trachea 

5 

bronchioles

which are less than a millimeter in diameter.

Macrophages

Mast cells

The respiratory system has high arterial compliance

which means

The alveoli have poor capillary bed exchange

True or Fales

Fales

Richest capillary bed

754-757 mmHg

if it is out of this range it indicates a problem

O2 transport-each 100 ml of blood contains

____ of O2 with __ % dissolved in plasma

20ml of O2

3% dissolved in plasma

Changes in PCO2 and ph sensed in anterior medulla

Changes in CSF H+ levels

What are the respiratory Lung Receptors

and where are they located?

Proprioceptors in muscles and joints

Pulmonary airway smooth muscle

Irritant receptors

Medical History/Occupational Exposures  Medications/Drugs

Cultural factors, Smoking history

Sputum, Cough, Chest Pain, Allergies

Good light

No clothes- LOOK at the chest, not the gown covering 

 Position pt  for comfort

Work from top down

anterior to posterior

move as little as possible

Do not to wear the patient out

A nurse is doing a respitory assessment and notices these things: Trachea midline, ↑ anterior Chest expansion, Tripoding.

What should the nurse report to the MD as an abnormality?

How would the nurse recognize a perforated septum

what may it indicate about ur pt

present on pen light inspection: if the light shines through the perforation into the opposite nostril. 

this condition is often found in cocaine users.

push the trachea away from the affected area: Tension pneumothorax, large pleural effusion, mediastinal mass, and neck tumors

pull the trachea toward the affected area: Pneumonectomy, fibrosis, and atelectasis

Observe the type of breathing:

What types may you see

Retractions are areas that get sucked inward when the patient inhales. This does not occur during normal respiratory effort.

occur when the patient is working hard to inhale around an obstruction.

slowed movement on one side

occurs with the presence of a pulmonary mass, pleural fibrosis, atelectasis, pneumonia, or a lung abscess.

Chronic airflow limitation or CAL, includes:

3

What conditions are referred to as COPD or chronic obstructive pulmonary disorder.

2

What is Pectus excavatum or Funnel chest

What is Pectus excavatum or Pigeon chest

What is the Criteria  for Chronic Bronchitis

Inflammation of the bronchichronic cough with excessive mucous

          3 months/yr. X 2 consecutive yrs.

Eventually constant

What is Chronic Bronchitis Disease Course

Initially affects large airways then eventually affects all airways

Secretions are thick & tenacious ® booger balls ®­ air trapping (ball-valve effect)

What may proceed the Onset of Chronic Bronchitis

Insidious  : May follow  Asthma, Influenza, Pneumonia

 Usu. seen in middle age   Early s/s often attributed to aging 

Chronic Bronchitis Clinical Manifestations Early

l   Cough with thick white mucus–        Esp. in A.M./P.M.

l   Bronchospasm during coughing episodes

l   Freq. resp. infections in winter-  May last several weeks

Chronic Bronchitis Clinical Manifestations: Disease Progression

Orthopneic/tripod,  (cor pulmonale)                                        Sputum becomes: Purulent yellow, Copious, Blood streaked after severe coughing.  Cyanosis/clubbing, confusion, photophobia.  Course crackles/rhonchi/wheezing. Speaks in short choppy sentences.  dyspnea at rest ¯ Mobility r/t SOB

Chronic Bronchitis Management Goals

Prevent irritation & infection of bronchial mucosa             Maintain resp. function, Remove secretions

increase in number of mucous glands

• production of large amounts of thick mucus

• bronchial walls thicken

• impaired airflow.

What is Emphysema

Abnormal, permanent enlargement of the air spaces distal to the terminal bronchioles accompanied by destruction of alveolar walls  

Imbalance in proteolytic enzyme & protease ® alveoli ¯ elasticity → air trapped → over inflation → destruction of alveolar walls → one great big alveoli (blebs & bullae) 

–        r/t smoking

–        Onset between 30-40 y/o if AAT

How might a pt's chest apper who has Emphysema

Why?

Increased A-P diameter (barrel shaped chest)                          Chest rigid ® inspiratory difficult

r/t hyper inflation & air trapping

What is the 1st S/S of Emphysema

Emphysema Clinical Manifestation  Advanced disease

Memory loss, Impaired judgment, Drowsy, confused     Increased PCO2, Muffled  sounds

How would a pt's PFT look if they have Emphysema

¯ overall lung function

­ ↑ Total lung capacity & residual volume

¯ Vital capacity & forced exp. volume

­ AP diameter                                                                                        

Like to sit leaning forward

Hypertrophy of accessory muscles of upper chest & neck

Which of these are you likely to observe in a pt with Emphysema

All:

AP diameter  

Like to sit leaning forward  

Hypertrophy of accessory muscles of upper chest & neck

T/F

a pt with Emphysema will need a high flow of o2

Fales 

Pt with Emphysema can be harmed by high o2 flow.            Don’t turn up O2 without MD's ok

–        Monitor air quality before going out

–        Avoid cold air & wind

l  Causes bronchospasms

–        Monitor & report sputum to MD

teach the pt to have pland rest

do activites in am when energy is high

Examples of Bronchodilators  

Steroids: Prednisone

Leukotriene antagonists: Accolate

Mast cell stabilizers: Cromolyn

Inhaled anti-inflammatory: new-Tilade (non-steroidals inhibit the release of inflammatory mediators from the respiratory epithilium)

With long term steroids you need to watch for:

7

What Surgeries are done for pts with COPD

Why?

lung transplantation, lung reduction.

