THE RESPIRATORY

SYSTEM

RESPIRATORY SYSTEM

NATOM
Y AND
HYSIOL
OGY

Nose

UPPER RESPIRATORY

Paranasal Sinuses
Pharynx
Larynx
Trachea

LOWER RESPIRATORY

LUNGS
PLEURA
MEDIASTINUM
LOBES

The
lungs

TRACH EA
P R IM A R Y B R O N C H I
SE C O N D A R Y BR O N C H U S
( 2 in L eft lu n g , 3 in R I g h t lu n d )
T E R T IA R Y B R O N C H U S

B R O N C H IO L E S

A l ve o l ar Duc t s
A l ve o l i

The Alveoli of the Lungs

Structures of the
Respiratory Zone

GAS
EXCHANGE

CHEST
WALL

The Pleura

Function of
Respiratory
System

OXYGEN TRANSPORT

VENTILATI
ON

Mechanics of Breathing
Ventilation is the movement of air into and out of

the lungs. Air moves from an area of higher

pressure to an area of lower pressure.

Inspiration occurs when the diaphragm

contracts and the external intercostal muscles lift

the ribcage, thus increasing the volume of the
thoracic cavity.
Expiration occurs when the diaphragm relaxes
and the internal intercostal muscles depress the
ribcage, thus decreasing the volume of the
thoracic cavity.

Mechanics of Breathing

Mechanics of Breathing
Lungs tend to collapse because of the

elastic recoil of the connective tissue,

and surface tension of the fluid lining the
alveoli.
The lungs normally do not collapse

because surfactant reduces the surface

tension of the fluid lining the alveoli, and
the visceral pleura tends to adhere to the
parietal pleura.

GAS EXCHANGE

PULMONARY DIFFUSION

ASSESSMENT
HEALTH HISTORY
PHYSICAL EXAMINATION
LABORATORY/ DIAGNOSTIC

TEST

HEALTH HISTORY
A. Presenting Problem: Subjective Data

1. Nose/ nasal sinuses

2. Throat
3. Lungs
a. Cough
b. Dyspnea
c. Wheezing
d. Chest pain

B. Lifestyle : smoking, occupation,

C. Nutrition / diet :
D. Past medical history

PHYSICAL EXAMINATION
A. Inspection for configuration of the chest
B. Rate and pattern of breathing
C. Palpate skin, subcutaneous structures, &
muscle for texture, temperature, & degree of
development.
D. Palpate for tracheal position, respiratory
excursion and fremitus
E. Percuss for lung fields
F. Auscultate for normal and adventitious breath
sounds

Symptoms of Pulmonary Disease

Dyspnea
Sensation of breathlessness that is excessive

for any given level of physical activity.

Paroxysmal nocturnal dyspnea

Inappropriate breathlessness at night.

Orthopnea
Dyspnea on recumbency.

Platypnea
Dyspnea on the upright position relieved by

recumbency.

Symptoms of Pulmonary Disease

Persistent cough
Always abnormal
Chronic persistent cough may be caused by

cigarette smoking, asthma, bronchiectasis or

COPD.
May also be caused by drugs, cardiac
disease, occupational agents and
psychogenic factors.
Complications include (1) worsening of
bronchospasm, (2) vomiting, (3) rib
fractures,
(4) urinary incontinence, and (5) syncope.

Symptoms of Pulmonary Disease

Stridor
Crowing sound during

breathing.
Caused by turbulent airflow through a

narrowed upper airway.

Inspiratory stridor implies extratracheal
variable airway obstruction.
Expiratory stridor implies intratracheal
variable airway obstruction.

Symptoms of Pulmonary Disease

Wheezing
Continuous musical or whistling noises

caused by turbulent airflow through narrowed

intrathoracic airways.
Most, but not all, are due to asthma.

Hemoptysis
Expectoration of blood.
Often the first indication of serious

bronchopulmonary disease.
Massive hemoptysis: coughing up of more than
600 ml of blood in 24 hours.

Signs of Pulmonary
Disease
Tachypnea
Rapid, shallow breathing.
Arbitrarily defined as a respiratory rate in

excess of 20/min.

Bradypnea
Slow breathing.

Hyperpnea
Rapid, deep breathing.

Hyperventilation
Increase in the amount of air entering the

alveoli.

Signs of Pulmonary
Disease
Kussmaul respiration (air hunger)
Deep, regular sighing respiration, whether

the rate be normal slow or fast.

