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

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

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

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

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

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

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

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

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

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

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

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

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

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

or bronchial obstruction . Renal compensation is slow.valve-mask (BVM) is indicated until the underlying problem can be addressed.35 with a PaCO2 greater than 45 mm Hg. neuromuscular diseases. After stabilization. rapidly resolvable causes are addressed immediately. Ph < normal 2.Hypoventilation due to pain. pneumothorax. or anesthesia . manual ventilation with a bag. Decrease blood pH ACID-BASE DISORDERS Respiratory Acidosis Respiratory acidosis is defined as a pH less than 7. Hydrogen ions are retained 3.Cells in the distal part of the renal tubules are sensitive to changes in the pH of the filtrate. ACIDEMIA 1. lowering the pH of the blood. thus. or abdominal distension Increasing ventilation will correct respiratory acidosis. pneumonia.Impaired respiratory muscle function related to spinal cord injury. Ph > normal 2. Kidneys cannot compensate for imbalances related to renal failure.Central nervous system depression related to medications such as narcotics. These conditions include: . HCO3 are excreted 4. sedatives. Any condition that results in hypoventilation can cause respiratory acidosis. chest wall injury/deformity. Acidosis is caused by an accumulation of CO2 which combines with water in the body to produce carbonic acid.Central nervous system depression related to head injury . Hydrogen ions are excreted 3. Increase blood pH ALKALEMIA 1.Pulmonary disorders such as atelectasis. The method for achieving this will vary with the cause of hypoventilation. HCO3 is formed and retained 4.Massive pulmonary embolus . If the patient is unstable. Causes that can be treated . pulmonary edema. or neuromuscular blocking drugs . it takes hours – days to make a compensation.

Diarrhea and intestinal fistulas may cause decreased levels of base. If the cause cannot be readily resolved.rapidly include pneumothorax. Although patients with hypoventilation often require supplemental oxygen. pain. Causes of increased acids include: . such as respiratory stimulants. or thyrotoxicosis .Salicylate intoxication Metabolic Alkalosis Metabolic alkalosis is defined as a bicarbonate level greater than 26 mEq/liter with a pH greater than 7. These conditions include: .Anaerobic metabolism . Respiratory Alkalosis Respiratory alkalosis is defined as a pH greater than 7. pregnancy. When the respiratory muscles become exhausted. excess use of bicarbonate.Pain .45.45 with a PaCO2 less than 35 mm Hg.Starvation . Either an excess of base or a loss of acid within the body can cause metabolic alkalosis. Patients presenting with respiratory alkalosis have dramatically increased work of breathing and must be monitored closely for respiratory muscle fatigue.Medications. . acute respiratory failure may ensue. such as fever.Psychological responses.35. the patient may require mechanical ventilation while treatment is rendered. Any condition that causes hyperventilation can result in respiratory alkalosis. it is important to remember that oxygen alone will not correct the problem. gastric .Diabetic ketoacidosis . or use of lactate in dialysis.Renal failure . other than CO2.Central nervous system lesions Treatment of respiratory alkalosis centers on resolving the underlying problem. Metabolic Acidosis Metabolic acidosis is defined as a bicarbonate level of less than 22 mEq/L with a pH of less than 7. Loss of acids can occur secondary to protracted vomiting.Increased metabolic demands. Metabolic acidosis is caused by either a deficit of base in the bloodstream or an excess of acids. Excess base occurs from ingestion of antacids. such as anxiety or fear . sepsis. and CNS depression related to medications.

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

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

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

Applying the concepts of acid.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. . A logical and systematic approach using these steps makes interpretation much easier.