respiratory system

respiratory system

• atmospheric air filtered, warmed & humidified

• gases exchanged (oxygen/carbon dioxide)

• consists upper & lower respiratory tract

pathway~ respiratory system

nose, pharynx, larynx, trachea, bronchi, bronchioles, alveoli

noses & sinuses

• mucus and hairs in the nostrils trap dust and particles

• cilia in the nose filter foreign particles send them through GI tract to be destroyed

• olfactory nerve in septum & nasal passages responsible for smell

• sinuses (mucus lined cavities) lighten skull & provide resonance for voice

upper respiratory tract

• pharynx extends from the nose to the larynx

• larynx extends from pharynx to trachea. the part of the larynx above the vocal chords is part of the upper respiratory tract

• epiglottis (flap of cartilage) drops down to cover the trachea and prevent food from entering it during swallowing

components of lower respitory tract

trachea, bronchi, bronchioles, lungs

trachea~ lower respiratory tract

• the vocal chords (directly behind the Adam’s apple) divide upper from lower respiratory tract. the cords and the part of the larynx below the vocal cords are part of the lower respiratory tract. air passes from larynx into trachea (windpipe)

• c rings of hyaline cartilage and connective tissue form a tube extending from the end of the larynx until it branches into R and L bronchi

bronchi~ lower respiratory tract

• 2 bronchial tubes descend from trachea

• each bronchus enter lung at hilum & branches off into tracheobronchial tree

• main (primary) bronchi→ secondary bronchi→ tertiary bronchi→ bronchioles→ alveoli

bronchi→ bronchioles→ alveoli

• as bronchi become smaller, walls become thinner

• amount of cartilage decreases, and they become bronchioles

• bronchi and bronchioles lined with ciliated mucous membrane

• tiny air sacks called alveoli, where gas exchange takes place, branch off from bronchi

lungs~ lower respiratory tract

• external respiration takes place in alveoli- O2 delivered and CO2 removed as waste product

• lungs are filled with alveoli, nerves and blood & lymph vessels

• right lung 3 lobes

• left lung 2 lobes & larger cardiac notch

the role of surfactant

lipoprotein, similar to detergent, secreted by alveolar cells- decreases surface tension of fluid lining alveoli and permits expansion as well as preserving elasticity of lungs, thus preventing collapse of alveoli (atelectasis) between breaths

• alveoli expands~ opens easily

pleura

• double layered sac covers lungs chest cavity; secretes lubricating fluid, preventing friction between lungs and chest wall

• visceral pleura- membrane covering lungs

• parietal pleura- membrane lining chest cavity

• pleural cavity (intrapleural space): potential space between two layers (parietal & visceral) of pleura, containing a tiny amount of fluid

apnea

cessation of beathing (may be temporary; permanent apnea= respiratory arrest and death)

eupnea

normal respirations (12-20 rpm)

bradypnea

slower than normal respirations (<12)

tachypnea

faster than normal resp (>20)

dyspnea

difficulty breathing

orthopnea

denotes dyspnea that is relieved when a person sits up

ventilation (breathing)

mechincal process respiration moves air to and from alveoli (2 part)

inhalation or inspiration

breathing air in; diaphragm contracts, chest cavity increases in size, creating internal vacuum and brining air into the lungs

exhalation or expiration

breathing out; passive movement; diaphragm relaxes and air moves out

intercostals~ mechanics of breathing

muscles between ribs contract down, forward and outward to lift and spread the ribs during inhalation, creating negative pressure to draw air in

assiting muscles~ mechanics of breathing

mastoid, trapezium, pectorals, abdominus rectus

diaphragm~ mechanics of breathing

dome shaped muscles separating thoracic and abdominal cavities which contracts & flattens to increase pleural space and vacuum

action of ventilation

normal breathing result of nervous stimulation of respiratory center in brain’s medulla. medulla sends impulses to diaphragm and intercostal muscles

medulla~ 3 factors that control breathing

medulla’s respiratory center automatically controls depth/rate without conscious thought

pons~ 3 factors that control breathing

work with medulla to produce normal rhythm

cerebral cortex~ 3 factors that control breathing

allow voluntary control over breathing, singing, earting, or changing rate of breathing. medulla will take over if needed: trying to hold breath

regulatory mechanisms of ventilation

• the level of CO2 in the blood is the primary regulator of breathing. as CO2 builds up, it makes the blood more acidic (drop in pH), which is detected by the chemoreceptors in the medulla

