What are the three main functions of the upper respiratory tract?

to warm, humidify, helps trap bacteria and filter the air

What is the function of the lower respiratory system?
it allows for gas exchange
What physiologic difference is there between the right and left bronchi?
- the right bronchi is shorter and wider than left bronchi and it is more vertical.
- the right bronchi is most often the site of aspiration
How many lobes are on the left and right lung?
- there are two on the left and three on the right
Structures of the Respiratory System (diagram)

Pleural Membranes (diagram)

How does the diaphragm affect breathing?

- when diaphragm goes down (contracts) --> air pressure drops and we breath in
- when diaphragm goes up (relaxes) --> air pressure increases and we breath out
What is the function of the epiglotis?
- it protects/covers the glotis
- it keeps food/drink from going down the trachea
What is the protective function of the pulmonary system?
- it mainly prevents against contamination
What are some of the protective mechanisms of the pulmonary tract?
- nasal hairs help trap
- trachea and bronchi and bronchioles have mucus blanket to trap
- cilia help move trapped particles up to either cough up or swallow
What removes bacteria from aveoli?
aveloar phagocytes
What areas have irritant receptors?
- the nares have irritant receptors --> causes sneeze
- the trachea and airways have irritant receptors --> cause cough
What is the mediastinum?
- the center portion of the thoracic cavity
- contains heart and large vessels and esophagus
What system transports O2 to the cells/tissue?
- cardiovascular system
- O2 goes to the cells via the blood
- O2 travels through the vessels to the caps and diffuses into the interstitial fluid and into
the cells
What is the difference between cellular respiration and respiration?
- O2 usage in the cells is cellular respiration and mitochondria use it
- respiration is gas exchange between atmospheric air and blood ( it then goes to the
blood and cells)
What is ventilation?
the act of breathing in and out (inspiration and expiration)
During ventilation, what are the different pressure systems in play?
- inspiration in negative pressure
- expiration is positive pressure
How does age affect lung capacity and volume?
- lung capacity and volume decreases with age
What are the neurologic control mechanisms of ventilation?
- Medulla oblongata: resp center of the brain - controls rate and depth
- Pons: controls transition from Inspiration to Expiration
- chemoreceptor: affects rate and depth of ventilation --> medulla responds to CSF
changes of pH (in response to pH changes in the blood)
- barorecptors: pressure, aortic and carotid bodies responds to pressure in blood -->
causes hypo and hyperventilation.
What are the physiologic factors that affect ventilation?
- air pressure variance: changes in low and high air pressures allow us to breathe
- airway resistance: think diameter. When there is a change it changes airway.
bronchial constriction, secretion, fluid reduces diameter of airway
- compliance: elasticity of the lungs (can they expand and recoil)
- alveoli have surfactant to keep it in low pressure and keep it from collapsing
(surfactant --> low surface tension to keep them open)
What are examples of High and Low Compliance of the Lungs:
- high compliance example --> emphysema: lungs lost elasticity
- low compliance example --> atalectasis, Pulmonary edema
What is Partial Pressure?
- the pressure exerted by each type of gas in a mixture of
gases
- nitrogen is 79% and O2 is 21%
What role does CO2 play in the body?
- it is a major determinant of acid-base balance in body
What is perfusion?
- blood flow through the pulmonary circulation
What allows for dilation?
- low pressure at capillary beds allow for gas exchange with with alveoli
- affected by pulmonary arterial pressure and by gravity and by pressures in the alveoli

- PAO2 is higher in the alveoli than in the caps so --> O2 gets pused out of the alveoli
into the caps (diffusion)
- PaCO2 is higher in the caps than in the alveoli so --> CO2 gets pushed out of the caps
and into the alveoli and breathed off
Partial Pressures for gases in the alveoli and capillaries that allow for diffusion
(diagram)
- o2 is attached to hemoglobin and dissolved in plasma
- PaO2 should be 80 - 100
- SaO2 should be 95-100

Why is the Ventilation/Perfusion (V/Q) ratio important?

- ventilation/perfusion (V/Q) ratio: tells us pathophysiology of a patient (why they have
certain issues)
- ventilation is flow of gas in and out of lungs
- perfusion is the filling of pulmanory caps with blood
- results can be normal, low, high, or absent
variances in vent or perfusion leads to pulmonary disease
V/Q Ratio Explanation:
Normal, Low, and High are qualifying the ventilation part of the ratio.

