OXYGEN, a clear, odorless gas that constitutes approximately 21% of the air we breathe, is necessary for proper functioning

of all living cells. Impaired function of the system can significantly affect our ability to breathe, transport gases, and participate in everyday activities. RESPIRATION is the process of gas exchange between the individual and the environment. 1. Pulmonary ventilation or breathing; 2. Gas exchange, 3. Transport of oxygen STRUCTURE of the Respiratory System The respiratory system is divided structurally into the upper respiratory system and the lower respiratory system. The mouth, nose, pharynx, and larynx compose the upper respiratory system. The lower respiratory system includes the trachea and lungs, with the bronchi, bronchioles, alveoli, pulmonary capillary network, and pleural membranes. Air enters through the nose, where it is warmed, humidified, and filtered. Large particles in the air are trapped as air changes direction on contact with the nasal turbinates and septum. The sneeze reflects is initiated by irritants in nasal passages. A large volume of air rapidly exits through the nose and mouth during a sneeze, helping to clear nasal passages. Inspired air passes from the nose through the pharynx. The pharynx is a shared pathway for air and food. It includes both nasopharynx and the oropharynx, which are richly supplied with lymphoid tissue that traps and destroys pathogens entering with the air. The larynx is a cartilaginous structure that can be identified externally as the Adams apple. In addition to its role in providing for speech, the larynx is important for maintaining airway patency and protecting the lower airways from swallowed food and fluids. During swallowing, the inlet to the larynx (the epiglottis) closes, routing food to the esophagus. The epiglottis is open during breathing, allowing air to move freely into the lower airways. Below the larynx, the trachea leads to the right and left main bronchi (primary bronchi) and the other conducting airways of the lungs. Within the lungs, the primary bronchi divide repeatedly into smaller and smaller bronchi, ending with the terminal bronchioles. Together these airways are known as the bronchial tree. The trachea and bronchi are lined with mucosal epithelium. These cells produce a thin layer of mucus, the mucous blanket, that traps pathogen and microscopic particulate matter. These foreign particles are then swept

upward toward the larynx and throat by cilia, tiny hairlike projections on the epithelial cells. The cough reflex is triggered by irritants in the larynx, trachea, or bronchi. Until air passes through the terminal bronchioles and enters the respiratory bronchioles and alveoli, no gas exchange occurs. The respiratory zone of the lungs includes the respiratory bronchioles (which have scattered air sacs in their walls), the alveolar ducts, and the alveoli. Alveoli have very thin walls, composed of a single layer of epithelial cells covered by a thick mesh of pulmonary capillaries. The alveolar and capillary walls form the respiratory membrane (also known as the alveolar/capillary membrane), where gas exchange occurs between the air on the alveolar side and the blood on the capillary side. The airways move air to and from the alveoli; the right ventricle and pulmonary vascular system transport blood to the capillary side of the membrane. The outer surface of the lungs is covered by a thin, double layer of tissue known as pleura. The parietal pleura lines the thorax and surface of the diaphragm. It doubles back to form the visceral pleura, covering the external surface of the lungs. Between these pleural layers is a potential space that contains a small amount of pleural fluid, a serous lubricating solution. This fluid prevents friction during the movements of breathing and serves to keep the layers adherent through its surface tension. Good breathing techniques has many benefits and is slow, full, deep and rhythmic and 1. Improves your sleep pattern. 2. It aids in calming the mind, nerves and emotion. 3. Improves all mental processes including concentration and memory. 4. Tension is released. 5. It supplies more oxygen to the body cells and so blood is purified. 6. Helps to overcome tiredness and to rejuvenate energy. BREATHING EXERCISES General Instructions - Breathe slowly and rhythmically to exhale completely and empty the lungs completely. - Inhale through the nose to filter, humidify, and warm the air before it enters the lungs. - If you feel out of breath, breathe more slowly by prolonging the exhalation time. - Keep the air moist with a humidifier. Diaphragmatic Breathing Goal: To use and strengthen the diaphragm during breathing

