Alterations in Gas Exchange

NUR 211
 Acute Respiratory Failure  Chest Traumas
 Acute Respiratory Distress  Bronchopulmonary Dysplasia
Syndrome (ARDS) (BPD)
 Acute Respiratory Failure (ARF)
 Failure
 Oxygenation
 Ventilation
 Both of the above
 Altered gas exchange (room air)
 PaO2 < 60 mm Hg
 PaCO2 > 50 mm Hg
 pH ≤ 7.30
 Failure of Oxygenation
 Hypoventilation
 Intrapulmonary shunting
 Ventilation-perfusion mismatch
 Diffusion defects
 Decreased barometric pressure
 Low cardiac output (nonpulmonary hypoxemia)
 Low hemoglobin level (nonpulmonary
hypoxemia)
 Hypoventilation
 Drug overdose
 Neurological disorders
 Abdominal or thoracic surgery
 Intrapulmonary Shunting
 Blood shunted from right to left side of heart
without oxygenation
 Qs/Qt disturbance
 Causes: atrial or ventricular septal defect,
atelectasis, pneumonia, pulmonary edema
 Why does administration of higher levels of
oxygen not help in shunt disorders?
Bubble Study
 V/Q Mismatch
 Most common cause of low O2
 Normal ventilation (V) is 4 L/min
 Normal perfusion (Q) is 5 L/min
 Normal V/Q ratio is 4/5 or 0.8
 A mismatch occurs if either
 V is decreased or
 Q is decreased
 What are causes of this condition?
 Diffusion Defects
 Diffusion of O2 and CO2 does not occur
 Fluid in alveoli
 Pulmonary fibrosis
 Low Cardiac Output
 Cardiac output must
be adequate to
maintain tissue
perfusion
 Normal delivery is
600 to 1000 mL/min
of oxygen
 Low Hemoglobin
 Hemoglobin necessary to transport oxygen
 95% of oxygen is bound to hemoglobin
 Tissue Hypoxia
 Some conditions prevent tissues from using
oxygen despite availability
 Cyanide poisoning
 Tissue hypoxia results in anaerobic metabolism
and lactic acidosis
 Acute Respiratory Failure:
Assessment: Recognize Cues
 Dyspnea
 Orthopnea
 ABGs = hypoxia and hypercarbia
 Restlessness, irritability, agitation

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 Failure of Ventilation
 Hypercapnia
 Related to:
 Alveolar hypoventilation—decrease in ventilation and
hypoxemia
 V/Q mismatch
 Acute Respiratory Failure:
Interventions: Take Action
 Oxygen therapy
 Drug therapy
 Position of comfort

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Assessment of Respiratory Failure
 Neurological—shows  Psychosocial
earliest signs of  Chest x-ray
hypoxemia and  Pulmonary function
hypercapnia tests
 Respiratory  Laboratory studies
 Cardiovascular  Arterial blood gases
 Nutrition (ABGs)
 Pulse oximetry and
end-tidal CO2
 Interventions
 Maintain a patent airway
 Optimize O2 delivery
 Minimize O2 demand
 Identify and treat the cause of ARF
 Prevent complications
 Nursing Diagnoses (1 of 2)

 Impaired ventilation
 Ineffective airway clearance
 Infection
 Anxiety
 Impaired skin integrity
 Ineffective coping
 Nursing Diagnoses (2 of 2)
 Ineffective breathing pattern
 Impaired gas exchange
 Impaired breathing pattern
 Fluid volume excess
 Altered nutrition
 Medical Management
 Oxygen
 Bronchodilators
 Corticosteroids
 Sedation
 Transfusions
 Therapeutic paralysis
 Nutritional support
 Hemodynamic monitoring
Acute Respiratory Distress
Syndrome (ARDS)
 ARDS
 Noncardiogenic pulmonary edema
 Diagnostic criteria
 PaO2/FiO2 ratio of less than 200
 Bilateral infiltrates
 Pulmonary capillary wedge pressure
< 18 mm Hg
 Acute lung injury scoring
 Acute Respiratory Distress Syndrome
(ARDS)
 Pathophysiology Overview
 Hypoxemia that persists even when 100% oxygen
is given
 Decreased pulmonary compliance
 Dyspnea
 Noncardiac-associated bilateral pulmonary edema
 Dense pulmonary infiltrates on x-ray

