Ana Corona, DNP, FNP-BC, Nursing Instructor July 2013

Functions

* Gas Exchange * Warms, moisturizes and filters air * Acid-base balance * Assist with speech

Anatomical Features

 Nasal cavity  Mouth  Larynx  Trachea  Lungs - two cone-shaped organs - right has 3 lobes, left has 2  Pleura - serous membrane of the lung - lines the whole thoracic cavity and contains pleura fluid for lubrication  Cilia - hair-like structures that move mucous and foreign debris out of the respiratory tract  Alveoli - units of lung tissue that perform exchange of gasses. Massed with capillaries which causes ventilation and perfusion to directly impact this system  Bronchi - branches off the hilus of the trachea - right is shorter, wider, and more vertical, allowing easier aspiration of large foreign objects

Respiratory Assessment

 Tracheal position - should be midline. Place the pad of your index finger in the suprasternal notch and lightly palpate for the trachea. - Deviation moves toward the affected side in pneumonia, away from the affected side in a pneumothorax (collapsed lung). - Trachea can also sometimes deviate due to an enlarged thyroid

 Respiration - normal value is 12-20 per minute. Count one inspiration and one expiration as a full respiratory cycle.

 Inspiration - diaphragm lowers and ribs expand  Expiration - diaphragm raises and ribs contract

 Tachypnea - (tack-ip-knee-uh) - fast breathing greater than 24 respirations per minute. Causes include hypoxia, stress, increased temperature (environmental or body), and increased oxygen demand (as for exercise), etc.

 Bradypnea - (braid-ip-knee-uh) - slow breathing less than 10 respirations per minute. Causes include increased pressure in the medulla oblongata, sleep, drug overdose, etc.

Breathing Mode

 Eupnea (Normal) - breathes through nose, thoracic movement only - no abdominal muscle involvement, normal pattern  Dyspnea - shortness of breath  Orthopnea - has to breath sitting up - sleeps in a reclining chair, for instance  Apnea - lack of respirations for 10 or more seconds (involuntary) - note time, duration, and frequency - try to find a pattern

Chest Excursion

   Tests for chest expansion symmetry - Anterior method - Place your thumbs below the costal margin (ribs) and observe them move apart (hopefully symmetrically) during inspiration - Posterior method (preferred method) - Place thumbs on either side of the spine at T8-T10 and press together to “tent" a small fold of skin up. Have the patient take a deep breath and watch the thumbs move evenly away as the pinched skin becomes relaxed

Clubbing

 Clubbing of the fingers - fingertips thicken and swell into rounded knobs  Nails grow around the fingers deeper than normal and become soft and easily punctured.  Clubbing denotes chronic hypoxia.

Auscultation

 Use the diaphragm of stethoscope, listen to both inspiration and expiration at every point.  Go from one side of the chest to the other, listening for symmetry, and work down toward the diaphragm.  Positions to use are preferably sitting or in semi fowlers to fowlers for anterior auscultation, and sitting for posterior auscultation.

Pulse Oximetry

 Detects oxygen saturation via infrared light.  Clipped to finger or earlobe  Normal value is 95-100%.  Inaccurate readings will be obtained over dark fingernail polish.

Airway Clearance

     Coughing - Descriptive terms for coughing include wet/loose, dry/hacking, harsh/barking Productive vs. Nonproductive should always be noted on the chart. Productive coughs should be assessed via the COCA model - Color, Odor, Consistency (thickness), Amount. Amount is often a comparative or subjective description (dime-sized, quarter-sized, small amount, etc.) Hemoptysis - blood in the sputum

Diagnostic Tests

 ABG - arterial blood gasses - collected from a peripheral artery (brachial, radial or femoral preferably) - not collected from temporal, carotid, or apical pulse points.  Can be collected by a deep stab method with a standard hypodermic, or through an arterial line (similar to a hep-lock IV) if blood will be drawn frequently.  Very painful procedure

