Critical Care Nursing A Holistic Approach

Critical Care Nursing
A Holistic Approach
Part 5
Anatomy and Physiology of the
Respiratory System
Chapter 23
Thorax
• Thoracic cage
– Ridged and flexible; protects organs
• Muscles of ventilation
– Diaphragm, external/internal intercostal muscles
• Lungs
• Pleural space
– Parietal pleura, visceral pleura
• Mediastinum
– Contains the heart, esophagus, vessels, thymus
Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition.
Airways
• Nasopharynx – warms, filters, and moisturizes

• Oropharynx
• Trachea – passageway, smooth muscle, cricoid cartilage
• Bronchi – right, left, carina (neuronal tissue)
• Bronchioles
• Terminal bronchioles
• Alveoli – gas exchange
Pulmonary Circulation
• Deoxygenated blood from right ventricle

• Pulmonary artery – arteriole
• Capillaries
– Wrap around every alveoli
– Thin-walled for efficient gas exchange
• Venules
• Pulmonary vein
• Left atrium
Physiology of Respiration
• Ventilation
– Movement of air between the alveoli and atmosphere
• Diffusion
– Movement of CO2 and O2 between alveoli and
capillaries
• Transport
– Movement of O2 from the alveoli to the cells
– Movement of CO2 from the cells to the alveoli
Process of Ventilation
• Movement of the diaphragm

• Changes in the transpulmonary pressure
• Lung compliance
• Airway resistance
Balance of Ventilation to Perfusion
• Alveolar dead space

– Collapsed alveoli from pneumonia or atelectasis
• Shunting
– Anatomical
• Blood moves from the right side to left side of the
heart without being oxygenated
– Physiological
• Blood moved by alveoli without picking up oxygen
VQ Mismatch
• Physiological shunt
– Low ventilation–perfusion ratio
• Alveolar dead space
– High ventilation–perfusion ratio
• Silent unit
– Both ventilation and perfusion are decreased
Patient Assessment:
Respiratory System
Chapter 24
History
• Dyspnea
• Chest pain
• Sputum production
• Cough
• Past history
• Family history
• Personal and social history
Inspection
• Respiratory rate, depth, and pattern of respiration

• Labored breathing, use of accessory muscles
• Cyanosis of skin
• A/P diameter of chest, and patient posture
• Chest expansion
• Chest deformities or scars
• IE ratio
• Clubbing of the fingers
Palpation
• Tactile fremitus
• Subcutaneous emphysema
• Thoracic expansion
• Trachea
Percussion
• Audible vibrations
• Tactile vibrations
Auscultation
• Tracheal breath sounds
– Over trachea, loud and harsh
• Bronchial breath sounds

– Over large airways they are normal; anywhere else they
are not normal
• Bronchovesicular breath sounds

– Medium in pitch; heard over bronchioles
• Vesicular breath sounds

– Heard over distal airway; quiet, low pitched
Pulse Oximetry
• Reflects the arterial oxygen
saturation of hemoglobin
• Saturations of 93% to 99% are
normal
• Not reliable in patients
– Using vasoconstricting
meds
– With known
dyshemoglobins
(carboxyhemoglobin or
methemoglobin)
– In shock, cardiac arrest
– With severe anemia
End-Tidal Carbon Dioxide Monitoring
Arterial Blood Gases
• pH: 7.35–7.45
• PaO2: 80–100 mm Hg
• PaCO2: 35–45 mm Hg
• HCO3: 22–26 mm Hg
• SaO2: 93–99%
Acid–Base Balance
• Respiratory acidosis
• Respiratory alkalosis
• Metabolic acidosis
• Metabolic alkalosis
Other Diagnostic Tests
• Chest X-ray
• Ventilation-perfusion scan
• Pulmonary angiogram
• Pulmonary function test (PFT)
• Bronchoscopy
• Thoracentesis
• Sputum culture
Patient Management:
Respiratory System
Chapter 25
Pulmonary Toilet
• Cough and deep breathing

• Chest physiotherapy
– Positioning
– “Good lung” down
– Postural drainage
– Percussion or vibration
Oxygen Delivery Systems
• Nasal cannula
– For children, blow-by
• Simple face mask
• Venturi mask
• Face tent
• Non-rebreather mask
Artificial Airways
• Nasopharyngeal / Oropharyngeal
– Size by placing device from ear lobe to corner of mouth
• Endotracheal tube
– Uncuffed tubes for children younger than 10 years of age
• Laryngomask airway (LMA)
– Sizes 1,2,3,4, and 5
– Sizes 3 and 4 for most of the population
• Tracheostomies
Chest Tubes
• Remove air and fluid from

the pleural space
• Re-expand a collapsed lung
• Restore negative pressure to
the pleural space
Reasons for a Chest Tube
• Hemothorax
• Pneumothorax
• Tension pneumothorax or hemothorax
• Fistula
Pharmacological Interventions
• Bronchodilators
• Anti-inflammatory agents
• Antibiotics
• Sedative agents
50/50 Rule of Respiratory Failure
• pH less than 7.25

