hi class my name is Professor Paul and today we're going to go over critical alterations in gas exchange learning objectives of this lecture is explain the path of ideology for alteration and gas exchange explore epidemiological and Theological risk factors that contribute to alteration and gas exchange Describe the impact of alteration and gas exchange on the client's overall health and differenti the client's presentation of a clients experiencing alteration and gas exchange explore the role of the nurse when caring for clients experience alteration and gas exchange and apply nursing process through use of the clinical judgment functions while providing care to clients experiencing alteration and gas exchange um we already go over alterations and gas exchange and this lecture is going to be just um covering of some critical conditions and I'm not going to go in depth for these critical conditions because you're going to do it an acute care it's just uh for you to know these conditions and again I'm not going to go over the anatomy of the uh respiratory system we know uh respiratory truck has upper Airway and lower airway uh and some disorders here for lower uh respiratory air uh respiratory tra we actually uh uh taking care of them as a critical it's like plural infusion tension patoro pulmonary embolism respiratory failure plural space is between the lining in and the lungs and the lining of the chest wall and slightly negative pressure creating in vacuum to allow allow air into the lungs and negative pressure in the lungs prevents lungs collapse plural Fusion it's um occures when there is an alteration in homeostasis caused by air or fluid and flute can be clear perent or bloody build up in the plural space um from an infection inflammation or injury and plural Fusion are categorized as transudative or exudative what is the transudative infusion it results from an imbalance of pressure and the capillar of the lungs from the heart failure therosis with itis or hypo albumin Amia exudative Fusion occures due to an increase in capillary permeability creating protein leakage and a build up of fluid into plural space caused by inflammation the inflammatory response is usually caused by bacteria if it's pneumonia tuberculosis or pancreatitis or tumors or hemor um if for example postcardiac uh injury risk factors for plural infusion can be associated with some treatments such as peronal dialysis or some indications or uh it can be associated with some comorbidities um ceris of the liver uh Left sided heart failure nephrotic syndrome cancer inflammatory disorders trauma smoking asisto Expos alcohol use impact on overall health of course prevalence reflects underlying disease process uh if the patient has for example lung cancer the possibility to have plural Fusion is higher prevalence equal between genders and races and uh clients age 65 and older are at increased risk why risk increases with age because of age related physiological and immunological changes the altine in around the lung lessons causing the potential for air trapping with age the ability to breathe effectively is impaired due to decreased chest wall compliance and increased anteroposterior diameter and a shortened torax uh older clients experience a decrease in Peak air flow vital capacity and lung function alterations in Mobility can contribute to an increase in the presence of immunoglobulins and microf fages with the lungs and increase in the presence of immunoglobulines and mcroof fages teaching provide encouragement and coaching to promote a healthy level of fitness and provide education regarding the value of deep breathing encouraging oral hygiene with help to reduce the risk of infection encourage frequent rest periods clinical presentation of plural Fusion dispnea platic chest pain particularly on inspiration results of plural inflammation mild or severe sharp or stabbing pain may be referred to the shoulder or uh abdomen C mild and nonproductive and decreased breath sounds what are diagnostic studies number one is a chest x-ray we are doing chest x-ray to actually find presence of or of increased plural fluids and usually cloudy areas white areas um telling us that it's a fluid there then we're doing CT skin because we need to know what's going on in the lungs why patient has this plural infusion maybe patient has um pneumonia maybe patient has cancer maybe patient has tuberculosis uh tus synthesis will help not only remove the fluid fluid also we can send this fluid to the lab and find out what actually going on we can find some bacteria virus and we know what caused this plural infusion ultrasound is is using to facilitate um needle placement with TOA synthesis plural fluid analysis first one analyzing by color if it's bloody it's probably hematoma or trauma milky it means this diffusion present for a long time purulent it's infection viscosus it's meoma CLE throw color it's a normal um without like without um adding any infection that's the color for plural infusion if the patient for example has CHF then we do some lab test and checking for some protein white blood cells red blood cells and bacterial culture what is the nursing role uh for infusion we monitor client's Vital Signs and respiratory status if client has a chest tube monitor connection and drainage assist with toos synthesis of done at bed side maintain oxygen delivery if