RESPIRATORY DISORDERS
Romeo T. Papa, DMD RN
Functions of the Respiratory System
• Oxygen supplier
• Elimination
• Gas exchange
• Passageway
• Humidifier
Anatomy: NOSE
• Nostrils aka nares
• Respiratory mucosa
• Mucus
• Ciliated cells
• Conchae
• Paranasal sinuses
• frontal, sphenoid, ethmoid, and maxillary
Anatomy: Pharynx
• Pharynx aka throat
• nasopharynx, oropharynx, laryngopharynx
• Pharyngeal tonsil
• Palatine tonsils
• Lingual tonsils
Anatomy: Larynx
• Structure. Located inferior to the
pharynx, it is formed by eight rigid
hyaline cartilages and a spoon-
shaped flap of elastic cartilage,
the epiglottis.
• Thyroid cartilage aka Adam’s apple
• Epiglottis
• Vocal folds
Anatomy: Trachea
• Aka windpipe
• trachea is lined with ciliated mucosa
that beat continuously and in a
direction opposite to that of the
incoming air as they propel mucus
Parts: Lower Respiratory
System
• Lungs, Pleura and mediastinum
• Lobes of the lungs: Left (upper &
lower); right (upper, middle, lower)
• Bronchi & bronchioles and the
alveoli (gas exchange)
The Lungs
• The lungs occupy the entire thoracic cavity
except for the most central area
• Pleura:
• Visceral Pleura – covers each surface of the lungs
• Parietal Pleura – lined the walls of the thoracic
cavity
• Pleural Fluid – a slippery serous secretion that
allows the lungs to glide over the thorax wall
• Pleural space. The lungs are held tightly to the
thorax wall, and the pleural space is more of a
potential space than an actual one.
Alveoli
• The alveoli (singular: alveolus) are tiny hollow air
sacs that comprise the basic unit of respiration.
• There are around 300 million to 1 billion alveoli in
the human lungs
• Alveoli contain two major types of epithelial cells:
• type 1 pneumocytes (95%) – squamous cells where gas
exchange occur
• type 2 pneumocytes (5%) – granular cells which
secretes surfactant
• Alveolar macrophages are also located in the alveoli.
RESPIRATION
• Oxygen diffuses from the air into
the blood at the alveoli to be
transported to the cells of the body.
• Carbon dioxide diffuses from the
blood into the air at the alveoli to
be removed form the body.
Gas Exchange
• Occurs in the lungs between alveolar air and blood of the pulmonary capillaries.
• For effective gas exchange to occur, alveoli must be ventilated and perfused.
• Ventilation (V) refers to the flow of air into and out of the alveoli, while perfusion (Q) refers to the
flow of blood to alveolar capillaries.
• Collective changes in ventilation and perfusion in the lungs are measured clinically using the ratio
of ventilation to perfusion (V/Q).
• Changes in the V/Q ratio can affect gas exchange and can contribute to hypoxemia
V/Q ratio
• When the V/Q is > 0.8, it means ventilation exceeds perfusion.
• Blood clots, heart failure, emphysema, or damage to the pulmonary capillaries may cause
this.
• When the V/Q is < 0.8, it means perfusion exceeds ventilation.
• Due to aspiration, blockage of bronchi by a foreign object, pneumonia, severe asthma,
pulmonary edema, or COPD.
Respiratory System
Assessment
Signs of
hypoxia
Signs of Hypoxia
Breath Sound
❑ BRONCHIAL (B)
❑ Exhales – just above the clavicles
on each side of the sternum
❑ BRONCHOVESICULAR (BV)
❑ Inhales and exhales – continuous
next to the sternum between the
scapula
❑ VESICULAR (V)
❑ Prolonged during inhalation
shortened during exhalation
❑ Remainder of the lungs.
Abnormal (adventitious) breath
sounds:
• Abnormal (adventitious) breath
sounds:
• Crackles (rales)
Abnormal (adventitious)
breath sounds:
Wheezes
• High pitch musical
• Heard during expiration
Abnormal (adventitious) breath
sounds:
• Friction rubs
• A pleural friction rub, or simply
pleural rub
• The pleural rub sound results
from the movement of inflamed
and roughened pleural surfaces
against one another during the
chest wall movement.
