Management of Clients The Upper Respiratory Tract

with Disturbances in Oxygenation The Lower Respiratory Tract

The Respiratory Tract 2 types of cells in the alveolar structures

Type I alveolar cells – flat squamous epithelial cells
across which gas exchange takes place
Type II alveolar cells – produces surfactant (a
lipoprotein substance that decreases the surface tension
within the alveoli)
Alveolar macrophages—removes offending substances
from the alveolar epithelium
Oxygenation

 The addition of oxygen to any system e.g. the

human body
 A constant supply of oxygen to support body
metabolism
Upper- lying above the sternal angle or above the glottis The Components Necessary in the Complex Process
and cricoid cartilage. of Oxygenation
Lower- ncludes the portion of the larynx below the 1. Adequate O2 and CO2 in the inspired air.
vocal cords Earth atmosphere contains:
 O2- 20.84%
 Nitrogen-78.62%
 CO2- 0.04%
 Water- 0.50%
 2. Adequate concentration of 02 in the alveoli
3. Alveolar status suitable to 02 diffusion from
alveoli in pulmonary capillary
-Functional pores of Kohn- small openings
interconnecting alveoli with another
4. Hemoglobin is capable of carrying 02 to cells and
tissues of the body
5. Circulatory system able to transport oxyhemoglobin
to tissues enough to meet tissue oxygen needs
 Pulmonary circulation
 Systemic circulation
a) central circulation
b) peripheral circulation
6. Body cells able to take up and use oxygen for
Two types of Respiration
6 Basic Requirements for Effective Oxygenation alveoli of the lungs; 0 or equal to atmospheric
pressure
1. Atmospheric air should contain 21% oxygen.
 Intrapleural pressure- pressure in the pleural
2. Airways must be patent and supporting
cavity; always negative in relation to alveolar
structures intact.
pressure, about
3. There must be adequate area for diffusion of
-4mm between breaths (when glottis is open and
gases.
alveolar spaces are open to the atmosphere)
4. Blood must be able to combine effectively with
oxygen.
 Intrathoracic pressure- pressure within the
5. The circulatory system must be able to deliver
thoracic cavity; equal to intrapleural pressure
oxygen to the tissues and cells.
and is the pressure to which the lungs, heart and
6. Cells must be able to utilize oxygen.
great vessels are exposed
Respiration
Process Involved in Gas Exchange
 Provision of oxygen to cells and the elimination
 Ventilation
of carbon dioxide from the cells.
 Diffusion
 These processes are necessary for production of
energy in the cells.  Perfusion
 Commonly referred to as “breathing”, a basic  Transport of Oxygen to tissues
human function involving inhalation and  Respiratory control
exhalation  Control of blood flow
 Different from breathing or ventilation VENTILATION- movement of air in and out of the
lungs

1. EXTERNAL RESPIRATION: exchange of oxygen a. compliance properties of the lungs and chest
and carbon dioxide between alveoli and blood wall (thorax)

2. INTERNAL RESPIRATION: exchange of oxygen b. surface tension

and carbon dioxide made between blood and cells c. muscular effort
Respiratory Pressures
metabolism  Intrapulmonary pressure or alveolar
pressure- pressure inside the airways and

