B.

RESPIRATORY
A.Respiratory Anatomy & Physiology
• General Respiratory Anatomy and Physiology
• The respiratory system is comprised of the upper airway and lower airway structures
• The upper respiratory system filters, moistens and warms air during inspiration
• The lower respiratory system is the site of gas exchange, regulating the body's oxygen (PaO2) and carbon dioxide (PaCO2)
levels and acid-base (pH) balance
• Gas-exchange in the respiratory system occurs in the alveoli and pulmonary capillaries
• B. Physiology of Breathing
• Inspiration: an active process
• contraction of the intercostal muscles and diaphragm expands the chest
• intrathoracic pressure decreases, drawing oxygenated air through the upper airway into the lungs
• Expiration: a passive process
• relaxation of the intercostal muscles increases intrathoracic pressure
• carbon dioxide, a waste product of metabolism, is exhaled from the lungs through the upper airway
• Gas exchange of oxygen and carbon dioxide occurs through diffusion across the alveolar-capillary membrane
• Neural control of breathing
• occurs through chemoreceptors in the medulla
• stimulated by the concentration of hydrogen ions in the blood
• increased hydrogen levels (acidosis) stimulate increased respiratory rate and volume - "blows off" acid (CO2)
• Chemical control of breathing
• occurs through chemoreceptors in the carotid arteries and aortic arch
• decreased blood pH and oxygen levels and increased carbon dioxide levels stimulate the respiratory center in the medulla
Acid-base balance - serum pH of 7.4 is necessary for optimal health
• respiratory system - maintains pH balance through the regulation of CO2 (an acid) by adjusting ventilation rate and
depth and this results in rapid restoration of pH balance
• correction of respiratory acid-base imbalance
• compensation in metabolic causes of acid-base imbalance
• the renal system also maintains a normal pH through the regulation of bicarbonate or HCO3 (a base) ion excretion
and this results in a slower correction of pH imbalance
• correction of metabolic causes of acid-base imbalance
• compensation for respiratory causes of acid-base imbalance.
• lab normals
• pH (partial pressure of hydrogen in blood) = 7.35 - 7.45
• PaCO2 (partial pressure of carbon dioxide in arterial blood) = 35 - 45 mm Hg
• HCO3 (bicarbonate level) = 22 - 26 mEq/L
• steps used to interpret arterial blood gases
• first - determine if it's compensated (within normal limits of pH) or uncompensated
• next - determine if it's acid or alkaline (based on pH)
• finally - look at CO2 and HCO3 to determine the cause (respiratory or metabolic)
• acid-base lab interpretation

pH HCO3 PaCO2

respiratory acidosis ↓ (< 7.35) ↑ (> 26) ↑ (> 45)

respiratory alkalosis ↑ (> 7.45) ↓ (< 22) ↓ (< 35)

metabolic acidosis ↓ (< 7.35) ↓ (< 22) ↓ (< 35)

metabolic alkalosis ↑ (> 7.45) ↑ (> 26) ↑ (> 45)

Remember acid-base lab interpretation using the acronym R.O.M.E.

R=Respiratory
O=Opposite
M=Metabolic
E=Equal
 C. Upper respiratory structures
• Nose and sinuses
• filters, warms and humidifies air
• first defense against foreign particles
• inhalation for deep breathing usually occurs through the nose
• exhalation usually occurs through the mouth
• Pharynx
• behind oral and nasal cavities
• nasopharynx
• behind nose
• soft palate, adenoids and eustachian tube
• oropharynx
• from soft palate to base of tongue
• palatine tonsils
• laryngopharynx
• base of tongue to esophagus
• where food and fluids are separated from air
• bifurcation of larynx and esophagus
• Larynx
• between trachea and pharynx
• commonly called the voice box
• vocal cords - responsible for voice, airway protection and control of airflow through trachea
• glottis - opening between vocal cords
• epiglottis - covers airway during swallowing, protecting against aspiration
• thyroid cartilage - Adam's apple
• cricoid cartilage
• contains vocal cords
• the only complete ring in the airway
D. Lower respiratory and other structures
• 1. Trachea
• anterior neck in front of esophagus
• carries air to lungs
• 2. Mainstem bronchi

• right and left

• older adults - right middle lobe is most likely to receive aspirate in people with swallowing difficulty
• 3. Conducting airways
• lobar bronchi
• surrounded by blood vessels, lymphatics, and nerves lined with ciliated, columnar epithelial cells
• cilia move mucus or foreign substances up to larger airways
• bronchioles
• no cartilage; collapse more easily
• no cilia
• do not participate in gas exchange
 4. Alveolar ducts and alveoli
lungs contain approximately 300 million alveoli
• alveoli surrounded by capillary network
• gas exchange happens at alveolar-capillary membrane (blood takes in O2, gives off CO2)
• alveoli are held open by surfactant which decreases surface tension to minimize alveolar collapse
• Accessory muscles of respiration - use indicates additional effort needed to breathe
• scalene muscles - elevate first two ribs
• sternocleidomastoid - raises sternum
• trapezius and pectoralis - stabilize shoulders
• abdominal muscles - puts power into cough and used most often with chronic respiratory problems and acute severe
respiratory distress
• In infants - nasal flaring, sternal or intercostal retractions, grunting
• older adults - respiratory changes with age include
• stiffening and reduced function of respiratory structures
• reduced capacity of respiratory defense mechanisms
• less effective respiratory control

 Upper Respiratory System Disorders

• A. Rhinitis
• Definition: inflammation of the mucous membrane of the nose marked especially by rhinorrhea, nasal congestion and
itching, and sneezing
• Etiology
• allergic (often called "hay fever") - caused by a exposure to various factors including environmental allergens, i.e. dust, mold,
dander, pollen
• infectious - caused by cold viruses, bacterial infections
• Findings
• excessive nasal drainage and congestion, postnasal drip with sore throat
• allergic causes: nasal itchiness and sneezing, watery eyes
• viral causes (common cold): sore throat, general malaise, fever, chills, headache
• bacterial causes: purulent nasal discharge, fever.
• Diagnostics: history of findings, type and color of drainage
• Management
• identify the cause
• relieve findings using antihistamines, decongestants, NSAIDs if headache
• bacterial causes: anti-infectives
• allergic causes: reduction of exposure to allergic causes and desensitization immunizations or treatments
• viral or bacterial causes:
• encourage more fluids
• rest
• gargling with salt water, vitamin C, zinc
• Nursing interventions
• administer prescribed medications for relief
• teach client
• environmental reduction of allergens
• specific medication information
• hand washing to avoid the spread of the common cold

