TLO 2.1 Respiratory Flashcards
The Respiratory System Upper Airway
Upper Airway • Nose • Pharynx • Adenoids & tonsils • Epiglottis • Larynx • Trachea
The Respiratory System Lower Airway
Lower Airway • Bronchi • Bronchioles • Alveolar ducts • Alveoli
The Respiratory System Lungs
Lungs • Right: 3 lobes - upper - mid - lower • Left: 2 lobes - upper - lower
The Respiratory System Chest Wall Structures
Chest Wall Structures
• Ribs
• Pleura
• Muscles (diaphragm)
Physiology of Respiration
Inspiration
Expiration
Ventilation – air moving from high
concentration to low
• Inspiration (active)
– Diaphragm
– Air moves down the pressure gradient
• Expiration (passive)
– Respiratory muscles relax returns to resting volume
Physiology of Respiration Passageway Resistance
Respiratory Passageway Resistance – friction within the bronchioles
• Mucus, infection, tumors
Physiology of Respiration
Lung Compliance
Lung Compliance – the distensibility of the lungs
A liquid film, primarily composed of water, covers the alveolar walls. At any gas-liquid boundary, the molecules of liquid are more strongly attracted to each other than to gas molecules. This produces a state of tension called surface tension, that draws the liquid molecules even more closely together. The water content of the alveolar film compacts the alveoli and aids in the lungs recoil during expiration.
Physiology of Respiration
Alveolar Surface Tension
Alveolar Surface Tension – draws liquid molecules
more closely together
• Surfactant – lipoprotein produced by alveolar cells
• Reduces surface tension, helping lungs expand
Oxygen and Carbon Dioxide Transport
Diffusion – movement from high concentration
to low across alveoli-capillary membrane
• PaO2 = amt of oxygen dissolved in plasma
• PaCO2 = amt of carbonic acid dissolved in plasma
• SaO2 = amt of oxygen bound to Hgb
• 100% SaO2 = max amt Hgb can carry
Controlling Respirations
Respiratory Centers = located in medulla oblongata and pons of the brain
Chemoreceptors = located in medulla and in the carotid and aortic bodies
• Respond to changes in arterial blood concentration of:
– Oxygen
– Carbon dioxide
– Hydrogen
Respiratory Alkalosis s/s
Seizures Deep, rapid breathing Hyperventilation Tachycardia Decrease or normal BP Hypokalemia Numbness/tingling of extremities Lethargy/confusion Light headedness N/V Causes: hyperventilation, anxiety, PE, fear
Respiratory Acidosis s/s
hypoventilation= hypoxia rapid, shallow respirations Decrease BP Skin/mucosa pale/cyanotic HA Hyperkalemia Dysrhythmias= increase K+ Drowsiness Dizziness Disorientation Muscle weakness Hyperreflexia Causes: resp depression, airway obstruction, overdose, increased cranial pressure, reduced alveolar cap diffusion
Respiratory Defense Mechanisms
Nasal Hair – filters our debris
Cilia – muscular, hair-like projections on cells that line the airway. Propels layer of mucus
Beats >1,000/min, moves mucous 0.5 to 1 cm/min
-Impaired by dehydration, smoking, infection, drugs
Mucus Layer – traps pathogens and other particles
Mucus and cilia are not in alveoli (bronchio tracks only)
Cough Reflex – high-pressure, high velocity airflow
Reflex Bronchoconstriction – prevents entry of irritants
Alveolar Macrophages – Phagocytize foreign particles
Subjective Respiratory Assessment
Review history - past diseases and
symptoms
• Medications – prescribed, OTC, herbals, PRNs, oxygen
• Surgery or treatments
• Family history
• Smoking history – often calculated in pack years or lifetime tobacco exposure.
• Pack year = twenty cigarettes smoked everyday for 1 year.
• Second-hand exposure
Subjective Respiratory Assessment
Assess health behaviors that affect respiratory status • Nutrition • Elimination • Physical activity & exercise • Sleep & rest • Coping • Roles & relationships
Objective Respiratory Assessment
Physical exam of respiratory structures
Inspection= appearance, symmetry, resp rate and ease, signs of distress (cyanotic, use of accessory muscles or retractions, positioning, nasal flaring)
Palpation= tracheal position, sinuses comfortable to palpation, chest expansion, fremitus
Percussion
Objective Respiratory Assessment
Auscultation
• Apex to bases
• Compare side-to-side
• On skin – NOT over clothing
Normal breath sounds:
• Bronchial, bronchio-vesicular, vesicular
Abnormal breath sounds:
• Crackles, rhonchi, wheezes, friction rubs, positive voice sounds
Crackles: pneumonia, bronchitis, CHF
Wheezes: bronchitis, emphysema, asthma
Friction rubs: pleural inflammation
Age Related Changes
Alterations in structure
Alterations in structure
• Decreased elastic recoil
• Decreased expiratory muscle strength
• Stiffening of chest wall = decreased compliance
• Increased AP diameter = barrel chest
• Spinal changes (kyphosis & lordosis) = decreased compliance
Age Related Changes
Reduced defense mechanisms
Reduced defense mechanisms • Decreased immunity: cell-mediated, antibody production • Decreased cilia function • Decreased cough force • Decreased alveolar function
Acidosis vs Alkalosis
Acidosis (increased H+, decreased pH, increased PaCO2) = increased resp rate and volume
