Respiratory System Disorders For 2 For Psychiatry Students: ND By: - Yonatan Solomon (BSC N, MSC N)

Respiratory System Disorders
for
2nd for Psychiatry Students
By: - Yonatan Solomon (BSc N , Msc N)
Outline
Objective
Review of anatomy and physiology of RS
Upper respiratory disorder
Lower respiratory disorder
11/22/2021 Yonatan S DN CMHS DDU 2

Objectives
At the end of the session, students will be able to:
Describe the structures of the upper and lower airways.
Explain the normal physiology of the respiratory system.
Differentiate respiration, ventilation, diffusion, and perfusion
 Describe the etiology, clinical manifestations, and management of
respiratory disorder.

Introduction
The respiratory system provides oxygen for cellular metabolic needs
and removes carbon dioxide (CO2), a waste product of cellular

metabolism.

Respiratory Anatomy
The respiratory system is divided into the upper airway and lower airway.
The upper airway consists of the nose, sinuses, turbinates, pharynx, and
larynx.
The lower respiratory airway consists of the trachea, bronchi,

bronchioles, lungs, and alveoli.
Accessory structures include the diaphragm, rib cage, sternum, spine,
muscles, and blood vessels.

Respiratory Physiology
The main function of the respiratory system is to exchange oxygen
and CO2between the atmospheric air and the blood and between the
blood and the cells.
This process is called respiration.

Upper Respiratory Disease
Pharyngitis
Laryngitis
Tonsilitis
Adenitis

Pharyngitis
Pharyngitis, inflammation of the throat, is often associated with
rhinitis and other URIs.
Viruses and bacteria cause pharyngitis.
The most serious bacteria are the group A streptococci, which cause a
condition commonly referred to as strep throat.

Cont...
Strep throat can lead to dangerous cardiac complications (endocarditis
and rheumatic fever) and harmful renal complications

(glomerulonephritis).
Pharyngitis is highly contagious and spreads via inhalation of or direct
contamination with droplets.
The incubation period for pharyngitis is 2 to 4 days.

Cont...
The first symptom is a sore throat, sometimes severe, with accompanying
dysphagia (difficulty swallowing), fever, chills, headache, and malaise.
Some clients exhibit a white or exudate patch over the tonsillar area and
swollen glands.
A throat culture reveals the specific causative bacteria.

Cont...
Early antibiotic treatment is the best choice for pharyngitis to treat the
infection and help prevent potential complications.
Penicillin or its derivatives are generally the antibiotics of choice.
Clients sensitive to penicillin receive erythromycin.
The antibiotic regimen is 7 to 14 days.

Laryngitis
Laryngitis is inflammation and swelling of the mucous membrane that lines the
larynx.
Edema of the vocal cords frequently accompanies laryngeal inflammation.
Laryngitis may follow a URI and results from spread of the infection to the
larynx.
Other causes include excessive or improper use of the voice, allergies, and
smoking.

Cont...
Hoarseness, inability to speak above a whisper, or aphonia (complete
loss of voice) are the usual symptoms.
Clients also complain of throat irritation and a dry, nonproductive
cough.

Cont...
The diagnosis is based on the symptoms.
If hoarseness persists more than 2 weeks, the larynx is examined
(laryngoscopy).
Persistent hoarseness is a sign of laryngeal cancer and thus merits
prompt investigation.

Cont...
Treatment involves voice rest and treatment or removal of the cause.
Antibiotic therapy may be used if a bacterial infection is the cause.
If smoking is the cause, encourage smoking cessation.

Tonsillitis and Adenoiditis
Tonsillitis is inflammation of the tonsils, and adenoiditis is

inflammation of the adenoids.
These conditions generally occur together—the common diagnosis is
tonsillitis.
Although both disorders are more common in children, they also may
be seen in adults.

Pathophysiology and Etiology
The tonsils and adenoids are lymphatic tissues and common sites of
infection.
Primary infection may occur in the tonsils and adenoids, or the infection
can be secondary to other URIs.
Chronic tonsillar infection leads to enlargement and partial upper airway
obstruction.

Cont...
Chronic adenoidal infection can result in acute or chronic infection in
the middle ear (otitis media).
If the causative organism is group A streptococcus, prompt treatment
is needed to prevent potential cardiac and renal complications.

Assessment Findings
Sore throat, difficulty or pain on swallowing, fever, and malaise are the
most common symptoms.
Enlarged adenoids may produce nasal obstruction, noisy breathing,
snoring, and a nasal quality to the voice.
Visual examination reveals enlarged and reddened tonsils.

Cont...
White patches may appear on the tonsils if group A streptococci are
the cause.
A throat culture and sensitivity test determines the causative
microorganism and appropriate antibiotic therapy.

Medical and Surgical Management
Antibiotic therapy, analgesics such as acetaminophen, and saline
gargles may be used to treat the infection and associated discomfort.
Chronic tonsillitis and adenoiditis may Require tonsillectomy,
operative removal of the tonsils, and adenoidectomy, operative

removal of the adenoids.

Cont...
The criteria for performing these procedures are repeated episodes of
tonsillitis, hypertrophy of the tonsils, enlarged obstructive adenoids,

repeated purulent otitis media, hearing loss related to serous otitis media
associated with enlarged tonsils and adenoids, and other conditions (e.g.,
asthma, rheumatic fever) exacerbated by tonsillitis.

Lower Airway Disorders
Pneumonia
An inflammation and infection of lung and lung parenchyma
Inflammatory infiltrate in alveoli (consolidation)
Common illness which occurs in all age group
Leading cause of M&M in Infants and Older People & people who are
chronically & terminal ill.

