Alterations in Oxygenation: Nursing Interventions and Clinical Management

1. Introduction to Oxygenation and Impaired Gas Exchange

1.1 Definition and Importance of Oxygenation

Oxygenation is the process by which oxygen is transported from the lungs to the tissues via the bloodstream, ensuring cellular respiration and energy production. Adequate oxygenation is vital for organ function and survival – every cell in the body requires a continuous supply of oxygen to carry out metabolic processes. The respiratory, cardiovascular, and hematological systems work in concert to achieve effective oxygenation: the lungs oxygenate the blood, the heart pumps the oxygen-rich blood to tissues, and hemoglobin in red blood cells binds and delivers oxygen to cells. Any impairment in these systems can disrupt oxygen delivery. For example, conditions like asthma, chronic obstructive pulmonary disease (COPD), pneumonia, heart failure, or anemia can impair the body’s ability to oxygenate tissues effectively. In nursing practice, maintaining optimal oxygenation is a priority – alterations in oxygenation can quickly lead to hypoxemia (low blood oxygen) and hypoxia (oxygen deficiency in tissues), which if untreated may cause organ damage or failure.

1.2 Pathophysiology of Impaired Gas Exchange

Impaired gas exchange refers to the inability of the lungs to adequately transfer oxygen from the alveoli into the blood and/or remove carbon dioxide from the blood into the alveoli. This can occur due to ventilation-perfusion (V/Q) mismatching, diffusion defects, or hypoventilation. In a healthy lung, each alveolus is ventilated and perfused in a balanced ratio (~0.8). Impaired gas exchange often arises when this balance is disrupted. For instance, in shunting (perfusion without ventilation), blood passes through lung areas that are not ventilated (e.g. atelectatic or consolidated alveoli) and returns to the heart without being oxygenated. In dead space ventilation (ventilation without perfusion), areas of the lung are ventilated but receive little or no blood flow (e.g. pulmonary embolism), so oxygen is not effectively taken up by the blood. Diffusion abnormalities (thickening of the alveolar-capillary membrane as in pulmonary fibrosis or edema) slow the transfer of oxygen across the membrane. Additionally, hypoventilation (reduced minute ventilation) can cause a buildup of carbon dioxide and low oxygen levels in the blood. Any of these mechanisms lead to inadequate oxygenation of arterial blood, resulting in hypoxemia. Prolonged hypoxemia causes the body to compensate in various ways – for example, increasing respiratory rate, heart rate, and cardiac output to improve oxygen delivery, and in chronic cases, increasing red blood cell production to carry more oxygen. If the underlying issue is not corrected, these compensatory mechanisms can fail, leading to tissue hypoxia and cellular dysfunction.

1.3 Clinical Signs and Symptoms of Oxygenation Impairment

Patients with impaired oxygenation often exhibit a range of signs and symptoms. Early indicators of hypoxemia include tachypnea (increased respiratory rate) as the body attempts to improve oxygen intake, and tachycardia (increased heart rate) to circulate blood more rapidly. The patient may appear restless, anxious, or confused due to reduced oxygen to the brain. As oxygenation worsens, more obvious signs develop: cyanosis (a bluish discoloration of the skin, lips, or nail beds) may be observed, although this is a late sign and may not be present in all cases (especially in darker skin tones). Other respiratory signs include nasal flaring, use of accessory muscles for breathing (e.g. suprasternal or intercostal retractions), and wheezing or crackles on auscultation if there is airway obstruction or fluid in the lungs. The patient might have a productive cough (if secretions are present) and report shortness of breath (dyspnea) or air hunger. In severe hypoxia, altered mental status can occur – from agitation to lethargy or unconsciousness – as the brain becomes hypoxic. Pallor or cool, clammy skin may also be noted due to vasoconstriction and poor perfusion. It is important for nurses to recognize these signs promptly; for example, diminished breath sounds or adventitious sounds on lung auscultation can indicate areas of poor ventilation, while changes in mental status can be an early warning of cerebral hypoxia. Any significant change in the patient’s respiratory status or oxygen saturation should trigger immediate nursing intervention, since impaired gas exchange can deteriorate rapidly.

1.4 Nursing Diagnosis: Impaired Gas Exchange

When a patient is experiencing inadequate oxygenation of blood, nurses often use the NANDA-I nursing diagnosis Impaired Gas Exchange. This diagnosis is defined as “excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane”. In simpler terms, it represents a state where the patient’s lungs are not effectively exchanging O₂ and CO₂. Impaired Gas Exchange is commonly associated with conditions like acute respiratory distress syndrome (ARDS), pneumonia, pulmonary edema, COPD, asthma, and other illnesses that affect ventilation or perfusion. The related factors (etiologies) for this diagnosis may include ventilation-perfusion imbalance, alveolar-capillary membrane changes (e.g. inflammation, fibrosis, fluid), hypoventilation, or decreased hemoglobin availability. As evidenced by the defining characteristics, the nurse will note clinical signs such as abnormal arterial blood gases (e.g. low PaO₂, high PaCO₂), hypoxemia on pulse oximetry, changes in respiratory rate or depth, adventitious breath sounds, restlessness, confusion, cyanosis, etc.. The overall goal for this nursing diagnosis is to optimize gas exchange and tissue oxygenation. Nursing interventions are aimed at improving oxygen supply (e.g. administering oxygen, positioning), enhancing ventilation (e.g. airway clearance, breathing exercises), and monitoring for complications. It’s important to differentiate Impaired Gas Exchange from other diagnoses: for example, Ineffective Airway Clearance refers to difficulty in removing secretions or obstructions from the airways, while Ineffective Breathing Pattern refers to the rate, depth, or rhythm of breathing being inadequate. Impaired Gas Exchange, by contrast, focuses on the actual exchange of gases at the alveolar level. By identifying Impaired Gas Exchange early and implementing appropriate interventions, nurses can help prevent progression to respiratory failure and improve patient outcomes.

2. Assessment of Oxygenation Status

2.1 Respiratory Assessment Techniques

A thorough respiratory assessment is the foundation for evaluating oxygenation. Nurses use inspection, palpation, percussion, and auscultation to gather data about the patient’s respiratory status. Inspection involves observing the rate, rhythm, and depth of respirations; the effort of breathing (e.g. presence of retractions or flaring); skin color and signs of cyanosis; and any use of accessory muscles. Normal respiratory rate in adults is 12–20 breaths per minute; tachypnea (>20) often indicates respiratory distress or hypoxemia. Palpation may reveal abnormalities such as tracheal deviation (suggesting tension pneumothorax if shifted away from an affected side), subcutaneous emphysema (air under the skin), or areas of tenderness. Percussion can detect dullness (indicating consolidation or fluid) or hyper-resonance (indicating air, as in pneumothorax) in lung fields, though this is a skill often practiced by advanced providers. Auscultation with a stethoscope is critical – the nurse listens to breath sounds over all lung lobes to assess airflow. Normal breath sounds include vesicular (soft over most lung fields), bronchovesicular, and bronchial (louder over trachea and large airways) sounds. Adventitious breath sounds such as crackles (fine or coarse rales, indicating fluid in small airways), wheezes (high-pitched musical sounds from airway narrowing), or rhonchi (low-pitched snoring sounds from secretions in larger airways) may indicate pathology affecting oxygenation. Diminished or absent breath sounds over an area can suggest atelectasis, pneumothorax, or pleural effusion. In addition to lung sounds, the nurse notes the patient’s vital signs – particularly heart rate (tachycardia can accompany hypoxemia) and blood pressure – and monitors the patient’s level of consciousness and skin perfusion. For example, an anxious or confused patient may be hypoxic, and cool, pale skin can indicate poor perfusion. By systematically assessing the respiratory system, nurses can identify early signs of oxygenation impairment and intervene promptly. Regular reassessment is important, especially for patients at risk, as changes can occur quickly.

