Gas Exchange and

Respiratory Function
Part One
By

Linda Self

Review of Terms
Cyanosisinfluenced

by polycythemia and anemia

Clubbing-Schamroth method
Hemoptysis
Perfusionactual blood flow through the
circulation
Ventilation----movement of gas into and out of the
alveoli
Diffusionoxygen and CO2 exchanged from
environment>trachea>bronchi>bronchioles and
alveoli
Compliance-measure of the elasticity,
expandability, and distensibility of lungs,
influenced by surfactant

VentilationPerfusion
Ratios
Normal

lung is 1:1
Shunts: when perfusion exceeds
ventilation, a shunt exists. Blood
bypasses the alveoli w/o gas
exchange occurring.
Pneumonia, atelectasis, tumors,
mucous plugs

Ventilation-Perfusion Ratios cont.

High

ventilation-perfusion ratio--Dead space

Ventilation exceeds perfusion
Alveoli do not have adequate
blood supply for gas exchange to
occur
Pulmonary emboli, pulmonary
infarction, cardiogenic shock

Ventilation-Perfusion Ratios cont.

Silent

unitabsence of
ventilation and perfusion
Seen in pneumothorax and
severe ARDS

Neurologic Control of Ventilation

Phrenic

nerve
Respiratory center in medulla
and pons
Central chemoreceptors in
medulla, influenced by chemical
changes in csf
Peripheral chemoreceptors in
aortic arch and carotid arteries,
respond first to changes in PaO2,
then PaCO2 and pH

Gerontologic
Considerations
Decreased

strength of respiratory

muscles
Decreased elasticity
Increased respiratory dead space
Decreased number of cilia
Decreased cough and gag reflex
Increased collagen of alveolar
walls

Respiratory Assessment
Health

History
Risk factors for respiratory diseasegenetics, smoking, allergens,
occupational and recreational exposure
Dyspnea, orthopnea
Cough, ?productive
Chest pain
Cyanosis
Lung sounds
Clubbingindicates chronicity

Diagnostic Evaluation
PFTs-assess

respiratory function,
screening, assess response to therapy
FVCvital capacity performed with a
maximally forced expiratory effort
Forced expiratory volumeFEV1
volume of air exhaled in the specified
time during the performance of forced
vital capacity. FEV1 is volume exhaled in
one second.
FEV1/FVC%--ratio of timed forced exp.
volume to forced vital capacity

Diagnostic Evaluation-ABGs
1.

pH
2. evaluate the PaCO2 and HCO33. Look to see if compensation
has occurred. If CO2 is >40,
respiratory acidosis; If HCO3<24, metabolic acidosis; next
look at value other than primary
disorder, if moving in same
direction as primary value,
compensation is underway.

ABGs continued
Can

have two acid-base disturbances at

same time
This can be identified when the pH does
not explain one of the changes, e.g.,
pH 7.2
PaCO2 52
HCO3 13
Notice that oxygen level is not a
component in determining the acidbase balance

ABGs cont.
Normal

values for arterial gases:

7.35-7.45, CO2 35-45 mm Hg,
HCO3 22-26 mEq/L, O2 80-100
mm Hg, BE +/-2 mEq/L
sat >94%
Mixed Venous Blood: 7.33-7.41,
CO2 41-51 mm Hg, HCO3 22-26
mEq/L, O2 35-40 mmHg, BE +/2mEq/L, sat 60-80%
See chapter 14 of text

Acidosis
Results

in decreased myocardial
contractility and a decreased
vascular response to
catecholamines. May interfere
with metabolism of certain
medications

Alkalosis
Can

radically impair oxygen

release from RBCs. For this
reason, use bicarbonate
infrequently in code situations

Other diagnostic studies

Pulse

oximetrynot reliable in severe anemia,

high CO levels, or in shock
CO2 monitoringtells us ventilation to lungs
is occurring, that CO2 is being transported to
lungs, exp. CO2 indicates adequate
ventilation
Cultures
Imagingchest xray, CT, MRI, lung scans
(inject isotope, inhale radioactive gas), PET
Bronchoscopy
Thoracentesis
others

Sleep Apnea
Associated

with frequent, loud

snoring with breathing cessation
for 10 seconds or long, at least 5
episodes per hour, followed by
awakening by a snort when O2
levels drop
May be associated with obesity
Decreased pharyngeal tone
(related to alcohol, sedatives,
neuromuscular disease)

Sleep Apnea
Diagnosed

by polysomnography
(ECG, EEG, EMG, pulse oximetry)
More common in men
High risk for CAD,
cerebrovascular disease and
premature death.
Results in hypoxia and
hypercapnia which trigger
sympathetic response. Can lead
to dysrhythmias and elevated BP

