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OXYGEN INSUFFICIENCY

INTRODUCTION

Homeostasis is the body's tendency to maintain a state of physiologic balance in the presence
of constantly changing conditions. Homeostasis is necessary if the body is to function
optimally at a cellular level and as a total organism. Normal physiologic processes depend on
a relatively stable state in the internal environment of the body.
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OXYGEN INSUFFICIENCY

Oxygen is one of the most important elements, without which life on earth would not be able
to exist.

 Discovered by Carl Wilhelm Scheele in Sweden in 1771 and then by Joseph Priestley
in 1774.
 Named by Antoine Laurent Lavoisier in 1774.

All life on earth is based on 5 basic elements: sulfur, nitrogen, hydrogen, carbon and oxygen.
Amongst these, the element that is most abundant is oxygen.

 Oxygen makes up about 65% of the human body.

 Odourless, tasteless, and colourless
 oxygen is one of the most important substances without which life would not be able
to exist.
 For example, we can go without food for a number of weeks and survive, we can
even go without water for 3-7 days, but we cannot survive without oxygen beyond 5
minutes.

Given the importance of this 'breath of life, here are some interesting facts about oxygen:

 Oxygen provides us with 90% of our nutritional energy, with just 10% coming from
the food we eat. The more our cells are saturated with stabilized oxygen, the lower is
the wear and tear that occurs in the body. Hence, oxygen is one of the most important
anti-aging substances.
 Oxygen's natural ability to oxidize or catabolize viruses, fungi and bacteria is vitally
important in order to sustain the cells' natural immortality factor and to prevent
degenerative diseases.
 Oxygen is also an essential factor for burning up the body's toxins-those that are
generated by us internally as well as those that we get from external sources such as
the environment, water, and food-particularly junk food. The lower the content of
oxygen, the less ability we have to burn up toxins, to heal, and to fight disease.
 Studies have also revealed that the oxygen level in the atmosphere was about 36-38%
about 200 years back. However, when recent measurements were done, it was
discovered that at present the earth's atmosphere just comprises of 19% concentration
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levels of oxygen. In some areas that are heavily industrialized, which have high levels
of pollution, the oxygen level is often as low as 9%.
 The level of oxygen in the earth's atmosphere has been seriously depleted due to
various factors, such as the industrial revolution, the carbon-based fuels we use, and
the depletion of large tracts of oxygen-generating forest areas. According to scientific
studies, it has been shown that the concentration level of oxygen in the atmosphere is
being depleted by 0.8% about every fifteen years or thereabouts.

The list of crucial roles played by oxygen is quite endless.

 It is necessary for oxidization, or combustion, and also acts as a preserver, sanitizer,

deodorizer and disinfectant.
 Our cells are energized by oxygen, which helps them to regenerate.
 Oxygen regulates all the functions of the body.
 Our ability to talk, sleep, eat, move, feel, and think are all dependent on the energy
that is generated by oxygen.
 Our body uses oxygen for the metabolism of food and the elimination of waste and
toxins via oxidation
 Oxygen is used by the brain to process any information.

Meaning of Oxygenation

"Oxygenation means the delivery of oxygen to the body tissues and cells." It is necessary to
maintain health.

PHYSIOLOGY OF OXYGENATION

 The respiratory and cardiac systems function to supply the body's oxygen demands.
 Blood is oxygenated through the mechanism of ventilation, perfusion and transport of
respiratory gases.
 Neural and chemical regulators control the rate and depth of respiration in response
to the changing tissue oxygen demands.
 Most cells in the body obtain energy from chemical reactions involving oxygen and
the elimination of carbon dioxide.
 Oxygen is transferred from the lungs to the blood, and carbon dioxide is transferred
from the blood to the alveoli to be exhaled as a waste product.
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 At the tissue level, oxygen is transferred from the blood to the tissues, and carbon
dioxide is transferred from tissues to the blood to return to the alveoli and be exhaled.

Oxygenation results from the co-operative function of 3 major systems:

1. Respiratory/Pulmonary system

2. Haematological system

3. Cardiovascular system.

Respiratory System

The main function of the respiratory system is to extract O, from the atmosphere, to deliver it
to the tissues and to take out CO, from the tissues and discharge it into the atmosphere. Body
tissues utilize oxygen and produce carbon dioxide as a result of metabolism.

Lung Volumes and Capacities

These can be divided into 2 major headings:

1. Static lung volumes and capacities

2. Dynamic lung volumes and capacities.

Static lung Tidal volume (500ml)

volumes Inspiratory reserve volume (3000ml)
Expiratory reserve volume (1000ml)
Residual volume (1500ml)

Inspiratory capacity
Static lung Functional residual capacity
capacities Vital capacity
Total lung capacity
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Pathway of Air

Nasal cavities (or oral cavity) > pharynx > trachea > primary bronchi (right and left) >
secondary bronchi > tertiary bronchi bronchioles > alveoli (site of gas exchange).

There are three steps in the process of oxygenation:

 Ventilation,
 perfusion and
 diffusion.

Ventilation

 Ventilation is the process of moving gases into and out of the lungs.
 Ventilation requires the coordination of the muscular and elastic properties of the
lung and thorax, as well as intact innervation.
 The major inspiratory muscle is diaphragm and it is innervated by the phrenic nerve,
which exits the spinal cord at the forth cervical vertebra.

Perfusion

Perfusion relates the ability of the cardiovascular system to pump oxygenated blood to the
tissues and return de-oxygenated blood to the lungs.

Diffusion

Diffusion relates to the exchange of gas molecules from the areas of high concentration to
areas of low concentration.

 Diffusion of respiratory gases occurs at alveolocapillary membrane and the rate of

diffusion can be affected by the thickness of membrane.
 Increased thickness of the membrane impedes diffusion because gases take longer to
transfer across.
 Clients with pulmonary oedema, pulmonary infiltrates, or a pulmonary effusion have
an increased thickness of the alveolocapillary membrane, resulting in slowed
diffusion, slowed exchange of respiratory gases, and impaired delivery of oxygen to
the tissues.

Pulmonary Ventilation
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It means movement of air into and out of lungs. Its main purpose is to supply fresh air.
Ventilation is composed of:

 Inspiration-when air flows into the lungs.

 Expiration-when air moves out of lungs.

Adequate ventilation depends upon:

 Clear airways.
 An intact central nervous system and respiratory center.
 An intact thoracic cavity capable of expanding and contracting.
 Adequate pulmonary compliance and recoil.

Alveolar Gas Exchange.

 After the alveoli are ventilated, the second phase of respiratory process is diffusion.
 Diffusion is movement of gases or other particles from an area of greater pressure or
concentration to an area of lower pressure or concentration.
 Here oxygen diffuses to pulmonary blood vessels.
 Diffusion of gases depends upon pressure differences on both sides.
 As in inspired air, concentration of CO, is less, so CO, diffuses from blood vessels to
alveoli and eventually it comes out of body through expiration.

CARDIOVASCULAR PHYSIOLOGY

 Cardiopulmonary physiology involves delivery of deoxygenated blood (blood high in

carbon dioxide and low in oxygen), to the right side of the heart and to the pulmonary
circulation and oxygenated blood from the lungs to the left side of the heart and the
tissues.
 The cardiac system delivers oxygen, nutrients and other substances to the tissues and
removes the waste products of cellular metabolism through the cardiac pump, the
circulatory vascular system, and the integration of other systems (e.g., respiratory,
digestive and renal).

OXYGEN TRANSPORT AND DELIVERY

 The oxygen transport system consists of the lungs and cardiovascular system.
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 Delivery depends on the amount of oxygen entering the lungs (ventilation), blood
flow to the lungs and tissues (perfusion), rate of diffusion, and oxygen carrying
capacity.
 The capacity of blood to carry oxygen is influenced by the amount of dissolved
oxygen in the plasma, amount of haemoglobin, and tendency of haemoglobin to bind
with oxygen.
 Only a relatively small amount of required oxygen, less than 1%, is dissolved in the
plasma.
 Most oxygen is transported by haemoglobin, which serves as a carrier for oxygen
and carbon dioxide.
 The haemoglobin molecule combines with oxygen to form oxyhaemoglobin. The
formation of oxyhaemoglobin is easily reversible, allowing haemoglobin and oxygen
to dissociate, which frees oxygen to enter the tissues.

PaO₂: The amount of oxygen dissolved in the plasma represents PaO₂ in arterial blood. It is
expressed in mm of mercury.

Sao₂: The amount of oxygen bound to haemoglobin in comparison with the amount of
oxygen the haemoglobin can carry. It is expressed as a percentage. For example, if
SaO₂ is 90%, it means 90% of haemoglobin attachments for oxygen have oxygen
bound to them.

Carbon Dioxide Transport

 Carbon dioxide diffuses into red blood cells and is rapidly hydrated into carbonic
acid because of the presence of carbonic anhydrase.
 The carbonic acid then dissociates into hydrogen and bicarbonate ions.
 The hydrogen ion is buffered by haemoglobin, and the bicarbonate ion diffuses
into the plasma.
 In addition, some of the carbon dioxide in the red blood cells reacts with amino
acid groups, forming carbamino compounds. This reaction can occur rapidly
without the presence of enzymes.
 Reduced haemoglobin (deoxyhaemoglobin) can combine with carbon dioxide
more easily than oxyhaemoglobin, and, therefore, venous blood transports the
majority of carbon dioxide.
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Regulation of Respiration

Regulation of respiration is necessary to ensure sufficient oxygen intake and carbon dioxide
elimination to meet body's demands, e.g., during exercise, infection or pregnancy. It includes:

Neural Regulation

It maintains rhythm and depth of respiration and balance between inspiration and expiration.

a. Cerebral cortex: Voluntary control of respiration delivers impulses to the respiratory

motor neurons by way of the spinal cord; accommodates speaking, eating and
swimming.
b. Medulla oblongata: Automatic control of respiration occurs continuously.

