RESPIRATORY SYSTEM

A. UPPER RESPIRATORY TRACT

(as airway passage only not respiration)
 Primarily air conduction system
 Air filtered, warmed, humidified here

 Includes nose, pharynx and larynx

 1. Nose – major function is warming,

moistening and filtering

 2. Pharynx – commonly called

“throat” composed of 3 sections:

 a. Nasopharynx
 Located above soft palate
 Contains adenoids and openings to the eustachian tube
 Eustachian tube – connection between nose and ears

 B. Oropharynx
 Located directly behind the mouth and tongue
 Contains palatine tonsils which filter bacteria and viruses in food
 Air and food enters thru it
 Area where gag reflex is checked

 C. Laryngopharynx – extends from glottis to 6th cervical level

 Extends from glottis to 6th cervical level
 Also called voice box
 Connects lower and upper airways
 Glottis – opening of larynx
 Epiglottis – covers glottis; closes when food enters pharynx
 Opens to allow respiration but closes to avoid aspiration
 Vocal cords of larynx permit speech and involved in the cough reflex (watch
dog of respiratory tract)
B. LOWER RESPIRATORY TRACT

TRACHEA-
 Supported by C-shaped cartilage rings
 Carina – area where trachea divides into 2
branches, endpoint for intubation

BRONCHI – formed by the division of trachea

into 2 parts:
1. Right mainstem bronchus
 Larger and straighter
 Divides into 3 lobar branches (upper,
middle, lower)
 If ET tube is passed too far it might
enter R main bonchus, only R lung will
be intubated
2. Left mainstem bronchus
 Divides into upper and lower lobar
bronchi

BRONCHOILE
 Major function is no longer air conduction but gas exchange between blood and
alveoli
 Transition to alveoli

 ANATOMY AND PHYSIOLOGY OF THE LUNGS

 LUNG
Major organ of respiration
2 sides: R lung and L lung
Each lung has lobes
 R – 3 lobes
 L – 2 lobes

Pleura – covering of the lung

 Parietal
 Visceral

12 pairs of ribs (that’s why

T12) that protects the lungs
Intercostal muscles – are in
between the ribs
 External intercostal muscles – raises rib cage during inspiration
 Internal intercostal muscles – lowers rib cage during expiration

 DIAPHRAGM
Muscle of respiration, innervated by the Phrenic Nerve (C3 and C5 of the spinal nerve)

 ALVEOLI
Functional unit of the lungs

Gas exchange (O2 and CO2 exchange)

It produces Surfactant – phospholipids
found in the fluid that lines the alveoli,
which reduces surface pressure and prevents
lung collapse. It increases the surface area of
the lungs (premature babies have no
surfactant)
 SEQUENTIAL ACTIVITY:
1. VENTILATION – movement of air in and out of the lungs
2. DIFFUSION – passive movement of gases from alveoli to blood
3. PERFUSION – movement of gas from blood to cell; availability of O2 for cellular use

 LUNG SOUNDS:
 Normal sounds – vesicular, bronchial, vesicobronchial

http://www.cvmbs.colostate.edu/clinsci/callan/breath_sounds.htm

 Abnormal sounds – adventitious sounds:

o Rales or Crackles – gurgling or crackling sound, crackles are discontinuous,

explosive, "popping" sounds that originate within the airways. the
dynamic airway obstruction can be caused by either accumulation of
secretions within the airway lumen or by airway collapse caused by
pressure from inflammation or edema in surrounding pulmonary
tissue. Crackles can be heard during inspiration when intrathorac

o Wheezing – musical sound, As the airway lumen becomes smaller, the air flow
velocity increases resulting in harmonic vibration of the airway wall and
thus the musical tonal quality. Wheezes can be classified as either high
pitched or low pitched wheezes. It is often inferred that high pitch
wheezes are associated with disease of the small airways and low pitch
wheezes are associated with disease of larger airways.

o Rhonchi – snoring sound,

o Pleural friction rub – grating sound
 -Stridor - Stridor is significant and indicates upper airway obstruction.

I. REQUIREMENTS FOR GOOD VENTILATION:

A. PATENT AIRWAY
 Initial and important intervention; priority problem
 Conduction portion: all anatomical structures which serves as passageway
(Problem:COPD)
 Respiration portion: alveoli where gas exchange takes place (Problem: Restrictive Lung
Dse.)

B. ELASTIC & EXPANSIBLE LUNGS & TRACHEOBRONCHIAL TREE

 COMPLIANCE: the expansibility property of the lungs & tracheobronchial tree;
abnormal conditions results by destruction of lung tissue, fibrotic alveoli, blocked
alveoli, pulmonary edema, chest deformity, muscular weakness usually due to
SMOKING

 ELASTIC RECOIL: ability of the alveoli to back to its original size & shape;
destroyed by smoking

 SURFACTANT: reduces surface tension

but increases surface area: makes
breathing easy;prevents lungs from
collapsing

C. EFFICIENT & ADEQUATE

MUSCULO-SKELETAL APPARATUS
o INSPIRATION: thorax expands
(anterior-posterior diameter increases);
external intercostals muscles raises ribs
o DIAPHRAGM: major muscle of
respiration
 o PHRENIC NERVE: innervates diaphragm

D. CONSTANT PRESSURE GRADIENT

 PRESSURES INVOLVED:
1.ATMOSPHERIC PRESSURE – the air around us; 760mmHg ( 20%)

2.INTRAPULMONIC PRESSURE – the air within the bronchioles & bronchi; varies
- above or below 760 mmHg

3.INTRAPLEURAL OR INTRATHORACIC PRESSURE – pressure in the pleural

space; normally less than atmospheric pressure; about 751 to 754 mmHg

 MOVEMENT OF AIR: flows from area of higher pressure to area of lower pressure;
air is pulled in because pressures within respiratory tract are less that atmospheric
pressure
 Lungs need constant pressure gradient – Negative Pressure;
 atmospheric air provides positive pressure

II. FACTORS AFFECTING DIFFUSION:

A. THICKNESS OF THE ALVEOLI MEMBRANE

 alveoli membrane must be thin to allow gases to diffuse
 affected by thick sputum or cancer growth

B. SURFACE AREA OF THE MEMBRANE

 decreased surface area lessens gas exchange

 Surfactant increases surface area – for gas exchange to take place properly

C. SOLUBILITY OF GASES
 Normal: more O2 in the lungs
 COPD: more CO2 in the lungs
 CO2: most potent stimulator of breathing
 O2: increases gas solubility

 PULMONARY AIR VOLUMES: (LUNG FUNCTION TEST-SPIROMETER)

A. TIDAL AIR – air that is moved during quiet inspiration & expiration; Normal: 500 ml

B. INSPIRATORY RESERVE – amount of air that can be forcibly inspired after normal
expiration; Normal: about 2,000 to 3000 ml

C. EXPIRATORY RESERVE – amount of air that can be forcibly expired after normal
inspiration; Normal: about 1,500 ml

D. RESIDUAL AIR – air that remains in the lungs; can’t be removed by forceful
expiration; purpose is to aerate the blood between breaths; Normal: about 1,000 to
1,200 ml

E. VITAL CAPACITY – air moved on deepest inspiration & expiration; MAXIMUM

AIR INSPIRED AND EXPIRED: Normal: 3,000 to 5,000 ml;
Affected by: anatomical built of a person; position during measurement; strength of
respiratory muscle; distensibility of the lungs & chest cage (pulmonary compliance)

F. INSPIRATORY CAPACITY – maximum amount of air an individual can inspire

after a normal inspiration; FORMULA: Tidal volume + Inspiratory reserve
volume; Normal: 2,500 to 3,500 ml.
 RESPIRATORY REGULATION OF ACID-BASE BALANCE:

 (BLOOD – SHOULD BE ALWAYS BE BALANCED (ACID-BASE) pH

--If blood is acidotic, can corrode the system. If alkalosis, can also be harmful to the
system. Thus, blood ph should be balanced.

