LATIHAN BATUK EFEKTIF

TEORI / KONSEP

A. Batuk efektif merupakan suatu metode batuk dengan benar, dimana klien dapat menghemat energi sehingga tidak mudah lelah dan dapat mengeluarkan dahak secara maksimal.

Adapun cara latihan batuk efektif yaitu dengan : anjurkan klien menarik nafas selama 3x kemudian anjurkan klien batuk secara menghentak.

Batuk secara terkekeh-tekeh dapat menyebabkan seseorang kehilangan banyak energi dan sulit untuk mengeluarkan dahak. Untuk mengantisipasi hal tersebut kita dapat menggunakan teknik batuk efektif.

B. Latihan batuk efektif
Berfungsi mengeluarkan sekresi ( Stari, 1992 ).

LATIHAN BATUK

Batuk merupakan cara efektif dan efisien untuk mengeluarkan lendir di saluran pernapasan. Agar batuk jadi efektif maka perlu diberikan latihan batuk. Namun latihan ini hanya bisa dilakukan pada anak yang sudah bisa diajak sedikit bekerja sama (kooperatif) atau mulai di usia balita. Untuk bayi, teknik batuk pada fisoterapi di rumah biasanya ditiadakan. Bayi biasanya mengeluarkan lendir dengan cara memuntahkannya.

Latihan Batuk merupakan cara yang paling efektif untuk membersihkan laring, trakea, bronkioli dari sekret dan benda asing.

Adapun latihan batuk yang bisa dilakukan adalah:
Anak duduk dengan agak membungkuk. Minta ia menarik napas dalam-dalam lalu tahan dan kontraksikan otot perut. Tiup napas lebih kuat dan batuk.

Latihan Batuk Efektif

Latihan batuk efektif juga sangat diperlukan bagi klien terutama klien yang mengalami operasi dengan anestesi general. Karena pasien akan mengalami pemasangan alat bantu nafas selama dalam kondisi teransetesi. Sehingga ketika sadar pasien akan mengalami rasa tidak nyaman pada tenggorokan. Dengan terasa banyak lendir kental di tenggorokan. Latihan batuk efektif sangat bermanfaat bagi pasien setalah operasi untuk mengeluarkan lendir atau sekret tersebut.

Pasien dapat dilatih melakukan teknik batuk efektif dengan cara :

- Pasien condong ke depan dari posisi semifowler, jalinkan jari-jari tangan dan letakkan melintang diatas incisi sebagai bebat ketika batuk.

- Kemudian pasien nafas dalam seperti cara nafas dalam (3-5 kali)

- Segera lakukan batuk spontan, pastikan rongga pernafasan terbuka dan tidak hanya batuk dengan mengadalkan kekuatan tenggorokan saja karena bisa terjadi luka pada tenggorokan.

- Hal ini bisa menimbulkan ketidaknyamanan, namun tidak berbahaya terhadap incisi.

- Ulangi lagi sesuai kebutuhan.

Jika selama batuk daerah operasi terasa nyeri, pasien bisa menambahkan dengan menggunakan bantal kecil atau gulungan handuk yang lembut untuk menahan daerah operasi dengan hati-hati sehingga dapat mengurangi guncangan tubuh saat batuk.

Batuk mempengaruhi interaksi personal dan sosial, mengganggu tidur dan sering menyebabkan ketidak nyamanan pada tenggorakan dan dinding dada.

Sebagian besar orang mencari pertolongan medis untuk batuk akur supaya mereda, sementara itu ada orang yang takut batuknya menjadi penyakit yang serius.

Batuk terjadi sebagai akibat stimulasi mekanik atau kimia pada nervus afferent pada percabangan bronkus.

Batuk efektif tergantung pada intaknya busur refleks afferent-efferent, ekspirasi yang adekuat dan kekuatan dinding otot dada dan normalnya produksi dan bersihan mukosiliar

Point penting
Umur
Durasi batuk
Dyspneu (saat istirahat atau aktivitas)
Gejala konstitusional
Riwayat merokok
Tanda vital (denyut jantung, respirasi, temperatur tubuh)
Pemeriksaan thorax
Radiologi thorax saat batuk yang tidak bisa dijelaskan terjadi lebih dari 3-6 minggu

Temuan Klinis

Gejala

Membedakan batuk akut (<> 3 minggu) merupakah langkah awal dalam mengevaluasi.
Pada individu dewasa yang sehat, sebagaian besar sindrom batuk diakibatkan oleh infeksi saluran respirasi oleh virus.
Batuk post infeksi yang berlangsung 3 – 8 minggu di sebut sebagai batuk sub akut untuk membaedakan dari batuk akut dan kronik.
Gejala klinik tambahan seperti demam, kongesti nasal dan radang tenggorokan dapat membantu dalam mendiagnosis.
Dyspneu ( saat istirahat atau aktivitas) mencerminkan kondisi yang serius dan memerlukan evaluasi lebih lanjut termasuk penilaian oksigenasi (pulse oksimetri atau pengukuran gas darah arteri), aliran udara (peak flow atau spirometri) dan penyakit parenkim paru ( radiologi thorax).

Waktu dan karakter batuk tidak bermanfaat untuk menentukan penyebab batuk akut ataupun persisten, meskipun varian batuk asma sebaiknya dipertimbangkan pada orang dewasa dengan batuk nokturna prominent.

Penyebab tidak umum batuk akut dicurigai pada orang dengan penyakit jantung (gagal jantung kongestif) atau hay fever (rhinitis alergi) dan orang dengan faktor resiko lingkungan (misalnya petani).

Batuk yang disebabkan oleh infeksi saluran respirasi akut membaik dalam 3 minggu pada 90% pasien.
Infeksi pertusis dicurigai pada orang dewasa yang sebelumnya di imunisasi dengan batuk persisten atau berat sekitar 2 – 3 minggu.
Saat tidak ditemukan terapi dengan obat ACE inhibitor, infeksi saluran respirasi akut dan radiologi thorax abnormal, sampai 90% kasus batuk persisten disebabkan oleh postnasal drip, asma atau gastroesophageal reflux disease (GERD).

Riwayat kongesti nasal atau sinus, wheezing atau rasa terbakar pada jantung (heartburn) sebaiknya cepat dievaluasi dan terapi. Kondisi tersebut sering menyebabkan batuk persisten pada keadaan batuk tanpa gejala lain yang terlihat.

Karsinoma bronkogenik dicurigai saat batuk disertai penurunan berat badan yang tidak diketahui sebabnya, demam dengan keringat malam terutama pada orang dengan riwayat merokok dan terpapar.
Batuk persisten yang disertai sekresi mukus yang banyak dicurigai bronkitis kronik pada perokok atau bronkiektasis pada pasien dengan riwayat pneumonia rekurent atau terjadi komplikasi, radiologi thorax dapat membantu.
Dyspneu pada istirahat atau aktifitas umumnya tidak terdapat pada pasien dengan batuk persisten. Dyspneu memerlukan penilaian lebih lanjut terhadap bukti lebih lanjut penyakit paru kronik atau gagal jantung kongestif.

Pemeriksaan Fisik
Pemeriksaan fisik dapat secara langsung sebagai alat diagnostik untuk batuk akut dan persisten. Pneumonia dicurigai saat batuk akut disertai dengan tanda vital yang abnormal (takikardi, takipneu, demam) atau ditemukan konsolidasi ruang udara (ronki, penurunan suara nafas, fremitus, egophny).
Meskipun sputum yang purulen berhubungan dengan infeksi bakteri pada pasien penyakit paru (misalnya Penyakit Paru Obstruktif Kronik (PPOK), cystik fibrosis), pada pneumonia merupakan prediktor yang jelek pada pasien dewasa sehat.

Terapi antibiotika pada orang dewasa dengan sputum yang purulen tidak menunjukan manfaat. Wheezing dan ronki sering ditemukan pada orang dewasa dengan bronkitis akut dan pada sebagian besar kasus tidak mencerminkan asma yang beronset pada dewasa.

Pemeriksaan fisik pada orang dewasa dengan batuk persisten kemungkinan dapat menunjukan bukti sinusitis kronik, syndrom post nasal drip atau asma.

Tanda dada dan jantung dapat membedakan PPOK dan GJK (Gagal Jantung Kongestif). Pada pasien batuk yang disertai dyspneu, test match normal (mampu membedakan match 25 cm jauhnya) dan tinggi laringeal maksimum 4 cm (diukur dari sternal notch ke kartilago cricoid pada akhir ekspirasi) menurunkan kemungkinan PPOK. Sama juga, tekanan vena jugularis dan reflux hepatojugular negatif menurunkan kemungkinan GJK biventrikular.