Airway resistance- The ratio of the pressure driving
inspiration or expiration to airflow
DIFFUSION-process of O2 and CO2 exchange at the
air and blood interface
a. external respiration-exchange of O2 and CO2 at the
alveolar-capillary level
b. internal respiration-exchange of O2 and CO2 at the
tissue level
O2 dissolved state (3%)
-leaves capillary
-crosses cell membrane
-participates in cell metabolism
O2 bound with Hgb (97%) forms oxyhemoglobin
-increased O2 content in the blood
-transport vehicle for O2
-binds O2 in the pulmonary capillary
-released O2 in the tissue capillary
4 Factors Affecting Diffusion
1. Gradient-pressure difference between atmosphere
and alveoli and the pulmonary capillaries
2. Surface area- the greater the surface area, the greater
the exchange or diffusion during a specific time period
3. Thickness- the thicker the surface, the lesser is the
diffusion; increasing membrane thickness are fluid in the
alveoli or interstitial space or both; inflammatory
processes, or fibrotic lungs
4. Length of Exposure- the longer the exposure, the
more gases are diffused
PERFUSION
-described as the flow of blood through the pulmonary
capillary bed
Primary Functions of Pulmonary Circulation:
1. Perform gas exchange portion of the lung
2. Facilitate gas exchange
3. Filter blood that moves from right to left side of the
circulation
4. Remove mostof the thromboembolics
5. Serve as reservoir of blood for the left side of the
heart
Factors Affecting Perfusion
1. Gravity-perfusion greatest in the dependent
areas, the bases in the upright person
2. Position- upright position less alveolar
ventilation in the apices than the bases
Ventilation-Perfusion Ratio-ratio of alveolar
ventilation to pulmonary capillary diffusion
Normal diffusion of gases
*balance of alveolar ventilation and pulmonary
perfusion
*ideal gas exchange=1:1 ratio; for every 1L of fresh air
coming into the alveoli, 1L of blood would flow past
through it
Matching Ventilation and Perfusion
Factors that interfere with matching:
1. Dead air space – the air that must be moved with
each breath but does not participate in gas exchange; 2
types: anatomic dead space and alveolar dead space
2. Shunting – refers to the blood that moves from the
right to the left side of the circulation without being
oxygenated; 2 types: physiologic shunt and anatomic
shunt
Pulmonary Shunting
Not all blood that flows through the lungs participates in
gas exchange.
Total normal physiologic shunting range=5-20% of
cardiac output
1. Anatomic shunt- blood that moves from right
heart to the left heart without coming into
contact with the alveoli
2. Capillary shunt- normal flow of blood pass
through unventilated alveoli
3. Shunt-like effect- when there is excess of
perfusion in relation to alveolar ventilation, as in
reduced ventilation
4 Ventilation-Perfusion Matches
1. Normal: ventilation matches perfusion • HCO3 (22-26mEq/L ) - the amount of bicarbonate ion
dissolved in the blood. It is the base balance component
2. Low ventilation-perfusion ratio: shunt producing
that reflects kidney function.
disorder; no gas exchange occurring
• SaO2 (95-100%) -represents the percentage of oxygen
3. High ventilation-perfusion ratio: dead space
carried by hemoglobin
producing disorder
• pH (7.35-7.45) - measures hydrogen ion (H+)
4. Silent unit: absence of ventilation and perfusion
concentration in the blood
Mismatching of Ventilation and Perfusion
Different Hemoglobins
• Perfusion without ventilation=low ventilation-
• Different organism have different hemoglobins, this
perfusion ratio (e.g. atelectasis)
depends upon the organism’s metabolism and
• Ventilation without perfusion=high ventilation- environment.
perfusion ratio (e.g. pulmonary embolism)
• Hemoglobins with a high affinity for oxygen. These
take up oxygen more easily but release it less readily
GAS EXCHANGE • Hemoglobins with a low affinity for oxygen. These
take up oxygen less readily but release it more readily
Arterial Blood Gases- Partial pressure exerted by the
gases in the circulatory system
• PaO2 (80-100 mmHg) reflecting the amount of
oxygen delivered into the blood stream.
Infant (40-70)
• PaCO2 ( 35-45 mmHg) to evaluate how effectively
the lungs eliminate carbon dioxide which is the
byproduct of metabolism.
 Oxygen-hemoglobin dissociation curve
- the relation between the oxygen carried in
combination with hemoglobin and the PO2 of
the blood
- Shows the relationship between the partial
pressures of O2 (PO2) and the percentage of
saturation of O2 (SaO2)
- The x-axis depicts the Po2; the left y-axis shows
the Hgb oxygen saturation and the right y-axis
shows the O2 content

