Oxygenation

Respiratory alkalosis

Arise in blood pH due to hyperventilation (excessive breathing) and a resulting decrease in CO2.

Sputum specimen collection

Most accurate when collected in the morning before the patient has had anything to eat or drink. Patients who can cough and breathe deeply can be coached to produce a sputum specimen and expel it into a collection container

Pursed lip breathing

a technique of exhaling against pursed lips to prolong exhalation, preventing bronchiolar collapse and air trapping; done to increase expiratory airway pressure, improve oxygenation of the blood, and help prevent early airway closure.

Implementing and evaluating oxygen delivery

-Assess patients for changes in status

-Assess comfort level to prevent the pt from removing the mask while unattended

Supplemental oxygen

Can be used on a temporary basic or permanent basis depending on the patient's diagnosis

What can increase COPD survival rate, function level, exercise capacity, and mental status?

O2 therapy for more than 15 hours a day

Does oxygen require an order?

Yes. No in emergencies. An oxygen order must have a goal, duration, and delivery route

Home oxygen use

A home oxygen test must be completed showing the need for it. A "walking test" is done before discharge by an RT and then CM sets up DME needs. Pt must be educated on home safety, including storage and smoking concerns

Ventilation-perfusion scan

Used to assess ventilation and perfusion of the lungs. IV radioscope is given to assess perfusion. For the ventilation portion, the patient inhales a radioactive gas that outlines the alveoli. Diminished or absent radioactivity suggest a lack of perfusion or airflow. Ventilation without perfusion can suggest a pulmonary embolus

Pulmonary angiogram

Used to visualize pulmonary vasculature and locate obstructions or pathologic conditions. Contrast medium is injected through a catheter that is threaded into the pulmonary artery or right side of the heart. Series of x-rays are taken after. CT scans are preferred because they are less invasive

Safety precautions for at home O2 use

-No smoking

-No open flames

-Avoid static electricity

-Store oxygen takes upright and secured

-Avoid petroleum-based products

-Have a fire extinguisher available

-Notify the local fire or electric department of O2 use

Treatments for PNA

-Antipyretics

-Abx

-O2

-Fluids

-Rest

-Cough suppressant

-Avoiding irritants

-Teach preventions such as vaccinations

Interventions for PNA

-Position pt into high Fowlers

-Encourage CDB and use incentive spirometer

-Determine pt physical limitations and incorporate rest periods

-Promote adequate nutrition and hydration

-Encourage verbalizing feelings

Pleurisy

Painful inflammation of the pleura

Who is most at risk for PNA

Elderly, the hospitalized, intubated, immunocompromised, and post op patients

Why are intubated patients for at risk for developing PNA?

Because the breathing tube bypasses natural airway defenses, impairs coughing and mucociliary clearance, and allows bacteria‑laden secretions to enter the lungs

Preventing PNA

vaccine, handwashing, smoking cessation, CDB

PNA complications

Pleurisy, pleural effusion, atelectasis, spread of infection

PNA symptoms

cough, dyspnea, +/- fever, +/-sputum, pleuritic CP, fatigue, nasal flaring, poor appetite

Tracheostomy

A surgical opening into the trachea through the neck. Can be permanent or temporary. Transtracheal oxygen bypasses the upper airway.

Pharyngeal airways

Provides an open-air passage by holding the tongue away from the back of the pharynx, air can flow around or through these artificial airways.

Types of pharyngeal airways

Oropharyngeal airway (OPA)

Nasopharyngeal airway (NPA)

Endotracheal airway

For patients who cannot breathe effectively due to an airway obstruction or respiratory/cardiac failure. These are artificial airways inserted directly into the trachea

Types of endotracheal airways

Orotracheal-through the mouth

Nasotracheal- through the nose

Tracheostomy- through an opening directly into the trachea

Intubation

insertion of a tube into the trachea, it is done to establish and maintain a secure and open airway when a patient cannot breathe adequately on their own.

What levels of asepsis is used during endotracheal care?

Typically, sterile is recommended for new tracheostomies or with patients with increased susceptibility to infection

Suctioning airways

Performed to remove secretions and prevent them from entering the lower airway, and it helps maintain patency

Signs that suctioning should be done

Agitation

Gurgling sounds during respirations

Restlessness

Labored breathing

Decreased O2 sat

Increased heart and respiratory rates

Adventitious breath sounds

Complications with suctioning

While it can remove secretions, it also removes air from the airways and causes o2 levels to fall. As a result, suctioning should be done quick and accompanied by supplemental oxygen. Suctioning can also irritate mucous membranes

Lower airway suctioning

Tracheal suctioning, a catheter is passed beyond the pharynx into the trachea to remove lower airway secretions. This is a sterile procedure

Types of tracheal suctioning

Orotracheal

Nasotracheal

Endotracheal

Mechanical ventilator

A machine used to inflate and deflate the lungs when a person cannot breathe on their own. Patients are intubated before being connected to a ventilator.

