hi everyone and welcome to part two of our respiratory lecture series and this is acute lower respiratory Health deviations but you can basically pause on here to look at these but just a little review of the anatomy and physiology and what's going on in that chest wall this is for everything that's below the uh below the larynx right so as we continue down in the bifurcation of the lungs so a reminder about pulmonary circulation about the arteries and the capillaries thank you what's involved in the chest cavity so we have our parietal pleura our visceral pleura and then in between those there's that Pleural fluid which provides lubrication and kind of prevents friction and allows expansion compliance is the ability of the lungs to stretch and expand and there you learned a lot of chronic disorders that can affect compliance and under um respiratory we start to think more about the acute disorders so if we can't stretch enough we can't oxygenate and if we're over stretched then it's hard for the lungs to then let their their air out and with air trapping so we will spend most of our time talking about those disorders which cause decreased compliance so pneumonia pneumothorax pulmonary edema ards so that's where we'll take off here Okay so chest pain can have many sources what are the most common complaints that people have is a is a pleurisy uh the thing is when somebody comes in complaining of chest pain we often think it's cardiac but sometimes it's not there's a lot of different reasons somebody could have chest pain so pleurisy is basically a result of inflamed pleura and one of the treatments for pleurisy is to help him lay on their affected side because it kind of makes a a built-in splint and reduces the friction as we continue on here some of the things that we need to kind of discuss when we talk about respiratory status is the pulse ox so these are some of the easy screening things that we do so normal pulse ox is from 94 to 100 we consider anything under 90 percent that the tissues are not receiving enough oxygen this can differ based on the patient's underlying comorbidities so for example somebody who has COPD we often allow them to have a lower pulse ox right because those folks are are working up the hypoxic drive of people with ALS we often want them to have a bit of a higher pulse ox and they're considered to be um hypoxic at like under 95 I believe and this is because of the diaphragm issues so pulse ox is only as good as the vein that we're looking at right so in the event that somebody has cold hands we know that their pulse ox isn't as accurate so anybody's got low perfusion right some people's got sepsis foreign be affected by people who have anemia and hypercapnia but in general it remains a Mainstay of diagnosis and treatment and monitoring so just know your normals and what can affect it if we can't get a pulse ox on a finger then we might have to go to a nose and earlobe but I put them on you know we wrap them on baby's feet but understand that the most accurate is going to be the arterial blood gas so bear that in mind if we're concerned about somebody's oxygenation the best thing to do is get the blood get and then the chest x-ray a very common tool that we use it will show fluid it will show air show the bones but um as far as anything else though CT is the way to go it's not this isn't going to show you any vasculature issues anything like that so So speaking of blood draws and blood gases so this is a difference between what we would see on an arterial blood gas and then a venous blood gas now they're of course the arterial would be the one that would be the most accurate for us and you could see those normals there you guys should have uh learned these already and then look at the Venus on the other side so pretty uh similar pH I mean a little a little more closed of a window because it's deoxygenated but look we allow for more CO2 and less oxygen for sure bicarb generally the same range but uh the venous oxygen 60 to 80 percent so we know that that blood is deoxygenated and that's why these different values when in doubt if you don't know whether you've got an arterial or venous blood gases you should when you draw them and that's that's a special skill you'll be taught if you if you need it but in general when the blood comes out of the artery it actually fills up the tube rather easily you can see the pulses of the heart the color looks very um very bright and Venus is darker because it's deoxygenated in order to do an arterial blood gas you do need to do the Allen test to confirm that they have circulation to their hand basically what we're doing is we're looking for collateral circulation and this means that uh in the event that we were to cause a blood clot or other problem with the artery that we are using to obtain our sample that the hand would still have blood flow to it they do these preoperatively for free flaps and all sorts of things but commonly done at the bedside to make sure before we do a blood gas that we can actually not cause harm to the patient so basically what we do is uh we pinch the radial and ulnar arteries have the patient squeeze their hand a few times not that hand should blanch and then we let the ulnar artery go while we keep the radial artery perfusing or I'm sorry blocked off and we check to see if the color returns to the hand if it does not right you have about six seconds if it does not then you should not use that radial artery for your blood gas which means go check the other side potentially use a brachial stick or ephemeral let me go back here and set up when we suspect some sort of disorder for our patients then we also can do CTS and MRIs these are going to be rather Mainstays especially if we're looking for um issues with the vasculature so PES and basically some of our cancers things like that so look at uh the nursing care understand that CT that uses dye can cause acute renal failure so it may not be indicated in our patients who already have renal disease or they may need to have dialysis right after it depends on how important the scan is but many times we'll just do them without contrast if at all possible and then MRI this is a giant magnet which will pull magnet uh we've had people who weren't truthful about their some of their stuff that they had like for example we had somebody who had some shrapnel maybe he wasn't that truthful maybe he just forgot I don't know but it really will pull them out of the body because that magnet is so strong so the VQ scan is a pretty important scan for us as far as looking for pulmonary embolism so basically it's a two-step process one in which that they inject uh an isotope to see the vasculature