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Stanley C. Luces MD
OBJECTIVES
Describe the structures and functions of the upper and lower respiratory tracts Describe ventilation, perfusion, diffusion, shunting, and relationship of pulmonary circulation to these processes. Discriminate between normal and abnormal breath sounds Use assessment parameters appropriate for determining the characteristics and severity of the major symptoms of respiratory dysfunctions. Identify the implications of the various procedures used for diagnostic evaluation of respiratory function.
Respiratory Anatomy
Respiratory Anatomy
Respiratory Anatomy
The NOSE
The NASAL cavity is made up of bones, cartilages and turbinates or conchae The nostril is the external opening The choanae is the internal opening
The Pharynx
Musculo-membranous tube from
behind the nasal cavity to the level of the cricoid cartilage (C6)
The Pharynx
3 component parts 1. Nasopharynx 2. Oropharynx 3. Laryngopharynx
The pharynx
The pharynx functions 1. As passageway for both air and foods (in the oropharynx) 2. To protect the lower airway
The Larynx
Upper expanded portion of the trachea Made up of cartilages Function: air passageway and phonation
Bronchus
RIGHT Bronchus Wide Short Slightly vertical LEFT Bronchus
Narrow Long Slightly horizontal
Bronchioles
Primary bronchussecondary bronchustertiary bronchus terminal bronchioles
Terminal bronchioles belong to the respiratory unit
Respiratory unit
Respiratory bronchioles Alveolar ducts Alveolar sacs Alveolus
occurs
The Pleura
Surrounds the lungs and provide protection 1. Parietal pleura- in the chest wall 2. Visceral pleura- intimately attached to the lungs 3. Pleural space- in between the two pleurae
MECHANICS OF BREATHING
A. Muscles of Inspiration 1. Diaphragm
- when contracts, abdominal contents are pushed downwards and the ribs are lifted upward & inward - increasing the volume of thoracic cavity
2. External intercostals - Elevates the ribs and sternum - Increases the thoracic volume by increasing the diameter of thoracic volume
Muscles of Expiration 1. Abdominal muscles - Compress the abdominal cavity push the diaphragm up, and push air out of the lungs. 2. Internal Intercostal muscles - Pulls the ribs downward and inward
Respiratory Muscles
Respiratory Physiology
1. Ventilation and gas exchange 2. Mechanics of breathing 3. Gas transport 4. Pulmonary volumes and capacities 5. Respiratory control
OXYGEN moves by the mechanism of DIFFUSION Exchange of gases across the respiratory membranes is influenced by: 1. Thickness of the membrane e.g. pulmonary edema thickness doubled > decreased rate of diffusion 2. Total surface area e.g. emphysema and lung Ca > restricted gas exchange 3. Concentration gradient for gases across the membrane.
Gas exchange
Mechanics of Breathing
"Work" of Breathing
Compliance work - that required to expand the lungs against its elastic forces
Recoil- that required to collapse the lungs
Pulmonary Pressures
Major factors in determining the extent of lung expansion and compliance during the processes of inspiration and expiration:
Alveolar pressure Intrapleural pressure Alveolar surfactant
During inspiration, the thoracic cage enlarges, enlarging both lungs and decreasing the pressures.
Pulmonary Pressures
Boyles Law: During inspiration, the enlargement of the thoracic cage decreases the pressure in the alveoli to about 3 mmHg. This negative pressure pulls air through the respiratory passageways into the alveoli.
Pulmonary Pressures
Boyles Law: During expiration, the exact mechanism and effects occur. Compression of the thoracic cage around the lungs increases the alveolar pressure to approximately +3 mmHg which pushes the air out of the alveoli into the atmosphere.
Pulmonary Pressures
Intrapleural Pressures:
Intrapleural space is the space between the lungs and the outer walls of the thoracic cavity. The pressure here is ALWAYS a few mmHg less than in the alveoli for the following reasons:
Surface tension of the fluid inside the alveoli always makes the alveoli try to collapse. Elastic fibers spread in all directions through the lung tissues and tend to contract the lungs.
These factors pull the lungs away from the outer walls of the pleural cavity, creating an average negative pressure of 5 mmHg.
