Transcript Respiratory System - Dr. NurseAna's Nursing Reviews

Ana Corona, DNP, FNP-BC,
Nursing Instructor
July 2013
Functions
* Gas Exchange
* Warms, moisturizes and filters air
* Acid-base balance
* Assist with speech
Anatomical Features
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Nasal cavity
Mouth
Larynx
Trachea
Lungs - two cone-shaped organs - right has 3 lobes, left has
2
Pleura - serous membrane of the lung - lines the whole
thoracic cavity and contains pleura fluid for lubrication
Cilia - hair-like structures that move mucous and foreign
debris out of the respiratory tract
Alveoli - units of lung tissue that perform exchange of
gasses. Massed with capillaries which causes ventilation and
perfusion to directly impact this system
Bronchi - branches off the hilus of the trachea - right is
shorter, wider, and more vertical, allowing easier aspiration
of large foreign objects
Respiratory Assessment
 Tracheal position - should be midline. Place the pad of
your index finger in the suprasternal notch and lightly
palpate for the trachea.
- Deviation moves toward the affected side in
pneumonia, away from the affected side in a
pneumothorax (collapsed lung).
- Trachea can also sometimes deviate due to an
enlarged thyroid
 Respiration - normal value is 12-20 per minute. Count
one inspiration and one expiration as a full respiratory
cycle.
 Inspiration - diaphragm lowers and ribs expand
 Expiration - diaphragm raises and ribs contract
 Tachypnea - (tack-ip-knee-uh) - fast breathing
greater than 24 respirations per minute. Causes
include hypoxia, stress, increased temperature
(environmental or body), and increased oxygen
demand (as for exercise), etc.
 Bradypnea - (braid-ip-knee-uh) - slow breathing
less than 10 respirations per minute. Causes
include increased pressure in the medulla
oblongata, sleep, drug overdose, etc.
Breathing Mode
 Eupnea (Normal) - breathes through nose,
thoracic movement only - no abdominal muscle
involvement, normal pattern
 Dyspnea - shortness of breath
 Orthopnea - has to breath sitting up - sleeps in a
reclining chair, for instance
 Apnea - lack of respirations for 10 or more seconds
(involuntary) - note time, duration, and frequency
- try to find a pattern
Chest Excursion
 Tests for chest expansion symmetry
 - Anterior method - Place your thumbs below the
costal margin (ribs) and observe them move apart
(hopefully symmetrically) during inspiration
 - Posterior method (preferred method) - Place
thumbs on either side of the spine at T8-T10 and
press together to “tent" a small fold of skin up.
Have the patient take a deep breath and watch the
thumbs move evenly away as the pinched skin
becomes relaxed
Clubbing
 Clubbing of the fingers - fingertips thicken and swell
into rounded knobs
 Nails grow around the fingers deeper than normal and
become soft and easily punctured.
 Clubbing denotes chronic hypoxia.
Auscultation
 Use the diaphragm of stethoscope, listen to both
inspiration and expiration at every point.
 Go from one side of the chest to the other,
listening for symmetry, and work down toward the
diaphragm.
 Positions to use are preferably sitting or in semifowlers to fowlers for anterior auscultation, and
sitting for posterior auscultation.
Pulse Oximetry
 Detects oxygen saturation via infrared light.
 Clipped to finger or earlobe
 Normal value is 95-100%.
 Inaccurate readings will be obtained over dark
fingernail polish.
Airway Clearance
 Coughing
- Descriptive terms for coughing include
wet/loose, dry/hacking, harsh/barking
 Productive vs. Nonproductive should always be
noted on the chart.
 Productive coughs should be assessed via the
COCA model - Color, Odor, Consistency
(thickness), Amount.
 Amount is often a comparative or subjective
description (dime-sized, quarter-sized, small
amount, etc.)
 Hemoptysis - blood in the sputum
Diagnostic Tests
 ABG - arterial blood gasses - collected from a
peripheral artery (brachial, radial or femoral
preferably) - not collected from temporal, carotid, or
apical pulse points.
 Can be collected by a deep stab method with a
standard hypodermic, or through an arterial line
(similar to a hep-lock IV) if blood will be drawn
frequently.