indicated monitor of for dehydration um and also provide client education recognize manifestation of plural fusions identify when to call the provider make sure they take medications what kind of treatments can be done and maintain healthy lifestyle um a couple things I want to tell you about plural fusions because plural fusions can be as acute as Chron chronic if patient has a chronic comorbidity such as a liver ceris therosis and you already have aitis and um of course plural Fusion is going to be recurent if we will do D synthesis and remove all the fluid it it doesn't mean that it will not come back it will come back back in a couple days for these patients um we use a catheter which is going to stay in the lung and drain this like every other days every couple days depends on the physician orders and um caregiver can do it at home patient doesn't need to be in the hospital to do that of course if the patient um plural Fusion caused by trauma or maybe pum IA or something acute disease uh we can just put a chest tube temporary uh treat it and then remove this chest tube and recur uh probably not going to happen um but uh with the patient who is chronic you you can expect to see catheter placed for a long time I'm not going to go over a lot over path of physiology of tension pumat tox um please listen lecture alterations in a gas exchange and we were talking about pumic there uh just a reminder that pneumat tox is a collapsing of lung due to most of the time is a trauma it can be outside trauma it's going to be orogenic trauma I already said tangent neumor as trauma is a number one e theology also scuba diving can cause that but if you see risk factors on the right side it is erogenic um what can cause uh um new attention numor during the any medical procedure we're not talking about trauma like bullet trauma penetration trauma or motor vehicle uh accident we're talking about what can happen what procedure can cause that's like central line placement mechanical ventilation lung biopsy tracheostomy broncoscopy inter Coastal neur block CPR pacemaker placement neat it is emergency situation it's required immediate action and uh healing process is really long that's why uh this care is costly patient with tension pneumat has increased heart rate decrease blood pressure jagular wear distension disia cyanosis sharp ltic pain radiating to back or shoulder acute respiratory failure and can have Cardiac Arrest Diagnostics studies ultrasound chest x-ray CT ECG and some lops hemat hematology studies cardiac enzymes arterial blood CES you probably heard the the term flail chest flail chest accused as a result of trauma to the Torx when three or more reaps are broken in at least two places the broken reap segments move independently from the rest of the chest wall stability of the chest wall is uh Disturbed chest wall moves inward with inspiration as the rest of the torax expands outward civility of the fla chest depends on the three factors plural pressure extent of the fla and movement of the inter Coastal muscles during Inspirations flail segments of the chest leads to hyperventilation with atelic stasis and Pulmonary contusion leading to edema and Hemorrhage reducing available lung space results of blond trauma to the to the chest such as um M vehicle collision FS or direct blow to the chest assault um also clients um who required mechanical ventilation can have fla chairs because of the B trauma or self extubation or ventilator cerated infection mortality of the FL FL chest is 10 to 20% and incident accounts for approximately 7% of chest trauma causes of course patient present when the FL child chest present present with a pain and altered gas exchange and it's a critical condition and we are monitoring and uh helping a patient with this critical condition um after uh we need to make sure that we educate our patient that patient probably need Physical Therapy that per permanent chest wall deiry will happen and patient is in increased risk for developing any respiratory distress clinical presentation you see on the picture a fracture of three ribs in two different places and um client will have severe chest wall pain and tpia and um splitting and resp respiratory in insufficiency the flail segment of the chest pulls inward inward during inspiration and the rest of the chest will expands and during expiration the flail segment is pushed out and the rest of the chest is pulled inward again it is a critical condition we're doing abgs X-ray and CT what is our role of course we are taking care of the symptoms if the patient is in in excruciating pain or patient has some respiratory distress we are managing it we are uh monitoring U Radiology results because we're going to check um do x-ray frequently a patient needs to work with a physical therapy um we of course we need to monitor for complications okay uh what are treatments like I said pain management we need to stabilize chest wall provide nutrition and we need to maintain ventilation and we ensure it's adequate ventilation but we always start with the least invasive to a more invasive it means intubation is probably going to be our last resort because it can cause even more trauma okay our next topic is pulmonary embolism it occures when circulation of blood through the pulmonary artery is interrupted by a trombos or another type of em embol fat air cancer cells when a pulmonary