NCM 102

ALTERATION IN OXYGENATION
Lecture Series 02

GENERAL RESPIRATORY ANATOMY AND PHYSIOLOGY

I. General Respiratory Anatomy and Physiology

A. The respiratory system is comprised of the upper airway and lower
airway structures.
B. The upper respiratory system filters, moistens and warms air during
inspiration.
C. The lower respiratory system enables the exchange of gases to
regulate serum PaO2, PaCO2 and Ph.

II. Upper Respiratory

A. Nose and sinuses
1. Filters, warms and humidifies air
2. First defense against foreign particles
3. Inhalation for deep breathing is to be done via nose
4. Exhalation is done through the mouth
B. Pharynx
1. Behind oral and nasal cavities
2. Nasopharynx
a. behind nose

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 b. soft palate, adenoids and eustachian tube
3. Oropharynx
a. from soft palate to base of tongue
b. palatine tonsils
4. Laryngopharynx
a. base of tongue to esophagus
b. where food and fluids are separated from air
c. bifurcation of larynx and esophagus
C. Larynx
1. Between trachea and pharynx
2. Commonly called the voice box
3. Thyroid cartilage - Adam's apple
4. Cricoid cartilage
a. contains vocal cords
b. the only complete ring in the airway
5. Glottis - opening between vocal cords
6. Epiglottis - covers airway during swallowing

III. Lower Respiratory and Other Structures

A. Trachea
1. Anterior neck in front of esophagus
2. Carries air to lungs
B. Mainstem bronchi
1. Right and left
2. Right is more vertical, so right middle lobe is more likely to
receive aspirate into it with the result of aspiraton pneumonia,
which is more commonly found in elderly populations

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 C. Conducting airways
1. Lobar bronchi
a. surrounded by blood vessels, lymphatics, nerves
b. lined with ciliated, columnar epithelial cell
c. cilia move mucus or foreign substances up to larger
airways
2. Bronchioles
a. no cartilage; collapse more easily
b. no cilia
c. do not participate in gas exchange
D. Alveolar ducts and alveoli
1. Lungs contain approximately 300 million alveoli
2. Alveoli surrounded by capillary network
3. Gas exchange area (blood takes O2, gives off CO2)
4. Gas exchange happens at alveolar-capillary membrane (al-cap
memb)
5. Held open by surfactant which decreases surface tension to
minimize alveolar collapse
E. Accessory muscles of respiration
1. Scalene muscles - elevate first two ribs
2. Sternocleidomastoid - raise sternum
3. Trapezius and pectoralis - stabilize shoulders
4. Abdominal muscles - puts power into cough and used most often
with chronic respiratory problems and acute severe respiratory
distress

IV. Physiology
A. Basic gas-exchange unit of the respiratory system is the alveoli.
B. Alveolar stretch receptors respond to inspiration by sending signals to
inhibit inspiratory neurons in the brain stem to prevent lung over
distention.
C. During expiration stretch receptors stop sending signals to inspiratory
neurons and inspiration is ready to start again.
D. Oxygen and carbon dioxide are exchanged across the alveolar capillary
membrane by process of diffusion.
E. Neural control of respirations is located in the medulla. The respiratory
center in the medulla is stimulated by the concentration of carbon
dioxide in the blood.
F. Chemoreceptors, a secondary feedback system, located in the carotid
arteries and aortic arch respond to hypoxemia. These chemoreceptors
also stimulate the medulla.

G. Ph regulation
1. Blood Ph (partial pressure of hydrogen in blood): a decrease in
blood Ph stimulates respiration hyperventilation, both through
the neurons of the brain's respiratory center and through the
chemoreceptors in carotid arteries and aortic arch.
2. Blood PaCO2 (partial pressure of carbon dioxide in arterial
blood): an increase in the PaCO2 results in decreased blood Ph,
and stimulates respiration.

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 3. Blood PaO2 (partial pressure of oxygen in arterial blood): a
decrease in the PaO2 results in a decreased blood Ph,
stimulating respiration.
4. When arterial Ph rises or the arterial PaCO2 falls, hypoventilation
occurs.