Breathing Patterns
DIAGNOSTIC TESTS
• Imaging tests
• Pulmonary function tests
• Arterial blood gases
• Sputum tests
• Thoracentesis
• Biopsies
Imaging and radiographs
• computed tomography (CT)
• Magnetic Resonance Imaging (MRI)
• Ultrasonography
• CT angiography (CTA)
• imaging test of choice for suspected pulmonary embolism (PE)
Xray Findings
• Atelectasis
• Consolidation
• lung-collapse is the result of loss of air
• result of replacement of air in the
in a lung.
alveoli by transudate, pus, blood, cells
or other substances.
Xray Findings
Cavitary
• A pulmonary cavity is a gas-filled area of the
lung in the center of a nodule or area of
consolidation
Pulmonary Function Tests
• Spirometry. A spirometer is a device with a
mouthpiece hooked up to a small electronic
machine.
• Normal findings
• FEV1/FVC ratio of greater than 0.70 and both
FEV1 and FVC above 80%
• TLC above 80% of the predictive value is
normal.
• Diffusion capacity above 75% of the predicted
value is also considered normal.
ARTERIAL BLOOD
GAS
• Measurement of arterial
oxygenation and carbon dioxide
levels.
• Also assesses acid base balance
• pH = 7.35 – 7.45 A
C B
A
• Decreased - Acidosis I
D S
E
• Increased – Alkalosis
• PaCO2 = 35 – 45 mmHg A
B
A
C
• Decreased – Alkalosis I
S
E
D
• Increased – Acidosis
• HCO3 = 22 – 26 mmHg A
B
C
• Decreased – Acidosis I A
S
D
• Increased - Alkalosis E
•pH = 7.20
•ACIDOSIS
•PaCO2 = 50 mmHg RESPIRATORY
•ACIDOSIS ACIDOSIS
•HCO3 = 24 mmHg
•NORMAL
Nursing Dx:
• Impaired Gas Exchange
• Ineffective Breathing Pattern
• Ineffective Tissue Perfusion
• Acute Confusion
• Risk for Injury
Implementation:
• Remain alert and report for critical changes
• Maintain adequate hydration.
• Maintain patent airway and provide humidification if
acidosis requires mechanical ventilation.
• Perform tracheal suctioning frequently and
vigorous chest physiotherapy, if ordered.
• Institute safety measures and assist patient
with positioning.
• Continuously monitor arterial blood gases.
•pH = 7.42
•Normal
•PaCO2 = 32 mmHg RESPIRATORY
•ALKALOSIS ALKALOSIS
•HCO3 = 20 mmHg
•ACID
Nursing Consideration
• Impaired Gas Exchange
• Ineffective Breathing pattern
• Ineffective Tissue perfusion
• Acute confusion
• Risk for injury
Implementation:
• Be alert for signs of changes in neurologic,
neuromuscular or cardiovascular functions.
• Institute safety measures
• Encourage the anxious patient to verbalize fears
• Administer sedation as ordered to relax the
patient
• Keep the patient warm and dry
• breathe into a brown paper bag (inspire CO2).
• Monitor ABGs, primarily PaCO2; a value less
than 35 mmHg indicates too little CO2 (carbonic
acid)
•pH = 7.00
•ACIDOSIS
•PaCO2 = 42 mmHg METABOLIC
•NORMAL ACIDOSIS
•HCO3 = 19 mmHg
•ACIDOSIS
Treatment
• Administration of sodium bicarbonate I.V. for
severe cases
• Evaluation and correction of electrolyte
imbalances and ultimately correction and
management of the underlying cause.
Implementation:
• Keep sodium bicarbonate ampules handy for
emergency administration.
• Monitor LOC
• Record intake and output accurately
• Management of vomiting (common to
metabolic acidosis), position the patient to
prevent aspiration.
• Seizures precautions
•pH = 7.60
•ALKALOSIS
•PaCO2 = 40 mmHg METABOLIC
•NORMAL ALKALOSIS
•HCO3 = 32 mmHg
•ALKALOSIS
Nursing Diagnosis
• Ineffective Tissue Perfusion
• Acute Confusion
• Risk for Injury
Implementation:
• Dilute potassium when giving via I.V.
• Monitor the infusion rate and watch out for
signs of phlebitis.
• Watch for signs of muscle weakness, tetany
or decreased activity.
• Monitor vital signs frequently and
record intake and output
• Observe seizure precautions.
PULSE OXIMETRY
A noninvasive method to monitor the
oxygen saturation of the blood.
Does not replace ABGs
Normal level is 95-100%.