and then they also breathe it in so basically they have oxygen and that uh Radioactive gas and they breathe it in and then they're able to see where the circulation is and then where the ventilation is and for example if we have good ventilation but not circulation so perfusion then that would roll them in for a pulmonary embolism and because this doesn't use CT dye for those people with renal disease that we suspect a PE the VQ scan may be appropriate for them gallium scan basically stages bronchogenic cancer and at this they're getting gallium and they have to go every few hours like at six hours 24 48 to look at how much of that gallium is being uptaken and then a PET scan pet scan is very common that once we have an initial diagnosis of cancer then we can use a pet scan to further identify areas of concern and look for Mets you have here a flexible flexible bronchoscopy this is a very common procedure it's usually done on an outpatient basis where the doctor will go down with a camera and a little arm there as you can see to grab samples so basically it's direct visualization the person does need to sign informed consent for this they are under conscious sedation and if you look at it we're taking their Airway and going down in there so they have to be NPO for you know at least eight hours prior to this so they usually say like at midnight the night before and you must check their gag reflex before feeding them or giving them anything to drink or else they will aspirate minor bleeding can be expected from this so things like blood pinched sputum right we might expect that after however um we do not expect them to have a massive amount of bleeding blood clots you need to always be concerned about their Airway after and then down here are some of the other reasons that we may do this bronchoscopy is uh somebody has a foreign body so somebody who's choking they can go down and get it we use flexible bronchoscopy and lavaging for people who have Burns and Airway Burns is a means of washing out their uh the bronchi they can even do some surgical procedures through there so again the priorities are going to be of course their Airway bleeding making sure they have their gag reflex the next one we have here is a thoroscopy I don't know why this is always moves on me every time I try and record these that's okay so the thoroscopy or thoracoscopy basically you can see here this is what we saw before it's a Vats and uh what do we expect to see here I mean think about this anytime we're going into somebody's chest like this we're giving them a pneumothorax right because we're entering that space so we usually expect chest tubes and uh monitoring them for worsening pneumothorax so if they become short of breath we always have these guys on cardiac monitor after surgery and that's always a possibility too for something like a flexible bronchoscopy that the doctor could actually cause a pneumothorax as well so throughout your reading about pneumothorax if we cause it it's called iatrogenic which means caused by a by Healthcare don't let them fool you that means we did it all right so thoracentesis this is a very common procedure so one that you need to be acutely aware of so basically the reason we do a thoracentesis is to get the fluid out of a lung in the plural space so not in the lung right it's in the plural space so that's very important to remember what it does why we're doing it all right A lot of times it's to drain a pleural effusion in that same vein we might have to do cytology on it in the case of malignant pleural effusions it could be cancerous if somebody has fluid in their plural space then they're likely having decreased lung expansion so things to know about thoracentesis absolutely the positioning there has not been any review that I've ever seen that doesn't ask you about thoracentesis positioning so here's a picture for you the patient should be sitting upright leaning on a table and in this basically the doctor and oh they say often done at the bedside the doctor will insert a needle and withdraw the fluid by a syringe or conversely they can insert the a tunneled catheter and leave it in place if by chance this person isn't able to sit up you they could lie on their affected unaffected side and be in position that way but ideally the person should sit up at the side of the bed and present their back to you know to the doctor by placing their arms on the over the bed table so some of the concerns about folks who have this procedure so if we take out large quantities of fluid this can cause a circulation shift into the pleural space so what does that mean right if the circulation kind of moves in that direction the person is going to present as a decreased blood pressure tachycardia they may need to have fluids to restore their volume as far as our patient teaching and our monitoring it is normal that people will have pain with this procedure we do use a local anesthetic but then afterwards like their breathing might be a little painful there should be some drainage on the dressing if there's a dressing Left Behind that's perfectly okay serosanguinous they may even complain of some chest pain what we will not see or should not see again are changes in vital signs to be worse and also we should not see them frankly coughing up blood because when we go into the lungs here remember we're not going into the lungs but rather into the pleural space there should be no communication with that lung tissue at all so if the person starts coughing up blood or hemoptysis as it's called then what we know is that that somehow they've gone further and from the plural space into the lung and this person would also be at risk for development of a pneumothorax as well okay so a little nod to oxygen toxicity I'm sure that you guys learned all about oxygen toxicity and how important it is not to give too much oxygen to a patient because if they have COPD you can make them stop breathing so I I want you to be aware here that we do care about oxygen toxicity as well um however our concern for it is a little bit different than the COPD person the one thing I want to make clear is that in the event of somebody in respiratory distress we will not be withholding oxygen okay because we want to make sure that we're treating those life threats first so if somebody I don't care if they have COPD or any other number of letters together if they are acutely short of breath and they are hypoxic we must give them the oxygen uh the concern we have here is oxygen toxicity for us would be too high of an oxygen concentration so greater than 60 oxygen uh given for over 48 hours so that is our definition of oxygen toxicity remember too much oxygen can