FUNCTION

A. Primary functions of the respiratory system

1. Provides oxygen for metabolism in the tissues
2. Removes carbon dioxide, the waste product of metabolism
B. Secondary functions of the respiratory system
1. Facilitates sense of smell
2. Produces speech
3. Maintains acid-base balance
4. Maintains body water levels
5. Maintains heat balance

ASSESSMENT OF RESPIRATORY FUNCTION

A. DIAGNOSTIC STUDIES

 Chest x-ray film (radiograph)

> Provides information regarding the anatomical location and
appearance of the lungs
Nursing Responsibilities
Preprocedure
a. Remove all jewelry and other metal objects from the chest area.
b. Assess the client's ability to inhale and hold his or her breath.
c. Question women regarding pregnancy or the possibility of
pregnancy.
 Sputum specimen
> Specimen obtained by expectoration or tracheal suctioning to
assist in the identification of organisms or abnormal cells
Preprocedure
a. Determine specific purpose of collection
b. Obtain an early morning sterile specimen
c. Instruct the client to rinse the mouth with water before collection.
d. Obtain 15 mL of sputum.
e. Instruct the client to take several deep breaths and then deeply to
obtain sputum.
f. Always collect the specimen before the client begins antibiotic
therapy.
3. Postprocedure
a. If a culture of sputum is prescribed, transport the specimen to the
laboratory immediately.
b. Assist the client with mouth care.
 Bronchoscopy

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 > Direct visual examination of the larynx, trachea, and bronchi with a
fiberoptic bronchoscope

Preprocedure
a. Obtain informed consent.
b. NPO post midnight
c. Obtain vital signs.
d. Remove dentures or eyeglasses.
e. Prepare suction equipment.
Postprocedure
a. Monitor vital signs.
b. Maintain the client in a semi-Fowler's position.
c. Assess for the return of the gag reflex.
d. Maintain NPO status until the gag reflex returns.
e. Have an emesis basin readily available for the client to expectorate
sputum.
f. Monitor for bloody sputum.
g. Monitor respiratory status
h. Monitor for complications
i. Notify the physician if fever, difficulty in breathing, or other signs of
complications occur following the procedure.
 Pulmonary angiography
> An invasive fluoroscopic procedure in which a catheter is inserted
through the antecubital or femoral vein into the pulmonary artery or
one of its branches
> Involves an injection of iodine or radiopaque contrast material
Preprocedure
a. Obtain informed consent.
b. Assess for allergies to iodine, seafood, or other radiopaque dyes.
c. NPO for 8 hours before the procedure.
d. Monitor vital signs.
e. Assess results of coagulation studies.
f. Establish an intravenous access.
g. Administer sedation as prescribed.
h. Instruct the client to lie still during the procedure.
i. Instruct the client that he or she may feel an urge to cough, flushing,
nausea, or a salty taste following injection of the dye.
j. Have emergency resuscitation equipment available.
Postprocedure
a. Monitor vital signs.
b. Avoid taking blood pressures for 24 hours in the extremity used for
the injection.
c. Monitor peripheral neurovascular status of the affected extremity.
d. Assess insertion site for bleeding.
e. Monitor for delayed reaction to the dye.
 Thoracentesis
> Removal of fluid or air from the pleural space via a transthoracic
aspiration
Preprocedure
a. Obtain informed consent.

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 b. Obtain vital signs.
c. Assess results of coagulation studies.
d. Place client in sitting position, with the arms and shoulders
supported by a table at the bedside during the procedure.
e. If the client cannot sit up, the client is placed lying in bed toward the
unaffected side, with the head of the bed elevated.
f. Instruct the client not to cough, breath deeply, or move during the
procedure.
Postprocedure
a. Monitor vital signs.
b. Monitor respiratory status.
c. Apply a pressure dressing, and assess the puncture site for bleeding
and crepitus.
d. Monitor for signs of pneumothorax, air embolism, and pulmonary
edema.
 Lung biopsy
> A percutaneous lung biopsy is performed to obtain tissue for analysis
by culture or cytological examination.
Preprocedure
a. Obtain informed consent.
b. Maintain NPO status of the client before the procedure.
c. Inform the client that a local anesthetic will be
d. Administer analgesics and sedatives as prescribed.
Postprocedure
a. Monitor vital signs.
b. Apply a dressing to the biopsy site and monitor for drainage or
bleeding.
c. Monitor for signs of respiratory distress.
d. Monitor for signs of pneumothorax and air emboli, and notify the
physician if they occur.
 Pulse Oximetry
 measures oxygen saturation of hemoglobin
 90-100%
 Arterial Blood Gas Analysis
 measures concentrations of blood gases and identifies acid base
balance of the body
 use of arterial blood
 Pulmonary Function Test
 Measures lung volumes and capacity
 Done by respiratory therapists; painless; client will breath into a
machine
 Tidal volume (VT)- volume of inhaled and exhaled during normal and
quiet breathing
 Inspiratory reserve volume (IRV)- maximum amount of air that can be
inhaled over and above the normal breath
 Expiratory reserve volume maximum amount of air that can be
exhaled following a normal exhalation
 Residual volume (RV)- amount of air remaining in the lungs after
maximal exhalation