Occurs in diabetic ketoacidosis and uremia,
as an exaggerated form of bradypnea.

Cheyne-Stokes respiration
Commonest form of periodic breathing.
Periods of apnea alternate regularly with series of

respiratory cycles. In each series, the rate and

amplitude increase to a maximum followed
by cessation.

Signs of Pulmonary
Disease
Biot breathing
Uncommon variant of Cheyne-Stokes respiration.
Periods of apnea alternate irregularly with

series of breaths of equal depth that

terminate abruptly.
Most often seen in meningitis.

Cyanosis
Bluish discoloration of skin or mucous

membranes.
Presents as either central or peripheral cyanosis

Signs of Pulmonary
Disease
Percussion sounds (resonance,

dullness, hyperresonance)
Auscultatory sounds (vesicular,
bronchial, bronchovesicular)
Adventitious sounds
Abnormal sounds on auscultation
May be classified as continuous (wheezes,

rhonchi) or discontinuous (crackles,

crepitations)

Signs of Pulmonary
Disease
Wheezes
High-pitched sounds which results from

bronchospasm, bronchial or bronchiolar

mucosal edema, or airway obstruction by
mucus, tumors, or foreign bodies.

Rhonchi
Low-pitched sounds caused by sputum in

large airways and frequently clear after

coughing.

Signs of Pulmonary
Disease
Crackles
Generated by the snapping open of small

airways during inspiration.

Fine crackles are heard in interstitial
diseases, early pneumonia or pulmonary
edema, patchy atelectasis and in some
patients with asthma or bronchitis.
Coarse crackles are heard late in the
course of pulmonary edema or pneumonia.

Signs of Pulmonary
Disease
Fremitus
Voice vibrations on the chest wall.
Localized reduction in fremitus occurs over

areas of air or fluid accumulation in the lungs.

Increased fremitus suggests lung consolidation.

Bronchophony
Increased intensity and clarity of the

spoken word during auscultation.

Heard over areas of consolidation or lung
compression.

Signs of Pulmonary
Disease
Whispered pectoriloquy
Extreme form of bronchophony in which

softly spoken words are readily heard

by auscultation.

Egophony
Auscultation of an a sound when the

patient speaks an e sound.

Laboratory/
Diagnostic
Tests

Arterial Blood Gases

A measurement of oxygen, CO2, and the pH of

the blood that provides a means of

assessing the adequacy of ventilation
(Paco2), oxygenation (PaO2).
Allows assessment of the acid-base (pH) status
of the body whether acidosis or alkalosis is
present.
Allows evaluation of response to clinical

interventions and diagnostic evaluation (oxygen

therapy, exercise testing).

Interpret ABG values by looking at the following

(normal values are listed):
PaO2partial pressure of arterial oxygen (80 to

100 mm Hg)
Paco2partial pressure of arterial carbon dioxide
(35 to 45 mm Hg)
Sao2arterial oxygen saturation (> 95%)
pHhydrogen ion concentration, or degree of

acid-base balance (7.35 to 7.45);

bicarbonate (HCO3-) ion primarily a metabolic

buffer22 to 26 mEq/L.

Routine Radiography
Integral part of the diagnostic

evaluation of diseases involving the

pulmonary parenchyma, the pleura, and
to a lesser extent, the airways and the
mediastinum.
Usually involves a postero-anterior
view and a lateral view.
Lateral decubitus views are often
useful for determining whether pleural
deformities represent freely flowing
fluid.

Chest Radiography

Ultrasonography
Used to assess various body

structures.
Used in conjunction with other
pulmonary diagnostic procedure such
as thoracentesis and biopsy to assess
fluid or fibrotic abnormalities.
Helpful in the detection and localization

of pleural fluid.

Computed Tomography
Offers several advantages over

conventional radiographs.
Use of cross-sectional images makes
it possible to distinguish between
densities.
Better at characterizing tissue densities
and providing accurate size of
lesions.

Computed Tomography

Magnetic Resonance
Imaging

Pulmonary Function Tests

Objectively measure the ability of the

respiratory system to perform gas

exchange by assessing ventilation,
diffusion and mechanical properties.
Composed of the spirometry test

and ventilation-perfusion (V/Q) test.