 Respiratory system helps to maintain the blood pH close to normal – 7.35 to 7.45
(although 6.8-7.8 is still compatible with life)

 Carbon dioxide: major product of cellular metabolism, MAJOR WASTE PRODUCT

OF METABOLISM

 Retention of CO2 increases formation of carbonic acid which increases acidity of

blood (below 7.5)

 NORMAL CONDITIONS: CO2 important stimulus for respiration (hold breath – too
much CO2 forces you to breathe rapidly until pH normalizes; hyperventilation eliminates
more CO2, respirations automatically becomes slower & shallower to retain enough CO2
to adjust blood pH.

HYPERVENTILATION – release of CO2, results to ALKALOSIS

DISORDERS OF RESPIRATORY ACID BASE

 RESPIRATORY ACIDOSIS:
 Elevated PaCO2 (Normal: 35 to 45mmHg); pH is less than 7.35

 Causes cerebrovascular vasodilation and increased blood flow to the brain

 SX&SY:
 mental cloudiness
 feeling of fullness in the head;
 if severe, may cause increased ICP

 VENTRICULAR FIBRILLATION: first sign of respiratory acidosis

 PREDISPOSING FACTORS: (COB)

 Chronic Emphysema
 Obesity
 Bronchitis

 MGT.:
 1. treat underlying cause,
 2. adequate hydration (2-3L/day) to liquefy secretions & facilitate removal,
 3. clear airway with mucus & purulent drainage,
 4. supplemental oxygen, mech. Ventilation

 MEDS:
 Bronchodilators (to reduce bronchial spasm);
 antibiotics (for respiratory infections);
 anticoagulants (used for pulmonary embolism)
  RESPIRATORY ALKALOSIS:
 Decreased PaCO2; pH more than 7.45

 MAJOR CAUSE: Always due to hyperventilation; causes excessive blowing off of

CO2

 Causes cerebrovascular constriction and decreased blood flow to the brain

 SX&SY:
 lightheadedness,
 inability to concentrate,
 numbness & tingling,
 tinnitus,
 loss of consciousness at times

 CAUSES:
 extreme anxiety,
 hypoxemia,
 early phase of salicylate (ASPIRIN) intoxication,
 inappropriate ventilator settings

 PREDISPOSING FACTORS:
 hepatic insufficiency &
 cerebral tumors

 MGT.:
 1. treat underlying cause, if with anxiety – ask pt to breathe more slowly or to breathe
into a brown bag,
 2. sedative to calm pt.

 LABORATORY/DIAGNOSIC TESTS:

1. SPUTUM EXAM for C & S – MOST DEFINITIVE TEST FOR TB

1. Culture: identify the microorganism
2. Sensitivity: identify what meds the M.O. is sensitive to, i.e. antibiotics and viral
meds. …and what makes them die.

Nursing Responsibility: (SPUTUM TEST- DONE IN THE MORNING)

1. Client Teaching: Deep breathing 3x
2. Then hacking cough (From the diaphragm)
3. Done first thing in the morning and gargle with plain water prior to collection,
but do not brush teeth before specimen is taken
4. 1 to 3 mL is needed of sputum (not saliva)
5. Usually given mucolytic(solmux/carbocistein)/aerosol therapy to liquiefy
mucous and to ensure sputum specimen; but not given a dose of antibiotic
6. Container must be sterile (ask from laboratory) with cover
7. Don’t delay specimen, as soon as it obtained deliver to laboratory right away to
avoid contamination.

2. TUBERCULIN TEST/ MANTOUX TEST/PPD(PURIFIED PROTEIN DERIVATIVE

TEST) –(skin test-ID) to test whether you had past exposure to Mycobacterium
tuberculosis (presence of antibodies)

Intradermal test
purified protein derivative (PPD)
2 ways to administer:
1. Mantoux Test
 2. Tine’s Test – uses a disc with needles

After 48 to 72 hours look for the induration(2-3 days): - (pagkaburut sa bleb or wheal)
IF WHEAL::
below 5mm is negative, (no antibodies against TB)
between 5 mm and 10mm - doubtful/probable
if above 10mm (+) – positive of exposure to TB

-Unless px is immunocompromised- below 5mm result is already positive

3. CHEST X-RAY (only shows consolidated areas/patches in the lungs- which is still not
definitive)
Contraindicated to pregnant women (teratogenic to the baby)
Instruct the client to hold his breath and remove metals from the chest

4. LUNG SCAN
Measures blood perfusion through the lungs.
Helps confirm pulmonary embolism or other blood-flow abnormalities.
After an injection with a radioisotope, scans are taken with a camera. (low dose only)
Remain still during the procedure.

5. THORACENTESIS
(**BQ**FAVORITE)
Insertion of a needle or catheter into
the chest-wall into the pleural space
(INVASIVE PROCEDURE)

For the ff purposes:

o To obtain specimen
o To aspirate excess fluids
o To introduce medication
thru the intrapleural space

Pre-Procedure Nursing
Intervention:
 1. Secure consent

 2. Take initial VS

 3. Position: upright leaning on over bed table (“Straddling or Orthopneic”

position) **BQ**

 4. Auscultate the lungs to determine area of puncture (usually diminished breath

sounds if filled with fluid)

 5. Puncture:
 Air- 2 or 3 ICS;
 Fluid – 6 or 7 ICS;
 Both – 6 or 7 ICS

 6. Instruct to remain still during the procedure

 7. Pressure sensation is felt upon needle insertion

Post-Procedure Nursing Intervention:

o 1. POSITION **BQ**
o Turn on unaffected side to prevent leakage from the thoracic cavity
RATIONALE: To avoid further leakage of pleural fluid
 o 2. Bed rest
o WOF: respiratory distress; pneumothorax (intrapleural space should maintain
negative pressure – atmospheric air is positive- pneumothorax may further result
to atelectasis

o 3. Check for expectoration of blood

o Monitor VS

6. BRONCHOGRAPHY (invasive)
Radiopaque medium is instilled directly to the trachea or any part of the bronchial tree
to be visualized through x ray.

Nursing intervention before the procedure are:

 Secure informed consent
 Check for allergy to food, iodine, anesthesia
 NPO for 6-8 hrs
 Pre-op meds:
 1. Atropine SO4 (SNS effect)- to dry up saliva since GI is down
 2. Valium,
 3. topical anesthesia (LIDOCAINE) and anesthesia to be injected into the larynx
– BUT- DON’T LET PX EAT UNTIL GAG REFLEX IS PRESENT TO
PREVENT ASPIRATION. (post op)

CHECK GAG- use tongue depressor

 4. Secure O2,

 5.antispasmodic agents at bedside – to prevent closing of airway

Nursing intervention after the procedure are:

 Side-lying position

 NPO until cough, gag reflex return

 Cough, deep breathing exercise


  Low-grade fever is common

7. BRONCHOSCOPY
Visual image by a fiber optic scope
Direct inspection and observation of the larynx,
trachea and bronchi through flexible or rigid
scope

Diagnostic uses:
1. to collect secretion, (eg. sputum)
2. to determine location of pathologic process
and collect specimen.

