Respiratory System

Disorders
Review of the System
Functions
Primary
Ventilation
Alveolar Diffusion
Secondary
Sense of smell
Speech

Structure
Upper airways

Nose
Sinuses
Pharynx
Epiglottis
Larynx
Lined with mucous secreting cells,
cilia and olfactory senses
Lower Airways

Trachea
Right and left
mainstream
bronchi
Segmental
Bronchi
Terminal
bronchioles
Alveoli (L:S)
LUNGS
Situated in the thoracic cavity, on
either side of the heart

Bound by clavicles, ribs, vertebrae
and diaphragm

Right 3 lobes
Left 2 lobes
Respiratory Muscles
Diaphragm
Intercostal Muscles

Control of Respirations
Respiratory Center
Medulla Oblongata
Upper Pons (Pneumotaxic)
Lower Pons (Apneustic)
Chemoreceptors
ANS (Sympa and Parasympa)


Respiration
(Gas Exchange)
Ventilation process of moving air
between the atmosphere and alveoli

Alveolar Diffusion
Process of exchange of oxygen and
carbon dioxide between the alveoli
and blood
Dependent upon pulmonary
perfusion

Transport of gases process of carrying
oxygen to cells via the circulatory system;
and carbon dioxide away from cells.

Cellular Diffusion process of moving
oxygen to cells and CO2 away from cells.
Assessment
Physical Assessment
Determine presence of adventitious breath
sounds
Crackles- usually heard during inspiration and
do not clear with cough.
Wheezes- may be heard during inspiration
and/or expiration, is caused by air moving
thru narrowed passages.
Pleural friction rub- heard on inspiration over
an area of pleural inflammation. Grating
sound.
Diagnostic Studies/Therapies
Mantoux Test
Also known as the PPD (Purified Protein
Derivative) test
Intradermal
Read within 48 to 72 hours after injection
Positive: Induration of 10 mm or more;
signifies exposure to Mycobacterium
tubercle bacilli
Chest X-ray
Radiographic visualization of the chest