embolism occures the pulmonary circulation becomes uded a large embolism that block the be forcation of the main pulmonary artery is called the saddle embolism smaller ambik can um abstract gas exchange in the pulmonary um ariolis when a blood clot is loded in the blood vessel of the lung it blocks the blood supply to the lungs which increase the blood pressure in the lungs making the heart pump much harder than usual leading to EV ventilation to perfusion mismatch pathophysiology when alv Al vation is unchanged but perfusion of the capillary bat is decreased that leads to a dead space of ventilation in hyp hypoxemia serotonin is released triggering contraction of the pulmonary vasculature and reducing blood flow to the lung hyperventilation and an alteration in lung surfactant a result of inflammatory mediators produced locally leads to hypocapnia and respiratory alkalosis and it will um also will increase right ventricular after load which impairs right ventricular outflow and cause right ventricular dilation okay let's talk about um uh ventilation uh perfusion mismatch V is a ventilation Q is perfusion what is the V the amount of air that enters the lungs and and Q is the amount of blood flow and capillari of the lung of the lungs and a normal per minute is a 4 L of air enter the respiratory tract and 5 L of blood flow through the capillaries four uh by five is 0.8 any level um above or below 0.8 it's already um ventilation perfusion mismatch two classifications of um uh ventilation perfusion mismatch that space there's the ventilation normal ventilation but inadequate perfusion so oxygen cannot enter the blood bloodstream like anatomic death space or um physiologic mismatch uh shant there's adequate blood flow perfusion is adequate but inadequate ventilation and it can be relative or absolute and relative Shand is um there is a small amount of ventilation Shand is Absolut there is no ventilation pneumonia and pulmonary edema are conditions associated with shs um and our treatment goal is improve blood flow and air flow in the lungs we need to treat underlying conditions first CPD asthma PE or patient if patient smoking um bronchodilators inhaled corticosteroids oral steroid and oxygen are used to treat shant related um mismatch you can see some risk factors of pulmonary embolism on on this slide and you can read them but I want to say three main factors um known as a wofes Triad that increase the risk of pulmonary embolism or hyper calul ability vessel War wall injury and Venus stasis most ambal arise from the lower extremity proximal veins IL femoral or papal veins when the Ambi breaks off and travels to the lungs the client has a pulmonary embolism if the client has a pulmonary embolism and a DVT the client is diagnosed with Venus TR embolism VTE and depends how big is the emali and Depends when it's stuck what size of the um artery pulmonary artery it's stuck it can be asymptomatic it can be lowrisk P or it can be intermediate risk or submassive P high risk or massive p and high risk or massive p is um life-threatening situational presentation is disia chest pain cough shock ariia Syncopy chest pain and hod Dynamic collapse collapse and diagnosis studies includes AB abgs analysis troponin levels D dier ECG ultrasound chest xay x-ray and lung uh craphy of course when we are talking about treatment uh and therapies of pulmonary embolism we are talking about two different things first thing if the patient is um in a critical condition and patient um cannot breathe we we're using a mechanical ventilation may be necessary or mechanical cardiopulmonary support but we also need to take care of the uh uh trombas we can uh Trum uh Trum ectomy can be done uh um if the patient has dvts uh also um uh an and uh pulmonary embolism is not as severe that doctors can place a filter to catch small um ambali where coming from from legs um anti-coagulation therapy is a number one therapy for for PE it's a standard therapy for PE uh low molecular weight happine everybody knows laveno using to do for that um uh uh it is anol to blocks blocks clotting factors in the blood in order to prevent prevent clots um Delta parin is the anti-ant that is giving for people who have restricted mobility and are at at greater risk for DVT um Alti Place uh is the clot busting drug it dissolves clot in the blood vessels and improves the flow of blood um many different uh anti-coagulant therapies known right now you can see patients with PE um or like on on Hain um like IV Hain or Hein shots lainox uh uh can be as a preventive treatment also it can be um treating DVT like for example if you see like 40 milligram of lainox it's a preventing DVT medication if we have like 90 120 milligrams we probably treating something um sometimes you see patients are on hearin and also taking for example Kadin Kadin is the old medication another name it's warfaring um it's it's really cheap medication and some you're still going to see some patients on warfare in especially older patient who doesn't want to change who doesn't want to switch to more um modern medications such as like Alois or zarela sometimes you see patients on Hein and plus on Kadin you need to know that we are kind of building a bridge because for Kadin we need to have therapeutic INR and therapeutic INR is between two and three and if your patient does not have a therapeutic INR yet and you