Adult III- Respiratory

Diaphragm descends and intercostals contract causing thoracic cavity to expand causing a drop in pressure. Air moves in to equalize pressure. (active)

• Diaphragm and intercostals relax and air moves out. (passive)
• Gas exchange occurs during the first third of expiration

• The volume of air inhaled and exhaled with each breath 500mL=normal may not vary even with severe disease.
• Normal: 500mLs or 5-10mLs/kg

• The maximum volume of air that can be inhaled after a normal inhalation 300mL
• Normal: 3000mLs

• The maximum volume of air that can be exhaled after a normal inhalation. Decreased with restrictive conditions ex-obesity, pregnancy etc Expiratory volume is decreased with restrictive conditions such as obesity, ascites, and pregnancy.
• Normal: 1100

• The volume of air remaining in the lungs after a maximum exhalation volume may be increased with obstructive disease
• Normal: 1200

• The maximum volume of air exhaled from the point of maximum normal value 4600mL A decrease in capacity may be found in neuromuscular disease, generalized fatigue, atelectasis, pulmonary edema, COPD, and obesity.
• Vital capacity = tidal volume + inspiratory reserve volume + expiratory reserve volume.
• Normal: 4600

• The maximum volume of air inhaled after a normal expiration normal about 3500mL decrease may indicate restrictive disease decrease in obesity A decrease may indicate restrictive disease or obesity. Inspiratory capacity = tidal volume + inspiratory reserve volume.
• Normal: 3500mLs

• The volume of air remaining in the lungs after a normal maybe increased by COPD and decreased with obesity and May be increased with COPD, and decreased in respiratory disease and obesity.
• Functional residual capacity = expiratory reserve volume + residual volume.
• Normal: 2300mLs

• The volume of air in the lungs after a maximum inspiration. Maybe increased with COPD, decreased May be decreased with restrictive disease such as atelectasis and pneumonia and increased in COPD
• Total lung capacity = tidal volume + inspiratory reserve volume + expiratory reserve volume.
• Normal 5800mLs.

the flow of gas in and out of the lungs

the filling of the pulmonary capillaries with unoxygenated blood from the right side of the heart

adequate ventilation and perfusion

• perfusion exceeds ventilation
• Causes may be obstruction of the distal airways, pneumonia, atelectasis, tumors, mucus plug, ARDS. Causes shunting. Shunting leads to hypoxia which is low level of cellular oxygen. Severe hypoxia results when the amount of shunting exceeds 20%

• ventilation exceeds perfusion
• Causes may be PE**, pulmonary infarction, cardiogenic shock. Causes dead space so the alveoli don’t have an adequate blood supply for gas exchange to happen.

absence of both ventilation and perfusion. Causes may be pneumothorax, severe ARDS (acute respiratory distress syndrome)

Normal pattern of breathing

Slower than normal rate, with normal depth and regular rhythm

Rapid, shallow breathing grater than 24 breaths/min

Shallow, irregular breathing

Increased rate and depth of breathing that results in decreased PaCO2 level. Inspiration and expiration nearly equal in duration, it’s associated with exertion, anxiety, and metabolic acidosis.

Temporary pauses of breathing. Sleep apnea

Regular pattern with the rate and depth of breathing increasing and then decreasing until apnea occurs. Duration of apnea may vary and progressively lengthen (associated w/ HF and damage to respiratory center)

Irregular cycled periods of apnea are interspersed with cycles of normal rate and depth. AKA ataxic breathing (associated w/ complete irregularity, OD, brain injury normally at the level of the medulla)

Discomfort in breathing when lying flat.

Functional obstruction in the mouth and throat Ex: tongue falls against soft palate during sleep and then the uvula falls against the throat

Episodes of apnea occur repeatedly during sleep, secondary to transient upper airway blockage

estimation of thoracic expansion and movement

the normal resonance of the lung stops at the diaphragm. The position of the diaphragm differs during inspiration and expiration. May occur with pleural effusion, diaphragmatic paralysis, or pregnancy.

a tremulous vibration of the chest wall during inspiration that is palpable on physical examination.

