1. Assisting with Respiration and Oxygen Delivery
Chapter 28
Assisting with Respiration and Oxygen Delivery
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

2. Learning Objectives Theory
Explain how the respiratory system functions.
Name three causes of hypoxia.
Identify procedures to follow in the event of respiratory or cardiac arrest.
Clinical Practice
Prepare to assist patients in clearing the airway via coughing, postural drainage, suctioning, abdominal thrusts (Heimlich maneuver), and inhalation therapy.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

3. Functions of Respiratory Structures
Upper airways carry air to and from the lungs
Humidification takes place in the upper airways
Bronchi channel air to and from the lungs
Cilia lining mucous membranes help trap and remove foreign particles in the respiratory tract
Cilia are hair-like structures in the nose and air passages that have an upward waving motion, assisting with the removal  of particles when the patient coughs.
Air becomes warm and moist as it passes through the organs of the upper respiratory system into the lungs. Oxygen therapy dries the respiratory passages and should pass through water before entering the system.  Change from "movement" OK?
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

4. Functions of Respiratory Structures (cont’d)
Alveoli contain macrophages that phagocytize inhaled bacteria
Mucus and cilia propel foreign substances to airway openings to be expelled
Central nervous system controls rate and depth of respiration
Chemoreceptors in the aorta and carotid bodies send signals to the brainstem
As inhaled bacteria come into contact with the blood in the alveoli, white blood cells destroy or contain the bacteria and keep them from spreading throughout the body.
The filtering action of the respiratory system is one of the body’s strongest defenses.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

5. Functions of Respiratory Structures (cont’d)
Chemoreceptors measure serum pH, serum carbon dioxide, and serum oxygen to trigger changes in rate and depth of respiration
Oxygen diffuses across the alveolar membranes into the blood
Carbon dioxide diffuses across the alveolar membranes out of the blood into the lungs for exhalation
Summarize: The respiration process is complex and is essential to life. Interruption of this vital function in the lungs and in the cells results in death of tissue and organs.
The organs of respiration and the brain are sometimes the first to suffer from respiratory failure.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

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

7. Hypoxemia Decreased amount of oxygen in the blood
Results in decreased oxygen at the cellular level (called hypoxia)
Also results in increased levels of carbon dioxide (called hypercapnia)
Onset may be rapid and obvious or insidious and gradual
Ask students to recall and recite definitions during the lecture.
Describe the symptoms of a sudden onset of hypoxia.
Describe the symptoms of a rapid onset of hypoxia.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

8. Hypoxemia (cont’d) Obstruction of the airway
Tongue, mucous secretions
Foreign body
Aspiration, vomitus
Burns, COPD
Near-drowning
Restriction of the thoracic cage
Chest injuries, flail chest
Pneumothorax
Extreme obesity, diseases
The tongue and throat are organs of the digestive system that may cause respiratory problems.
Discuss the sudden impact of a pneumothorax on a patient, and the corrective action for the problem.
How does obesity affect respiration in the chest cavity and in the cells?
How does exercise increase respiration and oxygenation in the body and tissues?
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

9. Hypoxemia (cont’d) Decreased neuromuscular function
Depressed central nervous system: drugs including sedatives, anesthetic agents, and analgesics, brain trauma; CVA
Coma (diabetic, uremic, brain injuries)
Diseases (multiple sclerosis, myasthenia gravis, poliomyelitis, Guillain-Barré syndrome)
Discuss the names and classification of drugs that may depress the neuromuscular system and interfere with normal respiration. (morphine, cocaine, and other respiratory depressants)
What is a CVA? How does this condition result in the death of brain tissue?
What is the relationship between hypoxemia and diabetic coma? Multiple sclerosis? Polio?
Briefly review how hypoxemia (lack of oxygen in the blood) affects brain tissue.
What is an iron lung, and how does it function to aid the respiratory system?
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10. Signs of Hypoxemia Restlessness, irritability, confusion
Difficulty in breathing (dyspnea)
Rapid breathing (tachypnea, stridor)
Abnormal lung sounds
Cyanosis, retractions, dysrhythmias
Acid-base imbalance
Decreased oxygen saturation
Cover the definitions on the slide and ask for student feedback:
Dyspnea
Tachypnea
Stridor
Cyanosis
Retractions
Dysrhythmias
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