Chemical Regulation

It maintains appropriate rate and depth of respirations based on changes in the body's carbon
dioxide, oxygen and hydrogen ion concentration.

a. Chemoreceptors: These are located in the medulla, carotid body and aortic body.
Changes in chemical content of oxygen, car- bon dioxide and hydrogen ion stimulate
chemoreceptors, which, in turn, stimulate neural regulators to adjust the rate and depth of
ventilation to maintain normal arterial blood gas levels. Chemical regulation can occur
during physical exercise and in some illnesses. It is a short-term adaptive mechanism.

The Oxygen Dissociation Curve

 The oxygen dissociation curve is a graph that shows the percent saturation of
haemoglobin at various partial pressures of oxygen.
 Commonly a curve may be expressed with the P50 value. This is a value which tells
the pressure at which the erythrocytes are fifty percent saturated with oxygen.
 The purpose of an oxygen dissociation curve is to show the equilibrium of
oxyhaemoglobin and nonbonded haemoglobin at various partial pressures.
 At high partial pressures of oxygen, usually in the lungs, haemoglobin binds to
oxygen to form oxyhaemoglobin.
 When the blood is fully saturated, all the erythrocytes are in the form of
oxyhaemoglobin. As the erythrocytes travel to tissues deprived of oxygen, the partial
pressure of oxygen will decrease. Consequently, the oxyhaemoglobin releases the
oxygen to form haemoglobin.
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 The sigmoid shape of the oxygen dissociation curve is a result of the cooperative
binding of oxygen to the four polypeptide chains. Cooperative binding is the
characteristic of haemoglobin to have a greater ability to bind oxygen after a subunit
has bound oxygen. Thus, haemoglobin is most attracted to oxygen when three of the
four polypeptide chains are bound to oxygen.

Factors that Influence Oxygen Binding

 Temperature: Increasing the temperature denatures the bond between oxygen and
haemoglobin, which increases the amount of oxygen and haemoglobin and decreases
the concentration of oxyhaemoglobin. The dissociation curve shifts to the right.
 pH: A decrease in pH (increase in acidity) by addition of carbon dioxide or other
acids causes a Bohr Shift. A Bohr Shift is characterized by causing more oxygen to be
given up as oxygen pressure increases and it is more pronounced in animals of smaller
size due to the increase in sensitivity to acid. The dissociation curve shifts to the right.
The Bohr Effect was defined by Danish physiologist, Christian Bohr in 1904. It is the
observation that in a lower pH (more acidic) environment, Haemoglobin will bind to
oxygen with less affinity. Blood pH is governed to a large degree on the balance
between CO, and O, partial pressures, carbon dioxide being acidic in nature and the
blood naturally alkaline. In addition, Haemoglobin bound to CO, loses its affinity to
O,, described by the Bohr effect, shifting the O,-Hb-Dissociation Curve to the right.
 Organic phosphates-2, 3: Diphosphoglycerate (DPG) is the primary organic
phosphate in mammals. DPG binds to haemoglobin which rearranges the
haemoglobin into the T-state, thus decreasing the affinity of oxygen for haemoglobin
(T and R State). The curve shifts to the right.

OXYGEN INSUFFICIENCY

 Lack of adequate oxygen, often referred to as oxygen insufficiency, can lead to a

number of serious health problems.
 Untreated oxygen deficiency can reduce lung function to the extent that long-term
oxygen therapy is required to continue normal bodily functions.
 Oxygen insufficiency has been linked to every major illness category including heart
disease, respiratory disease and cancer.
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 All heart attacks are brought about by the failure of the heart muscle's inability to
receive adequate supplies of oxygen.
 An inadequate oxygen level in the body weakens the immune system which can lead
to viral infections, damaged cells, inflamed joints and circulatory problems.

Factors Affecting Oxygenation

Adequacy of circulation, ventilation, perfusion and transport of respiratory gases to the

tissues is influenced by four types of factors:

 Physiological
 Behavioural
 Developmental
 Environmental

Physiological factors

Process Effect on oxygenation

Anaemia decreases oxygen carrying capacity of the blood by reducing the

amount of available haemoglobin to transport oxygen.
Toxic inhalant Decreases oxygen carrying capacity of the blood by reducing the
amount of available haemoglobin to transport oxygen.
Airway obstruction Decreases the fraction of inspired oxygen concentration (FiO₂),
thus limiting the delivery of inspired oxygen to alveoli.
High altitude Atmospheric concentration is lower, so inspiratory oxygen
concentration decreases.
Fever Increases metabolic rate and tissue oxygen demand.
Decreased chest wall Prevents lowering of diaphragm and reduces anteroposterior
motion diameter of thorax on inspiration, reducing the volume of air
inspired.
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Developmental factors

Process Effect on oxygenation

Fetus As the fetus grows during pregnancy, greater size of uterus

pushes abdominal contents upward against diaphragm. It results
in breathlessness.
Neonates and infants An infant born prior to 34 weeks may not have sufficient
surfactant produced leading to collapse of alveoli and poor gas
exchange.
Toddler, preschool- Before the end of late childhood and during adulthood, the
aged children and immune system is not prepared to protect the person from most
adolescents infections.
Older adults The tissues and airway of the respiratory tract become less
elastic. The power of the respiratory tract and abdominal
muscles is reduced and, hence, the diaphragm moves less
efficiently.

Behavioural factors

Process Effect on oxygenation

Lifestyle  Activity level and habits

 Cigarette smoking – active / passive
 Obesity- obese people have reduced lung volumes from
the heavy thorax and abdomen.
Medications Opioids, narcotics and sedatives – These drugs depress the
medullary respiratory centre such that the rate and depth of
respiration decrease.
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Environmental factors

The incidence of pulmonary disease is higher in smoggy, urban areas than the rural areas. In
addition, the client’s workplace may increase the risk for pulmonary disease. Occupational
pollutants include asbestos, talcum powder and dust.

Signs and Symptoms of Inadequate Oxygenation

Signs and symptom Onset

CNS
1. Unexplained apprehension Early
2. Unexplained restlessness or irritability Early
3. Unexplained confusion or lethargy Early or late
4. Combativeness Late
5. Coma Late
6. Muscle twitching or seizures Late
Respiratory
1. Tachypnoea Early
2. Dyspnea on exertion Early
3. Dyspnea at rest Early or late
4. Use of accessory muscles Late
5. Retractions of interspaces on inspiration Late
6. Pause for breath between sentences and words Late
Cardiovascular
1. Tachycardia Early
2. Mild hypertension Early
3. Dysrhythmias (e.g., premature ventricular Early or late
contractions)
4. Hypotension Late
Renal system
1. Decreased urinary output (<0.5ml /kg/hr) Early or late
Integumentary system
1. Diaphoresis Early or late
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2. Cool, clammy skin

3. Cyanosis Late
Late
Others
1. Unexplained fatigue Early or late

Variants of Oxygenation

These are:

1. Hypoxemia and

2. Hypoxia

HYPOXEMIA

Hypoxemia is a severe condition which can disrupt various functions of the human body
system, and cause a life-threatening situation. Basically, this disorder is characterized by
a fall in the oxygen level of the blood, which can eventually give rise to a wide range of
mild-to-severe complications. In fact, some of these complications can be severe enough
to result in death of the person.

Definition

Hypoxemia is a medical condition which is typically characterized by very low oxygen

level in the blood. The level of oxygen in arterial blood is measured by an oximeter, a
small device which is clipped onto the finger. On an average, the normal oxygen level in
our blood stream is around 85 mm Hg. In people suffering from hypoxemia, this falls
down to as low as 60 mm Hg. During hypoxemia, the oxygen saturation in the body is
less than 90 percent, while the normal requirements are 95 to 100 percent. If the same
falls below 80 percent, the condition is referred to as severe hypoxemia.

Causes of Hypoxemia

When we inhale oxygen, it makes its way through the lungs, air sacs, capillaries to the
blood stream, from where it is transported to various parts of the body. Any disturbance
in this process can disturb the flow, and result in lack of oxygen in the blood. In most of
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the cases, hypoxemia causes can be traced back to some problem with lung and heart,
both of which play a crucial role in transportation of blood throughout the body.

Causes are classified into 5 groups:

1. Low inspired partial pressure of oxygen (low PIO,)

2. Alveolar hypoventilation.

3. Impairment of diffusion across the blood-gas membrane

4. Ventilation perfusion inequality

5. Shunt

Conditions that result in hypoxemia act via one or more of these primary causes:

Low Inspired Oxygen Partial Pressure (Low PiO₂)

 If the partial pressure of oxygen in the inspired gas is low, then a reduced amount of
oxygen is delivered to the gas exchanging parts (alveoli) of the lung each minute.
 The reduced oxygen partial pressure can be as a result of reduced fractional oxygen
content (low FiO) or simply a result of low barometric pressure, as can occur at high
altitudes. This reduced PiO, can result in hypoxemia even if the lungs are normal.
 Additionally, it is the inspired oxygen content that is important in this case rather than
the atmospheric concentration as the person may not be breathing atmospheric gas
(e.g., during an anaesthetic).