2.2 Use of Pulse Oximetry in Monitoring Oxygenation

Pulse oximetry is a non-invasive monitoring technique that measures the oxygen saturation of arterial blood (SpO₂). It is a quick and painless way to assess oxygenation status and is widely used in both acute and chronic care settings. A pulse oximeter sensor (often a clip or adhesive probe) is attached to a vascular bed such as a finger, toe, or earlobe; the device emits light at two wavelengths and measures the amount of light absorbed by oxygenated vs. deoxygenated hemoglobin, thus calculating the percentage of hemoglobin saturated with oxygen. Normal SpO₂ is typically 95–100% on room air in healthy individuals. Readings below 90% generally indicate significant hypoxemia and warrant intervention. Nurses use pulse oximetry to continuously or intermittently monitor patients’ oxygenation, for example in hospitalized patients, postoperative units, or during transport. It helps guide decisions about oxygen therapy – for instance, if a patient’s SpO₂ falls below a target range, the nurse may increase the oxygen flow or initiate oxygen therapy. However, it’s important to understand the limitations of pulse oximetry. The device measures oxygen saturation but does not directly measure the partial pressure of oxygen or ventilation (CO₂ levels). It is also influenced by factors that affect perfusion or light absorption: poor peripheral perfusion (due to hypotension, hypothermia, or vasoconstriction) can yield inaccurate or no reading because the pulse signal is weak. Motion artifact (e.g. patient movement, shivering) can cause unreliable readings. Certain skin pigments or nail polish (especially dark or blue/black polish) may interfere with light transmission and should be removed or accounted for. Notably, pulse oximeters can be less accurate in patients with dark skin pigmentation, which has led to health disparities in oxygenation assessment. In fact, studies have shown that pulse oximeters tend to overestimate oxygen saturation in Black patients compared to white patients, potentially masking true hypoxemia. Additionally, abnormal hemoglobins can fool pulse oximetry: for example, in carbon monoxide poisoning, carboxyhemoglobin absorbs light similarly to oxyhemoglobin, so SpO₂ may read falsely high even though the blood’s oxygen-carrying capacity is impaired. Likewise, methemoglobinemia can cause SpO₂ readings to plateau around 85% regardless of true oxygenation. Nurses should be aware of these limitations and use pulse oximetry in conjunction with clinical assessment. If a patient has risk factors for inaccurate oximetry or is showing signs of hypoxia despite a normal SpO₂, arterial blood gas analysis may be warranted. Proper sensor placement and maintenance are also important – using the sensor on the correct body part (finger, toe, ear) as intended and ensuring a good pulse signal improves accuracy. Despite its limitations, pulse oximetry is a valuable tool for early detection of hypoxemia; for example, it can alert nurses to a drop in oxygen saturation before the patient shows obvious signs of distress. By promptly responding to low SpO₂ readings (e.g. repositioning the patient, administering oxygen, or calling for help), nurses can prevent complications of hypoxia.

2.3 Arterial Blood Gas (ABG) Analysis

Arterial blood gas (ABG) analysis provides a direct measurement of oxygenation and ventilation status by analyzing arterial blood. An ABG sample (usually drawn from the radial artery) is tested for partial pressure of oxygen (PaO₂), partial pressure of carbon dioxide (PaCO₂), pH, and bicarbonate (HCO₃⁻) levels, as well as oxygen saturation (SaO₂) from the blood. This test is considered the gold standard for assessing gas exchange and acid-base balance. In the context of oxygenation, the PaO₂ indicates how well oxygen is being transferred from the lungs into the blood. A normal PaO₂ on room air is typically 80–100 mmHg; values below 80 mmHg indicate hypoxemia. ABGs also measure SaO₂, which should correlate with pulse oximetry readings (SpO₂) in most cases. The PaCO₂ reflects ventilation – a high PaCO₂ (>45 mmHg) indicates hypoventilation and respiratory acidosis, while a low PaCO₂ (<35 mmHg) indicates hyperventilation and respiratory alkalosis. pH and HCO₃⁻ help determine if there is an acid-base imbalance and whether it is respiratory, metabolic, or a mix. Nurses often assist with obtaining ABG samples and are responsible for interpreting the results in conjunction with the patient’s clinical picture. For example, a patient with impaired gas exchange might have a low PaO₂ (hypoxemia) and possibly an elevated PaCO₂ if hypoventilation is present. ABG analysis is particularly useful in critical situations (e.g. acute respiratory failure, ARDS, severe asthma exacerbation) to guide interventions like intubation or mechanical ventilation. It can also help differentiate causes of hypoxia – for instance, a low PaO₂ with a normal PaCO₂ might suggest a V/Q mismatch or shunt (as in pulmonary edema or pneumonia), whereas a low PaO₂ with an elevated PaCO₂ suggests hypoventilation (as in opioid overdose). Nurses should be aware that obtaining an ABG is an invasive procedure that can be uncomfortable for the patient and carries a small risk of complications (bleeding, hematoma, nerve injury, or even arterial spasm). After drawing an ABG, pressure must be applied to the puncture site for several minutes to ensure hemostasis. In summary, ABGs provide precise data on oxygenation and ventilation that complement pulse oximetry and clinical assessment. By understanding ABG results, nurses can better evaluate the severity of Impaired Gas Exchange and the effectiveness of interventions (such as oxygen therapy or mechanical ventilation).

3. Maintaining a Patent Airway

3.1 Airway Clearance and Suctioning

Maintaining a patent (open) airway is the first priority in managing any patient with respiratory compromise. An airway can be obstructed by the tongue (especially in an unconscious patient), secretions (mucus, blood, vomit), or foreign objects. Nurses must be prepared to clear the airway and assist with airway management as needed. Suctioning is a key intervention to remove secretions that the patient cannot cough up effectively. There are different types of suctioning based on the route: oropharyngeal (through the mouth), nasopharyngeal (through the nose), and endotracheal/tracheal (through an endotracheal tube or tracheostomy). Oropharyngeal suctioning is used for accessible secretions in the mouth or throat, often in semi-conscious or unconscious patients who cannot swallow or cough them away. A rigid Yankauer suction tip is typically used for oral suctioning to clear saliva, vomit, or blood from the oropharynx. Nasopharyngeal suctioning involves passing a flexible catheter through the nostril into the pharynx to remove secretions from deeper in the upper airway. Both techniques require careful technique: the nurse should apply suction only during withdrawal of the catheter and limit each suction pass to 10–15 seconds to avoid hypoxia and mucosal injury. Before suctioning, hyperoxygenation (e.g. giving the patient 100% oxygen for a few breaths via a bag-mask device or ventilator) is often done to prevent desaturation during the procedure. For patients with an artificial airway (endotracheal or tracheostomy tube), endotracheal suctioning is performed to remove secretions from the trachea and bronchi. This should be done only as needed (prn) rather than on a strict schedule, to minimize trauma and oxygen desaturation. Indications for suctioning include visible secretions in the airway, adventitious breath sounds (e.g. crackles or rhonchi) suggesting retained secretions, increased peak airway pressures on a ventilator, or signs of respiratory distress or coughing that the patient cannot effectively clear. When suctioning an artificial airway, sterile technique is used: the nurse wears sterile gloves, introduces a sterile catheter through the tube without applying suction, then applies intermittent suction while withdrawing the catheter in a rotating motion. Suction pressure should be set appropriately – generally between 80–120 mmHg for adults (lower for children) to avoid excessive负压 that can damage mucosa. Each suction pass is kept brief (<15 seconds), and the patient is allowed to recover with oxygen in between passes. If secretions are thick, humidified air or saline instillation (a small amount of sterile saline into the trachea) may help loosen them, although routine saline instillation before suctioning is not recommended due to risk of hypoxia and infection. Proper suctioning technique is vital: it helps maintain airway patency, improves oxygenation and ventilation, and prevents complications like atelectasis or pneumonia from retained secretions. Nurses must also monitor for complications of suctioning, such as hypoxia (which can be mitigated by pre- and post-oxygenation), dysrhythmias (due to vagal stimulation or hypoxemia), mucosal trauma or bleeding, and bronchospasm. In addition to suctioning, other interventions to maintain airway clearance include encouraging coughing and deep breathing, hydration (to keep secretions thin), and use of humidification or nebulized treatments as ordered. By ensuring a patent airway, nurses lay the groundwork for effective oxygenation and ventilation.

