Respi-ca2.pdf

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

Anatomic and Physiologic Overview 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

UPPER RESPIRATORY TRACT • Upper airway structures consist of the 1. Nose 2. sinuses and nasal passages 3. pharynx, tonsils and adenoids, 4. larynx, and 5. trachea.

LOWER RESPIRATORY TRACT • The lungs are paired elastic structures enclosed in the thoracic cage, which is an airtight chamber with distensible walls

LOWER RESPIRATORY TRACT • Size of a football (approx.) • The lung fill the area from the collarbone to the bottom of the ribs. • Lung is the only organ in the body light enough to float.

LOWER RESPIRATORY TRACT LUNGS Each lung is divided into lobes Right---3 lobes Left---2 lobes The left lobe is slightly smaller than the right lobe.

PLEURA • Serous membrane that lined the lungs and wall of the thorax. • The visceral pleura covers the lungs; the parietal pleura lines the thorax.

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.

BRONCHI AND BRONCHIOLES • There are several division of the bronchi within each lobe of the lung

1. 2. 3. 4. 5. 6. 7. 8.

Right and left bronchi Lobar bronchi (three in the right and two in the left lung) Segmental bronchi (10 on the right and 8 on the left) Subsegmental bronchi Bronchioles Terminal bronchioles Respiratory bronchioles------ dead space (150mL of air) Alveolar ducts and sacs

ALVEOLI Oxygen and carbon dioxide exchange takes place in the alveoli. arranged in clusters of 15 to 20

ALVEOLI Three types of alveolar cells---(Pneumocyte) • Type I, II, and III

FUNCTION OF THE RESPIRATORY SYSTEM The respiratory system performs this function by facilitating life-sustaining processes such as: 1. oxygen transport 2. respiration and ventilation, and 3. gas exchange.

INSPIRATION TO EXPIRATION RATIO IS

1:2

LUNG VOLUMES AND LUNG CAPACITIES Lung function which reflects the mechanics of ventilation, is viewed in terms of lung volumes and lung capacities. Lung volumes: tidal volume, inspiratory reserve volume, expiratory reserve volume, and residual volume.

LUNG VOLUMES AND LUNG CAPACITIES Lung function which reflects the mechanics of ventilation, is viewed in terms of lung volumes and lung capacities. Lung capacity: • vital capacity, • inspiratory capacity, • functional • residual capacity, and • total lung capacity

LUNG VOLUMES Tidal volume (VT or TV) • The volume of air inhaled and exhaled with each breath • 500 mL or 5–10 mL/kg

LUNG VOLUMES Inspiratory reserve volume (IRV) • The maximum volume of air that can be inhaled after a normal inhalation • 3,000 mL

LUNG VOLUMES Expiratory reserve volume (ERV) • The maximum volume of air that can be exhaled forcibly after a normal exhalation • 1,100 mL

LUNG VOLUMES Residual volume (RV) • The volume of air remaining in the lungs after a maximum exhalation • 1,200 mL

LUNG CAPACITIES Vital capacity (VC) • The maximum volume of air exhaled from the point of maximum inspiration • 4,600 mL

LUNG CAPACITIES Inspiratory capacity (IC) • The maximum volume of air inhaled after normal expiration • 3,500 mL

LUNG CAPACITIES Functional residual capacity (FRC) • The volume of air remaining in the lungs after a normal expiration • 2,300 mL

LUNG CAPACITIES Total lung capacity (TLC) • The volume of air in the lungs after a maximum inspiration • 5,800 mL

PULMONARY DIFFUSION and PERFUSION PULMONARY DIFFUSION • process by which oxygen and carbon dioxide are exchanged from areas of high concentration to areas of high at the air–blood interface. PULMONARY PERFUSION • is the actual blood flow through the pulmonary circulation.

VENTILATION-PERFUSION RATIO VENTILATION MATCHES PERFUSION 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 • Pv–CO2 = partial pressure of venous carbon dioxide • P50 = partial pressure of oxygen when the hemoglobin is 50% saturated

Neurologic Control of Ventilation • 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.