Oxyhaemoglobin dissociation curve

 CARBON DIOXIDE TRANSPORT
• 200mL of carbon dioxide is produced and then
excreted every minute by lungs
Transported
in 3 forms in blood:
a. Dissolved in plasma-10%
b. Bound to hemoglobin
(carbaminohemoglobin)-30%
c. As bicarbonate ions in plasma (majority in
this form)- 60%
Carbon dioxide transport
• In systemic circulation, increase in carbon dioxide
causes more oxygen to dissociate from hemoglobin
allowing more carbon dioxide to combine with
hemoglobin and more bicarbonate ions to be generated
In pulmonary circulation, the situation is reversed:
uptake of oxygen facilitates release of carbon dioxide
• Normally 97.4% of hemoglobin saturated with oxygen;
hemoglobin fully saturated at PO2 of 70 mmHg
Carbon dioxide transport
•Temperature: affinity of oxygen and hemoglobin
decreases as temperature of body increases above
normal, oxygen unloading is enhanced; with chilling,
oxygen unloading is inhibited
• pH: oxygen-hemoglobin bond weakened by increased
hydrogen ion concentration; more acidic, oxygen
unloading is enhanced (also occurs with increase in
pCO2)
• Organic chemical 2,3- DPG formed in RBCs
enhances release of oxygen from hemoglobin during
times of increased metabolism
Peripheral Control-due to the sensing of the partial
pressure of O2 (pO2) and of partial pressure of CO2
(pCO2) in the blood
NEUROLOGIC CONTROL OF VENTILATION
CNS Control
a. Medulla-dorsal respiratory group provides
inspiration; ventral provides exhalation
b. Pons- apneutic center contains both inspiration and
expiration neurons
Upper pons- pneumotoxic center; fine tunes breathing
like talking while breathing
Rhythmic respiratory movement- output in the
respiratory neurons in the medulla
c. Cortex- allows voluntary control of breathing like
holding our breath
CONTROL OF BLOOD FLOW
a. Local control- governed by constant tissue
blood flow to organs like heart, brain and
kidneys
autoregulation- ability of the tissues to regulate their
own blood flow over a wide range of pressures
Tissue factors contributing to local control of blood
flow:
1. Histamine- vasodilator
2. Serotonin- vasoconstrictor
3. Kinins- cause relaxation of arterial smooth
muscle
4. Prostaglandins- synthesized from
constituents of the cell membrane
b. Neural Control-regulates cardiac function and blood
pressure located in the reticular formation of the lower
pons and medulla of the brain stem
Heart function is influenced by:
1. parasympathetic nervous system- regulates heart
rate through the vagus nerve
2. Sympathetic nervous system- has excitatory
influence on heart rate and contractility; serves as final
common pathway for controlling smooth muscle tone of
the blood vessels
2. During swallowing moves upward and Alveolar Macrophages
epiglottis covers opening to larynx
•A free mononuclear cell of the lower respiratory tract,
which has a high phagocytic capacity, and is responsible
for clearing inhaled particles and lung surfactant
PHYSICAL ASSESSMENT-RESPIRATORY
 Skin
Examine extremities for signs of the following:
1. Cyanosis
2. Clubbing