3.2 Airway Positioning and Adjuncts

Proper patient positioning is a simple yet powerful technique to maintain an open airway. In unconscious or unresponsive patients, the tongue can fall back and obstruct the pharynx. The head-tilt, chin-lift maneuver is the standard method to open the airway in a patient without a suspected neck injury: the nurse tilts the head back and lifts the chin, which pulls the tongue forward and clears the airway. If a cervical spine injury is suspected, the jaw-thrust maneuver is used instead (gently displacing the jaw forward without tilting the head) to minimize neck movement. Once the airway is opened, basic airway adjuncts may be inserted. An oropharyngeal airway (OPA) is a curved plastic device placed through the mouth into the pharynx to keep the tongue from blocking the airway; it is used in unconscious patients who do not have a gag reflex (to avoid stimulating vomiting). A nasopharyngeal airway (NPA) is a flexible tube inserted through the nostril into the pharynx and can be used in patients who still have a gag reflex or who cannot tolerate an OPA; it is sometimes called a “nasal trumpet.” These adjuncts help maintain airway patency, especially during bag-mask ventilation or in patients who are obtunded. For patients who are conscious but experiencing respiratory difficulty, positioning them upright can significantly improve breathing. The Fowler’s position (sitting upright at 45–90 degrees) or orthopneic position (leaning forward with arms supported) maximizes chest expansion by reducing pressure of the abdomen on the diaphragm and allowing gravity to assist in lung expansion. This can relieve dyspnea in conditions like pulmonary edema or COPD. Nurses should frequently reposition bedridden patients (at least every 2 hours) to promote airway clearance and prevent atelectasis. In patients with an endotracheal tube or tracheostomy, securing the airway tube and maintaining proper cuff inflation are part of airway management. Regular mouth care and cuff pressure checks are done to prevent complications. In summary, airway management starts with basic maneuvers: positioning the patient to open the airway, using airway adjuncts as needed, and performing suctioning to remove obstructions. These interventions ensure that oxygen can flow into the trachea and lungs without impedance, which is a prerequisite for effective oxygenation.

3.3 Tracheostomy Care and Management

A tracheostomy is a surgical opening into the trachea (through the neck) with an indwelling tube to serve as an airway. Patients with a tracheostomy require specialized nursing care to keep the airway patent and prevent complications. Tracheostomy suctioning is performed as needed (often more frequently than in patients with intact upper airways, because the natural humidification and filtering by the nose are bypassed). Secretions may be thicker and more abundant initially after tracheostomy placement. Nurses must suction the tracheostomy tube whenever the patient has audible or visible secretions, increased work of breathing, or decreased oxygen saturation, taking care to use proper technique and sterile equipment to avoid infection. Humidification is essential for tracheostomy patients – inspired air bypasses the nose, so a heated humidifier or humidified oxygen is used to keep secretions moist and prevent crusting in the tube. Tracheostomy tube care includes cleaning or changing the inner cannula (if present) regularly, and performing dressing changes around the stoma site. The nurse should inspect the stoma and surrounding skin for signs of infection (redness, swelling, pus) or irritation. A sterile half-inch gauze (or specialized tracheostomy dressing) is placed under the flange of the tube to absorb drainage, and kept dry to prevent skin breakdown. The tracheostomy ties that secure the tube should be snug but allow one finger to fit underneath; they may need to be changed if soiled or loose. In acute care settings, tracheostomy tubes often have an inflatable cuff; the nurse must monitor cuff pressure to ensure it is adequate to seal the airway (usually 20–30 cm H₂O) but not so high as to cause tracheal mucosal damage. Cuff deflation (if the patient is not on mechanical ventilation) should be done with caution and only if the patient can protect their airway, as secretions may pool above the cuff and need to be suctioned before deflation. For patients who are able to speak, a speaking valve (Passy-Muir valve) can be placed over the tracheostomy tube to allow air to flow upward through the vocal cords when the patient exhales, enabling speech. This is only done if the patient’s airway is otherwise clear and they can handle secretions. Emergency management of a tracheostomy is also critical knowledge for nurses: if a tracheostomy tube becomes dislodged or blocked, immediate action is needed to re-establish the airway. A tracheostomy obturator and an extra tube of the same size (and one size smaller) should be kept at the bedside at all times. In case of tube dislodgement in the first 72 hours post-surgery (before a tract is well-formed), the nurse may need to manually open the stoma and reinsert the tube or prepare for emergency intubation. After the tract is mature, the nurse can attempt to replace the tube using the obturator. If the tube is blocked (e.g. by a mucus plug), suctioning should be attempted; if that fails, the inner cannula should be removed (if applicable) and the tube changed. Patients with tracheostomies also require swallowing assessment and may need dietary modifications, as the presence of a tracheostomy can affect swallowing function. Speech therapy and respiratory therapy are often involved in their care. Overall, meticulous tracheostomy care by nurses – including suctioning, cleaning, humidification, and monitoring for complications – helps ensure the airway remains patent and the patient can breathe more easily. It also promotes healing of the stoma and reduces the risk of infections like tracheitis or pneumonia.

4. Oxygen Administration and Delivery Devices

4.1 Indications for Oxygen Therapy

Oxygen therapy is the administration of supplemental oxygen at higher concentrations than ambient air (which is 21% O₂) to treat or prevent hypoxemia. The primary indication for oxygen therapy is hypoxemia – whether acute or chronic, in any setting (hospital, home, or emergency). Common clinical situations where oxygen is given include: respiratory distress (e.g. asthma, COPD exacerbation, pneumonia), heart failure with pulmonary edema, shock or trauma, post-anesthesia recovery, and during procedures that may cause hypoxemia. Oxygen is often given during resuscitation (e.g. cardiopulmonary resuscitation) and in conditions like carbon monoxide poisoning (where high-flow oxygen is critical to displace CO from hemoglobin). In hospitalized patients, a common practice is to maintain SpO₂ within a target range (for example, 92–95% for most patients, or 88–92% for some patients with chronic hypercapnic COPD, based on clinical guidelines). If a patient’s oxygen saturation falls below the target, oxygen therapy is initiated or increased. It’s important to titrate oxygen to achieve the desired saturation, as too much oxygen in certain patients can be harmful (for instance, in some COPD patients, high oxygen may blunt the hypoxic drive to breathe or cause hypercapnia). Nurses must follow physician orders or protocols for oxygen therapy, but also use clinical judgment – if a patient is in obvious respiratory distress or has signs of hypoxia, oxygen should be given immediately while awaiting orders. The goal of oxygen therapy is to increase the PaO₂ and oxygen saturation to adequate levels, thereby ensuring sufficient oxygen delivery to tissues. By relieving hypoxemia, oxygen therapy can reduce symptoms like shortness of breath and anxiety, and help prevent complications of tissue hypoxia (such as cardiac arrhythmias or organ dysfunction). However, oxygen is a medication and should be used judiciously: unnecessary high-flow oxygen has been associated with adverse outcomes in some conditions (e.g. increased mortality in acute stroke or myocardial infarction in some studies). Thus, nurses monitor the patient’s response and adjust oxygen levels as needed, weaning to the lowest effective concentration that maintains the target saturation.

