Oxygenation

Function of the respiratory system ‫وظائف الجهاز التنفسي‬

• The function of the respiratory system is gas exchange between individual and
• environment .

The process of respiration involves three components:

• Pulmonary ventilation or breathing the movement of air between the atmosphere and the
alveoli of the lungs as we inhale and exhale.
• Gas Exchange : involves diffusion of Oxygen and Carbon dioxide between alveoli and
pulmonary
capillaries.
• Transport of oxygen from the lungs to the tissues and carbon dioxide from the tissues to the
lungs .
Structure and Function of the respiratory system ‫التركيب‬
Ventilation is also known as :
• Wheezing
• Pneumonia
• Breathing
• Lung Abscess
• Oxygen is needed to sustain life.
• Oxygen is odorless, colorless, tasteless gas that constitutes 21 % of the air we breathe.
• Oxygen facilitates burning, the greater the concentration of O 2 the more rapidly fires
start.
• Neural and chemical regulators control the rate and depth of respiration to maintain the
• correct concentration of oxygen and carbon
• dioxide. How?
Respiratory regulation
• Chemosensitive center in the medulla oblongata is highly responsive to increases in blood
CO 2 concentration, it can increase the depth and rate of respiration.
Special neural receptors sensitive to decreases in O 2 concentration is located outside the
CNS in the carotid and aortic bodies
• Decrease in arterial O 2 concentration stimulate these chemoreceptors and they in turn
stimulate the respiratory center to increase the ventilation
• The
• CO2 concentration has the strongest effect on stimulating respiration .
Factors Affecting Respiratory Function
 Age • Many physiological changes may occur through the aging
process loss of elasticity of airway passages, decrease in
cough reflex , osteoporosis). At birth , lung gradually expand,
reaching full expansion by 2 weeks )
Environment • Altitude, air pollution affect oxygenation. Air pollution cause
coughing
• The person at high altitude has increased respiratory and cardiac
rate (↑altitude → ↓ PO2).

Lifestyle • Physical exercise increases the rate and depth of respiration.

Certain occupation predisposes lung disease (e.g., Asthma more
often in factory workers).
Health status • In healthy person, the respiratory system can provide
sufficient oxygen Disease of respiratory system can
adversely affect blood oxygenation .
Nutrition • Obesity: Decrease lung expansion.
• Poor diet cause anemia.
Cigarette smoking • Associated with several diseases. Nicotine
• causes vasoconstriction and increase Blood pressure .
Substance abuse
• Alcohol & drugs depress the respiratory center and cause
bradypnea which impair tissue oxygenation.

Medications • A variety of medications can decrease the rate and depth of

respirations such as sedatives-hypnotics & antianxiety.
• Nurse must carefully monitor respiratory status to check for side
effects (respiratory depression).
Stress • Both psychologic and physiologic responses can affect
oxygenation (cause hyperventilation).
• Physiologically, the sympathetic nervous system is stimulated, and
epinephrine is release during stress causes bronchodilation,
increase blood flow and O2 delivery to muscles.
Factors Affecting Respiratory Function
Physiological factors
•Decreased inspired oxygen concentration (upper or lower airway obstruction).
•Hypovolemia (reduced circulating blood volume)
•Decreased oxygen-carrying capacity (haemoglobin)
•Alteration affecting chest wall movement → Next Slide
•Increased metabolic rate and O2 demand (exercise, wound healing)

Conditions affecting chest wall movement

• Pregnancy: (Decline in the inspiratory capacity in the last trimester resulting in
dyspnea on exertion and increased fatigue).
• Obesity: (Reduced lung volume from heavy abdomen when in supine position)
• Musculoskeletal abnormalities: (e.g., rib fractures , abnormal structural configuration)
• Neuromuscular disease: (e.g., muscular dystrophy, decrease ability to expand
and contract chest wall )
• Central nervous system alterations: (impaired respiration. e.g., paralysis due
to C3 C5 trauma affects the movement of the diaphragm)
 Alterations of Respiratory Function