Instruct the client to hold his breath and
remove metals from the chest
Lung Scan
Measures blood perfusion through the
lungs.
Helps confirm pulmonary embolism or
other blood-flow abnormalities.
After an injection with a radioisotope,
scans are taken with a camera.
Remain still during the procedure.
Lymph Node Biopsy
To assess lung cancer metastasis.
Bronchography
Radiopaque medium is instilled directly to the
trachea or any part of the bronchial tree to be
visualized through x ray.
Nursing intervention before the procedure are:
1. Secure informed consent
2. Check for allergy to food, iodine, anesthesia
3. NPO for 6-8 hrs
4. Pre-op meds: Atropine SO4, Valium, topical
anesthesia and anesthesia to be injected into
the larynx
5. Secure O2, antispasmodic agents at bedside
Nursing intervention after the procedure
are:
1. Side-lying position
2. NPO until cough, gag reflex return
3. Cough, deep breathing exercise
4. Low-grade fever is common
Bronchoscopy
Direct inspection and observation of the
larynx, trachea and bronchi through
flexible or rigid scope
Diagnostic uses: to collect secretion, to
determine location of pathologic process
and collect specimen.
Therapeutic uses: remove foreign object
and excise lesions
Nursing intervention before the
procedure:
1. Informed consent
2. Atropine, valium as premeds, topical &
local anesthesia
3. NPO for 6-8 hrs
4. Remove dentures, prosthesis, contact
lens
Nursing intervention after the procedure:
1. Side lying position
2. Check for coughing, gag reflex prior to
oral intake
3. Watch for signs of perforation of the
bronchial tree: cyanosis, hypotension,
tachycardia, hemoptysis, dyspnea
Sputum Exam
Sputum C & S
AFB staining
Early AM sputum
Rinse mouth with plain water
Use sterile container
Important: specimen for C & S is collected
before the first dose of antibiotic.
Pulmonary Function Test
Volume Symbol Measurement
Tidal Volume (about
500 ml at rest)
TV Amount of air that moves into and out of the
lungs with each breath.
Inspiratory Reserve
Volume
(approximately 3000
ml)
IRV Maximum amount of air that can be inhaled
from the point of maximum inspiration.
Expiratory Reserve
Volume
(approximately 3000
ml)
ERV Maximum volume of air that can be exhaled
from the resting end-expiratory level.
Residual Volume
(approximately 1200
ml)
RV Volume of air remaining in the lungs after
maximum expiration.
Functional
Residual Capacity
(approximately
2300 ml)
FRC Volume of air remaining in the lungs at
end-expiration.
RV + ERV
Inspiratory
Capacity
IC IRV + TV
Vital Capacity VC Maximum amount of air that can be
exhaled from the point of maximum
inspiration.
Total Lung
Capacity
TLC Total amount of air that the lungs can
hold.
The sum of all the volume components
after maximal inspiration.
20-25% less in females
Nursing care:
Carefully explain procedure will help allay
anxiety and ensure cooperation
Perform test before meals
Withhold medications that may later
respiratory function unless otherwise ordered
After procedure assess pulse and provide for
rest period.
Thoracentesis
Aspiration of fluid or air from the pleural cavity
May be used for diagnosis or therapy
Nursing intervention before the procedure:
1. Secure consent
2. Take initial VS
3. Position: upright leaning on over bed table
4. Instruct to remain still during the procedure
5. Pressure sensation is felt upon needle
insertion
Arterial Blood Gas Studies
Purpose is to assess ventilation and acid-
base balance
Radial artery common site of blood
extraction
10 ml pre-heparinized syringe
Container with ice
Normal Values
Parameter Arterial Venous
pH 7.35-7.45 7.32-7.38
PaCO2 35-45 mmHg 42-50 mmHg
HCO3 22-26 meq/L 23-27 meq/L
PaO2 80-100 mmHg 40 mmHg
O2Sat 95-100% 75%
Base E/D +/-2 +/-2
Alterations:
Disorder Initial Event Compensation
Respiratory
acidosis
High PaCO2, or
high N HCO3, low
pH
Kidneys eliminate
H, retain HCO3
Respiratory
alkalosis
Low PaCO2 or high
N HCO3, high pH
Kidneys conserve
H, excrete HCO3
Metabolic acidosis Low HCO3, or high
N PaCO2, low pH
Lungs eliminate
CO2, kidneys
conserve HCO3
Metabolic alkalosis High HCO3, or low
N PaCO2, high pH
Lung conserve
PaCO2, kidneys
conserve H
Steps in ABG Analysis:
1. Evaluate the pH.
Low pH = Acidic
High pH = Basic

2. Determine the area of affectation.
pCO2 = Respiratory (lungs / respiratory
system)
HCO3= Metabolic (kidneys / renal system)

3. Determine the level/degree of compensation.
Uncompensated
Partially compensated
Fully compensated
Common Respiratory
Interventions
Oxygen therapy
Tracheobronchial suctioning
Bronchial hygiene measures
Chest physiotherapy
Incentive Spirometry
Closed Chest Drainage/Thoracostomy
Tube
Oxygen Therapy
Most common therapy for clients with
respiratory disease
Indications include: arterial
hypoxemia;COPD;ARDS; tissue; cellular;
and circulatory hypoxia
Oxygen Therapy
Delivery systems
1. Low-flow system: delivers O2 at variable
liter flows designed to add to clients
inspired air.
a. Nasal Cannula 1-4 lpm w/ desired FiO2 range
of 24%-40%
b. Standard Mask-6-12 lpm w/ desired Fio2 range
of 40%-65%
c. Nonrebreathing mask- 6-15 lpm w/ desired FiO2
range of 60%-90%
Oxygen Therapy
2. High-flow system client receives entire
inspired gas from the apparatus
a. Venturi Mask provides precise delivery of O2
concentration of 24%-50%


Chest Physiotherapy
1. Used for individuals with increased
production of secretions or thick.
2. Techniques
a. Postural drainage
b. Percussion
c. Vibration
Chest Physiotherapy
3. Nursing care
a. Perform procedure before or 2-3 hours after
meals
b. Administer bronchodilators about 20 minutes
before the procedure
c. Place towel over area to be percussed
d. Percuss designated area for approximately 3
minutes during inspiration and expiration
e. Vibrate same designated area during
exhalations
Chest Tube
Chest Tube
Thoraseal
Atrium Oasis
Chest Tube
Inspiration Expiration
Chest Tube
Insertion of catheter into the intrapleural space
to maintain constant negative pressure when
air/fluid have accumulated.
Chest tube is attached to underwater drainage
to allow for the escape of air/fluid and to
prevent reflux of air into the chest
For evacuation of air, chest tube is placed in the
second or third intercostal space, anterior or
midaxillary line

