How to use more of your nursing skills to help your respiratory patients [Case Study]
I don’t need to tell you how challenging respiratory patients can be.
From the dyspnoeic emergency cat to the Frenchie with BOAS, us nurses have to react quickly to respiratory patients - but in the right way.
And in today’s post, we’ll explore the nursing considerations for a really challenging respiratory case - Lilah, a labrador with aspiration pneumonia after multiple episodes of regurgitation.
We’ll chat through her oxygen therapy, monitoring, nutrition, hydration, recumbency care and much much more - giving you lots of tips to take away and use with your own respiratory patients in practice.
Meet Lilah
Lilah is an 8-year-old FN Labrador.
Lilah has presented to you as an emergency with a 2 week history of progressive regurgitation, and a more recent history of exercise intolerance, progressive lethargy, pyrexia, anorexia and coughing. She’s now tachypnoeic and orthopnoeic with increased respiratory effort.
She comes straight down to the clinic, and you head out to reception to triage her.
Examination
You assess Lilah and find the following:
Lilah is quiet, but alert and responsive
She is lying down in sternal recumbency with her neck extended
She is tachypnoeic with a respiratory rate of 60 breaths per minute, and increased expiratory effort
She has pink, tacky mucous membranes with a CRT of 1.5 seconds
Her heart rate is 140 beats/minute with good quality, synchronous pulses
She has marked crackles on auscultation, particularly cranioventrally over both sides of the chest
Her SpO2 is 93% when standing, decreasing to 89% when she lies down
Stabilisation and Initial Results
You bring Lilah through to prep and ask a colleague to provide oxygen therapy whilst you speak to the vet. They ask you to:
Perform a point-of-care ultrasound of her chest, which reveals the presence of lots of B-lines across the lungs on both sides, indicating pneumonia
Secure IV access, and collect bloods for haematology, biochemistry, a venous blood gas, and PCV/total solids
Further diagnostics are delayed due to Lilah’s respiratory condition. Her biochemistry and haematology are largely unremarkable (except for increased white blood cells) and her venous blood gas shows a respiratory alkalosis (pH 7.48, pCO2 31 mmHg).
Lilah’s Initial Treatment
Lilah begins supportive treatment to manage her suspected aspiration pneumonia, including:
Placement of nasal oxygen catheters to provide longer-term oxygen support
IVFT with lactated Ringer’s solution at 4ml/kg/hour
Antibiotics with amoxicillin-clavulanic acid at 20mg/kg IV every 8 hours
A metoclopramide CRI at 2mg/kg/day, alongside maropitant at 1mg/kg IV every 24 hours, to manage her regurgitation
You continue monitoring Lilah’s respiratory status and find that her saturation remains <95% despite nasal oxygen therapy. You alert the vet and are asked to collect an arterial sample to assess oxygenation; this reveals a marked hypoxaemia with an arterial oxygen level of 58 mmHg on room air (normal > 85-90 mmHg).
The vet asks you to escalate Lilah’s treatment to provide high-flow oxygen therapy.
What is high-flow oxygen therapy?
High-flow oxygen therapy is the administration of high rates of warmed, humidified oxygen via a specialised machine. This is administered aseptically via specialised nasal prongs, that attach to a single-use breathing system and humidification chamber.
The higher flow rates (up to 10L/minute via the nasal prongs) provide some positive pressure and help to ‘force’ the alveoli open, improving gaseous exchange.
Patients on high-flow oxygen therapy typically require sedation to keep them calm and quiet, recumbency care, bladder and bowel management and respiratory physiotherapy in addition to more specific treatment for the cause of their underlying respiratory disease.
So back to Lilah and her nursing care…
Lilah is now in hospital, settled in your ward, and you’ve started her on high-flow oxygen therapy. To keep her quiet, calm, and still, you’ve started her on a butorphanol CRI and midazolam CRI.
Whilst we support her oxygenation and ventilation, and continue her treatment for her aspiration pneumonia, we need to plan the nursing care she’ll benefit from.