Alveolar Hypoventilation

 Ventilation problems in the lungs can lead to low oxygen levels in the blood,
especially if the alveoli in the lungs are not functioning properly.
 Sometimes, lung ventilation is disrupted when alveolar ventilation is not working in
a pattern of uniformity.
 This lack of harmony causes a disruption in normal gas exchange and can be present
even when the lungs are healthy.
 This pattern of alveolar insufficiency is sometimes referred to as 'alveolar
hypoventilation.
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 Our metabolism produces carbon dioxide at a rapid pace and if the body does not go
through the proper mechanics of breathing in oxygen and exhaling carbon dioxide,
the oxygen levels in the blood can plummet as carbon dioxide levels rise.
 Hypoventilation can result from the following conditions:
 Shallow breathing, Hypoventilation can be the result of breathing that is slow or
abnormal lung functioning.
 Obesity can also be a factor in hypoventilation.
 Deformity in the chest walls that affect the volume of air can also be a factor.
 Neurological disorders, such as anxiety, can also contribute to hypoventilation.
 If the alveolar ventilation is low, there may be insufficient oxygen delivered to
the alveoli each minute. This can cause hypoxemia.

Impaired Diffusion

 Diffusion capacity measures how smoothly air flows between the alveoli in
the lungs and the capillaries.
 Impaired diffusion across the blood-gas membrane in the lung can cause
hypoxemia.
 Oxygen levels in the blood are mostly affected by the decreased diffusion
capacity during exercise, but they may be affected at high altitudes as well.
 This condition can be easily rectified with the assistance of respiratory
therapy.
 However, this is a very rare cause as it is only in extremely unusual
circumstances that actually does cause a problem.

Shunt

 Normal levels of oxygen in the blood are highly dependent on healthy alveoli in the
lungs.
 Blood that is shunted (rerouted) through the veins without coming in contact with the
alveoli of the lungs will not be properly oxygenated.
 Shunting can result from stressors, such as pneumonia or pulmonary edema or
cardiac defects.
 The blood that enters the lungs from the heart is known as 'mixed venous blood,
which simply means that it has an equal mixture of carbon dioxide and oxygen.
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 Shunting results in higher levels of carbon dioxide in the blood and subsequent low
levels of oxygen.

A Right-to-Left Shunt
 A right-to-left shunting of blood from the right side to the left side of the circulation is
a powerful cause of hypoxemia.
 The shunt may be intracardiac or may be intrapulmonary.
 It has been traditionally thought that this cause could be readily distinguished from
the others as the only cause that cannot be corrected by the administration of 100%
oxygen.

A Left-to-Right Shunt
 This is another cause of hypoxemia.
 A left-to-right shunt is a condition when there is a transfer of blood from the left side
of the heart to its right side.
 This may occur as a result of a hole in the following walls: the arterial walls, the wall
separating the two upper chambers (left and right atrium) or the wall separating the
two lower chambers (left and right ventricles) of the heart.

Ventilation-Perfusion Inequality

 This is a condition in which an imbalance between the volume of gas expired by the
alveoli (alveolar ventilation) and the pulmonary capillary blood flow is seen.
 Ventilation-perfusion inequality (or ventilation-perfusion mismatch) is a common cause of
hypoxemia in people with lung disease.
 It is the areas of the lung with ventilation/perfusion ratios that are less than one (but not zero)
that cause hypoxemia by this mechanism.
 A ventilation/perfusion ratio of zero is considered a shunt.

Signs and Symptoms of Hypoxemia

 As blood oxygen dips down to 85 and 90 percent, cells cease to perform as usual,
upsetting the functioning of the organs and tissues.
 When this happens, the patient inevitably begins to manifest certain signs and
symptoms of this lack of oxygen in the blood, depending upon the severity, i.e. the
amount by which the partial pressure has reduced.
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 " Symptoms of mild hypoxemia:

 Restlessness
 Anxiety Disorientation, confusion, lassitude and listlessness
 Headaches
 Symptoms of acute hypoxemia:
 Cyanosis (Skin appearing bluish due to insufficient oxygen)
 Cheyne-Stokes respiration (irregular pattern of breathing)
 Increased blood pressure
 Apnoea (temporary cessation of breathing)
 Tachycardia (increased rate of heartbeats, more than 100 per minute)
 Hypotension (abnormally low blood pressure, below 100 diastolic and 40
systolic. Here, as an effect of an initial increase in cardiac output and rapid
decrease later.)
 Ventricular fibrillation (irregular and uncoordinated contractions of the ventricles)
 Asystole (severe form of cardiac arrest, heart stops beating)
 Polycythaemia (abnormal increase in RBCs. The bone marrow may be stimulated to
produce excessive RBCs in case of patients suffering from chronic hypoxemia)
 Coma

Treatment for Hypoxemia

 Prone Positioning Prone positioning refers to lying flat on the ground, with your face
downwards.
 It is known to increase oxygenation. It can be used as a treatment for mild hypoxemia.
 The effectiveness of prone positioning as a treatment of acute respiratory disorders is
still under suspicion.

Mechanical Ventilation

 Mechanical ventilation is a mechanism by which it is possible to aid or substitute

spontaneous breathing mechanically.
 Continuous Positive Airway Pressure (CPAP) is a device that provides mechanical
ventilation. It is an effective way of treating severe hypoxemia.
 This is a device that forces a steady stream of air into the nasal passage.
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 This flow, which is set at a pressure that can overcome obstructions, prevents the
airway from closing.
 The pressure to be maintained should be determined through careful observation.

Supplemental Oxygen Therapy (Oxygen Therapy)

 This form of treatment for hypoxemia includes administering oxygen to the patient,
using oxygen concentrators, cylinders or tanks.
 However, it is crucial that the precise levels of oxygen in accurate amounts be
administered.
 Special care needs to be taken during supplemental oxygen therapy for infants.
 Supplemental oxygen therapy and CPAP are usually prescribed together as a
treatment for hypoxemia.
 This is particularly efficient for the treatment of hypoxemia caused due to
hypoventilation.

Transfusion of Packed RBCs

 Packed red blood cells refer to the concentration of red blood cells obtained after the
removal of plasma in the blood.
 Packed red blood cells can be transfused as a treatment to patients suffering from
hypoxemia.
 This is known to increase the oxygen-carrying capacity of the blood.
 Sufficient care should be taken during the blood transfusion to avoid infections.
 This form of treatment cannot be used in case of patients who develop
polycythaemia (which is characterized by abnormally high RBC count) as a result of
chronic hypoxemia.

Increasing Inspired Oxygen

This form of treatment is an effective one for hypoxemia developed as a result of

hypoventilation or due to the reduction in inspired oxygen.

HYPOXIA

Definition
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Hypoxia is a pathological condition in which the body has a whole (generalized hypoxia) or
a region of the body (tissue hypoxia) is deprived of adequate oxygen supply.

 It causes an impairment or reduction in partial pressure of oxygen, inadequate oxygen

transport, or the inability of the tissues to use oxygen.
 When the oxygen carrying capacity of the blood is reduced due to circulation, liver,
or heart disorders, it prevents the blood from being adequately oxygenated and results
in tissue death.
 Hypoxia differs from hypoxemia; in the latter, the oxygen concentration within the
arterial blood is abnormally low.
 It is possible to experience hypoxia and have low oxygen content (e.g., due to
anaemia) but maintain high oxygen partial pressure (PO2).

Pathophysiology

Lungs

Oxygen, carbon dioxide and water

With the gradient, oxygen go to the blood

Then to the peripheral uses

Then to the cells

Into the mitochondria

Mitochondria have hydrogen (from various sources)

It burns oxygen to form water and carbon dioxide (carbon dioxide goes to the lungs)

But

When oxygen supply is limited

 H₂ will convert pyruvic acid to lactic acid (small amount of energy is produced)
20

But lactic acid builds up in the tissues (sign of decreased oxygen in the mitochondria)

And this leads to the cell death

Types of Hypoxias

Hypoxic Hypoxia

It is a generalized hypoxia, an inadequate supply of oxygen to the body as a whole. Hypoxic

hypoxia can be due to the following reasons:

i. When there is less than normal amount of oxygen inhaled:

 The air inhaled may be insufficient in oxygen either because the atmospheric
pressure is low (at high altitude) or when supply of fresh air is restricted.
 At high altitude, the air is "thinner". In that, every molecule of the gas
occupies a larger volume. The blood leaves the lungs carrying less oxygen
than normal.
 Therefore, the tissues are exposed to a lower oxygen level.
 If this is not too profound, they can still obtain oxygen at the required rate, at least for
resting metabolism because the rate of flow of blood can increase.
 When supply of fresh air is restricted, for example, in large enclosed space crowded
with people, oxygen is progressively depleted and exhaled carbon dioxide
accumulates.
 In some circumstances, there may be displacement of air by other irritants or toxic
gases, such as smoke, chlorine or sulfur dioxide and the effect of these gases can
complicate the effect of displacement of oxygen.
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ii. Low partial pressure of oxygen in the lungs when switching from inhaled
anaesthesia

iii. A decrease in oxygen saturation of blood caused by sleep apnoea or

hypopnea.

iv. Inadequate pulmonary ventilation:

 " When breathing becomes mechanically difficult in some types of lung diseases
(e.g., in chronic obstructive pulmonary disease, asthmatic attack or respiratory
arrest).
 When there is damage to the brain stem or to the upper spinal cord where nerves
arrive which activate the muscles of breathing.
 When the muscles themselves are weak.

v. Shunts in the pulmonary ventilation or a right-to-left shunt in the heart:

 Shunts can be caused by collapsed alveoli that are still perfused or a block in
ventilation to an area of lung.
 Whatever the mechanism, blood meant for pulmonary system is not ventilated and so
no gas exchange occurs.

