Download Respiratory Therapy - Arkansas Health Care Association

 Respiratory Therapy for the
LTC Nurse
Presented by: Jessica Fitzgerald-Denney RRT
Office: 866-280-2122
1) Oxygen Administration and Safety
 Pulmonary System/Medical conditions requiring oxygen
therapy/Assessment
 Delivery devices and oxygen interfaces
 Safe use and handling of oxygen equipment
 Infection Control
How a healthy person processes Oxygen:
When we inhale our respiratory system takes oxygen in through the nose,
warming as it moves down the trachea (windpipe), through the bronchial tree
to the alveoli. This is where the gas exchange takes place and O2 diffuses into
the capillaries, to then be carried by pulmonary circulation via the blood to the
tissues. CO2 builds up in the tissues because of metabolism and diffuses into
the capillary blood before being carried to the lung for exchange with alveolar
gases.
How O2 is delivered to the Cells of the body:
1. The lungs must be able to adequately ventilate in order to take in enough
oxygen.
2. There must be enough Hb to carry oxygen from the lungs to the cells.
3. The heart must have adequate cardiac output.
4. The cells of the body must be able to extract oxygen from the blood stream.
1 The information given is for education purposes only and is not intended to replace current policies or procedure(s) already in place. Training is provided by: Z & D Medical Services 1(866)‐280‐2122 Who requires O2 therapy?
1. Diffusion defects: Thickness of the alveolar wall, area available for gas
exchange and the partial pressure difference between the alveoli and the
capillaries. E.g. Lung fibrosis, pulmonary edema.
2. Ventilation perfusion mismatch: Deadspace: Alveoli are ventilated but
not perfused. E.g. PE.
Intrapulmonary shunt: Alveoli are perfused but not ventilated. E.g.
Atelectasis/ Consolidation
3. Decreased Cardiac Output.
4. Patients with sleep disorders such as sleep apnea may require O2.
Problems preventing the tissues from receiving adequate O2:
Respiratory
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COPD, Emphysema, Bronchitis, Asthma, Pulmonary edema, Pneumonia,
Pneumothorax, Lung CA, Rib fracture, Excessive sedation
Cardiovascular
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Congestive Heart Failure, dehydration, Myocardial infarction,
Arrhythmias, Pulmonary Embolus
Hemoglobin
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Decreased Hb reduces the ability to carry O2 from the lungs to the cells.
E.g. Anemia
Assessment for O2:
SPO2 less than 92% for non COPD patients; SpO2 less than 88% for COPD
patients.
Signs/Symptoms of hypoxemia: Tachypnea, Dyspnea(SOB), Tachycardia, use
of accessory muscles, restlessness, cyanosis
Check: Vital signs (heart rate, pulse ox, blood pressure), lung sounds, ABG’s,
CBC, H&H
Supplemental O2:
O2 therapy is the administration of oxygen at a concentration greater than that
in normal air, with the intent of treating or preventing the systems and
manifestations of hypoxia. A range of tubing, connectors, and masks are
available for the resident. Oxygen can be delivered via a tank, cylinder, or
concentrator.
2 The information given is for education purposes only and is not intended to replace current policies or procedure(s) already in place. Training is provided by: Z & D Medical Services 1(866)‐280‐2122 Room air =21% oxygen or FiO2 (fraction of inspired oxygen)
FiO2 varies with oxygen flow rate, patient’s peak inspiratory flow, and pts
minute ventilation (respiratory rate & tidal volume).
O2 benefits: decrease WOB, decrease hyperventilation, decrease tachycardia,
decrease work of heart
O2 Delivery Devices
Nasal Cannula
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Provides 1-6 lpm
Delivers a variable FiO2 between 24%-44% due to the patient’s
respiratory pattern.
3% x LPM + .21% = FiO2 (if using concentrator)
4% x Lpm + .21% = FiO2 (if using and E tank or piped in O2 where there
is 100% O2 @ 50 psi.
Use Humidity when >4 lpm
LPM = FiO2
1
2
3
4
5
lpm
lpm
lpm
lpm
lpm
=
=
=
=
=
24%
27-28%
30-32%
33-36%
36- 40%
Oxygen Mask
1. Simple Mask
Delivers 35%- 60% FiO2 @ flow rates of 6-10 lpm (If using a concentrator, you
need to use 6-10 lpm due to output pressure.)
REMEMBER never run a simple mask less than 6 LPM
2. OxyMask
Delivers 24%-90% FiO2, reduces the likelihood of CO2 rebreathing
1 lpm = 24%-27%
7 lpm = 48%- 80%
2 lpm = 27%-32%
10 lpm = 53%- 85%
3 lpm = 30%- 60%
12 lpm = 57%- 89%
4 lpm = 33%- 65%
>15 lpm = 60%- 90%
5 lpm = 36%- 69%
3 The information given is for education purposes only and is not intended to replace current policies or procedure(s) already in place. Training is provided by: Z & D Medical Services 1(866)‐280‐2122 3. Venturi Mask
Delivers 24%-50% via color connectors, run at LPM printed on each connector.
DO NOT USE WITH BUBBLE HUMIDIFIER FROM THE CONCENTRATOR.
4. Non-Rebreather Mask
Delivers 80-100% FiO2 @ 12-15 LPM
Device includes mask with openings and reservoir bag.
A minimum O2 flow of 12-15 lpm should be used to insure reservoir bag does
not deflate when inhaling; this also insures patient does not rebreathe CO2.
What about COPD patients?
COPD or Emphysema patient’s alveoli become ineffective in exchanging oxygen
for carbon dioxide. Supplemental O2 therapy helps meet the resident’s need for
O2.
How to Manage CO2 retainers:
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Treat Hypoxemia First!
CONTROLLED O2 Therapy: Aim for SpO2 88-92%
Don’t just leave your patients once O2 is increased; chart the change in
O2 and try and figure out what is causing the problem.
4 The information given is for education purposes only and is not intended to replace current policies or procedure(s) already in place. Training is provided by: Z & D Medical Services 1(866)‐280‐2122 Types of O2 delivery systems
Compressed Gas, Liquid Oxygen, Oxygen Concentrators
1. Compressed Gas (Cylinder):
Oxygen gas can be compressed and stored in tanks or cylinders of steel or
aluminum. These tanks come in many sizes and are refilled when empty.
Safety:
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Cylinders must be secured in a cart or stand at all times
Keep cylinders away from extreme heat or open flames
Close valves when not in use
Use no oil
Do NOT lay cylinders on the floor
Do NOT leave oxygen tanks in the room
O2 Regulators
Step 1
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Remove tape or plastic cover from stem of the cylinder. Under this should
be a plastic washer. Replace the old washer on regulator with new
washer from tank.
Step 2
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Place the regulator over the tank stem, lining up the pins on the
regulator with matching holes on stem. Next hand-tighten the T-handle.
Step 3
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Using the wrench, slowly and carefully turn the valve on the top of the
cylinder stem counter clockwise until you see the contents gauge register
pressure. Full tanks should be around 2000 psi. Caution: If the tank
hisses loudly, turn the valve off, and repeat steps 1 & 2.
Step 4
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Connect the oxygen tubing and device to the oxygen outlet on regulator.
Step 5
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Set the O2 to the prescribed flow of O2 using the control knob.
5 The information given is for education purposes only and is not intended to replace current policies or procedure(s) already in place. Training is provided by: Z & D Medical Services 1(866)‐280‐2122 2. Liquid Oxygen:
When oxygen is cooled, it changes to a liquid form. People who are more active
often use liquid O2 because larger amounts can be stored in a smaller
container.
Liquid O2 units equipped with:
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A liquid level indicator gauge.
