Unit 3
Alterations In Gas Exchange
Hypoventilation (just patho)
➔ Patho- delivery of air to alveoli is insufficient to provide O2 and remove O2
➔ Etiology-
◆ drugs that depress respiratory drive (morphine, barbiturates)
◆ Disorders such as obesity, myasthenia gravis, OSA, chest wall damage, paralysis
of respiratory muscles (or pain r/t surgery in thorax or abdomen)
➔ S/S- slow breathing, increased PAC02 (hypoxemia)
Hyperventilation (just patho)
➔ Patho- increase in air entering alveoli, which DROPS PaCO2 (hypocapnia)
➔ Etiology- hypoxic stimulation of peripheral chemoreceptors
◆ Pain, fever, anxiety
◆ LESS common: COPD, sepsis, brainstem injury
◆ Normal physiological response like high altitudes when on an airplane as a
compensatory mechanism
➔ S/S- drop in C02
Hypoxemia (just patho)
➔ Patho- deficient levels of blood oxygen
➔ S/S- SOB, increased HR and RR, can’t speak full sentences
➔ Dx- measured by ABGs or pulse ox
➔ Interventions- give 02
Hypoxia (just patho & goes with hypoxemia^)
➔ Decrease in tissue oxygenation
Hypoxic hypoxia- DROP in PaC02 despite normal O2 carrying capacity due to high
altitudes, hypoventilation, and airway obstruction
Anemic hypoxia- DROP in O2 carrying capacity due to any disorder causing low
hemoglobin
Circulatory hypoxia- low cardiac output that reduces blood flow despite normal O2
carrying capacity due to cardiac arrest, severe blood loss, or CHF
, Histotoxic hypoxia- a toxic substance leads to tissue inability to use oxygen, for example,
cyanide poisoning
Acute bronchitis (just patho)
➔ Patho- acute inflammation of the trachea and bronchi
◆ Capillary dilation narrows the airway r/t swelling from the exudation of fluid,
increasing mucus production
➔ Etiology- viruses (flu), non-viral (strep), heat and smoke inhalation
◆ If your pt smokes they are at high risk, also young children, and the elderly in
winter months
➔ S/S- mild and self limited, un/productive cough, fever, sore throat, fatigue, postnasal drip
➔ Dx- recent onset of cough**, chest radiograph to rule out pneumonia and confirm
bronchitis
Chronic bronchitis/COPD B “Blue Bloaters”
➔ Patho- chronic inflammation and swelling of the bronchial mucosa > scarring
➔ Etiology- smokers (90%!!), inhalation of physical or chemical irritants, genetic
predisposition, repeated airway infections!!
◆ Pt who are obese/overweight are at increased risk r/t airway obstruction! Also at
risk are men and older than 40, chronic/recurrent productive cough >3 months
>2+ years.
➔ S/S- SOB on exertion, excessive sputum, chronic cough (in the AM), edema or
hypervolemia, chills, malaise, muscle aches, clubbing (late sign), crackles/wheezes
(early), JVD
➔ Dx- recurrent cough longer than 3 months or 2 years, chest x-ray, pulmonary function test
(residual volume ^), ABGs, ECG, Polycythemia!! Low O2, high CO2, V/Q mismatch
➔ Interventions- increase HOB, small frequent meals, diaphragmatic breathing techniques,
increase fluids to 2L/day *cor pulmonae*. While the process of pulmonary HTN
continues right ventricular end diastolic pressure ^ leading to right ventricular dilation
(cor pulmonae) and right-sided HF.