Diagnosis Banding
Batuk akut
Batuk akut dapat merupakan tanda infeksi saluran respirasi akut, asma, rhinitis alergi dan gagal jantung kongestif.

Batuk persisten
Penyebab batuk persisten termasuk infeksi pertusis, syndrom post nasal drip (atau sundrom batuk jalan nafas atas), asma (termasuk batuk varian asma), GERD, bronkitis kronik, bronkiektasis, tuberkulosis atau infeksi kronik lainnya, penyakit paru interstitial dan karsinoma bronkogenik. Batuk persisten dapat juga psikogenik.

Pemeriksaan Diagnostik
Batuk akut
Radiolograpi thorax dipertimbangkan pada orang dewasa dengan batuk yang akut yang menunjukan tanda vital yang abnormal atau pada pemeriksaan thorax curiga pneumonia.

Batuk persisten
Radiography thorax indiksai jika telah disingkirkan kemungkinan pasien menjalani terapi dengan ACE inhibitor dan batuk post infeksi dengan anamnesis.
Pemeriksaan terhadap infeksi pertusis dilakukan dengan menggunakan polymerase chain reaction pada swab nasopharingeal atau spesimen hidung. Saat radiologinya normal, pertimbangkan kemungkinan postnasal drip, asma dan GERD.
Terdapatnya gejala-gejala umum tersebut sebaiknya dievaluasi lebih lanjut atau diberikan terapi empirik.
Akan tetapi, terapi empirik direkomendasikan untuk postnasal drip, asma atau GERD selama 2-4 minggu meskipun penyakit-penyakit tersebut yang bukan menyebabkan batuknya.
Sekitar 25% kasus batuk persisten disebabkan berbagai macam penyebab.
Spirometri dapat membatu obstruksi saluran nafas pada pasien dengan batuk persisten dan wheezing dan yang tidak respon terhadap pengobatan asma.
Ketika terapi empirik untuk sindrom postnasal drip, asma dan GERD tidak membantu, evaluasi lebih lanjut diperlukan melalui pH manometri, endoskopi, barium swallow, CT scan sinus atau thorax.


Terapi
Batuk Akut
Dalam memberikan terapi batuk akut sebaiknya berdasarkan penyebab penyakitnya, batuknya sendiri dan faktor-faktor tambahan yang membuat batuk kambuh.
Ketika diagnosa influenza ditegakkan, terapi dengan amantadine, rimantadine, oseltamivir atau zanamivir efektif ( 1 hari atau kurang) ketida dimulai 30-48 jam dari onset penyakit.
Pada infeksi Chlamydia atau Mycoplasma, antibiotik seperti ertiromysin, 250 mg oral 4 kali sehari selama 7 hari atau doksisiklin 100 mg oral 2 kali sehari selama 7 hari.
Pada pasien dengan bronkitis akut, terapi dengan inhalasi beta 2 -agonis dapat mengurangi keparahan dan durasi batuk pada beberapa pasien.
Bukti menunjukan pemberian dextromethorphan bermanfaat dalam meringankan batuk pada orang dewasa dengan infeksi saluran respirasi akut.
Terapi postnasal drip (dengan antihistamin, dekongestan, atau kortikosteroid nasal) atau GERD (dengan H2 blocker atau proton-pump inhibittor) yang disertai dengan batuk akut dapat menolong.
Terdapat bukti bahwa vitamin C dan echinacea tidak efektif dalam mengurangi keparahan batuk akut, tetapi terdapat bukti juga bahwa vitamin C (sedikitnya 1 gram sehari) bermanfaat dalam mencegah flu pada orang dengan stress fisik (misal: setelah marathon) atau malnutrisi.

Batuk Persisten
Saat dicurigai infeksi pertusis, terapi dengan antibiotika makrolid tepat untuk mengurangi penyebaran dan transmisi organisme.
Jika infeksi pertusis berlangsung 7-10 hari, terapi antibiotika tidak mengurangi durasi batuk yang dapat berlangsung selama 6 bulan.
Tidak ada bukti yang merekomendasikan berapa lama terapi batuk persisten dilanjutkan untuk postnasal drip, asma atau GERD.
Gejala yang kambuh lagi memerlukan evaluasi lebih lanjut.
Pasien dengan batuk persisten tanpa sebab yang jelas dikonsultasikan dengan otolaryngologist; terapinya dengan lidokain nebulasi.

DAFTAR PUSTAKA
Call SA et al. Does this patient have influenza? JAMA. 2005 Feb 23;293(8):987–97. [PMID: 15728170]

Haque RA et al. Chronic idiopathic cough: a discrete clinical entity? Chest. 2005 May;127(5):1710–3. [PMID: 15888850]

Hewlett EL et al. Clinical practice. Pertussis—not just for kids. N Engl J Med. 2005 Mar 24;352(12):1215–22. [PMID: 15788498]

Lin DA et al. Asthma or not? The value of flow volume loops in evaluating airflow obstruction. Allergy Asthma Proc. 2003 Mar–Apr;24(2):107–10. [PMID: 12776443]

Metlay JP et al. Testing strategies in the initial management of patients with community-acquired pneumonia. Ann Intern Med. 2003 Jan 21;138(2):109–18. [PMID: 12529093]

Pratter MR et al. An empiric integrative approach to the management of cough: ACCP evidence-based clinical practice guidelines. Chest. 2006 Jan;129(1 Suppl):222S–231S. [PMID: 16428715]

Schroeder K et al. Over-the-counter medications for acute cough in children and adults in ambulatory settings. Cochrane Database Syst Rev. 2004;(4):CD001831. [PMID: 15495019]

Wenzel RP et al. Acute bronchitis. N Engl J Med. 2006 Nov 16;355(20):2125–30. [PMID: 17108344]
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TINDAKAN POSTURAL DRAINAGE

1 ) Chest Physiotherapy atau Terapi Bagian Dada

Klien dengan keluhan batuk-pilek biasanya mendapat chest physiotherapy yang bermanfaat membersihkan saluran pernapasan dan memperbaiki pertukaran udara. Yang termasuk dalam fisioterapi ini di antaranya inhalasi/nebulizer, clapping, vibrasi dan postural drainage.

Inhalasi yaitu memasukkan obat-obatan ke dalam saluran pernapasan melalui penghirupan. Jadi, partikel obat dipecah terlebih dulu dalam sebuah alat yang disebut nebulizeer hingga menjadi molekul-molekul berbentuk uap. Uap inilah yang kemudian dihirup anak, hingga obat akan langsung masuk ke saluran pernapasan. Keuntungan cara ini, dosis obat jauh lebih kecil, hingga dapat mengurangi efek samping obat.

Obat-obat inhalasi yang umum diberikan adalah obat untuk melonggarkan saluran napas, pengencer dahak, dan NaCl sebagai pelembab saluran napas. Sedangkan lamanya setiap inhalasi cukup sekitar 10 menit. Tindakan lanjut untuk membantu pengeluaran lendirnya, antara lain clapping atau tepukan pada dada dan punggung. Bisa di sisi kanan, kiri, depan dada. Tepukan dilakukan secara kontinyu dan ritmik. Sertai pula dengan pengaturan posisi klien (postural drainage), semisal klien ditengkurapkan dengan posisi kepala lebih rendah dari badan, hingga lendir tersebut dapat mengalir ke cabang pernapasan utama sekaligus lebih mudah untuk dibatukkan. Ini akan menguntungkan karena biasanya pasien tak bisa meludah, hingga lendir yang menyumbat saluran pernapasan sulit dikeluarkan.

Khusus pada bayi atau anak di bawah usia 2 tahun, bila perlu, lakukan tindakan suction atau penyedotan lendir dengan alat khusus lewat hidung atau mulut. Bisanya tindakan ini dilakukan pada bayi dimana refleks batuknya belum cukup kuat untuk mengeluarkan lendir.

2 ) Postural drainage
Adalah posisi khuus yang digunakan agar kekuatan gravitasi dapat membantu di dalam pelepasan sekresi bronkhial dari bronkhiolus yang bersarang di dalam bronkhus dan trakhea, dengan maksud supaya dapat membatukkan atau dihisap sekresinya.

Biasanya dilakukan 2 - 4 kali sebelum makan dan sebelum tidur / istirahat.
Tekniknya :
• Sebelum postural drainage, lakukan :
- Nebulisasi untuk mengalirkan sekret
- Perkusi sekitar 1 - 2 menit
- Vibrasi 4 - 5 kali dalam satu periode
• Lakukan postural drainage, tergantung letak sekret dalam paru.

3 ) sumber : Wikipedia

Drainage used in bronchiectasis and lung abscess.

The patient's body is positioned so that the trachea is inclined downward and below the affected chest area ^[1].

Postural drainage is essential in treating bronchiectasis and patients must receive physiotherapy to learn to tip themselves into a position in which the lobe to be drained is uppermost at least three times daily for 10-20 minutes.

