LOADING

…
STRUCTURES
STRUCTURES OFOFTHE CONDUCTING
THE UPPER
AIRWAYS:
AIRWAYS:
1.1.NasalNasalCavity
Cavity
II.II.Pharynx
Pharynx
III.III.Larynx
Larynx
IV. Tracheobronchial tree

STRUCTURES
STRUCTURES OF THE
OFLOWER
THE
AIRWAYS:TISSUES:
RESPIRATORY
1.I.Trachea
Lungs
II.II.Bronchial
Alveoli Tree
III. Lungs
IV. Alveoli

STRUCTURAL
FUNCTIONAL DIVISION
Respiratory System
 NASOPHARYNX

LARYNGOPHARYNX
OROPHARYNX

Divisions of the PHARYNX

Conducting Airways
 LARYNX
Conducting Airways
 supported by HORSE-
SHOE C-SHAPED
CARTILAGES (C-rings)

 protection:
MUCOCILIARY BLANKET

 point of bifurcation:
CARINA
TRACHEA
Conducting Airways
 inactivates vasoactive substances
such as bradykinin

 converts angiotensin I to angiotensin

II

 reservoir for blood storage

 contains abundant heparin producing

cells located at the capillaries of the
lungs

Functions of the LUNGS

Respiratory Tissues
 Parts of the Respiratory System:
• Lungs – soft, spongy, elastic
structure, airtight chamber with
distensible walls; functional
structure of the respiratory
system; consists of an apex and
a base

• Lobules – functional units of the

lungs; consist of respiratory
bronchioles, alveoli and
pulmonary capillaries.

• Lung Tissues – made up of

elastin and collagen fiber that
encircle the airways and small
blood vessels.
 Parts of the Respiratory
System:
• Pleura – a thin, smooth, transparent, double-
layered serous membrane that lines the thoracic
cavity and encases the lungs; consists of a
visceral and parietal fluid layer.

• Pleural Space – area of negative pressures to

prevent lung from collapsing; contains pleural
fluid which separates the pleural layers.

• Alveoli – grapelike cluster, around 300 to 400

million in each lung where actual gas exchange
occur
 CIRCULATION
• the lungs are provided with a dual blood
supply:

Pulmonary Circulation – arises from the

pulmonary artery and provides for the
gas exchange functions of the lungs
Bronchial Circulation – distributes blood
to the conducting airways and
supporting structure of the lung.

• Heparin-producing cells – particularly

abundant in the capillaries of the lungs
where small clots are trapped.
Other Related Structures
MECHANICS OF BREATHING
 Ventilation – movement of air between
the atmosphere and the respiratory
portion of the lungs.
• Resistance – determined chiefly by the
radius of the airway through which the
air is flowing.
• Lung Compliance – refers to the ease
Compliant Lung
with which the lungs expands and
indicates the relationship between the
volume and the pressure of the lungs
Compliant Lung – distends easily when
pressure is applied
Noncompliant Lung – requires greater
than normal pressure to distend it.

SURFACE TENSION – result of air and liquid

interface, facilitated by type 2 cells Noncompliant Lung
MECHANICS OF BREATHING
 Perfusion – blood flow through the lungs

• Ventilation Perfusion Ratio (V/Q) – necessary

to meet adequate oxygenation of the blood.

 Diffusion – process by which oxygen and

carbon dioxide are exchanged at the air-blood
interface
 Intact and Normal Chest Normal nerve stimuli for Intact pleural
patent airway Anatomy Contraction and relaxation of membrane
Respiratory muscles

Normal Adequate Ventilation

Adequate amt
Contraction Of O2 in the
Of RV air
EFFECTIVE
Normal Adequate OXYGENATION Adequate Adequate amt
Pressure and Perfusion Diffusion Of RBC to
Resistance in Carry O2
The PV
Adequate bld
Intact Adequate Flow to the
Pulmonary Distribution of gases lungs
vessels

