RESPI PT 1

Upper Respiratory Tract

- Nose

- Paranasal Sinuses

- Pharynx/Throat

- Adenoids (Pharyngeal tonsils)

- Larynx (voice box)

- Epiglottis

- Trachea (windpipe)

Nose

passageway for air to pass to and from the lungs

Paranasal sinuses

- resonating chamber in speech

- common site of infection

Pharynx/Throat

divided into three regions:

- nasal

- oral

- laryngeal

passageway for the respiratory and digestive tracts

Adenoids

- pharyngeal tonsils

- guarding the body from invasion by organisms entering the nose and the throat

Larynx

- voice box

- connects the pharynx and the trachea and consist of the following:

* epiglottis

* glottis

* thyroid cartilage

* cricoid cartilage

* arytenoid cartilages

* vocal cords

Epiglottis

valve flap of cartilage that covers the opening to the larynx during swallowing

Trachea

- windpipe

- passage between the larynx and the right and left main stem bronchi

Lower Respiratory Tract

- Lungs

* Pleural Cavity

* Bronchi and Bronchioles

* Alveoli

Pleural Cavity

lubricate the thorax and the lungs and permit smooth motion of the lungs within the thoracic cavity during inspiration and expiration

Alveoli

the lung is made up of about 300 million of these, constituting a total surface area between 50-100 m^2

Gas Exchange

O2 and CO2 during the process of breathing in and breathing out

Dyspnea

subjective feeling of discomfort while breathing; its causes may include multiple physiologic, psychological, environmental, or social factors

Cough

- reflex that protects the lungs from the accumulation of secretions or the inhalation of foreign bodies

- irritation or inflammation of the mucous membranes anywhere in the respiratory tract

Sputum Production

may be:

- purulent

- thin mucoid

- gradually increase

- pink tinged

- frothy pink

- foul smelling

purulent

- thick, yellow, green, or rust

- indicates bacterial infection

thin mucoid

indicates viral bronchitis

gradual increase of sputum

indicates chronic bronchitis

pink tinged mucus

indicates lung tumor

frothy pink

- profused often welling up into the throat

- indicates pulmonary edema

foul smelling sputum and bad breath

indicates lung abscess, bronchiectasis

Chest pain

- may be sharp, stabbing, and intermittent, or it may be dull, aching and persistent pain

- usually is felt on the side where the pathologic process is located although it may be referred elsewhere

Hemoptysis

can present as small to moderate blood-stained sputum to a large hemorrhage and always warrants further investigation.

Clubbing

- sponginess of the nail bed and loss of the nail bed angle

- a sign of lung disease that is found in patients with chronic hypoxic conditions, chronic lung infections, or malignancies of the lung

Cyanosis

- bluish coloring of the skin

- a very late indicator of hypoxia

Chest Configuration

- Barrel Chest

- Funnel Chest

- Pigeon Chest

- Kyphoscoliosis

Barrel Chest

- result of overinflation of the lungs, which increases the anteroposterior diameter of the thorax

- occurs with aging

- hallmark sign of Emphysema and COPD

Funnel Chest

- Pectus Excavatum

- depression in the lower portion of the sternum

- may compress the heart and great vessels, resulting in murmurs

- may occur with rickets or Marfan syndrome

rickets

softening and weakening of bones due to extreme or prolonged Vit D. Deficiency

Marfan Syndrome

genetic disorder that changes the proteins that help make

healthy connective tissue

Pigeon Chest

- Pectus Carinatum

- anterior displacement of the sternum, increases the anteroposterior diameter

- may occur with rickets, Marfan syndrome, or severe kyphoscoliosis

Kyphoscoliosis

- elevation of the scapula and a

corresponding S-shaped spine

- may occur with osteoporosis and other skeletal disorders that affect the thorax

Breathing Patterns

- Eupnea

- Bradypnea

- Tachypnea

- Hyperventilation

- Hypoventilation

- Hyperpnea

- Apnea

- Cheyne-Stokes

- Biot's respiration

- Obstructive

Eupnea

- Normal breathing

- 12-20 breaths/min

Bradypnea

- Slower than normal rate with normal depth and regular rhythm

-

Tachypnea

- Rapid shallow breathing

- >24 breaths/min

- Associated with pneumonia, pulmonary edema, metabolic acidosis, septicemia, severe pain, or rib fracture

Hypoventilation

Shallow irregular breathing

Hyperpnea

Increased depth of respirations

Hyperventilation

- Increased rate and depth of breathing that results in DECREASED PaCO2 levels

- inspiration and expiration nearly equal in duration

- Associated with exertion anxiety and metabolic acidosis

- TTT: pursed lip breathing / closed mouthed + 1 nostril breathing

Kussmauls's respiration

hyperventilation associated with diabetic ketoacidosis or untreated kidney failure

