Chapter 21 Assessment of Respiratory Function Functions of the Respiratory System o Gas Exchange- allows oxygen from the atmosphere

e to enter the blood and allows carbon dioxide to leave the and enter the atmosphere o Regulation of Blood Ph level-through changing blood carbon dioxide levels. o Voice Production- Air movements past the vocal folds makes sound and speech possible o Olfaction- sensation of smell occurs when airborne molecules are drawn into the nasal cavity. o Protection- it provides protection against some microorganisms by preventing their entry into the body and by removing them from respiratory surfaces Anatomy and Histology of Respiratory System o Upper Respiratory System Nose External nose and nasal cavity the inner portion of which. Anterior nares(nostrils) are the external openings of the nasal cavities. Nasal cavity extends from the nares to the chonae(the opening to the pharynx; 3 bony ridges) The internal portion of the nose is a hollow cavity separated into the right and left nasal cavities by a narrow vertical divider, the septum. Each nasal cavity is divided into three passageways by the projection of the turbinate(called conchae) from the lateral walls. The nasal cavities are lined with highly vascular ciliated mucous membranes called nasal mucosa. Mucus secreted continuously by goblet cells, covers the surface of the nasal mucosa and is moved back by the nasopharynx by the action of the cilia(fine hairs). The nose serves as a passageway for air to pass to and from the lungs. It filters impurities and humidifies and warms the air as it is inhaled It is also responsible for olfaction (smell) because the olfactory receptors are located in the nasal mucosa, this function diminish with age. Paranasal sinuses It includes four pairs of bony cavities that are lined with nasal mucosa and ciliated pseudostratified columnar epithelium. By location: o Frontal, Ethmoidal, Sphenoidal, Maxillary Prominent function is to serves as a resonating (produce with reverberating sound Pharynx or throat A tube like structure that connects the nasal and oral cavities to the larynx. It is divided into three regions: nasal, oral, and laryngeal.

The nasopharynx is located posterior to the nose and above the soft plate.; lined with pseudo stratified ciliated columnar epithelium with goblet cells. o Posterior surface contains the pharyngeal tonsil or adenoids. The oropharynx houses the faucial, or platine tonsils; soft palate to epiglottis.; lined with moist stratified squamous epithelium. o Air, food, drink pass through which. o It contains the palatine tonsils and lingual tonsils The laryngopharynx extends from the hyoid bone to the cricoid cartilage.(tip of epiglottis to esophagus and passes posterior to the larynx.; lined with moist stratified squamous epithelium. o Food and drink pass through which with small amount of air. Tonsils These are important links in the chain of lymphnodes guarding the body from invasion by organisms entering the nose and the throat Larynx Voice organ; a cartilaginous epithelium-lined struture that connects the pharynx and the trachea. Major function is vocalization.; it also protects the lower airway from foreign substance and facilitates coughing,; prevents entry of swallowed materials into the lower respiratory tract and regulates the passage of air into and out of the lower respiratory tract. It consist of the: o Three unpaired Thyroid cartilage is the largest cartilage; part of which forms the adams apple Cricoid- the most inferior cartilage of the larynx; Epiglottis- a valve flap of cartilage that covers the opening to the larynx during swallowing. o Smeltzler: Epiglottisa valve flap of cartilage that covers the opening to the larynx during swallowing Glottisthe opening between the vocal cords in the larynx Thyroid cartilagethe largest of the cartilage structures; part of it forms the Adams apple Cricoid cartilagethe only complete cartilaginous ring in the larynx (located below the thyroid cartilage) Arytenoid cartilagesused in vocal cord movement with the thyroid cartilage Vocal cordsligaments controlled by muscular movements that produce sounds; located in the lumen of the larynx Trachea Windpipe; composed of smooth muscles with C-Shaped hyaline cartilage at regular intervals.