Normal: means air flow and blood flow match 1:1

Low: means air flow is blocked or lower than blood flow; therefore the the ventilation is
lower than the blood flow.

High: means blood flow is blocked or lower than ventilation; therefore the ventilation is
higher than blood flow.

Absent: means that both the air flow and blood flow are blocked. 0:0
What is the normal V/Q ratio ?
1:1

What does a low V/Q ratio mean?

- no ventilation but good perfusion --> atelectasis, pneumonia and mucus plugs -->
alveoli are collapsed
- perfusion exceeds ventilation

What does a High V/Q ratio mean?

- dead space exists
- ventilation exceeds perfusion
- gas is in the alveoli but there is no blood flow
- generally from pulm embolus and cardiogenic shock
- prevention of blood flow through the pulmonary caps.

What does an Absent V/Q ratio mean?

- AKA silent V/Q ratio
- no ventilation or perfusion or very limited.
- pneumothorax or adult respiratory distress syndrome or alveoli collapse
Nursing History for Respiratory Disorders chief complaint
- Hx of present illness
- what are some precipitating factors: smoking (paralyze cilia), job type
- risk factors: smoking, job, environment, comorbidity
- family hx: hx of asthma in family, lung cancer
What are common complaints of patients presenting with respiratory disorders?
- cough: wet/dry, prod/nonprod, onset, frequency, sputum prod (color, consistency), how
are they tx them, antitussives?
- dyspnea: when --> precip factors, what alleviates it, r/t to position?, associated
symtpoms: chest pain, fatigue,
- pain: charac, location, radiated, level, on inspir or expir?,
- sputum: color and consistency: change in color think bacterial; thin mucoid is viral,
pink tinged or hemoptosis or frothy think pulm edema; halatosis = oral care or anaerobic
bacterial
- adventitious sounds, bronchodilators (can affect heart and pulse, too)
Past medical Hx that affects respiratory disorders:
- COPD
- pneumonia
- frequent colds
- chronic bronchitis
- sinus and ear infections
- heart disease
- diabetes (r/t sugar hurting blood vessels and blood flow), - trauma to the lungs (blunt)
- surgery
- flu vaccines
- pneumococcal vaccine
- PPD
- TB
- smoking (packs per day and how many years),
- know their meds
Family Hx that affects respiratory disorders:
- cystic fibrosis
- hx of lung disease
- COPD
- asthma
- alpha 1 antitrypsin deficiency (protects tissue)
Functional assessment of patient with respiratory disorder:
- look for color and temperature
- nail beds: color; is there clubbing --> chronic hypoxia,
- think of occupation
- what are they exposed to
- what in a typical day that puts at risk for resp problems.
- ask about fatigue, fever, night sweats, sinus pain and ear aches, sore throat
What is alpha 1 antitrypsin
- it is protective of tissues against enzymes that leads to chronic lung problems
What to check during physical assessment of patient with respiratory disorders?
- upper airway structures;
- nose and sinuses
- pharynx and mouth
- trachea: pneumothorax can shift off mid-line
- rate and depth of breaths
- lower resp structure --> thorax
- chest config (symmetrical?)
- palpation
- auscultation: go over all of the lobes
- use of accessory muscles
General Survey of Patient with Respiratory issues:
- AOx4,
- posture,
- facial expression, speech pattern, observe how they breath
- vital signs: make sure to get height and weight for base line, get BMI,
- count resps and look for laboring,
- palpate for pulses, tachycardia is a concern r/t overworking due to hypoxia, look at BP,
if abnormal check their norms to see if they are different,
- nose: patency, flares, tenderness, discharge, bleeding, mucous membranes, colds
leave it hyperemic (more red), sinuses for pain, translumination for sinuses, nasal flaring
is sign of air hunger
- lips: cyanotic, color, moisture, pursed lips breathing (decrease dyspnea)
- pharynx: tonsils, exudate, enlarged tonsils, sore throat
- trachea: midline, pneumothorax can deviated,
- lymph nodes: enlarged and tender
- thorax: accessory muscles = retractions, shape, symmetrical, position, skin turgor,
color, hydrated, turgor relates to sub-q tissues hydration,
- abdomen: distension can affect diagphragm and lung expansion
- extremities: color, cap refill, clubbing, edema, pulses, homans, hair growth
Respiratory Disorders Signs and Symptoms: overall
cyanosis, clubbing, malnutrition, retractions, coughing, halatosis