Chest Tube
For drainage of fluid, chest tube is
placed in the 8
th
or 9
th
ICS, midaxillary
line.
1. One-bottle system
2. Two-bottle system
3. Three-bottle system
Chest Tube
Nursing care: w/o suction
1. Examine the entire system to ensure airtightness
and absence of obstruction from kinks or dependent
loops of tubing's
2. Note oscillation of fluid level w/in the water-seal
tube. It will rise on inspiration and fall on expiration.
3. Milk gently when ordered to dislodge mucus and
blood clots.
4. Check for the amount, color, and characteristics of
the drainage.
5. Always keep lower than level of the clients chest
6. Keep Vaseline gauze at bed side at all times in case
tube falls out.
7. Encourage coughing and deep breathing to facilitate
removal of air and drainage from pleural cavity
Chest Tube
Nursing care: w/ suction
1. There should be continuous bubbling in the
suction chamber and intermittent bubbling
in the water seal.
2 clamps at bedside incase for bottle
brakeage
Never clamp chest tubes unless a
specific order is written by the physician.
Clamping the chest tubes of a client with
air on the pleural space will cause
increased pressure buildup and possible
tension pneumothorax.

Chest Tube
Removal of chest tube: instruct patient
to perform valsalva manuever; apply a
vaseline pressure dressing to the site.
If water-seal bottle should breake,
immediately obtain some type of fluid-
filled container until a new unit can be
obtained.
Overview of
Pathophysiologic
Process
Restrictive Diseases
Disorders that limit lung expansion and restrict
chest wall expansion throughout the respiratory
cycle.

Result in decreased lung volume, pulmonary
compliance and increased work of breathing.

Includes atelectasis, pneumothorax and pleural
effusion. Also Pneumonia.

Caused by parenchymal or lung disease,
neuromuscular alterations, chest wall disorder,
musculoskeletal or neuromuscular disorder
(kyphosis, muscular dystrophy, Gullain Barre
syndrome, Myasthenia Gravis)

Other causes are obesity, pregnancy,
abdominal distention, pain or tight application
of bandage.
Risk factors include:
1. Occupational hazards (inhalation of
chemicals)
2. Trauma on chest wall / rib
3. Surgeries that render patients unable to
cough and deep breathe postop.
4. Past / Present history of musculoskeletal
diseases
Obstructive Diseases
Any disorder in which obstruction
impedes airflow to the lungs.
Can be:
1. Chronic asthma
2. a, bronchitis and emphysema
3. Acute ARDS, acute respiratory
failure, cystic fibrosis and cancer.
Also caused by edema of airway or
tongue from smoke inhalation, infection
or anaphylaxis.

Pulmonary related Cardiac
Diseases
MI, CHF and other related diseases result
from and to pulmonary disorders.

MANAGEMENT OF
CLIENT WITH
RESPIRATORY
DISORDERS
ATELECTASIS
Refers to collapse of previously
expanded lung tissue
A shrunken airless state of the
alveoli.

Can be primary or secondary.

Etiology
Primary
1. Lung tissue remains uninflated as a result
of insufficient surfactant production.
2. Present at birth typically on premature and
at-risk infants.
Secondary caused by airway
obstruction, lung compression and
increased recoil due to diminished
surfactants
Airway obstruction may be due to mucus
plugs, tumors or exudates.
Its risk increases after surgery
Pathophysiologic Processes and
Manifestations:
1. Surfactant must be constantly
replenished.
2. Ineffective cough reflex decreased
tidal volume and decreases sigh
mechanism poor alveolar expansion
3. Increased viscosity of sputum pooling
of secretions
4. Complete airway obstruction
absorption of oxygen from dependent
alveoli and collapse of that portion of
lung.
Symptoms may include:
1. Crackles and gurgles
2. Diminished breath sounds from
poor air entry
3. Dyspnea and tachycardia
4. Hypoxemia
Overview of Nursing Interventions:
1. Encourage deep breathing and
coughing
2. Encourage the performance of
incentive spirometry
3. Administer antibiotics as ordered
4. Administer oxygen if necessary
PNEUMOTHORAX
It is the accumulation of air in the pleural
space, which results in partial or complete
lung collapse.
Types are:

1. Tension air enters but cant leave
pleural space
2. Secondary air enters the pleural space
as a result of injury to the chest wall,
respiratory structures or esophagus
3. Spontaneous air enters the pleural
space when air-filled blebs (blisters) on
the lung surface rupture.
Etiology
Tension pneumothorax - unknown causes

Secondary pneumothorax injury to the
chest wall from trauma

Spontaneous ruptured bleb (common to
smokers).
Pathophysiologic Processes and
Manifestations
Severity of symptoms depends on the
size of injury and the amount of tissue
left intact.
Symptoms can include:
1. Pleuritic pain (sharp pain occurring
during inhalation)
2. Increased RR
3. Dyspnea
4. Asymmetry of chest wall (from rib
fractures)
In tension pneumothorax, onset is sudden and
painful.
5. Decreased breath sounds over the
area of pneumothorax
6. Trachea deviating to the injury site
7. Shifting of mediastinal structures to
unaffected side of unaffected chest
8. Signs of shock (due to large
pneumothorax)

Overview of Nursing Interventions:
Monitor V/S, signs of shock
Observe respirations; changing pattern
may indicate worsening situation
Semi-Fowlers position
Administer oxygen if necessary
Analgesics as ordered
Chest tube:
1. Maintain sterile dressing at chest tube
insertion site
2. Maintain patency and integrity of closed
chest drainage system
3. Evaluate amount of fluid and breath sounds.
PLEURAL EFFUSION
Description
Refers to an abnormal accumulation of
fluid in the pleural cavity.
Fluid may be transudate (hydrothorax),
exudates (empyema), blood (hemothorax)
or chyle (chylothorax) chyle is a milky
fluid found in lymph fluid from GI tract.

Etiology
Hydrothorax results from CHF; other
causes are RF, nephrosis and liver failure
Empyema from infections, malignancies,
SLE. May also be caused by direct spread
of bacterial pneumonia or trauma-related
infections
Hemothorax chest injuries, chest surgery
complications, malignancies, blood vessel
rupture
Chylothorax trauma, inflammation or
malignant infiltration
Pathophysiologic Processes and
Manifestations
1. 5 mechanisms:

a. Increase in capillary pressure failure to
shift the blood back towards the heart
b. Increase in capillary permeability - such as in
inflammation
c. Decrease COP
d. Increase in intrapleural negative pressure
e. Impairment in lymphatic drainage of the
pleura
2. Pleural effusion results in decreased lung
volume on the affected side and a
mediastinal shift on the other side
decreased lung volume on the other side
as well

3. Characteristic signs: diminished breath
sounds and flatness and dullness to
percussion.
1. Other symptoms are:
a. Dyspnea
b. Pleuritic pain
c. Constant discomfort
2. Severity of hemothorax is determined by
volume of fluid:
a. Minimal (300-500cc) resolves in 10-14 days
as small amounts of blood are naturally
absorbed from the pleural space.
b. Moderate (500-1000 cc) fills about 1/3 of
the pleural cavity lung compression and
signs of hypovolemia
c. Large (1000 cc or more) fills half or more
of the chest and requires immediate
drainage.
Overview of Nursing Interventions:
1. Observe patient for signs of shock
2. Administer analgesics as required
3. For moderate to large:
a. Maintain fluid replacement as ordered.
b. Assist with insertion of chest tubes are
ordered.
c. Maintain patency of tubes.
d. Prepare for surgery if bleeding doesnt
stop.
ADULT RESPIRATORY
DISTRESS SYNDROME
(ARDS)
Description
A sequela of several diseases in which the
lungs fill with water, making gas exchange
impossible

Etiology
Results from unknown cause.
Predisposing factors
Pneumonia
Near drowning
Reaction to drugs and inhaled
gases
Allergic reactions (pulmonary)
Shock Infection
Diabetic ketoacidosis
Trauma
Burns
Pathophysiology
Increased permeability of alveolar-
capillary membrane penetration of
protein and fluid from the IV
compartment into the pulmonary
interstitium and alveoli noncardiac
pulmonary edema
Plasma protein inactivates surfactant
injury to the alveolar cells
surface tension
Increased pressure from excessive
fluid and increased surface tension
alveolar collapse stiffening of the
lungs difficulty in inflation