Pulmonary Pressures
Surfactant:
Surface active agent Detergent that greatly decreases the surface tension of fluid lining the alveoli.
Ventilation
Ventilation is the movement of air into the lungs
Fig. 15.11a
Fig. 15.11b
Fig. 15.15
Control of Respiration:Peripheral
1. Chemoreceptors in the carotid and aortic bodies
Sensitive to changes in pH and O2 Decreased O2 (HYPOXIA) increase respiration Decreased pH (acidosis) increase respiration
2. Hering-Breurer reflex
Stretch receptors in the lungs limit the inspiration
Fig. 15.16
Respiratory muscles contract rapidly generating high pressures in the lungs while the vocal cords remain tightly closed.
Vocal cords open suddenly, allowing pressurized air in the lungs to flow out in a blast.
Respiratory muscles contract rapidly generating high pressures in the lungs while the vocal cords remain tightly closed.
Vocal cords open suddenly, allowing pressurized air in the lungs to flow out in a blast through the nose and mouth.
edema
tumor
Cough Find out whether cough is productive or nonproductive. Note how and when cough began (sudden or gradual). Identify what makes cough better and what makes it worse Determine how long it has been present and has there been any change in its characteristics
Sputum The goblet cells and mucous glands secrete mucus that coats the interior lung surface. Sputum is composed of mucus, cellular debris, microorganisms, blood, pus, and foreign particles is the substance ejected from the lungs by coughing or clearing the throat.
Sputum Descriptors:
Amount: Scant Copious
Wheezing Sound produced when air passes through partially obstructed or narrowed airways on expiration. Determine when wheezing occurs. Find out what makes the client wheeze. Determine whether wheeze is loud enough for others to hear. Ask what helps stop breathing
Cyanosis
Bluish discoloration of the skin
Cyanosis
Interventions:
Check for airway patency Oxygen therapy Positioning Suctioning Chest physiotherapy Measures to increased hemoglobin
Hemoptysis
Expectoration of blood from the respiratory tract Hemoptysis
Often the first indication of serious bronchopulmonary disease. Massive hemoptysis: coughing up of more than 600 ml of blood in 24 hours.
Common causes: Pulmo infection, Lung CA, Bronchiectasis, Pulmo emboli Bleeding from stomach acidic pH, coffee ground material
Hemoptysis Coughing up of blood or blood tinged sputum. The source of bleeding might be from anywhere in the upper or lower airways or from the lung parenchyma.
Hemoptysis
Interventions: Keep patent airway Determine the cause Suction and oxygen therapy Administer Fibrin stabilizers like aminocaproic acid and tranexamic acid
Chest pain The chest pain of pulmonary origin can derive from the chest wall, parietal pleura, visceral pleura, or the lung parenchyma Identify whether chest pain is respiratory or cardiac in origin
Characteristics Well-localized constant ache increasing with movement Sharp, abrupt onset increasing with inspiration or with sudden ventilatory effort (cough, sneeze), unilateral
Pleura
Lung Parenchyma
Pleural inflammation (pleurisy), pulmonary infarction, pneumothorax, tumors Benign pulmonary tumors, carcinoma, pneumothorax
Epistaxis
Bleeding from the nose caused by rupture of tiny, distended vessels in the mucus membrane A vast network of capillaries, called Kiesselbachs plexus, line the mucosa of the nasal cavity. Most common site- anterior septum Causes: 1. trauma 2. infection 3. Hypertension 4. blood dyscrasias , nasal tumor, cardio diseases
- Avoid petrolatum gauze - posterior plugs for post. Epistaxis (for 5 days) - arterial ligation: internal maxillary or ethmoid artery ligation.
Epistaxis
Interventions 1. Position patient: Upright, leaning forward, tilted prevents swallowing and aspiration 2. Apply direct pressure. Pinch nose against the middle septum x 5-10 minutes 3. If unrelieved, administer topical vasoconstrictors, silver nitrate, gel foams 4. Assist in electrocautery and nasal packing for posterior bleeding
expansion
Restlessness
Dyspnea Cyanosis Altered respiration Altered mentation Tachycardia Cardiac arrhythmias Respiratory arrest
Pulmonary function test ABG=pH below 7.35 CXR- pulmonary infiltrates ECG- arrhythmias
COPD
These are group of disorders associated with recurrent or persistent obstruction of air passage and airflow, usually irreversible.