cyanosis = late sign sometimes seen with anemic pts

Respiratory Disorders Signs and Symptoms: dyspnea
orthopnea, dyspnea may be r/t anemia, increased airway constriction, decreased lung
compliance, neuromuscular problems
Respiratory Disorders Signs and Symptoms: cough
- is protective
- violent coughs are bad and can develop spasm
- can cause syncope,
- GERD
- dry coughs are usually upper resp infection or ace-i,
- severe cough think cancer,
- cough in the morning = post nasal drip, sinusitis, bronchitis
- cough at night = may be left sided heart failure
- if recent cough = infection
Respiratory Disorders Signs and Symptoms: wheezing
- bronchoconstriction
- airway narrowing,
- note where wheeze is in the lungs (usu expirations),
- usu have bronchodilators order
Respiratory Disorders Signs and Symptoms: sputum production
- rxn to irritation
- fluids thin secretions
- with nebulizers: pt need to take deep breaths
Respiratory Disorders Signs and Symptoms: chest pain:
- pulm chest pain tends to be sharp and stabby, can be intermittent, dull achy or
persistent
- pain location is usu where the disease is,
- will have chest pain with pneumonia, pleuresy, PE
- plueritic pain is r/t loss of pleural fluid - sharp and stabby
- look at how pts splint
- can help with pain and efficacy of breathing with position
- analgesics and opiods may be given
Respiratory Disorders Signs and Symptoms: clubbing
- thickening of nailbeds r/t hypoxia and chronic lung infections
Respiratory Disorders Signs and Symptoms: hemoptysis
- r/t to lungs, usu sudden
- can be continous or intermittent
- most common from infxn or cancer or PE
- may check the pH (if from lungs it would be over 7 and if from stomach it will be under
7)
- hematemesis = bleeding from the stomach
Respiratory Disorders Signs and Symptoms: wheezing and inspirations
- bronchitis and wheezing on expiration = asthma
Respiratory Disorders Signs and Symptoms: ronchi
- low pitched and usu related to obstruction
Chest Configurations: Barrel Chest
over inflation due to emphysemia, AP gets larger, can see intercostal spaces and they
tend to bulge on inspiration, issue with o2 exchange
Chest Configurations: Funnel Chest
- pectus excavatum,
- depression in the lower portion of the sternum,
- effects cardiovascular;
- r/t rickets (vit d defic), morfans syndrome (r/t connective tissue)
Chest Configurations: Pigeon Chest
- pectus carinatum
- AP ratio is enlarged;
- displaced out
How does kyphoscoliosis affect respiration
- decreases lung expansion space
- usually r/t pre-existing osteoporosis
Kussmaul's Respiration
- usu r/t diabetic ketoacidosis: fruity breath r/t acetone
- rate and depth have increased - hyperventilation
Cheyne-Stokes Respiration
- is apnea with deep breathing (periods of one then the other) (depth goes from deep to
shallow),
- usually seen near death
- r/t severe HF,
- apnea gets progressively longer
Tachypnea
- over 24 reps per minute,
- usu r/t severe rib fracture or sepsis
Bradypnea
- less than 10 reps per minute
- usu r/t drug use and increased cranial pressure
hyperpnea
- increased depth of breathing when required to meet metabolic demand of body tissues
Biots Respiration
- normal breath and then apnea;
- usu with neuro patients
What are you looking for when you are performing thoracic palpation?
- masses and lesions and tenderness
- finger tips for sub q masses
- balls of hands for deeper masses tactile fremetious and excursion (helps measure
chest expansion and mobility)
Adventitious Breath Sounds: General Crackles
- Soft, high-pitched, discontinuous popping sounds that occur during inspiration (while
usually heard on inspiration, they may also be heard on expiration); may or may not be