ABGs

 pH of blood - Norms 7.35 to 7.45

 Oxygen saturation - 95-100% (same as pulse ox)  paCO2 - partial pressure of carbon dioxide - 35 45mmHg  paO2 - partial pressure of oxygen - 80-100mmHg  bicarbonate level: 22-26 (this is a pH buffer excreted and stored by the kidneys)

Diagnostic testing

       Hgb and Hct Pulmonary function tests - spirometry - used to detect peak flow, tidal flow, O2 remaining in lungs (typically performed by respiratory therapists) CXR - chest X-ray - detect infiltration (fluid in lungs) CT of lungs - magnetic 3D picture Lung scans Sputum specimens - collect in the early morning when patient is most likely to cough deeply, and have secretions that built up over night. Tests run on sputum specimens include cultures (detect bacteria), smears a and cytology (which look for abnormal body cells cancer)

 Bronchoscopy - invasive test in which a tube is inserted through the mouth and into the bronchi.  A camera transmits live pictures and tools attached to the scope are capable of suction and removal of foreign objects.  Looks for foreign bodies, secretions, inspection of larynx, trachea, and bronchi for lesions, tumors, etc.

Breath sounds can be divided and subdivided into the following categories:

Normal Abnormal Adventitious

Tracheal Absent/decrease Crackles/rales Vesicular Bronchial Bronchovesicular Bronchial Wheeze Rhonchi Stridor Pleural rub

Normal Breath Sounds

Tracheal Bronchial Bronchovesicular Vesicular

Normal Breath Sounds

 Vesicular: heard over most of the peripheral lung fields. Are described as soft, low pitched and with a gentile rustling quality.

 Tracheal: very loud, high pitch, harsh  Bronchial: loud, high pitch, tubular  Bronchovesicular: moderately loud, medium pitch, rustling

Abnormal Breath Sounds

 Adventitious breath sounds –  Abnormal breath sounds heard when listening to the chest.  Adventitious sounds may include crackles or rales, rhonchi or wheezes, or pleural friction rubs.  Adventitious sounds do not include sounds produced by muscular activity in the chest wall or noises made by a stethoscope on the chest wall.

Crackles

        Heard on ausculating the chest, produced by air passing over airway secretions. Caused by fluid in the small airways or atelectasis.

Is a discontinuous sound, as opposed to a wheeze, which is continuous. Fine or coarse and are also known as rales. Intermittent, nonmusical and brief. Heard on inspiration or expiration.

Associated with inflammation or infection of the small bronchi, bronchioles, and alveoli.

Crackles that don't clear after a cough may indicate pulmonary edema or fluid in the alveoli due to heart failure or adult respiratory distress syndrome (ARDS).

Wheezes

 Heard when listening to the chest as a person breathes.  Wheezes are continuous and musical sounding, and usually caused by airway obstruction from swelling or secretions.  Wheezes can be high or low pitched, and are also known as rhonchi

Sonorous Rhonchi

 A lower pitched wheeze; snoring or moaning adventitious breath sound.

 Secretions in large airways, such as occurs with bronchitis, may produce these sounds; they may clear with coughing.

Sibilant Rhonchi

 A high pitched wheeze  Musical and squeaky adventitious breath sound.

 Wheezes that are relatively high pitched and have a shrill or squeaking quality  They are often heard continuously through both inspiration and expiration and have a musical quality.  These wheezes occur when airways are narrowed, such as may occur during an acute asthmatic attack.

Stridor

 A high-pitched harsh sound heard during inspiration.  Stridor is caused by obstruction of the upper airway.  Is a sign of respiratory distress and thus requires immediate attention.

Pleural friction rubs

       Are low-pitched, grating, or creaking sounds Occur when inflamed pleural surfaces rub together during respiration. More often heard on inspiration than expiration, Is easy to confuse with a pericardial friction rub.

