask briefly every 2 to 4 hours to provide mouth and skin care along with fluids. Don’t apply oils or lotions under the mask—they may react with the mask seal material. Increase the length of time the mask is off as the patient’s ability to maintain oxygenation without CPAP improves.
Check closely for air leaks around the mask near the eyes (an area difficult to seal); escaping air can dry the eyes, causing conjunctivitis or other problems.
If the patient is using a nasal CPAP device for sleep apnea, watch for decreased snoring and mouth breathing while he sleeps. If these symptoms don’t subside, notify the physician; either the system is leaking or the pressure is inadequate to provide relief.
Endotracheal intubation
ET intubation involves insertion of a tube into the lungs through the mouth or nose to establish a patent airway. It protects patients from aspiration by sealing off the trachea from the digestive tract and permits removal of tracheobronchial secretions in patients who can’t cough effectively. ET intubation also provides a route for mechanical ventilation.
Drawbacks of ET intubation are that it bypasses normal respiratory defenses against infection, reduces cough effectiveness, may be uncomfortable, and prevents verbal communication.
Potential complications of ET intubation include:
bronchospasm or laryngospasm
cardiac arrhythmias
hypoxemia (if attempts at intubation are prolonged or oxygen delivery is interrupted)
injury to the lips, mouth, pharynx, or vocal cords
tooth damage or loss
tracheal stenosis, erosion, and necrosis.
In orotracheal intubation, the tube is inserted through the mouth. This type of intubation is preferred in emergencies because it’s easier and faster. However, maintaining exact tube placement is more difficult because the tube must be well secured to avoid kinking and prevent bronchial obstruction or accidental
extubation. It’s also uncomfortable for conscious patients because it stimulates salivation, coughing, and retching. Orotracheal intubation is contraindicated in patients with orofacial injuries, acute cervical spinal injury, and degenerative spinal disorders.
extubation. It’s also uncomfortable for conscious patients because it stimulates salivation, coughing, and retching. Orotracheal intubation is contraindicated in patients with orofacial injuries, acute cervical spinal injury, and degenerative spinal disorders.
In nasal intubation, the tube is inserted through a nasal passage. Nasal intubation is preferred for elective insertion when the patient can breathe on his own for a short period. Nasal intubation is more comfortable than oral intubation and is typically used in a conscious patient who’s at risk for respiratory arrest or who has a cervical spinal injury. It’s contraindicated in a patient with a facial or basilar skull fracture.
Nasal intubation is more difficult to perform than oral intubation. Because the tube passes blindly through the nasal cavity, it causes more tissue damage, increases the risk of infection by nasal bacteria introduced into the trachea, and increases the risk of pressure necrosis of the nasal mucosa.
PATIENT PREPARATION
If possible, explain the procedure to the patient and his family.
Obtain the correct size ET tube. The typical size for an oral ET tube for women is 7.5 mm (indicates the size of the lumen) and 8 mm for men.
Give medication as ordered to decrease respiratory secretions, induce amnesia or analgesia, and help calm and relax the conscious patient. Remove dentures and bridgework, if present, to prevent aspiration.
MONITORING AND AFTERCARE
After securing the ET tube, reconfirm tube placement by noting bilateral breath sounds and end-tidal carbon dioxide (ETCO2) readings. (See Securing an ET tube, page 130.)
Auscultate breath sounds and watch for chest movement to ensure correct tube placement and full lung ventilation.
A chest X-ray may be ordered to confirm tube placement.
Disposable ETCO2 detectors are commonly used to confirm tube placement in emergency departments, postanesthesia care units, and critical care units that don’t use continuous ETCO2 monitoring. Follow the manufacturer’s instructions for proper use of the device. Don’t use the detector with a heated
humidifier or nebulizer because humidity, heat, and moisture can interfere with device function. (See Analyzing CO2 levels.)
Follow standard precautions, and suction through the ET tube as the patient’s condition indicates, to clear secretions and prevent mucus plugs from obstructing the tube.
After suctioning, hyperoxygenate the patient being maintained on a ventilator with the handheld resuscitation bag.
If available, use a closed tracheal suctioning system, which permits the ventilated patient to remain on the ventilator during suctioning. (See Closed tracheal suctioning, pages 132 and 133.)
SECURING AN ET TUBE
Before securing an endotracheal (ET) tube, make sure that the patient’s face is clean, dry, and free from beard stubble. If possible, suction his mouth and dry the ET tube just before taping. Check the reference mark on the tube to ensure correct placement. After securing, always check for bilateral breath sounds to ensure that the ET tube hasn’t been displaced by manipulation. To secure the tube, use one of the methods described here.
Method 1
Cut one piece of 1″ cloth adhesive tape long enough to wrap around the patient’s head and overlap in front, and then cut an 8″ (20.3-cm) piece of tape and center it on the longer piece, sticky sides together.
Cut a 5″ (12.7-cm) slit in each end of the longer tape (as shown).
Apply benzoin tincture to the patient’s cheeks, under his nose, and under the lower lip. (Don’t spray benzoin directly on the patient’s face; the vapors can be irritating if inhaled and can harm the eyes.)
Place the top half of one end of the tape under the patient’s nose and wrap the lower half around the ET tube. Place the lower half of the other end of the tape along his lower lip and wrap the top half around the tube.
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Method 2
ET tube holders are available that can help secure an ET tube.
Made of hard plastic or of softer material, the tube holder secures the ET tube in place. The tube holder is available in adult and pediatric sizes. Some models come with bite blocks attached.
Place the strap around the patient’s neck and secure it around the tube with Velcro fasteners (as shown).
Because each model is different, check the manufacturer’s guidelines for correct placement and care.
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ANALYZING CO2 LEVELS
Depending on the end-tidal carbon dioxide (ETCO2) detector you use, the meaning of color changes within the detector dome may differ from the analysis for the Easy Cap detector described here.
The rim of the Easy Cap is divided into sections A, B, and C. Their control colors range from purple (in section A), signifying the absence of carbon dioxide (CO2), to beige, tan and, finally, yellow (in section C). The numbers in the sections range from 0.03 to 5 and indicate the percentage of exhaled CO2.
The color in the center rectangle reflects the patient’s CO2
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