Adequate pumping Intact Blood Adequate Hgb

action of cardiac Vessels
muscles
Cerebral Cortex

Respiratory Control
NEUROLOGIC CONTROL
• Medulla Oblongata –
controls respiration and
expiration
• Pons – controls rate and
depth of ventilation
Apneustic center – lower
pons; stimulates the
inspiratory medullary
center to promote deep,
prolonged inspiration
Pneumotaxic center –
controls pattern of
respiration

• Cortex – allows voluntary

control of breathing
 Receptor Sites that Assists in
Breathing
• Central chemoreceptors – located in the
medulla; respond to an increase or
decrease in the pH

• Peripheral chemoreceptors – located in

the aortic arch and carotid arteries;
respond to changes in PaCO2 and pH.
 Receptor Sites that Assists in
Breathing
• Stretch Receptors – located in the alveoli
• Hering-Breuer reflex - stimulated when
the lungs are distended and inhibits
respiration so that the lungs do not
become over distended
• Proprioceptors – located in the muscles and
joints; respond to body movements
• Baroreceptors – located in the aortic arch and
carotid bodies; respond to an increase or
decrease in arterial blood pressure causing a
reflex hypoventilation or hyperventilation
 NURSING ASSESSMENT
Nursing History: Risk factor Analysis
Cancer:
♥ cigarette smoking – 3 or 4
clients who develop
laryngeal cancer have
smoked or currently smoke
♥ alcohol – act synergistically
with tobacco
♥ occupational exposure –
asbestos, wood dust,
mustard gas, petroleum
products,other noxious
fumes
♥ Age
♥ Genetic Predisposition
 Nursing History: Risk factor Analysis
Asthma
♥ heredity
Pollen ♥ environmental factors
Dust
Mite
Grains ♥ excitatory states, exercise,
changes in temperature,
strong odors
House Dust

Chronic Obstructive Pulmonary

Disease (COPD)
♥ cigarette smoke- leading risk
factor
♥ aging process
♥ hereditary and genetic
predisposition
 Nursing History: Risk factor Analysis

Pulmonary embolism
♥ thrombi – most of which
originated in the deep
calf, femoral, popliteal or
lilac veins
♥ major operations
♥ tumors, air, fat, bone
marrow, amniotic fluid
Pulmonary
Tuberculosis
♥ repeated close contact
with an infected person
♥ low income population,
poor nutrition
♥ residents of long term care
facilities or institutional
settings
♥ homeless people
♥ health care workers
exposed to active TB
a. Biographical and Demographic Data
• Name, sex, and living situation
• Age – lung cancer and chronic lung
Lung Cancer
disorders make the client appear
older

b. Current Health: Chief Complaint

Dyspnea – difficult, uncomfortable or

unpleasant breathing indicative of
the discrepancy between the need
for ventilation and the ability to meet
the need; one of the most common
manifestations of clients with
pulmonary and cardiac disorders
Cough – a reflex that facilitates the removal of secretions
and foreign materials from the tracheobronchial tree and
the lungs
- Dry, hoarse, congested, barking, wheezing,
bubbling
- weakness/paralysis of resp muscles, prolongrd
inactivity, depression of medullary fxn
- may cause stress incontinence
-SPUTUM

Characterististics:
• Dry irritative cough
• Severe changing cough
• Cough at night
• Cough at AM
• Hemoptysis – refers to the blood
expectorated from the mouth in the form of
gross blood, frankly bloody sputum, or blood-
tinged sputum

– Blood from nose – due to sniffing/irritation

– Blood from lungs – bright red, frothy, salty
taste, alkalinic with tickling sensation on
throat, burning/bubbling sensation on
chest
– Blood from stomach – dark in color, acidic
 Current Health: Chief
Complaint
Wheezing – produced when air passes
through partially obstructed or
narrowed airways on inspiration and
expiration; may be audible or maybe
heard only with stethoscope