Apnea

- Period of Cessation of breathing, time, duration varies

- May occur briefly during other breathing disorders such as with sleep apnea

- life threatening if sustained

Cheyne-Stokes

- Regular cycle where the rate and depth of breathing increases, than decreases until apnea (usually about 20s) occurs

- Duration may vary & progressively lengthen ; should be timed and reported

- Associated with heart failure and damage to the respiratory center (drug induced, tumor trauma)

Medulla Oblongata

Respiratory center of the brain

Biot's Respiration

- Period of normal breathing (3-4 breaths) followed by a varying period of apnea (usually 10-60 s)

- also called as Ataxic breathing; associated with complete irregularity

- Associated with respiratory depression resulting from drug overdose and brain injury , normally at the level of the medulla

Obstructive

- Prolonged expiration

- Associated with airway narrowing and seen in Asthma, chronic obstructive pulmonary disease, and bronchitis

Respiratory Excursion

- assesses the patient for range and symmetry of excursion

- anterior assessment: the nurse places the thumbs along the costal margin of the chest wall and instructs the patient to inhale deeply.

- Posterior assessment: placing the thumbs adjacent to the spinal column at the level of the 10th rib

- Normal: symmetric

Tactile Fremitus

- vibrations of the chest wall that result from speech detected on

palpation

- patient is asked to repeat "ninety-nine" or "one, one, one" as the nurse's hands move down the patient's thorax

- an increase in solid tissue per unit volume of lung enhances fremitus, and an increase in air per unit volume of lung impedes

sound.

Emphysema

no tactile fremitus

Pneumonia/consolidation

increased tactile fremitus

Thoracic Percussion

- Resonant

- Dullness

Resonant

thoracic percussion of healthy lung tissue

Dullness

thoracic percussion of air-filled lung tissue replaced by fluid or solid tissue

Normal Breath Sounds

- Bronchial/Tracheal

- Bronchovesicular

- Vesicular

Bronchial/Tracheal

High pitched & loud

Bronchovesicular

Moderate pitch, moderate loudness

Vesicular

Low pitch and soft

Abnormal Breath Sounds

Adventitious Breath Sounds:

- Wheeze/rhonchi

- Stridor

- Crackles/Rales

Crackles/Rales

- wet lungs

- crackling/clicking/rattling

- Nonmusical, discontinuous, POPPING SOUNDS, usually heard during INSPIRATION

- BASES of the lungs, Secondary to fluid in the airway/alveoli

Crackles/Rales

Disorders:

- Pneumonia

- Pulmonary edema

- Heart failure

Types:

- Fine

- Coarse

Fine Crackles

sounds like hair rubbing together

Coarse crackles

low gurgling moist sound

Wheezing

- Continuous, musical, HIGH PITCHED, shrill sound usually heard on EXPIRATION

- Disorder: Asthma

Rhonchi

- DEEP LOW PITCHED rumbling sound (SNORING QUALITY)

- Caused by respiratory secretions

- May be CLEARED BY COUGHING

- Disorders: COPD, Bronchitis

Stridor

- Continuous, HIGH PITCHED, musical sound, HEARD OVER THE NECK (often no need stethoscope)

- Narrowing of upper respiratory tract; IMMEDIATE INTERVENTION is warranted

- Disorder: Epiglottis, Foreign Body Aspiration

Pleural Friction Rub

- LOW PITCHED GRATING sound

- Two pieces of leather rubbed together (sound imitated by rubbing thumb and finger together in the ear)

- Subside if px HOLDS BREATH; not cleared by coughing

- Heard in axillae and bases of lungs

- Disorder: Pleuritis

Voice Sounds/vocal resonance

-the sound heard through the stethoscope as the patient speaks

Bronchophony

- Describes vocal resonance that is more intense and clearer than normal

- Not normally heard

Egophony

- Describes voice sounds that are distorted

- best appreciated by having the patient repeat the letter E

- distortion produced by consolidation transforms the sound into a clearly heard A rather than E

Whispered Pectoriloquy

describes the ability to clearly and distinctly hear whispered sounds that should not normally be heard.

Diagnostic Evaluation

- Pulmonary Function test

- Arterial blood Gas

- Venous Blood gas

- Pulse Oximetry

- End-tidal carbon dioxide (ETCO2) monitoring

- Cultures

Diagnostic Evaluation

- Sputum Studies

- Chest X-ray

- CT Scan

- Pulmonary angiography

- Magnetic Resonance Imaging

- Radioisotope Diagnostic Procedures (Lung Scan)

Pulmonary Function test

test that show how well your lungs are working

Arterial blood Gas

assess the ability of the lungs ot provide adequate oxygen and remove carbon dioxide

Venous blood gas (VBG)

- provide additional data on oxygen delivery and consumption

- this test is performed to provide an estimation of this balance when the ability to draw ABGs is not feasible

Pulse oximetry

noninvasive method of continuously monitoring the oxygen saturation of hemoglobin

End-tidal carbon dioxide (ETCO2) monitoring

- noninvasive method of monitoring partial pressure of carbon dioxide (CO2) at end exhalation

- provides immediate information about ventilation, perfusion, and metabolism by determining the concentration of CO2.

