OXYGEN, a clear, odorless gas that constitutes approximately 21% of the air we breathe, is necessary for proper functioning

of all living cells. Impaired function of the system can significantly affect our ability to breathe, transport gases, and participate in everyday activities. RESPIRATION is the process of gas exchange between the individual and the environment. 1. Pulmonary ventilation or breathing; 2. Gas exchange, 3. Transport of oxygen STRUCTURE of the Respiratory System The respiratory system is divided structurally into the upper respiratory system and the lower respiratory system. The mouth, nose, pharynx, and larynx compose the upper respiratory system. The lower respiratory system includes the trachea and lungs, with the bronchi, bronchioles, alveoli, pulmonary capillary network, and pleural membranes. Air enters through the nose, where it is warmed, humidified, and filtered. Large particles in the air are trapped as air changes direction on contact with the nasal turbinate’s and septum. The sneeze reflects is initiated by irritants in nasal passages. A large volume of air rapidly exits through the nose and mouth during a sneeze, helping to clear nasal passages. Inspired air passes from the nose through the pharynx. The pharynx is a shared pathway for air and food. It includes both nasopharynx and the oropharynx, which are richly supplied with lymphoid tissue that traps and destroys pathogens entering with the air. The larynx is a cartilaginous structure that can be identified externally as the Adam’s apple. In addition to its role in providing for speech, the larynx is important for maintaining airway patency and protecting the lower airways from swallowed food and fluids. During swallowing, the inlet to the larynx (the epiglottis) closes, routing food to the esophagus. The epiglottis is open during breathing, allowing air to move freely into the lower airways. Below the larynx, the trachea leads to the right and left main bronchi (primary bronchi) and the other conducting airways of the lungs. Within the lungs, the primary bronchi divide repeatedly into smaller and smaller bronchi, ending with the terminal bronchioles. Together these airways are known as the bronchial tree. The trachea and bronchi are lined with mucosal epithelium. These cells produce a thin layer of mucus, the ‘mucous blanket,’ that traps pathogen and microscopic particulate matter. These foreign particles are then swept

upward toward the larynx and throat by cilia, tiny hairlike projections on the epithelial cells. The cough reflex is triggered by irritants in the larynx, trachea, or bronchi. Until air passes through the terminal bronchioles and enters the respiratory bronchioles and alveoli, no gas exchange occurs. The respiratory zone of the lungs includes the respiratory bronchioles (which have scattered air sacs in their walls), the alveolar ducts, and the alveoli. Alveoli have very thin walls, composed of a single layer of epithelial cells covered by a thick mesh of pulmonary capillaries. The alveolar and capillary walls form the respiratory membrane (also known as the alveolar/capillary membrane), where gas exchange occurs between the air on the alveolar side and the blood on the capillary side. The airways move air to and from the alveoli; the right ventricle and pulmonary vascular system transport blood to the capillary side of the membrane. The outer surface of the lungs is covered by a thin, double layer of tissue known as pleura. The parietal pleura lines the thorax and surface of the diaphragm. It doubles back to form the visceral pleura, covering the external surface of the lungs. Between these pleural layers is a potential space that contains a small amount of pleural fluid, a serous lubricating solution. This fluid prevents friction during the movements of breathing and serves to keep the layers adherent through its surface tension. Good breathing techniques has many benefits and is slow, full, deep and rhythmic and 
 
 1. Improves your sleep pattern.
 
 2. It aids in calming the mind, nerves and emotion.
 
 3. Improves all mental processes including concentration and memory.
 
 4. Tension is released.
 
 5. It supplies more oxygen to the body cells and so blood is purified.
 
 6. Helps to overcome tiredness and to rejuvenate energy. BREATHING EXERCISES General Instructions - Breathe slowly and rhythmically to exhale completely and empty the lungs completely. - Inhale through the nose to filter, humidify, and warm the air before it enters the lungs. - If you feel out of breath, breathe more slowly by prolonging the exhalation time. - Keep the air moist with a humidifier. Diaphragmatic Breathing Goal: To use and strengthen the diaphragm during breathing