So how would you do this? What would you do? Here are some prompts for you to think about:
Nutritional status and appetite support
Hydration status and fluid balance
Recumbency considerations
Eliminations (urination and defecation)
Vascular access
Respiratory physiotherapy
Oxygen therapy
Special sense care
Sedation
Gastrointestinal motility, regurgitation and gastric volume
Monitoring
So how will we nurse her?
There’s a lot to think about here. So let’s get straight into it:
Nutrition and Appetite Support
Though nutrition is a vital nursing consideration for any patient in the hospital, I’m going to say our priority with Lilah is going to be getting that breathing under control and improving her oxygenation.
Now I’m NOT saying that nutrition isn’t important - we know that Lilah has been anorexic and is regurgitating - but in this case, there’s a good chance that once she feels like she can eat and breathe at the same time, we’ll see her food intake improve.
So I’m not going to be really trying to get Lilah to eat voluntarily if she doesn’t want to. We’ll calculate her resting energy requirement, tempt her at an appropriate time, and measure her food intake, whilst managing her respiratory function and regurgitation, to maximise her wanting to eat.
If her anorexia continues in hospital despite respiratory improvements, though, we’ll need to of course intervene. She currently has nasal prongs in whilst receiving high-flow oxygen therapy, so a naso-oesophageal or nasogastric tube isn’t possible. This is a shame, because with her history of regurgitation, a NG tube would be ideal - allowing us to measure gastric residual volumes.
Our alternative options for feeding are going to be either an oesophagostomy tube, or a PEG tube. Lilah has regurgitation, so an oesophagostomy tube isn’t ideal - she could well have oesophagitis. That leaves us with a PEG tube.
PEG tubes are placed endoscopically into the stomach, through the abdominal wall. They’re minimally invasive and quick to place, but require specialised equipment and need to stay in for at least 10-14 days.
The other option would be parenteral nutrition - however, this isn’t without risk. When we feed parenterally, we bypass the GI tract, meaning our enterocytes don’t receive direct nutrition. This can compromise the integrity of the intestinal barrier, risking bacterial translocation.
Hydration and Fluid Balance
Respiratory patients can become dehydrated as a result of their increased respiratory losses - so monitoring hydration status is an important consideration for Lilah.
We want to keep an eye on her skin tenting, eye position, MM dryness, and bodyweight - alongside her perfusion signs (heart rate, pulses, MM colour and CRT).
Fluids should be adjusted based on these hydration assessments - remember, fluids are a drug and have contraindications just like any other treatment!
Recumbency Considerations and Eliminations
Lilah is currently sedated to receive her high-flow oxygen therapy. On top of this, she’s hypoxaemic, so even if she was conscious, she’d tire VERY easily going out to the toilet.
Both of these things mean we need to be very careful about how we manage her recumbency and eliminations.
First up, let’s look at her kennel environment. Being recumbent, she’s at risk of various complications - including hypostatic pneumonia (which will worsen her pre-existing respiratory disease), pressure sores, and soiling.
We want to adjust her position to minimise pressure sores and hypostatic pneumonia - whilst keeping her front end in sternal to aid respiration. We turned her hips every 4 hours, rotating between left lateral, sternal and right lateral.
To manage her soiling and eliminations, we placed an indwelling Foley urinary catheter. This also allowed us to monitor her urine output, and adjust her fluid rate as needed. Urinary catheters come with a high risk of hospital-acquired infection, so we need to be handling the catheter carefully, wearing gloves, using a closed collection system and cleaning the vulva and catheter/lines regularly.
We also monitored the frequency of her defecation, noting the days between bowel movements and performing enemas as required.
Vascular Access
Vascular access is another important consideration in critical or intensive patients. Lilah is receiving multiple CRIs, IV medications and fluid therapy currently - so placing a central venous catheter could be considered. This requires anaesthesia for placement, and she is high-risk given her hypoxaemia - so we need to weigh up the benefits a CVC brings with the risks of anaesthetising her. If we are anaesthetising her for any other reason, such as placing a PEG tube, we could consider popping a CVC in under the same anaesthetic.