 Very painful procedure
ABGs
 pH of blood - Norms 7.35 to 7.45
 Oxygen saturation - 95-100% (same as pulse ox)
 paCO2 - partial pressure of carbon dioxide - 35-
45mmHg
 paO2 - partial pressure of oxygen - 80-100mmHg
 bicarbonate level: 22-26 (this is a pH buffer excreted
and stored by the kidneys)
Diagnostic testing
 Hgb and Hct
 Pulmonary function tests - spirometry - used to detect
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peak flow, tidal flow, O2 remaining in lungs (typically
performed by respiratory therapists)
CXR - chest X-ray - detect infiltration (fluid in lungs)
CT of lungs - magnetic 3D picture
Lung scans
Sputum specimens - collect in the early morning when
patient is most likely to cough deeply, and have secretions
that built up over night.
Tests run on sputum specimens include cultures (detect
bacteria), smears a and cytology (which look for abnormal
body cells cancer)
 Bronchoscopy - invasive test in which a tube is
inserted through the mouth and into the bronchi.
 A camera transmits live pictures and tools attached to
the scope are capable of suction and removal of foreign
objects.
 Looks for foreign bodies, secretions, inspection of
larynx, trachea, and bronchi for lesions, tumors, etc.
Breath sounds can be divided and subdivided into the following
categories:
Normal
Abnormal
Adventitious
Tracheal
Absent/decrease Crackles/rales
Vesicular
Bronchial
Wheeze
Bronchial
Rhonchi
Bronchovesicular
Stridor
Pleural rub
Normal Breath Sounds
Tracheal
Bronchial
Bronchovesicular
Vesicular
Normal Breath Sounds
 Vesicular: heard over most of the peripheral lung
fields. Are described as soft, low pitched and with a
gentile rustling quality.
 Tracheal: very loud, high pitch, harsh
 Bronchial: loud, high pitch, tubular
 Bronchovesicular: moderately loud, medium pitch,
rustling
Abnormal Breath Sounds
 Adventitious breath sounds –
 Abnormal breath sounds heard when listening to the
chest.
 Adventitious sounds may include crackles or rales,
rhonchi or wheezes, or pleural friction rubs.
 Adventitious sounds do not include sounds produced
by muscular activity in the chest wall or noises made
by a stethoscope on the chest wall.
Crackles
 Heard on ausculating the chest, produced by air passing
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over airway secretions.
Caused by fluid in the small airways or atelectasis.
Is a discontinuous sound, as opposed to a wheeze, which is
continuous.
Fine or coarse and are also known as rales.
Intermittent, nonmusical and brief.
Heard on inspiration or expiration.
Associated with inflammation or infection of the small
bronchi, bronchioles, and alveoli.
Crackles that don't clear after a cough may indicate
pulmonary edema or fluid in the alveoli due to heart failure
or adult respiratory distress syndrome (ARDS).
Wheezes
 Heard when listening to the chest as a person
breathes.
 Wheezes are continuous and musical sounding, and
usually caused by airway obstruction from swelling or
secretions.
 Wheezes can be high or low pitched, and are also
known as rhonchi
Sonorous Rhonchi
 A lower pitched wheeze; snoring or moaning
adventitious breath sound.
 Secretions in large airways, such as occurs with
bronchitis, may produce these sounds; they may clear
with coughing.
Sibilant Rhonchi
 A high pitched wheeze
 Musical and squeaky adventitious breath sound.
 Wheezes that are relatively high pitched and have
a shrill or squeaking quality
 They are often heard continuously through both
inspiration and expiration and have a musical
quality.
 These wheezes occur when airways are narrowed,
such as may occur during an acute asthmatic
attack.
Stridor
 A high-pitched harsh sound heard during inspiration.
 Stridor is caused by obstruction of the upper airway.
 Is a sign of respiratory distress and thus requires
immediate attention.
Pleural friction rubs
 Are low-pitched, grating, or creaking sounds
 Occur when inflamed pleural surfaces rub
together during respiration.
 More often heard on inspiration than expiration,
 Is easy to confuse with a pericardial friction rub.
 To determine whether the sound is a pleural
friction rub or a pericardial friction rub, ask the
patient to hold his breath briefly.