B. Sinusitis
• Definition: inflammation of one or more of the paranasal sinuses
Etiology
• viral or bacterial upper respiratory infection
• tooth infection
• allergic rhinitis
• sniffing aerosols/powders
• structural defects of the nose
• underwater swimming
• Findings
• frontal headache
• tenderness over the affected sinus(es), especially when palpated or percussed
• purulent nasal drainage and congestion
• nasal obstruction
• malaise
• tooth pain
• fever
• Diagnostics: x-ray or CT shows fluid in sinuses and mucous membrane swelling
• Management
• pharmacologic
• nasal saline
• decongestants
• nasal corticosteroids
• mucolytics
• antihistamines
• antibiotics
• analgesics
• antipyretics
• surgery to drain and open sinuses
• antral irrigation (sinus irrigation)
• functional endoscopic sinus surgery
• Nursing interventions
• administer (and teach) about taking prescribed medications
• encourage fluid intake (non-carbonated, non-alcoholic) of at least 6 to 8 (8 ounces) glasses daily
• nasal cleaning techniques: hot showers, steam inhalation or nasal irrigation with saline spray followed by nose blowing
• nasal irrigation as needed
• client teaching
• importance of promoting sinus drainage
• proper use of antibiotics with follow-up if no symptom resolution
• reduction of environmental factors if allergies contribute

C. Upper airway obstruction - partial or complete

• This is a MEDICAL EMERGENCY!
• Etiology
• aspiration of food or foreign body
• laryngeal edema secondary to anaphylactic allergic response
• trauma
• Findings
• stridor: harsh, vibrating sound during inspiration
• inability to talk with complete obstruction
• restlessness
• accessory muscle use
• both hands of client around the throat
• tachycardia
• skin color changes, i.e. pallor, cyanosis
• in children, prolonged hypoxemia results in cardiac arrest secondary to inadequate ventilation, oxygen or circulation
Diagnostics: observations at time of occurrence
• Management: emergency treatment
• airway clearance techniques
• conscious victim:
• infants (less than 1 year): back blows and chest thrusts
• younger children: modified Heimlich maneuver ("astride")
• older children & adults: Heimlich maneuver
• unconscious victim - begin CPR
• endotracheal intubation
• cricothyrotomy (cut cricoid cartilage)
• tracheotomy/tracheostomy
• Nursing interventions: basic life support guidelines for obstructed airway

D. Pharyngitis
• Definition: inflammation of mucous membranes of pharynx
• Etiology: viral, bacterial (including beta-hemolytic strep) or fungal infections
• Findings
• scratchy throat
• throat pain, often severe, worsened by swallowing
• pharynx can appear red and edematous with or without patchy white or yellow exudates
Diagnostics: throat cultures and/or rapid strep antigen test
• Management
• pharmacologic
• antimicrobial therapy - penicillins for strep throat (erythromycin if allergic to penicillin)
• antifungal therapy such as nystatin for fungal causes
• analgesics such as ibuprofen or topical anesthetic sprays or lozenges
• symptomatic relief
• prevent secondary complications
• Nursing interventions
• administer prescribed medications
• encourage increased fluid intake of cool, bland liquids and gelatin; avoid citrus juices and carbonated beverages
• teach importance of taking all of prescribed antimicrobials to avoid complications of strep infection

E. Tonsillitis and adenoiditis

• Definition: inflammation and infection of the tonsils and especially the palatine tonsils
• Etiology: acute form is usually bacterial; typically viral in association with pharyngitis
• Findings
• sore throat - may be recurrent
• fever
• difficulty swallowing
• enlarged tonsils and adenoids - may be "kissing tonsils" (where they are touching)
• foul smelling breath (halitosis)
• noisy respirations - snoring loudly during sleep if enlarged adenoids
• recurrent ear infections
• Diagnostics: positive throat cultures for causative microbes
• Management
• anti-infectives, antipyretics, analgesics
• fluids, rest
• tonsillectomy and/or adenoidectomy if indicated (recurrent infections)
• Nursing interventions
• administer medication as prescribed
• provide postoperative care after tonsillectomy/adenoidectomy
• observe for postoperative complications (hemorrhage, airway obstruction)
• provide positioning that allows for comfort and drainage of mouth and pharynx (prone, head turned to the side)
• maintain ice collar for comfort
• client and family teaching
• findings of hemorrhage - frequent swallowing
• use of prescribed mouthwashes and pain medications
• semi-liquid diet 48 to 72 hours postoperative

F. Peritonsillar abscess
• Definition: complication of acute tonsillitis or pharyngitis with spread of tonsillar infection into the surrounding tissue
• Etiology: untreated bacterial tonsillar infection
• Findings
• inability to swallow saliva with drooling
• marked tonsillar enlargement, possibly threatening airway
• "hot potato" or muffled voice
• high fever and chills
• increased white blood cell count
• facial swelling
• Management
• intravenous antibiotics
• drainage of abscess
• possible emergency tonsillectomy
• Nursing interventions
• monitor airway patency and resolution of infection
• administer prescribed medications
G. Vocal cord disorders
• 1. Laryngitis
• definition: inflammation of vocal cords and surrounding mucous membranes
• etiology
• irritation of the larynx due to chemical, mechanical, infectious or allergic causes
• common with upper respiratory infections
• croup and epiglottitis are types of laryngeal inflammation that can lead to airway obstruction requiring emergency treatment
• findings
• hoarse voice
• swollen lymph nodes in neck (cervical lymphadenopathy)
• fever
• larynx blocked by edema, spasm or both causing stridor
• management
• rest voice
• treat findings
• gargle with warm salt water
• remove irritants
• cool or moist air may bring relief, steamy bathroom, outside in the cool night air, cool air vaporizer
• 2. Vocal cord paralysis
• etiology
• injury, trauma or disease of larynx, laryngeal nerves or vagus nerve
• may result as a complication after thyroidectomy surgery or endotracheal intubation
• damage to both laryngeal nerves may lead to airway obstruction - emergency treatment needed!
• findings: hoarse voice, difficulty swallowing
• diagnostics: laryngoscopy shows abnormal vocal cord movement.
• management
• swallowing evaluation to assess for aspiration
• voice therapy
• surgical treatment - to improve the voice by changing the position of the paralyzed vocal cord