A humidifier bottle or oxygen tubing adaptor if you do not use humidity.
Flow rate selector.
Condensation bottle, on stationary liquid O2 tanks.
3. Oxygen Concentrators:
An O2 concentrator is an electric device. It produces oxygen by concentrating
the O2 in the air and eliminating other gases. Cost effective, easier to maintain,
and no refilling required. In case of power failure back up methods should be
established. Device does have an audible alarm which will sound in the event
of a malfunction or power failure.
All units available are equipped with:
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A rocker or push button switch that turns the unit on and off.
Flow meter: Controls the O2 LPM
Alarms
Humidifier/ Tubing Adaptor
To Operate:
1. Plug the Concentrator into a suitable outlet.
2. Fill the humidifier bottle to indicated level with distilled water.
3. Attach bottle to the concentrator and attach tubing to the O2 adaptor
(Christmas tree).
4. Turn the unit ON. Set the Flow meter to prescribed flow rate.
5. Place O2 device on patient and confirm patient comfort.
Safety:
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The power cord should be connected only to a properly grounded outlet.
Always turn your unit off when not in use.
Do not use extension cords.
Do not place liquids on top of the concentrator.
Make sure unit is 12 inches away from any wall/ curtain.
6 The information given is for education purposes only and is not intended to replace current policies or procedure(s) already in place. Training is provided by: Z & D Medical Services 1(866)‐280‐2122 O2 Safety Guidelines:
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Always stabilize the O2 tanks. Tanks are under excessive pressures and
should always be handled with caution.
Close the O2 tank tightly when not in use.
O2 can cause an explosion; always keep tanks away from flammable
source.
A sign is usually placed on or near the door to alert O2 is in use.
Check the water level in the humidifier bottle often. If it is near empty
replace; always date when changed.
If the patient complains of his/her nose drying out use water-soluble
lubricant like K-Y Jelly to help moisturize nasal passages.
DO NOT USE PETROLEUM-BASED PRODUCTS
If irritation occurs from O2 device (behind the ears/side of face) place
skin protector on tubing.
If O2 supply is getting low (portable tanks 500 psi), exchange the tank.
Maintain the oxygen flow at prescribed rate. If flow isn’t felt check tubing
for kinks, blockages, or disconnection. Then make sure system is
plugged in and on. If you’re still unsure you can submerge nasal cannula
in water, with prongs pointing down. If bubbles appear, oxygen is
flowing.
DO NOT SMOKE or allow smoke near the O2 equipment.
Keep O2 concentrators away from curtains, walls and furniture to allow
air circulation.
Infection Control
1.
Wipe gauges, concentrator or liquid system with facility approved
disinfectant. Clean any filters with warm water and let dry before
placing back into machine.
2.
Nasal cannulas should be replaced by facility policy or once a week
if no policy stated.
3.
Humidifier bottles should be emptied every 2-3 days and water
replaced with fresh distilled water. Bottles and non-disposable
tubing should be soaked x 20 minutes in soapy water or 1 part
vinegar to 3 parts water solution every 1-2 weeks. Rinse all parts
and let dry.
7 The information given is for education purposes only and is not intended to replace current policies or procedure(s) already in place. Training is provided by: Z & D Medical Services 1(866)‐280‐2122 2) CPAP/ Bi-Level Therapy
 Theory of Operation
 Modes and Features
 Maintenance / Cleaning
 Types of Mask
 Troubleshooting
1.
Theory of Operation
Sleep disorder breathing is a medical term used for a sleeping disorder with
apneas and hypopneas. Apnea is the cessation of breathing lasting longer than
10 seconds. Hypopnea is a decrease in airflow by 50% or more for 10 seconds
or longer. Most apneas and hypopneas result from a full or partial obstruction
in the upper airway, but may also be a result of the bodies’ automatic drive to
breath (neuromuscular disease: E.g. ALS).

OSA (Obstructive Sleep Apnea)
OSA is a common sleeping disorder that is a result of upper airway
obstructions that cause snoring (partial obstruction) and apnea (full
obstruction). These obstructions occur during sleep because the upper
airway lacks muscle tone and the force of gravity. As muscles relax and due
to gravity, the tongue and soft palate fall to the back of the mouth and block
the upper airway, causing obstruction. Excess tissue and abnormalities of
the upper airway intensify these problems. Usually, the body will continue
to attempt to breath. However, during these apnea episodes the inability to
breath causes the brain to awaken the individual and in turn take a
sufficient breath. Many people are unaware of these interruptions during
sleep. Therefore, prevent them from getting effective sleep resulting in sleep
deprivation.
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Treatment with CPAP/ Bi-Level
CPAP: Continuous Positive Airway Pressure
The most common / effective non-surgical treatment for OSA/ snoring is
CPAP. CPAP machines deliver a steady, continuous stream of pressurized
air to the patient’s airways to prevent them from collapsing and causing
apnea events. A mask is fit to the patient; a large variety are available for
patient comfort. After a sleep study, the physician will determine the
optimal pressure settings for the CPAP.
8 The information given is for education purposes only and is not intended to replace current policies or procedure(s) already in place. Training is provided by: Z & D Medical Services 1(866)‐280‐2122 Bi-PAP: Bi-Level Positive Airway Pressure (VPAP, NIV, BPAP)
Bi-Level is another form of non-invasive ventilation used to treat OSA
and along with other disease processes that obstruct or restrict the lungs
and airways. Similar to the CPAP, a Bi-PAP machine also delivers
pressurized air through a mask to the patient’s airways. The air pressure
keeps the throat muscles from collapsing and reducing obstructions by
acting as a splint. Both CPAP and Bi-PAP machines allow patients to
breathe easily and regularly throughout the night.
What Makes a Bi-PAP different from CPAP?
Whereas a CPAP delivers a single continuous pressure, Bi-PAP combines
two pressures that are delivered during inhalation and exhalation. This
allows you to breathe out against a slightly lower pressure. The two phases
are independent from each other, which results in lower average airway
pressures than those produced by CPAP. The two pressures are referred to
as IPAP and EPAP, and the difference between the two is pressure support.
IPAP (inspiratory positive airway pressure) is a high level of pressure,
applied during inhalation. EPAP (Expiratory positive airway pressure) is a
low level of pressure exerted during exhalation.
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Pros of CPAP/ Bi-Level
i) Improves or resolves daytime sleepiness
ii) Heart function and hypertension improve
iii) Quality of life improves
iv) Therapy improves OSA and some central apneas
Cons of CPAP/ Bi-Level
i) Many residents find the mask uncomfortable or claustrophobic
ii) Since CPAP and BiPAP are not a cure and must be used every night
for life, non-compliance is a problem
iii) The sound of the machine may be disruptive to the resident or
roommate
Side effects relating to forced air delivery include:
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Difficulty exhaling
Sensation of suffocation
Inability to sleep
Nasal Congestion
Sore eyes
Sore or dry throat
Headaches
Abdominal bloating
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Chest muscle discomfort
caused by increased lung
volume
Mask related issues, such
as rash, skin breakdown
and conjunctivitis
9 The information given is for education purposes only and is not intended to replace current policies or procedure(s) already in place. Training is provided by: Z & D Medical Services 1(866)‐280‐2122 2.
Modes and Features
There are many different styles of CPAP and Bi-Level units. All machines
function on the same basic principle and have the same basic parts:
1.
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ON/OFF Button
Air inlet with filter
Air outlet that connects to the patient circuit
Patient circuit that includes tubing, headgear, and
mask(interface)
Optional Features include but not limited to:
1. Heated Humidifier
2. Ramp or Delay that starts your CPAP pressure at a lower setting and
automatically increases to prescribed pressure over a set time.