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  Total lung capacity (TLC)- total volume of lungs at maximum inflation;
VT + IRV + ERV + RV
 Vital capacity (VC)- total amount of air that can be exhaled after a
maximal inspiration; VT+ IRV + ERV
 Inspiratory capacity- total amount of air that can be inhaled following
normal quiet respiration; VT + IRV
 Functional residual capacity (FRC)- volume left in the lungs after
normal exhalation; ERV +RV
 Minute volume (MV)- total amount of air breathed in one minute

B. COMMON SIGNS AND SYMPTOMS:

 Cough
 Most common sign of respiratory disease
 Caused by irritation of mucous membranes
 Chief protection against accumulation of secretions and foreign
body
 Chest pain: may indicate hypoxia or damage to lungs
 Cyanosis and Clubbing of fingers: indicates hypoxia
 Hemoptysis: blood expectorated from the respiratory tract; caused by
trauma or break in the continuity of respiratory tract
 Effort in breathing: Dyspnea or Orthopnea
 Sputum production
 Reaction of lungs to constantly recurring irritation
 Thoracic sounds
 Crackles: loud, low pitched bubbling sound; results from air passing
through fluid
 Wheezes: musical sound; caused by air passing through narrowed
airways
 Stridor: loud, high pitched crowing sound
 Friction rub: grating, loud harsh sound
 Ronchi: sounds likes snores or moans
 Chest Configuration- AP: L= 1:2
 Barrel chest- increase in AP diameter
 Pigeon chest- increase in AP diameter; results from sternal
displacement
 Funnel chest- depression of lower portion of sternum

C. HISTORY:

1. Current respiratory problems:

 Changes in breathing pattern
 Activities that may cause symptoms
 How many pillows used at night
2. History of respiratory disease
 Any respiratory diseases or infections
 Frequency of occurrence

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  Exposure to pollutants
3. Lifestyle
 Smoking history
 Exposure to smoke and other respiratory irritants
 Alcohol use
 Exercise pattern
4. Presence of cough
 How often
 When does it occur
 Productive or dry
5. Description of sputum
 When it is produced
 Amount, color, thickness, odor
 Presence of blood

6. Presence of chest pain

 Location
 Description
 Does it occur with inspiration or expiration
 How long does it affect breathing
 Aggravating and alleviating factors
7. Presence of risk factors
 History of respiratory diseases in the family
8. Medication History
 OTC prescriptions for breathing e.g. bronchodilators

UPPER RESPIRATORY DISEASES

RHINITIS

Allergic Rhinitis

Definition: is a group of disorders characterized by inflammation and irritation of

the mucous membranes of the nose.
It may be classified as nonallergic or allergic.
Rhinitis may be an acute or chronic condition.
Cause: pollen, flowers, grasses and occur in spring/fall; last several weeks
while allergens are high.

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 Signs/Symptoms: rhinorrhea (excessive nasal drainage, runny nose)
nasal congestion
nasal discharge (purulent with bacterial rhinitis)
nasal itchiness
sneezing
Headache may occur, particularly if sinusitis is also present.

Treatment: Identify and avoid triggers

Antihistamines
Decongestants
Desensitization

Acute Viral Rhinitis

Definition: Common cold (“acute coryza”).

used when referring to an upper respiratory tract infection that is self-
limited and caused by a virus (viral rhinitis).

Cause: Virus that invades the upper respiratory tract. Is the most prevalent
infectious disease in the world and is spread by airborne droplets.

Signs/Symptoms: malaise
fever/chills
headache
nasal discomfort
dry, sore throat
cough (either productive or nonproductive)
mild leukocytosis

*Complications: laryngitis, sinusitis, otitis media, tonsillitis, and lung infection.

