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Friday, November 26, 2010

Ineffective Airway Clearance

Ineffective Airway Clearance

NANDA Definition
Inability to clear secretions or obstructions from the respiratory tract to maintain airway patency

Discussion of the Problem
Oxygen, a clear, odorless gas that constitutes approximately 21% of the air we breathe, is necessary for proper functioning of all living cells. The absence of oxygen can lead to cellular, tissue, and organism death. Thus, maintaining a patent airway is vital to life. The cough reflex is the main mechanism to clear airway secretions. Cough reflex is triggered when mucus and any foreign particles are dislodged from the lower respiratory and are propelled out. Though cough is a reflex that protects the lungs from the accumulation of secretions or the inhalation of foreign bodies, it can also be as symptom of a number of disorders of the pulmonary system or it can be suppressed in other disorders. The cough reflex may be impaired by weakness or paralysis of the respiratory muscles, prolonged inactivity, pain from surgical incisions, respiratory muscle fatigue, the presence of a nasogastric tube, or depressed function of the mudullary centers in the brain. Aside from the cough reflex, there are also other mechanisms in the lower bronchioles and alveoli to maintain the airway, and they are as follows: mucociliary system, macrophages, and the lymphatics. Factors such as anesthesia and dehydration can affect function of the mucociliary system. Furthermore, medical conditions, particularly, pneumonia, bronchitis, COPD, asthma, PTB, lung cancer, radical neck surgery, mechanical ventilatory assistance, seizures, disc surgery, thyroidectomy, laryngectomy, lymphomas, burns, and chemical irritants could overtax these mechanisms. Ineffective airway clearance can be an acute or chronic. Acute ineffective airway clearance occurs in conditions like postoperative recovery, while chronic ineffective airway clearance occurs in conditions like cerebrovascular accident [CVA] or spinal cord injury. Geriatric patients, who have an increased incidence of emphysema and a higher prevalence of chronic cough or sputum production, are at high risk. The overall managements for patients with oxygenation problems are to maintain a patent airway, improve comfort and ease of breathing, maintain or improve pulmonary ventilation and oxygenation, improve ability to participate in physical activities, and to prevent risks associated with oxygenation problems such as skin and tissue breakdown, syncope, acid-base imbalances, and feelings of hopelessness and social isolation.

Nursing Interventions Classification (NIC)
  • Airway Management
  • Airway Suctioning
  • Cough Enhancement

Nursing Outcomes Classification (NOC)
  • Respiratory Status: Airway Patency

Goal and Objectives
  • Patient will Identify potential complications and commence appropriate actions
  • Patient will mobilize secretions and airway will be maintained free of secretions, as evidenced by clear lung sounds, eupnea, and ability to effectively cough up secretions after treatments and deep breaths.
  • Patient will participate in management regimen, within the level of capability or condition

Subjective and Objective Data
  • Abnormal breath sounds (crackles, rhonchi, wheezes, stridor)
·         Anxiety/restlessness
·         Changes in depth/rate of respirations, use of accessory respiratory muscles
  • Chest wheezing
·         Cough effective or ineffective (persistent); with/without sputum production
  • Dyspnea, cyanosis
  • Fever
  • Hypoxemia/cyanosis
·         Statement of difficulty breathing
  • Tachycardia

Related Factors
·         Bronchospasm
·         Edema formation (surgical manipulation and lymphatic accumulation)
·         Fatigue/weakness, decreased energy, poor cough effort
·         Foreign body (artificial airway) in the trachea
  • Impaired respiratory muscle function
·         Increased production of secretions; retained secretions; thick, viscous, Copious tracheobronchial secretions or bloody secretions
·         Partial/total removal of the glottis, altering ability to breathe, cough, and swallow
  • Perceptual/cognitive impairment
·         Pleuritic pain
·         Restricted chest movement/pain
·         Temporary or permanent change to neck breathing (dependent on patent stoma)
·         Tracheal bronchial inflammation, increased sputum production
·         Tracheal/pharyngeal edema
  • Tracheobronchial obstruction (including foreign body aspiration)
  • Trauma

Assessment (Dx)
  • Check airway for patency. Maintaining patent airway is always the first priority, particularly in cases of trauma, acute neurological decompensation, or cardiac arrest.

  • Auscultate lungs for occurrence of normal or adventitious breath sounds, as in the following:
Ø  Diminished or absent breath sounds. These may signify presence of mucus plug or other major airway obstruction.
Ø  Wheezing. These may be a sign of increasing airway resistance.
Ø  Coarse sounds. These may signify presence of fluid along larger airways.

