Question

Summary:

Mr. Hayato is a 65 year old male brought to ER with severe SOB resp rate 40 pulse ox 93%. Past History of emphysema and longstanding chronic obstruction pulmonary disease (COPD) secondary to tobacco use and still smokes 2 PPD (packs per day) for 50 years.

Acute respiratory distress

COPD

Peripheral vascular disease

Hospital Stay: ABG’s ph 7.32 PCO2 60.6 PO2 56.2

In ER, endotracheal intubation with a # 8 endotracheal tube occurred and patient was placed on ventilator at 15 breath/min with FiO2 at 100%, peep + 5, Tidal volume 400. His CXR showed right lower pneumonia and ETT was at 5 cm above the carina. ABGs were used each morning to guide setting on ventilator setting. His ETT was 21 cm at the lip. His arterial blood gases continue to deteriorate. !00 % was decreased to 80% and peep was increased to +8. The nurse then notices that the patient is getting more tachypneic with tracheal deviation to the right and absent breath sounds on the left with subcutaneous emphysema present. Please answer questions below:

What is the difference between COPD and emphysema?

What is lung compliance and resistance? How are these lung functions affected by COPD?

Is this an acceptable placement of the ETT?

What does his initial arterial blood gases indicate?

What other type of external ventilation could have been used prior to intubation?

Why can’t the patient stay on 100% oxygen for long periods of time?

What is peep and why is it important for the lungs? What happens when peep is increased and the barometric pressure is changed in the lungs?

What has occurred and what action does the nurse need to take?

What has caused the tracheal deviation and what precautions does the nurse need to know about chest tubes?

What is subcutaneous emphysema?

Placement of ETT -https://www.radiologymasterclass.co.uk/tutorials/chest/chest_tubes/chest_xray_et_tubes_anatomy

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3237149/

https://www.medicalnewstoday.com/articles/322161.php#types

Oxygen- https://science.howstuffworks.com/question4931.htm

Chest tubes- wps.prenhall.com/wps/media/objects/737/755395/chest_tubes.pdf

Answer 1

What is the difference between COPD and emphysema?

the main difference between emphysema and COPD is that emphysema is a progressive lung disease caused by over-inflation of the alveoli (air sacs in the lungs), and COPD (Chronic Obstructive Pulmonary Disease) is an umbrella term used to describe a group of lung conditions (emphysema is one of them) which are characterized by increasing breathlessness. A person with emphysema has COPD; however, not everybody with COPD has emphysema.

What is lung compliance and resistance? How are these lung functions affected by COPD

lung compliance is defined as the change in lung volume per unit change in pressure. ... This increase is a function of elastic resistance of the lung and chest wall as well as airway resistance. The pressure then falls to a plateau level as the gas redistributes in alveoli.

COPD  increase pulmonary compliance due to the loss of alveolar and elastic tissue.

Is this an acceptable placement of the ETT ?

yes this is acceptablr position of endotracheal tube

The desired position of an ETT is 5 ± 2 cm above the carina, but markedly varies with neck position and rotation and hence, the inclusion of the mandible is a helpful indicator: flexed: 3 cm (± 2 cm) above carina. neutral: 5 cm (± 2 cm) above carina.

initial arterial blood gases indicate ?

ph 7.32 PCO2 60.6 PO2 56.2

it indicate respiratory acidosis

other type of external ventilation could have been used prior to intubation

Oxygen therapy

Oxygen is given to treat hypoxaemia. Patients should initially be given a high concentration. The amount can then be adjusted according to the results of pulse oximetry and arterial blood gas analysis

mechanical ventilation

natural ventilation

Why can’t the patient stay on 100% oxygen for long periods of time?

oxygen is generally bad, and toxic and leadd to collapse of alveoli

What is peep and why is it important for the lungs? What happens when peep is increased and the barometric pressure is changed in the lungs?

positive end-expiratory pressure. A method of ventilation in which airway pressure is maintained above atmospheric pressure at the end of exhalation by means of a mechanical impedance, usually a valve, within the circuit. The purpose of PEEP is to increase the volume of gas remaining in the lungs at the end of expiration in order to decrease the shunting of blood through the lungs and improve gas exchange. PEEP is done in ARDS (acute respiratory failure syndrome) to allow reduction inlevel of oxygen being given.

Applying PEEP increases alveolar pressure and alveolar volume. The increased lung volume increases the surface area by reopening and stabilizing collapsed or unstable alveoli. This splinting, or propping open, of the alveoli with positive pressure improves the ventilation-perfusion match, reducing the shunt effect

What causes tracheal deviation? precaution while placing chest tube

Tracheal deviation is most commonly caused by injuries or conditions that cause pressure to build up in your chest cavity or neck. Openings or punctures in the chest wall, the lungs, or other parts of your pleural cavity can cause air to only move in one direction inward

Frequent position changes, coughing, and deep breathing help reexpand the lung and promote fluid drainage. Avoid aggressive chest-tube manipulation, including stripping or milking, because this can generate extreme negative pressures in the chest tube and does little to maintain chest-tube patency.

subcutaneous emphysemas

Subcutaneous emphysema is the de novo generation or infiltration of air in the subcutaneous layer of skin

Subcutaneous emphysema can result from surgical, traumatic, infectious, or spontaneous etiologies

The development of subcutaneous emphysema is thought to be caused by the following mechanisms

• Injury to the parietal pleura that allows for the passage of air into the pleural and subcutaneous tissues

• Air from the alveolus spreading into the endovascular sheath and lung hilum into the endothoracic fascia

• The air in the mediastinum spreading into the cervical viscera and other connected tissue planes

• Air originating from external sources

• Gas generation locally by infections, specifically, necrotizing infections