To determine whether the sound is a pleural friction rub or a pericardial friction rub, ask the patient to hold his breath briefly. If the rubbing sound continues, its a pericardial friction rub because the inflamed pericardial layers continue rubbing together with each heart beat.

A pleural rub stops when breathing stops.

Respiratory Terms

 Ataxic breathing – also known as Biot's breathing, is characterized by unpredictable irregularity.  Barrel chest – a condition characterized by increased anterior-posterior chest diameter caused by increased functional residual capacity due to air trapping from small airway collapse. A barrel chest is frequently seen in patients with chronic obstructive diseases, such as chronic bronchitis and emphysema.

 Cheyne-Stokes respirations – a breathing pattern characterized by a period of apnea, followed by gradually increasing depth and frequency of respirations. (last breaths near dying)  Consolidation – the replacement of air in the lungs with fluid or a mass.

 Fremitus – a vibration felt while a patient is speaking and the examiner's hand is held against the chest.  Intercostal retractions – visible use of the muscles between the ribs (intercostal muscles) to aid in breathing. Are a sign of labored breathing.  Kussmal breathing – a very deep gasping type of respiration associated with severe diabetic acidosis and coma.

 Nasal flaring – intermittent outward movements of the nostrils with each inspiration; indicates an increase in the work needed to breathe.  Pleura – a serous membrane covering both lungs and the walls of the thorax and diaphragm.  Pursed lip breathing – partial closing of the lips to allow air to be expired slowly; used by patients with COPD.

Asthma

 Asthma is a condition in which the airways narrow— usually reversibly—in response to certain stimuli.

 Also known as bronchial asthma  Airways are hyperactive to a variety of stimuli  Airway resistance increases because of smooth muscle contraction, increased secretions, and inflammation of the bronchial walls

Causes of Asthma

 Mast cells in the airways are thought to be responsible for initiating the airway narrowing.  Mast cells throughout the bronchi, release substances such as histamine and leukotrienes, which cause smooth muscle to contract, mucus secretion to increase, and certain white blood cells to migrate to the area.  Eosinophils, a type of white blood cell found in the airways of people with asthma, release additional substances, contributing to airway narrowing.

Status Asthmaticus

        The most severe form of asthma. The lungs are no longer able to provide the body with adequate oxygen or adequately remove carbon dioxide. Many organs begin to malfunction.

Buildup of carbon dioxide leads to acidosis. Blood pressure may fall to low levels. The airways are so narrowed that it is difficult to move air in and out of the lungs.

Requires intubation and ventilator support as well as maximum doses of several medications. Support is also given to correct acidosis

Extrinsic Asthma

 Extrinsic asthma is caused by this type of immune system response to inhaled allergens such as pollen, animal dander or dust mite particles.

 An "allergen" or an "antigen" is a foreign particle which enters the body.  Our immune system over-reacts to these often harmless items, forming "antibodies" which are normally used to attack viruses or bacteria.  Mast cells release these antibodies as well as other chemicals to defend the body.

Intrinsic Asthma

 Intrinsic asthma is not allergy-related, in fact it is caused by anything except an allergy.  It may be caused by inhalation of chemicals such as cigarette smoke or cleaning agents, taking aspirin, a chest infection, stress, laughter, exercise, cold air, food preservatives or a myriad of other factors.

Asthma Symptoms

          Wheezing Usually begins suddenly Comes in episodes May be worse at night or in early morning Gets worse with cold air, exercise, and heartburn (reflux) May go away on its own Is relieved by bronchodilators (drugs that open the airways) Cough with or without sputum (phlegm) production Shortness of breath gets worse with exertion Intercostal retractions (pulling of the skin between the ribs when breathing)

Asthma DX tests

 Pulmonary function tests  Peak flow measurements  Chest x-ray  CBC  Arterial blood gas

Asthma TX

 Inhaled steroids (such as Azmacort, Vanceril, AeroBid, Flovent) prevent inflammation  Leukotriene inhibitors (such as Singulair and Accolate)  Anti-IgE therapy (Xolair), a medicine given by injection to patients with more severe asthma  Long-acting bronchodilators (such as Serevent) help open airways  Cromolyn sodium (Intal) or nedocromil sodium  Aminophylline or theophylline (not used as frequently as in the past)

Emphysema

    Emphysema is a respiratory disorder characterized by problems in breathing. The disorder is caused by the enlargement of air sacs in the lungs.