Settings
The prescribed settings will come from a sleep study. The user will first
get diagnosed with OSA. Then the patient will go through a sleep study and
sleep with an Auto-Titrating CPAP (Not all patients using CPAP/Bi-Level
machines have a sleep study). At this point it is determined of what pressure
eliminates or nearly eliminates the shallow breathing (hypopnea) and/or
apnea. Once the sleep disorder breathing patterns have been resolved or
greatly improved, the doctor can determine from the download what CPAP
pressure was used by the 95th percentile reading.
CPAP Modes
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CPAP- Delivers one constant level of pressure throughout breathing cycle.
Auto CPAP- Delivers your ideal pressure, on a breath by breath basis; machine
will adjust to meet specific needs of the patient.
Both CPAP and Auto CPAP offer comfort features depending on machine model:
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C-Flex:
Provides pressure relief upon exhalation to improve comfort based on patient
needs.
A-Flex/ C-Flex+:
Provides pressure relief taking place at the end of inhalation and at the start of
exhalation to improve comfort.
Delay/ Ramp:
This feature reduces the air pressure to a lower level for a set amount of time,
usually 20-30 minutes, and gradually increases (ramps) the pressure until the
prescribed pressure is reached.
10 The information given is for education purposes only and is not intended to replace current policies or procedure(s) already in place. Training is provided by: Z & D Medical Services 1(866)‐280‐2122 Example of Orders
CPAP Orders:
Auto CPAP Orders:
CPAP @ 10 cmH2O
Auto CPAP @ 6/14
CPAP @ 12 cmH2O w/ O2 @ 2lpm
(Minimum pressure is 6 and maximum
pressure is 14. Machine will auto adjust as
needed.)
Bi-Level Modes
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Bi-Level- Spontaneous breathing mode, provides an IPAP & EPAP
Example of order: Bi-PAP 12/5 (IPAP 12, EPAP 5)
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Auto Bi-PAP- Delivers spontaneous Bi-Level therapy while automatically
adjusting IPAP & EPAP levels to meet the patient’s needs.
Example of order:
Auto BiPAP IPAP Max 18/Min 12,
EPAP Max 8/Min 4
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Bi-PAP AVAPS- Average Volume Assured Pressure Support (AVAPS) Delivers a
consistent tidal volume through a unique algorithm which evaluates the
patient’s tidal volume over several breaths and then calculates the amount of
pressure needed to reach the ideal tidal volume. The machine then gradually
raises or lowers the IPAP pressure to achieve the proper pressure support.
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Bi-Level S/T- Machines are designed to initiate a breath which ensures patient
is receiving the minimum breaths per minute.
Example of Order:
Bi-PAP 12/5 rate 12 bpm
Bi-Level also offers comfort features depending on machine and model:
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Bi-Flex:
Bi-level therapy with pressure relief upon exhalation to improve patient comfort.
Ramp/ Delay:
This feature reduces the air pressure to a lower level for a set amount of time,
usually 20-30 minutes, and gradually increases (ramps) the pressure until the
prescribed pressure is reached.
If oxygen is ordered it will be connected to CPAP or Bi-Level circuit using an
oxygen pressure line adaptor, oxygen tubing and gas source.
11 The information given is for education purposes only and is not intended to replace current policies or procedure(s) already in place. Training is provided by: Z & D Medical Services 1(866)‐280‐2122 Using the Heated Humidifier:
The humidifier is an optional comfort feature on most CPAP/ Bi-Level
machines. This feature is used to reduce nasal dryness and/or warm the air
being delivered to patient. This is controlled by the user and is set to comfort.
Most devices settings range from 0-5, zero being no humidity five being the
warmest. When using a higher heat setting water may begin to pool in tubing
and in result spray user in the face, to eliminate this from happening decrease
heat setting. A good guide to follow is, in the summer place heater setting 1-3
and in the winter increase to 3-5. In the winter the heat from the building and
lack of humidity, due to colder temperatures, aid in drying the nasal passages;
therefore, the user requires an increase in heat setting. Whereas in summer
months there is more humidity in the air so the user doesn’t require as much.
 USE ONLY DISTILLED OR BOTTLED PURIFIED WATER IN CHAMBER.
NO TAP WATER. Fill only to fill line to prevent overflow into tubing.
 Always remove humidifier chamber before moving or transporting unit.
3.
Maintenance / Cleaning
Daily Cleaning/ Maintenance
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Wipe the portion of the mask that comes into contact with the skin with
damp cloth.
Check humidifier chamber water level, refill as necessary.
Weekly Cleaning
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Humidifier chamber should be soaked x 20 minutes in soap and water.
Unit should be wiped down with damp cloth as needed.
Tubing should be soaked x 20 minutes in soap and water and allowed to
air dry.
Headgear hand washed every 1-2 weeks, lay flat to dry.
Foam filters should be washed and allowed to air dry every 1-2 weeks.
Frequent Replacement items
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Tubing will be replaced once a month.
Mask and headgear every 60-90 days or as needed.
Filters as needed or every 6 months.
Humidifier chambers every month.
12 The information given is for education purposes only and is not intended to replace current policies or procedure(s) already in place. Training is provided by: Z & D Medical Services 1(866)‐280‐2122 4.
Types of Mask
A CPAP/ Bi-Level mask is the delivery system used to receive the pressurized air
generated by either machine. The mask should be comfortable and seal completely.
There are a wide variety of masks available in several different styles. A proper fitting
mask is the most important step in insuring patient compliance with CPAP/ Bi-Level
therapy.
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Nasal Mask: Fit over the nose
Nasal Pillows: Fit over each nostril
Full Face Mask: Fit over mouth and nose
Nasal and Full-Face Mask (FFM) Assembly
1. Arrange the headgear so the longer straps are at the top of the mask.
2. Loosely attach the straps to mask.
3. Place mask over nose (mouth and nose for full-face masks) and slide the
headgear over the head. Be sure to wipe or wash face before wearing.
4. Adjust straps until mask fits comfortably on patient.
5. DO NOT block exhalation port on mask. This port allows CO2 to be
flushed from circuit when patient exhales.
5.
Troubleshooting
1.
Mask is Leaking:
a) Adjust straps without over tightening
b) Check to be sure the seal on the mask is clean
c) Assure seal is seated in the frame correctly
2.
Discomfort from too much pressure
a) It will take time to adjust to CPAP/Bi-Level. Relax and breathe slowly.
b) Use RAMP comfort feature
c) Verify orders and compare to machine set pressures
3.
Dry Mouth/ Nose
a) Increase the humidity level until problem is corrected.
13 The information given is for education purposes only and is not intended to replace current policies or procedure(s) already in place. Training is provided by: Z & D Medical Services 1(866)‐280‐2122 3. Respiratory Assessment
Anatomy and Physiology
The respiratory system is made up of organs and tissues that help you to breathe. The
main parts of this system are the airways, lungs, linked blood vessels and the muscles
that enable breathing.
Airways (Respiratory Tracts)
The airways are pipes that carry oxygen-rich air to your lungs. They also carry
carbon dioxide (a waste gas) out of the lungs. The airways are divided into two distinct
parts:
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Upper Airway
 Mouth
 Nasal cavities
 Pharynx- Posterior portion of the nasal and oral cavities
Lower Airway (Tracheobronchial Tree)
 Larynx (Voice box)- contains the epiglottis and vocal cords
 Trachea (windpipe)
 Bronchus- Left and Right main stem bronchi that systematically branch,
narrow, shorten and increase in number toward the lung periphery and
are referred to as bronchioles
 Lungs- Right lung has 3 lobes (upper, middle, lower) and left lung has 2
lobes (upper, lower)
Air first enters your body through your nose or mouth, which humidifies and warms
the air. The air then travels through your larynx and down the trachea. The trachea
splits into two bronchial tubes that enter your lungs. The epiglottis covers the trachea
while swallowing, which prevents food and drink from entering the respiratory tract.