 Disorders of Lower Respiratory System - Obstructive

A. Chronic obstructive pulmonary disease (COPD)
• Definition: chronic irreversible airway obstruction with slowed exhalation
• 1. emphysema - walls of alveoli enlarge and lose elasticity, trapping air and decreasing capacity for vital gas exchange
• 2. chronic bronchitis - chronic inflammatory response in the bronchioles of the lung
• 3. cor pulmonale, with right heart failure, is a late complication of COPD-related pulmonary hypertension

• Etiology
• primary cause of COPD - environmental, due to smoking tobacco
• 3% of emphysema cases - genetic (due to alpha-1 antitrypsin deficiency), occur without tobacco exposure
• Findings
• cough
• sputum production - purulent with acute infection
• dyspnea on exertion - may occur with minimal activity or at rest in advanced stages and with acute exacerbation
• use of accessory muscles of breathing, particularly with severe COPD or respiratory distress
• restlessness with respiratory difficulty or distress
anxiety
• barrel chest (increased anterior-posterior diameter)
• weight loss if breathing difficulty interferes with eating
• rhonchi - associated with chronic bronchitis

• Diagnostics
• spirometry and other pulmonary function tests
• chest x-ray
• sputum examination
• arterial blood gases: increased PaCO2, decreased PaO2
• low oxygen saturation levels with higher hematocrit
Management
• reduction of risks - tobacco smoking cessation or reduction of exposure to tobacco smoke and other inhaled environmental
irritants
• pharmacologic treatments
• inhaled bronchodilators - albuterol (beta-adrenergic), ipratropium (anticholinergic)
• inhaled or oral corticosteroids - prednisone (IV during exacerbations), methylprednisolone
• expectorants - guaifenesin
• supplemental oxygen therapy - oxygen is titrated to lowest dose needed to maintain oxygen saturation around 90% with rest,
exercise, and sleep
• pulmonary rehabilitation exercise program
• airway clearance techniques - effective coughing, chest physiotherapy, postural drainage, vibration
• surgery - lung volume reduction surgery for emphysema
• Nursing interventions
• client and family teaching
• diaphragmatic breathing
• pursed-lip breathing
• inspiratory muscle training
• controlled coughing
• pacing of daily activities
• physical conditioning
• small frequent meals with nutritional supplements
• avoid temperature and humidity extremes, air pollution, and high altitudes
• check oxygen saturation at rest and with activity - administer oxygen at the lowest dose needed to maintain oxygen
saturation at least 90% with rest, exercise and sleep
• monitor for complications of COPD
• respiratory insufficiency
• respiratory failure
• dysrhythmias
• pulmonary infections
• cor pulmonale

B. Asthma
• Definition: a chronic lung disorder marked by recurrent episodes of bronchospasm-related airway obstruction triggered by
hyperreactivity to various stimuli, producing airway narrowing and tenacious, thick, excess, mucous
• characterized by remissions and exacerbations
• exacerbations - more prevalent during particular seasons, especially with extrinsic and infectious etiologies, i.e., ragweed
season, cold or flu season
• one of the most common chronic pediatric health problems
• Etiology
• extrinsic: asthma associated with inflammation and reactivity in response to a specific environmental exposure
• cold air
• humidity
• allergens such as pollens, molds, dust mites, animal dander
• drugs: aspirin & NSAIDs
• intrinsic: asthmatic inflammation and reactivity in response to physical stimuli
• respiratory infection
• exercise
• gastroesophageal reflux-related aspiration
• stress
Findings
• with asthma exacerbation
• (expiratory) wheezing, often audible - wheezing may decease or stop with worsening bronchoconstriction as airflow becomes
severely limited
• shortness of breath
• cough with sputum production
• normal or low oxygen saturation
• chest tightness
• tachycardia
• use of accessory respiratory muscles with respiratory distress
• high normal PaCO2 and low normal PaO2
• findings with exposure to trigger
• shortness of breath
• coughing
• chest tightness
• wheezing with bronchospasm
 • Diagnostics
• acute phase
• physical examination and history
• serum studies - arterial blood gases
• chest x-ray: hyperinflation, flattening of diaphragm
• pulmonary function tests: decreased FEV1, prolonged expiratory phase, reduced peak expiratory flow rate
• chronic phase
• peak expiratory flow rate monitoring to guide therapy and identify when to seek care.
• allergy testing: skin prick or serum RAST testing, IgE to identify allergic triggers
• pulmonary function tests: bronchial reactivity challenge testing with methacholine or specific antigen to identify severity of
airway reactivity
• bronchoscopy
• complications in acute or remission phases
• hypoxemia - low PaO2
• hypercapnia - high PaCO2
• recurrence of other respiratory infections
• respiratory failure
• absence of wheezing may be an indication of absence of airflow - emergency respiratory care is needed with possible
intubation
Management
• pharmacologic therapy
• long-acting control medications
• inhaled corticosteroids (ICS) - fluticasone, beclomethasone
• long-acting beta agonists (LABA) - salmeterol
• leukotriene antagonist - montelukast
• anticholinergic inhaler - tiotropium
• mast cell stabilizers - cromolyn sodium inhaler
• short-acting "rescue" medications
• short-acting beta agonists (SABA) as needed - albuterol inhaler or nebulizer
• exacerbation: oral (prednisone) or intravenous corticosteroids (methylprednisolone) with tapering dose as exacerbation
resolves
• peak flow monitoring
• oxygen for acute management
• anti-allergy therapy (immunotherapy)
• Nursing interventions
• client and family teaching
• diaphragmatic breathing
• pursed-lip breathing
• inspiratory muscle training
• controlled coughing
• pacing of daily activities
• physical conditioning
• avoid temperature and humidity extremes, air pollution, and high altitudes
• small frequent meals with nutritional supplements
• evaluate need for home oxygen therapy at rest and with activity
• asthma action plans and medication administration plans - include the school
• monitor for complications of COPD
• respiratory insufficiency
• respiratory failure
• dysrhythmias
• pulmonary infections
• cor pulmonale
  Restrictive Respiratory Disorders
• Overview
• Definition: irritants, e.g., toxic drugs, radiation, and industrial substances, cause damaging inflammation of the alveoli and
interstitial tissue of the lungs; as a result, the lungs become scarred, stiff, and noncompliant
• Intrapulmonary restrictive conditions - abnormality of lungs, pleura or pleural cavity
• -lung expansion restricted through stiffening of the lung tissue (pulmonary fibrosis, pulmonary sarcoidosis)
• -air or fluid occupying the pleural cavity causes lung tissue to collapse (pneumothorax, hemothorax, pleural effusion,
empyema)
• Extrapulmonary restrictive conditions - lungs are normal; restriction occurs through respiratory muscle weakness or
external compression of the chest wall
• -neuromuscular conditions that cause respiratory muscle weakness (spinal cord injury, muscular dystrophy, Guillain–Barré,
Myasthenia Gravis, poliomyelitis, amyotrophic lateral sclerosis)
• -central nervous system conditions that impair the respiratory center (head injury, CNS lesions, opioids)
A. Intrapulmonary restrictive conditions
• 1. Pulmonary fibrosis: intrapulmonary disorder of lung stiffening, with various etiologies
• idiopathic pulmonary fibrosis: chronic, progressive disorder of lung with inflammation and scarring
• occupational lung diseases
• coal worker's pneumoconiosis - risk increases with length of exposure to coal dust (>15 years), intensity of exposure, and
silica content of dust
• silicosis: workers who have inhaled silica dust
• asbestosis
• inhalation of asbestos fibers
• disease may develop 15 to 20 years after exposure
• high risk for mesothelioma (lung cancer specific to asbestos)
• findings of pulmonary fibrosis
• exertional dyspnea
• nonproductive chronic cough
• chronic inspiratory crackles
• nail clubbing possible
• 2. Sarcoidosis: intrapulmonary disorder of lung characterized by formation of granulomas in the lungs, as well as heart,
lymph nodes, bones and skin; may progress to fibrosis of lungs
• etiology: unknown; 3 to 4 times more prevalent in African Americans
• findings of sarcoidosis
• may be asymptomatic
• dyspnea
• cough
• chest pain
• Diagnostics for intrapulmonary restrictive conditions
• chest x-ray, chest CT - pulmonary lymph node enlargement and pulmonary infiltrates
• pulmonary function tests - used for disease staging and to guide treatment decisions
• bronchoscopy or closed lung biopsy - pulmonary granulomas
• Management of intrapulmonary restrictive conditions
• corticosteroid therapy to suppress the inflammatory response
• avoid environmental exposure to inhaled irritants
• proper use of personal protective respiratory equipment with high-risk occupations and hobbies
• Nursing interventions for intrapulmonary restrictive conditions
• prevent infection or exposure to infection including immunization to prevent influenza and pneumonia
• instruct client to pace activities to reduce oxygen demands and dyspnea
• administer oxygen as needed for hypoxemia and dyspnea, particularly in advanced stages of disease
• reinforce the need for small, frequent meals in advanced stages
• encourage daily activities and exercise within pulmonary tolerance
• provide referrals
• depression associated with disease
• smoking cessation support groups
• pulmonary rehabilitation
• occupational rehabilitation

