KABC - RESPI

ASSESSMENT OF RESPIRATORY FUNCTION

Anatomic and Physiologic Overview

Composed of:
1. upper respiratory tract
2. lower respiratory tract
Together, the two tracts are responsible for ventilation
* movement of air in and out of the airways

> The upper tract (upper airway) warms and filters inspired air so
that…
> The lower respiratory tract (the lungs) can accomplish gas
exchange.

Gas Exchange
> involves delivering oxygen to the tissues through the
bloodstream and expelling waste gases, such as carbon dioxide,
during expiration PLEURA
> Serous membrane that lined the lungs and wall of the thorax.
Upper Airway Structures consist of the > The visceral pleura covers the lungs; the parietal pleura lines the
1. Nose thorax.
2. Sinuses and Nasal Passages
3. Pharynx, Tonsils and Adenoids,
4. Larynx

MEDIASTINUM
> The mediastinum is in the middle of the thorax, between the
pleural sacs that contain the two lungs.
> Heart, thymus, the aorta and vena cava, and esophagus.

Lower Respiratory Tract

> The lungs are paired elastic structures enclosed in the thoracic
cage, which is an airtight chamber with distensible walls
> Size of a football (approx.)
> The lung fills the area from the collarbone to the bottom of the BRONCHI AND BRONCHIOLES

ribs. > There are several division of the bronchi within each lobe of the

> Lung is the only organ in the body light enough to float. lung
1. Right and left bronchi

LUNGS 2. Lobar bronchi (3 - right and 2 - left)

> Each lung is divided into lobes: 3. Segmental bronchi (10 - right and 8 - left)

o Right - 3 lobes 4. Subsegmental bronchi

o Left - 2 lobes 5. Bronchioles

> The left lobe is slightly smaller than the right lobe. 6. Terminal bronchioles
7. Respiratory bronchioles - dead space (150mL)

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8. Alveolar ducts and sacs o The maximum volume of air that can be exhaled forcibly
9. Alveoli after a normal exhalation
o 1,100 mL
ALVEOLI > Residual Volume (RV)
> Oxygen and carbon dioxide exchange takes place in the alveoli. o The volume of air remaining in the lungs after a
> arranged in clusters of 15 to 20 maximum exhalation
> Three types of alveolar cells---(Pneumocyte) o 1,200 mL
> Type I, II, and III
LUNG CAPACITIES
FUNCTION OF THE RESPIRATORY SYSTEM > Vital Capacity (VC)
> The respiratory system performs this function by facilitating o The maximum volume of air exhaled from the point of
life-sustaining processes such as: maximum inspiration
1. oxygen transport o 4,600 mL
2. respiration and ventilation, and > Inspiratory Capacity (IC)
3. gas exchange. o The maximum volume of air inhaled after normal
expiration
o 3,500 mL
"Inspiration occurs during the first third of the respiratory > Functional Residual Capacity (FRC)
cycle; expiration occurs during the latter two thirds ”. o The volume of air remaining in the lungs after a normal
expiration
INSPIRATION TO EXPIRATION RATIO IS o 2,300 mL
1:2 > Total Lung Capacity (TLC)
o The volume of air in the lungs after a maximum
inspiration
LUNG VOLUMES AND LUNG CAPACITIES o 5,800 mL
> Lung function which reflects the mechanics of ventilation, is
viewed in terms of lung volumes and lung capacities. PULMONARY DIFFUSION and PERFUSION
> Lung volumes:
o tidal volume, > PULMONARY DIFFUSION
o inspiratory reserve volume, o Process by which oxygen and carbon dioxide are
o expiratory reserve volume, and exchanged from areas of high concentration to areas of
o residual volume. high at the air –blood interface.
> Lung capacity:
o vital capacity, > PULMONARY PERFUSION
o inspiratory capacity, o It is the actual blood flow through the pulmonary
o functional residual capacity, and circulation.
o total lung capacity
VENTILATION-PERFUSION RATIO
LUNG VOLUMES
> Tidal Volume (VT or TV)
o The volume of air inhaled and exhaled with each breath VENTILATION MATCHES PERFUSION
o 500 mL or 5–10 mL/kg 1:1

GAS EXCHANGE
> Partial pressure of gases
> Pressure exerted by each type of gas in a mixture of gases.

