RESPIRATORY CHALLENGES

Gladys Ka Hei Lai RN, BScN, MHLP

LEARNING OUTCOMES

  • Explain respiratory system functions and interrelationships with other systems: The respiratory system is essential for gas exchange, which sustains oxygen levels and removes carbon dioxide. It closely interacts with the cardiovascular system for oxygen transport, the nervous system for respiratory control, and the muscular system for effective breathing.

  • Identify normal age-related changes associated with the respiratory system: With aging, the diaphragm weakens, ribcage becomes thinner, alveoli lose elasticity, and sensitivity to foreign particles decreases, among other changes, leading to increased susceptibility to pulmonary infections and reduced exercise capacity.

  • Describe the core patient/family assessments for the respiratory system: Assessments include obtaining subjective data on symptoms (e.g., shortness of breath, cough) and objective data (e.g., lung sounds, oxygen saturation).

  • Discuss major fluid, electrolyte, and acid/base imbalances that impact respiratory function: Conditions such as pulmonary edema can impair gas exchange and lead to hypoxemia or respiratory acidosis depending on the underlying cause.

  • Identify common respiratory health challenges: Common challenges include asthma, chronic obstructive pulmonary disease (COPD), pneumonia, and tuberculosis.

  • Identify key risk factors and risk reduction strategies for these health challenges: Factors include smoking, air pollution, and occupational hazards; risk reduction involves lifestyle changes, vaccinations, and public health initiatives.

  • Explain the basic pathophysiology of these health challenges: Understanding how inflammation and obstruction in airways, infection, or structural changes impact health is essential to managing these conditions.

  • Describe common respiratory diagnostic tests and nursing care: Tests include pulmonary function tests, blood gas analysis, and imaging studies; nursing care includes monitoring respiratory status and managing supportive therapies.

  • Discuss common medication classes: Medication classes include bronchodilators, corticosteroids, and antibiotics with specific indications, mechanisms of action, routes of administration, and side effects.

  • Consider the impact of developmental stage and social determinants of health: Recognizing how age, socioeconomic status, and health literacy influence health outcomes is crucial in nursing care.

  • Apply critical thinking and evidence-based practice using the Langara DMF: Utilize the framework to individualize care plans for patients and families based on best practices and patient-specific factors.

READING MATERIALS

  • Canadian Fundamentals of Nursing (7th ed.) by Potter, Perry, Stockert, Hall, Ross-Kerr, Wood, Duggleby, W.

    • Read Chapter 33 (Health Assessment & Physical Examination for respiratory system) and Chapter 40 (Cardiopulmonary Functioning and Oxygenation, excluding nursing skills).

  • Lewis Med/Surg Text: Read Chapters 28-31 covering nursing assessment and management of respiratory conditions including upper and lower respiratory conditions, and obstructive pulmonary diseases.

  • Canadian Lung Association website: Review their roles in primary prevention, health promotion, education, and research on respiratory health.

REVIEW OF RESPIRATORY SYSTEM

Five Main Functions of the Respiratory System:

  • Aids in breathing (pulmonary ventilation): Facilitates the movement of air into and out of the lungs.

  • Facilitates gas exchange (external respiration): Transfers oxygen from the air into the blood while removing carbon dioxide from the blood to be exhaled.

  • Removes carbon dioxide waste (internal respiration): Oxygen utilization by tissues which produces CO2 as a waste product for removal.

  • Assists with the sense of smell: Olfactory bulbs located in the nasal cavity detect airborne chemical substances.

  • Creates sound (voice): Produced by air passing through the vocal cords located in the larynx.

AGE-RELATED CHANGES

  • Inhalation/Exhalation: The ability to inhale/exhale diminishes with age, particularly noticeable during exercise.

  • Diaphragm Weakness: Respiratory muscles like the diaphragm lose strength, impacting breathing efficiency.

  • Ribcage Thinning: A thinner ribcage can cause increased difficulty in expanding lungs fully.

  • Hypoxemia and Hypercapnia Susceptibility: Older adults are more prone to low oxygen (hypoxemia) and high carbon dioxide (hypercapnia) levels.

  • Nerve Sensitivity: Decreased sensitivity to foreign particles affects the clearance of secretions in the airways.