Except for the mouth and some parts of the nose, all airways have fine hairs called
cilia that are coated with sticky mucus. The cilia trap germs and other foreign
particles that enter the airway. The cilia sweep the particles up to the nose or mouth,
where they are then swallowed, coughed, or sneezed out of the body. Nasal hair and
mouth saliva also trap particles and germs.
Lungs, Heart and Blood Vessels
The lungs and linked blood vessels deliver oxygen to the body and remove carbon
dioxide. The lungs lie on either side of the sternum; they are divided into five main
sections called lobes, which consist of various segments. Within the lungs the bronchi
branch into thousands of smaller tubes called bronchioles, which end in tiny round
air sacs of alveoli. FUN FACT: In the average adult lung there are about 480 million
alveoli.
Each alveolus is covered in a mesh of tiny blood vessels called capillaries. The
capillaries connect to a network of arteries and veins that move blood through the
body.
14 The information given is for education purposes only and is not intended to replace current policies or procedure(s) already in place. Training is provided by: Z & D Medical Services 1(866)‐280‐2122 The pulmonary artery and its branches deliver blood rich in carbon dioxide (lacking in
O2) to the capillaries that surround the alveoli. Inside the alveoli, CO2 moves from the
blood into the air. At the same time, O2 moves from the air into the blood in the
capillaries. The oxyhemoglobin then travels to the heart through the pulmonary vein
and its branches. The heart then pumps the oxygen rich blood to the body.
Muscles Used for Breathing
Muscles near the lungs help expand and contract the lungs to allow breathing. These
muscles include:
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Diaphragm
Intercostal muscles
Abdominal muscles
Muscles in the neck and collarbone area
The diaphragm is a dome-shaped muscle located at the lung base, it separates the
chest cavity and abdominal cavity. The diaphragm and intercostal muscles are the
primary muscles used for ventilation. The accessory muscles (abdominal & muscles of
the neck and collarbone area) assist ventilation when ventilatory demand increases.
Respiratory Assessment (Visual, Physical)
Normal adult Respiratory Findings
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General Appearance: Appears relaxed.
Breathing Pattern:
a) Breathing is quiet and easy without apparent effort.
b) Breathing is quiet and passive.
c) May have the occasional sighing respirations.
d) Diaphragmatic-thoracic pattern is smooth and regular.
Respiratory Rate: 12-20 bpm
Skin:
a) Appears well oxygenated, no cyanosis present.
b) Palpation of the skin and chest wall reveals smooth skin and stable chest
wall.
Nail Beds and Nail Configurations:
a) Minimum angulation between base of nail bed and finger; no thickening
of distal finger width.
Chest Wall Configuration:
a) Symmetric, bilateral muscle development
Tracheal Position:
a) Midline and straight
b) Older adults may be slightly deviated if kyphosis is present.
Auscultation:
a) Quiet breathing heard throughout all lung fields
b) Older adults- lung elasticity is diminished resulting in decreased
pulmonary compliance and airway resistance increases.
15 The information given is for education purposes only and is not intended to replace current policies or procedure(s) already in place. Training is provided by: Z & D Medical Services 1(866)‐280‐2122 An assessment of the respiratory resident includes review of pertinent history,
diagnostic evaluations and routine monitoring of the respiratory system.
Knowledge of the resident’s current and past respiratory includes:
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Prior O2 usage
Any lab results and/or diagnostics (CXR, CT, MRI, PFT, ect.)
Steroid use
Current medication use
Dietary requirements
Smoking history
Any history of cancer
Risk factors for pulmonary embolism
Sputum production to include color, amount, and odor
Sleeping position, such as number of pillows, fan use, ect.
Physical exam includes:
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Observation of the resident’s chest for:
 Scars
 A-P diameter of the chest, should be smaller than the lateral diameter
 Sternum should be located midline anterior
REMEMBER: the chest tends to become barrel shaped with lung disease.
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Chest Movement:
 Inspiratory intercostal retractions occur in residents with COPD, asthma,
pulmonary fibrosis.
 Use of accessory muscles during respiration suggests respiratory
distress; seen in residents with COPD and asthma.
 Abdominal breathing is seen in residents with COPD. During exhalation,
the resident must retract abdominal muscles to force trapped air from
alveoli.
Sternal abnormalities- if severe, any of the following can inhibit respiration and
ventilation:
 Pigeon chest can be associated with rickets or emphysema.
 Barrel chest occurs with emphysema or asthma. A-P dimension of the
chest enlarges; ribs tend to be more horizontal than sloped; no bulges or
depression.
 Funnel chest seen in rickets. Softening of the ribs causes depression of
the lower sternum.
Spinal abnormalities
 Kyphosis- Also known as round or hunchback, is a condition in which
the spine in the upper back has an excessive curvature.
 Scoliosis- lateral deviation of the spine, which results in an ‘S-shaped’)
curve.
 Kyphoscoliosis- a combination of kyphosis and scoliosis
16 The information given is for education purposes only and is not intended to replace current policies or procedure(s) already in place. Training is provided by: Z & D Medical Services 1(866)‐280‐2122 Examination of extremities:
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Clubbing of the digits is a significant sign of cardiopulmonary disease. Clubbing
is a painless enlargement of the terminal phalanges of the fingers and toes that
develops over time.
Pedal Edema
Cyanosis
Capillary Refill
Overview of Breath Sounds & Auscultation of Chest
Breath sounds are assessed in an orderly fashion utilizing a stethoscope. Auscultate
the lungs beginning with the anterior apical area upper lobes progressing to lower
lobes. Compare one side with the other as you work your way down. Continue in the
same manner with the posteriorly.
 Vesicular
Normal vesicular breath sounds are soft and low pitched with a rustling quality
during inspiration and are even softer during expiration. These are the most
commonly auscultated breath sounds, normally heard over most lung surface.
 Bronchial
Bronchial breath sounds are hollow, tubular sounds that are lower pitched.
They can be auscultated over the trachea where they are considered normal.
There is a distinct pause heard in the sound between inspiration and
expiration.
They are considered abnormal if heard over the peripheral lung fields. Bronchial
breath sounds other than close to the trachea may indicated pneumonia,
atelectasis, pleural effusion.
 Bronchovesicular
Inspiration to expiration periods are equal. These are normal sounds in the
mid-chest area or in the posterior chest between the scapula. They reflect a
mixture of the pitch of the bronchial breath sounds heard near the trachea and
the alveoli with the vesicular sound.
These are abnormal in the lung periphery and may indicated an early infiltrate
or partial atelectasis.
 Rhonchi
Low pitched wheezes (rhonchi) are continuous, both inspiratory and expiratory,
low pitched adventitious lung sounds that are similar to wheezes. They often
have a snoring, gurgling, or rattle-like quality.
Rhonchi occur in the bronchi. RHONCHI USUALLY CLEAR AFTER COUGHING.
Intensity usually is higher over the large airways where bronchi exist.
 Crackles (rales)
Fine crackles are brief, discontinuous, popping lung sounds that are highpithed (compared to wood burning in a fireplace).
17 The information given is for education purposes only and is not intended to replace current policies or procedure(s) already in place. Training is provided by: Z & D Medical Services 1(866)‐280‐2122 Crackles (rales) can be heard in both phases of respiration. Early inspiratory
and expiratory crackles are the hallmark of chronic bronchitis. Late inspiratory
crackles may mean pneumonia, CHF, or atelectasis.