4.2 Types of Oxygen Delivery Devices

Oxygen can be delivered via various devices, which are generally classified as low-flow or high-flow systems. The choice of device depends on the patient’s oxygen requirements, the degree of respiratory distress, and the setting. Key differences include the fraction of inspired oxygen (FiO₂) they can provide and whether they meet the patient’s entire inspiratory flow demand.

Low-flow devices do not provide the patient’s entire inspiratory gas flow; thus, the FiO₂ delivered can vary and is diluted by room air. Examples include:

• Nasal cannula (NC): A lightweight tube with two prongs that fit into the nostrils. It is the most common device for low-flow oxygen. Flow rates are typically 1–6 L/min in adults (higher flows may be uncomfortable and cause nasal dryness). The FiO₂ delivered ranges roughly from 24% at 1 L/min to about 44% at 6 L/min. Each liter per minute of oxygen increases FiO₂ by approximately 4% (this is a rough estimate and varies with patient breathing pattern). Nasal cannulas are simple and well-tolerated, allowing the patient to eat, talk, and cough with minimal interference. They are suitable for patients with mild to moderate hypoxemia and those who require long-term oxygen therapy. Humidification is often used with flows >4 L/min to prevent nasal mucosa drying.
• Simple face mask: A mask that covers the nose and mouth, secured with an elastic strap. It delivers higher FiO₂ than a cannula – typically 35–50% at flow rates of 5–8 L/min. Flow must be at least 5 L/min to flush out exhaled CO₂ that collects in the mask; otherwise, rebreathing of CO₂ can occur. Simple masks are used for short-term oxygen therapy in patients with moderate hypoxemia who can cooperate. One drawback is that the mask can be claustrophobic and impedes eating/drinking.
• Non-rebreather mask (NRB): A face mask with a reservoir bag and one-way valves that allow the patient to draw oxygen from the reservoir bag on inspiration and prevents exhaled air from entering the bag. With an oxygen flow of 10–15 L/min, a properly fitting NRB can deliver up to 80–95% FiO₂. The reservoir bag should remain at least half full during inspiration to ensure adequate oxygen supply. Non-rebreather masks are used in situations requiring high-concentration oxygen, such as severe hypoxemia, carbon monoxide poisoning, or during transport of critical patients. They are not meant for long-term use due to discomfort and the need for high oxygen flow.
• Venturi mask: A high-flow delivery system that uses the Venturi principle to mix a precise amount of oxygen with room air, delivering a fixed FiO₂. Different color-coded adapters or jets allow selection of specific FiO₂ levels (e.g. 24%, 28%, 31%, 35%, 40%, 60%) at specific flow rates. For example, a blue adapter might deliver 24% O₂ at 4 L/min, while a green adapter delivers 60% O₂ at 12 L/min. Because Venturi masks provide a known FiO₂ regardless of the patient’s breathing pattern (as long as flow is sufficient), they are very useful for patients with chronic lung disease who require controlled oxygen delivery to avoid suppressing their respiratory drive. The delivered FiO₂ is more consistent even with varying tidal volumes. Venturi masks typically require higher flow rates (4–12 L/min or more) to entrain enough air, so they are considered high-flow in terms of system design, but the total flow may not always meet very high inspiratory demands. They are commonly used for acute exacerbations of COPD to maintain oxygenation without causing excessive CO₂ retention.

High-flow oxygen devices provide a flow of gas that meets or exceeds the patient’s peak inspiratory flow, thereby delivering a more stable FiO₂ and often providing additional benefits like positive airway pressure or humidification. Examples include:

• High-Flow Nasal Cannula (HFNC): A specialized nasal cannula that can deliver heated, humidified oxygen at very high flow rates (up to 60 L/min in adults). HFNC systems have an air/oxygen blender to set FiO₂ from 21% to 100%, and they actively heat and humidify the gas to body temperature and near 100% humidity. Because the flow is high, it washes out the anatomical dead space in the nasopharynx, reduces the work of breathing, and can provide a small amount of positive end-expiratory pressure (PEEP) in the airways. This can improve oxygenation in patients with hypoxemic respiratory failure by keeping alveoli open and reducing the effort to inhale room air between breaths. HFNC has become popular in recent years for conditions like acute hypoxemic respiratory failure (e.g. pneumonia, ARDS) as it can sometimes avoid the need for intubation by improving oxygenation and patient comfort. It is also used in post-extubation patients to prevent reintubation. The heated humidification makes it more comfortable than standard oxygen at high flow and helps keep secretions thin. Nurses managing HFNC must monitor the flow and FiO₂ settings, ensure the humidifier is functioning and filled with sterile water, and observe the patient’s respiratory status closely – HFNC is typically managed in monitored settings (ICU or step-down units) because if the patient does not improve, prompt intubation may be needed. One advantage is that patients on HFNC can still talk, eat (with flow temporarily reduced), and are often more comfortable than with a tight-fitting mask.
• Noninvasive Positive Pressure Ventilation (NPPV): While not an oxygen delivery device per se, NPPV (such as BiPAP or CPAP) is often used in conjunction with oxygen to improve oxygenation and ventilation. NPPV delivers air (usually with added oxygen) through a mask or nasal pillows under positive pressure, which can help recruit alveoli and increase oxygenation (CPAP provides continuous positive pressure, BiPAP provides inspiratory and expiratory pressure support). NPPV is indicated for acute respiratory failure, especially in COPD exacerbations or cardiogenic pulmonary edema, to avoid intubation. Oxygen can be blended into the circuit to achieve the desired FiO₂. Nurses caring for patients on NPPV must ensure a good mask seal, monitor the patient’s respiratory effort and oxygen saturation, and watch for complications like skin breakdown from the mask or gastric distension.
• Bag-Mask Device: This is a hand-held resuscitation bag attached to a face mask and oxygen source (often 10–15 L/min O₂). It is used to manually ventilate a patient in respiratory arrest or during anesthesia induction. With an oxygen reservoir, a bag-mask can deliver nearly 100% FiO₂. Proper technique (head-tilt/chin-lift and mask seal) is required to effectively ventilate the patient. This device is critical in emergency airway management.

