Breathing Exercises

I. Diaphragmatic Breathing

Purposes:
1. To strengthen the diaphragm - the main respiratory muscle.
2. To decrease the use of accessory muscle during respiration
3. To gain control over breathing pattern especially during stressful situations.

Breathing exercises

Diaphragmatic Breathing
Procedure Rationale
Instruct the patient as follows:
1. Place one hand on the stomach just This helps the patient to become
below the ribs and the other hand on aware of the diaphragm and its
the middle of the chest functions in breathing
2. Breathe slowly and deeply through Slow inhalation provides ventilation
the nose, letting the abdomen enlarges and hyper inflation of the lungs.
during inspiration and decreases in size
during expiration.
3. Breathe out through pursed lips while Contracting the abdominal muscles
contracting/tightening the abdominal assist the diaphragm in rising to
muscles. empty the lungs.
Press firmly inward and upward on the The hand generates pressure on
abdomen while breathing out. the abdomen to facilitate more
complete expiration.
1. The chest should not move; Contraction of the abdominal
attention is directed at the abdomen muscles should take place during
not the chest. expiration.
2. Repeat for approximately 1 minute,
followed by a rest period of 2 minutes.
Work up to ten minutes, 4 times daily.
6. The chest should not move; Contraction of the abdominal
attention is directed at the abdomen muscles should take place during
not the chest. expiration.

II. Pursed Lip Breathing

Purposes:
1. To slow the respiratory rate.
2. To combat dyspnea due to exertion.

Pursed Lip Breathing

Procedure Rationale
Instruct the patient as follows:
1. Inhale through the nose
2. Exhale slowly and evenly against • Pursing the lips increase
pursed lip while contracting the intrabronchial pressure (helps the
abdominal muscles. Count to 7 bronchi in an open position) as well as
while prolonging expiration through intra-alveolar pressure.
pursed lips. The pursed lip maneuver also prolongs
the expiratory phase of breathing,
makes it easier to empty the air in the
lungs and promotes carbon dioxide
elimination.

Nebulizer Therapy
Equipment:
  Air Compressor
 Connection tubing
 Nebulizer
 Medication and saline solution

Administering Nebulizer Theraphy

Procedure Rationale
1. Monitor the heart rate before and Bronchodilators may cause
after the treatment for patients tachycardia, palpitations, dizziness,
using bronchodilator drugs nausea, or nervousness.
2. Explain the procedure to the Proper explanation of the procedure to
patient. This theraphy depends on ensure the patient’s cooperation and
the patients effort. effectiveness of the treatment.
3. Place the patient in a Diaphragmatic excursion and lung
comfortable sitting or a Semi- compliance are greater in this position.
fowler’s position. This ensure maximal distribution and
deposition of aerosolized particles to
basilar areas of the lungs.
4. Add the prescribed amount of A fine mist from the device should be
medication and saline to the visible.
nebulizer. Connect the tubing to the
compressor and set the flow
accordingly.
5. Instruct the patient to inhale.

Administering Oxygen Therapy

Oxygen is an odorless, tasteless, colorless, transparent gas that is slightly
heavier than air. oxygen can be dispensed from a cylinder tank, piped-in
system, liquid oxygen reservoir, or oxygen concentrator.
The method it may be administered depends on:

 the required concentration of oxygen

 desired variability in delivered oxygen concentration (none, minimal,
moderate)
 required ventilatory assistance (mechanical ventilator, spontaneous
breathing)

Oxygen therapy is commonly used to treat hypoxemia, or low blood oxygen,

which can be caused by a number of conditions:

Acute conditions
Respiratory distress, severe trauma, low cardiac output states with metabolic
acidosis, and severe pneumonia

Chronic conditions
Chronic obstructive pulmonary disease (COPD), cystic fibrosis, interstitial lung
disease (ILD), and pulmonary hypertension

Other conditions
Burn injuries, carbon monoxide or cyanide poisoning, gas embolism, sleep
apnea, and heart failure

Methods of Oxygen Administration

1. Nasal cannula - nasal prongs that deliver low flow of

oxygen.
 Most common; Requires nose breathing
 Cannot deliver oxygen concentration much higher
than 40%.
Indication: for short- and long-term therapy (i.e., COPD patients), mild
hypoxic, and are best used with stable patients who require low amounts of
oxygen.