While sitting in a chair: o Fold arms over the abdomen.While walking: o Inhale while walking two steps.After.Inhale through the nose while counting to 3 – the amount of time needed to say “Smell a rose.The knees and hips are flexed to promote relaxation and reduce the strain on the abdominal muscles while coughing. thus reducing the amount of trapped air and the amount of airway resistance .Place one hand on the abdomen (just below the ribs) and the other hand on the middle of the chest to increase the awareness of the position of the diaphragm and its function in breathing. .Repeat for 1 minute.” . .. several times a day (before meals and at bedtime) Pursed-Lip Breathing Goal: To prolong exhalation and increase airway pressure during expiration.” . exhaling through the mouth offers less resistance to expired air. This upright position permits a stronger cough.Do the diaphragmatic breathing in a sitting position. follow with a rest period of 2 minutes.Gradually increase duration up to 5 minutes.) . .The patient inhales slowly through the nose and exhales through pursed lips several times. .Exhale slowly and evenly against pursed lips while tightening the abdominal muscles. . o Inhale through the nose while counting to 3. .Breathe in slowly and deeply through the nose. (Pursing the lips increases intratracheal pressure.Press firmly inward and upward on the abdomen while breathing out. letting the abdomen protrude as far as possible.Count to 7 while prolonging expiration through pursed lips – the length of time to say “Blow out the candle. . o Exhale through pursed lips while walking four or five steps. . .Breathe out through pursed lips while tightening (contracting) the abdominal muscles. Effective Coughing Technique . . . the patient bends slightly forward. o Bend forward and exhale slowly through pursed lips while counting to 7.The patient should cough twice during each exhalation while contracting (pulling in) the abdomen sharply with each cough.

FUNCTIONAL RESIDUAL CAPACITY (FRC) 9. RESIDUAL VOLUME (RV) 5. and alveolar infiltrates evident on chest x-rays. Because oxygen supports combustion. malaise. VITAL CAPACITY 7. Oxygen therapy equipment is also a potential source of bacterial cross-infection. INSPIRATORY CAPACITY 8. Thus. there is always a danger of fire when it is used. thus. The resulting decrease in alveolar ventilation can cause a progressive increase in arterial carbon dioxide narcosis and acidosis. TOTAL LUNG CAPACITY (TLC) 6. with firm hand pressure or supports it with a pillow or rolled blanket while coughing. It is important to post “no smoking” signs when oxygen is in use. INSPIRATORY RESERVE VOLUME (IRV) 3. administration of a high concentration of oxygen removes the respiratory drive that has been created largely by the patient’s chronic low oxygen tension. paresthesias. fatigue. if any. progressive respiratory difficulty. Oxygen-induced hypoventilation is prevented by administering oxygen at low flow rates (1 to 2 LPM). (The nurse can initially demonstrate this by using the patient’s hands. TIDAL VOLUME (VT) 2.) OXYGEN TOXICITY Oxygen toxicity may occur when too high a concentration of oxygen (greater than 50%) is administered for an extended period (longer than 48 hours). dyspnea. the stimulus for respiration is a decrease in blood oxygen rather than an elevation in carbon dioxide levels. restlessness. the nurse changes the tubing according to infection control policy and the type of oxygen delivery equipment. EXPIRATORY RESERVE VOLUME (ERV) 4.The patient splints the incisional area. Signs and symptoms of oxygen toxicity include substernal distress.. PULMONARY VOLUMES and CAPACITIES 1. In patients with COPD. MINUTE VOLUME (MV) METHODS OF OXYGEN ADMINISTRATION .

Fill the humidifier bottle with distilled or tapped water in accordance with agency protocol. CANNULA a.Attach the flow meter to the wall outlet. b. Many different oxygen devices are used. OXYGEN ADMINISTRATION DEVICES 1. The appropriate form of oxygen therapy is best determined by arterial blood gas levels. Exhalation ports on the sides of the . and a flow meter regulates the flow of oxygen in liters per minute. It delivers a relatively low concentration of oxygen (23% to 45%) at floe rates of 2 to 6 L per minute.Attach the humidifier bottle to the base of the flow meter. Limitations of the cannula include inability to deliver higher concentrations of oxygen.Regulate the flow meter to the prescribed level. and is well tolerated by the client. It is easy to apply and does not interfere with client’s ability to eat or talk. The nasal cannula (nasal prong) is the most common and inexpensive device used to administer oxygen. . The line for the prescribed flow rate should be in the middle of the ball of the flow meter. c. The amount of oxygen delivered is expressed as a percentage concentration. d.Oxygen is dispensed from a cylinder or a piped-in system. . 2. which indicate the patient’s oxygenation status. A reduction gauge is necessary to reduce the pressure to a working level. To use an oxygen wall outlet. e. Above 6 L per minute. It is also relatively comfortable. Some humidifier bottles come prefilled by the manufacturer. permits some freedom of movement.Attach the prescribed oxygen tubing and deliver device to the humidifier. FACE MASK – Face masks that cover the client’s nose and mouth may be used for oxygen inhalation. and all deliver oxygen if used as prescribed and maintained correctly. This can be done before coming to the bedside. . and that it can be drying and irritating to mucous membranes. . the nurse carries out these steps: . The flow meter should be in the off position. Exerting firm pressure. the client tends to swallow air and the FiO2 is not increased: this may cause irritation and drying of the nasal and pharyngeal mucosa.