Each oxygen delivery device has its indications, advantages, and limitations. Nurses should be proficient in setting up and managing these devices. For example, with a nasal cannula, the nurse should ensure the prongs are correctly placed in the nostrils and the tubing is securely attached to the oxygen flowmeter; with a Venturi mask, the nurse must use the correct adapter for the prescribed FiO₂ and ensure the flow rate matches the adapter’s requirement. High-flow systems like HFNC require more setup (blender, humidifier, heated tubing) but can greatly improve patient comfort and oxygenation. In all cases, the nurse monitors the patient’s response to oxygen therapy – checking oxygen saturation, respiratory rate, and clinical status – and adjusts the device or notifies the provider if the patient is not improving. Oxygen therapy is often titrated based on these assessments: for instance, if a patient on 2 L/min NC has SpO₂ 98%, the flow may be decreased to 1 L/min or discontinued if appropriate; conversely, if a patient on 6 L/min NC is saturating 89%, the nurse may switch to a non-rebreather mask or initiate HFNC to provide higher FiO₂ and consult the physician. By selecting the right oxygen delivery device and optimizing its use, nurses help ensure the patient receives adequate oxygen while minimizing discomfort and complications.

4.3 Nursing Responsibilities in Oxygen Therapy

Nurses play a central role in the administration and monitoring of oxygen therapy. Key responsibilities include:

• Assessing Need and Monitoring Response: Nurses continuously assess the patient’s respiratory status and oxygenation (through clinical signs, SpO₂, and ABGs as needed) to determine if oxygen therapy is indicated and if it is effective. They titrate oxygen flow or change devices to maintain the target saturation range as ordered or per protocol. For example, if a patient’s SpO₂ drops during activity, the nurse may increase the oxygen flow temporarily and then wean back when the patient stabilizes.
• Correct Device Setup and Use: Nurses ensure the oxygen delivery device is properly set up and fitted. This includes checking that the oxygen flowmeter is correctly attached to a source (wall outlet or tank), the flow rate is set as prescribed, and the device is applied to the patient correctly (prongs in nose for cannula, mask sealed around face, etc.). For high-flow systems, nurses verify the humidifier is filled and functioning and that the blender is set to the correct FiO₂. They also use humidification for dry oxygen when appropriate (e.g. for flows >4 L/min via cannula or with masks for prolonged use, and always for high-flow systems) to prevent mucosal drying and irritation.
• Patient Education and Comfort: Nurses educate the patient and family about the purpose of oxygen therapy and how to use the equipment safely. This includes explaining that oxygen is a medication that helps breathing, demonstrating proper placement of the device, and teaching the patient not to adjust the flow without consulting staff. For patients on long-term home oxygen, nurses (or respiratory therapists) provide training on equipment use, safety (e.g. no smoking around oxygen), and signs of hypoxemia to report. Comfort measures are also important: for instance, applying water-based lubricant to the nostrils for cannula use, or using mask liners or padding to prevent pressure sores with face masks. Ensuring the patient is comfortable can improve compliance with oxygen therapy.
• Safety Precautions: Oxygen is non-flammable but supports combustion; thus, safety around oxygen is paramount. Nurses must post “No Smoking – Oxygen in Use” signs in the patient’s room. They ensure that electrical equipment in the room is in good working order (to avoid sparks) and that patients and visitors do not smoke or use open flames near oxygen. Oxygen tanks should be secured to prevent tipping and stored in well-ventilated areas. When using oxygen cylinders, nurses monitor the tank pressure and have a reserve tank available to avoid running out. In home settings, patients are educated about fire safety with oxygen. Nurses also ensure that oxygen tubing is properly routed (not under furniture or across walkways) to prevent tripping hazards and to avoid kinking which can obstruct flow.
• Documentation and Communication: Nurses document the type of oxygen device, flow rate or FiO₂, and the patient’s response (e.g. SpO₂ readings, respiratory rate, any changes in symptoms) in the medical record. If the patient requires changes in oxygen therapy (escalation or weaning), the nurse communicates with the physician or advanced provider to update orders as needed. In acute situations, if a patient’s condition deteriorates despite oxygen therapy (e.g. SpO₂ continues to fall or the patient’s work of breathing increases), the nurse must promptly notify the provider and be prepared to assist with more advanced interventions (like NPPV or intubation).

By fulfilling these responsibilities, nurses ensure that oxygen therapy is both effective and safe. Properly managed oxygen therapy can significantly improve a patient’s oxygenation and relieve hypoxemic symptoms, contributing to better outcomes in a variety of conditions. Nurses remain vigilant, however, to avoid potential complications of oxygen therapy, such as oxygen toxicity (with prolonged high FiO₂) or carbon dioxide retention in at-risk patients, by adhering to prescribed parameters and monitoring the patient closely.

5. Chest Physiotherapy Techniques

Chest physiotherapy (CPT) refers to a group of techniques aimed at improving ventilation and clearing secretions from the lungs. These techniques are often used in patients with excessive or thick pulmonary secretions that they are unable to cough up effectively, such as those with pneumonia, COPD, cystic fibrosis, bronchiectasis, or after major surgery (especially abdominal or thoracic surgery). The main goals of chest physiotherapy are to loosen mucus from the airways, move secretions toward the larger airways where they can be coughed out or suctioned, and improve lung expansion. By doing so, CPT helps prevent complications like atelectasis and pneumonia, and improves oxygenation and ventilation. The classic components of chest physiotherapy include chest percussion, vibration, and postural drainage, often used in combination. In recent years, adjunct devices and techniques (such as incentive spirometry, positive expiratory pressure devices, and high-frequency chest wall oscillation) have been developed, but traditional CPT remains an important nursing intervention in many settings.

5.1 Chest Percussion and Vibration

Chest percussion is the technique of rhythmically clapping on the chest wall over the lung segments that are congested, to mechanically dislodge secretions from the bronchial walls. The nurse or respiratory therapist cups their hands (forming a hollow cup) and rapidly claps on the patient’s chest in a rhythmic manner. This creates a vibration and pressure wave that loosens mucus. Percussion is applied over each lung lobe area for 1–2 minutes per area (or longer, up to 5 minutes per area in some protocols) while the patient breathes slowly and deeply. It is important to percuss only over bony areas (ribs) and to avoid the spine, sternum, breasts, or any area of tenderness or injury. A layer of clothing or a thin towel may be placed between the hand and skin to increase comfort. Vibration is often done after percussion on each area. During vibration, the nurse places the palms of both hands flat on the patient’s chest over the target area and applies a fine, shaking pressure during exhalation. The vibrations are synchronized with the patient’s exhalation – the nurse tenses and relaxes their arm and shoulder muscles rapidly while the patient exhales, effectively “shaking” the secretions loose. Vibration can also be done with a mechanical vibrator device. The purpose of vibration is to further mobilize mucus and assist the patient in coughing it up. After percussion and vibration of a given area, the patient is encouraged to cough or huff cough to expel the loosened secretions. This sequence (percuss → vibrate → cough) is repeated for each lung segment that needs drainage. In general, percussion and vibration are performed for about 5 minutes per segment, but the duration may vary based on the patient’s tolerance and the amount of secretions. These techniques are usually done 2–4 times daily, or more frequently if the patient has a large amount of secretions. Nurses must use proper technique: the clapping should be firm but not painful, and the vibration should be applied only during exhalation (not during inhalation). It’s important to monitor the patient during CPT – if the patient becomes short of breath, dizzy, or experiences pain, the procedure should be paused. Patients with certain conditions should not receive percussion or vibration: for example, those with fractures (rib or spine), osteoporosis (risk of fracture), lung cancer, pulmonary embolism, or untreated pneumothorax. In such cases, alternative airway clearance methods may be used. Overall, chest percussion and vibration are effective in loosening secretions in many patients, especially children with cystic fibrosis or adults with pneumonia, allowing them to cough up phlegm and breathe more easily.

