28
Supporting Ventilation
Eugene E. Mondor
http://evolve.elsevier.com/Lewis/medsurg/
CONCEPTUAL FOCUS
Acid-Base Balance Nutrition
Functional Ability Sleep
Gas Exchange
LEARNING OUTCOMES
1. Identify airway clearance techniques that promote gas 7. Select appropriate nursing interventions related to the care
exchange. of an intubated patient.
2. Describe the indications for O2 therapy, including delivery 8. Identify the steps involved in suctioning a patient with an
methods and complications. oral endotracheal tube or tracheostomy.
3. Explain the purpose, function, and nursing responsibilities 9. Describe complications of mechanical ventilation and
related to chest tubes and chest drainage systems. corrective actions to ensure optimal ventilation and safe
4. Identify the types of chest surgery and appropriate patient care.
perioperative care. 10. Describe the process of weaning from mechanical
5. Relate the important aspects of care for the patient ventilation.
receiving noninvasive ventilation. 11. Select appropriate nursing interventions related to care of
6. Distinguish the indications for and modes of mechanical the patient with a new tracheostomy.
ventilation. 12. Outline the essential teaching needed for the patient with
a permanent tracheostomy.
KEY TERMS
assist-control (AC) ventilation positive pressure ventilation (PPV)
chest physical therapy (CPT) pressure control (PC) ventilation
continuous positive airway pressure (CPAP) pressure support ventilation (PSV)
decannulation pressure ventilation
endotracheal (ET) tube pursed-lip breathing (PLB)
extubation synchronized intermittent mandatory ventilation (SIMV)
intubation thoracotomy
mechanical ventilation tracheostomy
negative pressure ventilation volume ventilation
noninvasive ventilation (NIV) weaning
positive end-expiratory pressure (PEEP)
The exchange of O2 and carbon dioxide (CO2) is vital for life. RESPIRATORY PHYSIOTHERAPY
The purpose of this chapter is to provide an overview of vari-
ous strategies we use to promote optimal ventilation and oxy- Breathing Exercises
genation. Promoting respiratory function is important for best Two main types of breathing exercises are diaphragmatic breathing
patient outcomes. Without an optimal route for ventilation, O2 and pursed-lip breathing. Diaphragmatic (abdominal) breathing
therapy will not benefit the patient. While providing optimal focuses on using the diaphragm instead of the accessory muscles of
ventilation is no guarantee that oxygenation will improve, with- the chest to achieve maximum inhalation and slow the respiratory
out a patent airway, the patient will die. rate. Ideal candidates for diaphragmatic breathing instruction are
539
,540 SECTION 6 Problems of Oxygenation: Ventilation
TABLE 28.1 PATIENT & CAREGIVER TABLE 28.2 PATIENT & CAREGIVER
TEACHING TEACHING
Pursed-Lip Breathing Effective Huff Coughing
Teach the patient to use PLB before, during, and after any activity that may Help the patient assume a sitting position with head slightly flexed, shoulders
cause them to be short of breath. relaxed, knees flexed, forearms supported by pillow, and, if possible, feet
1. Inhale slowly and deeply through the nose. on the floor.
2. Exhale slowly through pursed lips, as if whistling. Then teach the patient to:
3. Be sure to relax your facial muscles without puffing your cheeks—like 1. Inhale slowly through the mouth while breathing deeply from the diaphragm.
whistling—while you are exhaling slowly. 2. Hold the breath for 2–3 sec.
4. Make breathing out (exhalation) 3 times as long as breathing in (inhalation). 3. Forcefully exhale quickly as if they are fogging up a mirror with their breath
5. The following activities can help you get the “feel” of PLB: (thus creating a “huff”). This helps moves secretions into larger airways.
• Blow through a straw in a glass of water, forming small bubbles. 4. Repeat the “huff” 1 or 2 more times while refraining from a “regular” cough.
• Blow a lit candle enough to bend the flame without blowing it out. 5. Cough when mucus is felt in the airways (breathing tubes).
• Steadily blow a table-tennis ball across a table. 6. Rest for 5–10 regular breaths.