Most patients find that lying over the side of the bed with head and thorax down is the most effective position ^[2].

The treatment is often used in conjunction with a technique for loosening secretions in the chest cavity called chest percussion.

Chest percussion is performed by clapping the back or chest with a cupped hand. Alternatively, a mechanical vibrator may be used in some cases to facilitate loosening of secretions ^[3].

References

1. ^ Dorland's Medical Dictionary.
2. ^ Kumar and Clark's Clinical Medicine.
3. ^ http://www.merck.com/mmhe/sec04/ch040/ch040i.html

4 ). AARC Clinical Practice Guideline

Postural Drainage Therapy

PDT 1.0 PROCEDURE:

Postural drainage therapy (PDT) is a component of bronchial hygiene therapy.

It consists of postural drainage, positioning, and turning and is sometimes accompanied by chest percussion and/or vibration.

Cough or airway clearance techniques are essential components of therapy when postural drainage is intended to mobilize secretions.

(1-6) Postural drainage therapy is often used in conjunction with aerosol administration and other respiratory care procedures.

This procedure has been commonly referred to as(7-12)

chest physiotherapy,
chest physical therapy,
postural drainage and percussion, and
percussion and vibration.

PDT 2.0 DESCRIPTION/DEFINITION:

Postural drainage therapy is designed to improve the mobilization of bronchial secretions and the matching of ventilation and perfusion, and to normalize functional residual capacity (FRC) based on the effects of gravity and external manipulation of the thorax. This includes turning, postural drainage, percussion, vibration, and cough.

2.1 Turning

Turning is the rotation of the body around the longitudinal axis to promote unilateral or bilateral lung expansion and improve arterial oxygenation.

Regular turning can be to either side or the prone position, with the bed at any degree of inclination (as indicated and tolerated).

Patients may turn themselves or they may turned by the caregiver or by a special bed or device.

2.2 Postural Drainage

Postural drainage is the drainage of secretions, by the effect of gravity, from one or more lung segments to the central airways (where they can be removed by cough or mechanical aspiration). Each position consists of placing the target lung segment(s) superior to the carina.

Positions should generally be held for 3 to 15 minutes (longer in special situations). Standard positions are modifie

d as the patient's condition and tolerance warrant.

2.3 External Manipulation of the Thorax

2.3.1 Percussion

Percussion is also referred to as cupping, clapping, and tapotement.

The purpose of percussion is to intermittently apply kinetic energy to the chest wall and lung.

This is accomplished by rhythmically striking the thorax with cupped hand or mechanical device directly over the lung segment(s) being drained.

No convincing evidence demonstrates the superiority of one method over the other.

2.3.2 Vibration

Vibration involves the application of a fine tremorous action (manually performed by pressing in the direction that the ribs and soft tissue of the chest move during expiration) over the draining area. No conclusive evidence supports the efficacy of vibration, the superiority of either manual or mechanical methods, or an optimum frequency.

PDT 3.0 SETTING:

Although PDT can be used with neonates, infants, childrens, and adults, this Guideline applies primarily to older children and adults.
PDT can be performed in a wide variety of settings.

3.1 Critical care

3.2 In-patient acute care

3.3 Extended care and skilled nursing facility care

3.4 Home care

3.5 Outpatient/ambulatory care

3.6 Pulmonary diagnostic (bronchoscopy) laboratory

PDT 4.0 INDICATIONS:

4.1 Turning

4.1.1 inability or reluctance of patient to change body position. (eg, mechanical ventilation, neuromuscular disease, drug-induced paralysis)

4.1.2 poor oxygenation associated with position (eg, unilateral lung disease)

4.1.3 potential for or presence of atelectasis

4.1.4 presence of artificial airway

4.2 Postural Drainage

4.2.1 evidence or suggestion of difficulty with secretion clearance

4.2.1.1 difficulty clearing secretions with expectorated sputum production greater than 25-30 mL/day (adult)

4.2.1.2 evidence or suggestion of re-tained secretions in the presence of an artificial airway

4.2.2 presence of atelectasis caused by or suspected of being caused by mucus plugging

4.2.3 diagnosis of diseases such as cystic fibrosis, bronchiectasis, or cavitating lung disease

4.2.4 presence of foreign body in airway

4.3 External Manipulation of the Thorax

4.3.1 sputum volume or consistency suggesting a need for additional manipulation (eg, percussion and/or vibration) to assist movement of secretions by gravity, in a patient receiving postural drainage

PDT 5.0 CONTRAINDICATIONS:

The decision to use postural drainage therapy requires assessment of potential benefits versus potential risks.
Therapy should be provided for no longer than necessary to obtain the desired therapeutic results. Listed contraindications are relative unless marked as absolute (A).

5.1 Positioning

5.1.1 All positions are contraindicated for

5.1.1.1 intracranial pressure (ICP) > 20 mm Hg

5.1.1.2 head and neck injury until stabilized (A)

5.1.1.3 active hemorrhage with hemodynamic instability (A)

5.1.1.4 recent spinal surgery (eg, laminectomy) or acute spinal injury

5.1.1.5 acute spinal injury or active hemoptysis

5.1.1.6 empyema

5.1.1.7 bronchopleural fistula

5.1.1.8 pulmonary edema associated with congestive heart failure

5.1.1.9 large pleural effusions

5.1.1.10 pulmonary embolism

5.1.1.11 aged, confused, or anxious patients who do not tolerate position changes

5.1.1.12 rib fracture, with or without flail chest

5.1.1.13 surgical wound or healing tissue

5.1.2 Trendelenburg position is contraindicated for

5.1.2.1 intracranial pressure (ICP) > 20 mm Hg

5.1.2.2 patients in whom increased intracranial pressure is to be avoided (eg, neurosurgery, aneurysms, eye surgery)

5.1.2.3 uncontrolled hypertension

5.1.2.4 distended abdome

5.1.2.5 esophageal surgery

5.1.2.6 recent gross hemoptysis re-lated to recent lung carcinoma treated surgically or with radiation therapy(59)

5.1.2.7 uncontrolled airway at risk for aspiration (tube feeding or recent meal)

5.1.3 Reverse Trendelenburg is contraindicated in the presence of hypotension or vasoactive medication

5.2 External Manipulation of the Thorax

In addition to contraindications previously listed

5.2.1 subcutaneous emphysema

5.2.2 recent epidural spinal infusion or spinal anesthesia

5.2.3 recent skin grafts, or flaps, on the thorax

5.2.4 burns, open wounds, and skin infections of the thorax

5.2.5 recently placed transvenous pacemaker or subcutaneous pacemaker (particularly if mechanical devices are to be used)

5.2.6 suspected pulmonary tuberculosis

5.2.7 lung contusion

5.2.8 bronchospasm

5.2.9 osteomyelitis of the ribs

5.2.10 osteoporosis

5.2.11 coagulopathy

5.2.12 complaint of chest-wall pain

PDT 6.0 HAZARDS/COMPLICATIONS:

6.1 Hypoxemia

Action To Be Taken/Possible Intervention: Administer higher oxygen concentrations during procedure if potential for or observed hypoxemia exists. If patient becomes hypoxemic during treatment, administer 100% oxygen, stop therapy immediately, return patient to original resting position, and consult physician. Ensure adequate ventilation. Hypoxemia during postural drainage may be avoided in unilateral lung disease by placing the involved lung up-permost with patient on his or her side.(20,22,48-50)

6.2 Increased Intracranial Pressure

Action To Be Taken/Possible Intervention: Stop therapy, return patient to original resting position, and consult physician.

6.3 Acute Hypotension during Procedure

Action To Be Taken/Possible Intervention: Stop therapy, return patient to original resting position, and consult physician.

6.4 Pulmonary Hemorrhage

Action To Be Taken/Possible Intervention: Stop therapy, return patient to original resting position, call physician immediately. Administer oxygen and maintain an airway until

physician responds.

6.5 Pain or Injury to Muscles, Ribs, or Spine

Action To Be Taken/Possible Intervention: Stop therapy that appears directly associated with pain or problem, exercise care in moving patient, and consult physician.

6.6 Vomiting and Aspiration

Action To Be Taken/Possible Intervention: Stop therapy, clear airway and suction as needed, administer oxygen, maintain airway, return patient to previous resting position, and contact physician immediately.

6.7 Bronchospasm

Action To Be Taken/Possible Intervention: Stop therapy, return patient to previous resting position, administer or increase oxygen delivery while contacting physician. Administer physician-ordered bronchodilators.

6.8 Dysrhythmias

Action To Be Taken/Possible Intervention: Stop therapy, return patient to previous resting position, administer or increase oxygen delivery while contacting physician.

