Weber Ch 18 Respiratory

• Primary purpose of respiratory system = gas exchange
• Transfer of O2 & CO2 between atmosphere & blood
• Ventilation
• Diffusion

• UPPER
• NOSE
• PHARYNX
• EPIGLOTTIS
• LARYNX
• TRACHEA

• LOWER
• BRONCHI
• BRONCHIOLES
• AVEOLAR DUCTS ALVEOLI

RIGHT 3 LOBES/ LEFT 2 LOBES

• Tube about 5” long
• 1” in diameter
• Bifurcates into right and left mainstem bronchus at carina
• Right main-stem is shorter, wider, & straighter-aspiration more common

• 300,000,000 ALVEOLI
• SITE OF GAS EXGHANGE
• ALVEOLI COLLAPSE=ATELECTASIS (area of lung that is not working - collapse/ blockage/ etc.)
• Surfactant produced by lung cells to keep alveoli open
• Surfactant = lipoprotein produced by type II alveolar
• cells that decreases surface tension & permits alveolar expansion

• 24 RIBS (12 EACH SIDE/PAIRS)
• RIBS AND STERNUM PROTECT THE LUNGS AND HEART
• CHEST WALL PARIETAL PLEURA
• LUNGS WITH VISCERAL PLEURA
• SPACE BETWEEN THE PLEURAL LAYERS-filled with thin fluid <10ml
• -INCREASED AMT.of Fluid = PLEURAL EFFUSION - common in:
• - - MALIGNANCY, CHF, PNEUMONIA
• - - EMPYEMA=PURULENT PLEURAL FLUID
• pyema = purulent

• ON INSPIRATION, CONTRACTS, PUSHES THE ABDOMEN DOWN
• INCREASES LATERAL/ANTEROPOSTERIOR DIMENSION OF THE CHEST
• INCREASES SIZE OF THORACIC CAVITY
• INTRATHORACIC PRESSURE DECREASES, CAUSES AIR TO ENTER LUNG
• INNERVATED BY THE RIGHT AND LEFT PHRENIC NERVES, BETWEEN C3-C5
• INJURY TO THE PHRENIC NERVES-HEMIDIAPHRAGM PARALYSIS

• DECREASE IN ELASTIC RECOIL OF THE LUNG
• DECREASE IN CHEST WALL COMPLIANCE
• INCREASE IN ANTEROPOSTERIOR DIAMETER
• DECREASE IN FUNCTIONAL AVEOLI
• LOWER PaO2, HIGHER PaCO2
• DECREASE IN CELL-MEDIATED IMMUNITY DECREASE IN COUGH
• MORE SIGNIFICANT IF SMOKER, OBESE, OR CHRONIC DISEASE

• PROBLEM-BASED HISTORY/COMPLAINT
• COUGH (PRODUCTIVE OR NONPRODUCTIVE)
• SHORTNESS OF BREATH/DYSPNEA
• CHEST PAIN (RESPIRATORY vs.CARDIAC)
• -ask to take a deep breath and then hold their breath - if pain of inspiration, may be respirator - if pain while holding breath, may be cardiac
• HOARSENESS OR CHANGE IN VOICE
• WHEEZES

“OLD CARTS” MNEMONIC

• PAST HEALTH STATUS:
• CHRONIC ILLNESSES AFFECT RESP. SYSTEM
• LUNG PROBLEMS OR INJURY/SURGERY TO CHEST
• CURRENT MEDICATIONS AFFECT RESP. SYSTEM (Prescription & OTC)
• ALLERGIES (seasonal or anaphylactic reaction)
• USE OF INHALER OR HOME OXYGEN
• TRAVEL OUTSIDE/INSIDE U.S.
• LAST CXR, TB TEST, FLU & PNEUMONIA VACCINES

• FAMILY HISTORY: (lung cancer, asthma,
• bronchitis, emphysema, TB or cystic fibrosis)

• SMOKING (pack year history)
• ENVIRONMENTAL EXPOSURE (pollutants, allergens, 2nd hand smoke)
• OCCUPATIONAL EXPOSURE (coal, insecticides, paint, pollution, asbestos)
• STRESS
• ADL Difficulties

