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Course: Medical Surgical Nursing

Topic: Respiratory Care Modalities Part-II

The Nurses International Community

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COPYRIGHT

NI Privacy Policy and Terms of Use.

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Module Goals

Learners will be able to

Describe the indications for incentive spirometers, low volume nebulizers and chest physiotherapy modalities
Describe the nursing management of these respiratory care modalities:

Preparation of client
Preparation of equipment
Expected outcomes
Assessment of outcomes
Considerations for the gerontologic client
Client education

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Aerosol System

A suspension of liquid or solid in a gaseous medium

The aerosol system includes:

Medication
Aerosol device
Client's respiratory system

Used as adjunct therapy for a variety of respiratory diseases.

Princeton University, 2017

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Administering Inhaled Medications

Medications are dispersed via:

Aerosol spray
Mist
Powder

Inhaled medications have respiratory and systemic effects.
Used more frequently for asthma and chronic respiratory diseases.
Variety of inhalers are available with specific manufacturer's directions for administration.

Doyle & McCutcheon, 2015

Healthline, 2021

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Nebulizers

The process where medications are added to inspired air and converted into a mist that is inhaled by the client
Air droplets are finer than those created by metered dose inhalers
Delivery: Face mask or a mouthpiece held between the patient’s teeth.
Components:

Face mask
Medication chamber
Connecting tubes
Compressor

Doyle & McCutcheon, 2015

Healthline, 2021

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Small Volume Nebulizer

Indications:

Chronic obstructive pulmonary disease (COPD)
Asthma
Bronchiectasis
Cystic fibrosis
Pulmonary fibrosis

Healthline, 2021a

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Small Volume Nebulizer: Nurse’s Role

Prepare client

Validate prescription
Informed consent
Explain the procedure to the client
If using with a tracheostomy, suction properly before therapy
Ensure comfort and correct positioning
If client is receiving oxygen, continue to deliver nasal oxygen with nebulizer treatment

Doyle & McCutcheon, 2015

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Small Volume Nebulizer: Nurse’s Role (Continued)

Prepare the Equipment

Assemble nebulizer per manufacturer’s instructions
Ensure functioning of the machine and the tubing
Add prescribed medication into the nebulizer cup
Use a mask if client unable to tolerate a mouthpiece, and an adaptor if tracheostomy is present
Attach the nebulizer to compressed air if available; use oxygen if there is no compressed air

Doyle & McCutcheon, 2015

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Small Volume Nebulizer: Nurse’s Role (Continued)

Administration

Check MAR against provider’s orders
Perform the SEVEN MEDICATION RIGHTS
Assess pulse, respiratory rate, breath sounds, pulse oximetry, and peak flow measurement (if ordered) before beginning treatment
Attach the nebulizer to compressed air if available; use oxygen if there is no compressed air
Turn on air to nebulizer and ensure there is a sufficient visible mist

Doyle & McCutcheon, 2015

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Small Volume Nebulizer: Nurse’s Role (Continued)

Administration

If mouthpiece is being used, ensure lips are sealed around mouthpiece
Have client take slow, deep breaths
Have client repeat this breathing pattern until medication is complete
Tap nebulizer chamber occasionally and at the end of the treatment to ensure all medication is used

Doyle & McCutcheon, 2015

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Small Volume Nebulizer: Nurses Role (Continued)

Administration

Monitor patient’s pulse rate during treatment, especially if beta-adrenergic bronchodilators.
Once treatment is complete, turn flowmeter off and disconnect nebulizer.
Rinse, dry, and store nebulizer as per agency policy.
For steroid medications, rinse mouth and gargle with warm water.
Following treatment encourage deep breathing and coughing exercises to help remove expectorate.

Doyle & McCutcheon, 2015

Contact info: info@nursesinternational.org

A client has to rinse mouth and gargle with warm water after steroid medications. This is because some people get: sore mouth or throat, hoarse or croaky voice, cough. Steroids supressess the normal flora of the mouth which leads to cause opportunistic microbes grow and cause oral thrush – a fungal infection that causes white patches, redness and soreness in the mouth.