the nurse can correct this problem by increasing the liter flow of oxygen. To prevent carbon dioxide buildup. and dry and treat as needed. respectively. If this problem occurs. c. A variety of oxygen masks are marketed: a. The partial rebreather bag must not totally deflate during inspiration to avoid carbon dioxide buildup. The Venturi mask delivers oxygen concentrations varying from 24% to 40% or 50% at liter flows of 4 to 10 L per minute. The simple face mask delivers oxygen concentration from 40% to 60% at liter flows of 6 to 8 L per minute. FACE TENT a. the client’s facial skin must kept dry. 3. The partial rebreather mask delivers oxygen concentrations of 60% to 90% at liter flows of 6 to 10 L per minute. b. a blue adapter delivers a 24% concentration of oxygen at 4 L per minute. b. d. One-way valves on the mask and between the reservoir bag and the mask prevent the room air and the client’s exhaled air from entering the bag so only the oxygen in the bag is inspired. The oxygen reservoir bag that is attached allows the client to rebreathe about the first third of third of the exhaled air in conjunction with oxygen. for example. Face tents can replace oxygen masks when masks are poorly tolerated by clients.mask allow exhaled carbon dioxide to escape. As with face masks. Frequently inspect the client’s facial skin for dampness or chafing. For example. at liter flows of 10 to 15 L per minute. . c. and a green adapter delivers a 35% concentration of oxygen at 8 L per minute. the nurse increases the liter flow of oxygen. The nonrebreather mask delivers the highest oxygen concentration possible – 95% to 100% . Face tents provide varying concentrations of oxygen. respectively.by means other than intubation or mechanical ventilation. It employs the principle of air entrainment (trapping the air like a vacuum). 30% to 50% concentration of oxygen at 4 to 8 L per minute. which provides a high air flow with controlled oxygen enrichment. If it does. the nonrebreather bag must not totally deflate during inspiration. The Venturi mask has wide-bore tubing and color-coded jet adapters that correspond to precise oxygen concentration and liter flow.

Oxygen supply with a flow meter and adapter b. Tape e. Determine the need for oxygen therapy. Oxygen supply with a flow meter and adapter b. CANNULA a. Humidifier with distilled water or tap water according to agency protocol c. To provide a high flow of O2 when attached to Venturi system EQUIPMENT 1. and verify the order for therapy. Oxygen supply with a flow meter and adapter b. To deliver a relatively low concentration of oxygen when only minimal O2 support is required b. . Prescribed face mask of the appropriate size d. To provide high humidity b. Humidifier with distilled water or tap water according to agency protocol c. FACE MASK a. To provide oxygen when a mask is poorly tolerated c. CANNULA a. Face tent of the appropriate size IMPLEMENTATION Preparation 1. Humidifier with distilled water or tap water according to agency protocol c. Padding for the elastic band 3. FACE MASK a. Padding for the elastic band 2. To allow uninterrupted delivery of oxygen while the client ingests food or fluids 2. Nasal cannula and tubing d.SUMMARY WRAP PURPOSES 1. To provide moderate O2 support and a higher concentration of oxygen and/or humidity than is provided by cannula 3. FACE TENT a. FACE TENT a.

