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Respiratory Gas Physiology

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Respiratory Gas Physiology Non-Invasive Respiratory Gas Monitoring Module Endorsements This educational module has been Non-Invasive Respiratory endorsed by the following professional organizations: Gas Monitoring Bryan E. Bledsoe, DO, FACEP The George Washington University Medical Center 2 Review Board Roy Alson, MD, PhD, FACEP James Augustine, MD, FACEP Edward Dickinson, MD, FACEP Marc Eckstein, MD, FACEP RESPIRATORY GAS Steven Katz, MD, FACEP Mike McEvoy, PhD, RN, EMT-P PHYSIOLOGY Joe A. Nelson, DO, MS, FACOEP, FACEP Ed Racht, MD Mike Richards, MD, FACEP Keith Wesley, MD, FACEP Paula Willoughby-DeJesus, DO, MHPE, FACOEP 3 Respiratory Gasses Respiratory Gasses Normal Atmospheric Most important Gasses: respiratory gasses: Oxygen (O2) Oxygen (O2) Carbon Dioxide (CO2) Carbon Dioxide (CO2) Nitrogen (N2) Water Vapor (H2O) Trace gasses: Argon (Ar) Neon (Ne) Helium (He) Non-Invasive Respiratory Gas Monitoring Module Respiratory Gasses Respiratory Gasses Respiratory gasses often represented Determining partial pressures: based upon their partial pressures. PA = XA × P Dalton’s Law: Where: PA = pressure of the gas X = mole fraction of the gas “The total pressure in a container is the A P = total pressure of the mixture sum of partial pressures of all gasses in PO = 0.2095 × 760 mm Hg the container.” 2 PO2 = 159.22 mm Hg Partial pressure of oxygen in atmosphere at sea level = 159 mm Hg Atmospheric Gasses Respiratory Gasses GAS† PRESSURE PERCENTAGE Atmospheric Humidified Alveolar Expired Air Air Air Air (mm Hg) (%) GAS (mm Hg) (mm Hg) % % (mm Hg) % (mm Hg) % Nitrogen (N2) 593.408 78.08 78.6 74.0 74.9 74.5 N2 597.0 563.4 569.0 566.0 Oxygen (O2) 159.220 20.95 20.8 19.7 13.6 15.7 O2 159.0 149.3 104.0 120.0 Argon (Ar) 7.144 0.94 CO 0.3 0.04 0.3 0.04 40.0 5.3 27.0 3.6 Carbon Dioxide (CO2) 0.288 0.03 2 Neon (Ne) 0.013 0.0018 0.50 6.20 6.2 6.2 H2O 3.7 47.0 47.0 47.0 Helium (He) 0.003 0.0005 TOTAL 760 100 760 100 760 100 760 100 TOTAL 760 100 † = dry air at sea level. Oxygen Oxygen Odorless. Derived from plant Tasteless. photosynthesis: Colorless. Algae (75%). Terrestrial Plants Supports combustion. (25%). Present in the Oxygen atom must atmosphere as a share electrons for diatomic gas (O2). stability. Necessary for animal life. Non-Invasive Respiratory Gas Monitoring Module Carbon Dioxide Carbon Dioxide Colorless. Waste product of animal Sour taste at high life (carbohydrate and concentrations. fat metabolism). Found in very low Contains 2 atoms of concentrations in oxygen and 1 atom of fresh air. carbon. Asphyxiant. Abnormal Respiratory Gasses Carbon Monoxide Carbon monoxide Colorless (CO) Odorless Tasteless Results from incomplete combustion of carbon-containing compounds. Heavier than air. Respiratory Gas Transport Hemoglobin Oxygen Carbon Dioxide Protein-Iron Complex. 97% reversibly bound 70% as bicarbonate Transports oxygen to - to hemoglobin. (HCO3 ). peripheral tissues. 3% dissolved in 23% reversibly bound Removes a limited plasma. to hemoglobin. amount of carbon 7% dissolved in plasma. dioxide from the peripheral tissues. Non-Invasive Respiratory Gas Monitoring Module Hemoglobin Hemoglobin Binding Sites Human hemoglobin is made of various sub- units: 2 α sub-units 2 β sub-units 4 iron-containing heme structures. Deoxyhemoglobin Oxyhemoglobin Heme is in Fe2+ state and Heme is in Fe3+ state and domed. Can bind oxygen. planar. Oxygen bound. Also called the “T” state. Also called the “R” state. Hemoglobin Binding Sites Hemoglobin The binding of oxygen changes the conformation (shape) of the hemoglobin molecule. Deoxyhemoglobin is converted to oxyhemoglobin. Abnormal Hemoglobin States Carboxyhemoglobin (COHb) Carboxyhemoglobin Results from the Methemoglobin binding of CO to hemoglobin following CO exposure. Some always present in smokers. Non-Invasive Respiratory Gas Monitoring Module Carboxyhemoglobin (COHb) Methemoglobin CO has 250 times the Heme must be in the affinity for hemoglobin ferrous (Fe2+) state to bind O2. as does O2. Methemoglobin is CO displaces O2 from hemoglobin in the ferric hemoglobin. (Fe3+) state and cannot CO can be displaced bind O2. by high-concentration Normally < 1% of O . hemoglobin is 2 methemoglobin. Half-life is 4-6 hours. High levels lead to hypoxemia. Methemoglobin Oxygen Saturation Hereditary: Hemoglobin oxygen Hemoglobin M saturation is directly Enzyme deficiency related to the partial Acquired: pressure of oxygen in Nitrates the blood (PO2). Nitrites Venous blood Dyes saturation. Sulfonamides Lidocaine Arterial blood Benzocaine saturation. Factors Affecting Saturation 2,3-biphosphoglycerate Decreased saturation. Aids in oxygen Decreased pH (acidosis). release in the Increased CO . 