Types of ventilators

negative pressure, positive pressure

Chest drainage

Makes room for the lungs to fully expand by removing air and fluid from the pleural space.

Oxygenation meaning

How well the cells, tissues, and organs of the body are supplied with oxygen. Respiration and ventilation are two major processes that occur int he pulmonary system to oxygenate the blood

Ventilation meaning

Occurs as the air moves into the respiratory system when we breathe in air and the structures of our respiratory system filter and humidify the air

Respiration meaning

Occurs as the oxygen and carbon dioxide are exchanged. This takes place within the bronchiole's alveoli

The respiratory system consists of...

nose, mouth, pharynx, larynx, trachea, bronchi, bronchioles

Upper airway

nose, mouth, pharynx, larynx

Lower airway

trachea, bronchi, bronchioles, alveoli

Which part of the airway is sterile in a healthy person?

The lower airway

Pulmonary immune response mechanisms

-Triggered by invasion of an infectious agent

-Increased blood flow, increased vascular permeability, and activation of neutrophils

-Results in edema of airways as fluid leaks from capillaries and tissues into alveoli, thus affecting oxygen transport

-Leads to tachypnea, dyspnea, and tachycardia

-Leads to the development of PNA and atelectasis

Tachypnea

Fast breathing. Over 20 breaths per minute

Hypoxia

Low oxygen levels in the blood

Hypercapnia

High blood levels of carbon dioxide

Dyspnea

Difficulty breathing, SOB

Atelecatasis

Alveoli collapse or don't full expand; less air reaches the area, so there is less oxygen in the blood

Orthopnea

Difficulty breathing when lying down

Tachycardia related to breathing

Increased HR over 100 bpm because the heart is working harder to oxygenate the tissues of the body

Factors that can influence pulmonary function

-Lifespan and development

-Environment

-Lifestyle

-Smoking

-Medications

What are babies at risk for regarding the pulmonary system?

-Respiratory distress because of immature alveolar surfactant systems and immature pulmonary circulation. This leads to widespread atelectasis

-Infection because of immature immune systems. This can lead to their tiny airways being obstructed by mucous or meconium at

-Apnea risk due to CNS immaturity

-Choking or suffocation risk

What are toddlers and school age children at risk for regarding the pulmonary system?

-Tonsilitis

-Upper respiratory infections or URI's

-Viral infections such as croup or PNA

-Asthma

What are adolescents and young adults at risk for regarding the pulmonary system?

-Vaping or smoking, leading to addiction and lung irritation (chemical pneumonitis)

-Fewer routine healthcare visits

-Exercise induced asthma

What are older adults at risk for regarding the pulmonary system?

-Calcified costal cartilage reduces chest wall movement during breathing

-Alveoli lose elasticity

-Difficulty expelling mucous because it is thick and elderly patients tend to be dehydrated

-GERD poses an aspiration risk

-Declining immune response, at risk for flu and PNA

-Chemoreceptors respond more slowly to increased O2 demand or rising CO2 levels

-Diminished ability to meet oxygen demands when needed

-This population should be encouraged to vaccinate themselves yearly with flu, pneumococcal, and COVID vaccines

How does smoking affect the pulmonary system?

-Tobacco smoke contains at least 200 toxic chemicals that are known to cause cancer

-Constricted bronchioles, increased fluid secretion into airways, inflammation and edema of the bronchial lining, and paralyzed cilia

Smoking risks

COPD, cancer, MI, and stroke (to name a few)

Smoking cessation

-First step is to WANT to stop

-Pharmacologic treatments can be utilized such as Wellbutrin and nicotine patches

-Behavioral treatments and community education programs can be implemented to help as well

How can we assess oxygen status?

-Physical exam

-Breathing pattern

-Respiratory effort

-Pulse oximetry

-Inspect, palpate, percuss, and auscultate

Inspecting- respiratory physical assessement

-First step

-Assess LOC, speech, color (of lips, nailbeds, fingernails)

-Inspect nares, neck, and thorax

Normal breath rate for adults

12-20 breaths per minute

Normal breath rate for school age children

14-22 breaths per minute

Normal breath rate for infants

30-60 breaths per minute

Kussmaul breathing

Tachypnea and hypernea

Hypernea

Deep breathing

Cheyne-Stokes

Gradual increase and decrease of respirations with periods of apnea

Palpation- respiratory physical assessment

-Touch the trachea to ensure it is midline

-Check for crepitus or air trapped under the skin in the SQ tissue

-Assess for equal expansion of the lungs by placing hands on the posterior thorax and having the patient inhale and exhale. Both hands should rise and fall equally

Percussion- respiratory physical assessment

-Performed by an advanced practice nurse of MD

-Performed between the ribs

Auscultation- respiratory physical assessment

-Use the diaphragm of the stethoscope to listen and compare the right and left fields during inhalation and exhalation

-Make sure the patient breathes slowly to prevent dizziness and or fatigue

Pulse oximeters

An external monitor that measures the oxygen saturation level in the blood by shining red and infrared light through a body part and analyzing how much light is absorbed by oxygenated versus deoxygenated hemoglobin. Ensure the testing location is free of nail polish, artificial nails, and receives adequate circulation

What is the expected oxygen saturation for a patient with COPD?