Note: Turn on air to nebulizer and ensure that a sufficient mist is visible exiting nebulizer chamber. A flow rate of 6 to 10 L should provide sufficient misting. However, ensure that nebulizer chamber containing medication is securely fastened. During the nebulization process, have client take slow, deep, inspiratory breaths. Encourage a brief 2- to 3-second pause at the end of inspiration, and continue with passive exhalations.

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Case Study/ Critical Thinking Question/ What Would the Nurse Do?

A doctor has prescribed budesonide (Pulmicort) for a client diagnosed with asthma.

Which of the following aspects should the nurse focus on when providing client education about this mediation?

Assess the heart rate
Ask client to rinse mouth immediately
Ask client to take fast but deep breaths
Discontinue oxygen before doing nebulization

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Small Volume Nebulizer: Safety Precautions

Perform hand hygiene
Check room for additional precautions
Introduce yourself to client
Confirm client ID using two client identifiers
Check for any allergies
Complete necessary focused assessments and/ vital signs, and document on MAR
Provide client education as necessary

Doyle & McCutcheon, 2015

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Small Volume Nebulizer: Medication Safety Precautions

Plan medication administration to avoid disruption
Dispense medication in a quiet area
Avoid conversation with others
Follow agency’s no-interruption zone policy
Prepare medications for ONE client at a time
Follow the SEVEN RIGHTS of medication administration

Doyle & McCutcheon, 2015

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Small Volume Nebulizer: Cleaning

Remove mouthpiece/mask and medication container
Wash them with hot water and mild liquid dish soap
Rinse
Shake off the extra water
Let pieces air dry on clean towel

Healthline, 2021

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Small Volume Nebulizer: Disinfection

Remove detachable parts (mouthpiece and medication container)
Soak them in the solution recommended by care provider or one part white vinegar and three parts hot water
Let parts soak for 1 hour or as directed
Remove parts and let them air dry

Healthline, 2021

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Small Volume Nebulizer: Storage Tips

Once the parts have been cleaned and dried, store them in an airtight plastic container or bag
Keep in a cool, dry area
Keep nebulizer free of dust

(Healthline, 2021

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What Would the Nurse Do?

A client is on nebulizer therapy every 4 hours and is being discharged with the machine and the mask.

The husband will be cleaning the nebulizer.

The husband says he will boil the mask and the tube every day to ensure no bacterial growth.

�What should the nurse do?

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Incentive Spirometer

Mechanical handheld breathing device to encourage deep breathing.

Provides visual feedback on the volume of inhalation.

Franklin & Anjum, 2022

Contact info: info@nursesinternational.org

The incentive spirometer is a mechanical handheld breathing device in which the patient is instructed to take slow deep breaths through the device’s mouthpiece. The device gives the patient visual feedback on the volume of the inhalation. Incentive spirometers are available either by measuring the volume of inspiration (volume-oriented devices) or measuring the flow rate (flow-oriented devices). A standard flow-oriented incentive spirometer consists of three chambers in a row. The patient inhales through a mouthpiece connected to the unit with the three chambers. Each chamber contains a ball that has printed on the outside of the chamber the least amount of flow needed to raise the ball. With an airflow rate of 600 to 1200 milliliters (mL) per second, the deep breath lifts the balls. When all three balls reach the top of the unit, the patient has reached a flow speed of 1200 mL/second. The colored balls indirectly give the patient a visual indication of the inhaled volume. The visual feedback works to improve compliance in performing the slow, sustained deep inspiration.

