- Respiratory complications, atelectasis in
particular, account for the majority of
postoperative complications experienced by
patients. They result in prolonged
hospitalization, increased economie impact, and,
in some cases, loss of life. The most disturbing
aspect of this problem is that it is predictable
and preventable.
-
- It is the duty of the nurse to prevent
atelectasis. Traditionally, the intervention has
been to have the patient turn from side to side,
take deep breaths, and cough. The effectiveness
of the deep breath for all patients is
questionable. For patients who have had
abdominal surgery, the pain resulting from
increased tension on the incision may prevent
effective deep breathing. The yawn may be
more efficient and effective because it is a
deep inspiration held for a prolonged period of
time. It can be elicited by a simple command and
is difficult to stop once it bas been
initiated.
-
- Atelectasis. The etiology of
atelectasis is well known. If the patient is
given a general anesthesia and placed on a
respirator during the surgical procedure, some
degree of atelectasis is present when the
patient is removed from the operating table.
Atelectasis, the collapse of alveoli, results
from alveolar hypoventilation. The normal
respiratory pattern of spontaneously breathing
adults includes periodic sighs or deep breaths.
When the person is anesthetized, placed in one
position, and ventilated at a constant tidal
volume, the periodic sighs are eliminated and
alveoli collapse. The problem is further
complicated by the fact that the sigh reflex is
absent in spontaneously breathing postoperative
patients. The result is increased collapse of
alveoli, arteriovenous shunting of blood in the
pulmonary circulation, and systemic hypoxia.
Periodic hyperinflation of the lungs is
sufficient to reinflate collapsed alveoli.
-
- Development of hypoxia. The primary
problem to be dealt with is the hypoxia that
develops in clinically significant atelectasis.
The respiratory pattern exhibited in the
postoperative period is characterized by
increased respiratory rate, decreased tidal
volume, and loss of the sigh reflex. The result
is adequate excretion of CO2 by the lungs,
maintenance of arterial pH at normal levels, and
decreased arterial O2 levels.
-
- As alveoli collapse, there is less
respiratory membrane available for the exchange
of gases. The initial result is a buildup of
carbon dioxide in the bloodstream. An increase
in arterial carbon dioxide stimulates the
respiratory center located in the brain to
increase the respiratory rate. As the
respiratory rate increases, excess carbon
dioxide is blown off, but oxygen levels remain
low. It takes longer for oxygen to diffuse into
the bloodstream and attach to the hemoglobin
than it does for carbon dioxide to diffuse out
of solution into the alveoli. If the
postoperative patient's arterial blood gas
values were determined, they would indicate
normal arterial carbon dioxide, normal arterial
pH, and a lowered arterial oxygen level. This
hypoxia is the problem that nurses face. Hypoxia
feeds into the fatigue experienced by surgical
patients. It contributes to the confusion
experienced by elderly postoperative patients
and has some effect on the irritability and
discomfort experienced by postoperative
patients. The classic signs and symptoms of
hypoxia, such as cyanosis, tachypnea, shallow
breathing, altered breath sounds, hypertension,
and tachycardia, may not be readily evident in
the postoperative patient and to wait for them
to develop is unnecessary. All postoperative
patients experience some degree of atelectasis
and therefore hypoxia. The nurse should treat it
to prevent further complications.
-
- Treating and preventing atelectasis. Some
interventions traditionally used are
intermittent positive pressure breathing, blow
bottles, and incentive respirometers. Balagot
and Bandelin pointed out that "the occasional or
even frequent augmentation of inspiration (sigh)
may be more helpful in preventing atelectasis
than all the paraphernalia and accessories which
make inhalation therapy impressive and
expensive."