  • Alveolar Changes: Alveoli become baggier and lose structure, reducing gas exchange surface area.

  • Elasticity of Lungs: Lungs lose elastic recoil, making it harder to exhale fully.

  • Infection Vulnerability: Aging leads to a weakened immune system, increasing susceptibility to respiratory infections.

RESPIRATORY ASSESSMENT

Subjective Assessments:

  • Inquire about:

    • Shortness of breath (SOB): Conditions exacerbating it, lying flat impact

    • Cough: Presence of sputum or blood, characteristics, and onset

    • Chest Pain: Presence and relation to respiration

    • History: Previous lung infections, familial lung diseases

    • Allergies: Any known allergies and associated issues

    • Smoking History: Current or past exposure and risks

    • Medications: Use of respiratory support medications

Objective Assessments:

  • Evaluations include:

    • Lung sounds: Quality (wheezing, crackles)

    • Sputum: Quality and quantity

    • Oral Mucosa: Checking for color, moisture, and lesions

    • Chest Expansion: Symmetry, trachea alignment

    • Respiratory Metrics: SpO2, respiratory rate (RR), arterial blood gas (ABG) values.

RESPIRATORY SYSTEM DYSFUNCTION

  • Oxygen Deficiency Risks: Lack of available oxygen poses risks for tissue disruption and organ failure.

  • Fluid Balance Effects: Alterations in fluid balance can critically impact ventilation and oxygenation, such as in states of fluid overload.

CLINICAL PRESENTATION: SIGNS AND SYMPTOMS OF INADEQUATE OXYGENATION

Early Signs and Symptoms: Include:

  • CNS: Unexplained apprehension, restlessness

  • Respiratory: Tachypnea, dyspnea (difficulty breathing) on exertion

  • Cardiovascular: Tachycardia, mild hypertension

Later Signs:

  • CNS: Confusion, lethargy

  • Cardiovascular: Dysrhythmias

  • Other: Diaphoresis, reduced urinary output, fatigue

Critical Late Signs:

  • CNS: Combativeness, coma

  • Respiratory: Dyspnea at rest, accessory muscle use, interspace retraction, pauses in speech

  • Cardiovascular: Hypotension, cyanosis, cool and clammy skin

RESPIRATORY CONDITIONS

Common Respiratory Conditions:

  • Asthma

  • Chronic Obstructive Pulmonary Disease (COPD)

  • Pneumonia

  • Tuberculosis

  • Pulmonary Embolism (PE)

  • Cystic Fibrosis

  • Respiratory Failure

  • Lung Cancer

  • Emphysema

  • Mesothelioma

  • Pulmonary Hypertension

Chronic Obstructive Lung Disease (COPD):

  • Encompassing chronic bronchitis and emphysema, impacting mucous production, lung compliance, gas exchange.

  • Overlap with asthma may occur.

PATHOPHYSIOLOGY OF COPD

  • Mechanisms remain unclear but involve ongoing exposure to noxious inhaled substances (e.g., cigarette smoke, air pollutants).

  • This leads to a chronic inflammatory response causing pathological changes in airways and lung parenchyma.

  • Airway obstruction results in reduced ability to exhale effectively.

ABNORMAL HYPOXIC DRIVE IN COPD

  • In COPD patients with chronic high CO2 levels, the normal respiratory drive may be lost leading to hypoxia as the primary stimulus for respiration.

  • This recognition of low PaO2 levels becomes critical for those with compromised gas exchange.

RISK FACTORS FOR COPD

  • Common Risk Factors Include:

    • Smoking or second-hand smoke

    • Air Pollution (indoor and outdoor)

    • Occupational exposure to fumes and chemicals

    • History of severe childhood respiratory infections

    • Socioeconomic status

    • Genetics: Rare forms of COPD such as alpha-1 deficiency-related emphysema.

CLINICAL PRESENTATION OF COPD

Symptoms:

  • Increased sputum production, fatigue, anxiety, lethargy, barrel chest, decreased air entry, varying degrees of dyspnea, orthopnea, and increased work of breathing.

  • Cough may be productive.

COPD ASSESSMENT

  • Assessment may vary from asymptomatic to severely symptomatic patients.

  • Measurement of exacerbation frequency and the degree of airflow limitation is essential alongside comorbidities consideration.