This improves gas exchange in the patient with COPD. This can improve the FEV by 75% and reduce the TLC and RV while increasing quality of life and activity tolerance.

An intermittent process

Reversible airflow obstruction and wheezing

What are the common Asthma triggers

4

1. Cold air, dry air

2. air borne particles such as dust and dander.

3. Microorganisms.

4. Exercise.

Asthma

Pulmonary function tests that are affected include:

• FVC (forced vital capacity)

which is the air exhaled during a full exhalation phase,

goes down

Asthma

Pulmonary function tests that are affected include:

FEV1 (forced expiratory volume at 1 second)

volume blown out as hard and fast as possible during 1 second of the most forceful exhalation

goes down

Asthma

 Pulmonary function tests that are affected include:

the fastest airflow rate reached at anytime during the FVC.

A decrease in either the FEV1 or the PEF of 15% to 20% below expected levels for age/gender is common in asthma

What are the Goals of Asthma-treatment

3

Goals-improve airflow, relieve symptoms,

prevent episodes

Asthma  Diagnostic Findings

PFT’s –        ¯ Forced expiratory volume & forced vital capacity                                                                –        ­ Total lung capacity & functional residual volume                                                                    ABGs (during attack)  –        ¯PO2                                                                                                              –        ¯PCO2 (r/t ↑ resp. rate) – early                                                                                                          –        ­PCO2 ↑ late

Asthma Medical Management , Symptomatic during attack

Bronchodilators – SVN

Terbutaline-a bronchodilator SQ

Aminophyline -Xanthine derivative IV gtt.

Asthma Medications, Maintenance – MDI/PO

Steroids (prefer inhaler)

Mast cell inhibitors  :Cromyln inhaler

Leukotriene inhibitors:   Singulair, Accolate

Long acting bata agonist- Serevent

What Client Teaching would a nurse do for a pt with Asthma 5

Peak flow meter, Correct use of meds & MDI, Help ID & avoid triggers, Relaxation techniques,   Breathing exercises

when there are blood gas abnormal readings.

Specifically the PaO2 is less than 60mmHg, SaO2 is less than 90%, and PaCO2 is greater than 50mmHg with a pH <7.3.

oxygenation failure, ventilatory failure or a combination.

and Adult Respiratory Distress Syndrome

Dyspnea (difficulty breathing)

DOE (dyspnea on exertion)

Orthopnea-is shortness of breath changes in respiratory rate or pattern

Abnormal lung sounds-wheezing

 Decreased oxygen saturation

Abnormal ABGs

1. Hypercapnia- ↑ CO2

2. Hypoxemia- ↓ O2

Ventilation-perfusion (V/Q) mismatching

Perfusion is normal, ventilation is inadequate

 Inappropriate air movement in and out of lungs

 Insufficient oxygen reaches alveoli, carbon dioxide is retained

What Mechanisms can cause Ventilatory Failure

3

1. Abnormality of lungs or chest wall

2. Defect in respiratory control center in the brain

3. Impairment in function of the respiratory muscles

Thoracic pressure changes are normal

Lungs cannot oxygenate pulmonary blood

Result of V/Q mismatch

 Ventilation is normal, perfusion is decreased

1. Hypoventilation: insufficient respiratory movement

2. Inadequate gas exchange at alveolar-capillary membrane

Acute respiratory distress syndrome (ARDS) is acute respiratory failure with these indicators:

5

• Hypoxemia that persists even when 100% oxygen is given 

• Decreased pulmonary compliance

• Dyspnea

• Noncardiac-associated bilateral pulmonary edema

• Dense pulmonary infiltrates on x-ray (ground-glass appearance)

A nurses best action when a pt is diagnosed with ARDS is to tell the family that the pt has a very high chances of survival and not to worry.

T/F?

False

The mortality rate is high even when intensive interventions are used.

Lung tissue normally remains relatively dry.

 How will the lungs appear in patients with ARDS?

thoughs who have sustaind a Trauma

and or patients who have a hyper-inflammatory responses to injury (genetic)

Pts with ARDS have a widening alveolar oxygen gradient

What does this mean?

increased fraction of inspired oxygen [Fio2] does not lead to increased Pao2 levels

They can not use the oxygen they are breathing in.

Pt does not respond to high concentrations of oxygen

Pt is unable to use the oxygen that is inspired 

Hyperpnea, grunting respirations,

BS may be initially normal

Cyanosis, pallor

Diaphoresis

Hypotension

Tachycardia and tachypnea

Dysrhythmias

Decreased PaO2

 Treat underlying cause

 Endotracheal intubation

 Mechanical ventilation

 Drug/fluid therapy

 Steroids controversial-given early

Nutrition therapy- either tube feeding or TPN

The nurse knows that early intervention with ARDS crucial

so what should the nurse be assessing?