Cont…
Normally, Lungs Are Well Protected
For pneumonia to occur, at least one of the following three conditions
must occur:
Failure or Defect in Host Defenses
Exposure to Very Virulent Pathogens
Exposure to an Overwhelming Load of Pathogens

Cont…
Host Defenses
Natural Barriers of the Body
Antibodies or Immunoglobulin Production
Cellular Immunity by Phagocytosis

Cont…
Failure of Host Defenses
Hair of nares
Absence of Cough or Epiglottic (Gag) reflex
Dysfunctional Muco-ciliary blanket
Local production of secretory IgA is reduced
Normal flora adhering to mucosal cells of the oro-pharynx

Cont…
Failure of Host Defenses cont’d
Immune Response Stunted:
Defective Neutrophil Function
Decreased Immunoglobulin Production
Prior Viral Infection (Common Cold)
Compromises Overall Immunity
Systemic Sepsis Weakens Immune Response

Cont…
Failure of Host Defenses cont’d
Immunosuppressive drugs decrease host response
Cigarette/second-hand exposure or other toxic fume also weaken lung

system
Change in mental status (coma, seizure, drug intoxication)

Cont…
Predisposing factors
☞Decrease level of consciousness
☞Tracheal intubation
☞Malnutrition
☞Alcohol, cigarette smoking, Stroke, seizures

☞Advanced age
☞Asthma, cystic fibrosis, anemia etc
☞Increased gram-negative bacilli in oro-pharynx

Cont…
Cause
➢Pneumonia can result from a variety of causes:
▪ Bacterial (Gram-positive bacteria, Gram-negative bacteria, "Atypical" bacteria)
▪ Virus
▪ Fungi
▪ Parasites
▪ Chemical or physical injury to the lungs

Cont…
✓Streptococcus pneumoniae
Most common cause of uncomplicated in all age groups
✓Atypical Bacteria
▪ Mycoplasma
▪ Chlamydia
▪ Legionella

Cont…
Classification
Based on causative agent
Bacterial or typical pneumonia,
Atypical pneumonia
According to the X-ray appearance
Lobar pneumonia- homogeneous consolidation of one or more lung lobes
Broncho- pneumonia- multiple patchy shadows in a localized or segmental area.

Cont…

Cont…

Cont…
According to the setting or clinical and environmental

Community-acquired pneumonia
Hospital-acquired pneumonia
Aspiration pneumonia,
pneumonia in immuno-compromised host

Cont…
Community-acquired pneumonia (CAP)
Infectious pneumonia in a person who has not recently been hospitalized

& within the first 48 hrs after hospitalization.
Common type of pneumonia.
Infection usually spread by droplet inhalation.

Cont…
➢Risk factors include:
Cigarette smoking
Alcohol intake
Pre-existing lung disease
Old age, etc.

Cont…
Common causes
✓Streptococcus pneumoniae (the most common cause)
✓Viruses
✓The atypical bacteria
✓Haemophilus influenza

Cont…
Hospital-acquired pneumonia (HAP)
✓Also called nosocomial pneumonia, that acquired during or after

hospitalization -at least 48 hours after admission.
✓Up to 5% of patients admitted to a hospital for other causes subsequently

develop pneumonia.

Cont…
Nosocomial pneumonia is the 2nd most common hospital-acquired
infections.
Nosocomial pneumonia is the leading cause of death from hospital-

acquired infections.

Cont…
Hospitalized patients may have many risk factors for pneumonia:
▪ Mechanical ventilation (VAP)
▪ Prolonged malnutrition
▪ Underlying heart and lung diseases
▪ Decreased amounts of stomach acid
▪ Immune disturbances.

Cont…
Causative agent
✓More commonly by G(-) organisms, esp.
o Pseudomonas aeruginosa
o Enterobacteriaceae (klebsiella, Enterobacter, Serratia) or MRSA.
o E.coli
o H. influenza

Cont…
Methicillin-resistant Staphylococcus aureus (MRSA) seen more
commonly in patients
▪ Received corticosteroids
▪ Undergone mechanical ventilation >5 days
▪ Presented with chronic lung disease
▪ Had prior antibiotics therapy

Pathophysiology of Bacterial pneumonia
Port of Entry of bacteria to Lungs
Contiguous extension
Hematogenous
Inhalation
Aspiration

Cont…
Once inside, bacteria may invade the spaces b/n cells and b/n alveoli
through connecting pores.
Invasion triggers the immune system to send neutrophils
Neutrophils & macrophages engulf and kill the offending organisms
The alveolar macrophages also initiate the inflammatory response

Cont…
It releases cytokines, causing a general activation of the immune system.
Neutrophils, bacteria and fluid from surrounding blood vessels fill the
alveoli
Interrupt normal oxygen transportation and venous blood entering the

lungs passes through the under ventilated area.

Cont…
Bacteria often travel from an infected lung into the bloodstream, causing
serious or even fatal illness such as septic shock
Bacteria can also travel to the area between the lungs and the chest wall
(the pleural cavity) causing a complication called an empyema.

Generally
✓Four stage of pathophysiological change occur due to pneumonia
1. Congestion- occurs during the first 24 hrs
▪ Out pouring of fluid from tissue to alveoli- b/se of inflammatory process.
▪ Only a few neutrophils are seen at this stage.

Cont…
2. Red hepatization - Lungs look like the liver
✓There is massive capillary dilation
✓Characterized microscopically by the presence of many RBC,

neutrophils, micro-organisms , fibrins in the alveolar spaces

Cont…
3. Gray hepatization
▪ The lung is dry, friable and gray-brown to yellow as a consequence of a

persistent fibrinopurulent exudates
▪ WBC and fibrin consolidate the alveoli and lung
▪ Second and third stages last for 2 to 3 days each

Cont…
4. Resolution
✓Characterized by enzymatic digestion of the alveolar exudate;
✓Resorption, phagocytosis or coughing up of the residual debris and
✓Restoration of the pulmonary architecture.