5.2 Postural Drainage

Postural drainage involves positioning the patient in specific postures so that gravity assists in draining secretions from different lung lobes into the central airways. Each position is intended to target a particular lobe or segment of the lung. For example, to drain the lower lobes, the patient may be placed in a head-down (Trendelenburg) position on their side or abdomen; for the upper lobes, the patient may be upright or leaning forward. Pillows, wedges, or tilt tables can be used to achieve the required angles. The nurse will typically have the patient assume each drainage position for 5–10 minutes (or as tolerated) while percussion and vibration are applied to that area. After the specified time, the patient is encouraged to cough to bring up the drained secretions. The number of positions needed depends on which lung segments are involved – often 3–4 positions are done in one session, covering the right and left lung bases, lingula, and upper lobes as appropriate. Postural drainage is usually performed in the morning (to clear overnight secretions) and at bedtime, and sometimes after meals (though not immediately after eating to avoid nausea or aspiration). The Trendelenburg position (head down) can be uncomfortable for some patients and may not be tolerated in those with cardiovascular issues (it can increase intracranial pressure and venous return). In such cases, a modified position (less steep tilt or even just side-lying without steep head-down) may be used, trading off some drainage effectiveness for patient safety. After positioning, the patient should be helped back to a comfortable position (usually Fowler’s) and mouth care provided if they expectorated sputum. Nurses should monitor the patient during postural drainage for signs of distress (e.g. shortness of breath, palpitations, or discomfort). They also observe and record the amount, color, and consistency of sputum produced. Postural drainage, combined with percussion and vibration, is a powerful tool for airway clearance. It is commonly used in cystic fibrosis clinics and in patients with bronchiectasis or pneumonia who have copious secretions. Studies have shown that chest physiotherapy including postural drainage can improve outcomes such as reducing hospitalizations and improving lung function in patients with chronic lung diseases. However, in some acute settings, postural drainage is less frequently used due to patient instability or the availability of other techniques, but it remains an important option in the nurse’s toolkit for airway clearance.

5.3 Nursing Considerations and Contraindications

Before performing chest physiotherapy, nurses must consider the patient’s condition and any contraindications. Contraindications to percussion and postural drainage include: recent myocardial infarction (due to risk of arrhythmia or impaired coronary perfusion with positioning), unstable spinal fractures or spinal surgery (cannot safely position or percuss), rib fractures or flail chest (percussion could cause pain or further injury), untreated pneumothorax (percussion could worsen it or positioning could be dangerous), pulmonary embolism (percussion might dislodge clot), severe osteoporosis (risk of rib fracture with percussion), and lung cancer (especially if in an area to be percussed, due to risk of tumor trauma or hemorrhage). Patients who are hemodynamically unstable or have increased intracranial pressure should not be placed in Trendelenburg position for postural drainage. In such cases, alternative methods like directed coughing, incentive spirometry, or mechanical devices (oscillatory PEP, etc.) may be used. Nurses should also be cautious with patients who have a history of esophageal varices or recent hemoptysis (coughing up blood), as percussion could potentially exacerbate bleeding. Patient preparation is key: the nurse should explain the procedure to the patient, obtain consent, and ensure the patient has used any prescribed bronchodilator inhaler beforehand (as ordered), since a bronchodilator can make CPT more effective by opening airways. It’s generally recommended to schedule CPT sessions at least 1–2 hours after meals to reduce the risk of vomiting or aspiration. The nurse should also provide pain medication if needed, because coughing and percussion can be uncomfortable, especially in postoperative patients – adequate analgesia will allow the patient to cough more effectively. During the procedure, the nurse observes the patient’s respiratory status, oxygen saturation, and comfort level. Supplemental oxygen can be applied during CPT if the patient desaturates. After CPT, the nurse assists the patient to a comfortable position and offers mouth care. The amount and character of sputum expectorated should be recorded. Documentation may include the patient’s tolerance of the procedure, any changes in breath sounds after CPT, and the volume of sputum (e.g. “30 mL yellow sputum expectorated during postural drainage”). It’s also important to evaluate the effectiveness of CPT: improved breath sounds (fewer crackles/rhonchi), easier breathing for the patient, and increased sputum production indicate that the therapy is helping clear secretions. If the patient is not responding (no sputum, continued adventitious sounds, increased respiratory distress), the nurse should reassess the approach and consult with the healthcare team – perhaps a different technique or adjunct is needed. In summary, chest physiotherapy is a valuable nursing intervention when used appropriately, but nurses must use clinical judgment regarding its timing and technique for each patient. When done correctly and safely, CPT can significantly improve airway clearance and oxygenation, especially for patients with conditions that impair their natural ability to cough up secretions.

6. Chest Drainage Systems: Principles and Care

A chest drain (chest tube) is a flexible plastic tube inserted through the chest wall into the pleural space or mediastinum to remove air, fluid, or blood, and to re-expand the lung. Chest tubes are used to treat conditions like pneumothorax (air in the pleural space), hemothorax (blood in the pleural space), pleural effusion, empyema (pus in pleural space), or after thoracic or cardiac surgery to remove any accumulating fluid or air. The chest tube is connected to a closed drainage system that allows fluid/air to exit the pleural space but prevents anything from entering. Proper nursing care of chest drainage systems is essential to ensure they function correctly and to detect complications early.

6.1 Indications and Types of Chest Drains

Indications: Chest tubes are indicated when there is an accumulation of air or fluid in the pleural space that is causing lung collapse or respiratory compromise. Common indications include: traumatic pneumothorax or hemothorax, tension pneumothorax (after initial decompression with a needle, a chest tube is placed), spontaneous pneumothorax, large pleural effusions (especially if causing dyspnea), empyema that requires drainage, or postoperatively after lung surgery, heart surgery, or esophageal surgery to evacuate any air or blood that accumulates. By removing these substances, the chest tube allows the lung to re-expand and restores negative pressure in the pleural space. Types of chest tubes: Chest tubes come in various sizes (Fr diameters) – larger tubes (32–40 Fr) are used for removing blood or thick fluid, while smaller tubes (14–28 Fr) may be sufficient for pneumothorax or serous fluid. In some cases, smaller pigtail catheters (soft, coiled drains inserted via a needle) can be used for pneumothorax or effusion, especially in stable patients, as they are less invasive and more comfortable. The chest tube is inserted by a physician or other trained provider, usually at the bedside under local anesthesia (and sometimes conscious sedation). The insertion site is typically in the mid-axillary line, around the 4th–5th intercostal space for fluid (to drain the lower pleural space) or a more anterior site (2nd intercostal space mid-clavicular line) for pneumothorax (since air rises). Once inserted, the tube is secured to the skin with sutures and covered with an airtight dressing. The distal end of the tube is connected to a chest drainage system. Chest drainage systems are usually disposable, self-contained units that have several chambers: a collection chamber to collect fluid or blood, a water seal chamber that acts as a one-way valve (allowing air to exit from the pleural space but not re-enter), and a suction control chamber (if suction is applied) to regulate the amount of negative pressure. In a traditional wet suction system, the suction control chamber is filled with sterile water to a certain level (e.g. 20 cm H₂O) and connected to a vacuum source; the bubbling in this chamber indicates suction is active (though vigorous bubbling can evaporate the water quickly, so it must be monitored). Newer systems use a dry suction control mechanism (a dial and float valve) which does not require water and may reduce evaporation and noise. The water seal chamber typically has a water level of 2 cm; it should oscillate (tidaling) with respiration (rising on inspiration, falling on expiration) if the tube is patent and in the pleural space, indicating that the lung is attempting to re-expand. If tidaling stops, it could mean the lung has re-expanded fully or the tube is blocked. Air leaks (from the pleural space) will cause constant or intermittent bubbling in the water seal chamber; the amount of bubbling can indicate the size of the leak. Chest drainage systems are usually kept below the level of the patient’s chest (often hung on the bed frame) to facilitate drainage by gravity and to prevent fluid from backflowing into the pleural space. In summary, chest tubes are placed to re-establish normal intrapleural pressures and lung expansion, and they are connected to a closed drainage system that safely removes air and fluid from the chest.