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 PaO2/FiO2 Ratio
 How to Calculate the P/F Ratio: PaO2 / FIO2
 “P” represents PaO2 (arterial pO2) from the ABG. “F” represents the
FIO2 – the fraction (percent) of inspired oxygen that the patient is
receiving expressed as a decimal (40% oxygen = FIO2 of 0.40). P
divided by F = P/F ratio.
 Example:
PaO2 = 90 on 40% oxygen (FIO2 = 0.40):  90 / 0.40 = P/F ratio =
225.
A P/F ratio of 225 is equivalent to a pO2 of 45 mmHg, which is
significantly < 60 mmHg on room air.
 A nasal cannula provides oxygen at adjustable flow rates in liters of oxygen per
minute (L/min or “LPM”).  The actual FIO2 (percent oxygen) delivered by nasal
cannula is somewhat variable and less reliable than with a mask but can be
estimated as shown in the Table below as the accepted clinical standard for the
conversion. The FIO2 derived from nasal cannula flow rates can then be used to
calculate the P/F ratio. Note: Assumes room air is 20% (0.20) and each L/min of
oxygen = +4% (0.04). 

Example: A patient has a pO2 of 85mmHg on

ABG while receiving 5 liters/minute of oxygen. 5
L/min = 40% oxygen  = FIO2 of 0.40. The P/F
ratio = 85 divided by 0.40 = 212.5.
 ARDS Pathophysiology (1 of 2)
 Insult—systemic inflammatory response
syndrome (SIRS) (sepsis, pneumonia, shock,
and aspiration of gastric contents)
 Release of inflammatory mediators
 Damage to alveolar-capillary membrane
 Increased capillary permeability
 Pulmonary edema (noncardiogenic)
 ARDS Pathophysiology
(2 of 2)
 Microatelectasis
 Decreased compliance (stiff lungs)
 Decreased surfactant (damage to type II
pneumocytes)
 Impaired gas exchange
 V/Q mismatch
ARDS: Assessment: Recognize Cues

 Physical Assessment/Signs and Symptoms

 Hyperpnea, noisy respiration, cyanosis, pallor,
retraction intercostally or substernally
 Vital signs

 Diagnostic Assessment
 Lowered partial pressure of arterial oxygen
 P/F ratio < 200 mm Hg
 Sputum cultures
 Chest x-ray
 ECG

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 Symptoms of ARDS
 Dyspnea and tachypnea
 Hyperventilation with normal breath sounds
 Respiratory alkalosis
 Increased temperature and pulse
 Worsening chest x-rays that progress to “white
out”
 Increased PIP on ventilation
 Eventual severe hypoxemia
 ARDS: Health Promotion and
Maintenance
 Identify those at high risk
 Monitor those receiving tube feedings to prevent
aspiration
 Infection control guidelines

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 ARDS
 Three phases
 Exudative phase: dyspnea & tachypnea from alveoli
becoming fluid filled Tx: oxygen
 Fibrosing alveolitis phase: lung injury leads to
pulmonary hypertension; body is attempting to repair
damage and increasing lung involvement reduces gas
exchange & oxygenation; MODS Tx: adequate
oxygenation, prevent complications, support lungs
 Resolution phase: approx. 14 days, resolution of
injury; if not patient dies or has chronic disease;
ARDS patient often have neurological deficits
 ARDS:
Interventions: Take Action

 ET intubation and mechanical ventilation with

PEEP or CPAP
 Drug and fluid therapy
 Antibiotics
 Conservative fluid therapy
 Diuretics
 Nutrition therapy: enteral/parenteral as soon
as possible