It serves as the passage between the larynx and the bronchi. Anatomy of the Lower Respiratory Tract o Lungs Elastic structure that is housed in the thoracic cage, which is an airtight chamber with distensible(cause to swell from the inside) walls. Ventilation requires movements of the walls of the thoracic cage and of its floor, the diagphragm.; the effect of this movements is alternately to increase and decrease the capacity of the chest, when the capcity of the chest is increades, air enters through the trachea(inspiration) because of lowered pressure within and inflates the lungs. When the chest wall and diagphargm return to their previous position(expiration), the lung recoil and force of air out through the bronchi and trachea. The inspiratiry phase of respiration normally requires energy expiratory phase is normally passive inspiration occurs during the first and third of the respiratory cycle, expiration during the latter two thirds Right lung 3 lobes(Superior, middle and Inferior) 10 bronchopulmonary segments Bigger Left lung 2 lobes (Upper, Lower) 8 bronchopulmonary segments Smaller because it houses the cardiac notch, to accommodate the apex of the heart Lobes are divided by a fissure(horizontal [for Right lung]) and oblique) o Mediastinum Located in the middle of the thorax, between the pleural sacs that contain the two lungs, it extends from the sternum to the vertebral column. It contains all the thoracic tissue outside the lungs(heart, thymus, certain blood vessels(i.e aorta, vena cava) and esophagus. o Bronchi and Bronchioles Tracheobronchial tree Lobar bronchi(3 in the right; 2 in the left)segmental bronchi (10 on the right;8 on the left)subsegmental bronchi( surrounded by connective tissue that contains arteries, lymphatics and nerves.; have cilia)Bronchioles(no cartilage in walls; contains submucosal glands, which produce mucus that covers the inside lining of the airways.; have cilia)terminal bronchioles(no mucus glands or cilia)respiratory bronchioles(transitional passageway between the conducting airways and the gas exchange airways.; physiologic dead space 150ml of conducting airway that retains in the tracheobronchial tree) Respiratory bronchiolesalveolar ductsalveolar sacsalveoli o Alveoli Small, air-filled chambers where gas exchange between the air and blood takes place; there are 300 million in both lungs,arranged in cluster of 1520 Types of Alveolar cells o Type I- epithelial cells that form the alveolar wall

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Type II- alveolar cells that are metabolically active(surfactant; makes it easier to expand) Type III- macrophages that ingest foreign matter and acts as a defense mechanism

Functions of The Repiratory System o Oxygenation is the primary function of which to oxidize bodily tissues; however as a result of oxidation carbon dioxide is produced and must be removed to prevent buildup of acid waste products o Processes: Oxygen Transport- Oxygen is supplied and CO2 is removed from cells by way of circulating blood. Oxygen diffuses from the capillary to the capillary wall to the interstitial fluid, at this point it defuses to through the membrane of tissue cells, where it is used by mitochondria for cellular respiration. Co2 difuses in the opposite direction cellblood Respiration After the capillary exchange, blood enters the systemic veins(where it is called venous blood) and travels to the pulmonary circulation. Blood concentration within the capillaries of the lung is lower than in the alveoli; because of the concentration gradient, O2 diffuses from the alveoli to the blood. Carbon dioxide, which has higher concentration in the blood than in the alveoli, difusses from the blood into the alveoli. Movement of air in and out of the airways(ventilation)replenishes O2removes CO2 is called repiration Ventilation Inspiration is the movement of air atmosphere trachea bronchi bronchiolesalveoli; muscles for inspiration are the diagphragm, external intercostals, pector alis minor and scalenes and sternocleidomasteoid. Expiration is the reverse of which; muscles: abdominal muscles and internal intercostals. Mechanism of Ventilation: o Air pressure variances Air flows from region of higher concentration to lower concentration. During inspiration, movement of diaphragm and other muscles of respiration enlarge the thoracic cavity and thereby lower the pressure inside the thorax to a level below that of the atmospheric pressure (pressure exerted by the weight of the atmosphere), as a result air is drawn through the trachea to the alveoli. During expiration, the diaphragm relaxes and the lungs recoil, resulting in a decrease in the size of the thoracic cavity. The alveolar pressure then exceeds atmospheric pressure, and air flows from the lungs into the atmosphere. o Airway resistance

Determined by the size of the airway through which the air is flowing. Any changes in the diameter affects the rate of airflow for a given pressure gradient during respiration. With greater-than-normal respiratory effort is required to achieve normal levels of ventilation. Phenomena that may alter the bronchial diameter Contraction of bronchial mucosa in asthma Thickening of the bronchial mucosa- chronic bronchitis Obstruction of airway- mucus, tumor, foreign body Loss of lung elasticity- emphysema.

