Assessment & Disorders Respiratory System Assessment & Disorders 26/10/2009

Upper Respiratory System

Noses and Sinuses Nose Sinuses Begin respiratory system Filter and warm air Sinuses Openings in facial bones Lighten skull Assist in speech Produce mucus

Pharynx and Larynx Pharynx Larynx Nasopharynx Oropharynx Laryngopharynx Larynx Connects laryngopharynx to trachea Routes air and food to proper passageway

Lower Respiratory system

Lungs Separated by mediastinum Composed of elastic connective tissue Divided into lobes which are further divided into segments

Bronchi and Alveoli Trachea divides into right and left mainstem bronchi Bronchi continue to branch and get smaller (bronchioles) and end as alveoli Air moves through passageways to alveoli where gas exchange occurs

Bronchioles and Alveoli

Pulmonary Circulation Pulmonary arteries Pulmonary veins Pulmonary capillary network

Pleura Double-layered membrane that covers lungs Parietal Visceral Hold lungs out to chest wall

Rib Cage and Intercostal Muscles Protect lungs 12 pairs ribs Intercostal muscles are between ribs Assist with process of breathing

Ventilation Divided into inspiration and expiration Normal is 12–20 breaths per minute

Inspiration Lasts 1–1.5 seconds Diaphragm contracts and flattens Intercostal muscles contract Increases size of chest cavity Lungs stretch and volume increases Pressure in lungs slightly less than atmospheric Causes air to rush in

Expiration Lasts 2 to 3 seconds Passive Muscles relax Diaphragm rises Ribs descend Lungs recoil Pressure in chest cavity increases (compressing alveoli) Pressure in lungs higher than atmospheric causes gases to flow out of the lungs

Factors Affecting Respiration Respiratory center of the brain Chemoreceptors in the brain, aortic arch, and carotid arteries Airway resistance Compliance Elasticity Surface tension of alveoli

Respiratory Changes Associated with Aging Cartilage that connects ribs to sternum and spinal cord calcifies Anterior-posterior diameter of chest increases Respiratory muscles weaker Cough and laryngeal reflexes less effective

Respiratory Changes Associated with Aging Size of lungs decreases Alveoli less elastic Older client at greater risk for developing respiratory infections

Assessment Subjective Current complaint or existing condition Onset or duration of symptoms Ability to maintain ADL Nasal congestion, nosebleeds Sore throat, difficulty swallowing Changes in voice quality Difficulty breathing, orthopnea Pain on breathing

Assessment (continued) Subjective Presence of cough frequency, duration, productive or unproductive Sputum amount, color, and consistency Exposure to infections (colds or influenza) History of chronic lung conditions Occupational exposure to chemicals, smoke, asbestos

Assessment (continued) Subjective History of previous respiratory problems Allergies to medication or environmental allergens Use of tobacco, chewing tobacco, marijuana, cocaine, injected drugs, and alcohol

Assessment (continued) Objective Assess state of health Color Ease of breathing Note respiratory rate and pattern Observe nasal flaring Use of accessory muscles for breathing Listen for hoarseness in client’s speech

Assessment (continued) Objective Inspect mucosa of nose, mouth, and oropharynx Inspect neck, position of trachea Inspect anterior/posterior diameter of chest Palpate lips for nodules, chest for tenderness or swelling

Assessment (continued) Objective Auscultate breath sounds, note absence or presence and quality Note adventitious breath sounds (wheezing or crackles)

Pulse Oximetry Monitors oxygen saturation (SpO2) Nursing Care Amount of arterial hemoglobin that is combined with oxygen Nursing Care Apply to fingertip, forehead, earlobe, or nose Remove nail polish when using fingertip

Arterial Blood Gases Nursing care Apply pressure to site 2–5 minutes following arterial puncture

Serum Alpha1-Antitrypsin Deficiency in this serum protein contributing factor in emphysema and COPD Normal value in adults 150–350 mg/dL Fasting specimen obtained in client with elevated cholesterol or triglycerides

Sputum and Tissue Throat or nose swab Sputum specimen Culture and sensitivity Gram’s stain Acid-fast stain Cytology

Imaging Techniques X-rays CT scans Ventilation perfusion scans Nursing care and client teaching If contrast used remember to ask about allergies, especially iodine and seafood

Pulmonary Function Tests Measure lung volume and capacity Smoking, caffeine, and bronchodilators interfere with results Nursing care and client teaching Instruct client to stop bronchodilators 4–6 hours prior to test Instruct client not to smoke or drink caffeinated drinks prior to test

Lung Volumes and Capacities

Direct Visualization Direct or indirect laryngoscopy Used to identify and evaluate laryngeal tumors Nursing care and client teaching Make sure consent form has been signed Remove dentures, partial plates, bridges prior to procedure NPO before procedure NPO after procedure until gag reflex returns