Sleep Apnea signs and

symptoms
Excessive

daytime sleepiness
Frequent nocturnal awakening
Insomnia
Loud snoring
Morning headaches
Personality changes
Systemic hypertension
Dysrhythmias
Pulmonary hypertension, cor pulmonale
polycythemia

Management
Nurse

educates patient
Avoid alcohol and sedatives
Weight loss
CPAP or BiPAPCPAP prevents airway
collapse, BiPAP makes breathing easier
and results in lower airway pressure
Uvulopalatopharyngoplasty
Tracheostomy
Provigil, Provera, Diamox, Triptil may
help

Cancer of the Larynx

Squamous

cell most common95%

Increasing in women
More common in African Americans
Most common in individuals between
50-70 years of age
Carcinogenstobacco, alcohol,
exposure to asbestos, wood dust,
cement dust, tar products, leather and
metals
Most often affects glottic area

Laryngeal Cancer
Clinical

manifestations
1. Hoarseness of greater than two weeks duration
2. Persistent cough
3. Sore throat
4. Dysphagia
5. Dyspnea
6. Ulceration
7. Foul breath
8. Cervical adenopathy
9. Weight loss
10.Debilitation

Assessment and Diagnosis

H&P
Laryngoscopy

with
biopsy/staging of disease
CT and MRI to assess adenopathy
and further stageing

Laryngeal CancerManagement
Depends

on staging of tumor
Options include surgery,
radiation and chemotherapy
Sometimes combination therapy
Ensure any dental problems
corrected, usually before other
treatments

Surgical Management
Laser

surgery, supraglottic laryngectomy,

hemilaryngectomy, total laryngectomy
In case of total laryngectomy, advanced
cancer present
Laryngeal structures removed including
portion of trachea. Results in permanent
loss of voice and permanent tracheostomy
Often will have radical neck dissection
involves removal of sternocleidomastoid
muscle, lymph nodes, jugular vein,
surrounding soft tissue

Post-operative Care
Usually

ICU postop
Monitor airway, VS,
hemodynamic status and comfort
level
Monitor for hemorrhage
Monitor for infection
Monitor tracheal stoma
Have extra trach at bedside (of
same size!)

Post-operative Care
May

be on ventilator initially
Will have trach
Ensure humidity at all times
May have split thickness skin graft or trapezius
or pectoralis muscle graftsensure side of flap
or graft not in dependent position
May have PCA
NG, G tube or jejunostomy tube may be in
placenutrition important
Speech rehab, esophageal speech,
electrolarynges
Support group

Patients with chronic obstructive

pulmonary disorders
COPDnonreversible
Includes

emphysema and chronic

bronchitis
Can co-exist with asthma
Present with s/s in middle life and
incidence increases with age
FVC and FEV1 decreased

Chronic Bronchitis
Disease

of airways
Increased mucous production,
decreased ciliary activity,
inflammation, reduced alveolar
macrophage function

Emphysema
Lobulephysiologic

unit of lung consisting

of bronchiole and its branches (alveolar
ducts, sacs and alveoli)
Two typespanlobar and centrilobular
In Panlobartypedestruction of bronchiole,
alveolar duct and alveoli; little inflammation,
hyperexpanded chest, work on exhalation
Centrilobar typederangement of the V/Q
ratios, chronic hypoxemia, hypercapnea,
polycythemia and right sided heart failure
See p. 688 for schematic

Emphysema
Risk

factors include:
1. Cigarette smoking
2. Occupational dusts, chemicals,
pollution
3. Deficiency of alpha1-antitrypsin,
protective enzyme that protects
lung parenchyma from injury--seen in Caucasians

COPD clinical
manifestations
Chronic

cough, sputum
production, and dyspnea on
exertion (DOE)
Weight loss common
Increased number of respiratory
infections
In primary emphysema, will have
barrel chest

Diagnosis of COPD
Thorough

H&P
Spirometry to evaluate airflow
obstruction
FEV1/FVC will be less than 70%
Reversibility will be tested
Chest xray
ABGs
Screening for alpha1-antitrypsin
deficiency
Classified by five stages0 through
IV (see p. 690)

Medical Management
Smoking

cessation will slow progression

May use Chantix, Wellbutrin, nortriptyline,
clonidine
Bronchodilatorsbeta agonists,
anticholinergics, methyxanthines,
combinations, nebulized medications,
inhaled and systemic corticosteroids
Influenza and pneumococcal vaccines
Oxygen therapyusually started in severe
COPD
High fat, low CHO diet

Oxygen Therapy in COPD

Previously

felt that high levels of

O2 affected hypoxic drive
Now thought that Haldane effect
relates to ability of hgb to carry
O2 and CO2. With increased
levels of O2, increased
saturation, increased CO2 load
w/o being able to expel it. So,
increased hypercapnia.