 Nose and Sinuses

RESPIRATORY DEFENSE MECHANISMS
Inspect external nose for:
•Filtration of air Other protective mechanisms:
1. Alignment
•Muco-ciliary clearance system Trachea
2. Color
•Cough Reflex • Composed of C-shaped cartilage rings; contains
seromucous glands producing thick mucus which is 3. Nasal flaring lesions symmetry
•Reflex Broncho-constriction
moved toward throat by cilia 4. Discharges
•Alveolar macrophages
Lungs 5. Patency of nares
• Pulmonary arteries and veins; pulmonary capillary Inspect internal nose:
RESPIRATORY DEFENSE MECHANISMS network which surround the alveoli
-Note mucosa, Septum
• Tonsils and adenoids located in mucosa in posterior • Bronchial arteries supply lung tissue and drained by
wall; trap and destroy infectious agents bronchial and pulmonary veins  Respiratory Excursion
 Observe breathing pattern
• Larynx: Pleura
 Eupnea- good unlabored
1. Provides airway, routes air and food properly • Produce pleural fluid: lubricating serous fluid, which  Tachypnea- abnormally rapid
allows lungs to move easily over thoracic wall during
breathing
  Hyperpnea- increase in depth to meet o Vesicular Sputum collection:
metabolic demands (e.g. post exercise, climbing  Adventitious sounds
1. should be taken early morning
high altitudes)  Vocal resonance
 Hypopnea- slow shallow  Bronchophony- is the abnormal transmission of 2. ask client to take some deep breaths before coughing
 Bradypnea- very slow sounds from the lungs or bronchi.
 Orthopnea- shortness of breath when flat  Egophony- increased resonance of voice sounds
 Apnea- temporary cessation of breathing heard when auscultating the lungs,
 Cheyne-Stokes respiration- with cycles of
respiration that are increasingly deeper then
shallower with possible periods of apnea.
 Kussmaul’s respiration- deep and
labored breathing pattern often associated
with severe metabolic acidosis,
particularly diabetic ketoacidosis (DKA)
but also kidney failure.
 Biot’s respiration-characterized by
groups of quick, shallow inspirations
followed by regular or irregular periods of
apnea.
Palpation
 Note for crepitus, pulsations, swelling,
bulging, retractions, tenderness
 Tactile fremitus
Percussion
 Percuss between ribs; compare both sides

Auscultation

 Normal breath sound

o Bronchial
o Bronchovesicular
 PULMONARY FUNCTION • Pulse oximetry (SpO2) allows continuous, non-
STUDIES invasive monitoring of patient’s arterial O2 saturation
levels painlessly
1. Evaluation of lung volume and
capacities by spirometry • LED’s (Light Emitting Diodes) work by
(tidal volume, residual volume, etc.). 1. Measuring the absorption of transmitted light as
it passes through the vascular bed
2. Involves use of spirometer to diagram
2. Oxygenated and deoxygenated hemoglobin is
movement of air as client performs various
measured as they absorb red and infrared lights
respiratory maneuvers; shows restriction or
at different rates
obstruction to air flow or both
HEMATOLOGIC STUDIES (ESR, Hgb, Hct, WBC)
Nursing Care
• Reflects amount of hemoglobin available for
1. Carefully explain procedure
combination with oxygen
TUBERCULIN TEST
2. Perform test before meals
• Reflects ratio of blood cells to plasma
 Results: Read within 48- 72 hours;
3. Withhold meds that may aler respiratory function
 Inspect skin and circle zone of induration with a • Monitors inflammatory or malignant disease; speed of
unless otherwise ordered
pencil settling of RBC
 Measure diameter in mm 4. After procedure assess pulse and provide rest periods.
 NEGATIVE: diameter less than 5mm
Arterial Blood Gases
 DOUBTFUL: 5-10 mm THORACENTESIS-insertion of a needle through the
 POSITIVE: 10 mm or more • Partial pressure exerted by the gases in the circulatory chest wall into the pleural space to obtain a specimen for
system diagnosis, evaluation, removal of pleural fluid
accumulation or to instill medication into the pleural
• PaO2 (80-100 mmHg) reflecting the amount of space
oxygen delivered into the blood stream
• Nursing care: Pretest
• PaCO2 ( 34-46 mmHg) to evaluate how effectively
the lungs eliminate carbon dioxide 1. Confirm that a signed consent has been obtained

• HCO3 (22-26mEq/L ) - the amount of bicarbonate ion 2. Explain procedure: instruct not to cough or talk
dissolved in the blood during the procedure

