Respiratory

1

• Respiratory

Fiona Chatfield, RN, MSN, MBA, CCRN
2
Functions of the Respiratory System

• Gas Exchange
• O2 in
• CO2 out
• Regulation of Acid-Base balance
• Metabolism of Compounds
• Filtration

3
Anatomy of Pulmonary System

• Pleural Space
• Respiratory Muscles
• Conducting Airways
• Respiratory Airways
• Lung Circulation
• Bronchial Circulation
• Pulmonary Circulation

4
Regulation of Respiration

• Controlled by
• Nervous system regulation
• Brainstem
• Medulla
• Pons
• Cerebral cortex
• Voluntary control
• Chemical regulation
• Chemoreceptors which respond to
• Changes in blood pH
• Changes in oxygen levels
• Changes in CO2 in the blood

5
Chemoreceptors

• radar screens
• Monitoring O2 and CO2
• Message sent to control tower of brain

6
Central Chemoreceptors

• Respond to changes in C02
• In close contact with the CSF
• As CO2 increases, pH decreases
• Causes stimulation of ?d respirations
• Blow off CO2

7
Peripheral Chemoreceptors

• Located in aortic arch and carotid arteries
• Sensitive to changes in oxygen content
• Generally activated when p02 levels lt60 mm Hg
• Stimulate increased rate and depth of
  respirations to ? oxygen

8
Summary of Respirations
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Subjective Feelings

• Dyspnea
• The patients uncomfortable awareness that hes
  working too hard to breathe.

10
Respiratory Assessment

• When breathing is easy, we rarely give it a
  thought, but dyspnea can trigger panic and
  feelings of impending doom.
• When a patient has trouble breathing, you need to
  act fast to relieve his distress and ward off
  dangerous complications

11

• Always follow this rule
• Anyone who is experiencing shortness of breath
  needs immediate attention to his airway.
• Remember
• Fear worsens dyspnea

12
Quick Assessment and Interventions

• Assess level of consciousness (LOC)
• Assess airway status and breathing
• Assess central and peripheral pulses
• Measure respiratory rate and depth
• Assess blood pressure and heart rate

13
Quick Assessment and Interventions

• Measure SpO2 levels on room air
• Elevate the head of the bed
• Auscultate breath sounds
• Assess skin color, temperature and capillary
  refill to evaluate perfusion

14
Stop, Look and Listen

• Inspection
• Use of accessory muscles
• Symmetrical chest wall movement
• Rate, depth and rhythm of respirations
• Assess skin color
• Look for clubbing

15
Stop, Look and Listen

• Instruct patient to breathe slowly and deeply
  through the mouth
• Compare opposite sides of chest
• From the apices to the bases
• Listen for at least one cycle (inspiration and
  expiration)
• Figures 24-6, 24-7

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Finger Clubbing
17
Breath Sounds

• Normal breath sounds
• Vesicular
• Bronchovesicular
• Bronchial
• Abnormal breath sounds
• Crackles
• Rhonchi
• Wheezes
• Pleural friction rub

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Stop, Look and Listen

• Wheezing musical, whistling sound
• Usually more pronounced during expiration
• From narrowed airways
• Bronchoconstriction
• Secretions
• Interventions
• Bronchodilation
• Hydration
• Coughing

• Rhonchi bubbling
• The sound will be heard throughout inspiration
  and expiration.
• Louder than rales due to larger secretions
• Results from air bubbling past secretions in the
  airways
• Interventions
• Deep breathing
• Coughing
• Hydration (encourage fluids, if no restriction)
• Humidify air
• Mobilize

• Rales crackling sound
• Heard at the end of inspiration
• From collapsed or waterlogged alveoli
• Fine beginning of fluid buildup / or atelectasis
• Coarse greater volume of fluid buildup
• Interventions
• Manage fluids
• Budget volume resuscitation
• Diuretics
• Expectorate
• Turn position
• Deep breathing
• Forced expiration
• Vibration percussion

• Friction rub creaking, leathery sound
• End of inspiration and beginning of expiration
• Caused by rubbing of inflamed pleural surfaces
  against lung tissue.
• Interventions
• Chest x-ray
• Anti-inflammatory medications

