NUR 1213: MSN- OXY: RESPI

November 15, 2021 | FEU Lectures, PPTs & Handouts | CREATED BY: ALVAERA, YTABLE
OUTLINE - more simply “percent oxygen”. When we talk
1 BASIC CONCEPTS OF OXYGENATION: about “liters per minute” we are talking how
RESPIRATORY much oxygen flow is being instilled through
Terminologies, Definition of Terms, Anatomy and the device.
Physiology, Current Health History, Physical 8. Hypoxia
Assessment, Breath Sounds, Breathing Patterns - refers to a low oxygen level in the tissues.
2 PHYSICAL EXAMINATION ON ILL - Hypoxia is SpO2<90% as measured by
PATIENTS: PULSE OXIMETER.
Laboratory and Diagnostic Examinations,
Treatment Plans
9. Hypoxemia
3 DRUG THERAPHY & OTHER MEDICAL - low oxygen in arterial blood. While hypoxemia
INTERVENTIONS is typically measured arterially and a PAO2
below 80mmHG
4 CHEST PHYSIOTHERAPY
Acid Base Balance & Imbalance, ABG
Interpretation, ARDS, Atelectasis
GAS EXCHANGE
5 ASTHMA, COPD, BRONCHITIS, refers to the intake of oxygen and release of carbon
EMPHYSEMA dioxide
6 PNEUMOTHORAX,, HEMOTHORAX FOUR FACTORS INFLUENCING DIFFUSION
7 EMPHYSEMA, ARDS OF GASES IN THE LUNGS
8 ACUTE RESPIRATORY FAILURE 1. change in surface area available
2. thickening of alveolar-capillary membrane
3. partial pressure
MODULE 1: TERMINOLOGIES 4. solubility and molecular weight of the gas
basics of oxygenation, related topics, and nursing
assessment from normal to pathological finding; TRANSPORT OF RESPIRATORY GASES
nursing intervention and the application of the nursing - oxygen is carried in the body via plasma and
process. red blood cells
DEFINITION OF TERMS - most oxygen (97%) is carried by red blood cell
in the form of oxyhemoglobin
1. Oxygenation
- process of supplying oxygen to the body cells. DEVICES USED FOR OXYGEN THERAPY
2. Ventilation NASAL CANNULA
- process of exchanging oxygen and carbon • Description: NASAL PRONGS
dioxide, which is essentially breathing. • FLOW RATE: 1to6L/minute
Oxygen comes into the body via the airway.
• FiO2: 24-44percent
3. Diffusion
• ADVANTAGES
- involves substances moving across
concentration gradients from areas of higher • DISADVANTAGES
concentration to areas of lower concentration. SIMPLE FACE MASK
This is the process involved with gas • Description: STANDARD FACE MASK
exchange. • FLOW RATE: 6-8L/minute (borderline low-
4. Perfusion flow system
- the body process of supplying oxygenated • FiO2: 40 TO 60 percent
blood to the cells and is reliant on adequate
• ADVANTAGES
cardiac output to be optimal.
• DISADVANTAGES
5. Low Flow Systems (LIKE THE TRUSTY NASAL
CANNULA) ANATOMY AND PHYSIOLOGY
- deliver the oxygen at rate that is less than the
amount of air that the patient can inhale or UPPER RESPIRATORY TRACT
exhale in one minute (CALLED “MINUTE a. Nose
VENTILLATION.) External Portions
6. High Flow Systems - Nasal Bones & Cartilages
- are going to deliver oxygen at a rate higher - Anterior Nares (Nostrils)
than the patient’s minute per ventilation. - External Openings of the Nasal
Remember, this is not a hard AND fast 6liters Cavity
per minute rule Internal Portions
7. FiO2 or “fraction of inspired oxygen” - Hollow cavity

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November 15, 2021 | FEU Lectures, PPTs & Handouts | CREATED BY: ALVAERA, YTABLE
- Separated by a septum - ONLY complete cartilaginous ring in the
- Divided into three passageways larynx
- Lines by highly vascular ciliated j. Arytenoid Cartilage
mucous membranes - used in vocal cord movement with thyroid
- Mucus secretions are moved by the cartilages
action of Cilia
Functions k. Vocal Cords
- Passageway for air to pass to and - ligaments controlled by muscular
from the lungs movements producing sound
- filters impurities
- humidifies and warms the air LOWER RESPIRATORY TRACT
- olfaction which diminishes with age a. Trachea
b. Paranasal Sinuses • Windpipe
• Four Pairs of Bony Cavities • Smooth muscles
- Frontal • C-shaped rings of cartilages at regular
- Ethmoidal intervals
- Sphenoidal • Passages between the larynx and the
- Maxillary bronchi
• Lined with nasal mucosa and ciliated b. Lungs
pseudostratified columnar • paired elastic structure enclosed in the
epithelium thoracic cage
• Connected by a series of ducts that • Ventilation
drain into the nasal cavity movement of the walls of the thoracic
c. Turbinate Bones (Conchae) cage and diaphragm ž increase and
- Increases the mucus membrane surface decrease in the capacity of the chest
of the nasal passage upward to the nose • Inspiration is an active process, occurs in
to the Nasopharynx the first third of the cycle
d. Pharynx, Tonsils, & Adenoid • Expiration is passive, occurs in the latter
Pharynx – the throat 2/3
- Tube-like structure connecting the nasal c. Pleura- lining of the lungs
& oral cavities to the larynx Visceral Pleura - covers the lungs
Divided into three regions Parietal Pleura - lines the thorax
- nasal - posterior to the nose above the d. Mediastinum
soft palate • in the middle of the thorax
- oral - houses the facial or the palatine
• extends from the sternum to the vertebral
tonsils
column
- laryngeal - extends from the hyoid bone
e. Lobes
to the cricoid cartilage
• Left lung
e. Larynx
- Upper
- cartilaginous epithelium lined structure
- Lower lobes
- connects the pharynx to the trachea
• Right lung
- For vocalization and protects the airway
from foreign substances - Upper
- facilitates coughing - Middle
f. Epiglottis - Lower lobes
- a valve flap of cartilage covering the • Each lobe is subdivided into two to five
opening of the larynx during swallowing segments separated by fissures
g. Glottis f. Bronchi & Bronchioles
- opening between the vocal cords in the • Right and left bronchi begin at the carina
larynx • Functions for air passage
h. Thyroid Cartilage Right Bronchus
- largest of the cartilage structure, forms Wider, Shorter, more vertical
part of the Adams Apple Left Bronchus
i. Cricoid Cartilage Narrower, Longer, more horizontal
g. Alveoli

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 NUR 1213: MSN- OXY: RESPI
November 15, 2021 | FEU Lectures, PPTs & Handouts | CREATED BY: ALVAERA, YTABLE
• Acinus (acini)- respiratory unit n. weakness
• Consist of: o. SOB
- respiratory bronchiole 2) Relevant information, to include eleven
- alveolar duct functional patterns
- alveolar sac a. Health Perception management pattern
• Functions for gas exchange b. Nutritional/metabolic pattern
c. Elimination pattern
h. Types of alveolar Epithelial Cells d. Activity/exercise pattern
- Type I Pneumocytes e. Cognitive/perceptual pattern
- Type II Pneumocyte f. Sleep-rest patter
- Type III Pneumocytes g. Self-perception – self-concept pattern
h. Role relationship pattern Coping-stress
tolerance patter
FUNCTIONS OF THE RESPIRATORY i. value-belief pattern
TRACT 3) Family History
General Functions 4) Past Medical History
a. Gas exchange through ventilation, external 5) Social History
respiration and cellular respiration 6) Environmental/ Lifestyle patterns
b. Oxygen and carbon dioxide transport
c. Physiology of Respiration PRINCIPLES AND TECHNIQUES OF
d. Air enters the nose, warmed, filtered & passed PHYSICAL EXAMINATION
thru the nasal cavity In newborn children, adults, deviation from normal
e. Air passes thru the pharynx -larynx - trachea physical examinations
- bronchi – alveoli
f. Air exchange occur Air inhales is composed CHIEF COMPLAINTS
of Oxygen, Nitrogen, Water vapor, helium 1) Vital signs
g. and Carbon dioxide a. RR - 12-20cpm
Ventilation b. HR- 60-100bpm
a. mechanics of breathing in and out c. Axillary Temperature
b. muscles contract on inhalation, lifting the ribs 2) Inspection
and pulling them outward a. barrel chest
c. diaphragm moves downwards enlarging the b. funnel chest
chest cavity c. pigeon chest
d. reduction in air pressure causes air to enter d. lordotic
the lungs e. kyphosis
e. expiration reverses these step 3) Palpation
a. tactile fremitus
- nine nine/ tres-tres
CLINICAL HISTORY - vibrations of the sound waves
Identifies significant subjective data from the client - decreased fremitus fluid/air outside the
history related problems in oxygenation. lungs
CHIEF COMPLAINTS - increased fremitus consolidation
1) Check for the presence of the following 4) Percussion
a. dyspnea a. tapping the body with the fingertips to
b. orthopnea b. evaluates the size, borders and consistency
c. precipitating factors of some of the internal organs
d. frequency of DOB 5) Auscultation
e. effect on activity a. Normal BS
f. pain - Vesicular= rustling/swishing sound,
g. cyanosis higher pitch on inspiration, fades on
h. accumulation of mucus expiration
i. sputum production - Bronchovesicular= equal lung sounds
j. hemoptysis during inspiration to expiration periods
k. cough - Tracheal= I/E are both loud
l. fatigue b. Abnormal BS
m. clubbing of the fingers - Inspiratory Stridor

