OXYGENATION

Oxygenation is a basic human need. The Respiratory System replenishes the bodys oxygen supply and eliminates waste from the blood in the form of carbon dioxide. Terms and Definitions a. Respiration - breathing and exchange of oxygen and carbon dioxide within the body tissues b. Inspiration - inhaling, breathing in or drawing air into the lungs (active phase) c. Expiration - exhaling, breathing out or expelling air from the lungs (passive phase) d. Ventilation - it is the process by which gases are moved into and out of the lungs. It can be normal breathing or with mechanical assistance. e. Diffusion of gases - it is a natural process essential to respiration in which molecules of a gas pass from an area of greater concentration to one of lesser concentration (example: oxygen moving from inhaled air through capillaries into deoxygenated blood). f. Thorax - it is the chest or the upper part of the trunk between the neck and the abdomen. g. Mediastinum - the space between the lungs where the heart, great vessels (aorta and vena cava), esophagus, trachea, and major bronchi lie h. Anoxia - an abnormal condition characterized by a lack of oxygen i. Apnea - absence of spontaneous respiration j. Aspiration - taking foreign matter into the lungs during inhalation (e.g., vomitus) k. Bradypnea - an abnormally slow rate of breathing l. Cheyne-Stokes respiration - an abnormal pattern of respiration, characterized by alternating periods of apnea (10-20 sec) and deep, rapid breathing m. Dyspnea - shortness of breath or difficulty in breathing n. Hyperpnea - deep, rapid, or labored respiration

o. Hyperventilation - a ventilation rate that is greater than that metabolically necessary for the exchange of respiratory gases p. Hypoventilation - an abnormal condition of the respiratory system that is characterized by a reduced rate and depth of breathing q. Hypoxia - inadequate supply of oxygen to body tissue and cells r. Kussmaul breathing - abnormally deep and very rapid respiration characteristic of diabetic acidosis s. Respiratory arrest - cessation of breathing t. Respiratory failure - the inability of the cardiac and pulmonary systems to maintain an adequate exchange of oxygen and carbon dioxide in the lungs u. Suffocation - a condition characterized by inadequate oxygen and excessive carbon dioxide in the blood v. Tachypnea - an abnormally rapid rate of breathing w. Adventitious sounds - abnormal lung sounds heard with auscultation x. Rhonchi - abnormal lung sound heard on auscultation of the lungs. When the patients airways are obstructed with thick secretions. Can usually be cleared with coughing (snoring) y. Rales (crackles) - abnormal lung sound heard on auscultation characterized by fine bubbling sounds during inspiration. z. Wheezes (wheezing) - abnormal lung sounds caused by severely narrowed bronchus. Can be both inspiratory and expiratory. Common lung sound associated with asthma.

Anatomy and Physiology

Respiration- the process of gaseous exchange between the individual and the environment. 1. The Airways a. Upper Airways Nasal Cavity Pharynx Larynx Functions of the upper airways: Transport of gases to the lower airways Protection of the lower airway from foreign matter

 Warming, Filtration and humidification of inspired air b. Lower Airways Trachea Right and Left mainsteam bronchi Segmental bronchi Sub segmental bronchi Terminal bronchi Function of the lower airways: Clearance mechanism -cough -mucocilliary system -macrophages -lymphatic Immunologic responses -cell-mediated immunity in the alveoli Pulmonary protection in injury respiratory epithelium mucocilliary system

2. The Pleura 1. The pleurae are serous membranes that enclose the lungs. 2. The visceral pleura directly covers the lungs. (purple) 3. The parietal pleura lines the cavity of each hemithorax. (blue) 4. The pleural space is a potential space between the two pleurae. Only few ml of serous fluid is found in the pleural space, to serve as lubricant.

3. The Lungs 1. The right lung has three lobes, while the left lung has two lobes. 2. The two lungs are separated by a space called mediastinum. 3. There are approximately three hundred million alveoli in the lungs. 4. The right lung is broader, but shorter due to the presence of liver on the right side of the abdomen. Lung Volumes and Capacities Tidal Volume (TV) volume of one breath. Minute Ventilation (MV) the total volume of air inhaled and exhaled each minute = the respiratory rate multiplied by Tidal Volume. (RRxTv=MV) Alveolar Ventilation Rate is the volume of air per minute that reaches the alveoli and other respiratory portions. (Ex. 350mL per breath x 12 breaths/minute = 4200mL/minute) Inspiratory Reserve Volume refers to additional inhaled air when taking a very deep breath. Expiratory Reserve Volume refers to amount of air forcibly exhaled after normal inhalation. Forced Expiratory Volume- volume of air that can be exhaled from the lungs in 1 second with maximal effort following a maximal inhalation. Residual Volume- remaining amount of air in the lungs after forced exhalation. Minimal Volume- air remaining if the thoracic cavity is opened, and the intrapleural pressure rises to equal the atmospheric pressure and forces out some of the residual volume. Inspiratory Capacity- sum of the tidal volume and the inspiratory reserve volume Functional Residual Capacity- sum of residual volume and expiratory reserve volume Vital Capacity- sum of inspiratory reserve volume, tidal volume and expiratory reserve volume.