Anaemic Hypoxia

An oxygen deficiency in which arterial oxygen pressure is normal, but total oxygen content
of the blood is reduced.

Hypemic Hypoxia

Hypemic hypoxia is defined as the reduction in the oxygen carrying capacity of the blood.

 It is caused by reduced amounts of haemoglobin in the blood and red blood cells.
 This reduction in the oxygen transport capacity of the blood occurs through blood
donation, haemorrhage or anaemia.
 Reduction in the oxygen carrying capacity of the blood occurs through drugs,
chemicals, carbon monoxide poisoning or smoking.

Histotoxic Hypoxia
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 Hypoxia in which quantity of oxygen reaching the cells is normal, but the cells are
unable to effectively use the oxygen.
 Example: Carbon monoxide and cyanide poisoning. Certain narcotics, chewing
tobacco and alcohol also prevent oxygen use by the tissues.

Ischemic or Stagnant Hypoxia

 Hypoxia in which there is local restriction in the flow of otherwise well-oxygenated

blood.
 The oxygen supplied to the region of the body is then insufficient for its needs.
 Examples are cerebral ischemia, ischemic heart disease and intrauterine hypoxia,
which is an unchallenged cause of perinatal death.

Clinical Manifestations of Hypoxia

When hypoxia develops gradually, the symptoms include:

 Headaches
 Shortness of breath.
 Fatigue
 Nausea
 Restlessness
 Anxiety
 Agitation

In severe hypoxia, or hypoxia of very rapid onset:

 Changes in behaviour
 Loss of memory
 Clubbing of fingers
 Loss of consciousness
 Cyanosis

In paediatric clients, the symptoms include:

 Retractions
 Grunting
 Nasal flaring
 23

 Feeding problems

Diagnostic Evaluation

1. History taking

II. Clinical signs and symptoms

III. Arterial blood gas analysis

IV. Pulse oximetry

DIAGNOSTIC STUDIES

Haemoglobin

Description and Purpose

 Test reflects amount of haemoglobin available for combination with oxygen.

 Venous blood is used. Normal level for an adult male is 13.5-18 g/dL. Normal level
for an adult female is 12-18 g/dL.

Nursing Responsibilities

Explain the procedure and its purposes.

Haematocrit

Description and Purpose

 Test reflects ratio of blood cells to the plasma.

 Increased Haematocrit (Polycythaemia) is found in chronic hypoxemia.
 Venous blood is used. Normal value for an adult male is 40% -54%. Normal value for
an adult female is 38% -47%.

Nursing Responsibilities

Explain the procedure and its purposes.

Arterial Blood Gases

Description and Purpose

 Arterial blood is obtained through puncture of radial or femoral artery or through

arterial catheter.
 24

 ABG tests are performed to assess Acid-Base balance, ventilator status, need for
oxygen therapy or change in ventilator settings.
 Continuous ABG monitoring is also possible via a sensor or electrode inserted into
the arterial catheter.

Nursing Responsibilities

 Indicate whether the patient is using oxygen (percentage, L/min).

 Avoid change in oxygen therapy or interventions (e.g., suctioning, position change)
for 20 minutes before obtaining the sample.
 Assist with positioning (palm up, wrist slightly hyperextended, if radial artery is
used.)
 Collect blood into a heparinized syringe.
 To ensure accurate results, expel all air bubbles and place sample in ice, unless it will
be analysed in less than 1 minute.
 Apply pressure to artery for 5 minutes after the sample is obtained, to prevent
hematoma formation at the arterial puncture site.

Oximetry

Description and Purpose

 A device for measuring the oxygen saturation of arterial blood.

 Probe attaches to earlobe, finger, or nose for Spo₂, monitoring or is contained in a
pulmonary artery catheter for SpO₂ monitoring.
 Oximetry is used for intermittent or continuous monitoring and exercise testing.

Nursing Responsibilities

 Apply Probe when interpreting SpO₂ and Svo, values, first assess patient status and
presence of factors that can alter accuracy of pulse oximeter reading:
- For SpO₂ these include motion, low perfusion, cold extremities, bright lights, use
of intravascular dyes, acrylic nails, dark skin color, carbon monoxide poisoning and
disease states of anaemia.
- For SvO,, these include change in oxygen delivery or oxygen consumption.
 For SpO₂ notify healthcare provider of ± 4% change from baseline or to <90%.
 For SVO, notify healthcare provider of ± 10% change from baseline or ↓ to <60%.
 25

Treatment

Hypoxia can be a fatal condition.

1. Establish airway:
 If someone is suffering from hypoxia, it is very important to establish the
airway by assisted breathing.
 The individual should immediately be taken to a hospital, where he should be
put on a ventilator to assist in breathing.
2. The blood pressure and heart rate should be monitored. They should be kept in control
with the help of fluids or medicines.
3. Seizures, if any, should be suppressed.
4. Sometimes cold blankets are used as they slow down the activity of the brain cells and
decrease the need of oxygen.

These should be the primary steps in the treatment of hypoxia, before the underlying cause is
treated.

OXYGEN THERAPY

Definition

Oxygen therapy is defined as the administration of oxygen at a concentration greater than

that found in the atmosphere.

 The goal of oxygen therapy is to provide adequate transport of oxygen in the blood
while decreasing the work of breathing and reducing stress on myocardium.

Factors Affecting Oxygen Transport to the Tissues

Oxygen transport to the tissues depends on factors such as:

a. Cardiac output

b. Arterial oxygen content

c. Concentration of haemoglobin.

d. Metabolic requirements

These factors must be kept in mind when oxygen therapy is considered.

 26

OXYGEN SAFETY

1. Oxygen supports combustion. Therefore, no open flame or combustible products

should be permitted when oxygen is in use. These include petroleum jelly, oils, and
aerosol sprays. A spark from a cigarette, electric razor, or other electrical device
could easily ignite oxygen-saturated hair or bedclothes around the patient.
2. Explosion-proof plugs should be used for vaporizers and humidifier attachments.
3. Be sure to have a functioning smoke detector as well as a fire extinguisher at all
times.
4. Care must be taken with oxygen equipment used in the home or hospital. The
oxygen system should be kept clean and dust-free.
5. Cylinders should be kept in carts, or have collars for safe storage. If not stored in a
cart, smaller canisters may be laid on the floor.
6. Knocking cylinders together can cause sparks, so bumping them should be avoided.
7. Oxygen tanks should be kept in a well-ventilated area.
8. Oxygen tanks should not be kept in the trunk of a car.
9. "No Smoking-Oxygen in Use" signs should be used to warn visitors not to smoke
close to the patients.
10. Special care must be given when administering oxygen to the premature infants
because of the danger of high oxygen levels causing retinopathy of prematurity, or
contributing to the construction of ductus arteriosis. PaO, (partial pressure of oxygen) levels
greater than 80 mm Hg should be avoided.

Methods of Oxygen Administration

Oxygen Supply

 In the hospital, oxygen is supplied to each patient room via an outlet in the wall
 Oxygen is delivered from a central source through a pipeline in the facility.
 A flow meter attached to the wall outlet accesses the oxygen.
 A valve regulates the oxygen flow, and attachments may be connected to provide
moisture.
 At home, the oxygen source is usually a canister or air compressor.
 Whether in home or hospital, plastic tubing connects the oxygen source to the
patient.
 27

Types of Oxygen Storage Systems

Oxygen can be separated by a number of methods, including chemical reaction and

fractional distillation, and then either used immediately or stored for future use. The main
types of oxygen storage systems include:

 Compressed oxygen:
 The oxygen gas is compressed in a gas cylinder, which provides a
convenient storage, without the requirement for refrigeration found with
liquid storage.
 A flow meter and regulator are attached to the oxygen tank to adjust
oxygen flow.
 Large oxygen cylinders hold 6,500 litters and can last about two days at a
flow rate of 2 litres per minute.
 A small portable M6 (B) cylinder holds 164 or 170 litres and weighs about
1.3 to 1.6 kilograms.
 These tanks can last 4-6 hours when used with a conserving regulator,
which senses the patient's breathing rate and sends pulses of oxygen.
Conserving regulators may not be usable by patients who breathe through
their mouth.
 Liquid storage:
 Liquid oxygen is stored in chilled tanks until required, and then allowed to
boil (at a temperature of 90.188 K(-182.96°C)] to release oxygen as gas.
 This is widely used at hospitals due to their high usage requirements, but
can also be used in other settings.
 Oxygen concentrator:
 Electric oxygen delivery system is approximately the size of a large
suitcase.
 The concentrator extracts some of the air from the room, separates the
oxygen, and delivers it to the patient via a nasal cannula.
 A cylinder of oxygen is provided as a backup in the event of a power
failure, and a portable tank is available for trips outside the home.
 This system is generally prescribed for patients who require constant
supplemental oxygen or who must use it when sleeping.
 28

 Oxygen conserving device, such as a demand inspiratory flow system or

pulsed-dose oxygen delivery system: It uses a sensor to detect when
inspiration (inhalation) begins. Oxygen is delivered only upon inspiration,
thereby conserving oxygen during exhalation. These systems can be used
with either compressed or liquid oxygen systems, but are not appropriate
for all patients.

Oxygen Delivery

Oxygen delivery systems are classified as:

 Low-flow delivery systems

 High-flow delivery systems

Low-Flow Delivery Systems

 These contribute partially to the inspired gas the patient breathes.

 This means the patient breathes some room air along with oxygen.
 These systems do not provide a constant or known concentration of inspired oxygen.
 The amount of inspired oxygen changes as the patient's breathing pattern changes.