ii. Attach the prescribed oxygen tubing and delivery device to the humidifier. CANNULA i. 6. ii. b. If the cannula will not stay in place. fill the humidifier bottle. Turn on the oxygen at the prescribed rate and ensure proper functioning. mask. b.) c. a. You should feel the oxygen at the outlets of the cannula. FACE MASK i. Provide for client privacy. a. Prepare the client and support people. Attach the flow meter to the wall outlet or tank. . a. 2. why it is necessary. 2. 4. Perform a respiratory assessment to develop baseline data if not already available. 3. There should be bubbles in the humidifier as the oxygen flows through. if appropriate. d. Set up the oxygen equipment and the humidifier. Attach the humidifier bottle to the base of the flow meter. and the connections should be airtight. Apply the appropriate oxygen delivery device. or tent. Performance 1. (This can be done before coming to the bedside. and how he or she can cooperate. a. introduce self and verify the client’s identity using agency protocol. Pad the tubing and band over the ears and cheekbones as needed. with the outlet prongs fitting into the nares and the elastic band around the head. iii. Explain to the client what you are going to do. Fit the mask to the contours of the client’s face. Perform hand hygiene and observe appropriate infection control procedures. tape it at sides of the face. and apply it from the nose downward. The flow meter should be in off position.a. If needed. Put the cannula over the client’s face. Set the oxygen at the flow rate ordered. Guide the mask toward the client’s face. Some models have a strap to adjust under the chin. There should be no kinks in the tubing. b. Prior to performing the procedure. Check that the oxygen is flowing freely through the tubing. Assist the client to a semi-fowler’s position if possible. 5.

boosts immune system . 7. and ease of respirations. a.allows the body’s organs to carry out normal functions .. Pad the band behind the ears and over bony prominences.iii. Document findings in the client record using forms or checklists supplemented by narrative notes when appropriate. b. tachycardia. dyspnea. and provide support while the client adjusts to the device. color. depending on the client’s condition. restlessness. iv. Assess the client in 15 to 30 minutes. c.decreases shortness of breath . confusion.g. Check the liter flow and the level of water in the humidifier in 30 minutes and whenever providing care to the client. Be sure that water is not collecting in dependent loops of the tubing.prolongs life by reducing heart strain . and cyanosis. Assess the client’s vital signs.makes exercise more tolerable . the equipment on a regular basis a. 8. Review oxygen saturation or arterial blood gas results if they are available. check oxygen saturation to evaluate adequate oxygenation). c. b. Evaluation 1. Make sure that safety precautions are being followed. Secure the elastic band around the client’s head so that the mask is comfortable but snug. FACE TENT i. BENEFITS OF OXYGEN THERAPY .relieves nausea . Relate findings to previous to previous data if available (e. Perform follow-up based on findings that deviated from expected or normal for the client. Assess the client regularly for clinical signs of hypoxia. 2.can prevent heart failure in people with severe lung disease . level of anxiety. 9. Report significant deviations from normal to the primary care provider. Assess the client regularly.increased clarity . c. Place the tent over the client’s face.headache relief . and secure the ties around the head. and regularly thereafter.

NOTE: a modified or cut 4x4 cannot be used as a trach sponge.Complications from ET intubations .Less resistance airflow than ET Advantages .Requires surgical procedre to insert . tracheostomy dressing (trach sponge). pair of scissors . sterile gloves i. or innominate artery Equipment Needed a. trach ties k. minor dressing tray b. The open technique is done in operating room. sterile Q-tips (6 to 8) d. as small cut fibers could enter the stoma and trachea e.Failed or repeated intubations . hydrogen peroxide f. esophagus. A tube is usually through this opening and an artificial airway is created.Can be used long-term. garbage container near patient bedside j. and a surgical a surgical incision is made in the trachea just below the larynx.results in fewer days of hospitalization TRACHEOSTOMY A tracheostomy is an opening into the trachea through the neck.Patients can be taught how to take care for their tracheostomy at home Disadvantages . The percutaneous method can be done at the bedside in a critical care unit.Upper airway obstruction .More comfortable for the patient .Allows easy removal of secretions .Allows speaking and eating if respiratory status is stable . up to years .Long term use can cause fistulas between trachea and skin. clean gloves h. sterile normal saline g. Tracheostomy is done using one of two techniques: the traditional open surgical method or a percutaneous insertion. Preferred artificial airway for patients requiring long term mechanical ventilation (longer than 3 weeks) .. sterile pipe cleaners (3 or 4) (or trach brush) c.

