Week 5

Question 1

Restrictive Respiratory Disorders Overview

Answer 1

Pleural effusions and pneumothoraces are restrictive respiratory disorders that impair chest wall and diaphragm movement. Understanding the anatomy of the thoracic cavity and breathing physiology is crucial for caring for these disorders. Principles include chest movement, lungs pressure changes, and pleural space and linings.

Question 2

Pleural Effusion definition

Answer 2

A pleural effusion is the abnormal collection of fluid in the pleural space. The pleural space normally contains 5-15ml of fluid (pleural fluid) that acts as a lubricant between the chest wall (parietal pleura) and the lung (visceral pleura). Pleural effusion itself is not a disease, but a result of other disease processes.

Question 3

Pleural Effusion PATHOPHYSIOLOGY

Answer 3

To break this down a little more, the build up of fluid is a result of a combination of factors:
* increased capillary pressure (hydrostatic pressure in blood vessels)
* decreased oncotic pressure (pressure that proteins exert within tissue and vessels)
* increased pleural membrane permeability
* obstruction of lymphatic flow (remember that pleural fluid is constantly produced and drained away via the lymphatic system).

Question 4

Pleural Effusion- CLINICAL MANIFESTATIONS

Answer 4

Common signs and symptoms of pleural effusion are:
* dyspnoea
* cough
* sharp, non-radiating chest pain, worse on inspiration
* on examination there will be decreased movement of the chest on the affected side, dullness to percussion and diminished breath sounds over the affected area.
* If the effusion is empyema, there will also be fever, night sweats and possibly weight loss
A chest X-ray and/or CT will inform the size and location of the effusion.

Question 5

Pleural Effusion- NURSING ASSESSMENT

Answer 5

The assessment of patients with restrictive respiratory conditions will be the same as for all patients presenting with a respiratory condition. This can be completed as part of an admission, start of shift and/or as clinically indicated and include:
* Health history assessment including both subjective and objective data
* Primary assessment
* Secondary assessment - remember to include a detailed pain assessment here.
* Focused assessment

Question 6

Pleural Effusion- TREATMENT

Answer 6

Not all pleural effusions are drained and therefore an important consideration in your nursing care of patients who have a pleural effusion is to maximise their breathing capability. This includes:
* sitting up in high fowlers position or sitting out of bed if possible
* allowing a patient to tripod if needed
* allowing for breaks/rest between activities that require physical exertion as patient’s may tire quickly
* respiratory hygiene - deep breathing and coughing
* oxygenation when indicated

Question 7

Thoracentesis

Answer 7

aspiration of intrapleural fluid for diagnostic or therapeutic purposes. This can be done on the ward by a senior physician, or in the radiology department under the guidance of ultrasound imaging. A large bore needle is inserted into the pleural space, a syringe is attached and fluid is drawn out. This may only be sufficient for pathological examination, or they may draw off as much of the fluid as they are able to.

Question 8

Nursing Management post thoracentesis

Answer 8

Post procedure you will be required to undertake the following:
* monitoring of vital signs as per facility guidelines - This may be 15 minutely for the first hour, and then as guided by the facility and the patient’s condition. This will include:- BP, HR, RR, O2Sats, Temperature, pain, conscious state.
* visual inspection of patient’s respiratory effort for any signs of respiratory distress.
* visual inspection of the thoracentesis site or drain tube:-
- site - looking for any excess drainage - colour and volume
- draintube - volume and colour of drainage, emptying of drainage bag/collection chamber and documentation on either fluid balance chart (FBC)
* Encourage deep breathing and coughing post procedure as long as pain is managed.

Question 9

Pneumothorax
DEFINITION

Answer 9

when there is an accumulation of air or gas entering the pleural cavity. This can be from either a rupture in the visceral pleura or the parietal pleura and chest wall.

Question 10

Pneumothorax
PATHOPHYSIOLOGY

Answer 10

A pneumothorax will be suspected when a patient encounters trauma to the chest wall. Depending on the type of trauma the pneumothorax can be classified as “closed” when air does not enter through an external wound or “open” when air enters the lungs through an external wound.
The most significant and potentially life threatening complication of a pneumothorax is when it progresses to a tension pneumothorax.
If there is trauma/injury to the thoracic cavity from an assault, penetrating chest injury or blunt trauma, then bleeding from ruptured blood vessels will result in a haemothorax.