Stridor – harsh, high-pitched sound

produced when air passes through a
partially obstructed or narrowed upper
airway on inspiration; associated with
respiratory distress
 Current Health: Chief Complaint
Chest Pain – caused by coughing and pleuritic
infections
– Onset, location and radiation
– Duration and character or quality
– Frequency
– Factors that predispose or relieve the
pain
– RETROSTERNAL PAIN
– PLEURITIC CHEST PAIN
Cyanosis – bluish discoloration of the skin and
mucus membrane which occur when the
level of the hemoglobin present in the blood
is reduced
 Symptoms Analysis
• Setting – time and place or particular situation –
physical setting and psychological environment
in which the client experiences the complaint
• Timing – onset and period during which the
problem has occurred; specific time of day
• Client’s perception – unique properties of the
complaint
• Quantity and quality – amount, size, number, and
extent of the chief complaint
• Location – to determine whether the problem is
cardiac or respiratory in origin
• Aggravating and relieving factors – what
precipitates worsens or alleviates a symptom?
• Associated manifestations – chills, fever, night
sweats, anorexia, weight loss, excessive fatigue,
anxiety, hoarseness
 Past Health History
• Childhood and Infectious Diseases – occurrence of
TB, bronchitis, influenza, asthma and pneumonia
;existence of congenital problems; premature birth
history.
• Immunization – vaccination against pneumonia and
influenza; date of vaccination
• Major Illnesses and Hospitalization – previous
hospitalization for respiratory problems; medical
treatment; and the present status of the problem
• Medications – prescribed and OTC medications;
herbal remedies many products affect the respiratory
system
• Allergies – foods, medications, pollens, smoke,
fumes, dust and animal dander, molds allergic
manifestations (chest tightness, wheezing, cough,
rhinitis, watery eyes, scratchy throat)
Family Health History
• Identify blood
relatives and family
members who have
had respiratory
disorders, age and
cause of death of
deceased family
member; household
members who
smoke
 Psychosocial History
• Occupation - work environment and
hobbies; exposure to dust, asbestos,
beryllium, silica and other toxins or
pollutants
• Geographical Location – recent travel to
areas where respiratory disorders are
prevalent
• Environment – living conditions; how many
are in the household
• Habits – history of smoking; use of
smokeless tobacco; alcohol use; use of
recreational drugs
• Exercise – typical activities
• Nutrition – amount of caloric intake
Concept of Oxygenation
•ASSESSMENT
Physical Assessment
• establish the baseline
information and provide
framework for the detection of
any changes that might occur in
a client’s condition
 Inspection
• Head and Neck – inspect for gross
abnormalities that would interfere with
respiration; odor of breath
● Note nasal flaring, breathing with pursed
lips, or cyanosis
• Chest – observe chest wall configuration;
size, contour, and anteroposterior
diameter
• INSPECTION
 HEAD and NECK


CHEST Chest Wall
Configuration
* SHAPE OF THE CHEST: elliptical
CHEST WALL DEFORMITIES
TYPE OF DEFORMITY DESCRIPTION ETIOLOGY
BARREL CHEST APD = TD Chronic Airflow Disorder
FUNNEL CHEST Sternum is Congenital in nature
(Pectus excavatum) DEPRESSED, narrowing
of the APD
PIGEON CHEST Sternum projects Congenital in nature
(Pectus carinatum) forward,
increased APD, wider TD
Thoracic Kyphoscoliosis Appearance: hunch- Congenital in nature,
over, hunch back spinal TB, osteoporosis,
RA, poor posture
Chest movement
 Retractions – most prominent in the
lateral chest; indicative of labored
breathing
 Respirations
 Biot’s Respiration – irregular periods of
apnea that are followed by several
breaths that are even in rate and depth
 Cheyne – Stokes respiration –
characterized by periods of
hyperventilation alternating with
periods of apnea
 Kussmauls respiration – increased
depth in breathing
C. Pattern
 Rate
 Volume
 IRREGULAR BREATHING PATTERNS
TYPES OF IRRGULAR BREATHING
PATTERN
KUSSMAUL’S RESPIRATION
CHEYNE-STOKES RESPIRATION
(also classified under APNEIC
BREATHING PATTERNS)
BIOT’S (Cluster) RESPIRATION
(also classified under APNEIC
BREATHING PATTERNS)
DESCRITPTION
Blows more carbon dioxide through
DEEP and RAPID BREATHING.
Marked rhythmic, WAXING and
WANING, from, VERY DEEP and
VERY SHALLOW breathing and
TEMPORARY APNEA.
Common with CHF, ICP and drug
overdose.
SHALLOW BREATHS interrupted by
APNEA.
Common with CNS disorders.
•
INSPECTION
 HEAD and NECK