PDT 7.0 LIMITATIONS OF METHOD:

7.1 Presumed effectiveness of PDT and its application may be based more on tradition and anecdotal report than on scientific evidence. The procedure has been used excessively and in patients in whom it is not indicated.(11,40,61-63)

7.2 Airway clearance may be less than optimal in patients with ineffective cough.

7.3 Optimal positioning is difficult in critically ill patients.

PDT 8.0 ASSESSMENT OF NEED:

The following should be assessed together to establish a need for postural drainage therapy

8.1 excessive sputum production

8.2 effectiveness of cough

8.3 history of pulmonary problems treated successfully with PDT (eg, bronchiectasis, cystic fibrosis, lung abscess)

8.4 decreased breath sounds or crackles or rhonchi suggesting secretions in the airway

8.5 change in vital signs

8.6 Abnormal chest x-ray consistent with atelectasis, mucus plugging, or infiltrates

8.7 deterioration in arterial blood gas values or oxygen saturation

PDT 9.0 ASSESSMENT OF OUTCOME:

These represent individual criteria that indicate a positive response to therapy (and support continuation of therapy). Not all criteria are required to justify continuation of therapy (eg, a ventilated patient may not have sputum production > 30 mL/day, but have improvement in breath sounds, chest x-ray, or increased compliance or decreased resistance).

9.1 Change in sputum production

If sputum production in an optimally hydrated patient is less than 25 mL/day with PDT the procedure is not justified.(3,5,7,9,11,12,38,40,46,51-53) Some patients have productive coughs with sputum production from 15 to 30 mL/day (occasionally as high as 70 or 100 mL/day) without postural drainage. If postural drainage does not increase sputum in a patient who produces > 30 mL/day of sputum without postural drainage, the continuation of the therapy is not indicated. Because sputum production is affected by systemic hydration, apparently ineffective PDT probably should be continued for at least 24 hours after optimal hydration has been judged to be present.

9.2 Change in breath sounds of lung fields being drained

With effective therapy, breath sounds may 'worsen' following the therapy as secretions move into the larger airways and increase rhonchi. An increase in adventitious breath sounds can be a marked improvement over absent or diminished breath sounds. Note any effect that coughing may have on breath sounds. One of the favorable effects of coughing is clearing of adventitious breath sounds.

9.3 Patient subjective response to therapy

The caregiver should ask patient how he or she feels before, during, and after therapy. Feelings of pain, discomfort, shortness of breath, dizziness, and nausea should be considered in decisions to modify or stop therapy. Easier clearance of secretions and increased volume of secretions during and after treatments support continuation.

9.4 Change in vital signs

Moderate changes in respiratory rate and/or pulse rate are expected. Bradycardia, tachycardia, or an increase in irregularity of pulse, or fall or dramatic increase in blood pressure are indications for stopping therapy.

9.5 Change in chest x-ray

Resolution or improvement of atelectasis may be slow or dramatic.

9.6 Change in arterial blood gas values or oxygen saturation

Oxygenation should improve as atelectasis resolves.

9.7 Change in ventilator variables

Resolution of atelectasis and plugging reduces resistance and increases compliance.

PDT 10.0 RESOURCES:

10.1 Equipment

10.1.1 bed or table that can be adjusted for a range of positions from Trendelen-burg to Reverse Trendelenburg position

10.1.2 pillows for supporting patient

10.1.3 light towel for covering area of chest during percussion

10.1.4 tissues and/or basin for collecting expectorated sputum

10.1.5 suction equipment for patients unable to clear secretion

10.1.6 gloves, goggles, gown, and mask as indicated for caregiver protection

10.1.7 optional: hand-held and mechanical percussor or vibrator

10.1.8 oxygen delivery device

10.1.9 recent chest x-ray, if available

10.1.10 stethoscope for auscultation

10.2 Personnel

A spectrum of education and skill levels is required for personnel who administer postural drainage therapy. Different clinical situations warrant the degree of training necessary to provide optimal respiratory care.

10.2.1. The Level I care provider who provides routine maintenance therapy to the stable patient should possess the following skills and knowledge

10.2.1.1 proper technique for administration of PDT

10.2.1.2 proper use of equipment

10.2.1.3 breathing patterns and cough techniques

10.2.1.4 technique modification in re-sponse to adverse reactions

10.2.1.5 position or frequency modification in response to severity of symptoms

10.2.1.6 ability to assess patient condition and patient response to therapy including physical exam (auscultation and vital signs) and tests of expiratory flow or ventilator mechanics

10.2.1.7 ability to recognize and respond to adverse reactions to and complications of procedure

10.2.1.8 understanding of and compliance with Universal Precautions

10.2.2 For initial assessments and care of the unstable patient, the Level II care provider should possess

10.2.2.1 knowledge of proper use and limitations of equipment

10.2.2.2 ability to assess patient condition and patient response to therapy

10.2.2.3 ability to perform physical exam auscultation and vital signs

10.2.2.4 knowledge of effects of gravity and body position on ventilation, perfusion, and sputum mobilization

10.2.2.5 knowledge of procedures, indications, contraindications, and hazards for turning

10.2.2.6 knowledge of standard drainage positions, techniques for percussion and vibration, segmental and airway anatomy

10.2.2.7 ability to teach diaphragmatic breathing, relaxation, huff cough, forced expiration technique (FET), suctioning

10.2.2.8 ability to monitor effects and patient response to changes in position and other postural drainage therapy techniques

10.2.2.9 understanding of and ability to comply with Universal Precautions and infection control issues related to cleaning and maintaining equipment

10.2.2.10 ability to instruct patient/family/caregiver in goals of therapy and proper technique for administration of PDT and associated therapies

10.2.2.11 knowledge of proper use of equipment, including suction if re-quired

10.2.2.12 ability to prepare, measure, and mix medications if required

10.2.2.13 ability to clean equipment

10.2.2.14 knowledge of breathing patterns and cough techniques

10.2.2.15 abilty to modify techniques in response to adverse reactions

10.2.2.16 ability to modify dosage or frequency in response to severity of symptoms

10.2.3 The subject providing self administration of postural drainage should possess knowledge and skills related to

10.2.3.1 proper technique for administration

10.2.3.2 proper use of equipment

10.2.3.3 breathing patterns and cough techniques

10.2.3.4 technique modification in re-sponse to adverse reactions

10.2.3.5 position or frequency modification in response to severity of symptoms

PDT 11.0 MONITORING:

The following should be chosen as appropriate for monitoring a patient's response to postural drainage therapy, before, during, and after therapy.

11.1 Subjective response--pain, discomfort, dyspnea, response to therapy

11.2 Pulse rate, dysrhythmia, and EKG if available

11.3 Breathing pattern and rate, symmetrical chest expansion, synchronous thoracoabdom-inal movement, flail chest

11.4 Sputum production (quantity, color, consistency, odor) and cough effectiveness

11.5 Mental function

11.6 Skin color

11.7 Breath sounds

11.8 blood pressure

11.9 oxygen saturation by pulse oximetry (if hypoxemia is suspected)

11.10 intracranial pressure (ICP)

PDT 12.0 FREQUENCY:

The frequencies suggested are recommendations from group experience and apply to patients in whom the therapy is indicated. Careful assessment and prudent clinical judgment must be exercised by the caregiver.

12.1 Turning

Ventilated and critically ill patients: as necessary with goal of once each hour or every other hour as tolerated, around the clock. Less acute patients should be turned every 2 hours as tolerated.

12.2 Postural Drainage Therapy

12.2.1 In critical care patients, including those on mechanical ventilation, PDT should be performed from every 4 to every 6 hours as indicated. PDT order should be re-evaluated at least every 48 hours based on assessments from individual treatments.

12.2.2 In spontaneously breathing pa-tients, frequency should be determined by assessing patient response to therapy.

12.2.3 Acute care patient orders should be re-evaluated based on patient response to therapy at least every 72 hours or with change of patient status.