PARTIAL PRESSURE ABBREVIATIONS

P pressure

PO2 partial pressure of oxygen

PCO2 partial pressure of carbon dioxide

PAO2 partial pressure of alveolar oxygen

PACO2 partial pressure of alveolar carbon dioxide

PaO2 partial pressure of arterial oxygen

PaCO2 partial pressure of arterial carbon dioxide

Pv–O2 partial pressure of venous oxygen

> Inspiratory Reserve Volume (IRV)
Pv–Co2 partial pressure of venous carbon dioxide
o The maximum volume of air that can be inhaled after a
partial pressure of oxygen when the hemoglobin is 50%
normal inhalation P50
saturated
o 3,000 mL
> Expiratory Reserve Volume (ERV)
Neurologic Control of Ventilation

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> Resting respiration is the result of cyclical excitation of the

respiratory muscles by the phrenic nerve.
> The rhythm of breathing is controlled by respiratory centers in
the brain.
o Medulla oblongata and Pons

ASSESSMENT

HEALTH HISTORY
> Dyspnea
> Cough
> Sputum production
> Chest pain
> Wheezing
> Hemoptysis

> Bacterial infection

o Profuse amount of purulent sputum (thick and yellow,
green or rust colored)
> Viral bronchitis
o Thin mucoid sputum
> Chronic bronchitis/bronchiectasis
Funnel Chest (Pectus Excavatum)
o Gradual increase of sputum over time
> occurs when there is a depression in the lo wer portion of the
> Lung tumor
sternum.
o Pink-tinged mucoid sputum
> compress the heart and great vessels, resulting in murmurs.
> Pulmonary edema
> May occur with Rickets or Marfan’s Syndrome.
o Profuse, frothy, pink material
> Lung abscess
o Foul smelling sputum and bad breath

PHYSICAL ASSESSMENT OF THE LOWER RESPIRATORY STRUCTURES

AND BREATHING

Pigeon Chest (Pectus Carinatum).

> occurs as a result of displacement of the sternum.
> increase in the AP diameter.
> may occur with Rickets, Marfan’s Syndrome, or severe
Kyphoscoliosis

CHEST CONFIGURATION
> the ratio of the anteroposterior diameter to the lateral diameter
is 1:2
> four main deformities of the chest associated:
> barrel chest,
> funnel chest (pectus excavatum),
> pigeon chest (pectus carinatum), and
> kyphoscoliosis

Barrel Chest
> occurs as a result of over inflation of the lungs.
> increase in the AP diameter of the thorax
> Emphysema

HALLMARK SIGN OF EMPHYSEMA

Kyphoscoliosis
> characterized by elevation of the scapula and a corresponding S -
shaped spine.

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> limits lung expansion within the thorax.

> may occur with osteoporosis and other skeletal dis orders that
affect the thorax

BREATHING PATTERN AND RESPIRATORY RATES

> Average: 12-20 breaths per minute or 14 -20 breaths per minute
o Eupnea: normal cycle of breathing
o Bradypnea: slow breathing
o Tachypnea: rapid breathing
o Apnea: temporary pauses of breathing
o Obstructive sleep apnea: apneas occur repeatedly during
sleep, secondary to transient upper airway blockage

TACTILE FREMITUS/FREMITUS
> Sound generated by the larynx travels distally along the
bronchial tree to set the chest wall in resonant mo tion.
> TACTILE FREMITUS: detection of the resulting vibration on the
chest wall by touch
> “ninety-nine” or “one, two, three,” or “eee, eee, eee”
> The vibrations are detected with the palmar surfaces of the
fingers and hands, or the ulnar aspect of the extende d hands, on
the thorax.
> BONES ARE NOT ASSESSED!

