RESPIRATORY MODALITIES

OBJECTIVE
After the lecture, the learner will be able to:
Have enhanced knowledge on selected
respiratory diagnostic test and procedures (ie.
Pulse Oximeter, ABG Analysis and Chest Tubes)
Understand the implications of the test results
Identify the nursing implications of the various
procedures used for diagnostic evaluation of
respiratory function.
Provide optimal patient care before, during and
after the test or procedure.
Interpret arterial blood gas measurements.
Explain the principles of chest drainage and the
nursing responsibilities related to the care of the
 ANATOMY &
PHYSIOLOGY
PURPOSE OF THE RESPIRATORY
SYSTEM
The lungs, in conjunction with
the circulatory system, deliver
oxygen to and expel carbon
dioxide from the cells of the
body.
The upper respiratory system
warms and filters air.
The lungs accomplish gas
exchange.
 STRUCTURES OF THE UPPER
RESPIRATORY TRACT
Nose
Sinuses and nasal passages
Pharynx
Tonsils and adenoids
Larynx: epiglottis, glottis,
vocal cords, and cartilages
Trachea
PARANASAL SINUSES
CROSS-SECTION OF NASAL CAVITY
UPPER RESPIRATORY SYSTEM
STRUCTURES OF THE LOWER RESPIRATORY
SYSTEM

Lungs
Pleura
Mediastinum
Lobes of the lungs:
Left: upper and lower
Right: upper, middle, and lower
Bronchi and bronchioles
Alveoli
 AVEOLI

Where gas exchange

takes place
Alveolar-capillary
membrane
Types of alveolar cells
Surfactant
LOWER RESPIRATORY SYSTEM
THE LOBES OF THE LUNGS AND BRONCHIOLE TREE
VENTILATION: THE MOVEMENT OF AIR IN
AND OUT OF THE AIRWAYS.
Thoracic cavity
airtight chamber.
Diaphragm
Floor
Inspiration
contraction of the diaphragm
(movement of this chamber floor
downward)
contraction of the external intercostal
muscles increases the space in this
chamber
Lowered intrathoracic pressure
Expiration:
with relaxation
Diaphragm moves up and
intrathoracic pressure increases
Increased pressure pushes air
out of the lungs.
Expiration requires the elastic
recoil of the lungs.
Inspiration normally is 1/3 of the
respiratory cycle and expiration is
2/3.
GAS EXCHANGE AND RESPIRATORY
FUNCTION
VENTILATION-
PERFUSION RATIOS:
A- NORMAL RATIO
B- SHUNTS
C- DEAD SPACE
D- SILENT UNIT
 LIGHTER SIDE

HOW good
is your
clinical
eye?
READ OUT LOUD THE TEXT INSIDE
THE TRIANGLE BELOW.
 MORE THAN LIKELY YOU SAID,
"A BIRD IN THE BUSH."

If this IS what YOU

said, then you
failed to see that
the word
THE
is repeated twice!
             
Sorry, look again.
NEXT, LET'S PLAY WITH SOME
WORDS.
      WHAT DO YOU SEE?
WHAT DO YOU SEE?
 PULSE OXIMETRY
A noninvasive method to monitor the
oxygen saturation of the blood (SaO2)

Does not replace ABGs

Normal level is 95-100%.
May be unreliable
cardiac arrest

shock

when dyes (ie, methylene blue) or

vasoconstrictor medications

severe anemia

high carbon monoxide level.

 SPO2

Oxygen saturation
ratio of oxyhemoglobin
(HbO2) to the total
concentration of
hemoglobin (HbO2 +
deoxyhemoglobin)
Figure 2
660nm910nmHboHb20.110RedIRPhot
odiode
PULSE OXIMETER
 RECOMMENDED
CONTINUOUSLY FOR
critical or unstable airway

post-operative clients

conscious sedation for diagnostic procedure

history with risk for significant desaturation

known lung dysfunction

morbidly obese/obstructive apneas

with acute pain who received analgesics

cardiopulmonary disorder

transfers of critically ill clients

during hemodialysis
 INTERMITTENTLY

on supplemental oxygen
tracheotomy
long term mechanical
ventilator for stable,
chronic respiratory failure
 NOT RECOMMENDED

during cardiopulmonary
resuscitation
hypovolemia
assess of adequacy of
ventilatory support
detecting worsening lung
function in patients on high
concentration of oxygen
NURSING CONSIDERATIONS

