Deep breaths to improve Sats

#KYJ-Oxygen Saturations and Deep breaths.

Do you ask your patient to take a few deep breaths when the sats are being recorded?

You know the patient I'm talking about.  Old mate, lying there restfully in the bed, sats sitting at 91%, and you don't want to write that number on the colour coded obs chart; so you lean over, give him a nudge, and say...

"Mate, take 5 deep breaths for me"

....

Well stop it.

...

It doesn't work, its dishonest and it demonstrates that you believe that it puts more oxygen into the blood which is plain wrong.

... have I got your attention? 

Read on: 

The patient taking deep or fast breaths is breathing the same air you are breathing. The same air they were breathing 2 minutes before you woke him for obs.

21% or a fraction of inspired oxygen (fiO2) of 0.21.

This translates to roughly 100mmHg in his lungs, which diffused into his blood to saturate his haemoglobin.  Here’s the vid 

You cant increase blood oxygen unless you increase the concentration (fiO2) he is breathing. So take 5 breaths or 50 breaths, and it makes zero difference to his oxygenation.

So what does it do?

Why do you see the sats go up 1-2%?

Well takes few deep breaths, and you blow off CO2. In fact, the faster and deeper you breathe the more CO2 you rid from your blood. This does three things:

One: it raises your pH making your blood slightly alkalotic.

Alkalotic red blood cells (haemoglobin) binds to oxygen more readily raising the saturation.  It is temporary and lasts only 20-70 seconds. Before you finish the next patient's obs, old mate has desaturated right back to where he was at the beginning.

Two: Bohr's principle suggests that when decreasing 

CO2 bound in Red Blood cells, there is more room temporarily to transport more oxygen... again it it very very short lived.

Three: Taking deep breaths recruits more alveoli (the gas exchange air sacs).

This optimises ( not increases) diffusion. Here again it is temporary, and unless old mate continues to stay awake and rapidly deep breathe, his sats will base line out back at that number you didn't want to write in the chart.

So... what to do ?

Assess your patient.  Is he distressed? Does he have any other symptoms that could indicate respiratory discourse?

Triangulate your vital signs and talk to the patient. Normal is anything over 90% (93-96% ideal) when breathing room air.  Chronic lung disease patients may have an acceptable lower limit of normal for them (often 88-92%). But all of us when resting or sleeping drop, not just our sats, but also our resp rates, so take the data in context, investigate your patient, and stop bugging them to deep breathe just so your graph looks good.

Final word on deep breathing- its good to get all your patients to do this every hour. It prevents DVTs, pressure area ulcers, atelectasis/pneumonia, and helps clear pooled secretions in de-recruited lungs.

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Now Look at a video that discusses this 

Bronchial Thermoplasty

#KYJ Bronchial Thermoplasty

Have you lot heard much about this newish treatment.
I first heard about this treatment when I was teaching in our respiratory seminar and one of the nurses attending mentioned it. If you are listening nurse PW, thank you for getting the ball rolling.

Bronchial Thermoplasty- let's look at the word - bronchial, obviously means the Bronci and the larger bronchioles. Thermoplasty means the application of heat (Thermo) to create physical changes to tissue (plasty).

This is a procedure that can be performed under general anaesthesia for adults that meet certain severe asthma criteria. Usually requires a series of treatments a month apart each lasting about one hour.  I bronchoscoped is passed into the lungs, and a heating element is applied to the smooth muscle causing it to essentially scar and become hardened (stenosis).
This might sound like a bad idea but if you recall one of the fundamental pathophysiology's of asthma is that the smooth muscle surrounding the small airways undergo bronchospasm.  When stenosed, this is less likely.

For patients who have frequent asthma flareup, this treatment shows promise and reduces the number and severity of acute episodes. This treatment is not for everybody it's got a fairly hit and miss success rate the that is not that much better than (20-25%) placebo.  Interestingly, the research even demonstrated that up to 5% of asthmatic patients undergoing clinical trials, required more of their preventative medication after the treatment . This is no magic bullet, but if you were one of those patients in that success group, and it meant less asthma flareup and less preventative medication that arguably has its own problems; then I guess it's worth discussing treatment with your respiratory physician.