Treatment: no specific treatment for the common cold or influenza.

Symptomatic therapy.
Some measures include
 providing adequate fluid intake
 encouraging rest
 increasing intake of vitamin C
 using expectorants as needed.
 Warm salt-water gargles soothe the sore throat

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  nonsteroidal anti-inflammatory agents (NSAIDs) such as aspirin or
ibuprofen relieve the aches, pains, and fever in adults.
 Antihistamines are used to relieve sneezing, rhinorrhea,
 Nasal congestion. Topical (nasal) decongestant agents
 Echinacea, an herbal therapy, stimulates immune system and has
antibacterial and anti-inflammatory properties. Considered safe
when taken at recommended doses for 10 to 14 days. Do not take
for more than 8 weeks. Patients with immune disorders should not
use Echinacea.

INFLUENZA

Definition: “Flu”

Cause: Three groups of viruses (A, B & C, though C has little pathogenic
effects)

Signs/Symptoms: Abrupt onset of cough, fever, and myalgia often accompanied by

headache and sore throat. Symptoms of uncomplicated flu usually
subside within 7 days. Some experience weakness and lassitude,
hyperactive airways and chronic cough that may persist for weeks
(older adults, especially).
PNEUMONIA is the most common complication of flu.

Diagnostic Tests: Viral cultures or throat or nasal swabbings

Culture and Sensitivity Test

Treatment:
Other viral infection
Vaccine is 70 to 90% effective in preventing flu when given in the fall
(mid-Oct) before exposure occurs.
Treatment is primarily symptomatic
Acetaminophen is given for fever, headache, and myalgia
Rest and increase fluid intake
Antiviral Zanamivir(Relenza) and Oseltamivir (Tamiflu)
Amantadine (Symmetrel)

Bird Flu

SARS

aH1N1

LOWER RESPIRATORY DISEASES

ACUTE BRONCHITIS

Definition: Inflammation of the bronchi in the lower respiratory tract usually due
to infection.

Cause: Usually occurs as a complication of an upper respiratory tract infection

brought on by a virus (rhinovirus, influenza, corona virus, respiratory
synctial virus (RSV), adenovirus, influenza A and B, parainfluenza).

Bacterial infections are also common

Signs/Symptoms: Chilliness
Malaise

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 Soreness and constriction behind the sternum-worse patient cough
Slight fever
Cough, at first dry and painful; later, green or yellowish sputum with
pus cells
Persistent cough following an acute upper airway infection
(rhinitis/pharyngitis)

Diagnosis: When symptoms are severe, chest x-rays can differentiate acute
bronchitis from pneumonia (acute bronchitis has no evidence of
consolidation or infiltrates).

Treatment: Usually self-limiting; treatment is supportive…

• Fluids
• Rest
• Anti-inflammatory agents
• Antiviral medications
• Cough suppressant or bronchodilators for symptomatic
treatment of nocturnal cough/wheezing
• Other symptom relief to reduce complaints

PNEUMONIA

Definition: An acute inflammation of the lung parenchyma that commonly impairs

gas exchange.

Cause: Pneumonia may be viral, bacterial, fungal, protozoal (parasitic), or

chemical in origin.

Bacterial pneumonia:

• Infection initially triggers alveolar inflammation and edema,

which produces an area of low ventilation with normal
perfusion.
• Capillaries become engorged with blood, causing stasis.
• As alveolocapillary membrane breaks down, alveoli fill with
blood and exudate, resulting in atelectasis (lung collapse)
• Lungs look heavy and liver-like.
Viral pneumonia:

• The virus first attacks bronchiolar epithelial cells, which causes

interstitial inflammation and desquamation.
• The virus also invades bronchial mucous glands and goblet
cells.
• It spreads to the alveoli, which fill with blood and fluid.
Aspiration pneumonia:

• Inhalation of gastric juices or hydrocarbons trigger

inflammation and inactivates surfactant over a large area.

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 • Decreased surfactant leads to alveolar collapse.
• Acidic gastric juices may damage the airways and alveoli.
Particles containing aspirated gastric juices may obstruct the
airways and reduce airflow, leading to secondary bacterial
pneumonia.

