Care of Patients with Problems in

Oxygenation
Monday, 4 September 2023 1:11 pm

The Concept of Oxygenation Assessment

Oxygenation – mechanisms that facilitate or impair the body’s ability to supply oxygen to cells. 1. History
2. Physical Assessment
Respiration – an act of inhaling and exhaling air to transport oxygen to alveoli. 3. Inspection
So oxygen may be exchanged for carbon dioxide 4. Palpation
Carbon dioxide expelled from the body 5. Auscultation
6. Percussion
Ventilation – actual exchange of oxygen & carbon dioxide.
Pediatric Considerations
Breathing – contributes to vital oxygenation • Mouth & nose – generally, all structures are smaller and more easily obstructed than in adults.
• Pharynx – Infants’ and children’s tongues take up proportionally more space in the mouth than adults’.
Adequate oxygenation depends on a healthy & intact respiratory system. • Trachea – (windpipe)
• Infants and children have narrower tracheas that are obstructed more easily by swelling.
Steps in Oxygenation • Trachea is softer and more flexible in infants and children.
• Cricoid cartilage – like other cartilage in the infant and child, the cricoid cartilage is less developed and less rigid. It is the narrowest
• Ventilation – the process of moving gases into and out of the lungs. part of the infant’s or child’s airway.
• Diaphragm – chest wall is softer, and infants and children tend to depend more heavily on the diaphragm for breathing.
• Perfusion – the ability of the cardiovascular system to pump oxygenated blood to the
tissues and return deoxygenated blood to the lungs. Respiratory Rates
Infant: 30 - 60
• Diffusion – exchange of respiratory gases in the alveoli and capillaries. Child: 20 - 30
Adult: 12 - 20
What are the primary functions of the respiratory system?

Assessment
✓ Inspection
✓ Back & front
✓ Chest symmetry
✓ Tracheal deviation
✓ Skin & nail beds color
✓ Clubbing fingers
✓ RR & pattern
✓ Using accessory muscles
✓ Nasal flaring
✓ Purses of the lips during breathing
Primary Functions
Palpation  Percussion
• Delivers oxygen to the bloodstream and removes excess carbon dioxide from the body.
✓ Emphysema  Determine the presence of
• Gas exchange (O2 & CO2).
✓ Pain air, fluid, or mass
• Sound production & resonation
✓ Tenderness
• Protection (from dust and microbes entering the body through mucus production, cilia, and
✓ Symmetry
coughing).
✓ Warmth & dryness
Remember that we need the cardiovascular system to work intimately with the respiratory
system because the cardiovascular system helps us transport these gases (O2 & CO2).
Auscultation
✓ Air entry
Airways & Lungs
✓ Breath sounds
✓ Compare side to side
• Upper respiratory tract
✓ Quality of pitch
• Lower respiratory tract
• Two lungs are part of the lower airway & share space in the thoracic cavity with
the heart & great vessels, trachea, esophagus & bronchi.

Assessing Lung Sounds

Upper Respiratory Tract
✓ To auscultate lung sounds, use the diaphragm of your stethoscope.

There are three normal breath sounds

▪ ¤ Bronchial breath sounds
▪ ¤ Bronchovesicular breath sounds
▪ ¤ Vesicular breath sounds

Auscultation Landmarks
Auscultating the lungs is comprised of three parts:
 Landmarking correctly
 Being able to identify which lobe is being auscultated and
 The interpretation of adventitious sounds

Upper Respiratory Tract

❖ Nasal cavity
✓ Covered with mucous membrane which produces fluid for moistening
✓ Contains blood vessels for warming
✓ Hairs to filter the air. –
✓ Smell odor (olfactory nerve)
Function of the sinuses ???
Lighten the skull & voice

Bronchial Breath Sounds

 Loud, harsh, & high-pitched

 Heard over the trachea, bronchi
(between clavicles & mid-sternum),
and over the main bronchus

Bronchovesicular Breath Sounds

 Blowing sounds
 Moderate intensity & pitch
 Heard over large airways, on either side of the sternum,
at the sternal angle, and between scapulae