Continuous breath sounds of both rhonchi and wheezing; usually bronchodilator will help to alleviate this problem.
Expiratory grunt
A sign of distress, hypoxia, and/or increased work of breathing.
A fine crackle that can be heard during inspiration or expiration.
Coarse crackle sound that is more wet than a rale, suctioning recommended.
Usually caused by edema around the vocal cords or from an obstruction or tumor.
Wheeze ( whistling sound )
This is heard most commonly in asthmatics and CHF

  • Assess presence or degree of dyspnea. (For example, if the patient verbalizes “air hunger,” manifests restlessness, demonstrates anxiety, shows respiratory distress, or uses accessory muscles. Use 0-10 scale to rate dyspnea. Determine precipitating factors when possible. Distinguish acute episode form exacerbation of chronic dyspnea. Depending on the underlying process, respiratory dysfunction is variable. Note: Using a 0-10 scale to rate dyspnea helps in quantifying and tracking changes in respiratory distress. Sudden onset of acute dyspnea may echo pulmonary embolus.

  • Check for changes in vital signs and temperature. Increased work of breathing can lead to tachycardia and hypertension. In response to retained secretions/atelectasis, fever may develop.

  • Note cough for efficacy and productivity. Consider probable causes for unsuccessful cough such as the following:  respiratory muscle fatigue, severe bronchospasm, or thick tenacious secretions.

  • Note existence of sputum; assess quality, color, amount, odor, and consistency. Infection, bronchitis, chronic smoking, or other condition could lead to sputum production. Sputum that is no longer clear or white signifies infection. It can also have odor.

  • Note for changes in mental status. Increasing lethargy, confusion, restlessness, and/or irritability can be initial signs of cerebral hypoxia.

  • Note respirations. Note quality, rate, pattern, depth, flaring of nostrils, dyspnea on exertion, evidence of splinting, use of accessory muscles, and position for breathing. Abnormality signifies respiratory compromise.

Period of cessation of breathing
sustained maximal inhalation with pause
Ataxic patterns
Irregular and unpredictable pattern with periods of apnea
Biot’s respiration
Periods of normal breathing (3-4 breathes) followed by a varying period of apnea usually 10-60 seconds).
Slower than normal rate, <10 breathe/minute, with normal depth and regular rhythm
Cheyne-Stokes respiration

Regular cycle where the rate and depth of breathing increase, then decrease until apnea (usually about 20 seconds) occurs.
Normal, breathing at 12-18 breaths/minute
Increased rate and depth of breathing
Kussmaul’s respirations
Deep respirations with fast, normal, or slow rate
Rapid, shallow breathing, > 24 breaths/minute

  • Send a sputum specimen for culture and sensitivity as appropriate. Respiratory infections increase the work of breathing; antibiotic treatment is indicated.

  • Check arterial blood gases (ABGs), pulse oximetry, and chest X-ray. Signs of respiratory failure are the following: rising PaCO2 and diminishing PaO2. Creates baseline for monitoring development/weakening of disease process and complications. Note: pulse oximetry readings sense changes in saturation as they are occurring, helping to recognize trends before patient is symptomatic. Nevertheless, studies have revealed that the precision of pulse oximetry may be questioned if patient has severe peripheral vasoconstriction.

1. Note the pH.  Determine if it is acidosis or alkalosis.
2. Note the PaCO2.  Is it normal, increased, or decreased?
3. Note the HCO3.  Is it normal, increased, or decreased?
4. Note the base excess or deficit.
5. Note the PaO2 to determine if there is hypoxia.
7.35 - 7.45
35 - 45
80 - 100  ( in infants normal PaO2:  60 - 80 )
20 - 24

  • Assess for pain. Postoperative pain can produce shallow breathing and an unsuccessful cough.

  • Check for peak airway pressures and airway resistance, if patient is on mechanical ventilation,. Augmentation in these parameters signal collection of secretions/ fluid and likely for ineffective ventilation.

  • Review patient’s comprehension of disease process. Patient teaching will vary depending on the acute or chronic disease condition as well as the patient’s cognitive level.

Therapeutic Interventions (Tx)
  • Give warm or tepid fluids. Suggest drinking of fluids between, rather than during meals. Increase fluid drinking to 3 liters per day within cardiac tolerance. Using tepid liquids may reduce bronchospasm. Fluids in the period of meals can add to gastric distention and pressure on the diaphragm. Hydration helps reduce the thickness of secretions, facilitating expectoration.

  • Promote bedrest and offer care as needed during acute or prolonged exacerbation. Worsening respiratory involvement/hypoxia may necessitate cessation of activity to prevent more serious respiratory compromise.

  • Support patient in performing coughing and breathing maneuvers. These improve efficiency of the cough.

