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Ms. Gleason N520

Thursday, October 27, 2016
Chapters 34-36
Please take one PowerPoint packet, one of each handout, one
straw, and one paper towel tube

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• Step two: Text MOLLYGLEASON370 to “37607” to join the poll
• Step three: For each question, text the letter (A, B, C, or D) that corresponds with the
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Learning Objectives

Identify the structures of the pulmonary system

Identify the functions of the pulmonary system
C of pulmonary alterations
Be able to recognize clinical manifestations
Be able to identify disorders of the chest wall and pleura
Be able to identify lung disorders

Let’s get started!


Structure and Function of the Pulmonary System

Page 1225-1247
Structures of the Pulmonary System
• What is the purpose of the pulmonary system?
• The exchange of gases between the air we breathe and the blood in our bodies
• How does this occur?
• Ventilation
• Movement of air in and out of our lungs
• Diffusion
• Movement of gas between our lungs and our blood
• Perfusion
• Movement of blood into our lungs to our organs and tissues
• What system is in charge of this?
• Cardiovascular
Upper Airways

• Nasopharynx
• Oropharynx
• Ciliated mucosa
• Warms, filters, and humidifies the air
• Connected to the lower airways by
the larynx
Lower Airways
• The trachea connects the larynx to the bronchi
• Divides at the carina into two bronchi
• Right
• Larger and more vertical
• Left
• Smaller
Lower Airways
• The bronchi connect to the lungs
via the hila
• The bronchi divide into terminal
bronchioles and end in the
respiratory bronchioles
• These end in alveolar ducts, and
then alveolar sacs
• The bronchioles and alveoli are
responsible for gas exchange
• Lungs
• Right
• Lobes
• Upper
• Middle
• Lower
• Left
• Lobes
• Upper
• Lower
• When you are upright, gravity pulls the lungs down
Blood Vessels
• Blood vessels
• Responsible for gas exchange
• What controls the pulmonary
• Hint: It also controls the systemic
• The autonomic nervous system
• The entire amount of blood from the right
ventricle enters the pulmonary artery
• The alveolocapillary membrane is where
gas exchange occurs
• Thin with a large surface area
• The pulmonary capillaries drain into the
pulmonary veins which then enter the left
• Alveoli
• Primary area for gas-exchange
• Oxygen enters the blood
• CO2 is removed from the blood
• Adults have 480 million alveoli
• Surfactant
• Causes expansion during inspiration, lowers surface
tension at the end of expiration, and prevents lung
Thoracic Cage
• Thoracic cage
• Also called the chest wall
• Protects the lungs and performs the work of breathing
• The pleura is a serous membrane that adheres to the lungs
(visceral pleura) and to the chest wall (parietal pleura)
• The area between these two pleura is called the pleural space
• It is normal to have a thin layer of fluid in the pleural space to
allow for the two to slide over each other
• Has a negative pressure

• Diaphragm
• Performs the work of breathing
• Inhale: diaphragm contracts and flattens
• Exhale: diaphragm relaxes

• Mediastinum
• Space between the lungs that contain the
heart, great vessels, and esophagus
• Ventilation
• The movement of gas or air into and out of the
• Involuntary process by the respiratory center/ANS
• Often misnamed respiration (which is actually
the exchange of O2 and CO2)
• Cellular metabolism creates CO2
• CO2 must be eliminated to maintain a normal
PaCO2 (40 mmHg) and a normal acid-base
• How can you determine adequate ventilation?
• Hint: not by respiration rate
• Arterial blood glass analysis
Muscles of Breathing
• Inspiration
• Major muscles
• Diaphragm
• When it contracts, it flattens downward,
which increases the volume of the
thoracic cavity and creates a negative
pressure, which draws gas into the lungs
• External intercostal muscles
• When they contract, this elevates the
anterior portion of the ribs, which
increases the volume of the thoracic
cavity Accessory muscles
• Sternocleidomastoid
• Scalene
• Used with an increased work of breathing
Muscles of Breathing
• Expiration
• Normally is a passive process, no muscles used
• Elastic recoil
• The lungs return to normal state after inspiration
• Compliance
• Measure of the lung and chest wall’s stretch ability
• Increased = loss of elastic recoil
• Decreased = stiff and difficult to inflate lungs
Alveolar Surface Tension
• Alveolar Surface Tension
• Surface tension makes expansion more difficult
• Surfactant lowers the surface tension of the alveoli
• Lines the alveolar side of the alveolocapillary membrane
• Prevents alveolar collapse
Airway Resistance