c. or as per agency policy or order. Once all secretions are removed. Ties should be loose enough to slip two fingers between the tIes and neck. 11. Remove used trach sponge and assess for secretions. b. Wash hands. Suction secretions of the patient as necessary. Open Q-tip package. Cut off the old tie and discard it. Leave the previous trach tube ties secured to the flange and patient while attaching a new trach tie. Dry the stoma area. 9. Using sterile technique. Assemble equipment and prepare dressing tray: a.TRACHEOSTOMY CARE 1. Don sterile gloves. rinse the inner cannula well with normal saline. d. 8. 7. Decrease risk of infection 10. ready for use. Pour normal saline in one of the smaller compartments. This is done by dipping one end into the saline and then tippind the cannula the other direction. 13. Open pipe cleaner package and drop into center of the sterile field. Maintain skin integrity of stoma b. Don clean gloves. Maintain complete sterility. Move from the stoma and outwards (clean to dirty principle). f. introduce self and verify the client’s identity. Pour hydrogen peroxide in the largest compartment. 2. Change the trach ties if they are soiled. Thread the new tie through the flange tie holes and around the back of the patient’s neck. Explain procedure to patient. Assess site. 5. Maintain sterility of distal end of Q-tip. Open trach sponge onto sterile field. Use only a single sweep with each Q-tip. 12. Discard. 3. Prior to performing the procedure. Place stems at the edge of the sterile field. Clean tracheostomy site with sterile Q-tips and normal saline. using a sterile 2x2. 6. Tie it in a reef or square knot at the side of the patient’s neck. 4. Open outer package of the sterile gloves. use a pipe cleaner to clean inside the inner cannul and remove secretions. These measure serve to: a. if necessary. e. Immerse it in hydrogen peroxide. Remove the inner cannula fro m the trach tube. so the saline runs . and secure enough to ensure the trach tube will not dislodge.

The nurse explores strategies that will enable the patient to assume indicated positions at home. 14. The goals of chest physiotherapy are to remove bronchial secretions. Wash hands 18. It uses specific positions that allow the force of gravity to assist in the removal of bronchial secretions.The nurse teaches family members who will be assisting the patient at home to evaluate breath sounds before and after treatment. 1. Lock into place. improve ventilation. Remove gloves. the cardiac status.Auscultating the chest before and after the procedure helps to identify the areas needing drainage and to assess the effectiveness of treatment. Reinsert inner cannula. The secretions drain from the affected bronchioles into the bronchi and trachea and are removed by coughing or suctioning. chest percussion and vibration. This is generally considered to be a clean procedure. Apply new trach sponge. . cushions. Maintain sterile technique. Dispose of equipments. 16. This may require the creative use of objects readily available at home such as pillows. CHEST PHYSIOTHERAPY Chest physiotherapy includes postural drainage. Assess patient. 15. Shake cannula to remove excess saline. . In addition. or tap gently on inside surface of dressing tray.through it and rinses it. NURSING MANAGEMENT/CONSIDERATION in POSTURAL DRAINAGE . Document care given including assessment of secretions. and breathing exercises/breathing retaining. . b. and increase the efficiency of the respiratory muscles. 17. .The nurse should be aware of the patient’s diagnosis as well as the lung lobes or segments involved. and any structural deformities of the chest wall and spine. POSTURAL DRAINAGE (SEGMENTED BRONCHIAL DRAINAGE) a. It is used to prevent or relieve bronchial obstruction caused by accumulation of secretions. as well as the patient’s tolerance of the procedure. or cardboard boxes. teaching the patient effective coughing technique is an important part of chest physiotherapy. dressing and stoma.

it is important to perform postural drainage in a room away from other patients and/or family members and to use room deodorizers. b. decrease the thickness of mucus and sputum. It is important to evaluate the patient’s skin color and pulse the first few times the procedure is performed. the patient may find it refreshing to brush the teeth and use a mouthwash before resting. It may be necessary to administer oxygen during postural drainage. the nurse notes the amount. Thick secretions that are difficult to cough up may be loosened by tapping (percussing) and vibrating the chest. the nurse instructs caregivers in safe suctioning technique.The nurse makes the patient as comfortable as possible in each position and provides an emesis basin. and character of the ejected sputum. . It also may be necessary to use chest percussion and vibration to loosen bronchial secretions and mucus plugs that adhere to the bronchioles and bronchi and to propel sputum in the direction of gravity drainage. . If a position cannot be tolerated. the nurse helps the patient to assume a modified position. and paper tissue. color.Postural drainage is usually performed two or four times daily. the nurse explains how to cough and remove secretions. If suctioning is required at home. .The nurse instructs the patient to remain in each position for 10 to 15 minutes and to breathe in slowly through the nose and then breathe out slowly through pursed lips to help keep the airways open so that secretions can drain while in each position. CHEST PERCUSSION and VIBRATION a. . viscosity. The wrists are alternately flexed and extended so that the chest is cupped or clapped in a painless - . sputum cup. the nurse may need to suction the secretions mechanically. PERCUSSION is carried out by cupping the hands and lightly striking the chest wall in a rhythmic fashion over the lung segment to be drained.If the sputum is foul smelling. before meals (to prevent nausea. Chest percussion and vibration help to dislodge mucus adhering to the bronchioles and bronchi. vomiting. . After the procedure. water. 2. Prescribed bronchodilators. reduce bronchospasm. and combat edema of the bronchial walls. When patient changes position.If the patient cannot cough. and aspiration) and at bedtime. or saline may be nebulized and inhaled before postural drainage to dilate the bronchioles.After the procedure.