Medulla oblongata and Pons

Assessment

Assessment HEALTH HISTORY • Dyspnea • Cough • Sputum production • Chest pain • Wheezing • Hemoptysis

HEALTH HISTORY Bacterial infection • Profuse amount of purulent sputum (thick and yellow, green or rust colored) Viral bronchitis • Thin mucoid sputum Chronic bronchitis/bronchiectasis • Gradual increase of sputum over time

HEALTH HISTORY Lung tumor • Pink-tinged mucoid sputum Pulmonary edema • Profuse, frothy, pink material Lung abscess • Foul smelling sputum and bad breath

PHYSICAL ASSESSMENT OF THE LOWER RESPIRATORY STRUCTURES AND BREATHING

PHYSICAL ASSESSMENT OF THE LOWER RESPIRATORY STRUCTURES AND BREATHING 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

Chest configuration Barrel Chest occurs as a result of overinflation of the lungs. increase in the AP diameter of the thorax Emphysema

Hallmark sign of Emphysema

Chest configuration Funnel Chest (Pectus Excavatum) occurs when there is a depression in the lower portion of the sternum. compress the heart and great vessels, resulting in murmurs. May occur with rickets or Marfan’s syndrome.

Funnel Chest (Pectus Excavatum).

Chest configuration 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

Pigeon Chest (Pectus Carinatum).

Chest configuration Kyphoscoliosis • characterized by elevation of the scapula and a corresponding S-shaped spine. • limits lung expansion within the thorax. • may occur with osteoporosis and other skeletal disorders that affect the thorax

Kyphoscoliosis

BREATHING PATTERN AND RESPIRATORY RATES Average: 12-20 breaths per minute or 14-20 breaths per minute • Eupnea: normal cycle of breathing • Bradypnea: slow breathing • Tachypnea: rapid breathing • Apnea: temporary pauses of breathing • 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 motion. TACTILE FREMITUS: detection of the resulting vibration on the chest wall by touch

TACTILE FREMITUS/FREMITUS • “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 extended hands, on the thorax. • BONES ARE NOT ASSESSED!

TACTILE FREMITUS/FREMITUS

BREATH SOUNDS Normal breath sounds are identified as: vesicular, bronchovesicular, and bronchial (tubular) breath sounds

Abnormal (Adventitious) Breath Sounds • An abnormal condition that affects the bronchial tree and alveoli may produce adventitious (additional) sounds. • Adventitious sounds are divided into two categories: 1. Crackles: discrete, noncontinuous sounds 2. Wheezes: continuous musical sounds

Abnormal (Adventitious) Breath Sounds CRACKLES (RALES)

•Coarse crackles • Discontinuous popping sounds heard in early inspiration; harsh, moist sound originating in the large bronchi

•Fine crackles • Discontinuous popping sounds heard in late inspiration; sounds like hair rubbing together; originates in the alveoli

Abnormal (Adventitious) Breath Sounds WHEEZES Sibilant wheezes • Continuous, musical, high-pitched, whistle like sounds heard during inspiration and expiration caused by air passing through narrowed or partially obstructed airways; may clear with coughing • Bronchospasm, asthma, and build up of secretions

Abnormal (Adventitious) Breath Sounds WHEEZES Sonorous wheezes (rhonchi) • Deep, low-pitched rumbling sounds heard primarily during expiration; caused by air moving through narrowed tracheobronchial passages • Secretions or tumor

Abnormal (Adventitious) Breath Sounds FRICTION RUBS (Pleural friction rub) • Harsh, crackling sound, like two pieces 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: • The sound heard through the stethoscope as the patient speaks • larynx chest wall bronchi  alveolar tissue • During the process, the sounds are diminished in intensity and altered so that syllables are not distinguishable. • “ninety-nine” or “eee”

VOICE SOUNDS • Bronchophony describes vocal resonance that is more intense and clearer than normal. • Egophony describes voice sounds that are distorted (EA) • Whispered pectoriloquy: heard only in the presence of rather dense consolidation of the lungs. • All test for consolidation!