 If the rubbing sound continues, its a pericardial
friction rub because the inflamed pericardial
layers continue rubbing together with each heart
beat.
 A pleural rub stops when breathing stops.
Respiratory Terms
 Ataxic breathing – also known as Biot's
breathing, is characterized by unpredictable
irregularity.
 Barrel chest – a condition characterized by
increased anterior-posterior chest diameter caused
by increased functional residual capacity due to air
trapping from small airway collapse. A barrel chest
is frequently seen in patients with chronic
obstructive diseases, such as chronic bronchitis
and emphysema.
 Cheyne-Stokes respirations – a breathing pattern
characterized by a period of apnea, followed by
gradually increasing depth and frequency of
respirations. (last breaths near dying)
 Consolidation – the replacement of air in the lungs
with fluid or a mass.
 Fremitus – a vibration felt while a patient is speaking
and the examiner's hand is held against the chest.
 Intercostal retractions – visible use of the muscles
between the ribs (intercostal muscles) to aid in
breathing. Are a sign of labored breathing.
 Kussmal breathing – a very deep gasping type of
respiration associated with severe diabetic acidosis
and coma.
 Nasal flaring – intermittent outward movements of
the nostrils with each inspiration; indicates an
increase in the work needed to breathe.
 Pleura – a serous membrane covering both lungs and
the walls of the thorax and diaphragm.
 Pursed lip breathing – partial closing of the lips to
allow air to be expired slowly; used by patients with
COPD.
Asthma
 Asthma is a condition in which the airways narrow—
usually reversibly—in response to certain stimuli.
 Also known as bronchial asthma
 Airways are hyperactive to a variety of stimuli
 Airway resistance increases because of smooth muscle
contraction, increased secretions, and inflammation
of the bronchial walls
Causes of Asthma
 Mast cells in the airways are thought to be
responsible for initiating the airway narrowing.
 Mast cells throughout the bronchi, release
substances such as histamine and leukotrienes,
which cause smooth muscle to contract, mucus
secretion to increase, and certain white blood cells
to migrate to the area.
 Eosinophils, a type of white blood cell found in the
airways of people with asthma, release additional
substances, contributing to airway narrowing.
Status Asthmaticus
 The most severe form of asthma.
 The lungs are no longer able to provide the body
with adequate oxygen or adequately remove
carbon dioxide.
 Many organs begin to malfunction.
 Buildup of carbon dioxide leads to acidosis.
 Blood pressure may fall to low levels.
 The airways are so narrowed that it is difficult to
move air in and out of the lungs.
 Requires intubation and ventilator support as well
as maximum doses of several medications.
 Support is also given to correct acidosis
Extrinsic Asthma
 Extrinsic asthma is caused by this type of immune
system response to inhaled allergens such as
pollen, animal dander or dust mite particles.
 An "allergen" or an "antigen" is a foreign particle
which enters the body.
 Our immune system over-reacts to these often
harmless items, forming "antibodies" which are
normally used to attack viruses or bacteria.
 Mast cells release these antibodies as well as other
chemicals to defend the body.
Intrinsic Asthma
 Intrinsic asthma is not allergy-related, in fact it is
caused by anything except an allergy.
 It may be caused by inhalation of chemicals such as
cigarette smoke or cleaning agents, taking aspirin, a
chest infection, stress, laughter, exercise, cold air, food
preservatives or a myriad of other factors.
Asthma Symptoms
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Wheezing
Usually begins suddenly
Comes in episodes
May be worse at night or in early morning
Gets worse with cold air, exercise, and heartburn (reflux)
May go away on its own
Is relieved by bronchodilators (drugs that open the
airways)
 Cough with or without sputum (phlegm) production
 Shortness of breath gets worse with exertion
 Intercostal retractions (pulling of the skin between the ribs
when breathing)
Asthma DX tests
 Pulmonary function tests
 Peak flow measurements
 Chest x-ray
 CBC
 Arterial blood gas
Asthma TX
 Inhaled steroids (such as Azmacort, Vanceril,
AeroBid, Flovent) prevent inflammation
 Leukotriene inhibitors (such as Singulair and
Accolate)
 Anti-IgE therapy (Xolair), a medicine given by
injection to patients with more severe asthma
 Long-acting bronchodilators (such as Serevent)
help open airways
 Cromolyn sodium (Intal) or nedocromil sodium
 Aminophylline or theophylline (not used as
frequently as in the past)
Emphysema
 Emphysema is a respiratory disorder characterized
by problems in breathing. The disorder is caused
by the enlargement of air sacs in the lungs.