• when drop in pH is detected by the medulla, it signals the muscles of respiration to increase rate and depth of respiration

external respiration~ types of gas exchange (respiration)

(pulmonary) exchange of oxygen for carbon dioxide within the alveoli of the lungs

internal respiration~ types of gas exchange (respiration)

(tissue) exchange of O2 for CO2 within the cells

acid-base balance

CO2, a waster product of cellular respiration, is excreted through the respiratory system

high co2 (hypercapnia)

low pH (acidosis)

low co2 (hypocapnia)

high pH (alkalosis)

normal blood pH

7.35-7.45

diagnostic testing

• sputum specimen: detects presence blood/microorganisms

• throat culture: tests for presence of infection using mucus & secretions from back of throat (C&S)

• arterial blood gases (ABGs): PaO2, PaCO2, pH, HCO3, SaO2

• chest x ray (CXR) & CT scan: diagnose lung tumors, abscesses, TB, pneumonia

• magnetic resonance imaging (MRI): not as good as CT to dx lung disorders, but no radiation

• pulmonary function test (PFT): measured airflow and assesses general respiratory status

arterial blood gases

blood from an artery is tested to measure the levels of oxygen, carbon dioxide, and acid

• pH= blood acidity (7.35-7.45)

• PaO2= dissolved oxygen in arterial blood (75-100m mmHg)
  indicates lung efficiency in oxygenating blood

• PaCO2= dissolved carbon dioxide in the blood (35-45 mmHg)
  indicates ventilation status >45 = hypoventilation <35= hyperventilation

• HCO3= amount of bicarbonate in the blood (22-28 mEq/L)
  >28= metabolic alkalosis <22= metabolic acidosis

• SaO2= percentage of hemoglobin carrying oxygen (95-100%)

pulmonary function test (PFT)

measures inspiratory and expiratory volume using a spirometer

• dx disorders/assesses effectiveness of therapy

• ability/willingness to follow instructions is vital

• vital capacity: total lung capacity; amt air that forcibly exhaled after max breathe

• residual volume: amt of air remaining in lungs after forced exhalation

• tidal volume: volume of air in an average breath

diagnostic testing

• bronchoscopy- endoscope passed into trachea/bronchi for visualization/retrieval of tissue or foreign objects

• skin test- PPD tuberculin skin test (PST)

• lung scans- radioactive dye is injected or inhaled; cancerous cells, dead/diseased tissue detected

• thoracentesis- drawing fluid out of lungs for dx testing or relieve pressure and ease breathing

• paracentesis- fluid is drawn out of abdominal cavity to relieve breathing difficulties caused by immobilization of diaphragm by fluid accumulation

Mantoux Tuberculin Skin Test (TST)

• 0.1 mL purified protein derivative injected intradermally inner forearm

• after 48-72 hours area is examined for induration & erythema

• >15mm induration is positive result in a low risk individual

• positive individuals that have been exposed to TB or have TB antibodies due to BCG vaccine

• positive never repeated; CXR, sputum culture and/or quantiferon gold test to verify result

bronchoscopy

• endoscope inserted into trachea and bronchi for visualization or retrieval of tissue or foreign objects

• throat is anesthetized + benzodiazepine given for relaxation

• NPO 6-8 hours pre & post procedure (risk for aspiration)