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 Treatment of ARDS
 Treat the cause
 Oxygenation and ventilation
 Positive end-expiratory pressure (PEEP)
 Possible nontraditional modes of ventilation: high-frequency,
pressure-control, and inverse-ratio
 Airway Pressure Release Ventilation (APRV)
 High Frequency Oscillatory Ventilation (HFOV)
• Deliver higher airway pressures; must use paralytics with
HFOV
 Proning to promote gas exchange; less lung compression than
supine position
 Extracorporeal membrane Oxygenation (ECMO)
 Treatment of ARDS
 Comfort
 Sedation
 Pain relief
 Neuromuscular blockade
 Decrease O2 consumption
 Positioning
 Prone positioning
 Continuous lateral rotation therapy
 Treatment of ARDS
 Fluid and electrolyte balance
 Adequate nutrition
 Pharmacologic intervention
 Psychosocial support
 ARDS
 Be alert for complications:
 Multiple organ dysfunction syndrome
 Renal failure
 Disseminated intravascular coagulation
 Long-term pulmonary effects associated with high
oxygen and other therapies
Acute Respiratory Failure
in Chronic Obstructive
Pulmonary Disease
 ARF in Chronic Obstructive
Pulmonary Disease (COPD)
 Worsening V/Q mismatch (e.g., secretions and
bronchoconstriction can lead to ARF)
 Causes: acute exacerbations, CHF/ pulmonary
edema, dysrhythmias, pneumonia, dehydration,
and electrolyte imbalances
 Assessment
 Dyspnea
 Chronic cough
 Sputum production
 Postbronchodilator spirometry limitations
 Pulmonary function studies
 Chest wall changes (barrel chest)
 Accessory muscles used for breathing
 Clubbing of the fingers
 Wheezing and crackles
 ABG (hypoxemia and hypercapnia)
 Medical Management of ARF in
COPD
 Correct hypoxemia
 Cautious administration of O2
 Noninvasive positive-pressure ventilation
 Ventilatory assistance
 Medications
 Beta2 agonists (bronchodilators)
 Corticosteroids
 Antibiotics (depends on cause)
 Cautious administration of sedatives
 Pharmacologic Therapy
 Short-acting inhaled beta2-agonists
 Long-acting beta2-agonists
 Corticosteroids (prednisone)
 Antibiotics
ARF in Asthma
 Exacerbation of Asthma (1 of 2)
 Wheezing
 Dyspnea

 Chest tightness

 Use of accessory muscles

 Nonproductive cough

 Hyperventilation initially

 Peak expiratory flow reading is less than 50% of

normal values
What are some triggers?
 Exacerbation of Asthma
(2 of 2)
 Causes
 Bronchodilators no longer working
 Noncompliance with medications
 Effects
 Hyperventilation with air trapping results in respiratory
acidosis
 Severe hypoxemia
 Medical Management
 Oxygen; ventilation in severe cases
 IV corticosteroids
 Inhaled bronchodilators; rapid-acting beta2-
agonists
 Teaching
 ARF: Pulmonary Embolus (PE)
 Virchow’s triad
 Venous stasis
 Altered coagulability
 Damage to vessel wall
 Embolus results in a lack of perfusion to
ventilated alveoli (V/Q mismatch)
 PE Assessment
 Symptoms of deep venous thrombosis
 Chest pain (worse on inspiration)
 Dyspnea
 Tachycardia
 Tachypnea
 Cough; hemoptysis
 Crackles, wheezes
 Hypoxemia
 Diagnosis of PE
 Clinical signs and symptoms
 D-dimer assay (positive)
 V/Q scan with high probability of PE
 Duplex ultrasound (DVT)
 High-resolution multidetector computed
tomography angiography (MDCTA; spiral CT)
 Pulmonary angiogram
 Prevention of PE
 Medications
 Heparin, low–molecular weight heparin
 Mechanical
 Sequential compression devices
 Foot pumps
 Compression stockings
 Position changes
 Treatment of atrial dysrhythmias
 Prophylactic anticoagulant therapy
 Warfarin; long-term prevention
 Complications of PE
 Heart failure
 Obstructive shock
 Death
 Treatment for PE
 ABCs; oxygen
 Thrombolytics (dissolve the clots)
 Heparin
 Monitor laboratory results for
 Bleeding
 Thrombocytopenia
 Surgical procedures
 Embolectomy
 Vena cava umbrella (prevention)
 Chest Trauma
 Chest trauma is a contributing factor in about
50% of deaths of patients who experience
unintentional traumatic injuries
 Pulmonary contusion
 Rib fracture
 Flail chest
 Pneumothorax
 Hemothorax
 Tension pneumothorax