damage our cells and you can see those signs and symptoms here if they have oxygen toxicity that's what we might see so we need to reduce the oxygen concentration if that's the case so this is always our goal is to give the person the least amount of oxygen that's effective so how can we do this right this is where peep comes into play the higher the peep the lower the oxygen can go generally right so as we add more people we can kind of move some oxygen because the peop forces alveolar compliance and then a CPAP can allow less oxygen to be used in the references there for you for the 11th Edition all right so CPAP and BiPAP are two different modalities for delivering therapy to our patients we do use these ambulances are now able to use CPAP if they're um certified we might use CPAP initially and then if that's not working we go to BiPAP basically it allows us to delay or even avoid intubation were commonly seen CPAP being used at home for people with sleep apnea we also use it to end of life care if the patient will accept it it's good for those folks who need ventilatory support but they refuse to be intubated so this is considered non-invasive positive pressure ventilation so ways we would not want to use this so contraindications include those who are not breathing I know it sounds silly to say it out loud but if somebody is not breathing please do not place them on BiPAP it will not help anybody who has a serious dysrhythmia they're altered uh little advisement on that though altered mental status yes it's a contraindication but sometimes it's also the indication for BiPAP and anybody who has head and facial trauma because these machines can be rather tight and you don't want to cause increased trauma to them okay so the difference between CPAP and BiPAP is that CPAP just gives the pressure um it's set that way and it will just deliver that again person must breathe independently same thing with the BiPAP difference with the BiPAP is that it allows for two levels of pressure so one for inspiration and one for expiration so that's cons that's called the ipap and the e-pap so basically this is better for blowing off the person's CO2 so this is what we use for people who have acute COPD exacerbations and respiratory failure okay so the next thing we're going to talk about is pneumonia there are a couple different pneumonias that we concern ourselves with of course community acquired pneumonia people are coming in with it not much we can do as nurses to prevent that one however what we can do is help prevent Hospital acquired pneumonia and ventilator-associated pneumonia so there are things that we do that we never even think about as pneumonia prevention but washing our hands right number one thing for infection control is always to wash your hands it is basic uh turning coughing deep breathing using the incentive spirometer turn it in positioning getting our patients out of bed and walking them elevating the head of the bed decreasing sedation right so people can cough up secretions and breathe a little more normally and expand their lungs another type of pneumonia that we have is aspiration pneumonia and aspiration is due to basically a depressed cough so for one reason or another that the person may have some difficulty with their swallowing or they're unable to effectively clear their Airway so they couldn't protect or clear it so um folks with trachs as well any alteration in the airway so remember if they have tube feeds they have to have the head of the bed elevated um uh at least 30 degrees we checked their tube placement and residual volume some say even um you know absolutely before each feeding but and the what about continuous speeds right so at least every four hours we may need to give them medications of which we've talked about some under the cancer section so things like antiemetics and gastric motility agents those that increase the emptying of the gastric contents anybody who has an airway or at risk for aspiration issue they should have suction readily available all right so a pleurisy and we talked about that in the beginning so inflammation of the parietal visceral pleura so when they have the pain it's coming from the parietal pleura the patient when they have pleurisy they will complain of like a sharp stabbing pain usually one-sided and it gets worse on inspiration so we if it's inflammation and NSAIDs will generally work so indonesin and again splinting and turning them on that affected side to reduce the expansion that's all that's needed there and then of course treat the underlying cause and here we'll talk about a pleural effusion so pleural effusions can be either transitate or exudate so basically if it's thin and watery versus an actual bacterial infection or malignant from a tumor you could see the X-ray there you shows that layering out of the air fluid line if we were to percuss the patient we would hear a dull percussion so remember air gives you hyper resonance and fluids would give you dull resonance so and then there's also a role for a tactile fremitus which is something that you guys should have learned in your initial courses so basically that's where you're having the patient say 99 and you're trying to see how the uh how the vibrations are transmitted across the lungs so um anything that increases the space between the the lungs and you listening can cause decreased fremitus and things that cause a decreasing space would cause increase so consolidation in the form of pneumonia might cause that pneumothorax would decrease it pleural effusions would probably decrease it right because you're putting an extra space between the lungs and empyema is a lung infection as well so this is thick fluid that's in the pleural space does come from bacterial pneumonias and comes from abscesses basically the exudate kind of goes in there from the lungs okay some other reasons that somebody might get an empyema would be chest trauma we might have done it iatrogenic so signs and symptoms are listed here of the fever night sweats cough shortness of breath how do we treat it so you can see the dullness on percussion decreased breath sounds so it's treated with a long-term course of IV antibiotics we may need to do a aspiration or even a chest tube if we cannot heal the empyema it's possible that we have to do a thoracotomy to remove the disease tissue so basically empyemas are absolutely no fun for the patients it's a long-term course and often results in uh a longer disability right they need IV antibiotics for quite some time all right let's move this over here so what is a pleurodesis so and it's basically uh when a chemical irritant is placed between the pleural layers that decreases