Chapter 22 Assessment of the Respiratory System Notes

Assessment of the Respiratory System

Learning Outcomes

Use anatomy and physiology knowledge for focused respiratory system assessment.

Teach evidence-based health promotion to prevent respiratory system problems.

Use clinical judgment to interpret assessment findings for patients with respiratory issues.

Identify factors affecting health equity for patients with respiratory system problems.

Explain how genetics and physiologic aging affect gas exchange and perfusion.

Answer:

Age-related changes impact gas exchange and perfusion:

• Reduced Alveolar Surface and Diffusion:

  • Detail: Alveolar surface area decreases with age, reducing the area available for gas exchange. The alveolar walls also thicken, which increases the diffusion distance for gases.

  • Nursing Implication: Emphasize pulmonary hygiene, including encouraging deep breathing exercises and effective coughing techniques to maximize gas exchange.

• Decreased Elastic Recoil and Dilated Bronchioles:

  • Detail: Lungs lose elasticity with age, reducing their ability to recoil during exhalation. Bronchioles dilate, leading to air trapping and increased residual volume.

  • Nursing Implication: Promote upright positioning to facilitate lung expansion and improve ventilation. Teach pursed-lip breathing to help maintain airway pressure during exhalation.

• Weaker Cough and Airway Closure:

  • Detail: Respiratory muscle strength declines with age, resulting in a weaker cough. This, combined with early airway closure, increases the risk of aspiration and respiratory infections.

  • Nursing Implication: Conduct regular lung assessments to detect early signs of respiratory compromise. Encourage frequent position changes and assist with coughing and deep breathing exercises.

• Increased Residual Volume:

  • Detail: The amount of air remaining in the lungs after maximal exhalation increases with age due to reduced lung elasticity and airway closure.

  • Nursing Implication: Emphasize health maintenance strategies, such as regular exercise and avoiding respiratory irritants, to preserve lung function.

• Less Efficient Gas Exchange:

  • Detail: The efficiency of oxygen and carbon dioxide exchange decreases with age due to structural changes in the lungs and reduced pulmonary blood flow.

  • Nursing Implication: Monitor breathing patterns and oxygen saturation levels closely. Provide supplemental oxygen as needed to maintain adequate oxygenation.

• Decreased Elasticity:

  • Detail: The loss of elasticity in lung tissue leads to reduced lung compliance and increased work of breathing.

  • Nursing Implication: Ensure meticulous oral hygiene to prevent respiratory infections. Encourage adequate hydration to thin secretions and facilitate expectoration.

• Muscle Atrophy:

  • Detail: Respiratory muscle mass decreases with age, reducing respiratory strength and endurance.

  • Nursing Implication: Engage in face-to-face conversations to assess cognitive function, which may be affected by hypoxia. Provide respiratory muscle training exercises to improve strength and endurance.

• Vocal Cord and Laryngeal Changes:

  • Detail: Vocal cords become slack, and laryngeal muscles lose elasticity, affecting voice quality and increasing the risk of aspiration.

  • Nursing Implication: Assess the patient's level of consciousness and cognition, as hypoxia from acute respiratory conditions can cause confusion.

• Increased Vascular Resistance:

  • Detail: Pulmonary vascular resistance increases with age, reducing blood flow through the lungs and impairing gas exchange.

  • Nursing Implication: Watch for subtle manifestations of hypoxia, such as restlessness, confusion, and changes in skin color.

• Reduced Blood Volume:

  • Detail: Pulmonary capillary blood volume decreases, reducing the amount of blood available for gas exchange.

  • Nursing Implication: Provide increased rest periods to reduce oxygen demand and prevent respiratory fatigue.

• Higher Hypoxia Risk and Chest Issues:

  • Detail: Older adults are at higher risk for hypoxia and chest wall abnormalities due to age-related changes in respiratory structure and function.

  • Nursing Implication: Ensure adequate calcium intake to maintain bone density and support respiratory muscle function.

Interpret assessment findings for suspected or actual respiratory problems.

Plan evidence-based care and support for patients undergoing diagnostic testing.

Key Terms / Definitions

• Atelectasis: Alveolar collapse is a condition characterized by the collapse of lung tissue, leading to reduced gas exchange and potential respiratory complications. It can arise from various factors, including airway obstruction (such as mucus plugs or foreign objects), hypoventilation (insufficient ventilation), compression of lung tissue (due to tumors, fluid accumulation, or external pressure), and impaired surfactant production (surfactant reduces surface tension in the alveoli, preventing collapse). Atelectasis can manifest in different forms, such as absorption atelectasis (caused by the absorption of gas from obstructed alveoli), compression atelectasis (resulting from external compression on the lung), and adhesive atelectasis (due to surfactant deficiency). Clinically, it can present with symptoms like shortness of breath, cough, chest pain, and decreased oxygen saturation. Nursing implications involve comprehensive respiratory assessment, including monitoring breath sounds for decreased or absent sounds over affected areas. Encouraging deep breathing and coughing exercises helps to promote alveolar inflation and secretion clearance, while ensuring adequate hydration thins secretions and facilitates expectoration. In some cases, interventions like chest physiotherapy, bronchodilators, or mucolytic agents may be necessary to manage atelectasis effectively.

• Bronchoscopy: Insertion of a tube into airways to view structures and obtain tissue samples. Bronchoscopy is a procedure in which a flexible or rigid tube is inserted into the airways to visualize the bronchial passages, diagnose pulmonary diseases, and manage various respiratory conditions. The bronchoscope is equipped with a camera that allows real-time viewing of the airways on a monitor. Bronchoscopy is utilized to evaluate abnormalities detected on imaging studies, such as chest X-rays or CT scans, to identify the source of bleeding in the airway, to remove foreign objects or mucus plugs, and to obtain tissue or fluid samples for analysis. During bronchoscopy, the patient is typically sedated to minimize discomfort and suppress the gag reflex. Local anesthesia may be applied to the throat to further reduce discomfort. The bronchoscope is advanced through the nose or mouth, down the trachea, and into the bronchi. The physician can then inspect the airways for signs of inflammation, infection, tumors, or other abnormalities. If necessary, the physician can use instruments passed through the bronchoscope to collect samples of tissue or fluid for further examination. Potential Risks: Bronchospasm, bleeding, infection, and pneumothorax. Post Procedure Nursing Care: Monitor respiratory status, assess for complications, and ensure the return of the gag reflex before allowing the patient to eat or drink.