12.2.4 Domiciliary patients should be re-evaluated every 3 months and with change of status.

PDT 13.0 INFECTION CONTROL:

13.1 Implement Universal Precautions.(64)

13.2 Observe all infection control guidelines posted for patient.

13.3 Disinfect all equipment used between patients.

Bronchial Hygiene Guidelines Committee:

Lana Hilling RCP CRTT, Chairman,Concord CA
Eric Bakow RRT, Pittsburg PA
Jim Fink RCP RRT, San Francisco CA
Chris Kelly BS RRT, Oakland CA
Dennis Sobush MA PT, Milwaukee WI
Peter A Southorn MD, Rochester MN

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41. Pavia D, Thomson ML, Phillipakos D. A preliminary study of the effect of a vibrating pad on bronchial clearance. Am Rev Respir Dis 1976;113:92-96.
42. Maxwell M, Redmond A. Comparative trial of manual and mechanical percussion technique with gravity-assisted bronchial drainage in patients with cystic fibrosis. Arch Dis Child 1979;54:542-544.
43. Holody B, Goldberg HS. The effect of mechanical vibration physiotherapy on arterial oxygenation in acutely ill patients with atelectasis or pneumonia. Am Rev Respir Dis 1981;124:372-375.
44. Radford R, Barutt J, Billingsley JG, Hill W, Lawson WH, Willich W. A rational basis for percussion augmented mucociliary clearance. Respir Care 1982;27(5):556-563.
45. Barrell SE, Abbas HM. Monitoring during physiotherapy after open heart surgery. Physiotherapy 1978; 64(90):272-273.
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51. Anthonisen P, Riis P, Sigaard-Anderson T. The value of lung physiotherapy in the treatment of acute exacerbations in chronic bronchitis. Act Med Scand 1964; 175:715-719.
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53. Sutton PP, Pavia D, Bateman JRM, Clarke SW. Chest physiotherapy: a review. Eur J Respir Dis 1982;63:188-201.
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ADDITIONAL BIBLIOGRAPHY

Denton R. Bronchial secretions on cystic fibrosis: the effects of treatment with mechanical percussion vibration. Am Rev Respir Dis 1962;86:141-146.

Committee on Therapy, American Thoracic Society. Physical adjuncts in the treatment of pulmonary diseases. Am Rev Respir Dis 1968;97:725-736.

Barach AL, Dulfano MJ. Effect of chest vibration in pulmonary emphysema: a preliminary report. Ann Allergy 1968; 26:10-17.

March H. Appraisal of postural drainage for chronic obstruction pulmonary disease. Arch Phys Med Rehab 1972;52:528-530.Lefcoe NM, Paterson NAM. Adjunct therapy in chronic obstructive pulmonary disease. Am J Med 1973;54:343-350.

Schlenker JD, Hubay CA. The pathogenesis of post-operative atelectasis. Arch Surg 1973;107:846-850.

Laszlo G, Archer GG, Darrell JH, Dawson JM, Fletcher CM. The diagnosis and prophylaxis of pulmonary complications of surgical operation. Br J Surg 1973;60:129-134.

Ray JF, Yost L, Moallen S. Immobility, hypoxemia, and pulmonary arteriovenous shunting. Arch Surg 1974;109:537-541.

Martin CJ, Ripley H, Reynolds J, Best F. Chest physiotherapy and the distribution of ventilation. Chest 1976;69(2):174-178.

Chopra SK, Taplin GV, Simmons DH, Robinson GD Jr, Coulson A. Effects of hydration and physical therapy on tracheal transport velocity. Am Rev Respir Dis 1977;115:1009-1014.

Winning TJ, Brock-Utne JG, Goodwin NM. Bronchodilators and physiotherapy during long term mechanical ventilation of the lungs. Anaesth Intens Care 1977;5:48-50.

Newton DAG, Bevans HG. Physiotherapy and intermittent positive pressure ventilation of chronic bronchitis. Br Med J 1978;2:1525-1528.

Hedstrand U, Liw M, Rooth G, Lindgren CH. Effects of respiratory physiotherapy on arterial oxygen tension. Acta Anaesth Scand 1978;22:349-352.

Moody LE, Martindale CL. Effect of pulmonary hygiene measures on levels of arterial oxygen saturation in adults with chronic lung disease. Heart Lung 1978;7(2):315-319.

West JB. Regional differences in the lung. Chest 1978;74:426.

Seaton D, Lapp NL, Morgan WKG. Effect of body position on gas exchange after thoracotomy. Thorax 1979;34:518.

Barnes CA, Asonye UO, Vidyasagar D. The effects of bronchopulmonary hygiene on PtcCO2 values in critically ill neonates. Crit Care Med 1981;9:819-822

Remolina C, Khan AU, Santiago TV, Edelman NH. Positional hypoxemia in unilateral lung disease. N Engl J Med 1981;304:523.

Rossman CM, Waldes R, Sampson D, Newhouse MT. Effect of chest physiotherapy on the removal of mucus in patients with cystic fibrosis. Am Rev Respir Dis 1982;126:131-135.

Reines HD, Sade RM, Bradford BF, Marshall J. Chest physiotherapy fails to prevent post-operative atelectasis in children after cardiac surgery. Ann Surg 1982;195:451-455.

White DJ, Mawdsley RH. Effects of selected bronchial drainage positions and percussion on blood pressure of healthy human subjects. Phys Ther 1983;63:325-330.

Ford GT, Whitelaw WA, Rosenal TW, Cruse PJ, Guenter CA. Diaphragm function after upper abdominal surgery in humans. Am Rev Respir Dis 1983;127:431-436.

King M. Mucus and mucociliary clearance. Respir Care 1983;28:335-344.

Buscaglia AJ, St Marie MS. Oxygen saturation during chest physiotherapy for acute exacerbation of severe chronic obstructive pulmonary disease. Respir Care 1983;28:1009-1013.

King M, Phillips DM, Gross D, Vartian V, Changhk Eidulka A, et al. Enhanced tracheal mucus clearance with high frequency chest wall compression. Am Rev Respir Dis 1983; 128:511-515.

Mazzocco M, Kirilloff L, Owens G, Rogers R. Physiologic effects of chest percussion and postural drainage in patients with bronchiectasis (abstract). Am Rev Respir Dis 1984;129 (4, Part 2):A52.

Torrington KG, Sorenson DE, Sherwood LM. Postoperative chest percussion with postural drainage in obese patients following gastric stapling. Chest 1984;86:891-895.

King M, Phillips DM, Zidulka A, Chang HK. Tracheal mucus clearance in high-frequency oscillation. Am Rev Respir Dis 1984;130:703-706.

Rivington-Law BA, Epstein SW, Thompson GL, et al. Effect of chest wall vibrations on pulmonary function in chronic bronchitis. Chest 1984;85(3):378-381.

Britton S, Bejstedt M, Vedin L. Chest physiotherapy in primary pneumonia. Br Med J 1985;290:1703-1704.

Mackenzie CF, Shin B. Cardiorespiratory function before and after chest physiotherapy in mechanically ventilated patients with post-traumatic respiratory failure. Crit Care Med 1985;13:483-486.

McDonnell T, McNicholas WT, Fitzgerald MX. Hypoxemia during chest physiotherapy in patients with septic fibrosis. Ir J Med Sci 1986;155:345-348.

Johnson NT, Marini JJ, Pierson DJ, Hudson LD. Acute lobar atelectasis: effect of chest percussion and postural drainage (CPPL) on resolution (abstract). Am Rev Respir Dis 1987;135(4, Part 2):433.

Biddle CJ, Holland MS, Schreiber TR, Mathewson HS. Prevention of hypoxemia in good risk patients during postoperative transport by positioning and deep breathing. Respir Care 1987;32(1):24-28.

Bozynski MEA, Naglie RA, Nicks JJ, Burpee B, Johnson RV. Lateral positioning of the stable ventilated very low birth weight infant. AJDC 1988;142:200-202.

Kaminska TM, Pearson SB. A comparison of postural drainage and positive expiratory pressure in the domiciliary management of patients with chronic bronchial sepsis. Physiotherapy 1988;74(5):251-254.

Prasad A, Tasker R. Guidelines for the physiotherapy management of critically ill children with acutely raised intracranial pressure. Physiotherapy 1990;76(4):248-250

Ersson U, Carlson H, Mellström A, Ponten U, Hedstrand U, Jakobsson S. Observation on intracranial dynamics during respiratory physiotherapy in unconscious neurosurgical patients. Acta Anaesthesiol Scand 1990;34:99-103.

Interested persons may copy these Guidelines for noncommercial purposes of scientific or educational advancement. Please credit AARC and Respiratory Care Journal.

TERAPI OKSIGEN

Oksigen (O2) merupakan salah satu komponen gas dan unsure vital dalam proses metabolisme, untuk mempertahankan kelangsungan hidup seluruh sel tubuh.
Secara normal elemen ini diperoleh dengan cara menghirup udara ruangan dalam setiap kali bernafas.
Penyampaian O2 ke jaringan tubuh ditentukan oleh interaksi system respirasi, kardiovaskuler dan keadaan hematologis.

Adanya kekurangan O2 ditandai dengan keadaan hipoksia, yang dalam proses lanjut dapat menyebabkan kematian jaringan bahkan dapat mengancam kehidupan.
Klien dalam situasi demikian mengharapkan kompetensi perawat dalam mengenal keadaan hipoksemia dengan segera untuk mengatasi masalah.
Pemberian terapi O2 dalam asuhan keperawatan, memerlukan dasar pengetahuan tentang faktor-faktor yang mempengaruhi masuknya O2 dari atmosfir hingga sampai ke tingkat sel melalui alveoli paru dalam proses respirasi. Berdasarkan hal tersebut maka perawat harus memahami indikasi pemberian O2, metode pemberian O2 dan bahaya-bahaya pemberian O2.

