Breathe easy - how to nurse the respiratory patient

Respiratory patients can be so rewarding to nurse, but come with their challenges! They also provide us with lots of opportunities to use our skills, develop new practical skills, and promote patient-friendly care.

In the last post in our respiratory series, we’re talking all about nursing considerations for respiratory patients - from triage and general nursing to caring for ventilator patients.

Triage

Most of our respiratory patients present as an emergency in respiratory distress. These patients require prompt assessment and emergency care to improve their oxygenation.

Triage of the emergency patient can be divided into two sections - the primary survey and the secondary survey.

The primary survey assesses the major body systems. If there is a disorder of one of these systems, it requires emergency correction as it poses a threat to life. The major body systems are the central nervous system, respiratory system, and cardiovascular system. We can also use the mnemonic ‘ABCD’ to remember the parameters to check during the major body systems assessment:

• A = Airway

• B = Breathing

• C = Circulation

• D = Dysfunction of the central nervous system (CNS)

Parameters to assess in the primary survey include:

• Consciousness/mentation

• Heart rate and rhythm

• Pulse quality

• Respiratory rate, pattern and effort

• Mucous membrane colour

• Capillary refill time

After the primary survey is completed, any abnormalities in the parameters above are corrected urgently. Following this, a more thorough whole-body assessment is performed - known as the secondary survey.

Here are 9 questions to ask yourself when triaging the respiratory patient:

• What is the respiratory rate?

• What is the respiratory pattern/effort? Is the breathing rapid and shallow or deep?

• Is there abdominal or paradoxical respiration?

• Is the effort on inspiration or expiration?

• Has the patient changed their position? Are they able to sit/lie down? Is the head/neck extended? Are the elbows abducted?

• Is there cyanosis?

• Are there crackles, wheezes or dull lung sounds on auscultation? If so are they over the lungs or upper airways?

• What is the SPO2?

• What is the patient’s temperament/mentation?

General nursing care

There are lots of things to think about when planning care for the respiratory patient, including keeping the patient calm, providing oxygen, monitoring, nutrition, hydration, rest/exercise and physiotherapy.

Keeping Calm and Quiet

Dyspnoeic patients are on a knife-edge, balancing an increased demand for oxygen and impaired ventilation/oxygenation. Anything we do to increase their oxygen demand can tip this balance, so a 'hands off' approach is best. Delay any treatments, invasive diagnostics or intravenous catheter placement until the patient is stable, and administer sedatives if needed.

Provide Oxygen

Dyspnoeic patients require oxygen therapy to restore normal oxygenation and prevent increased respiratory effort, which, over time, leads to respiratory fatigue and hypoventilation. The most appropriate method of oxygen administration should be administered depending on the individual patient and their oxygenation levels.

Monitoring

Monitoring requirements for the respiratory patients are vast, and include:

• Respiratory rate

• Respiratory pattern and effort

• SPO2

• Mucous membrane colour

• ETCO2

• Arterial blood gas/PaO2 and PaCO2 levels

• Pain scoring

• Fluid balance

Hydration and Nutrition

Anorexia and adipsia are common in the dyspnoeic patient - we therefore need to think about nutrition and hydration. Dyspnoeic patients should be monitored closely, for signs such as skin tenting, tacky/dry MMs, sunken eyes, or changes to perfusion (heart rate, blood pressure, pulse quality, MM colour or CRT). Intravenous fluids should be administered as appropriate and the patient’s fluid balance reassessed regularly.

Where anorexia or hyporexia persists, nutritional support should be administered where safe to do so.

Exercise

Exercise is another important consideration in the respiratory patient. Most patients will not be able to exercise normally (including toilet walks) due to the risk of desaturation. Where patients are able to go outside, they should be prepared for walking prior to oxygen removal, and carried outside for the shortest time period, before being returned to their kennel and oxygen reinstated.

Exercise can also be very helpful in patients with pneumonia, where we need to encourage them to expel respiratory secretions. Walking these patients after nebulisation can be particularly useful here.

Physiotherapy

Physiotherapy is of huge benefit to the respiratory patient - and we can use a combination of nebulisation and physical techniques to expel respiratory secretions and mucous.