COPD
Asthma Chronic bronchitis Emphysema Bronchiectasis
COPD
The general pathophysiology In COPD there is airflow limitation that is both progressive and associated with abnormal inflammatory response of the lungs
ASTHMA
The acute episode of airway obstruction is characterized by
Asthma Pathophysiology
Immunologic/allergic reaction results
three main airway responses a. Edema of mucous membranes b. Spasm of the smooth muscle of
in histamine release, which produces
Assessment findings
Respiratory distress
Shortness of breath Expiratory wheeze Use of accessory muscles Irritability diaphoresis, cough, anxiety, weak pulse
Emphysema
There is progressive and irreversible alveolar destruction with abnormal alveolar enlargement
Emphysema
The result is INCREASED lung compliance, DECREASED oxygen diffusion and INCREASED airway resistance!
Emphysema
These changes cause a state of carbon dioxide retention, hypoxia, and respiratory acidosis.
Emphysema
Cigarette smoking Heredity, Bronchial asthma Aging process Disequilibrium between ELASTASE & ANTIELASTASE (alpha-1-antitrypsin)
Destruction of distal airways and alveoli Overdistention of ALVEOLI Hyper-inflated and pale lungs
Air trapping, decreased gas exchange and Retention of CO2 Hypoxia Respiratory acidosis
Emphysema Assessment
1. Anorexia, fatigue, weight loss
2. Feeling of breathlessness,
Emphysema Assessment
Hyper-resonance in percussion, decreased breath sounds with prolonged expiration Diagnostic tests: pCO2 elevated,
Chronic bronchitis
Chronic inflammation of the bronchial air passageway characterized by the presence of cough and sputum production for
mucus-secreting glands in the bronchi Decreased ciliary activity, chronic inflammation Narrowing of the small airways.
edema
Bronchiectasis
Permanent abnormal dilation
Bronchiectasis
Caused by bacterial infection or recurrent lower respiratory tract infections congenital defects (altered bronchial structures) lung tumors
Bronchiectasis: assessment
1. Chronic cough with production of
mucopurulent sputum, hemoptysis, exertional dyspnea, wheezing 2. Anorexia, fatigue, weight loss 3. Diagnostic tests
Bronchoscopy reveals sources and sites of secretions
Major Pathophysiology Bronchial hypersensitivity Distal airway DESTRUCTION Hyper-secretion of Mucus and inflammation
Major Manifestation
COPD
Wheezing (reversible) BARREL CHEST and thin body Abundant mucopurulent sputum and cough, Cor pulmonale Hemoptysis and infection
COPD Management
1. Rest- To reduce oxygen
demands of tissues
COPD Management
4. Diet
Moderate fats Low carbohydrate diet limits carbon dioxide production (natural end product).
COPD Management
5. O2 therapy 1 to 3 lpm (2 lpm
is safest)
Do not give high concentration of oxygen. The drive for breathing may be depressed.
COPD Management
6. Avoid cigarette smoking, alcohol, and environmental pollutants.
7. CPT percussion, vibration, postural drainage
COPD Management
8. Bronchial hygiene measures Steam inhalation Aerosol inhalation
COPD Management
Pharmacotherapy 1. Expectorants (guaiafenessin)/ mucolytic (mucomyst/mucosolvan) 2. Antitussives Dextrometorphan Codeine
COPD Management
Pharmacotherapy
3. Bronchodilators
Aminophylline (Theophylline) Ventolin (Salbutamol) Bricanyl (Terbutaline) Alupent (Metaproterenol)
Observe for tachycardia
Bronchodilators
Types Beta 2 agonists Examples Salbutamol Terbutaline Aminophylline Theophylline Ipratropium Action Stimulate Beta 2 receptor in bronchus Relaxes bronchial smooth muscle Blocks parasympathetic system
Direct Bronchodilator
Anti-cholinergic
COPD Management
Pharmacotherapy 4. Antihistamine Benadryl (Diphenhydramine) Observe for drowsiness
5. Steroids Anti-inflammatory effect 6. Antimicrobials
Oxygenation