• GENERAL APPEARANCE (apprehensive, restless, nasal flaring, use of accessory muscles)
• CHEST SYMMETRY & SHAPE
• POSTURE/TRIPOD POSITION
• BREATHING EFFORT/ RESP. RATE (12-20 adult, 16-25 elderly)
• SPINE
• Scoliosis - curvature of spine
• Kyphosis - hunch back
• Lordosis - sway back
• Pectus carinatum - pigeon chest/outward or forward protrusion of sternum
• Pectus excavatum - funnel chest/indented or sunken sternum/chest

• Pursed lips -(Pursed lips to slow expiration & keep alveoli open longer esp. asthma, emphysema & CHF)
• Orthopnea (tripod position)
• Accessory muscle use
• Splinting
• Increased AP diameter
• Tachypnea > 20 b/min.
• Cyanosis (late sign)
• Clubbing (after long period)
• COPD - Never put on more than 2L of O2 - oxygen level will be met and they will stop breathing

• NAIL, SKIN & LIP COLOR
• O2 SATURATION > 90 %
• ABNORMAL BREATHING PATTERNS
• Bradypnea/tachypnea - Bradypnea < 12 b/min & Tachypnea > 20 b/min
• Hyperventilation - increased rate & depth
• Kussmaul - deep & laborious hyperventilation with ketoacidosis (DKA to blow off CO2 in metabolic acidosis)
• Cheyne-Stokes -gradual increase in deep & rapid breathing with intervals of apnea (increased ICP, CHF & renal failure, infants)
• Air trapping - = rapid inspiration with prolonged expiration (pursed lips with emphysema); inspiration usually > expiration
• Biot - totally disorganized/irregular pattern (meningitis or severe brain damage)
• Stridor -harsh musical sound due to broncholaryngospasm (croup, epiglotitis, foreign body obstruction), vocal cord edema)

• Tracheal position - thumbs
• Anterior & posterior chest for tenderness/pain or warmth
• Crepitus - fingertips
• Vocal tactile fremitus (“99”) – palms -feel with palms or ulnar surface while pt. Says 99 or 123 should feel equal bilat. & slight decrease in bases normally
• decreased/absent fremitus when vibrations blocked from emphysema, pleural effusion, PE
• increased fremitus when vibrations enhanced such as pneumonia & tumor (consolidated)

• Normal v. increased v. decreased
• Thoracic expansion for symmetry
• Anterior
• – below xiphoid process
• Posterior
• – T9-10
• Normal

nFOR TONE

nResonance

nHyperresonance


nDull

nFlat

nTympany


nDIAPHRAGMATIC EXCURSION

nNormal

nAbnormal

• Memorize this:
• BRONCHIAL (LOUDER, HIGHER PITCH)
• EXPIRATION>INSPIRATION
• BRONCHIAL VESICULAR (MEDIUM PITCH)
• EXPIRATION=INSPIRATION
• VESICULAR (SOFT, LOW PITCH, RUSTLING)
• INSPIRATION>EXPIRATION

• Crackles/Rales = popping or bubbling sound at end of inspiration & don’t go away with coughing
• further define as fine, medium, or coarse (hear on expiration) due to air passing thru fluid
• Ex. - Pneumonia, CHF, asthma, bronchitis, emphysema

• Rhonchi - harsh, low pitch snoring/moaning sounds esp. expiration that may clear with coughing due to air
• passing thru airways narrowed by secretions
• Ex. - bronchitis, sleep apnea, stridor with broncholaryngospasm, or croup

• Wheezes - high pitch musical sound/squeak esp. on expiration not cleared by coughing due to air
• passing thru constricted bronchus (Ex. - asthma)

• Friction rub - low pitch grating or creaking sound like leather rubbing together on both inspiration & expiration not cleared by coughing due to
• inflammation of pleural surfaces (visceral & parietal surfaces)
• Ex. – pleuritis/pleurisy

Bronchophony (muffled 99, 123 v. clear)

Whispered Pectoriloquy (123 muffled v. clear)