• Blow a tissue held in the hand until it gently flaps. 7. Repeat the huffs (3–5 cycles) until you feel you have cleared mucus, or you
6. Practice 8–10 repetitions of PLB 3 or 4 times a day. become tired.
PLB, Pursed-lip breathing.
thoracic and abdominal surgery patients. Diaphragmatic breathing Chest Physical Therapy
in patients with chronic obstructive pulmonary disease (COPD) Chest physical therapy (CPT) consists of postural drainage,
may increase the work of breathing (WOB) and dyspnea. People percussion, and vibration. It can be done on spontaneously
with moderate to severe COPD with marked hyperinflation may breathing patients as well as those who are intubated and
not tolerate diaphragmatic breathing. mechanically ventilated. CPT is used for patients with excessive
The purpose of pursed-lip breathing (PLB) is to prolong bronchial secretions who have difficulty clearing them.
exhalation, which prevents bronchiolar collapse and air trap- CPT should be done by a physiotherapist or other trained
ping.1 PLB is simple, easy to teach, and easy to learn (Table person. Complications from improperly performed CPT include
28.1). It gives the patient more control over breathing, especially fractured ribs, bruising of the chest wall, hypoxemia, and dis-
during exercise and periods of dyspnea. PLB slows the respira- comfort. CPT may be stressful for some patients. Teaching can
tory rate and is easier than diaphragmatic breathing. Teach the help ease fear and anxiety and gain trust and cooperation.
patients to use “just enough” positive pressure with PLB because
excessive resistance may increase the WOB. In the patient with Postural Drainage
extreme acute dyspnea, focus on helping the patient slow the Postural drainage is the use of positioning techniques that drain
respiratory rate by using PLB. secretions from specific segments of the lungs and bronchi into
the trachea. The postural drainage position used depends on the
Airway Clearance Techniques areas of lung that are involved. This is determined by patient
Many patients with COPD or other respiratory conditions who assessment, chest x-rays, chest auscultation, and, when possible,
retain secretions, such as cystic fibrosis (CF) and bronchiecta- patient preference. For example, a patient with left lower lobe
sis, need help to adequately clear their airways. Airway clear- involvement needs postural drainage of only the affected region.
ance techniques (ACTs) loosen mucus and secretions so they On the other hand, a person with CF may need postural drain-
can be cleared by coughing. This helps maintain a patent airway. age of all segments.
Techniques include huff coughing, chest physiotherapy, pos- The purpose of various positions in postural drainage is to
tural drainage, airway clearance devices, and high-frequency drain each segment toward the larger airways. The patient who
chest ventilation. ACTs are often used with other treatments. cannot tolerate a head-down position may use a side-lying posi-
For example, the patient may receive bronchodilator therapy tion. We usually give aerosolized bronchodilators and hydration
before ACT. Then the ACT is used, followed by effective cough- therapy before postural drainage. The patient stays in the cho-
ing (e.g., huff coughing). Respiratory therapists (RTs), physical sen position for about 5 minutes during percussion and vibra-
therapists, and nurses can teach patients and caregivers ACTs. tion. A common order is to perform postural drainage 2 to 4
times a day. In acute situations, we may do postural drainage as
Huff Coughing often as every 4 hours.3 Schedule the procedure at least 1 hour
Huff coughing, or huffing, is a forced expiratory technique that before meals or 3 hours after meals.
consists of a series of smaller coughs. You can easily teach the Postural drainage is best for patients with atelectasis, CF, COPD,
patient huff coughing. Position the patient and ensure they are and pneumonia. Some commercially available specialty beds
breathing deeply from the diaphragm. After holding the breath can rotate and percuss the patient in various postural drain-
for a few seconds, the patient exhales with several small coughs, age positions. Patients with traumatic brain injury, neck injury,
then rests for several breaths, and repeats the cycle.2 Persons with chest trauma, hemoptysis, heart disease, or pulmonary embolus
COPD and emphysema benefit from huff coughing. Table 28.2 should not receive postural drainage. It is contraindicated in
outlines teaching about huff coughing. hemorrhage and when the patient is not stable.
, CHAPTER 28 Supporting Ventilation 541
nose or mouth, holds the breath for a few seconds, then exhales
through the resistor. The pressure indicator gives visual feed-
back about the pressure that the patient needs to hold during
exhalation to receive maximal benefit of PEP.