is performed for 3 to 5 minutes for each position. is not wearing restrictive clothing. A soft cloth or towel may be placed over the segment of the chest that is being cupped to prevent skin irritation and redness from direct contact. A scheduled program of coughing and clearing sputum. spine. and has not just eaten a meal. as prescribed. percussion over the chest drainage tubes. VIBRATION is the technique of applying manual compression and tremor to the chest wall during the exhalation phase of respiration. or breasts (in women) is avoided. Percussion. thus freeing the mucus. before percussion and vibration and splints the incision and provides pillows for support as needed. but focus is placed on the affected areas. using abdominal muscles. the nurse assists the patient to assume a comfortable position. together with hydration. kidneys. It is important to evaluate breath sounds before and after the procedures. c. As a precaution. This helps to increase the velocity of the air expired from the small airways. The positions are varied. On completion of the treatment. The uppermost areas of the lung are treated first.) d. The number of times the percussion and vibration cycle is repeated depends on the patient’s tolerance and clinical response.When performing chest physiotherapy. spleen.manner. reduces sputum in most patients. .The nurse must stop treatment if any of the following symptoms occur: o Increased pain o Increased shortness of breath o Weakness o Light headedness o Hemoptysis . . alternating with vibration. the patient is encouraged to cough. it is important to make sure that the patient is comfortable. liver. The patient use diaphragmatic breathing during this procedure to promote relaxation. Percussion is performed cautiously in the elderly because of their increased incidence of osteoporosis and risk of rib fracture. the sternum. NURSING MANAGEMENT/CONSIDERATIONS in CHEST PERCUSSION and VIBRATION .The nurse gives medications for pain. (Contracting the abdominal muscles increases the effectiveness of the cough. After three or four vibrations.

5. and when the chest x-ray is normal. Observe expansion of chest to ascertain that the patient is taking deep breaths. Disassemble and clean nebulizer after each use. hold breath briefly. Follow-up Phase 1. 9..air compressor . Add the prescribed amount of medication and saline to the nebulizer. and has normal breath sounds. encourage the patient to cough after several deep breaths. Performance Phase 1. then exhale. Explain the procedure to the patient. ADMINISTERING NEBULIZATION THERAPY Equipment .Therapy is indicated until the patient has normal respirations. Place the patient in a comfortable sitting or semi-fowler’s position. 7. . Tell the patient to take in a deep breath from the mouthpiece. Record medication used and description of secretions. On completion of the treatment. 2. The equipment is changed according to facility policy. Connect the tubing to the compressor and set the flow at 6 to 8 L/minute. Nose clips are sometimes used if the patient has difficulty breathing only through the mouth. 6.medication and saline solution Procedure Preparatory Phase 1.nebulizer . can mobilize secretions. 4. Instruct the patient to exhale. 2. 3. Instruct the patient to breathe slowly and deeply until all medication is nebulized.connection tubing . Keep this equipment in the patient’s room. 8. Monitor the heart rate before and after the treatment for patients using bronchodilator drugs.

The more H+ present. It is a blood test that is performed specifically on blood from an artery. the lower the pH will be. The usefulness of this diagnostic tool is dependent on being able to correctly interpret the results. (+) Retention of carbon dioxide 5. Decrease rate and depth of respiration 4. the fewer H+ present. It involves puncturing an artery with a thin needle and syringe and drawing a small volume of blood. Increase in blood pH 2. The Respiratory Buffer Response The respiratory center in the medulla (brain) is sensitive to concentrations of carbon dioxide and H+ in the body fluids. Stimulation of the respiratory center 3. Increase blood pH ALKALEMIA 1. Increase rate and depth of respiration 4. Likewise. It is inversely proportional to the number of hydrogen ions (H+) in the blood. A liquid with a pH of 7. Decrease in the blood pH 2. The pH of a solution is measured on a scale from 1 (very acidic) to 14 (very alkalotic). Decrease carbon dioxide 5. Inhibition of the respiratory center 3. Decrease blood pH . ACIDEMIA 1. ACID-BASE BALANCE The pH is a measurement of the acidity or alkalinity of the blood. such as water.ARTERIAL BLOOD GAS Arterial blood gas analysis is an essential part of diagnosing and managing a patient’s oxygenation status and acid-base balance. So how is the body able to self-regulate acid-base balance in order to maintain pH within the normal range? It is accomplished using delicate buffer mechanisms between the respiratory and renal systems. is neutral (neither acidic nor alkalotic). the higher the pH will be.

