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Oxygenation, Ventilation, and Respiration:

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Airflow follows the path of least resistance. Alveolar deadspace. V/Q Ratio ... Graph of relationship between dissolved oxygen and hemoglobin bound oxygen ... – PowerPoint PPT presentation

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Title: Oxygenation, Ventilation, and Respiration:


1
Oxygenation, Ventilation, and Respiration
  • Management of clients with critical alterations
    in respiratory function
  • Carol Isaac MacKusick, MSN, RN, CNN
  • Nursing 2904
  • January 12 and January 24, 2006

2
A Brief Review
  • Review respiratory assessment from Nursing 2903
  • Review basic alterations in respiratory function
    from Nursing 2903
  • Lecture from Fall, 2005 on web site for reference
    if needed
  • Terminology list
  • Basic / advanced

3
Pharmacology
  • Should review and KNOW
  • Bronchodilators
  • Beta-adrenergic agonists
  • Anti-inflammatory agents
  • Glucorticoids
  • Mast cell stabilizers
  • Leukotriene modifiers
  • Common cold agents
  • Antitussives
  • Expectorants
  • Mucolytics

4
Pharmacology
  • Need to KNOW
  • Medications that might induce respiratory
    depression
  • Barbiturate
  • Benzodiazepines
  • Opioids
  • Surfactant agents
  • Anticoagulation agents
  • TB agents
  • Anti-infectives
  • Vasodilators

5
Physiology Review
  • Respiration
  • Process by which the bodys cells are supplied
    with oxygen and carbon dioxide is removed as
    waste
  • Ventilation
  • Mechanical movement of airflow to and from the
    atmosphere and the alveoli

6
Compliance
  • Ease with which the lungs are able to expand
  • Determined in terms of lung volume and pressure
  • CL DV (mL) / DP (cm H2O)
  • Small / large balloons aveloli
  • Normal CL 50-100mL V / 1 cm H2O P

7
Compliance
  • Decreased compliance stiff lungs
  • More P needed to increase V
  • Increases work of breathing
  • Decreases tidal volume
  • Things that affect
  • Surfactant
  • Reduction
  • Pulmonary problems
  • Restrictive disorders
  • External / Internal

8
Diffusion
  • Movement high to low
  • Four factors that affect alveolar diffusion
  • Gradient
  • Surface area
  • Thickness
  • Length of Exposure

9
Ventilation (V) Perfusion (Q) Relationship
  • Ratio of alveolar ventilation to pulmonary
    capillary perfusion
  • Normal V/Q ratio 0.8
  • Pulmonary capillary perfusion is gravity
    dependent
  • Intrapulmonary shunting
  • Airflow follows the path of least resistance
  • Alveolar deadspace

10
V/Q Ratio
  • V/Q ratio gt 0.8 is dead space producing
  • Decreased cardiac output, PE, pneumothorax
  • V/Q ratio lt 0.8 is shunt producing
  • Hypoventilation, obstructive and restrictive lung
    dxs
  • With V/Q mismatch
  • PAO2 and O2 saturation decrease
  • Think positioning!!

11
Shunting
  • Pulmonary shunting major cause of hypoxemia
  • Physiologic shunt No alveolar-capillary
    diffusion taking place
  • Normal ranges from 2-5 of cardiac output
  • gt 15 respiratory failure

12
Oxyhemoglobin Dissociation Curve
  • Handout for further information
  • Graph of relationship between dissolved oxygen
    and hemoglobin bound oxygen
  • Initial part of curve steep but flattens at the
    top
  • Flat portion represents binding of oxygen to
    hemoglobin in the lungs

13
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14
Oxyhemoglobin Dissociation Curve
  • Shifting
  • Hemoglobin has a steady and predictable affinity
    for oxygen
  • Shifts in position mean that there is a change in
    the way oxygen is taken up by the hemoglobin
    molecule at the alveolar level as well as a
    change in the way oxygen is delivered at the
    tissue level