• side lying after to facilitate drainage

• watch for throat swelling, coughing up blood & dyspnea (emergency tracheostomy may be necessary)

• initiate clear liquid diet

common cold

viral URI, AKA acute rhinitis

allergic rhinitis

inflammation of nasal passages due to allergy

nasal polyps

growth in the lining of the nose

otitis media

middle ear infection, often associated with URTIs

sinusitis

inflammation of sinuses, often following a cold

pharyngitis

sore throat (viral or bacterial). strep throat when caused by group A steptococcus

laryngitis

inflammation of larynx (vocal chords) common sign of URI

tonsillitis

inflammation of the tonsils

epiglottitis

rare of serious inflammation of epiglottis

influenza

viral respiratory condition~ upper respiratory tract
highly contagious viral respiratory illness~ lower respiratory tract

common cold

• mild viral infection of the URT, mainly affecting the nose and throat

• the more frequent infectious disease in humans (adults average 2-3/yr; children experience more frequently)

• caused by over 200 viruses, most commonly rhinoviruses

• spreads through droplets from coughing or sneezing, and touching contaminated surfaces

• s/s: runny or stuffy nose, sore or scratchy throat, cough, sneezing, HA, mild body aches, fatigue

• tx: OTC meds to relieve pain and nasal/sinus congestion
  symptoms peak within 2-3 days and resolve in 7-10 days (cough may linger)

allergic rhinitis

allergic reaction to a protein substance (pollen, flowers, grasses, dust, feather, animal dander)

• risk factor- family history

• s/s- edema, itchy nose, excessive sneezing, profuse watery discharge from nose and eyes

• worsen on windy days and in the morning/evenings

• tx- avoid what causes it (avoiding animal contact, abstaining from a particular food, avoiding dusty places); corticosteroids for allergy attacks

nasal polys

• tumors that look like a cluster of grapes
  usually benign but can be malignant

• they can obstruct breathing and drainage of sinuses

• sometimes body absorbs it, can be surgically removed, checked for malignancy, may grow back

otitis media

• commonly seen in young children, but also affects adults

• infection or inflammation of the middle ear

• viral or bacterial: usually following a cold or respiratory infection

• s/s- Otalgia (ear pain), fever, hearing loss, fluid leakage from ear, burst eardrum

• 80% of cases resolve without antibiotics

sinusitis

• inflammation of sinuses that may be acute or chronic

• maxillary sinus most frequently affected by nasal passage infection. risk factors: people with allergies or have frequent colds

• dx: nasal endoscopy, CT, MRI, cultures, or biopsies

• s/s: pressure/congestion of sinus, pain in upper teeth, fever, fatigue, poor appetite, post nasal drip

• tx: allergy testing may be done, and desensitization injections given since in many cases sinusitis is result of allergies; increased fluids; antibiotics to control infection; analgesics to relieve pain; antihistamines; steam inhalation; moist hot packs; warm saline irrigation. Endoscopic sinus surgery can remove polyps, scar tissue or inflamed mucosa

pharyngitis

• sore throat (viral or bacterial)

• bacterial pharyngitis is usually caused by group A streptococcus (strep throat)

• viral pharyngitis treated supportively with rest, fluids, pain relievers

• bacterial pharyngitis should be treated with antibiotics

• untreated strep throat can lead to serous complications

  • rheumatic fever (develops 5 weeks after untreated strep infection). can lead to permanent heart dmg, stroke | glomerulonephritis | abscesses | pneumonia | meningitis | toxic shock syndrome, death

laryngitis

• inflammation of the larynx (voice box), causing hoarse, weak, or lost voice, sore throat, mild fever, cough

• can be acute or chronic

• caused by viral infection, voice overuse, irritants (smoke, chemicals, air pollution), bacterial or fungal infection, injury to vocal cords

• most cases resolve without treatment within 2 weeks

• antibiotics if bacterial

• corticosteroids may be used to restore voice

tonsillitis

• inflammation of the tonsils

• viral or bacterial (usually group A streptococcus or staphylococcus)