Question 11

Non-Traumatic- Spontaneous injury DEFINITION/CAUSE

Answer 11

These occur due to the rupture of small blebs (air-filled blisters) located on the apex a person’s lung. These blebs can occur in healthy, young individuals (tall, thin males) or as a result of lung disease such as COPD, asthma, cystic fibrosis and pneumonia). As there is no external trauma to the chest wall, this is classed as a ‘closed’ pneumothorax.

Question 12

Non-Traumatic- Spontaneous injury EMERGENCY/IMMEDIATE MANAGEMENT

Answer 12

These can quickly become a tension pneumothorax requiring emergency management.
This requires the insertion of a chest drain of some sort.

Question 13

Non-Traumatic- Iatrogenic injury DEFINITION/CAUSE

Answer 13

These can occur due to laceration or puncture of the lung during medical procedures. Some of these procedures include transthoracic needle aspiration, subclavian catheter insertion, pleural biopsy and transbronchial lung biopsy.
They can also occur due to excessive ventilatory pressure during mechanical ventilation.

Question 14

Non-Traumatic- Iatrogenic injury EMERGENCY/IMMEDIATE MANAGEMENT

Answer 14

Depending on the size of the pneumothorax, the cause and whether air is able to escape or not, will depend on the management. This may require insertion of a chest tube or needle aspiration may be sufficient.

Question 15

Traumatic

Penetrating chest wounds:
- Stabbing
- Gun shot
DEFINITION/CAUSE

Answer 15

Air enters the pleural space through the chest wall.
This may be a sucking chest wound where air gets pulled into the pleural space through the chest wall during each inspiration and may be seen as bubbles.

Question 16

Traumatic

Penetrating chest wounds:
- Stabbing
- Gun shot
EMERGENCY/IMMEDIATE MANAGEMENT

Answer 16

As these are open wounds, air is normally able to escape. However, a sucking chest wound will need to have a semi-occlusive dressing placed over the wound immediately with three sides covered and one left open to allow air to escape but preventing air from entering the pleural space. This will remain in place until the injury can be repaired and a chest drain inserted. Most patients with a traumatic pneumothorax will also have blood in their pleural cavity so will have a haemopneumothorax.

Question 17

Traumatic- Blunt trauma
DEFINITION/CAUSE

Answer 17

Fractured ribs resulting from blunt trauma can lacerate the lungs and cause air to enter the pleural space from inside. If a number of ribs are broken in more than one place, then the section can become flail resulting in opposite movement of the section of the rib cage with breathing.
If the air is able to escape at the same rate as it enters, it is a ‘simple’ pneumothorax. If the air is unable to escape (closed pneumothorax) then it will quickly become a tension pneumothorax.

Question 18

Traumatic- Blunt trauma
EMERGENCY/IMMEDIATE MANAGEMENT

Answer 18

Due to the opposite movement of the flail segment to the rest of the chest wall, air entry will be compromised and the patient will normally have severe pain on breathing. Management consists of pain control and often splinting of the chest wall to minimise this movement. If the pneumothorax is significant, a chest drain may be required

Question 19

Tension
DEFINITION/CAUSE

Answer 19

Tension pneumothoraxes result from air entering the pleural space and not being able to exit either back via the lungs or into the atmosphere through the chest wall. This results in the lung on the affected collapsing and the remainder of the chest cavity being compressed to the unaffected side due to the increase in pressure. This is known as a mediastinal shift, compromising oxygenation, reducing venous return and cardiac output.
This is a medical emergency.

Question 20

Tension
EMERGENCY/IMMEDIATE MANAGEMENT

Answer 20

This is a medical emergency. If the pressure continues to increase the resulting mediastinal shift will result in an inability to expand the lungs at all as well as cardiac standstill due to there being no room for the chambers of the heart to expand (and fill) for required contraction.
This will require decompression via either initial needle aspiration/insertion, insertion small bore tube with attachment to a Heimlich Valve (one way flutter valve to prevent air re-entering the chest cavity).