15
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16
Assessment
  • Review and know N2903 assessment information
  • Know Urden, 214-217
  • Review PFTs and implications
  • Urden, 217-224
  • SB, 482-490
  • Review and know respiratory / acid base
    calculations
  • Handouts for review
  • To be covered in seminar in detail

17
Restrictive Pulmonary Disorders
  • Problems with inflow of air
  • Decreased lung compliance -gt decreased lung
    expansion
  • Problem with volume not airflow
  • Total lung capacity is decreased
  • Includes
  • External
  • Obesity, chest burns, flail chest, NM dx
  • Internal
  • Pneumonia, atelectasis, CHF, pulm edema,
    fibrosis, tumors, pneumothorax

18
Restrictive Assessment
  • Common signs and symptoms
  • Increased respiratory rate
  • Decreased tidal volume
  • Normal to decreased PaO2
  • SOB
  • Cough
  • CP or discomfort
  • Fatigue
  • Weight loss

19
Obstructive Pulmonary Disorders
  • COPD
  • Air able to flow into lungs but becomes trapped,
    making it difficult to rid the lungs of inspired
    air
  • Increased expiration time so lungs may never be
    empty before time to inhale again
  • Frequently associated with increased lung
    compliance accompanied by loss of lung recoil

20
COPD
  • Chronic bronchitis V/Q ratio decreased
  • Emphysema V/Q ratio R/T both ventilation and
    perfusion are equally destroyed

21
Obstructive Assessment
  • Common signs and symptoms
  • Mucus
  • Wheezes, rhonchi
  • Dyspnea
  • Diminished breath / heart sounds
  • Barrel chest
  • Hypercapnia / respiratory acidosis
  • Hypoxemia
  • Cor pulmonale
  • Accessory muscle use
  • E gt I
  • nL to increased TLC
  • Increased FRC
  • Decreased FEV and VC

22
Cor Pulmonale
  • Seen with both restrictive / obstructive dx
  • Right ventricular hypertrophy and dilation
    secondary to pulmonary disease
  • Can cause right heart failure and is major cause
    of death in COPD clients
  • Elevated PVR

23
Chronic vs. Acute Respiratory Failure
  • Chronic Respiratory Insufficiency
  • Acceptable level of gas exchange is maintained
    only through cardiopulmonary compensatory
    mechanisms
  • Slow onset, progressive in nature
  • Can lead relatively normal life
  • Always has some degree of hypoxemia
  • ABGs Normal pH, high PaCO2, high HCO3
  • Always in state of impending respiratory failure

24
Acute Respiratory Failure
  • One of most common problems seen in critical care
  • Life-threatening
  • PaO2 lt 60 mmHg
  • SaO2 lt 90
  • PaCO2 gt 50 mmHg
  • pH lt 7.30
  • Always hypoxic
  • Can be ventilatory, oxygenation, or both

25
Ventilatory Failure
  • V inadequate Q normal
  • Complications
  • MODS, ARDS, Acute Tubular Necrosis
  • Clinical Criteria
  • PaCO2 gt 50, pH lt 7.30
  • Course ? PaO2 ? ?RR ? ? PaO2 ?PaCO2

26
Oxygenation Failure
  • V normal Q decreased
  • PaO2 lt 60 mmHg
  • CO2 able to diffuse
  • Right to left shunt occurs
  • Caused from
  • ARDS, pulmonary embolus, acute asthma attack,
    pneumonia
  • When fatigue occurs, ventilatory failure also
    occurs

27
Combination Failure
  • Course
  • ? RR also leads to ? metabolic rate ? ? O2
    consumption by tissues ? ? CO2 produced ?
    progression of ? CO2 and ? O2
  • If condition that causes ARF not managed
    adequately, level of respiratory failure worsens,
    increased work of breathing results, and
    respiratory muscle fatigue develops