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o Continuous, musical, high -pitched, whistle like sounds

heard during inspiration and expiration caused by air

BREATH SOUNDS passing through narrowed or partially obstructed
> Normal breath sounds are identified as: airways; may clear with coughing
o vesicular, o Bronchospasm, asthma, and buildup of secretions
o bronchovesicular, and > Sonorous wheezes (rhonchi)
o bronchial (tubular) breath sounds o Deep, low-pitched rumbling sounds heard primarily
during expiration; caused by air moving through
narrowed tracheobronchial passages
o Secretions or tumor

FRICTION RUBS (Pleural Friction Rub)

> Harsh, crackling sound, like two piece s of leather being rubbed
together.
> May subside when patient holds breath. Coughing will not clear
sound.
> Secondary to inflammation and loss of lubricating pleural fluid

VOICE SOUNDS
> Vocal Resonance
o The sound heard through the stethoscope as the patient
speaks
o larynx → chest wall → bronchi → alveolar tissue
o During the process, the sounds are diminished in
intensity and altered so that syllables are not
distinguishable.
o “ninety-nine” or “eee”

Abnormal (Adventitious) Breath Sounds

> Bronchophony - describes vocal resonance that is more intense
> An abnormal condition that affects the bronchial tree and alveoli
and clearer than normal.
may produce adventitious (additional) sounds.
> Egophony - describes voice sounds that are distorted (E A)
> Adventitious sounds are divided into two categories:
> Whispered pectoriloquy - heard only in the presence of rather
1. Crackles - discrete, non-continuous sounds
dense consolidation of the lungs.
2. Wheezes - continuous musical sounds
> All test for consolidation!

CRACKLES (RALES)
Diagnostic Evaluation
> Coarse crackles
> ARTERIAL BLOOD GAS STUDIES
o Discontinuous popping sounds heard in early inspiration;
> Allen’s Test/Modified Allen’s Test
harsh, moist sound originating in the large bronchi .
> Fine crackles
o Discontinuous popping sounds heard in late inspiration;
sounds like hair rubbing together; originates in the
alveoli.

WHEEZES
> Sibilant wheezes

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Other Diagnostic Examinations

> VENOUS BLOOD SPECIMEN
> PULSE OXIMETRY
o Method of continuously monitoring the oxygen
saturation of hemoglobin
> CULTURES
> SPUTUM STUDIES
> PPD

Sputum Exams
> Informed consent
> Sputum Analysis – gross appearance
> Consent
> For Culture and sensitivity – to detect the actual microorganism
> NPO 4-8 hours (reduce risk for aspiration)
causing the infection
> Fear — sedation
> For sputum cytology - to detect cancer cells
> Sedation given to patients with respiratory insufficiency may
> For sputum AFB:
precipitate respiratory arrest.
o To assist in the diagnosis of TB
> Remove dentures and other oral prosthesis
o For monitoring of the effectiveness of therapy
> Local anesthesia
> Topical anesthetic sprayed on the pharynx to suppress cough
Purified Protein Derivative s (PPD)
reflex and minimize discomfort
> Mantoux Test
> ID route
After the procedure
> •Read result after 48-72 hours after injection
> NPO until gag or cough reflex returns
> (+) Mantoux test is induration of 15mm or more
> A small amount of blood - tinged sputum and fever may be
> For HIV positive clients, induration of 5 mm is considered
expected within the first 24 hours.
positive
> (+) Mantoux Test signifies exposure to Mycobacterium Tubercle
THORACOSCOPY
Bacilli
> diagnostic procedure in which the pleural cavity is examined
with an endoscope

THORACENTESIS
> An accumulation of pleural fluid may occur with some disorders
> A sample of this fluid can be obtained by thoracentesis
> A needle biopsy of the pleura may be performed at the same
time.

ENDOSCOPIC PROCEDURES
> BRONCHOSCOPY
o the direct inspection and examination of the larynx,
trachea, and bronchi through either a flexible fiber optic
bronchoscope or a rigid bronchoscope.