• s/s: sore throat; red, swollen tonsils (sometimes with white or yellow spots); pain on swallowing, fever and chills, swollen lymph nodes in neck, bad breath, HA, earache

• tx: antibiotics for bacterial (penicillin or amoxicillin)

• tonsillectomy for severe or frequently recurring cases

epiglottitis

• life threatening inflammation and swelling of the epiglottis

• swelling can quickly block the airway

• causes: usually bacterial infection (Haemophilus influenza type B)

• less common since Hib vaccinations (prior to vaccine, child mortality was 1000/year)

• s/s: sudden severe sore throat, dysphagia, drooling, hoarse voice, high fever, stridor, tripod breathing

• emergency intubation or tracheostomy

influenza

highly contagious respiratory illness caused by viral strains that mutate regularly

• direct/indirect transmission: droplets, inhaled directly from cough/sneeze/talking, OR touching communal areas
  best prevention: handwashing; vaccination, avoid crowds

• primarily affects nose, throat, lungs

• s/s: sudden, muscle pain, fever, chills, HA, sneezing, cough, sore throat, N/V
  tx: fluids, rest, Tylenol, watch for chest pain, high temp, high pulse

• elderly, immune compromised, those with heart disease, pneumonia, encephalitis greater risk for death

bronchitis (acute)

inflammation of bronchi follows respiratory infection

• s/s: dry cough, then productive cough with mucus & pus, fever, malaise

• tx: bed rest, fluids, nutritious diet, humidified air, antibiotics if bacterial, salicylates

• care: cover mouth while coughing, dispose of sputum & tissues using standard precautions

• acute bronchitis may develop into chronic bronchitis

bronchitis (chronic)

• productive cough that lasts at least 3 months over the course of 2 years

• chronic inflammation of bronchi causes sticky mucus to build up in airways

• typically leads to COPD

• not caused by virus or bacteria- cigarette smoking is leading cause

• risk factors: repeated episodes of acute bronchitis; influenza; pneumonia; smoking; long term exposure to smoke, air pollution, chemical fumes, dust; age (usually over 40 years of age); genetics (alpha 1 antitrypsin deficiency);

• dx: hx of cough, habits, CXR, fluoroscopic exam, sputum test

• s/s: frequent chronic productive cough; wheezing; shortness of breath; chest tightness; may get frequent colds; expectoration of mucus & pus

• tx: bronchodilators, postural drainage & chest percussion to facilitate secretion removal; possible ABX

• care: prevent infection/inflammation, provide rest

bronchiectasis

chronic lung condition where bronchi become permanently widened and thickened d/t repeated inflammation or infections, impairing ability to clear mucus

• risk factors: cystic fibrosis, immunodeficiency; 40% of causes unknown etiology

• dx: CXR, CT, PFT, Bronchoscopy

• s/s: early morning productive cough, greenish yellow, foul smelling sputum and hemoptysis, wheezing, SOB, chest pain

• tx: postural drainage, TCDB, humidified air, expectorants, antibiotics for infections

• care: nutrient rich diet, fresh air, rest, mouth care, prompt tx of respiratory conditions

pneumonia

infection inflames alveoli in one or both lungs. alveoli fill with fluids or pus (immune cells, plasma proteins)

• s/s: severe sharp chest pains; chills; fever; cough; yellow, green, or brown sputum; high pulse & resp; cyanosis; increased WBC, mental changes

• dx: auscultation of lungs: bubbling or crackling sounds suggest pneumonia. CBC: elevated WBC. chest xray: determine extent & location of infection. pulse oximetry: pneumonia can prevent moving oxygen into bloodstream. C&S of sputum: type of organism and what antibiotic will be effective