High-frequency chest wall oscillation. High-frequency chest
wall oscillation uses an inflatable vest (e.g., Vest System, Smart
Vest) with hoses connected to a high-frequency pulse generator.
Fig. 28.1 Cupped-hand position for percussion. Cup the hand as though The pulse generator delivers air to the vest, which vibrates
scooping up water.
the chest. The high-frequency airwaves dislodge mucus from
the airways, mobilize the mucus, and move it toward larger
Percussion airways. The vest is easy to apply. It can be used without the aid
Percussion is done in the appropriate postural drainage posi- of another person. The unit weighs 23 to 30 lbs. (10 to 13 kg), are
tion. Place the hands in a cuplike position with the fingers and quiet, come in a suitcase, and are portable.
thumbs closed (Fig. 28.1). The cupped hand should create an
air pocket between the patient’s chest and the hand. Both hands
alternate in a rhythmic fashion. You will hear a hollow sound if
O2 THERAPY
done correctly. The air-cushion impact promotes the movement O2 therapy is a common treatment for hypoxemia and hypoxia.
of thick mucus. For patient comfort, place a thin towel over the O2 is a colorless, odorless, tasteless gas that constitutes 21% of
area you will percuss. The patient may choose to wear a T-shirt the atmosphere. Giving supplemental O2 increases the partial
or hospital gown. pressure of O2 (PO2) in inspired air. O2 therapy requires an HCP
order. The dose of O2 administered to patients is the fraction of
Vibration inspired oxygen (FIO2).
Vibration promotes movement of secretions to the larger air- We give O2 to treat hypoxemia caused by many problems,
ways. We perform vibration by tensing the hand and arm mus- such as shock, pneumonia, and pulmonary emboli. O2 ther-
cles repeatedly and pressing mildly with the flat of the hand on apy is tailored to meet each patient’s unique circumstances and
the affected area while the patient slowly exhales a deep breath. physiologic needs. For most patients, the goal of O2 therapy is
Commercially available mechanical chest vibrators are available to keep the SaO2 greater than 92% during rest, sleep, and activ-
for hospital and home use. ity, or the PaO2 greater than 60 mm Hg. We may modify these
Airway clearance devices. Airway clearance devices are goals depending on the patient’s clinical situation. For example,
available to help mobilize secretions. They are sometimes easier the HCP may accept an SpO2 an PaO2 greater than 88% for the
to tolerate than CPT and often take less time than CPT sessions. patient with longstanding COPD.
Popular devices include the Flutter, Acapella, and TheraPEP
Therapy System.
The Flutter mucus clearance device is a hand-held device. It DRUG ALERT
is shaped like a small, fat pipe. The Flutter has a mouthpiece, a O2
high-density stainless-steel ball, and a cone that holds the ball.
• O 2 is considered a drug.
To use the Flutter, the patient takes a slightly bigger than normal • A dministering high levels of O2 (FIO2 greater than 60% for more than 24 hr)
breath and exhales through the mouth and into the Flutter. As to mechanically ventilated patients can lead to O2 toxicity.
a result, the steel ball moves, which causes vibrations in the air- • Target FIO2 levels are to maintain SpO2 >92% and PaO2 between 60 and
ways. The vibration helps loosen mucus in the airways to allow 100 mm Hg.
improved expectoration. Flutter use should be followed by huff- • Assess PaO2 and SpO2 as needed.
ing and coughing. Clean a Flutter daily in warm, soapy water. • Monitor for manifestations of O2 toxicity: blurred vision, coughing, chest
The Acapella is another small hand-held device. It combines pain, dyspnea, seizures.
positive expired pressure (PEP) and airway vibrations to mobi-
lize secretions. It can be used in any setting. Patients are free to
sit, stand, or recline. Prior to use, the resistance dial on the device Methods of O2 Administration
needs to be set (1=minimal exhalation resistance, 5=high exha- There are various ways to administer O2 (Table 28.3). The device
lation resistance). The patient takes in a deep breath through the used depends on the patient’s underlying condition, the FIO2
nose or mouth, then seals their lips around the mouthpiece, and the patient needs, advantages and disadvantages of each device,
exhales through the device. You should hear the gentle noise comfort, cost, and financial resources.