- Place one hand on the abdomen (just below the ribs) and the other hand on the middle of the chest to increase the awareness of the position of the diaphragm and its function in breathing. - Breathe in slowly and deeply through the nose, letting the abdomen protrude as far as possible. - Breathe out through pursed lips while tightening (contracting) the abdominal muscles. - Press firmly inward and upward on the abdomen while breathing out. - Repeat for 1 minute; follow with a rest period of 2 minutes. - Gradually increase duration up to 5 minutes, several times a day (before meals and at bedtime) Pursed-Lip Breathing Goal: To prolong exhalation and increase airway pressure during expiration, thus reducing the amount of trapped air and the amount of airway resistance - Inhale through the nose while counting to 3 the amount of time needed to say Smell a rose. - Exhale slowly and evenly against pursed lips while tightening the abdominal muscles. (Pursing the lips increases intratracheal pressure; exhaling through the mouth offers less resistance to expired air.) - Count to 7 while prolonging expiration through pursed lips the length of time to say Blow out the candle. - While sitting in a chair: o Fold arms over the abdomen. o Inhale through the nose while counting to 3. o Bend forward and exhale slowly through pursed lips while counting to 7. - While walking: o Inhale while walking two steps. o Exhale through pursed lips while walking four or five steps. Effective Coughing Technique - Do the diaphragmatic breathing in a sitting position. - After, the patient bends slightly forward. This upright position permits a stronger cough. - The knees and hips are flexed to promote relaxation and reduce the strain on the abdominal muscles while coughing. - The patient inhales slowly through the nose and exhales through pursed lips several times. - The patient should cough twice during each exhalation while contracting (pulling in) the abdomen sharply with each cough.

- The patient splints the incisional area, if any, with firm hand pressure or supports it with a pillow or rolled blanket while coughing. (The nurse can initially demonstrate this by using the patients hands.)

OXYGEN TOXICITY Oxygen toxicity may occur when too high a concentration of oxygen (greater than 50%) is administered for an extended period (longer than 48 hours). Signs and symptoms of oxygen toxicity include substernal distress, paresthesias, dyspnea, restlessness, fatigue, malaise, progressive respiratory difficulty, and alveolar infiltrates evident on chest x-rays. In patients with COPD, the stimulus for respiration is a decrease in blood oxygen rather than an elevation in carbon dioxide levels. Thus, administration of a high concentration of oxygen removes the respiratory drive that has been created largely by the patients chronic low oxygen tension. The resulting decrease in alveolar ventilation can cause a progressive increase in arterial carbon dioxide narcosis and acidosis. Oxygen-induced hypoventilation is prevented by administering oxygen at low flow rates (1 to 2 LPM). Because oxygen supports combustion, there is always a danger of fire when it is used. It is important to post no smoking signs when oxygen is in use. Oxygen therapy equipment is also a potential source of bacterial cross-infection; thus, the nurse changes the tubing according to infection control policy and the type of oxygen delivery equipment. PULMONARY VOLUMES and CAPACITIES 1. TIDAL VOLUME (VT) 2. INSPIRATORY RESERVE VOLUME (IRV) 3. EXPIRATORY RESERVE VOLUME (ERV) 4. RESIDUAL VOLUME (RV) 5. TOTAL LUNG CAPACITY (TLC) 6. VITAL CAPACITY 7. INSPIRATORY CAPACITY 8. FUNCTIONAL RESIDUAL CAPACITY (FRC) 9. MINUTE VOLUME (MV) METHODS OF OXYGEN ADMINISTRATION

Oxygen is dispensed from a cylinder or a piped-in system. A reduction gauge is necessary to reduce the pressure to a working level, and a flow meter regulates the flow of oxygen in liters per minute. Many different oxygen devices are used, and all deliver oxygen if used as prescribed and maintained correctly. The amount of oxygen delivered is expressed as a percentage concentration. The appropriate form of oxygen therapy is best determined by arterial blood gas levels, which indicate the patients oxygenation status. To use an oxygen wall outlet, the nurse carries out these steps: - Attach the flow meter to the wall outlet. Exerting firm pressure. The flow meter should be in the off position. - Fill the humidifier bottle with distilled or tapped water in accordance with agency protocol. This can be done before coming to the bedside. Some humidifier bottles come prefilled by the manufacturer. - Attach the humidifier bottle to the base of the flow meter. - Attach the prescribed oxygen tubing and deliver device to the humidifier. - Regulate the flow meter to the prescribed level. The line for the prescribed flow rate should be in the middle of the ball of the flow meter. OXYGEN ADMINISTRATION DEVICES 1. CANNULA a. The nasal cannula (nasal prong) is the most common and inexpensive device used to administer oxygen. b. It is easy to apply and does not interfere with clients ability to eat or talk. c. It is also relatively comfortable, permits some freedom of movement, and is well tolerated by the client. d. It delivers a relatively low concentration of oxygen (23% to 45%) at floe rates of 2 to 6 L per minute. Above 6 L per minute, the client tends to swallow air and the FiO2 is not increased: this may cause irritation and drying of the nasal and pharyngeal mucosa. e. Limitations of the cannula include inability to deliver higher concentrations of oxygen, and that it can be drying and irritating to mucous membranes. 2. FACE MASK Face masks that cover the clients nose and mouth may be used for oxygen inhalation. Exhalation ports on the sides of the