Diagnostic Evaluation • ARTERIAL BLOOD GAS STUDIES • Allen’s Test/Modified Allen’s Test

Other Diagnostic Examinations • VENOUS BLOOD SPECIMEN • PULSE OXIMETRY Method of continuously monitoring the oxygen saturation of hemoglobin • CULTURES • SPUTUM STUDIES • PPD

Sputum Exams • Sputum Analysis – gross appearance • For Culture and sensitivity – to detect the actual microorganism causing the infection • For sputum cytology-to detect cancer cells • For sputum AFB: To assist in the diagnosis of TB For monitoring of the effectiveness of therapy

PPD (Purified Protein Derivatives) • Mantoux Test • ID route • Read result after 48-72 hours after injection • (+) mantoux test is induration of 15 mm or more • For HIV positive clients, induration of 5 mm is considered positive • (+)Mantoux Test signifies exposure to Mycobacterium Tubercle Bacilli

ENDOSCOPIC PROCEDURES BRONCHOSCOPY • the direct inspection and examination of the larynx, trachea, and bronchi through either a flexible fiberoptic bronchoscope or a rigid bronchoscope.

ENDOSCOPIC PROCEDURES • Informed consent • Consent • NPO 4-8 hours (reduce risk for aspiration) • Fear—sedation • Sedation given to patients with respiratory insufficiency may precipitate respiratory arrest.

ENDOSCOPIC PROCEDURES • Remove dentures and other oral prosthesis • Local anesthesia • Topical anesthetic sprayed on the pharynx to suppress cough reflex and minimize discomfort

ENDOSCOPIC PROCEDURES After the procedure • NPO until gag or cough reflex returns • A small amount of blood-tinged sputum and fever may be expected within the first 24 hours.

ENDOSCOPIC PROCEDURES THORACOSCOPY • 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.

Biopsy • excision of a small amount of tissue, may be performed to permit examination of cells from the pharynx, larynx, and nasal passages.

• Lung biopsy • Pleural biopsy • Lymph node biopsy

RESPIRATORY CARE MODALITIES

Noninvasive Respiratory Therapies OXYGEN THERAPY • Oxygen therapy is the administration of oxygen at a concentration greater than that found in the environmental atmosphere.

Noninvasive Respiratory Therapies OXYGEN THERAPY Indications • Hypoxemia • Hypoxia

COMPLICATIONS • OXYGEN TOXICITY Oxygen toxicity may occur when too high of oxygen concentration (greater than 50%) is administered for an extended period (longer than 24 hours).

• OXYGEN TOXICITY • It is caused by overproduction of oxygen free radicals, which are byproducts of cell metabolism. • If oxygen toxicity is untreated, these radicals can severely damage or kill cells.

• SUPPRESSION OF VENTILATION Clients with COPD usually only need low-flow oxygen because their drive to breathe is primarily based on their usual state of hypoxia. The chemoreceptors become insensitive to increased CO2 levels with longterm lung disease. Increased O2 (administering too much) may stop the hypoxic respiratory drive and cause CO2 narcosis.

• SUPPRESSION OF VENTILATION Low oxygen levels are what keeps the client breathing. As long as the client is hypoxic, he will breathe. If your client receives more than 2 to 3 L/min of oxygen with an increase in PaO2, he is no longer hypoxic and could stop breathing.

MANAGEMENT OF PATIENTS WITH CHEST AND LOWER RESPIRATORY TRACT DISORDERS

ATELECTASIS • Refers to the closure or collapse or airless condition of of alveoli • Often is described in relation to chest x-ray findings and/or clinical signs and symptoms.

ATELECTASIS Such pressure may be produced by: PLEURAL EFFUSION fluid accumulating within the pleural space PNEUMOTHORAX air in the pleural space HEMOTHORAX blood in the pleural space

ATELECTASIS Assessment findings • dyspnea • decreased breath sounds on affected side, • decreased respiratory excursion • dullness to flatness upon percussion over affected area

ATELECTASIS Assessment findings • Cyanosis • Tachycardia • Tachypnea • elevated temperature • Weakness • pain over affected area

ATELECTASIS Diagnostic tests a. Bronchoscopy: may or may not reveal an obstruction b. Chest x-ray shows diminished size of affected lung and lack of radiance over atelectatic area c. PaO2 decreased

ATELECTASIS The goal in treating the patient with atelectasis is to: improve ventilation remove secretions

ATELECTASIS TREATMENT • incentive spirometry, • chest percussion, • postural drainage, and • coughing and deep-breathing exercises

ATELECTASIS TREATMENT If these measures fail: • bronchoscopy may help remove secretions. • Humidity and bronchodilators *Atelectasis secondary to an obstructing neoplasm may require surgery or radiation therapy.

