1. Chapter 40
Oxygenation
Oxygen is a basic human need that is required for life.
Patients frequently are unable to meet their oxygenation needs, often as a result of an ineffective pump or ineffective gas exchange.

2. Factors Affecting Oxygenation
Physiological factors
Decreased oxygen-carrying capacity
Hypovolemia
Decreased inspired oxygen concentration
Increased metabolic rate
Conditions affecting chest wall movement
Pregnancy, obesity, neuromuscular disease, musculoskeletal abnormalities, trauma, CNS alterations
Influences of chronic diseases
Any condition that affects cardiopulmonary functioning directly affects the body’s ability to meet oxygen demands.
[Ask students if they can remember cardiac anatomy and physiology and to name some condition that would affect oxygenation. Answers may include conduction defects, valvular dysfunction, myocardial ischemia, cardiac myopathy, tissue hypoxemia on the cardiac side and hyperventilation on the respiratory side, hypoventilation, hypoxia, and others.]
[Ask students why hypovolemia affects gas exchange. Any condition that reduces chest wall movement will result in decreased ventilation. If the diaphragm is unable to descend fully with breathing, the volume of inspired air decreases, delivering less oxygen to the alveoli and all tissues.]
[Ask students if they can name some nervous system diseases that may affect breathing. Answers may include myasthenia gravis, Guillain-Barré, and polio.]
When patients take opioids, their respiratory center is depressed.

3. Alterations in Respiratory Functioning
Hyperventilation
Ventilation in excess of that required to eliminate carbon dioxide produced by cellular metabolism
Hypoventilation
Alveolar ventilation inadequate to meet the body’s oxygen demand or to eliminate sufficient carbon dioxide
Hypoxia
Inadequate tissue oxygenation at the cellular level
Cyanosis
Blue discoloration of the skin and mucous membranes
Illnesses or conditions that affect ventilation or oxygen transport cause alterations in respiratory functioning.
Impaired chest wall movement reduces the level of tissue oxygenation.
Hyperventilation can be caused by anxiety, infection, drugs, acid-base imbalance, fever, aspirin poisoning, or amphetamine use.
[Ask students: Why? Answers may include that an increase in respiratory rate causes excessive amounts of carbon dioxide elimination.]
Hypoventilation is caused by atelectasis and collapsed alveoli.
[Ask students to identify signs and symptoms. Answers may include dizziness, headache upon awakening, lethargy, cardiac dysrhythmias, electrolyte imbalances, convulsions, coma, and cardiac arrest.]
Hypoxia is life threatening. Causes may include: anemia, carbon monoxide poisoning, septic shock, cyanide poisoning, pneumonia atelectasis, cardiomyopathy, spinal cord injury, and head trauma.
Cyanosis, blue discoloration of the skin and mucous membranes caused by the presence of desaturated hemoglobin in capillaries, is a late sign of hypoxia.

4. Nursing Knowledge Base
Factors influencing oxygenation:
Physiological
Developmental
Lifestyle
Environmental
In addition to physiological factors, multiple developmental, lifestyle, and environmental factors affect patients’ oxygenation status.
It is important to recognize these as possible risks or factors that impact health care goals.

5. Developmental Factors
Infants and toddlers
School-aged children and adolescents
Young and middle-aged adults
Older adults
Developmental stage and age affect tissue oxygenation. [Ask students what factors apply to these age groups? Discuss the following.]
Problems that affect oxygenation in these age groups include
Infants and toddlers: upper respiratory infections (URIs), nasal congestion
School-aged children and adolescents: exposed to respiratory infections and secondhand smoke; plus danger of starting cigarette smoking
Young to middle-aged adults: exposed to cardiopulmonary factors, unhealthy diet, lack of exercise, stress, cigarette smoking, illegal substances; over-the-counter (OTC) and prescription drugs not used as intended
Older adults: calcification of valves, SA node, and costal cartilages; osteoporosis; atherosclerosis; enlarged alveoli, trachea, and bronchi
[See also Box 40-1 Focus on Older Adults: Oxygenation Changes in Older Adults.]