mask allow exhaled carbon dioxide to escape. A variety of oxygen masks are marketed: a. The simple face mask delivers oxygen concentration from 40% to 60% at liter flows of 6 to 8 L per minute, respectively. b. The partial rebreather mask delivers oxygen concentrations of 60% to 90% at liter flows of 6 to 10 L per minute, respectively. The oxygen reservoir bag that is attached allows the client to rebreathe about the first third of third of the exhaled air in conjunction with oxygen. The partial rebreather bag must not totally deflate during inspiration to avoid carbon dioxide buildup. If this problem occurs, the nurse increases the liter flow of oxygen. c. The nonrebreather mask delivers the highest oxygen concentration possible 95% to 100% - by means other than intubation or mechanical ventilation, at liter flows of 10 to 15 L per minute. One-way valves on the mask and between the reservoir bag and the mask prevent the room air and the clients exhaled air from entering the bag so only the oxygen in the bag is inspired. To prevent carbon dioxide buildup, the nonrebreather bag must not totally deflate during inspiration. If it does, the nurse can correct this problem by increasing the liter flow of oxygen. d. The Venturi mask delivers oxygen concentrations varying from 24% to 40% or 50% at liter flows of 4 to 10 L per minute. The Venturi mask has wide-bore tubing and color-coded jet adapters that correspond to precise oxygen concentration and liter flow. For example, a blue adapter delivers a 24% concentration of oxygen at 4 L per minute, and a green adapter delivers a 35% concentration of oxygen at 8 L per minute. It employs the principle of air entrainment (trapping the air like a vacuum), which provides a high air flow with controlled oxygen enrichment. 3. FACE TENT a. Face tents can replace oxygen masks when masks are poorly tolerated by clients. b. Face tents provide varying concentrations of oxygen, for example, 30% to 50% concentration of oxygen at 4 to 8 L per minute. c. Frequently inspect the clients facial skin for dampness or chafing, and dry and treat as needed. As with face masks, the clients facial skin must kept dry.

SUMMARY WRAP PURPOSES 1. CANNULA a. To deliver a relatively low concentration of oxygen when only minimal O2 support is required b. To allow uninterrupted delivery of oxygen while the client ingests food or fluids 2. FACE MASK a. To provide moderate O2 support and a higher concentration of oxygen and/or humidity than is provided by cannula 3. FACE TENT a. To provide high humidity b. To provide oxygen when a mask is poorly tolerated c. To provide a high flow of O2 when attached to Venturi system EQUIPMENT 1. CANNULA a. Oxygen supply with a flow meter and adapter b. Humidifier with distilled water or tap water according to agency protocol c. Nasal cannula and tubing d. Tape e. Padding for the elastic band 2. FACE MASK a. Oxygen supply with a flow meter and adapter b. Humidifier with distilled water or tap water according to agency protocol c. Prescribed face mask of the appropriate size d. Padding for the elastic band 3. FACE TENT a. Oxygen supply with a flow meter and adapter b. Humidifier with distilled water or tap water according to agency protocol c. Face tent of the appropriate size IMPLEMENTATION Preparation 1. Determine the need for oxygen therapy, and verify the order for therapy.