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> Increased O2 (admi nistering too much) may stop the hypoxic
Biopsy respiratory drive and cause CO2 narcosis.
> Excision of a small amount of tissue, may be performed to permit > Low oxygen levels are what keeps the client breathing. As long
examination of cells from the pharynx, larynx, and nasal as the client is hypoxic, he will breathe.
passages. > If your client receives more than 2 to 3 L/min of oxygen with an
o Lung biopsy increase in PaO2, he is no longer hypoxic and could stop
o Pleural biopsy breathing.
o Lymph node biopsy
MANAGEMENT OF PATIENTS WITH CHEST AND LOWER RESPIRATORY
TRACT DISORDERS
RESPIRATORY CARE MODALITIES
ATELECTASIS
Non-invasive Respiratory Therapies > Refers to the closure or collapse or airless condition of alveoli
> Often is described in relation to ches t x-ray findings and/or
OXYGEN THERAPY clinical signs and symptoms.
> Oxygen therapy is the administration of oxygen at a
concentration greater than that found in the environmental Such pressure may be produced by:
atmosphere. > PLEURAL EFFUSION
> Indications o fluid accumulating within the pleural space
o Hypoxemia > PNEUMOTHORAX
o Hypoxia o air in the pleural space
> HEMOTHORAX
o blood in the pleural space

COMPLICATIONS
> OXYGEN TOXICITY Assessment Findings:
o Oxygen toxicity may occur when too high of oxygen > dyspnea
concentration (greater than 50%) is administere d for an > decreased breath sounds on affected side,
extended period (longer than 24 hours). > decreased respiratory excursion
o It is caused by overproduction of oxygen free radicals, > dullness to flatness upon percussion over affected area
which are byproducts of cell metabolism. > Cyanosis
o •If oxygen toxicity is untreated, these radicals can > Tachycardia
severely damage or kill cells. > Tachypnea
> elevated temperature
SUPPRESSION OF VENTILATION > Weakness
> Clients with COPD usually only need low -flow oxygen because > pain over affected area
their drive to breathe is primarily based on their usual state of
hypoxia. Diagnostic tests
> The chemoreceptors become insensitive to increased CO2 levels a. Bronchoscopy - may or may not reveal an obstruction
with long term lung disease.

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b. Chest x-ray shows diminished size of affected lung and lack of c. Antibiotic therapy, chemotherapy, o r wound care
radiance over atelectatic area within 30 days of current infection
c. PaO2 decreased d. Hemodialysis treatment at a hospital or clinic
e. Home infusion therapy or home wound care
The goal in treating the patient with atelectasis is to: f. Family member with infection due to multi -drug
> improve ventilation resistant bacteria
> remove secretions
> If these measures fail: 3. Hospital-Acquired Pneumonia (HAP)
o bronchoscopy may help remove secretions. o Pneumonia occurring ≥48 hours after hospital admission
o Humidity and bronchodilators that did not appear to be incubation at the time of
admission
> Atelectasis secondary to an obstructing neoplasm may require
surgery or radiation therapy. 4. Ventilator-Acquired Pneumonia (VAP)
o A type of HAP that develops >48 hours after
PNEUMONIA endotracheal tube intubation
> Inflammation of the lung parenchyma caused by various
microorganisms, including bacteria, mycobacteria, fungi and Aspiration Pneumonia
viruses. > Refers to the pulmonary consequences resulting from entry of
> Inflammation of the alveolar spaces of the lung, resulting in endogenous and exogenous substances into the lower airway.
consolidation of lung tissue as the alveoli fill with exudates
AT RISK FOR ASPIRATION PNEUMONIA
> Geriatric clients.
> Clients with decreased level of consciousness (LOC).
> Post-operative clients.
> Clients with a poor gag reflex.
> Weak clients.
> Clients receiving tube feedings.
SPUTUM RAINBOW
> The colors of sputum and their corresponding bacteria
o Rust - Streptococcus pneumoniae
o Pink - Staphylococcus aureus
o Green with odor - Pseudomonas aeruginosa

DIAGNOSTIC EXAM
> Fungal/acid-fast bacilli cultures - identify etiologic agent.
> Sputum culture: positive for infecting organism.
> Bronchoscopy

MANAGEMENT
1. Facilitate adequate ventilation.
o Administer oxygen as needed and assess its
effectiveness.
o Place client in Fowler’s position.
o Turn and reposition frequently clients who are
immobilized/obtunded.
o Administer analgesics as ordered to relieve pain
associated with breathing
o Auscultate breath sounds every 2 —4 hours.
o Monitor ABGs.
PNEUMONITIS
> more general term that described the inflammatory process in
PULMONARY TUBERCULOSIS
the lung tissue that may predispose or place the patient at risk
> Infectious disease that primarily affects the lung parenchyma.
for microbial infection
> Also may be transmitted to other parts of the body — meninges,
kidneys, bones and lymph nodes
CLASSIFICATIONS:
> Mycobacterium tuberculosis
1. Community-Acquired Pneumonia (CAP)
> An acid-fast aerobic rod that grows slowly and is insensitive to
o Pneumonia occurring in the community
heat and ultraviolet light.