• Crepitus: Air trapped under the skin, felt as a crackling sensation (subcutaneous emphysema). Crepitus occurs when air escapes from the respiratory system and becomes trapped in the subcutaneous tissues. This can happen due to several reasons, including trauma to the chest or neck, surgical procedures, or conditions like pneumothorax or emphysema. When palpating the skin over the affected area, a crackling or popping sensation is felt as the air is compressed. The presence of crepitus indicates that there is an abnormal communication between the respiratory system and the subcutaneous tissues, which can lead to complications if not addressed promptly. To assess for crepitus, gently palpate the skin around the neck, chest, and upper extremities, noting any areas where the crackling sensation is present. Document the location and extent of crepitus, as well as any associated symptoms such as pain, swelling, or difficulty breathing. Monitor the patient closely for signs of respiratory distress or infection, and notify the healthcare provider immediately if new or worsening crepitus is detected.

• Fremitus: is the vibration of the chest wall that can be felt on the surface of the body when a person speaks. It is also known as tactile or vocal fremitus. To assess for fremitus, the healthcare provider places their hands on the patient's chest or back while the patient repeats a phrase such as "ninety-nine." The vibrations created by the patient's voice travel through the airways and lung tissue, and can be felt on the chest wall. The intensity of the fremitus can provide valuable information about the condition of the lungs. Decreased fremitus may indicate the presence of air or fluid in the pleural space, such as in cases of pleural effusion or pneumothorax. It may also be caused by obstruction of the airways, such as in cases of asthma or emphysema. Increased fremitus, on the other hand, may indicate consolidation of the lung tissue, such as in cases of pneumonia or lung tumors, because the increased density of the chest enhances vibration transmission.

• Gas Exchange: involves the transport of oxygen to cells and the removal of carbon dioxide through ventilation and diffusion. Ventilation is the mechanical process of moving air into and out of the lungs, enabling the intake of oxygen and the expulsion of carbon dioxide. Respiratory diffusion is the movement of oxygen and carbon dioxide across the alveolar and capillary membranes, driven by concentration gradients. Oxygen moves from the alveoli into the blood, while carbon dioxide moves from the blood into the alveoli. Perfusion is the arterial blood flow through the tissues (peripheral perfusion) and the blood pumped by the heart (central perfusion), ensuring that oxygenated blood reaches all body tissues and organs. Effective gas exchange is essential for maintaining cellular function and overall homeostasis.

• Hemoptysis: Blood in the sputum. Hemoptysis refers to the coughing up of blood or blood-tinged sputum from the respiratory tract. It can range from mild streaking of blood in sputum to the expectoration of large amounts of blood. The causes of hemoptysis are varied and can include bronchitis, pneumonia, tuberculosis, lung cancer, pulmonary embolism, and trauma to the airways. Assessment involves determining the amount and color of the blood, as well as associated symptoms such as cough, chest pain, and shortness of breath. Diagnostic evaluation may include chest X-ray, CT scan, bronchoscopy, and sputum analysis to identify the underlying cause. Management focuses on addressing the underlying cause and controlling the bleeding. Nursing interventions include monitoring vital signs, assessing respiratory status, providing supplemental oxygen if needed, and administering medications as prescribed. In severe cases, interventions such as bronchoscopy or surgical procedures may be necessary to remove obstructions or to control significant bleeding effectively.

• Hypoxemia: A condition characterized by abnormally low levels of oxygen in the blood.

  • Causes:

    • Pulmonary Conditions: Pneumonia, COPD, asthma, pulmonary embolism.

    • Cardiac Issues: Heart failure, congenital heart defects.

    • Other Factors: Anemia, high altitude, certain medications, hypoventilation.

  • Symptoms:

    • Shortness of breath (dyspnea)

    • Rapid breathing (tachypnea)

    • Increased heart rate (tachycardia)

    • Confusion or altered mental status

    • Cyanosis (bluish discoloration of skin, lips, and nail beds)

    • Restlessness

    • Headaches

  • Diagnosis:

    • Arterial Blood Gas (ABG) Analysis: Measures oxygen (PaO2) and carbon dioxide (PaCO2) levels in arterial blood.

    • Pulse Oximetry: Non-invasive method to estimate oxygen saturation (SpO2), but less accurate than ABG.

  • Treatment:

    • Supplemental Oxygen: Administered via nasal cannula, face mask, non-rebreather mask, or mechanical ventilation.

    • Address Underlying Cause: Treat the primary condition causing hypoxemia (e.g., antibiotics for pneumonia, bronchodilators for asthma).

    • Supportive Care: Positioning and comforting measures can enhance ventilation and improve oxygenation. This includes elevating the head to promote diaphragmatic movement and reduce the work of breathing.

• Hypoxia: Decreased tissue oxygenation resulting from inadequate oxygen delivery or utilization at the cellular level.

  Causes:

  • Hypoxemia: Low oxygen levels in the blood.

  • Ischemia: Reduced blood flow to tissues.

  • Anemia: Decreased oxygen-carrying capacity of the blood due to low hemoglobin levels.

  • Histotoxic Hypoxia: Cells unable to use oxygen effectively (e.g., cyanide poisoning).

  Symptoms:

  • Shortness of breath (dyspnea)

  • Rapid heart rate (tachycardia)

  • Increased breathing rate (tachypnea)

  • Confusion, disorientation, or altered mental status

  • Restlessness or anxiety

  • Cyanosis (bluish discoloration of skin, lips, and nail beds)

  • Headache

  • Fatigue or weakness

  Diagnosis:

  • Arterial Blood Gas (ABG) Analysis: Measures PaO2, PaCO2, pH, and oxygen saturation to assess oxygenation and ventilation.

  • Pulse Oximetry: Non-invasive measurement of oxygen saturation (SpO2).

  • Imaging Studies: Chest X-rays, CT scans, or MRIs to identify underlying pulmonary or cardiovascular conditions.

  Treatment:

  • Supplemental Oxygen: Administered via nasal cannula, face mask, non-rebreather mask, or mechanical ventilation.

  • Treat Underlying Cause: Address the primary condition causing hypoxia (e.g., antibiotics for pneumonia, bronchodilators for asthma).

  • Supportive Care: Positioning (e.g., elevating head), ensuring adequate ventilation, and providing rest.

• Mediastinal Shift: Shift of central thoracic structures to one side.

  • Can be caused by various conditions such as:

    • Tension pneumothorax: Accumulation of air in the pleural space, causing increased pressure.

    • Pleural effusion: Accumulation of fluid in the pleural space.

