Chapter 1: Gas Exchange and Respiratory Function (Part 2)

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

35-45 mmHg

Normal value of PaCO2

22-26 mEq/L

normal value of HCO3

80-100 mmHg

normal value of PaO2

8-20 mg/dL

normal value of BUN

0.6-1.2 mg/dL

normal value of creatinine for males

0.4-1.0 mg/dL

normal value of creatinine for females