Monitor ABG’s , lungs 

Judicial fluid status, sepsis possible

 Watch for oxygen toxicity

PEEP complications

Improves oxygenation and ventilation

Decreases amount of work for effective breathing

Provides respiratory support until lung function is adequate

Complications of Mechanical Ventilation

Cardiac

1. Hypotension

2. Fluid retention

Complications of Mechanical Ventilation

Lung

1. Barotrauma

2. Volutrauma

3. Acid-base abnormalities

Complications of Mechanical Ventilation

GI and nutritional

1. Stress ulcers

2. Paralytic ileus

3. Malnutrition

4. Carbohydrates increase CO2 production

5. Electrolyte imbalance

many patients die of a PE within 1 hour of the onset of symptoms or before the diagnosis has even been suspected.

T/F?

Nidus-sight of injury

Clotting cascade

Fibrin thrombus

Walls and valves inflammed

Attachment fragile- may break off

perfusion 

A PE will block pulmonary circulation

Decreased systemic oxygenation

Pulmonary tissue hypoxia→ tissue damage

Immobilization

Surgery

Obesity

Hypercoagulability

Smoking

Pregnancy

Estrogen Therapy (i.e birth control)

Trauma, certain diseases, central lines

Advancing age

History of embolus

Manifestations/Symptoms of a PE

Respiratory

dyspnea

tachypnea

pleuretic chest pain

hemoptysis- expectoration (coughing up) of blood

ABG=hypoxemia

Manifestations/Symptoms of a PE

Cardiac

tachycardia

syncope

cyanosis

S3, S4 possible

Manifestations/Symptoms of a PE

Miscellaneous

low grade fever

petechiea

nausea, vomiting, malaise

CXR

V/Q scan

CT contrast (pulmonary angiogram)

Ineffective Gas Exchange

Decreased cardiac output

Anxiety (possible impending doom)

Risk for Injury

Activity Intolerance

IV therapy

Drug therapy-Heparin, Lovenox, Coumadin

1. Embolectomy

2. Inferior vena caval interruption

Generally given IV

Blocks formation of thrombin to prothrombin

Prevents extension of clot, no lysis

Onset is 20-60 minutes, peak is within minutes

Duration is 2-6 hours

Half life is 90 minutes

Monday

Onset is 2-5 days, peak is 1/2 to 3 days, half life is 3 days

Coumadin/warfarin has less occurence with interactions with other medications this is why pts are swiched to it.

T/F?

False

Coumadin Interactions with other medications

pt are swiched because it is an oral med and easier to take

Synergistic effect ETOH, smoking

chronic laryngitis, voice abuse

Horseness or lump in the neck for longer than 3-4 weeks.

Persistant or recurrent sore throat.

Short of breath.

Difficulty swallowing.

Dx-Hx, Xray, bronchoscopy, laryngoscopy, MRI, CT

TNM(tumor nodes metastases), requires biopsy

What is the cure rate of Laryngeal Cancer type 1

and type 2

 T1, 90% curable with RT, 100% with Surgery

T2, 75-85 with RT, 90% with surgery

Client retains voice

•only  4-8 weeks of treatment

• Leaves with better voice quality

• Can be used with chemotherapy

no voice, permanent trach, loss of smell, can swallow,

removal of: epiglottis, thyroid cartilage, larynx, hypoid bone

Removal of regional metastasis

 May remove tongue, tonsil, lip, thyroid

what are the Complications of treating 

Laryngeal Cancer

7

Esophageal stenosis- stricture is a narrowing or tightening

• Salivary fistula

• Laryngeal edema

• Rupture of carotid-hemorrhage

• Nutritional deficits

• Breakdown of suture line

• Chemo-stomatitis-inflammation of the mucous lining of any of the structures in the mouth, pul fibrosis-the formation or development of excess fibrous connective tissue in the lungs

Breathing, swallow, drainage, labs

Nutritional

Psych/social

Communication

 Self-care

Rehabilitation

Altered body image

blunt trauma

Main problem is pneumothorax and PAIN.

Inability of air to escape-in an open wound, a flap may prevent air movement

Intrathoracic pressure increases, CO altered, compression of great vessels

Tension Pneumothorax Can occur if chest tubes are left clamped.

T/F?

Tension Pneumothorax is expected to happen when chaning tubing it is not a medical emergency.

T/F?

Fales

It is a medical emergency

only clamp tube for a brife time and only with an order.

Flail Chest- Fracture of 2 or more adjacent ribs in 2 or more places with loss of chest stability

chest Xray, ABG assessment

Ventilate, oxygenate, IV’s

Stabilize chest

Ensure airway

 High flow O2

 IV access

Assess for other significant injuries

Position in semi-fowlers if neck OK

May need chest tube placement. This is often placed at the bedside and you as the nurse may be assisting