B. Disorders in which lung tissue collapses

• Definition: any number of disorders in which the pleural space is abnormally occupied by air or fluid, resulting in reduced lung
capacity
Etiology of disorders in which lung tissue collapses
• 1. pneumothorax: air in the pleural space, causing lung collapse
• open pneumothorax: air enters the pleural space through a hole in the chest wall, e.g., gunshot wound
• closed pneumothorax: air enters the pleural space through a hole in the lung tissue, i.e., after lung resection
• tension pneumothorax: closed pneumothorax with rapid accumulation of air in pleural space, increasing pressure:
• high pressure causes mediastinal and tracheal shift away from the affected side, compressing the heart and preventing
adequate cardiac output
• results in cardiac tamponade (and possibly pulseless electrical activity) - emergency situation!
• all types of pneumothorax - treated with chest tube insertion
• 2. pleural effusion: fluid (transudate or exudate) in the pleural space; treated with thoracentesis or chest tube
• 3. hemothorax: blood in pleural space; treated with thoracentesis or chest tube
• 4. empyema: purulent drainage in pleural space; usually a complication of pneumonia, treated with chest tube and
antibiotics
• 5. chylothorax: milky white lymphatic fluid in pleural space, treated with thoracentesis or chest tube, pleurodesis or
surgery
Findings: worsening respiratory distress
• asymmetrical chest movement
• progressive dyspnea
• diminished or absent lung sounds on affected side
• low oxygen saturation levels
• fatigue and activity intolerance
• tachycardia
• restlessness, anxiousness
• chest pain
• progressive cyanosis
• pleural rub - if caused by pleural effusion or pneumothorax