of the rocker inside the device on exhalation. The Acapella can We classify O2 delivery systems as low-flow or high-flow sys-
help deliver aerosolized drugs. tems. Low-flow O2 delivery devices are appropriate for patients
The TheraPEP Therapy System is similar to the Acapella. It who are awake, alert, and spontaneously breathing with a stable,
uses PEP and can assist with airway clearance and deliver aero- intact respiratory drive. These devices provide O2 in concentra-
solized drugs. TheraPEP can have either a mouthpiece or mask tions that do not meet all the patient’s inspiratory demands.4
that is attached to tubing that is connected to a small adjustable Low-flow devices pull in a proportion of room air, which
resistor and a pressure indicator. The patient inhales through the makes the exact FIO2 unknown. We do know the range of FIO2
, 542 SECTION 6 Problems of Oxygenation: Ventilation
TABLE 28.3 Methods of O2 Administration
Description Nursing Interventions
Low-Flow Delivery Devices
Nasal Cannula
• Most commonly used. • Stabilize nasal cannula when caring for a
• O2 delivered through plastic tubing restless patient.
(prongs) that fits in the nares. • Amount of O2 inhaled depends on room air and
• Used for a patient requiring low O2 patient’s breathing pattern.
concentrations. • Most patients with COPD can tolerate 2–4 L/min
• Achieves O2 concentrations of 24% through a cannula.
(at 1 L/min) to 44% (at 6 L/min). • Assess the nares and ears for skin breakdown.
• Safe May need to pad tubing where it sits on ears.
• Easy to set-up and use • If flow rates are >5 L/min, nasal membranes may
• Patient can eat, talk, or cough while dry and place patient at risk for nose bleeds.
wearing device.
• Allows some freedom of movement.
O2-Conserving Cannula
• Generally indicated for longer- • More expensive than standard nasal cannula.
term O2 therapy at home (e.g., CF, • Cannula is highly visible.
pulmonary hypertension). • Assess the nares and ears for skin breakdown.
• Looks like a “moustache” May need to pad tubing where it sits behind
(Oxymizer) or “pendant” type. ears.
• Cannula has a built-in reservoir • Cannot clean cannula. Change cannula every
that ↑ O2 concentration and allows week.
patient to use lower flow, usually • May need ABGs and oximetry to determine
30%–50%, which increases correct flow rate.
comfort, lowers cost, and can
be increased with activities.
• Can deliver O2 flow rates up to
15 L/min.
Pendant-type O2-conserving cannula.
Partial and Non-Rebreather Masks
• Used for short-term therapy for • O2 flow rate must be sufficient to keep bag from
patients with higher O2 needs deflating during inspiration to avoid CO2 buildup
• Achieves O2 concentrations of and rebreathing of CO2.
60%–90% (with flow rates of • If deflation occurs, increase flowrate on flowmeter on
10–15 L/min). wall to keep bag inflated.
• O2 flows into reservoir bag and • Mask should fit snugly.
mask during inhalation. • With non-rebreather masks, make sure valves
• Bag allows patient to rebreathe open during expiration and close during
about first third of exhaled air (rich inhalation to prevent decrease in FIO2 or
in O2) in conjunction with flowing O2. build-up in CO2.
• Vents stay open on partial mask. • Monitor patient closely, since more advanced
Some agencies prefer this over interventions such as CPAP, Bi-PAP, or intubation
non-rebreather as a safety issue. with mechanical ventilation may be needed.
Simple Face Mask
• Covers the nose and mouth. • Wash and dry under mask q4hr and PRN.
• Achieves O2 concentrations of • Mask must fit snugly.
35%–50% with flow rates of • Must have flow rates of at least 6 L/min to wash
6–12 L/min. exhaled gases out of mask (if O2 flow rate not high
• Mask provides adequate enough, CO2 rebreathing is possible)
humidification of inspired air. • May change to nasal cannula while patient is
• Safe eating.
• Easy to set up and use • Watch for pressure necrosis at top of ears from
• Typically used only for short elastic straps if patient wears for a longer time.
periods. Gauze or other padding may alleviate this problem.