the pleural space to prevent pleural buildup so basically what we're trying to do here is cause scarring right the scar tissue allows those lungs it allows the lungs to expand because it sticks the visceral and the parietal together so in order to do a pleurodesis basically we have a chest tube and the chemical irritants are placed in there it's usually some sort of a sterile talc so that's done and then the chest tube is clamped or in some cases I've seen doctors basically hang it up on the IV pole but for NCLEX hospital we will always clamp it and then we turn the patient like a little rotisserie so that we can get that talc infused and settling where it needs to be so again the hope is that the scarring closes the spaces now if that doesn't work then we often have to go to more invasive procedures including wedge resections or economies even further potential removal of that lung tissue and as we kind of go down let's talk about lung cancer here so lung cancer we talked a little bit about lung cancer under our cancer section but I think we need to address it here as well of course smoking being the number one risk factor for lung cancers non-small cell lung cancers are the most common uh but the most aggressive of course are the small cell lung cancers so um treatment does a surgery radiation chemo just the same as we've talked about before but here's something to be uh concerned about so if there's any mediastinal involvement so remember what's in our mediastinum our hearts there that we could end up with cardiac tamponade pericardial effusions and dysrhythmias so in the event of cardiac tamponade that's Bex Triad which hopefully you guys have learned about if not I know we do address it at some point in this course but that's what we may see and then of course there are things that go along with some of our lung cancers it's a perineal plastic syndrome so basically those cytokines are messengers enzymes and antibodies they tend to destroy some healthy cells so when we talked about an oncological emergency of syndrome of inappropriate antidiuretic hormone secretion one of the main risk factors is that small cell lung cancer and sometimes these things in the perineoplastic syndromes they show up long before the cancer does of so basically I I think it's just important to know that like like uh Cushing syndrome can be a result of these lung cancers what else is on here like you can pause and take a look at these I put some of the most common and what causes it so people who have things like polycythemia it's because of too much erythropoietin but for us when we talk about lung cancer we're concerned with uh siadh hypercalcemia and Cushing syndrome and just like we talked about with cancer targeted therapy can be used to block tumor growth and targeted therapy if we can do targeted is preferred because it's less toxic and then um some of the other things we do so tyrosine kinase Inhibitors and I believe those are the ones that end with nibs and then angiogenesis Inhibitors so those ones would stop the vessels growing uh again those can also cause clotting and other problems whenever we start messing with our vessels and our red blood cells so let's talk about a lobectomy this is a pretty common surgery we try to do more tissue sparing these days but flopectomies are still going to be seen definitely much more often than a pneumonectomy you could see there's different types of surgeries on the right hand side of here the most tissue sparing would be the just getting the wedge out so they take a little spot of the lung around the mass and then they might have to take a segment a possible low back to me so they take the whole lobe and then an enuminectomy they actually take the whole side of the lung so things to think about one is that anytime we go in and do one of these surgeries we are causing a pneumothorax so with uh three of these surgeries they will always have a chest tube so the wedge the segment the lobectomy will have a chest tube sometimes two chest tubes so if they do have two one would be placed in the upper position to collect air and one more inferior to collect fluid and if they're just having a lobectomy segment or wedge the person can lay on any side right it's no activity restrictions as far as that goes so the issue comes in when we have a pneumonectomy right so pneumonectomy as you recall from the previous pictures the removal of the entire lung and this happens I mean if the cancer is large if it's based on where it's located and we do this for more than cancer we may do it for tuberculosis abscesses that we can't heal it is more dangerous to take out the right than the left because of think about it the left has two lobes and the right has three so definitely more vasculature there and they usually would have no drains no chest tube right we need the person to have an accumulation of the fluid to prevent that mediastinal shift and our post-operative care so let's let's keep going on here I will do pre-app and post apps so pre-app is uh definitely let the patient know that they're going to be an ICU they need the ventilator post-op that as they get better they'll start to move up to the regular floor that we will control their pain pain is expected that they may need blood products so just normal pre-op teaching right let them know what to expect and then for us for the care let me move this over so we can see we know that if we're removing a lung then they have decreased lung capacity we do keep our IV fluids at the lower rate because we do not want to cause pulmonary edema keep the head of the bed up 30 to 45 degrees once they're stabilized we want to keep the remaining lung in the uppermost position so good side up so if the left lung was removed then the right side should be up right so good lung up good side up this is different than some of our pneumonia teaching our pneumonia teacher says good lung down so uh good lung up for these guys all right these guys usually have an epidural um they need to work on their lung expansion range of motion monitor them from and for infection and then they may need also ventilator care so just uh little helpful hints there next we're going to talk about chest trauma uh a person can sustain chest drama either through blunt or penetrating means sometimes both right so a penetration would be things like a stab wound uh gunshot wound something impaling them and blunt would be of course blunt force so anytime we have somebody who has a chest trauma we always want to be concerned about their airways breathing and circulation a potential that they would need to be mechanically ventilated some of the things that you'll see are things like paradoxical chest wall