    • Hemothorax: Accumulation of blood in the pleural space.

    • Tumors: Masses in the chest that can displace mediastinal structures.

    • Diaphragmatic hernia: Displacement of abdominal organs into the chest.

  Symptoms include:

  • Partial or complete collapse of the lung

  • Pain on the affected side that is worse at the end of inhalation and the end of exhalation

  • Rapid heart rate

  • Rapid, shallow respirations

  • A feeling of air hunger

  • Prominence of the affected side that does not move in and out with respiratory effort

  • Trachea slanted more to the unaffected side instead of being in the center of the neck

  • New onset of nagging cough

  • Cyanosis

  • A mediastinal shift can lead to:

    • Compression of major blood vessels: Such as the vena cava, leading to decreased cardiac output and hypotension.

    • Compression of the trachea or esophagus: Causing difficulty breathing or swallowing.

    • Cardiac tamponade: Compression of the heart, impairing its ability to pump blood effectively.

    • Lung collapse: Further compromising respiratory function.

  Diagnosis:

  • Chest X-ray: To visualize the shift of mediastinal structures.

  • CT scan: Provides more detailed imaging of the chest and mediastinum.

  • Physical examination: Assessment of symptoms and clinical signs.

  Treatment:

  • Addressing the underlying cause: Such as draining pleural effusions, evacuating pneumothorax, or treating tumors.

  • Supportive care: Including oxygen therapy, mechanical ventilation, and monitoring of vital signs.

  • Surgical intervention: Maybe required in cases of severe obstruction, lung resection for tumors, or fixing structural abnormalities to restore normal function.

Orthopnea: Shortness of breath when lying down, relieved by sitting up.

Patients with orthopnea often use multiple pillows to prop themselves up or sleep in a recliner to alleviate the sensation of breathlessness.

Causes of Orthopnea:

• Heart Failure: Weakened heart muscle leads to fluid buildup in the lungs when lying down. This increases pulmonary venous pressure, causing pulmonary congestion and edema. Impaired left ventricular function is a common underlying issue.

• Pulmonary Edema: Excess fluid in the lungs impairs gas exchange. Fluid accumulates in the alveoli and interstitial spaces, reducing lung compliance and increasing the work of breathing.

• COPD (Chronic Obstructive Pulmonary Disease): Increased airway resistance and air trapping worsen when supine. Lying down can cause further compression of the airways, leading to increased dyspnea.

• Asthma: Bronchoconstriction and inflammation exacerbate breathing difficulties when lying flat. Supine positioning can promote mucus accumulation and airway narrowing.

• Obesity: Excess weight can compress the diaphragm and reduce lung capacity when lying down, contributing to orthopnea.

Bilateral Diaphragmatic Paralysis: Weakness or paralysis of the diaphragm muscles can impair the ability to breathe effectively when supine.

Assessment:

• Detailed History: Inquire about the number of pillows used and the severity of breathlessness when supine. Use a scale to quantify the severity of orthopnea and its impact on daily activities.

• Physical Examination: Observe respiratory rate, effort, and auscultate for adventitious breath sounds such as rales or wheezes. Assess for signs of fluid overload, such as edema and jugular venous distension.

• Diagnostic Tests: Chest X-rays can reveal pulmonary congestion or other abnormalities. Arterial blood gas (ABG) analysis helps evaluate oxygenation and acid-base balance. Pulmonary function tests (PFTs) can assess lung function and airflow limitation.

Nursing Interventions:

• Elevate Head of Bed: Use pillows or adjust the bed to a semi-Fowler's (30-45 degrees) or high-Fowler's (60-90 degrees) position. This helps reduce pulmonary congestion and improve diaphragmatic excursion.

• Administer Oxygen: Provide supplemental oxygen as prescribed to maintain adequate oxygen saturation (SpO2) levels, typically above 90%.

• Medication Management: Administer diuretics for heart failure to reduce fluid volume overload. Administer bronchodilators for COPD and asthma to relieve airway obstruction and improve airflow. Ensure timely administration and monitor for side effects.

• Pulmonary Hygiene: Encourage deep breathing and coughing exercises to mobilize secretions. Assist with postural drainage and chest physiotherapy as needed.

• Fluid Management: Monitor fluid intake and output. Restrict fluid intake as prescribed to reduce fluid volume overload in patients with heart failure.

Patient Education:

• Teach proper positioning techniques for sleep and rest. Educate on the importance of adhering to prescribed medications and potential side effects.

• Provide strategies for managing underlying respiratory or cardiac conditions. Instruct on recognizing and responding to worsening symptoms.

• Lifestyle Modifications: Encourage weight loss for obese patients to reduce pressure on the diaphragm. Advise patients with COPD to avoid lying flat after meals and to use pursed-lip breathing techniques to improve ventilation.

Complications:

• Hypoxia: Inadequate oxygenation due to impaired gas exchange, leading to tissue hypoxia and organ dysfunction.

• Sleep Disturbances: Disrupted sleep due to breathlessness, leading to daytime fatigue and impaired quality of life.

• Decline in Functional Status: Reduced ability to perform activities of daily living due to dyspnea and fatigue, leading to decreased independence and quality of life.

• Anxiety and Depression: Chronic breathlessness can lead to anxiety, depression, and reduced psychological well-being.

• Medication Adherence: Non-adherence to prescribed medications can worsen underlying conditions and exacerbate orthopnea.

• Pulmonary Hypertension: Chronic hypoxemia can lead to pulmonary hypertension, increasing the risk of right heart failure.

• Pack-Years: Packs per day multiplied by years smoked.

  Calculating pack-years helps determine a patient's risk for smoking-related diseases, such as lung cancer, COPD, and cardiovascular disease. It provides a standardized measure of cumulative tobacco exposure. A higher pack-year history indicates a greater risk. For example, a patient who has smoked one pack of cigarettes per day for 20 years has a 20 pack-year history, as does a patient who has smoked two packs a day for 10 years.

  Assessment:

  • Current Smoking Status: Determine if the patient is a current smoker, former smoker, or has never smoked.

  • Smoking History: Obtain a detailed smoking history, including the age of smoking initiation, duration of smoking, number of cigarettes smoked per day, and any periods of cessation.

  • Pack-Years Calculation: Calculate the pack-year history using the formula: (number of packs smoked per day) x (number of years smoked).

• Perfusion: Arterial blood flow through tissues (peripheral) and blood pumped by the heart (central).

  Types of Perfusion

  1. Central Perfusion:

     • Involves blood pumped by the heart to major organs.

