Management

of Gas
Exchange Disturbance
 Gas Exchange in the Lungs
PO2 in alveoli ~ 100 mm Hg
PO2 in pulmonary capillaries ~ 40 mm Hg
Result: O2 moves into pulmonary capillaries
PCO2 in pulmonary capillaries ~ 46 mm Hg
Average arterial blood gases equal
PO2 100 mm Hg
PCO2 40 mm Hg
Exchange of O2 for CO2 occurs by diffusion
Structure of gas exchange organs facilitates
diffusion
 Gas
Transport

Ventilation of alveoli CO2 diffusion from body

O2 diffusion from alveoli to
hemoglobin in RBCs
Equilibrium pO2 = 100 mmHg
Diffusion from hemoglobin to
body tissues
Equilibrium pO2 = 40 mmHg
tissues to hemoglobin
Equilibrium pCO2 = 45 mmHg
Diffusion from hemoglobin in
RBCs to alveoli
Equilibrium pCO2 = 40 mmHg
Ventilation of alveoli

Hemoglobin
Oxygen-hemoglobin
dissociation curve
Hb binds O2 at high pO2
Hb releases O2 at low pO2
Hemoglobin
Oxygen-hemoglobin
dissociation curve
Exercise lowers pO2 and pH in
muscles, higher temperature
Hb releases more O2 at low
pO2 , low pH, and high
temperature
 O2 and CO2
Movement

Copyright 2008 Pearson Education, Inc., publishing as

Benjamin Cummings.
O2 and CO2 Partial Pressures
O2 and CO2 Partial Pressures

Copyright 2008 Pearson Education, Inc., publishing as Benjamin Cummings.

Gas transfer capacity may be impaired by:

Thickening of membrane
The thicker the membrane, the slower the
rate of diusion. E.g., edema in the
intersPPal space increases the distance
gasses must diuse
ReducPon in surface area
If surface area decreases, the rate of
diusion will decrease. E.g., emphysema
causes dissoluPon of alveolar walls
Gas transfer capacity may be impaired by:

Diusion coecient
The diusion coecient is proporPonal to the
solubility
The greater the diusion coecient, the greater
the rate of diusion
So, a small molecule that is highly soluble diuses
fast (e.g., CO2). CO2 diuses ~ 20 x more rapidly
than O2
Dierence in parPal pressure
gases will diuse from areas of high parPal
pressure to areas of lower parPal pressure
Copyright 2008 Pearson Education, Inc., publishing as Benjamin Cummings.
 Assessment
Client history
Major signs and symptoms
Cough
Type, duraPon, length
Sputum producPon
Color, consistency, amount
Dyspnea
Rate of percepPon
ADLs
Paroxysmal nocturnal dyspnea
Orthopnea
Chest pain, wheezing, clubbing of nger/nails,
hemoptysis, cyanosis
 Risk Factors
Smoking
Personal / family history
OccupaPon
Allergens
RecreaPonal exposure
 Gerontologic Considerations (1)
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
 Gerontologic Considerations (2)
Vital capacity and respiratory muscle strength
peak between 20-25 and then decrease
Age 40 and older surface area in alveoli is
reduced
Age 50 alveoli loses elasPcity
Loss of chest wall mobility>decrease in vital
capacity
Amount of respiratory dead space increases with
age
Decreased diusion capacity with age lower
oxygen level in arterial circulaPon
 Common Management
PosiPon
Environmental control
AcPvity dan rest
Oral Hygiene
Adequate hydraPon
InfecPon prevenPon and control
Psychosocial support
 Respiratory Pharmacologic agent
AnPmicrobials (AnPbioPk)
Bronchodilators
a. -adrenergics, seperP : albuterol (ventolin)
b. Theophyline, seperP aminophyline
Adrenal GlucocorPcoids (Prednison)
AnPtusive
Mucolitycs
AnPallergenics
Vasoconstristor dan Decongestan
 Respiratory Assessment
Health History
Risk factors for respiratory disease-genetics,
smoking, allergens, occupational and recreational
exposure
Dyspnea, orthopnea
Cough, ?productive
Chest pain
Cyanosis
Lung sounds
Clubbingindicates chronicity
 Diagnostic Evaluation (1)
PFTs-assess respiratory function, screening, assess
response to therapy
FVCvital capacity performed with a maximally
forced expiratory effort
Forced expiratory volumeFEV1volume 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 (2)
ABGs:
1. pH
2. evaluate the PaCO2 and HCO3-
3. 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.
 Diagnostic Evaluation (3)
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
 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 8-11L/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.
 Tracheostomy (1)
Surgical procedure in which an opening is made
into the trachea
Tracheostomy tube
Temporary or permanent
Used to bypass an upper airway obstrucPon,
allow removal of tracheobronchial secrePons,
permit long term use of mechanical venPlaPon,
to prevent aspiraPon in unconscious paPent or
to replace endotracheal tube
 Tracheostomy (2)
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
 Tracheostomy (3)
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
aspiration
 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 15-20 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 build. Usually is twice tidal volume. If <
10mL/kg, will need respiratory assist)
 Thoracic Surgeries (1)
Pneumonectomy
Lobectomy
Segmental resection
Lung volume reduction, etc

Manage potential complication:

Monitor respiratory status
Vitals
For dysrhythmias
For bleeding, atelectasis and infection
Monitor chest tube drainage, for leaks, for tube kinks,
for excessive drainage
 Thoracic Surgeries (2)
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
PosiPon of Postural Drainage