Hypoxemia In

ICU
Prepared by Hadi Jazan
 Outlines
• Morton, P. Fontaine, D.

• Bein, T., Grasso, S. 2016. The standard of care of patients with

ARDS: ventilatory settings and rescue therapies for refractory
hypoxemia. Intensive Care Medicine. 42 (5): 699–711.
• Facchin, F., Fan, E. 2015. Airway pressure release ventilation
and high-frequency oscillatory ventilation: potential strategies
to treat severe hypoxemia and prevent ventilator-induced lung
injury. Respiratory Care. 60 (10): 1509–1521.
 Objectives
At the end of this seminar the audience will:
Differentiate between hypoxemia & hypoxia
Describe physiology of oxygenation
Discuss the main mechanisms of hypoxemia
Describe the criteria for hypoxemia
 Objectives
List 10 signs and symptoms of hypoxemia
Classify the severity of hypoxemia
List 10 causes of hypoxemia
Discuss medical management of hypoxemia
Discuss nursing management of hypoxemia
 Introduction

• Hypoxemia is derived from:

Hypo + Oxygen + Emia

• Hypoxemia is a condition in which there is

not adequate amount of oxygen in arterial
blood (decreased PaO2, SaO2, or hemoglobin
content).
 Introduction
• Hypoxia: Is the deficiency in the amount of
oxygen reaching the tissues (low O2 content,
low cardiac output, or low oxygen uptake at
the tissue level)

• Hypoxia is derived from:

Hypo + Oxygen + Ia
 Introduction

• hypoxemia is the result of inadequate gas

exchange at the A-C membrane, inadequate
transport or inadequate amounts of O2 binding
with hemoglobin.
 Introduction
Intensive care team devote considerable time
and effort to maintaining normal or near
normal arterial oxygen tension (PaO2) in their
patients, and a large amount of research is
carried out to develop more effective and
safer techniques to achieve this.
 Introduction
• Hypoxemia is one of the most serious
complications in ICU, occurs after surgery
(cardiovascular, pulmonary, abdomen), and it
contributes to increase the mortality rate and
prolong the hospital of stay.

• Severe hypoxemia is characterized by a partial

pressure of arterial oxygen (PaO2) of less than
50 mm Hg ) life-threatening problem(.
 Physiology
• Ventilation
• Diffusion
• Hemoglobin Binding
 Physiology
• Arterial oxygen content(CaO2)
CaO2 = Dissolved In Plasma + Bound O2 To Hb
Dissolved O2 = 0.003 x PaO2
Bound O2 = 1.34 x Hb x % O2 saturation
• Oxygen delivery (DO2)
DO2 = CaO2 x QT x 10
Pathophysiology
Pathophysiology
 Pathophysiology
• Low PIO2
• Hypoventilation
• Ventilation- perfusion(V/Q) mismatch
• Right-to-Lift shunting
• Diffusion impairment
 Symptoms of Hypoxemia
Early Late
• Dyspnea • Cyanosis
• Tachypnea • Bradycardia
• Anxiety • Little to no respiratory movement
• Tachycardia • Vomiting
• Increased use of accessory • Ventricular arrhythmias
muscles • Hypotension
• Nausea • Lethargy
• Coma
 Classification of Severity of
Hypoxemia
Classification PaO2 (mmhg) )%( SaO2
Normal 100– 80 95 >
Mild Hypoxemia 79 – 60 94 – 90
Moderate
59 – 40 89 – 75
Hypoxemia
Severe 40 < 75 <
 Causes of Hypoxemia

Defective ventilation
•Drugs
•Cerebral infarction
•Cerebral trauma
 Causes of Hypoxemia
Defective ventilation
•Myasthenia gravis
•Guillain-Barre
syndrome
•Brain or spinal injuries
•Polio
•Porphyria
•Botulism
 Causes of Hypoxemia
• Chronic
obstructive
pulmonary disease
• Acute severe
asthma
 Causes of Hypoxemia
• Interstitial lung disease
• Kyphoscoliosis
• Ankylosing spondylitis
• Bilateral diaphragmatic
palsy
• Severe obesity
 Causes of Hypoxemia
Impaired diffusion and
gas exchange
•Pulmonary edema
•Acute respiratory
distress syndrome
•Pulmonary
thromboembolism
•Pulmonary fibrosis
 Causes of Hypoxemia
Ventilation-perfusion
abnormalities
•Chronic obstructive
pulmonary disease
•Pulmonary fibrosis
•Acute respiratory distress
syndrome
•Pulmonary
thromboembolism
 Management of hypoxemia
The aims of therapy in hypoxemia are to
achieve and maintain adequate gas exchange
and reversal of the precipitating process that
led to hypoxemia
•ARDS
•Acute severe bronchial asthma
•Severe pneumonia
•Pulmonary thromboembolism
•Treatment of a specific cause when possible
 Nursing process
Assessment
 Neurological
 Respiratory
 Cardiovascular
 Integumentary
 Nursing diagnosis
• Impaired Gas Exchange
• Ineffective Airway clearance
• Ineffective Breathing Pattern
 Impaired Gas Exchange Related to Excessive
Secretions or Abnormal Viscosity of Mucus
evidence by abnormal ABGs values,
neurobehavioral changes, central cyanosis.