• Airway resistance
• Normally low
• Increases as the diameter of the airway decreases
• Increased with bronchoconstriction or edema
• Decreased with bronchodilation
Gas Transport: Steps
• Gas Transport
• Delivers O2 to the cells
• 1. Ventilation of the lungs
• 2. Diffusion of O2 from the alveoli into the
capillary blood
• 3. Perfusion of the systemic capillaries with
oxygenated blood
• 4. Diffusion of oxygen from systemic
capillaries into the cells
• 1 L of O2 is delivered to the cells every minute
Gas Transport: Steps

• Removal of CO2 from the cells

• 1. Diffusion of CO2 from the cells into
the systemic capillaries
• 2. Perfusion of the pulmonary capillary
bed by venous blood
• 3. Diffusion of CO2 into the alveoli
• 4. Removal of CO2 from the lungs by
• CO2 is a byproduct of cellular
Ventilation Video

Normal Age Related Changes to the Respiratory System

Age-related Changes
• Loss of elastic recoil
• Stiffening of chest wall
• Changes in gas exchange
• Increase in flow resistance
• Alveoli lose surface area
• Ribs become ossified
• Joints become stiffer
• Respiratory muscle strength decreases
• Vital capacity decreases
• Residual volume increases
• Increased risk of inflammation and infection
• Chemoreceptors lose sensitivity to gas partial pressures
• Greater risk for respiratory depression caused by medications

Alterations of Pulmonary Function

Page 1248-1289

• Discomfort with breathing, shortness of
breath, chest tightness, increased work of
• More severe symptoms include nasal
flaring, accessory muscles, retraction of
intercostal spaces
• Can be at rest, on exertion
• Orthopnea = when lying flat
• Paroxysmal nocturnal dyspnea = wakes
you up at night, must sit up to relieve the

• Cough
• Clears the airways by forced expiration
Abnormal Sputum

• Abnormal sputum
• Observe amount, consistency, color, and odor
• Hemoptysis = coughed up blood
Abnormal Breathing Patterns
• Eupnea = normal breathing pattern (8-16 breaths per minute) with tidal volume
between 400-800 mL and 10-12 sigh breaths per hour
Kussmaul Respirations
• Kussmaul respirations = tachypnea, increased ventilatory rate, large tidal volume, and
no expiratory pause
Labored Breathing

• Labored breathing = increased work of breathing

• Cheyne-Stokes respirations = alternating periods of deep and shallow breathing,
apnea of 15-60 seconds followed by ventilations that increase in volume until a peak is
reached, then back down to apnea

• Hypoventilation
• Inadequate alveolar ventilation in relation to metabolic demands
• CO2 removal does not keep up with CO2 production and paCO2 increases, causing hypercapnia and
respiratory acidosis
• Hyperventilation
• Alveolar ventilation that exceeds metabolic demands
• Lungs remove CO2 faster than it is produced by cellular metabolism, causing hypocapnia and respiratory

• Cyanosis
• Blue discoloration of the skin and mucous membrane
• Caused by increased amount of desaturated
• Peripheral = fingers and toes (best seen in the nail beds)
• Central = mucous membranes and lips
• Clubbing
• Enlargement of the end of a digit from an interference in oxygenation
• Pain
• In the pleurae, airways, or chest wall
• Hypercapnia
• Increased CO2 concentration in the arterial blood
• Hypoxemia
• Reduced oxygenation of arterial blood
• Hypoxia
• Reduced oxygenation of cells in the tissues
• Acute respiratory failure
• Inadequate gas exchange

Flail Chest
• Flail chest
• From rib fracture, causes paradoxical chest movement
• When the intrathoracic pressure is negative during inspiration, the fractured chest wall moves
inward and during expiration it moves outward, impairing gas exchange
• Pneumothorax
• Presence of air or gas in the pleural space,
causes pain, tachypnea, and absent breath
sounds on the affected side
• Different types
• Open pneumothorax: can be spontaneous or
• Tension pneumothorax
• Air is drawn in at the through the site of the
pleural rupture, air enters on inspiration, but
cannot escape during expiration
• As more and more air is drawn in, the pressure
in the pleural space exceeds the barometric
• This pressure compresses the already recoiled
lung and the heart and great vessels
• Causes hypotension tracheal deviation away
from the affected lung
• Insertion of chest tube is needed
Pleural Effusion
• Pleural effusion
• Presence of fluid in the pleural space
• Chylothorax: chyle
• Hemothorax: blood
• Empyema: pus, infected pleural effusion
• Clinical Manifestations: Dyspnea, cough,
chest pain
• Treatment: Antibiotics, thoracentesis, or
chest tube
Restrictive Lung Disorders