7. Changes Occurring with Aging
Decreased elasticity of thorax and respiratory muscles
Decrease in total body water, drier mucous membranes
Loss of elastic recoil during exhalation
Thickening of alveolar membrane; less efficient gas exchange
Less respiratory reserve
The elderly are more vulnerable to acute infections of the respiratory tract such as colds, pneumonia, and influenza.
There is an increasing number of chronic lung diseases in the elderly, including emphysema, pleurisy, and cancer.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

8. Lifestyle Risk Factors
Smoking
Associated with heart disease, COPD, and lung cancer
The risk of lung cancer is 10 times greater for a person who smokes than for a nonsmoker.
Substance abuse
Excessive use of alcohol and other drugs impairs tissue oxygenation.
Stress
A continuous state of stress or severe anxiety increases the metabolic rate and oxygen demand of the body.
•Cigarette smoking and secondhand smoke are associated with a number of diseases, including heart disease, COPD, and lung cancer. Cigarette smoking worsens peripheral vascular and coronary artery diseases.
•Women who take birth control pills and smoke cigarettes are at increased risk for thrombophlebitis and pulmonary emboli.
•Exposure to secondhand smoke is also dangerous.
•The body responds to anxiety and other stresses with an increased rate and depth of respiration. Most people adapt, but some, particularly those with chronic illnesses or acute life-threatening illnesses such as an MI, cannot tolerate the oxygen demands associated with anxiety.

9. Environmental Factors
The incidence of pulmonary disease is higher in smoggy, urban areas than in rural areas.
A patient’s workplace sometimes increases the risk for pulmonary disease.
Coccidioidomycosis
Asbestosis
Occupational pollutants include asbestos, talcum powder, dust, and airborne fibers.
For example, farm workers in dry regions of the southwestern United States are at risk for coccidioidomycosis, a fungal disease caused by inhalation of spores of the airborne bacterium Coccidioides immitis.
Asbestosis is an occupational lung disease that develops after exposure to asbestos. The lung with asbestosis often has diffuse interstitial fibrosis, creating a restrictive lung disease. Patients exposed to asbestos are at risk for developing lung cancer, and this risk increases with exposure to tobacco smoke.

11. Restlessness, irritability, confusion
Signs of Hypoxemia
Restlessness, irritability, confusion
Difficulty in breathing (dyspnea)
Rapid breathing (tachypnea, stridor)
Abnormal lung sounds
Cyanosis, retractions, dysrhythmias
Acid-base imbalance
Decreased oxygen saturation
Cover the definitions on the slide and ask for student feedback:
Dyspnea
Tachypnea
Stridor
Cyanosis
Retractions
Dysrhythmias
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

12. Clearing Airway Secretions: The Effective Cough
Most effective in the sitting position
Two deep breaths and then inhale deeply again
Breath rapidly and forcibly exhaled as quickly as possible with the mouth open
This moves secretions up the bronchial tree
Repeated forceful exhalation bring secretions up to where they can be more easily coughed up
Copyright © 2014 by Elsevier Inc. All rights reserved.