28
Acute Respiratory Failure
  • Nursing Diagnoses
  • Impaired Gas Exchange
  • Ineffective Breathing Pattern
  • Risk for Aspiration
  • Imbalanced Nutrition
  • Anxiety
  • Deficient Knowledge

29
Acute Respiratory Failure
  • Medical Management
  • Treat underlying cause
  • Increase oxygenation
  • Increase ventilation
  • Facilitate removal of secretions and dilate
    airways
  • May need neuromuscular paralytics

30
Acute Respiratory Failure
  • Medical Management
  • Correct acidosis
  • Nutritional support
  • Malnutrition decreases ventilatory drive and
    muscle strength
  • Overfeeding increases CO2 production
  • Nutritional support initiated before 3rd day of
    mechanical ventilation for well-nourished within
    24 hours for malnourished

31
Acute Respiratory Failure
  • Nursing Interventions
  • Positioning
  • Prevent desaturation
  • Rest and controlled activity
  • Sedation to control anxiety
  • Control fever
  • Continuous pulse oximetry
  • Promote secretion clearance
  • Monitor intake / output

32
Acute Respiratory Failure
  • Nursing Interventions
  • Client / Family Teaching
  • Pathophysiology of disease and specific etiology
  • Precipitating factor modification
  • Importance of taking medications
  • Breathing techniques
  • Measures to prevent infection
  • SS of infection
  • Cough enhancement techniques

33
Acute Respiratory Distress Syndrome (ARDS)
  • Distinct type of acute lung injury that leads to
    severe respiratory failure
  • Diffuse inflammatory injury to alveolar-capillary
    membrane ? noncardiogenic pulmonary edema
  • PaO2/FIO2 ratio lt 200 mmHg normal is gt350

34
ARDS
  • Precipitated by direct or indirect injury
  • Presentation
  • Onset occurs rapidly except in chronic disease
    where onset more insidious
  • Early Increased resp. distress that progresses,
    CXR initially clear acute respiratory alkalosis
    from hyperventilation absent or mild hypoxemia

35
ARDS
  • Progression of Presentation
  • Cyanosis and accessory muscle use cough and
    expectoration typical of pulmonary edema ABGs
    Increased hypoxemia refractory to increasing
    concentrations of oxygen PFTs consistent with
    restrictive lung disease bilateral infiltrates
    on CXR
  • PaO2 lt 55 FIO2 gt 50

36
ARDS
  • Mortality rate ranges from 50-85 highest with
    sepsis
  • Survivors have slow lung repair that terminates
    at 6 months following onset 50 have no
    significant permanent damage

37
ARDS
  • Nursing Diagnoses
  • Impaired gas exchange
  • Fatigue
  • Imbalanced nutrition
  • Risk for injury, aspiration and / or infection
  • Anxiety
  • Compromised family coping
  • Disturbed sleep patterns

38
ARDS
  • Interventions
  • O2 at lowest level to support tissue oxygenation
  • Position important
  • PEEP or CPAP
  • Assess lung sounds q hour
  • Tension pneumothorax
  • Sedation / paralysis
  • Ventilation
  • Permissive hypercapnia Pressure control Inverse
    Ratio

39
ARDS
  • Interventions
  • Tissue Perfusion
  • Investigational
  • Extracorporal/Intracorporal Gas Exchange (ECMO)
    is last resort
  • Surfactant Therapy
  • Partial liquid ventilation
  • Inhaled nitric oxide

40
ARDS
  • Nursing Management
  • Prone positioning when possible
  • Improve oxygenation
  • Administer high FIO2
  • Non-rebreather or CPAP
  • Mechanical ventilation if severe hypoxemia or CV
    instability
  • PEEP
  • Muscle relaxation sedation

41
ARDS
  • Nursing Management
  • Improve oxygenation
  • Decrease oxygen consumption
  • Improve oxygen carrying capacity transfusion
  • Minimize airway suctioning avoid oxygen
    desaturation
  • Reduce anxiety
  • Achieve effective communication