a. Perform a respiratory assessment to develop baseline data if not already available. 2. Prepare the client and support people. a. Assist the client to a semi-fowlers position if possible. Performance 1. Prior to performing the procedure, introduce self and verify the clients identity using agency protocol. Explain to the client what you are going to do, why it is necessary, and how he or she can cooperate. 2. Perform hand hygiene and observe appropriate infection control procedures. 3. Provide for client privacy, if appropriate. 4. Set up the oxygen equipment and the humidifier. a. Attach the flow meter to the wall outlet or tank. The flow meter should be in off position. b. If needed, fill the humidifier bottle. (This can be done before coming to the bedside.) c. Attach the humidifier bottle to the base of the flow meter. d. Attach the prescribed oxygen tubing and delivery device to the humidifier. 5. Turn on the oxygen at the prescribed rate and ensure proper functioning. a. Check that the oxygen is flowing freely through the tubing. There should be no kinks in the tubing, and the connections should be airtight. There should be bubbles in the humidifier as the oxygen flows through. You should feel the oxygen at the outlets of the cannula, mask, or tent. b. Set the oxygen at the flow rate ordered. 6. Apply the appropriate oxygen delivery device. a. CANNULA i. Put the cannula over the clients face, with the outlet prongs fitting into the nares and the elastic band around the head. Some models have a strap to adjust under the chin. ii. If the cannula will not stay in place, tape it at sides of the face. iii. Pad the tubing and band over the ears and cheekbones as needed. b. FACE MASK i. Guide the mask toward the clients face, and apply it from the nose downward. ii. Fit the mask to the contours of the clients face.

iii. Secure the elastic band around the clients head so that the mask is comfortable but snug. iv. Pad the band behind the ears and over bony prominences. c. FACE TENT i. Place the tent over the clients face, and secure the ties around the head. 7. Assess the client regularly. a. Assess the clients vital signs, level of anxiety, color, and ease of respirations, and provide support while the client adjusts to the device. b. Assess the client in 15 to 30 minutes, depending on the clients condition, and regularly thereafter. c. Assess the client regularly for clinical signs of hypoxia, tachycardia, confusion, dyspnea, restlessness, and cyanosis. Review oxygen saturation or arterial blood gas results if they are available. 8. the equipment on a regular basis a. Check the liter flow and the level of water in the humidifier in 30 minutes and whenever providing care to the client. b. Be sure that water is not collecting in dependent loops of the tubing. c. Make sure that safety precautions are being followed. 9. Document findings in the client record using forms or checklists supplemented by narrative notes when appropriate. Evaluation 1. Perform follow-up based on findings that deviated from expected or normal for the client. Relate findings to previous to previous data if available (e.g., check oxygen saturation to evaluate adequate oxygenation). 2. Report significant deviations from normal to the primary care provider. BENEFITS OF OXYGEN THERAPY - headache relief - increased clarity - boosts immune system - relieves nausea - can prevent heart failure in people with severe lung disease - allows the bodys organs to carry out normal functions - prolongs life by reducing heart strain - decreases shortness of breath - makes exercise more tolerable

- results in fewer days of hospitalization TRACHEOSTOMY A tracheostomy is an opening into the trachea through the neck. A tube is usually through this opening and an artificial airway is created. Tracheostomy is done using one of two techniques: the traditional open surgical method or a percutaneous insertion. The percutaneous method can be done at the bedside in a critical care unit. The open technique is done in operating room, and a surgical a surgical incision is made in the trachea just below the larynx. Preferred artificial airway for patients requiring long term mechanical ventilation (longer than 3 weeks) - Upper airway obstruction - Failed or repeated intubations - Complications from ET intubations - Allows easy removal of secretions - Less resistance airflow than ET Advantages - Can be used long-term; up to years - More comfortable for the patient - Allows speaking and eating if respiratory status is stable - Patients can be taught how to take care for their tracheostomy at home Disadvantages - Requires surgical procedre to insert - Long term use can cause fistulas between trachea and skin, esophagus, or innominate artery Equipment Needed a. minor dressing tray b. sterile pipe cleaners (3 or 4) (or trach brush) c. sterile Q-tips (6 to 8) d. tracheostomy dressing (trach sponge), NOTE: a modified or cut 4x4 cannot be used as a trach sponge, as small cut fibers could enter the stoma and trachea e. hydrogen peroxide f. sterile normal saline g. clean gloves h. sterile gloves i. garbage container near patient bedside j. trach ties k. pair of scissors

