Ventilatory Assistance

N4100 Med-Surg III

Patricia Harris PhD, RN, CNS
 Objectives

Brief review of respiratory anatomy

& physiology
Define respiratory terms
Describe essential interventions
 Respiratory Anatomy

Figure 9-1. Anatomy of the upper and lower respiratory tracts. The inset shows the grapelike
clusters of alveoli and their rich blood supply, which supports the exchange of oxygen and carbon
dioxide. (From Patton KT and Thibodeau GA. Anatomy and Physiology. 7th ed. St. Louis: Mosby;
2010.)
Copyright © 2013, 2009, 2005, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 3
 Biological Processes Required for
Gas Exchange
Ventilation is the movement of gas between lungs
and environment.
Oxygenation is the process of providing and
adding oxygen, and/or combining other gases with
oxygen
Perfusion is the delivery of oxygenated blood to
the capillary beds in order to reach an organ or
tissue.
Diffusion of O2 and CO2 occurs at cellular level. O2
moves into and and CO2 out of alveoli

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 Physiology of Breathing
Ventilation
 At rest:
 Intrapleural pressure < atmospheric
 Intraalveolar = atmospheric
 With inspiration:
 Intrapleural pressure more negative
 Intraalveolar negative = airflow
 With expiration:
 Passive when intrapulmonary pressure exceeds
atmospheric

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 Gas Exchange
Oxygenation occurs at level of alveoli and the capillaries within
pulmonary capillary bed
 Transport of CO2 to the right side of the heart
 To the Lungs
 Diffusion occurs within the alveolar tissues at the cellular
level, based on concentration gradients
 Out of the Lungs
 Transport of O2 to left side of heart
Perfusion - Oxygenated blood is transported out of the left side
of heart and distributed to the tissues throughout the body.
Diffusion occurs within the body’s tissues at the cellular level

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 Regulation of Breathing
 Normal respiration is stimulated by elevated CO2
 Not true for COPD
 Stimulus for breathing
is hypoxia
 Rationale for keeping
amount of delivered
oxygen low in patients
with COPD

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 Respiratory Terminology
Respiration

prefix = "re” means "again" (Latin)

root = "spire" means "to blow" or "to breathe" (Latin)

suffix = “ation” or "ion” means “entering, acting, or process"

(Latin)

Respiration is the process of breathing (again and again).

If you can’t breathe, nothing else matters.

– American Lung Association
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 Work of Breathing (WOB)

 Amount of effort required to maintain ventilation

 Respiratory pattern changes automatically

 WOB increases, more energy needed

 WOB high, respiratory failure

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 Compliance
 Distensibility or stretch
 Determined by elasticity, “recoil”
 Elastic recoil and compliance are inversely
related
 Types
 Static—measured under condition of no airflow
(inspiratory hold)
 Dynamic—measured while gases flowing

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 Resistance
 Opposition to gas flow in the airways
 Airway length
 Airway diameter
• Small tube
• Spasms
• Mucus
 Flow rate of gases
• Increased breathing effort

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 Volumes and Capacities
Assess baseline function
Monitor responses

Figure 9-5. Lung volumes and capacities. (From Hall JE, Guyton AC. Guyton and Hall Textbook of Medical
Physiology 12th ed. Philadelphia: Saunders; 2011.)
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Copyright © 2013, 2009, 2005, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
 Selected Measures
 Tidal Volume (VT)
 Normal breath; 500 mL or 5 to 7 mL/kg
 Functional Residual Capacity (FRC)
 Volume of gas remaining in the lungs at normal
resting expiration
 Average: 2300 mL
 Vital Capacity (VC)
 Maximum volume of gas forcefully expired after
maximum inspiration
 Average: 4600 mL

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 Abnormal Breathing Patterns
 Cheyne-Stokes: cyclical with apneic periods

 Biot’s: cluster breathing

 Kussmaul’s: deep, regular, and rapid

 Apneustic: gasping inspirations

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Abnormal Breathing Patterns

Figure 09-06. Breathing patterns.

