RESPIRATORY

Anatomy & Physiology

UPPER AIRWAY
a. nose b. pharynx c. larynx

LOWER AIRWAY
a. trachea b. bronchi c. bronchus d. lungs

NOSE-externally, a framework of bone& cartilage

PHARYNX-muscular passageway "THROAT"
LARYNX-"voice box",connects upper to lower airway
Major FXN: a. protection of airway b. respiration c. phonation
TRACHEA-11-13 cm in length, 1.5-2.5 cm in diameter
BRONCHI divided into:
a.RIGHT mainstem-3 lobes; 10 segments, larger & straighter
b.LEFT mainstem-2 lobes (upper &lower),8 segments

BRONCHIOLE-transition to alveolar epithelium

*respiratory epitehelium
-ciliated pseudostratified with goblet cells
*alveolar epithelium
-simple squamous; important for gas exchange

LUNGS -main organ of respiration

a. Respiration-process where exchange happen between atmosphere & cells of the body
b. Ventilation-movement of air in and out of airways; replenishing oxygen and removing CO2

ALVEOLI-functional cellular unit of lung where alveolar gas exchange happens

CHEST WALL
Includes :a. rib cage b. intercostal muscles d.diaphragm
-EXT ICS MUSCLES-raise ribcage during inspiration to increase size of thoracic cavity
-INT ICS MUSCLES-pull rib down & play a role in forced expiration
-DIAPHRAGM-major muscle of ventilation

CONTROL OF RESPIRATION

a. Voluntary
B. Involuntary-via respiratory center a. pons b. medulla

1. CO2-mainly stimulate respiratory center to increase strength in both inspiration & expiration
-very potent ACUTE effect in controlling respiration BUT WEAK CHRONIC EFFECT
2. Decreased Oxygen-"relative hypoxemia"
-pO2"=30-60 mmHg

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 ASSESSMENT:
a.Health History-focus on chief complaint
Presenting problems:
-cough-duration, frequency, type, productive/non-productive
-dyspnea-difficuty of breathing
-chest pain a.sharp b. stabbing c.increase with movement & deep breathing
- hemoptysis-expectoration of blood
b.Lifestyle
-smoking-slows ciliary action & decreases mucus clearance from lungs
-alcohol intake-large amount of alcohol depress gag reflex-->aspiration
-occupation
- environmental exposure
c.Nutrition/Diet-intake of fluid for 24 hours & intake of vitamin supplements

d.Past Medical History-immunizations & results of tuberculin testing

PHYSICAL EXAMINATION
a.Inspection -configuration of the chest
*normal:transverse 2x AP diameter
**increase APT diameter-->COPD
-presence of cyanosis
-respiration (rate, regularity, effort)
-presence of clubbing
*long standing hypoxia such as fibrosis, lung cancer, COPD

b.Palpation -tracheal position for masses & displacement

-excursion (symmetrical)
-fremitus:transmission of vibration of air movement in chest wall
-compare intensity of vibration produced
-increase: *pneumonia *pulmonary fibrosis *tumor
-decrease *COPD *pneumothorax *pleural effusion

c.Percussion-sounds produced by tapping

-look for resonance over normal lung tissue
-hyperresonance-->COPD -dullness-->pneumonia, cancer
d.Auscultation Breath Sounds
Normal:
*Vesicular- peripheral lung fields & small bronchioles & alveoli
*Bronchial- trachea & larynx
*Bronchovesicular- major bronchi with few alveoli, posteriorly, between scapulae, anteriorly, upper
sternum
Abnormal Sounds:
-wheezes-musical sound when air passes in a partially obstructed or narrowed airways during

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EXPIRATION
-stridor-harsh sound when air passes in a partially obstructed or narrowed UPPER airways
DURING INSPIRATION
-rales/crackles-sound produced with opening of small airways & alveoli

Laboratory/Diagnostic Test
Arterial Blood Gases-measures the following:
a. base excess & deficit b. O2 (saturation & content,PaO2) c. CO2 (total & PaCO2)

Nursing Care:-place bandage over puncture site

-maintain pressure with 2 fingers for 5 mins over radial & brachial; 10 mins over femoral sites
-rotate specimen gently in test tube to mix heparin with blood
-place in ice water till it can be analyzed