 Emphysema is the most common cause of death
from respiratory disease in the United States.
 A naturally occurring substance in the lungs called
alpha-1 antitrypsin may protect against this
damage.
 People with alpha-1 antitrypsin deficiency are at an
increased risk for this disease.
Causes of emphysema
 Cigarette smoking is the most common cause of
emphysema.
 Tobacco smoke and other pollutants are thought to
cause the release of chemicals from within the
lungs that damage the walls of the air sacs.
 This damage becomes worse over time.
 Persons with this disease have air sacs in the lungs
that are unable to fill with fresh air.
 This affects the oxygen supply to the body.
Symptoms of Emphysema
 Shortness of breath
 Chronic cough with or without sputum production
 Wheezing
 Decreased ability to exercise
 Anxiety
 Unintentional weight loss
 Ankle, feet and leg edema
 Fatigue
Physical Assessment
 Wheezing
 Decreased breath sounds
 Prolonged exhalation (exhalation takes more than
twice as long as inspiration).
 Barrel-shaped chest
 Decreased pulse oximetry
Diagnostic tests
 Pulmonary function tests
 Chest X-ray
 Arterial Blood Gases
Treatment for emphysema
 Smoking cessation
 Medications: bronchodilators, diuretics,
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corticosteroids,
Antibiotics (if infection)
Vaccines: flu and pneumonia (preventive)
Low-flow oxygen
Lung transplant
Complications of emphysema
 Recurrent respiratory infections
 Pulmonary hypertension
 Cor pulmonale (enlargement and strain on the right
side of the heart)
 Erythrocytosis (increased red blood cell count)
 Death
Chronic Bronchitis
 Inflammation of the main airways (bronchus) in
the lungs that continues for a long period or
recurrent.
 Is one form of COPD.
 Chronic bronchitis, emphysema and asthma are a
leading cause of death in the United States.
 Cigarette smoking is the main cause of chronic
bronchitis.
 Secondhand smoke may also cause chronic
bronchitis.
Symptoms of chronic bronchitis
 Cough that produces mucus (sputum), which may
be blood streaked
 Shortness of breath aggravated by exertion or mild
activity
 Frequent respiratory infections that worsen
symptoms
 Wheezing
 Fatigue
 Ankle, foot and leg edema
 Headaches
Diagnosis
 To be diagnosed with chronic bronchitis, the cough
and excessive mucus production must have occurred
for 3 months or more in at least 2 consecutive years
and not be due to any other disease or condition.
Diagnostic Tests
 Pulmonary function tests
 Arterial blood gas
 Chest X-ray
 Pulse oximetry
 CBC
 Exercise testing
 Chest CT scan
Treatment
 There is no cure for chronic bronchitis.
 The goal of treatment is to relieve symptoms and
prevent complications.
 Smoking cessation
 Respiratory irritants should be avoided.
 Inhaled medications
 Antibiotics for infections
 Corticosteroids during flare-ups of wheezing.
 Physical exercise programs, breathing exercises
 Oxygen therapy in severe cases.
 Lung transplant may be recommended.
Bronchiectasis
 Caused by recurrent inflammation or infection of the
airways.
 It may be present at birth.
 Most often begins in childhood as a complication from
infection or inhaling a foreign object.
Bronchiectasis Symptoms
 Chronic cough with large amounts of foul-smelling sputum
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production
Hemoptysis
Cough worsened by lying on one side
Shortness of breath (on exertion)
Weight loss
Fatigue
Clubbing (abnormal amount of tissue in the fingernail
beds)
Wheezing
Cyanosis
Pallor
Breath odor
Tests
may
include:
 Chest x-ray
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Chest CT
Sputum culture
CBC
Sweat test or cystic fibrosis testing
Serum Immunoglobulin analysis
Serum precipitins (testing for antibodies to the fungus
aspergillus)
 PPD: skin test for prior TB infection
Treatment for
bronchiectasis
 Aimed controlling infections and bronchial secretions,
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relieving airway obstruction, and preventing complications.