42
ARDS
  • Prevention of Complications
  • At higher risk of developing nosocomial pneumonia
  • Ventilator dependent for weeks - months
  • Additional
  • Barotrauma
  • Pulmonary embolism
  • GI bleeding
  • Electrolyte disturbances
  • Maintain adequate nutrition
  • Monitor I/O

43
Pulmonary Emboli (PE)
  • Clot or other matter lodges in pulmonary arterial
    system, disrupting the blood flow to a region of
    the lungs
  • Majority from DVT
  • Virchows triad Hypercoagulation, injury to
    vascular endothelium, and venous stasis (most
    significant)

44
Pulmonary Emboli
  • Presentation
  • Increased dead space Area of lung receiving
    ventilation without being perfused ? work of
    breathing
  • Localized bronchoconstriction to promote
    redistribution of ventilation to perfused areas
    of lungs ? atelectasis

45
Pulmonary Emboli
  • Presentation
  • Compensatory shunting ? hypoxemia
  • Hemodynamic consequences
  • Pulmonary hypertension ?? workload of R ventricle
    ? R ventricular failure ? ? L preload ? ? CO ? ?
    BP and shock
  • Common presenting symptoms Dyspnea, pleuritic
    pain, cough

46
Pulmonary Emboli
  • Presentation
  • Common physical signs Tachypnea, crackles,
    tachycardia, decreased breath sounds over
    affected areas, friction rub. S3 / S4, cough
  • Massive PE
  • Cyanosis, restlessness, anxiety, confusion,
    hypotension, cool, clammy skin, decreased UO
  • Submassive Pleuritic chest pain, hemoptysis
  • Most have decreased SaO2

47
Pulmonary Emboli
  • Labs
  • ABGs Hypoxemia, respiratory alkalosis
  • EKG Sinus tachycardia, T-wave inversion (v1-V4)
  • CXR will vary from normal to abnormal little
    value in confirming PE
  • Confirmation of high-probability V/Q scan,
    positive pulmonary angiogram, or strong suspicion
    with abnormal findings on DVT studies

48
Pulmonary Emboli
  • Medical Management
  • Prevention is key!
  • Treatment
  • Prevent recurrence
  • Heparin and coumadin
  • Stop Heparin with INR 3.0 and continue coumadin
  • Heparin to maintain PTT 1.5-2.5 X control
  • Continue coumadin 3-6 months unless recurrent
    venous thrombosis, then 6-12 months

49
Pulmonary Emboli
  • Medical Management
  • Greenfield filter into vena cava when
    anticoagulation contraindicated
  • Treat current PE
  • Thrombolytic agents have limited success and
    reserved for massive PE and hemodynamic
    instability
  • Reverse hemodynamic effects
  • Inotropic agents
  • IV Fluids

50
Pulmonary Emboli
  • Nursing Management
  • Prevention major focus
  • Optimize oxygenation and ventilation
  • Monitor for bleeding
  • Client education
  • Decrease anxiety
  • Family support
  • Review nursing diagnosis from N2903!

51
Severe Acute Respiratory Syndrome (SARS)
  • First identified China 11/02
  • Mortality rate 8-10
  • Higher in lower SEC
  • Pathophysiology
  • New virus from coronaviruses
  • RNA as genetic material
  • Coronaviruses cause many common colds
  • SARS mutated from common cold

52
SARS
  • Lives in respiratory passages
  • Develops at temperature slightly below core body
    temp
  • Easily spread via airborne droplets
  • Detail to isolation precautions must be taken
  • Survival on non living objects short
  • Those at greatest risk are individuals in close
    contact w/ infected persons
  • Portal of entry is mucous membranes, eyes, nose,
    throat

53
SARS
  • Assessment / Clinical Manifestation
  • Mimics other respiratory infections
  • Fever gt 100.4 F
  • Headache
  • General body aches
  • Malaise
  • Mild cold symptoms
  • Runny nose, sore throat, watery eyes