Supporting Ventilation
Eugene E. Mondor
http://evolve.elsevier.com/Lewis/medsurg/
CONCEPTUAL FOCUS
Acid-Base Balance Nutrition
Functional Ability Sleep
Gas Exchange
LEARNING OUTCOMES
1. Identify airway clearance techniques that promote gas 7. Select appropriate nursing interventions related to the care
exchange. of an intubated patient.
2. Describe the indications for O2 therapy, including delivery 8. Identify the steps involved in suctioning a patient with an
methods and complications. oral endotracheal tube or tracheostomy.
3. Explain the purpose, function, and nursing responsibilities 9. Describe complications of mechanical ventilation and
related to chest tubes and chest drainage systems. corrective actions to ensure optimal ventilation and safe
4. Identify the types of chest surgery and appropriate patient care.
perioperative care. 10. Describe the process of weaning from mechanical
5. Relate the important aspects of care for the patient ventilation.
receiving noninvasive ventilation. 11. Select appropriate nursing interventions related to care of
6. Distinguish the indications for and modes of mechanical the patient with a new tracheostomy.
ventilation. 12. Outline the essential teaching needed for the patient with
a permanent tracheostomy.
KEY TERMS
assist-control (AC) ventilation positive pressure ventilation (PPV)
chest physical therapy (CPT) pressure control (PC) ventilation
continuous positive airway pressure (CPAP) pressure support ventilation (PSV)
decannulation pressure ventilation
endotracheal (ET) tube pursed-lip breathing (PLB)
extubation synchronized intermittent mandatory ventilation (SIMV)
intubation thoracotomy
mechanical ventilation tracheostomy
negative pressure ventilation volume ventilation
noninvasive ventilation (NIV) weaning
positive end-expiratory pressure (PEEP)
The exchange of O2 and carbon dioxide (CO2) is vital for life. RESPIRATORY PHYSIOTHERAPY
The purpose of this chapter is to provide an overview of vari-
ous strategies we use to promote optimal ventilation and oxy- Breathing Exercises
genation. Promoting respiratory function is important for best Two main types of breathing exercises are diaphragmatic breathing
patient outcomes. Without an optimal route for ventilation, O2 and pursed-lip breathing. Diaphragmatic (abdominal) breathing
therapy will not benefit the patient. While providing optimal focuses on using the diaphragm instead of the accessory muscles of
ventilation is no guarantee that oxygenation will improve, with- the chest to achieve maximum inhalation and slow the respiratory
out a patent airway, the patient will die. rate. Ideal candidates for diaphragmatic breathing instruction are
539
,540 SECTION 6 Problems of Oxygenation: Ventilation
TABLE 28.1 PATIENT & CAREGIVER TABLE 28.2 PATIENT & CAREGIVER
TEACHING TEACHING
Pursed-Lip Breathing Effective Huff Coughing
Teach the patient to use PLB before, during, and after any activity that may Help the patient assume a sitting position with head slightly flexed, shoulders
cause them to be short of breath. relaxed, knees flexed, forearms supported by pillow, and, if possible, feet
1. Inhale slowly and deeply through the nose. on the floor.
2. Exhale slowly through pursed lips, as if whistling. Then teach the patient to:
3. Be sure to relax your facial muscles without puffing your cheeks—like 1. Inhale slowly through the mouth while breathing deeply from the diaphragm.
whistling—while you are exhaling slowly. 2. Hold the breath for 2–3 sec.
4. Make breathing out (exhalation) 3 times as long as breathing in (inhalation). 3. Forcefully exhale quickly as if they are fogging up a mirror with their breath
5. The following activities can help you get the “feel” of PLB: (thus creating a “huff”). This helps moves secretions into larger airways.
• Blow through a straw in a glass of water, forming small bubbles. 4. Repeat the “huff” 1 or 2 more times while refraining from a “regular” cough.
• Blow a lit candle enough to bend the flame without blowing it out. 5. Cough when mucus is felt in the airways (breathing tubes).
• Steadily blow a table-tennis ball across a table. 6. Rest for 5–10 regular breaths.