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 NUR 1213: MSN- OXY: RESPI
November 15, 2021 | FEU Lectures, PPTs & Handouts | CREATED BY: ALVAERA, YTABLE
- Rales/Rhonchi/ Crackles
- Wheezes
- Inspiratory Stridor= high pitch
wheezing sound as air enter the trachea
and the bronchi; usually appear in
inspiration; seen in patients with
laryngomalacia, foreign bodies, tumors,
infections.
- Rales/Rhonchi/Crackles - discrete non
continuous sound resulting from a
delayed reopening of a deflated airways;
indicates underlying inflammation or
congestion; usually seen in pneumonia,
bronchitis, heart failure, bronchiectasis
and pulmonary fibrosis
- Wheezes= usually as a result of
narrowing of the airway, producing a
vibration in the Larynx and transmitted to
the chest wall; commonly heard in
asthma, bronchiectasis & chronic
bronchitis
c. Breathing Patterns
- Eupnea
- Bradypnea
- Tachypnea
- Hypoventilation
- Hyperventilation/ Kussmaul’s respiration
- Apnea
- Cheyne stokes - alternating episodes of
apnea and deep breathing, which may
become shallow as it progresses; usually
seen in heart failure, damage to the
medulla as a result of drug induced
problems, tumor or trauma
- Biot’s Respiration - cluster breathing;
cycles of breath that vary in depth with
varying periods of apnea; usually seen in
CNS problems
MODULE 2: PHYSICAL
EXAMINATION ON ILL PATIENTS
Usually performed at bedside particularly important for
patients at risk for development pulmonary
complications; patients with limited external restrictions
like obesity, abdominal distension and who cannot
breathe deeply due to post op sedation.
LABORATORY/DIAGNOSTIC EXAM
Results and implications of diagnostic/ laboratory
examinations of clients with problems in oxygenation.
SCREENING PROCEDURE
1. Peak Flowmeter
1. portable, handheld device for those with
asthma that is used to measure how well air
moves out of your lungs.
DIAGNOSTIC PROCEDURE
1. Non-Invasive
- A medical procedure is defined as non-
invasive when no break in the skin is created
and there is no contact with the mucosa, or
skin break, or internal body cavity beyond a
natural or artificial body orifice.
2. Invasive
a. Arterial Blood Gas
- PaO2 (partial pressure of oxygen)
- PaCO2 (partial pressure of carbon
dioxide)
- PH
b. Sputum Analysis
- is a sample of the gooey substance that
often comes up from your chest when
you have an infection in your lungs or
airways.
c. Sputum Exam
- identify pathogenic organisms; determine
the presence of malignant cells.
NURSING INTERVENTION
1. Pre-Test
- Encourage to increase fluid intake prior
to test
- Best time to collect early in the morning
2. Intra and Post Test
- Provide oral hygiene, label specimen
correctly
- Document
- Rinse mouth with water only
- Instruct patient to take 3 deep breathes
and force cough
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CULTURES • Evaluate patients for magnetic implants like
1. Throat swabs in infections pacemakers, prosthetic values, metallic clips.
- a test commonly used to diagnose
bacterial infections in the throat. These DIAGNOSTIC PROCEDURES
infections can include strep throat, Results and implications of diagnostic/ laboratory
pneumonia, tonsillitis, whooping cough, examinations of clients with problems in oxygenation.
and meningitis.
2. Throat cultures NON-INVASIVE PROCEDURES
- a test to find germs (such as bacteria or defined as non-invasive when no break in the skin is
a fungus) that can cause an infection. created and there is no contact with the mucosa, or
3. Nasal swabs skin break, or internal body cavity beyond a natural or
- a method for collecting a clinical test artificial body orifice.
sample of nasal secretions from the back 1. CT Scan (computerized tomography)
of the nose and throat. - Combines a series of x ray images
ENDOSCOPIC STUDIES taken from different angles around
1. Bronchoscopy your body
- Direct inspection and examination of the - Useful in detecting internal injuries
larynx, trachea, and bronchi; use of - Well-suited for diagnosing diseases
fibrotic scope. and evaluating injuries
2. Fiberoptic - Imaging technique can help
- Thin flexible scope diagnose infections, muscular
- Directed to the segmental bronchi disorders and minute bone fractures
3. Rigid Bronchoscopy
- To guide invasive and non-invasive
- Hollow metal tube with light at its end
- Used for removal of foreign body, see the procedures for surgeries, biopsies,
source of massive hemoptysis and etc.,
perform - To monitor effectiveness of
treatments or medical interventions
PURPOSE OF DIAGNOSTIC BRONCHOSCOPY
2. Purified Protein Derivative Skin Test
• Examine tissues or collect secretions
- A test that determines if you have
• Determine the location & extent of the
pathologic process, obtain a tissue sample tuberculosis
- After the administration, wait for 48-
PURPOSE OF THERAPEUTIC BRONCHOSCOPY 72 hours
• Remove foreign body - Validating screening test to see the
• Remove secretions extent of exposure that the patient
COMPLICATIONS had to the causative agent
• Allergy to anesthesia 3. PPD/ Mantoux Test (tuberculin
• Infection due to instrumentation sensitivity/derivative test)
• Aspiration. - Screening test for TB
• Bronchospasm - One of the major tuberculin skin test
• Hypoxemia used around the world
• Pneumothorax - Largely replaces multiple-puncture
• Bleeding test such as tine test
• Gastrointestinal perforation (GP) 4. Pulse Oximetry
- Non-invasive method of monitoring o2
IMAGING STUDIES saturation of hemoglobin
• C-Xray - sensor probe Is attached to the fingertip
• Magnetic resonance imaging (MRI) or earlobe or forehead
• Fluoroscopic Studies
NURSING INTERVENTIONS
• Explain procedure to patients
• Assess ability to remain still in confined places

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INVASIVE PROCEDURES
1. Thoracoscopy
- Direct visualization of the plural
cavity with an endoscope
- For evaluation of pleural effusions,
pleural diseases, tumor staging
NURSING INTERVENTIONS
• Follow up the patients at a health care
facility or at home
• Minor activity restrictions
• Monitor for any shortness of breath
• Monitor chest drainage
2. Thoracentesis
- Aspiration of pleural fluid using fine
needle from the pleural space
- Used for biopsy
- May be used for instillation of
medication
NURSING INTERVENTIONS
• Check if chest x-ray had been done to
locate the lesion
• Assess any allergy history
• Inform patient of the nature of the
procedure
• Position the patient comfortably
• Reassure Patient
3. Biopsy
a) Pleural
- Procedure to remove a sample
of the pleura. This is the thin
tissue that lines the chest cavity
and surrounds the lungs
- It is done to check the pleura for
disease of infection
b) Lung Biopsy
- Samples of lung tissues are
removed to determine if lung
disease or cancer is present
- May be performed using a
closed or open method
c) Lymph Node
- Test that checks disease in your
lymph nodes
SURGICAL PROCEDURES
1. Tracheostomy
- A hole that surgeons make through the
front of the neck to the trachea
- Provides ab air passage to help you
breathe when the usual route for
breathing is somehow blocked or
reduced
2. Chest Tube Drainage (Thoracic Catheter)
- A sterile tube with a number of drainage
holes that is inserted into the pleural
space
- May require a chest drainage system any
time the negative pressure in the pleural
cavity is disrupted, resulting in respiratory
distress
- Gives area for the lungs to expand; can
be monitored through x-ray
- Another indication is the decreased or
zero volume of drainage that is noted
*hemothorax- blood pneumo-air hydro-water
3. Thoracotomy
- Surgery to open your chest
- Often done to treat lung cancer
THERAPIES AND TREATMENTS
1. Inhalation Therapy
- A group of respiratory or breathing
treatments designed to help restore or
improve breathing function in patients
with a variety of diseases, conditions, or
injuries
2. Mechanical Ventilation
- Used in patient who are in acute RDS in
an ICU set up
- May be a final attempt to continue
breathing
- Used primarily in the treatment if Sleep
Apnea
- Used with o2 therapy to reserve or
prevent micro atelectasis
PULMONARY FUNCTION TESTS
- Non-invasive test that show how well the
lungs are working
- Measures lung volume, capacity, rates of
flow, and gas exchange
LUNG CAPACITIES AND VOLUMES
- Measured in terms of lung volumes and
capacities
- Volume measures the amount of air for one
function (inhalation and exhalation)
- Capacity is any two or more volumes (how
much can be inhaled from end of a maximal
inhalation)
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MEDICAL INTERVENTIONS
1. Tidal Volume 1. Nebulization
- Volume of each breath - A drug delivery device used to administer
- Amount of air inspired and expired with medication in the form of a mist inhaled
each breath into the lungs. Nebulizers are commonly
- Reliable only if measurement of several used for the treatment of asthma, cystic
breaths are made and the ranger of TV fibrosis, COPD, etc.,
us noted the average 2. Oxygen Therapy
2. Inspiratory Capacity Nasal Cannula
- Equals Tidal Volume (TV) + Inspiratory - Used to deliver supplemental oxygen or
Residual Capacity (IRV) approx. 3500 increased airflow to a patient or person in
mL need of respiratory help
- Amount of air that a person can breathe Partial Re-breathing Mask
beginning at the normal expiratory level - is a device used in medicine to assist in
- Distending hid lungs to a maximum the delivery of oxygen therapy
amount Face Tent
3. Functional Residual Capacity (FRC) - are used to provide a controlled
- Amount of air remaining in the lungs after concentration of oxygen and increase
normal expiration moisture for patients who have facial
4. Vital Capacity burn or a broken nose, or who are
- Measured by having the patient take in a claustrophobic
maximal breath and exhale fully through Venturi Mask
a spirometer - also known as an air- entrainment mask,
- Normal value depends on the patient’s is a medical device to deliver a known
age, gender, body built, and weight oxygen concentration to patients
5. Total Lung Capacity on controlled oxygen therapy.
- Maximum volume to which lungs can be
expanded with greatest effort CHEST PHYSIOTHERAPY
- Volume of air in the lungs at this level is treatments generally performed by physical therapists
equal to FRC in young adult and respiratory therapists, whereby breathing is
improved by the indirect removal of mucus from the
OTHER DIAGNOSTIC TESTS breathing passages of a patient. Other terms include
1. Smoke Analyzer respiratory or cardio-thoracic physiotherapy.
- standardized test for nicotine
dependence PRINCIPLES
2. Pulmonary Angiography • To prevent chest complication
- Test to see hoe blood flows through the • To prevent circulatory complication
lung • To maintain good posture
- An imaging test that uses x-rays and a • To gain cooperation and confidence
special dye to see inside the arteries
3. Lung Scans CHEST PERCUSSION
- Imaging test to look at your lungs and Are treatments generally performed by physical
help diagnose certain lung problems therapists and respiratory therapists, whereby
- May be used to see how well a treatment breathing is improved by the indirect removal of mucus
is working from the breathing passages of a patient.
- A type of nuclear imaging test CHEST VIBRATION
is a technique that gently shakes the mucus so it can
NURSING DIAGNOSIS move into the larger airways.
1. Ineffective breathing pattern
2. Ineffective airway clearance POSTURAL DRAINAGE
3. Impaired has exchange uses gravity and percussion (clapping on the chest
4. Inability to sustain spontaneous ventilation and/or back) to loosen the thick, sticky mucus in the
5. Dysfunctional ventilatory weaning response lungs so it can be removed by coughing.
6. Decreased cardiac output (CO)
7. Altered tissues perfusion systemic.