Vesicular Breath Sounds

✓ Larynx  Soft breezy quality
Vocal cords (pitch, volume, resonance)  Low pitched
Glottis & Epiglottis  Heard over the peripheral lung area
✓ Glottis  Heard best at the base of the lungs
(space between the vocal cord)
✓ Epiglottis Adventitious Breath Sounds
(cartilage that keeps the food & 1. Crackles
liquid out of the respiratory tract) * Popping, crackling, bubbling, & moist sounds.
Humidifying, Filtering & warming * Heard on inspiration
Lung Problem:
 Pneumonia
 Pulmonary edema
 Pulmonary fibrosis

2. Rhonchi
* Rumbling sound

Quick Notes Page 1

 Lung Problem:
 Pneumonia
 Pulmonary edema
 Pulmonary fibrosis

2. Rhonchi
* Rumbling sound
Trachea * Heard on expiration
✓ C-shaped rings of cartilage ?? Lung Problem:
✓ To keep the trachea open & allow esophagus  Pneumonia
to expand during swallowing  Emphysema
✓ Humidifying, Filtering & warming  Bronchitis
✓ Cough reflex (vagus nerve)  Bronchiectasis
✓ Mucociliary escalator
(Push mucus & particles upwards 3. Wheezes
towards the larynx, cough, sneeze, * High-pitched musical sound
or blow). * Heard during both inspiration & expiration
* Louder on expiration
Lung Problem:
 Emphysema
 Asthma
 Foreign bodies

Upper Respiratory Infection 4. Pleural Friction Rub

These infections affect your sinuses and throat. * Dry, grating sound, leather on leather
▫ Common cold * Heard on both inspiration & expiration
acute illness of the upper respiratory tract caused * Created when the visceral and parietal pleurae become inflamed and roughened
by a virus (rhinovirus). * The inflamed membranes will stick together.
S/sx: runny nose, nasal congestion, itchy throat, watery eyes, & headache. Lung Problem:
 Pleurisy
▫ Epiglottitis  Pneumonia
inflammation and swelling of your epiglottis caused by  Pleural infarct
bacterial infection.
S/sx: pain when swallowing, severe sore throat, & Diagnostic Tests
difficulty breathing. • Chest Xray (CXR)
Four D’s Produce images of the heart, lungs, blood vessels, airways & the bones of the chest and spine.
a).Dysphagia – difficulty swallowing CXR detects and reveals:
b).Dysphonia –hoarseness or an abnormal voice * Heart-related lung problems
c).Drooling – saliva flows out in the * Collapsed lung
mouth involuntarily * Pneumonia
d).Distress – difficulty breathing or lack of oxygen * Emphysema
* Fractures
Epiglottitis is a medical emergency as the swelling blocks airflow into * Usually taken after full inspiration (deep breath)
the lungs. * Lungs are best visualized when they are well aerated

▫ Laryngitis (acute or chronic)

inflammation of your voice box (larynx) from overuse, irritation, or infection.
S/sx: hoarseness, sore throat, dry throat, & dry cough. • Arterial Blood Gases (ABG’s)

Sinusitis (sinus infection)
Acute Sinusitis – spaces inside your nose (sinuses) become
inflamed & swollen, interfere with drainage, & cause mucus to
buildup.
S/sx: runny nose, postnasal drainage, headache, pain, and
pressure around your forehead, & headache.
* ABG is a blood test that requires a sample from an artery
in your body to measure the levels of O2 & CO2 in the blood
Fatima Ivan Ceniza at 5 Sep 2023 8:21 am
* Check the balance of acids & bases in your blood,
known as the pH balance

▫ Pharyngitis (sore throat)

S/sx: throat pain, runny nose, nasal congestion, & swollen lymph
nodes. It is caused by bacterial or viral infection, tonsillitis, &
allergies. • Incentive Spirometry
* Helps promote lung expansion after prolonged bed rest or surgery
* Requires patient to take a deep breath and
Lower Respiratory Tract hold it for several seconds
Lung * Performing Incentive Spirometry:
✓ Bronchial & alveolar structures ✓ Increases lung volume
✓ Right & left lobes ✓ Boosts alveolar inflation
✓ Right lung – larger with (3) lobes ✓ Promotes venous return, which helps prevent atelectasis
✓ Left lung – smaller with (2) lobes & pneumonia
Why is the right lung bigger than the left lung?