Lung Compliance o Or distensibility, the elasticity and expandability of the lungs and thoracic structures. o It allows the lung volume to increase when the difference in pressure between the atmosphere and thoracic cavity causes air to flow in. Factors to determine the lung compliance is the Surface tension of the alveoli (low with the presence of surfactant Connective tissue (collagen and elastin) of the lungs o Is determined by examining the volume-pressure relationship in the lungs and the thorax. Normal; 1.0L/cm h20 if the lungs and thorax easily stretched and distend when pressure is applied. High or increased compliance if lungs have lost their elasticity and thorax is over distended (emphysema) Low or decreased compliance if the lungs and thorax is stiff. R/t to morbid obesity, pneumothorax, atelectasis, pulmonary fibrosis, and acute respiratory distress syndrome (ARDS); requires greater than normal energy expenditure by the patient to achieve normal levels of ventilation. o Is usually measured under static (no movement) conditions Lung Volumes and Capacities o Lung Volumes: Tidal Volume (TV) Volumes of air inhaled and exhaled with each breathe. 500mL Inspiratory reserve volume (IRV) Maximum volume of air that can be inhaled after a normal inhalation 3000mL at rest Expiratory reserve volume (ERV) Maximum volume of air that can be exhaled forcibly after a normal exhalation 1100mL Reduced with obesity, pregnancy, ascites Residual Volume (RV) Volume of air remaining in the lungs after a maximum exhalation. 1200mL Increased with obstructive diseases o Lung Capacities

Vital Capacity (VC) Maximum volume of air exhaled from the point of maximum inspiration VC=TV+IRV+ERV 4300mL Decreased can be found in COPD, generalized fatigue, atelectasis, pulmonary edema, and obesity Inspiratory capacity (IC) Maximum volume of air inhaled after normal expiration IC=TV+IRV 3500mL Decreased in restrictive diseases Functional residual capacity (FRC) Volume of air remaining in the lungs after a normal expiration FRV=ERV+RV 2300mL inc in COPD; dec in ARDS and obesity Total lung capacity(TLC) Volume of air in the lungs after a maximum inspiration TLC=TV+IRV+ERV+RV 5800mL dec with restrictive diseases and inc in COPD Pulmonary Diffusion and Perfusion o Diffusion-process by which O2 and CO2 are exchanged at the air-blood interface. o Pulmonary perfusion- actual blood flow through the pulmonary circulation (The blood is pumped into the lungs by the right ventricle through the pulmonary artery. The pulmonary artery divides into the right and left branches to supply both lungs. These two branches divide further to supply all parts of each lung. Normally about 2% of the blood pumped by the right ventricle does not perfuse the alveolar capillaries. This shunted blood drains into the left side of the heart without participating in alveolar gas exchange. The pulmonary circulation is considered a low-pressure system because the systolic blood pressure in the pulmonary artery is 20 to 30 mm Hg and the diastolic pressure is 5 to 15 mm Hg. Because of these low pressures, the pulmonary vasculature normally can vary its capacity to accommodate the blood flow it receives.) Is also influenced by the alveolar pressure. Ventilation Diffusion and Perfusion Ratio(V/Q ) o Normal Ratio Ventilation is matched with an equal perfusion Ratio is 1:1 o Low-Ventillation-Perfusion Ratio:Shunts Perfusion exceeds ventilaton Blood bypasses the alveoli without gas exchange occurring. Seen with Obstruction of the distal airways, such as with pneumonia, atelectasis, tumor or a mucus plug o High Ventilation-Perfusion Ratio:Dead space Ventilation exceeds perfusion

Alveoli do not have an adequate blood supply for gas exchange to occur. Seen with pulmonary emboli, pulmonary infarction, and cardiogenic shock. Silent Unit Absence of ventilation and perfusion or with limited ventilation and perfusion Seen with pneumothorax and severe acute respiratory distress syndrome

Assessment Present illness/ Current health problems o Determine: When did it started? How long it lasted How it was relieved How relief is obtained o Nurse collect information about : Precipitating factors Duration Severity Associated factors and symptoms Risk factors Genetic factors History o Age, Gender, race o Family history (asthma, allergies, etc.) o Medical history Underlying illness (CV, diabetes, etc) History of allergies o Personal and social history Smoking(packyears) Drinking Dyspnea Subjective feeling(inability to get enough air) Labored breathing, breathlessness, shortness of breath In exertion is due to an increase myocardial demand. Acute dyspneapulmonary embolism Cough A reflex that protects the lungs from accumulation of secretions and inhalation of foreign substance Types: o Productive-able to expectorate o Nonproductive- unable to expectorate Sputum Production Mucoid and foamy sputum can be sign of CHF Pink tinged- pulmonary embolism Whitish is more viral in nature Profuse, Frothy pink- pulmonary edema Increased sputum- chronic bronchitis or bronchiectasis Change in color other than the above is bacterial such as green