May be unreliable
Nursing Management of
Patient with Respiratory
Problems
Deep Breathing Technique Coughing Exercises
• Recommended Post-Op • Best to do when patient is
• More effective in sitting fresh and comfortable
position • Upright or lying if unable to
• Deep inhalation then hold assume fowler’s position
for about 3 seconds and • Take several deep breaths
exhales slowly through then cough firmly
pursed lip • Use pillow support on
incision site if post-op
Oxygen inhalation
Means of O2 delivery
• Venturi Mask
• Controlled delivery of O2
• usually used with COPD patients
• It can also be helpful for asthma
exacerbations and general respiratory
distress
Means of O2 delivery
AIRWAY
MANAGEMENT
1. OROPHARYNGEAL AIRWAY (OPA)
• Also known as Oral bite block
• Relieves upper airway obstruction
• Tongue relaxation, secretions, seizures
• Not recommended for alert clients
• May trigger gag and cause vomiting
Nursing Responsibility
• Frequent assessment of the lips and tongue to
identify pressure areas
• Removed at least q24 hours to check for pressure
areas and to provide oral hygiene
AIRWAY
MANAGEMENT
2. NASOPHARYNGEAL AIRWAY
• a.k.a. Nasal trumpet
• Maintains airway patency
• Also used to facilitate nasotracheal suctioning
• Size: French 26-35
Complications
• Bleeding
• Sinusitis
• Erosion of the mucus membranes
Nursing Responsibility
• Assessment of the pressure areas and occlusion due to
secretions
• Rotation of tube from nostril to nostril daily
AIRWAY MANAGEMENT
Laryngeal Mask
• An ET with a small mask on one end that can be
passed orally over the larynx
• Provides ventilatory assistance and prevent
aspiration
Combitube
• o Esophageal/tracheal double lumen airway
• o Used for difficult or emergency intubation
• o Permits blind placement
AIRWAY MANAGEMENT
4. Endotracheal (ET) tube
• Inserted into the trachea through the mouth or nose
Insertion of Endotracheal (ET)Tube
• Using laryngoscope to visualize the upper airway
• Inserted through the vocal cords into the trachea
• 2-4 cm above the carina
• Anchored by inflating the cuff (prevents air leakage and
aspiration)
Chest Tube
(Thoracostomy
Tube)
Mechanical
Ventilation
POSITIVE PRESSURE
VENTILLATION (PPV)
• Most common form of mechanical ventilation
used in the acute care setting
• Forces oxygen into the lungs with each breath
through an endotracheal tube or tracheostomy
tube
• Volume-cycled modes (deliver breath until preset
tidal volume is reached with each breath)
• Pressured-cycled modes (deliver breath until a
preset pressure is achieved within the airway)
Assist-control Ventilation (ACV)
• Provides full ventilator
support to the patient.
• If triggered by patient
additional ventilatory
breath is delivered
• Used in patients with
weak respiratory muscles
Synchronized
Intermittent Mandatory
Ventilation (SIMV)
• Breaths are given are given at
a set minimal rate, however if
the patient chooses to breath
over the set rate no additional
support is given
• Prevents competition between
patient and ventilator
• Common mode for patients
requiring minimal ventilation
• Used for WEANING for
ventilator support
Additional Mode
Positive End Expiratory Pressure Constant Positive Airway Pressure
(PEEP) (CPAP)
• Holds positive pressure in the alveoli • Similar to PEEP but provides positive
during expiration pressure during spontaneous breaths
• used as a supplement to most modes • Increases oxygenation by preventing
closure of alveoli
• Range: 2 to 24 cmH2O pressure
• General range: 5-10 cmH2O; more than
10cmH20 = hypotension/pneumothorax
Positive end-expiratory pressure (PEEP)
• Holds positive pressure in the alveoli Advantages:
during expiration • Prevents alveoli from collapsing at end-
expiration
• improves oxygenation
• Frequently used as a supplement to most • Increases functional residual capacity
modes of ventilation
• Range: 2 to 24 cmH2O pressure
Disadvantage:
• PEEP greater than 10 cmH2
• Increased intrathoracic pressure that causes
decreased venous return and decreased cardiac
output (HYPOTENSION)
• Increase preload with fluids or vasopressors
Mechanical
Ventilator
Alarm
Methods of Weaning
• ACV
• SIMV
• T-piece
Nursing Management:
• WOF: rapid or shallow breathing, use of accessory muscles, decrease in LOC, increase in
CO2 levels, decrease O2 saturation and tachycardia
Respiratory Disorders
Pulmonary Embolism (Pulmonary Embolus)
• Thrombotic or non-thrombotic embolus that lodges in the pulmonary artery
system.