Question 21

Haemothorax
DEFINITION/CAUSE

Answer 21

An accumulation of blood in the pleural space due to an injury to the chest wall, diaphragm, lung, blood vessels or mediastinum. When it occurs with a pneumothorax, it is called a haemopneumothorax.

Question 22

Haemothorax
EMERGENCY/IMMEDIATE MANAGEMENT

Answer 22

Management of a haemothorax requires the insertion of a drain tube to drain the blood whilst preventing air entering the pleural cavity. This requires the drain tube to be attached to an underwater sealed drainage (UWSD) system to prevent air going back up the tube

Question 23

Chylothorax
DEFINITION/CAUSE

Answer 23

This occurs when lymphatic fluid collects in the pleural space due to an abnormal circulation of lymphatic fluid. This may result from surgery, trauma or lung cancer.

Question 24

Chylothorax
EMERGENCY/IMMEDIATE MANAGEMENT

Answer 24

Management of a chylothorax is dependent on the underlying cause. Whilst this could be multifactorial, for patients with large fluid collections this will require the insertion of a chest drain.

Question 25

Pneumothorax DIAGNOSIS

Answer 25

Diagnosis of a pneumo- or haemothorax is based on presentation, clinical manifestations and patient assessment. Definitive diagnosis occurs with a chest x-ray.

Question 26

Pneumothorax- CLINICAL MANIFESTATIONS

Answer 26

The size of a pneumothorax (or haemothorax) may vary depending on the severity of injury. The severity of the symptoms therefore depends on the size of the pneumothorax. Signs and symptoms of a pneumo- (haemo-) thorax include: * Dyspnoea * Tachypnoea * Tachycardia * Chest pain * Hypoxia * Reduced or absent breath sounds over the affected area on auscultation * Tension pneumothorax results in severe hypoxaemia, marked tachycardia, neck vein distension, cyanosis, profuse sweating (diaphoretic), tracheal deviation (mediastinal shift) and hypotension (reduced cardiac output).

Question 27

Pneumothorax- NURSING ASSESSMENT

Answer 27

The assessment of patients with restrictive respiratory conditions (pneumothorax, pleural effusion) will be the same as for all patients presenting with a respiratory condition. This can be completed as part of an admission, start of shift and/or as clinically indicated and include: * Health history assessment including both subjective and objective data * Primary assessment * Secondary assessment - remember to include a detailed pain assessment here * Focused assessment - it is important here to also include an assessment of the position of the trachea both visually and via palpation.

Question 28

Pneumothorax- TREATMENT

Answer 28

As with the clinical manifestations, the treatment of a pneumothorax depends on its severity and the underlying cause. If the patient is stable and there is minimal air and fluid in the intrapleural space, there may be no treatment required and the pneumothorax may resolve spontaneously.

Question 29

HEIMLICH VALVE

Answer 29

these valves maintain the negative pressure of the pleural space by allowing air to escape but not to re-enter on inspiration. These may be used for patients with a simple, spontaneous pneumothorax

Question 30

UWSD SINGLE COLLECTION SYSTEM

Answer 30

this is a chamber system which incorporates the air seal, suction attachment and collection chambers all in one. There are a number of different versions of these.

Question 31

THREE BOTTLE SYSTEM

Answer 31

whilst these are not common any longer, you may still see them in some healthcare facilities. These systems utilise three collection bottles when using suction.

Question 32

Set-up and insertion- ICC

Answer 32

Whilst it is not our role to insert the ICC or to obtain consent, this is the doctor's responsibility. We can ensure the patient is aware of the procedure and what is going to happen. As a nurse, we may be required to support the doctor with the insertion of the ICC either on the ward or in a critical care setting. * Ensure patient is aware of the procedure * Consider pain relief * Gather equipment as per facility procedure and doctor's requirements * Prepare the UWSD system - this may require the addition of sterile water (often provided in the packaging) to create the seal as per equipment being used * Position and support the patient to minimise movement * Monitor the patient's condition including oxygen saturations, respiratory rate and haemodynamic status.