-
- In practice, it is sometimes difficult to
attain the cooperation of patients when
encouraging them to deep breathe and cough. This
is particularly true of patients who have had
thoracic or abdominal surgery. In these cases,
incisional pain may decrease the respiratory
effort the patient can exert. Also, tthese
patients require pain medications that may
suppress the respiratory center and cough
reflex. It is difficul to be certain that when a
patient is asked to take a deep breath, they are
indeed increasing their inspiratory volume
sufficiently to reexpand collapsed alveoli. For
a deep breath to ventilatte the lungs
sufficiently to reinflate collapsed alveoli, it
must be at least twice age tidal volume, include
high alveolar inflating pressure, be applied for
a prolonged period of time, and achieve maximum
inspiratory volume. The particular respiratory
maneuver that does all these things is a
yawn.
-
- The yawn maneuver. The yawn maneuver
has advantages over deep breathing. In a study
conducted by Ward and others, it was concluded
that a yawn, which was defined as a deep breath
held for three seconds, significantly increased
arterial oxygen levels over series of deep
breaths and a single deep breath. In another
study where the subjects were asked to yawn, the
increased inspiratory volume wa maintained a
mean time of 5.21 seconds. All patients know
what it feels like to yawn, so when they are
asked to yawn, they know when they have
succeeded. This yawn maneuver itself possesses
certain features that make it useful in clinical
situations. First, the yawn is a spontaneous
deep inspiration difficult to stop once it bas
started. So, the patient who has been reluctant
to takea deep breath because of incisional pain
will find it difficult to stifle a yawn once it
is initiated. Second, the initiation of a yawn
is relatively easy. Since the yawn can be
elicited by suggestion, the nurse need only ask
the patient to yawn, discuss yawning, or yawn
herself to obtain the desired patient response.
In one study, the regular use of the yawn
maneuver reduced postoperative pulmonary
complications by 20%.
-
- Summary. Postoperative respiratory
complications are frequent. The main
complication is atelectasis, with hypoxia as a
primary problem. Hypoxia is a result of venous
or unoxygenated blood flowing past collapsed
alveoli and mixing with oxygenated blood.
Alveolar collapse is the result of the absence
of the sigh reflex in the postoperative
respiratory pattern of patients. Alveolar
collapse can be reversed by increasing the depth
of inspiration to three times the average tidal
volume and prolonging the inspiratory phase of
the respiratory excursion. Another name for this
type of respiratory movement is a yawn. The yawn
is easily elicited in patients by suggestion or
contagion.
-
- It is within the scope of nursing care to
prevent atelectasis from developing in patients.
The usual treatment includes turning, coughing,
and deep breathing by the patient at least every
two hours. The yawn maneuver should be
substituted for deep breathing because it has
been shown to be more effective in reinflating
collapsed alveoli and, therefore, in treating or
preventing hypoxia.
-
- Notes
-
- 1. A J Okinaka, "The pattern of breathing
after operation" Surgery, Gynecology and
Obstetrics 125 (1967) 785-790.
-
- 2. A C Guyton, Textbook of Medical
Physiology, 4th ed (Philadelphie: W B Saunders
Co, 1971) 5.
-
- 3. M B Laver, H H Bendixen, "Atelectasis in
the surgical patient: Recent conceptuel
advances" Progress in Surgery 5 (1966)
1-39.
-
- 4. R C Balagot, V R Bandelin, "Preoperative
and postoperative inhalation therapy" Surgical
Clinics of North America 4 (February 1968)
29-36.
-
- 5. R H
Bartlett, et al, "Physiology of yawning and
its application to postoperative care," Surgical
Forum 21 (1970) 222-224.
-
- 6. R J Ward, et al, "An evaluation of
postoperative respiratory maneuvers," Surgery,
Gynecology and Obstetrics 123 (1966) 51-54.
-
- 7. Cheryl A Cahill, "Comparison of the yawn
maneuver to a deep breath," master's thesis
University of Washington, Seattle, 1973.
-
- 8. R H
Bartlett, A B Gazzaniga, T Geraghty, "The
yawn maneuver: Prevention and treatment of
operative pulmonary complications" Surg Forum 22
(1971) 196-198.
-
|
