Drowning: Pathophysiology of Delayed Respiratory Complications (Nursing)

00:01 There's also a case of delayed respiratory complications.

00:04 Now, I wanted to bring this to your attention. So we're going to take a separate section and talk about it here.

00:09 This has significance, clinical significance because this phenomenon of delayed pulmonary effects is sometimes called secondary drowning or delayed drowning in lay terminology.

00:22 But medical professionals generally avoid these terms now and simply refer to it as delayed respiratory complications of drowning.

00:30 Now, the key nursing implications for you include.

00:33 You need to recognize that an initially well-appearing drowning patient may not remain stable. So you need to understand that the pathophysiological basis for delayed deterioration is why you're going to be on your toes.

00:46 You've got to keep an eye on monitoring that patient.

00:49 So you're going to want to implement appropriate monitoring protocols that are based on the risks that patient has experienced.

00:55 Now you're going to educate families and patients about the potential for delayed symptoms. If they are going home, you want them to know what to look for.

01:04 Make sure that if you have the slightest level of uncomfortableness about this patient, what you want you to have what we call a low threshold for having them stay longer or for escalating care.

01:16 If anything about this patient makes you feel unsettled, contact the health care provider.

01:21 Tell them what you're observing and how you're feeling, and make sure you have that conversation.

01:26 Sometimes your gut instinct is spot on and you'd rather be safe than sorry. Now, if you are going to discharge the patient, make sure the family is very clear on the discharge instructions and what to look for and the plans for follow up.

01:40 Now, it's important if the patient does experience delayed secondary pulmonary effects, that they're recognized and they're managed.

01:48 They've got to be monitored closely.

01:50 And I want to talk about what you do initially for patients who are asymptomatic.

01:55 It's unfortunate. But delayed secondary pulmonary effects are critical but sometimes underappreciated aspect of drowning management because the client has the potential to develop serious respiratory complications even up to hours after appearing stable or even asymptomatic. So it's important that you, as a nurse, are able to recognize and manage delayed respiratory deterioration.

02:20 You're going to have to monitor them closely, even if they're initially asymptomatic.

02:25 So let's break down the phenomenon of delayed deterioration and look at the pathophysiology. See, initially the patients may appear stable because of their compensatory mechanisms.

02:35 But over time 1 to 24 hours.

02:39 Typically, it's between 4 to 8 hours, but over a period of 1 to 24 hours, several processes can happen.

02:45 So you've got surfactant dysfunction.

02:48 Remember this is a drowning client.

02:50 So the water exposure can either damage or wash out the pulmonary surfactant. So they've got progressive, meaning it's getting worse, dysfunction of their surfactant.

03:00 Well, surfactants job is to keep that alveoli opens.

03:04 You can have gas exchange without the surfactant or with the dysfunction of the surfactant, the alveoli are going to collapse.

03:11 And that's what we call atelectasis.

03:13 Now you're going to have more and more alveoli collapse as the surfactant function decreases.

03:20 So the more problems you have with your surfactant, the more alveoli that will collapse and be unable to exchange oxygen for carbon dioxide. So, as this progresses, you can also have inflammatory mediators. Now these inflammatory mediators are activated in response to the chemical irritation the lungs have experienced.

03:40 So now you have capillary leak.

03:42 And this leads to increasing pulmonary edema.

03:45 Anyone with pulmonary edema you know they have really poor gas exchange because you end up with this ventilation perfusion mismatch gets even worse.

03:54 So, the lungs become what we would call stiffer.

03:57 But we also say that as pulmonary compliance decreases because of all this. Let's go back and review.

04:05 The surfactant is dysfunctional, right? It's not doing what it should do.

04:09 The alveoli collapse, the inflammatory mediators come out because of the chemical irritation.

04:15 The capillaries start leaking.

04:16 You have more pulmonary edema.

04:18 You've got a ventilation perfusion mismatch and the lungs get stiffer. All of that adds up to really poor oxygen being delivered. So you have hypoxemia low or inadequate oxygen in the bloodstream.

04:34 Now this either develops or worsens even though the patient may have been initially completely asymptomatic.

04:41 Now that we've established what happens in pathophysiology of this delayed response, let's take a look at the signs you should be looking for.

04:50 Look at their respiratory rate. When you start to see it going up without a reason.

04:54 They're not just excited or in pain.

04:56 You see that respiratory rate going up.

04:58 That could be a sign they're having to work harder to breathe.

05:02 Might also see retractions that keep getting worse.

05:05 They might be suprasternal or intercostal or subcostal.

05:08 Keep an eye on those. Retractions are never a good sign.

05:12 Watch their oxygen sats.

05:14 Are they dropping? Also listen to their lungs.

05:17 Are the rails or crackles getting worse or are they just appearing either way? All of these are signs of clinical deterioration, particularly in the respiratory system.

05:28 Now if this is happening, they might start to have a change in mental status. They might become irritable or lethargic or confused.

05:36 Anytime a patient has a change in mental status, always think about their oxygenation.

05:42 Now because of their irritated they've had water in their lungs, they might develop a cough or that cough might be getting worse.

05:48 If you see pink frothy sputum, that's going to be a really severe case of pulmonary edema. And the patient may even tell you, I just feel like I'm having a hard time breathing.

06:00 That may be the very first symptom or sign that you see.