  • Coach patient in the following:
    1. Having optimal positioning (sitting position)
    2. Using pillow or hand splints when coughing
    3. Using abdominal muscles for more forceful cough
    4. Using  quad and huff techniques
    5. Use of incentive spirometry
    6. significance of ambulation and frequent position changes
The splinting of the abdomen and sitting positionuphold more efficient coughing by augmenting abdominal pressure and rising diaphragmatic movement. Directed coughing methods aids to mobilize secretions from smaller airways to larger airways because the coughing is performed at different times.

  • Use positioning for example, adjusting head of bed at 45 degrees, sitting in chair and ambulating. These uphold better lung expansion and better air exchange.

  • Regularly check the patient’s position so the patient does not slide down in bed If patient is bedridden. This may cause the abdomen to constrict the diaphragm, which would lead to respiratory compromise.

  • If cough is unsuccessful, use nasotracheal suctioning as ineffective:
    1. Give details about the procedure to patient.
    2. Utilize soft rubber catheters. This avoids trauma to mucous membranes.
    3. Utilize curved-tip catheters and if not contraindicated, head positioning. These promote secretion elimination from a specific side (right versus left lung).
    4. Coach the patient to take a number of deep breaths before and after each nasotracheal suctioning process and employ supplemental oxygen as appropriate. This avoids suction-related hypoxia.
    5. Discontinue suctioning and give supplemental oxygen if the patient experiences bradycardia, and rise in ventricular ectopy, and/or desaturation.
    6. Employ universal precautions (gloves, goggles, and mask as fitting). If sputum is purulent, precautions should be observed before obtaining the culture and sensitivity report. Suctioning is specified when patients are incapable to eliminate secretions from the airways by means of coughing due to weakness, thick mucus plugs, or too much mucus production.

  • For acute problem, help out in bronchoscopy. This acquires lavage samples for culture and sensitivity, and gets rid of mucus plugs.

  • For patients with lowered energy level, schedule activities and enforce planned rest periods. Uphold energy-conservation strategies. Fatigue is a causative factor to ineffective coughing.

  • For patients with persistent problems with bronchoconstriction, coach in use of metered-dose inhaler (MDI) or nebulizer as ordered.

  • Give medications as prescribed, such asantibiotics, mucolytic agents, bronchodilators, expectorants, noting efficacy and side effects.

  • Institute proper isolation precautions for positive cultures, tuberculosis, for example.

  • Organize best possible time for postural drainage and percussion, at least an hour after eating, for example. This avoids aspiration.

  • Talk to respiratory therapist for chest physiotherapy and nebulizer management as indicated. Chest physiotherapy consists of the techniques of postural drainage and chest percussion to mobilize secretions in smaller airways that cannot be eliminated by means of coughing or suctioning.

  • Utilize humidity (humidified oxygen or humidifier at bedside). This loosens secretions, and it could be essential for episodes of respiratory distress or presence of hypoxia.

  • If secretions cannot be mobilized, anticipate the need for an intubation. Once intubated:
    1. Initiate suctioning of airway as determined by occurrence of adventitious sounds.
    2. Utilize sterile saline instillations for the period of suctioning. This helps facilitate elimination of viscous sputum.

·         Perform cardiopulmonary resuscitation (CPR) maneuvers, for patients with complete airway obstruction.

Educative (Edx)
·         Demonstrate and educate coughing, deep breathing, and splinting technique. Patient will comprehend the underlying principle and proper techniques to keep the airway clear of secretions.

·         Educate caregivers in suctioning techniques. Give opportunity for return demonstration. Adjust technique for home setting.

·         Educate patient about environmental factors that can initiate respiratory problems.

·         Encourage oral intake of fluids within the restrictions of cardiac reserve. Increased fluid intake lowers the viscosity of mucus formed by the goblet cells in the airways. It is easier for the patient to eliminate thinner secretions with coughing.

·         Give explanation on effects of smoking, as well as second-hand smoke. Smoking adds to bronchospasm and enlarging mucus production in the airways.

·         Persuade verbalization of feelings. Recognize reality of situation. Anxiety adds to oxygen demand, and hypoxemia potentiates respiratory distress or cardiac symptoms, which in turn increases anxiety.

·         Refer to pulmonary clinical nurse specialist, home health nurse, private nurse, or respiratory therapist as needed.

·         Teach caregiver in chest physiotherapy as appropriate for patients with incapacitating disease such as CVA and neuromuscular impairment being cared for at home. This may also be helpful for the patient with bronchiectasis who is ambulatory but needs chest physiotherapy because of the amount of secretions and the incapability to effectively clear them.

·         Teach patient how to utilize prescribed inhalers, as suitable.

·         Teach patient on indications for, frequency, and side effects of prescribed drugs.

·         Teach patient on warning signs of awaiting or chronic pulmonary problems.

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