motion it's very important that you understand what that is and what it means if there's any shift in the trachea from its normal midline position that could be a sign of tension pneumothorax listening to their breath sounds becomes a very important because anybody who has a hemo or pneumothorax will have a decreased breath sounds management of these patients does include making sure they have at least two IV access to large bore IVs and that we may have to give them fluids including blood products Labs would be type and type and cross we do chest x-rays potentially CTS we need blood gases uh heart monitoring right and ultrasounds potentially remember to completely undress your patients so that you do not miss any wounds and you're looking for entry and exit in any impaled objects distended neck veins just coming back to that that should be under the assessment section if a person is bleeding we would expect to see a flat veins but distended could also mean that you have a big problem above too with uh some shunting a subcutaneous emphysema means that there is air Under the Skin where it doesn't belong and that is a sign of potentially a pneumo and barotrauma so lung injury bruising potential always want to check their peripheral pulses to make sure they're not going into shock foleys may be needed for shock management as well nasogastric tubes and then chest tubes to monitor the intrathoracic bleeding so anytime somebody has a an open wound like that an open pneumothorax the treatment for it is to apply the three-sided dressing so what we do with that is you put the occlusive dressing over it and then you tape up three sides and you leave one open so basically as the patient breathes in it blocks them from sucking the air in and then um as they breathe out it allows the air to escape and that prevents the buildup of into attention pneumo and uh I think we may talk about this um later but the three-sided dressing very important uh we're more likely to get a sternal fracture through things like massive trauma you've got to think how strong that bone is so motor vehicle crashes where people are hitting the front of the car and wave the dashboard or their steering wheel if they have flailed chest we'll talk about that in a minute and some of the things they might complain about would be anterior chest pain that you'll see bruising feel the crepitus they may have a chest wall deformity think about what's under the ribs and where they're located as to what may be damaged by this so ribs five through nine those are the ones that are not as large as one through three and these are the ones that underneath our lying our liver and our spleen so these people often will have like a spleen laceration liver laceration very hard to break ribs one through three um but if you do do that through that blunt trauma there's a lot of vasculature that's through there including the subclavian artery and people can bleed out pretty quickly and our older folks do not tend to do as well with rib fractures so if they have at least three rib fractures they're more than five times likely to die from it so some of the um complications from our rib fractures really is pneumonia so I mean outside of the initial life threats but they they tend to get pneumonia because this is very very painful and if that's the that's the case people tend not to breathe as deep which leads to atelectasis and then of course the bacteria come and a person dies of atelectasis and pneumonia so there's uh we used to I I say kill them with kindness we used to splint their rib fractures and uh it would be very comfortable but again increased mortality so now we don't generally splint rib fractures anymore it's no longer recommended but instead we need to make sure we're giving these people adequate pain control and encouraging that incentive spirometer right even when they leave the hospital they need to take it with them they need to keep doing it at home a flail chest is a type of rib fractures where you have at least three adjacent ribs fractured at least two sites um basically what happens here is now you have a free agent right we've got this rib segment that are floating around they can actually work as a sharp object and additionally they can no longer expand that part of the lung right because you need those those ribs to be moving in unison to provide that so and that causes that paradoxical chest wall motion and paradoxical movement so basically when they breathe in that that rib gets sucked in and when they breathe out the rib section bulges out and that causes them to have increased work of breathing they're usually in extremists they are short of breath dyspneak if it's bad enough they may need to have intubation and surgery is to stop that piece from flailing so they may need to have that put back in order and one of the other things is uh that we need to be concerned about with chest trauma is and a flail chest but chest trauma in general is a pulmonary contusion if a person has a pulmonary contusion we may not see that right away right because think about a bruise inside the lungs so the the bruising can eventually lead to problems later on we may not be like we hit our arm we don't see a bruise for several hours same thing with the lungs we may hit the lungs and not have that bruising occur for several hours so what we would see is after the initial injury we would then see the signs of shortness of breath this is not something we can see from the outside right so we need to be aware and continue to monitor our patients who have sustained trauma and then this just shows you the mechanism of a flail chest and you can see that paradoxical movement I encourage you guys to watch the video and see what it looks like so one of the dangers of course is the pneumothorax which we've sort of talked about already so pneumothorax can be caused by trauma or it can be spontaneous so the questions we need to ask ourselves is what's the cause so um patho really is the air entering the pleural cavity could be due to let's say due to trauma and if and it's either going to be open or closed right so open means that there is an opening in the chest wall these are the sucking chest wounds they literally make that sound as if the air is sucking through and under close there's no external wound so these would be um perhaps caused by let's say somebody had a bronchoscopy that would be a closed pneumothorax somebody who has an emphysemidis bleb that ruptures that would be closed the one that's of course the the most dangerous would be the closed because there's nowhere for the air to go that can lead to attention pneumothorax and for us the Hallmark sign is going to be the decreased