Respirations …

Mary J. Aigner RN, MSN,

FNPC
 Anatomy/Physiology Review
 What parts of the body?
• Upper?
• Nose, mouth, pharynx, larynx
• Lower?
• Trachea, lungs
• Further divided into?
• Bonchi, bonchioles, alveoli
• Pulmonary capillary network
• Pleural membranes
 Eethmoidall Sphenoidal Sinus (2)
Sinuses (2) Nose
Maxillary Sinuses (2)
Frontal Sinuses (2)

Pharynx
Nasopharynx Oropharynx

Also known as? Larynx

trachea
Left
Right
Main
Main (Lungs)
Bronchi
Bronchi

Smaller bronchi
Smaller bronchi

Smaller & smaller bronchioles Smaller & smaller bronchioles

More about sinuses
 Sinusitis –
 Called paranasal • 14% population gets acute
sinuses (total 8, 4 infection yearly
each side)l • Over 2 billion$ spent
• Open areas within
skull  Suggested when
• Named for bones in • Symptoms > l week
which sinuses lie • Pain unilaterally
• Passages from the • Change in secretions
sinuses allow drainage • From watery/mucoid to
into nasal cavities purulent green or yellow
• Occ. Visible swelling or
erythema over sinus
 Maxillary most common
Sinusitis
• Pain may refer to upper incisor
and canine teeth
• Via trigeminal nerve
• May result from dental infection
 Ethmoid – often w/max.
• Pain pressure over nose
 Sphenoid
• HA middle of head/vertex
 Frontal
• Pain/tenderness forehead
• Can elicit through palpation
just under lateral eyebrow
More on sinusitis
 Imaging -Sinus XRays
• not cost effective
• Not recommended
• But sometimes helpful!
 CT limited coronal
• Sometimes helpful
 MRI
• if malignancy suspected
 Intubated pts
• Up to 40% prevalence of
nosocomial sinusitis
 2/3’s improve without Rx within
2 weeks
 Antibiotics reduce by 50%
incidence of clinical failure
• Amoxicillin **or Amox w/
clavulanate*
• TMP/SMZ*, **
• Cephalexin
• Cefuroxime
• Cefalor
• Quinolones*
• Macrolides*
 Decongestants may help
 Cancer
Part of
RX not perfect Differential
diagnosis

 Infection may recur

 May be resistant
 May develop into worse
infection
• Osteomyelitis
• Mucocele
• In elderly – any resp
infection may lead to
pneumonia
 May need referral to a
specialist (ENT)
 Bless you!
Ah – choo!
 Our noses do what?
• Warm, humidify, filter air
• Large particles trapped by entrance hair
• Small particles filtered/trapped as air direction
changes through turbinates and septum

 The sneeze reflex

• Irritants in passage, a large volume of air exits
the nose/mouth, clearing of irritants
 (oropharynx) PHARYNX (nasopharynx)

 Shared pathway  Tonsillitis – infection

• Food & air of tonsils
 Lymphoid tissue  Pharyngitis –
• Traps and destroys inflammation of
pathogens that enter pharynx
with air
• Includes tonsils,
palate,uvula
 Good handwashing  Both T & P
can prevent spread • >10% office visits
of infections! • 50% outpt ATB use
Obstructive Sleep Apnea
(2-10% population has this. Men > Women)

 Partial or complete
airway obstruction
• Results in apnea and
hypopnea (abnormal
shallow/slow resp)
 Tongue and soft
palate fall back
• Lasts 15-90 seconds
• Severe hypoxemia
• Hypercapnia (>
PaCO2)
More on Sleep Apnea
 Apneic/arousal cycles
• Up to 200-400 x during
6-8 hours
 Symptoms
• Frequent awakening
• Insomnia
• Excessive daytime
sleepiness
• Witness apnea (night)
COMPLICATIONS:
• Loud snoring
HTN
• Morning HA (from >CO2)
arrhythmias
 Larynx (Adam’s Apple)
 2 purposes
• 1a.Maintains airway
patency
• 1b. Prevents
food/liquids from
entering lower system
• 2. speech
 Opening: epiglottis
• Or vocal cords
• Open/respirations
• Closed/swallowing
Laryngeal polyps

 Polyps on vocal
cords
• Vocal abuse
• Excessive talk, sing
• Irritation (eg. smoking,
intubation)
 Symptom
• Horaseness
• Large may cause
stridor or dyspnea
 Trachea then to R/L main
bronchi
 Trachea:  The main bronchi keep
subdividing like tree
• Lined w/mucosal
branches
epithelium
• Produces thin mucus • Smaller and smaller bronchi,
bronchioles
layer
• Traps particulates • Ends in terminal or
respiratory bronchioles
that go up to larynx
via cilia • Then alveoli