13. Implementation: Acute Care
Dyspnea management
Airway maintenance
Mobilization of pulmonary secretions
Hydration
Humidification
Nebulization
Coughing and deep-breathing techniques
Chest physiotherapy
(postural drainage)
Dyspnea is difficult to measure and treat. Treatments are individualized, and more than one therapy can be implemented.
Airway maintenance requires mobilization of secretions by increased fluid intake, humidification, or nebulization.
Breathing exercises improve ventilation, oxygenation, and sensations of dyspnea.
The airway is patent when the trachea, bronchi, and large airways are free from obstructions. Proper coughing techniques will help to keep the airway patent and free from obstruction.
The ability of a patient to mobilize pulmonary secretions makes the difference between a short-term illness and a long recovery involving complications. In patients with adequate hydration, pulmonary secretions are thin, white, watery, and easily removable with minimal coughing.
Humidification is necessary for patients receiving more than 4 L/min of oxygen. Bubbling oxygen through water adds humidity to oxygen.
Nebulization adds moisture or medications to inspired air by mixing particles of varying sizes with the air.
Directed coughing is a deliberate maneuver that is effective when spontaneous coughing is not adequate.
Diaphragmatic breathing/belly breathing is a technique that encourages deep breathing to increase air to the lower lungs.
Chest physiotherapy is a group of therapies used to mobilize pulmonary secretions. These include postural drainage, chest percussion, and vibration. You will want to work collaboratively with respiratory therapists when using these techniques.
[See Box 40-7 on text p. 843 Guidelines for Chest Physiotherapy.]
[Review Table 40-6 on text pp Positions for Postural Drainage.]

14. Pulse Oximetry Pulse oximeter
Used to monitor any patient at risk for hypoxia
Measures changes in serum oxygen continuously
Sensor attached to fingers, toes, ears, or skin
Helps track changes in oxygen therapy
Oximetry is the photoreaction of oxygen in the bloodstream.
It is a painless, noninvasive monitor.
To take the best readings, avoid direct sunlight.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

15. Monitoring oxygen saturation with pulse oximeter
Have students look at the picture and text while you emphasize the use of the machine.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

16. Percussion
This photo shows chest wall percussion, alternating hand clapping against the patient’s chest wall.
Chest percussion involves rhythmically clapping on the chest wall over the area being drained to force secretions into larger airways for expectoration.
Percussion is contraindicated in patients with bleeding disorders, osteoporosis, or fractured ribs.
[Shown is Figure 40-9 from text p. 845.]

17. Implementation: Suctioning Techniques
Oropharyngeal and nasopharyngeal
Used when the patient can cough effectively but is not able to clear secretions
Orotracheal and nasotracheal
Used when the patient is unable to manage secretions
Tracheal
Used with an artificial airway
Suctioning is necessary when patients are unable to clear respiratory secretions from the airways by coughing or other less invasive procedures. Suctioning techniques include oropharyngeal and nasopharyngeal suctioning, orotracheal and nasotracheal suctioning, and suctioning of an artificial airway (discussed on a later slide).
Each type of suctioning requires the use of a round-tipped, flexible catheter with holes on the sides and end of the catheter. When suctioning, you apply negative pressures (not greater than 150 mm Hg) during withdrawal of the catheter, never on insertion.
You will learn various suctioning techniques in the nursing skills lab.
You will differentiate between when to use sterile and when to use clean techniques. If you suction the patient too much, he or she can be at risk for hypoxemia, hypotension, dysrhythmias, and trauma to the mucosa of the lungs.
(Tracheal suctioning is described on the next slide.)

18. Artificial Airways Oral airway
Prevents obstruction of the trachea by displacement of the tongue into the oropharynx
Endotracheal and tracheal airways
Short-term use to ventilate, relieve upper airway obstruction, protect against aspiration, clear secretions
Tracheostomy
Long-term assistance, surgical incision made into trachea
Airway maintenance may require use of artificial airways and suctioning.
An artificial airway is used for a patient with a decreased level of consciousness or an airway obstruction and aids in removal of tracheobronchial secretions.
The presence of an artificial airway places a patient at high risk for infection and airway injury. Use clean technique for oral airways, but use sterile technique in caring for and maintaining endotracheal and tracheal airways to prevent health care–associated infections (HAIs). Artificial airways need to stay in the correct position to prevent airway damage.
The most common complication of a tracheostomy tube is partial or total airway obstruction caused by buildup of respiratory secretions.