• Peak Flow

• Pulse Oximetry
Pleura (Serous Membrane) * A non-invasive method of continuously monitoring the oxygen saturation of hemoglobin.
✓ Visceral pleura covers the lung * It does not replace ABG measurement;
✓ Parietal pleura lines the thoracic cavity & contains it is an effective tool for monitoring subtle oxygen saturation changes.
nerve endings
✓ Pleural fluids between the two layers of the
pleura
✓ Lubricate the thorax and lungs
✓ Allow layers to slide smoothly over each other as
the chest expands & contracts (inspiration & 
expiration). • Magnetic Resonance Imaging (MRI)
* MRI uses magnetic field & radio frequency signals instead
of a narrow beam x-ray.
* Yield a much more detailed diagnostic image than CT scans.
* Evaluate inflammatory activity in interstitial lung disease,
acute pulmonary embolism, & chronic thrombolytic
pulmonary hypertension.

• Fluoroscopic Studies
* Assist with invasive procedures like chest needle or
trans-bronchial biopsy to identify lesions.
* Study the movement of the chest wall, mediastinum,
heart & diaphragm, to detect diaphragm paralysis, &
to locate lung masses

• Lung Function Test

• Bronchoscopy
Bronchi & Bronchioles 
* Direct inspection & examination of the larynx, trachea,
Bronchi (Sing. Bronchus): & bronchi using either flexible or rigid fiberoptic bronchoscope
Each bronchus leads into a lung and branches into * Examine tissues or collect secretions
smaller and smaller bronchioles, resembling an inverted * Determine the location & extent of the pathologic process &
tree. to obtain a tissue sample for diagnosis.
Bronchioles * Determine if a tumor can be resected surgically or diagnose
▫ Fine tubes that allow passage of air. bleeding sites
▫ Epithelium of bronchioles is covered with cilia and
mucus to trap and remove dust and other particles. • Lung Biopsy
▫ Bronchioles end in tiny air sacs called alveoli • Sputum studies
Alveoli • Cultures
Type I cells
□ Alveolar wall (the barrier between air & the

Quick Notes Page 2

 ▫ Fine tubes that allow passage of air. bleeding sites
▫ Epithelium of bronchioles is covered with cilia and
mucus to trap and remove dust and other particles. • Lung Biopsy
▫ Bronchioles end in tiny air sacs called alveoli • Sputum studies
Alveoli • Cultures
Type I cells
□ Alveolar wall (the barrier between air & the • Computed Tomography (CT)
alveolar surface) * Lungs are scanned in successive layers by a
□ Gas exchange (O2 & CO2) narrow-beam x-ray.
Type II cells * Produce & provide a cross-sectional view of the chest.
□ Surfactant * Distinguish fine tissue density.
□ Lipid-type substance that coats the alveoli
Type III cells
□ Alveolar macrophages (defense mechanism)

SOME FACTS
 Alveoli: functional units of the lungs where O2 is
exchanged
 The wall of the alveoli are only 1 cell thick
 Surfactant lines the alveoli walls and helps keep alveoli
from collapsing
 60-80square meters in the lungs for gas exchange
 Alveoli are grouped in clusters.
 A network of capillaries surrounds each alveolus.
• Fluoroscopic Studies
* Assist with invasive procedures like chest needle
or trans-bronchial biopsy to identify lesions.
* Study the movement of the chest wall, mediastinum,
* heart & diaphragm, to detect diaphragm paralysis, & to
locate lung masses.