Pulmonary Function Tests

Spirometry
Allows for the determination of the presence

and severity of obstructive and

restrictive pulmonary dysfunction.
The hallmark of obstructive pulmonary
dysfunction is reduction of airflow rates.
Restrictive pulmonary dysfunction is
characterized by reduction in pulmonary
volumes.

Pulmonary Function Tests

Ventilation-Perfusion Lung Scan

(V/Q scan)
Assess lung ventilation and lung perfusion.
Measures the degree of ventilation of the

individual lung segments and the perfusion

of respective segments to detect any
shunting or mismatch.

Biologic Specimen
Collection
Sputum collection
Spontaneous expectoration or sputum

induction

Percutaneous needle aspiration

Usually carried out under CT or ultrasound

guidance.
Potential risks include intrapulmonary
bleeding and creation of a pneumothorax.

Biologic Specimen
Collection
Thoracentesis
Insertion of needles through the chest wall

into the pleural space to obtain a specimen

for diagnostic evaluation, removal of pleural
fluids, or to instill medication into the
pleural space.

Biologic Specimen
Collection
Bronchoscopy
Provides for direct visualization of the

tracheobronchial tree.
Rigid bronchoscopy is performed in an
operating room on a patient under general
anesthesia.
Flexible bronchoscopy may be done
under local anesthesia / sedation.
Diagnostic uses include histologic
identification or neoplasms and
identification of sources of hemoptysis.

Biologic Specimen
Collection
Bronchoscopy
Therapeutic indications are retrieval of

foreign bodies and control of bleeding.

Biologic Specimen
Collection
Video-Assisted Thoracic Surgery

(VATS)
Operator can biopsy lesions of the pleura

under direct vision for both diagnostic and

therapeutic purposes.

Thoracotomy
Frequently replaced by VATS.
Provides the largest amount of biologic

specimen for histologic study.

ANALYSIS
Nursing Diagnoses
a. Impaired gas Exchange
b. Ineffective breathing Pattern
c. Impaired Verbal Communication
d. Impaired Airway Clearance
e. Activity Intolerance
f. Anxiety
g. Impaired Nutrition: Less than body
requirements
H. Risk for infection

PLANNING &
IMPLEMENTATION
Adequate Ventilation will be maintained
Maintain of patent airway
Effective breathing patterns will be

maintained
Client will communicate in an effective
manner
Client will demonstrate increased tolerance
for activity
Anxiety will be reduced
Adequate nutritional status will be maintained
Clients remains free from infections

INTERVENTIONS

Chest Drainage Systems

Chest Physiotherapy
Oxygen Therapy
Tracheobronchial Suctioning
Postural Drainage

Chest
Physiotherapy

Chest physiotherapy is the

term for a group of treatments
designed
to
improve
respiratory efficiency, promote
expansion
of
the
lungs,
strengthen respiratory muscles,
and eliminate secretions from
the respiratory system.

 Postural drainage
Uses force of gravity to assist in

effectively draining secretions from

the lungs and into the central airway
where they can either be coughed
up or suctioned out.
- Patient is placed in a head or chest
down position and is kept in this
position for up to 15 minutes.

 Percussion
Consists of rhythmically striking

the chest wall with cupped hands.

Also called cupping, clapping,

or tapotement.
To break up thick secretions in

the lungs.
Performed on each lung segment

for one to two minutes at a time.

 Vibration
-To help break up lung secretions
- Could either be mechanical or manual
- Performed as the patient breathes deeply
- Manual : person performing the vibration
places his or her hands against the patient's
chest and creates vibrations by quickly
contracting and relaxing arm and shoulder
muscles while the patient exhales
- Repeated several times each day for about
five exhalations

 Turning
- Permits lung expansion
- Head of the bed can be elevated to
promote

drainage

- Critically ill patients and those

dependent on mechanical respiration
are turned once every one to two
hours around the clock.

 Coughing
-Helps break up secretions in the
lungs
-Patients sit upright and inhale
deeply through the nose
- Exhale in short puffs or coughs
- Repeated several times a day

 Deep Breathing
- Helps expand the lungs and
forces better distribution of the
air into all sections of the lung
- Done several times each day
for short periods

Nursing Management

Pt. Comfort
Non-restrictive clothing
Avoid eating before
Medicate for pain
Splint incisions

Nursing Management:
PERCUSSION and VIBRATION

Avoid eating
Comfort
Avoid restrictive clothing
Medicate
Splint for comfort
STOP c/o pain