Emphysema is the most common cause of death from respiratory disease in the United States.

A naturally occurring substance in the lungs called alpha-1 antitrypsin may protect against this damage. People with alpha-1 antitrypsin deficiency are at an increased risk for this disease.

Causes of emphysema

 Cigarette smoking is the most common cause of emphysema.  Tobacco smoke and other pollutants are thought to cause the release of chemicals from within the lungs that damage the walls of the air sacs.  This damage becomes worse over time.  Persons with this disease have air sacs in the lungs that are unable to fill with fresh air.  This affects the oxygen supply to the body.

Symptoms of Emphysema

 Shortness of breath  Chronic cough with or without sputum production  Wheezing  Decreased ability to exercise  Anxiety  Unintentional weight loss  Ankle, feet and leg edema  Fatigue

Physical Assessment

 Wheezing  Decreased breath sounds  Prolonged exhalation (exhalation takes more than twice as long as inspiration).  Barrel-shaped chest  Decreased pulse oximetry

Diagnostic tests

 Pulmonary function tests  Chest X-ray  Arterial Blood Gases

Treatment for emphysema

 Smoking cessation  Medications: bronchodilators, diuretics, corticosteroids,  Antibiotics (if infection)  Vaccines: flu and pneumonia (preventive)  Low-flow oxygen  Lung transplant

Complications of emphysema

 Recurrent respiratory infections  Pulmonary hypertension  Cor pulmonale (enlargement and strain on the right side of the heart)  Erythrocytosis (increased red blood cell count)  Death

Chronic Bronchitis

 Inflammation of the main airways (bronchus) in the lungs that continues for a long period or recurrent.

 Is one form of COPD.  Chronic bronchitis, emphysema and asthma are a leading cause of death in the United States.

 Cigarette smoking is the main cause of chronic bronchitis.

 Secondhand smoke may also cause chronic bronchitis.

Symptoms of chronic bronchitis

       Cough that produces mucus (sputum), which may be blood streaked Shortness of breath aggravated by exertion or mild activity Frequent respiratory infections that worsen symptoms Wheezing Fatigue Ankle, foot and leg edema Headaches

Diagnosis

 To be diagnosed with chronic bronchitis, the cough and excessive mucus production must have occurred for 3 months or more in at least 2 consecutive years and not be due to any other disease or condition.

Diagnostic Tests

 Pulmonary function tests  Arterial blood gas  Chest X-ray  Pulse oximetry  CBC  Exercise testing  Chest CT scan

Treatment

          There is no cure for chronic bronchitis. The goal of treatment is to relieve symptoms and prevent complications.

Smoking cessation Respiratory irritants should be avoided.

Inhaled medications Antibiotics for infections Corticosteroids during flare-ups of wheezing.

Physical exercise programs, breathing exercises Oxygen therapy in severe cases. Lung transplant may be recommended.

Bronchiectasis

 Caused by recurrent inflammation or infection of the airways.  It may be present at birth.

 Most often begins in childhood as a complication from infection or inhaling a foreign object.

Bronchiectasis Symptoms

           Chronic cough with large amounts of foul-smelling sputum production Hemoptysis Cough worsened by lying on one side Shortness of breath (on exertion) Weight loss Fatigue Clubbing (abnormal amount of tissue in the fingernail beds) Wheezing Cyanosis Pallor Breath odor

Tests may include:

 Chest x-ray  Chest CT  Sputum culture  CBC  Sweat test or cystic fibrosis testing  Serum Immunoglobulin analysis  Serum precipitins (testing for antibodies to the fungus aspergillus)  PPD: skin test for prior TB infection

   

Treatment for bronchiectasis

Aimed controlling infections and bronchial secretions, relieving airway obstruction, and preventing complications.

