I do apologize if some of my posts seem very elementary. I need to review the basics to move on to the more complex. Every organ and tissue in our body is important (well, I guess there’s some debate about the appendix), but without our lungs and our heart, nothing could function properly. These two organs (in good working condition and in conjunction with the vasculature) ensure that our bodies get the oxygen and nutrients they need to work. So often I don’t give them the credit they are due. The job of the lungs is to get oxygen into your body to hitch a ride on the hemoglobin in your blood. Your heart gets the blood to the entire body. These two elements provide our body the ventilation (V) and perfusion(Q) it needs in order to survive. As nurses, we want to ensure the best match of gas in the alveolar sacs to the amount of blood that comes in contact with the alveoli.
This makes our goal to get and keep the alveoli and capillaries open.
How can we do this?
Alveoli Open: Have the patient use the incentive spirometer or if the patient is on a ventilator use PEEP (positive expiratory end pressure).
Capillary Open: Ensure good RV (right ventricular) function, adequate volume, and monitor the pulmonary artery pressures.
When is ventilation and perfusion mismatched?
When you are sitting up, you naturally have a V/Q mismatch. When you are lying down, blood naturally pools where gravity pulls it: toward the back of the lungs. During exercise, there is a perfect V/Q match. So when our patients are lying on their backs, not getting out of bed they are having issues with V/Q mismatch.
Solution: Get my patients up and running the halls! Get that V/Q match perfect! Well, that would be nice, but I work night shift in progressive care and my patients are usually sleeping, on a ventilator, a quadriplegic, or are far too weak to get up and walk. Then how do we keep the alveoli open?
- On the ventilator, we use PEEP.
- If the patient is not on the vent, I can teach and encourage my patient to use the incentive spirometer. But let’s say the patient thinks that that incentive spirometer (IS) is dumb and it hurts and it’s not doing a darn thing. Explain again why you want them to do it and if they still refuse TCDB (turn, cough, deep breathe). The IS may actually hurt less than turning and coughing.
- Turn the patient. Since most of my patients can’t turn by themselves anyway I turn them. During this time I instruct them to take a deep breath (if they are able) when lying on the side. The big breath will help get oxygen in and keep the alveoli open. Turning is not just for the bum, my friend! Work on that ventilation! Remind the patient that if they don’t take deep breaths, oxygen is not getting into their lungs which means it’s also not getting to their other tissues and that is dangerous.
Intentionality: I often forget that the simple tasks I need to complete can be some of the best for helping my patient heal. It’s so easy to turn the patient and chart TCDB (turn, cough, deep breathe) every two hours when they’ve only breathed because I’ve interrupted their sleep by turning them and they gasped. When they are awake (because yes, they need their sleep too!), I need to make an effort to ensure that their lungs are performing how they are intended.
How do you help your patients breathe and ventilate?