• can be used to assess location and pathology in underlying tissue and structures produces audible and tactile vibration and allows the nerves to determine whether underlying tissues are filled with air, fluid, or solid material. Healthy tissue is resonant, dull sound heard when percussing over fluid such as pleural effusion.
• When might you hear a dull sound- over fluid

condition that occurs when your lungs can’t remove all of the carbon dioxide produced by your body

occurs when high levels of carbon dioxide disrupt the bloods acid-base balance (hyperventilation)

too much acid accumulates in the body. Kidney failure, ingestion of certain drugs or toxins

• N/V
• headache
• increased respiratory rate
• confusion

a disorder that elevates the serum bicarbonate. Prolonged vomiting, hypovolemia, diuretic use, and hypokalemia

relax the muscles in the lungs and widening the airways (albuterol)

anti-inflammatory medicine. Reduces inflammation and suppress the immune system

helps clear mucous stimulates cough

blocks the action of histamines, which can cause fever, itching, sneezing, runny nose and watery eyes.

controls cough

penicillin’s cephalosporins, doxycycline

drugs used to manage mucus hypersecretion and its sequelae like recurrent infections in patients

reduces swelling and opens airway

• Inflammation process that results in pulmonary edema, it’s a 12-48hr onset after the initial insult
• Sudden Rapid onset**
• Life threatening ** ⅓ die, ⅓ recover fully, ⅓ are left w/ permanent deficits such as lung damage and memory loss d/t brain anoxia

• Aspiration
• Chemical inhalation
• Pneumonia
• Sepsis
• Covid 19
• Shock
• Trauma
• Fatter aerialism

• Inflammatory trigger initiates release of cellular and chemical mediators
• Trigger: aspiration, chemicals that cause inflammation
• Alveolar capillary membrane injured and the gas exchange is impaired
• Alveolar collapse occurs d/t filling with fluid
• Lung compliance decreases d/t lung becomes stiff because surfactant is destroyed, the surfactant allows the aviolate to be elastic
• Severe hypoxemia- Late sign of severe hypoxemia is diaphoresis
• Process progress quickly to respiratory failure, pts are critically ill and in the ICU on ventilators

• *Key characteristic*- Arterial hypoxemia despite high FiO2, Bilateral infiltrates
• Onset 12-48 hrs. after insult
• Severe dyspnea
• Intercostal retractions
• Crackles

• arterial blood gas will show low pH, high PCO2 and low O2
• serial chest X-ray will show worsening infiltrates
• labs look at CBC, electrolytes, PT INR, PTT

• primarily supportive- allow the lungs to heal**
• Mechanical ventilation heavily sedated to prevent excessive oxygen consumption

• Positive end expiratory pressure- requires less oxygen pressure allows lower FiO2 to prevent lung damage
• amount of pressure to keep alveoli open in between inspiration
• higher peep=not as much O2=lower FIO2
• Pressure added to system on exhalation to extend expiration and allow longer gas exchange

• Change in respiratory rate or pattern**
• hypoxemia decreased oxygen content on RBC

O2 sats < 90% diminished oxygen delivery to the cells, can’t perform aerobic metabolism efficiently or effectively so they shift from aerobic where they byproducts are CO2 and water to anaerobic where the byproducts are lactic acid. This is d/t decreased blood volume.

where the red cells fail to carry enough oxygen to each cell

is a toxic substance like cyanide, prevents the cells from using oxygen

• restlessness
• tachypnea
• confusion
• lethargy

• diaphoresis #1 sign**
• shock like symptoms
• central cyanosis
• cool extremities

• Increased risk when fio2 is > 50% for more than 48 hours
• Caused by the overproduction of free radicals that damage lung tissues

• dyspnea
• restlessness
• alveolar infiltrates
• paresthesias

• This is important for those with lung disease who are co2 retainers
• Lose respiratory drive because of chronically high pco2, now must use hypoxic drive to maintain respirations
• Must keep oxygen sat < 90%

• examples are the iron lung, and turtle shell
• Very old style

• Increase the pressure to give the desired volume
• Unreliable
• Volume changes usually decreases with position changes, secretions, lung stiffness, wheezing
• Pt’s would develop pneumothorax when pressure becomes to high causing alveoli to burst

• most commonly used
• Pressure adjusts to deliver preset volume
• Very reliable
• Machine will cut off when pressure become to high
• Prevents pneumothorax

• Continuous positive airway pressure
• Pt breathes on their own but system has positive pressure to allow easier breathing for pt.