19
Stop, Look and Listen

• Practice listening to breath soundshttp//medocs
  .ucdavis.edu/IMD/420C/sounds/lngsound.htm

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Stop, Look, Listen and Feel

• Palpation
• Crepitus
• Fremitus

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Ventilation

• Air Movement
• Gases move from an area of higher pressure to
  lower pressure
• Expansion and Contraction of lungs
• Diaphragm
• Intercostal muscles
• Pressures within lungs

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Lung Compliance

• How easily the lung tissue can stretch
• ?d compliance, lung is stiffer and more
  difficult to expand
• ?d compliance, lung is easier to expand
• Surfactant
• Decreases surface tension of alveoli

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Ventilation

• Minute Ventilation
• Amount of air inhaled and exhaled per minute
• Dead Space
• Anatomic dead space
• Physiological dead space

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Diffusion

• Diffusion of O2
• From alveoli into the capillaries
• Diffusion of CO2
• From pulmonary capillaries to alveoli

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Normal Airway Defense Mechanisms

• Filtration of air
• Humidification and warming of inspired air
• Epiglottis closure over the trachea
• Cough reflex
• Mucociliary escalator mechanism
• Secretion of Immunglobulin A (IgA)
• Alveolar macrophages

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Respiratory Defense Mechanisms

• Efficient
• Protect us from
• Toxic gases
• Inhaled particles
• Microorganisms
• Mechanisms
• Filtration of Air
• Mucociliary Clearance System
• Cough reflex
• Reflex bronchoconstriction
• Alveolar Macrophages

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Filtration of Air

• Nasal hairs serve as filters
• Mucosal lining traps particles and bacteria
• Large particles 5 microns
• Sedimentation in larynx
• 1-5 microns
• Deposit in alveoli
• Small particles less than 1 micron

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Mucociliary Clearance System

• AKA mucociliary elevator
• Mucus continually secreted by goblet cells
• Mucus blanket contains impacted particles and
  debris
• Immunoglobulin A (IgA) protects against bacteria
  and viruses

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Cough Reflex

• High pressure, high velocity airflow
• When mucociliary system is overwhelmed

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Reflex Bronchoconstriction

• Response to inhaled irritants
• Asthma causes bronchoconstriction in response to
  cold air, perfumes, etc.

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Alveolar Macrophages

• No ciliated cells below the level of the
  bronchioles
• Alveolar macrophages are primary defense
  mechanism at this level
• Phagocytize inhaled particles and bacteria
• Impaired by smoking

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Gas Exchange
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Gas Exchange/Diffusion
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Oxyhemoglobin Dissociation Curve
35
Shifts in the Oxyhemoglobin Dissociation Curve

• Changes from these values are called "shifts".
• Factors
• variation in pH,
• temperature,
• 2,3,-DPG
• a metabolic by-product which competes with O2 for
  binding sites.

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Shifts in the Oxyhemoglobin Dissociation Curve

• Shift to the Left
• ? oxygens affinity for hemoglobin
• Oxygen held tightly
• Less released to tissues
• Seem with ?d pH, ?CO2, ? body temp.
• Shift to the Right
• ? oxygens affinity for hemoglobin
• Oxygen released more readily
• Less picked up at the lungs
• Seen in ? pH, ?CO2, ?temp

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Carbon Dioxide Transport

• Metabolic byproduct
• Carried in blood in 3 forms
• Dissolve CO2 (10)
• Attached to hemoglobin ( 30)
• As bicarbonate (60)
• Increased rate of exhalation leads to greater
  elimination of CO2
• ?RR ? ? CO2
• ?RR ? ? CO2
• Normal p CO2 is 35-45 mm Hg

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Respiratory Monitoring PaO2

• PaO2 the partial pressure of oxygen dissolved
  in blood (3 of oxygen)
• Normal value
• 80-100 mm Hg
• Measured by Arterial Blood Gas (ABG)

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Respiratory Monitoring Pulse Oximetry

• 97 carried by Hgb in RBCs
• Amount of oxygen that hemoglobin (hgb) is
  carrying compared with amount that it can carry
• Known as Sa02
• Normal 93-99
• Great for monitoring trends

