1. Critical Care Nursing A Holistic Approach Part 5

2. Anatomy and Physiology of the Respiratory System
Chapter 23

3. Thorax Thoracic cage Ridged and flexible; protects organs
Muscles of ventilation
Diaphragm, external/internal intercostal muscles
Lungs
Pleural space
Parietal pleura, visceral pleura
Mediastinum
Contains the heart, esophagus, vessels, thymus

7. Airways Nasopharynx – warms, filters, and moisturizes Oropharynx
Trachea – passageway, smooth muscle, cricoid cartilage
Bronchi – right, left, carina (neuronal tissue)
Bronchioles
Terminal bronchioles
Alveoli – gas exchange

11. Pulmonary Circulation
Deoxygenated blood from right ventricle
Pulmonary artery – arteriole
Capillaries
Wrap around every alveoli
Thin-walled for efficient gas exchange
Venules
Pulmonary vein
Left atrium

15. Physiology of Respiration
Ventilation
Movement of air between the alveoli and atmosphere
Diffusion
Movement of CO2 and O2 between alveoli and capillaries
Transport
Movement of O2 from the alveoli to the cells
Movement of CO2 from the cells to the alveoli

16. Process of Ventilation
Movement of the diaphragm
Changes in the transpulmonary pressure
Lung compliance
Airway resistance

20. Balance of Ventilation to Perfusion
Alveolar dead space
Collapsed alveoli from pneumonia or atelectasis
Shunting
Anatomical
Blood moves from the right side to left side of the heart without being oxygenated
Physiological
Blood moved by alveoli without picking up oxygen

21. VQ Mismatch Physiological shunt Low ventilation–perfusion ratio
Alveolar dead space
High ventilation–perfusion ratio
Silent unit
Both ventilation and perfusion are decreased

24. Patient Assessment: Respiratory System
Chapter 24

25. History Dyspnea Chest pain Sputum production Cough Past history
Family history
Personal and social history

26. Inspection Respiratory rate, depth, and pattern of respiration
Labored breathing, use of accessory muscles
Cyanosis of skin
A/P diameter of chest, and patient posture
Chest expansion
Chest deformities or scars
IE ratio
Clubbing of the fingers

29. Palpation Tactile fremitus Subcutaneous emphysema Thoracic expansion
Trachea

33. Percussion
Audible vibrations
Tactile vibrations

36. Auscultation Tracheal breath sounds Bronchial breath sounds
Over trachea, loud and harsh
Bronchial breath sounds
Over large airways they are normal; anywhere else they are not normal
Bronchovesicular breath sounds
Medium in pitch; heard over bronchioles
Vesicular breath sounds
Heard over distal airway; quiet, low pitched

38. Pulse Oximetry Reflects the arterial oxygen saturation of hemoglobin
Saturations of 93% to 99% are normal
Not reliable in patients
Using vasoconstricting meds
With known dyshemoglobins (carboxyhemoglobin or methemoglobin)
In shock, cardiac arrest
With severe anemia

39. End-Tidal Carbon Dioxide Monitoring

40. Arterial Blood Gases pH: 7.35–7.45 PaO2: 80–100 mm Hg
PaCO2: 35–45 mm Hg
HCO3: 22–26 mm Hg
SaO2: 93–99%

41. Acid–Base Balance Respiratory acidosis Respiratory alkalosis
Metabolic acidosis
Metabolic alkalosis

42. Other Diagnostic Tests
Chest X-ray
Ventilation-perfusion scan
Pulmonary angiogram
Pulmonary function test (PFT)
Bronchoscopy
Thoracentesis
Sputum culture

43. Patient Management: Respiratory System
Chapter 25

45. Pulmonary Toilet Cough and deep breathing Chest physiotherapy
Positioning
“Good lung” down
Postural drainage
Percussion or vibration

47. Oxygen Delivery Systems
Nasal cannula
For children, blow-by
Simple face mask
Venturi mask
Face tent
Non-rebreather mask

48. Artificial Airways Nasopharyngeal / Oropharyngeal
Size by placing device from ear lobe to corner of mouth
Endotracheal tube
Uncuffed tubes for children younger than 10 years of age
Laryngomask airway (LMA)
Sizes 1,2,3,4, and 5
Sizes 3 and 4 for most of the population
Tracheostomies