• Blow a tissue held in the hand until it gently flaps. 7. Repeat the huffs (3–5 cycles) until you feel you have cleared mucus, or you
6. Practice 8–10 repetitions of PLB 3 or 4 times a day. become tired.
PLB, Pursed-lip breathing.
thoracic and abdominal surgery patients. Diaphragmatic breathing Chest Physical Therapy
in patients with chronic obstructive pulmonary disease (COPD) Chest physical therapy (CPT) consists of postural drainage,
may increase the work of breathing (WOB) and dyspnea. People percussion, and vibration. It can be done on spontaneously
with moderate to severe COPD with marked hyperinflation may breathing patients as well as those who are intubated and
not tolerate diaphragmatic breathing. mechanically ventilated. CPT is used for patients with excessive
The purpose of pursed-lip breathing (PLB) is to prolong bronchial secretions who have difficulty clearing them.
exhalation, which prevents bronchiolar collapse and air trap- CPT should be done by a physiotherapist or other trained
ping.1 PLB is simple, easy to teach, and easy to learn (Table person. Complications from improperly performed CPT include
28.1). It gives the patient more control over breathing, especially fractured ribs, bruising of the chest wall, hypoxemia, and dis-
during exercise and periods of dyspnea. PLB slows the respira- comfort. CPT may be stressful for some patients. Teaching can
tory rate and is easier than diaphragmatic breathing. Teach the help ease fear and anxiety and gain trust and cooperation.
patients to use “just enough” positive pressure with PLB because
excessive resistance may increase the WOB. In the patient with Postural Drainage
extreme acute dyspnea, focus on helping the patient slow the Postural drainage is the use of positioning techniques that drain
respiratory rate by using PLB. secretions from specific segments of the lungs and bronchi into
the trachea. The postural drainage position used depends on the
Airway Clearance Techniques areas of lung that are involved. This is determined by patient
Many patients with COPD or other respiratory conditions who assessment, chest x-rays, chest auscultation, and, when possible,
retain secretions, such as cystic fibrosis (CF) and bronchiecta- patient preference. For example, a patient with left lower lobe
sis, need help to adequately clear their airways. Airway clear- involvement needs postural drainage of only the affected region.
ance techniques (ACTs) loosen mucus and secretions so they On the other hand, a person with CF may need postural drain-
can be cleared by coughing. This helps maintain a patent airway. age of all segments.
Techniques include huff coughing, chest physiotherapy, pos- The purpose of various positions in postural drainage is to
tural drainage, airway clearance devices, and high-frequency drain each segment toward the larger airways. The patient who
chest ventilation. ACTs are often used with other treatments. cannot tolerate a head-down position may use a side-lying posi-
For example, the patient may receive bronchodilator therapy tion. We usually give aerosolized bronchodilators and hydration
before ACT. Then the ACT is used, followed by effective cough- therapy before postural drainage. The patient stays in the cho-
ing (e.g., huff coughing). Respiratory therapists (RTs), physical sen position for about 5 minutes during percussion and vibra-
therapists, and nurses can teach patients and caregivers ACTs. tion. A common order is to perform postural drainage 2 to 4
times a day. In acute situations, we may do postural drainage as
Huff Coughing often as every 4 hours.3 Schedule the procedure at least 1 hour
Huff coughing, or huffing, is a forced expiratory technique that before meals or 3 hours after meals.
consists of a series of smaller coughs. You can easily teach the Postural drainage is best for patients with atelectasis, CF, COPD,
patient huff coughing. Position the patient and ensure they are and pneumonia. Some commercially available specialty beds
breathing deeply from the diaphragm. After holding the breath can rotate and percuss the patient in various postural drain-
for a few seconds, the patient exhales with several small coughs, age positions. Patients with traumatic brain injury, neck injury,
then rests for several breaths, and repeats the cycle.2 Persons with chest trauma, hemoptysis, heart disease, or pulmonary embolus
COPD and emphysema benefit from huff coughing. Table 28.2 should not receive postural drainage. It is contraindicated in
outlines teaching about huff coughing. hemorrhage and when the patient is not stable.
, CHAPTER 28 Supporting Ventilation 541
nose or mouth, holds the breath for a few seconds, then exhales
through the resistor. The pressure indicator gives visual feed-
back about the pressure that the patient needs to hold during
exhalation to receive maximal benefit of PEP.