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Sputum Studies

• Sputum Samples
• expectoration
• tracheal suction
• Bronchoscopy
• Used to
• identify infecting organisms
• Confirm presence of malignant cells

41
Chest x-ray

• Most common diagnostic respiratory test

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Radiologic Studies

• Chest CT
• MRI Chest
• Ventilation-Perfusion Scan
• Pulmonary Angiography

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Chest CT

• Used to diagnose lesions
• Shows images in cross section

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MRI Chest

• Useful for diagnosing lesions

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Bronchoscopy
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Lung Biopsy

• Specimens obtained via bronchoscopy or open-lung
  biopsy

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Thoracentesis

• Used to obtain pleural fluid for analysis
• Patient position
• Edge of bed with arms/body leaning over bedside
  table
• Needle inserted between ribs
• Fluid withdrawn with syringe or tubing connecte4d
  to sterile vacuum bottle

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Acute Respiratory Failure

• Respiratory Failure occurs when gas exchange
  functions are inadequate
• CO2 retention
• Inadequate oxygenation
• Hypoxemia
• pO2 lt 50
• Hypercapnea/Ventilatory failure
• pCO2 gt 50
• Acidemia
• Arterial pH lt7.35

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Acute Respiratory Failure

• Goals
• Maintaining adequate oxygenation
• Maintaining adequate ventilation
• Treatment modalities
• Airway Maintenance
• Oxygen therapy
• Mobilization of secretions
• Ventilatory assistance

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Respiratory Failure
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Types of Respiratory Failure

• Hypoxemic respiratory failure
• Hypercapneic respiratory failure

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Hypercapneic Respiratory Failure

• Common causes
• Asthma
• COPD
• Sedative narcotic use
• Head trauma
• Thoracic trauma
• Pain
• Obesity
• Guillain-barre and other CNS disorders

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Respiratory Failure

• Clinical manifestations
• Extent of the change in pO2 or pCO2
• Rapidity of the change
• Ability to compensate to overcome the change
• Tachycardia
• Mild hypertension

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Hypoxia

• Cells shift from aerobic to anaerobic metabolism
• Increased use of ATP
• Less energy output
• Increase in end-product ? lactic acid

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Determination of Respiratory Failure

• Clinical condition
• Arterial Blood Gases (ABGs)

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Oxygen Therapy

• Frequently used for COPD and other problems
  associated with hypoxemia
• Supplemental O2 increases the partial pressure
  (p02) of inspired air
• Considered a drug

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Indications for O2 therapy

• Treatment of hypoxia
• COPD, pneumonia, atelectasis, lung cancer,
  pulmonary emboli
• Cardiovascular disorders
• MI, arrhythmias, angina, cardiogenic shock
• CNS disorders
• Narcotic overdose, head injury, sleep apnea

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Nasal Cannula

• Low flow delivery device
• 2 l/min 28
• Higher flow rates (gt5 l/min) dry nasal membranes

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Simple Face Mask

• Flow rates 6-12 l/min
• Delivers 35-50 O2
• Pt comfort issues

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Non-Rebreathing Mask

• Delivers accurate, high concentrations of oxygen
• Achieves 60-90 O2 delivery

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Oxygen Conserving Cannula

• Built in oxygen reservoir
• 30-50 O2 delivery
• Increased comfort

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Tracheostomy Collar
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Venturi Mask

• Moderate Oxygen Flow
• Delivers precise, high-flow rates
• 24-50
• Humidification available
• Requires face mask

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Vapotherm

• High Flow Therapy
• 1-40 l/min via Nasal Cannula
• Molecular Vapor
• Warmth and humiditygt tolerance by patients
• 100 relative humidity
• body temperature

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Nebulizers/Humidifiers

• 02 is drying to mucous membranes
• Nebulizers
• Bubble-through humidifier
• gt4 l/min
• Humidifiers
• Heated water

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Tracheostomy

• Preferred artificial airwayfor long-term
  mechanicalventilation (gt3 wks)
• Used to
• Bypass upper airway obstr
• Facilitate removal of secretions
• Manage long-term mechanical ventilation

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Ventilators

• Negative Pressure
• Iron lung
• Negative pressure caused chest wall to expand,
  pulled air into the lungs
• Rarely used now