ASESSING COPD SEVERITY

Diagnostic Tests for COPD: Include:

  • No single test confirms COPD; diagnosis relies on:

    • Clinical history and physical examination

    • Airflow obstruction evidence via Pulmonary Function Tests (PFTs)

    • Peak Expiratory Flow (PEF), imaging studies (e.g., chest X-ray, CT scan)

  • Blood tests evaluating ABGs and complete blood counts.

COPD TREATMENT

  • Medical Treatments:

    • Drug therapies (bronchodilators, corticosteroids)

    • Immunizations (pneumococcal)

    • Home oxygen therapy and non-invasive ventilation therapy

    • Referral to pulmonary rehabilitation programs

    • Surgical options like lung-volume reduction surgery.

ASTHMA

  • Definition: A heterogeneous syndrome triggered by various stimuli leading to chronic airway inflammation.

  • Characterized by systemic inflammation involving mast cells, eosinophils, and T-helper cells (Th2).

ASTHMA PATHOPHYSIOLOGY

  • Variability in asthma types correlates with inflammatory cell infiltration in airway walls.

  • Eosinophilic Asthma: Elevated eosinophils and epithelial damage.

  • Non-eosinophilic Asthma: May present without eosinophil involvement but still lead to airway remodeling.

CLINICAL PRESENTATIONS OF ASTHMA

  • Typical Symptoms: Recurrent cough, wheezing, chest tightness, shortness of breath worsening in the presence of irritants or allergens.

  • Assess for history of allergic rhinitis or atopic dermatitis.

ASTHMA DIAGNOSTICS

  • Diagnostic tests include:

    • Pulmonary Function Tests (PFTs), Methacholine challenge, allergy tests, sputum eosinophils, and imaging studies (chest X-ray, CT).

ASTHMA TREATMENT

  • Common Treatments Include: Medications (e.g., inhaled corticosteroids, leukotriene receptor antagonists) and community-based pulmonary rehabilitation programs.

GLOBAL INITIATIVE FOR ASTHMA (GINA) 2019 CHANGES

  • Recommendations: Avoid SABA-only treatment for adults.

  • GINA indicates the necessity for all adults/adolescents with asthma to receive ICS-containing treatments to prevent severe exacerbations.

  • Emphasizes a population-level risk reduction strategy.

PULMONARY EMBOLISM (PE)

Definition: An occlusion of pulmonary vessels that can severely impair gas exchange.

  • Signs and Symptoms: Dyspnea out of proportion to findings, tachycardia, hypoxemia, and anxiety.

  • Risk Factors: History of deep vein thrombosis, immobility, obesity, and certain surgical procedures.

PE DIAGNOSTICS

  • Diagnostic tools include ABGs, 12-lead ECG, CT scans, V/Q scans, D-dimer tests to assist diagnosis.

PE TREATMENT

  • Management involves anticoagulants, fibrinolytics in severe cases, and addressing underlying causes.

RESPIRATORY FAILURE

  • Defined by inadequate gas exchange categorized into hypoxemic (Type 1) or hypercapnic (Type 2) respiratory failure.

PROFESSIONAL PRACTICE

  • Emphasizes the importance of interprofessional collaboration in patient care, involving nursing, respiratory therapy, and other health professionals.

NON-INVASIVE VENTILATION (NIV)

  • Application: Positive airway pressure systems used in stable patients for conditions such as COPD and heart failure.

  • Mechanisms include enhancing alveolar ventilation, oxygen delivery, and reducing respiratory work.

  • Indications and contraindications: Specific to patient conditions and respiratory effort.

COMMON DRUG CLASSIFICATIONS IN RESPIRATORY CARE

  • Beta2-adrenergic agonists: Used in both asthma and COPD for bronchial relaxation.

  • Anticholinergic agents: Compete with acetylcholine for receptor activity causing bronchodilation.

  • Corticosteroids: Decrease inflammation via immunosuppressive action in various routes of administration.

SUMMARY

  • Understanding of Anatomy and Physiology: Essential for managing respiratory conditions and improving health outcomes. Emphasizes person/family-centered care approaches and outcomes-based evaluations of nursing practices.

RESOURCES

  • Updated guidelines for asthma management, Canadian Lung Association, and inhaler tutorials.