Copyright © 2013, 2009, 2005, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 16
 Arterial Blood Gases
 Adequacy of oxygenation and ventilation
 Acid-base status
 Interpret in conjunction with:
 Clinical history
 Physical assessment

What is hypoxemia?
Decrease in
oxygenation of
arterial blood
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 Oxygenation
PaO2 ─ partial pressure of oxygen dissolved in
arterial blood
 Normal value 80 to 100 mm Hg
 Decreases in elderly
 Value < 60 mm Hg treated
SaO2 ─ amount of oxygen bound to hemoglobin
 Normal value 92% to 99%
 Frequently measured via pulse oximetry (SpO2)

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 What happens in
respiratory failure?
Hypoxia: decreased oxygenation at tissue level
Hypoxemia: decrease oxygenation in the blood

Differentiate between hypoxia and hypoxemia in

acid-base conditions:
“oxia”= tissue level
“emia” = blood content

Hypercapnia: increased amount of carbon dioxide,

the waste product of respiration, in the blood
(A.K.A. hypercarbia) 19
 Oxygenation
 Pulse oximetry (SpO2)
 Value of 90% = PaO2 60 mm Hg
 Ensure accurate readings
 Limit movement
 Avoid edematous areas
 Effect of sunlight, fluorescent light, nail polish, artificial
nails, and dyes
 Periodic ABGs to compare value with SaO2

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 Assessment of Ventilation
 End-tidal CO2 (ETCO2)
 Must compare with ABGs and use for trending
 Values tend to be 2 to 5 mm Hg less than PaCO2

 Calorimetric CO2 detector

 Disposable devices

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 Airway Management
 Positioning

 Devices
 Oral airway
 Nasopharyngeal airway
 Endotracheal intubation
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 Airway Management
 Devices
 Oral airway

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 Airway Management
 Devices
 Nasopharyngeal airway

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 Airway Management
 Devices
 Endotracheal intubation

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 Oxygen Administration
Gas Exchange
 Oxygen to treat or prevent hypoxemia
 Improving gas exchange - Oxygenation
 Humidification
 Flow rates > 4 L/min
 Mechanical ventilation

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 Oxygen Delivery Devices
Improving Gas Exchange
 Fraction of delivered oxygen (FiO2)
 Room air 21% or 0.21 FiO2
 Low flow: Nasal cannula = 0.24-0.44 FiO2
 High flow: Nasal cannula = 0.60-0.90 FiO2
 Simple face mask = 0.30-0.60 FiO2
 Air-entrainment mask = 0.24-40 FiO2
 Face masks w/ reservoirs
 Partial rebreather = 0.35-0.60 FiO2
 Nonrebreather = 0.60-0.80 FiO2
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 Oxygen Delivery Devices
 Nasal Cannula – Low flow

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Oxygen Delivery Devices

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 Oxygen Delivery Devices

 Air-entrainment
mask = varied
depending on
size of jet orifice

Figure 9-13. Air-entrainment (Venturi)

mask with various jet orifices. Each
orifice provides a specific delivered FiO 2.
(Modified from Kacmarek RM, Dimas S,
Mack CW. The Essentials of Respiratory
Care. 4th ed. St. Louis: Mosby; 2005.)
Copyright © 2013, 2009, 2005, 2001, 1997,
1993 by Saunders, an imprint of Elsevier Inc.
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 Oxygen Delivery Devices

Figure 9-12. Partial rebreathing and non-rebreathing oxygen masks. (From

Kacmarek RM, Dimas S, Mack CW. The Essentials of Respiratory Care. 4th ed.
St. Louis: Mosby; 2005.)
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Copyright © 2013, 2009, 2005, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc.
 Oxygen Delivery Devices
Additional Types of Masks

Figure 9-14. Devices used to apply high-flow, high-humidity oxygen therapy. A, Aerosol mask.
B, Face tent. C, Tracheostomy collar. D, Briggs T-piece. (From Kacmarek RM, Dimas S, Mack
CW. The Essentials of Respiratory Care. 4th ed. St. Louis: Mosby; 2005.)
Copyright © 2013, 2009, 2005, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 32
 Ventilatory Assistance
 Manual resuscitation bags
 15 L/min to deliver 1.00 FiO2

Plus oxygen delivery

Improves gas
exchange
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 Thanks

This slide presentation was prepared with the

assistance of teaching resource materials
provided by
 Elsevier Saunders Evolve website (2013)
 Dr. June Wilson
 Medscape Nurses – www.medscape.com
 UpToDate – Dominican Library
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