• PaCO2 greater than 50 mm Hg
• PaO2 less than 50 mm Hg
Mechanical Ventilators
• Negative–pressure
ventilator
• Positive–pressure
ventilator
• Pressure ventilator
• High-frequency ventilator
Modes of Ventilation
• Assist-control
• Synchronized intermittent mandatory ventilation (SIMV)
• Pressure-support
• Pressure-controlled ventilation
• Volume-guaranteed pressure option
• Continuous positive airway pressure (CPAP)
• Positive end-expiratory pressure (PEEP)
Ventilator Settings
• FiO2
• Respiratory rate
• Tidal volume
• Peak flow
• Pressure limit
• PEEP
• Sensitivity
Complications
• Aspiration
• Barotrauma
• Ventilator–associated Pneumonia (VAP)
• Decreased cardiac output
Common Respiratory Disorders
Chapter 26
Pneumonia
• Community-acquired pneumonia
• Hospital-acquired pneumonia
• Bacteria
• Viruses
• Mycoplasma
• Fungi
• Chemical
Pneumonia
is an inflammatory response
to the uncontrolled
multiplication of
microorganisms invading the
lower respiratory tract.
Pneumonia
• Studies
– CXR, sputum culture, bronchoalveolar lavage
• Management
– Antibiotics, oxygen, pulmonary toilet
• Supportive care
– Nutrition, hydration, rest
• Prevention
– Pneumococcal and influenza vaccines
Pleural Effusion
• Accumulation of pleural fluid secondary to increased fluid

formation
– Increased capillary permeability
– Deceased colloid osmotic pressure of the blood
– Increased intrapleural negative pressure
– Impaired lymphatic drainage
– Increased pressure in the capillaries or lymphatics
Assessment of Pleural Fluid
• H/P finding
– Shortness of breath, chest pain
– Tachypnea, hypoxemia, pleural rub
• Diagnostic studies
– CXR – lateral decubitus
– Thoracentesis
Pneumothorax
• Sudden onset of pleuritic chest pain

– Dyspnea, shortness of breath, increased work of
breathing
• Diagnostic test
– CXR
• Management
– Oxygen
– Possible placement of chest tube
Pulmonary Embolism
• Part of a deep vein thrombosis that has traveled and

lodged in the pulmonary arteries
• Severity depends on the extent of occlusion
• Mismatch of ventilation and perfusion
• Testing
– VQ scan or a pulmonary angiogram
• Management
– Anticoagulation
COPD
• History
– Exposure to risk factors, comorbidities, current
medical treatment (beta blockers)
• Tests
– Spirometry, ABGs
• Management
– Oxygen, education, drug therapy, nutrition, exercise,
surgical intervention
Asthma
• A chronic inflammatory disease of the airways

• Airway hyperresponsiveness
• Variable airway obstruction
• Resolves spontaneously or after using a bronchodilator
Asthma
• Testing
– Spirometry
– Pulmonary function testing
• Management
– Education, prevent exacerbation, optimize
pharmacotherapy
Acute Respiratory Failure
• A sudden and life–threatening deterioration in gas

exchange
• Type I – Acute hypoxemic respiratory failure
• Type II - Acute hypercapnic respiratory failure
• Type III – Combined hypoxemic and hypercapnic failure
Acute Respiratory Failure
• Tests
– ABGs, CXR, PFTs, CT, thoracentesis
• Management
– Correction of gases, oxygen therapy
– Reversal of any narcotics
– Possible mechanical ventilation
Acute Respiratory Distress
Syndrome
Chapter 27
ARDS
• Complex clinical syndrome

• Acute hypoxic injury
• Caused by direct or indirect pulmonary injury
– Direct injury - aspiration, pulmonary infection, near
drowning, thoracic trauma or toxic inhalation
– Indirect injury – shock, sepsis, hypothermia, DIC,
multiple transfusion eclampsia, pancreatitis, burns
Phases of ARDS
Diagnostic Studies
• Blood cultures
• Bronchoalveolar lavage – detection of interleukin-1 and
tumor necrosis factor-
• Blood gas
• CXR
• Lung compliance, airway resistance, and pressure

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Critical Care Nursing

• Nasopharynx – warms, filters, and moisturizes

• Deoxygenated blood from right ventricle

• Movement of the diaphragm

• Alveolar dead space

• Respiratory rate, depth, and pattern of respiration

• Bronchial breath sounds

• Bronchovesicular breath sounds

• Vesicular breath sounds

• Cough and deep breathing

• Remove air and fluid from

• pH less than 7.25

• Accumulation of pleural fluid secondary to increased fluid

• Sudden onset of pleuritic chest pain

• Part of a deep vein thrombosis that has traveled and

• A chronic inflammatory disease of the airways

• A sudden and life–threatening deterioration in gas

• Complex clinical syndrome

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