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MODULE 3: DRUG THERAPY &
SURGICAL INTERVENTIONS
The broad spectrum of respiratory disease implies that
the range of therapeutic options is similarly wide.
Where appropriate, preventive measure should be
applied-smoking cessation, immunization and
improvements in air quality should be particularly
encouraged.
DRUGS
ANTIHISTAMINES
• Antihistamines, compete with histamine for
receptor sites thus preventing a histamine
response.
• When the H1 receptor is stimulated, the
extravascular smooth muscles, including
those lining the nasal cavity, are constricted.
It decreases nasopharyngeal secretions by
blocking the H1 receptor.
THERAPEUTIC ACTION
• Potent histamine (H1) receptor antagonist;
inhibits histamine release and eosinophil
chemotaxis during inflammation, leading to
reduced swelling and decreased
inflammatory response
STEROIDS
• Acts as an anti-inflammatory agent in cases
of severe anaphylaxis, (allergic reactions)
where there is bronchoconstriction
THERAPEUTIC ACTIONS
• Binds to intracellular corticosteroid receptors,
thereby initiating many natural complex
reactions that are responsible for its anti-
inflammatory and immunosuppressive effects
BRONCHODILATORS
• The second major group of bronchodilators
used to treat asthma are the methyxanthine
(xanthine) derivatives.
• The following are xanthines:
1. Aminophylline
2. Theophylline
THERAPEUTIC ACTIONS
• Relaxes bronchial smooth muscle, causing
bronchodilation and increasing vital capacity,
which has been impaired by bronchospasm
and air trapping;
ADRENERGIC DRUGS
• Drugs that mimic the effect of norepinephrine are
called adrenergic drugs, sympathomimetic, or
adrenomimetics.
• The following are adrenergic drugs: 1. Epinephrine
2. Albuterol
3. Clonidine and methyldopa
THERAPEUTIC ACTIONS
• Naturally occurring neurotransmitter, the
effects of which are mediated by alpha or beta
receptors in target organs.
EXPECTORANTS
• Expectorants loosen bronchial secretions so
they can be eliminated by coughing.
• The most common expectorant in such
preparation is guaifenesin (ROBITUSSIN -
LICQUIK).
MUCOLYTICS
• Mucolytic act like detergents by liquefying and
loosening thick mucous secretions so they
can be expectorated.
• The bronchodilator should be given 5 minutes
before the mucolytic. Side effects include
nausea and vomiting, stomatitis and runny
nose.
ANTIMICROBIALS
• Antimicrobials are drugs that are designed to
act selectively on foreign organisms that have
invaded and infected the body.
MECHANISM OF ACTIONS
• some interfere with the biosynthesis of the
bacterial cell wall
• some inhibit bacterial enzyme and cellular
metabolism
• some inhibit protein synthesis
• some change cellular permeability
• some inhibit DNA synthesis
TYPES OF ANTIMICROBIALS
1. Penicillin
- produces bactericidal effects by
interfering with the ability of susceptible
bacteria from biosynthesizing the
framework of the cell wall.
2. Cephalosporins
- First generation- are largely effective
against the same gram positive
organisms affected by penicillin.
- Second generation- are effective
against those strains as well as H.
influenza, E. aeogenes and Neisseria sp.
These drugs are less effective against
gram positive bacteria.
- Third generation- relatively weak
against gram positive bacteria but more
potent against gram negative bacteria.
- Fourth generation- are developed
against the resistant gram negative
bacteria.
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AMINOGLYCOSIDES
• These drugs are group of powerful antibiotics
that are used to treat serious infections
caused by gram negative aerobic bacilli.
MACROLIDES
• Antibiotics that interfere with protein synthesis
insusceptible bacteria. They are broad
spectrum antibiotics named after their
relatively large size. The first drug made was
Erythromycin.
TETRACYCLINES
• The tetracyclines inhibit protein synthesis in
susceptible bacteria leading to the inability of
the bacteria to multiply .
FLUOROQUINOLONES
• Are broad spectrum antibiotics. These agents
enter the bacterial cell by diffusion through
cell channel.
MAST CELLS STABILIZERS
• Used for treatment of allergies
• Side effects can be mild
• Cromolyn nasal drops
LEUKOTRINE MODIFIERS
• Long-term control modifiers to prevent mild
asthma, allergy Should be given in
combination with long-term control
medications Side effects: headache, gastritis
and flu-like symptoms.
SURGICAL INTERVENTIONS
1. Tracheotomy
- Is a surgical incision into the trachea
through overlying skin and muscles for
airway management.
2. Tracheostomy
- is the surgical creation of a stoma, or
opening, into the trachea through the
underlying skin
- Can be performed as an emergency
procedure or as an elective procedure
depending on the indication
- Indications For Tracheostomy
• Relief of acute or chronic upper
airway obstructions
• Access for continuous mechanical
ventilation
• Prevention of aspiration pneumonia
• Promotion of pulmonary hygiene
• Bilateral vocal cord paralysis.
3. Chest Tube Insertion
- Also called thoracostomy
- A chest tube can drain air, blood or fluid
from the space surrounding the lungs
(pleural space)
- It’s typically an emergency procedure. It
may also be done after surgery on organs
or tissues in the chest cavity.
- You may need a chest tube if you have
any of the following:
• A collapsed lung
• A lung infection
• Bleeding around the lungs especially
after a trauma
• Fluid build-up due to another
medical condition such as cancer or
pneumonia
• Breathing difficulty due to build-up of
fluid or air
• Surgery, especially lung, heart or
esophageal surgery.
4. Thoracotomy
- is a surgery to open a chest. During this
procedure, a surgeon makes an incision
in the chest wall between your ribs,
especially to operate on the lungs.
- Through this incision, the surgeon can
remove part or all of the lung. This is
done often to treat lung cancer.
- Thoracotomy can also be used to help
diagnose disease. (it can able a surgeon
to remove a piece of tissue for further
examination such as biopsy)
INHALATION THERAPY
1. Mechanical Ventilation
- Mechanical ventilation is ordered for
patients in acute respiratory distress, and
is often used in an intensive care
situation.
- In some cases, mechanical ventilation is
a final attempt to continue the breathing
function in a patient and may be
considered "life-sustaining."
2. CPAP
- allows patient to breath spontaneously
applying positive pressure to open alveoli
3. Metered Dose Inhaler
- Metered dose inhalers (MDIs) are
pressurized, hand-held devices that use
propellants to deliver doses of
medication to the lungs of a patient.
- These delivery devices are critically
important to public health and are used to
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administer various active ingredients for NURSING INTERVENTIONS
a range of medical conditions. 1. Make sure the patient is comfortable, wearing
- MDIs play a particularly significant role in loose clothing
the treatment of asthma and chronic 2. Uppermost areas of the lungs are treated first
obstructive pulmonary disease (COPD). 3. STOP treatment if: there is pain, increased
The MDI accounts for 70% of all SOB, weakness, lightheadedness or
inhalation therapy in the world's fifteen hemoptysis
largest patient.
4. Chest Physiotherapy REGULATION OF ACID BASE
- Chest Percussion BALANCE AND IMBALANCE
- Chest Vibration THE BODY AND PH
- Postural Drainage • Homeostasis of pH is tightly controlled
NURSING INTERVENTIONS • Extracellular fluid = 7.4
Assess for: • Blood = 7.35 – 7.45
• Tachypnea • < 6.8 or > 8.0 death occurs
• Tachycardia • Acidosis (acidemia) below 7.35
• Reduced tidal volume • Alkalosis (alkalemia) above 7.45
• Decreased oxygen saturation and Small changes in pH can produce major
CO2 disturbances
• Most enzymes function only with narrow pH
MODULE 4: ranges
CHEST PHYSIOTHERAPY • Acid-base balance can also affect electrolytes
(Na+, K+, Cl-)
CHEST PHYSIOTHERAPY (CPT) • Can also affect hormones
CHEST PHYSIOTHERAPY PRINCIPLES
The body produces more acids than bases
1. Chest Percussion- light blows to the chest
• Acids take in with foods
wall to loosen secretions
2. Chest Vibration- Vibrating the chest wall to • Acids produced by metabolism of lipids and
loosen secretions proteins • Cellular metabolism produces CO2.
3. Postural drainage- use of specific positions • CO2 + H20 ↔ H2CO3 ↔ H+ + HCO3-
that allow the force of gravity to assist in the CONTROL OF ACIDS
removal of bronchial secretions. 1. Buffer systems
GOALS OF CPT - Take up H+ or release H+ as conditions
• Remove bronchial secretions change
• Improve ventilation - Buffer pairs – weak acid and a base
• Increase the efficiency of the respiratory - Exchange a strong acid or base for a
muscles weak one
- Results in a much smaller pH change
POSTURAL DRAINAGE 2. Respiratory Mechanisms
NURSING INTERVENTIONS - Exhalation of carbon dioxide
1. Know the medical diagnosis, lung or lobes - Powerful, but only works with volatile
involve acids
2. Advice patient to perform drainage 2-4x daily - Doesn’t affect fixed acids like lactic acid
3. Done before meals and at bedtime - CO2 + H20 ↔ H2CO3 ↔ H+ + HCO3-
4. Evaluate skin color and pulse prior to - Body pH can be adjusted by changing
procedure rate and depth of breathing
3. Kidney Excretion
CHEST PERCUSSION AND VIBRATION
- Can eliminate large amounts of acid
• Help to dislodge mucus adhering to the
- Can also excrete base
bronchioles and bronchi
- Can conserve and produce bicarb ions
• Performed 3-5 mins for each position - Most effective regulator of pH
• Vibration is when you apply manual - If kidneys fail, pH balance fails
compression and tremor to the chest wall
during exhalation phase