TRACHEOSTOMY CARE 1. Prior to performing the procedure, introduce self and verify the clients identity. 2. Wash hands. 3. Explain procedure to patient. Suction secretions of the patient as necessary. 4. Assemble equipment and prepare dressing tray: a. Pour hydrogen peroxide in the largest compartment. b. Pour normal saline in one of the smaller compartments. c. Open trach sponge onto sterile field. d. Open Q-tip package. Place stems at the edge of the sterile field, ready for use. Maintain sterility of distal end of Q-tip. e. Open pipe cleaner package and drop into center of the sterile field. Maintain complete sterility. f. Open outer package of the sterile gloves. 5. Don clean gloves. 6. Remove the inner cannula fro m the trach tube. 7. Immerse it in hydrogen peroxide. 8. Remove used trach sponge and assess for secretions. Discard. Assess site. 9. Clean tracheostomy site with sterile Q-tips and normal saline. Use only a single sweep with each Q-tip. Move from the stoma and outwards (clean to dirty principle). Dry the stoma area, if necessary, using a sterile 2x2. These measure serve to: a. Maintain skin integrity of stoma b. Decrease risk of infection 10. Change the trach ties if they are soiled, or as per agency policy or order. Leave the previous trach tube ties secured to the flange and patient while attaching a new trach tie. Thread the new tie through the flange tie holes and around the back of the patients neck. Tie it in a reef or square knot at the side of the patients neck. Ties should be loose enough to slip two fingers between the tIes and neck, and secure enough to ensure the trach tube will not dislodge. Cut off the old tie and discard it. 11. Don sterile gloves. 12. Using sterile technique, use a pipe cleaner to clean inside the inner cannul and remove secretions. 13. Once all secretions are removed, rinse the inner cannula well with normal saline. This is done by dipping one end into the saline and then tippind the cannula the other direction, so the saline runs

through it and rinses it. Maintain sterile technique. Shake cannula to remove excess saline, or tap gently on inside surface of dressing tray. 14. Reinsert inner cannula. Lock into place. 15. Apply new trach sponge. This is generally considered to be a clean procedure. 16. Assess patient. 17. Dispose of equipments. Remove gloves. Wash hands 18. Document care given including assessment of secretions, dressing and stoma, as well as the patients tolerance of the procedure. CHEST PHYSIOTHERAPY Chest physiotherapy includes postural drainage, chest percussion and vibration, and breathing exercises/breathing retaining. In addition, teaching the patient effective coughing technique is an important part of chest physiotherapy. The goals of chest physiotherapy are to remove bronchial secretions, improve ventilation, and increase the efficiency of the respiratory muscles. 1. POSTURAL DRAINAGE (SEGMENTED BRONCHIAL DRAINAGE) a. It uses specific positions that allow the force of gravity to assist in the removal of bronchial secretions. The secretions drain from the affected bronchioles into the bronchi and trachea and are removed by coughing or suctioning. b. It is used to prevent or relieve bronchial obstruction caused by accumulation of secretions. NURSING MANAGEMENT/CONSIDERATION in POSTURAL DRAINAGE - The nurse should be aware of the patients diagnosis as well as the lung lobes or segments involved, the cardiac status, and any structural deformities of the chest wall and spine. - Auscultating the chest before and after the procedure helps to identify the areas needing drainage and to assess the effectiveness of treatment. - The nurse teaches family members who will be assisting the patient at home to evaluate breath sounds before and after treatment. - The nurse explores strategies that will enable the patient to assume indicated positions at home. This may require the creative use of objects readily available at home such as pillows, cushions, or cardboard boxes.

Postural drainage is usually performed two or four times daily, before meals (to prevent nausea, vomiting, and aspiration) and at bedtime. Prescribed bronchodilators, water, or saline may be nebulized and inhaled before postural drainage to dilate the bronchioles, reduce bronchospasm, decrease the thickness of mucus and sputum, and combat edema of the bronchial walls. - The nurse makes the patient as comfortable as possible in each position and provides an emesis basin, sputum cup, and paper tissue. - The nurse instructs the patient to remain in each position for 10 to 15 minutes and to breathe in slowly through the nose and then breathe out slowly through pursed lips to help keep the airways open so that secretions can drain while in each position. If a position cannot be tolerated, the nurse helps the patient to assume a modified position. When patient changes position, the nurse explains how to cough and remove secretions. - If the patient cannot cough, the nurse may need to suction the secretions mechanically. It also may be necessary to use chest percussion and vibration to loosen bronchial secretions and mucus plugs that adhere to the bronchioles and bronchi and to propel sputum in the direction of gravity drainage. If suctioning is required at home, the nurse instructs caregivers in safe suctioning technique. - After the procedure, the nurse notes the amount, color, viscosity, and character of the ejected sputum. It is important to evaluate the patients skin color and pulse the first few times the procedure is performed. It may be necessary to administer oxygen during postural drainage. - If the sputum is foul smelling, it is important to perform postural drainage in a room away from other patients and/or family members and to use room deodorizers. After the procedure, the patient may find it refreshing to brush the teeth and use a mouthwash before resting. 2. CHEST PERCUSSION and VIBRATION a. Thick secretions that are difficult to cough up may be loosened by tapping (percussing) and vibrating the chest. Chest percussion and vibration help to dislodge mucus adhering to the bronchioles and bronchi. b. PERCUSSION is carried out by cupping the hands and lightly striking the chest wall in a rhythmic fashion over the lung segment to be drained. The wrists are alternately flexed and extended so that the chest is cupped or clapped in a painless