Types & Classifications: Community-Acquired Pneumonia (CAP)

• “A lower respiratory tract infection of the lung parenchyma

with onset in the community or during the first 2 days of
hospitalization.”
• Highest incidence in winter months
• Smoking is a high risk factor
Hospital-Acquired Pneumonia (HAP)

• “Pneumonia occurring 48 hours or longer after hospital

admission and not incubating at the time of hospitalization.”
• Risk for HAP in mechanically ventilated patients is 6 to 20
times higher than other patients.
• Inpatient mortality rates much higher than mortality for CAP
(1-5% vs. 12%)
Aspiration Pneumonia

• “The sequelae occurring from abnormal entry of secretions or

substances into the lower airway. Usually follows aspiration of
material from the mouth or stomach into the trachea and
subsequently the lungs.”
• Usually patient has a history of loss of consciousness (seizure,
anesthesia, head injury, stroke, alcohol intake), with gag and
cough reflex depression or is on tube feedings.
Opportunistic Pneumonia

• Affects patients with compromised immune systems.

o Pneumocystis carinii = HIV/AIDS. Chest x-ray shows
diffuse bilateral alveolar pattern of infiltration. In
widespread disease, lungs are massively consolidated.
Treat with Bactrim.
o Cytomegalovirus (type of herpes virus) = organ
transplant patients. Gives rise to latent infections and
reactivation with virus shedding. May be mild or can
be fulminant and produce pulmonary insufficiency
leading to death. In pneumonia, may be combined
with other bacteria and fungi. Treat with Cytovene.
Signs/Symptoms:

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 Diagnosis: Chest x-ray…

Sputum cultures…

• For drug-resistant pathogens

• Organisms not responsive to empiric treatment (broad-
spectrum antibiotics)
• Should be done before administration of antibiotics
Blood tests…

• For seriously ill patients, collect two cultures before treatment

• ABGs usually reveal hypoxemia
• Leukocytosis found in bacterial pneumonia
(>15,000/microliter)

Treatment: Supportive measures:

• Oxygen therapy (hypoxemia)

• Analgesics for chest pain
• Antipyretics (aspirin/Tylenol) for fever
• Restrict activity and encourage rest
Viral pneumonia

• No definitive treatment is recommended

• Prevent or treat flu
o Flu vaccine
Empiric treatment of flu includes amantadine,
o
rimantadine or a neuraminidase inhibitor
Pneumococcal vaccine

• For people at risk…

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 o Chronic illness (lung/heart disease; diabetes)
o Recovering from severe illness
o 65 years or older
o Living in a long-term care facility
Nutritional therapy

• Fluid intake of at least 3 L per day to support treatment; may

need to be administered by IV
• Minimum of 1500 calories per day
• Eat small, frequent meals.
Role of Nurse: Goals

• Clear breath sounds

• Normal breathing patterns
• No signs of hypoxia
• Normal chest x-ray
• No complications related to pneumonia

TUBERCULOSIS

Definition: An infectious disease caused by Mycobacterium tuberculosis. Usually

involves the lungs, but may occur in the larynx, kidneys, bones,
adrenal glands, lymph nodes and meninges and can be disseminated
throughout the body.

Cause: M. tuberculosis is a gram-positive, acid-fast bacillus that is spread from

person to person via airborne droplets, which are produced when the
infected individual with pulmonary or laryngeal TB coughs, sneezes,
speaks or sings.

Risk factors:

• Poor, under-served minorities

• Homeless people
• Residents of inner-city neighborhoods
• Foreign-born people
• Older adults
• Institutionalized people
• IV/injection drug users
• Socioeconomically disadvantaged
• Medically underserved of all races
• Immunosuppressed people (HIV, cancer, organ transplant)
• Health care workers
TB is not highly infectious and transmission usually requires close,
frequent or prolonged exposure.

Signs/Symptoms:

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 Diagnosis:

Tuberculin Skin Testing

o Antigen/Antibody reaction test…uses purified protein

derivative (PPD) of tuberculin to detect TB antibodies from a
previous immune response.
o Once acquired, sensitivity to TB persists throughout life.
o Reaction of >5 mm induration is positive for patients with…
o Recent close contact with person diagnosed with
infectious TB
o Chest x-ray with fibrotic lesions likely to be healed TB
o Known or suspected HIV infection
Organ transplants and other immunosuppressive
o
conditions
o Reaction of >10 mm induration is positive for patients…
o With other medical risk factors known to substantially
increase risk of TB once infection has occurred
(diabetes, renal disease, cancer)
o Who recently immigrated from (in past 5 years) from
areas of high prevalence
o Who are medically under-served or homeless
o Who reside in long-term care facilities and prisons
o Who use IV drugs