Examples of low-flow systems include:

 Nasal cannula.
 Simple mask
 Oropharyngeal catheter
 Partial rebreather mask.

High-Flow Delivery Systems

 These provide the total amount of inspired air.

 A specific percentage of oxygen is delivered independent of the patient's breathing.
 High-flow systems are indicated for patients who require a constant and precise amount of
oxygen.

Examples of such systems include:

 Transtracheal catheters:
 Venture masks
 Tracheostomy collars
 29

 Face tents.
 Aerosol masks
 T- piece

Oxygen Administration Devices

Device Suggested O₂ % Advantages Disadvantages

flow rate setting
Low -flow systems
Nasal cannula 1 24 Provide low Must have patent nasal
2 28 moderate oxygen passages
3 32 concentration (22- May cause abdominal
4 36 40) distention and
5 40 Able to eat and talk discomfort or vomiting
6 44 while getting oxygen
Oropharyngeal 1–6 23 – 42 Inexpensive, does Nasal mucosa irritation
catheter not require a Catheter should be
tracheostomy changed frequently to
alternate nostrils
Mask, simple 6–8 40 – 60 Simple to use, Poor fitting, Variable
inexpensive FiO₂, remove to eat

Mask, partial 8 -11 50 -75 Moderate oxygen Warm, poor fitting,

rebreather concentration must remove to eat
Mask, non- 12 80 - 100 High oxygen Poorly fitting
rebreather concentration
High - flow systems
Transtracheal ½-4 60 – 100 More comfortable, Requires frequent and
catheter concealed by regular cleaning,
clothing, less oxygen requires surgical
litters per minute intervention
needed than nasal
cannula
 30

Mask, venturi 4–6 24, 26, Provide low level of Must remove to eat
6–8 28 supplemental O₂
30, 35, Precise FiO₂,
40 additional humidity
available

Mask, aerosol 8 – 10 30 – 100 Good humidity, Uncomfortable for

accurate FiO₂ some
Tracheostomy 8 – 10 30 – 100 Good humidity, Uncomfortable for
collar comfortable, fairly some
accurate FiO₂
T – piece 8 -10 30 -100 Good humidity, Heavy with tubing
comfortable, fairly
accurate FiO₂
Face tent 8 – 10 30 – 100 Good humidity, Bulky and cumbersome
comfortable, fairly
accurate FiO₂

Oxygen Toxicity

 Oxygen is non – addictive and causes no side effects when used as prescribed
 Complications from oxygen therapy used in appropriate situation are infrequent
 Respiratory depression, oxygen toxicity, and absorption atelectasis are the most
serious complications of oxygen overuse.

A physician should be notified and emergency services may be required if the following
symptoms develop:

 Frequent headaches.
 Anxiety
 Cyanotic (blue) lips or fingernails
 Drowsiness
 Confusion
 Restlessness
 31

 Slow, shallow, difficult or irregular breathing.

Oxygen delivery equipment may present other problems.

 Perforation of the nasal septum as a result of using a nasal cannula and non-
humidified oxygen has been reported.
 In addition, bacterial contamination of nebulizer and humidification systems can
occur, possibly leading to the spread of pneumonia.
 High-flow systems that employ heated humidifiers and aerosol generators, especially
when used by patients with artificial airways, also pose a risk of infection.

Aftercare

 Once oxygen therapy is initiated, periodic assessment and documentation of oxygen

saturation levels are required.
 Follow-up monitoring includes blood gas measurements and pulse oximetry tests.
 If the patient is using a mask or a cannula, gauze can be tucked under the tubing to
prevent irritation of the cheeks or the skin behind the ears.
 Water-based lubricants can be used to relieve dryness of the lips and nostrils.

Methods Used in Case of Paediatrics

Oxygen Hood

It is the rigid plastic dome that encloses on an infant's head; it provides precise oxygen levels
and high humidity.

Special Considerations

The gas should not be allowed to blow directly into the infant's face and hood should not rub
against the infant's face, neck, chin or shoulder.

 Flow rate is adjusted at 10-15 litters/minute after flooding the tent for 5 minutes.
 Cover the child with a gown or blanket and prevent darkness.

Nursing Responsibilities for Administration of Oxygen

 Check for the name, bed number and other identification marks of the patient.
 Confirm the diagnosis and need of the patient for oxygen therapy.
 32

 Assess the patient for any clinical anoxia, e.g., Cyanosis and also assess the breathing
pattern.
 Monitor for the results of ABG.
 Since oxygen is a drug, it should be monitored for toxicity.
 Check that the oxygen is properly humidified.
 Every precaution should be taken to prevent entry of infection.
 Discontinue oxygen therapy gradually; the patient is weaned from dependence on
oxygen by reducing the dosage and administering it intermittently.
 Place a calling device near the patient in case if the nurse is not close to him.
 Pay attention to the kinks in the tubing, loose connection and faulty humidifying
apparatus as it interferes with the flow of oxygen.
 For fear of retrolental fibroplasias, give oxygen to the new born babies for a short
period at very low concentration.
 Since oxygen supports combustion, fire precautions are to be taken as oxygen is on
flow. Give proper instructions to the relatives of the client regarding this.

Patient/Family Teaching Regarding the Use of Oxygen Therapy

 Explain the importance of not using tobacco or any open flames in the room with
oxygen administration to avoid combustion and fire or explosion.
 Explain the necessity of checking all the electrical equipment used in the same room.
 Instruct about proper removal and reposition of oxygen equipment because the
patient may need to wipe off and dry his/her face and nose.
 Teach the patient about proper oxygen concentration delivery ordered and the
importance of maintaining the appropriate flow rate.
 Explain the importance of humidification and adequate hydration, as oxygen dries the
mucus membrane.

Artificial Airways

 Artificial airways provide a link between the ventilator and the patient.

Two main airways used in conjunction with mechanical ventilators are:

 33

 Endotracheal tubes:
It involves passing an endotracheal tube through the mouth and nose into the trachea.
ET is used if the patient requires an artificial airway for a brief period (e.g., 10 days or
less) and full recovery is expected.
 Tracheostomy tubes:
Tracheotomy:
It is a surgical procedure in which an opening is made into the trachea. The
indwelling tube inserted into the trachea is called tracheostomy tube. It is
preferred if the patient's condition is critical and recovery is not expected anytime
soon (e.g. more than 21 days).

Special Airways

Oropharyngeal Airway

It is used to relieve upper airway obstruction if airway maneuvers fail to do so.

 Facilitate effective ventilation during bag-mask ventilation.

 To be used in the sedated or unconscious patients.
 For conscious patients, insertion of this airway may cause gag reflex, vomiting,
and aspiration of stomach contents into the lungs.

Oesophageal Obturator Airway

 An EOA is inserted into the oesophagus.

 Used as an alternative to bag and mask ventilation
 Disposable tube consists of an opening at the proximal end, many holes near the
upper end and a blind distal end.

Oesophageal Gastric Tube Airway

 It has two ports on masks: (Ventilation/Gastric tube).

 Ventilation holes along the proximal end of the tube are absent.
 Ventilation is provided through the mask by traditional manual resuscitation bag
attached to the ventilation port.
 It has an opening at the distal end. It allows removal or aspiration of air and
gastric contents from the stomach via a gastric tube.
 34

 This design provides relief of gastric distension that may occur during bag-to-
mask ventilation.

Laryngeal Mask Airway.

 It resembles a short endotracheal tube with small cushioned, oblong-shaped mask

on the distal end.
 The cushioned mask of the LMA provides a seal over the laryngeal opening. So,
it is not necessary for the LMA to enter the larynx or trachea.
 Reusable device is made primarily of medical-grade silicone rubber and is latex-
free.
 LMA should be considered when tracheal intubation is precluded by lack of
expertise or equipment or attempts at endotracheal intubation have failed.
 Also indicated as a method of establishing a patent airway during resuscitation in
the profoundly unconscious patient with absent glossopharyngeal and laryngeal
reflexes, who may need assisted ventilation.

Pharyngeal-tracheal Lumen Airway

 Also called oesophageal-tracheal airway, it is a combination of oesophageal and

endotracheal tube in one unit.
 Can be inserted blindly either into the trachea or oesophagus.
 Can be inserted easily by unskilled personnel.
 There are 2 cuffs on the PTLA, one near the proximal end and the other near the distal
end.
 After the placement of the PTLA, both the cuffs are inflated.
 When the tube enters the oesophagus, the distal cuff seal off the oesophagus and lumen
number 1 is used to ventilate the patient via the openings between the cuffs.
 When the tube enters the trachea, the proximal cuff seals the trachea and lumen number 2
is used to provide ventilation directly into the trachea.

Hazards of Oxygen Inhalation

 Infection: May occur because of the use of contaminated equipments.

 35

 Combustion: As oxygen supports combustion, so there is a chance of the occurrence

of fire.
 Drying of mucus membrane of the respiratory tract: If oxygen is administered
without sufficient humidity, it causes drying and irritation of the mucus membrane.
 Atelectasis: Increased oxygen concentration is inspired. leads to depletion of nitrogen
(as nitrogen helps to keep the alveoli expanded), so atelectasis may occur.
 Oxygen-induced apnoea: Since carbon dioxide is washed off completely from the
blood by high concentration of oxygen, the respiratory centre is not stimulated
sufficiently, which leads to cessation of respiration.
 Retrolental fibroplasia: Oxygen therapy may affect the eyes, especially in infants. In
infants, the very high concentration of oxygen will develop fibreoptic changes behind
the lens which impairs light penetration to the retina.
 Asphyxia: May occur because of the unexpected and unobserved depletion of
oxygen in oxygen cylinders in case of patient getting oxygen by mask and closed
tents.
 Oxygen toxicity: It can occur if high concentration of oxygen is greater than 60%
given for 48 hours. Symptoms of oxygen toxicity initially include those of a mild
tracheobronchitis. Starting as a tracheal irritation cough proceeded by dryness and
irritation of mucus membrane, substernal pain, nausea and vomiting.
 CNS toxicity: Nausea, anxiety, numbness, muscular twitching, substernal pain with
deep inspiration.
 Circulatory depression: Following pulmonary capillary wedge pressure (PCWP),
central venous pressure (CVP), visual impairment, tearing eyes and papilledema.