The most common volume-oriented incentive spirometer is a mechanical hand-held device that uses a one-way valve to block exhalation into the device. It consists of a corrugated hose and a mouthpiece that connects the patient to a plastic chamber. Next to the central chamber of the spirometer is a slider. The medical provider can use this slider to set a target breath volume. The target breath volume can be based on the patient's age, height, health, and condition. When the patient breathes in through the corrugated hose, the piston in the chamber rises, which indicates the volume of displacement via an indicator on the device. There is a smaller chamber on the spirometer that measures the speed of the breath. The ball in this chamber will go to the top if the patient breathing in too quickly, and will go to the bottom if breathing too slowly. Many spirometers have a line on this chamber to indicate the optimal speed.

Once the patient has achieved maximal inspiratory volume to the best of their ability, the patient is requested to hold the piston in the same position for 5 to 10 seconds. After completing the inhalation and maintaining that inhalation for the appropriate amount of time, the patient is instructed to remove the mouthpiece, allowing gravity to return the piston to its original starting point.

Video Demonstration on Incentive Spirometer by My Doctor - Kaiser Permanente

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Incentive Spirometer: Indications

Post surgery
Prolonged bed rest
Neuromuscular disease or spinal cord injury
Cerebral palsy
Rib fractures
Pulmonary diseases (Chronic obstructive pulmonary)
Sickle cell disease
Ankylosing spondylitis, multiple sclerosis
Parkinson’s disease
Mild to moderate asthma, pneumonia, COVID-19

MedlinePlus, 2021

Health Line, 2021b

Franklin & Anjum, 2022

Contact info: info@nursesinternational.org

There are many indications for inspiratory muscle training, including but not limited to the following.