Chest pain Asses quality, intensity, and radiation of pain Identify and explore precipitating factors, along with their relation to patients position Asses the relationship of pain to inspiration and expiration May occur with pneumonia, pulmonary embolism with lung infarction, pleurisy, or as a late symptom of bronchogenic carcinoma. Wheezing A high pitched musical sound heard mainly on expiration (asthma) or inspiration (bronchitis) Hemoptysis Expectoration of blood from the respiratory tract. Skin Asses color, temperature, hair growth, nails Capillary refill, clubbing or sponginess of fingers Physical Assessment Nose and sinuses o External Nose: Note for lesions, asymmetry or inflammation o Internal Nose: Inspect mucosa for color, swelling, exudates, bleeding and mucus production o Sinuses Frontal and Maxillary Palpate and Transluminate Pharynx o Use tongue depressor o Note: color, symmetry, evidence of exudate , ulceration, or enlargements. Neck o Asses symmetry, mass and nodes Chest o Upright position o Asses for symmetry, breathing rate and pattern o Configurations Barrel Chest. Barrel chest occurs as a result of overinflation of the lungs. There is an increase in the anteroposterior diameter of the thorax. In a patient with emphysema, the ribs are more widely spaced and the intercostal spaces tend to bulge on expiration. The appearance of the patient with advanced emphysema is thus quite characteristic and often allows the observer to detect its presence easily, even from a distance. Funnel Chest (Pectus Excavatum). Funnel chest occurs when there is a depression in the lower portion of the sternum. This may compress the heart and great vessels, resulting in murmurs. Funnel chest may occur with rickets or Marfans syndrome. Pigeon Chest (Pectus Carinatum). A pigeon chest occurs as a result of displacement of the sternum. There is an increase in the anteroposterior diameter. This may occur with rickets, Marfans syndrome, or severe kyphoscoliosis.

Kyphoscoliosis. A kyphoscoliosis is characterized by elevation of the scapula and a corresponding S-shaped spine. This deformity limits lung expansion within the thorax. It may occur with osteoporosis and other skeletal disorders that affect the thorax.

Cyanosis o Bluish discoloration of the skin o Central cyanosis Face and chest o Peripheral cyanosisextremities Clubbing of Fingers o Found in patients with chronic hypoxic conditions, chronic lung infections or malignancies of the lung. Process of Assessment Inspection Palpation Percussion Auscultate Respiratory rate Tachypnea= higher than 20 breaths/min Bradypnea= lower than 12 breaths/min Hyperpnea= increase in depth of respirations Eupnea= normal breathing @ 12-18 breaths/min Hypoventilation= shallow, irregular rhythm Hyperventilation= Increase rate and depth of breathing that results in dec PCO2 Apnea=period of cessation of breathing Cheyne stokes= Normal HyperpneaApnea Biots respiration= NormalApneaNormalApnea. Kussmauls= Hyperventilation in diabetic ketoacidosis Palpation Percussing the chest

Auscultation

Adventitous Breath Sound Crackles Soft, high-pitched, discontinuous poppingsounds that occur during inspiration Secondary to fluid in the airways or alveoli or to opening of collapsed alveoli Coarse crakles Discontinuous popping sounds heard in early inspiration; harsh, moist sound originating in the large bronchi Associated with obstructive pulmonary disease Fine crackles Discontinuous popping sounds heard in late inspiration; sounds like hair rubbing together; originates in the alveoli Associated with interstitial pneumonia, restrictive pulmonary disease (eg, fibrosis). Fine crackles in early inspiration are associated with bronchitis or pneumonia. Sonorous Wheeeze (Ronchi) Deep, low-pitched rumbling sounds heard primarily during expiration; caused by air moving through the narrowed tracheobronchial passages Sibilant Wheeze Continuous, musical, high-pitched, whistlelike sounds heard during inspiration and expiration caused by air passing through narrowed or partially obstructed airways; may clear with coughing Bronchospasm, asthma, and buildup of secretions Pleural friction rub Harsh, crackling sound, like two pieces of leather being rubbed together. Heard during inspiration alone or during both inspiration and expiration. May subside when patient holds breath. Coughing will not clear sound. Diagnostic Examination o Pulmonary Function test Measures Lung Volumes, Ventilatory function