Be familiar with the

manufacturer's
recommendations for the
device.
Use the correct size to
avoid skin complications
and ensure accurate
readings
NURSING CONSIDERATIONS

Reevaluating the sensor site

periodically.
When using disposable sensors, assess
the site every two to four hours and
replace the sensor every 24 hours.
When using a reusable sensor, the site
should be checked every two hours
and changed every four hours.
Manufacturer's recommendations
regarding cleaning agents should also
be followed.
NURSING CONSIDERATIONS
Check that the right type of
sensor is being used.
To exclude motion artifact
caused by shivering, patients
should be kept warm.
To avoid potential interference
from ambient light, the sensor
can be covered with the
patient's linens. Nail polish or
artificial nails should be
NURSING CONSIDERATIONS

Nurses should explain why

pulse oximetry is being used,
how it works, and what the
readings indicate in language
the patient and family can
comprehend.
HOW GOOD IS YOUR CLINICAL
EYE?
 ARTERIAL BLOOD GASES

Measurement of arterial
oxygenation and carbon
dioxide levels.
Used to assess the adequacy
of alveolar ventilation and the
ability of the lungs to provide
oxygen and remove carbon
dioxide.
Also assesses acid-base
 ABG ANALYSIS

Pre-test:
Secure equipments-
heparinized syringe, needle,
container with ice
Choose site carefully, perform
the Allen’s test
Intra-test: Obtain a 5 mL
specimen from the artery
(brachial, femoral and radial),
no air on the syringe
Post-test:
Apply firm pressure for 5 minutes or 15
minutes with patients on
anticuagulants,
Label specimen correctly noting
oxygenation and amount or room air if
applicable,
Place in the container with ice
Assess for swelling, bruising, numbness,
tingling, and pain
pH/PaCO2/PaO2/HCO3       O2 saturation on a
specified FiO2

pH  =  arterial blood pH

PaCO2 (or PCO2)  =  arterial pressure of CO2,

in mm Hg

PaO2 (or PO2)  =  arterial pressure of O2, in

mm Hg

HCO3  =  serum bicarb. conc., in mEq/liter

O2 saturation  =  % hemoglobin saturated

with O2
7.49/42/88/32       97% O2 saturation on
100% O2

7.41/39/88/32       95% O2 saturation on

100% O2
7.21/75/41/20 on room air
7.32/50/98/22      99% O2 saturation
on room air
 ABG ANALYSIS

ABG normal values

pH 7.35- 7.45
PaCO2 35-45 mmHg
HCO3 22- 26 mEq/L
PaO2 80-100 mmHg
O2 Sat 95-99%
 THE 6 EASY STEPS TO
ABG ANALYSIS:
1. Is the pH normal?
2. Is the CO2 normal?

3. Is the HCO3 normal?

4. Match the CO2 or the HCO3 with the

pH
5. Does the CO2 or the HCO3 go the
opposite direction of the pH?
6. Are the PaO2 and the SaO2
METABOLIC ACIDOSIS

Due to renal failure

Manifestations: headache, confusion,
drowsiness, increased respiratory rate
and depth, decreased blood pressure,
decreased cardiac output, dysrhythmias,
shock; if decrease is slow, patient may
be asymptomatic until bicarbonate is 15
mEq/L or less
Correct the underlying problem and
correct the imbalance; bicarbonate may
be administered
With acidosis, hyperkalemia may
occur as potassium shifts out of
the cell

As acidosis is corrected, potassium

shifts back into the cell and
potassium levels decrease

Monitor potassium levels

Serum calcium levels may be low

with chronic metabolic acidosis
METABOLIC ALKALOSIS

Most commonly due to vomiting or

gastric suction; may also be caused by
medications, especially long-term
diuretic use
Hypokalemia will produce alkalosis
Manifestations: symptoms related to
decreased calcium, respiratory
depression, tachycardia, and symptoms
of hypokalemia
Correct underlying disorder, supply
chloride to allow excretion of excess
bicarbonate, and restore fluid volume
RESPIRATORY ACIDOSIS