1. Hypoxia ‫نقص االكسجين‬

Hypoxia is Inadequate tissue oxygenation at the cellular level
Hypoventilation→ Alveolar ventilation inadequate to meet the body s oxygen demand or to eliminate
sufficient carbon dioxide
• May occur because of diseases of the respiratory muscles, drugs, or anesthesia.
• CO 2 accumulates in the blood Hypercarbia or hypercapnia
Hypoxemia refers to reduced O 2 in the blood and is characterised by low partial pressure of O 2 in the
arterial blood or low Hb saturation
Cyanosis:
• Blue discoloration of the skin and mucous membranes, when
• there is hypoxemia (late sign)
Signs and symptoms of Hypoxia
• Disorientation/ decreased ability to concentrate
• Restlessness/anxiety
• Increased fatigue
• Dizziness.
• Increased Pulse rate (PR)
• Cyanosis
• Rapid respiration (RR) and dyspnea
• Flaring of nares
• Substernal or intercostal retraction
2. Altered breathing patterns
• Tachypnoea: Rapid rate –seen with fever, pain and hypercapnia or hypoxemia
• Bradypnea: is abnormally slow respiratory rate, may be seen in clients who have taken drugs such
morphine or with or have increased intracranial pressure.
• Apnea: Is the cessation of breathing
• Hyperventilation: Is an increased movement of air into and out of lungs. (CO2eliminated).
Kussmaul’sbreathing with metabolic acidosis (rapid & deep).
• Orthopnea: Is the inability to breathe except in an upright or standing position.
• Dyspnea: Difficult or uncomfortable breathing, patient appears anxious with SOB.
3. Obstructed Airway
• Upper airway obstruction : complete or partial obstruction can occur in the nose, pharynx, or larynx
due to:
• Foreign object such as food.
• Tongue falls back into the oropharynx when
• person is unconscious
• Secretions collect in the passageways .

Partial obstruction is indicated by:

• low pitched snoring sound during inhalation.
Complete obstruction is indicated by:
• Extreme inspiratory efforts, dyspnea.
 • No chest movement
• Inability to cough or speak
• Stridor → a harsh, high pitched sound during inspiration
• Restlessness, dyspnea
• Altered arterial blood gases level
Lower airway obstruction:
• partial or complete occlusion of the passageways of the bronchi
and lungs due to
Increased accumulation of mucus or inflammatory exudate.
Remember:
• assessment and maintaining airway patent is the nurse’s
responsibility
Assessment: Nursing History
• Current and past respiratory problems -Dyspnea, orthopnea, wheezing
• Presence of chest Pain
• Presence of cough Description of sputum
• Haemoptysis (bloodstained sputum )
Risk factors :
Family history of lung cancer, cardiovascular disease, or tuberculosis
• Risk factors Environmental exposures & Lifestyle
• History of Respiratory disease and infection
• Medications for breathing
Assessment: Physical Examination
Inspection: anterior and posterior thorax
• Breathing patterns (rate, depth, rhythm, and quality)
• Chest wall shape, symmetry, and movements (retraction, accessory
muscles)
• Level of consciousness (LOC)
• Colours of nails and mucous membrane, clubbing (prolonged O2
deficiency)

Palpation: anterior and posterior chest

• Thoracic expansion
• Tactile fremitus (vibration) both sides.
• Abnormal mass, swelling, tenderness.

Percussion: anterior and posterior chest.

• Percuss both sides, in the ICS at about 5 cm interval in systematic sequence.
• Compare percussion note bilaterally.
• Determine whether underlying lung tissue is filled with air, liquid or solid material.
• Resonancesound is normal.

Auscultation: anterior and posterior chest.

• Lung sounds: use the same sequence for percussion and compare both sides.
• Normal lung sounds: bronchial (anterior), broncho-vesicular, vesicular.
• Adventitious lung sounds:
 Assessment: Diagnostic Studies
1. Pulmonary Function Tests: Measures the lung volume and capacity
• Tidal volume, minute volume Total lung capacity , Residual volume
Vital capacity, Inspiratory & Expiratory reserved volume

2. Blood Studies
• Arterial blood gas (ABGs)
• Complete blood count
• Serum electrolytes

3. Visualization examinations
• Chest X ray examination: to show lung fields
• Bronchoscopy: direct visual of tracheobronchial tree
• Lung scan: computerized tomography (CT)
4. Cellular examination
• Throat cultures
• Sputum specimens
• Thoracentesis

Pulmonary Function Test (PFT)

Nursing Diagnosis and planning

Nursing Diagnosis Planning (Goals and outcomes )
 • Ineffective airway Goal:
• clearance • Maintain a patent airway.
• Patient’s lungs will be clear to auscultation.
• Patient coughs effectively and move sputum out of
airway
• Ineffective breathing Goal:
• pattern • Improve comfort and ease of breathing
• Patient achieves good bilateral lung expansion .
• Impaired gas Goal:
• exchange • Maintain or improve pulmonary ventilation and
• oxygenation.
• Pulse oximetry (SpO2) is maintained or improved.
• Activity intolerance Goal:
• Improve ability to participate in physical activities

Implementation: Health Promotion

Vaccinations
• Annual Influenza
• Pneumococcal Vaccine
• Avoiding Environmental pollutants
• Smoking, Second-hand smoke, work chemicals and pollutants
• Healthy lifestyle behaviour
• Eliminate risk factors ,eat right, regular exercise, minimize risk of
infection.