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 Pulmonary Contusion
 Potentially lethal injury
 May be asymptomatic at first, later develop
respiratory failure and possibly pneumonia
 Decreased breath sounds, crackles, wheezes
 Treatment—Maintenance of ventilation and
oxygenation

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 Rib Fracture
 Often caused by direct blunt trauma to the
chest
 Pain on movement, chest splinting
 Uncomplication rib fractures reunite
spontaneously; focus is on pain management

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 Flail Chest
 Paradoxical chest movement

Image to the right: Flail chest.

Normal respiration: A,
Inspiration; B, Expiration.
Paradoxic motion: C,
Inspiration —area of the lung
underlying unstable chest wall
sucks in on inspiration. D,
Expiration—unstable area
balloons out. Note movement
of mediastinum toward
opposite lung during
inspiration.

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 Pneumothorax/
Hemothorax

 Pneumothorax
 Spontaneous or
simple
 Traumatic
 Tension
pneumothorax
 Hemothorax
 Simple
 Complex
 Ineffective
Breathing: Etiology Interventions
Tension pneumothorax Needle decompression
Prepare for chest tube insertion on affected side.

Pneumothorax Prepare for chest tube insertion on affected side.

Open chest wound Seal the wound with an occlusive dressing and tape on
three sides.
Prepare for chest tube insertion on affected side.

Pulmonary contusion Prepare for early intubation and mechanical ventilation.

Flail chest Prepare for early intubation and mechanical ventilation.

Administer analgesics as ordered.

Copyright © 2013, 2009, 2005, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc. 58
Open Pneumothorax and Tension
Pneumothorax
60
Sealing the Open Wound

Asherman chest seal is very effective

 Sealing
the Open  You can use impervious material
taped on three sides

Wound
 Lung Cancer
 Pathophysiology overview
 Poor long-term survival
 SCLC and NSCLC
 Metastasis
 Paraneoplastic syndromes
 Staging
 Incidence and Prevalence
 Repeated exposure to inhaled substances that
cause chronic irritation or inflammation
 Cigarette smoking is major risk factor

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 Lung Cancer:
Etiology and Genetic Risk
 Nonsmokers exposed to secondhand and
thirdhand smoke have risk
 Chronic exposure to chemicals and inhalants
 Sometimes occurs in adults who never smoked,
especially in women

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 Lung Cancer:
Health Promotion and Maintenance
 Reduce tobacco smoking
 Screening as secondary prevention
 Assessment: Noticing
 History
• Risk factors
• Hoarseness, cough, sputum, hemoptysis, SOB, endurance changes, chest
pain
 Physical Assessment/Signs & Symptoms
• Pulmonary
• Non-pulmonary
 Psychosocial Assessment

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 Lung Cancer:
Assessment: Noticing (2 of 2)
 Diagnostic assessment
 Chest x-ray
 CT
 Biopsy or pleural effusion fluid
 Thoracoscopy
 MRI
 Radionucleotide scans
 PET

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 Lung Cancer:
Interventions: Take Action
 Nonsurgical management
 Chemotherapy
 Targeted therapy
 Immunotherapy
 Radiation therapy
 Photodynamic therapy
 Surgical management
 Removal of lobe or entire lung
• Chest tube

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Lung Cancer: Surgical Management
 Lobectomy
 Pneumonectomy
 Segmentectomy
 Wedge resection

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 Pneumonectomy

Lobectomy

Segmentectomy

Thoracic
Wedge Resection
Surgeries &
Procedures
Bronchoplastic or sleeve
resection
Lung Volume Reduction

Video Thorascopy
 Risk Factors for lung
surgeries
 Preoperatively
 Intraoperatively
 Postoperatively
Lung Cancer: Chest Tube Placement

The image to the

right demonstrates
proper chest tube
placement.

