Respiratory System

Assessment & Disorders

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Upper Respiratory System

Noses and Sinuses

Nose
Begin respiratory system Filter and warm air

Sinuses
Openings in facial bones Lighten skull Assist in speech Produce mucus

Pharynx and Larynx

Pharynx
Nasopharynx Oropharynx Laryngopharynx

Larynx
Connects 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 ribs
Assist with process of breathing

Ventilation
Divided into inspiration and expiration Normal is 1220 breaths per minute

Inspiration
Lasts 11.5 seconds Diaphragm contracts and flattens Intercostal muscles contract
Increases 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
Subjective
Current 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)
Subjective
Presence 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)
Subjective
History of previous respiratory problems Allergies to medication or environmental allergens Use of tobacco, chewing tobacco, marijuana, cocaine, injected drugs, and alcohol

Assessment (continued)
Objective
Assess 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 clients speech

Assessment (continued)
Objective
Inspect 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)
Objective
Auscultate 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 Care
Apply to fingertip, forehead, earlobe, or nose Remove nail polish when using fingertip

Arterial Blood Gases

Nursing care
Apply pressure to site 25 minutes following arterial puncture

Serum Alpha1-Antitrypsin
Deficiency in this serum protein contributing factor in emphysema and COPD Normal value in adults 150350 mg/dL Fasting specimen obtained in client with elevated cholesterol or triglycerides

Sputum and Tissue

Throat or nose swab Sputum specimen Culture and sensitivity Grams 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 teaching
Instruct 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 laryngoscopy
Used to identify and evaluate laryngeal tumors

Nursing care and client teaching

Make 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

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

Hypoxia Confusion Increased heart rate & blood pressure Respiratory rate up to 40/minute & pursed lip breathing Use of accessory muscles Diaphoresis & 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
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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: Antiinflammatory

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

Leukotriene modifiers
Interfere with synthesis or block action of leukotrienes Have both bronchodilation and anti-inflammatory properties Not recommended for acute asthma attacks Should not be used as only therapy for persistent asthma Accolate, Singulair, Zyflo

Cromolyn & nedocromil

Inhibits immediate response from exercise and allergens Prevents late-phase response Useful for premedication for exercise, seasonal asthma Intal, Tilade
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Asthma Medications: Bronchodilators

2-adrenergic agonists
Rapid 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 cont

Methylxanthines
Less effective than betaadrenergics 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
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Anticholinergics
Inhibit parasympathetic effects on respiratory system Increased mucus Smooth muscle contraction Useful for pts w/adverse reactions to betaadrenergics or in combination w/betaadrenergics

Ipratropium [atrovent]
Ipratropium + albuterol [Combivent]
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Management of Asthmatic Patient

Identify and assess status Avoid precipitating factors Bring inhaler for each appointment Drug considerations: Avoid ASA, NSAIDs, barbiturates, and narcotics Drug interactions with asthmatic medications (ex. Theophylline vs. Antibiotics, Cimetidine) Chronic corticosteroid users may require steroid supplementation For 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 attack
Dyspnea, 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 diagnosis
Ineffective airway clearance r/t secretions Impaired gas exchange r/t altered supply O2 Altered health maintenance r/t ineffective individual coping Risk for infection r/t inadequate defense system Knowledge deficit of COPD Altered role performance r/t changes in role

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Nursing DX
Ineffective breathing pattern r/t musculoskeletal impairment , decreased energy Inability to sustain spontaneous ventilation r/t muscle fatigue Activity 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
Spirometry
Breathing test which measures the amount and rate at which air can pass through the airways

Bronchodilator Reversibility Testing

Relaxing tightened muscles around the airways and opening up airways quickly to ease breathing

Other pulmonary function testing

Diffusion capacity

Chest X-ray Arterial Blood Gas

Shows 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 23L/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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