CCRN Review: Pulmonary Audrey Roberson, MS, RN, CPAN, CNS-BC Nurse Manager, Medical Respiratory Intensive Care Unit Virginia Commonwealth University Health System Please make sure all phones and pagers are switched to mute or vibrate! Objectives At the end of this presentation, the participants will: Apply knowledge of pulmonary physiology and arterial blood gases to  collaboratively manage acute and chronic pulmonary disorders, with and without mechanical ventilation. Differentiate acute hypoxic pulmonary failures (Pulmonary Embolis,  ARDs, Pneumonia, Airleaks) and determine collaborative management strategies for each. Describe collaborative interventions for managing patients with airway  disorders (COPD, Asthma, Emphysema). Relate nursing interventions for thoracic traumas/surgeries and  pulmonary hypertension. Test Plan Acute Lung Injury COPD, Asthma, Chronic   Bronchitis, Emphysema ARDS  Acute Pulmonary Embolus Pulmonary Hypertension   Acute Respiratory Failure Status Asthmaticus   Acute Respiratory Thoracic Surgery   Infections Thoracic Trauma  Pneumonia  Fractured Ribs  Bronchiolitis  Lung Contusions  Air-leak Syndromes   Tracheal Perforation Aspiration Pneumonia  Review of Pulmonary Anatomy The transfer of inhaled  oxygen and exhaled carbon dioxide occurs at the alveoli. Each alveoli is  surrounded by a capillary bed that reaches the lungs from the pulmonary arteries. Physiology of Gas Exchange Respiration is the process  by which O2 is transferred from the air to the tissues and CO2 is excreted in the expired air. Respiration involves a 3  Step Process: Ventilation  Diffusion  Transport  Control of Breathing Respiratory pacemaker is located in medulla  Generates rhythmic cycle  Breathing is spontaneous, but becomes irregular if input  from the pons is disrupted. Chemoreceptors  Oxygen receptors are located in carotid / aortic bodies  PaO2 must be <60 to activate  Carbon Dioxide receptors located in the medulla are the  main respiratory regulators. PaCO2 > 70-80 can depress CNS  Work of Breathing The amount of effort required to maintain a given  level of ventilation. Determined by:  Lung Compliance - Measure of elasticity of the lungs  and thorax. Airway Resistance - The opposition to gas flow in the  airways. Mainly due to diameter of airways. Small changes in diameter produce large changes in  resistance. Autonomic nervous system and inflammatory mediators affect  resistance: Parasympathetic  Sympathetic  Histamine  Oxygen Transport Oxygen is carried in the  blood in two ways: Bound to hemoglobin in  RBC’s (SaO2) Dissolved in plasma  (PaO2) Oxyhemoglobin dissociation  curve Shows the relationship  between O2 saturation and PaO2. Describes the ability of  hemoglobin to bind to O2 Carbon Dioxide Transport Carried in the blood in three ways:  Dissolved in the plasma (PaCO2)  Chemically combined with hemoglobin  As bicarbonate through a conversion reaction:  CO2 +H20  H2CO3  H + HCO3  KEY CONCEPT: The amount of CO2 in the plasma determines the acidity of the blood.