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Caring for theBreathless Patient

Chris Hill

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Learning outcomes

Critically appraise the history and assessment

process when a patient presents withbreathlessness;

Critically evaluate the role of the interdisciplinary

team when caring for the breathless patient; Critically examine the management strategies

and nursing interventions for breathless patients.

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Anatomy and physiology Functions of the lung

Get oxygen into the body

Get carbon dioxide out

Alveoli are where gas exchange takes place

150 million alveoli in each lung

Conducting airways take gas to the alveoli

Blood flow also needed to each alveolus

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Assessment Inspection

AIRWAY (eg ability to speak) Position

Distress, facial expression, sweating

Audible noises, stridor, wheezing Respiratory rate / pattern

Symmetry of chest movement

Accessory muscles, movement of chest vs. abdomen

Palpation, percussion, auscultation

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Pulse oximetry 5th vital sign

Shines a red light and infrared light through(typically) a finger, measures absorption at these

wavelengths

Measures the percentage of haemoglobinsaturated with oxygen in arterial blood

Needs a good signal ie good pulse, not good if

cold / peripherally shut down

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History Chronic respiratory problems? drug history,

home oxygen, smoking (family, friends) Current respiratory drugs

Secretions

Amount

Character

Colour

Consistency Blood stained

Normal for patient?

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Useful images:

http://meded.ucsd.edu/clinicalmed/lung.htm

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Clubbing(http://commons.wikimedia.org/wiki/File:Acopaquia.jpg)

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Respiratory support AIRWAY

Treat cause of the problem Positioning

Oxygen therapy (wont stop people feeling breathless if

SpO2 is normal) + humidification of inspired gas Drugs / inhalers / nebulisers

Physiotherapy

Non-Invasive Ventilation (NIV) Invasive ventilation

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Positioning

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Oxygen

Oxygen should be regarded as a drug. It isprescribed for hypoxaemic patients

(my emphasis)

(British National Formulary 61, March 2011)

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Oxygen Flow MeterFlow = 2 L/min

1

5

1

5

(BTS guidelines)

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Nasal Cannulae

2-6 L/min gives approx

24-50% FIO2 Variable performance

(percentage oxygen

breathed by the patientwill depend on respiratory

rate / pattern)

Comfortable and easilytolerated

http://www.novapex.com.tw

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Simple face mask Can deliver 35% - 60%

Oxygen with flow 5-10 L/min

Variable performance(percentage oxygenbreathed by the patient will

depend on respiratory rate /pattern)

BTS recommendation is thatflow should be at least 5

L/min

http://www.novapex.com.tw

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Delivers 60 90%oxygen

Should not be used longterm

Critical illness / Trauma

patients

Post-cardiac orrespiratory arrest.

15 L/min oxygen flowneeded

Non re-breathing Reservoir Mask

http://www.novapex.com.tw

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Venturi Masks Delivers prescribed O2 (fixed) concentrations

irrespective of respiratory pattern. Various models available

2[\JHQ2[\JHQ2[\JHQ2[\JHQ

(QWUDLQHGDLU

'LOXWHGR[\JHQ'LOXWHGR[\JHQ'LOXWHGR[\JHQ'LOXWHGR[\JHQ

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Peak inspiratory flow

Start End

Flow

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Variable performance device

O2%=?

O24L/m

in

Air

Air

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O24L/m

in

Air

Air28% O2at 45L/min

28%O

2

Fixed performance device

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In use

When recording oxygen saturation, the

delivered oxygen must be recorded Delivery devices and/or flow rates should

be adjusted to keep oxygen saturation inprescribed range

If a patients oxygen needs increase this

should be reported

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Humidification Why?

Types

Advantages and disadvantages

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Key points

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References and recommended reading

Currie GP, Douglas JG (2006) ABC of chronic

obstructive pulmonary disease: Oxygen andinhalers BMJ 333:34-36

Harris S (2007) COPD and coping with

breathlessness at home: a review of theliterature British Journal of Community Nursing

12(9): 411 - 415

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References and recommended reading

ODriscoll BR, Howard LS, Davison AG (on

behalf of the British Thoracic Society EmergencyOxygen Guideline Development Group) (2008)

Guideline for emergency oxygen use in adult

patients Thorax63:Supp. VI Simpson H. (2006) Respiratory assessment.

British Journal of Nursing, 15(9):484-8.

Walsh M, Crumbie A (2007) Watsons Clinicalnursing and related sciences, 7th ed. Ballire

Tindall, London.