PROSES RESPIRASI
Proses respirasi merupakan proses pertukaran gas yang masuk dan keluar melalui kerjasama dengan sistem kardiovaskuler dan kondisi hematologis.

Oksigen di atmosfir mengandung konsentrasi sebesar 20,9 % akan masuk ke alveoli melalui mekanisme ventilasi kemudian terjadi proses pertukaran gas yang disebut proses difusi.
Difusi adalah suatu perpindahan/ peralihan O2 dari konsentrasi tinggi ke konsentrasi rendah dimana konsentrasi O2 yang tinggi di alveoli akan beralih ke kapiler paru dan selanjutnya didistribusikan lewat darah dalam 2 (dua) bentuk yaitu :

(1) 1,34 ml O2 terikat dengan 1 gram Hemoglobin (Hb) dengan persentasi kejenuhan yang disebut dengan “Saturasi O2” (SaO2),

(2) 0,003 ml O2 terlarut dalam 100 ml plasma pada tekanan parsial O2 di arteri (PaO2) 1 mmHg.

Kedua bentuk pengangkutan ini disebut sebagai kandungan O2 atau “Oxygen Content” (CaO2) dengan formulasi :
CaO2 = (1,34 x Hb x SaO2) + (0,003 x PaO2)

Sedangkan banyaknya O2 yang ditransportasikan dalam darah disebut dengan “Oxigen Delivery” (DO2) dengan rumus :
DO2 = (10 x CaO2) x CO

Dimana CO adalah “Cardiac Output” (Curah Jantung).
CO ini sangat tergantung kepada besar dan ukuran tubuh, maka indikator yang lebih tepat dan akurat adalah dengan menggunakan parameter “Cardiac Index” (CI).
Oleh karena itu formulasi DO2 yang lebih tepat adalah :
DO2 = (10 x CaO2) x CI

Selanjutnya O2 didistribusikan ke jaringan sebagai konsumsi O2 (VO2)
Nilai VO2 dapat diperoleh dengan perbedaan kandungan O2 arteri dan vena serta CI dengan formulasi sebagai berikut :
VO2a = (CaO2 – CvO2) x CI

Selain faktor difusi dan pengangkutan O2 dalam darah maka faktor masuknya O2 kedalam alveoli yang disebut sebagai ventilasi alveolar.

VENTILASI ALVEOLAR
Ventilasi alveolar adalah salah satu bagian yang penting karena O2 pada tingkat alveoli inilah yang mengambil bagian dalam proses difusi.
Besarnya ventilasi alveolar berbanding lurus dengan banyaknya udara yang masuk keluar paru, laju nafas, udara dalam jalan nafas serta keadaan metabolik.

Banyaknya udara masuk keluar paru dalam setiap kali bernafas disebut sebagai “Volume Tidal” (VT) yang bervariasi tergantung pada berat badan.
Nilai VT normal pada orang dewasa berkisar 500 – 700 ml dengan menggunakan “Wright’s Spirometer”.
Volume nafas yang berada di jalan nafas dan tidak ikut dalam pertukaran gas disebut sebagai “Dead Space” (VD)(Ruang Rugi) dengan nilai normal sekitar 150 - 180 ml yang terbagi atas tiga yaitu :
(1) Anatomic Dead Space,
(2) Alveolar Dead Space,
(3) Physiologic Dead Space.

Anatomic Dead Space yaitu volume nafas yang berada di dalam mulut, hidung dan jalan nafas yang tidak terlibat dalam pertukaran gas.
Alveolar Dead Space yaitu volume nafas yang telah berada di alveoli, akan tetapi tidak terjadi pertukaran gas yang dapat disebabkan karena di alveoli tersebut tidak ada suplai darah. Dan atau udara yang ada di alveoli jauh lebih besar jumlahnya dari pada aliran darah pada alveoli tersebut.
Ventilasi alveolar dapat diperoleh dari selisih volume Tidal dan ruang rugi, dengan laju nafas dalam 1 menit.
VA = (VT – VD) x RR

Sedangkan tekanan parsial O2 di alveolar (PaO2) diperoleh dari fraksi O2 inspirasi (FiO2) yaitu 20,9 % yang ada di udara, tekanan udara, tekanan uap air, tekanan parsial CO2 di arteri (PaCO2).

PaO2 = FiO2 (760 – 47) – (PaCO2 : 0,8)

Demikian faktor-faktor yang mempengaruhi proses respirasi dimana respirasi tidak saja pertukaran gas pada tingkat paru (respirasi eksternal) tetapi juga pertukaran gas yang terjadi pada tingkat sel (respirasi internal).


TERAPI OKSIGEN
Terapi O2 merupakan salah satu dari terapi pernafasan dalam mempertahankan okasigenasi jaringan yang adekuat.
Secara klinis tujuan utama pemberian O2 adalah
(1) untuk mengatasi keadaan Hipoksemia sesuai dengan hasil Analisa Gas Darah,
(2) untuk menurunkan kerja nafas dan meurunkan kerja miokard.

Syarat-syarat pemberian O2 meliputi :
(1) Konsentrasi O2 udara inspirasi dapat terkontrol,
(2) Tidak terjadi penumpukan CO2,
(3) mempunyai tahanan jalan nafas yang rendah,
(4) efisien dan ekonomis,
(5) nyaman untuk pasien.

Dalam pemberian terapi O2 perlu diperhatikan “Humidification”.
Hal ini penting diperhatikan oleh karena udara yang normal dihirup telah mengalami humidfikasi sedangkan O2 yang diperoleh dari sumber O2 (Tabung) merupakan udara kering yang belum terhumidifikasi, humidifikasi yang adekuat dapat mencegah komplikasi pada pernafasan.

INDIKASI PEMBERIAN O2
Berdasarkan tujuan terapi pemberian O2 yang telah disebutkan, maka adapun indikasi utama pemberian O2 ini adalah sebagai berikut :
(1) Klien dengan kadar O2 arteri rendah dari hasil analisa gas darah,
(2) Klien dengan peningkatan kerja nafas, dimana tubuh berespon terhadap keadaan hipoksemia melalui peningkatan laju dan dalamnya pernafasan serta adanya kerja otot-otot tambahan pernafasan,
(3) Klien dengan peningkatan kerja miokard, dimana jantung berusaha untuk mengatasi gangguan O2 melalui peningkatan laju pompa jantung yang adekuat.

Berdasarkan indikasi utama diatas maka terapi pemberian O2 dindikasikan kepada klien dengan gejal :
(1) sianosis,
(2) hipovolemi,
(3) perdarahan,
(4) anemia berat,
(5) keracunan CO,
(6) asidosis,
(7) selama dan sesudah pembedahan,
(8) klien dengan keadaan tidak sadar.

METODE PEMBERIAN O2
Metode pemberian O2 dapat dibagi atas 2 tehnik, yaitu :

1. Sistem aliran rendah
Tehnik system aliran rendah diberikan untuk menambah konsentrasi udara ruangan.
Tehnik ini menghasilkan FiO2 yang bervariasi tergantung pada tipe pernafasan dengan patokan volume tidal pasien.
Pemberian O2 sistem aliran rendah ini ditujukan untuk klien yang memerlukan O2 tetapi masih mampu bernafas dengan pola pernafasan normal, misalnya klien dengan Volume Tidal 500 ml dengan kecepatan pernafasan 16 – 20 kali permenit.

Contoh system aliran rendah ini adal;ah :
(1) kateter naal,
(2) kanula nasal,
(3) sungkup muka sederhana,
(4) sungkup muka dengan kantong rebreathing,
(5) sungkup muka dengan kantong non rebreathing.