CHEST Chest Wall
Chest Movement
Configuration
* normal
 FINGERS respiratory
and TOES rate (accdg.
to KOZIER)
 observe for = 12 – 22 cpm.
clubbing
* men: abdominal breathers
 perform the Schamroth’s Test
* women: thoracic breathers
 perform the Blanch Test
 SKIN
 Palpation
• Trachea – palpate for
masses, crepitus (air
in the subcutaneous
tissues), or deviation
from the midline
• Tacrile
Fremitus/Vocal
Fremitus
• Thoracic excursion
•
PALPATION TRACHEA
> Place the thumb of the palpating hand on one
side of the trachea and the remaining of the
fingers on the other side.
> Move the trachea gently from side-to-side along
its length while palpating for masses, crepitus or
deviations from the midline.
NORMAL FINDINGS: trachea is movable
and
CHEST WALL quickly returns to midline after
displacement.
> Holding the HEEL or ULNAR ASPECT OF THE
HAND against the client’s chest.
> Palpate for the ribs and intercostal spaces.
> Locate the angle of Louis (manubriosternal
junction) by first palpating the clavicle and
following its course of attachment at the
•
PALPATIONCHEST WALL: POSTERIOR THORACIC
> Place the palms of both hands overEXCURSION
the lower
thorax with the thumbs adjacent to the spine
and fingers stretched laterally.
> Ask the client to take a deep breath while
observing the movement of the hands an any lag
in movement.
NORMAL FINDINGS: full and symmetric chest
expansion (thumbs should move apart with an
equal distance at the same time. Approximately 3
to 5 cmWALL:
CHEST (1.5 to 2 in).
ANTERIOR THORACIC
EXCURSION
> Place the palms of both hands on the lower
thorax with fingers laterally along the lower rib
cage and thumbs along the costal margin.
> Ask the client to take a deep breath while
observing the movement of the hands and any
 Percussion
Sounds
• Resonant sounds – low pitch hollow sounds heard
over normal tissue
• Hyperresonant sounds – louder and lower pitch
than resonant which indicate increases amount of
air in the lungs or pleural space (EMPHYSEMA,
PNEUMOTHORAX)
• Dull sounds – thudlike and medium pitch and
normally heard over the liver and heart, occur over
dense lung tissue such as tumor or consolidation
• Flat notes – soft high pitch heard during percussion
of airless tissue (bony structure)
• Tympanic notes – high, drumlike sounds heard with
percussion over the stomach, a large tension on
pneumothorax or a large air-filled chamber
 •
AUSCULTATIO
NORMAL BREATH SOUNDS UPON AUSCULTATION
BREATH SOUNDS N DESCRIPTION LOCATION CHARACTERISTIC

VESICULAR Soft-intensity, low- Peripheral INSPIRATION.

pitched, “gentle- lungs,
sighing” sounds bases of the About 2.5 times
created by air lungs longer than the
moving through expiratory phase
smaller airways (2:1).
(bronchioles &
alveoli).

BRONCHOVESICULAR Moderate intensity Between the Equal inspiratory and

and moderate scapulae and expiratory phases
pitched blowing lateral to the (1:1).
sounds created by sternum at
air moving through the 1st and 2nd
larger airways ICS.
(bronchi).
 •
AUSCULTATIONORMAL BREATH SOUNDS UPON AUSCULTATION
BREATH SOUNDS N
DESCRIPTION LOCATION CHARACTERISTIC

BRONCHIAL High-pitched, loud, Trachea. Louder than

“harsh-sounds”. vesicular sounds.