Any general surgery requiring hospital admission beyond one day: Incentive spirometry use by itself is not appropriate in the preoperative and postoperative setting to prevent postoperative pulmonary complications. Instead, incentive spirometry can be used with other aspects of pulmonary rehabilitation, including deep breathing techniques, directed coughing, adequate pain control, and early mobilization to prevent postoperative pulmonary complications. The incentive spirometer regimen includes ten workouts per day, used correctly (i.e., inspire up to 500 ml ten times per workout). Other postoperative interventions to prevent lung complications include but are not limited to oral care, elevating the head of the bed at least 30 degrees, dangling legs the day of surgery if indicated, transferring multiple times per day when cleared by the surgeon, ambulation, and sitting up for meals.[6]
Prolonged bed rest: Prolonged immobilization affects almost every organ system in the body. Respiratory complications include decreased ventilation, atelectasis, and pneumonia. Atelectasis is the collapse of the entire lung or part of the lung. It occurs when the alveoli within the lungs become deflated or possibly filled with fluid. Atelectasis is one of the most common respiratory complications after surgery.
Patients with neuromuscular disease or spinal cord injury: Cervical and upper thoracic spinal cord injury cause impairments in respiratory muscle performance, leading to pulmonary dysfunction and making deep breathing difficult for affected individuals. Patients with tetraplegia have a more compromised pulmonary function as compared with patients with paraplegia. Respiratory muscle training should be a focus in all spinal cord injury rehabilitation programs, especially for patients with tetraplegia, as well as those with chronic spinal cord injury.
Children with cerebral palsy: Incentive spirometry has been shown to enhance pulmonary function and breath control for speech production in children with cerebral palsy.
Rib fractures: Several complications can follow rib fracture, including hemothorax, pneumothorax, lung contusion, atelectasis, respiratory failure, flail chest, and even death. Patients suffering from rib fractures frequently complain of chest pain, which can be caused by obstruction of the lower airway or damaged lung hygiene. This can lead to atelectasis and hypoventilation. Atelectasis is the most common complication following rib fractures. Incentive spirometry has been shown to decrease pulmonary complications in patients with rib fractures and improve pulmonary function.
Chronic obstructive pulmonary disease (COPD): COPD is a common, preventable lung disease characterized by progressive difficulty with breathing, often with systemic manifestations, in response to tobacco smoke and/or other harmful exposures to the lungs. The reported benefits of pulmonary rehabilitation on COPD exacerbations have been mixed, but the balance of evidence supports its use. Pulmonary rehabilitation may reduce future COPD exacerbations by targeting risk factors that may cause readmission to the hospital, such as physical inactivity, reduced activity tolerance, impaired physical function, desensitization to shortness of breath, anxiety, and depression. Short-term inspiratory muscle training and incentive spirometer use have beneficial effects on exercise capacity and exertional dyspnea in patients with COPD. Pulmonary rehabilitation of a patient with COPD needs to be used in conjunction with lifestyle changes, smoking cessation, and physical exercise to better manage the disease; incentive spirometry cannot be used alone.
Video-assisted thoracoscopic surgery (VATS) for lung cancer: The use of incentive spirometry and inspiratory muscle training for patients with lung cancer that choose to undergo surgical resection via VATS has been shown to assist with lowering hospitalization costs and decreasing the prevalence of pneumonia incidents.
Sickle Cell Disease: Acute chest syndrome is a frequent cause of acute lung dysfunction in children with sickle cell disease. Management of acute chest syndrome includes immediate diagnosis, intravenous fluids, incentive spirometry, analgesics, supplemental oxygen or respiratory support, antibiotics, and transfusion therapy.
Ankylosing Spondylitis: Incentive spirometry may improve pulmonary function and arterial blood gases in patients with ankylosing spondylitis.
Parkinson's disease: Respiratory dysfunction is not a well-known feature of Parkinson's disease. Inspiratory muscle weakness may be present early in the course of the disease. In the more advanced stages, limited chest mobility, poor posture, and lung expansion contribute to less effective coughing. This could lead to the occurrence of aspiration pneumonia, which is among the highest risk factors for mortality for patients in the advanced stages of Parkinson's disease. Inspiratory muscle training can be helpful when people with Parkinson's disease are experiencing respiratory dysfunction.
Mild to moderate asthma: Breathing exercises may positively affect the quality of life, hyperventilation symptoms, and lung function in adults with mild to moderate asthma.
Cystic Fibrosis: The incentive spirometer may aid airway clearance and improve lung function in patients with cystic fibrosis.
COVID-19: Pulmonary rehabilitation, including inspiratory muscle training, is indicated in patients with mild to severe COVID-19 symptoms, including pneumonia and difficulties with secretion clearance. Training of inspiratory musculature also has significant benefits in patients who have been treated with mechanical ventilation. In patients with a dry, nonproductive cough, fever, and/or demonstrate no changes in thorax radiography, breathing techniques are not indicated.
Idiopathic pulmonary fibrosis: Pulmonary rehabilitation has been shown to alleviate respiratory symptoms and improve exercise tolerance. The improvements may be related to the chest expansion during deep-breathing exercises and the stretching of the thoracic muscles resulting in a more efficient breathing pattern, improved respiratory muscle strength, and pulmonary compliance. Most studies on pulmonary rehabilitation in idiopathic pulmonary fibrosis combine aerobic activity (walking and/or cycling) with resistance and flexibility exercises for peripheral skeletal muscles. Pulmonary rehabilitation should be considered at any stage of the idiopathic pulmonary fibrosis disease process and in patients awaiting lung transplantation.
Interstitial Lung Disease: Interstitial lung disease is one of the most serious pulmonary complications of connective tissue diseases. Non-pharmacological interventions include exercises such as walking, strength training, inspiratory muscle training, and breathing exercises.
Multiple Sclerosis: Resistive inspiratory muscle training may effectively improve maximal inspiratory pressure in people with mild to moderate multiple sclerosis.

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Incentive Spirometer: Nurse’s Role

Instruction to client:

Sit up right and hold the device
Place the mouthpiece spirometer in the mouth
Ensure good seal with lips over the mouthpiece
Inhale slowly and deeply
Exhale normally

MedlinePlus, 2021

Health Line, 2021b

Franklin & Anjum, 2022

Contact info: info@nursesinternational.org

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Incentive Spirometer: Nurse’s Role (Continued)

The ball in the incentive spirometer will rise as the client breathes

Have client raise ball as high as they can.
Strive to keep the ball or disk in the spirometer in the middle of the marked chamber while inhaling for as long as possible.
Hold breath for 3 to 5 seconds then slowly exhale.
Take 10 to 15 breaths with the spirometer every 1 to 2 hours, or as often as instructed.