ABG ANALYSIS Values:

pH 7.35-7.45 pCO2 35-45 HCO3 22-26 paO2 80-100 mmHg
1.Assess the degree of hypoxemia-->decreased O2 in arterial blood
a.mild <80 b.moderate <60 c.severe <40
Tx: O2 therapy
2.Assess ventilatory state
-->paCO2 it evaluates efficiency of alveolar ventilation
Alveolar HYPOventilation= >50 mmHg due to CO2 retention
Alveolar HYPERventilation =<30 mmHg due to over breathing
3.Assess acid-base imbalance
Thoracentesis
-needle is inserted in chest wall into the pleural space to obtain specimen for diagnostic purposes,
removal of accumulated fluid or air & instill medication into pleural space (instructed to roll about
to have the medication coat the entire pleural space
Nursing care:-informed consent -do not cough/speak during procedure
-position: side of the bed with upper torso supported on overhead table
-post-procedure: -apply pressure to the site
-watch out for pneumothorax, shock, respiratory arrest, leakage of air from pleural cavity=SQ
EMPHYSEMA

Bronchoscopy
-insertion of a fiberscope into bronchi for diagnosis, biopsy & removal of foreign body
-uses local anesthetic spray to minimize gagging while inserting the bronchoscope
Nursing Care:-informed consent -position: supine with head hyper-extended
-NPO for 6-12 hours prior to procedure -NO dentures; maintain good oral hygiene
Post-Procedure:-position: side or semi fowler's
-NPO till gag returns then start with ice chips sips of watersoft dietregular
-ice bags to throat -minimize talking, coughing, laughing
-warm saline gargles -assess for respiratory distress

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 Mechanical Ventilation
-ventilation by mechanical means in a person unable to maintain normal levels of oxygen &
CO2, eq.
-COPD -thoracic trauma -ARDS -neuromuscular diseases
Indications: a. inadequate ventilation b. hypoxemia
Types:
a. Positive Pressure-Cycled
-push air into the lungs until a predetermined PRESSURE is reached in the tracheo-
bronchial tree
b. Volume-Cycled-deliver air into lungs till a predetermined TIDAL VOLUME is reached till
termination
c. Time-Cycled-delivers air into lungs till a predetermined PRESET TIME reached &
inspiration is terminated
Modes:
a. Assist/Control Mode-client's inspiratory effort triggers ventilation
b. Intermittent Mandatory Ventilation-client breath at own rate & IMV delivered under positive
pressure
-popular in weaning client mechanical ventilator
c. Positive-End Expiratory Pressure -delivers positive pressure at the end of expiration
-helps keep alveoli open enlarging the surface area for oxygenation
d. Continuous Positive Airway Pressure-done on adults on T-piece, same as PEEP

Nursing Care:
-monitor for barotraumas
-assess ventilator setting every 3-4 hours
-assess breath sounds every 2 hours
-physical exam every shift
-WOF: GI problems such as stress ulcers
ALARMS:
a. High-Pressure Alarms -->OBSTRUCTION
-client biting on the tube -ventilator tubing is kinked
-bronchospasm -mucus plug-->suction
-there is water in tubing -px is breathing against an incoming
mechanical breath
b.Low-Pressure Alarms-->LEAK
-disconnected tubing -there is cuff leak

c.Minute Ventilation Alarms-something wrong with RR

d.Oxygen Alarms-oxygen amount

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 Chest Tubes/Water Seal Drainage
"Closed Chest Drainage"

-insertion of catheter into intrapleural space to maintain constant (-) pressure when air or fluid
has accumulated
Purpose:
a. foster & permit drainage of air & serosanguinous fluid from pleural space
b. help re-expand remaining lung tissue by re-establishing normal negative pressure
c. prevent mediastinal shift & lung collapse

DRAINAGE SYSTEM
A.ONE-BOTTE SYSTEM
-serves as both collection chamber & water seal
-USE: Empyema
B.TWO-BOTTLE SYSTEM
-drainage collection
-water seal
-USE: after a thoracic surgery, pneumothorax
C.3-BOTTLE SYSTEM
-drainage collection chamber
-water seal
-suction control bottle
-USE: after a thoracic surgery, pneumothorax
D.COMMERCIAL UNITS
*PLEUR-EVAC-most popular
-lightweight & disposable
-function like 3 pay bottle