PNEUMONIA • Inflammation of the lung parenchyma caused by various microorganisms, including bacteria, mycobacteria, fungi and viruses.

• Inflammation of the alveolar spaces of the lung, resulting in consolidation of lung tissue as the alveoli fill with exudates

PNEUMONIA PNEUMONITIS more general term that described the inflammatory process in the lung tissue that may predispose or place the patient at risk for microbial infection

PNEUMONIA CLASSIFICATIONS: 1. Community-Acquired Pneumonia (CAP) 2. Health-Care Acquired Pneumonia (HCAP) 3. Hospital-Acquired Pneumonia (HAP) 4. Ventilator-Acquired Pneumonia (VAP)

PNEUMONIA 1. Community-Acquired Pneumonia (CAP) Pneumonia occurring in the community

PNEUMONIA 2. Health-Care Acquired Pneumonia (HCAP) Pneumonia occurring in the non hospitalized patient with extensive health care contact with one or more of the following:

PNEUMONIA Hospitalization for >2 days in an acute care facility within 90 days of infection Residence in a nursing home or long-term care facility Antibiotic therapy, chemotherapy, or wound care within 30 days of current infection Hemodialysis treatment at a hospital or clinic Home infusion therapy or home wound care Family member with infection due to multi-drug resistant bacteria

PNEUMONIA 3. Hospital-Acquired Pneumonia (HAP) Pneumonia occurring >48 hours after hospital admission that did not appear to be incubation at the time of admission

PNEUMONIA 4. Ventilator-Acquired Pneumonia (VAP) A type of HAP that develops >48 hours after endotracheal tube intubation

PNEUMONIA *Aspiration Pneumonia Refers to the pulmonary consequences resulting from entry of endogenous and exogenous substances into the lower airway.

PNEUMONIA 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.

PNEUMONIA SPUTUM RAINBOW The colors of sputum and their corresponding bacteria Rust Streptococcus pneumoniae  Pink Staphylococcus aureus  Green with odor Pseudomonas aeruginosa

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

PNEUMONIA MANAGEMENT 1. Facilitate adequate ventilation. a. Administer oxygen as needed and assess its effectiveness. b. Place client in Fowler’s position. c. Turn and reposition frequently clients who are immobilized/obtunded.

PNEUMONIA MANAGEMENT 1. Facilitate adequate ventilation. d. Administer analgesics as ordered to relieve pain associated with breathing e. Auscultate breath sounds every 2—4 hours. f. Monitor ABGs.

PULMONARY TUBERCULOSIS • Infectious disease that primarily affects the lung parenchyma. • Also may be transmitted to other parts of the body— meninges, kidneys, bones and lymph nodes • Mycobacterium tuberculosis • An acid-fast aerobic rod that grows slowly and is insensitive to heat and ultraviolet light.

PULMONARY TUBERCULOSIS Transmission and risk factors: • TB spreads from person to person by AIRBORNE transmission. • An infected person releases droplet nuclei (usually particles 1 to 5 mcm in diameter) through talking, coughing, sneezing, laughing or singing.

PULMONARY TUBERCULOSIS Transmission and risk factors: • Larger droplets settle • Smaller droplets remain suspended in the air and are inhaled by a susceptible person.

PULMONARY TUBERCULOSIS Transmission and risk factors: • Transmitted thru droplet nuclei --- 3 ft or 1 meter away • Transmitted airborne--- beyond 3 feet or 1 meter.

PULMONARY TUBERCULOSIS RISK FACTORS Close contact with someone who has active TB. Immunocompromised status Substance abuse Pre-existing medical conditions or special treatment Immigration from countries with a high prevalence of TB

PULMONARY TUBERCULOSIS RISK FACTORS Institutionalization (long-term care facilities, psychiatric institutions, prisons) Living in overcrowded, substandard housing Being a health care worker performing high-risk activities

PULMONARY TUBERCULOSIS Areas with high resistance rates: • National Capital Region, including Laguna • Cebu • Davao • Zamboanga • Cavite • Pampanga Areas with low resistance rates: • Palawan • Mountain Province and Benguet