Home Care Planning

The home oxygen is provided in one of the three ways:

i. Compressed gas in a cylindrical tank.

ii. Liquid oxygen in a reservoir.
iii. An oxygen concentrator.

Nursing Management of a Patient with Oxygen Insufficiency

Assessment
 36

Nursing health history: It includes exploration of present problems, any past respiratory
disease. Cough, pain, characteristics of cough and sputum, lifestyle and medication used for
breathing.

Physical Examination

Inspection.

The nurse performs a head-to-toe observation of the client for skin and mucus membrane
color, general appearance, level of consciousness, breathing pattern and chest wall
movements.

Palpation

It will reveal vocal fremitus and displacement of trachea. Perfusion deficit is noted by
change in pulse rate or character, and clammy skin ulcer in the lower extremities.

Percussion

May reveal hyper-resonance, dull percussion tone or changes in the density of the lungs and
the surrounding tissues.

Auscultation

 Breath sounds
 Normal
 Vesicular-soft-low pitched breezy sounds heard over most of the peripheral lung field.
 Bronchovesicular: Harsh sounds heard over the main stem bronchi.
 Bronchial: Loud, course, blowing sound heard over the trachea.

Adventitious (Abnormal)

 Rales (Crackles): Crackling or gurgling sounds heard on inspiration.

 Wheezes: Squeaky sounds heard during inspiration and expiration.
 Pleural friction rubs or striders: Grating sound or vibration heard during
inspiration and expiration.

Diagnostic Studies

PFT (Pulmonary Function Test)

It is done to evaluate pulmonary status and detect abnormalities.

 37

These are used to find:

 Volume of air in the lungs at various phases of the ventilatory cycle.

 Speed and ease of air flow through airways.
 Strength of respiratory muscles.

Procedure

 In this, the technician uses a spirometer that has a volume collecting device attached
to a recorder that demonstrates volume and time simultaneously.

The findings of PFT are:

 Tidal volume (TV): The amount of air inspired and expired in a normal respiration.
Normal is 500 mL.
 Inspiratory reserve volume (IRV): The amount of air that can be inspired beyond tidal
volume. Normal is 3100 ml.
 Expiratory reserve volume (ERV): The amount of air that can be exhaled beyond
tidal volume. Normal is 1200 mL.
 Residual volume (RV): The amount of air remaining in the lungs after a maximal
expiration. Normal is 1200 mL.
 Vital capacity (VC): The maximal amount of air that can be exhaled after a maximal
inhalation. Normal is 4800 mL.
 Inspiratory capacity (IC): The largest amount of air that can be inhaled after normal
quiet exhalation. Normal is 3600 ml.
 Functional residual volume (FRV): Equal to expiratory reserve volume plus the residual
volume. Normal is 2400 mL.
 Total lung capacity (TLC): The sum of the TV, IRV, ERV and RV. Normal is 6000 mL.

NURSE'S RESPONSIBILITY FOR PFT

A nurse should explain the whole procedure to the client in order to win his cooperation,
which is very necessary to perform this procedure, because these tests are very tiring. So, she
should arrange, so that the patient cn take rest properly.

Pulse Oximetry

It measures the oxygen saturation (SaO2) of arterial blood.

 38

 It is useful for monitoring people on oxygen, those at risk for hypoxia and
postoperative patients.
 A range of 95-100% is considered normal oxygen saturation (SaO2); value less than
85% indicates that oxygenation to the tissues is inadequate.

Comparing Oxygen Saturation to Partial Pressure of Arterial Oxygen (PaO2)

Oxygen Saturation (%) PaO2 (%) Client status

50 25 Life threatening hypoxemia
50 25 Life threatening hypoxemia
50 55 Mild hypoxemia

ABG (Arterial Blood Gas Analysis)

This test measures the adequacy of oxygenation, ventilation and perfusion. Normal results
are: Ph (7.35-7.45)

PCO2 (35-45 mm Hg)

PO2 (80-100 mm Hg) and

HCO2 (22-26 mEq/L).

The sample of arterial blood is generally taken from the radical, brachial or femoral artery
and then is sent for analysis. The nurses should obtain or assist the physician in drawing
sample, labelling and transportation of sample to the laboratory.

Table: ABG
Componen Normal value Respiratory acidosis Respiratory alkalosis
t
pH 7.35-7.45 <7.35 indicates excess of >7.45 indicates excess of base
acid
PCO2 34-35 mm Hg >45 mm HG <35 mm Hg
HCO2 22-26 mEq/L <22mEq/L >26mEq/L
PO2 90-110 mm Hg <80 mm Hg: Hypoxia >100mmHg:
Hyperoxygenation

Haematocrit and Haemoglobin

 39

Haematocrit and haemoglobin are also measured and used to assess the effectiveness of
body's oxygen delivery to the tissues.

 A deficiency in RBCs decreases the oxygen-carrying capacity because there are fewer
Hb molecules available to carry oxygen to the tissues.
 Chest X-ray and CT scan.
 Bronchoscopy.
 Pulmonary angiography
 Sputum studies
 Thoracentesis

Nursing Care Plan of a Patient with Oxygen Insufficiency

As mentioned above, the nursing assessment of the client is made from nursing history,
physical assessment and results of diagnostic examination.

Prioritize the problems on the basis of:

A. Airway

B. Breathing

C. Circulation

Ineffective Airway Clearance

May be related to:

 Obstruction of airway by the tongue
 Upper airway obstruction caused by edema of larynx or glottis.
 Obstruction of trachea or a bronchus by foreign body aspiration.
 Partial occlusion of the bronchi and bronchioles by infection (bronchitis,
bronchiolitis) or occlusion or compression by a tumour mass.
 Occlusion of the more distal airways by association with emphysema.

Goal

 To promote airway clearance.

 To maintain a patent airway.

Nursing Interventions
 40

1. Teach effective coughing:

 Effective coughing should be preceded by slow, deep breaths.
 If the client is recovering from thoracic or abdominal surgery, splinting the
incision site by holding a pillow firmly against it will reduce the pain caused by
coughing.
 Assisting the client to a sitting position will increase the effectiveness of cough.
 Provide oral care such as mouth rinse after sputum has been expectorate.
 Assess the sputum produced by coughing, noting the amount, color and odor.
2. Initiate postural drainage and chest physiotherapy because it promotes drainage
of secretions from the lungs.
3. Monitor hydration status of the client as it will help thinning of Pulmonary secretions
(helping in case of pneumonia, bronchitis and asthma).
4. Administer the prescribed medication.

Drug type Common examples Action

Beta-adrenergic Epinephrine, Isoproterenol, Causes bronchial smooth
sympathomimetics Albuterol, Terbutaline muscle relaxation (dilates
bronchi).
Corticosteroids Beclomethasone, Anti-inflammatory
prednisone, prednisolone
hydrocortisone
Mast cell stabilizers Cromolyn sodium Prevents histamine release
from mast cells
Methylxanthines Aminophylline, Theophylline Dilates bronchi and increases
ciliary movements
Mucolytic/expectorants Mucomyst (acetylcysteine) Thins respiratory secretions by
increasing the amount of fluid
produced.

5. Monitor environment and lifestyle conditions because allergic conditions may

improve dramatically if the allergens to which the client is sensitive are identified and
removed from the client's environment.
6. Introduce artificial airways in case where obstruction cannot be removed by
conservative means or who requires mechanical support.
 41

These include:

Nasal airways:

 To keep upper airway open.

 It helps in nasotracheal suctioning while minimizing trauma to the nasal mucosa.

Oral airways:

 Prevent tongue fall (not well tolerated in conscious individuals because they may gag
or vomit), e.g., tubes bypass the upper airway structures altogether by a nose or mouth
and are passed beyond the vocal cords into the trachea.

Tracheotomy:

 It is a surgical procedure to provide long-term airway support when an ET cannot be

placed successfully.
 Suction the airway.

Ineffective Breathing Pattern

May be related to:

1. Restricted pulmonary disease or CNS disorder or thoracic surgery.

2. Any major abdominal or thoracic surgery or whose mobility is restricted.

3. neuromuscular disease that can weaken the respiratory muscles, e.g., Gullein Barre disease
and Myasthenia Gravis.

4. Abnormal curvature like alteration of spine (Scoliosis, Kyphosis, Chest wall injuries and
Pleural defects).

Goal

 To promote lung expansion.

 To improve breathing pattern.

Interventions

Proper Positioning
 42

 Fowler position by supporting the client with an elevation of the head of the bed with
pillows can reduce workload on heart and minimize fatigue.

Teach Controlled Breathing Exercises

Pursed-lip breathing:

 This technique involves forced exhalation against pursed (partially closed) lips in
order to maintain positive pressure in the lungs during the expiratory phase and
prevents collapse of smaller airways.