4. The Thorax and the Diaphragm The thorax provides protection for the lungs, heart and great vessels. The diaphragm is the main respiratory muscle for inspiration. The following are the accessory muscles for inspiration: sternocleidomastoid, scalene, parasternal, trapezius and pectoralis muscles. They are used during increased work of breathing. 5. Respiratory Control a. Central Nervous System Control Medulla oblongata (central chemoreceptors) Pons (apneustic center, pneumatoxic center) b. Reflex Control Cough reflex c. Peripheral Control Carotid and aortic bodies Measures that promote adequate respiratory function: 1. Adequate oxygen supply from the environment. 2. Deep breathing and coughing exercises. 3. Positioning. 4. Patent airway. Causes of Airway Obstruction Tongue (among unconscious clients, the tongue tends to fall back) Mucous secretions Edema of airways (rhinitis, laryngitis, bronchitis) Spasm of airways (laryngospasm, bronchospasm) Foreign bodies (aspirated foods, fluids) 5. Adequate hydration 6. Avoid environmental pollutants, alcohol and smoking 7. Chest Physiotherapy (CPT) 8. Bronchial Hygiene measures a. Steam Inhalation Purposes: To liquefy mucous secretions. To warm and humidify inspired air. To relieve edema of airways. To soothe irritated airways. To administer medications. b. Aerosol inhalation - done among pediatric clients to administer bronchodilators or mucolyticexpectorants.

c. Medimist inhalation - done among adult clients to administer bronchodilators or mucolyticexpectorants. 9. Suctioning Purpose: to clear airways from mucous secretions Oropharyngeal and nasopharyngeal suctioning Indications: Audible secretions during respiration Adventitious breath sound (auscultated) Position: Conscious: Semi- Fowlers position Unconscious: Lateral position Pressure of suction equipment: 1. Wall Unit: a. Adult: 100-120 mmHg b. Child: 95- 110 mmHg c. Infant: 50- 95 mmHg 2. Portable Unit: a. Adult: 10-15 mmHg b. Child: 5- 10 mmHg c. Infant: 2-5 mmHg Appropriate size of sterile suction catheter a. Adult: Fr. 12- 18 b. Child: Fr. 8- 10 c. Infant: Fr. 5- 8 10. Incentive Spirometry - done to enhance deep inspiration

11. Intermittent Positive Pressure Breathing - done to administer oxygen at pressures higher than the atmospheric pressure.

12. Administration of supplemental oxygen Oxygen therapy the administration of oxygen to the client by any route to prevent or relieve hypoxia. The provision of oxygen to the client with higher concentration than that found in the air. Hypoxia decrease oxygen in the cells Hypoxemia decrease oxygen in the blood Indication: hypoxemia Signs of hypoxemia: restlessness (initial sign) Increased pulse rate Rapid, shallow respiration and dyspnea Light- headedness Flaring of nares Substernal or intercostals retraction Cyanosis (Late sign)

The oxygenation status of the patient can be determined at bedside by performing focused assessment, monitoring the ABG (Arterial Blood Gas) levels and pulse oximeter. Five signs of inadequate oxygenation: 1. Restlessness 2. Rapid breathing 3. Rapid heart rate 4. Sitting up to breathe 5. Using accessory muscles. Nurses can improve a patients oxygenation status by elevating the patients head and chest and by instructing patient to perform breathing exercises. Oxygen Systems 1. Low flow administration devices 1. Nasal Cannula (24- 25% at 2- 6 LPM)

May be used in clients with COPD at 2-3 LPM if venturi mask is not available Nasal Cannula/prongs- a simple, comfortable low-flow (24% - 25%) device inserted in the nostrils to deliver oxygen at a rate to five -6 liters/min. It consists of a rubber or plastic tubing that extends around the face with to inch prongs that fit into the nostrils. Delivers low concentration of oxygen when only minimal support is required Allows uninterrupted delivery of oxygen when the client ingests foods or fluids. Permits some freedom and movement and comfort to the client. Nasal catheter a plastic or rubber tubing of different sizes that can be inserted into the nose to the nasopharynx to administer oxygen -Provide an efficient means of administering high concentration oxygen. 2. Simple Face Mask (40- 60% at 5-8 LPM)- a device that covers the clients nose and mouth for oxygen inhalation. They are made of a clear, pliable plastic or rubber that can be molded to fit the face. Held to the clients face with elastic bands, some have a metal clip that can be bent of

the bridge of the nose for a snug fit. There ARE Several holes on the sides of the mask (exhalation port) to allow escape of carbon dioxide To provide moderate oxygen support and a higher concentration of oxygen or humidity than is provided by the nasal cannula.