2. Health-Care Acquired Pneumonia (HCAP)

Transmission and risk factors:
o Pneumonia occurring in the non-hospitalized patient
> TB spreads from person to person by AIRBORNE transmission.
with extensive health care contact with one or more of
> An infected person releases droplet nuclei (usually particles 1 to
the following:
5 mcm in diameter) through talking, coughing, sneezing,
a. Hospitalization for ≥2 days in an acute care facility
laughing or singing.
within 90 days of infection
> Larger droplets settle
b. Residence in a nursing home or long -term care
facility

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> Smaller droplets remain suspended in the air and are inhaled by
a susceptible person. TREATMENT
> Transmitted thru droplet nuclei - 3ft or 1m away > A private room with negative airflow ventilated to the outside is
> Transmitted airborne - beyond 3ft or 1m necessary.
> Drug therapy must be continued for 6 -12 months
RISK FACTORS > Client is generally considered noninfectious after 1-2 weeks of
> Close contact with someone who has active TB. continuous drug therapy.
> Immunocompromisedstatus > Drugs taken for 6-12 months--Rifampicin, INH, Streptomycin and
> Substance abuse Ethambutol
> Pre-existing medical conditions or special treatment > Non-compliance can lead to drug -resistant PTB.
> Immigration from countries with a high prevalence of TB
> Institutionalization (long-term care facilities, psychiatric PREVENTIVE THERAPY
institutions, prisons) > Isoniazid preventive therapy for 6 to 12 months (prophylaxis)
> Living in overcrowded, substandard housing > Vaccine:
> Being a health care worker performing high -risk activities o BCG administration

Areas with high resistance rates: NURSING MANAGEMENT

> National Capital Region, including Laguna > Teach the isolated patient to cough and sneeze into tissues and
> Cebu to dispose of secretions properly.
> Davao > Instruct the patient to wear a mask when he leaves his room.
> Zamboanga Visitors and personnel should wear high -efficiency particulate
> Cavite air respirator masks when in his room. (N95 MASK)
> Pampanga > Rest
Areas with low resistance rates:
> Palawan
> Mountain Province and Benguet

Clinical Manifestations
> Low grade fever
> Cough
> Night sweats
> Fatigue
> Weight loss
> Hemoptysis
> eat balanced meals. Record weight weekly.
> Teach him the signs of adverse medication effects; warn him to
Diagnostic Tools
report them immediately.
> Direct Sputum Smear Microscopy
> Emphasize the importance of regular follow -up examinations to
o Sputum AFB
watch for recurring tuberculosis.
> Chest X-ray
o Cavitation
PULMONARY HEART DISEASE
> PPD
> COR PULMONALE
> Condition that results from PH, which causes the right side of
Common medication given
the heart to enlarged because of the increased work required to
> R - Rifampicin
pump blood against high resistance through the pulmonary
> I - Isoniazid (INH)
vascular system.
> P - Pyrazinamide
> Causes right sided heart failure
> E - Ethambutol
> S – Streptomycin
PULMONARY EMBOLISM
> This refers to the obstruction of the pulmonary artery or one of
> Rifampicin — red to red orange urine/secretions
its branches by a blood clot (thrombus) that originates
> INH - increased tingling sensation/numbness -peripheral neuritis
somewhere in the venous system or in the right side of the heart .
> Pyranizinamide - purine accumulation/ increased uric acid
> Most commonly, pulmonary embolism is due to a clot or
> Ethambutol - eyes or ocular neuritis (visual alteration) not given
thrombus from the deep veins of the lower legs.
for less than 12 years old
> Thrombus dislodges from moves into the lungs the legs or pelvis
> Streptomycin - ototoxicity
> Thrombus dislodges from clot forms on heart valve and breaks
loose; heart valve smaller growths break off and form embolus
> Rifampicin-increased fluid intake
> Atrial fibrillation - Atrial quiver causing turbulent blood flow;
> INH-VitB6 (Pyridoxine)
could cause clot that travels to lungs
> Pyranizinamide-increased fluid intake/allupurinol
> Ethambutol-eye examination/ refer to MD
CAUSES:
> Streptomycin-refer to MD
> Central Venous Catheters
> Fractures
ALL CAN CAUSE HEPATOTOXICITY!
> Immobility
- Check AST and ALT
> Dehydration
- Jaundice - STOP drugs!
> Polycythemia Vera