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RATES OF CORRECTION • Acute Conditions:

• Buffers function almost instantaneously - Adult Respiratory Distress Syndrome
• Respiratory mechanisms take several - Pulmonary edema
minutes to hours Renal mechanisms may - Pneumothorax
take several hours to days • Compensation for Respiratory Acidosis:
- Kidneys eliminate hydrogen ion and
ACID BASE IMBALANCES
retain bicarbonate ion
• pH< 7.35 acidosis
• Signs and Symptoms of Respiratory
• pH > 7.45 alkalosis
Acidosis:
• The body response to acid-base imbalance is - Breathlessness
called compensation - Restlessness
• May be complete if brought back within - Lethargy and disorientation
normal limits - Tremors, convulsions, coma
• Partial compensation if range is still outside - Respiratory rate rapid, then gradually
norms. depressed
COMPENSATION - Skin warm and flushed due to
• If underlying problem is metabolic, vasodilation caused by excess CO2.
hyperventilation or hypoventilation can help : • Treatment:
respiratory compensation. - Restore ventilation
• If problem is respiratory, renal mechanisms - IV lactate solution
can bring about metabolic compensation. - Treat underlying dysfunction or disease
Respiratory Alkalosis
ACIDOSIS
• Principal effect of acidosis is depression of the RESPIRATORY ALKALOSIS
CNS through ↓ in synaptic transmission. • Carbonic acid deficit
• Generalized weakness • pCO2 less than 35 mm Hg (hypocapnea)
• Deranged CNS function the greatest threat • Most common acid-base imbalance
• Severe acidosis causes • Primary cause is hyperventilation
- disorientation • Conditions that stimulate respiratory
- coma center:
- death - Oxygen deficiency at high altitudes
- Pulmonary disease and Congestive heart
ALKALOSIS failure – caused by hypoxia
• Alkalosis causes over excitability of the - Acute anxiety
central and peripheral nervous systems. - Fever, anemia
• Numbness - Early salicylate intoxication
• Lightheadedness - Cirrhosis
• It can cause : - Gram-negative sepsis
- Nervousness • Compensation of Respiratory Alkalosis:
- muscle spasms or tetany - Kidneys conserve hydrogen ion
- Convulsions - Excrete bicarbonate ion
- Loss of consciousness • Treatment:
- Death - Treat underlying cause
RESPIRATORY ACIDOSIS - Breathe into a paper bag
• Carbonic acid excess caused by blood levels - IV Chloride containing solution- Cl ions
of CO2 above 45 mm Hg. replace lost bicarbonate ions
• Hypercapnia – high levels of CO2 in blood METABOLIC ACIDOSIS
• Chronic conditions: • Bicarbonate deficit - blood concentrations of
- Depression of respiratory center in brain bicarb drop below 22mEq/L
that controls breathing rate – drugs or • Causes:
head trauma - Loss of bicarbonate through diarrhea or
- Paralysis of respiratory or chest muscles renal dysfunction
- Emphysema

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- Accumulation of acids (lactic acid or
ketones)
- Failure of kidneys to excrete
• H+ Symptoms of Metabolic Acidosis:
- Headache, lethargy
- Nausea, vomiting, diarrhea
- Coma
- Death
• Compensation for Metabolic acidosis
- Increased ventilation
- Renal excretion of hydrogen ions if
possible
- K+ exchanges with excess H+ in ECF
- (H+ into cells, K+ out of cells)
• Treatment:
- IV lactate solution
METABOLIC ALKALOSIS
• Bicarbonate excess - concentration in blood is
greater than 26 mEq/L
• Causes:
- Excess vomiting = loss of stomach acid
- Excessive use of alkaline drugs
- Certain diuretics
- Endocrine disorders
- Heavy ingestion of antacids
- Severe dehydration
1. Compensation for Metabolic Alkalosis:
- Alkalosis most commonly occurs with
renal dysfunction, so can’t count on
kidneys
- Respiratory compensation difficult –
hypoventilation limited by hypoxia
2. Symptoms:
- Respiration slow and shallow
- Hyperactive reflexes ; tetany
- Often related to depletion of electrolytes
- Atrial tachycardia
- Dysrhythmias
3. Treatment:
- Electrolytes to replace those lost
- IV chloride containing solution
- Treat underlying disorder
ABG ANALYSIS
• This helps to evaluate gas exchange in the
lungs by measuring the gas pressures and pH
of an arterial samples.
Pre -test: Choose site carefully, perform the Allen’s
test, secure equipment’s – syringe, needle container
with ice.
Intra-test : Obtain a 5 ml specimen from the artery
(brachial, femoral and radial)
Post -Test: Apply firm pressure for 5 minutes, label
specimen correctly, place in the container with ice
ABG NORMAL VALUES
DIAGNOSIS OF ACID-BASE IMBALANCES
1. Note whether the pH is low (acidosis) or high
(alkalosis)
2. Decide which value, is outside the normal
range and could be the cause of the problem.
If the cause is a change in the problem is
respiratory.
3. Look at the value that doesn’t correspond to
the observed pH change. If it is inside the
normal range, there is no compensation
occurring. If it is outside the normal range, the
body is partially compensating for the
problem.
ACUTE RESPIRATORY
DISTRESS SYNDROME (ARDS)
• a sudden and progressive form of acute
respiratory failure in which the alveolar
capillary membrane becomes damaged and
more permeable to intravascular fluid
resulting in severe dyspnea, hypoxemia and
diffuse pulmonary infiltrates.
ETIOLOGY & RISK FACTORS
1. Direct Lung Injury
Common Causes:
• Aspiration of gastric contents or other
substances
• Viral/Bacterial pneumonia
Less Common Causes:
• Chest trauma
• Embolism :fat, air, amniotic fluid o
Inhalation of toxic substances
• Near drowning
• O2 toxicity
• Radiation pneumonitis
2. Indirect Lung Injury
Common Causes:
• Sepsis
• Severe traumatic injury
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Less Common Causes: *Person with ARDS are hospitalized and require
• Acute pancreatitis treatment in an intensive care unit.
• Anaphylaxis *No specific therapy for ARDS exists.
• Prolonged cardiopulmonary bypass SUPPORTIVE MEASURES
surgery Disseminated intravascular • Supportive measures:
coagulation
- Supplemental oxygen
• Multiple blood transfusion - Mechanical respirator
• Narcotic drug overdose • Positioning strategies
• Non pulmonary systemic diseases - Turn the patient from supine to prone
• Severe head injury - Another position is lateral rotation
• Shock therapy
• Massive blood transfusion • Fluid Therapy
CLINICAL MANIFESTATIONS • Medications:
Early Signs/Symptoms - Antibiotics
- Restlessness - Anti-inflammatory drugs such as
- Dyspnea corticosteroids
- Low Blood Pressure - Diuretics
- Confusion NURSING MANAGEMENT
- Extreme Tiredness The principles of nursing management of
- Change in Patient’s behavior (mood swing, clients with pulmonary edema and care of the client
disorientation, change in LOC) requiring mechanical ventilation are appropriate in the
- If pneumonia is causing ARDS, then client care of the client with ARDS. Placing a client in prone
may have cough and fever. position clearly is within the realm of nursing.
Late Signs/Symptoms Evaluation of the client’s response to
- Severe difficulty in breathing (labored, rapid treatment as well as careful monitoring for potential
breathing) complication is essential.
- Shortness of breath
- Tachycardia NURSING DIAGNOSIS
- Cyanosis (Blue Skin, lips, and nails) 1. Ineffective breathing pattern related to
decreased lung compliance, decreased
EVALUATION energy as characterized by dyspnea,
• History of above symptoms abnormal ABG’s, cyanosis. And use of
• On physical examination accessory muscles.
- Auscultation reveals abnormal breath 2. Impaired gas exchange related to diffusion
sounds defect as characterized by hypoxia,
• The first tests done are: hypercapnia, tachycardia and cyanosis.
3. Risk for decreased cardiac output related to
- Arterial blood gas analysis
positive pressure ventilation
- Blood tests
4. Ineffective protection related to positive
- Chest x-ray
pressure ventilation, decreased pulmonary
- Bronchoscopy
compliance and increased secretions as
- Sputum cultures and analysis
characterized by crepitus, altered chest
• Other tests are:
excursion, abnormal ABG’s and restlessness.
- Chest CT scan
- Echocardiogram
ATELECTASIS
COMPLICATIONS • Collapse of part or all of a lung due to
• Nosocomial pneumonia bronchial obstruction.
• Barotrauma • May be caused by:
• Renal failure - Intrabronchial obstruction
• O2 toxicity - Tumors, bronchospasm
• Stress ulcers - Foreign bodies
• Tracheal ulceration - Extra bronchial compression (tumors,
• Medical Management enlarged lymph nodes)