 Cough Reflex
 (Cilia are like little
hairs on the epithelial
• Triggered by irritants
• Larynx, trachea, or bronchi
cells).
Gas Exchange
 Between alveoli
• and
 Pulmonary capillaries

 Both single-celled

 Gas exchange occurs

through combined
respiratory membrane
 Outside the lungs
 Pleura – thin double layer of tissue
• The parietal pleura lines the thorax then
• Doubles back over the surface of diaphragm
• Forming the visceral pleura
• Covers entire external lung surface
• There is a potential space in between the two

 Potential space:
• small amt pleural fluid (serous lubricating solution)
• Prevents friction
• Keeps layers adherent via surfactant
 More Respiratory Terminology
 Lung Compliance
• Expansibility or stretchability of
tissue
• Alveoli stiff at birth, become >
compliant
• Alveoli compliance < with aging
• Thus – both newborns and aged
more at risk for atelectasis
 Compliance important in
inspiration
 Lung recoil
• Tissue tends to collapse away
from chest wall … therefore need
recoil for expiration
 Surfactant
• Lipoprotein (produced by
special alveoli cells)
• Acts like a detergent to
reduce surface tension
• This surface tension of
fluid lining alveoli has
most effect on ability for
lung to recoil
 No surfactant?
• Expansion difficult
• Lungs collapse
The very act of Breathing
 Inspiration
• Air flows into lungs
 Expiration
• Air flows out of lungs
 Requires
• Clear airways
• Intact CNS/resp center
• Intact thoracic cavity
• Can contract/expand
• Adequate pulmonary
compliance/recoil
How nervous system stimulates
the respiratory system
 Respiratory centers
• In medulla and pons of
brain stem

 Control breathing
• Drugs that depress
CNS affect this
• Severe head injuries
 What does pressure have to do
with it?
 Intrapulmonary pressure
 Intrapleural pressure
• Pressure within lungs
• Always slight – compared
• Equalizes w/atmos pres
to atmospheric pressure
 Inspiration
• - is essential … creates
• Diaphragm and intercostal
suction that holds v. + p.
muscles contract
pleura together as rib cage
expands/contracts • Increases size of thoracic
cavity
• Intrapleural fluid also helps
• Lung volume increases
pleura adhere together
• Intrapulmonary pres decreases
• Air rushes into lungs to
 Recoil tendency of lungs equalize this pressure with the
atmospheric pressure
• Major factor in creating –
pressure
Expiration
 The diaphragm and
muscles (intercostal)
relax
• Volume in lungs
decreases
• Intrapulmonary
pressure increases
• Air is expelled
Tidal Volume
 Normal breathing
• 500 ml. air inspired &  Diseases or Trauma
expired with breath
 Strenuous activity
• > 1500 ml. air
 This volume (ml air)
is called Tidal
Volume
 Accessory muscles
• Resp: neck, intercostal
and abdomen
• Eg. Muscular
dystrophy
• (affects muscles)
• Gunshot to chest wall
• May allow intrapleural
pressures to equalize
w/atmos causing lung
to collapse
(pneumothorax)
Gas exchange – alveolar (2nd
phase of respiratory process)
 Oxygen diffuses
• from alveoli
• into pulmonary blood
vessels
 Ditto with CO2 but in
reverse
Differences in pressure
Cause gas (O2) to
Diffuse from a to p
 Oxygen-hemoglobin dissociation
curve
 This curve (page 546 in Lewis text) demonstrates the
affinity of Hgb for O2
• Ease with which Hbg releases O2 to tissues (Hgb saturation)

Top of Curve: Lower part of Curve:

Despite large decreases in
PaO2, only small changes in
Hgb occur (Hgb saturation).
Even 40mm drop in PaO2
To 60 mm Hg. Is ok as
Increasing PaO2 above
60 doesn’t increase
Hgb saturation much.
As Hgb desaturates, larger amounts
Of O2 are released for tissue use.
This maintains pressure gradient
Between blood and tissues and
Ensures adequate O2 supply to
Periphery.
Shifts in the Oxygen-Hgb
dissociation curve
 Shift to the left
• Blood picks up O2 easier
in lungs but delivers less
easily to tissues
• Eg: alkalosis,
hypothermia after heart
bypass surgery, or when
PaCO2 decreased
 Hypothermia:
• May need higher O2
concentrations until
temperature normalizes
 Shift to the right
• Opposite reaction: blood
picks up O2 less readily
in lungs but delivers it
more readily to tissues
• eg. acidosis,
hyperthermia, or when
PaCO2 increased
Measured by ABG
or O2 Sat
 O2 and CO2 transport – 3rd phase
of respiratory process
O2 Need: 1. cardiac output
2. # RBCs and blood Hct
3. Exercise (+20% athletes)
 O2 transported from
lungs to tissue
• Most via hemoglobin
as oxyhemoglobin
• Remainder dissolved
in plasma and cell fluid
 CO2 transported
back to lungs from
tissue – 3 ways
1. 65% in RBC as
HCO3
2. 30% w/hemoglobin
as carbhemoglobin
3. 5% as solution in
plasma or carbonic
acid (CO2 + H2O)
 Altitude
Normal O2 transport Sickness
Is HH