• Restrictive lung disorders: caused by decreased compliance of the lungs

• Takes more effort to inflate the lungs
• Chest wall restriction
• Restricted breathing = stiffened lungs/chest wall, decreased compliance, small tidal volumes
and tachypnea
• Compromised ventilations and decreased tidal volume
• Causes: obesity, kyphoscoliosis, pectus excavatum, muscular dystrophy
• Common findings are dyspnea, increased respiratory rate, decreased tidal volume, and a
decrease in FVC
• Aspiration
• Passage of fluid and particles into the lungs
• The right lung is more susceptible because the branching angle is straighter than that of the left
main stem bronchus
• Clinical manifestations: sudden onset of choking, cough, vomiting, fever, dyspnea, wheezing
• Treatment: Oxygen, mechanical ventilation, fluid restriction to reduce pulmonary edema,
corticosteroids, and antibiotics
• Collapse of lung tissue
• Three types
• Compression: caused by external pressure exerted on
the lung tissue (tumors, fluid, or air)
• Absorption: caused by gradual absorption of air
• Surfactant: caused from decreased surfactant
• Clinical manifestations: dyspnea, cough, fever,
• Treatment: deep breathing exercises, position
changes, early ambulation
Pulmonary Fibrosis

• Pulmonary Fibrosis
• Excessive amount of fibrous or connective tissue in the lung
• Clinical manifestations: loss of lung compliance, decrease in
the diffusing capacity, hypoxemia, dyspnea on exertion,
inspiratory crackles
• Treatment: avoidance of the triggers, corticosteroids, cytotoxic
drugs, anti-fibrotic drugs, interferon, anticoagulation, lung
Pulmonary Edema
• Pulmonary Edema
• Excess water in the lung
• Most common cause = left-sided heart disease
• When the left ventricle fails, this causes an increase
in pulmonary capillary pressure. The fluid then
moves into the interstitial space. Normally, the
lymphatic system is able to remove this fluid, but
when the amount of fluid is too great, edema
• Clinical manifestations: dyspnea, orthopnea,
hypoxemia, increased work of breathing,
inspiratory crackles, S3 gallop, pink frothy
• Treatment: correct the cause, diuretics,
vasodilators, drugs to increase contractility of
the heart, supplemental oxygen, end-
expiratory pressure ventilation
Obstructive Pulmonary Disease

• Obstructive pulmonary disease: airway obstruction that is worse with expiration

• More force is used to empty the lungs and it takes more time
• Major signs include dyspnea and wheezing
• Asthma (Acute Attack)
• Chronic inflammation of the bronchial
mucosa that causes bronchial hyper-
response, airway constriction, and variable
airflow obstruction
• Phases
• Early asthmatic response
• Late asthmatic response
• Airway remodeling
• Clinical manifestations: chest constriction,
wheezing, dyspnea, nonproductive cough,
prolonged expiration, tachycardia,
tachypnea, pulsus paradoxus, bronchospasm,
status asthmaticus
• Treatment: oxygen administration, inhaled
beta-agonist bronchodilators, corticosteroids
• COPD (Chronic Obstructive Pulmonary
• The third leading cause of death in the US
• Chronic bronchitis
• Hypersecretion of mucus and chronic productive
• Emphysema
• Abnormal permanent enlargement of gas-exchange
airways accompanied by destruction of alveolar
walls, loss of elastic recoil
• Clinical Manifestations: decreased exercise
tolerance, wheezing, shortness of breath,
productive cough, tripod position, increased AP
diameter (barrel chest) thin stature, right sided
heart failure
• Treatment: inhaled bronchodilators, deep
breathing, postural drainage, pursed-lip
breathing, oxygen, mechanical ventilation, oral
corticosteroids, antibiotics
Respiratory Tract Infections
• Pneumonia
• Infection of the lower respiratory tract
• Sixth leading cause of death in the US
• Clinical manifestations: URI, cough,
dyspnea, fever, chills, malaise, pleuritic
chest pain
• Treatment: antibiotics and supportive
• Tuberculosis
• Mycobacterium tuberculosis infection of the lungs
• Transmitted through airborne droplets
• If a bacilli is inspired, it is then isolated, and forms a
• This can stay dormant for life and may never become an
active disease
• Will still have a positive PPD (skin test)
• Clinical manifestations: asymptomatic until the
disease is active, then fatigue, weight loss, lethargy,
anorexia, low-grade fever, night sweats, cough with
purulent sputum, dyspnea, chest pain, hemoptysis
• Treatment: antibiotic combinations (isoniazid,
rifampin, pyrazinamide, ethambutol)
Pulmonary Vascular Disease
Pulmonary Embolism
• Pulmonary embolism
• Occlusion of the pulmonary artery or its branches by
an embolus (most often from a DVT)
• Can be thrombotic, tissue, lipid, foreign body, or air
• Clinical manifestations: sudden pleuritic pain,
dyspnea, tachypnea, tachycardia, anxiety, fainting,
• Treatment: heparin, filter placement, oxygen, fluids,
fibrinolytic agent, embolectomy
Pulmonary Artery Hypertension