Less than 89-90%

Why is it bad to give a COPD patient excess oxygen?

-Excess oxygen can worsen CO2 retention

-These patients rely on low oxygen to stimulate breathing

What is the goal of oxygen therapy?

-Decrease symptoms related to low O2 and decrease the cardiovascular system workload

-Symptoms include: tachycardia, tachypnea, low O2 stat, cyanosis, distress, and anxiety

What happens if a patient is showing severe signs of hypoxia?

Give oxygen, do not wait on a doctor's order. Get a doctor's order ASAP after giving oxygen

What is this?

Nasal cannula

What is this?

Face tent- large, open plastic mask that fits under the chin. It is open at the top and is held in place with an elastic band around the head

What is this?

Oxygen face mask- a clear, flexible mask that covers the nose and mouth and delivers oxygen flow into the mask

What is this?

Partial rebreather mask- uses the reservoir bag to capture some exhaled gas for rebreathing

What is this?

Non-breather mask- a type of reservoir bag mask. A valve keeps exhaled air from entering the reservoir bag

What is this?

Venturi mask- a cone-shaped adapter that serves as a mixing valve to control the same amount of O2 and room air that flows through the mask

Nasal cannula

-Used for low flow supplemental oxygen

-Flow rate can be between 0.5 to 6 LPM

-Use humidifier if above 3L

-Skin breakdown risk especially around the ears

How much oxygen is in normal room air?

21%

How much oxygen is in 1L?

24%

How much oxygen is in 2L?

28%

How much oxygen is in 4L?

36%

How much oxygen is in 6L?

44%

Oxygen face mask

-Used when more oxygen is needed

-Covers the nose and mouth

-5 to 10 liters per minute

-40% to 60% fraction of inspired oxygen

-Not well tolerated because of the tight fit, muffled feeling, and heat

Partial rebreather

-6 to 15 LPM

-FiO2 50-90%

-Ports allow CO2 to escape, delivers slightly lower oxygen concentration-works for COPD patients

Non-rebreather mask

-6 to 15 LPM

-FiO2 70-100%

-Contains only oxygen, which allows for higher FiO2 delivery

-Rare for 100% oxygen delivery because the seal rarely seals perfectly to the patient's face

-Ideal for emergencies where rapid oxygenation is needed for trauma or acute respiratory distress

Venturi mask

-54 to 50% FiO2

-The adapter at the base of the mask allows a precise FiO2 to be delivered; meaning the patient gets a precise and consistent O2 delivery regardless of their breathing pattern

-Ideal for COPD patients

Incentive spirometer

-Teaches deep breathing and coughing to promote ventilation and gas exchange

-Coughing after deep breathing promotes mobilized secretions, which keeps airways and alveoli open to provide better surface area for gas exchange

-Designed to encourage patients to take deep breaths by reaching a goal-directed volume of air

-Used for patients at risk for developing atelectasis or PNA

-Offers various visual cues to show the patient that they are inhaling deep enough

Spirometer use for patients with chronic lung disease

Have the patient exhale through pursed lips and cough throughout expiration in several short bursts to avoid high expiratory pressures which can collapse diseased airways

Obstructive sleep apnea

A condition where the upper airway is obstructed during sleep, causing a narrowing of one or more sites of the upper airway, resulting in intermittent breathing patterns including periods of apnea

Who is at risk for OSA

Obesity, A Fib, HTN, DM II, male, alcohol use, cigarette use, and upper airway soft tissue abnormalities

What is the treatment for OSA?

CPAP

What is CPAP

Continuous positive airway pressure. It provides positive pressure during inspiration and expiration to keep alveoli open in a spontaneously breathing patient

What is BIPAP

Bilevel Positive Airway Pressure; similar to CPAP but there are two levels of pressure given

Factors that affect ventilation

Respiratory rate and depth, lung compliance, lung elasticity, airway resistance

Respiration and depth effect on ventilation

Rate is how fast you breathe and depth is how much your lungs expand to take in air. These processes affect oxygen and carbon dioxide levels in the blood

Lung compliance effect on ventilation

Refers to the ease of lung inflation. It can be reduced by edema, loss of surfactant, or conditions that cause elastin fibers in the lungs to be replaced with scar tissue

Lung elasticity effect on ventilation

AKA elastic recoil. Refers to the tendency of elastic fibers to return to their original position away from the chest wall after being stretched. Alveoli that have been overstretched, they lose their elastic recoil over time. Their loss of elasticity allows the lungs to inflate easily but inhibits deflation, leaving stale air trapped in the alveoli