19. Artificial Airways (cont’d)
The left photo shows artificial oral airways. The oral airway extends from the teeth to the oropharynx, maintaining the tongue in the normal position.
The right diagram shows an endotracheal tube inserted into the trachea. The cuff is inflated to maintain position. The tube is passed through the patient’s mouth, past the pharynx, and into the trachea.
[Shown are Figures and from text p. 846.]

20. Types of airways Endotracheal Tube Nasopharyngeal Oropharyngeal
List the reasons why airways would be used.
Oropharyngeal
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

21. Inline Suction Catheter
Shown is a Ballard tracheal care, closed suction catheter.
You perform tracheal suctioning through an artificial airway such as an endotracheal (ET) or tracheostomy tube.
The two current methods of suctioning are open and closed methods. Open suctioning involves using a new sterile catheter for each suction session. Closed suctioning involves using a reusable sterile suction catheter that is encased in a plastic sheath to protect it between suction sessions.
[See also Box 40-8 Evidence-Based Practice: The Effectiveness of Instilling Normal Saline into Artificial Airways Before Suctioning on text p. 846, and Box 40-9 on text p. 847 Procedural Guidelines: Closed (In-Line) Suction Catheter.]
[Shown is Figure from text p. 845.]

22. Maintenance and Promotion of Lung Expansion
Ambulation
Positioning
Reduces pulmonary stasis, maintains ventilation and oxygenation
Incentive spirometry
Encourages voluntary deep breathing
Noninvasive ventilation
Maintains positive airway pressure and improves alveolar ventilation
Promotion of lung expansion can be achieved by mobility, positioning, incentive spirometry, and chest tube insertion.
Early ambulation studies indicate that the therapeutic benefits of activity include an increase in general strength and lung expansion.
The most effective position for promotion of lung expansion is the 45-degree semi-Fowler’s position. This position uses gravity to assist in lung expansion and reduces pressure from the abdomen on the diaphragm.
Patients use incentive spirometry to prevent or treat atelectasis. You will learn this technique in the nursing skills lab.
Noninvasive positive-pressure ventilation (NPPV) is used to prevent the use of invasive artificial airways (endotracheal [ET] tube or tracheostomy) in patients with acute respiratory failure, cardiogenic pulmonary edema, or exacerbation of COPD. This prevents or treats atelectasis by inflating the alveoli, reducing pulmonary edema by forcing fluid out of the lungs back into circulation, and improving oxygenation in those with sleep apnea. Ventilatory support is achieved using a variety of modes, including continuous positive airway pressure (CPAP) and bilevel positive airway pressure (BiPAP).

23. Promotion of Lung Expansion
On the left, flow-oriented incentive spirometer. The photo on the right shows a CPAP mask.
Flow-oriented incentive spirometers consist of one or more plastic chambers that contain freely moving colored balls. A patient inhales slowly and with an even flow to elevate the balls and keep them floating as long as possible to ensure a maximally sustained inhalation.
CPAP treats patients with obstructive sleep apnea, those with congestive heart failure, and preterm infants with underdeveloped lungs. In obstructive sleep apnea, airways collapse, causing shallow or absent breathing. Any air moving past the obstruction results in loud snoring.
[Shown are Figures and from text p. 848.]

24. Quick Quiz!
2. A patient with a tracheostomy has thick tenacious secretions. To maintain the airway, the most appropriate action for the nurse includes A. Tracheal suctioning. B. Oropharyngeal suctioning. C. Nasotracheal suctioning. D. Orotracheal suctioning.
Answer: A

25. Maintenance and Promotion of Lung Expansion
Chest tube
A catheter placed through the thorax to remove air and fluids from the pleural space, to prevent air from re-entering, or to re- establish intrapleural and intrapulmonic pressures
Pneumothorax
Hemothorax
Special considerations
You will learn about various types of chest tubes in the nursing skills lab. You will specifically discuss the type used in your health care facility.
One type is the closed drainage system in a single chamber. The chamber serves as both collector and water seal.
Another type is the two-chamber system, which permits liquid to flow into the collection chamber as air flows into the water-sealed chamber.
A newer type is the dry chest tube system, which does not use water in the suction chamber. The automatic control valve (ACV) continuously balances the force of the suction with the atmosphere.
A pneumothorax is a collection of air in the pleural space.
A hemothorax is an accumulation of blood and fluid in the pleural cavity between the parietal and visceral pleurae, usually owing to a trauma.