Have short
inspiratory and long
expiratoryphases
(1:2).
 •
AUSCULTATIO
ABNORMAL BREATH SOUNDS UPON AUSCULTATION
BREATH N
DESCRIPTION COURSE LOCATION
SOUNDS
CRACKLES/ High-pitched. Air passing through fluid Bases of the
RALES Fine, short, interrupted or mucus in any air lower lung
crackling sounds. passage. lobes.
Sounds like rubbing
locks of hair between CONDITION:
thumbs and fingers Pulmonary Edema,
fibrosis, pneumonia
Heard during
INSPIRATION and do
not clear with cough
GURGLES/ Continuous, low- Air passing through Most lung
RONCHI pitched, coarse, narrowed air passages areas but are
gurgling, harsh, louder as a result of secretions, louder on the
sounds, with moaning swelling and tumors. trachea and
and snoring quality. CONDITION: bronchi.
PNEUMONIA,
EXPIRATION (can be BRONCHITIS,
heard on both) BRONCHIECTASIS
 •
AUSCULTATIO
ABNORMAL BREATH SOUNDS UPON AUSCULTATION
BREATH N
DESCRIPTION COURSE LOCATION
SOUNDS
FRICTION Superficial grating or Rubbing together Heard most often in
RUB creaking sound . of inflamed pleural areas of greater
“2 pcs of leather rubbing surfaces. thoracic expansion
together” (lower anterior and
CONDITION: lateral chest).
INSPIRATION and Pleurisy,
EXPIRATION Pneumonia, Pleural
infarct
WHEEZE Continuous, high- Air passing through On all lung fields.
pitched, squeaky, constricted
musical sounds. bronchus as a
result of secretions,
EXPIRATION. swelling or tumors.

CONDITION:
Asthma
 INSPECTION OF AN OBSTRUCTED AIRWAY

UPON INSPECTION INTERPRETATION

Low-pitched snoring sound during Partial obstruction of the upper

inhalation, labored breathing airway

Absence of sounds and rise and Complete/total airway obstruction

fall, accompanied (at times seen
with deep retractions)

Stridor (a harsh high-pitched sound Lower airway obstruction

heard during inspiration)

Other adventitious breath sounds

DIAGNOSTIC
PROCEDURES
 PULMONARY FUNCTION
TESTS
Nursing Responsibilities:
– Determine whether an analgesic
that may depress the respiratory
>function
Provide information about
is being administered.
– respiratory function
Advise the client not to SMOKE OR by
measuring
EAT A HEAVY lung
MEALvolume,
= 4 to 6lung
hrs
mehanics
before the test. and diffusion
– capabilities
Withhold of the lungs
BRONCHODILATOR
medications for 6 hrs before the
test.
 PULMONARY FUNCTION
TESTS
– Instruct the client to void before the
procedure and wear loose clothing.
– Remove dentures.
– The client is asked to breathe through
the mouth only. A nose clip is used to
prevent air from escaping. The client
is asked to perform different
breathing maneuvers while
measurements are obtained
 PULSE OXIMETRY

• Pulse oximeter measures the

• REMINDERS:
percentage of Hemoglobin saturated
– Sensor NOT placed distally in BP
with OXYGEN.
cuffs, pressure dressings etc.
– Sensor should NOT be taped into the
•finger.
Pulse oximeter passes a beam of
light through the tissue and the
– No dark nail polish.
sensor measures the AMOUNT of
– Normal O2 Sat. by
light absorbed 90-100%
O2- saturated
HgB.
 ARTERIAL BLOOD GAS
ANALYSIS
• Use of ARTERIAL BLOOD to
measure:
• Nurse’s
– PaO2, Responsibilities:
PaCo2, pH
– Educate the client regarding the
need for the test.
– Explain to the client the need to
hold still.
– Perform the Allen’s Test.
– Keep the client calm.
– 5 – 10 mL of arterial blood is
 ARTERIAL BLOOD GAS
Arterial Blood Gas Analysis
ANALYSIS
• A needle connected to a heparinized
syringe is utilized.
• Most common site for blood withdrawal
is the RADIAL ARTERY.
• Apply continuous pressure to the site for
5 minutes and 10 minutes for femoral
sites.
• Place specimen on a container with ice &
transport immediately to the lab.
 ABG INTERPRETATION
• Oxygenation Status
– O2 Therapy

• Acid – Base Interpretation

– pH: 7.35 – 7.45
– PaCO2: 35- 45 mmHg
– HCO3: 22- 26mEq/L

• Presence of and degree of compensation

 CHEST X – RAY
• Visualization of lungs, heart and
surrounding structures.
– Routine screening procedure
– Suspicion of pulmonary disease
– Monitor status of respiratory
disorders
– Evaluate extent of traumatic
chest injury
– Provide radiographic information
 CT SCAN
• Cross – sectional view of anatomic
structures.