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> Pregnancy
> Vein disorders: varicose veins
> Sickle cell disease
> Thrombophlebitis
> Birth control pills/hormone
> Smoking
> Cancer
> Amniotic fluid Ruptured

SIGNS AND SYMPTOMS

> Shortness of breath/restless—first sign
> Chest pain: sharp, substernal
> Cough (hemoptysis)
> Restlessness
> Tachycardia
> Low-grade fever Inflammation
> Cyanosis
> Crackles; pleural rub-heard at embolism site due to inflammation
> Pulmonary hypertension

DIAGNOSTIC EXAM
> ABGs: hypoxemia.
> D-dimer test positive: increases with PE; increases if clot is
present in the body.
> Chest x-ray: small infiltrate or effusion.
> Lung perfusion scan: ventilation –perfusion mismatch.

Patient Teaching for prevention of Pulmonary Embolism

> Active leg exercises to avoid venous stasis
> Early ambulation PENETRATING INJURY CAUSES:
> Use of elastic compression stockings > Knife
> Avoidance of leg-crossing and sitting for prolonged periods > Gunshot
> Drink fluids > Stick
> Arrow
CHEST TRAUMA > Occupational Injury
> Blunt thoracic injuries
> form of injury to the chest including the ribs, heart and lungs,
great vessels, trachea and esophagus

BLUNT TRAUMA
> Rib Fracture:
o Most common chest injury.
o May interfere with ventilation and may lacerate
underlying lung.

BLUNT INJURY CAUSES

> Motor vehicle accident
> Pedestrian accident
> Fall
> Sports injury
> Crush injury
> Explosion

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CLINICAL MANIFESTATIONS
> Anterior chest pain
> Overlying tenderness
> Ecchymosis
> Crepitus
> Swelling

> To reduced pain, the patient splints the chest by breathing in a

shallow manner and avoids sighs, deep breaths, coughing and Assessment findings

movement 1. Sudden sharp pain in the chest, dyspnea, diminished or absent

breath sounds on affected side, tracheal shift to the opposite

> Give analgesics to assist in effective coughing and deep side (tension pneumothorax accompanied by mediastinal shift)

breathing. 2. Weak, rapid pulse; anxiety; diaphoresis

> Encourage deep breathing with strong inspiration; give local

support to injured area by splinting with hands. Nursing interventions
1. Provide nursing care for the client with an endotracheal tube:

PNEUMOTHORAX suction secretions, vomitus, blood from nose, mouth, throat, or

> occurs when the parietal or visceral pleura is breached and the via endotracheal tube; monitor mechanical ventilation.

pleural space is exposed to positive atmospheric pressure. 2. Restore/promote adequate respiratory function.

> Pneumothorax is when the lung collapses due to air accumulating a. Assist with thoracentesis and provide appropriate

in the pleural space nursing care.

b. Assist with insertion of a chest tube to water -seal
drainage and provide appropriate nursing care.
c. Continuously evaluate respiratory patterns and report
any changes.
3. Provide relief/control of pain.
a. Administer narcotics/analgesics/sedatives as ordered and
monitor effects.

HEMOTHORAX
> Blood in pleural space as a result of penetrating or blunt chest
trauma.
> Accompanies a high percentage of chest injuries.
> Can result in hidden blood loss.