Cont…
Clinical manifestations
Cough producing greenish or yellow sputum
High fever that may be accompanied by shaking chills
Shortness of breath
Tachypnea
Pleuritic chest pain
Headaches

Cont…
Sweaty and clammy (moist) skin,
Loss of appetite
Fatigue
Blueness of the skin
Nausea, vomiting
Mood swings
Joint pains or muscle aches

Cont…
Diagnosis
History
Physical examination
Inspection
▪ Increase respiratory rate
▪ cyanosis
Palpation
Increase vibration of the chest when speaking
The way of chest expands

Cont…
Percussion
Dullness
Auscultation
A lack normal breath sounds
Crackle sounds
Increase loudness of whispered speech
Ego phony

Cont…
Chest x-ray
❖Chest x-rays can reveal areas of opacity (seen as white) which represent
consolidation.
Blood tests- a CBC may show a high WBC count.
Sputum cultures
Chest CT scan or other tests may be needed to distinguish pneumonia

from other illness.
Cont…
Medical management
➢Most cases of pneumonia can be treated without hospitalization.
➢Typically, oral antibiotics, rest, fluids and home care are sufficient for
complete resolution
➢People with pneumonia who are having trouble breathing, other medical
problems & the elderly may need more advanced treatment.

Cont…
✓Initially be treated with a broad-spectrum antibiotic regimen aimed at
covering all likely bacterial pathogen
✓This regimen should subsequently be narrowed, according to the result

of culture

Cont…
E.g. according to DACA
For community acquired ambulatory pts (mild pneumonia):-
• Amoxicillin
OR
• Erythromycin
OR
• Doxycyciline

Cont…
For community acquired hospitalized pts (severe pneumonia):-
Non-Drug treatment:
Bed rest
Frequent monitoring of temperature, blood pressure and pulse rate.
Give attention to fluid and nutritional replacements.
Administer Oxygen
Analgesia for chest pain

Cont…
Drug treatment:
Benzyl penicillin PLUS Gentamicin OR Ceftriaxon.
Pneumonia due to staphylococcus aureus should be treated as follows:

Cloxacillin 1-2 gm, IV or IM QID for 10-14 days.

HAP (nosocomial pneumonias)
Antimicrobials effective against gram-negative & gram-positive should

be given combination. Suitable combination is:
Cloxacillin plus Gentamicin OR Ceftriaxon plus Gentamicin
Ciprofloxacin
Pneumocytis pneumonia responds to Trimethoprin + Sulfamethoxazole

Cont…
Complications
Shock and respiratory failure
Empyema
Pleural effusion
Atelectasis
Abscess formation
Bacteremia
Chronic obstructive pulmonary disease (COPD)
Disease of airflow obstruction that is not totally reversible
COPD may include
▪ Emphysema
▪ Chronic bronchitis and combination of these disease.

Cont…
Incidence
➢Nearly 16 million people in the US suffer from COPD.
➢Causes more than 96,000 deaths annually, (the 4th leading cause of
death).
➢More common in men than women

Chronic bronchitis
Presence of recurrent or chronic productive cough for a minimum of 3
months for 2 consecutive years.
Etiology/ risk factors

▪ Bronchial irritants (e.g. cigarette smoke, exposure to pollution)
▪ Genetic predisposition
▪ Secondary bacterial or viral infections

Chronic Bronchitis: Pathophysiology
Chronic inflammation
Hypertrophy & hyperplasia of bronchial glands that secrete mucus
Increase number of goblet cells
Cilia are destroyed

Cont…
Narrowing of airway
• airflow resistance
• work of breathing
Hypoventilation & CO2 retention ➔ hypoxemia & hypercapnea

Cont…
Bronchial walls thickened, bronchial lumen narrowed, and mucus may
plug in the airway
Alveoli become damaged and fibrosed,
Altered function of the alveolar macrophages.
The patient becomes more susceptible to respiratory infection.

Cont…

Cont…
Mucus plug
Normal lumen

Chronic Bronchitis: Pathophysiology
It is characterized by:-
An increase in the size and number of sub mucous glands in the large
bronchi
An increased number of goblet cell
Impaired cilliar function
Bronchial mucosa inflammation
Bronchial smooth muscle hyper reactivity

Cont…
Clinical manifestations
In early stages
Clients may not recognize early symptoms
Symptoms progress slowly
May not be diagnosed until severe episode with a cold or flu
➢Productive cough (copious)
➢Cyanosis
➢Dyspnea
➢Tachypnea
➢Wheezing
Cont…
Diagnoses
Hx (e.g., smoking, occupation, environmental exposure)
Physical exam
Radiology
Sputum culture
ABG analysis ( PaCo2, decrease PaO2)

Chronic Bronchitis: Management
The treatment is complex and depends on the stage of bronchitis and
whether other health problems are present.
Lifestyle changes, such as quitting smoking or polluted air, controlled

regular exercise.
Supplemental oxygen
Treat other respiratory infections
Nutritional support, Fluid intake ~3 lit/day

Cont…
Medical management
Medications
Inhaled bronchodilators
▪ Short acting B2-agonists (albuterol)
▪ Long-acting B2-agonists(salmeterol)
▪ Methylxanthines (theophylline)
Anti-inflammatory
▪ Corticosteroids

Cont…
Expectorants for cough
▪ Codeine phosphate
▪ Dextromethorphan hydro bromide
Antipyretics for fever
Mucolytics, e.g. Acetylcysteine

Cont…
Prognosis
➢The progression of chronic bronchitis may be slowed, and an initial

improvement in symptoms may be achieved.
➢However, there is no cure for chronic bronchitis, and the disease can
often lead to or coexist with emphysema.

Emphysema
is a chronic disease characterized by an abnormal distention of the alveoli
/air spaces beyond the terminal bronchioles, with destruction of the
alveoli result impaired gas exchange.
The alveolar walls and capillary beds also show marked destruction.
This process of destruction occurs over a long period.