Principles Used:
GRAVITY
-fluid and air flow from higher level to lower level
-->keep below level of client's chest
WATER SEAL
-water acts as a seal; provides barrier between atmospheric air & subatmospheric intrapleural
pressure
-must be AIRTIGHT
-leak can go back into the pleural space=(+) pressure
-must have AIRVENT
-provides escape route for air, prevent builds up in water seal chamber
SUCTION
-applied if air leaking in the pleural space is faster than it can be removed by water seal
apparatus
-speeds up removal of air from pleural space

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Nursing Care:
a.drainage should be lower than the chest
b.examine the entire system for air tightness & absence of obstruction
c.measure & document amount & character of drainage coming out; during first 24 hours--
>500- 1000 ml is expected, excessive needs further evaluation
d.note for oscillation/fluctuations/ tidalling of fluid level within the water seal tube
-->means that system is patent & functioning properly
-->IF IT STOP!!>obstruction or re-expanded lungs
e.observe for INTERMITTENT BUBBLING ---normal in water seal
f. assess suction apparatus : normal=CONTINOUOS BUBBLING
g. have the ff at BEDSIDE
-rubber-shod clamps
-vaselinized gauze
-extra bottle with sterile water
h. make sure a chest XRay is requested to assess proper placement
i. maintain dry, sterile, occlusive dressing
j. WOF:respiratory distress from air or fluid accumulation

PNEUMONIA
-inflammation of alveolar lung spaces resulting into consolidation of the lung as exudates fill
alveoli
CAUSES:
-infections
-aspiration of food
-inhalation of toxic or caustic substances
Common Infecting Organisms:
GRAM POSITIVE
-Strep pneumonia: community acquired pneumonia (cap)
-Staph. Aureus:DM, drug users, patient's on hemodialysis
GRAM NEGATIVE
-H. influenza: children
-P.aeroginosa:hospital acquired
-L.pneumophila:inhalation with airconditioning units
FUNGAL
-P. carinii:AIDS, transplanted, chemotherapy or corticosteroid therapy, malnourished infants
Tx: cotrimoxazole
-H. capsulatum:bird & bat manure
S/SX:
-cough with sputum -respiratory distress -rales/crackles
-fever & chills -cyanosis -pleuritic chest pain
-tachycardia -hemoptysis
Diagnosis:
- CXR-->hazy infiltrates on lower lung fields -CBC (increase WBC)
-Dullness on percussion -definitive: sputum c & s

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Nursing Care:
a. facilitate adequate ventilation
b.facilitate removal of secretions
c. isolation precautions
-MRSA: contact precaution--private room
d. administer medications as ordered
e. deep breathing exercises

Chest Physiotherapy -used to mobilize secretions

Techniques:
a.postural drainage :uses gravity & various positions
b.percussion :clapping with cupped hands
c.vibration :flat hand firmly pressed over affected segment with use of isometric contraction
Nursing Care:
a. done before meals or 2-3 hours after meals to decrease the risk of aspiration
b. dilators given about 20-30 mins prior
c. remove all tight / constricting clothings
d. postural drainage position:3-5 mins
e. percussion: 2-3 minutes duration
f. perform vibration during exhalation

Chronic Obstructive Pulmonary Disease (COPD)

aka.Chronic Airflow Limitation (CAL)
-group of disorders that affect movement of air in & out of lungs
-USA:1/14 people age >45
-RISK FACTORS:
-smoking
-air pollution
-aging
EMPHYSEMA
-enlargement & destruction of alveolar walls
-main problem:ELASTICITY
-there is difficult expiration due to destructed walls/septa between alveoli-->OBSTRUCTION
-aka. PINK PUFFERS due to their normal arterial oxygen levels and marked dyspnea
Causes:
-smoking -infection -inhaled irritants
-heredity -allergic factors -aging
S/SX:
-dyspnea on exertion -cough & sputum -signs of respiratory distress
-fatigue -weight loss -PE: hyper resonant on percussion
Nursing Care:
a. administer medications as ordered
b.O2 at 1-3LPM ONLY
c. facilitate removal of secretions
d. teach about pursed-lip breathing
e. diet: increase protein, carbohydrates & vitamin C