giving kumin that kumin is not working yet it means you need to keep Haine going until until you will get actual therapeutic INR and then you can stop Hein let's talk a little bit about respiratory failure now respiratory failure as a failure in gas exchange can be classified as hypoxemic and hyperopic hypoxemia occures when a partial O2 is less than 60 but CO2 is normal or low and is associated with many lung disease in which fluid feeling or collapse of Alvi AC cures hyperopic respiratory failure can be identified by CO2 level more than 50 but if the patient has hyperopic respiratory failure hyp hypoxemia will occur in client in those clients and uh uh the client who has hyper cing respiratory failure and breathing room air will have hypoxemia um respiratory fail is not considered a disease process but is classified as a syndrome hypoxemic respiratory failure is more common than hyperopic respiratory failure is a result of impairment of this or dysfunction of the structures responsible for ventilation or a condition disease that result in hyper perfusion of the lungs a result of uh decre disease process that involves the ventilatory capacity of the lungs such as COPD or cystic fibros and we were talking about ventilation perfusion mismatch or Shand some ethiology and comorbidities uh can cause a respiratory failure uh pulmonary conditions tumor blocking the TR asthma cystic fibrosis pneumonia pulmonary edema non-pulmonary conditions like neurological conditions like maybe brain damage uh peripheral nervous system damage or central nervous system damage and some comorbidities like Gan bar gravis obesity CD bronchial asthma pulmonary edema pneumonia respir uh respiratory failure impact on overall health uh first of all we need to talk about uh with patient how to reduce or even prevent this and of course we need to talk about underlying conditions some comorbidities and how to keep them under control um these clients May I need some oxygen therapy at home and right now uh this these clients can leave um uh normal life because they have a portable tanks they can go outside and these tanks are delivered to their to their home um I mean I mean it's not ideal but the patient still can live their their life um we need to definitely educate patient about um uh ability participate in Social and uh physical activities uh we need to talk about um maybe some Financial issues uh associated with the medical care and respiratory failure and of course about safety at home because of the patient and on oxygen uh smoking at home um is not allowed and smoking is not allowed with the patient who has respiratory failure but but always check if the patient is ready to be educated that is the most important thing manifestation of respiratory failure result from hypoxemia or hyperopia and respiratory failure is further classified as acute or chronic and what is the cause of the hypoxemia or hyperopia usually is like pneumonia asthma and COPD and a clinical presentation it's going to be as exageration of these uh conditions what tests and diagnostic studies we can do of course ebgs uh and chest x-ray it's a number one for all respiratory problems CBC electrolytes pum culture blood culture Ur urine culture thyroid function test pulmonary function test AKG uh patients who have respiratory failure usually uh care card but many um Physicians we have like a main physician and we have a lot of consults pulmonologist cardiologist neurologist and respiratory therapies are involved um a medications uh Administration usually it's a loop diuretic nitrate uh um opioid um anatropin better to antagonist um some other inhalers cortical steroids if necessary mechanical ventilation can be done um and we need to ass assess and maintain um ABCs our goal is to correct hypoxemia and respiratory acidosis and rest ventilatory muscles it means we are going to give oxygen and ventilatory support we can we can start with just normal oxygen we can bring a um um we can increase how many liters patient is um how on on how many liters patient on then we might need to bring high flow canula maybe patient needs needs to be on a bip poop and we are progressing and progressing to toward to me mechanical ventilation if needed and of course we need to dissolve hypercapnea by treating underlying cause of respiratory next topic is acute respiratory distress syndrome acuse acute respiratory distress syndrome is an acute condition that begins within 7 days after lung injury art develops very quickly and it is lifethreatening condition fluid buildups and alveoli and surf surfactant of the lungs break down the lungs become stiff and are not able to move enough oxygen throughout the body for normal function um you you can see uh on the picture that patient is in a prone position and um that is the evidence-based um practice that patient can heal uh better if people will put them in the pr position lungs become stiff and poorly uh irated lifethreatening hypoxemia resulting from edema and a and loss of elasticity of the lung uh Arts may be uh unresponsive to oxygen irregular pattern in the lungs and uh Vu mism caused by shunting common causes of Arts are sepsis pneumonia and aspiration and people who are are drinking alcohol over 60 and females have a higher risk uh to get it um 10% of this admission to ICU 24% of the clients required mechanic IAL ventilation and mortality rate is