Lilah would also benefit from an arterial catheter. Since she’s hypoxaemic and at risk of respiratory fatigue, we probably want to be performing regular arterial blood gases - and an arterial catheter would make this much easier. We could also measure her direct blood pressure via the catheter - however, these devices require careful management to prevent complications such as clots, and medications must never be given through them (aside from 0.9% saline flushes as needed).
Respiratory Physiotherapy
Physiotherapy is really important when managing respiratory patients. As well as providing support during Lilah’s recumbency - through techniques like passive range of motion - we can use techniques like nebulisation, position changes, and gentle exercise/movement (once Lilah is stable enough) to improve her respiratory function.
Nebulisation - especially with hypertonic saline - will act as a mucolytic, loosening respiratory secretions and making them easier to eliminate. After nebulising, Lilah should be walked (once she is stable enough) to help expel those loosened secretions. Even a few steps around the ward will help - and when it comes to walking her outside, we can use a portable oxygen cylinder to continue giving her oxygen outside.
Oxygen Therapy
Speaking of oxygen, this is another important consideration for Lilah. She’s currently receiving intensive oxygen therapy via High-Flow - which is a technique reserved for some of our most hypoxaemic patients at risk of fatigue.
Whilst she’s receiving her high flow, we want to check her nasal prongs are in place regularly, note the flow rate and FiO2 she’s receiving, and ensure the humidification chamber contains enough sterile water.
Once Lilah’s respiratory status improves, we’ll reduce her to bilateral nasal oxygen cannulas, then a unilateral cannula, before weaning down (and ultimately off!) the flow rate.
Whilst she’s receiving oxygen, we need to ensure we lubricate her eyes regularly, since oxygen is drying and can risk corneal drying and ulceration.
Special Sense Care
As well as oxygen drying Lilah’s eyes, she’s also receiving multiple sedative CRIs - all of which can cause corneal drying, and therefore ulceration. We want to lubricate her eyes regularly, and fluorescein stain them and check them for ulcers daily.
In anaesthetised patients, we can also perform oral care - cleaning the mouth with oral chlorhexidine rinse to minimise the oral bacterial load. If Lilah ended up being transitioned to mechanical ventilation, then we’d need to add this in to her nursing care.
Sedation and Monitoring
Lilah needs intensive monitoring with her degree of hypoxaemia and severe respiratory disease, alongside the sedatives she’s receiving. We need to keep and eye on her vitals - not just the numbers, but her respiratory pattern and effort, degree of orthopnoea, pulse quality, MM colour and behaviour/fear and stress levels.
We need to balance the need for monitoring with the stress that regular examinations bring - grouping treatments and assessments together to allow rest time and observing as much from a distance as possible.
Gastrointestinal Motility and Regurgitation
We know that Lilah has a history of regurgitation - which is what has caused her aspiration in the first place. We also know that she’s currently receiving multiple sedative medications - these will affect her gastrointestinal motility, reducing it in a patient already at risk of ileus.
We’ll manage this by continuing her metoclopramide and maropitant; and keeping some backup options on standby in case her current treatment isn’t enough to stop her regurgitating. Ondansetron can be added as another antiemetic, and cisapride, magnesium and erythromycin are other prokinetics that could be considered.
We also need to be careful when moving Lilah, since we can see regurgitation more when our patients are moving. Turning should be performed carefully, keeping her head up to avoid further aspiration/regurgitation.
Ideally, we’d place a nasogastric tube to measure her gastric residuals and aspirate the stomach - but with her nasal prongs in currently, this isn’t possible. If she’s still regurgitating when her oxygen therapy is de-escalated, we could consider placing one at that point - labelling it carefully so people know it isn’t a nasal oxygen catheter.
There are SO many other considerations for Lilah - including TLC, family visits, postural feeding (once she is awake and stable enough to eat for herself) and more - which just goes to show how much we can do to support these patients!
How did you find this case? Was there anything on your list of considerations that I missed? DM me on Instagram and let’s chat about it!