Course crackles are discontinuous, brief, popping lung sounds. Compared to
fine crackles they are louder, lower in pitch and last longer. They can be
described as a bubbling sound.
Chronic Bronchitis course crackles would be heard over most of the A-P chest
walls.
Early inspiratory crackles begin during the early part of inspiration. The pitch is
lower than late inspiratory crackles. A resident’s cough may decrease or clear
these lung sounds. Early inspiratory crackles are characteristic of COPD.
Chronic Bronchitis early inspiratory crackles are heard over all chest walls,
along with loud noisy mouth breathing.
Late inspiratory crackles begin in late inspiration and increase in intensity.
They are normally higher pitched and can vary in loudness. They are heard over
the posterior bases of the lungs. They may clear in changes in posture or
several deep breaths. They do not clear with coughing.
Late inspiratory fine crackles are sometimes associated with interstitial fibrosis,
pneumonia, CHF, or atelectasis. Also heard over the posterior lung bases.
 Wheezes
Wheezes are lung sounds that are continuous with a musical quality. Wheezes
can be high or low pitched. Wheezes are caused by narrowing of the airways.
In this case, expiratory wheezes are heard over most of the chest wall. This may
indicate airway obstruction. The higher the pitch, the longer the wheeze, the
greater the obstruction.
 Stridor
Stridor is caused by upper airway narrowing or obstruction. Severe stridor can
be heard without a stethoscope. Auscultation of the lungs on the chest wall will
be normal.
Stridor is a loud, high-pitched crowing breath sound heard during inspiration
but may also occur throughout respiration. Causes include: pertussis, croup,
epiglottitis, aspirations.
18 The information given is for education purposes only and is not intended to replace current policies or procedure(s) already in place. Training is provided by: Z & D Medical Services 1(866)‐280‐2122 Pulse Oximetry
Measuring the amount of O2 absorbed in the arterial blood will provide an
indication of the effectiveness of the resident’s breathing and/or O2 therapy. A
pulse oximeter is a two-sided probe which transmits a light through the finger,
toe, or earlobe. The wavelength of the light that emerges indicates the
percentage of oxyhemoglobin present in the capillaries.
Normal values of oxygen saturation are 95%-99%. COPD patient’s normal
could be as low as 88%.
Factors that may affect readings include, but are not limited to:
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Inappropriately placed probe
Motion artifact, such as tremors
Low perfusion
Skin pigmentation
Skin lotions
Nail polish
Artificial fingernails
Cold extremities
Poor circulation
19 The information given is for education purposes only and is not intended to replace current policies or procedure(s) already in place. Training is provided by: Z & D Medical Services 1(866)‐280‐2122 4. Nebulizers/ MDI’s/ Medications
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Indications
Proper Use and Maintenance
Goals of Therapy and Proper Assessment
Respiratory Medication Overview
Types of Aerosol Generators
Three common types are used for inhaled drug delivery:
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Small-volume Nebulizer: The SVN converts liquid drug solutions or
suspensions into aerosol, it is powered by compressed air, oxygen, a
compressor, or an electrically powered device.
Pressurized Metered-dose Inhaler: The MDI is a small, portable selfcontained drug device that dispenses multiple doses by metered value.
Dry-powdered Inhaler: The DPI is an aerosol device that delivers drug in
a powdered form, typically with a breath-actuated dosing system.
Indications for Breathing Treatments
Keep in mind a bronchodilator only treats a bronchospasm. Likewise,
rescue inhalers used properly with spacer are proven to be as effective in most
cases as a breathing treatment.
Indications include, but not limited to:
1.
2.
3.
4.
5.
Asthma
Bronchitis (acute or chronic)
Emphysema
Cystic Fibrosis
Bronchospasm secondary to other disease process such as CHF, pneumonia,
pulmonary fibrosis, RSV, lung cancer, sinusitis, bronchiectasis, ect.
6. Bronchospasm secondary to allergic reaction
Proper Use and Maintenance
Nebulizer
Nebulizers are used to turn liquid medication into a mist (aerosol) so that it can
be inhaled. Nebulizer therapy uses a prescription drug. The frequency or
volume of medication given should never be increased without an order from
the physician. Monitor before, during and after each treatment for heart rate,
breath sounds, respiratory rate, pulse oximetry and effectiveness of treatment.
Components of a Small Volume Nebulizer:
Medication cup, T-piece, mouthpiece or mask, and thin extension tubing.
20 The information given is for education purposes only and is not intended to replace current policies or procedure(s) already in place. Training is provided by: Z & D Medical Services 1(866)‐280‐2122 How to Use a Nebulizer:
1. Wash hands.
2. Measure the correct amount of medication and normal
saline as directed by physician. Medication may also
come in a premixed solution.
3. Place medication in the nebulizer medication cup, attach
lid.
4. Connect mask or T-piece (if using mouthpiece) to the lid.
5. Connect mouthpiece to T-piece.
6. Connect extension tubing to the bottom port of the
nebulizer cup and the other end of tubing to the
compressor.
7. Turn on the air compressor to start treatment.
Delivering the Treatment:
1) Position the resident in a comfortable, sitting position that will allow them to
take a deep breath.
2) Turn compressor to “ON”
3) Check to see if aerosol is being created. If not, re-check tubing attachment
points at the nebulizer and the compressor. If at this point aerosol is still
not being produced use another nebulizer cup.
4) Place mouthpiece between resident’s teeth and on top of tongue. If using
mask secure to face and have the resident inhale through mouth.
5) Instruct resident to breathe normally through mouth, periodically inhaling
deeply and holding for 3-5 seconds.
6) Monitor for side effects. If the resident experiences any of the following, stop
the treatment, rest for 5-10 minutes. If the sensation goes away, continue
the treatment. If physical problem persists, stop treatment and notify the
physician.
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Increase in pulse by 20 bpm
Palpitations (noticeable heart beat)
Dizziness
Uncontrolled Coughing
Shakiness
Nausea
Chest Pain
Facial redness
Hyperventilation
7) Continue treatment until medication is gone. Periodically tap side of the
nebulizer cup to cause any residual medication to go to the bottom of the
cup where they can be nebulized.
21 The information given is for education purposes only and is not intended to replace current policies or procedure(s) already in place. Training is provided by: Z & D Medical Services 1(866)‐280‐2122 After the Treatment
1. Turn the compressor off and unplug the machine.
2. If needed, have the resident cough several times to loosen and bring up
mucus.
22 The information given is for education purposes only and is not intended to replace current policies or procedure(s) already in place. Training is provided by: Z & D Medical Services 1(866)‐280‐2122 Common Problems & Solutions
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Medication is not generating an aerosol.
Probable Cause:
i) Neb cup is not properly assembled.
ii) Neb cup is not clean.
Solution:
i) Reassemble neb cup.
ii) Clean neb cup.
iii) Discard and use a new neb cup.
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Compressor does not turn on.
Probable Cause:
i) Unit is not plugged in.
ii) Electrical outlet is nonfunctioning.
Solution:
i) Plug in.
ii) Plug into an alternate outlet; notify maintenance.

Medication leaks out of nebulizer cup.
Probable Cause:
i) Nebulizer cup is cross threaded.
ii) Nebulizer cup is cracked.
Solution:
i) Unscrew cap from nebulizer and reassemble.
ii) Discard nebulizer and use a new setup.
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Compressor unit does not produce enough flow.
Probable Cause: Compressor filter dirty. Solution: Clean/ Replace Filter.