Decreased lung compliance and
increased work of breathing
Symptoms include:
Crackles and gurgles
Hypoxemia due to poor
diffusion
Respiratory distress
X-ray result mass consolidation
ABG Analysis: Respiratory
acidosis
Nursing Interventions
Monitor fluid intake
Administer steroids as ordered
reduce inflammation
Assess for complication like
pneumothorax
Institute PEEP as ordered
Provide care necessary for a
mechanical ventilator
Protect the airway from injury
Relieve anxiety
PNEUMONIA
An acute infection of the lung
parenchyma varying in severity.
Etiology
Include bacteria, viruses, fungi and
protozoa
Pathophysiology
Organisms enter via the respiratory
tract (Staphylococcus and gram
negative bacilli by hematogenous)

Defense system activates (Mucociliary
transport, pulmonary macrophagus).

Fails in overwhelming infection and
immunosuppression
Invading organisms multiplies

releases toxins

Increase in capillary permeability

edema of the lung parenchyma

cellular debris and exudates

if filled, may lead to airless state

consolidated state

Severity may depend on extent present
(partial/full lobar or diffused
bronchopneumonia.

Symptoms as follows;
Fever - Malaise
Chills - Cough
Rales and Rhonchi - Pleuritic pain
Dyspnea

Nursing Interventions
Administer antibiotics specific for the
causative organism, as ordered
Control fever.
Encourage adequate fluid intake.
Provide bronchial hygiene.
Maintain adequate nutritional status
Chest physiotherapy
Oxygen, as ordered
CHRONIC OBSTRUCTIVE
PULMONARY DISEASE
Chronic Obstructive Pulmonary Disease
(COPD)


Chronic bronchitis
smoking,RTI, pollution
inflammation
Bradikinin, histamin,
prostaglandins
A. Increased capillary permeability
B. Fluid/cellular exudation
C. Edema of mucous membrane
A. Hypersecretion of mucous
B. Persistent cough
C. bronchoconstriction
Emphysema
Smoking, heredity,aging
Disequilibrium of elastase/antielastase
Overdistension of alveoli
Retention of CO2
hypoxia Resp acidosis
Chronic Obstructive Pulmonary Disease

Assessment
Cough
Dyspnea
Chest pain
Sputum production
Adventitious BS
Pursed lip
appearance
Alteration in LOC
Alteration in skin
color
Decreased metabolism
Weakness
Fatigue
Anorexia
Wt loss
Voice changes
Alteration in thoracic
anatomy (barrel chest)
Clubbing of fingers
polycythemia
Chronic Obstructive Pulmonary Disease
Collaborative Management
Rest
Increased oral fluids, 3 liters per day
Good oral care
Diet: calorie, CHON, CHO
O2 therapy not > 3LPM
Avoid smoking, pollutants
CPT, Deep breathing
Bronchial hygiene measures steam, aerosol,
medimist inhalation
Facilitate removal of secretions, Suction as needed

Chronic Obstructive Pulmonary Disease
Pharmacotherapy
Expectorants/mucolytic
Guaiafenessin/ musolvan
Antitussives
Dextrometorphan, codeine
Bronchodilators
Aminophylline, ventolin, bricanyl, alupent
Antihistamines
diphenhydramine
Steroids
Antimicrobials

Pulmonary Emphysema
A lung disease which involves damage to
the air sacs (alveoli) in the lungs. The air
sacs are unable to completely deflate
(hyperinflation) and are therefore unable
to fill with fresh air to ensure adequate
oxygen supply to the body.
Barrel chest
pink puffer
Bronchiectasis
Permanent abnormal dilatation of bronchi
with destruction of muscular and elastic
structure of the bronchial wall.
Caused by bacterial infection; recurrent
lower respiratory tract infections;
congenital defects; lung tumors; thick
tenacious secretions.
Chronic Bronchitis
Excessive production of mucus in the bronchi
with accompanying persistent cough.
Hypertrophy/hyperplasia of the mucus secreting
glands in the bronchi, decreased ciliary activity,
chronic inflammation, and narrowing of the
small airways.
Caused by the same factors that cause
emphysema.
blue bloater
Bronchial Asthma
Bronchial obstruction is due to:
Bronchoconstriction
Hypersecretion of mucous
Bronchial wall inflammation with edema
Triggers or precipitating factor:
Inhaled allergens
Dust mites
Pollens
Food allergens
Non allergenic
Viral respiratory infection
Weather changes
Fumes, strong odors
Smoking
Exercise
Drugs- aspirin, NSAIDS