breath sounds right diminished our absent breath sounds over uh over this over the place where the pneumothorax is so just a a reminder there that uh what the pneumothorax is that it can be open or closed if we have an open pneumothorax it is appropriate to put that three-sided dressing on the patient and if it's closed we may need to we would need to have a chest tube inserted or a needle decompression if they had a tension pneumo all right so they say this kind of backs up a little but the signs and symptoms we see on a pneumo really depend on how big the pneumothorax is so a small one person may be completely ambulatory heart rate increased maybe take a little shortness of breath but a large pneumothorax the person will be in respiratory distress foreign and then there's the types which again we've already kind of addressed so it's just written there for you you see here our open pneumothorax and the treatment you see that three-sided dress that gives you that flutter valve uh tension pneumothorax is a medical emergency and that this is what we'll see in the patient severe dyspnea tachycardia Hallmarks Hallmarks for you guys tracheal deviation right that's a Hallmark there so anytime we see tracheal deviation you're going to want to act quickly to make sure that we relieve it so either by chest tube or needle decompression neck vein distension could be seen in the tension pneumo and here you have another representation of it the mediastinals shift so the you have tracheal deviation away from the side that's affected concerns here would be that of decreased cardiac output due to decreased return to the right side of the heart right so if we can't squeeze in we can't let out so uh so venous return is affected and we know the veins go to the right side of the heart at the left and that causes decreased output and so here is the treatment so foreign secure that dressing onto three sides for uh be prepared to insert a chest tube and for tension needle decompression or a chest tube if there is an impaled object in your patient please do not remove it instead you stabilize it with a bulky dressing and don't pull it out so now let's start to talk about the chest tubes a little bit that'll be our next section okay so the first thing to look at is where does the chest tube go all right so it goes in the intercostal space right so it goes between the rib cage and goes into the plural space and that's where it can do its magic right that's where it can either drain fluid or air you may be tasked with assisting with placing a chest tube and that's a well within your scope of practice and a very common thing that you would see so we do prefer to do them under non-emergent conditions so that would be the ideal doesn't always work that way but if we can definitely make sure we have local anesthetics and have everything set up you need a thoracotomy tray the chest tube the doctor will tell you what size they want but in general we use smaller tubes for air so even up to something we call like a pigtail catheter and then larger chest tubes if we think there's going to be a lot of fluid or blood and then positioning we put the patient flat wedge under the shoulder blades even like a rolled up blanket and then the arm that we're going to be working with over their head all right so and then I also put on here where they put the needle decompression for the tension pneumo doesn't necessarily belong there but um kind of kind of does right so remember if we're doing something superiorly it's to relieve air and inferiorly would be for drainage so you may get air and drainage from the lower ones as well so you see here of a common chest tube this is Atrium it's considered a name brand so Atrium is the the manufacturer and this one is called an ocean but we also have things like Oasis it's just the model uh what's important to know is what the different sections are of the chest tube and what they do and in your packet that I've created for you if you're listening to this and don't have a packet something I've given out in classes you have a chest tube which you can label and you can look and see what the different sections are and you should know them right a lot of a lot of times nurses are sort of quizzed on you know what's going on and taking care of the patient depends on you knowing what's Normal and abnormal so the collection chamber is to the far right sometimes called a trap chamber and that's basically coming from the patient and through there air so if there's air coming from like a pneumothorax we'll go through there as well as any drainage right usually serosanguinous but can be bloody depending on what's Happening it could even turn into that Kyle like we talked about under the head and neck cancers where you know you could have that thick milky drainage which is significant for a lymphatic leak and then from The Collection chamber we end up going into the water seal so there's a one-way valve there it stops the air from going backwards up to the chest and then it kind of as the air moves over it that's where you have the bubbling right so intermittent bubbling is good in the Water Seal um you may have continuous bubbling as we if it's just inserted or you have a rather large pneumothorax but it should settle down if it doesn't or if it starts when it wasn't there we would consider that to be an air leak and then we uh have the whole titling so that's uh that's the next section we have where we can uh title in that area as the person breathes in and out it should the ball should rise and fall with the respirations interestingly enough if they're on a mechanical ventilator it's backwards because the ventilator is a negative it's positive pressure not negative and then the suction control chamber uh so it depends on the type if of chest tube the ones that you see here would have you put the water in to give it to the negative pressure um the newer some of the other ones that aren't this type you can just dial them and then there's even a spot up at the top that we can hook this up to wall suction and sometimes we need to do that to uh to make sure that the treatment is uninterrupted and that it provides better expansion caring for a chest tube is going to be one of your responsibilities so it's very important to know the do's and do Nots right so chest tubes need to be kept lower than the level of the chest of course because they're draining by gravity and we wouldn't want things to back up you are responsible to collect and record that output as part of your output so we do have some norms and abnormals so over 200 mls in the first hour or more than 100 MLS an hour thereafter per NCLEX standards is reportable we want to make be