     • A healthy heart function is essential for central perfusion, requiring adequate cardiac output and blood pressure.

  2. Peripheral Perfusion:

     • Involves blood flow to tissues and organs, ensuring oxygen and nutrients reach the cells.

     • Peripheral perfusion relies on healthy blood vessels and adequate blood volume.

  Factors Affecting Perfusion

  1. Cardiac Output:

     • Heart rate and stroke volume determine cardiac output.

     • Conditions affecting heart rate (e.g., arrhythmias) or stroke volume (e.g., heart failure) can impair perfusion.

  2. Blood Pressure:

     • Adequate blood pressure is necessary to maintain perfusion pressure.

     • Hypotension can reduce blood flow to tissues, leading to ischemia and organ damage.

  3. Blood Volume:

     • Adequate blood volume is required for effective perfusion.

     • Hypovolemia (e.g., due to dehydration or hemorrhage) can decrease blood flow to end organs.

  4. Vascular Resistance:

     • Vasoconstriction and vasodilation affect blood flow to tissues.

     • Peripheral vascular disease can impair blood flow, leading to ischemia and necrosis.

  5. Oxygenation:

     • Adequate oxygen-carrying capacity of the blood is essential for tissue perfusion.

     • Anemia and hypoxemia can impair oxygen delivery to tissues.

  Assessment of Perfusion

  1. Central Perfusion:

     • Assess heart rate, blood pressure, and cardiac output.

     • Evaluate for signs of heart failure, such as edema, dyspnea, and jugular venous distension.

  2. Peripheral Perfusion:

     • Assess skin color, temperature, and capillary refill.

     • Evaluate peripheral pulses for strength and symmetry.

     • Check for signs of ischemia, such as pain, pallor, and pulselessness.

  Conditions Affecting Perfusion

  1. Cardiovascular Disease:

     • Atherosclerosis, coronary artery disease, and heart failure can impair perfusion.

  2. Peripheral Artery Disease (PAD):

     • PAD reduces blood flow to the extremities, leading to claudication and limb ischemia.

  3. Shock:

     • Hypovolemic, cardiogenic, and distributive shock can compromise perfusion.

  4. Thrombosis and Embolism:

     • Thrombi and emboli can obstruct blood flow, leading to ischemia and infarction.

  Interventions to Improve Perfusion

  1. Medications:

     • Vasopressors and inotropes can improve blood pressure and cardiac output.

     • Anticoagulants and antiplatelet agents can prevent thrombosis and embolism.

  2. Fluid Management:

     • Intravenous fluids can restore blood volume in hypovolemic patients.

  3. Oxygen Therapy:

     • Supplemental oxygen can improve oxygen delivery to tissues.

  4. Surgical Interventions:

     • Angioplasty, bypass surgery, and embolectomy can restore blood flow in occluded vessels.

  Nursing Implications

  1. Monitoring: Continuously assess vital signs, peripheral pulses, and signs of ischemia.

  2. Positioning: Elevate extremities to improve venous return and reduce edema.

  3. Education: Instruct patients on risk factors for impaired perfusion and lifestyle modifications to improve vascular health.

  4. Medication Management: Administer prescribed medications to improve circulation and manage underlying conditions, and ensure adherence to the medication regimen by providing clear instructions.

  5. Referral: Consider referring patients to specialists as needed, such as cardiologists or vascular surgeons, for further evaluation and management of complex cases. Follow-up: Schedule regular check-ups to monitor patients' progress and adjust treatment plans as necessary, ensuring ongoing support and education about maintaining respiratory and circulatory health.

• Respiratory Diffusion: Movement of gases across alveolar and capillary membranes.

• Surfactant: Fatty protein lining alveoli, reducing surface tension.

• Thoracentesis: Needle aspiration of pleural fluid or air. Thoracentesis is the needle aspiration of pleural fluid or air from the pleural space for diagnostic or therapeutic purposes. It is often performed at the bedside by a nurse practitioner or a physician, although CT or ultrasound may be used to guide it. The person performing the procedure and any assistants wear goggles and masks to prevent accidental eye or oral splash exposure to the pleural fluid. After the skin is prepped, a local anesthetic is injected into the selected site to relieve blood vessel or lung compression and the respiratory distress caused by cancer, empyema, pleurisy, or tuberculosis. A maximum of 1000 ml is typically removed at any given time to prevent pulmonary edema. The patient is positioned to widen the spaces between the ribs. Post-procedure, a chest x-ray is performed to rule out mediastinal shift. Complications can include reaccumulation of fluid in the pleural space, subcutaneous emphysema, infection, and tension pneumothorax. Symptoms of complications include partial or complete lung collapse, pain on the affected side (worse at the end of inhalation and exhalation), rapid heart rate, rapid and shallow respirations, air hunger, prominence on the affected side, tracheal deviation, new cough, and cyanosis.

  Risks:

• Pleural Effusion: An abnormal accumulation of fluid in the pleural space, which may lead to respiratory distress.

• Reaccumulation of Fluid: The reappearance of fluid in the pleural space after initial removal, necessitating further intervention.

• Infection: Can occur at the site of the procedure or within the pleural cavity, increasing the risk of sepsis.

• Tension Pneumothorax: A life-threatening condition where air becomes trapped in the pleural space, causing increased intrathoracic pressure and compromising cardiopulmonary function.

• Pulmonary Edema: A condition characterized by excess fluid in the lungs, which may lead to respiratory distress and requires prompt medical attention.

• Ventilation: Movement of air into lungs and carbon dioxide removal.

Priority and Interrelated Concepts

• Priority Concept: Gas Exchange

• Interrelated Concept: Perfusion

Anatomy and Physiology Review

• Respiratory system includes upper airways, lungs, lower airways, and alveolar air sacs.

• Gas exchange: Oxygen transport to the cells and carbon dioxide transport away from cells through ventilation and diffusion.

• Ventilation: Movement of atmospheric air higher in oxygen into the lungs and removal of the carbon dioxide produced during metabolism

• Respiratory diffusion: Movement of gases down their concentration gradients across the alveolar and capillary membranes.

• Perfusion: Arterial blood flow through the tissues (peripheral perfusion) and blood that is pumped by the heart (central perfusion).

Upper Respiratory Tract

• Includes nose, sinuses, pharynx, and larynx; influences speech and smell.

Nose and Sinuses

• The nose is the organ of smell, with receptors from cranial nerve I (olfactory) located in the upper areas.