• Risk Factors
1. Injury causing blood clot formation
2. Prolonged inactivity
3. Medical conditions or treatment induing blood clot
Pulmonary Embolism: Clinical Manifestations
• Virchow’s triad:
• venous stasis, coagulation problems, vessel wall injury
• Chest pain
• Tachycardia, tachypnea
• Anxiety, restlessness
• Clammy or bluish skin
Pulmonary Embolism: Diagnostics
• 1. CXR – to rule out other disorders with the same presenting
manifestations
• 2. ABG analysis
• 3. D-dimer test – detects clot fragments from clot lysis
• 4. ECG
• 5. V/Q scan / Pulmonary angiography / spiral CT scan
Pulmonary Embolism:
Treatment
1. Oxygenation (ET and mechanical
ventilation)
2. Heparin therapy
3. Surgery – umbrella filter,
pulmonary embolectomy
4. Prevention of development of
DVT
Acute Respiratory Distress
Syndrome (ARDS) / Lung Injury
• This is a syndrome with
inflammation and increased
permeability of the
alveolocapillary membrane
resulting to lung injury.
1. Critically ill patients
2. Age (60y/o and above)
(ARDS):
Risk 3. Malignancy (cancers)
Factors 4. Cigarette smoking, COPD
Causes: Aspiration pneumonia or systemic
illness (e.g. burns, sepsis, drug overdose)
Signs and symptoms are often exhibited within
24-48 hours after initial insult to the lungs
(ARDS):
1. Restlessness,
Clinical
Manifesta 2. Hyperventilation, tachycardia, SOB
tions
3. Hypoxemia
4. Severe: hypotension, cyanosis, decreased
UO
(ARDS):
DIAGNOSTIC TEST
Chest x-ray
“white out lungs”
ARDS: Treatment
• Goal: improving and maintaining oxygenation and prevent respiratory and
metabolic complications
• 1. Fluid management to maintain tissue perfusion
• 2. Corticosteroid therapy to decrease permeability of the alveolocapillary
membrane
• 3. Nutrition – enteral feeding
• 4. Supplemental oxygen: Mechanical Ventilation
It is a change in respiratory
gas exchange such that
Acute normal cellular function is
jeopardized.
Respiratory
ARF is defined as’pO2 of less
Failure than 50 mmHg and a pCO2
of greater than 50 mmHg
and a pH of less than 7.30.
ARF: Types
Type I: Hypoxemic Type II: Hypercapnic
Lung failure due to respiratory Pump failure, ventilatory failure
insufficiency Failure to eliminate C02
Associated with: Associated with:
Pulmonary edema Drug overdose
ARDS Neuromuscular diseases
Pneumonia Chest wall deformity
COPD
Chronic obstructive
pulmonary disease
(COPD)
• COPD is a group of lung
diseases that block airflow and
make breathing difficult
• It is an umbrella term to
describe various diseases
• (e.g. chronic bronchitis,
emphysema, chronic asthma)
Peak flow meter
• Peak flow reading percentage measures lungs expiration
capacity
Spirometer
Asthma • A spirometer measures how much air your lungs can hold
and how quickly you can breathe out.
• measurement is called forced expiratory volume (FEV-1)
Diagnosis Pulse oximeter
• measures the amount of oxygen in your blood.
Nitric oxide measurement
• measures nitric oxide gas in breath during exhalation.
• High nitric oxide readings = swelling or other immune
system activity in the lungs.
ASTHA TREATMENT
Emergency treatment:
Quick-relief medicines include:
• Albuterol • Oxygen
• (ProAir HFA, Proventil-HFA, Ventolin • Quick-relief medicines
HFA)
• Ipratropium (Atrovent HFA)
• Levalbuterol
• Corticosteroids
• (Xopenex, Xopenex HFA).
A – adrenergic Agonist
Asthma: S – Steroid
Nursing T – Theophyline
Intervention H – Hydration (IV)
M – Mask for O2 inhalation
A – Anticholinergic
Theophyline
• methylxanthine derivative • Nursing Responsibility:
• relaxes the smooth muscle of the • WOF S/Sx of toxicity
bronchial airways and pulmonary • Tachyarrythmias
blood vessels • N/V
• Hypotension due to vasodilation
• reduces airway responsiveness to • Agitation, tremor Seizure
histamine, methacholine, adenosine,
• Normal =10-20 mcg/ml
and allergen.
• Mild toxicity = 20-40 mcg/ml
• Hepatic biotransformation • Moderate = 40-70 mcg/ml
• Severe = < 70 mcg/ml
Chronic Bronchitis
• Chronic bronchitis occurs when the airways
in your lungs become inflamed.