• tx: administration of O2, assess VS & oxygen saturation, push fluids, small frequent meals, high fowler’s position, turn, cough, deep breathing, antibiotics or antifungals depending upon cause

bacterial pneumonia

common in immune compromised cold/flu, age, poor, health, 2 pneumococcal pneumonia vaccines given at 65 protects against pneumonia caused by streptococcus

viral pneumonia

caused by variant flu virus; rarely fatal

fungal pneumonia

immunocompromised individuals; soil & bird droppings; Pneumocystis Jiroveci opportunistic infection with HIV/AIDS/chemo pt

aspiration

fluid/foreign object drawn into lungs, causing inflammation, fluid accumulation, edema and pneumonia

pleurisy

inflammation of the pleura, causing sharp chest pain that worsens with breathing, coughing, or sneezing
can result from infections (pneumonia), autoimmune diseases (lupus, rheumatoid arthritis), pulmonary embolism, or lung injuries

• dx: auscultation for pleural friction rub, blood tests to check for injection or autoimmune disease, chest x-ray, ct scan

• tx: treat underlying cause, NSAIDs, corticosteroids, cough suppressants, lying on the affected side

empyema (pyothorax)

collection of pus in the pleural cavity

• cause: acute secondary infection after TB, lung abscess, or pneumonia or introduced by trauma. difficult to diagnose because primary causes mask symptoms

• s/s: unilateral chest pain, cough, fever, dyspnea, and malaise

• dx: chest xray, thoracentesis and CT scan

• tx: cure the infection with antibiotics and drain the chest of pus with a chest tube

pulmonary abscess

a localized, pus filled cavity within lung tissue, surrounded by inflamed tissue

• usually caused by aspiration of oral bacteria due to anesthesia, sedation, neurologic disorders; can be spread from infection elsewhere in the body

• s/s: gradual onset: cough, fever, halitosis, chest pain, fatigue, anorexia

• dx: chest xray, ct scan, sputum specimen

• tx: prolonged IV antibiotics, drain large abscess

pulmonary fibrosis

progressive scarring of lung tissue, making it increasingly difficult to breathe
scarring is permanent and usually worsens overtime

• s/s: SOB on exertion, dry cough, fatigue, and weakness, unexplained weight loss, chest discomfort

• environmental exposure to hazardous chemicals, autoimmune disease (rheumatoid arthritis, scleroderma, systemic lupus erythematosus. Cause often unknown

• tx: supportive; prevent infections

cystic fibrosis

autosomal recessive disease, thicky, sticky mucous affects respiratory, GI (pancreas & liver) reproductive function (mainly men)

• clogs airway, breathing problems and bacterial lung infections coughing, wheezing, inflammation

• permanent lung dmg over time, with formation of scar tissue (fibrosis) and cysts

• affects pancreatic function/digestive enzyme production, diarrhea, malnutrition, poor growth, weight loss

• dx: genetic testing, newborn screening, sweat test

• tx: percussion (oscillation) vest, antibiotics acute infection, corticosteroids, bronchodilators, mucus thinners, enzyme therapy, oxygen decrease hearts workload

• care: encourage vaccination, push fluids, teach hand hygiene, compliance; prevent infection Avg lifespan 26 in 2008, 66 in 2022

tuberculosis

airborne respiratory disease caused by Mycobacterium.
tuberculosis attack lungs

• risk factors: HIV, substance abuse, renal failure, age, immunosuppression, DM, crowded or unclean living conditions, homelessness, poor diet

• dx: tst skin test. QuantiFERON gold test, chest xray, sputum sample (C&S). if initial TST positive, QuantiFERON gold test is done

• s/s: cough, thick sputum (possibly blood streaked), fatigue, gradual weight loss, low grade fever, nocturnal diaphoresis, severe chest pains, dyspnea

• tx: multiple meds for 3-9 months, same time each day, diet high protein, vitamins A & C, no alcohol

• meds: INH (isoniazid) + Rifampin or INH+ Ethambutol
  monitor for hepatotoxicity