• Diagnostics
• chest x-ray that supports diagnosis
• white blood cell count - high in empyema
• HCT/HGB - below baseline in hemothorax
• Management
• treatment of cause
• placement of chest drainage device
• thoracentesis with or without chest drainage device in pleural effusion or hemothorax
• Nursing interventions
• position client for comfort and to promote ease of breathing
• monitor respiratory status and effort
• administer pain medications as ordered
• maintain/monitor chest tube and closed chest drainage system
• ensure that the chest tube drainage system is closed, has no leaks, all connections are taped or secured, and there are no
kinks or dependent loops in the tubing
• monitor volume and characteristics of drainage - notify surgeon if drainage exceeds 100 mL/hour and/or sudden bright red or
free-flowing drainage
• keep the collection device below chest level or insertion site at all times
• fluctuations of the water level with client's respirations (tidaling) is an expected finding
• do not routinely strip tubing
• occlusive dressing - prevents air from entering pleural space through insertion site (reinforce as necessary)
• ensure that client has appropriate chest x-rays - daily, following changes to chest tube status and when tube is removed
CHEST TUBES
Trauma, disease, or surgery can interrupt the closed negative-pressure system of the lungs, causing a lung to collapse and
air or fluid to fill the pleural cavity. A chest tube is inserted and a closed chest drainage system is attached to remove air
and/or fluid.
• Chest drainage unit (CDU) has 3 chambers
• Water seal chamber
• acts as a one-way valve
• filled with specified amount of sterile saline, usually to the 2 cm mark
• tubing should stay in fluid
• expect water level to fluctuate with respirations (this is called tidaling)
• add water as needed (be sure to first turn off suction temporarily)
• Suction control chamber
• filled with sterile water to the 20 cm H2O level, or as prescribed
• to start suction, connect tubing on the suction control chamber to a suction source; turn up the pressure until gentle, steady
bubbling is observed in the chamber
add water as needed (be sure to first turn off suction temporarily)
• Collection chamber
• Client care
• Assess and document vital signs
• Assess and document breath sounds over affect lung area
• Assess chest movement - report paradoxical chest movement and tracheal deviation (which could indicate a tension
pneumothorax)
• Observe chest tube dressing; change according to policy
• Assess chest tube insertion site, palpating around site for any crepitus or subcutaneous emphysema (sounds like "Rice
Krispies" under the skin)
• Assess tubing for patency - there should be no kinks, dependent loops or clots in the tubing
• Make sure all connections are securely taped and that the chest tube is secured to the client
• Coil excess tubing on mattress next to client and secure to bed
• Chest drainage system should be upright and positioned below level of tube insertion
• Position client:
• semi-Fowler's (to evacuate air with pneumothorax)
• high-Fowler's (to drain fluid with hemothorax)
• Reposition client frequently and assist with ambulation or to sit in chair
• Assess pain using pain intensity rating scale; optimal pain management can prevent hypoventilation and complications, e.g.,
atelectasis, pneumonia
• Note and record amount and color of drainage
• level of drainage should be marked at the end of each shift
• report drainage greater than 100 mL/hour and/or changes in character (bright red or free-flowing)
• Potential problems
• Continuous bubbling in water-seal chamber indicates a leak in the system - assess the system from the insertion site back to
the CDU
• If tidaling does not occur - suspect the tubing is kinked or clamped or a dependent tubing section has become filled with fluid
• Visible clots in tubing - squeeze hand-over-hand along tubing and release the tubing between squeezes - avoid aggressive
chest tube manipulation (no stripping or milking)
• If tubing becomes disconnected from the drainage system - submerge the tube 1" to 2" (2 to 4 cm) below the surface of a
250 mL bottle of sterile water or saline solution until new CDU is set up
• Tension pneumothorax findings:
• severe respiratory distress or chest pain
• absence of breath sounds on affected side
• hyperresonance on affected side with mediastinal shift to unaffected side
• Removal of a chest tube
• The lung has fully expanded
• No air leak has developed during a 24 to 48 hour period
• Less than 150 mL of fluid has drained in a 24-hour period

C. Neuromuscular diseases that affect breathing

1. Guillain–Barré syndrome (see also Lesson 8 C: Neurological - Degenerative Disorders)
• definition: a group of autoimmune peripheral neuropathies resulting in symmetric and ascending motor paralysis; an acute
condition; potentially fatal if respiratory muscles are affected
• etiology: unknown; often follows stimulation of immune system such as after an infection, surgery, trauma, viral
immunization or HIV
• progressive phase of the syndrome lasts from a few days to four weeks
• plateau phase
• resolution of findings varies
• findings
• typically begins with weakness accompanied by tingling sensation in the extremities
• ascending paralysis begins in the lower extremities and may affect the entire body
• autonomic nervous system involvement may include fluctuations in blood pressure and dysrhythmias, usually with severe
disease
• pain - hyperesthesias, paresthesias, muscle aches and cramps
• when the weakness/paralysis reaches the respiratory muscles the client is unable to maintain an adequate respiratory effort
• diagnostics: EMG shows abnormal nerve conduction
• management
• supportive care including mechanical ventilation if indicated during acute phase
• plasmapheresis or intravenous immunoglobulin
2. Myasthenia gravis (see also Lesson 8 C: Neurological - Degenerative Disorders)
• definition: autoimmune disorder with fluctuating weakness of skeletal muscle
• etiology: antibodies attack acetylcholine receptors in the neuromuscular junction
• findings
• skeletal muscle weakness with a pattern of fluctuation, and improved strength after rest
• muscles most commonly involved are facial muscles including those responsible for chewing and swallowing and speech -
risk for aspiration
• proximal muscle weakness in neck, shoulders and hips
• exacerbations can be caused by stress, temperature extremes, pregnancy, certain drugs
• myasthenic crisis can cause respiratory failure and need for emergent care
• diagnostics
• EMG
• anticholinesterase (Tensilon) test - improved muscle contractility following administration (note: atropine should be available
for emergency use during this test)
• management
• pharmacologic: anticholinesterases and cholinesterase inhibitors
• pyridostigmine
• neostigmine
• ambenonium
• corticosteroids and other immunosuppressive agents
• plasmapheresis
• thymectomy (if thymus dysplasia exist)
• nursing interventions
• monitor neurologic and respiratory status for disease progression
• aspiration precautions if swallowing is affected
• schedule periods of rest between activities
• discuss potential triggers and reduction or avoidance techniques
• educate about importance of adherence to medications to promote muscle strength and avoid complications
3. Poliomyelitis
• definition: viral infection that can affect nerves and can lead to partial or full paralysis
• etiology - virus spread by person-to-person contact, contact with infected mucus or phlegm from the nose or mouth, contact
with infected feces
• findings
• subclinical infection (95% of cases): ranging from no findings to malaise, headache, red throat, slight fever, vomiting
• nonparalytic: back pain, diarrhea, fatigue, headache, irritability, leg pain, moderate fever, muscle stiffness, neck pain and
stiffness, rash
• paralytic: fever; abnormal sensations; bloated feeling in abdomen; difficulty breathing, constipation; muscle pain, contraction
or spasms; sensitivity to touch; stiff neck and back
• post-polio syndrome: a complication that develops in some people, usually 30 or more years after initial infection
• complications may include aspiration pneumonia, cor pulmonale, kidney stones, urinary tract infections, shock
• management
• prevention - vaccination
• based on form of disease and findings
4. Amyotrophic lateral sclerosis (ALS; also called Lou Gehrig's Disease) (see also Lesson 8
C: Neurological - Degenerative Disorders)
• definition: a disease of the nerve cells in the brain and spinal cord that control voluntary muscle movement
• etiology: loss of motor neurons responsible for supplying electrical stimulation to the muscles
• genetic defect in 10% of cases; otherwise cause is unknown
• occurs in mid-life affecting men more often than women
• chronic, progressive, and irreversible
• findings
• usually begins in upper extremities
• progressive neuromuscular weakness, spasticity, inability to communicate or move voluntarily, loss of involuntary reflexes
such as blinking and gag reflex
• autonomic, sensory and mental function unchanged
• leads to respiratory failure and death within 2 to 6 years
• ethical issues
• whether clients want mechanical ventilation or nutritional support
• they may want to die before the disease becomes severe
• importance of advanced care planning and hospice referral
5. Muscular dystrophies
• progressive symmetrical wasting of voluntary muscles with no nerve effect
• as thoracic muscles weaken, breathing becomes more difficult
• may not swallow well; risk for aspiration with loss of protective airway reflexes
• Nursing interventions common to neuromuscular disorders affecting breathing
• monitor frequently for changes in respiratory status such as respiratory failure and infection
• regularly assess swallowing and ability to protect the upper airway
• discuss client preferences for mechanical ventilation or nutritional support; communicate and advocate for client wishes
• assist with coughing and secretion clearance as indicated
• prevent respiratory infection through reduction of risk and immunization (influenza & pneumococcal vaccines)
• assess for depression and anxiety, common with these diseases, and provide appropriate referrals
• administer medications specific to the disease condition
• assist/provide occupational or/and physical rehabilitation as indicated
• maintain adequate nutrition utilizing appropriate methods to reduce risk of aspiration if swallowing affected
• with terminal disorders, provide for referrals for family such as palliative care and hospice

