Respiratory Package (Addenbrooke's)

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Addenbrooke's Hospital

Physiotherapy Department

Respiratory care package

Summer 2000

1



Respiratory physiotherapy check list for new staff

!bser"e• Paediatrics PICU

• NCCU and wards

• General ICU, PCU

• General medical chests

#ndications and contraindications• Suctioning - nasal

- oral airway

• Bagging

• Vibrations, shaing and !ercussion

•Saline

$heory behind• "y!es o# $entilation

• %i##erences between adults and children

• Positioning

• I&C&P&, C&P&P& le$els with neuro !atients

• Normal le$els

• 'umidi#ication

• (luid balance le$els

• )* "hera!y

• Nebuli+ers

• "racheostomies

*



Assessment of a respiratory patient

%rom patient&s notes

• 'PC history !resent condition . current !roblems

• P/' !ast medical history . res!iratory disease, CV, %/, CV0, oint !roblems

• 2("3s lung #unction tests . P4(5, (4V, (VC&

• 'b

• 0BGs baseline and acute

• %rug 'istory

Charts6 Note the trend

• "em!erature

• (luid balance

• BP

•/edication

• P4(5

• )* !rescri!tion

• Pea #low

Social history6

• 2e$el o# su!!ort

• 'ousehold duties

• Stairs

• Smoing history

• )ccu!ation and hobbies

Sub(ecti"e assessmentPre"ious physiotherapy

• ty!e o# treatment

• immediate and long term e##ects

)eneral

• S)B - V0S, Borg, #unctional scale,

- dressing, taling, waling 7etc&

• (atigue, weaness, chest tightness, !ain, nausea&• 0n8iety, de!ression, stress

• 'ome 9 wor en$ironment

• (amily su!!ort

• Present and !re$ious smoing history

• 4ase in clearing s!utum

• :uestions eg6 a!!etite, e8ercise habits, slee!, 0%2, smoing, consti!ation,

management o# drugs and o8ygen, trans!ort, de!ression, an8iety, !anic attacs&

;



!bser"ation

• Breathing rate, breathing !attern

• General a!!earance

• Con#usion . cause<

• Posture, gait, =uality o# mo$ement

• Colour

• 'ands

• 0nles

• Chest sha!e

*ough

• "y!e . baring9whee+y

• %ry 9 Producti$e

• "iming6 early morning9nocturnal

•

(re=uency

Sputum

• Colour

• Consistency

• :uantity

Purulent - thic, green9yellow - <in#ection

+ucopurulent - thic, sticy, green9yellow - <in#ection

(oul smelling > green ? Pseudomonas

%rothy - white, !in, green . !ulmonary oedema

Haemoptysis bright red #ran P&4&, "&B&, Ca lung

!in . mi8ed with s!utum Bronchiectasis

rusty brown . old blood Pneumonia, "rauma

+ucoid . sticy, creamy9grey . chronic bronchitis

$enacious mucoid - thic !lugs . asthma

*hest pain

• /usculoseletal

• Pleural

• "racheal in#lammation

!b(ecti"e assessment)eneral

• 2e$el o# consciousness

• Initial obser$ations . S)B, )*, distress

• 0!!aratus - )* <humidi#ied

- %ri!s

- %rains

• Posture . thin9obese

• (acial e8!ression

• Sin condition

@



*olour

• Pin9cyanosis

• Central cyanosis . tongue > mouth

• 'y!o8aemia where there is an increase in the amount o# 'b not bound to )*&

• Peri!heral cyanosis . toes, #ingers and earlobes&

Hands

• (ind tremor . high dose bronchodilators

• Aarm and sweaty with irregular #la!!ing tremor . acute C) * retention

• Nicotine staining

• Clubbing

Peripheral oedema

• Cardiac #ailure

• 2ow albumon le$el

• Im!aired $enous or lym!hatic #unction

• 'igh dose steroids

!bser"ation of chest*hest shape

• y!hosis

• 'y!hoscoliosis

• Pectus e8ca$atum tunnel chest

• Pectus carinatum !igeon chest - se$ere asthma

•

'y!erin#lation - se$ere em!hysema

,reathing pattern

• Normal6

• regular 1D-*D breaths !er minute

• ins!iration acti$e - e8!iration !assi$e

• ratio o# 161&E - 16*

• )bstructi$e lung disease - !rolonged e8!iration

• ratio o# 16; - 16@

• Pursed li! breathing - se$ere airways disease

• 0!noea - F1E seconds

• 'y!oa!noea

• Cheyne-stoe res!iration - irregular breathing consisting o# a #ew dee! breaths,