Question 33

Patient Assessment/Clinical Status- ICC

Answer 33

When a patient has an ICC with UWSD we often focus first on the drainage system and what is happening with it, however, our focus should always be on the patient themselves. Remember: * Primary/start of shift assessment - DRSABCDE * Emergency bedside equipment check - in this case, apart from equipment identified in Module one you will find that most health services will require two, surgical tubing clamps if a patient has an ICC

Question 34

Drainage System- ICC

Answer 34

* Keep all tubing loosely coiled below chest level. * Tubing should have no dependent loops. Dependent loops prevent drainage of fluid into the collection chamber increasing the backward pressure in the tubing and impacting effective drainage of both fluid and air from the pleural space. Keep the tubing above the level of the insertion point on the UWSD system. * Ensure tubing is not compressed against bedside rails, mattress or other equipment at the bedside. Compressed tubing prevents air and fluid escaping resulting in increasing positive pressure in the pleural space potentially resulting in re-collapse of the lung and possibly tension pneumothorax. * Connections between the ICC and UWSD system should be checed to ensure they are tight and taping is secure. It is important that any tape used does not obscure the entire diameter of the tube so contents can still be visualised. How this is done will differ between health facilities and sugeons/physicians, but an example is: * Tubing will normally be secured to the patient's chest to prevent pulling at the insertion site. Again, this may be different between health facilites but an example may be: Note how the tape is transparent. * The collection chamber must always be in the upright position to maintain the water seal. Air can re-enter the pleural space if the water seal is not maintained. * The collection chamber must always be kept below the level of the patient's chest to prevent fluid and air flowing back into the pleural space, so do not pass the drain over the patient to get it from one side of the bed to the other when you reposition your patient. * Care should be taken when a patient is getting out of bed or moving around the bed so that they do not accidentally pull on the tubing.

Question 35

AIRWAY OBSTRUCTION

Answer 35

Upper airway obstructions affect the trachea, larynx, pharynx (naso- and oro-) and can result from inflammation, trauma, loss of muscle tone or growths whether benign or malignant. Whilst partial obstruction will affect the work of breathing, complete obstruction is a medical emergency as the person will not be able to breath at all.

Question 36

Nose and Sinuses

Answer 36

Hayfever or the common cold can cause inflammation of the nose and sinuses, which may not cause complete airway obstruction. However, significant inflammation of the oropharynx, epiglottis, larynx, and trachea can cause obstruction, causing oedema, redness, and pain. This can become a medical emergency.

Question 37

Pharynx

Answer 37

Pharyngitis, a sore throat symptom, can be viral or bacterial, causing symptoms like scratching throat, severe pain, fever, and cervical lymph adenopathy. It can also cause peritonsillar abscess, which can lead to airway obstruction. Management involves infection control, symptom relief, and prevention of secondary infections.

Question 38

Epiglottis

Answer 38

Epiglottitis is a viral infection that causes inflammation and swelling of the fibrocartilage lid over the larynx during swallowing. This can occur in adults and children, causing symptoms like high fever, sore throat, difficulty breathing, and irritability. Intubation is necessary to maintain a patent airway, and a tracheostomy may be necessary.

Question 39

Larynx

Answer 39

Laryngitis is an inflammation of the larynx, causing hoarseness, difficulty speaking, sore throat, fever, and cough. It usually doesn't require hospitalization. However, severe laryngeal oedema can be a medical emergency, potentially leading to airway occlusion and respirator arrest post-surgery.

Question 40

UPPER AIRWAY TRAUMA

Answer 40

Maxillofacial trauma can result in life-threatening airway and haemorrhage problems leading to obstruction of the airway. This may be caused by: * burns (heat or chemical) that cause swelling to the epiglottis and mucous membranes around the larynx * gunshots, knife wounds or blunt trauma wound that collapse portions of the airway or cause continuous bleeding or vomiting that obstructs the airway. These injuries will be managed within the emergency department and theatre, however, you may care for them on the wards post treatment requiring you to monitor the person's airway carefully. If the injuries are likely to take a long time to heal and ongoing airway obstruction, they may require insertion of a tracheostomy tube.