 Disorders of the Lower Respiratory System - Infectious

• A. Pneumonia
• Definition: disease of the lungs, primarily caused by infection, characterized by inflammation and consolidation of lung tissue
followed by resolution; accompanied by fever, chills, cough, and difficulty breathing
Etiology
• community-acquired: exposure to infectious organisms outside of hospital
• hospital-acquired: secondary to infectious organism exposure, i.e., pseudomonas, or risk factors associated with a health
care setting and occurring 48 hours or more after admission
• aspiration: chemical irritation and inflammation associated with aspiration of food or stomach contents or normal oral flora
• opportunistic: caused by microorganisms that are usually harmless but that can be pathogenic in individuals with depressed
immune function, such as Pneumocystis carinii, Cytomegalovirus, and Legionnaires' disease
• pneumonia is the leading cause of death from infectious causes
• risk factors
• preexisting pulmonary disease
• depressed immune function such as HIV, chemotherapy and other immunosuppressant drugs
• atelectasis secondary to surgery or immobility
• mechanical ventilation or artificial airway
• advanced age, particularly with chronic illness, frailty
• decreased ability to protect airway, swallow safely or cough effectively
Findings
• fever, chills, malaise
• shortness of breath with decreased oxygen saturation
• productive cough with purulent sputum
• pleuritic chest pain
• crackles or rhonchi in affected lobe(s), egophony, whispered pectoriloquy
• age-related findings
• older adults - atypical presentation is common with acute confusion while other findings may be less evident
• in infants and young children, lethargy, crankiness and poor appetite may indicate an acute infection such as pneumonia.
• Diagnostics
• chest x-ray - reveals consolidation or infiltrates in affected lobes
• labs
• complete blood count - increased white blood cells
• arterial blood gases - respiratory acidosis (low pH, high PaCO2), hypoxemia (low PaO2)
• sputum culture, sensitivity and microscopic analysis, Gram stain, cytology - identify causative organism and appropriate
treatment
• bronchoscopy - to obtain sputum specimen when organism is difficult to identify
• Management
• pharmacologic
• antimicrobials (depends on pathogen) - monitor for signs of resolving infection
• antipyretic, analgesic - acetaminophen or NSAIDs
• expectorants - guaifenesin
• antitussives - dextromethorphan, codeine
• respiratory support as needed, may include mechanical ventilation in severe cases
• Nursing interventions
• monitor pulse oximetry, titrate oxygen as indicated
• promote hydration to liquify secretions
• monitor respiratory status including rate, effort, signs of failure or distress, auscultate lungs
• teach effective coughing techniques to minimize energy expenditure
• teach the need to continue entire course of antimicrobial therapy which is usually 7 to 10 days
• teach that improvement of findings should occur within 48 to 72 hours of initial therapy - contact provider if not improving
• encourage influenza and pneumococcal vaccine for high-risk groups

B. Pulmonary tuberculosis (PTB)

• Definition: a chronic infection caused by an acid-fast bacillus, generally transmitted by inhalation or ingestion of infected
droplets
Etiology: mycobacterium tuberculosis, which is often dormant, later reactivating
• typically bacilli lodge in alveoli but can affect almost any organ
• pulmonary infiltrates
• increased prevalence of multi-drug resistant PTB, especially among the homeless and AIDS victims
• Findings
• weakness with fatigue
• anorexia with weight loss
• night sweats
• chest pain
• cough - begins dry and progresses to a productive cough with purulent and/or blood tinged sputum
Diagnostics
• laboratory
• culture for sputum and gastric contents - analysis for the presence of acid-fast bacilli
• interferon-gama release assay (IGRA) - blood test to measure immune system response
• chest x-ray - for presence of active or calcified lesions ("coin" lesions)
• Mantoux skin test
• positive if > 10 mm induration in healthy persons (or positive if > 5 mm induration in clients who are immunosuppressed) -
additional tests are needed
• false-negative responses - common in people who are immunosuppressed; two-step Mantoux is used for this population (and
health care providers)
• false positives - may occur for those who have received the BCG vaccine (commonly administered outside the U.S.)
• diagnosis of TB requires all of the following: medical history, physical exam, TB skin test or blood test, chest x-ray and
sputum or other culture
• Management
• long-term (6 to 24 months) - antimicrobial therapy with isoniazid (INH) or rifampin; ethambutol in some cases
• activity as tolerated
• surgical resection of involved lung if medication is not effective
• high carbohydrate, high protein diet with frequent small meals
• TB is a reportable disease - report to appropriate agencies; family and close contacts must be tested for disease
 • Nursing interventions
• with active infection
• airborne precautions and client placed in negative airflow room in the hospital
• use NIOSH-approved N95 particulate filtering facepiece respirator when providing care; visitors can wear surgical masks
• provide client with surgical mask if transport needed
• obtain sputum specimen early in morning - best for definitive diagnosis
• teach client
• proper techniques to prevent spread of infection, including hand washing
• report bloody sputum
• not to use over-the-counter medications without health care provider's approval due to possible drug-drug interactions
• not to wear soft contact lenses if taking rifampin (can cause reddish-orange discoloration of saliva, sweat, tears, urine, skin)
• importance of taking medications as prescribed
• adherence to treatment regimen
• return at scheduled times for lab testing of liver enzymes
• an increase in B6 (or B complex) vitamin minimize peripheral neuropathies (a common side effect of antituberculars)