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> Ventilatory Support

> Clearing secretion from the lungs
> Controlling pain

CARDIAC TAMPONADE
> Compression of the heart as a result of accumulation of fluid
within the pericardial space.
> Caused by penetrating injuries, metastasis, and other disorders.
> Pericardiocentesis

MANAGEMENT OF PATIENTS WITH CHRONIC PULMONARY DISEASE

> Assist with thoracentesis to aspirate blood from pleural space, if
being done before a chest tube insertion. Chronic Obstructive Pulmonary Disease (COPD)
> Assist with chest tube insertion and set up drainage system for > Preventable and treatable slowly progressive respiratory disease
complete and continuous removal of blood and air. of airflow obstruction involving the airways, pulmonary
> Auscultate lungs and monitor for relief of dyspnea. parenchyma, or both
> Monitor amount of blood loss in drainage. > obstruction to airflow impedes breathing.
> Replace volume with I.V. fluids or blood products. > “chronic airflow limitation”
> not fully reversible
FLAIL CHEST
> Loss of stability of chest wall as a result of multiple rib Lung parenchyma
fractures, or combined rib and sternum fractures. > Includes any form of lung tissue, including:
> When this occurs, one portion of the chest has lost its bony o bronchioles,
connection to the rest of the rib cage. o bronchi,
> During respiration, the detached part of the chest will be pulled o blood vessels,
in on inspiration and blown out on expiration (PARADOXICAL o interstitium and
MOVEMENT) o alveoli.
> Normal mechanics of breathing are impaired to a degree that
seriously jeopardizes ventilation, causing dyspnea and cyanosis. > name given to a condition in which two pulmonary diseases exist
at the same time, primarily chronic bronchitis and emphysema.
> Also, chronic asthma with either emphysema or chronic
bronchitis may cause COPD.

CHRONIC BRONCHITIS
> occurs when the bronchi stay inflamed due to infection or
irritation causing obstruction of the small and large airways.

Bronchitis signs and symptoms

> Excessive mucous production - early sign
> Chronic cough 3 months every year for two years
> Airflow obstruction
> Dyspnea with increased intolerance to exercise; labored
breathing at rest—early sign
> Accessory muscle use
> Wheezes/rhonchi/crackles of expiration
> Prolonged expiration
> Stabilize the flail portion of the chest with hands; apply a > Polycythemia
pressure dressing and turn the patient on injured side > Pulmonary hypertension resulting in right sided heart failure
> Thoracic epidural analgesia may be used for some patients to > Edema; ascites
relieve pain and improve ventilation

Medical Management
> Supportive

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Emphysema
1. Panlobular Emphysema
2. Centrolobular (Centroacinar)

Emphysema
> condition in which the lungs have lost their elasticity, thus
impeding gas exchange.
> Hyperinflation of alveoli
> Destruction of alveolar walls
> Destruction of alveolar capillary walls
> Narrowed tortuous, small airways
> Loss of lung elasticity. Emphysema signs and symptoms
> Dyspnea; tachypnea; air hunger
> Barrel-shaped chest

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o Indoor and outdoor air pollution as to the total burden of

inhaled particles on the lung
o Deficiency of Alpha1-antitrypsin

Clinical Manifestations-COPD
> Cough
> Sputum production
> Dyspnea of exertion
> Patient’s inability to participate even in mild exercises
> Occurs even at rest
> Barrel chest thorax configuration
> Chronic hyperinflation

Emphysema signs and symptoms Assessment and Diagnostic Findings

> Dyspnea; tachypnea; air hunger > Pulmonary Function Test

> Barrel-shaped chest > Bronchodilator Reversibility testing

> Accessory muscle use > Arterial blood gas measurement

> Prolonged expiration > X-ray

> Clubbing of fingers and toes > Alpha1 antitrypsin deficiency screening

> Inspiratory crackles, wheezes

> Decreased chest expansion Factors that determine the clinical course and survival of patients with

> Pursed lip breathing; puffer breathing COPD

> Client prefers “seated” position > History of cigarette smoking

> Weight loss > Passive smoking exposure

> Respiratory acidosis > Age

> Productive morning cough > Hypoxemia

> PAP
> Resting HR
> Weight loss
> Reversibility of airflow obstruction
> Stressors that leads to exacerbations
> Psychosocial factors

Complications of COPD
> Respiratory insufficiency and failure
> Respiratory infections
> Pulmonary edema
> Cor-pulmonale
> Spontaneous pneumothorax from ruptured of emphysematous
bleb

> Sleep-onset dyspnea and frequent or early morning awakenings

Medical Management
> Pharmacologic therapy
o Bronchodilators
o Metered dose inhalers