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 o Who are health care workers
o Who are low risk for TB
o Reaction of >15 mm induration is positive for all others at low
risk.
Chest X-ray

Bacteriologic Studies

o True diagnosis can only be made by demonstrating the

presence of tubercle bacilli.
o Stained sputum smear for acid-fast bacilli is usually the first
bacteriologic evidence of infection.
o Three consecutive sputum specimens collected on
different days are tested.
Treatment: Outpatient Treatment

o Patient may continue to work and maintain lifestyle

o Hospitalization is only for diagnosis or for severe illness,
adverse drug reactions or treatment failures.
Drug Therapy

o Active Disease
o Treatment usually consists of a combination of at least
four drugs.
o Five primary drugs currently used are:
 Isoniazid (INH)
 Rifampin (Rifamate)
 Pyrazinamide
 Streptomycin
 Ethambutol (Myambutol)
o Fixed-dose combo drugs (INH/rifampin and
INH/rifampin/pyrazinamide) are available and may
enhance compliance to treatment
o Therapy must be continued for 6 to 9 months.
o Monitor the effectiveness of drugs and the
development of toxic side effects.
o Follow-up care ensures adherence to the treatment
regimen with Directly Observed Therapy (DOT) with
patients known to be at risk for noncompliance.
o The major side effect of INH, rifampin and
pyrazinamide is HEPATITIS.
Vaccine

o Immunization with bacilli Calmette-Guerin (BCG)

vaccine prevents.

Role of Nurse: Goals:

o Patient will comply with therapeutic regimen

o Patient will have no recurrence of disease
o Patient will have normal pulmonary function

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 o Patient will take appropriate measures to prevent the spread of
disease.
Interventions:

o Assess symptomatic patient for exposure to persons with TB.

o Patients strongly suspected of having TB should…
o Be placed on respiratory isolation
o Receive four-drug therapy
o Receive an immediate medical work-up, including
chest x-ray, sputum smear and culture
o Use a negative pressure isolation room that offers six
or more exchanges per hour to isolate patient.
o Teach patient to cover the nose and mouth with paper tissue
every time he or she coughs, sneezes or produces sputum.
The tissues should be burned, flushed down the toilet or
thrown into a paper bag and disposed of with the trash.
o Instruct the patient about certain factors that could reactivate
TB such as immunosuppressive therapy, malignancy and
prolonged debilitation.

OBSTRUCTIVE PULMONARY DISEASE

The most common chronic lung diseases and are characterized by increased resistance to
airflow as a result of airway obstruction or airway narrowing.

Includes four conditions:

o Asthma (allergic reaction)

o Emphysema (COPD)
o Chronic Bronchitis (COPD)

ASTHMA

Definition: An obstructive pulmonary disease characterized by airway inflammation, and

non-specific hyperirritability or hyper-responsiveness of the tracheobronchial
tree (bronchospasm). The hyper-responsiveness seen in asthma is caused
by bronchoconstriction in response to physical, chemical and
pharmacological agents.

Cause: Allergens

• Exaggerated allergic response (IgE) to environmental factors (dust,

pollen, grass, mites, roaches, mold, dander, etc.).
Exercise

• “Exercise-Induced Asthma”
• Occurs within several minutes of vigorous exercise

Respiratory Infections

• Most common precipitating factor of an acute asthma attack.

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 • Bacterial infections cause inflammatory changes

Nose, Sinuses and Drugs/Food Additives

• “Asthma-Triad”….Nasal polyps, asthma, sensitivity to aspirin and

NSAIDS
• Nose and Sinus Problems
o Allergic rhinitis (seasonal or perennial) and nasal polyps
contribute to asthma problems
o Treat/prevent sinusitis and remove large nasal polyps
• Drug Allergies
o Exposure to ASA/NSAIDS = wheezing within 2 hours
o Avoid Beta blockers (propranolol, timolol, other “-olol” drugs)
o Avoid ACE inhibitors

• Food Allergies
o Avoid exposure to Tartrazine (yellow dye #5 found in many
foods)
o Avoid vitamins
o Avoid sodium metabisulfite (food preservative in fruit,
beer/wine and salad bars).
Emotional Stress