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 f. immunize against pneumonia & influenza
g. avoid smoking, abrupt changes in temperature
h. exercise: walking
i. plan activities with adequate rest
COMPLICATIONS;
-acute respiratory failure
- pneumothorax due to bleb rupture
-cor pulmonale due to increase cardiac workload

CHRONIC BRONCHITIS
-inflammation of the bronchi with excessive production of mucus accompanied by persistent
cough
-chronic inflammation results to:
-hypertrophy & hyperplasia of
mucus secreting glands
-decrease ciliary activity
-narrowing of small airways
Diagnostic Criteria:
-symptoms must continue for 3 months for 2 consecutive years
S/SX:
- productive cough with copious sputum - dyspnea on exertion
- rales/rhonchi -cyanosis

BRONCHIAL ASTHMA
-chronic inflammatory disorder of the airways where many cells play a role
-REVERSIBLE obstructive disease of the lower respiratory tract with 3 main airway responses
Categories:
a. Extrinsic (Allergic) -due to dust, pollen, insects, smoke, medications , food
b.Intrinsic (Non-allergic) -due to pathophysiologic conditions within the respiratory tract
-->BOTH: AIRWAY IS HYPERACTIVE!
S/SX:
Cardinal:
-waxing & waning with nocturnal occurrence
-dyspnea
-expiratory wheeze
-cough
-chest discomfort/tightness
-irritability
-diaphoresis
-cyanosis (late)

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DIAGNOSIS:
Spirometry:
-decrease VC
-increase FRC
-increase TLC
-increase RV
Hallmark: Reversibility of increase 200 ml FEV1 with bronchodilator
COMPLICATION: - Status Asthmaticus
Nursing Care:
a.administer medications as ordered
-reliever medications
-controller medications
-antibiotics
b.position: High Fowlers
c. oxygen as needed
d. chest percussion & postural drainage when bronchodilation improves
-Discharge Planning:
-well ventilated room -damp dusting, avoid rugs,stuffed animals, natural
fibers
-moderate exercise: swimming -deep breathing exercises
-early treatment for URTI -avoid extremes of temperature
-avoid powerful odors

Pulmonary Tuberculosis
-reportable communicable, infectious, inflammatory disease that can occur in any part of the
body
-a chronc disorder characterized by formation of granuloma/tubercles in the lung
-spreads via AIRBORNE DROPLET
**Mycobacterium tuberculosis
-aerobic
-acid fast bacilli
-transmitted by droplet nuclei
-non-motile
-killed by heat & ultraviolet light
S/SX:
Constitutional
-weight loss -afternoon fever -night sweats
-anorexia -body malaise
Local
-cough -dyspnea -hemoptysis
-rales/crackles
Diagnosis:
-CXR
-Skin test (PPD):>10 mm after 48hr
-sputum examination: one needs 3 samples to make a positive diagnosis
-Culture:GOLD STANDARD

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 -WBC & ESR: elevated
WHO CLASSIFICATION:
PTB exposure PPD TOD SSx
I + - - -
II + + - -
III + + + +
IV + + + -
V + + +/- +/-

TB TREATMENT
Preventive Measures
-give Isoniazid, 300mg for 9-12 months
-WHO:
-newly infected (+PPD)
-close household contact
-susceptible healthcare workers
-(+) PPD + AIDS, steroid therapy, CRF
-inactive TB (+ PPD,CXR)
Therapeutic
2 Phases
a.Intensive Phase
-uses 2-3 drugs
-"bactericidal" phase
b.Maintenance Phase
-uses 2 drugs
-"sterilizing" phase
**done in 6,9,12,24 months
MEDICATIONS:
Primary Anti-tubercular Agents
Rifampicin
-Rifadin;impairs RNA synthesis
-negates effects of OCPs
-s/e: hepatitis or yellowish
discoloration of urine & sweat, nausea, vomiting ,thrombocytopenia,
drowsiness
*monitor liver function test
*teach about color changes of urine, feces (red-orange)
*avoid activities that require alertness
Isoniazid
-INH; interfers with DNA synthesis
-used as prophylactic tx
-s/e: peripheral neuritis & hepatotoxicity
-->Pyridoxine (B6) used to counteract effects of INH