Therapeutic uses: remove foreign object and excise lesions

Pre-Procedure Nursing Interventions:

 Informed consent
 Atropine, valium as premeds, topical &
local anesthesia
 NPO for 6-8 hrs
 Remove dentures, prosthesis, contact lens

Post-Procedure Nursing Interventions:

 1. Side lying position (prevents aspiration)

 2. Check for coughing, gag reflex prior to

oral intake

 3. Watch for signs of perforation of the

bronchial tree: cyanosis, hypotension,
tachycardia, hemoptysis, dyspnea

8. ARTERIAL BLOOD GASES (MEMORIZE -**BQ**)

 Purpose is to assess ventilation and acid-base balance

 Radial artery – common site of blood extraction

 ALLEN’S TEST – should be done first before extracting radial artery site
(compress the radial and ulnar arteries, palmar pallor, then release radial artery- if color
comes back – means radial artery is patent- can do ABG)

 10 ml pre-heparinized syringe

 Place syringe in a Container with ice

 Should be analyzed within 20 minutes after it was drawn to ensure accurate result

NOTE: MEMORIZE HEMATOLOGIC NORMAL VALUES

BLEEDING TIME – 2-7 MINS. (platelet function)
PTT -
PT -

MEMORIZE THESE *BQ*- ESP ABG’s

 Disorder Initial Event Compensation

Respiratory acidosis High PaCO2, or high Kidneys eliminate H,

N HCO3, low pH retain HCO3

Respiratory alkalosis Low PaCO2 or high Kidneys conserve H,

N HCO3, high pH excrete HCO3

Metabolic acidosis Low HCO3, or high Lungs eliminate

N PaCO2, low pH CO2, kidneys
conserve HCO3
Metabolic alkalosis High HCO3, or low Lung conserve
N PaCO2, high pH PaCO2, kidneys
conserve H

 How to evaluate ABGs:

1. FIRST Evaluate the pH – below 7.35 (Acidosis); above 7.45 (Alkalosis)

2. Determine primary cause of disturbance –

2 sources:
A. PaCO2 (Respiratory);
B. HCO3 (Metabolic)

ROME: Respiratory – Opposite (↑pH - ↓PaCO2; ↑pH - ↓PaCO2)

Metabolic – Equal (↑pH - ↑HCO3; ↓pH - ↓HCO3)

3. Find out if there is compensation – look at the value other than primary disturbance, it
should move at the same direction of the primary value.

Example:
pH= 7.2; PaCO2= 60mmHg; HCO3= 24mEq/L (Resp. Acidosis Uncompensated)
pH= 7.2; PaCO2= 60mmHg; HCO3= 37mEq/L (Resp. Acidosis Compensated)
NOTE: if the 2nd value (HCO3) follows the primary value (CO2) – COMPENSATED

EG: PH= 7.31, PACO2= 50, HCO3 = 27 ==RESP. ACIDOSIS, COMPENSATED

EG: PH= 7.48, PACO2= 32, HCO3 = 24 ==RESP. ALKALOSIS, UNCOMPENSATED

EG: PH = 7.47, PACO2= 47, HC03= 37 == METABOLIC ALKALOSIS, COMPENSATED
(if paCo2= normal = uncompensated)

PH 7.33, PACO2= 33, HCO3= 21 = METABOLIC ACIDOSIS, COMPENSATED

PH= 7.59, PACO2= 49, HCO3= 48, PO2= 58 (up)= metabolic alkalosis,partially comp.

NOTE: DIARRHEA – ACIDOTIC (coz intestines alkaline)

NOTE: VOMITING – ALKALOTIC (coz suka ug acidic)

NOTE: GLUCOSE LEVEL: 80-120mg/dL or divided by 16= m osmoles

9. PULSE OXIMETRY – measures OXYGEN SATURATION

O2 SAT – AMOUNT OF O2 IN THE BLOOD READY TO BE DISTRIBUTED TO
THE DIFFERENT ORGANS AND TISSUES OF THE BODY

 The pulse oximeter passes a beam of light through the tissue & a sensor attached to the
fingertip, toe or earlobe.

 It measures the amount of light absorbed by the oxygen saturated hemoglobin.

 Motion of the sensor site changes light absorption. The motion mimics the pulsatile
motion of the blood & because the detector cannot distinguish between movement of
finger from blood, results can be inaccurate. (THUS, TELL PX NOT TO HAVE
UNECCESSARY MOVEMENTS – coz sensor can detect all motions.

 The sensor should not be placed distal to BP cuffs, pressure dressings, arterial lines or
any invasive catheters.

 The sensor should not be taped to the client’s finger, but the sensor should be
protected from direct ray of light

 If values fall below preset norms (usually 90%) the client should be instructed to deep
breathe; it is not necessary to call the doctor ASAP.

DISORDERS OF THE RESPIRATORY SYSTEM

I. DISORDERS OF THE UPPER RESPIRATORY TRACT

A. SINUSITIS
o Infection of the paranasal sinuses
o Common complication of URTI because mucous membrane that lines these sinuses are
continuous with the URT

o SX&SY: mouth breathing, phony voice sound

o TX:
o 1. Treat underlying cause;
o 2. Nose drops – Phenylephrine “Disudrine Drops” to decrease swelling and facilitate
drainage

B. EPISTAXIS
 Nosebleed; maybe caused by trauma, ulceration in lining of nose, breathing dry air, small
tumors or polyps; could be a symptom of ↑BP

 MGT: Apply pressure on nasolacrimal duct for several minutes; Apply ice pack (for
vasoconstriction)
C. TONSILITIS
o Inflammation of the palatine tonsils
o (MAY LEAD TO RHEUMATIC HEART DISEASE- ENDOCARDITIS, ESP. IN
CHILDREN)

o SX&SY: pain on swallowing, fever, chills, malaise

o MGT:
o 1. rest,
o 2. analgesic (for fever),
o 3. ↑ fluid intake,
o 4. appropriate antibiotics

o Usually self-limiting but sometimes with serious complications: otitis media,

rheumatic heart fever (RHD)

o Chronic Tonsilitis may require tonsillectomy

SX: TONSILECTOMY AND ADENOIDECTOMY

POST OP POSITION: **BQ** PRONE POSITION WITH HEAD ON SIDE, TO

PREVENT ASPIRATION OF SECRETION

D. CROUP (ACUTE SPASMODIC LARYNGITIS)

 URTI usually viral in nature
 commonly affects children between three months to 4 yo

 SX&SY:
 respiratory distress, (due to laryngospasm)
 inspiratory stridor,
 barking cough

 -TX:
 1.adequate hydration,
 2.aerosol therapy,
 3. cool mist inhalation, (CROUP TENT- child inside the tent) – MIST TENT
 PURPOSE OF MIST: DECONGESTION
 NSG CARE: EXTRA SHIRTS FOR CHILD TO KEEP DRY SINCE MIST IS WET
 DON’T GIVE TOYS THAT ARE COMBUSTIBLE- use plastic toys

 acetaminophen

E. EPIGLOTTITIS
o Acute bacterial inflammation of the epiglottis

o life threatening, may cause airway obstruction- since it is inflammed

o often seen in male children

o SX&SY:
o fever,
o sore throat,
o difficulty swallowing,
o drooling & stridor,

o position: sitting position with neck hyperextended, mouth open & tongue protruding
(to reduce airway obstruction)

o DX: direct observation of cherry-red epiglottis,

o Neck Xray (swollen epiglottis)
 o MGT:
o placement of artificial airway (Nasotracheal intubation) until edema is relieved;
o antibiotics,
o O2 therapy

II. DISORDERS OF THE LUNGS & PLEURA

A. OBSTRUCTIVE PULMONARY DISEASE

 Respiratory conditions that produce obstruction to airflow
 Any disorder in which obstruction impedes airflow to the lungs.
 Can be:
 Chronic – asthma, bronchitis and emphysema (COPD)**BQ**

 Acute – ARDS, acute respiratory failure, cystic fibrosis and cancer.