Cont…
Types of emphysema
Two main types, both may occur in the same patient.
1. Pan lobular- there is destruction of the respiratory bronchioles,

alveolar duct and alveoli.
2. Centrilobular- pathologic changes take place mainly in the center of

the secondary lobule, preserving the peripheral portions or alveoli
unchanged.

Cont…

Cont…
Etiology /risk factors
▪ Actual cause is unknown
Tobacco smoking (80%)
Other percentages is caused by inhaling too many air pollutants

(especially in occupational setting)
Underlying respiratory disease
Congenital-alpha 1-antitrypsin deficiency

Pathophysiology
In emphysema, the alveoli lose elasticity, trapping air that the client
normally would expire.
On microscopic examination, the alveolar walls are broken down,

forming one large sac instead of multiple, small air spaces.

Cont…
The capillary beds, previously located within the alveolar walls, are
destroyed, and fibrous scarring replaces much of the tissue.
Formation of fibrous tissue and destruction of the alveoli prevent the

proper exchange of oxygen and CO2during respiration.

Cont…
Pathophysiology
Smoking damages cleansing mechanism of lung
Airflow is obstructed and
Air becomes trapped behind the obstruction.
Affects alveolar membrane
Destruction of alveolar wall
Loss of elastic recoil
Over distended alveoli
Smoking also irritates the goblet cells and mucus glands- infection and damage
to the lung.
Cont…
Walls of the alveoli are destroyed that causing
An increase in dead space &
Impaired oxygen diffusion.
In later stages of disease, carbon dioxide elimination is impaired
Resulting in increase carbon dioxide tension in arterial blood and

causing respiratory acidosis.

Cont…
Clinical manifestation
➢Early stages ✓Wheezing
✓Barell chest ✓Chronic fatigue
✓Central cyanosis ✓Difficult in sleeping
✓Hypoxia
✓Finger clubbing
✓Polycythemia
✓Dyspnea
✓Cough & sputum production

Cont…
➢Later stages
▪ Hypercapnea
▪ Purse-lip breathing
▪ Use of accessory muscles to breathe
▪ Underweight
No appetite & increase breathing workload

Normal chest wall Barrel-shaped chest of emphysema

Cont…

Cont…
Diagnoses
Hx (smoking, occupational exposure),
Physical exam
Chest-X-ray
ABG analysis
▪ Normal in moderate disease
▪ Later: hypercapnia and respiratory acidosis
CBC
▪ Increase RBC
▪ Leukocytes

Cont…
Management
Medications
Anti-inflammatory- Corticosteroids
Bronchodilators
▪ Beta-adrenergic agonist
▪ Methylxanthines
▪ Anticholinergics (tiotropium bromide)
Mucolytics
Expectorants
Cont…
Anti-infective drugs
Steroid medications- Prednisolone.
Oxygen
Surgery : in advanced emphysema.

✓ Transplantation of either one or both lungs

Cont…
Client teaching
Support to stop smoking
Conservation of energy
Breathing exercises
• Pursed lip breathing
Chest physiotherapy
▪ Percussion, vibration
▪ Postural drainage

Cont…
Prognosis
It is a serious and chronic disease that cannot be reversed.
Overall, the prognosis for patients with emphysema is poor
If detected early, the effects and progression can be slowed.
Complications of emphysema include: higher risks for pneumonia and

acute bronchitis.
However, individual cases vary and many patients can live much longer
with supplemental oxygen andYonatan
11/22/2021 other treatment
S DN CMHS DDU 103
Bronchiectasis
A chronic, irreversible dilation of the bronchi and bronchioles
Dilation of the bronchial walls results

Airflow obstruction
Impaired clearance of secretions
Causing sputum to pool inside the dilated areas instead of being pushed
upward

Cont…
The pooled sputum provides an environment conducive to the growth of
infectious pathogens, and these areas of the lungs are thus very vulnerable
to infection.
Bronchiectasis is usually localized, affecting a segment or lobe of a lung,

most frequently the lower lobes

Cont…
Causes/risk factors
✓Air way obstruction
✓Diffuse air way injury
✓Pulmonary infection
✓Genetic disorder such as cystic disorder
✓Inhalation of noxious gases
✓Repeated pneumonia
Cont…
✓Respiratory irritation- smoking
✓Repeated URTI
✓Underlying disease (e.g. cystic fibrosis, immunodeficiency, TB)
✓Complications of measles & pertussis (whooping cough)

Cont…
Pathophysiology
Inflammations associated with pulmonary infection damages bronchial wall

and causing loss of its supportive structure
Diminish cilia function
Retention of secretion& obstruction
Collapse of alveoli distal to obstruction
Increase mucus production, reduced elasticity

Cont…
Pathophysiology…
Permanent dilation of anxious areas in the tracheobronchial tree.
Inflammatory scaring or fibrosis replaces functioning lung tissue.
Respiratory insufficiency, decrease ventilation, increase the ratio of

residual volume
Ventilation- perfusion imbalance, hypoxemia

Cont…
Chronic productive cough
▪ Copious
▪ Purulent
▪ Foul smelling
Hemoptysis
Clubbing of the fingers
Repeated episodes of pulmonary infection
Fever, malaise, wheezing
Night sweating, weight loss, anorexia
Cont…

Cont…
Diagnosis
History
Radiology
CT scan detects cystic fibrosis and rule out neoclassic obstruction
Bronchography

Cont…
Medical Management
✓Postural drainage (drainage by gravity )
✓Mucopurulent sputum must be removed by bronchoscopy.
✓Antibiotic to treat of bacterial
✓Bronchi dilators
✓Vaccination against influenza & pneumococcus pneumonia
✓Surgery (resection or lung transplantation)

Reading assignment
How do bronchodilators work with bronchiectasis?