Question 41

FOREIGN OBJECTS AND GROWTHS

Answer 41

Airway obstruction resulting from foreign bodies require emergency management. Once cleared, most of these patients will not require inpatient treatment. Upper airway malignancies are another source of airway obstruction and may result from a number of upper airway structures. It is beyond the scope of this module to delve into these. Nursing care of these patients will revolve around symptom management and airway protection as guided by the patient and medical staff.

Question 42

LOSS OF MUSCLE TONE

Answer 42

Loss of muscle tone within the upper airway will result in the inability to protect the airway and may be a result of loss of consciousness due to cardiac arrest, head trauma or other medical condition, or some neurological conditions including some high spinal cord injuries. When a patient is unable to protect their upper airway for a prolonged period of time, they will require intubation and/or mechanical ventilation

Question 43

Tracheostomy

Answer 43

A tracheostomy is a procedure where an artificial opening is established in the trachea, bypassing the patient's existing airway (nose and mouth). Tracheostomies may be temporary or permanent and are used to: * bypass an upper airway obstruction * facilitate removal of secretions for patients with a reduced ability to cough * permit long term mechanical ventilation or facilitate weaning from mehanical ventilation * protect the airway of patients with a reduced ability to swallow saliva

Question 44

Physical impact of a tracheostomy

Answer 44

The upper airway is lined with ciliated mucus membrane which warms, moistens and filters the air as it passes on inspiration. Bypassing this with a tracheostomy tube means that the air that is inspired is colder and drier than normal. Consider the impact of this on the lower airway. The larynx (voice box) is also bypassed with a tracheostomy tube, this means that the patient will not be able to speak. Consider the impact on communication. Not only is the patient's ability to speak affected, but their sense of smell and potentially taste are also impacted. Whilst the above are negative impacts of a tracheostomy, there is also a positive in that, bypassing the upper airway means that the work of breathing requires less effort as there is less airway resistance. If the tracheostomy is permanent, consider the impact of the change in body image that occurs.

Question 45

TO CUFF OR NOT TO CUFF?

Answer 45

Cuffed tubes seal the airway and cause the patient to breathe entirely through the tracheostomy tube when it is inflated. This means that no air can pass through the upper airway. (Remember the impact this has on communication) The cuff can be inflated with air or water, depending on manufacturer's instructions. Cuffed tubes are used for patients that: * require mechanical ventilation to ensure all of the air is delivered to the patient * are unable to protect their own airway or manage their secretions

Question 46

SECURING THE TUBE

Answer 46

Whilst the cuff maintains a secure seal for the tube, it will not ensure that it remains in place. Tracheostomy tubes are initially secured in place with sutures that may be removed after 7-10 days, however they are also kept stable with the use of tapes. Below are two different methods used for securing the tube, soft foam velcro tape on the left and tied cotton tape on the right.

Question 47

TRACHEOSTOMY COMPLICATIONS

Answer 47

Whilst a tracheostomy provides a secure airway for a patient, there are a number of complications that need to be monitored for. * Airway leak * Airway obstruction * Altered body image * Aspiration * Bleeding * Fistula formation - tracheo-oesophageal or tracheo-innominate artery * Impaired cough - inability to close epiglottis to generate force for a cough * Infection - wound or respiratory tract * Subcutaneous emphysema * Tracheal stenosis * Tracheal necrosis * Tube displacement

Question 48

tracheostomy Nursing Management

Answer 48

An important note here is that the patient with a tracheostomy, has no other options for an alternative airway. In a patient who is breathing normally through their upper airway, if a blockage occurs, then a tracheostomy can be formed to bypass the blockage. Patients with tracheostomies no longer have this option, so we must ensure that this airway remains patent at all times. It is important that we remember here, that in our start of shift or primary assessment, we start with A for airway. The tracheostomy is this patient's airway so must be included as part of your initial assessment for your patient.

Question 49

Correct PPE tracheostomy

Answer 49

Remember that whenever you are undertaking activities that relate to blood and body fluid exposure, you must protect yourself. This means: * use of goggles and potentially masks when suctioning or manipulating the tracheostomy tubes (changing of dressings, tape and cuff manipulation). This may stimulate the patient to cough, expectorating mucus through their stoma. * Gloves (clean or sterile depending on facility policy) * Apron - optional to protect clothing.