• Nasal or oral
• Soft cuff, so large so if fills space b/n tube and trachea
• Prevent tracheal necrosis keep pressures low yet sealing the space b/n tube and trachea. Old trach tubes had narrow cuff that dug into the tracheal tissue to maintain seal which caused tracheal bleeding and led to ischemia necrosis.
• Prevent aspiration inflated cuff prevents food, drink, and stomach contents from entering the lungs

• place stethoscope on side of neck
• Will hear loud air leak – gently inflate cuff until barely hear air leak yet able to maintain ventilation
• If using manometer to measure pressures – want to maintain cuff pressures between 15 – 20 mm Hg

Seals trachea

Seals trachea however when internal canula removed an opening in top of tube allows lumen air to move through upper airway, used for weaning when wanting to remove tracheostomy

used with kids and adults for long term trach, can be metal or plastic

• Priority care is to keep airway patent
• Daily cleaning is clean rather than sterile
• Keep internal canula sterile
• Change ties or tapes daily or when dirty or wet
• Always place new ties – to prevent pt. coughing out trach when being manipulated

• Humidified air thins secretions
• Pre oxygenate pt. by increasing fio2 while suctioning pt.
• Suction for no more than 10-15 seconds***
• If heart rate decreases – stop suctioning

• Obstruction of a pulmonary artery or one of its branches by a thrombus (DVT in lower extremities)
• Thrombus
• Venous stasis
• Injury to intima of vein this is the innermost
• Vasoconstriction of surrounding capillaries

• Increased platelet clumping on valves in deep veins
• Clot forms
• Small piece of clot breaks off
• Moves through right heart
• Occludes pulmonary artery or its branches

• Venous Stasis
• Hypercoagulability due to release of tissue thromboplastin after injury/surgery
• Venous Endothelial Disease
• Certain Disease States (heart disease, trauma, postoperative, DM, COPD, Cancers)
• Other Predisposing Conditions (advanced age, obesity, pregnancy, oral contraceptive use, constrictive clothing, long air travel)

• Depends on size and area involved
• Most frequent symptom dyspnea***
• Most frequent sign tachypnea***
• Chest pain
• Tachycardia
• Anxiety, apprehension

• D-dimer blood test if elevated you do a CAT scan
• CAT scan – standard for diagnosing PE
• *V/Q scan – used when there is no access to CT or pulmonary angiography.
• Pulmonary Angiography – reasonable alternative to CT allows visualization under fluoroscopy of the arterial obstruction and accurate assessment of the perfusion deficit.
• EKG- nonspecific ST-T wave abnormalities
• Venous dopplers look at blood flow in extremities

If unstable emergent measures are initiated to improve respiratory and cardiovascular status

• Is indicated to prevent recurrence or extension of the thrombus and may continue for 10 days.
• Initial anticoagulants are Enoxaparin, heparin, or direct thrombin inhibitor (dabigatran)

• Dissolve the embolus and prevent new ones from forming
• T-PA or other agents such as reteplase
• Increase risk for bleeding
• Need to check INR, aPTT, hematocrit, and platelet counts before starting therapy

Rarely performed but may be indicated if there are contraindications to thrombolytic therapy

• Requires regular blood draws for INR monitoring (2-2.5)
• Higher bleeding risk
• Vitamin K
• Dietary restrictions

• Do not require regular blood test monitoring
• More costly

Not usually given as long-term therapy since it is given subcutaneous

• Accounts for approx ½ of all head and neck cancers
• Cancer of the voice box
• Potentially curable if detected early

• Tobacco #1
• Combined effect of tobacco and ETOH #2
• Age
• Genetics

• Hoarseness #1
• Raspy voice
• Burning in throat

• Dysphagia
• Dyspnea
• Foul breath

• History and physical exam of head and neck
• CT
• MRI
• PET

• Cancer limited to 1 vocal cord
• Portion of larynx removed along with one vocal cord and tumor
• All other structures remain the same
• Swallow preserved
• Rarely mets
• Voice quality may be hoarse

• Stage 1 & 2
• Hyoid bone, glottis, false cords removed along with tumor
• True vocal cords, cricoid cartilage and trachea remain intact
• Airway preserved
• Swallow preserved

• Indicated for tumors <1 cm in size
• Thyroid cartilage of larynx split in the midline of the neck
• Portion of vocal cord removed with tumor, aryenoid cartilage and ½ thyroid removed
• Airway preserved
• Swallow preserved