Iron lung ward filled with Polio patients, Rancho
Los Amigos Hospital, ca. 1953
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Ventilators

• Positive Pressure
• Volume cycled
• Pressure cycled
• Flow cycled
• Time cycled

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Volume Cycled Ventilators

• Delivers preset tidal volume
• Most commonly used in hospitals today

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Pressure Cycled Ventilators

• Delivers gases until preset pressure is reached
• Advantage
• Decreased risk of lung damage from increased
  inspiratory pressure
• Disadvantage
• Pt may get inadequate Tidal Volume (VT) if lung
  compliance is poor or airway resistance is
  increased

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Flow Cycled Ventilators

• Delivers gases until a preset flow rate is
  achieved during inspiration

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Time Cycled

• Delivers breath over preset period of time
• Rarely used today

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Ventilator Settings

• Respiratory Rate (RR)
• Fraction of Inspired Oxygen (FIO2)
• Tidal Volume (VT)
• Pressure Control
• Ventilator Mode

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Modes of Ventilation

• Controlled Mandatory Ventilation (CMV)
• Assist-Control Mechanical Ventilation (A/C)
• Synchronized Intermittent Mandatory Ventilation
  (SIMV)
• Pressure Support Ventilation (PSV)

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Fraction Inspired Air (Fi02)

• Percentage of oxygen inhaled (on or off
  ventilator)
• 21-100

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Tidal Volume (Vt)

• Volume of inspired air in a single breath
• Lung Capacity in adults 6 liter
• In normal adults 500cc
• Larger volumes Smaller volumes
• Males females
• tall people shorter people
• Nonsmokers heavy smokers
• professional athletes non-athletes
• people living at high people living at low
  altitudes altitudes

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Mechanical Ventilation

• Nursing Management
• Risk for injury r/t artificial/altered airway,
  possible machine malfunction, accidental
  discontinuation, asynchrony with ventilator

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Responding to a Ventilator Alarm

• Remember A ventilator is primarily a pump
• Alarm? something wrong with the pressure, volume
  or rate of air being delivered
• Your role immediately check the patient and the
  equipment, figure out and fix the problem
• If you cant immediately do thisdisconnect the
  pt from the vent, manually resuscitate the
  patient and call for help

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Mechanical Ventilation

• Nursing Management
• Ineffective Airway Clearance r/t
  artificial/altered airway, problems with
  positioning, accumulation of secretions,
  immobility
• Impaired Physical Mobility r/t restricted
  movement
• Anxiety r/t clinical condition, inability to
  communicate, fear of death
• Risk for infection r/t exposure to pathogens,
  loss of normal protective barrier

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Complications Associated with Mechanical
Ventilation

• Ventilator Associated Pneumonia (VAP)
• Q Why are ventilator patients at risk?
• A
• Bypass normal upper airway defenses
• Poor nutrition
• Immobility
• Underlying disease state

81
Complications Associated with Mechanical
Ventilation

• GI Complications
• Stress related to intubation
• Corticosteroids
• Circulatory compromise
• Ischemia of GI tract
• Risk for developing GI bleeding and stress
  ulcers

82
Complications Associated with Mechanical
Ventilation

• Musculoskeletal System
• Maintenance of muscle strength
• Problems of immobility

83
Complications Associated with Mechanical
Ventilation

• Psychosocial Needs
• Physical and emotional stress
• Inability to speak
• Inability to move
• Inability to eat
• Fear

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• Arterial Blood Gases ABGs

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What can you tell from an ABG?

• ABG measurements give insights into your
  patients ability to
• Maintain oxygenation
• Maintain acid-base balance
• Respiratory compensation mechanisms
• Metabolic compensation mechanisms

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ABG Normal Ranges
87
Acid-Base Balance

• To maintain homeostasis
• Protein and phosphate buffer system
• fast
• Respiratory System
• CO2 H2O ??H2CO3 (carbonic acid)
• 15 minutes
• Kidneys
• HCO3- (bicarbonate) slowly binds with H
• 2-3 days

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Acid-Base Parameters
89
Acid-Base Imbalance