Regular, daily drainage to remove bronchial secretions.

Postural drainage and effective coughing exercises, Antibiotics, bronchodilators, and expectorants Influenza vaccine  Surgical lung resecti on

Complications of bronchiectasis

 Cor pulmonale  Recurrent pneumonia  Coughing up blood (hemoptysis)  Low oxygen levels (if severe)

Tuberculosis

 Contagious bacterial infection caused by the bacterium Mycobacterium tuberculosis.  Disseminated if it has spread from the lungs to other organs of the body by the blood or lymph system  Infection can develop after inhaling droplets sprayed into the air from a cough or sneeze by someone infected with Mycobacterium tuberculosis.  The disease is characterized by the development of granulomas (granular tumors) in the infected tissues.

TB

 The usual site of the disease is the lungs.

 Other organs may be involved.

 Primary infection usually has no symptoms.  In the U.S., 95% of individuals the primary tuberculous lesions will heal and there will be no further evidence of disease.  Disseminated disease develops in the minority of infected individuals whose immune systems do not successfully heal the primary infection.

     TB may occur within weeks after the primary infection Or may lie dormant for years before causing illness. Hospitalization may be necessary to prevent spread of TB until the infectious period is over, usually 2-4 weeks after the start of therapy. Infants, elderly, and those infected with HIV are at higher risk for rapid progression to disease, because of their weaker immune systems.

The risk of contracting TB increases with the frequency of contact with people who have the disease, in crowded or unsanitary living conditions, and with poor nutrition.

Disseminated organs:

           Pericardium Peritoneum Larynx Bronchus Cervical lymph nodes Bones and joints Genitourinary system Eye Stomach and small bowel Meninges Skin

Symptoms

            Sweating Fatigue Malaise Weight loss Cough Shortness of breath Fever pallor Arthralgia (joint pain) Chills Swollen lymph glands ascites

Diagnostic tests

           Chest X-ray Sputum cultures Tuberculin skin test Bronchoscopy for biopsy or culture Open lung biopsy Pleural biopsy Biopsies and cultures of affected organs or tissues Retinal lesions revealed with fundoscopy Peripheral smear Serum calcium (may be elevated) Mycobacterial culture of bone marrow

Tuberculin Skin Test

    5 mm of induration at the site) is considered to be positive in people who have HIV, who are taking steroid therapy, or who have been in close contact with a person who has active tuberculosis.

Greater than or equal to 10 mm are considered positive in people with diabetes or kidney failure, and in health care workers, among others.

In people with no known risks for tuberculosis, a positive reaction requires 15 mm or more of hard swelling at the site per Centers for Disease Control & Prevention (CDC)?

Los Angeles County: 10 mm (+) positive general population.

Treatment for TB

 Antitubercular drugs:  Pyrazinamide  isoniazid (INH)  Rifampin  Ethambutol  Ethionamide  para-aminosalicylic acid (PAS)  Amikacin  streptomycin  Daily oral doses are continued for 1 year or longer.

 A minimum of three drugs are started for treatment for drug resistant strains.

Complications of TB

Medications toxicity:  Rifampin, pyrazinamide, and isoniazid may cause a non-infectious liver inflammation.  Rifampin may also cause an orange or brown coloration of tears and urine, and can stain contact lenses and undergarments.  Ethambutol may reduce visual acuity or cause color blindness.

Other complications

 Drug resistance  Relapse of the disease  Tuberculous meningitis  Respiratory failure  Adult respiratory distress syndrome (ARDS)

Prevention

 Vaccination BCG for tuberculin-negative persons exposed to persons with untreated TB is given in some situations, but its effectiveness is under dispute.  It is rarely used in the U.S. but is often used abroad, in countries with higher rates of tuberculosis.