• Psychological or emotional stress may be a trigger

• Panic and anxiety during an attack may exacerbate and prolong the
attack
Signs/Symptoms:

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 Early-Phase Response

 bronchospasm
 inflammatory response.
 Immediate response that peaks within 30 to 60 minutes of exposure to
the trigger.
 Symptoms: wheezing, chest tightness, dyspnea and cough.
Late-Phase Response

 Characterized by inflammation, constriction of bronchioles and

excess mucus.
 Late-phase response peaks 5 to 6 hours after exposure and may last
for days.
 WBC infiltration
 This activity increases airway reactivity which worsens the symptoms
of future attacks, and makes them easier to trigger.
 increased work of breathing.

 airway remodeling.
Clinical Manifestations of asthma:

• Recurrent episodes of wheezing, breathlessness, dyspnea, chest

tightness and cough (particularly at night and in the early morning)
after exposure to a trigger
• Characterized by prolonged expiration (wheezing upon expiration, air
trapping and hyperinflation).
• Diminished or absent breath sounds during attack is an ominous sign
• Person may sit upright or slightly bent forward using the accessory
muscles of respiration to try to get enough air.
• Attacks may last a few minutes to several hours.
• Symptoms of hypoxia occur: restlessness, anxiety, inappropriate
behavior, increased pulse and blood pressure, significantly increased
respiratory rate (>30 breaths per minute) with use of accessory
muscles.
* Status Asthmaticus

• Severe, life-threatening attack that does not respond to usual

treatment.
• “The longer it lasts, the worse it gets and the worse it gets, the
longer it lasts.”
• Caused by viruses; aspirin/NSAIDS; stress; environmental pollutants;
allergens; abrupt discontinuation of drug therapy (corticosteroids);
abuse of aerosol medication; use of beta-blockers.
• Symptoms same as asthma, but more severe and more prolonged
with extreme anxiety, fear of suffocation, diaphoresis and severely
increased work of breathing.
• Chest remains in hyperinflated state; hypertension, sinus tachycardia
and ventricular arrhythmias may occur (related to hypoxemia).

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 Diagnosis:

• History and physical examination

• Pulmonary function studies including response to bronchodilator
therapy
• Peak expiratory flow monitoring
• Chest X-Ray
• Measurement of ABGs or Oximetry
• Allergy skin testing (if indicated)
• Blood level of eosinophils and IgE.
Treatment: Acute Episode:

o Oxygen therapy immediately with pulse oximetry and ABGs

o Inhaled B2-agonists by metered-dose inhaler (MDI) with
spacer or nebulizer every 20 minutes to 4 hours as
necessary.
o If no response in 30 to 60 minutes, use oral corticosteroids,
or if severe—IV corticosteroids. IV aminophylline may be
considered, but effectiveness is questionable.
o Continue treatment until patient breathes comfortably,
wheezing has stopped and pulmonary function results are
near baselines.
• Status Asthmaticus:
o Correct hypoxemia and improve ventilation
o Same interventions as for acute asthma (above), but may
need to increase the frequency and dose of inhaled
bronchodilators to 2 to 6 puffs every 5 to 20 minutes
(depending upon medication).
o Continuous monitoring of patient is critical.
o If B2-agonists do not work, use IV corticosteroids
(methylprednisolone) every 4 to 6 hours (peaks in 12 hours).
o IV mag sulfate and subcutaneous epinephrine may act as
bronchodilators. If administered, monitor BP and EKG
closely.
o Oxygen therapy and IV fluids (for hydration) are usually
required.
o Severe, non-responsive attacks may require mechanical
ventilation.
• Even after bronchospasm resolves, inflammation, edema, and
viscous mucus plugs remain for several days.
• Drug classifications
o Two categories:

 Long-term control (achieve/maintain control of

persistent asthma)
• Coricosteroids (anti-inflammatory)

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  Quick-relief (treat symptoms and exacerbations)
• Mast cell stailizers (cromolyn, nedocromil)
• Bronchodilators
o B2-agonists (albuterol)
o Anticholinergics (Atrovent)
o methylxanthine derivatives
(theophylline)

Role of Nurse: Interventions

• Administer oxygen
• Administer bronchodilators
• Perform chest physiotherapy
• Administer medications as ordered
• Continuously monitor patient’s condition
• Monitor effectiveness of treatments
• Decrease the patient’s sense of panic; encourage slow breathing
using pursed lips for prolonged exhalation
• Provide rest and a quiet, calm environment for the patient

COPD/EMPHYSEMA & CHRONIC BRONCHITIS

Definition: Group of diseases with the major characteristic of airflow obstruction and
hyper-reactivity of airway. Symptoms include difficulty with exhalation
caused by airway obstruction from edema or excessive mucus production.
Lung hyperinflation causes alveolar air trapping and leads to frequent
pulmonary infections. Symptoms are usually progressive and irreversible.