• Respiratory Acidosis
• Respiratory Alkalosis
• Metabolic Acidosis
• Metabolic Alkalosis

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Respiratory Acidosis

• Occurs when ventilation drops, excess CO2 builds
  up in alveoli
• Excess carbonic acid creates an acidic environment

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Respiratory Acidosis

• Causes
• CNS-related
• Sedative overdose
• Respiratory arrest
• Pulmonary-related
• COPD
• ABG criterion
• pCO2 gt 45 mm Hg

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Respiratory Alkalosis

• Ventilation is excessive
• Too much CO2 is eliminated from the alveoli
• Compensation Mechanism
• H2CO3 ? CO2 H2O
• Carbonic dissociates
• Acid into

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Respiratory Alkalosis

• Causes
• Pneumonia
• Atelectasis
• ARDS
• ABG Criterion
• pCO2 lt35 mm Hg

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Metabolic Acidosis

• Develops when body gains acid or loses base
• Causes
• Acid Gain
• Diabetic Ketoacidosis
• Renal Failure
• Anaerobic metabolism
• Base Loss
• Diarrhea

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Metabolic Acidosis

• ABG Criteria
• HCO3- lt22 mEq/L
• Base excess (BE) lt -2 mEq/L

96
Metabolic Alkalosis

• Caused by either a base gain or an acid loss
• Causes
• Base Gain
• Excess intake of sodium bicarbonate or antacids
• Acid Loss
• Vomiting
• NG suction

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Metabolic Alkalosis

• ABG Criteria
• HCO3 gt 26 mEq/L
• BE gt 2 mEq/L

98
Interpreting ABGs

• Follow this systematic 6 step format
• Step 1 Evaluate the pH
• Step 2 Evaluate the ventilation
• Step 3 Evaluate metabolic processes
• Step 4 Determine primary and compensating
  disorder
• Step 5 Evaluate oxygenation
• Step 6 Interpret

99
Step 1 Evaluate the pH

• A pH below 7.35 reflects acidemia
• A pH above 7.45 reflects alkalemia
• If the patient has more than one acid-base
  imbalance, the pH identifies the process in
  control

100
Step 2 Evaluate Ventilation

• pCO2 is normally 35-45
• A pCO above 45 indicates ventilatory failure and
  respiratory acidosis
• A pCO2 less than 35 indicates alveolar
  hyperventilation and respiratory alkalosis

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Step 3 Evaluate Metabolic Processes

• A bicarbonate (HCO3-) less than 22 mEq/L and/or a
  BE less than 2 reflect metabolic acidosis
• A bicarbonate (HCO3-) more than 26 mEq/L and/or a
  BE greater than 2 reflect metabolic alkalosis
• If there is a conflict between HCO3- and BE, BE
  is better indicator of metabolic status

102
Step 4 Determine Primary and Compensating
Disorder

• If two acid-base balances coincide, one is
  primary and the other is the bodys attempt to
  return the pH to normal
• To decide which is which, check the pH.
• Only a process of acidosis can make pH acidic
  only a process of alkalosis can make the pH
  alkaline.

103
Step 4 Determine Primary and Compensating
Disorder

• Three states of compensation
• Noncompensated alteration of only pCO2 or HCO3-
• Partial compensation when both pCO2 and HCO3-
  are abnormal and pH is also abnormal
• Complete compensation when both pCO2 and HCO3-
  are abnormal, but pH is normal (7.40)

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Step 5 Evaluate Oxygenation

• Normally pO2 remains between 80-100
• pO2 between 60 80 mm Hg reflects mild hypoxemia
• pO2 between 40-60 mm Hg moderate hypoxemia
• pO2 below 40 mm Hg is severe hypoxemia

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Step 6 Interpret

• Your final analysis should include
• The degree of compensation
• The primary disorder
• and the oxygenation status
• partially compensated respiratory acidosis with
  moderate hypoxemia

106
Case Study 1

• Marie Hodges is brought to the ED semi comatose
  and breathing deeply at a rate of 32/min. ABGs
  are done on room air, after which she is given O2
  at 2L/min. The ABG results are as follows
• pH 7.28
• pCO2 28.9 mm Hg
• HCO3- 11.0 mEq/L
• BE - 13
• pO2 Sat 96