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

12. Figure 28-2: Monitoring oxygen saturation with pulse oximeter
Have students look at the picture and text while you emphasize the use of the machine.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

13. Airway Obstruction Common airway obstructions Respiratory secretions
Choking; obstruction by the tongue, foreign bodies, or food
Abdominal thrusts (Heimlich maneuver) used to clear foreign objects
Respiratory secretions
Complete or partial obstruction
Present with different disease states such as pneumonia or COPD
Usually can be cleared by coughing; can be facilitated by postural drainage
Four ways to remove airway obstruction:
Abdominal thrusts (Heimlich maneuver)
Finger sweep of airway opening
CPR to cause artificial cough
For infant, five blows between the shoulder blades
What are the common causes of airway obstruction in children and adults? (food or foreign objects)
Why should family members know how to perform the Heimlich maneuver?
What is COPD? (chronic obstructive pulmonary disease)
What is the universal sign for choking?
What is the best sign that an infant’s airway is not obstructed?
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

14. Figure 28-3: Universal signal for choking
Review the signs of choking and list ways to promote oxygenation.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

15. Clearing Airway Secretions: The Effective Cough
Most effective in the sitting position
Two deep breaths and then inhale deeply again
Breath rapidly and forcibly exhaled as quickly as possible with the mouth open
This moves secretions up the bronchial tree
Repeated forceful exhalation bring secretions up to where they can be more easily coughed up
The simplest method of clearing the air passages is to cough effectively.
Deep-breathing and coughing are two standard measures used to clear secretions and prevent hypoxia.
Ineffective coughing spasms may produce additional hypoxia, lead to the rupture of the alveoli, or even precipitate the collapse of air passages.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

16. Clearing Airway Secretions: Postural Drainage
Different positions drain different segments of the lungs
Specific segments drained into the bronchi to facilitate coughing
Each position assumed for 5 to 15 minutes two to four times a day as tolerated
Percussion used: rhythmic clapping with cupped hands over the thoracic area, avoiding spine or sternum
Four ways to remove airway obstruction:
Abdominal thrusts (Heimlich maneuver)
Finger sweep of airway opening
CPR to cause artificial cough
For infant, five blows between the shoulder blades
What are the common causes of airway obstruction in children and adults? (food or foreign objects)
Why should family members know how to perform the Heimlich maneuver?
What is COPD? (chronic obstructive pulmonary disease)
What is the universal sign for choking?
What is the best sign that an infant’s airway is not obstructed?   Dupe of slide 19. OK?
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

17. Question 1 The most common cause of respiratory insufficiency is:
chronic obstructive pulmonary disease.
pneumothorax.
obstruction of the airway.
asthma.
Answer: 3
Rationale: The most common cause of respiratory insufficiency is obstruction of the airway. Fortunately, obstruction is usually easily reversed through positioning and suctioning techniques.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

18. Question 2
Bruce’s patient is showing early signs of hypoxia. Which of the following signs is not an early sign of hypoxia? 
His patient sits up to breathe
Restlessness
Mental dullness
Cyanosis  
Answer: 4
Rationale: Cyanosis is a late sign of hypoxia and respiratory insufficiency. A patient sitting up to breathe, restlessness, and mental dullness are all indicators of early signs of hypoxia and respiratory insufficiency.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

19. Oxygen Administration
Oxygen: colorless, tasteless, odorless gas present in the air
Although essential for life, use of oxygen is not without its disadvantages
High concentrations cause fires to burn very rapidly
Very drying to the tissues of the respiratory tract
Equipment needed for oxygen therapy
Oxygen source, the flowmeter, the humidifier, the tubing, and the appropriate appliance for the method ordered
If the patient cannot maintain a sufficient amount of oxygen in the body, supplemental oxygen is often ordered.
What is the normal flow rate of oxygen and on what is it based?
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

20. Figure 28-5: Wall oxygen flowmeter and humidifier setup
Discuss the use of oxygen flowmeters and humidifier.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

21. Oxygen Administration (cont’d)
Used to supplement oxygen in inspired air
Inspired air is 21% oxygen
Can be delivered by nasal cannula, mask, tent, croupette, or catheter
Requires humidification, flow rate prescribed by a physician
Common flow rates are 4-6 L/min
COPD patients given only 2 to 3 L/min to prevent causing respiratory arrest
Why is humidification important in oxygen administration? (unhumidified oxygen dries the tissues of the respiratory tract)
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