PULMONARY TUBERCULOSIS Clinical manifestations Low grade fever Cough Night sweats Fatigue Weight loss Hemoptysis

PULMONARY TUBERCULOSIS Diagnostic Tools

Direct Sputum Smear Microscopy Sputum AFB

Chest X-ray Cavitation

PPD

PULMONARY TUBERCULOSIS Common medication given Rifampicin Isoniazid (INH) Pyrazinamide Ethambutol Streptomycin

PULMONARY TUBERCULOSIS • Rifampicin—red to red orange urine/secretions • INH-increased tingling sensation/numbness-peripheral neuritis • Pyranizinamide- purine accumulation/ increased uric acid • Ethambutol-eyes or ocular neuritis (visual alteration) not given for less than 12 years old • Streptomycin-ototoxicity ALL CAN CAUSE HEPATOTOXICITY!

PULMONARY TUBERCULOSIS • Rifampicin- increased fluid intake • INH- Vit B6 (Pyridoxine) • Pyranizinamide- increased fluid intake/allupurinol • Ethambutol- eye examination/ refer to MD • Streptomycin- refer to MD ALL CAN CAUSE HEPATOTOXICITY! Check AST and ALT Jaundice- STOP drugs!

PULMONARY TUBERCULOSIS TREATMENT • A private room with negative airflow ventilated to the outside is necessary. • Drug therapy must be continued for 6-12 months • Client is generally considered noninfectious after 1-2 weeks of continuous drug therapy.

PULMONARY TUBERCULOSIS TREATMENT • Drugs taken for 6-12 months--Rifampicin, INH, Streptomycin and Ethambutol • Non-compliance can lead to drug-resistant PTB.

PULMONARY TUBERCULOSIS PREVENTIVE THERAPY • Isoniazid preventive therapy for 6 to 12 months (prophylaxis) • Vaccine: • BCG administration

PULMONARY TUBERCULOSIS NURSING MANAGEMENT Teach the isolated patient to cough and sneeze into tissues and to dispose of secretions properly. Instruct the patient to wear a mask when he leaves his room. Visitors and personnel should wear highefficiency particulate air respirator masks when in his room. (N95 MASK) rest

PULMONARY TUBERCULOSIS NURSING MANAGEMENT eat balanced meals. Record weight weekly. Teach him the signs of adverse medication effects; warn him to report them immediately. Emphasize the importance of regular follow-up examinations to watch for recurring tuberculosis.

PRACTICE QUESTION

PULMONARY HEART DISEASE • COR PULMONALE • Condition that results from PH, which causes the right side of the heart to enlarged because of he increased work required to pump blood against high resistance through the pulmonary vascular system. • Causes right sided heart failure

PULMONARY EMBOLISM This refers to the obstruction of the pulmonary artery or one of its branches by a blood clot (thrombus) that originates somewhere in the venous system or in the right side of the heart. Most commonly, pulmonary embolism is due to a clot or thrombus from the deep veins of the lower legs.

PULMONARY EMBOLISM • Thrombus dislodges from moves into the lungs the legs or pelvis • Thrombus dislodges from clot forms on heart valve and breaks loose; heart valve smaller growths break off and form embolus • Atrial fibrillation--Atrial quiver causing turbulent blood flow; could cause clot that travels to lungs

PULMONARY EMBOLISM • Central venous catheters • Fractures • Immobility • Dehydration • polycythemia vera

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

PULMONARY EMBOLISM Signs and symptoms • Shortness of breath/restless—first sign • Chest pain: sharp, substernal • Cough (hemoptysis) • Restlessness • Tachycardia

PULMONARY EMBOLISM Signs and symptoms • Low-grade fever Inflammation • Cyanosis • Crackles; pleural rub-heard at embolism site due to inflammation • Pulmonary hypertension

PULMONARY EMBOLISM 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.