Regular, daily drainage to remove bronchial secretions.
Postural drainage and effective coughing exercises,
Antibiotics, bronchodilators, and expectorants
Influenza vaccine
Surgical lung resection
Complications of bronchiectasis
 Cor pulmonale
 Recurrent pneumonia
 Coughing up blood (hemoptysis)
 Low oxygen levels (if severe)
Tuberculosis
 Contagious bacterial infection caused by the
bacterium Mycobacterium tuberculosis.
 Disseminated if it has spread from the lungs to
other organs of the body by the blood or lymph
system
 Infection can develop after inhaling droplets
sprayed into the air from a cough or sneeze by
someone infected with Mycobacterium
tuberculosis.
 The disease is characterized by the development of
granulomas (granular tumors) in the infected
tissues.
TB
 The usual site of the disease is the lungs.
 Other organs may be involved.
 Primary infection usually has no symptoms.
 In the U.S., 95% of individuals the primary
tuberculous lesions will heal and there will be no
further evidence of disease.
 Disseminated disease develops in the minority of
infected individuals whose immune systems do
not successfully heal the primary infection.
 TB may occur within weeks after the primary
infection
 Or may lie dormant for years before causing
illness.
 Hospitalization may be necessary to prevent
spread of TB until the infectious period is over,
usually 2-4 weeks after the start of therapy.
 Infants, elderly, and those infected with HIV are at
higher risk for rapid progression to disease,
because of their weaker immune systems.
 The risk of contracting TB increases with the
frequency of contact with people who have the
disease, in crowded or unsanitary living
conditions, and with poor nutrition.
Disseminated organs:
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Pericardium
Peritoneum
Larynx
Bronchus
Cervical lymph nodes
Bones and joints
Genitourinary system
Eye
Stomach and small bowel
Meninges
Skin
Symptoms
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Sweating
Fatigue
Malaise
Weight loss
Cough
Shortness of breath
Fever
pallor
Arthralgia (joint pain)
Chills
Swollen lymph glands
ascites
Diagnostic tests
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Chest X-ray
Sputum cultures
Tuberculin skin test
Bronchoscopy for biopsy or culture
Open lung biopsy
Pleural biopsy
Biopsies and cultures of affected organs or tissues
Retinal lesions revealed with fundoscopy
Peripheral smear
Serum calcium (may be elevated)
Mycobacterial culture of bone marrow
Tuberculin Skin Test
 5 mm of induration at the site) is considered to be
positive in people who have HIV, who are taking
steroid therapy, or who have been in close contact
with a person who has active tuberculosis.
 Greater than or equal to 10 mm are considered
positive in people with diabetes or kidney failure,
and in health care workers, among others.
 In people with no known risks for tuberculosis, a
positive reaction requires 15 mm or more of hard
swelling at the site per Centers for Disease Control
& Prevention (CDC)?
 Los Angeles County: 10 mm (+) positive general
population.
Treatment for TB
 Antitubercular drugs:
 Pyrazinamide
 isoniazid (INH)
 Rifampin
 Ethambutol
 Ethionamide
 para-aminosalicylic acid
(PAS)
 Amikacin
 streptomycin
 Daily oral doses are
continued for 1 year or
longer.
 A minimum of three
drugs are started for
treatment for drug
resistant strains.
Complications of TB
Medications toxicity:
 Rifampin, pyrazinamide, and isoniazid may cause
a non-infectious liver inflammation.
 Rifampin may also cause an orange or brown
coloration of tears and urine, and can stain contact
lenses and undergarments.
 Ethambutol may reduce visual acuity or cause
color blindness.
Other complications
 Drug resistance
 Relapse of the disease
 Tuberculous meningitis
 Respiratory failure
 Adult respiratory distress syndrome (ARDS)
Prevention
 Vaccination BCG for tuberculin-negative persons
exposed to persons with untreated TB is given in some
situations, but its effectiveness is under dispute.
 It is rarely used in the U.S. but is often used abroad, in
countries with higher rates of tuberculosis.