Question 50

Maintaining a Safe Environment tracheostomy

Answer 50

As tracheostomies are the patient's airway, not preparing safety equipment can be the difference between life and death - it is too late to realise an essential piece of equipment is missing during an emergency! Ensure all safety and equipment checks are completed prior to commencing your shift, also, ensure you are familiar with your organisations emergency tracheostomy kit equipment.

Question 50

HUMIDIFICATION

Answer 50

There are a number of different devices that can be used to humidify the oxygen delivered to a patient with a tracheostomy. Each health facility will have their own devices that you will need to become familiar with when you care for a patient with a tracheostomy. Devices can be electronic and are called 'Active heated humidifiers'. This is where the equipment heats water in a container to 37oC which increases the heat and water vapour content of the inspired gas.

Question 51

TRACHEOSTOMY STOMA CARE

Answer 51

The tracheostomy, whether surgically created or percutaneous, is considered an open wound and requires dressing accordingly. Adding to the complexity is the exposure the wound has to respiratory secretions. This can cause skin irritation and possibly a skin infection. Cleaning of the stoma must occur regularly with normal saline and kept dry. Whilst most of you will not be caring for a patient within 24 hours of tracheostomy creation, it is important that you are aware of the need to leave the dressing intact for 24 hours post creation to avoid movement or displacement of the tube. The priority during this period is the security of the tube. Whenever you are undertaking wound care, you should maintain asepsis and ensure that you are carefully inspecting the wound and surrounding skin for any signs of irritation or infection. TRAMS identifies the following points of inspection when assessing your patient's tracheostomy site and surrounding skin: * Tracheostomy tube midline with tapes secure * Monitor for any signs of new or excessive bleeding * Monitor skin for any signs of breakdown * Infection (purulent discharge, local pain, odour, abscess formation, cellulitis or discolouration) * Increase in stoma size * Appearance of stoma edges * Hypergranulation (increased granulation at wound surface) tissue formation * Allergic reaction to dressing products (erythema) * Any signs of pulsation * Any pressure related injuries

Question 52

restrictive respiratory disorders- Pharmacists

Answer 52

Patients with ICC and UWSD systems will require analgesia and those with pleural effusions may have underlying conditions requiring new or ongoing medications. Pharmacists can provide advice and ongoing education for the patient.

Question 52

DECANNULATION

Answer 52

This is the planned removal of the tracheostomy tube by experienced nursing or medical staff. The decision to remove the tracheostomy tube is based on the patient's ability to maintain their own airway, clear their own secretions and able to breathe adequately without the assistance of a ventilator. It also requires input from a number of disciplines, depending on the original reason for insertion of the tube.

Question 53

restrictive respiratory disorders- Dieticians

Answer 53

Depending on the reason for an ICC and UWSD, the patient may present with nutritional problems. The dietician can provide dietary guidelines and advice for the patient, their family and carers.

Question 54

restrictive respiratory disorders- Social Workers

Answer 54

Depending on the patient's circumstances, the social worker can provide support for any home assistance that may be required or support groups that the patient can connect with.

Question 55

restrictive respiratory disorders- Physiotherapists

Answer 55

Physiotherapists play a vital role in pulmonary hygiene for a patient with an ICC and UWSD. Breathing exercises and splinting techniques are important to prevent an overlying chest infection which could lead to pneumonia.

Question 56

restrictive respiratory disorders- Occupational Therapists

Answer 56

* Depending on the patient's circumstances and their underlying physical condition, home supports may be required on discharge such as rails and shower chairs etc. * They are also able to provide equipment to support communication if the patient has a tracheostomy such as communication boards etc.

Question 57

restrictive respiratory disorders- Speech Pathologist

Answer 57

Patients with a tracheostomy, depending on the reason for their insertion, may need assessment and support from a Speech Pathologist in relation to swallowing difficulties and communication support.

Question 58

restrictive respiratory disorders- Respiratory Physician/Specialist

Answer 58

Whilst in hospital the patient will be under the care of a respiratory physician or surgeon depending on the reason for their ICC. They will guide care, and for some patients, they will continue to monitor their progress post discharge.

Question 59

restrictive respiratory disorders- GP

Answer 59

An individual's GP will monitor ongoing progress post discharge including any further investigations.