Bronchoscopy Visualize trachea, bronchi and bronchioles Tumors and structural disorders Obtain tissue biopsy Obtain sputum specimen Removal of foreign body Nursing care and teaching

Dr Ibrahim Bashayreh, RN, PhD. Asthma and COPD Dr Ibrahim Bashayreh, RN, PhD. 25/10/2010

Asthma Asthma is a chronic inflammatory pulmonary disorder that is characterized by reversible obstruction of the airways 26/10/2009

Asthma Asthma is a chronic (long-term) disease that makes it hard to breathe. Asthma can't be cured, but it can be managed. With proper treatment, people with asthma can lead normal, active lives. 26/10/2009

Etiology Cause of asthma is unknown but many factors play a part: Genetic factors: Asthma tends to run in the family Environmental factors: pollen, dust, mold, tobacco smoke Occupational exposure: chemicals and gases 26/10/2009

Normal bronchiole/ Asthmatic bronchiole 26/10/2009

How asthma works If you have asthma, your airways (breathing passages) are extra sensitive. When you are around certain things, your extra-sensitive airways can: Become red and swollen - your airways get inflamed inside. They fill up with mucus. The swelling and mucus make your airways narrower, so it's harder for the air to pass through. 26/10/2009

Cont. Become "twitchy" and go into spasm - the muscles around your airways squeeze together and tighten. This makes your airways narrower, leaving less room for the air to pass through. The more red and swollen your airways are, the more twitchy they become. 26/10/2009

Symptoms Hard breathing caused by irritants Asthma inducers: If you breathe in something you're allergic to- for example, dust or pollen- or if you have a viral infection- for example, a cold or the flu- your airways can become inflamed (red and swollen). 26/10/2009

Cont. Asthma triggers: If you breathe in an asthma trigger like cold air or smoke, or if you exercise, the muscles around your airways can go into spasm and squeeze together tightly. This leaves less room for air to pass through. It's important for every person with asthma to know what they triggers and inducers are. 26/10/2009

What are the Triggering Factors? Domestic dust mites Air pollution Tobacco smoke Occupational irritants Animal with fur Pollen 26/10/2009

Triggering Factors ( cont.) Respiratory (viral) infections Chemical irritants Strong emotional expressions Drugs ( aspirin, beta blockers) 26/10/2009

Asthma: Early Clinical Manifestations Expiratory & inspiratory wheezing Dry or moist non-productive cough Chest tightness Dyspnea Anxious &Agitated Prolonged expiratory phase Increased respiratory & heart rate 26/10/2009

Asthma: Early Clinical Manifestations Wheezing Chest tightness Dyspnea Cough Prolonged expiratory phase [1:3 or 1:4] 26/10/2009

Asthma: Severe Clinical Manifestations Hypoxia Confusion Increased heart rate & blood pressure Respiratory rate up to 40/minute & pursed lip breathing Use of accessory muscles Diaphoresis & pallor Cyanotic nail beds Flaring nostrils 26/10/2009

Classification At risk- breathing test normal, mild symptoms Mild- breathing test shows mild limitation, increasing symptoms Moderate- person will typically seek care for symptoms, shortness of breath with significant exertion, lung tests abnormal Severe- shortness of breath with limited activity, lung tests abnormal Review. Ask them to describe someone they’ve worked with who had COPD and determine at what level that person might have been. 26/10/2009 48

Asthma: Diagnostic Tests Pulmonary Function Tests FEV1 decreased Increase of 12% - 15% after bronchodilator indicative of asthma PEFR decreased Symptomatic patient eosinophils > 5% of total WBC Increased serum IgE Chest x-ray shows hyperinflation ABGs Early: respiratory alkalosis, PaO2 normal or near-normal severe: respiratory acidosis, increased PaCO2, 26/10/2009

Asthma: Nursing Diagnoses Ineffective airway clearance r/t bronchospasm, ineffective cough, excessive mucus Anxiety r/t difficulty breathing, fear of suffocation Ineffective therapeutic regimen management r/t lack of information about asthma Knowledge deficit 26/10/2009

Medical Management of Asthmatic Patient Limit exposure triggering agents Medications such as: inhaled corticosteroids, inhaled beta2 adrenergic agonist, and cromolyn sodium 26/10/2009

Asthma Medications: Anti-inflammatory Leukotriene modifiers Interfere with synthesis or block action of leukotrienes Have both bronchodilation and anti-inflammatory properties Not recommended for acute asthma attacks Should not be used as only therapy for persistent asthma Accolate, Singulair, Zyflo Corticosteroids Not useful for acute attack Beclomethasone: vanceril, beclovent, qvar Cromolyn & nedocromil Inhibits immediate response from exercise and allergens Prevents late-phase response Useful for premedication for exercise, seasonal asthma Intal, Tilade 26/10/2009