manner. A soft cloth or towel may be placed over the segment of the chest that is being cupped to prevent skin irritation and redness from direct contact. Percussion, alternating with vibration, is performed for 3 to 5 minutes for each position. The patient use diaphragmatic breathing during this procedure to promote relaxation. As a precaution, percussion over the chest drainage tubes, the sternum, spine, liver, kidneys, spleen, or breasts (in women) is avoided. Percussion is performed cautiously in the elderly because of their increased incidence of osteoporosis and risk of rib fracture. c. VIBRATION is the technique of applying manual compression and tremor to the chest wall during the exhalation phase of respiration. This helps to increase the velocity of the air expired from the small airways, thus freeing the mucus. After three or four vibrations, the patient is encouraged to cough, using abdominal muscles. (Contracting the abdominal muscles increases the effectiveness of the cough.) d. A scheduled program of coughing and clearing sputum, together with hydration, reduces sputum in most patients. The number of times the percussion and vibration cycle is repeated depends on the patients tolerance and clinical response. It is important to evaluate breath sounds before and after the procedures. NURSING MANAGEMENT/CONSIDERATIONS in CHEST PERCUSSION and VIBRATION - When performing chest physiotherapy, it is important to make sure that the patient is comfortable, is not wearing restrictive clothing, and has not just eaten a meal. The uppermost areas of the lung are treated first. - The nurse gives medications for pain, as prescribed, before percussion and vibration and splints the incision and provides pillows for support as needed. The positions are varied, but focus is placed on the affected areas. On completion of the treatment, the nurse assists the patient to assume a comfortable position. - The nurse must stop treatment if any of the following symptoms occur: o Increased pain o Increased shortness of breath o Weakness o Light headedness o Hemoptysis

- Therapy is indicated until the patient has normal respirations, can mobilize secretions, and has normal breath sounds, and when the chest x-ray is normal.

ADMINISTERING NEBULIZATION THERAPY Equipment - air compressor - connection tubing - nebulizer - medication and saline solution Procedure Preparatory Phase 1. Monitor the heart rate before and after the treatment for patients using bronchodilator drugs. Performance Phase 1. Explain the procedure to the patient. 2. Place the patient in a comfortable sitting or semi-fowlers position. 3. Add the prescribed amount of medication and saline to the nebulizer. Connect the tubing to the compressor and set the flow at 6 to 8 L/minute. 4. Instruct the patient to exhale. 5. Tell the patient to take in a deep breath from the mouthpiece, hold breath briefly, then exhale. 6. Nose clips are sometimes used if the patient has difficulty breathing only through the mouth. 7. Observe expansion of chest to ascertain that the patient is taking deep breaths. 8. Instruct the patient to breathe slowly and deeply until all medication is nebulized. 9. On completion of the treatment, encourage the patient to cough after several deep breaths. Follow-up Phase 1. Record medication used and description of secretions. 2. Disassemble and clean nebulizer after each use. Keep this equipment in the patients room. The equipment is changed according to facility policy.

ARTERIAL BLOOD GAS Arterial blood gas analysis is an essential part of diagnosing and managing a patients oxygenation status and acid-base balance. The usefulness of this diagnostic tool is dependent on being able to correctly interpret the results. It is a blood test that is performed specifically on blood from an artery. It involves puncturing an artery with a thin needle and syringe and drawing a small volume of blood. ACID-BASE BALANCE The pH is a measurement of the acidity or alkalinity of the blood. It is inversely proportional to the number of hydrogen ions (H+) in the blood. The more H+ present, the lower the pH will be. Likewise, the fewer H+ present, the higher the pH will be. The pH of a solution is measured on a scale from 1 (very acidic) to 14 (very alkalotic). A liquid with a pH of 7, such as water, is neutral (neither acidic nor alkalotic). So how is the body able to self-regulate acid-base balance in order to maintain pH within the normal range? It is accomplished using delicate buffer mechanisms between the respiratory and renal systems. The Respiratory Buffer Response The respiratory center in the medulla (brain) is sensitive to concentrations of carbon dioxide and H+ in the body fluids. ACIDEMIA 1. Decrease in the blood pH 2. Stimulation of the respiratory center 3. Increase rate and depth of respiration 4. Decrease carbon dioxide 5. Increase blood pH