MRI SCAN
• Use of magnetic field to provide a
more detailed imagery than a CT
scan.
• May permit visualization of
structures as they function.
 ULTRASONOGRAPHY
• Helpful and accurate in
detecting the amount and
location of 50mL or less of
pleural fluid.
• Permits visualization for
obtaining an adequate amount
of pleural fluid for laboratory
analysis without unnecessary
puncturing and probing.
• 15 – 30 minutes in duration.
 BRONCHOSCOPY
• Pre - procedure
• Post
– Explain. - procedure
Obtain informed consent. The test
• Diagnostic/ Therapeutic
lasts 30 – 45 minutes in duration.
– Monitor patient’s vital signs.
• Permits
– NPO 6 hoursvisualization
prior to the test. of the
– Take
– Client mustnote of dentures,
remove the patient’s
contact lenses
bronchial
andrespiratorytree via a lighted
status.
other prosthesis.
bronchoscope
– IV sedatives are administered to suppress
– Observe
cough expectorated secretions.
and anxiety.
– NPO
– Topical until reflex
anesthetic will be returns.
applied at the back
of the mouth to decrease the gag reflex.
– Feeding begins with ice chips.
– Patient is positioned supine with head
– Monitor lung sounds.
hyperextended.
– Inform the client that it is normal for the
client to feel sore in the throat and difficulty
 LARYNGOSCOPY
• Permits visualization of the
larynx
– INDIRECT
•Use of a mirror to visualize
nasopharynx for drainage,
bleeding and ulceration.
– DIRECT
•Use of an endoscope to
visualize the movement and
 ALVEOLAR LAVAGE
• Sterile saline injected to wet
the tissue, then aspirated to
examine atypical cells.
 PULMONARY
ANGIOGRAPHY
• Assessment of pulmonary vascular
structuressedation
-Administer throughasanprescribed
injection of a
contrast medium through an
- Avoid takingcatheter.
indwelling BP for 24 hrs in the
involved extremity
• NURSING RESPONSIBILITIES:
-Monitor peripheral
– Obtain informed neurovascular
consent
status of extremities
– Assess of allergies to iodine,
seafood & other rediopaque dyes
– NPO for 8 hrs before the test
 THORACENTESIS
• NURSING RESPONSIBILITIES:
Pre-procedure:
– Obtain informed consent
– Ask pt. to sit upright while leaning on
the tray table.
– Instruct the client to hold still.
Post-procedure:
- Position pt. on the UNAFFECTED SIDE.
- Apply pressure dressing & assess
puncture site for bleeding & crepitus
- Monitor for signs of pneumothorax, air
embolism & pulmonary edema.
 SPUTUM COLLECTION
• Acid – fast bacillus staining/
sputum culture
– Indirect
• Direct method:
method:
• Sterile suction catheter with an
– Obtain early morning specimen (15
attached sputum trap or transtracheal
ml)aspiration.
– Instruct client to rinse mouth with
water
• Gastric lavage
– Deep breathing
– Cough
Note color,
outconsistency, odor and
sputum in container
amount
 NOSE AND THROAT
CULTURE
• Swab nose and
throat with the
use of sterile
cotton swab.
 LUNG BIOPSY
• Open Lung Biopsy
• Aspiration Biopsy
– After identification of the lesion
via CXR and fluoroscopy, a
needle will be inserted
through the chest wall into
the lung tissue and the lesion.
– Definitive diagnosis of malignant
neoplasms and granulomas
– CX: hemoptysis,
 SKIN TEST/MANTOUX
TEST
• PPD (Purified Protein Derivative)
• Intradermal
• Read within 48-72 hrs after
injection
• (+) = induration of 10 mm or more
• HIV (+) clients = 5 mm induration
is (+)
• (+) result = exposure to
Mycobacterium tubercle bacilli