50. Chest Tubes Remove air and fluid from the pleural space
Re-expand a collapsed lung
Restore negative pressure to the pleural space

51. Reasons for a Chest Tube
Hemothorax
Pneumothorax
Tension pneumothorax or hemothorax
Fistula

53. Pharmacological Interventions
Bronchodilators
Anti-inflammatory agents
Antibiotics
Sedative agents

54. 50/50 Rule of Respiratory Failure
pH less than 7.25
PaCO2 greater than 50 mm Hg
PaO2 less than 50 mm Hg

55. Mechanical Ventilators
Negative–pressure ventilator
Positive–pressure ventilator
Pressure ventilator
High-frequency ventilator

56. Modes of Ventilation Assist-control
Synchronized intermittent mandatory ventilation (SIMV)
Pressure-support
Pressure-controlled ventilation
Volume-guaranteed pressure option
Continuous positive airway pressure (CPAP)
Positive end-expiratory pressure (PEEP)

57. Ventilator Settings FiO2 Respiratory rate Tidal volume Peak flow
Pressure limit
PEEP
Sensitivity

58. Complications Aspiration Barotrauma
Ventilator–associated Pneumonia (VAP)
Decreased cardiac output

59. Common Respiratory Disorders
Chapter 26

60. Pneumonia Community-acquired pneumonia Hospital-acquired pneumonia
Bacteria
Viruses
Mycoplasma
Fungi
Chemical

61. Pneumonia
is an inflammatory response to the uncontrolled multiplication of microorganisms invading the lower respiratory tract.

62. Pneumonia Studies CXR, sputum culture, bronchoalveolar lavage
Management
Antibiotics, oxygen, pulmonary toilet
Supportive care
Nutrition, hydration, rest
Prevention
Pneumococcal and influenza vaccines

63. Pleural Effusion
Accumulation of pleural fluid secondary to increased fluid formation
Increased capillary permeability
Deceased colloid osmotic pressure of the blood
Increased intrapleural negative pressure
Impaired lymphatic drainage
Increased pressure in the capillaries or lymphatics

64. Assessment of Pleural Fluid
H/P finding
Shortness of breath, chest pain
Tachypnea, hypoxemia, pleural rub
Diagnostic studies
CXR – lateral decubitus
Thoracentesis

65. Pneumothorax Sudden onset of pleuritic chest pain
Dyspnea, shortness of breath, increased work of breathing
Diagnostic test
CXR
Management
Oxygen
Possible placement of chest tube

67. Pulmonary Embolism
Part of a deep vein thrombosis that has traveled and lodged in the pulmonary arteries
Severity depends on the extent of occlusion
Mismatch of ventilation and perfusion
Testing
VQ scan or a pulmonary angiogram
Management
Anticoagulation

69. COPD
History
Exposure to risk factors, comorbidities, current medical treatment (beta blockers)
Tests
Spirometry, ABGs
Management
Oxygen, education, drug therapy, nutrition, exercise, surgical intervention

73. Asthma A chronic inflammatory disease of the airways
Airway hyperresponsiveness
Variable airway obstruction
Resolves spontaneously or after using a bronchodilator

74. Asthma Testing Spirometry Pulmonary function testing Management
Education, prevent exacerbation, optimize pharmacotherapy

76. Acute Respiratory Failure
A sudden and life–threatening deterioration in gas exchange
Type I – Acute hypoxemic respiratory failure
Type II - Acute hypercapnic respiratory failure
Type III – Combined hypoxemic and hypercapnic failure

77. Acute Respiratory Failure
Tests
ABGs, CXR, PFTs, CT, thoracentesis
Management
Correction of gases, oxygen therapy
Reversal of any narcotics
Possible mechanical ventilation

78. Acute Respiratory Distress Syndrome
Chapter 27

79. ARDS Complex clinical syndrome Acute hypoxic injury
Caused by direct or indirect pulmonary injury
Direct injury - aspiration, pulmonary infection, near drowning, thoracic trauma or toxic inhalation
Indirect injury – shock, sepsis, hypothermia, DIC, multiple transfusion eclampsia, pancreatitis, burns

80. Phases of ARDS

83. Diagnostic Studies Blood cultures
Bronchoalveolar lavage – detection of interleukin-1 and tumor necrosis factor-
Blood gas
CXR
Lung compliance, airway resistance, and pressure