Respiratory Conditions in the Nursing Home Environment
Care home residents are susceptible to respiratory tract infections (RTIs), with a prevalence of 0.5 to 4.4 per 1,000 resident days. Pneumonia is reported as the leading infective cause of death amongst care home residents, with mortality rates between 6% and 23% (Gordon et al, 2010).
With the winter fully upon us now and the recent drop in temperatures, cold temperatures and low humidity are associated with increased occurrence of RTIs, and a decrease in temperature and humidity precedes the onset of the infections (Makinen et al, 2008.)
Infections are very common in the setting of long term care facilities and represent a major cause of morbidity and mortality among institutionalised elderly individuals. RTIs are any infection of the sinuses, throat, airways or lungs. They are usually caused by viruses, but can be caused by bacteria.
Respiratory tract infections are classified into two categories-
Upper respiratory tract infections which affect the nose, sinuses and throat
• Main symptom is cough but usually not a severe cough
Lower respiratory tract infections which affect the airways and lungs.
• Cough is usually more severe
• Residents may bring up phlegm and mucus
• May present with ‘tight’ feeling in chest
• Increased rate of breathing, breathlessness and wheezing
Effects of Ageing on Respiratory System
Older adults and especially those in a long term residential setting are more susceptible to respiratory infections and the possibility of further complications due to:
• Chest wall loses its elasticity and becomes rigid (rib calcification)
• Respiratory muscles become weaker
The sensory receptors in the airways, which have the job of monitoring the airways, and produce the cough reflex if it is needed to dislodge or expel something inhaled, lose their sensitivity with age. Therefore, the diminished cough reflex enables debris and irritants to reach the deep lung tissues, which can cause respiratory tract infections.
How we can tell if it is a chest infection
Five cardinal symptoms of a chest disease:
• Coughing
• Shortness of breath
• Sputum
• Wheeze
• Chest pain
There are two main types of coughs- Dry (non-productive) associated with upper respiratory tract infections, Asthma, early stages of pneumonia and moist (productive) occurs in lower respiratory tract infections, chronic obstructive pulmonary disease (COPD) and bronchiectasis.
What is shortness of breath telling us?
Breathlessness is defined as “an unpleasant or uncomfortable awareness of breathing or need to breath”. It is the most predominant symptom of both cardiac and respiratory diseases. Classified as chronic and acute. Chronic is when the difficulty lasts for a month or more while acute is a month or less. There are many reasons why shortness of breath can occur. In people with a chronic lung disorder (such as chronic obstructive pulmonary disease) or heart disorder (such as heart failure), the most common cause of breathless is a flare-up of the chronic disorder.
What is sputum/phelgm trying to tell us - what actions might we take.
Sputum is a mucousy substance that is secreted into the airways of the respiratory tract. The term sputum and phlegm are used interchangeably. It is made up of a combination of cells and other matter that is present in the airways. It is coughed up from the lower airways in the respiratory tract rather than the glands in the mouth and throat. It can be many colours and consistency, and these can help define certain conditions and this is valuable information that you can pass onto your physiotherapist and/or G.P. This can be particularly relevant as the residents may not be able to produce sputum when examined.
Colours
Clear - usually normal - Monitor
Dark yellow/ green sputum - A type of white blood cell known as neutrophils have a green colour to them. These types of white cells are attracted to the scene of bacterial infections. And therefore, bacterial infections of the lower respiratory tract, such as pneumonia, may result in the production of green sputum.- Review by Physiotherapist
Brown sputum - Occurs due to a presence of tar and is generally found in fungal infections.- Review by Physiotherapist and GP
Pink sputum - Pink, especially frothy pink sputum may come from pulmonary oedema, a condition in which fluid and small amounts of blood leak from capillaries into alveoli of the lungs.- Review by GP
Bloody sputum - Bloody sputum, even just a trace of blood tinged sputum, should always be evaluated- Review by GP
How can your team help?
1) MOBILISATION
Immobility and complete bed rest can lead to physical and psychological complications and consequences. Immobility can adversely affect all physiological bodily systems. Some adverse respiratory system effects relating to immobility include:
• the thickening of respiratory secretions
• the pooling of secretions
• an increased inability of the client to mobilise and expectorate these secretions
Some of these complications of immobility can be prevented with respiratory hygiene measures such as:
• deep breathing
• coughing
• postural drainage
• percussion
• vibrations
Your physiotherapist can assist you with some of the techniques mentioned.
2) POSITIONING
Positioning is in essence “gravity management”. Body position has profound acute effects on cardiovascular and respiratory function. As the body is never beyond the influence of gravity, positioning should be integral to respiratory care
Not Appropriate
Supine position
Placing a resident in a supine position (lying on their back) alters the position of the diaphragm, decreases lung volume as space is taken up by abdominal contents and in turn decreases airway clearance and increases their work of breathing.