26. Oxygen Administration
Oxygen: colorless, tasteless, odorless gas present in the air
Although essential for life, use of oxygen is not without its disadvantages
High concentrations cause fires to burn very rapidly
Very drying to the tissues of the respiratory tract
Equipment needed for oxygen therapy
Oxygen source, the flowmeter, the humidifier, the tubing, and the appropriate appliance for the method ordered

27. Wall oxygen flowmeter and humidifier setup

28. Oxygen Administration (cont’d)
Used to supplement oxygen in inspired air
Inspired air is 21% oxygen
Can be delivered by nasal cannula, mask, tent, croupette, or catheter
Requires humidification, flow rate prescribed by a physician
Common flow rates are 4-6 L/min
COPD patients given only 2 to 3 L/min to prevent causing respiratory arrest

29. Oxygen Administration: Cannula
A plastic tube with short, curved prongs that extend into the nostril about ¼ to ½ inch
Held in place by looping it over the ears and cinching under the chin; can be easily adjusted for the patient’s comfort

31. Oxygen Administration: Masks
Various types available for administering oxygen in concentrations ranging from 24% to 55% at flows of 3 to 7 L/min
Oxygen concentrations above 60% rarely used because of the danger of oxygen toxicity

32. Oxygen Delivery
The left photo shows a simple face mask; on the right is a plastic face mask with a reservoir.
The simple face mask (left) is used for short-term oxygen therapy. It fits loosely and delivers oxygen concentrations from 35% to 50% fraction of inspired oxygen concentration (FiO2). The mask is contraindicated for patients with carbon dioxide retention because retention can be worsened. Flow rates should be 5 L or more to avoid rebreathing exhaled carbon dioxide retained in the mask. Be alert to skin breakdown under the mask with long-term use.
A plastic face mask with a reservoir bag (right) is capable of delivering higher concentrations of oxygen. A partial rebreather mask is a simple mask with a reservoir bag that should be at least one third to one half full on inspiration and delivers from 40% to 70% FiO2 with a flow rate of 6 to 10 L/min. When used as a nonrebreather mask, a similar face mask has one-way valves that prevent exhaled air from returning to the reservoir bag. The flow rate should be a minimum of 10 L/min and should deliver FiO2 of 60% to 80%.
Frequently inspect the reservoir bag to make sure that it is inflated. If it is deflated, the patient is breathing large amounts of exhaled carbon dioxide. High-flow oxygen systems should be humidified.
[Shown are Figures and from text p. 852.]

33. Venturi Face Mask
The Venturi mask delivers higher oxygen concentrations of 24% to 60% with oxygen flow rates of 4 to 12 L/min, depending on the flow control meter selected.
[Shown is Figure from text p. 852.]

34. Home Oxygen Systems Indications
Arterial partial pressure (PaO2) of 55 mm Hg or less
–or–
Arterial oxygen saturation (SaO2) of 88% or less on room air at rest, on exertion, or with exercise
Administered via nasal cannula or face mask
T tube or tracheostomy collar used if patient has a permanent tracheostomy
Beneficial effects for patients with chronic cardiopulmonary disease
Home oxygen therapy improves patients’ exercise tolerance and fatigue levels and in some situations assists in the management of dyspnea.
Three types of oxygen delivery systems are used: compressed gas cylinders, liquid oxygen, and oxygen concentrators. Before placing a certain delivery system in a home, assess the advantages and disadvantages (see Table 40-8) of each type, along with the patient’s needs and community resources.
[Review Table 40-8 Home Oxygen Systems on text p. 853.]
In the home, the major consideration is the oxygen delivery source.
Patients and their family caregivers need extensive teaching to be able to manage oxygen therapy efficiently and safely. Teach the patient and family about home oxygen delivery (i.e., oxygen safety, regulation of the amount of oxygen, and how to use the prescribed home oxygen delivery system) to ensure their ability to maintain the oxygen delivery system.
The home health nurse coordinates the efforts of the patient and family, home respiratory therapist, and home oxygen equipment vendor. The social worker usually assists initially with arranging for the home care nurse and oxygen vendor.