• Nasal septum divides the nose into two cavities lined with mucous membranes and rich blood supply.

• Anterior nares are external openings, posterior nares connect to the throat.

• Turbinates increase surface area for filtering, warming, and humidifying air.

• Paranasal sinuses (frontal, ethmoid, maxillary, sphenoid) give resonance to speech, decrease skull weight, and act as shock absorbers.

Pharynx

• Passageway for respiratory and digestive tracts, divided into nasopharynx, oropharynx, and laryngopharynx.

• Nasopharynx: Contains adenoids and eustachian tube openings, traps organisms, and equalizes middle ear pressure.

• Oropharynx: Used for breathing and swallowing, contains palatine tonsils for immune defense.

• Laryngopharynx: Divides into larynx and esophagus.

Larynx

• Voice box composed of cartilages (thyroid, cricoid).

• Cricothyroid membrane used for emergency access to lower airways (cricothyroidotomy).

• Contains false and true vocal cords; glottis is the opening between true vocal cords.

• Epiglottis prevents food from entering the trachea during swallowing.

Lower Respiratory Tract

• Includes trachea, bronchi, bronchioles, alveolar ducts, and alveoli.

• Tracheobronchial tree: branching tubes formed by muscle, cartilage, and elastic tissues. decrease in size as they progress down the airway, which allows movement of air/gases. Gas exchange occurs in the lung capillaries and alveoli.

• The trachea branches into the right and left mainstem bronchi at the carina junction and contains 6 to 10 C-shaped rings of cartilage.

• Right bronchus is wider, shorter, and more vertical, increasing risk of intubation or aspiration.

• Mainstem bronchi branch into lobar bronchi.

• Bronchioles branch into terminal and respiratory bronchioles without cartilage, relying on lung elasticity.

• Alveolar ducts and sacs contain alveoli for gas exchange. A pair of healthy adult lungs has about 290 million alveoli, which are surrounded by lung capillaries.

• Acinus is the structural unit, includes a respiratory bronchiole, an alveolar duct, and alveolar sacs.

• Type II pneumocytes secrete surfactant to reduce alveolar surface tension; lack of surfactant causes atelectasis.

Lungs

• Elastic, cone-shaped organs in the pleural cavity, composed of alveoli, ducts, bronchioles, and bronchi.

• Right lung has three lobes (upper, middle, lower); left lung has two lobes.

• Right lung handles 55-60% of lung function.

• Pleura: Continuous membrane enclosing lungs, with parietal (chest cavity lining) and visceral (lung covering) layers lubricated by fluid.

• Blood flow through bronchial (oxygenates lung tissues) and pulmonary (gas exchange) systems.

Accessory Muscles of Respiration

• Changes in chest cavity size and pressure facilitate breathing.

• Back and abdominal muscles aid when breathing work increases.

Respiratory Changes Associated With Aging

• Changes occur due to heredity and environmental pollutants.

• Respiratory disease is a major cause of illness and chronic disability in older patients.

• Respiratory function declines with age.

Age-Related Changes in the Respiratory System & Nursing Implications

• Decreased alveolar surface area and diffusion capacity require pulmonary hygiene.

• Decreased elastic recoil and dilated bronchioles necessitate upright positioning.

• Decreased cough ability and early airway closure need lung assessments.

• Increased residual volume mandates health maintenance.

• Decreased oxygen and carbon dioxide exchange efficiency requires monitoring for abnormal breathing.

• Decreased elasticity requires frequent oral hygiene.

• Muscle atrophy calls for face-to-face conversations.

• Vocal cords become slack. Laryngeal muscles lose elasticity and airways lose cartilage, requiring assessment of patient's level of consciousness and cognition because hypoxia from acute respiratory conditions can cause confusion.

• Increase in vascular resistance to blood flow through pulmonary vascular system requires subtle manifestations of hypoxia.

• Pulmonary capillary blood volume decreases, requiring increased rest periods.

• Risk for hypoxia increases and chest wall abnormalities are possible, leading to need for adequate calcium intake.

Health Promotion and Maintenance

• Lung problems are common causes of death in North America.

• Smoking, especially cigarette smoke, is the most common cause of chronic respiratory problems.

• Smoking increases the risk for cardiovascular disease, stroke, and many types of cancer.

• Assessing smoking habits, actively promoting smoking cessation, determining exposure to other inhalation irritants, and teaching adults to protect the respiratory system are important nursing functions.

Assessing Smoking Habits

• Determine if the patient is a current smoker or has ever smoked.

• Record smoking history in pack-years (number of packs smoked per day multiplied by years smoked).

• Assess exposure to others' smoke: secondhand (direct exposure) and thirdhand (indirect exposure from residue).

• Hookah smoking has risks as great as or greater than cigarette smoking.

• Electronic nicotine delivery systems (ENDS) or vaping have risks of burns and lung toxins.

Electronic Nicotine Delivery Systems (ENDS) and Vaping

• Alternatives to traditional cigarettes, sometimes used for quitting.

• Vape pens are larger devices with greater liquid volume.

• Lithium batteries can cause burns and traumatic injuries.

• Liquids and vapors contain nicotine, and flavorings have lung toxins.

• In 2019, CDC and FDA investigated e-cigarette or vaping product use-associated lung injury (EVALI).

• As of February 2020, 2807 cases of hospitalized e-cigarette, or vaping, product use-associated lung injury
  (EVALI) have been reported in the United States with 68 deaths. Higher risk of EVALI is associated with e-cigarettes that contain
  tetrahydrocannabinol (THC).

Promoting Smoking Cessation

• Use the 5 As model: Ask, Advise, Assess, Assist, Arrange.

5 A's Model

• Ask: Identify and document tobacco use.

• Advise: Urge every user to quit.

• Assess: Determine willingness to quit.

• Assist: Offer drug therapy or NRT, counseling, and support groups.

• Arrange: Follow-up contacts.
  *Nicotine replacement therapies (NRTs) (patches, gums, lozenges, nasal sprays, inhalers) are available OTC and by prescription to help with smoking cessation.

Nursing Safety Priority: Drug Alert

• Smoking while taking NRT drugs increases nicotine levels, raising the risk for stroke or heart attack.

Additional Drug Therapy

• Bupropion: Decreases cravings and withdrawal symptoms, and reduces depression from nicotine withdrawal.

• Varenicline: Interferes with nicotine receptors, reducing pleasure from nicotine and withdrawal symptoms.