careful not to kick the unit break the unit um if by chance the unit breaks then you need to restore that water seal and we usually say put it into centimeters of sterile water we never milk or strip the chest tubes and a little bit about titling so we expect titling when the person is breathing because that is like the difference in the pressures from negative to positive pressure as they breathe however as the patient heals uh and that plural space decreases we'll see less titling so what to do if the patient doesn't have titling first make sure that there's no kinks in the tubing make sure you don't have it accidentally clamped or something going on and understand that it may be a normal process what I look at is is something new right if somebody's been titling the whole time at eight o'clock and then I go back from meds at 8 30 and they're no longer titling more than likely they've uh it's not connected somehow it's occluded or you know might be something going on there and then also a media spinal tube we often put them to the same exact apparatus right so it just look like a chest tube but you have to know where it's placed there's no titling in the mediastinum so um you wouldn't expect to see titling so mediastinal drains are often used post surgeries like Open Hearts so if it's not in the plural space it's not going to title all right so other care issues we don't clamp the chest tube used to be we would clamp them or transferring and going to certain places we found uh whoops we've caused attention pneumothorax when we did that so we don't do that anymore so um the only time that we tend to clamp the chest tube is during a chest tube change of the suction canister or the collection so that's when we clamp it and it's a very brief and I can show you on class how brief if by chance the person were to completely dislodge their chest tube we then need to treat that as an open pneumothorax and apply that three-sided dressing okay a little more on chest tubes subcutaneous emphysema means that there's been barotrauma um right it means that the the chest tube could be dislodged it may not be in the spot that it was so what's the problem with subcutaneous emphysema is that uh it can impair the patient's Airway we we do sometimes see a measure of subcutaneous emphysema just right around the chest tube insertion site and you can press your fingers around it and kind of feel that kind of Pops the air underneath your fingers and generally localized but if subcutaneous emphysema were allowed to spread it could go up and affect the airway I've seen patients literally turn into the stay puffed marshmallow man with all of the edema from the subcutaneous emphysema we want to always always make sure that we're taking good care of our chest tubes when we ambulate patients we don't have that tube wrapped around them we carry it on you know the same side that it's coming out of be very very careful not to knock it over otherwise damage it make sure that the patient doesn't accidentally Kink that tubing when they're sitting up and down in their chairs we never milk chest tubes you'll see doctors doing it we don't and then of course the patient needs to turn cough and deep breathe as well so we want to promote lung expansion for us we know it's time to take the chest tube out when the chest x-ray basically says that right the lungs expanded the patient has been off of suction they can go to water seal and they're tolerating that well then um that would be a good a good indicator that they're healing look at me I'm always ahead of myself indications for chest tube removal here it is so and then this picture is kind of interesting so this is what we call a heimlich valve it's a one-way valve that's just used for for a chest drainage and uh they patients can go home with these little heimlich valves so people have like persistent pneumos and sometimes now we even have like um portable atriums very interesting people don't have to stay in the hospital as long these days as a result of some of this technology all right so here's just a little nod to cardiac tamponade which like I say could always be a concern with uh with any problem in the mediastinum any of our um lung cancers you absolutely need to know this stuff right it's cardiac tamponade basically the fluids filling the pericardial space which every time that happens the heart can't beat appropriately and they can't fill so what do you see a decrease cardiac output if the heart can't fill then we see the backup of the blood into the jugular veins and then muffled heart sounds so back to Triad that's must know information okay some of the last things we're going to talk about in this section will in it will be the pulmonary embolism so basically a pulmonary embolism is a blockage of an artery one or more that basically causes that ventilation perfusion mismatch so they they are clots that travel usually from the deep veins of the legs but can be from other places uh and based on the level of occlusion is like what signs and symptoms we're going to see how distressed the patient is so look at some of the risk factors right so here we have tons of risk factors for PE Ace immobility reduced Mobility especially any surgeries uh within the last three months especially the pelvic or lower extremities so somebody who has like a hip replacement knee replacement orifs anything like that obesity people who are on oral contraceptions hormone therapy any clotting disorders pregnancy so the the risk for getting a PE is actually pretty large um but less common causes of PE would include those fat emboli which we'll talk about in musculoskeletal air embolism from improperly administered IV therapy or central line removal and the treatment for an air embolism is a little bit different and of amniotic fluid embolisms and and even tumors so so here's your assessments and Diagnostics so what we're going to see in the patient really is tachycardia dyspnea they'll have potentially um cyanosis a kind of a a later sign but depending on how large it is um they may be a cyanotic if you look in their ABG it definitely would show some decreased aeration if they had a massive PE some of these are deadly right away um person has altered mental status and hypotension as far as Labs we do look at the D dimer so a d dimer is basically degradation products of a clot so anytime it's elevated it means the body's breaking down clots somewhere so what does that mean depends on the size of the PE so it may not be elevated if it's just a small PE so a a negative D-dimer doesn't mean they don't have one but a positive D-dimer means they definitely have a clot somewhere we use that spiral CT that's the most common and