!rolonged shallow breaths and a!noea then slowly increasing dee! breaths -

se$ere neurological damage or drugs narcotics&

*hest mo"ements

• Symmetrical

•

0cti$e e8!iration - contraction o# abdominal and internal intercostal muscles&

E



• Intercostal indrawing - sin between ribs is drawn inwards during ins!iration ?

!atients with se$ere ins!iratory air#low resistance seen less in adults&

Palpation

• "rachea - de$iation

• Chest e8!ansion - com!are le#t with right& Poor 9 #air 9 good&

• Parado8ical breathing - eg6 #lail chest loose segment drawn inwards as chest wall

mo$es out

• Surgical em!hysema - air in subcutaneous tissues o# chest, nec and #ace&

- !neumomediastinum tracs outwards&

Auscultation,reath sounds

• Normal - generated by turbulent air#low in trachea and large airways

• Bronchial breath sounds - normal tracheal and large airway sounds transmitted

throughout airless lung consolidated lung& 2oud, high !itched with harsh =uality&

• %iminished sounds - reduced #low due to muscle weaness or !ain - which

decreases the amount o# dee! breathing&

• 2ocally decreased breath sounds - obstruction o# bronchus - s!utum !lugs or

tumour&

Added sounds

• Ahee+e - air#low $ibrating in a narrow or com!ressed airway, eg6 bronchos!asm,

mucosal oedema, s!utum, #oreign bodies&

• Cracles - o!ening o# !re$iously closed al$eoli and small airways during

ins!iration& 4arly 9 late, #ine 9 coarse, localised 9 wides!read&• Pleural rub - !leural sur#aces are roughened by in#lammation, in#ection or

neo!lasm&

$ests

• P4(5 Pea 48!iratory (low 5ate and techni=ue

• 0BGs

• C5

• Cough - e##ecti$e 9 ine##ecti$e, !roducti$e 9 non-!roducti$e&

• 48ercise tolerance

H minute distance or * minute stair climb6 standardised instructions, eg6 walas #ast as you reasonably can, at the end you should #eel as i# you couldn3t

ha$e gone any #urther3

record6 distance, sym!toms, Sa )*, time taen #or rest&

• Shuttle test6

48ternally moti$ated, one !ractice wal needed&

H



Suctioning

#ndications• 5etained secretions in !atients whose ability to cough is diminished es!ecially i#

secretions are causing distress and9or im!airment o# res!iratory #unction&

• "o clear secretions #rom intubated !atients or those with trachieostomies&

• "o obtain a s!utum s!ecimen es!ecially in babies and in#ants

Specifications

Catheter Si+e 1D Blac NP suction

Si+e 1* Ahite "racheal suction

Si+e 1@ Green "hic secretions

"he diameter o# catheter selected #or an intubated !atient should not e8ceed hal# the

internal diameter o# the 4""&

Pressure JD-1DDmm'g 9 1D-1@ Pa

%uration o# !rocedure 1E-;D seconds

Saline #or instillation *-Emls

Saline is not !o!ular due to research showing !roblems with in#ection ICU are

discouraging its use&

+ode of entry

-aso.pharyn/

0im6 "o stimulate cough re#le8&

"ry to !osition !atient in side lying or with head turned to side to a$oidas!iration should $omiting occur&

48tend nec

2ubricate catheter with K elly

Use si+e 1D or 1* catheter

J



!ro.pharyn/

0im6 "o stimulate cough re#le8

"o clear secretions #rom u!!er airways

2ess !re#erred method o# entry but may be necessary at times&

Ahen using this method, the insertion o# an airway may be needed to !re$ent

the !atient biting on the catheter&

1uipmentPre!are be#ore starting6

• Suction machine or wall

• Catheters correct si+e

• Sterile glo$es

• 2ubricating gel i# re=uired

• Saline

• Aater to #lush tube

• S!utum tra! i# s!ecimen is re=uired

• Goggles i# re=uired

+ethod

1& Pre-o8ygenate !atient as necessary*& Using sterile techni=ue, remo$e catheter #rom !acet and lubricate i# necessary&