Keuntungan dan kerugian dari masing-masing system :
a. Kateter nasal
Merupakan suatu alat sederhana yang dapat memberikan O2 secara kontinu dengan aliran 1 – 6 L/mnt dengan konsentrasi 24% - 44%.
- Keuntungan
Pemberian O2 stabil, klien bebas bergerak, makan dan berbicara, murah dan nyaman serta dapat juga dipakai sebagai kateter penghisap.
- Kerugian
Tidak dapat memberikan konsentrasi O2 yang lebih dari 45%, tehnik memasuk kateter nasal lebih sulit dari pada kanula nasal, dapat terjadi distensi lambung, dapat terjadi iritasi selaput lendir nasofaring, aliran dengan lebih dari 6 L/mnt dapat menyebabkan nyeri sinus dan mengeringkan mukosa hidung, kateter mudah tersumbat.

b. Kanula nasal
Merupakan suatu alat sederhana yang dapat memberikan O2 kontinu dengan aliran 1 – 6 L/mnt dengan konsentrasi O2 sama dengan kateter nasal.
- Keuntungan
Pemberian O2 stabil dengan volume tidal dan laju pernafasan teratur, mudah memasukkan kanul disbanding kateter, klien bebas makan, bergerak, berbicara, lebih mudah ditolerir klien dan nyaman.
- Kerugian
Tidak dapat memberikan konsentrasi O2 lebih dari 44%, suplai O2 berkurang bila klien bernafas lewat mulut, mudah lepas karena kedalam kanul hanya 1 cm, mengiritasi selaput lendir.

c. Sungkup muka sederhana
Merupakan alat pemberian O2 kontinu atau selang seling 5 – 8 L/mnt dengan konsentrasi O2 40 – 60%.
- Keuntungan
Konsentrasi O2 yang diberikan lebih tinggi dari kateter atau kanula nasal, system humidifikasi dapat ditingkatkan melalui pemilihan sungkup berlobang besar, dapat digunakan dalam pemberian terapi aerosol.
- Kerugian
Tidak dapat memberikan konsentrasi O2 kurang dari 40%, dapat menyebabkan penumpukan CO2 jika aliran rendah.

d. Sungkup muka dengan kantong rebreathing :
Suatu tehinik pemberian O2 dengan konsentrasi tinggi yaitu 60 – 80% dengan aliran 8 – 12 L/mnt
- Keuntungan
Konsentrasi O2 lebih tinggi dari sungkup muka sederhana, tidak mengeringkan selaput lendir
- Kerugian
Tidak dapat memberikan O2 konsentrasi rendah, jika aliran lebih rendah dapat menyebabkan penumpukan CO2, kantong O2 bisa terlipat.

e. Sungkup muka dengan kantong non rebreathing
Merupakan tehnik pemberian O2 dengan Konsentrasi O2 mencapai 99% dengan aliran 8 – 12 L/mnt dimana udara inspirasi tidak bercampur dengan udara ekspirasi
- Keuntungan :
Konsentrasi O2 yang diperoleh dapat mencapi 100%, tidak mengeringkan selaput lendir.
- Kerugian
Kantong O2 bisa terlipat.

2. Sistem aliran tinggi
Suatu tehnik pemberian O2 dimana FiO2 lebih stabil dan tidak dipengaruhi oleh tipe pernafasan, sehingga dengan tehnik ini dapat menambahkan konsentrasi O2 yang lebih tepat dan teratur.
Adapun contoh tehnik system aliran tinggi yaitu sungkup muka dengan ventury.

Prinsip pemberian O2 dengan alat ini yaitu gas yang dialirkan dari tabung akan menuju ke sungkup yang kemudian akan dihimpit untuk mengatur suplai O2 sehingga tercipta tekanan negatif, akibatnya udara luar dapat diisap dan aliran udara yang dihasilkan lebih banyak. Aliran udara pada alat ini sekitas 4 – 14 L/mnt dengan konsentrasi 30 – 55%.
- Keuntungan
Konsentrasi O2 yang diberikan konstan sesuai dengan petunjuk pada alat dan tidak dipengaruhi perubahan pola nafas terhadap FiO2, suhu dan kelembaban gas dapat dikontrl serta tidak terjadi penumpukan CO2
- Kerugian
Kerugian system ini pada umumnya hampir sama dengan sungkup muka yang lain pada aliran rendah.


BAHAYA BAHAYA PEMBERIAN OKSIGEN

Pemberian O2 bukan hanya memberiakan efek terapi tetapi juga dapat menimbulkan efek merugikan, antara lain :

1. Kebakaran
O2 bukan zat pembakar tetapi O2 dapat memudahkan terjadinya kebakaran, oleh karena itu klein dengan terapi pemberian O2 harus menghindari :
Merokok, membuka alat listrik dalam area sumber O2, menghindari penggunaan listrik tanpa “Ground”.

2. Depresi Ventilasi
Pemberian O2 yang tidak dimonitor dengan konsentrasi dan aliran yang tepat pada klien dengan retensi CO2 dapat menekan ventilasi

3. Keracunan O2
Dapat terjadi bila terapi O2 yang diberikan dengan konsentrasi tinggi dalam waktu relatif lama. Keadaan ini dapat merusak struktur jaringan paru seperti atelektasi dan kerusakan surfaktan. Akibatnya proses difusi di paru akan terganggu

ASUHAN KEPERAWATAN
Terapi O2 merupakan salah satu intervensi keperawatan yang bersifat kolaboratif yang merupakan bagian dari paket intervensi keperawatan yang diberikan kepada klien berdasarkan diagnosa keperawatan yang dirumuskan.
Oleh karena itu maka langkah pertama yang perawat lakukan adalah melakukan pengkajian.

Pengkajian ini ditujukan kepada keluhan-keluhan klien serta hasil pemeriksaan baik yang sifatnya pemeriksaan fisik maupun pemeriksaan penunjang dan pememriksaan diagnostik yang berkaitan dengan system pernafasan serta system lain yang terlibat.
Pengkajian keperawatan dapat dilakukan dengan metode wawancara yang berkaitan dengan keluhan klien antara lain : batuk dan lendir, sesak nafas, serta keluhan lain yang berkaitan dengan masalah transportasi O2.
Metode yang lain adalah metode observasi dengan melakukan pemeriksaan fisik pernafasan.

Data yang didapa dapat berupa :
kecepatan, iram dan kedalam pernafasan, usaha nafas, sianosis, berkeringat, peningkatan suhu tubuh, abnormalitas sistem pernafasa serta kardiovaskular.
Selanjutnya data-data ini dapat didukung oleh hasil pemeriksaan penunjang seperti gas darah arteri serta pemeriksaan diagnostik foto torak.

Tahap beikutnya adalah perumusan Diagnosa Keperawatan yang berorientasi kepada pada yang dirasakan oleh klien. Diagnosa ini dirumuskan berdasarkan hasil pengkajian yang disebutkan diatas

Berdasarkan diagnosa-diagnosa keperawatan yang dirumuskan maka disusunlah intervensi keperawatan (Rencana Tindakan) yang bertujuan untuk “Problem Solving” (penyelesaian masalah) klien.

Rencana ini selajutnya ditindak lanjuti atau di”Implementasi” dan pada akhirnya akan di”Evaluasi” sejauh mana tindakan dapat mencapai tujuan sehingga tindakan dapat dilajutkan, dimodifikasi atau diganti.


KESIMPULAN
Terapi O2 merupakan suatu upaya yang dilakukan oleh tenaga kesehatan termasuk keperawatan terhadap adanya gangguan pemenuhan oksigen pada klien.
Pengetahuan perawat yang memadai terhadap proses respirasi dan indikasi serta metode pemberian O2 merupakan bekal bagi perawat agar asuhan yang diberikan tepat guna dengan resiko seminimal mungkin.

DAFTAR PUSTAKA :
Black, Joyce M. Medical Surgical Nursing ; Clinical Management For Continuity Of Care, W.B Sunders Company, 1999
Brunner & Suddarth. Buku Ajar Medikal Bedah, edisi bahasa Indonesia, vol. 8, Jakarta, 2001
Carpenito, LYnda Juall. Rencana Asuhan dan Dokumentasi Keperawatan, EGC, Jakarta, 1999
Doengoes, Merilin E. Rencana Asuhan Keperawatan, Edisi ketiga, Jakarta, EGC, 1999
Engram, Barbara. Rencana Asuhan Keperawatan Medikal Bedah, EGC, Jakarta, 1999
Long, Barbara C. Perawatan Medikal Bedah, YIAPK, Bandung, 1996
Potter, Patricia A. Perry, Anne G. Fundamental of Nursing ; Concepts, Process and Practice, Mosby Year Book, St. Louis, 1997
Taylor, Calor. Et al. Fundamentals of Nursing ; The Art and Science of Nursing Care, Lipincott, Philadelphia, 1997
……………, Dasar Dasar Keperawatan Kardiotarasik, Edisi ketiga, Rumah Sakit Jantung “Harapan Kita”, Jakarta 1993
©2004 Digitized by USU digital library 6

TINDAKAN SUCTIONING

suctioning
AIRWAY MANAGEMENT

1. HUMIDIFICATION – heated cascade provides 100% humidification of inhaled gases. Ensure systemic hydration is monitored to help keep secretions thin.
2. AEROSOL THERAPY – nebulizers delivering aerosols increase secretion clearance and liquefy mucus; nebulizers may become a source of bacterial contamination.
3. CUFF MANAGEMENT – essential for prevention of necrosis and aspiration. Two different cuff-inflation techniques are currently used:
4. Minimal leak technique (ML) – inject air into cuff until no leak is heard and then withdrawing the air until a small leak is heard on inspiration. (Problems are related to maintaining PEEP, aspiration around the cuff, and increased movement of the tube.)
5. Minimal occlusive volume technique (MOV) – inject air into cuff until no leak is heard, then withdrawing the air until a small leak is heard on inspiration, and then adding more air until no leak is heard on inspiration. (Problems are related to higher cuff pressures than ML technique.) Use only if patient needs a seal to provide adequate ventilation and/or is at high risk for aspiration.
6. Monitor cuff pressures at least q. 8 h. Maintain pressure 18 to 22 mm Hg (25 to 30 cm H2O. Greater pressures decrease capillary blood flow in tracheal wall and lesser pressures increase risk of aspiration. Do not routinely deflate cuff.
7. POSTURAL DRAINAGE & POSITIONING (see respiratory references).
8. Key Point: Pneumonia = "Good lung down position"
9. ARDS = prone positioning for improved oxygenation
10. SUCTIONING – perform as sterile procedure only when patient needs it and not on a routine schedule. Observe for hypoxemia, atelectasis, bronchospasms, cardiac dysrhythmias, hemodynamic alterations, increased intracranial pressure, and airway trauma.