107

• Step 1 Evaluate the pH
• Step 2 Evaluate the ventilation
• Step 3 Evaluate metabolic processes
• Step 4 Determine primary and compensating
  disorder
• Step 5 Evaluate oxygenation
• Step 6 Interpret

108
Case Study 2

• Ed Jones had a cholecystectomy today he was
  returned to your unit an hour ago. He is now
  lethargic and breathing shallowly at 8/min. Stat
  ABGs on room air are as follows
• pH 7.15
• pCO2 80 mm Hg
• HCO3- 28 mEq/L
• BE 0
• pO2 52
• O2 sat 91

109

• Step 1 Evaluate the pH
• Step 2 Evaluate the ventilation
• Step 3 Evaluate metabolic processes
• Step 4 Determine primary and compensating
  disorder
• Step 5 Evaluate oxygenation
• Step 6 Interpret

110
Case Study 3

• Three days after undergoing major abdominal
  surgery, Jack Green is complaining of weakness
  and difficulty breathing. He had been receiving
  5 glucose in Ringers lactate at 100 ml/hr and
  40 mg Lasix IV per day. Nasogastric drainage has
  been 150-300 ml/shift. ABGs on room air are
• pH 7.46
• pCO2 45
• HCO3 32
• BE 8
• pO2 76
• O2 sat 94

111

• Step 1 Evaluate the pH
• Step 2 Evaluate the ventilation
• Step 3 Evaluate metabolic processes
• Step 4 Determine primary and compensating
  disorder
• Step 5 Evaluate oxygenation
• Step 6 Interpret

112
Pulmonary Embolism

• Most (80-90) arise from thrombi in deep veins of
  the legs
• Most lethal clots from the iliac and femoral
  veins
• Right side of the heart
• Especially with A-fib
• Upper extremities, pelvic veins
• Lodge in pulmonary veins because of arterial and
  capillary network

113
Other sources of Pulmonary Emboli

• Fat Emboli
• From fractured long bones
• Air Emboli
• From IVs
• Amniotic fluid
• Tumors

114
Clinical Manifestations of Pulmonary Embolus

• Sudden, unexplained dyspnea, tachypnea or
  tachycardia
• Cough
• Chest pain
• Hemoptysis
• Sudden changes in mental status (hypoxia)

115
Management Pulmonary Emboli

• Anticoagulation therapy
• Heparin
• Coumadin for 6 months
• Thrombolytic therapy
• Use very cautiously only for acute, massive PE
• Urokinase, Streptokinase tPA
• Inferior Vena Cava filter

116
Diagnosing Pulmonary Embolism

• Ventilation-Perfusion Scan
• Nuclear imaging test
• Determines percentage of each lung that is
  functioning normally
• Pulmonary Angiography

117
IVC Filters

• Greenfield Filter

• Birds Nest Filter

118
Lung Cancer

• Most common malignancy in the world
• Affects gt3 million people
• 1 cause of cancer-related deaths
• Kills more people than breast, colon, and
  prostate cancer combined
• Overall cancer rates are dropping, lung cancer
  remains on the rise
• Smoking is a contributing factor in 87 of cases

119
Cellular Changes of Lung Ca

• Malignant cells proliferate and multiply at an
  uncontrolled rate
• Resulting mass disrupts normal lung structure and
  function
• Malignant cells may migrate to create secondary
  tumors ?metastasis

120
Types of Lung Cancer

• Small cell lung cancer (SCLC)
• 15 of Lung Cancers
• Non-small cell lung cancer (NSCLC)
• 85 of Lung Cancers

121
SCLC

• Strongly linked to smoking
• Small/oat cell carcinoma
• Mixed cell carcinoma
• Combined small cell carcinoma
• Spreads quickly
• Metastatic sites are sometimes first sign/symptom
• Poor prognosis
• Not usually surgically resectable
• Chemotherapy
• Radiation Therapy

122
NSCLC

• Slower spreading
• Squamous cell
• 25-30 of lung Ca in US
• Slow growing
• Adenocarcinoma
• 40 of lung Ca in US
• Commonly affects non-smokers, women
• Large cell carcinoma
• 10-15 of lung Ca in US