Bronchial Asthma
Management goals
Relieve bronchoconstriction
Maintain alveolar ventilation
Reduce airway inflammation/hyperreactivity
Mobilize secretions
Avoid drug toxicity

Bronchial Asthma
Pharmacotherapy
Adrenergic B 2-agonist
Anticholinergic
Corticosteroids
Supportive Care:
O2 inhalation
Hydration
Serial monitoring of ABGs
Psychosocial support

Pulmonary Tuberculosis
Classification:
Class I: no exposure
Class II: exposure no infection
Class III: disease, clinically active
Class IV: treated, disease not clinically
active
Class V: suspect
Pulmonary Tuberculosis
Client Education
TB is infectious, can be cured with antimicrobial
Transmitted by droplet
Cover mouth, nose when coughing, sneezing or
laughing
Wash hands
Wear masks when advised
Take medication religiously as prescribed
Primary anti-TB drugs includes
Rifampicin
Isoniazid
Pyrazynamide
Ethambutol
Streptomycin
Pulmonary Embolism
Causes:
Fat embolism
Multiple trauma
PVCs
Abdominal surgery
Immobility
Hypercoagulability

Assessment:
Restlessness
(hallmark)
Dyspnea
Stabbing chest pain
Cyanosis
Signs of shock
Pulmonary Embolism
Nursing Intervention
O2 therapy STAT
Early ambulation post
op
Do not massage legs
post op
HOB elevated
Heparin (2 wks) then
coumadin (3-6) months
Patient teaching
Dos
Observe for bleeding
Use soft toothbrush,
electric razor
Evaluate use of
contraceptives
Don'ts
Take ASA with
coumadin
Restrictive clothing on
legs
Prolonged
sitting/standing
Smoking

Histoplasmosis
Etiologic Factors
Commonly seen in Rural Midwest,
Southeastern US
Not spread from human to human
Fungus seen in pigeon, chicken manure
Manifestation:
Cough
Fever
Joint pains
Malaise

Histoplasmosis
Diagnosis
CXR
Histoplasmin Skin Test (same PPD)

Management
Amphotericin B
Toxicity: anorexia, chills, fever, nephrotoxicity,
headache, adrenal failure
Teach farmers to wet chicken manure
before shoveling so that dust does not
become airborne
Pneumoconiosis
An occupation-related respiratory disorder
caused by prolonged inhalation of high
concentration of industrial dust
Etiology:
Asbestosis (asbestos)
Silicosis (silicon)
Bagossis (hay dust)
Coal workers Pneumoconiosis (black lung)
LUNG CANCER
Description
Refers to malignant tumor growth
within the bronchial tissue or lung
parenchyma.
Types include:
Squamous cell 35 50% of all lung
cancers.
Adenocarcinoma 15 35% of all lung
cancers.
Small cell (oat cell) 20-25% of all lung
cancers
Large cell 10-15% of all lung cancers
Etiology and Incidence
Predisposing factors chronic exposure to
pulmonary irritants

Family history of lung cancer

Tend to have poor prognosis, unless it is
very well defined and removed by surgery.
Pathophysiology
As the lung tissue experiences
irritation, it undergoes a series of
changes and eventually gives rise to a
tumor.
Metastases can occur, especially when
the mother tumor is near areas of
lymph drainage.
Some tumors secrete hormones:
ADH reabsorption of water
ACTH stimulates adrenal glands to
produce steroids
Symptoms may include:
Cough
Wheezing
Shortness of breath
Chest pains
Hoarseness
Dysphagia (compression of esophagus)
Weight loss
Nursing Interventions
Prepare the patient for surgery if tumor is
small enough to be removed
Prepare patient for planned treatments
chemotherapy / radiation therapy
Analgesics as ordered to control pain
Adequate oxygenation through oxygen
therapy or planned activity-rest
Maintain nutritional status
Provide emotional support to the patient
and family