Flow rate: Flow rate 1-4L/min (4L will dry the nose, 2L is more comfortable),
with a 4% increase in FiO2 for every liter of oxygen, resulting in range of
fraction of inspired oxygen (FiO2) levels of 24-44%.

Advantages: easy to use, inexpensive, and disposable. They are convenient

because the patient can talk and eat while receiving oxygen.

Limitations: easily dislodged, especially when the patient is sleeping.

 The tubing placed on the face can cause skin breakdown in the nose and
above the ears, so the nurse must vigilantly monitor these areas.
 The nurse should add padding to the oxygen tubing as needed to avoid
skin breakdown and may apply a water-based lubricant to prevent
drying. However, petroleum-based lubricant should not be used due to
the risk of flammability.
 Nasal cannulas are not as effective if the patient is a mouth breather or
has blocked nostrils, a deviated septum, or nasal polyps

2. Simple Face Mask - mask that delivers moderate

oxygen flow to nose and mouth.
a. Delivers oxygen concentrations to 40% to 60%.

Flow Rate: 6 to 10 L/min, resulting in oxygen

concentration (FiO2) levels of 35%-50%. The flow rate
should never be set below 6 L/min because this can result
in the patient rebreathing their exhaled carbon dioxide.

Advantages: Face masks are used to provide moderate oxygen

concentrations. Their efficiency in oxygen delivery depends on how well the
mask fits and the patient's respiratory demands.

Disadvantages: Face masks must be removed when eating, and they may
feel confining for some patients who feel claustrophobic with the mask on.

3. Venturi Mask - mask with device that mixes air and

oxygen to deliver constant oxygen concentration.

a. It mixes a fixed flow of oxygen with a high but variable

flow of air to produce a constant oxygen concentration.
Oxygen enters by way of a jet (restricted opening) at a
high velocity. Room air also enters and mixes with oxygen
at this site. The higher the velocity (smaller the opening),
the more room air is drawn into the mask.

Types:
 BLUE = 2-4L/min = 24% 02
 WHITE = 4-6L/min = 28% 02
 YELLOW = 8-10L/min = 35% 02
 RED = 10-12L/min = 40% 02
 GREEN = 12-15L/min = 60% 02

… Venturi Mask
c. Virtually eliminates rebreathing of carbon dioxide.Excess gas leaves
through openings in the mask, carrying with it the expired carbon dioxide.

Indication: often used in COPD, where it is important not to over-oxygenate

the patient.

Flow rate: The flow rate depends on the adaptor and does not correspond to
the flow meter. Consult with a respiratory therapist before changing the flow
rate.
Advantages: A specific amount of FiO2 is delivered to patients whose
breathing status may be affected by high levels of oxygen.

... Nonrebreathing Mask

C. Optimally, all the patient's inspiratory volume will be
provided by the mask/reservoir, allowing delivery of nearly
100% oxygen.

1. Nonrebreathing Mask - has an inflatable bag to

store 100% oxygen and a one-way valve between
the bag and mask to prevent exhaled air from
entering the bag.
 Has one-way valves covering one or both the exhalation ports to prevent
entry of room air on inspiration.
 Has a flap or spring-loaded valves to permit entry of room air should the
oxygen source fail or patient needs exceed the available oxygen flow.

Indication: used for patients who can breathe on their own but require
higher concentrations of oxygen to maintain satisfactory blood oxygenation
levels.

Flow rate: minimum of 10 to 15 L/minute. The reservoir bag should be

inflated prior to placing the mask on the patient. With a good fit, the non-
rebreather mask can deliver between 60% and 80% FiO2.

Advantages: Non-rebreather masks deliver high levels of oxygen

noninvasively to patients who can otherwise breathe unassisted.