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 Pyrazinamide
-s/e: hyperuricemia
Ethambutol
-Myambutol; impairs RNA synthesis
-s/e:optic neuritis, skin rash
Streptomycin
-s/e: ototoxicity (8CN damage)
-use in caution in renal patients
Nursing Care
a. respiratory precautions:2-4 weeks
b. needs well ventilated private room
c. mask to all visitors & staff, discard mask after use
d. strict handwashing after each contact with patient
e. small frquent meals with suppements
f. activity as tolerated
g. take medications as prescribed

Laryngeal Cancer
-accounts only 2-3% of all malignancy but care presents a unique challenge to nurse because
of functional & cosmetic deformities commonly seen when disorder is treated
-untreated patient will die in 3 yrs
Risk Factors
-smoking -excessive alcohol consumption
-chronic laryngitis -vocal abuse
-family predisposition
Types
a.Supraglottic
-"extrinsic" laryngeal CA
-involves epiglottis & false cords
-usually assymptomatic until advance stage
b.Glottic
-"intrinsic" laryngeal CA
-involves true vocal cords
-produces early symptoms as :progressive hoarseness & dyspnea
Management
-Radiation
-Chemotherapy
-Surgery
a. partial laryngectomy
-patient can talk but can have difficulty swallowing
*Supraglottic Laryngectomy
-problem: ASPIRATION due to removal of epiglottis which closes over the larynx
b.Total Laryngectomy
-pharyngeal opening to trachea is closed & remaining trachea ,out to neck to form
permanent tracheostomy

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 Problem -loss of normal speech
-loss of olfaction
-loss of normal breathing pattern
Nursing Care
Pre-operative
-explain procedure with emphasis to changes that will happen after surgery
-introduce client to changes in modes of communication
-etablish method os communication to be used immediately post-op
Post-operative
-promote optimum ventilatory status
-suction secretions regularly
-routine care for tracheostomy
-pain relief
-lean forward when expectorating
-wear ID bracelet at all times reminding everybody that patient is neck breather
-teach about proper exercises to increase ROM & muscle strength
*COMMUNICATION
>1-3 days post op :writing
>3-5 days post op :artificial larynx & esophageal speech

PLEURAL EFFUSION
-collection of fluid in the pleural space
-a symptom, NOT a disease which is caused by a lot of conditions
Classification:
a.Transudative
-systemic causes
-due to accumulation of protein poor & cell poor fluid such as :CHF, nephrosis, cirrhosis
-often called "hydrothorax"
b.Suppurative
-"empyema"-->pus
-accumulation of cells with high specific gravity & lactate dehydrogenase such as:
-malignancies
-infections
-inflammatory reactions
S/SX:
-dyspnea
-dullness on affected area
-absent or decreased BS on
affected area
-pallor
-fatigue
-fever

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Diagnosis: -CXR -biopsy:
Management:
a. identify & treat the cause
b. thoracentesis
c. drug therapy
d. closed chest drainage

Bronchogenic Cancer
-pathologic changes:
-non-specific inflammation -hypersecretion of mucus
-hyperplasia -obstruction
2 Major categories
-Small Cell CA
-Non Small Cell CA
a. squamous cell b. adenoCA c. large cell CA
Risk Factors
-inhaled carcinogens
-existing pulmonary disorder
-familial tendency
S/SX
-persistent cough -chest pain -dyspnea
-fatigue -anorexia -pallor -weight loss

Diagnosis
-CXR
-Sputum microscopy
-Bronchoscopy
-Thoracentesis
-Biopsy of scalene nodes
Management
-Radiation
-Chemotherapy
-Surgery
-Pneumonectomy
-removal of entire lung
-position: operative side or affected part
-no chest tube
-Lobectomy
-removal of 1 lobe
-position: unaffected part to promote expansion of affected lung
-compensatory emphysema of remaining lung fills the thoracic space
-Segmental Resection
-remove 1 or more segment
-Wedge Resection
-remove a lesion that occupy only a segment of the lung

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Nursing Care
a. provide adequate ventilation
b. suction secretions regularly
c. pain relief
d. ROM exercises
e. high protein diet, adequate fluid
COMPLICATIONS
a. Respiratory Insufficiency
b. Pneumothorax
c. Subcutaneous Emphysema
d. Pulmonary Embolism
e. Pulmonary Edema
f. Bleeding
g. Shock

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