High-frequency chest wall oscillation. High-frequency chest
wall oscillation uses an inflatable vest (e.g., Vest System, Smart
Vest) with hoses connected to a high-frequency pulse generator.
Fig. 28.1 Cupped-hand position for percussion. Cup the hand as though The pulse generator delivers air to the vest, which vibrates
scooping up water.
the chest. The high-frequency airwaves dislodge mucus from
the airways, mobilize the mucus, and move it toward larger
Percussion airways. The vest is easy to apply. It can be used without the aid
Percussion is done in the appropriate postural drainage posi- of another person. The unit weighs 23 to 30 lbs. (10 to 13 kg), are
tion. Place the hands in a cuplike position with the fingers and quiet, come in a suitcase, and are portable.
thumbs closed (Fig. 28.1). The cupped hand should create an
air pocket between the patient’s chest and the hand. Both hands
alternate in a rhythmic fashion. You will hear a hollow sound if
O2 THERAPY
done correctly. The air-cushion impact promotes the movement O2 therapy is a common treatment for hypoxemia and hypoxia.
of thick mucus. For patient comfort, place a thin towel over the O2 is a colorless, odorless, tasteless gas that constitutes 21% of
area you will percuss. The patient may choose to wear a T-shirt the atmosphere. Giving supplemental O2 increases the partial
or hospital gown. pressure of O2 (PO2) in inspired air. O2 therapy requires an HCP
order. The dose of O2 administered to patients is the fraction of
Vibration inspired oxygen (FIO2).
Vibration promotes movement of secretions to the larger air- We give O2 to treat hypoxemia caused by many problems,
ways. We perform vibration by tensing the hand and arm mus- such as shock, pneumonia, and pulmonary emboli. O2 ther-
cles repeatedly and pressing mildly with the flat of the hand on apy is tailored to meet each patient’s unique circumstances and
the affected area while the patient slowly exhales a deep breath. physiologic needs. For most patients, the goal of O2 therapy is
Commercially available mechanical chest vibrators are available to keep the SaO2 greater than 92% during rest, sleep, and activ-
for hospital and home use. ity, or the PaO2 greater than 60 mm Hg. We may modify these
Airway clearance devices. Airway clearance devices are goals depending on the patient’s clinical situation. For example,
available to help mobilize secretions. They are sometimes easier the HCP may accept an SpO2 an PaO2 greater than 88% for the
to tolerate than CPT and often take less time than CPT sessions. patient with longstanding COPD.
Popular devices include the Flutter, Acapella, and TheraPEP
Therapy System.
The Flutter mucus clearance device is a hand-held device. It DRUG ALERT
is shaped like a small, fat pipe. The Flutter has a mouthpiece, a O2
high-density stainless-steel ball, and a cone that holds the ball.
• O 2 is considered a drug.
To use the Flutter, the patient takes a slightly bigger than normal • A dministering high levels of O2 (FIO2 greater than 60% for more than 24 hr)
breath and exhales through the mouth and into the Flutter. As to mechanically ventilated patients can lead to O2 toxicity.
a result, the steel ball moves, which causes vibrations in the air- • Target FIO2 levels are to maintain SpO2 >92% and PaO2 between 60 and
ways. The vibration helps loosen mucus in the airways to allow 100 mm Hg.
improved expectoration. Flutter use should be followed by huff- • Assess PaO2 and SpO2 as needed.
ing and coughing. Clean a Flutter daily in warm, soapy water. • Monitor for manifestations of O2 toxicity: blurred vision, coughing, chest
The Acapella is another small hand-held device. It combines pain, dyspnea, seizures.
positive expired pressure (PEP) and airway vibrations to mobi-
lize secretions. It can be used in any setting. Patients are free to
sit, stand, or recline. Prior to use, the resistance dial on the device Methods of O2 Administration
needs to be set (1=minimal exhalation resistance, 5=high exha- There are various ways to administer O2 (Table 28.3). The device
lation resistance). The patient takes in a deep breath through the used depends on the patient’s underlying condition, the FIO2
nose or mouth, then seals their lips around the mouthpiece, and the patient needs, advantages and disadvantages of each device,
exhales through the device. You should hear the gentle noise comfort, cost, and financial resources.