22. Oxygen Administration: Cannula
A plastic tube with short, curved prongs that extend into the nostril about ¼ to ½ inch
Held in place by looping it over the ears and cinching under the chin; can be easily adjusted for the patient’s comfort
The nares should be checked to be certain they are unobstructed and are not becoming excoriated
When would a cannula be useful for oxygen administration?
Cannot be used for more than 6L/min and must be humidified over 3L/min
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23. Figure 28-8: Oxygen cannula in use by home care patient
Discuss the use of oxygen cannulas and masks.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

24. Oxygen Administration: Masks
Various types available for administering oxygen in concentrations ranging from 24% to 55% at flows of 3 to 7 L/min
Oxygen concentrations above 60% rarely used because of the danger of oxygen toxicity
Some patients may dislike this method of oxygen administration because the mask must be placed over the face and they feel that the mask will suffocate them.
See chart pg. 517
Simple mask – good for mouth breathers % O2 at 5-10 L/min- delivers higher concentration of O2 than cannula
Venturi mask- most consistent flow of O2 – 24-50%- mixes room air with O2
Non rebreather – when >40% is required bag must be filled at all times with O2- can deliver 80-95% O2- best for emergency
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25. Oxygen concentraters pull oxygen from the air and concentrated to desired amt of O2

26. Oxygen Administration Artificial Airways
Several purposes:
Relieve an obstruction, protect the airway, facilitate suctioning, and provide artificial ventilation
Nasopharyngeal and oropharyngeal airways
Keep the tongue from falling back into the throat
Endotracheal tubes maintain an airway in those who are unconscious or unable to ventilate on their own
An endotracheal tube may cause a mucosal ulcer after 5 to 7 days of use, depending on cuff pressures or type of cuff used.
What should be done if an endotracheal tube is needed for a long period of time?
Tracheostomy if prolonged airway support needed
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

27. Figure 28-10: Types of airways
List the reasons why airways would be used.
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28. Tracheostomy
A surgical opening into the trachea to facilitate insertion of a cuffed tracheostomy tube
Cuff enables controlling the airway and preventing aspiration
Maintains a patent airway; facilitates suctioning and mechanical ventilation
May be temporary or permanent
When are tracheostomies considered to be temporary procedures?
When is a tracheostomy made permanent?
Briefly discuss the variations in nursing care of patients with temporary or permanent tracheostomies.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

30. Suctioning
Required for patients unable to clear secretions from their own airway effectively
Nasopharyngeal
Oral suction
Can be performed with a Yankauer suction tip or with a 14 to 16 Fr. suction catheter attached to wall suction
Negative pressure set between 80 and 120 mm Hg
Aseptic technique used for airway suctioning
Describe the suctioning technique and its purposes.
Why is an aseptic technique used for airway suctioning?
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31. Nasopharyngeal Suctioning
Maintain patent airway by removing accumulated secretions
Involves upper air passages of nose, mouth, and pharynx
Used most often for infants, gravely debilitated or unconscious patients, and those who have an ineffective cough
Suction pressure set between 80 and 120 mm Hg
Oral suctioning is usually tried before nasopharyngeal suctioning because it is a more comfortable procedure for the patient.
A Yankauer suction tip is attached to the suction connecting tubing, and the mouth and top of the pharynx are suctioned.
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32. Tracheobronchial Suctioning
Deep suctioning to remove secretions from the trachea and bronchi using sterile technique
Most often performed on intubated patients or patients with a tracheostomy
Patients need preoxygenation
Sterile technique is mandatory
Should be performed no longer than 10 seconds at a time, with oxygenation in between
When is deep suctioning performed?
How does the patient reaction to deep suctioning differ from nasopharyngeal suctioning?
Why is preoxygenation necessary before performing the procedure?
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