Cont…
Complication
Atelectasis
Pneumonia
Respiratory failure

Asthma
A chronic inflammatory disease of the airways that characterized by reversible
airflow obstruction which causes:
✓Airway hyper responsiveness
✓Mucosal edema
✓Mucus production
Patients with asthma may experience symptom-free periods alternating with

acute exacerbations, which last from minutes to hours or days.

Cont…
Asthma is characterized as:
Reversible inflammation and obstruction
Intermittent attacks
Sudden onset
Varies from person to person
Severity varies from shortness of breath to death

Cont…
Etiology/ predisposing factors
Allergens
Genetic predisposition
Common allergens
✓ Seasonal
✓ Perennial
Common triggers for asthma symptoms and exacerbations:-
✓ Extrinsic agents
✓ Intrinsic agents

Clinical classification of severity
Use of short-acting
Severity in Interference beta2 agonist for
Symptom Nighttime %FEV1 of
patients ≥ 12 with normal symptom control
frequency symptoms predicted
years of age activity (not for
prevention)
Intermittent ≤2 per week ≤2 per month ≥80% None ≤2 days per week
>2 per week Minor >2 days/week

Mild persistent 3-4 per month ≥80%
but not daily limitation but not daily
Moderate >1 per week but

Daily 60–80% Some limitation Daily
persistent not nightly
Severe Throughout the Frequent (often Extremely Several times per

<60%
persistent day 7x/week) limited day

Cont…
The most common three symptoms are:-
▪ Cough
▪ Dyspnea (Chest tightness)
▪ Wheezing (Prolonged expiratory phase)
If exacerbation progresses:-
▪ Diaphoresis
▪ Tachycardia
▪ Central cyanosis (hypoxemia)
Cont…
C/M…
✓Hypoxia
✓Confusion
✓Increased heart rate & blood pressure
✓Respiratory rate up to 40/minute & pursed lip breathing
✓Use of accessory muscles
✓Flaring nostrils
Cont…
Diagnosis
Hx
Chest X-ray
Sputum increase viscosity
CBC- eosinophills
Lung Function Tests
Arterial blood gas analysis and pulse oximetry

Cont…
Medical management
Non-drug treatment: Prevention of exposure to known allergens and inhaled irritants.
Drug treatment
Broncho dilators-
2-adrenergic agonists
Methylxanthines
Corticosteroids
Leukotriene modifiers
Anticholinergics

Cont…
According to DACA:
Initial treatment
✓Salbutamol (metered dose inhaler MDI).
Alternatives
✓Aminophylline, 5mg/kg by slow I.V. push over 5 minutes. OR
✓Adrenaline, 0.5ml sc.

Cont…
Maintenance therapy for chronic asthma in adults:
❖Requires prolonged use of anti-inflammatory drugs mainly in the form of
steroid inhalers
Intermittent asthma:
▪ Salbutamol, inhaler 200 microgram/puff,1-2 puffs to be taken as needed but not
more than 3-4 times a day
Alternative
▪ Ephedrine + Theophylline

Cont…
Persistent mild asthma
✓Salbutamol, inhaler, 200 micro gram/puff 1-2 puffs to be taken, as needed but
not more than 3-4 times/day PLUS
✓Beclomethasone, oral inhalation 1000mcg QD for two weeks
Alternative
✓Ephedrine + Theophylline (11mg + 120mg), P.O. two to three times a day

PLUS
✓Beclomethasone oral inhalation 1000mcg QD for two weeks.

Cont…
Persistent moderate asthma
Salbutamol, inhalation 200microgram/puff 1-2 puffs as needed PRN not

more than 3-4 times a day.
PLUS
Beclomethasone, 2000mcg, oral inhalation QD for two weeks and reduce

to 1000 mcg if symptoms improve.

Cont…
Severe persistent asthma
✓Salbutamol, inhalation , 200 micro gram/puff 1-2 puffs not more than 3-4
times a day
PLUS
✓Beclomethasone, 2000 mcg, oral inhalation daily

Cont…
Complications
Respiratory failure
Pneumonia
Atelectasis
Status asthmatics

Cont…
Status asthmatics
Severe & persistent asthma that does not respond to conventional therapy
can be experienced as a complication.
Pts aware of increasing chest tightness, wheezing, and dyspnea that are
often not or poorly relieved
The attacks can last longer than 24 hours.

Clinical Manifestations
➢The clinical manifestations are the same as those seen in severe asthma:
✓Labored breathing,
✓Prolonged exhalation,
✓Engorged neck veins, and
✓Wheezing
➢As the obstruction worsens, wheezing may disappear, a sign of

impending respiratory failure.
Cont…
Mgt of status asthmatics
Pts requires supplemental Oxygen administration and IV fluid administration
▪ Oxygen therapy is initiated to treat dyspnea, central cyanosis, and hypoxemia.
Initially pts treated with high dose of short acting beta-adrenergic agonist &
corticosteroids
▪ If there is no response to repeated treatments, hospitalization is required.

Pneumothorax
The term pneumothorax literally means “air in the chest” and is used to describe
conditions in which air has entered the pleural space outside the lungs.
Pneumothorax occurs when the parietal or visceral pleura is breached and the pleural
space is exposed to positive atmospheric pressure.
Normally the pressure in the pleural space is negative or sub-atmospheric; this

negative pressure is required to maintain lung inflation.
When either pleura is breached, air enters the pleural space, and the lung or a portion
of it collapses.
Pathophysiology and Etiology
Recall that the pleural cavity has visceral and parietal pleurae.
These membranes normally are separated only by a thin layer of

pleural fluid.
Each time a breath is taken in, the diaphragm descends, creating

negative pressure in the thorax.
This negative pressure pulls air into the lungs via the nose and mouth.
If either the visceral pleura or the chest wall and parietal pleura are
perforated, air enters the pleural space, negative pressure is lost, and the
lung on the affected side collapses.
Each time the patient takes a breath, the temporary increase in negative
pressure draws air into the pleural space via the perforation.
During expiration, air may or may not be able to escape through the
perforation.
Types of Pneumothorax
Types of pneumothorax include simple, traumatic, and tension

pneumothorax.