CAUSES:
 1.Also caused by edema of airway or tongue from smoke inhalation,
 2. infection or anaphylaxis
 Can result from mucociliary transport caused by chemical damage or by chronic
irritation from cigarette smoking. Mucociliary blanket (mucosa of lungs with
hairlike projections) will trap the mucus/bacteria. But cigarette smoking will
destroy the cilia. Thus, smoking is the main cause of cancer.

 Risk factors Include:

 1. Cigarette smoking (causes loss of recoil in time)
 2. Prolonged exposure to pulmonary irritants

B. RESTRICTIVE LUNG DISORDERS ( A-P-P-P )

 Disorders that limit lung expansion and restrict chest wall expansion throughout the
respiratory cycle.

 Result in decreased lung volume, pulmonary compliance and increased work of

breathing.

 Includes atelectasis, pneumonia, pneumothorax and pleural effusion

` CAUSES:
 1. parenchymal or lung disease,
 2. neuromuscular alterations,
 3. chest wall disorder,
 4. musculoskeletal or neuromuscular disorder (kyphosis, muscular dystrophy, Gullain
Barre syndrome-paralyzed diaphragm (ascending), Myasthenia Gravis- paralyzed
diaphragm (descending))

C. RESPIRATORY TRACT INFECTION

 Affect airway clearance and breathing patterns by changing the amount and character of
secretions
 Severe RTI include PNEUMONIA and PTB

 Risk factors:
1. Exposure to infected person
2. Stress or other immunocompromised states that may allow easy proliferation of
microorganisms
 OBSTRUCTIVE LUNG DISEASES (WITH RESPIRATORY ACIDOSIS)

1. CHRONIC BRONCHITIS (blue bloaters)- usually overweight pxs

o Defined in clinical terms: ↑in coughing & mucus production for at least 3mos per
year for 2 consecutive years
o ↑ activity of mucuciliary blanket (cilia + mucus secreted by goblet cells)

o SX&SY:
o 1. productive cough,
o 2. dyspnea on exertion,
o 3. scattered rales, wheezing & rhonchi;
o 4. slight cyanosis (“blue bloaters”)

o CAUSES:
o 1. heavy smoking, infections,
o 2. inhaled irritants; pts. usually overweight

o DX: ↑pCO2, ↓PO2 causes vasoconstriction in the heart

o WOF complication:
o COR PULMONALE – right sided heart enlargement due to respiratory acidosis &
hypoxemia.

o Vasoconstriction ↑ blood flow resistance to the lungs; right side of the heart enlarges
as an attempt to maintain normal output.

2. EMPHYSEMA (“pink puffers” / “hangakers”)

 Defined in anatomic terms: enlargement and destruction of the alveolar, bronchial,
bronchiolar tissues
 Results to loss of elastic recoil (lungs cant go back to normal size), air trapping, sputum
accumulation

 CAUSES: same factors that causes bronchitis; pt. usually older & thin

 SX&SY:
 1. ↑ anterior-posterior chest diameter (barrel chest – due to residual volume);
 2. diminished breath & cardiac sounds (due to ↑ AP dia. – more air between chest wall
& lungs/heart);
 3. no sputum (unless bronchitis is also present); feeling of breathlessness

 DX: ↑ or N PCO2; N or slightly ↓ PO2 (no cyanosis – “pink puffers”)

3. BRONCHIECTASIS
o Irreversible dilation of the bronchial tree due to repeated pulmonary infection

o DIAG: CT Scan

o SX&SY:
o Asymptomatic;

o only hallmark sign – layering of sputum

o TX of Choice: Chest Physiotherapy

3. BRONCHIAL ASTHMA
 Obstructive disease of the lower respiratory tract

 Often caused by allergic reaction to environmental allergen

 allergic reaction results in histamine release which produces three airway responses:
(S-E-A)
a. Spasm of smooth muscle of bronchi & bronchioles (CONSTRICTED
AIRWAY)

b. Edema of mucous membranes

c. Accumulation of tenacious secretions

o SX&SY:
o 1. respiratory distress – shortness of breath,
o 2. expiratory wheeze,
o 3. air trapping (barrel chest if chronic),
o 4. irritability (from hypoxia),
o 5. diaphoresis, change in sensorium if severe attack

o COMPLICATION: STATUS ASTHMATICUS: little response to treatment &

symptoms persist

 INTERVENTIONS WITH COPD PATIENTS:

A. Position – position of comfort; orthopneic position / TRIPOD

B. Breathing Exercises (facilitate removal of CO2) –

1. Pursed lip breathing, (ON EXHALATION- MORE CO2 out)

2. Incentive Spirometry (Incentive devices provide the stimulus for a spontaneous

deep breath.

3. Spontaneous deep breathing using the sustained maximal inspiration concept,

reduces atelectasis, opens the airway, stimulates coughing & actively encourages
individual participation in recovery.)
 C. CHEST PHYSIOTHERAPY – to remove secretions; best done in the morning
or before or 3 hours after meals
--Always follows the principle of gravity

o 1. Administer bronchodilators about 20mins before procedure to liquefy

secretions

o 2. Assist patient to correct positioning (assume position 3-5 minutes)

o 3. Auscultate lungs to know where to drain off ( areas with dull sounds)

 Right upper lobe – High Fowlers (about 60-75 degrees)

 Right middle lobe – Pt. right shoulder elevated with pillow, foot part
elevated 16 inches

 Right lower lobe – Pt. side lying, foot part elevated 20 inches

 Apical segment, left upper lobe – Pt. sitting, leaning forward on a table

 Inferior segment, left upper lobe – Pt. left shoulder elevated with pillow,
foot part elevated 16 inches

 Left lower lobe – Pt. side lying, foot part elevated 20 inche

 4. Do Chest Percussion – put towel over to be percussed , Chest clapping, Chest

tapping, Chest Vibration

 5. Postural Drainage (let patient cough)

 6. Provide oral care after postural drainage

 7. Post Procedure: maintain position 5-20 minutes after

D. O2 administration – never give ↑ concentration of O2 (may cause respiratory

arrest);
1-3L/M by nasal cannula
- can’t give O2 6l/min for COPD pxs, coz stimulus for breathing is CO2, can
cause respiratory arrest.

E. Medications:
1. Bronchodilators: Epinephrine (SNS), Terbutaline, Salbutamol (S/E: palpitations,
tremors)

2. Xanthine Derivatives: Aminophyline, Theophyline – used for Status

Asthmaticus (S/E: GIT stress, palpitations, tremors)

3. Mucolytic to liquefy secretions: Acetylcysteine “Mucomyst” thru inhalation;

wipe face of pt. after administration (sticky);
Mucomyst - also antidote for Acetaminophen poisoning.

4. Steroids to ↓ inflammation: Prednisone **BQ**, Hydrocortisone

Prednisone- with meals (GI irritant), decrease immune system coz anti-
inflammatory, (If taking insulin, increase insulin since prednisone will increase
SSS. And if stool is black, may indicate GI bleeding.)