Implementation: Promoting Oxygenation

• Encouraging and providing frequent changing in position to allow
maximum chest expansion, because inadequate expansion cause pooling of respiratory
secretions, which harbor microorganisms and promote infection
• Encourage client to turn from side to side frequently to permit maximum expansion.
• Encouraging ambulation.
• Implement measures that promote comfort such as giving pain medication.

• The semi-fowler’s or high-fowler’s position allows maximum

chest expansion, especially for patients with dyspnea.

• Patient with orthopnea(dyspnea in supine position), should sit in

bed and lean over the bed table, with a pillow for support. This
orthopneic position has advantages that the abdominal
organs are not pressing on the diaphragm.

• Patient with orthopnea(dyspnea in supine position), should sit in

bed and lean over the bed table, with a pillow for support. This orthopneic position has
advantages that the abdominal organs are not pressing on the diaphragm.

Implementation: Hydration
• Adequate hydration maintains the moisture of the mucous membranes. With dehydration
secretions
 • become thick and sticky.
• Fluid intake should be as great as client can tolerate.
• Humidifiers are devices that add water vapor to
• inspired air. (Bubbling water through oxygen)
• Nebulizers are used to deliver humidity and
• medications. (Add normal saline or medications).
• They are used with O2 delivery systems to provide
• moistened air directly to client and to loosen secretion
for easier expectoration.
Implementation: Deep Breathing &
coughing exercises
Breathing exercises are frequently indicated for clients with
restricted chest expansion (e.g. COPD, post thoracic surgery)
Breathing techniques
• Abdominal (diaphragmatic) breathing allow deep full
breaths with little efforts -diaphragm descends during
inspiration-(belly moves out) and ascends during expiration
(belly sinks in).
• Pursed-lip breathing helps client develop control over
breathing. (Deep inspiration and prolonged expiration to
prevent alveolar collapse).
• The pursed lips create resistance to the air flowing out of the lungs, that prolonging exhalation
and preventing airway collapse

Coughing
• will remove the secretion from the airway by raising secretions high enough
so the client can expectorate (spit them out). Forceful coughing is less effective than
controlled or huff cough.
Controlled and Huff Coughing:
• Inhale deeply and hold your breath for a few seconds.
 • Cough twice. The first cough loosens the mucus; the second expels secretions.
• For huff cough , lean forward and exhale sharply with a huff ” sound. This technique
• helps keep your airways open while moving secretions up and out of the lungs.
• Inhale by taking rapid short breaths in sequence (sniffing) to prevent mucus from
• moving back into smaller airways.
• Rest. Try to avoid prolonged episodes of coughing because these may cause fatigues
• and hypoxia.

Q What is the first thing you do when someone has difficulty

a. Have them raise their feet

b. Sit them up in high upright position

c. Give them water to drink

d. Take their blood pressure

Techniques for supporting incision before deep

breathing and coughing

Implementation: Incentive spirometry

Incentive spirometry measure the flow of air inhaled through the mouthpiece and used to:
• Encourages deep breathing and improve ventilation
• Loosen respiratory secretion
• Expand collapsed alveoli and prevent atelectasis
• Facilitate respiratory gaseous exchange
When used client should be assisted in an upright sitting position in bed or chair to
facilitate maximum ventilation.
Spirometry measures the volume of air entering or leaving the lungs
Client’s Teaching
•
• Hold or place spirometer in upright position
• Exhale normally and completely.
• Seal the lips tightly around the mouthpiece.
• Take in slow, deep breath to elevate the balls or cylinder and then hold the breath for 2 seconds
initially, then increasing to 6 seconds.
• Remove the mouthpiece and exhale through pursed lips.
• Cough after incentive effort; deep ventilation may loosen
• the secretions and coughing facilitate removal
• Relax and take several normal breaths , repeat the procedure 5 10 times hourly.
• Clean the mouthpiece with water and shake it dry.
Implementation: Chest Physiotherapy (CPT)
Percussion, Vibration and Postural Drainage
• Chest physiotherapy (CPT) are dependent nursing
• function performed according to the physician order.
1. Percussion (Clapping): forceful striking on the skin with
• cupped hands, this can mechanically dislodge thick & sticky
• secretion. Avoided over the breast, sternum, spinal
• column, kidneys.
Nurse follows these steps:
• Cover area with towel to reduce discomfort.
• Ask client to breathe deeply and slowly for relaxation.
• Alternately flex and extend the wrist rapidly to slap the
• chest.
• Percuss each affected lung segment for 1 2 minutes.
2. Vibration : Forceful shaking produced by hands that are
• placed flat against client s chest wall. Used alternately with
• percussion to loosen the secretion.
Nurse follows these steps:
• Place palms down on chest, one hand over the other with fingers together and extended. Ask
client to inhale deeply and exhale slowly through pursed lips.
• During exhalation, tense all hand and arm muscles, use heel of the hand, vibrate the hands,
moving them downward. Stop the vibrating when client inhale.
• Vibrate during 5 exhalations over one affected lung segment. Then encourage client to cough
and expectorate secretions.
3. Postural drainage : is drainage of secretion by gravity from various lung segments. Wide variety
of position is necessary to drain all segment.This treatment is done 2to 3 times/day based on
lung congestion & patient tolerance.
Implementation: Oxygen therapy