Simple Pneumothorax
A simple, or spontaneous, pneumothorax occurs when air enters the pleural space
through a breach of either the parietal or visceral pleura.
Most commonly, this occurs as air enters the pleural space through the rupture of a
bleb (vesicle) or a bronchopleural fistula.
A spontaneous pneumothorax may occur in an apparently healthy person in the

absence of trauma due to rupture of an air-filled bleb, or blister, on the surface of the
lung, allowing air from the airways to enter the pleural cavity.
It may be associated with diffuse interstitial lung disease and severe emphysema.
Cont…
If no injury is present, the pneumothorax is considered spontaneous.
This occurs mostly in tall, thin individuals and in smokers.
Patients who have had one spontaneous pneumothorax are at greater risk for a
recurrence.
Patients with underlying lung disease (especially emphysema) may have blister like
defects in lung tissue, called bullae or blebs, that can rupture, allowing air into the
pleural space.
Weakened lung tissue from lung cancer can also lead to pneumothorax.
Traumatic Pneumothorax
 A traumatic pneumothorax occurs when air escapes from a laceration in the lung itself and
enters the pleural space or from a wound in the chest wall.
 It may result from blunt trauma (eg, rib fractures), penetrating chest or abdominal trauma
(eg, stab wounds or gunshot wounds), or diaphragmatic tears.
 Traumatic pneumothorax may occur during invasive thoracic procedures (i.e.,

thoracentesis, transbronchial lung biopsy, insertion of a subclavian line) in which the
pleura is inadvertently punctured, or with barotrauma from mechanical ventilation.

Cont...
Traumatic pneumothorax can also be classified as either open (when atmospheric
air enters the pleural space) or closed (when air enters the pleural space from the
lung).
Open traumatic pneumothorax constitutes a life-threatening emergency.
Open pneumothorax is one form of traumatic pneumothorax.
It occurs when a wound in the chest wall is large enough to allow air to pass freely
in and out of the thoracic cavity with each attempted respiration.

Cont...
In such patients, not only does the lung collapse, but the structures of
the mediastinum (heart and great vessels) also shift toward the
uninjured side with each inspiration and in the opposite direction with
expiration.
This is termed mediastinal flutter or swing, and it produces serious

circulatory problems

Cont...
Penetrating trauma to the chest wall and parietal pleura allows air to enter the pleural
space.
This can occur as a result of a knife or gunshot wound or from protruding broken ribs.
OPEN PNEUMOTHORAX. If air can enter and escape through the opening in the
pleural space, it is considered an open pneumothorax.
CLOSED PNEUMOTHORAX. If air collects in the space and is unable to escape, a

closed pneumothorax exists.

Cont...
A traumatic pneumothorax resulting from major injury to the chest is

often accompanied by hemothorax (collection of blood in the pleural
space resulting from torn intercostal, lacerations of the great vessels,
or lacerations of the lungs).
Often both blood and air are found in the chest cavity
(hemopneumothorax) after major trauma.

HEMOTHORAX
☞The term hemothorax refers to the presence of blood in the pleural

space.
☞This can occur with or without accompanying pneumothorax

(hemopneumothorax) and is often the result of traumatic injury.
☞Other causes include lung cancer, pulmonary embolism, and

anticoagulant use.

Tension Pneumothorax
☞A tension pneumothorax occurs when air is drawn into the pleural space from a
lacerated lung or through a small opening or wound in the chest wall.
☞It may be a complication of other types of pneumothorax.
☞In contrast to open pneumothorax, the air that enters the chest cavity with each
inspiration is trapped; it cannot be expelled during expiration through the air passages
or the opening in the chest wall.
☞In effect, a one-way valve or ball valve mechanism occurs where air enters the pleural
space but cannot escape.

Cont…
☞With each breath, tension (positive pressure) is increased within the affected pleural
space.
☞This causes the lung to collapse and the heart, the great vessels, and the trachea to
shift toward the unaffected side of the chest (mediastinal shift).
☞Both respiration and circulatory function are compromised because of the increased
intrathoracic pressure, which decreases venous return to the heart, causing decreased
cardiac output and impairment of peripheral circulation.
☞In extreme cases, the pulse may be undetectable

Cont…
☞If a pneumothorax is closed, air, and therefore tension, builds up in the pleural space.
☞As tension increases, pressure is placed on the heart and great vessels, pushing them
away from the affected side of the chest.
☞This is called a mediastinal shift.
☞When the heart and vessels are compressed, venous return to the heart is impaired,
resulting in reduced cardiac output and symptoms of shock.
☞Tension pneumothorax is often related to the high pressures present with mechanical
ventilation.
☞It is a medical emergency.

Comparison
☞In open pneumothorax, air enters the chest during inspiration and exits during expiration.
☞A slight shift of the affected lung may occur because of a decrease in pressure as air moves
out of the chest.
☞In tension pneumothorax, air enters but cannot leave the chest.
☞As the pressure increases, the heart and great vessels are compressed and the mediastinal
structures are shifted toward the opposite side of the chest.
☞The trachea is pushed from its normal midline position toward the opposite side of the chest,
and the unaffected lung is compressed.

Signs and Symptoms
 Sudden dyspnea, chest pain, tachypnea, tachycardia, restlessness, and anxiety
occur with pneumothorax.
 On examination, asymmetrical chest expansion on inspiration may be noted.
 Breath sounds may be absent or diminished on the affected side.
 In a “sucking” chest wound, air can be heard as it enters and leaves the wound.
 If tension pneumothorax develops, the patient becomes hypoxemic and
hypotensive as well.
 The trachea may deviate to the unaffected side.
 Heart sounds may be muffled.
 Bradycardia and shock occur if emergency intervention is not provided.