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- Endobronchial disease (bronchogenic
carcinoma, inflammatory structures)
ASSESSMENT FINDINGS
• Signs and symptoms may be absent
depending upon the degree of collapse and
rapidity with which bronchial obstruction
occurs.
• Dyspnea, decreased breath sounds on
affected side, decreased respiratory
excursion, dullness to flatness upon
percussion over affected area.
• Cyanosis, tachycardia, tachypnea, elevated
temperature, weakness, pain over affected
area.
• Diagnostic Tests:
a) Bronchoscopy – may or may not reveal
an obstruction
b) Chest X-ray shows diminished size of
affected lung and lack of radiance over
atelectatic area
c) pO2 decreased
MODULE 5: ASTHMA, COPD,
BRONCHITIS, EMPHYSEMA
ASTHMA
In asthma there is inflammation in the airways which
makes the muscles in the airways constrict. This
causes the airways to narrow. The symptoms tend to
come and go, and vary severity from time to time.
Treatment to reduce inflammation and to open up the
airways usually works well.
SYMPTOMS
• coughing, chest tightness, wheezing and
trouble breathing
• Mild asthma symptoms in response to certain
activities like exercising.
• severe and frequent symptoms may need
treatment with medication.
What causes asthma?
● The underlying cause of asthma is not known,
but it's thought to be due to a combination of
genetic and environmental factors. People with
asthma may have genetic risk factors that
make them more susceptible to the disease,
and certain environmental factors, such as
exposure to allergens or certain viral infections
in infancy, may increase the risk of developing
the disease, according to the National Heart,
Lung and Blood Institution
TRIGGERS/PRECIPITATING FACTORS
● tobacco smoke, dust mites, air pollution,
pollen, mold, respiratory infections, physical
activity, cold air and allergic reactions to some
foods.
TREATMENT
● There is no cure for asthma. Consult with
your doctor about how to best treat and
manage their condition.
● Avoiding asthma triggers, and taking
medications to prevent or treat symptoms.
MEDICATION
● There are two types of medications to treat
asthma: quick-relief medications and
long-term medications.
○ Quick-relief medications provide
relief from acute asthma
symptoms. A common quick-relief
medication is inhaled short-acting
beta2-agonists, which help relax
muscles around the airways,
allowing more air to flow through
them. A common medication is
inhaled corticosteroids, which
reduce airway inflammation and
make airways less sensitive.
○ Other long-term medications
include omalizumab, a shot given
one or two times a month to
prevent the body from reacting to
asthma triggers, and inhaled long-
acting beta2-agonists, which help
open airways
BRONCHITIS
● Bronchitis is inflammation or swelling of the
bronchial tubes (bronchi), the air passages
between the nose and the lungs.
● More specifically, bronchitis is when the
lining of the bronchial tubes becomes
inflamed or infected.
● Bronchitis is caused by viruses, bacteria,
and other particles that irritate the bronchial
tubes.
● Secondary to:
○ URTI
○ Inhalation of physical and
chemical agents, gases and other
air contaminants
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Types of Bronchitis
Acute bronchitis
· Acute bronchitis is a shorter illness that
commonly follows a cold or viral infection,
such as the flu
· Usually lasts a few days or weeks
Chronic bronchitis
· Characterized by a persistent, mucus-
producing cough on most days of the
month, three months of a year for two
successive years in absence of a
secondary cause of the cough.
Etiology & Risk factors
● Smokers
● People who are exposed to a lot of
secondhand smoke
● People with weakened immune systems
● The elderly and infants
● People with gastroesophageal reflux
disease (GERD)
● People who are exposed to air pollution
Signs & Symptoms of Bronchitis
● Inflammation or swelling of the bronchi
● Coughing
● Production of clear, white, yellow, grey, or
green mucus (sputum)
● Shortness of breath
● Wheezing
● Fatigue
● Fever and chills
● Chest pain or discomfort
● Blocked or runny nose
Diagnostic Evaluation
● History collection
● Physical examination
● Chest x-rays
● Sputum cultures
● Pulmonary function test
● Spirometer excercises
● Bronchoscopy
Pharmacologic Management
● Antibiotics - these are effective for bacterial
infections, but not for viral infections. They
may also prevent secondary infections.
● Cough medicine - one must be careful not
to completely suppress the cough, for it is
an important way to bring up mucus and
remove irritants from the lungs.
● Bronchodilators - these open the bronchial
tubes and clear out mucus.
● Mucolytics - these thin or loosen mucus in
the airways, making it easier to cough up
sputum.
● Anti-inflammatory medicines and
glucocorticoid steroids - these are for more
persistent
● symptoms.
● Pulmonary rehabilitation program - this
includes work with a respiratory therapist to
help breathing.
Nursing Diagnosis
● Ineffective breathing pattern related to
shortness breathing ,mucus or broncho
constriction.
● Ineffective airway clearance related to
bronchoconstriction.
● Self care deficit related to fatigue
secondary to increased effort for breathing.
● Activity intolerance due to fatigue and
ineffective breathing patterns
Nursing Management
● Assess The Condition Of Patient.
● Assess The Vital Signs
● Provide Comfortable Position.
● Change The Position Periodically.
● Maintain Personal Hygiene.
● Use pulse oximetry & Suction.
● Deep Breathing Exercise Learn To Patient.
● Refer To Physiotherapist (if Need).
● Provide Oxygen According To Physician
Order.
● Provide Psychological Support To Patients.
● Provide Knowledge About Chronic
Bronchitis.
● administer medication according to
physician order.
● Bronchodilators,antibiotics,mucolytics
Health Education
● Avoiding tobacco smoke and exposure to
second hand smoke
● Quitting smoking
● Avoiding people who are sick with colds or
the flu
● Getting a yearly flu vaccine
● Getting a pneumonia vaccine (especially
for those over 60 years of age)
● Washing hands regularly
● Avoiding cold, damp locations of areas with
a lot of air pollution
● Wearing a mask around people who are
coughing and sneezing
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Complications What Are The Causes?
● Asthma Most common causes:
● Bronchiectasis ● Smoking
● Tuberculosis ○ SMOKING FACTS ON EMPHYSEM
● Sinusitis ■ 80 percent of emphysema
causes restfit from the long term
Chronic Obstruction Bronchitis "Blue elects of smoking cigarettes
Bloater" ■ About 90 percent of emphysema
● Clients with COB appears bloated, have causes are heavy smokers
large barrel chest and peripheral edema, ● Prolonged exposure to secondhand smoke
cyanotic nail beds and circumoral ● Chemical fumes
cyanosis ● Dust
● Air pollution
EMPHYSEMA
What are the Effects to Our Body?
What is Emphysema? ● People with emphysema will not
A condition in our body in which the air sacs of the oxygenated their blood well.
lungs, called alveolus are damaged and enlarge, ● They can't remove carbon dioxide from
causing breathlessness. their blood and lungs.
● They have a rapid breathing rate
Type of Emphysema
There are four type:
1. Centriacinar Who is at risk?
2. Panacinar ● Emphysema affects both men and women.
3. Paraseptal [Distal acinar] ● Usually does not appear until the sixties.
4. Mixed and unclassified [Irregular] ● But the disease can appear as early as
forty depending on certain factors.
Centriacinar ● Any ethnic group can develop emphysema.
[centrilobular, Proximal acinar] ● One exception is the inherited form that
• Dilatation of Respiratory Bronchiole mainly affects Europeans.
• Upper lobes - severely involved
• Can coexist with chronic bronchitis Occurrence among Male and Female
• Invariably occurs in smokers ● Occur more in male than females due to
• Coal mine workers {carbon, dust] the percentage of male smokers. As the
number of female smokers increases,
Panacinar Emphysema: emphysema also develops rapidly.
• Whole of Acinus uniformly affected ● Death rate increase rapidly
• Lower lobes severely involved
• Association: Symptoms of Emphysema
● A1AT deficiency ● Coughing with or without phlegm
● Cigarette smokers (sometimes referred to as "smokers
cough")
Paraseptal (Distal Acinar) ● Dyspnoea (shortness of breath)
• Localized along pleura - peripheral part of the acinus ● Trouble catching one's breath
• Predisposes to spontaneous peumothorax ● Fatigue
• Adjacent to foci of fibrosis ● Wheezing
• Least common ● Barrel- like distended chest
● Lethargy or difficulty concentrating
Mixed - irregular emphysema: ● Difficulty sleeping
• Most Common
• Least Significant Diagnosis
• Common around scar tissue ● History
• Combination of Types ● Physical examination