• SaO2 (95-100%)- represents the percentage of oxygen 3. Position client at side of bed, with upper torso
carried by hemoglobin supported on over bed table, feet and legs well supported
4. Assess vital signs 3. Assess and report frank bleeding -After intake of chemicals that interfere with the
balance of normal flora (aerosolized mucolytics,
4. Apply ice bags to throat for comfort, discourage
steroids, antibiotics)
talking, coughing, smoking for a few hours to decrease
• Nursing care: Post thoracentesis
irritation  Hydration
1. Observe for signs and symptoms of pneumothorax, -Liquefy secretions
shock and leakage at puncture site -Prevents constipation and fluid imbalances
Pediatric -Should consider disease conditions that
2. Auscultate chest to ascertain breath sounds warrants fluid limitations
• Pulmonary function testing should not be done under  Infection and control
age 6 years since children have difficulty following  Psychosocial support
Pleurodesis- Instillation of antibiotics into the pleural directions
space to cause closure of openings in the alveoli and TREATMENT MODALITIES
• Chest x-rays: avoid unnecessary exposure; protect
stop escape of air and fluid into the pleural space. Pharmacologic interventions
gonads and thyroid
BRONCHOSCOPY-insertion of a fiberscope into the I. Antimicrobials/antibiotics
bronchi for diagnosis, biopsy, specimen collection,
 Usually tetracycline and ampicillin, very
examination of structures/tissues, removal of foreign
few antiviral medications
body
 Given to those with viral infections since
these clients are predisposed to bacterial
COMMON RESPIRATORY INTERVENTIONS infections
• Nursing Care: Pretest
I. General Interventions
1. Confirm that a signed permit has been obtained  Positioning and posture
 Environmental control
2. Explain procedure, remove dentures and provide good
oral hygiene -Smoke-free; Clean Air Act II. Bronchodilators
 Activity and rest
3. Keep client NPO 6-12 hours prior to test  Oral hygiene  Act directly on bronchial smooth muscles to
relieve bronchospasm
-Mouth breather dries mucosa leading to  Beta adrenergics-albuterol
stomatitis
• Nursing Care: Post Test  Beta adrenergics- epinephrine, with lesser side
-Use of antiseptic mouthwash effects (tachycardia, nausea and tremors)
1. Position client on side or in semi-Fowler’s
 Theophylline preparations- aminophylline
2. Keep NPO status until return of gag reflex
  Side effects:Increase heart rate, palpitations, 1. O2 therapy Oxygen Delivery
nervousness, skeletal muscle tremors, nausea,
2. Humidity and aerosol therapy  Cannula 28-44% (2-6
anorexia
L/min)
3. Suctioning
III. Adrenal Glucocorticoids  Mask 40-60% (5-8 L/min)
4. Facilitating coughing-chest physiotherapy  Face Tent/ 21-100% trach collar
 Reduce inflammation; prevent bronchospasm
 Venturi mask 24-50%
 Decrease responsiveness of the cells to allergic 5. Artificial airways
 Partial rebreather 35-60% (6-15L/min)
stimuli thus reducing bronchoconstriction
6. Mechanical ventilators  Non-rebreather 90% or > (12-15L/min)
 Prednisone, Beclomethasone, Triamcilone
 T tube 21-100%
Oxygen Therapy
IV. Antitussives  CPAP mask 21-100%
• To give the patient more oxygen to meet increased
 Inhibit cough reflex Oxygen -related Problems
needs triggered by fever, massive tissue damage
 Coats and protects mucosa
Oxygen toxicity
 Has soothing effect; do not drink water • To correct hypoxemia
• High O2 concentrations (50%>) for a prolonged period
V. Mucolytics • To decrease respiratory effort by increasing O2
may eliminate nitrogen from the lungs inactivate
diffusion and alveolocapillary membrane function.
 Liquefies secretions pulmonary surfactant and lead to ARDS

VI. Antiallergenics
 Stabilizes mast cells, inhibiting release of
mediators such as histamine and SRSA
 Cromolyn Na (Intal)
VII. Vasoconstrictors and Decongestants
 Used to treat allergic reactions
 Should be used for short periods (<1 week), can
produce nasal congestion and rebound effect,
worsening nasal congestion
RESPIRATORY THERAPY
Types of Oxygen Flow
• High flow – venturi mask, CPAP mask, tent or T-tube
attached to a venturi jet nebulizer.
• Low flow – canula, simple face mask, partial or non –
rebreather mask, trach collar, face tent and T-tube
• N.I. – monitor arterial blood gas levels and PaO2 to
ensure optimal oxygenation with the least amount of
oxygen delivered
• Respiratory depression- increasing oxygen removes
the stimulus for breathing in COPD
• Circulatory depression- O2 reverses vasoconstriction
and significant BP drop
• Absorption atelectasis – High oxygen concentrations
washes away the normal nitrogen content of the alveoli
• Retrolental fibroplasia– happens after exposure to
100% oxygen in adults or 40% in children and increase
in PaO2 of 150mmHg >
 -hydration and humidified oxygen • Postural drainage