Cont…
 The signs and symptoms associated with pneumothorax depend on its size and cause.
 Pain is usually sudden and may be pleuritic.
 The patient may have only minimal respiratory distress with slight chest discomfort
and tachypnea with a small simple or uncomplicated pneumothorax.
 If the pneumothorax is large and the lung collapses totally, acute respiratory distress
occurs.
 The patient is anxious, has dyspnea and air hunger, has increased use of the accessory
muscles, and may develop central cyanosis from severe hypoxemia.
Cont…
 In assessing the chest for any type of pneumothorax, the nurse assesses tracheal alignment, expansion
of the chest, breath sounds, and percussion of the chest.
 In a simple pneumothorax, the trachea is midline, expansion of the chest is decreased, breath sounds
may be diminished, and percussion of the chest may reveal normal sounds or hyperresonance
depending on the size of the pneumothorax.
 In a tension pneumothorax, the trachea is shifted away from the affected side, chest expansion may be
decreased or fixed in a hyper-expansion state, breath sounds are diminished or absent, and percussion to
the affected side is hyper-resonant.
 The clinical picture is one of air hunger, agitation, increasing hypoxemia, central cyanosis, hypotension,
tachycardia, and profuse diaphoresis.

Diagnostic Tests
History, physical examination, and chest x-ray examination are used to

diagnose pneumothorax.
Chest x-ray examinations are repeated to monitor the resolution of the

pneumothorax with treatment.
Arterial blood gases and oxygen saturation are monitored as needed

throughout the course of treatment.

Therapeutic Interventions
☞A small pneumothorax may absorb with no treatment other than rest,

or the trapped air may be removed with a small bore needle inserted
into the pleural space.
☞Chest tubes connected to a water seal drainage system are used to

remove larger amounts of air or blood from the pleural space.

Medical Management
 Medical management of pneumothorax depends on its cause and severity.
 The goal of treatment is to evacuate the air or blood from the pleural space.
 A small chest tube (28 Fr) is inserted near the second intercostal space; this space is used because it is the thinnest
part of the chest wall, minimizes the danger of contacting the thoracic nerve, and leaves a less visible scar.
 If a patient also has a hemothorax, a large-diameter chest tube (32 Fr or greater) is inserted, usually in the fourth or
fifth intercostal space at the midaxillary line.
 The tube is directed posteriorly to drain the fluid and air.
 Once the chest tube or tubes are inserted and suction is applied (usually to 20 mm Hg suction), effective
decompression of the pleural cavity (drainage of blood or air) occurs.

Cont…
The severity of open pneumothorax depends on the amount and rate of

thoracic bleeding and the amount of air in the pleural space.
The pleural cavity can be decompressed by needle aspiration

(thoracentesis) or by chest tube drainage of the blood or air.
The lung is then able to re-expand and resume the function of gas
exchange.

Cont…
 The patient with a possible tension pneumothorax should immediately be given a
high concentration of supplemental oxygen to treat the hypoxemia, and pulse
oximetry should be used to monitor oxygen saturation.
 In an emergency situation, a tension pneumothorax can be decompressed or
quickly converted to a simple pneumothorax by inserting a large-bore needle (14-
gauge) at the second intercostal space, midclavicular line on the affected side.
 This relieves the pressure and vents the positive pressure to the external
environment.
 A chest tube is then inserted and connected to suction to remove the remaining air
and fluid, reestablish the negative pressure, and re-expand the lung.
 If the lung re-expands and air leakage from the lung parenchyma stops, further
drainage may be unnecessary.
 If a prolonged air leak continues despite chest tube drainage to underwater seal,
surgery may be necessary to close the leak.
Pulmonary Embolism
Pulmonary embolism (PE) refers to the obstruction of the pulmonary
artery or one of its branches by a thrombus (or thrombi) that originates
somewhere in the venous system or in the right side of the heart.
Most commonly, PE is due to a blood clot or thrombus.
However, there are other types of emboli: air, fat, amniotic fluid, and
septic (from bacterial invasion of the thrombus).
Cont…
It is estimated that more than half a million people develop PE yearly,
resulting in more than 50,000 deaths.
PE is a common disorder and often is associated with:

o trauma, surgery (orthopedic, major abdominal, pelvic, gynecologic), pregnancy,
o heart failure, age older than 50 years, hypercoagulable states, and prolonged
immobility.
o It also may occur in an apparently healthy person.

Pathophysiology
 When a thrombus completely or partially obstructs a pulmonary artery or its
branches, the alveolar dead space is increased.
 The area, although continuing to be ventilated, receives little or no blood flow.
 Thus, gas exchange is impaired or absent in this area
 In addition, various substances are released from the clot and surrounding area,
causing regional blood vessels and bronchioles to constrict.
 This causes an increase in pulmonary vascular resistance.
 This reaction compounds the ventilation–perfusion imbalance.

Clinical Manifestations
The symptoms of PE depend on the size of the thrombus and the area of
the pulmonary artery occluded by the thrombus; they may be nonspecific.
**Dyspnea is the most frequent symptom; tachypnea is the most

frequent sign.
The duration and intensity of the dyspnea depend on the extent of

embolization.
Cont…
Chest pain is common and is usually sudden and pleuritic.
It may be substernal and mimic angina pectoris or a myocardial

infarction.
Other symptoms include anxiety, fever, tachycardia, apprehension,

cough, diaphoresis, hemoptysis, and syncope
A massive embolism is best defined by the degree of hemodynamic

instability rather than the percentage of pulmonary vasculature occlusion
Cont…
 **. It is described as an occlusion of the outflow tract of the main pulmonary artery or
the bifurcation of the pulmonary arteries that produces pronounced dyspnea, sudden
substernal pain, rapid and weak pulse, shock, syncope, and sudden death
 Multiple small emboli can lodge in the terminal pulmonary arterioles, producing
multiple small infarctions of the lungs.
A pulmonary infarction causes ischemic necrosis of an area of the lung and occurs in
less than 10% of cases of PE.
Cont…
The clinical picture may mimic that of bronchopneumonia or heart failure
In atypical instances, the disease causes few signs and symptoms,
whereas in other instances it mimics various other cardiopulmonary
disorders.
Diagnostic Findings
Death from PE commonly occurs within 1 hour of symptoms; thus,
early recognition and diagnosis are priorities.
Because the symptoms of PE can vary from few to severe, a diagnostic

workup is performed to rule out other diseases.
Deep venous thrombosis is closely associated with the development of