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● The most common physical change may
be in the chest, which takes on a barrel-like
appearance
● pursed-lip breathing the breath sounds
become quite diminished
● if any wheezing, and exhalation becomes
prolonged (exhalation takes more than
twice as long as inhalation)
● Bluish discoloration of the lips and nail
beds
Investigation
Chest X-ray
● A plain chest x-ray may show lungs that
have become too inflated and too lucent,
signs that lung tissue destruction has
occurred.
Radiologic Findings
● Chest radiograph
● Translucent (dark) lung fields
● Depressed or flattened diaphragms
● Long and narrow heart
● Enlarged heart
● Increased retrosternal air space (lateral
radiograph)
● Blood test & Arterial Blood Gas (ABG)
● Lung Function Test also called Pulmonary
● Function Test or PFT (most common)
● Spirometry measures how fast and how
much air you breathe out
Breath Sound in Emphysema
● Diminished breath sound with prolong
expiration.
● Wheeze (in severe cases).
Treatment
● STOP smoking (if you smoke)
● Bronchodilators (inhalers) Ex. Atrovent,
Spiriva, Serevent, Foradil. and Albuterol
● Anti-inflammatory medication Ex. Singulair
and Roflin
● Antibiotics
● Oxygen therapy
● Pulmonary rehabilitation
● Conserve energy, improve stamina, and
reduce breathlessnes
● Surgery
● physiotherapy
● Other things include
● Avoid being around smoke and other
irritants
● Avoiding the cold
Prognosis
● Mild emphysema- 80% of patients are alive
after 4 years
● Moderate emphysema- 60-70% are alive
after 4 years
● Severe emphysema- 50% are alive after 4
years
● Very severe emphysema- short life
expectancy
Complication
● Enlargement and strain on the right side of
the heart may occur, resulting in swelling of
the feet and legs.
● Respiratory infections are frequent may
often result in hospitalization
● Other possible complications, collapsed
lung (are pneumothorax), and giant bulla.
Chronic Obstructive Pulmonary Disease
(COPD)
● Current Health
● History, Physical
● Examination, Norma
● and Abnormal
● Breath Sounds,
● Breathing Patterns
● It affects more than 5 percent of the
population and is associated with high
morbidity and mortality
● It is the third-ranked cause of death in the
United States, killing more than 120,000
individuals each year
Burden of COPD
● Increase in coming decades due to
continued exposure to COPD risk factors
and the aging of the world's population,
● Significant economic burden.
Definition of COPD
● COPD, a common preventable and
treatable disease, is characterized by
persistent airflow limitation that is usually
progressive and associated with an
enhanced chronic inflammatory response
in the airways and the lung to noxious
particles or gases.
COPD Includes
1) Chronic Bronchitis
2) Emphysema
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Chronic bronchitis
● Defined as a chronic productive cough for
three months in each of two successive
years in a patient in whom other causes of
chronic cough have been excluded
Emphysema
● Abnormal and permanent enlargement of
the airspaces distal to the terminal
bronchioles that is accompanied by
destruction of the airspace walls, without
obvious fibrosis
Pathology
Airways
● Chronic inflammation
● Increased numbers of goblet cells
● Mucus gland hyperplasia
● Fibrosis
● Narrowing and reduction in the number of
small airways
● Airway collapse due to the loss of tethering
caused by alveolar wall destruction in
emphysema
Subtype of emphysema:
Centrilobular emphysema (Proximal acinar)
● Abnormal dilation or destruction of the
respiratory bronchiole, the central portion
of the acinus. It is commonly associated
with cigarette smoking,
Panacinar emphysema
● Refers to enlargement or destruction of all
parts of the acinus.
● Seen in alpha-1 antitrypsin deficiency and
in smokers
Paraseptal emphysema
● Distal acinar
● the alveolar ducts are predominantly
affected
Pulmonary Vasculature
● Intimal hyperplasia and smooth muscle
hypertrophy or hyperplasia thought to be
due to chronic hypoxic vasoconstriction of
the small pulmonary arteries
● Destruction of alveoli due to emphysema
can lead to loss of the associated areas of
the pulmonary capillary bed and pruning of
the distal vasculature
Risk Factors for COPD
● Cigarette smoké
● Occupational dust and chemical
● Environmental tobacco smoke ETS
● Indoor and outdoor air pollution
● Genes
● Infections
● Socio-economic status
Genetics
● Alpha 1-antitrypsin deficiency is a genetic
condition that is responsible for about 2%
of cases of COPD.
● In this condition, the body does not make
enough of a protein,alpha 1-antitrypsin.
● Alpha 1-antitrypsin protects the lungs from
damage caused by protease enzymes,
such as elastase and trypsin, that can be
released as a result of an inflammatory
response to tobacco smoke
Symptoms of COPD
● Chronic and progressive dyspnea, cough,
and sputum production that can be variable
from day-to-day.
● Dyspnea: Progressive, persistent and
characteristically worse with exercise.
● Chronic cough: May be intermittent and
may be unproductive.
● Chronic sputum production: COP patients
commonly cough up sputum.
Other Clinical Features
● Wheezing
● Chest tightness
● Wt.loss
● Respiratory infections
Physical Signs:
*Inspection:
● Barrel-shaped chest
● Accessory respiratory muscle participate ,
● Prolonged expiration during quiet
breathing.
● Expiration through pursed lips
● Paradoxical retraction of the lower
interspaces during inspiration (ie, hoover's
sign)
● Tripod Position
Tripod Position
● Patients with end-stage COPD may adopt
positions that relieve dyspnea, such as
leaning forward with arms outstretched and
weight supported on the palms or elbows.
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Chest X-Ray- Emphysema
Clinical Manifestations ● Marked over inflation is noted with flattened
*Palpation: and low diaphragm
● Decreased fremitus vocalis ● Intercostal space becomes widen
*Percussion: ● A horizontal pattern of ribs
● Hyperresonant ● A long thin heart shadow
● Depressed diaphragm, ● Decreased markings of lung peripheral
● Dimination of the area of absolute cardiac vessels
dullness,
*Auscultation: CT(Computed tomography)
● Prolonged expiration ● Greater sensitivity and specificity for
● Reduced breath sounds; emphysen
● The presence of wheezing during quiet ● For evaluation of bullous disease
breathing
● Crackle can be heard if infection exist. Labortory Examination

*Diagnosis of COPD: Spirometry (Required to Blood examination

establish diagnosis) ● In excerbation or acute infection in airway,
leucocytosis may be detected.
Symptoms Sputum examination
● shortness of breath ● Streptococcus pneumonia
● chronic cough ● haemophilus influenzae
● sputum ● moraxella catarrhalis
● klebsiella pneumonia
Exposure to Risk Factors
● tobacco Arterial blood gas measurements (in hospital).
● occupation ● PaO2 < 8.0 kPa with or without PaCO, >
● indoor/outdoor pollution 6.7 kPa when breathing room air indicates
respiratory failure.
Diagnosis
● The presence of a post-bronchodilator Management
FEV1/FVC < 0.70 confirms the presence of Based on the principles of
persistent airflow limitation and thus of ● Prevention of further progress of disease
COPD. ● Preservation and enhancement of
pulmonary functional capacity
Classification of Severity of Airflow Limitation in ● Avoidance of exacerbations in order to
COPD improve the quality of life
In patients with FEV,/FVC<0.70:
1.Bronchodilators
● !"#$%&'%()*+%,-./%0%123%456+)786+
● Bronchodilators are central to the
● !"#$%9'%(:+65;86%<23%=%,-./%>%123% symptomatic management of COPD.
● Improve emptying of the lungs,reduce
456+)786+
dynamic hyperinflation and improve
● !"#$%?'%@6A656%?23%=%,-.B%>%<23% exercise performance .
456+)786+ Three major classes of bronchodilators:
● GOLD 4: Very Severe FEV, < 30% B2 - agonists:
predicted ● Short acting: salbutamol & terbutaline
*Based on Post-Bronchodilator FEV ● Long acting :Salmeterol & formoterol

Chest x-ray-Chronic bronchitis Anticholinergic agents:

● No apparent abnormality ● Ipratropium,tiotropium
● Or thickened and increased lung markings
are noted.