2 peripheral tissues. Increased temperature. Increased BPG (2,3- Higher levels found in biphosphoglycerate) people who live at Increased saturation. high altitudes. Increased pH (alkalosis) Helps mitigate the Decreased CO2. Decreased temperature. effects of hypoxia. Decreased BPG (2,3- biphosphoglycerate) Non-Invasive Respiratory Gas Monitoring Module Carbon Dioxide Transport Carbon Dioxide Transport Some CO is Majority of CO2 transported in the form of 2 bicarbonate ion (HCO -). transported on 3 hemoglobin. Binds to a different CO + H O → H CO → H+ + HCO - site than O2 (binds to 2 2 2 3 3 an amino acid). Resultant compound is called Carbonic Anhydrase increases carbaminohemoglobin speed of reaction 5,000 fold. (CO2Hb). Bohr Effect Haldane Effect Increases in CO2 Binding of oxygen to hemoglobin tends to levels in the blood displace CO2. cause oxygen to be displaced from Oxyhemoglobin is more acidic than hemoglobin. deoxyhemoglobin: Increases oxygen Promotes removal of CO2 in the alveoli. transport. Promotes release of hydrogen ions which combine with bicarbonate ions to form H2O and CO2 which are eliminated. Haldane Effect Respiratory Gas Measurement Arterial Blood Gas Sampling Pulse Oximetry Capnography Transcutaneous CO2 Monitoring Non-Invasive Respiratory Gas Monitoring Module Arterial Blood Gasses Arterial Blood Gasses Gold standard for Excellent diagnostic Parameter Normal respiratory gas tool. pH 7.35-7.45 monitoring. Impractical in the PO2 80-100 mm Hg Invasive prehospital setting. Expensive PCO2 35-45 mm Hg Painful - HCO3 22-26 mmol/L Difficult BE -2 - +2 SaO2 > 95% Pulse Oximetry Introduced in early 1980s. Non-invasive OXYGEN measurement of oxygen saturation. Safe Inexpensive Pulse Oximetry Pulse Oximetry How it works: Some light is Probe is placed over a absorbed by: vascular bed (finger, Arterial blood earlobe). Venous blood Light-emitting diodes Tissues (LEDs) emit light of two different Light that passes wavelengths: through the tissues is Red = 660 nm detected by a Infrared = 940 nm photodetector. © Brook Wainwright Non-Invasive Respiratory Gas Monitoring Module Pulse Oximetry Only inflow of blood is used to determine SpO2. Hence the name “Pulse Oximetry” Hb and HbO2 absorb light and different rates due to color and conformation. Pulsatile Flow Oximetry Probe Placement Finger Earlobe Heel (neonates) This is the band used to measure SpO2. Oximetry Probe Placement Pulse Oximetry Accuracy falls when LEDs and Some manufacturers use reflective oximetry for photoreceptors poorly aligned. monitoring. Accuracy decreases with lower pulse LEDs and photodetectors in same electrode. oximetry readings. Light reflected from the tissues and detected by photodetectors and findings interpreted by the software in the oximeter. Can be used on forehead or back. Non-Invasive Respiratory Gas Monitoring Module Pulse Oximetry Perfusion Index HbO2 absorbs more Reflects the pulse infrared light than Hb. strength at the Hb absorbs more red light monitoring site. than HbO . 2 Ranges from 0.02% Difference in absorption is measured. (very weak pulse Ratio of absorbance strength) to 20% (very strong pulse matched with SpO2 levels stored in the strength). microprocessor. Helps determine best site to place probe. Pulse Oximetry Pulse Oximetry Pulse oximetry tells you: SpO SaO or SpO ? 2 2 2 Pulse rate SaO2 used for oxygen saturation readings Pulse oximetry cannot tell you: derived from arterial blood gas analysis. O2 content of the blood SpO used for oxygen saturation readings 2 Amount of O dissolved in blood from pulse oximetry. 2 Respiratory rate or tidal volume (ventilation) SpO and SaO are normally very close. 2 2 Cardiac output or blood pressure. Who Should Use? Prehospital Indications Any level of 1. Monitor the adequacy of prehospital care arterial oxyhemoglobin saturation (SpO2) provider who 2. To quantify the SpO2 administers O2. response to an First Responders intervention. EMTs 3. To detect blood flow in EMT-Intermediates endangered body regions (e.g., Paramedics extremities) Non-Invasive Respiratory Gas Monitoring Module Limitations First-Generation Oximeter Problems Oximetry is NOT a measure of ventilation False Readings: Hypotension. (EtCO2 a better measure of ventilation). Hypothermia. Vasoconstriction. Oximetry may lag behind hypoxic events. Dyes/pigments (e.g., nail polish). Oximetry is not a substitute for physical Movement may cause false reading in absence of pulse. Abnormal hemoglobin: examination. COHb. Very low saturation states may be METHb. Oximeter can’t perform: inaccurate due to absence of measured Bright ambient lighting. SpO2 levels in the database. Shivering. Helicopter transport. First-Generation Oximeter Problems Second-Generation Technology Motion, noise, and Newer technology low perfusion states uses signal can cause artifacts processing to and false oximetry minimize artifacts and false readings. readings: These have been Adaptive
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