PE.
Cont…
Typically, patients report sudden onset of pain and/or swelling and
warmth of the proximal or distal extremity, skin discoloration, and
superficial vein distention.
The pain is usually relieved with elevation.
The diagnostic workup includes:, pulmonary angiography, chest x-ray,

ECG, peripheral vascular studies,, and arterial blood gas analysis.
Pulmonary Embolism Prevention
☞For those at risk, the most effective approach to preventing PE is to prevent deep
venous thrombosis.
☞Active leg exercises to avoid venous stasis, early ambulation, and use of elastic
compression stockings are general preventive measures
☞Because PE is often a medical emergency, emergency management is of primary

concern.
☞After emergency measures have been taken and the patient’s condition stabilizes, the
treatment goal is to dissolve (lyse) the existing emboli and prevent new ones from
forming.
Medical Management
• The treatment of PE may include a variety of modalities:
1. General measures to improve respiratory and vascular status
2. Anticoagulation therapy
3. Thrombolytic therapy
4. Surgical intervention
Emergency Management
• Massive PE is a life-threatening emergency.
- immediate objective is to stabilize the cardiopulmonary system.
• A sudden rise in pulmonary resistance increases the work of the right

ventricle, which can cause acute right-sided heart failure with cardiogenic
shock.
• Most patients who die of massive PE do so in the first 1 to 2 hours after

the embolic event.
Cont…
• Emergency management consists of the following:
• Nasal oxygen is administered immediately to relieve:
- hypoxemia,
-respiratory distress, and
-central cyanosis.
• Intravenous infusion lines are started to establish routes for medications or fluids
that will be needed.

Respiratory System Disorders For 2 For Psychiatry Students: ND By: - Yonatan Solomon (BSC N, MSC N)

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Respiratory System Disorders For 2 For Psychiatry Students: ND By: - Yonatan Solomon (BSC N, MSC N)

Uploaded by

Copyright:

Available Formats

Respiratory System Disorders

Review of anatomy and physiology of RS

Upper respiratory disorder

Lower respiratory disorder

11/22/2021 Yonatan S DN CMHS DDU 2

Describe the structures of the upper and lower airways.

Explain the normal physiology of the respiratory system.

Differentiate respiration, ventilation, diffusion, and perfusion

 Describe the etiology, clinical manifestations, and management of

11/22/2021 Yonatan S DN CMHS DDU 3

The respiratory system provides oxygen for cellular metabolic needs

and removes carbon dioxide (CO2), a waste product of cellular

11/22/2021 Yonatan S DN CMHS DDU 4

The lower respiratory airway consists of the trachea, bronchi,

Accessory structures include the diaphragm, rib cage, sternum, spine,

muscles, and blood vessels.

The main function of the respiratory system is to exchange oxygen

This process is called respiration.

11/22/2021 Yonatan S DN CMHS DDU 6

11/22/2021 Yonatan S DN CMHS DDU 8

Pharyngitis, inflammation of the throat, is often associated with

rhinitis and other URIs.

Viruses and bacteria cause pharyngitis.

condition commonly referred to as strep throat.

11/22/2021 Yonatan S DN CMHS DDU 9

Strep throat can lead to dangerous cardiac complications (endocarditis

and rheumatic fever) and harmful renal complications

Pharyngitis is highly contagious and spreads via inhalation of or direct

contamination with droplets.

The incubation period for pharyngitis is 2 to 4 days.

11/22/2021 Yonatan S DN CMHS DDU 10

dysphagia (difficulty swallowing), fever, chills, headache, and malaise.

A throat culture reveals the specific causative bacteria.

11/22/2021 Yonatan S DN CMHS DDU 11

infection and help prevent potential complications.

Penicillin or its derivatives are generally the antibiotics of choice.

Clients sensitive to penicillin receive erythromycin.

The antibiotic regimen is 7 to 14 days.

11/22/2021 Yonatan S DN CMHS DDU 13

Edema of the vocal cords frequently accompanies laryngeal inflammation.

11/22/2021 Yonatan S DN CMHS DDU 14

Hoarseness, inability to speak above a whisper, or aphonia (complete

loss of voice) are the usual symptoms.

Clients also complain of throat irritation and a dry, nonproductive

11/22/2021 Yonatan S DN CMHS DDU 15

The diagnosis is based on the symptoms.

If hoarseness persists more than 2 weeks, the larynx is examined

Persistent hoarseness is a sign of laryngeal cancer and thus merits

11/22/2021 Yonatan S DN CMHS DDU 16

Antibiotic therapy may be used if a bacterial infection is the cause.

If smoking is the cause, encourage smoking cessation.

11/22/2021 Yonatan S DN CMHS DDU 17

Tonsillitis is inflammation of the tonsils, and adenoiditis is

These conditions generally occur together—the common diagnosis is

11/22/2021 Yonatan S DN CMHS DDU 18

can be secondary to other URIs.

Chronic tonsillar infection leads to enlargement and partial upper airway

11/22/2021 Yonatan S DN CMHS DDU 19

Chronic adenoidal infection can result in acute or chronic infection in

the middle ear (otitis media).

If the causative organism is group A streptococcus, prompt treatment

is needed to prevent potential cardiac and renal complications.