Egophony (eee sounds like eee v. aaa)

• If palpate fremitus with “99” then listen with stethoscope posteriorly for these
• All the above vocal sounds indicate consolidation if
• clearly heard (should be muffled normally except eee,
• abnormal if aaa sound)
• Increased fremitus with consolidation v. decreased fremitus with air trapping (COPD)
• Listen with stethoscope to posterior

• Inflammation of mucous membranes of bronchial tree due to viral/bacterial infection
• Nonproductive cough becomes productive in few days
• Fever, malaise, tachypnea, & chest pain
• Rhonchi, crackles, or wheezing

• Acute bronchitis = nasal cold goes to chest
• Viral bronchitis with clear sputum or nonproductive
• cough
• Bacterial bronchitis with white, yellow, or green sputum with odor & productive cough

• Typical Pneumonia Syndrome
• Sudden onset
• Chills
• Fever, tachycardia, tachypnea
• Productive cough (purulent)
• Pleuritic chest pain (worse with coughing or deep resp.)
• Pulmonary consolidation
• - Dullness of percussion
• - fremitus
• - Bronchial breath sounds
• - Crackles
• Rhonchi
• Nasal Flaring
• Confusion/stupor in elderly

• Pneumonia = acute inflammation of lung parenchyma due to bacteria, virus, fungi, parasites, or chemicals (aspirate gastric acid)
• Elderly may not show typical s/s of fever & tachycardia but rather confusion/stupor

• Fatigue
• Malaise
• Anorexia
• Weight loss
• Low grade fever
• Night sweats
• Cough - non productive then later productive with reddish/brown sputum

• Mycobacterium Tuberculosis (airborne droplets /isolation)
• Multi drug resistant strains esp. in Africa & AIDS
• pts.
• Very prevalent in HIV
• Tubercles = areas of TB with outer granular mass /
• calcified
• Caseation = inner necrotic center like cheeselike with TB

• Degree of symptoms depends on amount of fluid
• Dyspnea
• Intercostal bulging
• Decreased chest wall movement
• Diminished fremitus over effusion
• Percuss dull to flat
• Diminished breath sounds

• Normally < 10 ml of fluid in pleural space between
• visceral & parietal pleura.
• Fluid accumulates due to inflammation, infection, CA or injury

• 3 Types PNEUMOTHORAX
• Closed spontaneous
• Open due to penetrating injury
• Tension with trapped air
• (trachea shifts to OPPOSITE SIDE)
• SOB, Anxious, Chest pain
• Tachypnea & Dyspnea
• Cyanosis
• Hyperresonance
• Decreased chest wall movement on affected side or paradoxical movement
• Booming percussion
• Tracheal displacement toward unaffected/ opposite side

• Due to blood in pleural space usually from chest injury or thoracic surgery
• Symptoms similar to Pneumothorax
• Distant muffled breath sounds
• Percusses dull over affected area

• Tachypnea with prolonged expiration
• Wheezing, cough, dyspnea,
• Decreased tactile fremitus
• Hyperresonance in children & adults
• Severe diminished breath sounds

• Signs & Symptoms:
• SOB/dyspnea
• Barrel chest
• Use of accessory muscles
• Pursed lip breathing
• Retractions
• - PCO2 Resp. Acidosis
• - secretions
• Orthopnea/Tripod position
• Hyperresonance

• Collapsed alveoli due to accumulation of secretions or hypoventilation
• Diminished breath sounds
• Decreased fremitus
• Dull percussion
• O2 saturation < 90 %
• Area above with egophony & whispered pectoriloquy

• INEFECTIVE BREATHING PATTERN
• INEFFECTIVE AIRWAY CLEARANCE
• IMPAIRED GAS EXCHANGE
• IMPAIRED VENTILATION
• ACTIVITY INTOLERANCE/FATIGUE RT DYSPNEA
• RISK FOR RESP. INFECTION
• ANXIETY RT FEAR OF SUFFOCATION
• KNOWLEDGE DEFICIT RT ASTHMA MEDS
• DISTURBED SLEEP RT COUGH OR DYSPNEA