of the rocker inside the device on exhalation. The Acapella can We classify O2 delivery systems as low-flow or high-flow sys-
help deliver aerosolized drugs. tems. Low-flow O2 delivery devices are appropriate for patients
The TheraPEP Therapy System is similar to the Acapella. It who are awake, alert, and spontaneously breathing with a stable,
uses PEP and can assist with airway clearance and deliver aero- intact respiratory drive. These devices provide O2 in concentra-
solized drugs. TheraPEP can have either a mouthpiece or mask tions that do not meet all the patient’s inspiratory demands.4
that is attached to tubing that is connected to a small adjustable Low-flow devices pull in a proportion of room air, which
resistor and a pressure indicator. The patient inhales through the makes the exact FIO2 unknown. We do know the range of FIO2
, 542 SECTION 6 Problems of Oxygenation: Ventilation
TABLE 28.3 Methods of O2 Administration
Description Nursing Interventions
Low-Flow Delivery Devices
Nasal Cannula
• Most commonly used. • Stabilize nasal cannula when caring for a
• O2 delivered through plastic tubing restless patient.
(prongs) that fits in the nares. • Amount of O2 inhaled depends on room air and
• Used for a patient requiring low O2 patient’s breathing pattern.
concentrations. • Most patients with COPD can tolerate 2–4 L/min
• Achieves O2 concentrations of 24% through a cannula.
(at 1 L/min) to 44% (at 6 L/min). • Assess the nares and ears for skin breakdown.
• Safe May need to pad tubing where it sits on ears.
• Easy to set-up and use • If flow rates are >5 L/min, nasal membranes may
• Patient can eat, talk, or cough while dry and place patient at risk for nose bleeds.
wearing device.
• Allows some freedom of movement.
O2-Conserving Cannula
• Generally indicated for longer- • More expensive than standard nasal cannula.
term O2 therapy at home (e.g., CF, • Cannula is highly visible.
pulmonary hypertension). • Assess the nares and ears for skin breakdown.
• Looks like a “moustache” May need to pad tubing where it sits behind
(Oxymizer) or “pendant” type. ears.
• Cannula has a built-in reservoir • Cannot clean cannula. Change cannula every
that ↑ O2 concentration and allows week.
patient to use lower flow, usually • May need ABGs and oximetry to determine
30%–50%, which increases correct flow rate.
comfort, lowers cost, and can
be increased with activities.
• Can deliver O2 flow rates up to
15 L/min.
Pendant-type O2-conserving cannula.
Partial and Non-Rebreather Masks
• Used for short-term therapy for • O2 flow rate must be sufficient to keep bag from
patients with higher O2 needs deflating during inspiration to avoid CO2 buildup
• Achieves O2 concentrations of and rebreathing of CO2.
60%–90% (with flow rates of • If deflation occurs, increase flowrate on flowmeter on
10–15 L/min). wall to keep bag inflated.
• O2 flows into reservoir bag and • Mask should fit snugly.
mask during inhalation. • With non-rebreather masks, make sure valves
• Bag allows patient to rebreathe open during expiration and close during
about first third of exhaled air (rich inhalation to prevent decrease in FIO2 or
in O2) in conjunction with flowing O2. build-up in CO2.
• Vents stay open on partial mask. • Monitor patient closely, since more advanced
Some agencies prefer this over interventions such as CPAP, Bi-PAP, or intubation
non-rebreather as a safety issue. with mechanical ventilation may be needed.
Simple Face Mask
• Covers the nose and mouth. • Wash and dry under mask q4hr and PRN.
• Achieves O2 concentrations of • Mask must fit snugly.
35%–50% with flow rates of • Must have flow rates of at least 6 L/min to wash
6–12 L/min. exhaled gases out of mask (if O2 flow rate not high
• Mask provides adequate enough, CO2 rebreathing is possible)
humidification of inspired air. • May change to nasal cannula while patient is
• Safe eating.
• Easy to set up and use • Watch for pressure necrosis at top of ears from
• Typically used only for short elastic straps if patient wears for a longer time.
periods. Gauze or other padding may alleviate this problem.