123
Lung Cancer

• Signs Symptoms
• Review in text
• Diagnostic Testing
• Chest x-ray
• consolidations
• Spiral CT
• Tumor mass, lymph nodes
• FDG-PET
• Radioactive glucose highlights area of ?d
  metabolism
• CT scans
• MRI
• Sputum cytology
• Bronchoscopy
• Needle biopsy

124
Staging Lung Cancer

• Based on size, primary tumor size and location,
  lymph node involvement, presence of distant
  metastasis
• Guides treatment
• Determine prognosis

125
Staging Lung Cancer

• SCLC
• Limited or extensive
• NSCLC
• TNM system
• Primary tumor
• Involvement of lymph nodes
• Presence of metastasis

126
Treatment of Lung Cancer

• Surgery
• Depends on type, location of lesion the age and
  health of the individual
• Radiation therapy
• External beam radiation
• Intensity modulated radiation therapy
• Proton beam therapy
• Brachytherapy

127
Treatment of Lung Cancer contd

• Chemotherapy
• Used to slow lung tumor growth
• Drug selection varies by tumor size, type and
  stage
• Cisplatin
• Makes tumor more sensitive to radiation
• Platinum based agents preferred
• Cisplatin
• Etoposide
• Topotecan

128
Post Surgical Patients

• Thoracic surgery recovery can be difficult
• Vigilantly monitor
• airway gas exchange
• LOC
• Pulmonary status breath sounds, resp rate,
  depth, pattern. ABGs.
• Cardiac status
• Reposition pts frequently
• Elevate HOB 30 45o
• OOB as tolerated
• Supplemental O2
• Mobilization of secretions
• TCDB
• Nebulized medications
• Chest tube output
• Pain
• Risk for DVT
• Surgical incision
• IO, fluid electrolyte status

129
Lung Cancer Palliative Therapy

• Treatment to limit tumor growth when cure is not
  possible
• Radiofrequency ablation
• Delivery of current and heat that destroys tumor
  cells
• Photodynamic therapy
• To shrink tumors that obstruct bronchus

130
Supportive Care and End of Life Measures

• Controlling signs and symptoms of disease
• Dyspnea
• Nebulizer treatments
• Secretion clearance
• Positioning
• Decreasing oxygen requirements
• Morphine
• Pain
• Opioids
• NSAIDs
• Complementary/Alternative therapies
• Acupuncture
• Relaxation techniques
• Massage therapy

131
Obstructive Sleep Apnea

• Partial or complete upper airway obstruction
  during sleep
• Apnea-cessation of spontaneous respirations
• Hypopnea-abnormally shallow and slow respirations
• Tongue and soft palate fall backward and
  partially/completely obstruct the pharynx

132
Sleep Apnea Cycle

• Obstruction of 15-90 seconds ?
• ? oxygen (hypoxemia) ? CO2 (hypercapnea) ?
• Stimulation of ventilation, partial awakening ?
• Generalized startle reflex ?
• Tongue and soft palate move forward ? airway
  opens

133
Clinical Manifestations

• Excessive daytime sleepiness
• Frequent awakening
• Insomnia
• Morning Has
• Irritability
• Impaired memory
• Inability to concentrate

134
Sleep Apnea

• Affect on partner/significant other
• Diagnosis
• Polysomnography
• SpO2
• Heart rate , respiratory rate and patterns

135
Sleep Apnea Management

• Weight loss
• Oral appliance
• Nasal Continuous Airway Pressure (CPAP)

136
CPAP Masks
137
Pneumothorax

• Air in the pleural space
• Closed pneumothorax
• Spontaneous pneumothorax
• Open pneumothorax
• Cover with vented dressing
• Leave the object in place!

138
Pneumothorax

• Diagnostic Tests
• CXR
• ABGs
• Treatment dependent on severity of pneumothorax
  and nature of the underlying disease
• Supplemental 02
• Chest tube

139
Tension Pneumothorax
140
Chest Trauma/Thoracic Injuries

• Blunt Trauma Penetrating Trauma
• Blunt trauma
• Contracoup trauma
• contrecoup (kon'tr?-ku')n. Injury to a part
  opposite the site of the primary injury, as an
  injury to the skull opposite the site of a blow.
• Internal organs rapidly forced back and forth
  against bony structures
• Injuries incurred at site of the impact and the
  opposite side

141
Chest Tubes Pleural Drainage

• A chest tube is used to remove fluid and/or air
  from the space between the lungs and the wall of
  the chest.
• The tube is placed between the ribs and into the
  space between the inner lining and the outer
  lining of the lung (pleural space).