5. Antihistamine to block release of histamine: Diphenhydramine; S/E:

drowsiness

6. Metered-Dose Inhaler (MDI): (Steroids, Bronchodilators)

 o Shake the inhaler
o Inhaler should be upside down
o Breathe out fully (up to 3x) - exhale
o Open mouth & tilt head slightly; hold inhaler about 2 inches away from
mouth (**BQ**) (new)
o Press metal canister to release medication & at the same time begin to inhale
slowly; breathe in slowly & deeply for 3-5 seconds (**BQ**)
o Hold breath for about 8-10 seconds
o Slowly breathe out through nose & pursed lips
o Wait about 1-2 minutes before the next puff, shake inhaler & repeat if
necessary
o Rinse mouth with water or gargle

7. Nebulization (bronchodilators)

F. Desensitization: for asthma

 DIAGNOSTIC TEST FOR COPD:

a. Pulmonary Function Test – determine lung volume & lung capacity using
a Spirometer
b. ABGs – measure level of oxygen in the blood
c. O2 Saturation – should be ↑90%; uses Pulse Oximeter, if less than 90%,
let px do deep breathing
d. Skin Testing – “METACHOLINE SKIN TEST”: to determine type of
allergy

 RESTRICTIVE LUNG INFECTIONS

A. PNEUMONIA

 An inflammation of alveolar spaces of the lung

 Results in consolidation of lung tissue as the alveoli fill with exudates

 CAUSE: Streptococcus, Haemophilus, Staphylococcus

 PHASES:
1st Phase – “ CONGESTION PHASE”; initial response (inflammation); vague
manifestations: low grade fever, easy fatigability, occasional cough;
whitish serous phlegm; ↑ capillary permeability (fluid goes out from the
capillaries)

2nd Phase – “RED HEPATIZATION PHASE”; RBC leakage out of the

alveoli; transforms lungs into red color;

** PATHOGNOMONIC SX- appearance of brick red sputum; **

 OTHER SIGNS AND SYMPTOMS:
1. already full blown pneumonia: (fever, chills, chest pain, weakness,
malaise, rales, crackles, dullness on percussion, stridor, cough, intercostal
rib retraction, weight loss);
2. releases antibody; antigen-antibody reaction (most critical period)

3rd Phase – “GRAY HEPATIZATION PHASE/ recovery phase”; collection

of dead cells; turns lungs into grayish color; gradual decline of fever;
recovery stage

o DX: Culture & Sensitivity Test

o ANTIBIOTICS: backbone of treatment

o MGT.:
 1. O2 administration

 2. Position: Semi – High Fowlers

 Facilitate removal of secretions (suctioning, deep breathing & coughing,
expectorants, nebulizer, mist inhalation, chest physiotherapy)

 3. Adequate rest (limit physical activity, limit visitors, limit conversations)

 4. Prevent transmission-DROPLET (isolation, cover mouth when coughing,

proper disposal of tissues

 5. Control fever & chills (antipyretics, ↑ OFI, clothing & linen changes)

B. PULMONARY TUBERCULOSIS **BQ**FAVORITE

 Bacterial infection of the lungs caused by Mycobacterium Tuberculosis

 Spread via droplet or airborne or both when infected person cough, sneeze or
laugh

NOTE: AIRBORNE – TB, VARICELLA, MEASLES

SX&SY:
 cough with yellow mucoid sputum for several months;
 dyspnea,
 hemoptysis,
 Fatigue & malaise,
 weight loss,
 afternoon low-grade fever,
 rales & crackles at apex of the lungs; night sweats)

 DX:
 Chest Xray;
 PPD Skin Test (Mantoux or Tine)- test for antibodies against tb;
 Sputum Culture – MOST DEFINITIVE TEST

DSSM- TEST IN COMMUNITY

 MGT:
 1. Prevent transmission: strict isolation, well-ventilated private room with
door closed; (LAMINAR FLOW-changes air flow inside the room as much
as 12 changes PER HOUR)
 IMPT: CLOSE DOOR, OPEN WINDOW

 2. visitors & staff wear mask; discard mask before leaving;

 But px wears mask if he goes out of the room
  3. strict washing of hands or contaminated articles

 4. Adequate nutrition: small, frequent feeding, weigh client at least 2x a

week (coz tb pxs usually become anorexic)

 CATEGORIES: (TUBERCULOSIS)
I: Sputum (+); Xray(+) with extensive damage; severe Extra Pulmonary
TB (EPTB) such as POTT’S dse – TB of bones; SCROFULODERMA – TB
of lymph nodes; LUPUS VULGARIS – TB of skin.
II: TB relapse
III: Sputum (-); Xray (+) minimal, (-) EPTB (tb of the bone- POTT’S
disease, Scrofuloderma –tb of lymph nodes, Lupus vulgaris – tb of skin)

**MEMORIZE:**
Category I = (+)Sputum , (+) xray , severe EPTB, Extensive damage
Category II = TB relapse , Treatment failure, discontinuance of tx
Category III = (-) sputum smear, + x-ray, minimal infiltration
Category IV = all meds and tx ineffective and pxs not cured, referred to
lung ctr

DOTS – DIRECT OBSERVED TREATMENT STRATEGY

- Used in the community to monitor compliance of people taking MDT (multi drug
therapy)

 MEDICATIONS: Multidrug Therapy (MDT)

 Why use multidrug therapy– to prevent resistance

Direct Observed Treatment Strategy (DOTS) – monitor compliance

-- 2 months of taking RIPES, px is not communicable anymore

 RIFAMPICIN:
 A/E: hepatotoxic (sign: jaundice; don’t give to children; monitor liver
enzymes – AST/ALT);
 body fluids (urine, tears, saliva) may turn orange.

 ISONIAZID:
 A/E – peripheral neuritis (tingling & numbness of hands & feet);
 given with Vit. B6 (pyridoxine) to treat the condition;

 hepatotoxic; given on an empty stomach for better absorption.

 Interferes with the absorption of oral contraceptives (pillsl) so advice px to
take other ways of contraception.
 Vit. B6- have neurology effects
 Isoniazin interferes with the absorption of vit. B6

 PYRAZINAMIDE:
 hepatotoxic;
 ↑uric acid levels, may lead to gout (monitor uric acid levels and liver
enzymes)

 ETHAMBUTOL: E_EYES A/E – Optic Neuritis (loss of red-green color

discrimination, ↓ visual acuity);
 don’t drive (can’t distinguish colors of traffic light)

 STREPTOMYCIN:
 A/E – damage to CNVIII (vestibule – dizziness, vertigo, tinnitus; auditory
– hearing loss);
  nephrotoxic;

 MGT: renal & audiology studies

 ADMINISTRATION: **(MEMORIZE)**
Category Intensive Maintenance (months)
I RIPE (2) RI (4) total 6 mos

II RIPES (2) RIE (5) total 8 mos

RIPE (1)

III RIPE (2) RI (2) total 4 mos

C. HISTOPLASMOSIS
o Systemic fungal disease caused by inhalation of dust contaminated by
Histoplasma capsulatum which is transmitted thru bird manure

o SX&SY:
o 1. sometimes asymptomatic;
o 2. symptoms similar to TB and pneumonia (fever, cough, malaise, joint pains,
night sweats)

o DX:
o 1. Chest Xray (similar to TB);

o 2. Histoplasmin Skin Test (read the same as PPD)- MOST DEFINITIVE

TEST FOR HISTOPLASMOSIS

o MGT:
o 1. Amphotericin B - (antifungal agent but very toxic – anorexia, chills, fever,
headache, renal failure); not given in home setting;
o 2. Acetaminophen, Benadryl & steroids are given along with Amphotericin B
to prevent reactions.

o Other Nsg Mgt: the same with Pneumonia & TB

 COMPLICATION OF LUNG INFECTIONS – PLEURAL EFFUSION

 Accumulation of fluids in the pleural space/cavity

 Fluid may be transudate (hydrothorax),

 exudates (empyema),
 blood (hemothorax) or
 chyle (chylothorax) – chyle is a milky fluid found in lymph fluid from GI tract.