• vitamin B6 to prevent peripheral neuropathy

• when treating individuals with active infection: airborne isolation (negative pressure room & N95 mask)

• test exposed healthcare personnel with TST or QuantiFERON Gold

latent/inactive TB

granuloma in lungs encapsulates bacteria spores; no s/s, not infectious, positive TST, must be treated

active TB

immunocompromised, body unable to contain TB spores, bacteria grows & destroy lungs

airborne precautions

• tb, measles, chickenpox, disseminated herpes zoster

• source control: put a past on the pt, limit transport

• ensure appropriate patient placement in an airborne infection isolation room (AIR)

• restrict susceptible healthcare personnel

• personal protective equipment (PPE)

• immunize susceptible persons ASAP following unprotected contact with vaccine-preventable infections

valley fever (Coccidioidomycosis)

• fungus in soil in southwestern and western US, Mexico, Central & S America

• caused by breathing in spores; usually self limiting

• risk factors: immunodeficiency (HIV, age, steroid use, pregnancy)

• s/s: none or flu like (fatigue, cough, fever, SOB, HA, night sweats, muscle aches, joint pain, upper body or leg rash, if untreated can develop into meningitis)

• prevention: N95 mask when outdoors in endemic areas; keep down dust when working soil by spraying water

• tx: 3-6 months fluconazole antifungal

histoplasmosis

lung infection caused by inhaling fungal spores from bird and bat droppings

• mainly found in central and eastern US, but cases are increasing in CA

• most cases asymptomatic or mild

• s/s: fever, chills, HA, muscle aches, fatigue, cough, chest pain, body aches

• can spread to brain, liver, spleen, in people with compromised immune systems (disseminated histoplasmosis)

• antifungal medication (up to 1 year) for symptomatic cases

pulmonary hypertension

abnormally high BP in arteries of the lungs

• causes: hypertrophy of right ventricle

• s/s: SOB, fatigue, chest pain, dizziness, LE edema

• can result in R side heart failure

• can be caused by COPD, emphysema, pulmonary fibrosis

• tx: vasodilators, diuretics, anticoagulants, digoxin, O2 therapy, low Na diet, exercise

pulmonary embolism

dvt clot travels to pulmonary artery; can be fatal. commonly dx during autopsy

• causes: immobility, post surgical complication, increased coagulation, trauma, indwelling venous catheters

• s/s: dyspnea, chest pain and hemoptysis, syncope (fainting), SOB, shoulder pain, chest wall tenderness, wheezing, upper abdominal pain and cardiac arrhythmias

• treatment: oxygen, analgesics, anticoagulants and blood thinners. in severe cases, alteplase (clot buster drug) or surgical embolectomy

asthma

chronic, but reversible, inflammation of the bronchial lining

• risk factors: family history, viral or respiratory infection in infancy/childhood, irritant exposure in childhood

• paroxysmal episodes triggered by cold air, physical exertion, animal dander, overeating, stress & antigen exposure

• s/s: coughing, wheezing, chest constriction, bronchospasm and difficulty in expiration, accompanied by pallor and possibly followed by expectoration of thick, white mucous

• dx: lung function test, CXR, sinus xray

• tx: bronchodilators & anti-inflammatory meds

• nursing considerations: route & emergency med use, peak flow meter usage, teach trigger management; rinse mouth after steroid inhaler use, to avoid fungal infections of the mouth

• status asthmaticus: severe asthma attack unresponsive meds (epinephrine, albuterol, corticosteroids); medical emergency immediate treatment

pulmonary emphysema

progressive dmg to alveoli due to cigarette smoking or breathing polluted air. dmg to alveoli causes trapped air

• risk factors: smoking; long term exposure to smoke, air pollution, chemical fumes, dusk; age (usually over 40 years of age); genetics (alpha 1 antitrypsin deficiency)

