SPECIAL RESPIRATORY CARE PROCEDURES

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CHAPTER 5 SPECIAL RESPIRATORY CARE PROCEDURES

PRETEST QUESTIONS

Answer the pretest questions before studying the chapter. This will help you determine your strong and weak areas in the material covered.

1. Which of the following are complications associated with bronchoscopy?

1. Pulmonary hemorrhage
2. Pneumothorax
3. Hypoxemia
A. 1 only
B. 2 only
C. 1 and 3 only
D. 1, 2, and 3

2. While assisting with a bronchoscopy, you note that the physician is having difficulty entering the trachea. This may be the result of which of the following?

A. Pneumothorax
B. Hypoxemia
C. Laryngospasm
D. Pulmonary hemorrhage

3. After a bronchoscopy, the respiratory therapist notes that it is taking more ventilator pressure to ventilate the patient’s lungs than before the procedure. This could be caused by which of the following?

1. Bronchospasm
2. Pneumothorax
3. Hypoxemia
4. Pulmonary hemorrhage
A. 1 and 2 only
B. 2 and 3 only
C. 1, 2, and 4 only
D. 2, 3, and 4 only

4. To aid in the evacuation of air from the pleural space, a chest tube should be inserted at what level?

A. Supraclavicular space
B. Second intercostal space anteriorly
C. Sixth intercostal space anteriorly
D. Eighth intercostal space anteriorly

5. The respiratory therapist notices on a patient’s chest tube drainage system that there is fluctuation of the water level in the water-seal chamber with each patient breath and air bubbles seen only in the suction control chamber, which has a suction pressure of −15 cm H2O. The most appropriate action is which of the following?

A. Clamp the chest tube and check for leaks.
B. Insert the chest tube farther, until bubbling stops in the vacuum chamber.
C. Withdraw the chest tube until bubbling starts in the water-seal chamber.
D. Recommend a chest radiograph to determine whether the pneumothorax has resolved.

6. The respiratory therapist observes that, during a patient’s breathing cycle, there is no fluctuation in the water-seal chamber of the pleural drainage system. The most appropriate action is which of the following?

A. Withdraw the tube until fluctuation is seen.
B. “Strip” the chest tube to clear a possible obstruction.
C. Increase the vacuum pressure.
D. Clamp the chest tube and observe for leaks.

See answers and rationales at the back of the text.

REVIEW

I. BRONCHOSCOPY

CRT Exam Content Matrix: IC2, IIA25, IIIJ2

RRT Exam Content Matrix: IC3, IIA11, IIIJ2

A. A technique for assessing and examining the bronchi by means of a bronchoscope, which is used for both therapeutic and diagnostic purposes
B. Types of Bronchoscopes
1. Rigid bronchoscope

image

FIGURE 5-1 Rigid bronchoscope.

From Scanlan CL, Simmons KF: Airway management. In Scanlan CL, Wilkins RL, Stoller JK: Egan’s fundamentals of respiratory care, ed 7, St Louis, 1999, Mosby.

a. Consists of a hollow metal tube with a light on its distal end.
b. Tube is inserted orally, then passed between the vocal cords into the trachea.
c. Is useful for removing aspirated foreign bodies and thick secretions from the lungs.
2. Fiberoptic bronchoscope

image

FIGURE 5-2 Fiberoptic bronchoscope.

From Scanlan CL, Simmons KF: Airway management. In Wilkins RL, Stoller JK, Kacmarek R: Egan’s fundamentals of respiratory care, ed 9, St Louis, 2009, Mosby.