35. Epiglottis

37. Esophagus

38. The Epiglottis
Is a flap made of Elastic Cartilage tissue covered with a Mucus Membrane, attached to the entrance of the Larynx.
It projects obliquely upwards behind the Tongue and the Hyoid bone, pointing dorsally. It stands open during breathing, allowing air into the larynx.
During swallowing, it closes to prevent aspiration, forcing the swallowed liquids or food to go down the esophagus instead.
It is thus the valve that diverts passage to either the trachea or the esophagus.

39. Assesment & Evaluation
Perform
Observe respiratory rate before, during, and after any activity.
Assess any sputum produced.
Auscultate lung sounds for improvement in adventitious sounds.
Patient expectations evaluate the care from the patient’s perspective. Consider the use of survey tools such as the COPD Self-Efficacy Scale, the Chronic Respiratory Disease Questionnaire, and the Pulmonary-Specific Quality of Life for COPD Scale.
In addition (to tasks on the slide), you will need to evaluate pulse oximetry changes to decreases in oxygen delivery, and to monitor arterial blood gas levels, pulmonary function tests, chest x-ray films, ECG tracings, and physical assessment data to provide objective measurement of the success of therapies and treatments.

40. Suctioning
Required for patients unable to clear secretions from their own airway effectively
Nasopharyngeal
Oral suction
Can be performed with a Yankauer suction tip or with a 14 to 16 Fr. suction catheter attached to wall suction
Negative pressure set between 80 and 120 mm Hg
Aseptic technique used for airway suctioning

41. WHEN TO SUCTION
Suctioning is done only for patients who can’t clear their own airways. Its timing should be tailored to each patient rather than performed on a set schedule.
Start with a complete assessment. Findings that suggest the need for suctioning include increased work of breathing, changes in respiratory rate, decreased oxygen saturation, copious secretions, wheezing, and the patient’s unsuccessful attempts to clear secretions.

42. Nasopharyngeal Suctioning
Maintain patent airway by removing accumulated secretions
Involves upper air passages of nose, mouth, and pharynx
Used most often for infants, gravely debilitated or unconscious patients, and those who have an ineffective cough
Suction pressure set between 80 and 120 mm Hg

43. Tracheobronchial Suctioning
Deep suctioning to remove secretions from the trachea and bronchi using sterile technique
Most often performed on intubated patients or patients with a tracheostomy
Patients need preoxygenation
Sterile technique is mandatory
Should be performed no longer than 10 seconds at a time, with oxygenation in between

44. Tracheostomy
A surgical opening into the trachea to facilitate insertion of a cuffed tracheostomy tube
Cuff enables controlling the airway and preventing aspiration
Maintains a patent airway; facilitates suctioning and mechanical ventilation
May be temporary or permanent

45. Lisa’s patient has an order for nasopharyngeal suction
Lisa’s patient has an order for nasopharyngeal suction. Which one is not true regarding nasopharyngeal suctioning?
The purpose of suctioning is to maintain a patent airway by removing accumulated secretions.
The amount of suction pressure should be set between 40 and 80 mm Hg.
It is best to use aseptic technique for all airway suctioning.
A catheter that has been used in the mouth is not used again for nasopharyngeal or tracheobronchial