• dx: ct scan of alveoli

• s/s: SOB with activity, becoming worse with time; wheeze, cough, fatigue, barrel chest, pursed lip breathing, weight loss; frequent chronic productive cough; chest tightness; may get frequent colds; dyspnea following exertion; tripoding; accessory muscle breathing
  leads to COPD

• tx: bronchodilators, corticosteroids, antibiotics, morphine at end of life comfort

• care: prevent infection inflammation, provide rest

chronic obstructive pulmonary disease (COPD)

• chronic & irreversible

• risk factors: smoking; asthma- 40% with asthma have COPD

• s/s: chronic coughing, wheezing, dyspnea and shortness of breath that gets worse with age

• dx: pulmonary function tests, CXR, CT, ABGs

• tx: medications: bronchodilators, corticosteroids, expectorants, mucolytics (liquefying agent), postural drainage, gravity to ease expectoration, increase fluids to 3 L/day, makes mucus thinner

• caution: no O2>3L; high levels of O2 administration suppresses respiratory drive because pt is on hypoxic drive (used to high levels of CO2, so switches to hypoxic drive)

• care: breathing exercises to increase exhalation volume, avoid extreme temps, eat small frequent meals, relaxation techniques, avoid irritants (smog/smoke), give fly and pneumococcal vaccines, provide fowlers/orthopneic positioning

pneumothorax

air in pleural cavity or between pleura from bleb rupture (spontaneous), trauma or surgical complication, causing the lung to collapse

• a serious condition resulting in less air exchange

• risk factors: chest surgery, chest tube drainage, thoracentesis

• s/s: SOB, severe dyspnea, asymmetrical chest, sudden sharp chest pain, hypotension (sudden drop in BP), weak pulse, tachycardia, cyanosis, change in level of consciousness

• tx: may resolve on its own; if not, remove air from chest cavity with aspiration needle or chest tube placement

• if due to chest tube disconnect, clamp chest tubes immediately and call for help

hmothorax

blood in pleural cavity from trauma or surgical complication, causing lung to collapse

• blood collects in lower part of pleural cavity

• risk factors: blunt or penetrating trauma; most serious post op complication from surgery

• s/s: SOB, severe dyspnea, asymmetrical chest, sudden sharp chest pain, hypotension, weak pulse, tachycardia, cyanosis, LOC change

• tx: remove blood from chest cavity using chest tubes

atelectasis

collapsed alveoli

• risk factors: surgery, injury, cystic fibrosis, lung disease; most commonly after surgery

• s/s: sob, tachypnea, wheezing, cough

• tx: deep breathing, coughing, postural drainage, incentive spirometer, CPAP

acute respiratory distress syndrome (ARDS)

• severe and life threatening

• inflammatory or immune response causes leaking of fluid into alveoli and results in hypoxemia

• progressive O2 deprivation following serious illness/injury

• risk factors: sepsis is the most common cause, burns, multiple blood transfusions, pancreatitis, drug OD, near drowning, pneumonia, aspiration

• s/s: hypoxemia that doesn’t improve with O2, intermittent crackles, SOB, tachypnea, low O2, hypotension, confusion, cyanosis

• tx: mechanical ventilation, prone position, corticosteroids, treat cause

mechanical ventilators

• used when a person cannot breathe adequately on their own:

• respiratory failure (ARDS, severe lung infection, chronic disease)

• during surgery with general anesthesia

• neurological injuries

• severe illness or injury (drug OD, toxin buildup, very weak muscles)

cancer of the larynx

• risk factors: males over 45 y/o (increasing in women) may be hereditary, chronic laryngitis, heavy drinkers and smokers

• s/s: chronic hoarseness, decreased ability to speak, painful swallowing/breathing, earache that won’t go away, mass is seen on the neck

• tx: radiation; removal of entire larynx (laryngectomy); if vocal cords also removed, will have tracheostomy