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Mechanism of breathing, diffusion, and gas exchange. Using a Spirometer Arterial Blood Gas Studies Measures Blood pH, Arterial Oxygen (PaO2) and Carbon Dioxide(PaCO2) Indications: Perform Allens Test Before procedure Use Heparinized Syringe (Rationale: to prevent blood to clot. Put Specimen in Ice Normal Values: pH: 7.35-7.45 o Acidosis or Alakalosis PaO2-83-100 o Increase PaO2-Excessive Oxygen Administration o Decrease PaO2- COPD/Asthma PaCo2: 3.5-4.5 HCO3: 22-26 mEq/L Pulse Oximetry Non-invasive procedure measuring the Oxygen saturation Probe is attached to the fingertip, forehead, earlobe or bridge of the nose. Normal value of SpO2 is 95%-100% Cultures For identification of organisms such pharyngitis Nsg Responsibility: Container must be sterile Sputum Studies For analysis to identify pathogenic organisms and to determine whether maliganant cells are present. Done through expectoration Acid Fast Bacilli is the Gold Standard Diagnostic Method for Tuberculosis. Chest X-ray Done to detect densities by fluids, tumors, foreign bodies, and other pathologic conditions Two Views: Posteroanterior projection(PA) Lateral projection Taken during full inspiration(deep breath) Computerized Tomography CT is an imaging method in which the lungs are scanned in successive layers by a narrow-beam xray. It produce a cross-sectional view of the chest. It contrast between body densities such as bone, soft tissue, and air. In mediastinum contrast agents is necessary Magnetic Resonance Imaging(MRI) Same as CT scan but magnetic fields and radiofrequency signals are used. More Detailed than CT scan Is used to characterize pulmonary nodules, stage bronchogenic carcinoma(assessment of chest wall invasion), evaluate inflammatory activity in intestinal lung disease, acute pulmonary embolism and chronic thrombolytic pulmonary hypertension.

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Fluoroscopic studies Is used to assist with invasive procedures, such as chest needle biopsy or transbronchial biopsy and to locate masses. Pulmonary Angiography Is used to invstigate thromboembolic disease in the lungs, such as pulmonary emboli and congenital abnormalities of the pulmonary vascular tree. It involves a rapid injection of a radiopaque agent into the vasculature of the lungs. Nursing Responsibility: Asses for hypersensitivity to dye. Radioisotope Diagnostic Procedure (V/Q) scan performed by injecting a radioactive agent into a peripheral vein this is performed to measure the integrity of the pulmonary vessels relative to blood flow making it possible to trace and measure blood perfusion through the lung. Gallium scan Positron emission tomography(PET) Endoscopic Procedures Bronchoscopy Is the direct inspection and examination of the larynx, trachea and bronchi through a flexible fiberoptic bronchoscope Purpose of Diagnostic Bronchoscopy: o To examine the tissues and collect secretions. o To determine location and extent of pathologic process and to obtain a tissue sample for diagnosis o To determine whether a tumor can be resected surgically o To diagnosis bleeding sites (source of hemoptysis) Purpose of Therapeutic Bronchoscopy: o To remove foreign bodies from the tracheobronchial tree o Remove secretions obstructing the tracheobronchial tree when the patient cannot clear them. o Treat postoperative atelectasis o Destroy and excise lesions. Possible complications o Reaction to local anesthetic, infection, aspiration, bronchospasm, hypoxemia( low blood oxygen level) Nursing Responsibilty: o Obtain Informed consent. o NPO 6 hours (rationale: to reduce risk of aspiration when the cough reflex is blocked by the anesthesia.) o Nurse explains the procedure. o Sedate Patient Nursing ALERT! Sedation given to patients with respiratory insufficiency may precipitate respiratory attack. o Patient must remove dentures and other orals prostheses. o Topical anesthetic is sprayed on the pharynx or dropped on the epiglottis and vocal cords and into the trachea Thoracoscopy

Pleural cavity is examined. Indicated to: pleural effusion, pleural disease and tumor staging. o Procedure: Small incision is made into the pleural cavity in an intercostal space Thoracentesis o For diagnostic and therapeutic reasons: Removal of air and fluid in the pleural cavity. Aspiration of pleural fluid for analysis. Pleural Biopsy Instiallation of medication into the pleural space.

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Biopsy Pleural Biopsy o Needle biopsy of the pleura or by pleuroscopy, for culture or staining the tissue to identify tuberculosis or fungi. Lung Biopsy o If chest x-ray are inconclusive or show pulmonary density(indicating an infiltrate or lesion), biopsy may be performed to obtain lung tissue for examination to identify nature of lesion. Lymph node biopsy