Surgical Management
Bullectomyhave

blebs or
enlarged airspaces that do not
contribute to ventilation
Lung volume reduction surgery
may improve quality of life but
not life expectancy
Lung transplantation

Nursing Management
Key

is education
Breathing exercises
Inspiratory muscle trainingbreathe
against a set resistance
Activity pacing
Self-care activities
Physical conditioning
Oxygen tx
Nutritional therapy
Coping measures

Bronchiectasis
Chronic,

irreversible dilation of the bronchi

and bronchioles
Caused by: inflammation d/t recurrent
infections damaging bronchial walls, thick
sputum and decreased mucociliary clearance;
genetic disorders like CF, idiopathic causes
Results in atelectasis, fibrosis, VQ mismatch
R/O TB or other pathology
Tx-chest PT, smoking cessation, continuous
abx tx, possible surgical resection of affected
areas

Asthma
Chronic

inflammatory disease
characterized by mucosal edema,
airway hyperreactivity, and
mucous production
Largely reversible
Allergy is strongest predisposing
factor
Poorly controlled asthma can
result in remodeling. Bronchial
muscles and mucous glands
enlarge, alveoli hyperinflate and

Asthma
Cells

that play role in inflammation

of asthma include: leukotrienes,
bradykinins, prostaglandins, mast
cells, neutrophils, eosinophils
Beta receptor stimulation results in
decrease of chemical mediators and
causes bronchodilation
Three most common symptoms of
asthma are cough, dyspnea and
wheezing

Asthma
Family,

environmental and
occupational history is necessary
Comorbid conditions like GERD,
drug-induced asthma and allergic
bronchopulmonary aspergillosis
may be present

Asthma
Triggers
Complicationsstatus

asthmaticus
Rescue and maintenance
medications
Peak flow monitoringmeasure
highest airflow during a forced
expiration. See asthma action
plan on p. 715. Height, age and
sex are variables to consider in

Status Asthmaticus
Severe

and persistent asthma that does not

respond to conventional therapy. Can be
precipitated by infection, irritants, ASA or others
Severe bronchospasm with mucous plugging
leading to asphyxia
Labored breathing, engorged neck veins, cough,
wheezing
ABGs indicated
O2, IV fluids, burst of steroids, short acting
corticosteroids, possibly magnesium sulfate
Nurse monitors, administers fluids and meds,
ensures no irritants in environment

Atelectasis
Closure

of collapse of alveoli
Often occurs in postoperative
setting and in those who are
immobilized
Can result from any obstruction
that blocks air to and from alveoli

Atelectasis
Clinical

manifestationscough,
sputum, low grade fever. In
severe cases, tachycardia,
tachypnea, central cyanosis
Chest xray may reveal patchy
infiltrates, crackles will be heard
over affected area, O2 saturation
may be lower than 90%

Atelectasis
Preventionturning,

mobilizing
patient, deep breathing
maneuvers, incentive spirometry,
secretion management such as
suctioning, nebulizers, chest PT
ManagementIPPB, chest PT,
nebulizer tx, bronchoscopy,
possible ventilator support,
thoracentesis

Pneumonia
Is

an inflammation of the lung

parenchyma caused by
microorganisms
Community acquiredusually
caused by: Strep pneumo,
Hemophilus influenza, Legionella,
Mycoplasma pneumoniae,
Chlamydia, viral
Hospital acquired
Pseudomonas, Staph aureus,

Pneumonia
Pneumonia

in the
immunocompromised patient
Aspergillus, Pneumocystis,
Mycobacterium tuberculosis
Aspiration pneumonia
Is the most infectious disease
causing death in the United
States

Pathophysiology of pneumonia
Arises

when normal flora has

been aspirated, when host
defenses are down or from
bloodborne organisms that enter
the pulmonary circulation
Affects ventilation and diffusion
will have adequate perfusion but
not ventilation

Risk factors for

Pneumonia

Conditions resulting in mucous

obstruction (cancer, smoking,
COPD)
Immunosuppression
Prolonged immobility
Depressed cough
NPO, ETT, NG or OG tubes
Alcohol intoxication
Advanced age
Medications that depress

Clinical Manifestations of
Pneumonia
Not

possible to diagnose a
certain type by manifestations
alone
May be sudden in onset with
fever, chills and pleuritic pain as
seen in pneumococcal
pneumonia
May be gradual in onset with low
grade fever, HA, pleuritic pain,
myalgias and pharyngitis