a. Consists of a collection of thin, threadlike glass strands called fiberoptic filaments with a light source projected to its distal end for visualization.
b. Is better tolerated by patients than the rigid bronchoscope because of its more flexible nature; it is therefore more commonly used.
c. Preparatory regimen for fiberoptic bronchoscopy
(1) Because bronchoscopy is uncomfortable, a mild sedative should be administered to the patient 1 to 2 h before the procedure. Commonly, diazepam (Valium) or midazolam (Versed) is used for this purpose. The level of sedation, referred to as conscious sedation, should be just enough to allow the patient to follow commands yet still be comfortable.
(2) The airway must be dry during the procedure to aid in visualization, which is usually achieved by administering atropine 1 to 2 h before the procedure. Atropine may also decrease vagal tone, resulting in a decreased potential for bradycardia and hypotension, which can occur during the procedure.
(3) The tube may be inserted orally, nasally, or through the ET tube. The bronchoscopic tube should be lubricated with a water-soluble jelly for easier nasal insertion. Often, lidocaine (Xylocaine) jelly is used both as a lubricant and for its anesthetic effects. In some cases, the RCP administers aerosolized lidocaine before the procedure.
(4) Because of its flexibility, a fiberoptic bronchoscope can be advanced farther into the airway than a rigid one, thereby allowing more visualization of the conducting airways.
(5) Biopsy forceps and brushes may be inserted through the bronchoscope to obtain tissue samples.
C. Indications for Bronchoscopy
1. Removal of foreign bodies
2. Removal of mucus plugs and thick secretions
a. Is normally performed when secretions cannot be removed by routine suctioning techniques
b. Once the site of the secretions is visualized, the area should be lavaged with saline before suctioning.
3. Atelectasis that affects a lobe or an entire lung
4. Pulmonary hemorrhage
a. To locate the area of bleeding
b. To control bleeding by instillation of epinephrine or iced saline lavage at the bleeding site
5. When tracheal intubation is difficult as a result of upper airway trauma, obesity, tumors, or spinal deformity
a. The ET tube is slipped over the fiberoptic bronchoscope; the scope should protrude well past the end of the ET tube.
b. The vocal cords are visualized, and the scope is advanced through the cords to the midtracheal level, where the ET tube is then advanced over the scope to the proper position. The scope is then withdrawn.
6. Biopsy of suspected tumors
7. When sputum is needed for culture and sensitivity studies
D. Complications of Bronchoscopy
1. Hypoxemia
a. Monitor oxygen saturation during procedure.
b. Increase oxygen percentage during procedure.
2. Laryngospasm
a. Makes advancing the tube more difficult.
b. Bronchodilator should be readily available.
3. Bronchospasm
a. Results from irritation of the airway.
b. Bronchodilator should be readily available.
4. Arrhythmias
a. Result from vagal stimulation.
b. Monitor ECG and remove bronchoscope until cardiac status is stabilized.
5. Hemorrhage
a. May occur during insertion.
b. May occur after biopsy.
6. Respiratory depression
a. Results from sedatives given before the procedure.
b. Monitor respiratory status closely.
7. Hypotension
a. Results from vagal nerve stimulation.
b. May result from sedatives given before the procedure.
8. Pneumothorax
a. Results from inadvertent puncture of the lung.
b. Monitor respiratory status closely.

E. Respiratory Therapist’s Responsibilities during Bronchoscopy

image Responsibilities of the RCP vary according to the institution’s protocols. Those listed below are among the most common responsibilities.

1. Prepare the patient and explain the procedure.
2. Administer aerosolized local anesthetic to the patient’s upper airway.
3. Conduct patient monitoring throughout the procedure.
a. Pulse and blood pressure
b. Respiratory rate
c. ECG
d. Oxygen saturation
e. Level of consciousness
4. Collect sputum and tissue samples that the physician has obtained and prepare them for laboratory analysis.
5. Clean the bronchoscope properly after the procedure. The Centers for Disease Control and Prevention recommends that bronchoscopes be sterilized by immersion in glutaraldehyde (Cidex) for 3 to 10 h.

II. CHEST TUBE INSERTION AND MONITORING

CRT Exam Content Matrix: IIIJ5

RRT Exam Content Matrix: IIIJ5

A. Chest tubes are used to drain substances that accumulate in the pleural space.
B. Substances that may accumulate in the pleural space and their diagnoses include:
1. Air: pneumothorax
2. Blood: hemothorax
3. Lymph: chylothorax
4. Serous fluid: pleural effusion
5. Pus: pyothorax or empyema

image The term hydrothorax is often used to refer to lymph, serum, or plasma in the pleural space.

C. To help evacuate air (pneumothorax) from the pleural space, the chest tube is usually inserted in the second, third, or fourth intercostal space. To remove fluids, the tube is placed lower, usually in the sixth or seventh intercostal space.
D. Chest tube insertion is done under local anesthesia; for large tubes, regional anesthesia with an intercostal block is used.
E. Chest tubes are sutured in, and the insertion distance should be monitored daily to ensure the tube is not migrating outward. If the proximal hole on the chest tube slips out of the chest, air enters the tube, resulting in bubbling in the system, which appears to be a persistent leak in the lung.

image Once the air is evacuated from the pleural space, spontaneous healing or sealing of the leak in the lung usually occurs.

F. Chest Tube Drainage Systems
1. One-bottle system

image

FIGURE 5-3 One-bottle system.

From O’Toole M, editor: Miller-Keane encyclopedia and dictionary of medicine, nursing, and allied health, revised revision, Philadelphia, 2005, Saunders.

a. Fluid or air drains from the pleural space through the chest tube and enters the drainage bottle through a glass tube, which is submerged under water. This forms a seal that acts like a one-way valve to prevent air from entering the pleural cavity.
b. Air entering the bottle is then vented out the short tube in the top of the bottle.
c. The one-bottle setup is both a water-seal container and a collection container.
2. Two-bottle system

image

FIGURE 5-4 Two-bottle system.