•Expected outcome:
ABGs values are within patient’s baseline.
Absence of central cyanosis.
 Nursing intervention
• Assess causative/contributing factors
• Evaluate degree of compromise
Evaluate respirations
Evaluate lungs
Character and effectiveness of cough
Evaluate skin/mucous membrane
 Nursing intervention
Encourage deep-breathing/coughing exercises
Provide supplemental oxygen
Ensure availability of proper emergency equipment

Maintain adequate fluid intake for mobilization of

secretions
Monitor therapeutic responses( Pulse oximetry,
Capnography)
 Nursing intervention
• Promote wellness Teaching/Discharge Considerations
Review oxygen-conserving techniques

Discuss implications of smoking related to the illness

Discuss home oxygen therapy use &instruct in safety

concerns

Emphasize the importance of good general nutrition

Impaired Gas Exchange Related to Alveolar
Hypoventilation as evidence by Abnormal ABGs
value, Neurobehavioral changes, Tachycardia or
dysrhythmia, Central cyanosis.
 Nursing intervention
 Position patient in high-Fowler’s position .
 Assist with deep breathing exercises and/or
incentive spirometry 5 to 10 times/hr .
 Monitor carbon dioxide

 Administer supplemental oxygen via appropriate

oxygen delivery device
Ineffective breathing pattern related to
musculoskeletal fatigue or Neuromuscular
Impairment as evidence by unequal chest
movement, shortness of breath, dyspnea, use
of accessory muscle, tachypnea. nasal flaring.
 Expected outcome
• Respiratory rate, rhythm, and depth return to
baseline.
• Minimal or absent use of accessory muscles.
• Chest expands symmetrically.
• ABG values return to baseline
 Nursing intervention
• Prevent unnecessary exertion.
• Instruct patient in energy-saving techniques
• Supervise use of respirator/diaphragmatic
stimulator, rocking bed, apnea monitor
• Assist with pursed-lip and diaphragmatic
breathing techniques
• Administer oxygen at lowest concentration
• Assist patient in the use of relaxation techniques
 Nursing intervention
• Avoid overeating/gas-forming foods
• Encourage use of incentive spirometer
• Medicate with analgesics as appropriate
• Splint rib cage during deep-breathing
exercises/cough if indicated
• Record response to deep-breathing exercises
• Instruct in/assist with use of incentive
spirometer.
Ineffective Airway clearance Related to
Excessive Secretions or Abnormal Viscosity of
Mucus as evidence by adventitious sounds,
diminished or absent breath sounds,
ineffective cough ‘with or without sputum,
tachypnea, dyspnea, verbal reports of inability
to clear airway.
 Expected outcome
 Cough produces mucus.
 Lungs are clear to auscultation.
 Respiratory rate, depth, and rhythm return
to baseline
 Nursing intervention
 Maintain patent airway
Position head midline with flexion appropriate for age
Suction airway to clear secretions as needed
Keep environment allergen free
 Mobilize secretions
Encourage deep-breathing and coughing exercises
Give expectorants/bronchodilators as ordered
 Nursing intervention
Increase fluid intake .
Perform and assist client with postural drainage
Provide humidification to airways
Collaborate with the physician regarding the
administration of (Bronchodilators, expectorants,
Antibiotics)
Administer aerosol every 4 hours as indicated
 Nursing intervention
 Assess changes and note complications
Auscultate breath sounds and assess air movement
Observe for signs of respiratory distress
Observe for signs/symptoms of infection
Obtain sputum specimen
Assess sputum for color, consistency, and amount...