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 Chest Tube Drainage System

The images above show a chest tube drainage system (left) and a diagram of the
sections and flow of the drainage system (right).

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Purpose of Chest Tubes
Remove accumulated air or fluid from the pleural cavity
• Pus, blood, serous fluid, gastric juices, chyle

Restore negative pressure in the pleural cavity

Re-expand a partially or totally collapsed lung

 Types of Chest Tubes

 Straight
 Placed anterior/superior
 Right Angle
 Placed posterior/inferior
 Straight with Trocar
 Inserted via stab like wound made by
surgeon
 Used in emergencies
 3 Bottle System

Pleur-Evac

• Works like 3 bottle setup with suction

• One-piece disposable plastic unit with 3 chambers
Chest Tube
• Chamber one:
• Collects fluid from patient – drainage collection
Drainage
• Chamber two:
System • Water seal that prevents air from moving back into the
pleural space
• Receives air from chamber one
• Chamber three:
• Suction regulator – when suction is applied

Flutter valve to straight drainage (gravity)

Heimlich Valve
  Placed via
 Stab wound with local anesthesia
 Incision from chest surgery
 Usually sutured to skin
 Tube positioned between lung
Insertion of & chest wall: between visceral
and parietal pleura
Chest  After chest surgery, two tubes
are usually placed to drain air
Tubes and fluid after surgical
procedure
 Chest tube in apex of lungs:
drains air
 Chest tube in base of lungs:
drains fluid
  Set up insertion tray for M.D.
 Assist with procedure
 Make sure water seal is ready
 Connect chest tube to drainage
system
 Dress insertion site with petroleum-
based occlusive dressing (Vaseline
Nursing 
gauze)
Extra dressing at bedside and
Role during padded clamps X2 at bedside
 Order portable CXR to confirm
Insertion placement
 Take VS q 15 min for 1st hr then q 1
hr for 2 h
 Auscultate breath sounds with each
VS and q4h to assess air exchange
in affected lung
  Mark the original fluid level
 Mark hourly/daily increments
 Ensure that the tubing is not looping or
interfering with the movements of the patient
 When the patient is in the lateral position,
place a rolled towel under the tubing to protect
it from the weight of the patient’s body
 Encourage the patient to change position

Nursing 
frequently
Put the arm and shoulder of the affected side
through range of motion exercises several
Management 
times daily
Some pain medication may be necessary
 “Milk” the tubing in the direction of the
drainage bottle hourly if needed with alcohol
swab
 “Milking” generates a high negative
pressure in the system
 MD will usually inform staff of need to
milk tubing or not
  Make sure there is fluctuation
of the water seal level
(Chamber 2)
 If no fluctuations:
 Check for patient lying on
tube
Nursing
 Check for clot in the tube
Management  Observe for air leaks in the
Con’t drainage system. Indications for
air leak include:
 Constant\excessive bubbling
in the water seal chamber
 External leaks with
connections
  Observe and immediately report:
 Rapid and shallow breathing
 Cyanosis
 Pressure in the chest
 Symptoms of hemorrhage
 Significant changes in VS
 Encourage deep breathing and
Nursing coughing
Management  Teach proper technique for incentive
Con’t spirometry
 Transporting with a chest tube
 Chest drainage system should
be placed below the chest level
 Do NOT clamp the chest tube
during transport
  Provide adequate pain
medication prior to removal
 Instruct client to take deep
breaths and hold a deep
breath while tube is removed
 Occlusive Vaseline gauze
covered by a 4x4 gauze pad
Nursing Care applied to the site
immediately following
during Removal removal
 Thoroughly cover and seal
with non-porous tape
 Assess patient frequently for
respiratory or LOC changes
that might indicate return of
problem that required tube
 Bronchopulmonary Dysplasia

 Chronic obstructive
pulmonary disease
 Thicking of the
alveolar walls &
bronchial epithelium
 Occurs primarily in low
birth weight &
premature infants who
were ventilated for
long periods