From O’Toole M, editor: Miller-Keane encyclopedia and dictionary of medicine, nursing, and allied health, RR, Philadelphia, 2005, Saunders.

a. In this system, a second bottle is added to collect air exiting the pleural space. Liquid drains into the first bottle.
b. The purpose of this system is to better control the amount of suction applied. A suction source may be connected to the vent of the water-seal bottle.
3. Three-bottle system

image

FIGURE 5-5 Three-bottle system.

From O’Toole M, editor: Miller-Keane encyclopedia and dictionary of medicine, nursing, and allied health, RR, Philadelphia, 2005, Saunders.

a. A third bottle may be added to determine the amount of subatmospheric pressure in the water-seal bottle.
b. The amount of suction is determined by how far under the water the tube is submerged.
c. A suction source may be attached to the third bottle’s vent to maintain a desired constant subatmospheric pressure.
d. The most common chest tube drainage system is a plastic three-chambered system (Pleur-Evac).

image

FIGURE 5-6

From Wilkins RL, Stoller JK, Kacmarek R: Egan’s fundamentals of respiratory care, ed 9, St Louis, 2009, Mosby.

G. Important Points Concerning Chest Tube Drainage
1. The water level in the water-seal bottle fluctuates with changes in pleural pressure that occur with normal breathing. If no fluctuation is occurring in the water-seal bottle, obstruction of the tube should be suspected.
2. Chest tubes may become obstructed as a result of blood clots or kinks in the tube itself. Obstructed chest tubes may result in a tension pneumothorax.
3. To ensure adequate drainage and tube patency, “strip” or “milk” the tube every 1 to 2 h. Accomplish this by compressing and releasing the tubing, which will create a sudden gush of suction, thereby clearing the tube of an obstruction caused by a clot.
4. Occasional bubbling in the water-seal bottle is normal as air enters from the pleural space. Excessive or persistent bubbling may indicate air leaks in the system. The absence of bubbling indicates that no air is being removed from the pleural space, which is a sign of the patient’s improvement.
5. If an air leak is suspected, the chest tube should be clamped to identify the source of the leak.
6. Clamping of the tube is required when changing drainage bottles but must be done with caution in patients with pleural air leaks because a tension pneumothorax may result.
7. The drainage and collection bottles must be kept at a level below the chest to prevent backflow.
8. The drainage and collection system must be kept airtight; there can be no leaks around the connections. The glass tube must always be kept submerged under the water.
9. If a suction source is connected to the vent tube in the suction bottle, a negative pressure (not to exceed −15 cm H2O) is usually necessary.
10. After the lung reexpands, the chest tube should remain in place for another 1 to 2 days. After the tube is removed, the wound should be covered with a sterile petroleum jelly dressing to prevent air from entering the pleural space.

POSTCHAPTER STUDY QUESTIONS

1. List five indications for bronchoscopy.

2. List eight complications of bronchoscopy.

3. Name one medication that is commonly used to achieve conscious sedation before bronchoscopy.

4. What is the purpose of administering atropine before bronchoscopy?

5. How should the bronchoscope be cleaned after the procedure?

6. What is the purpose of inserting a chest tube?

7. If the water in the water-seal bottle is not fluctuating, what should be suspected?

8. If a chest tube becomes obstructed, what may occur?

9. If an air leak from a chest tube is suspected, what should be done first?

10. How much negative pressure is generally required to help evacuate fluid or air from the pleural space?

See answers at the back of the text.

BIBLIOGRAPHY

Des Jardins T. Cardiopulmonary anatomy and physiology: essentials for respiratory care, ed 4. Albany: Delmar; 2002.

Hess D, Respiratory care principles and practice, ed 1, Philadelphia, Saunders, 2002.

O’Toole M, ed. Miller-Keane encyclopedia and dictionary of medicine, nursing, and allied health. RR, Philadelphia: Saunders, 2005.

Scanlan CL, Simmons KF, Airway management. Scanlan CL, Wilkins RL, Stoller JK. Egan’s fundamentals of respiratory care, ed 7, St Louis: Mosby, 1999.

Scanlan CL, Simmons KF, Airway management. Wilkins RL, Stoller JK, Kacmarek R. Egan’s fundamentals of respiratory care, ed 9, St Louis: Mosby, 2009.

Wilkins RL, Stoller JK, Kacmarek R. Egan’s fundamentals of respiratory care, ed 9. St Louis: Mosby; 2009.

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