➔ Tx- corticosteroids, adrenergics (albuterol), mucolytics (acetylcysteine), expectorants
(guaifenesin)
➔ Patient education- get vaccines and smoking cessation
,Emphysema/ COPD A “Pink Puffers”
➔ Patho- destructive changes of alveolar walls w/o fibrosis, release of proteolytic enzymes
from immune cells
➔ Etiology- smoking, air pollution, certain occupations, antitrypsin deficiency
◆ At risk pts: smoking 70 pack/year, 50+ years old, thin/underweight, women
➔ S/S- progressive exertional dyspnea, VERY THIN, use of accessory muscles, pursed lip
breathing, digital clubbing, barrel chest** d/t loss of elastic tissue d/t chronic
hyperinflamation, decreased breath sounds, minimal or absent cough, wheezing, sits
hunched over
➔ Dx- chest x-ray, presence of bullae/blebs (cysts in the lungs) , ABGs (normal CO2),
Ventilation and perfusion matching near normal gas exchange, ^ lung compliance,
Residual Volume ^
➔ Interventions- SAME AS COPDB, corticosteroids, albuterol- beta 2 adrenergic agonist,
bronchodilators
➔ Tx- SAME AS COPDB, ^ HOB, fluids 2L/day, Diaphragmatic breathing techniques!!!!!
➔ Patient education- same as COPDB, add high calories to diet but small frequent meals ,
SMOKING CESSATION
Restrictive Pulmonary Disorders:
Sarcoidosis
➔ Patho- multiple uniform noncaseating epitheioloid granulomas that affect multiple organ
systems - lymph nodes and lung tissue (most common). Common feature CD4 +T cells.
Activation of the alveolar macrophage from an unknown antigen trigger.
➔ Etiology- pt who had a prior TB infection! More common in women, having a 1st degree
family member!!! 20-40 yrs old
➔ S/S- dry cough, erythema, macules & papules, hyperpigmentation, subq nodules,
enlarged lymph nodes/arthritis (flu-like symptoms), Wt loss,
cough/non-productive/congested, dyspnea, hypercalcemia, Uveitis (SWOLLEN EYES),
➔ Dx- chest x-ray (show hilar adenopathy, CT, transbronchial biopsy (to rule out cancer),
blood gases - hypoxemia
, ➔ Interventions- achieve airway clearance, improve breathing, monitor and manage
complications, monitor glucose (70-110), monitor for GI upset, peptic ulcer, weak
immune, brittle bones
➔ Tx- corticosteroids (prednisone tapered doses for 12 months)
➔ Patient education- follow-ups required every 3-6 months, monitor glucose levels, pt can
go into remission w/o treatment, can cause hyperglycemia & hypercalcemia
Hypersensitivity pneumonitis (restrictive) Extrinsic allergic alveolitis!
➔ Patho/Etiology - Inhaled organic agents responsible for inflammatory process (More
common in non-smokers). Causative antigen combines with serum antibody in the
alveolar walls → type III hypersensitivity reaction → lung tissue injury/thickening of
alveolar walls/formation of exudate in bronchiolar lumen, Pulmonary fibrosis!!! In upper
lobes
➔ S/S - Start 4-6 hours after exposure, resolve within 18-24 hours. Chills, sweating,
myalgias, nausea, lethargy, HA, fever, dyspnea at rest, dry cough, tachypnea, cyanosis,
crackles, hypoxemia worsened by exercise
◆ Chronic - diffuse pulmonary fibrosis in upper lobes, eventually cor pulmonae
➔ Dx - Chest x-ray, ↑ WBC, ↓ PaO2, ↓ PFTs, ↑ ESR, ↑ CRP, skin testing- red indurated
hemorrhage reaction 4-12 hours after injection!!!
➔ Interventions -
➔ Tx - Prevent exposure to causative agent, oral corticosteroids.
➔ Patient education - inhalation of organic particles, overtime - cor pulmonae
Pneumothorax
➔ Patho/Etiology - Accumulation of air in pleural space.
◆ Primary - Spontaneous. Occurs in men 20 - 40 y/o. Smoking ↑ risk. More
common in men than women. Rupture of blebs in apices. Lung collapses and
ribcage springs out.
◆ Secondary - Complication from underlying lung problem. Rupture of cyst/bleb.
◆ Tension - “Sucking chest wound”. Traumatic. Medical emergency. Penetrating or
non-penetrating injury. Build-up of air under pressure in pleural space. Air comes
in during inhalation but can’t escape during exhalation. Lung on the same side
collapses, mediastinum and trachea shift. ↓ cardiac output.