Cleaning Procedure
Cleansing and decontamination of respiratory equipment in the nursing home
is of major concern. To prevent equipment contamination, a simple but
effective cleaning procedure must be carried out on a routine basis.
AFTER EACH TREATMENT
1) Disassemble the nebulizer cup and empty.
23 The information given is for education purposes only and is not intended to replace current policies or procedure(s) already in place. Training is provided by: Z & D Medical Services 1(866)‐280‐2122 2)
3)
4)
5)
6)
Rinse each piece with warm water.
Shake off excess water.
Let air-dry on clean paper or cloth or towel. Cover to keep dust free.
Once dry, reassemble for next treatment.
Always store clean reassembled nebulizer in a clean/dry plastic bag.
TWICE A WEEK
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Soak the nebulizer pieces in warm soapy water for 20-30 minutes.
Replace nebulizer circuits per facility policy, or every 1-2 weeks.
Metered Dose Inhalers (MDI) & Dry-powdered Inhaler (DPI)
Metered Dose Inhalers (MDI)
A MDI delivers a specific amount of medication in aerosol form from a
pressurized canister in a plastic case with mouthpiece. It’s important to use a
MDI correctly in order to get the full dosage. A good technique can assist in
reducing the side effects of medication and increase in effectiveness when it
reaches the small airways. MDI’s are commonly used to treat asthma, COPD,
and other respiratory conditions.
Steps for Using a MDI:
1. Remove the cap from the MDI.
2. Hold the MDI with the mouthpiece at the bottom and shake to mix
medication properly.
3. Before first use and when MDI hasn’t been used for several days, prime
inhaler by pointing into the air and actuating.
4. Have patient seal lips tightly around the mouthpiece.
5. Instruct patient to breath out normally.
6. Instruct the patient to inhale with a deep breath for 3-5 seconds on the
count of 2.
7. Actuate the inhaler on the count of 2.
8. Instruct the patient to hold their breath for up to 10 seconds.
9. Resume normal breathing.
Dry Powder Inhaler (DPI)
A DPI is typically a breath-actuated dosing system. With a DPI, the patient
creates the aerosol by drawing air through a dose of finely milled drug powder
with sufficient force to disperse and suspend the powder in the air.
Steps for Use of a DPI:
24 The information given is for education purposes only and is not intended to replace current policies or procedure(s) already in place. Training is provided by: Z & D Medical Services 1(866)‐280‐2122 1.
2.
3.
4.
5.
6.
Assemble the inhaler.
Load dose, keeping device upright.
Exhale slowly BEFORE PLACING LIPS ON INHALER!
Seal lips around the mouth piece.
Inhale deeply and forcefully (>60L/min)
Repeat process until dose is complete.
Respiratory Medication Overview
The following medications are commonly used; the list is not all inclusive:
1. Albuterol - Bronchodilator (Rescue)
 Proventil – SVN: 0.5 ml of 0.5% in 2.5 ml saline TID or QID or
Ventolin – MDI: 2 puffs 90 mcg puff TID or QID
 Onset occurs in 15 minutes
 Peak occurs in 30 – 60 minutes
 Duration is for 5 – 8 hours
 Monitor blood pressure, pulse
 Contraindicated in residents with known heart disease
 Side effects include palpitations, anxiety, headache, dizziness and
sweating
 Medication safety includes no exposure to heat, light and air; store
in amber bottles
2. Levalbuterol - Bronchodilator
 Xopenex – SVN: 0.63 mg/3 ml TID; 1.25 mg/3 ml TID or
Xopenex – MDI: 2 puffs every 4 – 6 hours TID; 1 puff every 4 hours
 Onset occurs in 15 minutes
 Peak occurs in 30 – 60 minutes
 Duration is for 5 – 8 hours
 Monitor blood pressure, pulse
 Side effects include dizziness, tremor, nervousness, anxiety,
headache, cough, runny nose, nausea and leg cramps
 Medication safety includes foil pouches stored at room
temperature, no exposure to heat or light
3. Ipratropium Bromide - Bronchodilator
 Atrovent – SVN: 2.5 ml of 0.02% strength (500 mcg) TID or QID or
Atrovent – MDI: 2 puffs 18 mcg/puff QID
 Onset occurs in 15 minutes
 Peak occurs in 1 – 2 hour
 Duration is for 4 – 6 hours
 Monitor blood pressure, pulse; protect eyes from medication
25 The information given is for education purposes only and is not intended to replace current policies or procedure(s) already in place. Training is provided by: Z & D Medical Services 1(866)‐280‐2122 
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Contraindicated in residents with known hypersensitivity to
soybeans or peanuts
Side effects include palpitations, anxiety, headache, dizziness,
tremors, nervousness and dry mouth
4. Ipratropium Bromide/Albuterol – Bronchodilator
 Duoneb – SVN: Ipratropium 0.5 mg/Albuterol sulfate 3mg QID or
Combivent – MDI: 2 puffs 18 mcg/puff of Ipratropium with 90
mcg/puff Albuterol QID
 Onset occurs in 15 minutes
 Peak occurs in 1 – 2 hour
 Duration is for 4 – 6 hours
 Monitor blood pressure, pulse
 Contraindicated in residents with known hypersensitivity to
soybeans or peanuts
 Side effects include bronchitis, coughing, headache, dizziness,
tremors, shortness of breath, upper respiratory tract infection,
fatigue and dry mouth
5. Tiotropium Bromide – Bronchodilator
 Spiriva – DPI: 18 mg/inhalation 1 inhalation daily
 Onset occurs in 30 minutes
 Peak occurs in 3 hours
 Duration is for 24 hours
 Monitor blood pressure, pulse
 Side effects include blurred vision, constipation, indigestion,
muscle aches, nosebleed, runny nose, sore throat, stomach pain,
vomiting, yeast infection and dry mouth
6. Acetylcysteine – Reduce Mucus and Secretions
 Mucomyst – SVN: 3 - 5 ml, 10% or 20% strength TID or QID
 Onset occurs in 15 minutes
 Peak occurs in 1 – 2 hour
 Duration is for 4 – 6 hours
 Monitor blood pressure, pulse
 Precautions: will cause bronchospasms, do not use alone must use
with a bronchodilator; cannot be mixed with antibiotics, can be
given aerosolized if antibiotic is given by another route
 Side effects include rash, cold, clammy skin, drowsiness, fever,
inflammation of mouth or tongue, nausea, runny nose and sore
throat
7. Fluticasone Propionate and Salmeterol – Reduce and Control
Inflammation
26 The information given is for education purposes only and is not intended to replace current policies or procedure(s) already in place. Training is provided by: Z & D Medical Services 1(866)‐280‐2122 
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Advair Diskus – DPI: 100 mcg, 250 mcg and 500 mcg of fluticasone
with 50 mcg salmeterol, one inhalation BID or
Advair – MDI: 45 mcg, 115 mcg and 230 mcg of fluticasone with 21
mcg salmeterol, one inhalation BID
Monitor blood pressure, pulse
Precautions: always rinse resident’s mouth after use
Side effects include palpitations, nausea, dizziness, headache,
tremor, constipation, diarrhea, bronchitis, fungal infection of
mouth and muscle pain
8. Budesonide/Formoterol Fumarate – Reduce and Control Inflammation
 Symbicort – MDI: 80 mcg/4.5 mcg or 160 mg/or BID in divided
doses 4.5 mcg 2 puffs BID, morning and evening
 Monitor blood pressure, pulse
 Precautions: always rinse resident’s mouth after use
 Side effects include dizziness, dry mouth, headache, nausea,
nervous
 Medication safety includes protecting from light, stomach pain,
stuffy nose, throat irritation, tiredness, tremor, trouble sleeping
and vomiting
27 The information given is for education purposes only and is not intended to replace current policies or procedure(s) already in place. Training is provided by: Z & D Medical Services 1(866)‐280‐2122 Capturing Respiratory Therapy for Medicare Part A
There is an area with Medicare A that you can increase your revenue.