Asthma Medications: Bronchodilators 2-adrenergic agonists Rapid onset: quick relief of bronchoconstriction Treatment of choice for acute attacks If used too much causes tremors, anxiety, tachycardia, palpitations, nausea Too-frequent use indicates poor control of asthma Short-acting Albuterol[proventil]; metaproterenol [alupent]; bitolterol [tornalate]; pirbuterol [maxair] Long-acting Useful for nocturnal asthma Not useful for quick relief during an acute attack Salmeterol [serevent] 26/10/2009

Asthma Medications: Bronchodilators con’t Methylxanthines Less effective than beta- adrenergics Useful to alleviate bronchoconstriction of early and late phase, nocturnal asthma Does not relieve hyperresponsiveness Side effects: nausea, headache, insomnia, tachycardia, arrhythmias, seizures Theophylline, aminophylline Anticholinergics Inhibit parasympathetic effects on respiratory system Increased mucus Smooth muscle contraction Useful for pts w/adverse reactions to beta- adrenergics or in combination w/beta- adrenergics Ipratropium [atrovent] Ipratropium + albuterol [Combivent] 26/10/2009

Management of Asthmatic Patient Identify and assess status Avoid precipitating factors Bring inhaler for each appointment Drug considerations: Avoid ASA, NSAIDs, barbiturates, and narcotics Drug interactions with asthmatic medications (ex. Theophylline vs. Antibiotics, Cimetidine) Chronic corticosteroid users may require steroid supplementation For sedation, nitrous oxide/oxygen and/or small doses of oral diazepam is recommended 26/10/2009

Asthma: Client Teaching Correct use of medications Signs & symptoms of an attack Dyspnea, anxiety, tight chest, wheezing, cough Relaxation techniques When to call for help, seek treatment Environmental control Cough & postural drainage techniques 26/10/2009

COPD Chronic obstructive pulmonary disease is a slowly progressive disease that is characterized by a gradual loss of lung function COPD includes chronic bronchitis, chronic obstructive bronchitis, or emphysema, or combinations of these conditions 26/10/2009

Epidemiology 20.3 million Americans report having asthma 5,000 deaths annually from asthma 12.1 million Americans reported being diagnosed with COPD 119,000 deaths annually from COPD COPD is the 4th leading cause of death in the U.S. 26/10/2009

Chronic Bronchitis Inflammation of the main airway passages (bronchi) to the lungs, which results in the production of excess mucous, a reduction in the amount of airflow in and out of the lungs, and shortness of breath 26/10/2009

Emphysema A respiratory disease characterized by breathlessness brought on by the enlargement, or over-inflation of, the air sacs (alveoli) in the lungs 26/10/2009

Signs and symptoms Wheezing Coughing Sputum production Shortness of breath Chest tightness ASK the learners. Go back to the breath through the closed hand exercise to discuss s/s. 26/10/2009 61

Diagnosis Clinical symptoms Chest x-ray Lung function tests ABGs Discuss briefly 26/10/2009 62

COPD Nursing diagnosis Ineffective airway clearance r/t secretions Impaired gas exchange r/t altered supply O2 Altered health maintenance r/t ineffective individual coping Risk for infection r/t inadequate defense system Knowledge deficit of COPD Altered role performance r/t changes in role 26/10/2009

Nursing DX Ineffective breathing pattern r/t musculoskeletal impairment , decreased energy Inability to sustain spontaneous ventilation r/t muscle fatigue Activity intolerance r/t imbalance of O2 supply 26/10/2009

Clinical Features of COPD Patients Mild COPD: no abnormal signs, smokers cough, little or no breathlessness Moderate COPD: breathlessness with/without wheezing, cough with/without sputum Severe COPD: breathlessness on any exertion/at rest, wheeze and cough prominent, lung inflation usual, cyanosis, peripheral edema, and polycythemia in advanced disease 26/10/2009

Diagnosis Spirometry Bronchodilator Reversibility Testing Breathing test which measures the amount and rate at which air can pass through the airways Bronchodilator Reversibility Testing Relaxing tightened muscles around the airways and opening up airways quickly to ease breathing Other pulmonary function testing Diffusion capacity Chest X-ray Arterial Blood Gas Shows oxygen level in blood 26/10/2009

Medical Management of COPD Patient Smoking cessation and elimination of environmental pollutants Palliative measure such as regular exercise, good nutrition, flu and pneumonia vaccines Bronchodilators, corticosteroids, anticholinergics, and NSAIDs 26/10/2009

Management of COPD Patient Review history for concurrent heart disease Avoid treatment if upper respiratory tract infection is present Treat in upright position Avoid rubber dam in severe cases Use pulse oximetry (if pulse ox <91%, use low flow 2-3L/min) Avoid Nitrous oxide/oxygen in severe cases Avoid barbiturates, narcotics, antihistamines, and anticholinergics If patient is on steroid regimen, supplement as needed Drug interactions with COPD medication 26/10/2009

26/10/2009