• nursing considerations: speech retraining; mechanical speech device; esophageal speech; emotional support, trach must be covered in shower

lung cancer

• description: more men than women age 45-70
  caused by smoking, industrial pollutants
  symptoms don’t occur until the disease is well advanced

• s/s: fever, chills, fatigue, chest pain, dry cough, dyspnea, coughing up mucus with blood, unexplained weight loss, by the time a person seeks medical attention the disease is likely to be advanced stage

• dx: bronchoscopy, sputum test, chest x ray

• tx: if tumor is localized it can be removed. removal of all or part of the lung (lobectomy). chemotherapy. radiation. can spread to lymph nodes and other organs, primarily the brain.

• treatment: usually does not cure the disease, can slow it down and improve the quality of life

sleep apnea

5 cessations of airflow for >10 seconds per hour of sleep, lasting up to 90 seconds each time

• common in middle aged overweight men, occlusion of throat by soft tissue

• dx: unexplained fatigue, difficulty concentrating, memory loss, inability to perform job duties, falling asleep during the day, witness to apnea

• tx: weight reduction, smoking cessation, alcohol avoidance, elevation of HOB, CPAP

• CPAP room air or O2 delivered at night via machine. continuous positive pressure holds alveoli open & prevents obstruction, increases oxygen, reduces breathing effort

alternatives to CPAP for sleep apnea

½ of pt stop using CPAP within the first year

alternatives:

• oral appliance therapy

• MADs (mandibular advancement device) move the jaw forward to open the airway

• TRDs (tongue retaining device) prevent the tongue from blocking the airway

• tongue muscle stimulation devices strengthen the tongue muscles with electrical signals

surgery

• UPPP (uvulopalatopharyngoplasty)

• inspire implant device stimulates muscles to keep airways open

• weight loss, positional therapy, exercise

vicious cycle

respiratory disease raises caloric need while making eating harder

• dyspnea > hard to eat > poor intake- weight and muscle loss > weaker breathing muscles

• the cycle repeats

• the diaphragm is a skeletal muscle. losing lean muscle weakens the diaphragm, making respiration more difficult and increasing infection risk

why malnutrition is so common in respiratory disease

• dyspnea while eating (chewing and swallowing interrupt breathing)

• early fullness (flat diaphragm and air trapped crowd the stomach)

• altered taste (mouth breathing, oxygen, steroid dry mucosa)

• fatigue (high work of breathing tires the pt)

• decreased appetite (hypoxia, medications, chronic illness)

• depression/isolation (chronic illness burden)

macronutrients & CO2

different fuels produce different amounts of CO2 per unit of oxygen used (the respiratory quotient)

• RQ= volume of CO2 produced/volume of O2 consumed

• fat= lowest CO2 RQ 0.7

• protein= moderate CO2 RQ 0.8

• carbohydrate= highest CO2 RQ 1.0

carbohydrates produce the most CO2. for a CO2 retainer (COPD), a higher fat, lower carb diet with adequate protein produces less CO2 to exhale. adequate total calories matter most- strict carb restriction is reserved mainly for documented CO2 retention

making eating easier~ nursing interventions that work

• small, frequent meals (5-6/day)

• largest meal early in the day

• meals timed after treatments and rest

• bronchodilators administered before meals

• sit upright (high Fowler’s)

maximize nutrition~ nursing interventions that work

• calorie and protein dense foods

• soft, easy to chew options

• supplements between meals

• avoid gas forming/carbonated foods and beverages

support and monitor~ nursing interventions that work

• oral care before meals

• keep prescribed O2 on (check nasal cannula placement)

• fluids between meals

• track weight, intake, albumin level

aspiration safety

• respiratory pt tire and may be sob while eating, raising aspiration risk

• position (upright at 90 degrees while eating; stay upright 30-60 min after)

• pace (small bites, slow pace, full swallow before next time)

• watch (cough, choking, or a wet/gurgly voice- report dysphagia)