Disadvantages: Due to the one-way valves in non-rebreather masks, there is

a high risk of suffocation if the gas flow is interrupted. The mask requires a
tight seal and may feel hot and confining to the patient. It will interfere with
talking, and the patient cannot eat with the mask on.

2. Partial Rebreather Mask - has an inflatable bag

that stores 100% oxygen.
a. On inspiration, the patient inhales from the mask and
bag; on expiration the bag refills with oxygen and expired
gases exit through perforations on both sides of the mask
and some enters bag.
b. High concentrations of oxygen (50% to 75%) can be
delivered.

The partial rebreather mask looks very similar to the non-rebreather mask.
The difference between the masks is a partial rebreather mask does not
contain one-way valves, so the patient's exhaled air mixes with their inhaled
air. A partial rebreather mask requires 10-15 L/min of oxygen, but only
delivers 35-50% FiO2.

... Transtracheal Catheter

 3. Transtracheal Catheter - accomplished by way of a small (8Fr)
catheter inserted between the second and third tracheal cartilage.
 Does not interfere with talking, drinking, or eating and can be
concealed under a shirt or blouse.
 Oxygen delivery is more efficient because all oxygen enters the
lungs.
 Patients who meet criteria for continuous home oxygen therapy
(Pa02 < 55 mmg on room air) may use this delivery method instead
of nasal cannula.

4. Continuous Positive Airway Pressure (CPAP)

Mask - is used to provide expiratory and inspiratory positive airway pressure
in a manner similar to positive end expiratory pressure (PEEP) and without
endotracheal intubation.

a. Has an inflatable cushion and head strap designed to tightly seal the mask
against the face.
b. A PEEP valve is incorporated into the exhalation port to maintain positive
pressure on exhalation.
c. High inspiratory flow rates are needed to maintain positive pressure on
inspiration.

... Continuous Positive Airway Pressure (CPAP) Mask

Indication: used for people who are able to breathe spontaneously on their
own but need help in keeping their airway unobstructed, such as those with
obstructive sleep apnea

Consists of a special mask that covers the patient's nose, or nose and mouth,
and is attached to a machine that continuously applies mild air pressure to
keep the patient's airways from collapsing.

5. ВіРАP
A Bilevel Positive Airway Pressure (BiPAP) device
is similar to a CPAP device in that it is used to prevent
airways from collapsing, but BiPAP devices have two
pressure settings. One setting occurs during inhalation
and a lower pressure setting is used during exhalation.

Patients using BiPAP devices in their home

environment for obstructive sleep apnea often find
these two pressures more tolerable because they don't
have to exhale against continuous pressure.

In acute-care settings, BiPAP devices are also used for patients in acute
respiratory distress as a noninvasive alternative to intubation and mechanical
ventilation and are managed by respiratory therapists. BiPAP devices in home
settings are set up in a similar manner as CPAP machines for ease of use.
6. T-piece (Briggs) Adapter - is used to administer oxygen to patient
with endotracheal and tracheostomy tube who is breathing
spontaneously.
  High concentration of humidity and oxygen delivered through wide
bore tubing.
 Expired gases exits through open reservoir tubing.

.. Manual Resuscitation Bag (Ambu Bag)

7. Manual Resuscitation Bag (Ambu

Bag) - delivers high concentration of
oxygen to patient with insufficient
inspiratory effort.

 With mask, uses upper airway by

delivering oxygen to mouth and nose of
patient.
 Without mask, adapter fits on
endotracheal or tracheostomy tube.

c. Usually used in cardiopulmonary arrest,

hyperinflation during suctioning, or transport of ventilator-dependent patients.

When using a bag mask valve, the rescuer manually compresses the bag to
force air into the lungs. Squeezing the bag once every 5 to 6 seconds for an
adult or once every 3 seconds for an infant or child provides an adequate
respiratory rate.

Flow rate: The flow rate for a bag valve mask attached to an oxygen source
should be set to 15 L/minute, resulting in FiO2 of 100%.

Advantages: A bag valve mask is portable and provides immediate

assistance to patients in respiratory failure or respiratory arrest. It also can be
used to hyperoxygenate patients before procedures that can cause hypoxia,
such as tracheal suctioning.