Central nervous system depression related to medications such as narcotics. Ph < normal 2. Acidosis is caused by an accumulation of CO2 which combines with water in the body to produce carbonic acid. The method for achieving this will vary with the cause of hypoventilation.Pulmonary disorders such as atelectasis. If the patient is unstable. HCO3 is formed and retained 4.valve-mask (BVM) is indicated until the underlying problem can be addressed.Central nervous system depression related to head injury . Hydrogen ions are excreted 3. or neuromuscular blocking drugs . sedatives. These conditions include: .Massive pulmonary embolus . After stabilization. or abdominal distension Increasing ventilation will correct respiratory acidosis. thus. HCO3 are excreted 4. neuromuscular diseases. Causes that can be treated .Impaired respiratory muscle function related to spinal cord injury. Kidneys cannot compensate for imbalances related to renal failure. or anesthesia . Decrease blood pH ACID-BASE DISORDERS Respiratory Acidosis Respiratory acidosis is defined as a pH less than 7.35 with a PaCO2 greater than 45 mm Hg.Cells in the distal part of the renal tubules are sensitive to changes in the pH of the filtrate. pulmonary edema. Hydrogen ions are retained 3. Any condition that results in hypoventilation can cause respiratory acidosis. manual ventilation with a bag. Renal compensation is slow. Increase blood pH ALKALEMIA 1. ACIDEMIA 1. chest wall injury/deformity. Ph > normal 2. pneumonia. or bronchial obstruction . rapidly resolvable causes are addressed immediately. it takes hours – days to make a compensation. lowering the pH of the blood.Hypoventilation due to pain. pneumothorax.

pregnancy.Increased metabolic demands. acute respiratory failure may ensue. excess use of bicarbonate. . Respiratory Alkalosis Respiratory alkalosis is defined as a pH greater than 7. the patient may require mechanical ventilation while treatment is rendered. or use of lactate in dialysis.Pain .Central nervous system lesions Treatment of respiratory alkalosis centers on resolving the underlying problem. other than CO2. gastric . Metabolic Acidosis Metabolic acidosis is defined as a bicarbonate level of less than 22 mEq/L with a pH of less than 7.Anaerobic metabolism . Diarrhea and intestinal fistulas may cause decreased levels of base. Patients presenting with respiratory alkalosis have dramatically increased work of breathing and must be monitored closely for respiratory muscle fatigue. such as fever. Metabolic acidosis is caused by either a deficit of base in the bloodstream or an excess of acids.Renal failure .rapidly include pneumothorax. When the respiratory muscles become exhausted. Although patients with hypoventilation often require supplemental oxygen. Causes of increased acids include: .Medications.Starvation . Any condition that causes hyperventilation can result in respiratory alkalosis. pain.Psychological responses. sepsis.Salicylate intoxication Metabolic Alkalosis Metabolic alkalosis is defined as a bicarbonate level greater than 26 mEq/liter with a pH greater than 7.45. Either an excess of base or a loss of acid within the body can cause metabolic alkalosis. or thyrotoxicosis . Loss of acids can occur secondary to protracted vomiting. such as anxiety or fear . such as respiratory stimulants.45 with a PaCO2 less than 35 mm Hg. and CNS depression related to medications.35.Diabetic ketoacidosis . it is important to remember that oxygen alone will not correct the problem. These conditions include: . Excess base occurs from ingestion of antacids. If the cause cannot be readily resolved.