C. Lung abscess
• Definition: localized collection of purulent fluid in the lung with cavity formation
• Etiology: usually a complication of pneumonia, TB or aspiration
• Management
• broad-spectrum antimicrobial treatment after culture of fluid
• percutaneous imaging or surgical resection - to drain abscess if the infection does not resolve with pharmacologic treatment

D. Severe acute respiratory syndrome (SARS)

• Definition: respiratory illness caused by the coronavirus (called SARS-associated coronavirus)
• Etiology: infection is spread by close person-to-person contact by direct contact with infectious material (respiratory
secretions or contact with persons or objects infected with infectious droplets)
• Findings
• syndrome begins with a fever, overall feeling of discomfort, body aches, and mild respiratory symptoms; dry cough and
dyspnea may develop later
• last pandemic occurred in 2003
• Diagnosis: laboratory confirmation of SARS-CoV infection
• Management
• hospitalization if radiographically confirmed pneumonia (or acute respiratory distress syndrome) of unknown etiology
• contact and airborne precautions
• report to Centers for Disease Control and Prevention (CDC)
• supportive care; no specific treatment has been shown to consistently improve the outcome of the ill persons
• Nursing interventions
• assess temperature and monitor for signs of pneumonia
• instruct clients to avoid contact with those suspected of having SARS and to avoid travel to countries where an outbreak of
SARS exists
• frequent hand hygiene; persons with suspected disease should wear mask to prevent transmission
• PPE for staff - gown, gloves, N95 respirators and eye protection

 Disorders of Lower Respiratory System - Miscellaneous

• A. Pulmonary embolism
• Definition: blood clot prevents blood from perfusing the "bed" of arteries that feed the lung, resulting in pulmonary infarction
and decreased cardiac output; emboli can also be composed of air or fat
Etiology
• matter blocks blood from the "bed" of arteries that feed the lung so client is breathing but gases are not exchanged
• hypoxemia occurs
• can be mild or immediately fatal, based on the size and location of matter
• symptoms develop over a period of minutes and require emergency treatment!
• types of embolus
• -blood clot - has usually traveled from deep veins in the leg or pelvis
• -fat - from fractured femur, hip
• -amniotic fluid - postdelivery
• -air- from injection of large air bolus through IV or arterial line
• primary cause is prolonged immobility
• poor hydration and conditions that impair circulation (atrial fibrillation, heart failure) contribute to clot development
• with fat embolism, findings occur about 24 hours after the initial fracture
• Findings
• small embolus - client may be asymptomatic
• large embolus
• sudden onset of dyspnea and cough with low oxygen saturation
• pleuritic chest pain
• anxiety, apprehension - feeling of "impending doom"
• cough - productive or nonproductive
• tachycardia and tachypnea
• Diagnostics
• chest CT with contrast (spiral CT)
• D-dimer - elevated
• ventilation/perfusion (V/P) scan (also called V/Q scan)
• arterial blood gases - low PaO2, high PaCO2
• ECG
• Management
• prevention is best treatment - preventive anticoagulants with orthopedic surgeries and when bed-bound
• oxygen titrated to correct hypoxemia - may need mask or high-flow oxygen
• pharmacologic
• anticoagulation - heparin IV or low molecular weight heparin for acute PE; warfarin chronically to reduce risk of recurrence
• thrombolytics (for large emboli)
• pain and anxiety
• filter surgically placed in vena cava for long term prevention
• Nursing interventions
• monitor for changes in respiratory and cardiovascular status
• early ambulation and compression stocking use during hospitalization to prevent deep vein thrombosis

B. Acute respiratory distress syndrome (ARDS); called acute lung injury (ALI) in early stages
• Definition: unregulated inflammatory response to a significant acute injury or inflammatory process anywhere in the body
results in damage to the alveolar capillary membrane resulting in a non-cardiac pulmonary edema
• Etiology
• alveolar capillary membrane becomes more permeable to fluids
• increased extravascular lung fluid
• pulmonary compliance decreases
• intrapulmonary shunt increases
• refractory hypoxemia
• usually seen after lung injury or massive multi-system organ disease
• Findings
• restlessness, anxiety - ill appearance
• does not respond to oxygen therapy
• tachycardia
• cyanosis (late)
• intercostal retractions, accessory muscle use
• early lung sounds are clear; coarse crackles later
• interstitial fibrosis develops in some patients who survive ARDS
• Diagnostics
• clinical presentation and history of findings
• arterial blood gases - hypoxemia and respiratory acidosis despite increasing inspired oxygen level
• chest x-ray - diffuse infiltrates
• Management: treat precipitating condition, e.g., antibiotics for sepsis
• optimize oxygenation to maintain saturation > 88% and to correct respiratory acidosis:
• mechanical ventilation with PEEP, possible extracorporeal membrane oxygenation (ECMO)
• sedation may be required
• paralytic agents may be necessary
• corticosteroids to reduce inflammation
• antibiotics for infectious causes
• fluid restriction may be used to reduce pulmonary microvascular pressure with central venous pressure monitoring to guide
therapy
• nutritional management via tube feeding or other method when mechanically ventilated
• Nursing interventions
• bed rest with frequent position changes
• range of motion exercises
• monitor trends in oxygenation status, arterial blood gases
• observe for behavioral changes and signs of confusion
• monitor vital signs, respiratory effort
• care of client receiving corticosteroids
• prevent and treat complications, e.g., malnutrition, deep vein thrombosis, healthcare-acquired infections (HAIs), DIC, skin
breakdown, inadequate nutrition, GI hemorrhage, pneumothorax
• work with interdisciplinary team for transfer of client to tertiary care facility