PULMONARY EMBOLISM Patient Teaching for prevention of Pulmonary Embolism Active leg exercises to avoid venous stasis Early ambulation Use of elastic compression stockings Avoidance of leg-crossing and sitting for prolonged periods Drink fluids

CHEST TRAUMA • Blunt thoracic injuries

• form of injury to the chest including the ribs, heart and lungs, great vessels, trachea and esophagus

BLUNT INJURY CAUSES • Motor vehicle accident • Pedestrian accident • Fall • Sports injury • Crush injury • Explosion

PENETRATING INJURY CAUSES: • Knife • Gunshot • Stick • Arrow • Occupational injury

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

BLUNT TRAUMA Clinical manifestations • Anterior chest pain • Overlying tenderness • Ecchymosis • Crepitus • Swelling

BLUNT TRAUMA • To reduced pain, the patient splints the chest by breathing in a shallow manner and avoids sighs, deep breaths, coughing and movement

BLUNT TRAUMA Rib Fracture: • Give analgesics to assist in effective coughing and deep breathing. • Encourage deep breathing with strong inspiration; give local support to injured area by splinting with hands.

PNEUMOTHORAX • occurs when the parietal or visceral pleura is breached and the pleural space is exposed to positive atmospheric pressure. • Pneumothorax is when the lung collapses due to air accumulating in the pleural space

PNEUMOTHORAX

PNEUMOTHORAX Assessment findings 1. Sudden sharp pain in the chest, dyspnea, diminished or absent breath sounds on affected side, tracheal shift to the opposite side (tension pneumothorax accompanied by mediastinal shift) 2. Weak, rapid pulse; anxiety; diaphoresis

PNEUMOTHORAX Nursing interventions 1. Provide nursing care for the client with an endotracheal tube: suction secretions, vomitus, blood from nose, mouth, throat, or via endotracheal tube; monitor mechanical ventilation.

PNEUMOTHORAX Nursing interventions 2. Restore/promote adequate respiratory function. a. Assist with thoracentesis and provide appropriate 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.

PNEUMOTHORAX Nursing interventions 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.

HEMOTHORAX • Assist with thoracentesis to aspirate blood from pleural space, if being done before a chest tube insertion. • Assist with chest tube insertion and set up drainage system for complete and continuous removal of blood and air. • Auscultate lungs and monitor for relief of dyspnea. • Monitor amount of blood loss in drainage. • Replace volume with I.V. fluids or blood products.

FLAIL CHEST • Loss of stability of chest wall as a result of multiple rib fractures, or combined rib and sternum fractures. • When this occurs, one portion of the chest has lost its bony connection to the rest of the rib cage.

FLAIL CHEST • During respiration, the detached part of the chest will be pulled in on inspiration and blown out on expiration (PARADOXICAL MOVEMENT) • Normal mechanics of breathing are impaired to a degree that seriously jeopardizes ventilation, causing dyspnea and cyanosis.

FLAIL CHEST

FLAIL CHEST • Stabilize the flail portion of the chest with hands; apply a pressure dressing and turn the patient on injured side • Thoracic epidural analgesia may be used for some patients to relieve pain and improve ventilation

FLAIL CHEST Medical management • Supportive • 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.

CARDIAC TAMPONADE • pericardiocentesis

MANAGEMENT OF PATIENTS WITH CHRONIC PULMONARY DISEASE

Chronic Obstructive Pulmonary Disease (COPD) • Preventable and treatable slowly progressive respiratory disease of airflow obstruction involving the airways, pulmonary parenchyma, or both

Lung parenchyma Includes any form of lung tissue, including: bronchioles, bronchi, blood vessels, interstitium and alveoli.

Chronic Obstructive Pulmonary Disease (COPD) • Preventable and treatable slowly progressive respiratory disease of airflow obstruction involving the airways, pulmonary parenchyma, or both • obstruction to airflow impedes breathing. • “chronic airflow limitation” • not fully reversible

Chronic Obstructive Pulmonary Disease (COPD) •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

Bronchitis signs and symptoms • Accessory muscle use • Wheezes/rhonchi/crackles of expiration • Prolonged expiration

•Polycythemia • Pulmonary hypertension resulting in right sided heart failure • Edema; ascites

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 1. Panlobular Emphysema 2. Centrolobular (Centroacinar)

Emphysema

Emphysema signs and symptoms • Dyspnea; tachypnea; air hunger • Barrel-shaped chest

Emphysema signs and symptoms • Dyspnea; tachypnea; air hunger • Barrel-shaped chest • Accessory muscle use • Prolonged expiration • Clubbing of fingers and toes • Inspiratory crackles, wheezes • Decreased chest expansion