This is in the way of respiratory therapy. You can get a special care high for
this skill.
This has to occur:
1) A licensed respiratory therapist has to come in and do training with all
licensed nurses (LPN and RN), there has to be an outline describing all
the training the therapist went over with the nurses. You will have to
have a file with the respiratory therapist license and information. An
individual sign sheet, for each nurse to sign, with outline and any
educational papers will need to be placed in the nurse employee record.
The therapist needs to conduct “train the trainer” training with at least 2
RN. These Trainers will be the trainers for the new nurses hired over the
next year. The trainer will go over the training material and have a
individual sign in sheet with the outline from the in-service for each new
nurse(s) hired. This will be placed in the nurse’s employee record.
2) We then have to have the physician orders that explain why the
treatments are needed. If the resident has asthma, emphysema,
bronchitis, ect…
3) Next you will need to have documentation of the treatment(s) and the
minutes that it took to give the treatment with the skills preformed
during the treatment.
4) The nurse CAN NOT LEAVE THE ROOM while the resident is preforming
the nebulizer treatment. This is very, very important.
5) You will need for the respiratory treatment to count 15 minutes per day 7
days per week. Most resident’s get 2-4 nebulizer treatments per day and
most treatments last 7-11 minutes. Therefore, you shouldn’t have a
problem getting 15 minutes per day.
6) You will need to have a respiratory therapist come back yearly to do
updates with all the nurses.
28 The information given is for education purposes only and is not intended to replace current policies or procedure(s) already in place. Training is provided by: Z & D Medical Services 1(866)‐280‐2122 Common Respiratory Disorders
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COPD, Asthma, Chronic Bronchitis, Pneumonia, Emphysema,
Pneumothorax, Pulmonary Edema, Pulmonary Embolism
Diagnosis/Evaluation/Assessment
Management/ Treatment
Respiratory Disorders
As a person ages, changes occur to the respiratory system include:
o Decreased exchange of oxygen and carbon dioxide, caused by decreased
circulation.
o Increased anterior/posterior diameter of the chest due to skeletal
changes associated with aging (kyphosis).
o Chest wall becomes stiffer and more difficult to move.
o Respiratory muscles may weaken.
o Lungs lose some of their elastic recoil (like a rubber band in the sun).
o Muscles of the larynx and pharynx atrophy.
o Decreased vital capacity, residual volume and functional capacity.
o Increased airway resistance.
o Impaired cough mechanism.
Asthma
Etiology and Pathophysiology
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A pulmonary disease characterized by reversible airway
obstruction, airway inflammation and increased airway
responsiveness to a variety of stimuli
Airway obstruction is due to combination of factors that include
bronchoconstriction (narrowing of the airways), bronchospasm,
airway edema and excess mucus production
Extrinsic or intrinsic factors
Influenced by secondary factors
Antigen-antibody reaction
Signs and Symptoms
 Mild asthma
 Dyspnea on exertion
29 The information given is for education purposes only and is not intended to replace current policies or procedure(s) already in place. Training is provided by: Z & D Medical Services 1(866)‐280‐2122 
Wheezing
 Acute asthma attack
 Tachypnea
 Expiratory wheezing; productive cough
 Use of accessory muscles; nasal flaring
 Cyanosis
Medical Management/Nursing Interventions
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Maintenance therapy
 Serevent inhalant, prophylactic
 Corticosteroid inhalant
 Avoid allergens
Acute or rescue therapy
 Proventil inhalant
 Aminophylline IV
 Corticosteroid and epinephrine, oral or subcutaneous
 Oxygen
Did you know?
That residents with acute severe asthma should have their nebulizers
administered via oxygen or they will become hypoxic. If necessary, low-flow
oxygen may be administered via nasal cannula to residents while a drug is
nebulized with air. This is because it requires high-flow oxygen to nebulize a
drug (6-8 liters/minute) and if the resident has chronic respiratory disease he
will only require a low-flow of oxygen to stimulate his respiration.
Atelectasis
Etiology and Pathophysiology
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Incomplete expansion of the lung tissue usually caused by pressure from
exudate, fluid, tumor or an obstructed airway; may involve a lung
segment or an entire lobe.
Collapse of lung tissue due to occlusion of air to a portion of the lung
Signs and Symptoms
30 The information given is for education purposes only and is not intended to replace current policies or procedure(s) already in place. Training is provided by: Z & D Medical Services 1(866)‐280‐2122 
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Dyspnea
Tachypnea
Tachypnea
Pleural friction rub
Crackles
Restlessness
Elevated temperature
Decreased breath sounds
Medical Management/Nursing Interventions
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Cough and deep-breathe
Analgesia
Early ambulation
Incentive spirometry
Intermittent positive-pressure breathing (IPPB)
Oxygen
Chest percussion and postural drainage
Bronchodilators
Antibiotics
Mucolytic agents
Chest tube
Bronchitis
Etiology and Pathophysiology
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Inflammation of the trachea and bronchial tree
Usually secondary to upper respiratory infection
Exposure to inhaled irritants
Hypertrophy of mucous glands causes hypersecretion and alters cilia
function
Increased airway resistance causes bronchospasm
Signs and Symptoms
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Productive cough
Dyspnea
Use of accessory muscles to breathe
Wheezing
Chest pain
31 The information given is for education purposes only and is not intended to replace current policies or procedure(s) already in place. Training is provided by: Z & D Medical Services 1(866)‐280‐2122 
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Low-grade fever
Malaise
Headache
Medical Management/Nursing Interventions
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Bronchodilators
Mucolytic
Antibiotics
Oxygen (low-flow)
Pursed-lip breathing
Cough suppressants
Antitussives
Antipyretics Vaporizer
Encourage fluids
Chronic Obstructive Pulmonary Disease (COPD)
Etiology and Pathophysiology
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Gradual, irreversible process that involves chronic dilation of bronchi
resulting in loss of elasticity and obstructed airflow or exhalation.
Chronic bronchitis, emphysema and asthma are types of obstructive
lung disease.
Signs and Symptoms
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Dyspnea
Coughing
Wheezes and crackles
Cyanosis and clubbing of fingers
Fatigue
Weakness
Loss of appetite
Some additional characteristics that are often experienced by the elderly with
COPD:
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Frequent pneumonia
High anxiety levels
Increased respiratory rate
32 The information given is for education purposes only and is not intended to replace current policies or procedure(s) already in place. Training is provided by: Z & D Medical Services 1(866)‐280‐2122 
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Decreased breath sounds
Increased sputum production
Lower oxygen saturation
Confusion and somnolence
Demanding behavior
Medical Management/Nursing Interventions
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Oxygen (low-flow)
Chest physiotherapy
Hydration
Mucolytic agents
Antibiotics
Bronchodilators
Cool mist vaporizer
Surgery, such as a lobectomy
Did you know?
The administration of oxygen, except in a very low concentration (24-28%)
could be fatal to residents with chronic pulmonary disease. This is because
carbon dioxide is retained in the blood and the chemoreceptors in the brain
become less sensitive to high blood levels of carbon dioxide. The resident can
then become dependent on low oxygen (hypoxia) to stimulate respiration.
Therefore, if oxygen is given to correct the hypoxia, the resident’s respiratory
drive may be removed.