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Theophylline
● a weak bronchodilator, which may have
some anti-inflammatory properties
2. Glucocorticoids
● Regular treatment with inhaled
glucocorticoids is appropriate for
symptomatic patients with an
FEV1<50%pred and repeated
exacerbations.
● Chronic treatment with systemic
glucocorticoids should be avoided because
of an unfavorable benefit-to-risk ratio.
3. Combination Therapy
● Combination therapy of long acting B2-
agonistsand inhaled corticosteroids show a
significant additional effect on pulmonary
function and a reduction in symptoms.
● Mainly in patients with an FEV1<50%pred
4.Others:
● Antioxidant agents
● Mucolytic
Phosphodiesterase-4 Inhibitors
● In patients with severe and very severe
COPD (GOLD 3 and) and a history of
exacerbations and chronic bronchitis, the
hospodiesterase-4 inhibitor, roflumilast,
reduces xacerbations treated with oral
glucocorticosteroids.
Other Pharmacologic Treatments
● Influenza vaccines can reduce serious
illness. Pneumococcal polysaccharide
vaccine is recommended for COPD
patients 65 years and older and for COPD
patients younger than age 65 with an FEV1
< 40% predicted.
● The use of antibiotics, other than for
treating infectious exacerbations of COPD
and other bacterial infections, is currently
not indicated.
Oxygen Therapy
● Oxygen >15 h /d
● Long-term oxygen therapy (LTOT)
improves survival, exercise, sleep and
cognitive performance in patients with
respiratory failure.
● The therapeutic goal is to maintain Sa02 2
90% and Pa02 2 60mmHg at sea level and
rest.
Other Treatments
● •Pulmonary rehabilitation
● •Nutrition
● *Surgery:
○ Bullectomy
○ Lung volume reduction surgery
○ Lung transplantation
Smoking Cessation
● Smoking cessation has the greatest
capacity to influence nce the natural history
of COPD
● Pharmacotherapy and nicotine
replacement reliably increase long-term
smoking abstinence rates
● Nicotine replacement therapy (nicotine
gum, inhaler, nasal spray, transdermal
patch, sublingual tablet, or lozenge) as well
as pharmacotherapy with varenicline,
bupropion, and nortriptyline reliably
increases long-term smoking abstinence
rates and are significantly more effective
than placebo.
Brief Strategies to Help the Patient Willing to
Quit Smoking
● ASK - Systematically identify all tobacco
users at every visit
● ADVISE - Strongly urge all tobacco users
to quit
● ASSESS - Determine willingness to make
a quit attempt
● ASSIST- Aid the patient in quitting
● ARRANGE- Schedule follow-up contact.
Complications
● Pneumothorax
● Cor pulmonale
● Exacerbations of copd
● Respiratory failure
COPD Comorbidities
COPD patients are at increased risk for:
● Cardiovascular diseases
● Osteoporosis
● Respiratory infections
● Anxiety and Depression
● Diabetes
● Lung cancer
● Bronchiectasis
*These comorbid conditions may influence mortality
and hospitalizations and should be looked for
routinely, and treated appropriately.
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MODULE 6 Manifestation
Pneumothorax 1. Sudden pain tachypnea
· A pneumothorax is present when there is 2. Chest discomfort
air in the pleural space. Pneumothoraces 3. Air Hunger
are classified as spontaneous, which 4. Increased tympany on the chest wall
develop without preceding trauma or other 5. Decreased breath sounds on
obvious cause, and traumatic, which auscultation
develop as a result of direct or indirect
trauma to the chest. Diagnostic Exams
Hemothorax · Chest x-ray reveals area and degree of
· Hemothorax can be pathologically defined pneumothorax
as blood within the pleural space. The most · pCO2elevated
common cause of hemothorax is from · pH decreased
trauma resulting in injury to the chest wall,
intercostal arteries or veins, lung, General Management
mediastinum, or diaphragm. Goal of Treatment
· to evacuate the air or blood from the
Pneumothorax pleural space
· Partial or complete collapse of the lung due · is to relieve the pressure on your lung,
to an accumulation of air or fluid in the allowing it to re-expand.
pleural space · Depending on the cause of the
· Occurs when the parietal or visceral pleura pneumothorax, a second goal may be to
is breached, and the pleural space is prevent recurrences.
exposed to a positive atmospheric
pressure Nursing Interventions
· Provide nursing care for the client with
an endotracheal tube: suctionsecretions,
Types of Pneumothorax vomitus blood from nose, mouth, throat,
· Simple/Spontaneous Pneumothorax or via endotracheal tube;
· Traumatic/Open Pneumothorax · monitor mechanical ventilation
· Tension Pneumothorax · Restore/promote adequate respiratory
function
Simple/Spontaneous Pneumothorax
· The most common type of closed pneumothorax; air Complications
accumulates within the pleural space without an · Cardiac Tamponade
obvious caused Rupture of a small bleb on the o is a serious medical condition in
visceral that is most frequently produces this type of which blood or fluids fill the space
Simple pneumothorax. between the sac that encases the
heart and the heart muscle.
Traumatic/Open Pneumothorax · Respiratory Failure
· Air enters the pleural space through an opening in o Sudden threatening
the chest wall; usually caused by stabbing or gunshot o deterioration of the gas function of
wound the lungs
· May occur with trauma or procedures o Occurs when the lungs no longer
· Often accompanied by hemothorax meet the body’s metabolic needs
· AKA “sucking wound”

Tension Pneumothorax Respiratory Failure

· Air enters the pleural space with each inspiration but Defined clinically as:
cannot escape; causes increased intrathoracic · Pa02 of less than 50 mmHg
pressure and shifting of the mediastinal contents to · PaC02 of greater than 50 mmHg
the unaffected side (mediastinal shift) · Arterial pH of less than 7.35

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Causes
· CNS (Central nervous system)
depression- head trauma
· Sedatives Cyclical vomiting syndrome
(CVS)
· Diseases- MI
o is a disorder that causes
sudden, repeated attacks—
called episodes— of severe
nausea and vomiting.
· Congestive heart failure (CHF
· Pulmonary embolism
· Airway irritants-smoke
· Metabolic alkalosis
o pH of tissue is elevated beyond
the normal range (7.35– 7.45).
· Thoracic abnormalities or chest trauma.
Pathophysiology
· Decreased Respiratory Drive Brain
injury, sedatives, metabolic disorders
· impair the normal response of the brain
to normal respiratory stimulation
Hemothorax
· (derived from hemo- [blood] + thorax
[chest], plural hemothoraces) is an
accumulation of blood within the pleural
cavity.
· The symptoms of a hemothorax include
chest pain and difficulty breathing, while
the clinical signs include reduced breath
sounds on the affected side and a rapid
heart rate.
Pathophysiology
· There are two layers of pleura. One of
which covers the lung surface (visceral
pleura) and the other the inside of the
chest wall (parietal pleura).
The pathophysiology of pneumothorax include:
· Negative pressure.
· Breach.
· Collapse.
Causes
The most common cause of hemothorax is chest
trauma. Hemothorax can also occur in people who
have:
· Blood clotting defect
o is a condition that affects the way
your blood normally clots. The
clotting process, also known as
coagulation, changes blood from
a liquid to a solid.
o Sometimes, certain conditions
prevent blood from clotting
properly, which can result in
heavy or prolonged bleeding.
· Chest (thoracic) or heart surgery Death
of lung tissue (pulmonary infarction)
o A pulmonary infarction, also called
lung infarction, occurs when a
section of lung tissue dies
because its blood supply has
become blocked.
· Lung or pleural cancer -- primary or
secondary (metastatic, or from another
site)
o Pleural cancer occurs outside the
lungs in the chest or pleural cavity
and along the pleural lining, the
membrane that surrounds the
lungs and covers the inside of the
chest cavity.
· Tear in a blood vessel when placing a
central venous catheter or when
associated with severe high blood
pressure
· Tuberculosis
o Is a disease caused by bacteria
called Mycobacterium
tuberculosis. The bacteria usually
attack the lungs, but they can also
damage other parts of the body.
What are the symptoms of hemothorax?
The most common symptoms of hemothorax include:
· pain or feeling of heaviness in your
chest
· feeling anxious or nervous
· dyspnea, or having trouble breathing
· breathing quickly
· abnormally fast heartbeat
· breaking out in cold sweats
Diagnosis
· Chest x-ray
o Hemothorax is suspected
based on symptoms and
physical findings. Diagnosis is
typically confirmed by chest x-
ray.
Treatment
· Fluid resuscitation as needed
· Usually tube thoracostomy
· Sometimes thoracotomy
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Complications
· Losing a lot of blood from this condition
can cause your body to go into shock
because of the lack of blood and
oxygen.
· hypovolemic shock and permanent
damage to your organs, including your
heart, lungs, and brain.
· Blood getting into your chest cavity can
infect fluid in the area around your lungs
or empyema.
· An untreated empyema infection can
lead to sepsis, which happens when
inflammation occurs thro
Clinical Manifestations
The signs and symptoms associated with
pneumothorax depend on its size and cause.
· Pain.
· Minimal respiratory distress.
· Dyspnea.
· Central cyanosis.
· Chest expansion.
· Breath sounds.
· Tracheal alignment.
Medical Management / Pharmacological
Nursing Interventions
Nursing interventions appropriate for the patient are:
· Re-expansion.
o The patient is instructed to inhale
and strain against a closed glottis
to re-expand the lung and eject
the air from the thorax.
· Sterile covering.
o The opening is plugged by sealing
it with gauze impregnated with
petrolatum.
· Oxygen saturation.
o Pulse oximetry is used to monitor
oxygen saturation.
o is the fraction of oxygen-saturated
hemoglobin relative to total
hemoglobin (unsaturated +
saturated) in the blood.
MODULE 7
EMPHYSEMA & ACUTE RESPIRATORY DISTRESS
SYNDROME
Pulmonary Emphysema
· permanent distension of air spaces
· Major cause is cigarette smoking
Signs & Symptoms
· Barrel chest
· DOB
· Diminished breath sounds
· Decreased fremitus
· Hyperresonance
· Hypoxemia and hypercapnia
Three Types of Emphysema
● Centrilobular (centriacinar)
○ Most common
○ Affects upper lung region
● Panlobular (Lower lung)
○ commonly in smokers
● Paraseptal lower lobes
○ form blebs
○ spontaneous pneumothorax
Diagnostic Tests
● Chest radiograph
● Chest CT scan
● Pulmonary function tests
● Pulse oximetry
● Arterial blood gases
Therapy
● Alpha1-antitrypsin therapy
● Antacid: Aluminum Hydroxide gel
(alternaGEL)
● Antibiotic according to sensitivity of
infective organism
● Bronchodilators: terbutaline (Brethine),
aminophylline (Aminophyllin), theophylline
(Theo-dur);
● via nebulizer or metered-dose inhaler:
albuterol (Proventil), Ipratropium (Atrovent),
Metaproterenol ( Alupent)
● Diuretic: Furosemide (Lasix)
● Expectorant: quaifenesin (Robitussin)
● Steroids: hydrocortisone (Solu-Cortef),
methylprednisolone(Solu-Metrol)
● •Steroids (via nebulizer or metered-dose
inhaler) :beclomethasone (Vanceril),
Triamcinolone(Azmacort)
Treatment
1. Chest physiotherapy, postural drainage
and incentive spirometry
2. Dietary changes, including establishing a
diet high in protein, vitamin C, calories
3. Fluid intake up to 3,000 ml/day, and if not
contraindicated
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4. O2 therapy at 2-3 L/minute, transtracheal
therapy for home Oz therapy
5. Ultrasonic or mechanical nebulizer
treatments
Nursing Intervention
1. Administer low-flow Oz
2. Administer medications, as prescribed
3. Allow activity, as tolerated
4. Assess respiratory status, (V/S) and pulse
oximeter (O2 sat)
5. Assist with turning, coughing, and deep
breathing
6. Assist with diaphragmatic and pursed-lip
breathing
7. Place the patient in high Fowler's position
8. Maintain the patient's diet and administer
small, frequent feedings
9. Monitor and record the color, amount, and
consistency of sputum
10. Monitor and record cardiovascular status
and vital signs
11. Monitor intake and output and daily weights
12. Provide chest physiotherapy, postural
drainage, incentive spirometry and suction
● Massive transfusions
Complications
● Pulmonary fibrosis
● pneumonia (ventilator induced)
● pneumothorax
Signs and symptoms
● Dyspnea (audible, labored breathing,
shortness of breath)
● Tachypnea (abnormally rapid breathing)
● Severe hypoxemia (decreased oxygen
concentration in the blood)
● Pulmonary hypertension (high blood
pressure in the pulmonary arteries)
● Cyanosis (bluish discoloration of the skin
due to poor oxygenation of the blood)
● resence of abnormal deposits in the lungs
detected by chest x-rays)
Treatment
Mechanical ventilation:
● The overall goal is to maintain acceptable
gas exchange and to minimize adverse
effects in its application.