cleared by coughing
- Secondary to fluid in the airways or alveoli or to delayed opening of collapsed alveoli
- Associated with heart failure and pulmonary fibrosis
Adventitious Breath Sounds: Coarse Crackles
- Discontinuous popping sounds heard in early inspiration; harsh, moist sound
originating in the large bronchi
- Associated with obstructive pulmonary disease
Adventitious Breath Sounds: Fine Crackles
- Discontinuous popping sounds heard in late inspiration; sounds like hair rubbing
together; originates in the alveoli
- Associated with interstitial pneumonia, restrictive
pulmonary disease (eg, fibrosis); fine crackles in early
inspiration are associated with bronchitis or pneumonia
Adventitious Breath Sounds: General Wheezes
- Usually heard on expiration, but may be heard on inspiration
depending on the cause
- Associated with bronchial wall oscillation and changes in airway diameter
- Associated with chronic bronchitis or bronchiectasis
Adventitious Breath Sounds: Sonorous Wheezing (Ronchi)
- Deep, low-pitched rumbling sounds heard primarily during expiration; caused by air
moving through narrowed tracheobronchial passages
- Associated with secretions or tumor
Adventitious Breath Sounds: Sibilant Wheezing
- Continuous, musical, high-pitched, whistlelike sounds heard
during inspiration and expiration caused by air passing through narrowed or partially
obstructed airways; may clear with coughing
- Associated with bronchospasm, asthma, and buildup of secretions
Adventitious Breath Sounds: Pleural Friction Rub
- Harsh, crackling sound, like two pieces of leather being
rubbed together (sound imitated by rubbing thumb and finger together near the ear)
- Heard during inspiration alone or during both inspiration
and expiration.
- May subside when patient holds breath; coughing will not
clear sound
- Best heard over the lower lateral anterior surface of the thorax
- Sound can be enhanced by applying pressure to the chest wall with the diaphragm of
the stethoscope
- Secondary to inflammation and loss of lubricating pleural fluid
Vesicular Lung Sounds
- Inspiratory sounds last longer than expiratory ones
- Soft
- Relatively low pitched
- can be heard over the entire lung field except over the upper sternum and between the
scapulae
Bronchovesicular Lung Sounds
- Inspiratory and expiratory sounds are about equal
- Intermediate intensity
- Intermediate pitch
- Often in the 1st and 2nd interspaces anteriorly and between the scapulae (over the
main bronchus)
Bronchial Lung Sounds
- Expiratory sounds last longer than inspiratory ones
- Loud
- Relatively high pitched
- Over the manubrium, if heard at all
Tracheal Lung Sounds
- Inspiratory and expiratory sounds are about equal
- Very loud
- Relatively high pitched
- Over the trachea in the neck
What nursing dx would you expect to use with a patient that is experiencing respiratory
difficulties?
- ineffective airway clearance
- imbalanced nutrition: lower than body requirements
- risk for aspiration
- activity intolerance
- impaired gas exchange
- breathing pattern changes
- risk for fluid volume deficit
- pain
Dx Studies for Respiratory Disorders:
- cultures and sensitivites
- throat cultures (cultures and sensitivities)
- sputum studies: deep breath and cough up sputum, cough with diaphragm, into sterile
container; cells studies to check for cancer;
- AFB's = TB
- ABG's : O2 helps determine ventilation, 80-100 PaO2, 95-100 SaO2
pulse ox: 95-100%
- PFT's: pulmonary function tests: used to assess chronic resp disorders, gas exchange,
no smoking, no eating heavy meal 4-6 hrs, no restrictive clothing. look at table 21-8
- CBC: RBC, H&H, WBC
Pulmonary Function Tests (diagram)