Emphysema: an abnormal, permanent enlargement of the airspaces distal

to the terminal bronchioles, accompanied by destruction of their walls and
without obvious fibrosis.

Chronic Bronchitis: the presence of a chronic productive cough for 3

months in each of 2 successive years in a patient in whom other causes of
chronic cough have been excluded.

NCM 102 Med-Surg Nsg Respiratory Disorders

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 Cause: Cigarette Smoking….

Infection

Heredity

Aging

Signs/Symptoms: Emphysema:

• Two types…but may overlap in some patients

o Centrilobular

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  Involves central part of the lobule
 Bronchioles enlarge, walls are destroyed and
bronchioles become confluent (merge together)
o Panlobular
 Involves distention and destruction of the whole
lobule.
 Bronchioles, alveolar ducts and sacs, and alveoli are
affected
 Progressive loss of lung tissue and decreased
alveolar-capillary surface area results

• Barrel chest;
• Underweight
• Hypoxemia (early sign) and hypercapnia (late sign)

Chronic Bronchitis

• Hyperplasia of mucus-secreting glands in the trachea and bronchi

• Increase in goblet cells
• Disappearance of cilia
• Chronic inflammatory changes and narrowing of small airways
• Altered function of alveolar macrophages, leading to increased
bronchial infections
• High colonization with microorganisms = increased infection risks

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 • Chronic inflammation causes narrowing of the airway lumen =
diminished airflow
• Hypoxemia and hypercapnia develop more frequently than in
emphysema

• Diminished respiratory drive (hypoventilation and retention of CO2)

Symptoms

Diagnosis: H & P; chest x-ray; pulmonary function tests; sputum specimens for
culturing; ABGs; EKGs; exercise testing with oximetry; cardiac nuclear scans

Treatment: Goals:

• Improve ventilation
• Promote secretion removal
• Prevent complications and progression of symptoms
• Promote patient comfort and participation in care

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 • Improve quality of life as much as possible
• Avoid environmental pollutants
• Treat infections immediately
• Stop smoking
Drug therapy:

• Bronchodilators (as a maintenance therapy, not for acute symptoms)

o Beta-2 agonists are commonly used
o MDI or nebulizer
o Anticholinergics are more effective in emphysema

• Oxygen therapy
o Raises the partial pressure of O2 in inspired air to treat
hypoxemia
o Humidification and nebulizers

 O2 is dry and irritating and must be humidified before

delivery
o Complications of O2 Therapy

 Combustion

 CO2 Narcosis (“Oxygen-Drive” for breathing may get

eliminated if oxygen is administered)

 O2 Toxicity (from prolonged exposure to O2; may

inactivate pulmonary surfactant and lead to ARDS
(acute respiratory distress syndrome).
 Infection (humidity encourages growth of bacteria in
lungs)
Respiratory Therapy

• Breathing retraining (pursed lip breathing; diaphragmatic/abdominal;

practice 8 -10 reps; 3-4 x per day )
• Effective coughing techniques
• Chest physiotherapy
• Exercise; pulmonary conditioning; smoking cessation and COPD
support groups
Nutritional Therapy

• Maintain weight
• Rest for 30 minutes before eating
• Use bronchodilator before meals
• Eat five to six small meals (avoid bloating which puts pressure on
diaphragm)
• Liquid/pureed diets may be helpful
• Avoid foods that require a lot of chewing

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 • Avoid exercise within 1 hour of eating
• Bloating/early satiety may be related to swallowing air, position of
diaphragm or side effects of meds
• High calorie/high protein recommended for emphysema

• High carbs metabolize into high CO2, and should be avoided

• Fluid intake should be at least 3 L per day unless contraindicated,
and between meals rather than with meals

NCM 102 Med-Surg Nsg Respiratory Disorders

Prepared by: Lindsay Carmelle I. Nate, R.N.