Nebulisation with 0.9% saline (or hypertonic saline in some cases) is helpful, to loosen respiratory secretions and encourage their expulsion. 

Patient positioning is also an important consideration; positioning the patient with their head end up (e.g. on a wedge) can aid ventilation, whereas positioning patients with their head down for short periods can aid in the expulsion of respiratory secretions.

Oxygen supplementation

There are a variety of methods of supplementing oxygen, from flow-by all the way to mechanical ventilation. Each has their own advantages and disadvantages, and provides differing concentrations of inspired oxygen (FiO2).

So, how do we select the most appropriate route for our patients? Well, it depends on their degree of hypoxaemia. The lower the patient's SPO2 (or PaO2 if you're monitoring blood gases), the higher the FiO2 you need to achieve. We also need to take the specific patient into consideration, for example, we would want to avoid nasal cannulas or prongs in a patient with nasal disease.

Flow-By

Suggested flow rate: 2-10litres/min

Approximate FiO2: 30-40%

Advantages: Causes less stress to the patient than use of a mask

Disadvantages: Inefficient technique which is unlikely to achieve FiO2 levels over 40%

Face Mask

Suggested flow rate: 2-5 litres/min

Approximate FiO2: 40-50

Advantages: Simple and quick to use and requires no specialised/additional equipment. A high percentage of FiO2 (80-90%) can be achieved in a sedated/recovering patient providing the mask is a proper fit.

Disadvantages: Can cause stress and exacerbate dyspnoea. If used in conscious patients who will not tolerate a well-fitting mask, low FiO2 is achieved (35-55%). Can promote re-breathing and increase FiCO2 when tight-fitting masks are used.

Oxygen Tent

Suggested flow rate: 10-12 litres/min

Approximate FiO2: 40-50%

Advantages: Convenient and easy to use, well tolerated by patients.

Disadvantages: Size limiting. Increasing FiO2 above 50% can be difficult. Hyperthermia can result if incubator has no thermostatic control. Monitoring can be difficult and oxygen level drops when doors are opened.

Crowe Collar (Buster Collar and Cling Film)

Suggested flow rate: 2-5 litres/min

Approximate FiO2: 30-40%

Advantages: Well tolerated, requires lower oxygen flow rate than other methods.

Disadvantages: Potential for hyperthermia; a gap at the top of the collar should be left to allow venting of humid air. High flow rate required initially to fill collar with oxygen.

Nasal Prongs

Suggested flow rate: 50-100ml/kg/min

Approximate FiO2: 30-50%

Advantages: Provide higher inspired oxygen levels than flow-by or mask techniques. Considerably lower oxygen flow rate required than other methods.

Disadvantages: Easily dislodged. Need to be secured with adhesive/buster collar to prevent removal. Not suitable for patients with sneezing or nasal disease. Not tolerated in restless/stressed patients. Efficiency reduces in panting patient/mouth breathing patients as they exhale inspired oxygen.

Nasal Cannulas

Suggested flow rate: 50-100ml/kg/min

Approximate FiO2: 40-50% (unilateral), 60-70% (bilateral)

Advantages: Provide higher inspired oxygen levels than flow-by or mask techniques. Placement of bilateral catheters increases FiO2 further. Considerably lower oxygen flow rate required than other methods.

Disadvantages: Need to be secured with adhesive/buster collar to prevent removal. Not suitable for patients with sneezing or nasal disease. Not tolerated in restless/stressed patients. Efficiency reduces in panting patient/mouth breathing patients as they exhale inspired oxygen.

Chest drain care

Chest drains are commonly placed to manage pleural space disease in practice. These have several specific nursing considerations:

Aseptic Technique

When handling the drain, strict aseptic technique should be followed, with gloves worn whenever the drain is handled, and sterile gloves worn when handling the drain sites themselves. The sites should be checked, cleaned (if appropriate) and re-dressed at least twice daily. In between uses, the drain ports should be cleaned with alcohol swabs or covered with alcohol caps.