;& Insert catheter $ia !re#erred Lmode o# entryM with no suction a!!lied& Proceed

until cough re#le8 is stimulated or resistance is #elt&

@& Aithdraw catheter slightly, a!!ly suction $ia control !ort while continuing to

remo$e catheter&

E& %is!ose o# used catheter and glo$es&

H& %) N)" reinsert same catheter or LtromboneM catheter in and out&

*ontraindications

• NP suction should be a$oided in !atients with stridor because o# the danger o#

total airway obstruction&

• CS( lea such as a#ter #rontal sull #ractures contraindicates NP suction because

o# in#ection ris to the CS(&

• (or !atients who ha$e clotting disorders or are recei$ing he!arin, suction should

be a$oided or !er#ormed with care to a$oid bleeding&

• I# a !atient has !ulmonary oedema, suction does not hel! the condition and will

remo$e sur#actant i# !er#ormed re!eatedly&

• Suction aggra$ates bronchos!asm but so does s!utum&

• (ollowing recent a !neumonectomy or b oeso!hagectomy the catheter should

not be taen beyond the !haryn8 in case it a im!inges on the bronchial stum! or

b misses the trachea and damages the oeso!hageal anastamosis&



!/ygen therapy

)8ygen is re=uired to allow e##icient release o# energy within cells& 0ll cells re=uire a

su!!ly o# o8ygen in order to allow energy to be released #rom glucose NB rebs

cycle&

)8ygen is an e8!ensi$e, odourless, colourless gas&

)8ygen is a drug and must there#ore B4 P54SC5IB4%&

ses• Presence o# hy!o8aemia . Pa)* less than HD mm'g 9 Pa

• Sa)* less than EO

• Pre9Post suction as suction can decrease Pa)*

• Post-o!erati$ely

• 'el!#ul in breathlessness but not an indication #or

Dangers• Patient de!endency&

• )8ygen to8icity . can cause an in#lammatory res!onse in the lungs, im!act action

o# cilia, sur#actant and macro!hages&

• (ire 'a+ard&

• Can decrease the res!iratory dri$e in !atients who rely on low Pa) * as a

$entilatory stimulus&

• Cause absor!tion atelectasis . increase in o8ygen can dis!lace nitrogen, which

acts to s!lint airways o!en and there#ore causes colla!se&

• %rying Gas . can cause damage to mucosa and cilia, eye irritations and general

discom#ort&

Deli"ery De"ices

3ow flow masks

• 2ow #low mass deli$er a #low rate less than the !atient3s own #low rate $ia a

su!!ly o# o8ygen and a mas with two holes to dilute the o8ygen&

• Normally E-1D l9min #low rate !ro$ides ;E-JDO o8ygen, but the concentration isine8act& Suitable #ollowing /I or uncom!licated surgery&



High flow masks

• 'igh #low mass deli$er a #low rate abo$e @Dl9min, inde!endent through

breathing rate and !attern&

• 0n accurate !ercentage o# o8ygen is deli$ered through $enturi mass, which

assumes the $enturi !rinci!le, in which a !redictable amount o# room air is sucedin through side holes by an e8act #low rate that is s!eci#ied on the mas colour

coded&

• 'umidi#ication is recommended when on high #low o8ygen to maintain moisture

in the airways&

• Used #or !atients who need accurate and controlled o8ygen thera!y such as

breathless !atients, !atients needing high concentration o# o8ygen, !atients

de!ending on hy!o8ic dri$e&

3arge capacity masks 4 reser"oir bags

• "hese can deli$er a !ercentage o# o8ygen u! to DO but is less accurate than high