Emphysema signs and symptoms •Pursed lip breathing; puffer breathing • Client prefers “seated” position • Weight loss • Respiratory acidosis • Productive morning cough

Risk Factors of COPD Chronic bronchitis and emphysema are both primarily caused by:

cigarette smoking

Risk Factors of COPD Others: • Prolonged and intense exposure to occupational dusts and chemicals • Indoor and outdoor air pollution as to the total burden of inhaled particles on the lung

•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

Assessment and Diagnostic Findings • Pulmonary Function Test • Bronchodilator Reversibility testing • Arterial blood gas measurement • X-ray • Alpha1 antitrypsin deficiency screening

Factors that determine the clinical course and survival of patients with COPD • History of cigarette smoking • Passive smoking exposure • Age • Hypoxemia • PAP • Resting HR

Factors that determine the clinical course and survival of patients with COPD • 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

Spontaneous pneumothorax from ruptured of emphysematous bleb

Complications • 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 •Bronchodilators •Metered dose inhalers

Classes of bronchodilators: •Beta-adrenergic Agonists •Anticholinergic Agents •Methylxanthines

Medical Management •Pharmacologic therapy •Cortecosteroids • Beclomethasone • Budesonide • Flunisolide • Fluticasone • Triamcinolone

Medical Management •Oxygen Therapy • Long term continuous therapy • <55 mmHg or less PaO2 • Night time oxygen therapy • Intermittent oxygen therapy

BRONCHIECTASIS •An irreversible condition marked by chronic abnormal dilation of bronchi and destruction of bronchial walls •Occurs throughout the tracheobronchial tree or can be confined to one segment or lobe

•Separate disease from COPD

BRONCHIECTASIS Causes: • Airway obstruction • Diffuse airway injury • Pulmonary infections and obstruction of bronchus or complications of long term pulmonary infections • Genetic disorder (CF)

BRONCHIECTASIS Inflammatory process with pulmonary infections  damage to the bronchial wall loss of supporting structure  production of thick sputum obstruction of bronchi permanently distended and distorted walls impaired mucociliary clearance inflammation and infection extended to the peribronchial tissues

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

BRONCHIECTASIS Assessment and Diagnostic Findings •A definitive sign is sputum consistently negative for tubercle bacilli *CT scan—presence of bronchial dilatation

BRONCHIECTASIS Medical management •Chest physiotherapy •Smoking cessation •Anti-microbial therapy •Vaccination (Flu Vaccine and Pneumococcal Vaccine) •Bronchodilators

BRONCHIECTASIS Surgical interventions •Pneumonectomy •Lobectomy •Segmental resection

BRONCHIECTASIS Nursing management •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

ASTHMA Symptoms: •Cough •Chest tightness •Wheezing •Dyspnea

ASTHMA Causes: •Allergens •Airway irritants •Exercise •Stress and emotional upsets

• Sinusitis with post nasal drip

•Medications • Viral respiratory tract infections

•GERD

ASTHMA Pathophysiology: Causes and contributing factors of asthma diffused airway inflammation hyperresponsiveness of airways limited airflow symptoms of asthma

ASTHMA Assessment and diagnostic findings •Positive family, environmental and occupational history •Sputum and blood test •Elevated serum level of immune globulin E if allergy is present •Presence of hypocapnia and respiratory alkalosis •Patient becomes more fatigued.

ASTHMA Prevention: •Avoid causative agent •Knowledge in the care of self

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

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

ASTHMA Nursing management: •Implement basic asthma management principles •Establish programs for asthma education •Give the patient knowledge about inhalers, antiallergy 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.

STATUS ASTHMATICUS Causes: •Infection •Anxiety •Nebulizer abuse •Dehydration •Increased adrenergic blockage •Non-specific irritants

STATUS ASTHMATICUS Clinical manifestations: •Labored breathing •Prolonges exhalation •Engorged neck veins •Wheezing

STATUS ASTHMATICUS Assessment and diagnostic findings: •PFT: most accurate •ABG: positive respiratory alkalosis

STATUS ASTHMATICUS Medical management •Short-acting beta-adrenergic agonist and corticosteroids •Oxygen therapy •Mechanical ventilation PRN