Emphysema
Etiology and Pathophysiology
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The bronchi, bronchioles, and alveoli become inflamed as a result of
chronic irritation
Air becomes trapped in the alveoli during expiration, causing alveolar
distention, rupture, and scar tissue
A main complication that can occur, “cor pulmonale” (right-sided
congestive heart failure due to pulmonary hypertension)
Signs and Symptoms
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Dyspnea on exertion
Sputum
33 The information given is for education purposes only and is not intended to replace current policies or procedure(s) already in place. Training is provided by: Z & D Medical Services 1(866)‐280‐2122 
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Barrel chest
Chronic weight loss
Emaciation
Clubbing of fingers
Medical Management/Nursing Interventions
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Oxygen (low-flow)
Chest physiotherapy
Bronchodilators
Corticosteroids
Antibiotics
Diuretics
Humidifier
Pursed-lip breathing
High-protein, high-calorie diet
Pneumonia
Etiology and Pathophysiology
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Is best defined as an inflammation of the lung parenchyma, regardless of
the type of pneumonia
This inflammatory process of the bronchioles and the alveolar spaces due
to infection
The most common types of pneumonia found in the long-term setting are
aspiration, bacterial and viral
 Aspiration pneumonia is the pathologic consequence of abnormal
entry of fluids, particulate matter or secretions in the lower
airways
Signs and Symptoms
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Productive cough
Severe chills
Elevated temperature
Increased heart rate
Increased respiratory rate
Dyspnea
34 The information given is for education purposes only and is not intended to replace current policies or procedure(s) already in place. Training is provided by: Z & D Medical Services 1(866)‐280‐2122 
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Myalgia
Headache
Mucopurulent sputum
Medical Management/Nursing Interventions
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Oxygen
Chest percussion and postural drainage
Encourage to cough and deep-breathe
Antibiotics
Analgesics
Expectorants
Bronchodilators
Nebulizer treatments
Pneumothorax
Etiology and Pathophysiology

Is an accumulation of air or gas within the pleural cavity, causing the
lung to collapse
Signs and Symptoms
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Decreased breath sounds
Sudden, sharp chest pain with dyspnea
Diaphoresis
Tachycardia
Tachypnea
No chest movement on affected side
Sucking chest wound
Medical Management/Nursing Interventions
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Chest tube to water-seal drainage system
Oxygen
Analgesics
Encourage fluids
35 The information given is for education purposes only and is not intended to replace current policies or procedure(s) already in place. Training is provided by: Z & D Medical Services 1(866)‐280‐2122 Pulmonary Edema
Etiology and Pathophysiology

An excessive accumulation of serous fluid within the interstitial tissue
and alveoli
Signs and Symptoms
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Dyspnea
Cyanosis
Tachypnea
Tachycardia
Pink or blood-tinged, frothy sputum
Restlessness
Agitation
Wheezing
Crackles
Decreased urinary output
Sudden weight gain
Medical Management/Nursing Interventions
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Oxygen
Mechanical ventilator (acute care setting, LTAC)
Diuretics
Narcotic analgesics
Strict I&O
Daily weight
Low-sodium diet
Pulmonary Embolism
Etiology and Pathophysiology
 A sudden lodgment of a foreign substance in a pulmonary artery with
subsequent obstruction of blood supply to the lung parenchyma Blood
clot, fat, air, or amniotic fluid
36 The information given is for education purposes only and is not intended to replace current policies or procedure(s) already in place. Training is provided by: Z & D Medical Services 1(866)‐280‐2122  The most common type of pulmonary embolus is a thrombus that
usually has migrated from a leg or pelvic vein
Signs and Symptoms
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Sudden, unexplained dyspnea
Tachypnea
Hemoptysis
Chest pain
Elevated temperature
Increased white blood cells (WBCs)
Medical Management/Nursing Interventions
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Oxygen
Head of bed (HOB) elevated 30 degrees
Anticoagulants
Fibrinolytic agents
Recap of Nursing Interventions for the Respiratory Resident
Throughout the above listed respiratory disorders, various nursing
interventions were utilized. In review, the following are the most common
interventions utilized regardless of the cause of the respiratory disorder:
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Frequent position changes
Maintain position to facilitate ventilation (semi-fowler’s)
Protect from infection
Protect from sources of lung irritants
Cool the environment
Cough and deep breathing exercises
Provide rest periods between activities of daily living
Encourage the resident to use adaptive breathing techniques, such as
pursed-lip breathing
Provide alternative method of communication if needed
Encourage fluids
Ensure good nutrition
Provide good skin care
Provide good oral care
Bedrest as indicated
37 The information given is for education purposes only and is not intended to replace current policies or procedure(s) already in place. Training is provided by: Z & D Medical Services 1(866)‐280‐2122 Did you know? & Common Respiratory Scenarios
Exacerbation of COPD
The resident is end stage COPD with a long history of home oxygen and
nebulizer treatments. He has a history of Prednisone use and is a DNR.
Normal oxygen saturation readings are 89 – 90% with an apical heart rate 100.
The resident presents with complaints of tightness in the chest and increased
difficulty breathing, increased sputum production, oxygen saturation of 85%,
respiratory rate of 30, apical heart rate of 110 and is very anxious. The resident
is insisting to return to the hospital.
Your first response is to give this resident a STAT nebulizer treatment while
you reposition him in an upright sitting position. You should talk to the
resident in a calm and relaxing voice as you encourage him to take slow, deep
breaths; repeat as necessary. Give anti-anxiety medications and cool the
resident’s room temperature. Notify the physician and request CXR and
weaning process for Prednisone. Monitor frequently until the episode passes.
Tracheal Occlusion
The resident is a recent tracheostomy resident with complications due to
surgery. The resident has no previous respiratory history but is unable to
wean from continuous oxygen to her trach at this time. Oxygen is being
delivered at 35% via tracheostomy mask.
You begin to suction her and notice that you cannot pass the suction catheter.
Oxygen saturations are falling and the resident is starting to utilize her
accessory muscles.
Your first response is to remove the inner cannula and check for occlusion.
You immediately clean the inner cannula, remembering to increase oxygen
levels for the resident as you clean). Replace the inner cannula and increase
humidity to the resident. Leave increased oxygen level until the resident
stabilizes. If the inner cannula was not occluded, check inflation of the cuff
and verify that it is deflated; deflate if indicated.
Your next response to this situation would be to lavage and suction the
resident. Hyperoxygenate by using an ambu-bag hooked up to an oxygen
source. Lavage, suction and hyperoxygenate the resident until the plug is
dislodged. Repeat as necessary. Leave the resident on the higher oxygen until
she stabilizes. Check the humidification device and water levels.
38 The information given is for education purposes only and is not intended to replace current policies or procedure(s) already in place. Training is provided by: Z & D Medical Services 1(866)‐280‐2122 Pulmonary Embolism
The resident has had recent repair of a hip fracture due to a fall. No previous
respiratory history is available. He complains suddenly of shortness of breath.
Room air saturation is 97%. He continues to complain of increased shortness
of breath and room air saturation drops to 95%.
Your first response is to immediately place oxygen at 2 liters/minute per nasal
cannula, place on bedrest and notify the physician due to possible pulmonary
embolism.
Aspiration of Tube Feeding in a Tracheostomy Resident
The resident is noted to have tube feeding coming from the trach site; she has
no cough reflex.
Your first response is to immediately inflate trach cuff and suction resident.
Airway is protected by cuff inflation. Numerous suction attempts need to be
performed to prevent pneumonia. Lavage and suction your resident.
39 The information given is for education purposes only and is not intended to replace current policies or procedure(s) already in place. Training is provided by: Z & D Medical Services 1(866)‐280‐2122