Nursing Safety Priority: Drug Alert

• Bupropion has a black box warning for increased risk of suicidal thoughts; monitor and report any changes in behavior immediately.

Patient-Centered Care: Veteran Health

• Cigarette smoking is higher among military veterans.

• Assess the smoking status of all veterans and inform them of smoking-cessation assistance from the U.S. Department of Veterans Affairs

Assessing Particulate Matter Exposure

• Use the I PREPARE model.

I PREPARE Model

• I - Investigate all exposures to inhalation irritants.

• P - Present Work: Ask about exposure to industrial dusts, fumes, or chemicals that may cause breathing disorders.

• R - Residence: Ask about the type of heat used at home and whether other people in the same residence have similar breathing problems.

• E - Environment: Determine the geographic location of the residence and whether it is in an area with higher levels of air pollution.

• P - Past Work: Because chronic particulate matter exposure may take years to affect respiratory function, ask the patient about all previous types of work and work environments.

• A - Activities: Ask about hobbies in which the patient or other members of the household may engage, such as painting, ceramics, model airplanes, refinishing furniture, or woodworking, for possible exposure to harmful chemical fumes.

• R - Resources and Referrals: Provide patients with informative pamphlets and websites that can help them understand the risks for particulate matter exposure and what types of protection can be used.

• E - Educate: Determine the patient's literacy level and how the patient best acquires new information. Provide information and encourage the use of credible resources.

Patient-Centered Care: Gender Health

• Females have greater bronchial responsiveness (bronchial hyperreactivity) and larger airways than males which increases risk for decline in lung function.

Recognize Cues: Assessment

• Accurate patient information is important for identifying the type and severity of breathing problems that may interfere with gas exchange.

• Age, gender, and race can affect the physical and diagnostic findings related to breathing.

• Explore the home, community, and workplace for environmental factors that could cause or worsen lung disease.

Patient History

• Respiratory history, smoking history, drug use, travel, and area of residence.

• Document smoking history in pack-years.

• Drug use, both prescribed drugs and illicit drugs, can affect lung function, even when taken systemically.

• Allergies can affect breathing.

Nursing Safety Priority: Action Alert

• Document any known allergies, especially to drugs, and the specific type of allergic response experienced in a prominent place in the patient's medical record.

• Travel and geographic area of residence may reveal exposure to certain diseases.

Family History and Genetic Risk

• Family history of respiratory disorders with a genetic component, such as cystic fibrosis and emphysema.

Current Health Problems

• Cough, sputum production, chest pain, and shortness of breath.

• Cough: duration, time of day, relation to activity, sputum or dry.

• Sputum production: color, consistency, odor, amount (thin, thick, watery, frothy, mucoid).

• Chest pain: continuous or related to breathing, swallowing.

Quantification of Sputum Production

*Teaspoon, tablespoon, cup. Normally the lungs produce up to $90 mL$ of sputum per day.

Dyspnea

*Dyspnea (difficulty in breathing or breathlessness) is a subjective perception and varies among patients. Therefore, asking
about breathlessness and using a visual analog scale (Fig. 22.7)
to assess its severity may provide more accurate information
about changes from a patient's baseline ease of breathing.

*Use visual analog scale to assess severity.
*Quantify dyspnea by determining if it interferes with ADLs.
*Assess for orthopnea (shortness of breath when lying down, relieved by sitting up) and paroxysmal nocturnal dyspnea (PND).

Physical Assessment

Assessment of the Nose and Sinuses

• Inspect the patient's external nose for deformities and the nares for symmetry of size and shape.

• Observe the interior nose, inspect for color, swelling, drainage, bleeding, and polyps.

• Check the nasal septum for bleeding, perforation, or deviation.

• Block one naris at a time to check how well air moves through the unblocked side.

Assessment of the Pharynx, Trachea, and Larynx

• Use a tongue depressor to examine the posterior pharynx, observe the rise and fall of the soft palate and inspect for color and symmetry, drainage, edema or ulceration, and enlarged tonsils.

• Inspect the neck for symmetry, alignment, masses, swelling, bruises, and the use of accessory neck muscles in breathing.

• Palpate lymph nodes and the trachea for position, mobility, tenderness, and masses.

• The larynx is usually examined by a specialist with a laryngoscope. An abnormal voice, especially hoarseness, may be heard when there are problems of the larynx.

Assessment of the Lungs and Thorax

• Inspection: Observe chest movement, symmetry, shape (AP diameter vs. lateral), intercostal space, and retractions.

• Palpation: Assess chest expansion, abnormalities, tenderness, and crepitus (subcutaneous emphysema).
  *Fremitus is felt as a vibration of the chest wall produced when the patient speaks. Fremitus is decreased if sound wave transmission from the larynx to the chest wall is slowed as when the pleural space is filled with air (pneumothorax) or
  fluid (pleural effusion) or when the bronchus is obstructed. Fremitus is increased with pneumonia and lung abscesses
  because the increased density of the chest enhances vibration
  transmission

• Percussion: Assess for pulmonary resonance, organ boundaries, and diaphragmatic excursion.

• Auscultation: Listen for normal breath sounds (bronchial, bronchovesicular, vesicular) and abnormal (adventitious) sounds. Adventitious sounds are additional breath sounds along with
  normal sounds, and indicate pathologic changes in the lung.
  Adventitious sounds: crackle, wheeze,
  rhonchus, and pleural friction rub.

Other Indicators of Respiratory Adequacy

• Skin color, mucous membrane changes (cyanosis), and finger clubbing (long-term hypoxia).

• General appearance includes muscle development and general body build. Long-term respiratory problems results in weight
  loss and a loss of general muscle mass.

• Endurance decreases when breathing is inadequate for gas exchange.

Psychosocial Assessment

• Breathing difficulty often induces anxiety because of cerebral hypoxia or the sensation of not getting enough air is frightening.

• Chronic respiratory disease may cause changes in family roles or relationships, social isolation, financial problems, and unemployment or disability.

Diagnostic Assessment

Laboratory Assessment

• RBC count: Provides data about oxygen transport. Measures the number of red blood cells, which are essential for carrying oxygen throughout the body. Abnormalities in RBC count can indicate conditions affecting oxygen-carrying capacity, such as anemia (low RBC count) or polycythemia (high RBC count).

• ABG analysis: Assesses gas exchange and perfusion. Arterial Blood Gas analysis measures the levels of oxygen (PaO2) and carbon dioxide (PaCO2) in arterial blood, as well as pH and bicarbonate levels. This test provides crucial information about the efficiency of gas exchange in the lungs and the acid-base balance in the body. It helps in diagnosing respiratory and metabolic disorders.