from 27 to 45% depending on severity most of the patients with Arts are intubated and intubated for a long time it means we cannot keep them intubated for a long time we usually Place tracheostomy um and uh patients cannot eat we put a g tube for nutrition support and cause some muscle wasting and weight loss and of course functional impairment and over all cognitive losss okay how diagnose art diagnoses based on a Berlin criteria onet occurs within 7 Days of initial respiratory distress event noncardiac origin Imaging um indicating bilateral lung INF Imaging indicating bilateral lung infiltrates abnormal oxygenation and partial of fiio ratio uh less than 30 uh this ratio is the partial pressure of arterial oxygen to fraction of inspired oxygen uh and it is indicator of Auden status and it can be mild moderate or severe what is the role of the nurse uh this patient is probably going to be classic um ICU patient we need to continue assessment of L result we need to do frequent skin assessment because patient is um ventilated and cannot actually move and sedated pain assessment and management family engagement and of course care coordination with interdisciplinary team and I will tell you with patients like this every possible um um member of this team will be involved um we control ventilatory support we set inspired oxygen concentration to lowest level to facilitate oygen ation like I said prone positioning is really helpful helpful with Arts Administration and management of sedation because patient who is ventilated is sedated and conservative fluid replacement with diuretic and nutritional support and let's talk a little bit about mechanical ventilation because we were talking much about arts and um respiratory distress and I was I was saying our patient can be ventilated Cas would be ventilated okay what is the mechanical ventilation mechanical ventilation used to increase partial O2 and to lower partial CO2 provides an opportunity to respiratory muscles to rest we are giving rest our patient and machine is is breathing when um lungs are healing ventilation control it's controlled ventilation ventilator delivers assistance without the client's respiratory efforts or client initiated ventilation as the ventilator delivers assistant as a response to the client inspiratory efforts and there so many different um uh levels of the machine uh when we talking about total control uh we put what what how many respirations we want to send to this patient how big the respiration is going to be like 400 MLS uh each um uh rest or 500 MLS depends how big is the patient depends on patient weight those um uh orders will be given by The Physician and patient is not breathing um at all this machine is giving as exact amount of um uh respirations we set we set up but when we're trying to win patient from this machine we cannot just EXT toate and okay go ahead and breathe we need to check if patient is can actually breathe we're trying trying to uh let patient to initiate some um breathes for example we can call Se popping on the vent machine patient can SE popping that way we uh P machine is a super sensitive and the patient will just try to initiate the breath machine will send the full amount of air and patient will take the uh take the full breath but patient needs to initiate if the patient has some brain injury and cannot initiate the breath machine will start alarming and we will switch this patient back back to controlled ventilation first of all uh what is our role we are helping with endot tral tube intubation and then um when patient is already intubated we are during medication administration patient who is intubated is usually sedated monitor we're monitoring Vital Signs we are identifying some ventilator related complications we perform frequent ventilator checks regular check and the track2 placement and positioning we say for PID and Airway and lung sounds we're providing suctioning provide effective Communications with interdisciplinary team client and uh client family we assess Readiness for winning from the ventilator and we provide some safety we provide all the care patient needs because these patients cannot move we need to turn them we need to check their skin we need to provide Oral Care to prevent some infections and our last couple slides we will just talk a little bit about ecma it's a extra Corporal membrane oxygenation it's a modality of cardiopulmonary support with some patient with um massive PE if we were able to resuscitate the patient and we can put them on acma um uh blood is pumped outside the body to oxygenate the blood um blood hemog hemoglobin and remove carbon dioxide and then return to the body honestly acma it's like a lung outside of the body um most of the time Amma is not like we do not like like on my experience I remember only one patient on acma at Mount car East Hospital most of the time this patients like an at OSU this patient required one onone care if the patient is on acma the nurse has only one patient um the nurse needs to do assessment and um identify early manifestations of internal hemorrhaging monitor neurological function monitor for sepsis uh renal failure and prevent pulmonary complications and of course of course it is a really complicated procedure and Mortal mortality rate is really high our um lecture is over if you have any questions please email me and paa mccn.edu