Alkalosis (decreased H+, increased pH, decreased PaCO2) = decreased resp rate and volume
Respiratory Diagnostic Studies
Laboratory
Laboratory Sputum Gram stain Culture & Sensitivity Cytology Arterial Blood Gases
Respiratory Diagnostic Studies
Radiology
Radiology CXR CT Scan MRI PET
Respiratory Diagnostic Studies
Bedside or OP Visit
Bedside or OP Visit Peak Flow Pulmonary Function Skin tests Pulse Oximetry
Respiratory Diagnostic Studies
Procedural
Procedural Thoracentesis Endoscopy Laryngoscopy Bronchoscopy Mediastinoscopy Biopsy
Classification of Respiratory Disease
Restrictive and Obstructive
Restrictive
- Ventilation disorders
- Decreased lung expansion
- Decreased lung compliance/capacity
Obstructive
- Gas exchange disorders
- Increased compliance
- Increased airway resistance
Restrictive Pulmonary Diseases
Pathophysiology: Decreased lung or thoracic compliance
Lung function: Decrease lung volume/capacities
Diseases Tissue damage: Scarring or inflammation -Limits lung expansion -Impairs gas exchange -“Stiff” lungs = lower lung volumes -Pneumonia, TB, Fibrosis, Silicosis, Asbestosis, Tumors
Mechanical impairment: Limits chest wall and lung expansion
-Scoliosis, Obesity, Kyphosis, Lordosis
Restrictive Pulmonary Diseases
Pneumonia
Acute inflammation of lung parenchyma
- Significant morbidity & mortality in elderly
- Infectious or noninfectious
Entry of organisms:
- Aspiration – food, saliva, liquids, or emesis
- Inhalation – microbes in air or droplets
- Bloodstream – microbes move into the lungs
Lower pulmonary response:
- Inflammation & alveoli edema
- Exudate - mucous
- Consolidation – lobar or bronchopneumonia
- Resolution - macrophages
Restrictive Pulmonary Diseases
What is pneumonia?
In pneumonia, the inflammatory response causes fluid to accumulate in the alveoli and edema to form as alveolar capillaries dilate and allow fluid to leak into interstitial tissues.
Restrictive Pulmonary Diseases
Types of Pneumonia
Community Acquired
Streptococcus pneumoniae – most common. Symptoms within first 2 days of hospitalization
Hospital Acquired
Onset > 48 hrs after admission
Aspiration
Chemical injury – acidic GI contents
Increased risk with enteral feedings
Opportunistic
Due to altered immune response. (HIV, malnourished, chemo, steroids)
Gradual onset
Secondary
Due to weakness form a concurrent illness. Think pneumocystis
Restrictive Pulmonary Diseases
Pneumonia – Clinical Manifestations
Onset of S/S usually sudden
- Fever, SOB, cough, purulent sputum, pleuritic chest pain
- Elderly – confusion often primary sx.
- Other- atypical sx seen in older adults; HA, myalgias, fatigue, N/V/D, sore throat
- Viral- “walking pneumonia”, less common, interstitial involvement, flu like sx, dry cough
Physical Exam
pulmonary congestion (bronchial breath sounds with crackles)
Increased fremitus
Restrictive Pulmonary Diseases
Primary Atypical Pneumonia
Mycoplasma pneumoniae
Mycoplasma pneumoniae - “walking pneumonia”
-College students and military recruits
-Highly contagious
–Pharyngitis or bronchitis
–Dry, hacking, nonproductive cough
–Systemic manifestations
Fever
Headache
Myalgias
Arthralgias
Viral Pneumonia
Mild disease
Greater incidence in:
- Older adults
- Chronic conditions
- Cytomegalovirus (CMV) pneumonia is increasing in immunocompromised people.
Community epidemics
Influenza and adenovirus
-Dry cough, flu-like symptoms
Restrictive Pulmonary Diseases
Pneumocystis Pneumonia
This type of pneumonia is caused by the yeast like fungus
Pneumocystis jiroveci. This fungus is common in the environment and does not cause illness in healthy people.
Pneumocystis jirovenci
- Opportunistic or Secondary
- AIDS, cancer, & other immunocompromised, chronic use of corticosteroids, organ/bone transplant
-Patchy involvement
Alveoli thicken, swell, and fill with fluid
May also have pneumatoceles
Restrictive Pulmonary Diseases
Manifestations of Pneumocystis Pneumonia
Tachypnea SOB Dry, nonproductive cough Intercostal retractions Cyanosis Fever
Restrictive Pulmonary Diseases
Aspiration Pneumonia
Risk Factors: Emergency surgery, depressed cough reflexes, dysphagia, enteric feedings, decreased LOC
Aspiration of gastric contents into lungs
Low p H of gastric contents causes inflammation
Pulmonary edema/respiratory failure can result
Complications: abscesses, bronchiectasis, gangrene of pulmonary tissue
Restrictive Pulmonary Diseases
Common symptoms of pneumonia
Sneezing, runny nose Productive cough Sore throat Chest pain Fatigue, muscle aches Gray/bluish skin color Sweats/chills
Restrictive Pulmonary Diseases
Pneumonia - Complications Pleurisy
Inflammation of pleura
Painful – teach splinting
Restrictive Pulmonary Diseases
Pneumonia - Complications Pleural effusion
Fluid in pleural space
Restrictive Pulmonary Diseases
Pneumonia - Complications Atelectasis
Collapsed, airless alveoli
Restrictive Pulmonary Diseases
Pneumonia - Complications Bacteremia (sepsis)
Bacterial infection in blood
Bacteremia or sepsis is a leading cause of death for hospitalized elderly patients