MedlinePlus, 2021

Health Line, 2021b

Franklin & Anjum, 2022

Contact info: info@nursesinternational.org

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Incentive Spirometer: Special Considerations

If dizzy or lightheaded, remove the mouthpiece and breathe normally; then continue.

MedlinePlus, 2021

Health Line, 2021b

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Critical Thinking Question

A nurse is teaching the patient how to perform incentive spirometry. (Select all that apply).

What is the correct teaching method?

Inhale and exhale quickly and deeply
Try to keep the ball elevated for as long as possible
Performing a series of short inspirations
Assume an upright position in bed or on a chair

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Chest Physiotherapy

Involves external *mechanical maneuvers to clear airway secretions.
Used for a variety of respiratory conditions.
Improves gas exchange.
Reverses pathological progression.
Reduces or eliminates the need for artificial ventilation when provided at an early stage.

Abdullahi, 2020

Levine & Stankiewicz , 2022

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Chest Physiotherapy (Continued)

Process Involves:

Postural drainage
Chest percussion
Vibration
Breathing retraining

Effective coughing technique is the core of chest physiotherapy

Abdullahi, 2020

Levine & Stankiewicz , 2022

Contact info: info@nursesinternational.org

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Postural Drainage

Technique to drain mucus from the lungs by means of gravity, and position changes.
Safe for people of all ages.
Can be done at home/ hospital/ nursing facility.
Often done along with percussion, vibration, deep breathing, and huffing and coughing.

Evans, 2018

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Postural Drainage: When And How To Do It?

The best time is on an empty stomach
OR an hour and a half after a meal

Positions:

Sitting
Supine prone, or side lying
Sitting or lying with head flat, up, or down

Medline Plus, 2022

Contact info: info@nursesinternational.org

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Percussion

Helps break up thick fluids in the lungs.
Done while clapping a hand on the ribs while client is in prone position.

Done this with or without clothing on the chest:

Form a cup shape with the hand and wrist.
Clap the hand and wrist against the chest.
A hollow or popping sound should be heard, not a slapping sound.
Clapping should be gentle not so hard that it hurts.

Medline Plus, 2022

Contact info: info@nursesinternational.org

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Vibration

Vibration is like percussion, but with a flat hand that gently shakes the ribs.

Ask client to take a deep breath, then blow out hard.

With a flat hand, gently shake the ribs.
A special designed vest for vibration can be use.
Do percussion or vibration for 5 to 7 minutes in each area of the lungs.
When finished, ask client to take a deep breath and cough while splinting incision.

Medline Plus, 2022

Contact info: info@nursesinternational.org

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Breathing Retraining

Includes breathing exercises to increase lung capacity and improve ventilation.

Deep breathing exercises Include:

Diaphragmatic Breathing
Pursed Lip Breathing

Gotter, 2022

Contact info: info@nursesinternational.org

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Diaphragmatic Breathing or “Belly Breathing”

Engages the diaphragm
Instruct client to:

Relax their shoulders and sit back or lie down.
Place one hand on the abdomen and one on the chest.
Inhale through the nose for 2 seconds, feeling the air move into the abdomen and feel the stomach expand.
The stomach should move more than the chest does.
Press the stomach, breathe out for 2 seconds through pursed lips.
Repeat

Gotter, 2022

Contact info: info@nursesinternational.org

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Pursed-Lips Breathing

Slows down the breathing, reduces the work of breathing by keeping airways open longer.
Makes it easier for the lungs to function.
Improves oxygen and carbon dioxide exchange.
Instruct client to:

Inhale slowly through the nose.
Purse the lips, as if about to blow on something.
Breathe out as slowly as possible through pursed lips.
Exhale should take least twice as long as inhale.
Repeat

Gotter, 2022

Contact info: info@nursesinternational.org

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Chest physiotherapy: Contraindications

Bleeding diathesis (including therapeutic anticoagulation)
Discomfort due to physical positions or manipulations
Elevated intracranial pressure
Recent hemoptysis
Rib fractures
Vertebral fractures or osteoporosis

Levine & Stankiewicz, 2022

Contact info: info@nursesinternational.org

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Case Study

A client with asthma has been prescribed chest physiotherapy twice daily.

