Respiratory System

Assessment & Disorders

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Upper Respiratory System

Noses and Sinuses

NoseBegin respiratory system

Filter and warm air

SinusesOpenings in facial bones

Lighten skull

Assist in speech

Produce mucus

Pharynx and Larynx

PharynxNasopharynx

Oropharynx

Laryngopharynx

LarynxConnects laryngopharynx to trachea

Routes air and food to proper passageway

Lower Respiratory system

Lungs

Separated by mediastinum

Composed of elastic connective tissue

Divided into lobes which are further divided into segments

Bronchi and Alveoli

Trachea divides into right and left mainstem bronchi

Bronchi continue to branch and get smaller (bronchioles) and end as alveoli

Air moves through passageways to alveoli where gas exchange occurs

Bronchioles and Alveoli

Pulmonary Circulation

Pulmonary arteries

Pulmonary veins

Pulmonary capillary network

Pleura

Double-layered membrane that covers lungs

Parietal

Visceral

Hold lungs out to chest wall

Rib Cage and Intercostal Muscles

Protect lungs

12 pairs ribs

Intercostal muscles are between ribsAssist with process of breathing

Ventilation

Divided into inspiration and expiration

Normal is 12–20 breaths per minute

Inspiration

Lasts 1–1.5 seconds

Diaphragm contracts and flattens

Intercostal muscles contractIncreases size of chest cavity

Lungs stretch and volume increases

Pressure in lungs slightly less than atmospheric

Causes air to rush in

Expiration

Lasts 2 to 3 seconds

Passive

Muscles relax

Diaphragm rises

Ribs descend

Lungs recoil

Pressure in chest cavity increases (compressing alveoli)

Pressure in lungs higher than atmospheric causes gases to flow out of the lungs

Factors Affecting Respiration

Respiratory center of the brain

Chemoreceptors in the brain, aortic arch, and carotid arteries

Airway resistance

Compliance

Elasticity

Surface tension of alveoli

Respiratory Changes Associated with Aging

Cartilage that connects ribs to sternum and spinal cord calcifies

Anterior-posterior diameter of chest increases

Respiratory muscles weaker

Cough and laryngeal reflexes less effective

Respiratory Changes Associated with Aging

Size of lungs decreases

Alveoli less elastic

Older client at greater risk for developing respiratory infections

Assessment

SubjectiveCurrent complaint or existing condition

Onset or duration of symptoms

Ability to maintain ADL

Nasal congestion, nosebleeds

Sore throat, difficulty swallowing

Changes in voice quality

Difficulty breathing, orthopnea

Pain on breathing

Assessment (continued)

SubjectivePresence of cough frequency, duration, productive or unproductive

Sputum amount, color, and consistency

Exposure to infections (colds or influenza)

History of chronic lung conditions

Occupational exposure to chemicals, smoke, asbestos

Assessment (continued)

SubjectiveHistory of previous respiratory problems

Allergies to medication or environmental allergens

Use of tobacco, chewing tobacco, marijuana, cocaine, injected drugs, and alcohol

Assessment (continued)

ObjectiveAssess state of health

Color

Ease of breathing

Note respiratory rate and pattern

Observe nasal flaring

Use of accessory muscles for breathing

Listen for hoarseness in client’s speech

Assessment (continued)

ObjectiveInspect mucosa of nose, mouth, and oropharynx

Inspect neck, position of trachea

Inspect anterior/posterior diameter of chest

Palpate lips for nodules, chest for tenderness or swelling

Assessment (continued)

ObjectiveAuscultate breath sounds, note absence or presence and quality

Note adventitious breath sounds (wheezing or crackles)

Pulse Oximetry

Monitors oxygen saturation (SpO2)

Amount of arterial hemoglobin that is combined with oxygen

Nursing CareApply to fingertip, forehead, earlobe, or nose

Remove nail polish when using fingertip

Arterial Blood Gases

Nursing careApply pressure to site 2–5 minutes following arterial puncture

Serum Alpha1-Antitrypsin

Deficiency in this serum protein contributing factor in emphysema and COPD

Normal value in adults 150–350 mg/dL

Fasting specimen obtained in client with elevated cholesterol or triglycerides

Sputum and Tissue

Throat or nose swab

Sputum specimen

Culture and sensitivity

Gram’s stain

Acid-fast stain

Cytology

Imaging Techniques

X-rays

CT scans

Ventilation perfusion scans

Nursing care and client teaching

If contrast used remember to ask about allergies, especially iodine and seafood

Pulmonary Function Tests

Measure lung volume and capacity

Smoking, caffeine, and bronchodilators interfere with results

Nursing care and client teachingInstruct client to stop bronchodilators 4–6 hours prior to test

Instruct client not to smoke or drink caffeinated drinks prior to test

Lung Volumes and Capacities

Direct Visualization

Direct or indirect laryngoscopyUsed to identify and evaluate laryngeal tumors

Nursing care and client teachingMake sure consent form has been signed

Remove dentures, partial plates, bridges prior to procedure

NPO before procedure

NPO after procedure until gag reflex returns

Bronchoscopy

Visualize trachea, bronchi and bronchioles

Tumors and structural disorders

Obtain tissue biopsy

Obtain sputum specimen

Removal of foreign body

Nursing care and teaching

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Asthma and COPD

Dr Ibrahim Bashayreh, RN, PhD.