Drainage

Chest drains should be drained at regular intervals depending on the veterinary surgeon’s assessment. Volumes of fluid and air retrieved from each drain should be recorded and a drain output in ml/kg/hour calculated. 

During drainage, care should be taken to prevent excessive negative pressure on the drain, as this can cause pleural trama. Negative pressure volumes of above 2-3ml should be avoided.

Analgesia

Chest drains are painful and so appropriate analgesia should be provided based on pain assessments. Local anaesthetic solutions such as bupivacaine (+/- bicarbonate to reduce stinging) can also be instilled via the drain for additional analgesia.

Preventing Interference

Using a ‘string vest’ or medical protection shirt can help secure the drains to the body and avoid them being pulled or caught, as well as prevent patient interference. Preventing patient interference is vital in the chest drain patient, since damage to the drain can cause air intake and a resultant pneumothorax.

Elizabethan collars should be placed in patients at risk of causing damage to their drain. In addition, gate clamps should be kept closed at any time a syringe is not attached to the drain, and centesis valves can be used to allow drainage without disconnection of syringes or three way taps.

Care of the Ventilator Patient

At times, no matter how much oxygen we provide by ‘traditional methods’, we need to do more.

If a patient remains hypoxaemic for prolonged periods, they will put more and more effort into breathing to try and improve their oxygenation. As they do this, their respiratory muscles begin to fatigue, and CO2 levels rise. If this continues without intervention, respiratory failure can result.

Mechanical ventilation is used in these cases. This provides varying inspired oxygen concentrations (adjustable up to 100%) and has a variety of modes to support and control ventilation (e.g. pressure control, pressure support, and C-PAP).

Ventilator patients require 1-on-1 intensive nursing care. When nursing the ventilator patient, here are a few specific points we need to think about:

Monitoring

Patients require general anaesthesia and endotracheal intubation. With this, comes lots of monitoring requirements - heart rate, blood pressure, end tidal CO2 levels, SPO2 levels, temperature, signs of anaesthetic depth, arterial blood gas results, etc!

Recumbency Care

Ventilator patients require regular turning, bladder and bowel management. Urinary catheterisation is advised to allow urination without scalding, and to facilitate measurement of urine output.

Special Sense Care

Ocular and oral care is required in the ventilator patient. Regular eye lubrication is needed to prevent corneal ulceration; fluorescein staining every 24 hours is also recommended to catch any ulcers at an early stage.

Regular oral care is also required to reduce the oral bacterial load. The mouth should be rinsed with chlorhexidine oral rinse on a regular basis. It is also recommended to wrap the tongue with something like glycerine, to prevent dryness. Mouth gags should be used to prevent pressure on the tongue and ranula formation.

Aseptic Technique

Hospital-acquired pneumonia is a significant risk in ventilator patients. The breathing systems should be prepared aseptically, wearing sterile gloves and using sterile water bottles to fill humification chambers. The patient must be intubated with a sterile ET tube, and depending on the duration of ventilation, breathing systems and ET tubes should be changed regularly. A non-wicking, wipe-clean ET tube tie should be used (such as one designed for dental patients).

ET Tube Care

The ET tube cuff should be inflated to a pre-measured point using a Posey cufflator or Magill cufflator syringe. The cuff should be deflated, the tube repositioned, and the tube re-inflated at regular intervals, to prevent excessive pressure on one point of the trachea. Ideally, a tube with a low-pressure, high-volume cuff should be used.

In addition to the points we've mentioned above, we also need to add all our general care requirements in too - nutrition, hydration, pain management, grooming, IV catheter care and much much more! These patients get you thinking so much, they are fantastic cases to nurse.

So that’s an overview of the nursing considerations for our respiratory patients - as you can see, there is a lot to think about!

What do you love most about nursing the respiratory patient? DM me on Instagram and let me know!

References:

1. Merrill, L. 2012. Small Animal Internal Medicine for Veterinary Technicians and Nurses. Iowa: Wiley-Blackwell.

2. Kirby, R. and Linklater, A. 2016. Monitoring and intervention for the critically ill small animal: the rule of 20. Wiley-Blackwell.