When should the assigned nurse schedule the procedure for the client?

After having had tea and just before having dinner
Either on an empty stomach or 2 hours after a meal
30 minutes after breakfast and 30 minutes before dinner
Immediately after having deep breathing exercise

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Red Flags

Shortness of breath associated with chest pain
Respiratory arrest
Respiratory distress
Oxygen saturation below 92%
Greasing or oiling oxygen flowmeter

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Cultural Considerations

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

Health beliefs: In some cultures talking about a possible poor health outcome will cause that outcome to occur.
Health customs: In some cultures family members play a large role in health care decision-making.
Ethnic customs: Differing gender roles may determine who makes decisions about accepting & following treatment recommendations.

AHRQ, 2020

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Cultural Considerations (Continued)

Religion, culture, beliefs, and ethnic customs can influence how families understand and use health concepts:

Religious beliefs: Faith and spiritual beliefs may affect health seeking behavior and willingness to accept treatment.
Dietary customs: Dietary advice may be difficult to follow if it does not fit the foods or cooking methods of the family.
Interpersonal customs: Eye contact or physical touch may be ok in some cultures but inappropriate or offensive in others.

AHRQ, 2020

Contact info: info@nursesinternational.org

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References

Abdullahi, A. (2020). Safety and Efficacy of Chest Physiotherapy in Patients With COVID-19: A Critical Review. Front. Med. 7:454. doi: 10.3389/fmed.2020.00454

Agency for Healthcare Research. (2020). Health Literacy Universal Precautions Toolkit, 2nd Edition. https://www.ahrq.gov/health-literacy/improve/precautions/tool10.html

Doyle, G. R., McCutcheon, J. A. (2015). Clinical procedures for safer patient care. BCcampus. https://opentextbc.ca/clinicalskills/

Evans, J. R. (2018, September 18). Postural Drainage: Does It Really Work? https://www.healthline.com/health/postural-drainage

Contact info: info@nursesinternational.org

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References

Franklin E, Anjum F. ( 2022, Jun 19). Incentive Spirometer and Inspiratory Muscle Training. In: StatPearls [Internet]. StatPearls Publishing; https://www.ncbi.nlm.nih.gov/books/NBK572114/

Gotter, A. (2022, September 28). Breathing Exercises to Increase Lung Capacity. https://www.healthline.com/health/how-to-increase-lung-capacity

Levine , A. R., Stankiewicz , J. (2022). Chest Physiotherapy. MSD Manual. https://www.msdmanuals.com/professional/pulmonary-disorders/pulmonary-rehabilitation/chest-physiotherapy

MedlinePlus.(2021, October 23). Using an incentive spirometer. https://medlineplus.gov/ency/patientinstructions/000451.htm

Contact info: info@nursesinternational.org

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References

Medline Plus.(2022, June 7). Medical Encyclopedia: Postural Drainage. https://medlineplus.gov/ency/patientinstructions/000051.htm

Healthline. (2021a, Nov 15). Using a Nebulizer. https://www.healthline.com/health/asthma-nebulizer-machine

Healthline. (2021b, Nov 9). What You Need to Know About Using an Incentive Spirometer for Lung Strength. https://www.healthline.com/health/incentive-spirometer

Princeton University. (2017). Assessing Selected Respiratory Therapy Modalities: Trends and Relative Costs in the Washington D C Area . https://www.princeton.edu/~ota/disk3/1981/8102/810205.PDF

Contact info: info@nursesinternational.org

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