• Sputum specimens: Identify organisms or abnormal cells. Sputum specimens can be analyzed to diagnose infections, such as pneumonia or tuberculosis, and to monitor treatment efficacy.

Imaging Assessment

• Chest x-rays: Evaluate chest status; assess lung pathology (pneumonia, atelectasis, pneumothorax, tumor).

• Sinus and facial x-rays: Assess fluid levels in sinus cavities.

• Computed tomography (CT): Assesses soft tissues. Ask about shellfish allergy to determine whether there was an increased risk or sensitivity to contrast to enhance visibility of tumors, blood vessels, and heart chambers.

  • If the patient takes metformin, the drug may be stopped 24 hours before contrast medium is used and is not restarted until adequate kidney func-tion is confirmed.

Other Noninvasive Diagnostic Assessments

• Pulse Oximetry

*Pulse oximetry is a noninvasive method
to identify hemoglobin saturation with oxygen. The pulse oximeter uses a wave of infrared light and a sensor placed on the patient's finger, toe, nose, earlobe, or forehead.

• Normal values are 95% to 100%.

• Factors causing low readings: patient movement, dark skin color, hypothermia, decreased peripheral blood flow, ambient light, decreased hemoglobin, edema, and fingernail polish.
  *Skin color can affect the reliability of pulse oximetry assessment and
  recent studies indicate that hypoxia went undetected more
  often in patients with darker skin.
  Actual values can be lower than detected.

• Results lower than 90% in an adult who does not have a chronic respiratory problem require immediate assessment and intervention.

Capnometry and Capnography

• Measure the amount of carbon dioxide present in exhaled air.

• Provide information about carbon dioxide production, pulmonary perfusion, alveolar ventilation, respiratory patterns, ventilator effectiveness, and possible rebreathing of exhaled air.

• A more sensitive indicator of gas exchange adequacy than pulse oximetry.
  *Normal value of the partial pressure of end-tidal car
  bon dioxide (PETCO 2) ranges from 35 to 45 mm Hg.

Pulmonary Function Tests (PFTs)

• Assess lung function and breathing problems.

• Measure lung volumes and capacities, flow rates, diffusion capacity, gas exchange, airway resistance, and distribution of ventilation.
  Indicates respiratory muscle strength and ventilatory reserve Reduced in
  obstructive and restrictive diseases
  Patient Preparation: Explain, advise NPO to cease smoking 6-8hrs before, bronchodilator drugs
  may be withheld for 4 to 6 hours before the test. Patients with breathing issues also likely suffer from anxiety so help educate them on how to reduce it
  *Procedure: breathing through the mouthOnly
  Post procedure : Assess the patient for increased dyspnea
  or bronchospasm after these studies. Document any drugs given
  during testing

Exercise Testing

• Assesses the patient's ability to work and perform ADLs, differentiates reasons for exercise limitation, evaluates disease influence on exercise capacity, and determines whether supplemental oxygen is needed during exercise.

Other Invasive Diagnostic Assessments

Endoscopic Examinations

• Bronchoscopy, laryngoscopy, and mediastinoscopy. Bronchoscopy is
  the insertion of a tube in the airways as far as the secondary bronchi to view airway structures and obtain tissue samples. It is used to diagnose and manage pulmonary
  diseases. Rigid bronchoscopy is more invasive and flexible is less invasive, allowing for a broader range of applications and patient comfort during the procedure.

• Bronchoscopy: A procedure that allows direct visualization of the airways and collection of tissue samples. This technique can help diagnose lung diseases, such as tumors or chronic infections, and assess the extent of respiratory conditions. It's primarily used for imaging and diagnostic purposes, though it can also be used for therapeutic interventions like tissue biopsies or collecting samples for lab analysis

• For bronchoscopy, patients must be NPO for 4-8 hours before procedure to reduce the risk for aspiration.
  Patient Identifiers Verify the patient's identity with two types of identifiers before a bronchoscopy.
  Post procedure :Ensure GAG reflex before feeding or drinking patient

Thoracentesis

*Thoracentesis is the needle aspiration of pleural fluid or air from the pleural space for diagnostic or management purposes.
Is often performed at the bedside by a nurse practitioner or a physician, although CT or ultrasound may be used to guide it. The person performing the procedure
and any assistants wear goggles and masks to prevent accidental
eye or oral splash exposure to the pleural fluid. After the skin is prepped, a local anesthetic is injected into the selected site to relieve blood vessel or lung compression and the respiratory
distress caused by cancer, empyema, pleurisy, or tuberculosis. 1000 ml max at any given time to prevent pulmonary edema
Posture to widen spaces between ribs
Post procedure chest x-ray is perofrmed to rule out mediastial shift.

Pleural Effusion

Reaccumulation of fluid in the pleural space, subcutaneous
emphysema, infection, and tension pneumothorax are the dangers of pleural effusion
Symptoms include:
Partial or complete collapse of the lung
Pain on the affected side that is worse at the end of inhalation
and the end of exhalation
Rapid heart rate
Rapid, shallow respirations.
A feeling of air hunger
Prominence of the affected side that does not move in and
out with respiratory effort
Trachea slanted more to the unaffected side instead of being
in the center of the neck
New onset of nagging cough
Cyanosis

Lung Biopsy

• Performed to obtain tissue for histologic analysis, culture, or cytologic examination.
  There are several types of lung
  biopsies. The site and extent of the lesion determine which
  one is used. Transbronchial biopsy (TBB) and transbronchial
  needle aspiration (TBNA) are performed during bronchoscopy.
  Transthoracic needle aspiration is performed through the
  skin (percutaneous) for areas that cannot be reached by
  bronchoscopy.
  Pneumothorax is a known complication. Also, monitor for
  hemoptysis (which may be scant and transient) or, in rare cases,
  for frank bleeding from vascular or lung trauma.

Assessment of the Patient Receiving Oxygen Therapy

Overview

• Oxygen (O2) is both an atmospheric gas and a drug. Oxygen therapy can be used in any health care setting and may be prescribed through the patient's primary health care
  provider without the patient's first having been hospitalized.

• Prescribed for hypoxemia and hypoxia from respiratory and cardiac problems, fever, sepsis, and anemia.
  Ideally, oxygen therapy uses the lowest fraction of inspired
  oxygen (Fio₂) to have an acceptable blood oxygen level with
  out causing harmful side effects. Although oxygen improves the
  PaO2 level, it does not cure the cause of the problem. Most patients
  with hypoxia require an oxygen flow of 2 to 4 L/min via nasal
  cannula or up to 40% via Venturi mask to achieve an oxygen
  saturation of at least 95%.