S/S of Atelectasis • Specific precautions Artificial Airways

• Vague discomfort and anxiety  monitor status • Tracheostomy devices- disposable or reusable
 hyperventilate/ hyperoxygenate
• Tachypnea and tachycardia • Tracheostomy care- Hydrogen peroxide, NSS, ties
 stop if with cardiac difficulty
and dressings
• Fever and cough  aseptic technique
 discard solutions after 24 hours • Patient teaching and support- Communication
• Shortness of breath  change suction catheters
 promote relaxation • Oropharyngeal airways – should match the distance
• Sub -sternal retractions between the lips and the angle of the jaw
 neck in neutral position
• Absent or diminished breath sounds  lubricate catheters as needed • Nasopharyngeal airways- smaller than the nostril
 sedatives with a length from the nose to the earlobe
• ABG’s showing hypoxemia from intrapulmonary
shunting Coughing and Chest Physiotherapy • Endotracheal tubes- Inserted via mouth or nose into
• Correct performance of the deep breathing and the trachea to lodge just above the carina
coughing exercise
Humidity and Aerosol Therapy
• Inhalation Exhalation ratio 1:2 Mechanical Ventilators
•Humidification – prevents drying or loosens secretions
• Positioning and vibration depending on location of • Artificially controls or supports breathing efforts of a
•Nebulization - Water, saline, bronchodilators pulmonary secretions. patient who is suffering from respiratory failure.
Suctioning Guidelines
• Helps prevent alveolar collapse by supplying
• Evaluate the risk of complications adjunctive therapies such as
Other interventions…
-bleeding, increased ICP, compromised CV and -Continuous positive airway pressure (CPAP)
• Incentive spirometry – encourage maximal deep
respiratory status
breathing by visualizing the amount of air volume - Positive end expiratory pressure (PEEP)
• Provide safety and comfort achieved in inspiration.

-suction pressure not > 120mmHg • Breathing retraining

-avoid suctioning more than 15 secs.
-use small catheter
Types of Ventilators
• Diaphragmatic breathing
• Negative pressure ventilators
• Percussion and vibration
• Volume cycled ventilator
• Pressure cycled ventilator •Provide nutrition  Blood clots
 MOSF
• High frequency ventilators •Promote mobility
Post-op Course
•Promote communication
• Day 1-patient is placed in ICU for monitoring and
Disorders which may require MV •Maintain oral hygiene
treating hemodynamic instability and assessing
• Gas Exchange disorders respiratory status since risk of pneumonia is great

-RTI Cardiovascular /Blood Modalities • Day 2- patient is asked to ambulate 3x; IV lines and
tubes are discontinued; discharge teaching begins
-Pulmonary emboli •Blood transfusion
• Day 3- pacer wires are removed
-ARDS •Bone marrow transplantation
•Extra-pulmonary disorders •Iron replacement
-Guillain-Barre syndrome •Vitamin supplements and nutrition
-Flail chest •Treatment for autoimmune disorders
-Other musculoskeletal disorders •Support
Adjuncts to mechanical ventilation
• PEEP – for pts. with acute restrictive lung disease or Coronary Artery Bypass Graft-involves the bypass of
intra thoracic bleeding. a blockage in one or more of the coronary arteries using
the saphenous veins, mammary artery or radial artery as
• CPAP – for pts. with decreased FRC, fluid filled
conduits or replacement vessels.
alveoli, atelectasis, post-operatively
Possible Benefits
• Adverse effect: Barotrauma – caused by too high-
pressure settings  Prolongation of life
 Increased exercise tolerance
 Reduced need for medication
Nursing care Guidelines for MV  Ability to resume former activities Possible
Complications
•Suction the patient’s airway  Post-op bleeding
•Provide medications  Wound infection, dehiscence