that uses the contrast and if not we would use that ventilation perfusion scan which we talked about earlier in this presentation so treatment right treatment is to Immediate Care is to take care of the patient right set them up get that oxygen atom it's a little different than air embolism treatment air embolism we wouldn't want to set the patient up and uh reasons are of course air would rise and could actually worsen but for signs of a pulmonary embolism Sit Them Up get that oxygen on them and we may need to treat them for shock uh an initial treatment for most patients is anticoagulation usually with Lovenox or a Heparin drip putting them on coumadin if it's a massive PE we may need to actually break up the clot we might have to go in and actually remove the clap with an emboleectomy and then IVC filter is more of a preventative for people with known dvts or who cannot have anticoagulation so a little nod to anticoagulants is that um basically they're pretty dangerous right somebody is on a Heparin drip we need to monitor them so carefully because of the risk for bleeding and then also the risk for heparin-induced thrombocytopenia syndrome so our no acts are now called thoughax we'll talk about that I I still keep the old terminology because you might see a doctor talk about the noax but uh uh aspirin and Plavix are not total anticoagulants what they are anti-platelet aggregators so um but they can lead to bleeding because it keeps you from letting your platelets stick together so those are the meds they are kind of must know meds so let's talk about heparin um the first thing I do want to back up and say that when we're treating these blood clots these PES outside of actually going in and doing fibrinolysis or an ambolectomy we're not actually treating the clot that's already there what we're doing is preventing the body from enlarging that clot and making more so um Heparin can prevent that it starts immediately we give it to them we usually give them a bullish dose if we're doing a Heparin drip weight-based and we may do a continuous infusion and remember anything that can cause that's like an anticoagulant can cause bleeding so always be mindful we monitor this with the PTT newer and most direct action of Heparin is monitored by the anti uh Factor 10A so anti-axa you'll often hear and monitoring their platelets we need their platelets to not drop because if their platelets drop we are concerned about heparin-induced thrombocytopenia uh there is an antidote for Heparin and anytime there's a med that has an antidote you would be wise to remember it a Lovenox is heparin it's just a low molecular weight Heparin so do not be confused a person with an allergy to Heparin is also allergic to Lovenox they cannot have that ever but Lovenox is um is decent because it can Bridge Coumadin people can go home and take lovenax it's a basically has the same reversal agent and it's used in pregnancy and elderly it's a little bit easier uh they can they say do it at home and it doesn't require lab values to monitor it as much as something like Heparin or Warfarin does so usual dose one milligram per kilogram every 12 hours most normal adults will take a 40 milligram dose subcutaneous twice a day sometimes even once a day now depending on if it's just preventative but if they're being treated for a blood clot it would be twice a day and then uh Warfarin which was a you know very interesting if if you ever want to nerd out or something go look at how Warfarin was uh created and introduced and sold and everything but so warfarin it takes about 36 to 72 hours to start working and then to be therapeutic five to seven days this is why we tend to bridge people with uh lovenax as they start on Warfarin for this we do monitor the PT i and r so the INR is what we base our dosing off of generally we want that inrb between like two and three for most folks and those with mechanical heart valves we can keep them a little thinner like two and a half to three and a half antidote is Vitamin K so this is why diet is so important with these people um used to be like they say like don't take any vitamin K containing foods like keep them decreased um we're more patient-centric now so basically we say that if they eat green leafies every day then they should continue to eat them every day because otherwise um they could inadvertently deactivate their their warfarin the one thing I've noticed is as excuse me as people get sick their INR tends to go up it was just a very interesting thing I think it probably has to do with how it's metabolized when we have inflammation and the different cascading like our intrinsic pathways but it's a pretty interesting so always watching for signs of bleeding these are the folks that if they fall and bump their head they need to have CTS right we are very concerned about them all right so let me move this over again I have no idea why it does this and on some slides and not the other but it is what it is so uh so Plavix is again we use this after stenting it's a platelet aggregation inhibitor uh we don't usually see it as prevention of CVA um for like just CVA itself it's people who have stenting so people who have had surgeries on their legs to restore circulation people have stents in their heart we'll see it for that and then the uh again they call them new oral they're not called that anymore they're now called thoughax or direct oral anticoagulants these meds are great meds in that they don't require monitoring they actively work on Factor 10. uh they're coming down in price when they came out they were very expensive but the other issue is that there's no antidote to these so if there is um a problem with this somebody needs surgery whatever we have to really or they have a reaction we have to really support them uh through it until the medication wears off again there's no antidote okay and uh I guess the last thing we'll talk about in this section is the green filled filter uh falling out of favor these days so we don't see them that often but you may still see them and patients may have them so you should know about them basically it's a filter that's placed in the IVC and that basically collect clots so that they wouldn't travel up and become pulmonary enveli or you know into the brain so anybody who can't have anticoagulation this would potentially be the procedure for them uh the problem is that if you can look at these little legs that are here they they tend to actually break off and enter circulation and become embolic events themselves so a lot of lawsuits on it and uh they're they're kind of falling out of favor all right guys this was long so I appreciate your uh attention during it thank you so much