Deep breathing and abdominal breathing exercises:

 Motivate the patient to use abdominal muscle to pull the diaphragm downwards.
 Apical and basal expansion exercises:
 Direct the client to focus on achieving maximal expansion of the lungs lobes
(apices) and lower lobes (bases) respectively.
 Incentive spirometry:
 This is the technique used to encourage deep breathing.
 Client draws air through the spirometry device, which measures the volume
of air displaced by moving a float ball or similar device up a column.

Introduced Chest Drainage System

 Improve breathing pattern by removing accumulation of air and/or fluid from the
pleural space, permitting the lungs to return to the normal expansion level.

Impaired Gas Exchange

This may be related to:

 Ventilation-Perfusion mismatching.
 Widespread shunting as with atelectasis and pneumonia.

Goal

To improve oxygen uptake and delivery.

Interventions
 43

 Administer oxygen to the client.

Special Considerations

 Give low flow oxygen in the clients who have chronic pulmonary disease associated with
CO2 retention hypercapnia, because excessive O2 may deliberate the hypoxic derive resulting
in apnoea.
 Administer blood components if the client's oxygenation is impaired because of decreased
circulating volume, decreased Hemoglobin concentration in the blood or hemorrhage.

Decreased Cardiac Output

This may be related to:

 CHF causing pulmonary edema, Heart failure or shock.

Goal

To maintain a normal cardiac output.

Interventions

Manage fluid balance by:

 Limited sodium and reduced fluid intake in case of CHF

 Give diuretics.
 Maintaining daily weight and intake output.

Monitoring electrolyte balance if the client is receiving diuretics:

 Suggest activity restrictions and assistance with activities of daily living in order to decreased
oxygen demand in the body.
 Proper positioning, preferably sitting, in order to decrease fluid load to heart and
pulmonary edema.
 Administer medication: Medication to improve cardiac output including diuretics,
cardiac glycosides, etc.
 Antihypertensives, nitrates, and vasodilators may be given to increase cardiac O,
supply or reduce the myocardial oxygen demand.

Emergency Interventions

Complete airway obstruction, cardiac arrest and respiratory emergencies may result in death.
In this case:
 44

1. Remove airway obstruction (complete airway obstruction by food or by some other

foreign object into the trachea, characterized by an inability to speak or cough).
2. If unrelieved, CPR may be initiated.

Associated Nursing Diagnosis

A. Activity intolerance R/T dyspnea and hypoxia.

Goal

 Explore lifestyle and activity adaptations.

Interventions

• R/T lifestyle and activity have three purposes:

- To minimize energy and oxygen consumptions.

- To reduce factors that contribute to disease process.
- To systematically increase activity intolerance.
B. Altered nutrition R/T dyspnea and cough
 In case of CV disease, reduce sodium intake, so as to reduce fat.
 Encourage patient to take small feeds.
 Food should be served in an attractive manner.
C. Deficient knowledge related to disease process, diagnostic procedures and
treatment modalities.
 Instruct the patient about the signs and symptoms to report on healthcare
provider in an appropriate manner.
 Describe the disease process in an appropriate manner.
 Discuss the lifestyle changes that may be necessary to prevent complications
in future.
 Discuss the choice of therapy or treatment.

MECHANICAL VENTILATION TO THE PATIENT WITH OXYGEN

INSUFFICIENCY

In case of oxygenation failure, mechanical ventilation is used to restore and maintain lungs
volume. Inspiratory ventilation is usually supported to reduce oxygen requirements and
increase patient comforts.
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Definition

Mechanical ventilation is the use of a mechanical device (machine) to inflate and deflate the
lungs.

Purpose

Mechanical ventilation provides the force needed to deliver air to the lungs in a patient who’s
own ventilatory abilities are diminished or lost.

Indications

Common medical indications for use include:

 Apnoea with respiratory arrest, including cases from intoxication.

 Chronic obstructive pulmonary disease (COPD)
 Acute respiratory acidosis with partial pressure of carbon-dioxide (PCO) >50 mm Hg
and pH<7.25, which may be due to paralysis of the diaphragm due to Gullian-Barre
syndrome, Gravis, spinal injury, or the effect of anaesthetic and muscle relaxant
drugs.
 Increased work of breathing as evidenced by significant tachypnoea, retractions, and
other physical signs of respiratory distress.
 Hypoxemia.
 Hypotension including sepsis, shock, congestive heart failure
 Coma.

Types

Negative Pressure Ventilation

 This exerts negative pressure to the external chest, which, in turns, decreases
intrathoracic pressure during inspiration and allows the air to flow to the lungs, filling
its volumes.
 These are mainly used in case of clients with neuromuscular condition.

Positive Pressure Ventilation

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 This inflates the lungs by exerting the pressure on the airways, forcing the alveoli to
expand during inspiration.
 Expiration occurs passively, which further includes time-cycled ventilators, pressure-
cycled ventilators and volume-cycled ventilators.

Pressure-cycled Ventilation

 Terminates inspiratory phase at a pre-set PIP

- TV varies directly with lung compliance and inversely with airway resistance
- Advantages: Reduced barotrauma which has been implicated secondary to high PIP
- Important to monitor patient's expired TV

Volume Cycled Ventilation

 Terminates inspiratory phase at a pre-set TV or high-pressure limit reached

- Advantages: Patient is guaranteed to receive a pre-set TV under normal operating
conditions
- Disadvantages: PIP may rise high enough to cause barotrauma

Flow Cycled Ventilation

 Terminates the inspiratory phase when inspiratory flow reaches a predetermined

minimal level
- Measured during spontaneous ventilation.
- Mostly seen in pressure support modes of ventilation.

Time Cycled Ventilation

• Terminates the inspiratory phase when a preset inspiratory time has been reached

- Advantages: Ease to regulate I:E ratio especially when inverse ratio ventilation is
desired.
- Disadvantages: Delivered TV is dependent on airway resistance and compliance
characteristics

VENTILATOR MODES

Ventilator modes refer to how breaths are delivered to the patient. The most commonly used
modes are:
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 assist control
 intermittent mandatory ventilation
 synchronized intermittent mandatory ventilation
 pressure support ventilation
 airway pressure release ventilation.

Assist Control Mode

 This provides full ventilatory support by delivering a preset tidal volume and
respiratory rate.
 If the patient initiates a breath between the machine's breaths, the ventilator delivers at
the preset volume.
 The cycle does not adapt to patient's spontaneous efforts; every breath is preset
volume.

Intermittent Mandatory Ventilation

 This provides a combination of mechanically assisted breaths and spontaneous

breaths.
 Therefore, the patient can increase the respiratory rate, but each spontaneous breath is
limited to the tidal volume the patient generates.
 Mechanical breaths are delivered at preset intervals and a preselected tidal volume,
regardless of the patient's efforts. IMV allows the patients to use their own muscle
atrophy.

Synchronized Intermittent Mandatory Ventilation (SIMV)

 Delivers a preset tidal volume and number of breaths per minute.

 Between ventilator-delivered breaths, the patient can breathe spontaneously with no
assistance from the ventilator on those extra breaths.
 As the patient's ability to breathe spontaneously increases, the preset number of
ventilator breaths is decreased and the patient does more of the work of breathing.

Pressure Support Ventilation (PSV)

 It assists SIMV by applying a pressure plateau to the airway throughout the patient-
triggered inspiration to decrease resistance within the tracheal tube and ventilator
tubing.
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 Pressure support is reduced gradually as the patient's strength increases.

Airway Pressure Release Ventilation (APRV)

 It produces tidal ventilation by release of airway pressure from an elevated

baseline airway pressure to stimulate expiration.
 APRV is a time-triggered, pressure-limited, time-cycled mode of mechanical
ventilation that allows unrestricted, spontaneous breathing throughout the
ventilatory cycle.
 It also allows alveolar gas to be expelled through the lungs' natural recoil.

Positive end expiratory pressure

 Airway pressure with varying levels of positive end expiratory pressure (PEEP).
 Note that at end expiration, the airway is not allowed to return to zero. (FRC:
Functional Residual Capacity)

COLLABORATIVE PROBLEMS OR POTENTIAL COMPLICATIONS

 Alterations in cardiac function

 Baro trauma (trauma to the alveoli) and pneumothorax
 Pulmonary infection
 Sepsis

NURSING CARE OF THE PATIENT ON VENTILATORS

Assessment

1. The nurse has a vital role in assessing the patient's status and the functioning of the
ventilator.
2. In assessing the patient, the nurse evaluates the patient's physiologic status and how
he or she is coping with mechanical ventilation.
3. Physical assessment includes systematic assessment of all body systems, with an in-
depth focus on the respiratory system.
4. Respiratory assessment includes vital signs, respiratory rate and pattern, breath
sounds, evaluation of spontaneous ventilatory effort, and potential evidence of
hypoxia.
5. Increased adventitious breath sounds may indicate a need for suctioning.
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6. The nurse also evaluates the settings and functioning of the mechanical ventilator, as
described previously.
7. Observe the physical signs such as color, secretions, breathing pattern and state of
consciousness.
8. Observe the tidal volume and pressure manometer regularly. Intervene when they are
abnormal (i.e., suction if airway pressure increases).
9. Pulmonary auscultation and interpretation of ABG. Note changes that signals the
development of a serious problems such as pneumothorax, tube displacement and
pulmonary embolus.
10. The nurse should continually assess the patient for adequate gas exchange, signs and
symptoms of hypoxia, and response to treatment.
11. Continuous PPV increases the production of secretions regardless of the patient's
underlying condition. The nurse should assess for the presence of secretions by lung
auscultation every 2-4 hours.
12. Perform measures to clear the airway of secretions by doing suctioning, chest
physiotherapy, frequent position changes. and increased mobility as soon as possible.
13. Maintain humidification of the airway via the ventilator to liquefy secretions so that
they are easily removed.
14. Monitor vital signs as directed.
15. Monitor for adequate fluid balance by assessing for the presence of pulmonary
edema, calculating daily intake and out- put, and monitoring daily weights.
16. Maintain oral hygiene frequently in the intubated and compromised patient because
oral cavity is a primary source of contamination of the lungs in such patients.
17. Maintain aseptic technique to prevent infection.
18. The nurse should assist a patient whose condition has become stable to get out of bed
and to a chair as soon as possible. If the patient cannot move out of bed, the nurse
encourages the patient to perform active range-of-motion exercises every 6-8 hours. If
the patient cannot perform these exercises, the nurse performs passive range of
motion exercises every 8 hours to prevent contractures and venous stasis.
19. Develop alternative methods of communication for the patient on a ventilator, such as lip
reading, notepad and pencil or magic slate, gesturing, etc.