As you know it's asthma week this week.  If you have an opportunity to support research and treatment and ongoing knowledge in this field now would be a great time to surf over to the asthma Council of Australia website and the supporting foundations.  There is a lot to read, there is a lot to learn and that's all good for CPD.
For more information on Bronchial Thermoplasty and have a look at this link.
https://www.asthmaaustralia.org.au/national/about-asthma/manage-your-asthma/special-and-new-treatments

Link to AsthmaAustralia page

The Silent Chest - severe asthma

I had a colleague who asked me to post about the "Silent Chest" 

....

#KYJ Beware the silent chest. 

In the world of chronic disease, there exists, a classification or grading system that generally numbers Stage 1 through to stage 4 or 'End Stage'.

These grading or staging systems carry with them a set of typical symptoms that define the patients severity of disease.

Typically this staging system follows a predictable model of percentages of each stage.

35% with stage 1 illness generally have no obvious red flag symptoms, are often undiagnosed and live life ignorant of the fact they actually have chronic disease.

Stage two illness often recognise symptoms, and may flag these to their GP who diagnose disorders based on symptoms.  These patients make up another 35%.

Stage 3 patients will be well into recognition of their disease, will often be medicated, and perhaps experience frequent acute exacerbations of their chronic disease, which results in infrequent hospitalisations. These stage 3 people make up 20-25% of patients with the respective chronic condition.

Then there is the real sickies, stage 4 or End Stage patients, who make up 5-10%.

These patients are often in hospital or ED with acute exacerbation. They have lives that are limited in activity/ or ability to function too far from their specialist/GP or healthcare support network.

Unique to the end stage chronic disease patient is a unique symptom set, that by their very features, sets them apart from the other 90-95% of sufferers of their disease.

For the Chronic renal patient it may be the need for dialysis.

For the chronic Heart failure patient it might be frequent episodes of severe Pulmonary oedema.

For the COPD patient, it might be the development of CO2 retention and permanent home oxygen.

For Asthma, it is the frequent presentation of Asthma flare-ups, which often have a silent chest on auscultation.

Now a non wheezing asthmatic patient may be a red herring.

It might be nothing, but it might be significant.

The real danger, it can be misleading or distract an unsavvy clinician; but make no mistake, you want to assess your patient with a silent chest well.  Get this wrong, and your patient is making it to ICU if you (and they) are lucky.

Let's review wheeze.  Wheeze is the sound of air being squeezed through narrowed bronchi and bronchioles.  Say it aloud...slowly "squeeeeeezed"

Right in that word is "wheeeeze".

Frequently a symptom of mild to moderate asthma, a wheeze is audible when enough air is forced through bronchospastic airways.   In end stage, preterminal exacerbation, the severe asthma flare may not be physically moving enough or any air through their low airways, meaning that no vibration or sound is audible.

This is badness!

Lack of air movement is gas trapping and not only represents a massive risk of desaturation, but also a risk of pneumothorax .

Frequently, the silent chest is a symptom of the severest form of asthma flare... the Status Asthmaticus.

This pre-arrest condition often progresses to acute respiratory failure (PaO2<60mmHg), and imminent respiratory arrest.

With limited air reaching alveoli, the wheeze disappears, oxygenation decreases, CO2 is retained, and level of consciousness rapidly declines.  In adults, we have physiological reserves to keep struggling to breathe. We fight for our breaths using our developed chest and shoulder muscles (laboured breathing); but in children, especially those under 8, these kids die from shear exhaustion.

Until proven to be an irrelevant symptom, the silent chest must be regarded as a medical emergency.

So when is the silent chest, not a problem?

In a mild asthma presentation, the work of breathing is not markedly increased.  The patient may be coughing, but is not distressed, cerebrally irritated, or desaturated.

In the "I can hear you wheezing from across the room" type presentations, place your stethoscope over the patients throats before auscultation grandson their chest.  If the wheeze is heard in the throat, and not in the lung fields, then the presentation is likely to be anxiety induced vocal cord dysfunction, and not asthma.

The true asthmatic silent chest is as sick as an asthmatic can be.  Believe them! Look at sats, their work of breathing, and history of ICU admissions, to guide your index of suspicion that this patient is sicker than they sound.

It echoes, the sound, of silence.

Interested in more?

You could attend our Respiratory seminar.  http://www.ect4health.com.au/respiratory-failure-nursing-seminar/

Link to Seminar on Respiratory Failure Nursing