Most Appropriate
Upright Supine position
The upright position is essential to maximise lung volume and flow rates, and this position is the only means of optimising fluid shifts such that circulating. The upright position coupled with movement is necessary to promote normal fluid regulation and balance.
Side Lying position
Side to side positioning is frequently used in residents with unilateral lung disease and is mostly effective when the affected lung is uppermost. If a right sided lower respiratory tract infection has been diagnosed and consolidation is present, the residents will benefit from being positioned on their left-hand side.
3) OXYGEN THERAPY
Titrating oxygen appropriately in the nursing home environment is challenging as residents in this setting can be affected by too much or too little oxygen. It must be remembered that most residents with a background of advanced respiratory disease, spend much of their lives with an abnormally low blood oxygen level and have adjusted physiologically.
The body of a resident with COPD becomes accustomed to lower oxygen levels than residents without. The British Thoracic Society Emergency Oxygen guidelines (2017) recommends that the saturation should be maintained 88%- 92% in most cases of exacerbation. Oxygen is best prescribed to achieve a desirable target range rather than a fixed dose of oxygen.
Consequences of inappropriate oxygen prescription-
Oxygen is widely available and commonly administered by the nursing staff in nursing homes. When administered correctly it may be lifesaving, but oxygen is sometimes given without careful evaluation of its potential benefits and side effects. Like any drug there are clear indications for treatment with oxygen and appropriate methods of delivery. Vigilant monitoring to detect and correct adverse effects swiftly is essential.
Points to remember
For most acutely ill residents a target saturation of 94-98% should be desirable. The oxygen concentration can be adjusted using nasal cannulae at 1-6L/min to maintain this target range.
For resident specific and those whom are at risk of retaining carbon dioxide i.e COPD desirable oxygen saturation range between 88-92%. If unable to achieve this range, oxygen should be started via nasal cannulae using 1-2l/min. This can be adjusted upwards or downwards to maintain the target saturation range.
The importance of titrating oxygen was noted by Austin et al (2010), whom stated that titrated oxygen reduced mortality by 58% for all residents and by 78% for residents with confirmed COPD.
As mentioned above oxygen is a drug and therefore resident would require continuous and medical review i.e GP or Hospital in some cases.
Oxygen therapy should be stopped when a resident is clinically stable on low oxygen concentration and is within desired saturation range.
Once oxygen therapy has stopped, residents should be monitored for 5minutes, if saturations are maintained they should again be reviewed in 1 hour.
If the saturation falls below target range on stopping oxygen therapy, restart the lowest concentration that maintained the resident in the target range and monitor for 5minutes. If this is not achievable the resident should have a clinical review to establish the cause for this deterioration.
It is important to note that some residents may already be prescribed nebulisers in the nursing home setting, therefore nurses should continue to administer these nebulisers especially during acute respiratory distress to aid with airway clearance (i.e. saline neb) or open airway (bronchodilator i.e Salbutamol neb). Never stop oxygen therapy while administering a nebuliser via a compressor.
Nurses while monitoring oxygen saturations should also be monitoring residents- respiratory rate, pulse, BP, temperature and level of consciousness and reporting all abnormalities to GP or hospital if needed.
All the above information has been derived from the British Thoracic Society (2017).
4) MANAGING BREATHLESSNESS
Different things work best for different people, but these are all techniques to try: Relaxed slow deep breathing: breathe in gently through your nose and breathe out through your nose and mouth. Try to feel relaxed and calm each time you breathe out. Pursed-lips breathing: breathe in gently through your nose and breathe out with your lips pursed as if you are whistling.
Blow as you go: use this when you’re doing something that makes you breathless, such as standing up. Breathe in before you make the effort. Then breathe out while making the effort. Try using pursed lips as you breathe out.
Paced breathing: this is useful when you’re active, such as climbing stairs. You pace your steps to your breathing. For example, breathe in when on the stair, and breathe out as you go up a stair.
THINGS TO REMEMBER
Not all coughs are related to respiratory infections, think of other causes such as aspiration. Has the resident got any difficulty with swallowing foods, drinks or saliva?
Coughing and Shortness of breath can also be related to cardiac diseases. Look for past medical history of any cardiac complaints, review resident for pedal oedema.
If a resident is in respiratory distress e.g. shortness of breath, coughing, never position resident flat and always place in an upright supine position when eating or drinking.
Remember a resident with COPD should never have SpO2 96% or above, use of a pulse oximeter to monitor and maintain SpO2 between 88-92% and oxygen should be increased or decreased to maintain this. Avoid giving too much oxygen as this can lead to the resident retaining carbon dioxide, signs of which would be increased confusion and decreased glasgow coma scale.
Thank you to our Senior Physiotherapist Emma Connolly for the above information, which we hope you and your team find useful.