Risk Factors of COPD > Classes of bronchodilators:

> Chronic bronchitis and emphysema are both primarily caused by: o Beta-adrenergic Agonists

o cigarette smoking o Anticholinergic Agents

> Others: o Methylxanthines

o Prolonged and intense exposure to occupational dusts

and chemicals

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 KABC - RESPI

↓
permanently distended and distorted walls
↓
impaired mucociliary clearance
↓
inflammation and infection extended to the peribronchial tissues

Symptoms
> Chronic cough
> Production of purulent sputum in copius amount
> Hemoptysis
> Clubbing of fingers
> Repeated episodes of pulmonary infection

> Corticosteroids Assessment and Diagnostic Findings

o Beclomethasone > A definitive sign is sputum consistently negative for tubercle
o Budesonide bacilli
o Flunisolide > *CT scan—presence of bronchial dilatation
o Fluticasone
o Triamcinolone Medical management
> Chest physiotherapy
> Oxygen Therapy > Smoking cessation
o Long term continuous therapy > Anti-microbial therapy
o <55 mmHg or less PaO2 > Vaccination (Flu Vaccine and Pneumococcal Vaccine)
o Night time oxygen therapy > Bronchodilators
o Intermittent oxygen therapy

Surgical interventions
BRONCHIECTASIS > Pneumonectomy
> An irreversible condition marked by chronic abnormal dilation of > Lobectomy
bronchiand destruction of bronchial walls > Segmental resection
> Occurs throughout the tracheobronchial tree or can be confined to
one segment or lobe Nursing management
> Separate disease from COPD > Avoid exposure to others with upper respiratory infections
> Early detection of signs and symptoms
> Nutritional status and adequate diet

ASTHMA
> Chronic inflammatory disease of the airways that causes airway
hyperresponsiveness, mucosal edema and mucus production
> Largely irreversible

Symptoms:
> Cough
> Chest tightness
> Wheezing
> Dyspnea

Causes:
> Allergens
> Airway irritants
Causes:
> Exercise
> Airway obstruction
> Stress and emotional upsets
> Diffuse airway injury
> Sinusitis with post nasal drip
> Pulmonary infections and obstruction of bronchus or
> Medications
complications of long term pulmonary infections
> Viral respiratory tract infections
> Genetic disorder (CF)
> GERD

Inflammatory process with pulmonary infections

Pathophysiology:
↓
Causes and contributing factors of asthma
damage to the bronchial wall
↓
↓
diffused airway inflammation
loss of supporting structure
↓
↓
Hyperresponsiveness of airways
production of thick sputum
↓
↓
limited airflow
obstruction of bronchi

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 KABC - RESPI

↓ > Labored breathing

symptoms of asthma > Prolonged exhalation
> Engorged neck veins
Assessment and diagnostic findings > Wheezing
> Positive family, environmental and occupational history
> Sputum and blood test Assessment and diagnostic findings:
> Elevated serum level of immune globulin E if allergy is present > PFT: most accurate
> Presence of hypocapnia and resp iratory alkalosis > ABG: positive respiratory alkalosis
> Patient becomes more fatigued.
Medical management
Prevention: > Short-acting beta-adrenergic agonist and corticosteroids
> Avoid causative agent > Oxygen therapy
> Knowledge in the care of self > Mechanical ventilation PRN

Complications:
> Status asthmaticus
> Respiratory failure
> Pneumonia
> Atelectasis
> Hypoxemia
> Insensible fluid loss from hyperventilation

Medical management
> Long-acting control medications
o Corticosteroids
o Long-acting beta 2-adrenergic agonists
> Quick relief medications
o Short acting beta-adrenergic agonists
o Anti cholinergics

Nursing management:
> Implement basic asthma management principles
> Establish programs for asthma education
> Give the patient knowledge about inhalers, anti -allergy therapy
and avoidance measure
> Give the patient a brief background about asthma.

STATUS ASTHMATICUS
> Severe and persistent asthma that does not respond to
conventional therapy.
> The attacks can last longer than 24 hours.

Causes:
> Infection
> Anxiety
> Nebulizer abuse
> Dehydration
> Increased adrenergic blockage
> Non-specific irritants

Clinical manifestations:

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