 Etiology:
o Hydrothorax (transudate) – results from CHF; other causes are RF, nephrosis
and liver failure

o Empyema (exudates) – from infections, malignancies, SLE. May also be

caused by direct spread of bacterial pneumonia or trauma-related infections

o Hemothorax (blood)– chest injuries, chest surgery complications, malignancies,

blood vessel rupture

o Chylothorax (chyle) – trauma, inflammation or malignant infiltration

 Pathophysiology/Mechanism of the Disease: (PLEURAL EFFUSION)

 5 mechanisms:
  1. Increase in capillary pressure – failure to shift the blood back towards
the heart

 2. Increase in capillary permeability(manipis na) - such as in inflammation

 3. Decrease COP

 4. Increase in intrapleural negative pressure

 5. Impairment in lymphatic drainage of the pleura

 Pleural effusion results in decreased lung volume on the affected side and a
mediastinal shift on the other side  decreased lung volume on the other side as
well
 Characteristic signs: diminished breath sounds and flatness and dullness to
percussion.

 OTHER SX&SY:
 dyspnea,
 dullness over affected area on percussion,
 absent or ↓ breath sounds,
 dry cough,
 pleural friction rub,
 pallor, fatigue,
 fever (with empyema)

 SEVERITY OF HEMOTHORAX DETERMINED BY VOLUME OF FLUID

o Minimal (300-500cc) – resolves in 10-14 days as small amounts of blood are
naturally absorbed from the pleural space.

o Moderate (500-1000 cc) – fills about 1/3 of the pleural cavity  lung
compression and signs of hypovolemia

o Large (1000 cc or more) – fills half or more of the chest and requires
immediate drainage.

 DX: Xray - >fluid; Thoracentesis may contain blood

 MGT:
 1. Observe px for signs of shock
2. Administer analgesics as required
3. For moderate to large:

 Maintain fluid replacement as ordered.

 Assist with insertion of chest tubes are ordered.
 Maintain patency of tubes.
 Prepare for surgery if bleeding doesn’t stop.

 4. Identify & treat underlying cause; Antibiotics (either systemic or injected
directly into pleural space by thoracentesis)

o 5. Chest drainage

 CHEST INJURIES/TRAUMA:

A. FLAIL CHEST
 Fracture of several ribs that leads to instability of chest wall usually caused by
trauma
 Chest wall no longer able to provide structure to maintain ventilation

SX&SY:
 paradoxical breathing – flail portion is sucked in on inspiration and bulges out
on expiration; (hallmark sign)
 hypoxia,
 hypercapnia,
 ↑ retained secretions,
 severe dyspnea –
 rapid, shallow, grunty breathing;
 cyanosis,
 neck vein distention,
 tachycardia,
 hypotension
 DX: ↓pO2; ↑pCO2; ↓pH
 MGT: open airway (suction secretions/ blood via ET tube); placed on mech vent,
encourage turning, coughing, & deep breathing; monitor for signs of shock

B. PNEUMOTHORAX/HEMOTHORAX
o Partial or complete collapse of the lung due to an accumulation of air or fluid in
the pleural space

o Types:
1. Spontaneous Pneumothorax (CLOSED PNEUMOTHORAX) – no trauma,
(no entry, no exit) ,most common type of closed pneumothorax;

CAUSES: could be S/E thoracentesis, overdistended alveoli (emphysema), rupture

of a small bleb on visceral pleura

2. Open Pneumothorax – air enters the pleural space thru an opening in the
chest wall (by stabbing or gunshot wound); no build up of pressure – air enters
& exits the pleural space

3. Tension Pneumothorax – entry of air into pleural space without exit point;
causes build up of pressure – an emergency; onset is sudden & painful; leads
to mediastinal shift – pushes lung to unaffected side

4. Hemothorax – accumulation of blood in the pleural space frequently found in

open pneumothorax resulting in hemopneumothorax

 SX&SY:
  #1Manifestation – diminished or absent breath sounds on affected side;
 sudden sharp pain in the chest,
 dyspnea;
 weak, rapid pulse;
 anxiety,
 diaphoresis;

 DX: Xray – reveals area & degree of pneumothorax; ↑pCO2, ↓PO2

MGT:
 1. Intubate first,
 2. suction secretions,
 3. monitor mech vent,
 4. assist w/ thoracentesis, or chest tube drainage,
 5. provide relief/control of pain
 6. (high Fowler’s, narcotics/analgesics)

C. ATELECTASIS
o Collapse of part or all of a lung; a shrunken airless state of the alveoli
o Can be primary or secondary

 1. Primary
 Lung tissue remains uninflated as a result of insufficient surfactant
production. (surfactant increases surface area in the lungs)
 Present at birth typically on premature and at-risk infants.

 2. Secondary – caused by airway obstruction, lung compression

(pneumothorax, pleural effusion) and increased recoil due to diminished
surfactants
 Airway obstruction may be due to mucus plugs, tumors or exudates.
 Its risk increases after surgery

o SX&SY: dyspnea, decreased breath sounds, cyanosis, weakness, pain over

affected area, tachycardia, tachypnea

o DX:
o Bronchoscopy may reveal obstruction (mucus-bronchitis, tumor, exudates);
o Xray- diminished size of affected lung; ↓pO2

o MGT: Prevention of atelectasis in a hospitalized pt is an important nursing

responsibility.

o (PULMONARY TOILET-)
o COUGHING,
 o DEEP BREATHING,
o SUCTIONING,
o TURNING TO SIDES EVERY 2 HOURS)

1. Turn & reposition q2hours

2. Encourage mobility (if permitted)
3. Deep breathing & coughing exercises
4. Promote liquification and removal of secretions

 ADULT RESPIRATORY DISTRESS SYNDROME (ARDS)

 A sequela of several diseases in which the lungs fill with water, making gas exchange
impossible
 Results from unknown cause

 Predisposing factors
 Pneumonia
 Near drowning
 Reaction to drugs and inhaled gases
 Allergic reactions (pulmonary)
 Shock Infection
 Diabetic ketoacidosis
 Trauma
 Burns

 Pathophysiology:
 Increased permeability of alveolar-capillary membrane  penetration of protein and
fluid from the IV compartment into the pulmonary interstitium and alveoli 
noncardiac pulmonary edema
 Plasma protein inactivates surfactant  injury to the alveolar cells  surface tension
 Increased pressure from excessive fluid and increased surface tension  alveolar
collapse  stiffening of the lungs  difficulty in inflation
 Decreased lung compliance and increased work of breathing

 Clinical Manifestations:
 Symptoms include:
 Crackles and gurgles
 Hypoxemia due to poor diffusion
 Respiratory distress (px can’t breath on his own anymore, needs mech vent)

 DX: X-ray result – mass consolidation

 ABG Analysis: Respiratory acidosis

 Nursing Interventions:
 1. Monitor fluid intake

 2. Administer steroids as ordered  reduce inflammation

 3. Assess for complication like pneumothorax

 4. Institute PEEP as ordered

o Positive end-expiratory pressure (PEEP) is a critical part of the treatment of
ARDS.
o PEEP usually improves oxygenation, but it does not influence the natural history of
the syndrome.
o Use of PEEP helps to increase functional residual capacity and reverse alveolar
collapse by keeping the alveoli open, resulting in improved arterial oxygenation and a
reduction in the severity of the ventilation–perfusion imbalance.
o By using PEEP, a lower FiO2 (fraction of inspired air) may be required. The goal is a
PaO2 greater than 60 mm Hg or an oxygen saturation level of greater than 90% at the
lowest possible FiO2.
  5. Provide care necessary for a mechanical ventilator

 6. Protect the airway from injury

 7. Relieve anxiety

 RESPIRATORY SYSTEM SURGERIES:

A. EXPLORATORY THORACOTOMY – anterior or posterolateral incision through the 4th,

5th, 6th or 7th ICS

B. LOBECTOMY – removal of one lobe of a lung;

TX for bronchiectasis, bronchogenic CA, emphysematous blebs, lung abscesses

C. PNEUMONECTOMY – removal of an entire lung( either left or right), most commonly

done as treatment for bronchogenic CA;

Position post op on affected side to prevent blood from entering other lung

D. SEGMENTAL RESECTION – removal of one or more segments; most often done with
bronchoectasis;
Left lung : 8 segments;
Right lung: 10 segments

E. WEDGE RESECTION – removal of lesions that occupy only a part of a segment of lung
tissue; for excision of small nodules or to obtain a biopsy

F.DECORTICATION – stripping off or removal of adhesion between parietal & visceral pleura

 All have chest tube drainage post-op except Pneumonectomy – should not drain out
fluid since one lung has been removed. Need to let fluid remain in the empty space to
prevent mediastinal shift.