- can indicate early respiratory depression and impaired airway function sooner than other devices

Cultures

- an identify pathogens responsible for respiratory infections

- Ideally, all cultures should be obtained prior to the initiation of antibiotic therapy

- Results = 48-72 hrs ; preliminary reports = within 24 hrs

Sputum Studies

- Analysis to identify pathogenic organism and to determine whether malignant cells are present

- Obtained EARLY MORNING before eating or drinking

Sputum Collection

- patient is instructed to clear the nose and the throat and rinse the mouth to decrease contamination of the sputum and not to simply spit saliva into the container

- after taking a few deep breaths, the patient coughs deeply and expectorates sputum from the lungs into a sterile container.

Chest X-ray

to best visualize the lungs, the patient must be able to take a deep breath and hold it without discomfort, while the technician takes the images

CT Scan

- more detailed, fine tissue density

- may be used to define pulmonary nodules and small tumors adjacent to pleural surfaces that are not visible on routine chest x-rays

Types of CT Scan

- Plain

- With Contrast

CT Scan with contrast

Assess the following:

- Kidney function test (creatinine, BUN)

- Allergy to iodine or shellfish

- Pregnant, claustrophobic, severe obesity

- If taking metformin, withhold 24-48 hours before the test to prevent from developing lactic acidosis

- NPO 4 hrs before the test

Pulmonary Angiography

- used ot investigate congenital abnormalities of the pulmonary vascular tree

- To visualize the pulmonary vessels, a radiopaque agent is injected through a catheter, which has been initially inserted into a vein (e.g., jugular, subclavian, brachial, or femoral vein) and then threaded into the pulmonary artery.

- The nurse should instruct patients that they may experience a warm flushing sensation or chest pain during the injection of the dye

Contraindications of Pulmonary angiography

- allergy to radiopaque agent

- pregnancy

- bleeding abnormalities

Potential Complications of Pulmonary angiography

- acute kidney injury

- acidosis

- cardiac arrhythmias

- bleeding

- Introduction of the catheter into the right ventricle may trigger ventricular irritability, monitor for PVCs (cardiac monitor)

Magnetic Resonance Imaging

- Magnetic fields + radiofrequency signals are used instead of radiation

- able ot better distinguish between normal and abnormal tissues than CT

- yields a much more detailed diagnostic image

Contraindications of MRI

- severe obesity

- claustrophobia

- confusion and agitation

- implanted metals

Magnetic Resonance Imaging

- instruct patient to remove all metal items such as hearing aids, hair clips, and medication patches with metallic foil components

- lie flat and remain still for between 30 and 90 minutes

- patients will hear a loud humming or thumping noise (earplugs provided)

Radioisotope Diagnostic Procedures/Lung Scan

- Via IV using RADIOISOTOPES

- C/I = pregnant

- V/Q scan, gallium scan, positron emission tomography (PET) scan

positron emission tomography (PET) scan

- Evaluate lung nodules for malignancy

- More accurate in detecting malignancies than CT

- has equivalent accuracy ni detecting malignant nodules when compared with invasive procedures such as thoracoscopy

positron emission tomography (PET) scan

- No caffeine, alcohol and tobacco 24 hrs prior

- abstain from food and fluids for 4 hours prior to the scan

- EOF to flush isotopes in the urine after the procedure

Endoscopic Procedures

- Bronchoscopy

- Thoracoscopy

- Thoracentesis

Bronchoscopy

- visualize, collect, determine if ti can be resected, and diagnose source of hemoptysis

- Fiberoptic or Rigid

Fiberoptic bronchoscopy

can be performed at bedside

Rigid bronchoscopy

- inside OR

- used mainly for removing foreign substances

Bronchoscopy

Nursing Interventions:

- food and fluids are withheld for 4 to 8 hours before the test - patient must remove dentures and other oral prostheses

- Give preop (Atropine, sedative, opioid)

- Postprocedure - NPO until cough reflex returns

- Offer ice chips and then fluids once with cough reflex

- Monitor respi status

- small amount of blood-tinged sputum and fever may be expected within the first 24 hours

Thoracoscopy

- pleural cavity is examined with an endoscope and fluid and tissues can be obtained for analysis

- Small incisions are made into the pleural cavity in an intercostal space at the location indicated by clinical and diagnostic findings

Thoracentesis

- aspiration of fluid and air from the pleural space

- aspiration of pleural fluid for analysis; pleural biopsy

7.35-7.45

normal value of pH of blood