Always due to a respiratory problem with

inadequate excretion of CO2

With chronic respiratory acidosis, the

body may compensate and may be
asymptomatic; symptoms may include a
suddenly increased pulse, respiratory
rate, and BP; mental changes; feeling of
fullness in the head
Potential increased intracranial pressure
Treatment is aimed at improving
ventilation
RESPIRATORY ALKALOSIS

Always due to
hyperventilation

Manifestations:
lightheadedness, inability to
concentrate, numbness and
tingling, and sometimes loss
of consciousness

Correct cause of
O2 SATURATION VS.
ABG
 MEMORIZE THESE 4 SETS OF
NUMBERS:

mm Hg O2 sat.      

27   50%   - 50% saturation.

40 75%    -PvO2

60 90%    - Sats < 90% are entering

the steep

100   98%    -PaO2

GAS EXCHANGE AND RESPIRATORY
FUNCTION
 LET’S EXERCISE!
P S
HCO3 PaO2
pH aCO2 aO2 Remarks
mEq/L mmHg
mmHg %

7.27 53 24 50 79

7.52 29 23 100 98

7.18 44 16 92 95

7.60 37 35 92 98

7.30 30 14 68 92
Lighter Side
 CAN YOU READ THIS?

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iprmoatnt tihng is taht the frist and lsat
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be a taotl mses and you can sitll raed it
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 CHEST DRAINAGE

Used to treat spontaneous and

traumatic pneumothorax
Used postop to re-expand the
lung & remove excess air, fluid,
blood
by restoring negative intrapleural
pressure.

To assess and measure drainage

from the intrapleural space.
 CHEST TUBES
long, semi-stiff, clear plastic tubes that are
inserted into the chest, so that they can drain
collections of fluids or air from the space
between the pleura
 INDICATION
Pneumothorax: a collection of air in the
pleural space.
Closed

Open

Tension

Hemothorax: a collection of blood in the

pleural space, maybe from surgery, maybe
from a traumatic injury.

Empyema: Pus can collect in the pleural

space

Pleural effusion: Fluid, usually serous,

64
67
69
76
CLOSED-CHEST DRAINAGE
SYSTEM
CHEST TUBE DRAINAGE SYSTEM
 DO

Keep the system closed and below

chest level.

Make sure all connections are taped

and the chest tube is secured to the
chest wall.

Ensure that the suction control

chamber is filled with sterile water to the
20-cm level or as prescribed.

If using suction, make sure the suction

unit’s pressure level causes slow but
 DO
Make sure the water-seal chamber is
filled with sterile water to the level
specified by the manufacturer. You
should see fluctuation (tidaling) of the
fluid level in the water-seal chamber; if
you don’t, the system may not be patent
or working properly, or the patient’s
lung may have reexpanded.
Look for constant bubbling in the water-
seal chamber, which indicates leaks in
the drainage system. Identify and
correct external leaks. Notify the health
care provider immediately if you can’t
 DO
Assess the amount, color, and
consistency of drainage in the
drainage tubing and in the
collection chamber.
Mark the drainage level on the
outside of the collection chamber
(with date, time, and initials) every
8 hours or more frequently if
indicated.
Report drainage that’s excessive,
 DO
Encourage the patient to perform
deep breathing, coughing, and incentive
spirometry. Assist with repositioning or
ambulation as ordered. Provide
adequate analgesia.

Assess vital signs, breath sounds,

SpO2, and insertion site for
subcutaneous emphysema as ordered.
When the chest tube is removed,
immediately apply a sterile occlusive
petroleum gauze dressing over the site
to prevent air from entering the pleural
space.
 DON’T
• Don’t let the drainage tubing kink,
loop, or interfere with the patient’s
movement.
• Don’t clamp a chest tube, except
momentarily when replacing the
CDU, assessing for an air leak, or
assessing the patient’s tolerance of
chest tube removal, and during
chest tube removal.
• Don’t aggressively manipulate
the chest tube; don’t strip or milk it.
“Knowing is not
enough; we
must apply.
Willing is not
enough; we
must do.”
-
Knowledge is a
process of piling
up facts;
wisdom lies in
their
 THANK YOU!

QUIZ TIME!