Diagnosis of Pneumonia
History
Physical

exam
Sputum cultures
Blood cultures
Chest xray
Possible bronchoscopy depending
on severity

Medical Management
Antibiotic

depending on Gram

stain
Often treat empirically, intervene
promptly
CAP-tx with Zithromax, Biaxin,
doxy, or fluoroquinolone. With
comorbidities, may use
Augmentin, Vantin, Ceftin, and a
macrolide or doxy. Symmetrel for
Flu A, Tamiflu for Flu A/B. Bactrim

Medical Management
cont.
Hospital

acquiredIV antibiotics
such as second generation
cephalosporins, carbapenems,
fluoroquinolones. If MRSA, use
vancomycin, Zyvox. For
Pseudomonas, use Timentin,
Unasyn, and an aminoglycoside.
Viral pneumonia is supportive
care only.
Hydration is important in all

Other treatments
Antihistamines
Nasal

decongestants
Antipyretics
Monitoring O2 saturation,
possibly ABGs
Serial xrays

Gerontologic
Considerations
In

elderly the classic s/s of cough,

chest pain, sputum production
and fever may be absent
May be difficult to distinguish
heart failure from pneumonia
Xrays particularly helpful in this
population

Nursing the patient with

pneumonia
Frequent

assessmentnight
sweats, fever, chills, cough, lung
sounds
Encourage hydration as
hydration thins and loosens
secretions
Humidification w/or w/o oxygen
Encourage cough, chest
physiotherapy
Promote rest

Respiratory Care
Modalities
Nasal

cannulaup to 6L/min. Delivers up to

42% oxygen
Simple maskflow rate 6-8L/min. Delivers
40-60% oxygen.
Partial rebreather maskflow rate is 811L/min. Delivers 50-75% oxygen.
Nonrebreather maskflow at 12 L/min.
Delivers 80-100% oxygen.
Venturi mask4-6 L/min, 6-8 L/min. Deliver
respective oxygen concentration of 24, 26,
28 or 30, 35, 40% oxygen. Most accurate
delivery.

Respiratory Care
Modalities
Oxygen

Hypoxemiadecrease

in arterial oxygen

tension in blood
Hypoxiadecrease on oxygen supply to
tissues
Oxygen toxicitycan occur if delivering
>50% for longer than 48h. Caused by free
radical production.
Signs/symptoms of oxygen toxicity
paresthesias, fatigue, refractory hypoxemia,
alveolar atelectasis, alveolar infiltrates

Consider

alveolar collapse with

high levels of oxygen

Tracheostomy
Surgical

procedure in which an opening

is made into the trachea
Tracheostomy tube
Temporary or permanent
Used to bypass an upper airway
obstruction, allow removal of
tracheobronchial secretions, permit long
term use of mechanical ventilation, to
prevent aspiration in unconscious
patient or to replace endotracheal tube

Complications of tracheostomy
Bleeding,

pneumothorax, air
embolism, aspiration,
subcutaneous or mediastinal
emphysema, recurrent laryngeal
nerve damage
Airway obstruction from
accumulation of secretions
,tracheoesophageal fistula,
tracheal ischemia

Nursing Care of the Patient with

Tracheostomy
Initially,

semi-fowlers position to
facilitate ventilation, promote
drainage, minimize edema, and
prevent strain on the sutures
Allow method of communication
Ensure humidity to trach
Suction secretions as needed
Manage cuffusually keep
pressure less than 25 mm Hg but
more than 15 mm Hg to prevent

Endotracheal Intubation
Pass

ETT via nose or mouth into

trachea
Method of choice in emergency
situation
Passed with aid of a laryngoscope
ETT generally has a cuff, ensure
that cuff pressure is between 1520 mm Hg.
Use warmed, humidified oxygen
Should not be used for more than
3 week

Preventing Complications Associated with

Endotracheal and Tracheostomy Tubes
Administer

adequate warmed humidity

Maintain cuff pressure at appropriate level
Suction as needed
Maintain skin integrity
Auscultate lung soundsETT can lodge in right
mainstem bronchus
Monitor for s/s of infection
Monitor for cyanosis
Maintain hydration of patient
Use sterile technique when suctioning and
performing trach care
Monitor O2 sat

Mechanical Ventilation
Used

to control patients
respirations, to oxygenate when
patients ventilatory efforts are
inadequate, to rest respiratory
muscles
Can be positive pressure or
negative pressure
Key for the nurse is assess
patientnot the ventilator