 All will be positioned post op on unaffected side to allow affected lung to reexpand;
except Pneumonectomy (although position post op sometimes ordered by the DR)

 Pneumonectomy – position on the affected size, for the fluid to stay on the empty
space left by the removed lung.

 INTERVENTIONS FOR RESPIRATORY PROBLEMS:

 ARTIFICIAL AIRWAYS
 Aka as “intubation”; a tube is inserted to maintain a patent air passage for pts whose airway
has become or may become obstructed.

 Common Types of Intubation:

1. Oropharyngeal Intubation
 Done most frequently for pts who had general anesthesia & for those who are
semiconscious & are likely to obstruct their own airways with their tongues.

 In some instances, it is inserted for pharyngeal suctioning

 Not inserted in pts who are conscious bec it stimulates gag reflex (causes vomiting)

 To insert an oropharyngeal airway:

* Don disposable gloves
 * Open pt’s mouth
* Position pt in supine with neck hyperextended or with pillow placed under the
shoulders so that the tongue cannot fall back to block the pharynx
* Before insertion, lubricate the airway with water-soluble lubricant & advance the
airway sideways along the roof of the mouth until the flange touches the lips.
* While observing the position of the tongue in the mouth, rotate the airway when
introducing it over the tongue to the pharynx
* If necessary, tape the airway in position & suction secretions as necessary

 Nursing Interventions:
* Maintain the pt in a lateral or semiprone position so that blood, vomitus & mucus
will drain out of the mouth & not be aspirated
* Remove the airway once the pt has regained consciousness & has the swallow, gag &
cough reflexes
*Transfer tube from right to left every 8 hours to prevent irritation of the mucosa

2. Nasopharyngeal Intubation
 Carried out if the oropharyngeal route is contraindicated
 Tube is inserted through a nostril & terminates in the pharynx below the upper edge of
the epiglottis
 Tubes vary in size for adults, children, & infants & are usually made of latex rubber

 To insert a nasopharyngeal tube:

* Lubricate the entire tube with a topical anesthetic (if ordered) to prevent irritation of the
nasopharyngeal mucosa & undue discomfort
* Hold the airway by the wide end & insert the narrow end into the nares, applying gentle
inward & downward pressure when advancing the airway to follow the natural course
of the nasal structures.
* Remove excess lubricant from the pt’s face & nares before securing the tube in place
with tape

 Nursing Interventions:
* Remove the tube & insert it in the other nostril at least every 8 hours or as ordered by
the physician or more often to prevent irritation of the mucosa
* Provide nasal hygiene every 4 hours or more often if needed
* Monitor the pt closely for stimulation of the vagus nerve if nasotracheal suctioning is
carried out. Vagal stimulation can lead to cardiac arrest

3. Endotracheal Tube (mouth – trachea)

 Most commonly inserted for pts who have had general anesthetics or for those in
emergency situations where mechanical ventilation is required.
 Tube is a curved polyvinylchloride that is inserted through either mouth or the nose into
the trachea with the guide of a laryngoscope.
 The tube terminates just superior to the bifurcation of the trachea into the bronchi
 Since the ET tube passes through the epiglottis & splits it open, an inflated cuff is needed
to close the system

 Nursing Interventions:
* Maintain the pt in a lateral or semiprone position so that blood, vomitus, or
secretions can drain from the mouth & are not aspirated
* Provide oral or nasal hygiene every 3 hours or as needed

* For an oral insertion, provide a bite block so that the pt cannot bite the tube & occlude
the airway

* Assess the condition of the nasal or oral mucosa for irritation & notify DR should the
need to change a nasal ET tube arise; reposition an oral ET tube from one side of the
mouth to the other every 8 hours or as required

* Closely monitor the air pressure in the endotracheal cuff; if it is greater than
20mmHg, necrosis(mamatay ang tissues) of the tracheal tissues can result(cuff-
20mmHg)

* Tape the airway in place to prevent accidental slippage or extubation

* Change the tape daily & position the tube on the opposite side of the mouth at each
change
* Provide continuous humidification or aerosol therapy to prevent undue drying of the
mucous membranes, if the tube is left in for more than a short time (ex. for days or
weeks)
* Deflate & reinflate the cuff according to the manufacturer’s directions
* Communicate frequently with the pt & provide a notepad or other means for the pt to
communicate. Most pts cannot speak with an inflated cuff because no air can pass over
the vocal chords.

4. Tracheostomy Tube
 Indications:
* to provide & maintain a patent airway
* to remove tracheobronchial secretions from pts unable to cough
* to replace endotracheal tubes
* to permit the use of positive pressure ventilation
* to prevent unconscious pts from aspirating secretions

 Inserted through a surgical insertion just below the first & second cartilage

 Parts of the Tracheostomy Set:

* 1. Outer tube
* 2. Inner tube (inner cannula) - withdrawn for brief periods to be cleansed
* 3. Obturator -is used only to insert the outer tube. It is removed once the outer tube is
in place; kept at bedside always with pts on tracheostomy
* 4. Cuff – at the lower end of the inner tube; inflatable & produces an airtight seal
between the tube & trachea

 Cleaning the Cannula **BQ**

1. Don sterile gloves & suction the entire length of the inner cannula prior to its
removal to remove secretions & ensure a patent airway.
2. Unlock the inner cannula by turning the lock 90 degrees counterclockwise
3. Gently pull out the cannula toward you in line with its curvature
4. Soak cannula in hydrogen peroxide solution for several minutes (kidney basin)
 5. Suction the outer cannula
6. Change gloves & clean the cannula (use sterile gloves for both hands)
7. Remove the cannula from the soaking solution; clean the lumen & entire inner
cannula thoroughly using the pipe cleaners or brush moistened with sterile saline
8. Thoroughly rinse the cannula by agitating it for several seconds in the sterile saline
9. Inspect the cannula for cleanliness by holding it at eye level & looking it into the
light; if encrustations are evident, repeat the above steps
10. After rinsing the cannula, gently tap it at the inside edge of the sterile solution bowl
11. Dry the inside of the cannula but do not dry the outer surface
12. Suction the outer cannula if secretions are excessive
13. Insert the inner cannula & secure it
14. Clean the outer flange of the outer cannula

 Changing the Tracheostomy Dressing & Tapes

1. Remove the tracheostomy dressing with working gloves
2. Open sterile equipment & don sterile gloves
3. Clean the incision site & tube flange using gauze squares & applicator sticks
dampened with sterile saline; wipe only once with each gauze square & then discard
it.
4. Thoroughly rinse the cleaned area then dry it.
5. **BQ** How to change the tie of tracheostomy: TIE THE NEW TIE FIRST
BEFORE REMOVING THE OLD TIE, TO PREVENT MOVEMENT AND
REMOVAL OF THE TRACHEOSTOMY. INSERT TWO FINGERS
BETWEEN NECK TO TIE TO ENSURE ENOUGH TYING AND NOT TOO
TIGHT.