Three parameters are used:

ACUTE RESPIRATORY DISTRESS
SYNDROME (ARDS)
DISORDER OF RESPIRATORY FAILURE
● lung swelling and fluid build up in the air
sacs.
● It is a form of pulmonary edema
1. PEEP (positive end-expiratory pressure, to
maintain maximal recruitment of alveolar units)
2. mean airway pressure (to promote recruitment and
predictor of hemodynamic effects)
3. plateau pressure (best predictor of alveolar
overdistension).

Alternative Name Treatment

● DA NA LUNG OR WET LUNG ● Prevention, diagnosis and therapy of
● WHITE LUNG infections and superinfections
● SHOCK ● Minimizing the accumulation of pulmonary
● STIFF LUNG edema fluid without compromising renal
function.
Causes ● Adequate nutritional support.
Direct lung injury ● Corticosteroids: The initial regimen
consists of methylprednisolone 2 mg/kg
● Pneumonia
● To control the process in the lungs
● Aspiration of gastric contents
● Inhalation injury thatallows fluid to leak out of the blood
● Near drowning Pulmonary contusion vessels.
● At present there is no certain way to
● Fat embolism
● Reperfusion pulmonary edema post lung achieve
● this.
transplantation or pulmonarv embolectomy
● Certain steroid hormones have been
triedbecause they can combat
Indirect lung injury
● Sepsis inflammation, butthe actual results have
● Severe trauma been disappointing.
● To make sure the patient gets enough
● Acute pancreatitis
oxygen until the lung injury has had time to
● Cardiopulmonary bypass

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Pathophysiology
● Injury reduces normal blood flow to the
lungs, allowing platelets to aggregate.
● These platelets release substances, such
as serotonin, bradykinin and, especially,
histamine.
● These substances inflame and damage the
alveolar membrane and later increase
capillary permeability.
● At this early stage, signs and symptoms of
ARDS are undetectable
● Histamine and other inflammatory
substances increase capillary permeability,
allowing fluid to shift into the interstitial
space.
● As a result, the patient may experience
tachypnea, dyspnea, and tachycardia.
● As capillary permeability increases,
proteins and more fluid leak out, increasing
interstitial osmotic pressure and causing
pulmonary edema.
● At this stage, the patient may experience
increased tachypnea, dyspnea, and
cyanosis.
● Hypoxia (usually unresponsive to
increased fraction of inspired air),
decreased pulmonary compliance, and
crackles and rhonchi may also develop.
● Fluid in the alveoli and decreased blood
flow damage surfactant in the alveoli,
reducing the cells' ability to produce more.
● Without surfactant, alveoli collapse,
impairing gas exchange.
● Look for thick, frothy sputum and marked
hypoxemia with increased respiratory
distress.
● The patient breathes faster, but sufficient
oxygen (O2) can't cross the
alveolocapillary membrane.
● Carbon dioxide (CO2), however, crosses
more easily and is lost with every
exhalation. O2, and CO2, levels in the
blood decrease.
● Look for increased tachypnea, hypoxemia,
hypocapnia
● Pulmonary edema worsens.
● Meanwhile, inflammation leads to fibrosis,
which further impede, gas exchange.
● The resulting hypoxemia leads to metabolic
acidosis.
● At this stage, look for increased partial
pressure of arterial carbon dioxide,
decreased pH and partial pressure of
arterial oxygen, and mental confusion.
Nursing Management of ARDS
● Perform early clinical determination of
respiratory difficulty.
● Perform objective assessment with arterial
blood gas and chest radiograph.
● Provide supplemental oxygen, monitor
saturation, and investigate risk factors for
ARDS.
● Determine the need for intubation and
mechanical ventilation:
○ Use low tidal volume, low plateau
pressure, lung-protective ventilator
strategies.
○ Optimize fluid status, nutrition, and
pulmonary toilet, and treat
complications.
○ Consider transfer to tertiary centers
for clinical trials and advanced
techniques.
MODULE 8
Acute Respiratory Failure
· Respiratory failure is not a disease but a
symptom of an underlying condition
affecting lung function, O2 delivery,
cardiac output (CO) or the baseline
metabolic state. It is a condition that
occurs because of one or more diseases
involving the lungs or other body
systems.
ACUTE RESPIRATORY FAILURE
● Sudden and life-threatening deterioration of
the gas-exchange function of the lungs
● Occurs when the lungs no longer meet the
body's metabolic needs
● Defined clinically as:
○ Pa02 of less than 50 mmHg
○ PaC02 of greater than 50 mmHg
○ Arterial pH of less than 7.35
Causes of Acute Respiratory Failure
● CNS depression- head trauma, sedatives
● CVS diseases- MI, CHF, pulmonary emboli
● Airway irritants- smoke, fumes
● Endocrine and metabolic disorders-
myxedema, metabolic alkalosis
● Thoracic abnormâlities- chest trauma,
pneumothorax
ALVAERA, M., YTABLE A. 25
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Pathophysiology
Decreased Respiratory Drive
● Brain injury, sedatives, metabolic disorders
to > impair the normal response of the
brain to normal respiratory stimulation
● Dysfunction of the chest wall
○ Dystrophy, MS disorders, peripheral
nerve disorders
■ disrupt the impulse
transmission from the nerve
to the diaphragm
■ abnormal ventilation
● Dysfunction of the Lung Parenchyma
○ Pleural effusion, hemothorax,
pneumothorax, obstruction>
interfere ventilation > prevent lung
expansion
Assessment Findings
● Restlessness
● dyspnea
● Cyanosis
● Altered respiration
● Altered mentation
● Tachycardia
● Cardiac arrhythmias
● Respiratory arrest

Diagnostic Findings
● Pulmonary function test- pH below 7.35
● CXR- pulmonary infiltrates
● ECG- arrhythmias

Medical Treatment
● Intubation
● Mechanical ventilation
● Antibiotics
● Steroids
● Bronchodilators

Nursing Interventions
● Maintain patent airway
● Administer 02 to maintain Pa02 at more
than 50 mmHg
● Suction airways as required
● Monitor serum electrolyte levels
● Administer care of patient on mechanical
ventilation

ALVAERA, M., YTABLE A. 26