33. Question 3
Lisa’s patient has an order for nasopharyngeal suction. Which one is not true regarding nasopharyngeal suctioning?
The purpose of suctioning is to maintain a patent airway by removing accumulated secretions.
The amount of suction pressure should be set between 40 and 80 mm Hg.
It is best to use aseptic technique for all airway suctioning.
A catheter that has been used in the mouth is not used again for nasopharyngeal or tracheobronchial suctioning.
Answer: 2
Rationale: The amount of suction pressure should be set at 80 to 120 mm Hg. The remaining answers are all correct regarding nasopharyngeal suctioning.
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34. Question 4
Linda’s patient has a tracheostomy. Which is true regarding tracheostomy care?
Tracheostomy care is performed every 12 hours.
Ties are replaced when soiled or at least weekly.
A tracheostomy tube has an inflatable cuff, which must be deflated every 24 hours.
Tracheobronchial suctioning is a sterile procedure.
Answer: 4
Rationale: Tracheobronchial suctioning is a sterile procedure. Tracheostomy care is performed every 8 hours, and ties are replaced when soiled or at least daily. Tracheostomy tubes must be deflated every 8 hours.
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35. Question 5
Linda’s patient cannot maintain a sufficient amount of oxygen in his body. Linda must administer oxygen to her patient. Oxygen should be administered by:
mask, cannula, tent, or catheter only.
anyone; a physician’s order is not necessary.
nebulizer.
humidified apparatus to prevent drying to the mucosa.
Answer: 4
Rationale: Oxygen should be humidified because it is very drying to the mucosa. Oxygen may be delivered by mask, cannula, tent, catheter, croupette, or ventilator, with a physician’s order and a flowmeter used to deliver it.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.

36. Chest Drainage Tubes
Used to remove air from patient with a pneumothorax or hemothorax or after chest surgery
Connected to a drainage device that allows air or drainage to escape and not enter the cavity
May require suction to operate or may use gravity drainage
Tubes are removed and an occlusive dressing is applied when the air is removed from the plural space
Chest tubes are used to remove air, fluid, or blood from the chest cavity so that lungs can expand.
Chest drainage systems must be airtight.
Chest drainage may be assisted with light regulated suctioning or may function by gravity if there is enough pressure inside the chest cavity.
Gravity drainage is facilitated when the drainage tube and containers are on the floor or significantly below the chest wall.
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37. Disposable chest drainage device- 3 chambers 1 for drainage from pt
Disposable chest drainage device- 3 chambers 1 for drainage from pt. 2 to suction and 3 water seal chamber- water seal chamber should have constant bubbling if no bubbling leak in system. Chest tubes are removed by Dr. once x-ray shows lung is reinflated. If chest tube comes out put occlusive dressing over opening in chest

38. Figure 28-13: Disposable chest drainage unit
Discuss the use of chest drainage units and how these help the patient.
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39. Nursing Role in Airway Support
Always maintain a patent airway
Patients should be turned and encouraged to cough and deep-breathe every 2 hours when in bed
Splint surgical patients with a pillow to help them deep-breathe and cough
For unconscious patients, use an oral or nasal airway to keep the tongue from obstructing the airway, and suction as necessary
Encourage use of an incentive spirometer
Review patient education about coughing and deep-breathing exercises for alert patients.
For unconscious patients, keep air passages clear of obstruction and secretions.
Change the patient’s position every 2 hours.
Administer oxygen as needed.
Discuss the use of an incentive spirometer and its effect on respiration.
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40. Figure 28-17: Teaching the patient to splint incision while coughing
Discuss how to teach the patient to use a pillow or blanket to splint an incision while coughing.
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41. Figure 28-19: Teaching use of incentive spirometer
Discuss the use of incentive spirometers and how these prevent complications from surgery.
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42. Nursing Diagnoses
Ineffective airway clearance related to muscle weakness and impaired cough; decreased level of consciousness; or thick secretions
Impaired gas exchange related to retained respiratory secretions
Risk for infection related to alteration in airway (tracheostomy)
Deficient knowledge related to use of oxygen equipment, tracheostomy, ventilator, or incentive spirometer
Risk for injury related to improper safety precautions when using oxygen
Review patient education about coughing and deep-breathing exercises for alert patients.
For unconscious patients, keep air passages clear of obstruction and secretions
Change the patient’s position every 2 hours.
Administer oxygen as needed.
Discuss the use of an incentive spirometer and its effect on respiration.
Copyright © 2014, 2009 by Saunders, an imprint of Elsevier Inc. All rights reserved.