142
Chest Tube Insertion and Set-up

• Inserted in ED, OR, or at bedside
• Purpose is to remove air and fluid from the
  pleural space and restore normal intrapleural
  pressure
• Goal is re-expansion of the lung

143
Pleural Drainage

• 3 compartments
• Collection chamber
• Water seal chamber
• Suction control chamber

144
Pleural Drainage

• Collection chamber (1st Chamber)
• Air
• Blood
• Exudate (empyema)

145
Pleural Drainage

• Water Seal Chamber (2nd Chamber)
• Contains 2 cm of water
• Acts as a one-way valve
• Incoming air enters from the collection chamber
  and bubbles in the water seal chamber as a
  pneumothorax is evacuated
• tidaling fluctuations with pts respiratory
  cycle
• Rise with inspiration (extubated pt)
• Fall with expiration
• If no fluctuation is seencheck for kinks, or
  the lung has re-expanded

146
Pleural Drainage

• Suction Control Chamber (3rd Chamber)
• Applies controlled suction to the chest drainage
  system
• Typically filled to 20 cm of water
• Amount of suction applied is regulated by the
  depth of the water and NOT the amount of suction
  applied to the system
• Normal suction pressure ordered is -20 cm H20

147
Nsg Management of Chest Tubes

• http//www.nursewise.com/courses/chestubes_hour.h
  tm

148
Nursing Considerations for Patients with Chest
Tubes and Pleural Drainage

• Keep tubing straight or loosely coiled
• Tape connections
• Add sterile water as needed to keep water levels
  appropriate
• Mark, measure drainage levels
• Monitor fluid output so that no more than
  1000-1200 ml of fluid is drained at one time

149
Nursing Considerations for Patients with Chest
Tubes and Pleural Drainage

• Observe for bubbling in the water-seal chamber
• Monitor vital signs
• Never elevate chest drainage system above the
  level of the chest
• Encourage periodic coughing deep breathing
• Do not strip the chest tubes routinely
• If the drainage system breaks, place the chest
  tubing connection in a container with 2 cm of
  sterile water
• Keep clamps at bedside only for special procedures

150
Chest Tube Removal

• When CXR shows re-expansion of the lung
• When fluid drainage has ceased
• Generally suction is discontinue first? gravity
  drainage prior to discontinuation
• Pain medication
• Apply sterile petroleum jelly gauze dressing
• Deep breath, bear down, remove the tube

151
Chest Surgery

• Performed for respiratory, cardiac and some GI
  conditions
• Pre-op teaching
• Deep breathing and incentive spirometry
• Anticipatory teaching about pain management
• Chest tube insertion

152
Types of Chest Surgery

• Lobectomy
• Pneumonectomy
• Wedge resection
• Segmental resection
• Thorascopy

153
Thoracotomy

• Surgical incision into the chest
• Median sternotomy
• Posterolateral thoracotomy
• Anterolateral thoracotomy

154
Wedge Resection

• Segmental resection/Wedge resection
• Removal of wedge-shaped portion of lung tissue
• Usually used to remove tumor

155
Lobectomy

• Right lung3 lobes
• Left lung2 lobes
• Lobectomyremoval of one lobe of a lung
• Usual indication is lung cancer
• Occasionally cystic fibrosis

156
Pneumonectomy

• Removal of entire lung
• Most common indication is lung cancer

157
Video Assisted Thoracic Surgery (VATS)

• Similar to laparoscopic surgery
• Increasingly used
• Robotic surgery
• New
• Rare
• Questionable advantages

158
Lung Volume Reduction Surgery

• For treatment of emphysema
• Removal of most damaged parts of lungs in order
  to allow for full function of remaining lung
  structure
• Investigational
• ? Long term benefits
• vs.
• Surgical risk/mortality