• Indicated for advanced cancer
• All laryngeal structures removed- Hyoid bone, epiglottis, cricoid cartilage, two or three rings of trachea
• Tongue, pharyngeal walls, trachea preserved
• Permanent tracheostomy will be required
• Voice loss permanent
• Mucus production will eventually decrease (will have a lot in the beginning and you should tell your patients that)
• Swallow preserved

• Radiation
• Chemotherapy
• Speech
• Esophageal speech
• Electric Larynx
• Tracheoesophageal Puncture**
• oMost widely used now
• oSpeech more normal

• Airway
• Breathing
• Circulation
• Communication
• Anxiety
• Nutrition
• Self-care management
• Potential problems
• Humidification system for the home- good education point to help decrease mucous production

• Arise from a single transformed epithelial cell in the tracheobronchial tree
• Classification
• oSmall cell
• oNon-small cell

• Smoking
• 2nd hand smoke
• Environmental
• oRadon
• oIndustrial carcinogens
• Genetic

• #1 cough or change in chronic cough
• Dry, persistent
• No sputum production
• 20% have wheezing

• CXR
• oCotton ball effect
• CT scan
• oIdentify small nodules not seen on cxr
• Sputum
• oRarely diagnostic
• Fine needle aspiration-to send off for like biopsies and stuff

• Surgery
• o 1st choice**
• Radiation
• Chemotherapy
• Palliative Therapy

• Sudden compression or positive pressure inflicted on the chest wall
• Most often life threatening

Motor vehicle, Bikes, Motorcycles, Falls, Violence

Airway obstruction, Tension pneumothorax, Open pneumothorax, Massive hemorrhage, Flail chest, Cardiac tamponade

Simple pneumothorax, hemothorax, pulmonary contusion, traumatic aortic rupture, penetrating wounds

• Inspection of airway, thorax, neck veins for any distention, and breathing difficulties
• Specific abnormalities such as stridor, cyanosis, nasal flaring, use of accessory muscles, drooling, overt trauma to face, mouth, or neck
• The chest is assessed for symmetric movement, symmetry of breath sounds, open chest wounds, entrance or exit wounds, impaled objects, tracheal shift, subcutaneous emphysema, and paradoxical chest wall motion.
• Vital signs and skin color are assessed for signs of shock
• The thorax is palpated for tenderness and crepitus, and the position of the trachea

• Chest X-ray
• CT Scan
• ABGs
• CBC, CMP
• Clotting studies
• Type and cross
• ECG trauma could’ve caused an arrhythmia
• O2

• Immediately established with O2 support
• Agitation and irrational and combative behavior are signs of decreased oxygen delivery to the cerebral cortex.

Hypovolemia, low cardiac output (could be signs of blood loss)

• Stabilizing and reestablishing chest wall integrity
• Occluding any opening into the chest
• Draining or removing air or fluid from the thorax
• Controlling hemorrhage

• Direct blow to sternum
• Potential for cardiac contusion
• Most likely to see these factors in women over 50

• Anterior chest pain
• Tenderness
• Ecchymosis

• Fractures of ribs 1-3 least common high impact
• Fractures of ribs 5-9 if its left sided you need to look/assess at the spleen

• Blunt force
• Potential for pulmonary contusion

• Severe pain
• Point tenderness
• Muscle spasms of fx area

• Evaluation for cardiac injuries
• oCT scan
• oechocardiogram
• Chest x-ray
• ECG
• Continuous pulse ox
• ABGs

• Pain Control
• Avoid excess activity
• Heal within 3-6 weeks
• Rarely need surgery
• Taping or chest binder typically not recommended because inhibits chest wall expansion

• Chest wall loses ability to stabilize
• Injury to underlying pleura and lungs can occur
• *Three or more adjacent ribs fractured at two or more sites
• Primary cause steering wheel impact

• Paradoxical movement
• Chest wall expands with inspiration
• oFractured section pulled inward
• Chest wall contracts on expiration
• oIncreased intra-thoracic pressure pushes fractured section outward
• Reduces amount of inspired air
• Impaired ability to exhale

• may require serial chest x-rays to monitor rib healing
• Abg’s initially to follow ph and pco2
• Cont. pulse ox with supplemental oxygen
• Pain management with iv opioids to start then changing to oral agents

• Life-threatening with intubation and mechanical ventilation with peep to stabilize chest and allow gas exchange
• May be breach of pleural space causing bleeding, and pneumothorax
• Puncture of lung tissue