The normal range is 35 to 45 mm Hg. seizures and coma. hypochloremia. excess administration of diuretics. Bicarbonate excretion through the kidneys can be stimulated with drugs such as acetazolamide (DiamoxTM). In severe cases. (A negative base excess indicates a base deficit in the blood. The normal range is 7. disorientation. or high levels of aldosterone. It is significant to note that metabolic alkalosis in hospitalized patients is usually iatrogenic in nature. but resolution of the imbalance will be slow.) . The normal range is 95% to 100%. Neurologic symptoms include dizziness. The normal range is –2 to +2 mEq/liter.35 to 7. SaO2 The arterial oxygen saturation.45 PaO2 The partial pressure of oxygen that is dissolved in arterial blood. Symptoms of metabolic alkalosis are mainly neurological and musculoskeletal. muscle cramps and tetany. The normal range is 80 to 100 mm Hg. The normal range is 22 to 26 mEq/liter B. The patient may also experience nausea. Metabolic alkalosis is one of the most difficult acid-base imbalances to treat. Musculoskeletal symptoms include weakness.E. IV administration of acids may be used. PaCO2 The amount of carbon dioxide dissolved in arterial blood.suction. vomiting. muscle twitching. Components of the Arterial Blood Gas The arterial blood gas provides the following values: pH Measurement of acidity or alkalinity. lethargy. based on the hydrogen (H+) ions present. and respiratory depression. The base excess indicates the amount of excess or insufficient level of bicarbonate in the system. HCO3 The calculated value of the amount of bicarbonate in the bloodstream.

so should the HCO3. each representing separate conditions. alkalotic or acidotic. If it is below 7. normally as the pH increases.35. Compare the pH and the PaCO2 values. the body attempts to compensate. then the problem is primarily metabolic in nature. assess the PaCO2 level. Acid-base evaluation requires a focus on three of the reported components: pH. assess the HCO3 value. If the pH rises above 7. Compensation When a patient develops an acid-base imbalance. then the problem is primarily respiratory in nature. as the pH decreases. the blood is acidotic. Remember that with a respiratory problem. the blood is alkalotic. we now need to determine if it is caused primarily by a respiratory or metabolic problem.Steps to an Arterial Blood Gas Interpretation The arterial blood gas is used to evaluate both acid-base balance and oxygenation.35. The body tries to overcome either a respiratory or metabolic dysfunction in an attempt to return the pH into the normal range. Step One Assess the pH to determine if the blood is within normal range.45. This process involves three steps. Step Two If the blood is alkalotic or acidotic. If it is above 7. Likewise. Step Three Finally. PaCO2 and HCO3. . the HCO3 should also increase. the PaCO2 should rise. If pH and PaCO2 are indeed moving in opposite directions.45. Recall that with a metabolic problem. The following chart summarizes the relationships between pH. as the pH decreases below 7. Compare the two values. PaCO2 and HCO3. To do this. Remember that the lungs and the kidneys are the primary buffer response systems in the body. If they are moving in the same direction. the PaCO2 should fall.

and that the kidneys. the decreasing PaCO2 indicates that the lungs. Assess the pH. In our original uncompensated examples. 3.A patient can be uncompensated. the pH remains outside the normal range. 2. the pH and HCO3 move in the same direction. the pH has returned to within the normal range. In fully compensated states. this would be described as a metabolic disorder with a partial respiratory compensation. This step remains the same and allows us to determine if an acidotic or alkalotic state exists.base disorder is either uncompensated or partially compensated. review the following three steps: 1. In an uncompensated state. In this case. Be aware that neither system has the ability to overcompensate. we have already seen that the pH and PaCO2 move in opposite directions when indicating that the primary problem is respiratory. If evidence of compensation is present. are compensating by retaining HCO3. indicating that the primary problem was metabolic. We would then conclude that the primary problem was metabolic. But what if our results show the pH and HCO3 moving in opposite directions? That is not what we would expect to see. or fully compensated. We would conclude that the primary acid-base disorder is respiratory. When an acid. ultimately attempting to return the pH back towards the normal range. But what if the pH and PaCO2 are moving in the same direction? That is not what we would expect to see happen. Assess the HCO3. partially compensated. . acting as a buffer response. although the other values may still be abnormal. In order to look for evidence of partial compensation. again acting as a buffer response system. are attempting to correct the pH back into its normal range by decreasing the PaCO2 (“blowing off the excess CO2”). Assess the PaCO2. but the pH has not yet been corrected to within its normal range.

Applying the concepts of acid. A logical and systematic approach using these steps makes interpretation much easier.Understanding arterial blood gases can sometimes be confusing. .base balance will help the healthcare provider follow the progress of a patient and evaluate the effectiveness of care being provided.