Alterations In Gas Exchange
Hypoventilation (just patho)
➔ Patho- delivery of air to alveoli is insufficient to provide O2 and remove O2
➔ Etiology-
◆ drugs that depress respiratory drive (morphine, barbiturates)
◆ Disorders such as obesity, myasthenia gravis, OSA, chest wall damage, paralysis
of respiratory muscles (or pain r/t surgery in thorax or abdomen)
➔ S/S- slow breathing, increased PAC02 (hypoxemia)
Hyperventilation (just patho)
➔ Patho- increase in air entering alveoli, which DROPS PaCO2 (hypocapnia)
➔ Etiology- hypoxic stimulation of peripheral chemoreceptors
◆ Pain, fever, anxiety
◆ LESS common: COPD, sepsis, brainstem injury
◆ Normal physiological response like high altitudes when on an airplane as a
compensatory mechanism
➔ S/S- drop in C02
Hypoxemia (just patho)
➔ Patho- deficient levels of blood oxygen
➔ S/S- SOB, increased HR and RR, can’t speak full sentences
➔ Dx- measured by ABGs or pulse ox
➔ Interventions- give 02
Hypoxia (just patho & goes with hypoxemia^)
➔ Decrease in tissue oxygenation
Hypoxic hypoxia- DROP in PaC02 despite normal O2 carrying capacity due to high
altitudes, hypoventilation, and airway obstruction
Anemic hypoxia- DROP in O2 carrying capacity due to any disorder causing low
hemoglobin
Circulatory hypoxia- low cardiac output that reduces blood flow despite normal O2
carrying capacity due to cardiac arrest, severe blood loss, or CHF
, Histotoxic hypoxia- a toxic substance leads to tissue inability to use oxygen, for example,
cyanide poisoning
Acute bronchitis (just patho)
➔ Patho- acute inflammation of the trachea and bronchi
◆ Capillary dilation narrows the airway r/t swelling from the exudation of fluid,
increasing mucus production
➔ Etiology- viruses (flu), non-viral (strep), heat and smoke inhalation
◆ If your pt smokes they are at high risk, also young children, and the elderly in
winter months
➔ S/S- mild and self limited, un/productive cough, fever, sore throat, fatigue, postnasal drip
➔ Dx- recent onset of cough**, chest radiograph to rule out pneumonia and confirm
bronchitis
Chronic bronchitis/COPD B “Blue Bloaters”
➔ Patho- chronic inflammation and swelling of the bronchial mucosa > scarring
➔ Etiology- smokers (90%!!), inhalation of physical or chemical irritants, genetic
predisposition, repeated airway infections!!
◆ Pt who are obese/overweight are at increased risk r/t airway obstruction! Also at
risk are men and older than 40, chronic/recurrent productive cough >3 months
>2+ years.
➔ S/S- SOB on exertion, excessive sputum, chronic cough (in the AM), edema or
hypervolemia, chills, malaise, muscle aches, clubbing (late sign), crackles/wheezes
(early), JVD
➔ Dx- recurrent cough longer than 3 months or 2 years, chest x-ray, pulmonary function test
(residual volume ^), ABGs, ECG, Polycythemia!! Low O2, high CO2, V/Q mismatch
➔ Interventions- increase HOB, small frequent meals, diaphragmatic breathing techniques,
increase fluids to 2L/day *cor pulmonae*. While the process of pulmonary HTN
continues right ventricular end diastolic pressure ^ leading to right ventricular dilation
(cor pulmonae) and right-sided HF.