Basically, bruised lungs from blunt force trauma

• Trauma- injury occurs
• Impaired gas exchange
• Increased pulmonary vascular resistance and pulmonary artery pressure
• Hypoxemia
• Co2 retention

• Mild to severe depending how much lung tissue has been damaged
• Symptoms include tachypnea, tachycardia, pleuritic chest pain, bloody sputum,
• If more severe contusion pt. may have decreased level of consciousness, severe hypoxia with co2 retention requiring intubation and ventilation

• Serial chest X-rays
• ABGs

• Airway – maintain airway – suctioning if secretions build up
• Breathing – continuous pulse ox to monitor O2 sats, titrate oxygen, monitor resp rate
• oIf pt. on vent will need ICU care
• Circulation – monitor bp, peripheral circulation, IV fluids for replacement – if enough plasma leaks out of vessels will need IV fluids to keep circulating volume
• Pain control – IV opioids, good pain control also decreases oxygen consumption of cells and conserving oxygen use
• Antibiotics – IV antibiotics to prevent infection or treat infection

• Foreign object penetrates chest wall
• Pleural space penetrated

• Knife
• Gunshot
• Impaled

• CXR
• Cat Scan
• Cardiac echo
• Abdominal ultrasound

• Goal
• oRestore and maintain cardiac and pulmonary function
• Adequate airway is ensured, and ventilation is established
• Exam for shock and intrathoracic and intra-abdominal injuries

• Visceral pleura that covers the lungs is ruptured
• The parietal pleura remains intact

• can be spontaneous esp. in tall thin people
• May be d/t a ruptured bleb in pt.'s with COPD
• Bronchopleural fistula – causes leak of air into the pleural space, seen in pts with COPD or pulmonary fibrosis

• Lung biopsy –taken by bronchoscopy
• Rib fractures tear parietal pleura
• Invasive procedures – pacemaker placement, subclavian central line placement

• Depends on size and cause
• Sudden pain
• Air hunger
• Tachypnea
• Auscultation
• oNo breath sounds on affected side
• Percussion
• oTympanic

• Open chest wound
• Parietal pleura penetrated
• Air moves in and out of chest

• Cover with 4x4
• Tape on 3 sides- to allow air to come out still without it sucking back in

• Air in chest cavity unable to escape
• One way valve effect
• oAir trapping
• oMediastinal shift- causing impaired cardiac output

• Blunt chest trauma
• Penetrating chest wounds
• Clamped or occluded chest tubes
• Total occlusion of an open chest wound

• Simple
• oChest tube
• Open
• oChest tube
• osurgery
• Tension
• o14 g needle
• oChest tube
• oSurgery

• Pneumonectomy
• Removal entire lung
• Mediastinal shift
• Space fills with fluid
• Remaining lung overinflates

• Removal of lobe of lung
• More common than pneumonectomy

remove section of lung

remove a triangle shaped slice of tissue

• Pulmonary function tests
• odone to ensure patient has adequate functioning capacity without affected lobe or lung
• ABGs
• Bronchoscopy
• PET scan

• Ideal is to instruct prior to surgery
• Improve airway clearance
• Stop smoking
• Humidified oxygen
• Instruct
• oIncentive spirometer
• oBreathing techniques
• oDiaphragmatic breathing

• Standard post-op care
• Oxygen management
• Chest tube management
• Watch for complications
• Discharge instructions
• Call MD if sputum color changes

Reestablish pleural space

• 3 chambers
• Collection
• Water seal
• Wet suction control

Reservoir for fluid draining from pleural space

• Reflects intrapleural space pressure
• Normal pressure -2cm

• Water seal moves up and down with inspiration/expiration
• Indicates chest tube working properly

• Intermittent normal
• Continuous bubbling abnormal
• Sign of air leak

• Suction may be added
• Promote drainage of fluid
• Promote air removal
• When suction turned on
• Continuous bubbling appears in suction chamber
• Water seal chamber has one way valve
• Prevents movement of air back into pleural space

• 3 chambers
• Collection
• Water seal
• Suction chamber regulated with valve

• oDisposable
• oSingle use
• o< 30 ml drainage

• Auscultate lungs
• Maintain drainage system upright
• Dressing
• Connections
• Measure drainage each shift
• Pre medicate prior to activity