Disadvantages: The rate and depth of compression of the bag must be

closely monitored to prevent injury to the patient. In the event of respiratory
failure when the patient is still breathing, the bag compressions must be
coordinated with the patient's inhalations to ensure that oxygen is delivered
and asynchrony of breaths is prevented. Complications may also result from
overinflating or overpressurizing the patient. Complications include lung injury
or the inflation of the stomach that can lead to aspiration of stomach
contents.

8. Endotracheal Intubation
When a patient is receiving general anesthesia prior to a procedure or surgery
or is experiencing respiratory failure or respiratory arrest, an endotracheal
tube (ET) is inserted by an advanced practitioner, such as a respiratory
therapist, paramedic, or anesthesiologist, to maintain a secure airway. The ET
tube is sealed within the trachea with an inflatable cuff, and oxygen is
supplied via a bag valve mask or via mechanical ventilation.
9. Tracheostomy
A tracheostomy is a surgically-made hole called a stoma that goes from the
front of the patient's neck into the trachea. A tracheostomy tube is placed
through the stoma and directly into the trachea to maintain an open (patent)
airway and to administer oxygen. A tracheostomy may be performed
emergently or as a planned procedure.

Pulse Oximetry
Pulse oximetry (SpO2) is a non-invasive optical method of monitoring arterial
oxygen saturation. It provides an early and immediate warning of impending
hypoxemia.
Oximeters function by passing a light beam through a vascular bed, such as
the finger or earlobe to determine the amount of light absorbed by
oxygenated (red) and deoxygenated (blue) blood.
 Calculates the amount of arterial blood that is saturated with oxygen and
displays as a digital value.

Indications include:
a. Unstable patient who may experience sudden changes in oxygen level
b. Evaluation of need for home oxygen therapy
c. Need to follow the trend but need to decrease number of arterial blood gas
(ABG) drawn.

Using a Pulse oximeter

ACTION RATIONALE
1. Identify the patient at least two Positive identification of the patient is
methods. essential to ensure the intervention is
administered to the correct patient.
2. Explain what are you going to do Explanation relieves anxiety and
and why are you going to do it with facilitates cooperation.
the patient.
3. Perform hand hygiene. This deters the spread of
microorganism.
4. Select an adequate size for the Inadequate circulation can interfere with
application of the sensor. the oxygen saturation reading.
a. Use the patient's index or ring Fingers are easily accessible
finger
b. Check the proximal pulse and Brisk capillary refill and a strong puise
capillary refill indicate that circulation to the site is
adequate
c. If circulation at site is These alternate sites are highly vascular
inadequate, consider using the alternatives
earlobe or bridge of nose

a. Use the toe only if lower Peripheral vascular disease is common

extremity circulation is not in lower extremities
compromised.
5. Select proper equipment:
a. If one finger is too large for the Inaccurate readings can result if probe
probe, use a smaller one. A is not attached accurately.
pediatric probe may be used for a
small adult.
b. Use probes appropriate for Probes comes in adult, pediatric, and
patient's age and size. infant sizes.
c. Check if patient is allergic to A reaction may occur if patient is
adhesive. A non-adhesive finger allergic to adhesive substance.
clip or reflectance sensor is
available,
6. Prepare the monitoring site. Skin oils, dirt, or grime on the site,
Cleanse the selected area with polish and artificial nails can interfere
alcohol wipe or disposable cleaning with the passage of light waves.
cloth. Allow the area to dry. If
necessary, remove nail polish and
artificial nails after checking the
manual.

7.Check oxygen saturation at Monitoring SpOz provides ongoing

regular intervals, as ordered by assessment of patient's condition. A low
physician and signaled by alarms. hemoglobin level may be satisfactorily
Monitor hemoglobin level. saturated yet inadequate to meet
patient's oxygen needs.
8. Remove sensor on a regular Prolonged pressure may lead to tissue
basis and check for skin irritation or necrosis. Adhesive sensor may cause
signs of pressure (every 2 hours for skin irritation.
spring tension sensor or every 4
hours for adhesive finger or toe
sensor).