Indications for Mechanical

Ventilation
PaO2

<50 mm Hg with FiO2

>0.60
PaO2 >50 mm Hg with pH <7.25
Vital capacity < 2 times tidal
volume
Negative inspiratory force < 25
cm H20
Respiratory rate > 35 bpm
( *vital capacity is dependent on
age, gender, weight and body

Classification of Ventilators
Negative Pressure
Used

for patients with polio,

muscular dystrophy, ALS,
myasthenia gravis
Examples include the iron lung
chamber, pneumo wrap and
tortoise shell (portable devices
with rigid shell to create a
negative pressure)

Ventilatorspositive
pressure
Inflate

lungs by exerting positive

pressure on the airway
Usually requires trach or ETT
Used in home setting as well
Pressure cycled, time cycled and
volume cycled
Noninvasive positive pressure
ventilation is an option, does not
require ETT

Positive Pressure
Ventilators
Pressure

cycled ventilators
delivers air until reaches a preset
pressure, then cycles off, then
passive expiration
Can vary as patients airway
resistance or compliance changes
Volume delivered thus will vary
and may compromise ventilation

Positive Pressure
Ventilators
Time cycled rarely seen in adults
(used in newborns and infants)
Volume cycledmost common.
Delivers a preset volume usually
8-10ml per kg
Noninvasive positive pressure
ventilationCPAP and BiPAP.
CPAP indicated for sleep apnea,
BiPAP esp. useful to avoid
intubating patients and in those
with neuromuscular disorders,

Ventilator Modes
Assist

control
Intermittent mandatory control
Synchronized intermittent
mandatory ventilation
Pressure supportassists SIMV,
applies pressure plateau to spont.
resp. during inspiratory phase
New modes incl. computerized
systems

Initial Ventilator Settings

Tidal

volume
Lowest concentration of oxygen
to maintain PaO2 80-100 mm Hg
Peak inspiratory pressure
ModeAC or SIMV, possibly PEEP
Sensitivity so that patient can
trigger the vent. With minimal
effort
Check ABGs after being on vent.
for 20-30 minutes

Remember..
If

patient becomes agitated,

confused, tachycardic, blood
pressure increases for some
unexplained reason, assess for
hypoxia and manually ventilate
on 100%.
If patients heart rate slows and
BP drops during suctioning,
possible vagal stimulation. Stop
suctioning and give 100% O2.

Bucking the ventilator

Occurs

when the patients

inspiration and expiration are out
of synch with the ventilator
Anxiety, hypoxia, increased
secretions, hypercapnia, others
Sedatives, muscle relaxants,
paralytics may be necessary

Monitoring and Managing

Potential Complications
associated with the
ventilator
See handout
Alterations

in cardiac function
Barotrauma and volutrauma
resulting in pneumothorax
Vagal stimulation
Pulmonary infectionsuse
chlorhexidine gluconate in oral
care

Weaning from the Ventilator

criteria for weaning
Vital

capacityamount of air
expired after maximum
inspiration. Should be 1015mL/kg.
Maximum inspiratory pressureused to assess the patients
respiratory muscle strength
should be at least -20cm H20
Tidal volumevolume of air that
is inhaled or exhaled during

Weaning criteria cont.

Minute

ventilationequals resp
rate times tidal volume. Normal is
6 L/min.
PaO2 greater than 60 mm Hg
with FiO2 <50%, stable vital
signs, adequate nutritional status
Would refrain from sedating
patient during weaning

Thoracic Surgeries
Pneumonectomy
Lobectomy
Segmental

resection
Lung volume reduction
others

Risk factors for thoracic surgery

related atelectasis and pneumonia
Preopage,

obesity, poor
nutritional status, smoking,
preexisting lung disease,
comorbid states
Intraoperativethoracic incision,
prolonged anesthesia
Postopimmobile, supine,
inadequate pain management,
prolonged intubation/ventilator,

Care of Patient after

Thoracotomy
Maintain

airway clearance
Positioning-lobectomy turn either
side,pneumonectomy turn on
affected side, segmental
resection varies per doctor
Chest tube drainage/care
Relieve pain
Promote mobility
Maintain fluid volume and
nutrition

Care of Patient after Thoracotomymonitor

and manage potential complications

Monitor

respiratory status

Vitals
For

dysrhythmias
For bleeding, atelectasis and
infection
Monitor chest tube drainage, for
leaks, for tube kinks, for
excessive drainage

Chest tube drainage

system
Based

on three bottle system

Drainage chamber
Water seal
Wet or dry suction
Monitor water seal for bubbling
Check for subq emphysema
Gently milk tube
Occlusive dressing
Monitor drainage