• Pulmonary artery hypertension

• A mean pulmonary artery pressure
greater than 25 mmHg at rest
• Clinical manifestations: peripheral
edema, JVD
• Treatment: oxygen, diuretics,
vasodilators, and anticoagulants
Cor Pulmonale
• Cor Pulmonale (Right Sided Heart Failure)
• Secondary to pulmonary artery hypertension, right ventricular enlargement from chronic
pressure overload and overwork of the right ventricle
• Clinical manifestations: decrease in cardiac output with exercise, chest pain, pulmonic valve
murmur, peripheral edema, hepatic congestion, JVD
• Treatment: oxygen, diuretics, and anticoagulants
Malignancies of the Respiratory Tract
Laryngeal Cancer
• Laryngeal cancer
• Clinical manifestations: hoarseness, dyspnea, and cough
• Treatment: chemotherapy and radiation, surgery
Lung Cancer
• Lung cancer
• Non-small cell lung cancer
• Large cell carcinoma
• Neuroendocrine lung tumors
• Clinical manifestations: chest pain,
coughing, excessive sputum production,
hemoptysis, pneumonia, airway obstruction,
pleural effusions, weight loss
• Treatment: chemotherapy and radiation,

Alterations of Pulmonary Function in Children

Page 1290-1318
Alterations of Pulmonary Function in
• Smaller diameter airways
• Until the third month of age, infants are obligatory nose breathers
• Surfactant production starts at 20-24 weeks gestation, and is complete by 30 weeks
• Higher chest wall compliance which leads to paradoxical breathing
• Basal metabolic rate is greater, so the oxygen consumption is greater per unit of body
• Until the third week of age, there is a blunted ventilatory response for hypoxia
Disorders of the Upper Airways
• Infections
• Croup
• Acute Epiglottitis
• Tonsillar Infections
• Bacterial Tracheitis
• Retropharyngeal Abscess
• Aspiration of Foreign Bodies
• Angioedema
• Congenital Malformations
• Laryngomalacia and Tracheomalacia
• Vocal Cord Paralysis
• Obstructive Sleep Apnea Syndrome
Disorders of the Lower Airways
• Disorders of the Lower Airways
• Respiratory Distress Syndrome of the Newborn
• Bronchopulmonary Dysplasia
• Respiratory Tract Infections
• Bronchiolitis
• Pneumonia
• Aspiration Pneumonitis
• Bronchiolitis Obliterans
• Asthma
• Acute Respiratory Distress Syndrome
• Cystic Fibrosis
Sudden Infant Death Syndrome
• Most common cause of unexplained infant death in Western countries
• Characterized by a sudden, unexplained death of an infant under 1 year of age which
remains unexplained after a thorough case investigation (complete autopsy, examination of
death scene, and review of clinical history)
• Incidence peaks between ages 2-4 months
• More common in male infants
• Almost always occurs during nighttime sleep
• Avoidable risk factors:
• Prone positioning
• Soft bedding
• Overheating
• Bed sharing with an adult
• Parent who smokes
• Identify the structures of the pulmonary system
• Upper and lower airways
• Identify the functions of the pulmonary system
• Ventilation, diffusion, perfusion
• Be able to recognize general clinical manifestations of pulmonary alterations
• Dyspnea, cough, sputum, abnormal breathing patterns, cyanosis, clubbing
• Be able to identify disorders of the chest wall and pleura
• Flail chest, pneumothorax, pleural effusion
• Be able to identify lung disorders
• Restrictive
• Aspiration
• Atelectasis
• Pulmonary fibrosis
• Systemic
• Pulmonary edema
• Obstructive
• Asthma
• Infections
• Pneumonia
• TB
• Acute bronchitis
• Pulmonary vascular disease
• PE
• Cor Pulmonale
• Cancer
• Laryngeal cancer
• Lung cancer

Please read Chapters 40-42 in your McCance textbook as Mrs. Huffman-Frazee will
be going over musculoskeletal system at our next class on November 10.

Please complete the on-line post lecture quiz:
• McCormack, M, Stoller, J, Hollingsworth, H. (2016, September). Diffusing capacity. UpToDate.
Retrieved from
• Mayo Clinic. (2014, July 11). Spirometry. Retrieved from
• Mayo Clinic. (2015, December 25). Hypoxemia. Retrieved from
• NCLEX – Respiratory. (2014). Retrieved from
• Rinehart, W. Hurd, C. Sloan, D. (2010, December 27). NCLEX-RN Exam Cram: Caring for the Client
with Disorders of the Respiratory System. Pearson. Retrieved from