54
SARS
  • Assessment
  • Within 2-7 days
  • Dry cough
  • Difficulty breathing
  • Hypoxia
  • Cyanosis
  • Low O2 saturation
  • Feelings of breathlessness / air hunger
  • CXR similar to pneumonia / RDS

55
SARS
  • Diagnosis
  • Made by r/o other infections
  • No rapid test exists at present time
  • At day 28
  • Serum shows positive presence of RNA of SARS
  • Client generally well or deceased by this time
  • Currently, no known SARS cases in the world
  • http//www.cdc.gov/ncidod/sars/situation.htm
  • Last cases April, 2004

56
SARS
  • Interventions
  • No known effective treatment at this time
  • Standard AB therapy or antiviral therapy not
    effective
  • Should focus on strength and energy conservation
  • Improve overall well being of client and clients
    immune system

57
SARS
  • Interventions
  • Oxygen therapy if hypoxia develops
  • If gas exchange not improved, intubation and
    mechanical ventilation may be required
  • Respiratory therapy to aid in mucous secretion
    movement may be beneficial and promote comfort
  • Bacterial pneumonia may occur and should be
    treated
  • Sputum cultures may be necessary

58
SARS
  • Interventions
  • Education of client and family
  • Relieve anxiety
  • Promote comfort
  • Position as appropriate
  • Prevention is key!
  • Handwashing
  • Strict airborne isolation
  • Particulate masks should be worn
  • N-99 / N-95 /N-100 (used w/ TB)
  • Strict contact precautions
  • Use eye shields / gowns / gloves

59
SARS
  • Interventions
  • Client should wear mask if outside isolation
    environment
  • Evaluation
  • Client / family return to normal functioning
    state
  • Anxiety decreased
  • Air exchange appropriate

60
Aspiration Pneumonia
  • Review N2903 notes r/t aspiration pneumonia
  • Interventions
  • Establish airway
  • Minimize pulmonary damage
  • Right side slight Trendelenburg
  • Bronchoscope
  • To remove large particulate
  • To confirm unwitnessed aspiration

61
Aspiration Pneumonia
  • Interventions
  • Support / optimize ventilation / oxygenation
  • Monitor volume status
  • Dont forget to record IO
  • Appropriate positioning
  • Identify patients at risk
  • Institute safety measures

62
Status Asthmaticus
  • Review N2903 notes!
  • Know ABG changes
  • Hypocapnea and respiratory alkalosis at onset
  • Developing / progressing to respiratory and
    metabolic acidosis
  • Classic deterioration in PFTs seen
  • Monitor closely / maintain calm, secure
    environment
  • Ventilator support may be needed in deteriorating
    conditions

63
Pleurisy
  • Ineffective breathing pattern r/t pain
  • Review N2903 notes!
  • Offer pain medication / alternative pain therapy
    as needed
  • Teach splinting techniques
  • Treat underlying cause
  • Monitor for pleural effusion!

64
Respiratory Syncytial Virus
  • Updated information can be found at
  • http//www.rsvinfo.com/sequelae/sequelae.html
  • Generally seen with newborns
  • Premature infants at greatest risk
  • Most children develop dx by age three
  • Can cause RDS in children
  • Antiviral therapy may be indicated

65
RSV
  • Can play a major role in development of COPD /
    asthma in children
  • Severe implications in those immunocompromised
    children
  • Upper and lower respiratory tracts infected
  • Lower most common sight
  • Nursing / medical interventions dependent upon
    severity
  • Family support / education important

66
Whats Next?
  • Class on 1/25
  • Ventilator management
  • Nursing interventions r/t ventilator dependent
    clients
  • Seminar on 1/27
  • ABG review
  • Compensated acidosis / alkalosis
  • Worksheet for practice problems
  • Exam 2/7

67
Questions?
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