#low mass ie6 acute res!iratory #ailure&

-asal cannulae

• Nasal cannulae deli$er a #low rate o# 1-@ l9min a!!ro8 *@-;EO o8ygen, but

$aries de!ending on the !atients minute $olume&

• Nasal cannulae are chea!er, com#ortable and as accurate as low #low mass&

• "hey are ideal in long term o8ygen thera!y so that !atients can tal, eat and cough

easily and #or con#used !atients&

• Nasal cannulae are used dry because the narrow tubing would cause condensation

o# moisture, and at low #low rates the !atient3s nose !ro$ides ade=uate

humidi#ication&

$ents 4 Headbo/es

• "hese allow deli$ery o# humidi#ied o8ygen, o#ten used with babies& 0n accurate

o8imeter is re=uired in the headbo8 as o8ygen can lea #rom the sides&

1D



+odes of "entilation

*+5 6 *ontinuous +andatory 5entilation7 also known as 5* 6 5olume

*ontrolled and #PP5 6 #ntermittent Positi"e Pressure 5entilation

"he !atient has no s!ontaneous breathing at all&

Pressure *ontrolled 5entilation

(ull $entilation usually used in children with uncu##ed tubes&

VC and sigh . e$ery 1DDth breath deli$ered at double tidal $olume to !re$ent

atelectasis& Ne$er used in the clinical situation&

S#+5 6 Synchronised #ntermittent +andatory 5entilation

Used #or weaning& Ventilator breaths are set and the !atient can breath in between&

"here#ore i# the number o# breaths recorded ? *D and SI/V dial set at 1D the !atient

is achie$ing 1D breaths 9 minute& 0lso timed with !atients breathing to coincide with

ins!iration&

PS 6 Pressure Support7 also known as #PP, 6 #ntermittent Positi"e Pressure

,reathing

"he !atient controls by initiating breaths to a !re-set !ressure& "he !atient regulates

the rate and tidal $olume&

S#+5 and PS

0 combination o# the two abo$e&

*PAP 6 *ontinuous Positi"e Airway Pressure

"he !atient is sel# $entilating but with a !ositi$e !ressure to maintain o!en al$eoli toachie$e better gas e8change&

PP 6 Positi"e nd /piratory Pressure

/easured in cms o# '*)& 0s CP0P e8ce!t !atient is on $entilator&

,#PAP 6 ,iphasic Positi"e Airway Pressure

/aintaining two le$els o# CP0P eg Ecms and 1Dcms& 0lternate breaths will ha$e

alternate le$els o# P44P& 0llows !atients to breath at all !hases o# the $entilatory

cycle&

++5 6 +andatory +inute 5olume"he !atient maintains own minute $olume but will be assisted by $entilator i# he does

not reach the target&

H%85 6 High %re1uency 8et 5entilation

Small !ulses o# air are LshuntedM down the 4" tube at a rate o# between 1ED-;DD

breaths !er minute&

11



+anual Hyperinflation

Aims

"o e8!and areas o# lung not in#lated during the ins!iratory cycle o# the

$entilator hel!ing to !re$ent atelactasis and aid the remo$al o# secretions&

I# used ina!!ro!riately, it can cause maor !roblems& "here#ore use with

caution on critically ill !atients and use only when there are $alid indications&

#ndications

• 5ein#lation o# atelectasis

• 5emo$al o# secretions

• "o stimulate cough

• "o im!ro$e lung $olume

• "o im!ro$e o8ygen saturation

• "o im!ro$e lung com!liance

Ad"erse effects of manual hyperinflation

• (all in cardiac out!ut and !)* due to an increase in intrathoracic !ressure causing

a decrease in $enous return, resulting in a #all in blood !ressure and cardiac

out!ut& Aatch !atient monitors #or #alls in blood !ressure and 9 or slowing o# heart

rate&

• Barotrauma&

• Pneumothora8 may be caused by o$erin#lating the lungs o# !atients with chronic

lung disease or bullae&

*ontraindications

• Undrained !neumothora8

• Unstable cardio$ascular system

• 'igh !ea airway !ressures

• Se$ere bronchos!asm

• P44P F 1Dcm'*) 9 05%S

• 'aemo!tysis

• 0cute !ulmonary oedema

9ith caution

• 5aised ICP

1*



$echni1ue

Aide $ariety o# circuits . tae all into account and use what you are con#ident

with&

)8ygen deli$ery . 1Elitres9minute or 1DDO

%low ratesIns!iration . slow dee! ins!iration encourages aeration o# al$eoli and re-

e8!ansion o# segmental colla!se&

48!iration . #aster than ins!iration as high #low rate increases secretion

clearance =uic release techni=ue&

Pressures studies ha$e di##ering recommendations&

)$erall it is suggested that7

Pea airway !ressure F JD cm '*) - 'igh !robability o# barotrauma

F ED-JD cm '*) - /oderate !robability o# barotrauma

Q ED cm '*) - 2ow !robability o# barotrauma

1;