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Asthma

Asthma is a chronic inflammatory pulmonary disorder that is characterized by reversible obstruction of the airways

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Asthma

Asthma is a chronic (long-term) disease that makes it hard to breathe. Asthma can't be cured, but it can be managed. With proper treatment, people with asthma can lead normal, active lives.

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Etiology

Cause of asthma is unknown but many factors play a part:

Genetic factors: Asthma tends to run in the family

Environmental factors: pollen, dust, mold, tobacco smoke

Occupational exposure: chemicals and gases

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Normal bronchiole/ Asthmatic bronchiole

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How asthma works

If you have asthma, your airways (breathing passages) are extra sensitive. When you are around certain things, your extra-sensitive airways can:

Become red and swollen - your airways get inflamed inside. They fill up with mucus. The swelling and mucus make your airways narrower, so it's harder for the air to pass through.

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Cont.

Become "twitchy" and go into spasm - the muscles around your airways squeeze together and tighten. This makes your airways narrower, leaving less room for the air to pass through.The more red and swollen your airways are, the more twitchy they become.

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Symptoms

Hard breathing caused by irritants

Asthma inducers: If you breathe in something you're allergic to- for example, dust or pollen- or if you have a viral infection- for example, a cold or the flu- your airways can become inflamed (red and swollen).

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Cont.

Asthma triggers: If you breathe in an asthma trigger like cold air or smoke, or if you exercise, the muscles around your airways can go into spasm and squeeze together tightly. This leaves less room for air to pass through.

It's important for every person with asthma to know what they triggers and inducers are.

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What are the Triggering Factors?

Domestic dust mites

Air pollution

Tobacco smoke

Occupational irritants

Animal with fur

Pollen

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Triggering Factors ( cont.)

Respiratory (viral) infections

Chemical irritants

Strong emotional expressions

Drugs ( aspirin, beta blockers)

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Asthma: Early Clinical Manifestations

Expiratory & inspiratory wheezing

Dry or moist non-productive cough

Chest tightness

Dyspnea

Anxious &Agitated

Prolonged expiratory phase

Increased respiratory & heart rate

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Asthma: Early Clinical Manifestations

Wheezing

Chest tightness

Dyspnea

Cough

Prolonged expiratory phase [1:3 or 1:4]

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Asthma: Severe Clinical Manifestations

HypoxiaConfusionIncreased heart rate & blood pressure Respiratory rate up to 40/minute & pursed lip breathingUse of accessory musclesDiaphoresis & pallor Cyanotic nail beds Flaring nostrils

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Classification

At risk- breathing test normal, mild symptoms

Mild- breathing test shows mild limitation, increasing symptoms

Moderate- person will typically seek care for symptoms, shortness of breath with significant exertion, lung tests abnormal

Severe- shortness of breath with limited activity, lung tests abnormal

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Asthma: Diagnostic Tests

Pulmonary Function Tests FEV1 decreased

Increase of 12% - 15% after bronchodilator indicative of asthma

PEFR decreased

Symptomatic patient eosinophils > 5% of total WBC

Increased serum IgE

Chest x-ray shows hyperinflation

ABGs Early: respiratory alkalosis, PaO2 normal or near-normal

severe: respiratory acidosis, increased PaCO2,

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Asthma: Nursing Diagnoses

Ineffective airway clearance r/t bronchospasm, ineffective cough, excessive mucus

Anxiety r/t difficulty breathing, fear of suffocation

Ineffective therapeutic regimen management r/t lack of information about asthma

Knowledge deficit

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Medical Management of Asthmatic Patient

Limit exposure triggering agents

Medications such as: inhaled corticosteroids, inhaled beta2 adrenergic agonist, and cromolyn sodium

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Asthma Medications: Anti-inflammatory

Corticosteroids Not useful for acute attack Beclomethasone: vanceril, beclovent, qvar

Cromolyn & nedocromil Inhibits immediate response from exercise and allergens

Prevents late-phase response Useful for premedication for exercise, seasonal asthma Intal, Tilade

Leukotriene modifiers Interfere with synthesis or block action of leukotrienes

Have both bronchodilation and anti-inflammatory propertiesNot recommended for acute asthma attacks Should not be used as only therapy for persistent asthma Accolate, Singulair, Zyflo