Oxygen Delivery Systems

• Classified as low-flow or high-flow systems.

• What type of delivery depends on:

  • Required oxygen concentration

  • Oxygen concentration that is achievable

  • Patient comfort

  • Humidity Use

Low-Flow Oxygen Delivery Systems include the regular nasal cannula, simple
face mask, partial rebreather mask, and nonrebreather mask
High-flow systems have a flow rate designed to supply
the total oxygen volume by adjusting the amount of room air
that is entrained within the delivery system. These systems are
used for critically ill patients and when delivery of precise levels
of oxygen is needed.

Nursing Considerations

• If the patient needs a mask but is able to eat, request an order for a nasal cannula to be used at mealtimes only.
  *To increase mobility, up to 50
  feet of connecting tubing can be used with connecting pieces,
  although long tubing can be a safety issue for patients who are
  unsteady while ambulating.

• These systems are easy to use but the amount of oxygen delivered varies based on patient flow and breathing.

Nasal Cannula:

• Prongs are used at 1 to 6 L/min. Oxygen concentrations of
  24% (at 1 L/min) to 44% (at 6 L/min) can be achieved. Flow
  rates greater than 6 L/min do not increase gas exchange because
  the anatomic dead space
  is full.

Face masks

*Simple Face Masks:
Can not be 5L/min - 8LMin for concentration between 40%-60% for short term and emergencies
Vents so it does NOT rebreathe carbon dioxide.
Partial rebreather masks provide oxygen concentrations of
60% to 75% with flow rates of 6 to 11 L/min. For best oxygen delivery, be sure that the bag
remains slightly inflated at the end of inspiration. If needed, call
the respiratory therapist for assistance.
*Must maintain reservoir bag up to 2/3rds full for proper installation

Non-Rebreather Mask:

• Masks delivery of oxygen at the highest level (but NOT THE MOST ACCURATE)
  *Has a one way valve to draw from the bag only and valves to
  Prevent from air getting in through exhalation ports. Check Hourly
  for safety
  *Rate is 10-15 L/min to keep bag inflated; Assess safety feature at least hourly

High-Flow Oxygen Delivery Systems

• Include the venturi mask, aerosol mask, face tent, and high-flow nasal cannula (HFNC).
  These deliver an accurate oxygen level when properly fitted, with oxygen concentrations from 24% to 100% at 8 to 15 L/min.
  HFNC:
  More flow at temperature
  Can be maintained at a precise rate -liter flows of 30 to
  60 L/min.
  HFNC: improves secretion and is better tolerated

Venturi masks (Ventimasks)

• Deliver the most accurate without intubation by pulling in room air depending on oxygen flow.
  *Has a dial to manipulate exact 02 level, has different flow for
  each adapter. Also can cause dry mucus membrane
  *High humidity with a nebulizer with a large water reservoir.

Noninvasive Positive-Pressure Ventilation. Can be 3 types

• CPAP, BiPAP, NPPV
  NPPV is used commonly for sleep apnea (see Chapter 23
  for a full discussion of sleep apnea and NPPV). The effect is to
  hold open the
  upper airways
  (Fig. 22.20). Patients using CPAP
  or BiPAP at home for sleep apnea often bring their home equip-
  ment to the hospital. They feel more comfortable using their
  own equipment. The reasons for using NPPV remain when
  the patient enters the hospital, and the need continues while
  hospitalized.

Hazards and Complications of Oxygen Therapy

• Combustion, oxygen toxicity, absorptive atelectasis, drying of mucous membranes, and infection.

Combustion

Oxygen enhances ignition however is flammable by itself. So fires burns better in its presence, but it does not burn or explode
Post an “oxygen in use” sign on
the door of the patient's room.
Ensure that all electrical equipment in rooms where oxygen
is in use are grounded (have three prongs) and are plugged into
grounded outlets to prevent fires from electrical arcing sparks.
Frayed cords are not used because they can spark and ignite a
flame. Flammable solutions (containing high concentrations of
alcohol or oil) are not used in rooms in which oxygen is in use.
(This restriction does not include alcohol-based hand rubs.)
Surgical fires are caused by cautary or lasers in the room
Improvements have been made by limiting the oxygen-rich
atmosphere (without causing hypoxia) and minimizing the
exposure to flammable pharmaceutical agents, such as large
volumes of alcohol-based skin preparation liquids.

Oxygen Toxicity

• Related to concentration, duration, and lung disease.

• Continuous levels greater than 50% for more than 24-48 hours can injure the lung.
  Symptoms start with dyspnea,
  nonproductive cough, chest pain beneath the sternum, GI
  upset, and crackles on auscultation. As exposure to high levels of oxygen continues, problems become more severe, with
  decreased vital capacity, decreased compliance, and hypoxemia.
  Continued exposure to high oxygen levels leads to atelectasis,
  pulmonary edema, hemorrhage, and hyaline membrane formation. Surviving oxygen toxicity depends on correcting the
  underlying disease process and decreasing the oxygen amount
  delivered

• Minimize the exposure to oxygen by not making it above $90 mm Hg$.

Absorptive Atelectasis

• High oxygen levels dilute nitrogen, oxygen diffuses from alveoli into blood, and alveoli collapse.

• Monitor for new onset of crackles and decreased breath sounds.
  *Nitrogen helps keeps the alveoli open- making 79% of room air

Drying of Mucous Membranes

*When the prescribed oxygen flow rate is higher than 4 L/min,
humidify the delivery system. Condensation tends to form more so be aware
For the patient to receive humidified oxygen, the humidifier or nebulizer must have enough sterile water, and the flow rate must be adequate. Condensation often forms in the
Ensure that oxygen bubbles through the water in the humidifier. A heated nebulizer raises the
humidity even more and is used for oxygen delivery through an artificial airway.

Infection

• Humidifier or nebulizer may be a source of bacteria and fungus.

Home Care Oxygen Therapy

• Medicare covers for sever hypoxemia (partial pressure of arterial oxygen less than $55 mm Hg$ or arterial oxygen saturation less than 88%.

• Oxygen can be tank or cylinder with compressed gas, liquid container, or oxygen concentrator.

• Patients should be educated on the proper use and maintenance of their oxygen delivery systems to avoid complications and ensure efficacy.