6.2 Nursing Management of Chest Tubes

Nurses have several key responsibilities in the care of a patient with a chest tube:

• Monitoring the System and Drainage: The nurse must frequently inspect the chest drainage unit to ensure it is functioning properly. This includes checking that the tubing is not kinked, clamped, or dependent (hanging in loops which can trap fluid). The system should be kept upright and below the patient’s chest at all times. The nurse observes the water seal chamber for tidaling – the water level should rise with inspiration and fall with expiration in spontaneously breathing patients (or the opposite in mechanically ventilated patients). The presence of tidaling confirms that the chest tube is patent and in the pleural space; if tidaling ceases, it may indicate the lung has re-expanded or there is a blockage in the tube. The nurse also notes any bubbling in the water seal: intermittent bubbling during expiration or coughing is normal if there is an air leak (for example, after a pneumothorax), but continuous bubbling may indicate an air leak in the system (such as a loose connection or crack in the tubing) or a persistent large leak from the lung. The nurse should attempt to identify the source of continuous bubbling by momentarily clamping the tubing (with physician approval) at various points to see if it stops – if clamping at the patient end stops bubbling, the leak is likely in the patient’s lung; if not, it may be in the tubing or system. The collection chamber is monitored for the amount, color, and character of drainage. The nurse records output at regular intervals (e.g. every shift or more frequently in the immediate postoperative period). A sudden increase in drainage (for example, >100 mL/hour of bloody fluid in a postoperative patient) should be reported to the physician promptly, as it could indicate active bleeding. Any change in drainage characteristics (such as a sudden gush of fluid, or drainage that becomes cloudy or foul-smelling) should be noted.
• Assessing the Patient: The nurse performs ongoing respiratory assessments of the patient with a chest tube. This includes monitoring vital signs (especially respiratory rate, oxygen saturation, and heart rate), auscultating lung sounds on both sides (the affected side should have improved breath sounds as the lung re-expands), and observing the patient for signs of respiratory distress. The insertion site is inspected for signs of infection (redness, swelling, pus) or subcutaneous emphysema (air under the skin, felt as a crackling sensation). The dressing should be kept occlusive and dry; if it becomes wet or soiled, it should be changed using sterile technique. The nurse also assesses the patient’s pain level – chest tube insertion and the presence of the tube can be very painful, so analgesia is important to ensure the patient can breathe and cough effectively. Splinting the chest with a pillow during coughing can help reduce pain. If the patient is on mechanical ventilation, the nurse monitors ventilator parameters and may notice changes like decreased peak inspiratory pressures if the lung re-expands.
• Maintaining Tube Patency and Position: To keep the chest tube patent, the nurse can gently milk or strip the tubing if ordered or if there is evidence of clot or obstruction, but routine stripping (vigorous milking) is generally avoided because it can generate very high negative pressures in the pleural space and cause tissue injury or bleeding. Instead, if the tubing has clots, the nurse may “milk” it by squeezing the tubing just above the clot and sliding the clot down toward the drainage chamber in a controlled manner, only if clinically indicated. Most protocols prefer to let gravity drain the blood unless clots are obstructing flow. The chest tube is secured with sutures and tape, but the nurse should ensure it is not pulled or twisted. If the patient is ambulatory or being moved, the tube should be clamped only if necessary and for the shortest time (clamping a chest tube can lead to tension pneumothorax if air continues to accumulate). In general, chest tubes are not clamped without specific orders, except during transport if the drainage system cannot be kept below the chest, or when changing the drainage unit. The nurse keeps a padded clamp at the bedside as an emergency measure (for example, if the drainage system breaks or cracks, the tube can be clamped near the insertion site to prevent air from entering the pleural space until a new system is attached). However, clamping should be done with caution and only when necessary, as prolonged clamping can be dangerous. If the chest tube accidentally dislodges from the chest, the nurse must immediately cover the insertion site with an occlusive dressing (e.g. petroleum gauze and tape on three sides) to prevent air from rushing in (a three-sided dressing allows air to escape if a tension pneumothorax develops, while preventing air entry). The physician should be notified immediately, as the patient may need the tube reinserted or at least a thorough assessment.
• Chest Tube Removal and Aftercare: When the lung is re-expanded and drainage has ceased or is minimal, the physician will remove the chest tube. Nurses often assist with chest tube removal: ensuring consent is obtained, preparing supplies (sterile dressing, suture removal kit), and coaching the patient (often to perform a Valsalva maneuver or a breath-hold on expiration to minimize air entry when the tube is pulled). After removal, the nurse applies an occlusive dressing and monitors the patient closely for any signs of recurrence of pneumothorax (shortness of breath, chest pain, decreased breath sounds, tachycardia). Chest X-ray is usually done after removal to confirm the lung remains expanded. The nurse continues to monitor the site for drainage or infection in subsequent days.

By carefully managing chest drainage systems and observing the patient, nurses help ensure that chest tubes effectively re-expand the lung and that complications are caught early. Proper nursing care of chest tubes can reduce the risk of infection, prevent tube dislodgement or blockage, and contribute to a smoother recovery for the patient.

6.3 Complications and Emergency Interventions

While chest tubes are generally safe and effective, several complications can occur, and nurses must be prepared to recognize and manage them:

• Tension Pneumothorax: This is a life-threatening condition where air accumulates in the pleural space under pressure, collapsing the lung and shifting the mediastinum to the opposite side. It can occur if a chest tube is blocked or kinked, or if a large air leak continues but the chest tube is not adequately evacuating air. Signs include severe respiratory distress, tracheal deviation away from the affected side, jugular venous distension, hypotension, and absent breath sounds on the affected side. If tension pneumothorax is suspected (especially while awaiting chest tube insertion in an emergency), immediate needle decompression is done. In a patient with an existing chest tube, if tension is suspected due to tube malfunction, the nurse should unclamp the tube (if it was clamped) and check for any obstruction. If the tube is blocked by a clot, the nurse may milk it to clear the clot, but if the situation is critical, the physician may need to insert a new tube. Nurses should never clamp a chest tube without indication, as this can precipitate tension pneumothorax.
• Continued Air Leak: A persistent air leak (bubbling in the water seal) can indicate that the lung is not sealing (for example, a large bronchopleural fistula). If the leak does not resolve over time, it may require surgical intervention. The nurse monitors the amount of bubbling and reports if it increases or if the patient’s condition worsens. In some cases, suction may be increased or a Heimlich valve (a one-way flutter valve) may be used if the patient is being discharged with a small persistent pneumothorax.
• Hemorrhage: Excessive bleeding into the pleural space can occur, for instance after trauma or surgery. The nurse monitors the chest tube output closely; if drainage is >150–200 mL/hour or if the patient shows signs of shock (tachycardia, hypotension, pallor), this suggests significant hemorrhage. The nurse should notify the physician immediately and prepare for possible blood transfusion or surgical exploration (thoracotomy) to control bleeding.
• Infection: Any invasive procedure carries infection risk. A chest tube can lead to local infection at the insertion site or deeper infections like empyema or pneumonia. The nurse observes for fever, increased white blood cell count, purulent drainage from the site, or foul-smelling drainage. Prophylactic antibiotics are sometimes given if the tube is inserted in a non-sterile field (e.g. trauma) but not routinely otherwise. The nurse ensures strict sterile technique when performing dressing changes and when connecting or disconnecting the system. If infection is suspected, cultures of the drainage may be taken and antibiotics started.
• Subcutaneous Emphysema: This is the presence of air in the subcutaneous tissues, often around the insertion site or extending to the neck and face. It feels like rice crispies under the skin. A small amount is common after chest tube insertion, but extensive subcutaneous emphysema can indicate that air is leaking from the pleural space into the soft tissues (perhaps due to a poor seal around the tube or a large air leak). The nurse should report expanding subcutaneous emphysema, as it can sometimes impair ventilation if it’s severe in the neck or interfere with circulation. Usually, once the lung re-expands and the air leak is resolved, the subcutaneous air is reabsorbed.
• Tube Dislodgement or System Breakage: If a chest tube comes out or the drainage system cracks, air can freely move in and out of the pleural space (open pneumothorax) or the system can lose its seal. As mentioned, if the tube dislodges, the nurse must immediately cover the site with an occlusive dressing (taped on three sides) and call for help. If the drainage tubing disconnects from the system, the nurse can submerge the end of the tube in a cup of sterile water (to create a water seal) temporarily while setting up a new drainage unit. If the system cracks or leaks, the nurse clamps the tube near the patient (if safe) and replaces the system. These situations require prompt action to prevent tension pneumothorax or further lung collapse.
• Pain and Patient Discomfort: Chest tubes can be very painful. If the patient is in severe pain, it can lead to shallow breathing and ineffective cough, which in turn can cause atelectasis or retained secretions. The nurse should ensure the patient has adequate analgesia (often IV opioids in the acute period, or intercostal nerve blocks in some cases). Pain management is not only for comfort but also for proper respiratory function.

In all cases of complications, clear communication with the physician and rapid intervention are key. Nurses should also educate the patient with a chest tube about what to expect – for example, warning them not to pull on the tube, how to splint the tube site when coughing, and signs to report (like increased shortness of breath or pain). By being vigilant and prepared, nurses can manage most chest tube complications effectively, ensuring patient safety and optimal outcomes.

7. Best Practices and Global Perspectives

Effective management of oxygenation and airway issues is a cornerstone of nursing care worldwide. Different healthcare settings and regions may have varying resources, but the underlying principles remain the same: maintain a patent airway, ensure adequate oxygenation, and prevent complications. In high-resource settings (such as modern ICUs in developed countries), nurses have access to advanced tools like pulse oximetry, capnography, high-flow oxygen, and mechanical ventilators, which greatly assist in monitoring and supporting oxygenation. For example, continuous pulse oximetry monitoring has become standard in many hospitals to catch hypoxemia early. However, studies have shown that over-reliance on alarms can lead to alarm fatigue – in one observation, 90% of pulse oximeter alarms were false or non-actionable. This has prompted best practice recommendations to optimize alarm settings and not substitute oximetry for clinical assessment. In low-resource settings or developing regions, nurses often must be even more resourceful. Oxygen may be a scarce commodity, and advanced devices like ventilators may not be available. In such cases, emphasis is placed on basic interventions: positioning, airway clearance, and efficient use of limited oxygen. For instance, in areas with high tuberculosis prevalence and limited oxygen tanks, nurses prioritize oxygen for the most hypoxemic patients and use techniques like postural drainage and percussion to improve oxygenation without supplemental O₂. The World Health Organization (WHO) has published guidelines on oxygen therapy in low-income countries, stressing the importance of having oxygen available in all health facilities and training healthcare workers in its use, as access to oxygen can significantly reduce mortality from conditions like severe pneumonia in children. Another global perspective is the recognition of health disparities in oxygenation monitoring – as noted, pulse oximeters can be less accurate in people with darker skin, leading to potential delays in treatment. Nursing organizations in the U.S. and Europe are now advocating for improved device calibration and increased awareness among nurses to avoid relying solely on oximetry readings in assessing hypoxia, especially in patients of color. Evidence-based practice is a common theme across regions: nurses are encouraged to follow the latest research and clinical practice guidelines. For example, the American Association for Respiratory Care (AARC) and other bodies regularly update guidelines on suctioning, chest physiotherapy, and ventilator weaning, which nurses use to inform their care. In the era of COVID-19, global collaboration led to rapid sharing of best practices for managing hypoxemic respiratory failure – nurses worldwide learned to use high-flow nasal cannula, proning of patients, and noninvasive ventilation effectively to prevent intubation when possible. Patient education is another best practice that transcends borders: empowering patients with chronic respiratory conditions (like COPD or asthma) to manage their oxygenation at home through proper use of oxygen equipment, inhalers, and airway clearance techniques can greatly improve outcomes and quality of life. Nurses often lead these educational efforts, whether in a clinic in New York or a community health center in rural India. Finally, a global best practice in critical care is the concept of the “ABCs” – Airway, Breathing, Circulation – which reminds healthcare providers of the priority of securing the airway and ensuring adequate breathing (oxygenation and ventilation) before addressing other issues. This simple mnemonic is ingrained in nursing and medical training worldwide and underscores the fundamental importance of oxygenation in patient care.

8. Conclusion

Alterations in oxygenation are a common challenge in nursing care, arising from a wide range of acute and chronic conditions. The ability to assess, intervene, and educate in the realm of oxygenation is a critical skill for nurses. In this comprehensive overview, we have explored how the process of oxygenation can be impaired and how nurses can recognize those impairments through clinical assessment, pulse oximetry, and ABG analysis. We discussed the nursing diagnosis of Impaired Gas Exchange and the importance of addressing it promptly to prevent complications. A patent airway was identified as the first priority, and we reviewed techniques like suctioning, positioning, and tracheostomy care that nurses use to ensure air can flow freely into the lungs. Oxygen therapy emerged as a cornerstone intervention for hypoxemia, with various delivery devices suited to different patient needs – from the simple nasal cannula to advanced high-flow systems. We also highlighted the nurse’s role in safely administering oxygen and monitoring its effects. Chest physiotherapy techniques, including percussion, vibration, and postural drainage, were examined as methods to assist patients in clearing secretions and improving ventilation, with important considerations for their safe application. Finally, we delved into chest drainage systems, explaining their purpose and the meticulous care required to manage chest tubes and detect complications. Throughout each section, the emphasis was on evidence-based practice and patient-centered care – using the latest guidelines and tailoring interventions to the individual patient’s condition. By mastering these concepts and skills, nurses can make a profound difference in patient outcomes. Whether it’s the rapid action to open an airway in an emergency, the careful titration of oxygen to avoid complications, or the consistent performance of chest physiotherapy that helps a patient breathe easier, each nursing intervention contributes to optimizing oxygenation. In essence, nurses are the frontline guardians of oxygenation for their patients. Their vigilance and expertise in maintaining airway patency, ensuring adequate oxygen supply, and facilitating gas exchange can mean the difference between life and death, or between a full recovery and lingering complications. As healthcare continues to evolve, nurses will undoubtedly encounter new technologies and protocols in the field of oxygenation – from improved monitoring devices to novel ventilation strategies. The underlying principles, however, will remain the same: to keep the airways open, the blood oxygenated, and the patient safe and comfortable. By staying informed and practicing competently, nurses can confidently meet the challenges of oxygenation alterations and provide the highest quality of care to those in their charge.