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Asthma Medications: Bronchodilators

2-adrenergic agonistsRapid onset: quick relief of bronchoconstriction

Treatment of choice for acute attacks If used too much causes tremors, anxiety, tachycardia, palpitations, nausea Too-frequent use indicates poor control of asthma Short-acting

Albuterol[proventil]; metaproterenol [alupent]; bitolterol [tornalate]; pirbuterol [maxair]

Long-acting

Useful for nocturnal asthma

Not useful for quick relief during an acute attack Salmeterol [serevent]

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Asthma Medications: Bronchodilators con’t

Methylxanthines Less effective than beta-adrenergics

Useful to alleviate bronchoconstriction of early and late phase, nocturnal asthma Does not relieve hyperresponsiveness Side effects: nausea, headache, insomnia, tachycardia, arrhythmias, seizures Theophylline, aminophylline

Anticholinergics Inhibit parasympathetic effects on respiratory system

Increased mucus

Smooth muscle contraction Useful for pts w/adverse reactions to beta-adrenergics or in combination w/beta-adrenergics

Ipratropium [atrovent]

Ipratropium + albuterol [Combivent]

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Management of Asthmatic Patient

Identify and assess statusAvoid precipitating factorsBring inhaler for each appointmentDrug considerations: Avoid ASA, NSAIDs, barbiturates, and narcoticsDrug interactions with asthmatic medications (ex. Theophylline vs. Antibiotics, Cimetidine)Chronic corticosteroid users may require steroid supplementationFor sedation, nitrous oxide/oxygen and/or small doses of oral diazepam is recommended

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Asthma: Client Teaching

Correct use of medications

Signs & symptoms of an attackDyspnea, anxiety, tight chest, wheezing, cough

Relaxation techniques

When to call for help, seek treatment

Environmental control

Cough & postural drainage techniques

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COPD

Chronic obstructive pulmonary disease is a slowly progressive disease that is characterized by a gradual loss of lung function

COPD includes chronic bronchitis, chronic obstructive bronchitis, or emphysema, or combinations of these conditions

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Epidemiology

20.3 million Americans report having asthma

5,000 deaths annually from asthma

12.1 million Americans reported being diagnosed with COPD

119,000 deaths annually from COPD

COPD is the 4th leading cause of death in the U.S.

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Chronic Bronchitis

Inflammation of the main airway passages (bronchi) to the lungs, which results in the production of excess mucous, a reduction in the amount of airflow in and out of the lungs, and shortness of breath

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Emphysema

A respiratory disease characterized by breathlessness brought on by the enlargement, or over-inflation of, the air sacs (alveoli) in the lungs

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Signs and symptoms

Wheezing

Coughing

Sputum production

Shortness of breath

Chest tightness

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Diagnosis

Clinical symptoms

Chest x-ray

Lung function tests

ABGs

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Nursing diagnosisIneffective airway clearance r/t secretionsImpaired gas exchange r/t altered supply O2Altered health maintenance r/t ineffective individual copingRisk for infection r/t inadequate defense systemKnowledge deficit of COPDAltered role performance r/t changes in role

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Nursing DX

Ineffective breathing pattern r/t musculoskeletal impairment , decreased energyInability to sustain spontaneous ventilation r/t muscle fatigueActivity intolerance r/t imbalance of O2 supply

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Clinical Features of COPD Patients

Mild COPD: no abnormal signs, smokers cough, little or no breathlessness

Moderate COPD: breathlessness with/without wheezing, cough with/without sputum

Severe COPD: breathlessness on any exertion/at rest, wheeze and cough prominent, lung inflation usual, cyanosis, peripheral edema, and polycythemia in advanced disease

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Diagnosis

SpirometryBreathing test which measures the amount and rate at which air can pass through the airways

Bronchodilator Reversibility TestingRelaxing tightened muscles around the airways and opening up airways quickly to ease breathing

Other pulmonary function testingDiffusion capacity

Chest X-ray

Arterial Blood GasShows oxygen level in blood

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Medical Management of COPD Patient

Smoking cessation and elimination of environmental pollutants

Palliative measure such as regular exercise, good nutrition, flu and pneumonia vaccines

Bronchodilators, corticosteroids, anticholinergics, and NSAIDs

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Management of COPD Patient

Review history for concurrent heart disease

Avoid treatment if upper respiratory tract infection is present

Treat in upright position

Avoid rubber dam in severe cases

Use pulse oximetry (if pulse ox <91%, use low flow 2-3L/min)

Avoid Nitrous oxide/oxygen in severe cases

Avoid barbiturates, narcotics, antihistamines, and anticholinergics

If patient is on steroid regimen, supplement as needed

Drug interactions with COPD medication

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