PFT Pulmonary Volumes (diagram)

What is being measured in PFT's?

lung volume, ventiliatory funxn, assessing the mechanics of breathing, diffusion and gas
exchange
Diagnostic Assessment: Imaging studies for Respiratory Disorders
- Chest x-ray
- Computed Tomography
- Fluoroscopic studies
- Angiographic studies
- Magnetic Resonance Imaging
Chest X-ray
- screen and dx respir disorders
- radio-logic, notes density
- want to take a full breath before xray to well aerate the lung and lower the diaphragm
- sees bone soft tissue and air
Computed tomography (CT scan):
- narrow beams of xray
- look in cross section/layers
- see more fine tissue density, visualize lesions and tumors,
- more radiation than xrays, need to be still,
- sometimes use contrast medium (allergy to iodine),
- may need to be NPO;
- if contrast - drink fluid to excrete,
- may causes NVD and HA
Fluoroscopic studies:
- motion radiograph
- looking at motion
- look at thorax contents, good way to assess diaphragm and locating masses
- sometimes used for needle biopsy guidance
angiographic studies:
- looking at diseases of the vessels in the lungs,
- looking for thrombo-embolic disease, PE,
- helps observe congenital malformities of the bronchial tree
- opaque radio dye, in the arm or in the femoral (needle or catheter)
MRI:
- magnetic fields and radio frequency signals,
- detailed imaging at lesions, tumors or any abnormality,
- need to be still, no metal, pacemaker, red tattoos
- claustrophobic, loud,
Diagnostic Assessments Scans for Respiratory Disorders
- Lung scans
- Bronchoscopy
- Thoracoscopy
- Thoracentesis
- Biopsy
Lung scans:
- look at lung funxn
- look at vessels for pulm supply
- assess gas exchange
- V/Q scan (radioactive agent - ventilation/perfusion), goes into the lungs and can see
the funxn,
- can see PE and obstructive problems, can see perfusion
- gallium scan (radioisotope lung scan),
- helps see inflam, assess absess, adhesions, tumors,
- can help stage bronchial cancer,
- scans in intervals (6, 12, 24) assessing gallium uptake;
PET scans
- (radioisotope study) more advanced,
- can see lung nodules and tell if cancer,
- looks at metaboilic function, radioisotope combines with glucose and is taking in by the
cancer cells (faster than normal cells) can differentiate between normal and cancer, can
tell if good, dead or dying tissue
- can tell malignancies
- can not eat for 4 hrs before the test r/t glucose combine
Bronchoscopy
- assess bronchi, trachea, larynx, used to inspect
- can be flexible (at the bedside) or rigid (done in the OR)
- need consent
- visualize and examine tissue, collect secretions, can perform biopsy, can check to see
cause for hemoptosis,
- local anesthetic is used (gag reflex suppressed)
- invasive
- think of bleeding and infection,
- may be at risk for aspiration (elevate HOB),
- may cause bronchospasm, may cause hypoxemia, pneumothorax, perf lung,
- can remove foreign body from bronchial tree, can remove sputum plugs;
- pre-procedure: consent form, NPO for 6 hrs to decrease risk of aspiration, receive
preop med (atropine - dries secretions) opioid, be aware of vagal stimulation, sedate
decreases anxiety, may use spray lidocaine;
- post-procedure: NPO until gag reflex returns, be aware of facial and throat swelling,
bilateral breath sounds, symetry, if c/o dyspnea tell MD,

need air tight dressing, apply sterile, prob petroleum based

Thorascopy
- dx procedure
- uses endoscope
- pleural cavity is observed
- little incision in the intercostal spaces and look inside,
- after incision a chest tube may be placed to water seal and for drainage,
- can be used to look for lesions, tumors, etc, effusions
- postop: breath sounds r/t pneumothorax, SOB, r/t chest tube: suction, drainage, lines,
- check chest tube apparatus to ensure correct water for seal, low for drainage, no
kinks.

need air tight dressing, apply sterile, prob petroleum based

Thorascopy (diagram)

Thoracentesis
- insert large bore needle to aspirate fluid from the pleural space (fluid, blood or air),
- can admin med this way too,
- can perform needle biopsy, cytology, gram stain, etc;
- need consent form,
- do not move or cough,
- position on non affected side
- may need post chest xray for hemothorax/pneumothorax, PE, pulm edema
- if uneven chest movement, bleeding, resp distressed, decrease BP or tachycardia,
uneven lung sounds call MD.

need air tight dressing, apply sterile, prob petroleum based

Thoracentesis (image)

Bronchoscopy
- look to see if benign or cancer (cytology),
- can be done for all areas of the respir system
- where you biopsy determines type of meds given during biopsy.
- pleural biopsy (pleura), be aware of pleural spcae and intactness of the lungs, uses
bronchoscope or needle biopsy
- helps determine what you are seeing,
- can go through the skin (percutaneous),
- transbronchial and brush cells or biopsy,
- monitor for bleeding, infxn, fever.
- lymph node biopsy, important for metastesis;
- when thinking of the lungs think of the scalene lymph nodes (they drain lungs and
mediastinum), also biopsy this area when concerned about hodgkins, with this area a
chest tube is almost always used;
- provide O2 and med for pain if needed, can go home after a few hours

bronchosopy may go through the mouth or the nose