• Causes:
• Smoking
• Air pollution
• Family History
Chronic Bronchitis
Emphysema
• Emphysema is a lung
disease characterized
by damage to lung
parenchyma, which is
the lung tissue that
carries out gas
exchange.
Pneumonia
• Pneumonia is an inflammation of
the lung, which is characterized by
exudation into the alveoli.
microorganisms
that can cause
Pneumonia
• • Streptococcus pneumoniae (90% of
cases)
• • Haemophilus influenzae
• • Staphylococcus aureus
• • Legionella species
Types of Pneumonia
Community Ventilator
Hospital acquired Aspiration
acquired associated
• Non-hospitalized • more than 48 h • more than 48–72 • micro-aspiration
or not residing in between h between of bacteria
a long-term care admission and intubation and colonizing the
facility for ≥ 14 onset of onset of upper respiratory
days prior to symptoms. symptoms. tract, macro-
onset of aspiration of
symptoms gastric contents,
inhaled aerosols
The clinical findings are often referred to as
consolidation.
• Expansion is reduced on the affected side.
• There is percussion dullness over the area of
Pneumonia: consolidation.
• Breath sounds are bronchial; adventitious
Assessment crackles.
• Tachypnea and central cyanosis.
findings
• Fever, sweats, and rigors.
• Cough and sputum.
Pneumonia: Diagnostics and Laboratory
• Sputum microscopy,
culture, and sensitivity.
• CXR.
• ABG (if SpO2 is <93% on
room air) and pulse oximetry
Initial (ED) management:
• Supplemental O2 to maintain saturations at >93%
PNEUMONIA:
• IV fluids (if the patient is dehydrated)
Management
• Medications: IV antibiotics, analgesia, antipyretic
• Bronchoalveloar lavage may be used for patients who
are immunocompromised, those who do not respond to
antimicrobial.
• Positioning (upright)
Pneumonia: • Ensure timely antimicrobial therapy
Nursing • Monitor hemodynamics, fluid and
Management electrolytes and imbalances
• Adherence to infection prevention and
control.
• Ventilator-associated pneumonia care
bundle
VAP: Clinical signs
pyrexia > 38°C raised or reduced new-onset purulent increased respiratory worsening gas
white blood cell (WBC) sputum secretions/suctioning exchange.
count requirements
A. Care Bundle approach for the
prevention of ventilator-
VAP: associated pneumonia
Management: • Elevation of the head of the bed to 30–
45° (unless contraindicated)
• Sedation level assessment
• Oral hygiene
• Subglottic aspiration
• Tube cuff pressure
• Stress ulcer prophylaxis
Scoring the severity of Pneumonia: CURB- 65 score
ANTIBIOTICS
Tuberculosis
• Pathogen: Mycobacterium • The following people are at
tuberculosis (M tuberculosis). higher risk of active TB or
• AEROBIC bacteria reactivation of TB:
• Older adults
• MoT = Droplets
• Infants
• Incubation Period: 3-6 weeks • People with weakened immune
systems
• Are around people who have TB
• Live in crowded or unclean living
conditions
• Have poor nutrition
Active and Latent Tuberculosis
• Latent tuberculosis infection (LTBI): • Active TB:
• dormant and being controlled by the • immune system isn’t able to contain the
immune system….it’s encapsulated bacteria
• NOT contagious No S/Sx • Mostly are relapse from Latent TB
• Normal xray and negative sputum test • CONTAGIOUS AND HAS
• Positive Skin test SIGNS/SYMPTOMS
• Positive blood test • positive PPD or blood test,
• ABNORMAL chest x-ray
• positive sputum culture
Signs and Symptoms
• Breathing of
difficulty
• Chest pain
• hemoptysis
TB Diagnosis
• Skin Test
• Interferon-Gamma Release Assays (IGRA
Test): starting to become more popular
• Sputum culture
• Xray
TB Treatment
• Rifampin: Bactericidal by stopping RNA- polymerase
• Orange secretions
• Hepatotoxic
• Isoniazid (INH): bactericidal/Bacteriostatic
• decrease Vitamin B6 levels
• Monitor Liver function
• Pyrazinamide: bactericidal
• Precaution for pt with diabetic or kidney problems
• Ethambutol: stop RNA synthesis/bacteriostatic
• Can inflame optic nerve
• Peripheral neuropathy – WOF numbeness
• Streptomycin: protein synthesis and kills the bacteria
• still used for TB, but not as the first line
• Ototoxicity