• The goal: To prevent or relieve hypoxia by delivering oxygen at concentrations greater

ambient air(21%)
• O2 therapy is prescribed by physician who specifies the concentration, method of
delivery and liter flow per minute. Requires medical order unless an emergency
• Humidifier for liter flows over 2 L per minute to prevent drying. Nasal cannula on 1-2L/min
do not require humidifier.
• Oxygen has dangerous side effects such as oxygen toxicity. Follow Six rights of
medication administration

Oxygen Therapy: Equipment

• Oxygen source – Cylinder , wall-outlet
• Flowmeter
• Humidifier
• Tubing
• Appropriate appliance for the method
• ordered.
 O2 delivery systems
• Number of systems are available to deliver O2.
• The choice depends on the client’s O2 need, comfort level.
• The O2 delivered
• mixes with room air before being inspired
Simple:

• nasal canula
• face mask
• Intermediate:
• venturi mask
• nonrebreather mask
Advanced:
• high flow nasal canula
• BIPAP
Nasal Cannula (nasal Prongs):
• The most common and inexpensive device.
• Easy to apply
• Does not interfere with talking or eating.
• Allow freedom of movement
• Delivers low O2 concentration ( 24 45 %) at flow rates 2 6 L/min.
Simple Face Mask:
• Cover the patient s nose and mouth.
• Delivers O 2 concentration from 40 60 % at liter flow ( 5 8 L/min)
Partial Rebreathing mask:
• Delivers O2 concentration of 60 to 90% at liter flow of
(6 10L/min).
• The O2 reservoir bag allow the client to rebreathe about the first third
of exhaled air in conjunction with O2. it must not totally deflate during
inspiration to
• avoid CO2 build-up.
Nonrebreather mask:
• Delivers O2 concentration of 95 100% at liter flow of
(10 15L/min).
• One way valve on the mask and between the reservoirs
bag and the mask prevent room air and exhaled air
from entering the bag, only O2 is inspired.
Venturi mask:
• Deliver O 2 concentration varying
• from 24 40 % or 50 % at liter flows of
4 10 L/min.
• It has wide bore tubing and color
code jet adapters that correspond to a
precise O 2 concentration and liter flow.
• E.g., Blue adapter 24 % at 4 L/min
• Green
• 35 % at 8 L/ min

Causes of Airway Obstruction

• Foreign body
• Tongue
• Laryngeal edema
• Laryngeal spasm
• Trauma
• Aspiration
• Infection or severe allergic
• reaction
Artificial airways
Artificial airways: inserted to maintain patent air passages for client
whose airway has become or may become obstructed by tongue.
Oropharyngeal and nasopharyngeal
• Easy to insert; have low risk of complications.
• Sizes vary and should be appropriate to the pt.'s size and age.
• The airway should be well lubricated with water-soluble
• gel prior to insertion.
Oropharyngeal is used for unconscious clients who have no gag
reflex.
Nasopharyngeal for alert clients with gag reflex, use when mouth
trauma present, permits suctioning. Do
not use with trauma to the
nose or skull fracture

Tracheal airway

• Endotracheal airway (
• -(Oro tracheal, naso tracheal)
• Tracheostomy Tube (TT)

Principles of suctioning

• Suctioning: is the aspiration of secretion through catheter connected to a suction machine

or wall suction outlet.

• Oral and oropharyngeal suctioning remove

secretion from upper airway-not sterile procedure

• Nasotracheal, tracheostomy tube, and

endotracheal tube suctioning provide closer
access to trachea and require sterile technique.

Ensure suction apparatus is working, Choose right size suction catheter or Yankauer catheter for
oral cavity.

• PPE–gloves, goggles and gown is required.

 • Suction applied only as catheter withdrawn. Performed quickly-no longer than 15 sec.

• Allow patient to restin between suctions

Chest Tube and drainage system

Chest tubes: A catheter placed through the thorax to remove
air and fluids from the pleural space or to prevent air from re-
entering or to re-establish pressures.
In which cases chest tube inserted?
• Pneumothorax –collection of air in pleural space –
(trauma or spontaneous)
• Hemothorax–collection of blood in pleural space -
(trauma)
• Empyema-collection of infected fluid or pus in the
pleural space.