C. Cor pulmonale
• Definition: right heart failure that develops due to sustained lung resistance in chronic lung disease, i.e., COPD
Etiology: heart must pump against great resistance to move blood from the right heart to the left heart through the
lung's blood vessels; increased pulmonary vascular resistance (PVR)
• right ventricular hypertrophy and subsequent chronic heart failure
• increased PVR results from chronic lung disease, pulmonary hypertension, pulmonary fibrosis
• Findings
• fatigue, tachypnea, exertional dyspnea, and cough
• anginal chest pain - due to right ventricular ischemia or pulmonary artery stretching
• hemoptysis
• Diagnostics
• pulmonary artery pressure readings via PA catheter
• echocardiogram
• chest x-ray
• arterial blood gases
• ECG
• Management
• manage underlying lung disease
• administer oxygen as ordered to prevent hypoxemia
• monitor oxygenation with pulse oximeter
• frequent rest periods
• medications: cardiac glycosides, pulmonary artery vasodilator, diuretics
• restricted fluid intake as indicated
• Nursing interventions
• monitor for changes in oxygenation status
• monitor effects of medications
• pace activities for clients who tire easily
 D. Respiratory failure
 Definition: lungs cannot maintain arterial oxygen levels or eliminate carbon dioxide
 Etiology
• lung diseases that harden the alveolar-capillary membrane, trap O2
• a multitude of conditions can cause respiratory failure
• neuromuscular or musculoskeletal disorders:
• respiratory drive dulled or blunted
• respiratory muscles weak
 Findings
• PaCO2 > 50 mm Hg
• PaO2 < 60 mm Hg
• clients with chronic lung disease precautions
• look for drop from baseline function
• clients are always hypoxemic and hypercarbic
• classic presentation: the three "H's" or hypoventilation, hypoxemia, hypercapnia
 Diagnostics: arterial blood gases, history
 Management
• emergency care!
• oxygen per mask, CPAP, or intubation and mechanical ventilation
• control anxiety (not being able to breath is scary, thus anxiety increases which increases oxygen needs)
• monitor for improvement in the underlying cause for the respiratory failure
 Nursing interventions
• observe for signs of hypoxia and respond to prevent occurrence of respiratory failure
• administer medications and oxygen as prescribed
• supportive care for emotions, skin integrity, gastrointestinal function, renal function

 POINTS TO REMEMBER
• Cough; exertional dyspnea; fatigue; fainting; swelling of feet or ankles = COR PULMONALE
• Barrel chest; chronic cough, shortness of breath, wheezing; weight loss = EMPHYSEMA
• Chest pain; muffled heart and lung sounds; mediastinal shift; respiratory distress = TENSION P.T
• Difficulty swallowing; ear pain; fever & chills; headache; sore throat = TONSILLITIS
• Ptosis; difficulty chewing & swallowing; weakness in arms & legs; shortness of breath=M.GRAVIS
• Cough; difficulty breathing; fatigue; fever greater than 100.4 F (38 C); headache; myalgia = SARS
• Fever, chills, productive cough, dyspnea, pleuritic pain, use of accessory muscles = PNEUMONIA
• Thick, sticky mucus, wheezing, exercise intolerance, repeated lung infections = CYSTIC FIBROSIS

• Oxygen is essential for life; therefore a priority nursing action is to keep the airways open and ease
breathing effort.
• COPD causes poor gas exchange in the lungs, leading to decreased oxygen levels and increased
carbon dioxide levels in the blood and shortness of breath.
• Nursing interventions for clients with chronic lung disease should include pacing of activities,
because these clients have little reserve for exertion.
• Treatment of COPD consists of cessation of smoking, medications to open the airways and
decrease inflammation, prevention of lung infections, oxygen supplementation, and pulmonary
rehabilitation, i.e., using diaphragmatic breathing and pursed-lip breathing, proper use of respiratory
equipment, and occupational or physical therapy.
• Second-hand smoke increases the risk of developing asthma or other chronic lung diseases in
children.
• Clients with asthma must understand the different types of inhalers and when to use each
type.
• Acute dyspnea: "rescue" or short-acting beta agonists (SABA) inhalers
• Maintenance or prevention: inhaled corticosteroid (ICS) and/or long-acting beta-agonists (LABA) inhalers
• Asthma is not a disease but an inflammatory disorder.
 • To maximize therapeutic effect of inhalers, the key is technique; teach clients the right technique
and observe how well they use the inhaler.
• Clients who have difficulty using inhalers properly (children, confused adults) should use a spacer
device.
• A pulse oximeter reading is simply one element of an assessment; it is not the whole picture.
Arterial blood gases will give a more complete picture of oxygenation.
• If a client is in respiratory distress, typical orders are to administer oxygen by nonrebreather mask
at 10 to 15 liters per minute until the client's condition improves or stabilizes.

Cyanosis, a late finding, is determined by oxygenation and hemoglobin content. Remember to

check nail beds and mucous membranes for changes; don't forget different skin coloring affects
the appearance of anemia.
• Anemic clients may be severely hypoxemic and never turn blue - rather, they become dusky, grey, or ashen
in color.
• Polycythemic clients with high hemoglobin and hematocrit levels may be cyanotic with adequate tissue
oxygenation.

• Any incidence of pulmonary tuberculosis (TB) must be reported.

• Clients diagnosed with pulmonary TB need intensive community follow up to ensure that they
continue with long term pharmacological treatment. Clients who stop therapy too soon are a source
for more deadly multi-drug resistant forms of pulmonary TB.
• Don't rely on the equipment to tell you about changes - always look at the client and determine if
there is difficulty breathing, anxiety, or restlessness. If a client states something is
wrong...immediately assess client and intervene as necessary.
• If an alarm sounds on a ventilator, first assess the client. If the alarm continues to sound and the
client develops distress, disconnect the client from the ventilator, use a manual resuscitation bag to
ventilate with 100% oxygen, and page or call the respiratory therapist or the rapid response team
immediately.
• If the high pressure alarm sounds on the ventilator, the nurse should check for some type of
obstruction or occlusion of the airway: mucous plugs, biting of the tube by the client, the tube has
slipped into right main stem bronchus, or increased secretions.
• The best approach to pulmonary embolus is prevention; use compression stockings (TEDS), along
with sequential compression devices (SCDs), range of motion exercises (passive or active), and
repositioning, to help prevent clots in the deep veins.
• When caring for a client who just had a chest tube inserted, validate that there's no leak from the
lung. Only when there is no leak should an occlusive dressing be applied.
• Gentle tidaling is expected in the water seal chamber of a chest tube; continuous bubbling indicates
an air leak and requires immediate intervention.