!n call procedure

#ntroduction

0n on-call emergency ser$ice is !ro$ided to all wards on the 0ddenbrooes site& It is

a$ailable 1H&;D-D&;D& "he switchboard holds the list o# on-call !hysiothera!ists&

Contracted sta## are e8!ected to !artici!ate in this ser$ice on a rota basis& 0 #orm is

circulated through the units allowing indi$idual selection o# on-call duties& Newly

=uali#ied sta## do not !artici!ate until they ha$e wored on either Surgical9Paediatric

or NeurosciencesR other new sta## !artici!ate only a#ter #ull orientation& "his !olicy is

now being re$iewed and newly =uali#ied sta## may need to obtain a le$el o#

com!etence !rior to on-call duties&

Prior to first call.out

2iaison with the rele$ant senior members o# sta## to arrange a $isit to the acute units

!rior to your on-call is ad$isable&

(or newly =uali#ied sta## and less e8!erienced sta## a senior res!iratory

!hysiothera!ist can be a!!ointed as your mentor who can be contacted by tele!hone

#or ad$ice& In#orming your mentor o# your on-call commitment is there#ore essential&

!rganisational arrangements

Contact number6 Please in#orm Switchboard o# any changes to your contact number

be#ore lea$ing the hos!ital&

Blee!6 Kou may borrow any blee! !ro$ided you tell switch which one you ha$e&

/obile tele!hone6 "here is a mobile tele!hone in oo!s o##ice that you can also

borrow - this needs to be signed in and out&

Car !aring6 (or !ersonal sa#ety !ar as close to the hos!ital entrances as !ossible&

"a8i6 I# you do not ha$e a car, a ta8i can be organised through Switchboard&

'os!ital tele!hone number6 D1**;-*@E1E1

In#orm Switch on arri$al and de!arture #rom the hos!ital&

Pre-arranged $isits may be re=uested $ia the ward !hysiothera!ist to ensure

continuation o# treatment&

1@



$he *all !ut

0 new re#erral should be made by a senior 'ouse )##icer or abo$e&

"he #ollowing in#ormation is re=uired6

1& Name, grade o# doctor and blee! number

*& Name and age o# the !atient

;& Aard o# !atient@& Patients diagnosis, this should include6

0& 'istory o# !resent condition -

• 5eason #or admission

• Current !roblems

• 'as the !atient deteriorated since he9she was last seen by the !hysiothera!ist

• Is the !atient re=uiring $entilatory su!!ort i&e& CP0P

• 5e=uiring o8ygen& I# so how much& < humidi#ied&

• Saturations

• 0rterial blood gases• ICP9CPP

• C5

• (luid balance

• /ental status

• 4##ecti$e cough - e8!ectorating9suction

• Nebulisers

• /edication

• Position in bed

B& 5ele$ant !ast medical history

0#ter assessment 9 treatment the date, time and #indings will be documented in the

!atients records& "he doctor who re=uested the call out must be contacted to #eedbac

e##ecti$eness o# treatment and any change in the !atients condition&

*onditions suitable for call out

"he ser$ice is a$ailable only to !atients where chest condition is liely to deteriorate

i# le#t to the morning, and !atients who re=uire the silled assistance to e8!ectorate

secretions& Patients who only re=uire suction or who need only to be ased to coughare not within the criteria #or an emergency call out&

"he #ollowing situations are not suitable #or emergency call out6

1& /obilising 9 setting u! continuous !assi$e mo$ement machines&

*& Pro$iding waling aids&

;& )rganising on-going care, e&g& as an out-!atient&

1E



*ompletion of on.call forms

(ollowing on-call or weeend wor it is the res!onsibility o# the indi$idual member

o# sta## to com!lete6

1& )n-call #orm*& "ra$el e8!ense #orm

;& )n-call diary

N&B& 0ll wor com!leted in a single calendar month to be #illed in on one #orm&

%ollowing on.call

Please in#orm the rele$ant !hysiothera!ist o# any treatment and change in the !atients

condition #irst thing the ne8t morning&

1H

Respiratory Package (Addenbrooke's)

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