D 4 O2 molecules
O
C Hgb molecules
DOCK
K STREAM (circulation) (tissue)
(l
U Normal: O2 travels via Hgb from lungs to tissue (CO2 reverse)
N Hypoxic Hypoxia: not enough O2 molecules
G Anemic Hypoxia: not enough boats Hgb molecules
s) Stagnant Hypoxia: stream stagnant, circulation failing
Histotoxic Hypoxia: O2 reaches tissue but cells can’t utilize it
Eg. poisoned w/cyanide or necrotic tissue
What affects respiratory
function?
 Lifestyle
• Physical activity
• Occupations
• Hobbies
• Smoking

 Medications
• Eg. sedatives, hypnotics

 Stress
What can affect Resp function?
3 conditions and 3 alterations
 Conditions that …
• Affect movement in and out of lungs
• Diffusion O2 and CO2 between a and pc
• Transport O2 and CO2 via blood to/from tissue

 3 main alterations are:

1. hypoxia,
2) altered breathing pattern, and
3) obstructed (fully/partially) airway
 Altered Pattern
 Normal = eupnea
 Rapid = tachypnea
 Slow = Bradypnea
 None = apnea*
• * or dead
 Upright only = orthopnea
 Difficult/painful = dyspnea
 Shortness of breath = a
feeling of breathlessness,
being unable to breath or
get enough air
 Hyperventilation
 Kussmaul’s resp
• Pursed lip breathing
 Cheyne-Stokes resp
• Eg. from CHF, >
intracranial pressure,
drug overdose, dying
 Biot’s (cluster) resp
• Shallow, then apnea
 Obstruction of the Airway
 Upper – nose, pharynx, larynx
• Foreign object
• Tongue falls back in oropharynx (eg. coma)
• Secretions block airway
• Resp will sound gurgly as air tries to pass through
• May hear low-pitched snoring sound
 It’syour responsibility to maintain open
airway … may require immediate action
Obstructed lower airway
 Complete
• No chest movement

 Partial
• Stridor (high-pitch
sound on inspiration)
• Altered ABGs
• Adventitious breath
sounds (abnormal)
• Restlessness
• dypsnea
History first !
Problem cues
 Shortness of breath
(dyspnea)
 Wheezing
 Pleuritic chest pain
 Cough
 Sputum production
 Hemoptysis
 Voice change
 fatigue
Auscultation
 Vesicular sounds  Bronchial/tubular
• Insp > exp • Exp > insp
• Low pitch • High pitch
• Soft intensity • Louder intensity
• Heard in most of lungs • Over the trachea

 Bronchovesicular
• Insp = exp  Website to hear sounds
• Medium pitch http://medocs.ucdavis.edu/IMD/42
• Medium intensity
• Near main stem bronchi
(below clavicle and
between scapulae, esp
R)
Other physical assessment
 Inspection  Percussion sounds
• Resonance
 Palpation • Hyperresonance

• Trachea (position) • Tympany

• Estimate thoracic • Dull

expansion (554L) • flat
• Fremitus (say 99 while
palms on chest)

 percussion
  Blood
Studies • Hbg, Hct, ABG
 Endoscopy  Pulse oximetry
• Bronchoscopy,  Sputum
mediastinoscopy, • C&S, Gm stain
 Biopsy  Skin
 Other tests
• Allergy, exposure (Ppd)
• Thoracentesis • Old test for CF
• Pulmonary function  Radiologic
tests
• CXR, CT, MRI,
ventilation perfusion
scan, pulmonary
angiography, positron
emission tomography
Resp differences in the elderly
 < recoil  < response to
 < compliance hypoxemia
 > anteroposterior  < response to
diameter hypercapnia
 < functioning alveoli
 < cell-mediated
immunity
 < specific antibodies
 < cilia function
 < cough force
 < alveolar macrophage
function
O2 delivery Nebulizer treatments (aerosol)
given via Mask or trach,
 Nasal cannula not nasal cannula
 Masks
• Simple (35-50% O2)
• Venturi
• High air flow system
• Flex tube
• Mixture 100% O2/air
• Non or partial
rebreathing
• Reservoir bag
• 100% O2 fills bag but
actual % varies with
respirations
 Concentrator
More O2 Delivery
 CPAP Mask  Tracheostomy tube
• Continuous positive
airway pressure  Endotracheal tube
• • often via ventilator
 BIPAP Mask
• or by T-bar
• Bilevel positive airway
positive pressure device
 Manual
 Transtracheal catheter
• with bag

(pg 251 L)
• with mouth in CPR
(w/barrier)
• Immature or mature tract