➔ Tx- corticosteroids, adrenergics (albuterol), mucolytics (acetylcysteine), expectorants
(guaifenesin)
➔ Patient education- get vaccines and smoking cessation
,Emphysema/ COPD A “Pink Puffers”
➔ Patho- destructive changes of alveolar walls w/o fibrosis, release of proteolytic enzymes
from immune cells
➔ Etiology- smoking, air pollution, certain occupations, antitrypsin deficiency
◆ At risk pts: smoking 70 pack/year, 50+ years old, thin/underweight, women
➔ S/S- progressive exertional dyspnea, VERY THIN, use of accessory muscles, pursed lip
breathing, digital clubbing, barrel chest** d/t loss of elastic tissue d/t chronic
hyperinflamation, decreased breath sounds, minimal or absent cough, wheezing, sits
hunched over
➔ Dx- chest x-ray, presence of bullae/blebs (cysts in the lungs) , ABGs (normal CO2),
Ventilation and perfusion matching near normal gas exchange, ^ lung compliance,
Residual Volume ^
➔ Interventions- SAME AS COPDB, corticosteroids, albuterol- beta 2 adrenergic agonist,
bronchodilators
➔ Tx- SAME AS COPDB, ^ HOB, fluids 2L/day, Diaphragmatic breathing techniques!!!!!
➔ Patient education- same as COPDB, add high calories to diet but small frequent meals ,
SMOKING CESSATION
Restrictive Pulmonary Disorders:
Sarcoidosis
➔ Patho- multiple uniform noncaseating epitheioloid granulomas that affect multiple organ
systems - lymph nodes and lung tissue (most common). Common feature CD4 +T cells.
Activation of the alveolar macrophage from an unknown antigen trigger.
➔ Etiology- pt who had a prior TB infection! More common in women, having a 1st degree
family member!!! 20-40 yrs old
➔ S/S- dry cough, erythema, macules & papules, hyperpigmentation, subq nodules,
enlarged lymph nodes/arthritis (flu-like symptoms), Wt loss,
cough/non-productive/congested, dyspnea, hypercalcemia, Uveitis (SWOLLEN EYES),
➔ Dx- chest x-ray (show hilar adenopathy, CT, transbronchial biopsy (to rule out cancer),
blood gases - hypoxemia
, ➔ Interventions- achieve airway clearance, improve breathing, monitor and manage
complications, monitor glucose (70-110), monitor for GI upset, peptic ulcer, weak
immune, brittle bones
➔ Tx- corticosteroids (prednisone tapered doses for 12 months)
➔ Patient education- follow-ups required every 3-6 months, monitor glucose levels, pt can
go into remission w/o treatment, can cause hyperglycemia & hypercalcemia
Hypersensitivity pneumonitis (restrictive) Extrinsic allergic alveolitis!
➔ Patho/Etiology - Inhaled organic agents responsible for inflammatory process (More
common in non-smokers). Causative antigen combines with serum antibody in the
alveolar walls → type III hypersensitivity reaction → lung tissue injury/thickening of
alveolar walls/formation of exudate in bronchiolar lumen, Pulmonary fibrosis!!! In upper
lobes
➔ S/S - Start 4-6 hours after exposure, resolve within 18-24 hours. Chills, sweating,
myalgias, nausea, lethargy, HA, fever, dyspnea at rest, dry cough, tachypnea, cyanosis,
crackles, hypoxemia worsened by exercise
◆ Chronic - diffuse pulmonary fibrosis in upper lobes, eventually cor pulmonae
➔ Dx - Chest x-ray, ↑ WBC, ↓ PaO2, ↓ PFTs, ↑ ESR, ↑ CRP, skin testing- red indurated
hemorrhage reaction 4-12 hours after injection!!!
➔ Interventions -
➔ Tx - Prevent exposure to causative agent, oral corticosteroids.
➔ Patient education - inhalation of organic particles, overtime - cor pulmonae
Pneumothorax
➔ Patho/Etiology - Accumulation of air in pleural space.
◆ Primary - Spontaneous. Occurs in men 20 - 40 y/o. Smoking ↑ risk. More
common in men than women. Rupture of blebs in apices. Lung collapses and
ribcage springs out.
◆ Secondary - Complication from underlying lung problem. Rupture of cyst/bleb.
◆ Tension - “Sucking chest wound”. Traumatic. Medical emergency. Penetrating or
non-penetrating injury. Build-up of air under pressure in pleural space. Air comes
in during inhalation but can’t escape during exhalation. Lung on the same side
collapses, mediastinum and trachea shift. ↓ cardiac output.