ALKALEMIA 1. Increase in blood pH 2. Inhibition of the respiratory center 3. Decrease rate and depth of respiration 4. (+) Retention of carbon dioxide 5. Decrease blood pH

Cells in the distal part of the renal tubules are sensitive to changes in the pH of the filtrate. Renal compensation is slow; it takes hours days to make a compensation. Kidneys cannot compensate for imbalances related to renal failure. ACIDEMIA 1. Ph < normal 2. Hydrogen ions are excreted 3. HCO3 is formed and retained 4. Increase blood pH ALKALEMIA 1. Ph > normal 2. Hydrogen ions are retained 3. HCO3 are excreted 4. Decrease blood pH ACID-BASE DISORDERS Respiratory Acidosis Respiratory acidosis is defined as a pH less than 7.35 with a PaCO2 greater than 45 mm Hg. Acidosis is caused by an accumulation of CO2 which combines with water in the body to produce carbonic acid, thus, lowering the pH of the blood. Any condition that results in hypoventilation can cause respiratory acidosis. These conditions include: - Central nervous system depression related to head injury - Central nervous system depression related to medications such as narcotics, sedatives, or anesthesia - Impaired respiratory muscle function related to spinal cord injury, neuromuscular diseases, or neuromuscular blocking drugs - Pulmonary disorders such as atelectasis, pneumonia, pneumothorax, pulmonary edema, or bronchial obstruction - Massive pulmonary embolus - Hypoventilation due to pain, chest wall injury/deformity, or abdominal distension Increasing ventilation will correct respiratory acidosis. The method for achieving this will vary with the cause of hypoventilation. If the patient is unstable, manual ventilation with a bag- valve-mask (BVM) is indicated until the underlying problem can be addressed. After stabilization, rapidly resolvable causes are addressed immediately. Causes that can be treated

rapidly include pneumothorax, pain, and CNS depression related to medications. If the cause cannot be readily resolved, the patient may require mechanical ventilation while treatment is rendered. Although patients with hypoventilation often require supplemental oxygen, it is important to remember that oxygen alone will not correct the problem. Respiratory Alkalosis Respiratory alkalosis is defined as a pH greater than 7.45 with a PaCO2 less than 35 mm Hg. Any condition that causes hyperventilation can result in respiratory alkalosis. These conditions include: - Psychological responses, such as anxiety or fear - Pain - Increased metabolic demands, such as fever, sepsis, pregnancy, or thyrotoxicosis - Medications, such as respiratory stimulants. - Central nervous system lesions Treatment of respiratory alkalosis centers on resolving the underlying problem. Patients presenting with respiratory alkalosis have dramatically increased work of breathing and must be monitored closely for respiratory muscle fatigue. When the respiratory muscles become exhausted, acute respiratory failure may ensue. Metabolic Acidosis Metabolic acidosis is defined as a bicarbonate level of less than 22 mEq/L with a pH of less than 7.35. Metabolic acidosis is caused by either a deficit of base in the bloodstream or an excess of acids, other than CO2. Diarrhea and intestinal fistulas may cause decreased levels of base. Causes of increased acids include: - Renal failure - Diabetic ketoacidosis - Anaerobic metabolism - Starvation - Salicylate intoxication Metabolic Alkalosis Metabolic alkalosis is defined as a bicarbonate level greater than 26 mEq/liter with a pH greater than 7.45. Either an excess of base or a loss of acid within the body can cause metabolic alkalosis. Excess base occurs from ingestion of antacids, excess use of bicarbonate, or use of lactate in dialysis. Loss of acids can occur secondary to protracted vomiting, gastric