ENDOTRACHEAL/ TRACHEAL SUCTIONING PROCEDURE

OBJECTIVES:

The nurse performs endotracheal and tracheostomy suctioning to:

1. Maintain a patent airway.
2. To improve oxygenation and reduce the work of breathing.
3. To remove accumulated tracheobronchial secretions using sterile technique.
4. Stimulate the cough reflex.
5. Prevent pulmonary aspiration of blood and gastric fluids.
6. Prevent infection and atelectasis.

EQUIPMENT:

Sterile normal saline
Suction source
Ambu bag connected to 100% O2
Clear protective goggles/mask or face shield
Sterile gloves for open suction
Clean gloves for (in-line) closed suction
Sterile catheter with intermittent suction control port or In-line suction catheter

PROCEDURE:

1. Wash hands. Reduces transmission of microorganisms.

2. Assess patient’s need for suctioning. Since endotracheal suctioning can be hazardous and causes discomfort, it is not recommended in the absence of apparent need.

Coarse breath sounds
Coughing; increased respirations
Increased PIP on ventilator

3. Don goggles and mask or face shield. Potential for contamination

4. Turn on suction apparatus and set vacuum regulator to appropriate negative pressure. Recommend 80-120 mmHg; adjust lower for children and the elderly. Significant hypoxia and damage to tracheal mucosa can result from excessive negative pressure.

5. Prepares suction apparatus. Secure one end of connecting tube to suction machine, and place other end in a convenient location within reach.

6. Use in-line suction catheter or open sterile package (catheter size not exceeding one-half the inner diameter of the airway) on a clean surface, using the inside of the wrapping as a sterile field.

7. Prepares catheter and prevents transmission of microorganisms. Catheter exceeding one-half the diameter increases possibility of suction-induced hypoxia and atelectasis.

8. Prepare catheter flush solution.With in-line catheter use sterile saline bullets to flush catheter. With regular suctioning set up sterile solution container and being careful not to touch the inside of the container, fill with enough sterile saline or water to flush catheter.

9. With in-line suction catheter use clean gloves. With regular suctioning, done sterile gloves. Maintain sterility. Universal precautions. In regular suctioning the dominant hand must remain sterile throughout the procedure.

10. Pick up suction catheter, being careful to avoid touching nonsterile surfaces. With nondominant hand, pick up connecting tubing. Secure suction catheter to connecting tubing. Maintains catheter sterility. Connects suction catheter and connecting tubing

11. Ensures equipment function. Check equipment for proper functioning by suctioning a small amount of sterile saline from the container. (skip this step in in-line suctioning)

12. Remove or open oxygen or humidity device to the patient with nondominant hand. (skip this step with in-line suctioning). Opens artificial airway for catheter entrance. Have second person assist when indicated to avoid unintentional extubation.

13. Replace O2 delivery device or reconnect patient to the ventilator. Hyperoxygenate and hyperventilate via 3 breaths by giving patient additional manual breaths on the ventilator before suctioning. Hyperoxygenation with 100% O2 is used to offset hypoxemia during interrupted oxygenation and ventilation. Preoxygenation offsets volume and O2 loss with suctioning. Patients with PEEP should be suctioned through an adapter on the closed suction system.

14. Without applying suction, gently but quickly insert catheter with dominant hand during inspiration until resistance is met; then pull back 1-2 cm. Catheter is now in tracheobronchial tree. Application of suction pressure upon insertion increases hypoxia and results in damage to the tracheal mucosa.

15. Apply intermittent suction by placing and releasing dominant thumb over the control vent of the catheter. Rotate the catheter between the dominant thumb and forefinger as you slowly withdraw the catheter. With in-line suction, apply continuous suction by depressing suction valve and pull catheter straight back. Time should not exceed 10-15 seconds. Intermittent suction and catheter rotation prevent tracheal mucosa when using regular suctioning methods. Unable to rotate with closed- suction method.

16. Replace oxygen delivery device.

Hyperoxygenate between passes of catheter and following suctioning procedure. Replenishes O2. Recovery to base PaO2 takes 1 to 5 minutes. Reduces incidence of hypoxemia and atelectasis.

17. Rinse catheter and connecting tubing with normal saline until clear. Removes catheter secretions.

18. Monitor patient’s cardiopulmonary status during and between suction passes. Observe for signs of hypoxemia, e.g. dysrhythmias, cyanosis, anxiety, bronchospasms, and changes in mental status.

19. Once the lower airway has been adequately cleared of secretions, perform nasal and oral pharyngeal or upper airway suctioning.

Removes upper airway secretions. The catheter is contaminated after nasal and oral pharyngeal suctioning and should not be reinserted into the endotracheal or tracheostomy tube.

20. Upon completion of upper airway suctioning, wrap catheter around dominant hand. Pull glove off inside out. Catheter will remain in glove. Pull off other glove in same fashion and discard. Turn off suction device. Reduces transmission of microorganisms.

21. Reposition patient. Supports ventilatory effort; promotes comfort; communicates caring attitude.

22. Reassess patient’s respiratory status. Indicates patient’s response to suctioning

23. Dispose of suction liners and connecting tubing, sterile saline solution every 24 hours and set up new system. Decreases incidence of organism colonization and subsequent pulmonary contamination. Universal precautions.

PRECAUTIONS:

1. Minimize suctioned-induced atelectasis and hypoxemia:

a. Avoid using catheters larger than one-half the diameter of the airway.

b. Administer one or more postsuctioning hyperinflations, using manual or sigh breaths on the ventilator or ambu bag if not ventilated.

2. Maintain rigorous sterile technique when suctioning the intubated patient. Impaired pulmonary defense systems and invasive instrumentation of the pulmonary tract predisposes these patients to colonization and infection. Never use same catheter to suction the trachea after it has been used in the nose or the mouth.

3. Limit the frequency of suctioning and avoid, as much as possible, catheter impaction in the bronchial tree when the patient is anticoagulated or when hemorrhage from suction-induced trauma is evident.

4. Minimize the frequency and duration of suctioning when patient is on positive end-expiratory pressure (PEEP) greater than 5 cm or continuous positive airway pressure (CPAP). Small suctioning-induced changes may have profound effects on these marginally oxygenated patients.

5. Maintain awareness of the limitations of ET/tracheal suctioning. Maneuvers and catheter design have been proposed to increase the likelihood of passage into the left bronchus; however, these have been shown to be of limited success. Because the left main stem bronchus emerges from the trachea at the 45-degree angle from the vertical, suction catheters are almost inevitable passed into the right bronchus (when they pass the carina) despite head-turning, etc.

6. The use of saline installations for loosening secretions has been controversial and recent research shows that in fact it is detrimental and poses a greater risk of pneumonia for the patient.

RELATED CARE:

1. Include strategies to move secretions through peripheral airways. These measures are: appropriate hydration and adequate humidification of inspired gases (to keep secretions thin); coughing and deep breathing; frequent position changes (may need rotation bed); chest physiotherapy; and bronchodilating agents as ordered.

2. Monitor the patient carefully during ET/tracheal suctioning for ectopic dysrhythmias aggravated by suction-induced hypoxemia and other dysrhythmias, particularly conduction disturbances, related to catheter irritation of vagal receptors within the respiratory tract (requires immediate cessation of suctioning and hyperoxygenation).

POTENTIAL COMPLICATIONS

Hypoxemia

Atelectasis

Dysrhythmias

Nosocomial pulmonary tract infection

Sepsis

Mucosal trauma with increase secretions

Cardiac arrest