3. Partial Rebreathing Mask (60- 90% at 6- 10 LPM) consist of a mask with a reservoir bag that provides an oxygen concentration of 70% - 90%, with flow rates of 6 15 L/min

4. Non- Rebreathing Mask (95- 100% at 6- 15 LPM) most frequently used in clients with deteriorating respiratory system who might require intubations. The nonrebreather most has a one-way valve between the mask and the reservoir and two flaps over the exhalation ports. The valve allows the client to draw the entire quantity of oxygen in the reservoir bag.

5. Croupette

6. Oxygen tent

7. Aerosol mask used for clients requiring high humidity after extubation or upper airway surgery, or for clients with thick secretions.

2. High flow administration devices 1. Venturi mask- Low- concentration venture- type mask is preferred for clients with COPD (chronic obstructive pulmonary disease) because it provides accurate amount of oxygen. They require 2-3 LPM or 28% oxygen. -An adapter is located between the bottom of the mask and the oxygen source, the adapter contains holes of different sizes that allow only specific amounts of air to mix with oxygen.

2.

Face Mask- fits over the clients chin with the top extending halfway across the face. -Oxygen concentration varies but the face tent is useful instead of a tight fitting mask for the client who has facial trauma or burns.

3.

Oxygen hood- Can be used for low and high flow concentration. Incubator/ Isolette. Can be used for low and high flow concentration

Note: Oxygen is colorless, odorless, tasteless and dry gas that supports combustion. Nursing Implications: 1. Since oxygen is colorless, odorless, tasteless gas, leakage cannot be detected. 2. Since oxygen is dry gas, it can irritate mucous membrane of the airways. 3. Since oxygen supports combustion, it can cause fire. When giving oxygen therapy caution must be made to avoid highly flammable materials/ substances: 1. Prominently display NO SMOKING sign on the door, at the foot of the bed, head of bed, or on the oxygen equipment. 2. Remove matches, cigarettes, and lighters from the bedside when oxygen is in use. 3. Inspect all electrical equipment in the immediate vicinity. 4. Avoid using wool blankets. 5. Do not give electric or friction toys to children in oxygen therapy. Remove alcohols, cosmetics, and lubricants which are oil-based from the bedside

Abdominal (diaphragmatic) and Pursed Lip Breathing and Coughing 1. Assume a comfortable semi-sitting position on bed or chair or a lying position on bed with one pillow. 2. Flex your knees to relax the muscles of your abdomen. 3. Place one or both hands or your abdomen, just below the ribs. 4. Breathe in deeply through the nose keeping the mouth closed. 5. Concentrate on feeling your abdomen rise as far as possible. Stay relaxed and avoid arching your back. If you have difficulty rising your abdomen, take a quick, forceful breath through the nose. 6. Then purse your lips as if about to whistle, and breathe out slowly and gently, making a slow whooshing sound without puffing out the cheeks. The pursed lip breathing creates a resistance to air coming out of the lungs, increases pressure within the bronchi, and minimizes collapsed of smaller airways, a common problem of patients with chronic obstructive pulmonary disease (COPD). 7. Concentrated on feeling the abdomen fall or sink and tighten (contract) he abdominal muscles when breathing out to enhance effective exhalation. Count to seven during exhalation. 8. If indicated cough two or more times during exhalation. 9. Use this exercise whenever feeling short of breath, and increase gradually to 5-10 minutes 4 times a day.

Alterations in Respiratory Function 1. Hypoxia insufficient oxygenation of tissues Late Signs Bradycardia Dyspnea Decreased systolic BP Cough Hemoptysis expectoration of blood

Clinical Signs of Hypoxia Early Signs Tachycardia Increased rate and depth of respiration Slight increase in Systolic BP

Other Clinical Signs of Acute Hypoxia nausea and vomiting 6. irritability oliguria, anuria 7. memory loss headache apathy dizziness

Other Clinical Signs of Chronic Hypoxia 1. fatigue, lethargy 2. pulmonary ventilation increases 3. RBC count increases 4. Hgb concentration increases 5. clubbing of fingers

2. Altered Breathing Patterns a. Rate Tachypnea- rapid respiratory rate Bradypnea- slow respiratory rate Apnea- cessation of breathing b. Volume 1. Hyperventilation excessive amount of air in the lungs it results from deep, rapid respirations 2. Hypoventilation decreased rate and depth of respiration it causes retention of carbon dioxide c. Rhythm 1. Cheyne- stokes. Marked rhythmic waxing and waning of respirations from very deep to very shallow breathing and temporary apnea

3. Kussmauls (Hyperventilation). Increased rate and depth of respiration, seen in metabolic acidosis and renal failure.

3. Apneustic. Prolonged gasping inspiration followed by a very short, usually inefficient expiration.

4. Biots. Shallow breaths interrupted by apnea.

d. Ease of effort. 1. Dyspnea. Difficult or labored breathing 2. Orthopnea. Inability to breath except in upright or sitting position