suction, hypochloremia, excess administration of diuretics, or high levels of aldosterone. Symptoms of metabolic alkalosis are mainly neurological and musculoskeletal. Neurologic symptoms include dizziness, lethargy, disorientation, seizures and coma. Musculoskeletal symptoms include weakness, muscle twitching, muscle cramps and tetany. The patient may also experience nausea, vomiting, and respiratory depression. Metabolic alkalosis is one of the most difficult acid-base imbalances to treat. Bicarbonate excretion through the kidneys can be stimulated with drugs such as acetazolamide (DiamoxTM), but resolution of the imbalance will be slow. In severe cases, IV administration of acids may be used. It is significant to note that metabolic alkalosis in hospitalized patients is usually iatrogenic in nature. Components of the Arterial Blood Gas The arterial blood gas provides the following values: pH Measurement of acidity or alkalinity, based on the hydrogen (H+) ions present. The normal range is 7.35 to 7.45 PaO2 The partial pressure of oxygen that is dissolved in arterial blood. The normal range is 80 to 100 mm Hg. SaO2 The arterial oxygen saturation. The normal range is 95% to 100%. PaCO2 The amount of carbon dioxide dissolved in arterial blood. The normal range is 35 to 45 mm Hg. HCO3 The calculated value of the amount of bicarbonate in the bloodstream. The normal range is 22 to 26 mEq/liter B.E. The base excess indicates the amount of excess or insufficient level of bicarbonate in the system. The normal range is 2 to +2 mEq/liter. (A negative base excess indicates a base deficit in the blood.)

Steps to an Arterial Blood Gas Interpretation The arterial blood gas is used to evaluate both acid-base balance and oxygenation, each representing separate conditions. Acid-base evaluation requires a focus on three of the reported components: pH, PaCO2 and HCO3. This process involves three steps. Step One Assess the pH to determine if the blood is within normal range, alkalotic or acidotic. If it is above 7.45, the blood is alkalotic. If it is below 7.35, the blood is acidotic. Step Two If the blood is alkalotic or acidotic, we now need to determine if it is caused primarily by a respiratory or metabolic problem. To do this, assess the PaCO2 level. Remember that with a respiratory problem, as the pH decreases below 7.35, the PaCO2 should rise. If the pH rises above 7.45, the PaCO2 should fall. Compare the pH and the PaCO2 values. If pH and PaCO2 are indeed moving in opposite directions, then the problem is primarily respiratory in nature. Step Three Finally, assess the HCO3 value. Recall that with a metabolic problem, normally as the pH increases, the HCO3 should also increase. Likewise, as the pH decreases, so should the HCO3. Compare the two values. If they are moving in the same direction, then the problem is primarily metabolic in nature. The following chart summarizes the relationships between pH, PaCO2 and HCO3.

Compensation When a patient develops an acid-base imbalance, the body attempts to compensate. Remember that the lungs and the kidneys are the primary buffer response systems in the body. The body tries to overcome either a respiratory or metabolic dysfunction in an attempt to return the pH into the normal range.

A patient can be uncompensated, partially compensated, or fully compensated. When an acid- base disorder is either uncompensated or partially compensated, the pH remains outside the normal range. In fully compensated states, the pH has returned to within the normal range, although the other values may still be abnormal. Be aware that neither system has the ability to overcompensate. In order to look for evidence of partial compensation, review the following three steps: 1. Assess the pH. This step remains the same and allows us to determine if an acidotic or alkalotic state exists. 2. Assess the PaCO2. In an uncompensated state, we have already seen that the pH and PaCO2 move in opposite directions when indicating that the primary problem is respiratory. But what if the pH and PaCO2 are moving in the same direction? That is not what we would expect to see happen. We would then conclude that the primary problem was metabolic. In this case, the decreasing PaCO2 indicates that the lungs, acting as a buffer response, are attempting to correct the pH back into its normal range by decreasing the PaCO2 (blowing off the excess CO2). If evidence of compensation is present, but the pH has not yet been corrected to within its normal range, this would be described as a metabolic disorder with a partial respiratory compensation. 3. Assess the HCO3. In our original uncompensated examples, the pH and HCO3 move in the same direction, indicating that the primary problem was metabolic. But what if our results show the pH and HCO3 moving in opposite directions? That is not what we would expect to see. We would conclude that the primary acid-base disorder is respiratory, and that the kidneys, again acting as a buffer response system, are compensating by retaining HCO3, ultimately attempting to return the pH back towards the normal range.

Understanding arterial blood gases can sometimes be confusing. A logical and systematic approach using these steps makes interpretation much easier. Applying the concepts of acid- base balance will help the healthcare provider follow the progress of a patient and evaluate the effectiveness of care being provided.