Nursing diagnosis
 50

1. Impaired gas exchange related to underlying illness, or ventilator setting adjustment

during stabilization or weaning
2. Ineffective airway clearance related to increased mucous production associated with
continuous positive pressure mechanical ventilation
3. Risk for trauma and infection related to endotracheal intubation or tracheostomy
4. Impaired physical mobility related to ventilator dependency
5. Impaired verbal communication related to endotracheal tube and attachment to
ventilator
6. Defensive coping and powerlessness related to ventilator dependency

Planning and Goals

1. achievement of optimal gas exchange

2. maintenance of a patent airway
3. absence of trauma or infection
4. attainment of optimal mobility
5. adjustment to nonverbal methods of communication
6. acquisition of successful coping measures
7. absence of complications.

Nursing interventions

1. Enhancing Gas Exchange

 to optimize gas exchange by maintaining alveolar ventilation and oxygen delivery.
 assesses the patient for adequate gas exchange, signs and symptoms of hypoxia, and
response to treatment.
 judicious administration of analgesic agents to relieve pain without suppressing the
respiratory drive
 frequent repositioning to diminish the pulmonary effects of immobility.
 monitors for adequate fluid balance by assessing for the presence of peripheral edema,
 calculating daily intake and output, and monitoring daily weights.
 administers medications prescribed to control the primary disease and monitors for their
side effects.
2. Promoting Effective Airway Clearance
 The nurse assesses for the presence of secretions by lung auscultation at least every 2 to 4
hours.
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 Measures to clear the airway of secretions include suctioning, chest physiotherapy,

frequent position changes, and increased mobility as soon as possible. Frequency of
suctioning should be determined by patient assessment. If excessive secretions are
identified by inspection or auscultation techniques, suctioning should be performed.
 Humidification of the airway via the ventilator is maintained to help liquefy secretions so
they are more easily removed.
 Bronchodilators are administered to dilate the bronchioles and are classified as adrenergic
or anti cholinergic. Adrenergic bronchodilators are mostly inhaled and work by
stimulating the beta receptor sites, mimicking the effects of epinephrine in the body. The
desired effect is smooth muscle relaxation, thus dilating the constricted bronchial tubes.
Medications include Albuterol (Proventil, Ventolin), soetharine (Bronkosol),
isoproterenol (Isuprel), metaproterenol (Alu pent, Metaprel), pirbuterol acetate (Maxair),
salmeterol (Serevent), and terbutaline (Brethine, Brethaire, Bricanyl). Tachycardia, heart
palpitations, and tremors are side effects that have been reported with use of these
medications.
 Anticholinergic bronchodilators such as ipratropium (Atrovent) and ipratropium with
Albuterol (Combivent) produce airway relaxation by blocking cholinergic induced
broncho constriction.
 Patients receiving bronchodilator therapy of either type should be monitored for adverse
effects including dizziness, nausea, decreased oxygen saturation, hypokalaemia, increased
heart rate, and urine retention.
 Mucolytic agents such as acetyl cysteine (Mucomyst) are administered as prescribed to
liquefy secretions so that they are more easily mobilized.
 Nursing management of patients receiving mucolytic therapy includes assessment for an
adequate cough reflex, sputum characteristics, and improvement in incentive spirometry.
Side effects include nausea, vomiting, bronchospasm, stomatitis (oral ulcers), urticaria,
and runny nose.
3. Preventing trauma and Infection
 Airway management must involve maintaining the endotracheal or tracheostomy tube.
 The nurse Positions the ventilator tubing so that there is minimal pulling or distortion of
the tube in the trachea; this reduces the risk of trauma to the trachea.
 Cuff pressure is monitored every 8 hours to maintain the pressure at less than 25 cm H20.
 The nurse evaluates for the presence of a cuff leak at the same time.
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 Patients with endotracheal intubation or a tracheostomy tube do not have the normal
defences of the upper airway. In addition, these patients frequently have multiple
additional body system disturbance that led to immune compromise.
 Tracheostomy care is performed at least every 8 hours and more frequently if needed,
because of the increased risk of infection.
 The ventilator circuit and in-line suction tubing is replaced periodically, according to
infection control guidelines, to decrease the risk of infection.
 The nurse administers oral hygiene frequently because the oral cavity is a primary source
of contamination of the lungs in the intubated and compromised patient.
 The presence of a nasogastric tube in the intubated patient can increase the risk for
aspiration, leading to nosocomial pneumonia.
 The nurse positions the patient with the head elevated above the stomach as much as
possible.
 Antiulcer medications such as sucralfate (Cara fate) are given to maintain normal gastric
pH; research has demonstrated a lower incidence of aspiration pneumonia when
sucralfate is administered.
4. Promoting Optimal Level of Mobility.
 The patient's mobility is limited because he or she is connected to the ventilator.
 The nurse should assist a patient whose condition has become stable to get out of bed and
to a chair as soon as possible. Mobility and muscle activity are beneficial because they
Stimulate respirations and improve morale.
 If the patient cannot get out of bed, the nurse encourages the patient to perform active
range-of-motion exercises every 6 to 8 hours.
 If the patient cannot perform these exercises, the nurse performs passive range-of motion
exercises every 8 hours to prevent contractures and venous stasis.

5. Promoting Optimal Communication

 It is important to develop alternative methods of communication for the patient on a
ventilator.
 The nurse assesses the patient's communication abilities to evaluate for limitations.
Questions to consider when assessing the ventilator-dependent patient's ability to
communicate include the following:
- Is the patient conscious and able to communicate?
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- Can the patient nod or shake the head?

- ls the patient's mouth unobstructed by the tube so that words can be mouthed?
- Is the patient's hand strong and available for writing? (For example, if the patient is
right-handed, the intravenous line is placed in the left arm if possible so that the right
hand is free.)
 Once the patient's limitations are known, the nurse offers several appropriate
communication approaches:
- lip reading (use single key words).
- pad and pencil or Magic Slate
- communication board
- gesturing, or electric larynx.
 Use of a "talking" or fenestrated tracheostomy tube may be suggested to the physician;
this allows the patient to talk while on the ventilator.
 The patient must be assisted to find the most suitable communication method. Some
methods may be frustrating to the patient, family, and nurse; these need to be identified
and minimized.
 A speech therapist can assist in determining the most appropriate method.
6. Promoting Coping Ability
 Dependence on a ventilator is frightening to both the patient and family and disrupts even
the most stable families. Encouraging the family to verbalize their feelings about the
ventilator, the patient's condition, and the environment in general is beneficial.
 Explaining procedures every time they are performed helps to reduce anxiety and
familiarizes the patient with ventilator procedures.
 To restore a sense of control, the nurse encourages the patient to participate in decisions
about care, schedules, and treatment when possible. The patient may become withdrawn
or depressed while on mechanical ventilation. Especially if it's use is prolonged.
 To promote effective coping the nurse informs the patient about progress when
appropriate.
 It is important to provide diversions such as watching television, play1ng music, or taking
a walk (if appropriate and possible).
 Stress reduction techniques (e.g., a backrub, relaxation measures) help relieve tension
and help the patient to deal with anxieties and fears about both the condition and the
dependence on the ventilator.
 54

MONITORING AND MANAGING POTENTIAL COMPLICATIONS

1. Alterations in Cardiac Function

 Alterations in cardiac output may occur as a result of positive pressure ventilation.
 The positive intra thoracic pressure during inspiration compresses the heart and great
vessels. thereby reducing venous return and cardiac output.
 This is usually corrected during exhalation when the positive pressure is off.
 Patients may have decreased cardiac output and resultant decreased tissue perfusion and
oxygenation.
 To evaluate cardiac function. the nurse first looks for signs and symptoms of hypoxia
(restlessness, Apprehension, Confusion, tachycardia, tachypnoea, laboured breathing,
pallor progressing to cyanosis. Diaphoresis, transient hypertension and decreased urine
output).
 If a pulmonary artery catheter is in place. cardiac output, cardiac index. and other
hemodynamic values can be used to assess the patient's status.
2. Barotrauma and Pneumothorax
 Excessive positive pressure may cause baro trauma, which results in a spontaneous
pneumothorax.
 This may quickly develop into a tension pneumothorax, further compromising venous
return, cardiac output, and blood pressure.
 The nurse should consider any sudden onset of changes in oxygen saturation or
respiratory distress to be a life-threatening emergency requiring immediate action.
3. Pulmonary Infection
 The patient is at high risk for infection, as described above. The nurse should report fever
or a change in the colour or odour of sputum to the physician for follow-up.

CONCLUSION