Gas Exchange
 Gas exchange takes place in the alveoli. • Pulmonary Angiography
 Oxygen diffuses into the blood. * Investigate thrombo-embolic disease of the lungs,
 Carbon dioxide in the blood diffuses into the alveolus e.g., pulmonary emboli & congenital abnormalities of the
pulmonary vascular tree.
* Rapid injection of a radiopaque agent for radiographic study of the
pulmonary vessels.

Why are we talking about pulmonary surfactant?

 Synthesized by type II cellular cells
 Reduces surface tension (prevents alveolar collapse during expiration) • Thoracentesis
 Prevents bacterial invasion * Aspiration of fluid & air from the pleural space.
 Cleans alveoli surface * Diagnostic or therapeutic reasons.
* Removal of fluids & air (rare)from the pleural cavity.
Surface Tension * Aspiration of pleural fluid for analysis, pleural biopsy
Liquid molecules line the alveolar walls and attract each other & instillation of medication into the pleural space.
This attractive force is called surface tension
These attractive forces MUST BE overcome to expand lung
SURFACTANT reduces surface tension

Lower Respiratory Diseases

▪ Asthma
- breathing is impaired by constriction of bronchi and bronchioles. Inflammation
of the lining of the bronchial airways.
▪ Causes: precipitated by inhalation of allergens (e.g., pollen & cats), pollutants,
infection, or emotional stress.
▪ Cells that line the bronchi release chemicals that cause inflammation when
they are stimulated by irritants or allergens.
▪ S/sx: SOB, wheezing, chest tightness, & pallor

▪ Bronchitis
- inflammation of the mucous membranes of the bronchi.
S/sx: cough, fever, chest or back pain, & fatigue.
Causes: smoking, pollution, & bacterial or viral infections.

▪ Pneumonia
- acute lung tissue inflammation with alveoli consolidation commonly impairs
gas exchange.
Causes: Bacterial, fungal, or viral infections.
S/sx: dyspnea, high fever, chills, headache, severe cough, & chest pain & rusty
colored sputum.

▪ Emphysema
- permanent and irreversible destruction of
alveolar walls, resulting in loss of lung elasticity & gas exchange surface.
Air that is normally exchanged becomes trapped in the alveoli.
Unable to exhale, lungs become distended & muscles suffer from lack of O2,
becoming less elastic.
S/sx: SOB, chronic cough, weakness, drowsy, & barrel shaped chest.
Causes: Smoking, pollution, old age, & infections.

If fresh gas is not delivered to the alveoli

and blood is not delivered to the alveolar
capillaries, or if the alveolar surface is
Factors Affecting Ventilation damaged, oxygenation or CO2 elimination
may be impaired
▪ Compliance
What is lung compliance?
* lungs’ ability to stretch
* lungs’ ability to expand

Elastance
ability of a structure to return to its resting
position after being stretched
Elastic recoil
magnitude of the force to return to its resting
position
Decreased compliance occurs if the lungs and
the thorax are stiff.

How do lungs adapt and why?

Compliance of the lungs occurs due to elastic forces.
A. Elastic forces of the lung tissue itself
B. Elastic forces of the fluid that lines the inside walls of alveoli and
other lung air passage

Quick Notes Page 3

other lung air passage
A B
Elastin + Collagen Fibres Is provided by the substance
called surfactant that is present
inside walls of the alveoli.

What would influence elastance and elastic recoil?

• Disease
• Pulmonary Fibrosis
• Aging
• Emphysema (COPD)
• Obesity
• Pneumothorax

What is resistance?
* force opposes flow from one point to another (opposition of the flow of gases)
* dynamic force - involved only during movement
* Primary factors that determine resistance are:
* Size and radius (or diameter) of the airway
* Flow rate
* Secretions/water in the airway system

Could having a tracheostomy affect resistance?

* Flow into and out of the lungs will be adversely affected by obstructed airways
* Airways get smaller & shorter during exhalation = greater resistance

Causes of Increased Resistance

• Small endotracheal tube
• Bronchospasm
• Mucosal edema
• Airway obstruction (mucus, tumor, or a foreign body)
• Secretions

Quick Notes Page 4