 SUCTIONING
 Suctioning is the aspiration of secretions often through a rubber or polyethylene catheter
connected to a suction machine or wall outlet
 It is a sterile technique to prevent introducing microorganisms in the respiratory tree

 Suctioning is indicated when a pt:

1. is unable to expectorate coughed secretions
2. is unable to swallow
3. makes light bubbling or rattling breath sounds that signal the accumulation of
secretions

 Routes of Suctioning: Nasopharyngeal, Oropharyngeal, Endotracheal

 Sizes of Suction Catheters: **BQ**

 Fr. #12-18 (adults);
 Fr. #8-10 (children);
 Fr.#5-8 (infants)

 Salient Points: **BQ**

 Position: Semi-Fowler’s (conscious pt with the head turned to one side & the neck
hyperextended - these positions facilitate the insertion of the catheter & helps prevent
aspiration);
 Lateral facing you(unconscious pt) – this position allows the tongue to fall forward so that
it will not obstruct the catheter insertion. Lateral position also facilitates drainage of
secretions from pharynx & prevents possibility of aspiration.

 Suction Pressure: **BQ**

 1. Wall unit (Adult: 100-120; Children: 95-110; Infant: 50-95mmHg)

2. Portable unit (Adult: 10-15; Children: 5-10; Infant: 2-5mmHg)

 Hyperoxygenate the pt first with 100% O2 before and after starting the suctioning
  Complications of Suctioning:
 Hypoxemia
 Trauma to the airway
 Nosocomial infections
 Cardiac dysrhythmias (overstimulation of vagus nerve)
 Stimulates cough reflex & stimulates cells in the bronchi to secrete more mucus

 When introducing the catheter, do not apply suction (that is, leave your finger off the port)

 Depth of catheter insertion: Nasopharyngeal (3-4 inches); Oropharyngeal (5-6inches);

Endotracheal (7-8 inches); mark the position on the tube with the fingers of the gloved
hand.
 Variations in insertion of catheter for ET suctioning:
o Nasal-Tracheal: measure distance from the tip of the nose to the earlobe & then along side
of the neck to the thyroid cartilage (Adam’s Apple)

o Oral-Tracheal: measure from the mouth to the midsternum

o Have the pt inhale while you insert the catheter to facilitate its entry into the trachea
because the epiglottis is open during inhalation.
o Have the pt hyperextend the head & extend the tongue with mouth open to place the glottis
in line with the trachea thereby easing entry into the trachea rather than into the esophagus
 Never force a catheter against an obstruction; insert until coughing or resistance is felt &
withdraw 1cm to move away from the mucosa
 When performing suctioning, apply your finger to the suction port & gently rotate the
catheter (360 degrees rotation)
 Apply intermittent suction for 5 to 10 seconds (max. 15 seconds- intermittent)

 Allow 20-30 second intervals between each suction & limit suction to 5 minutes in total

 Encourage the pt to breathe deeply & to cough between suctions

 Change collection bottles & tubing daily

 OXYGEN THERAPY (memorize O2 concentration deliveries)

 Indicated for pts with hypoxemia or hypoxia
 Hypoxemia – present when the oxygen tension in the arterial blood is below normal
 Hypoxia – present when there is an insufficient amount of oxygen available in the tissue
cells to meet the requirements of an organ or tissue at that moment

 Parts:
 1. Flow Meter;
 2. Humidifier – adds water to inspired air; when oxygen passes through sterile distilled water
or tap water then along a line to the device through which the moistened oxygen is inhaled.
Humidifiers prevent mucous membranes from drying & becoming irritated & loosens
secretions for easier expectoration. Oxygen passing thru water picks up water vapor before it
reaches the pt. The more bubbles created during this process, the more water vapor will be
produced.

 Oxygen Therapy Safety Precautions:

 1. Place sign “No Smoking; Oxygen in Use” on the pt’s door, at the foot or head of the bed,
& on the oxygen equipment (OXYGEN SUPPORTS COMBUSTION)

 2. Make sure that electrical devices (ex. razors, radios, television) are in good working order
to prevent the occurrence of short-circuit sparks

 3. Avoid materials that generate static electricity such as woolen blankets & synthetic fibers;
cotton blankets should be used

 4. Avoid the use of volatile, flammable materials such as oils, greases, alcohol, ether near pts
receiving oxygen. Avoid alcohol back rubs & take nail polish removers or the like away
from the immediate vicinity
  5. Ground electric monitoring equipment, suction machines & portable diagnostic machines
 Make known the location of the fire extinguishers & make sure personnel are trained in their
use

 6. Oxygen cylinders need to be handled & stored with caution & strapped securely wheeled
transport devices or stands to prevent possible falls & outlet breakages. They should be
placed away from the traffic areas & heaters.

 Oxygen Delivery:
 1. Low-Flow System – O2 mixed with atmospheric air

o Oxygen is delivered via small bore tubing

o Generally used for pts who have a respiratory rate below 25 breaths per minute & a
regular & consistent breathing pattern

o Contraindicated for pts who require carefully monitored concentrations of oxygen

o Devices:
o nasal cannula,
o simple face mask,
o partial rebreathing mask,
o humidity tent,
o oxygen tent

Humidity Tent Nasal Cannula Oxygen Hood

  High-Flow System
o Supply all of the gas required during ventilation in précised amounts, regardless of
the pt’s respiratory status
o Oxygen is delivered via a Venturi device & a large-bore tubing

o Devices: venturi mask, face tent, oxygen hood

VENTURI MASK

 Devices:
 1. Nasal Cannula (Nasal Prongs)
o The most common, inexpensive low-flow device used to administer oxygen
o Consists of a rubber plastic tube that extends around the face with ¼ to ½ inch prongs that
fit into the nostrils
o Cannula is often held in place by an elastic band that fits around pt’s head or under the chin
o Is easy to apply & does not interfere with pt’s ability to eat or talk
o Relatively comfortable, permits some freedom of movement & is well tolerated by the pt
o Delivers a relatively low concentration of oxygen (24-45%) at flow rates of 2-6 lpm
o Above 6lpm, there is a tendency for pt to swallow air & for nasal & pharyngeal mucosa to
become irritated

 2. Face Mask
o Made of clear, pliable plastic or rubber that can be molded to fit the face
o They are held to the pt’s head with elastic bands
o Some have clips that be bent over the bridge of the nose for a snug fit
o There are several holes on the sides of the mask (exhalation ports) to allow the escape of
exhaled carbon dioxide
o Mask is guided toward the pt’s face & applied from the nose downward.
o The mask should fit the contours of the pt’s face so that very little oxygen escapes into the
eyes or around the cheeks or chin

o Kinds of Face Masks:

The face mask must be applied over the nose & mouth with a snug fit, which is necessary
to maintain positive pressure on the client’s airways. The nurse obtains baseline
respiratory assessment & ABGs but these are not done to ↑ effectiveness of the
procedure. A disadvantage of the CPAP face mask is that the client must remove it for
coughing, eating, or drinking. This removes the benefit of positive pressure in the airway
each time it is removed.
 Simple Face Mask – (low-flow system) delivers O2 concentration from 40-60% at
5-8lpm

 Partial Rebreather Mask – with bag (plastic)

 A low flow system that delivers O2concentration of 60-90% at 6-10lpm
 A reservoir bag is attached that allows the pt to rebreathe about the first third of
the exhaled air in conjuction with oxygen
 Rebreather bag must not totally deflate during inspiration to avoid CO2 build up;
 Rebreathing masks have a reservoir bag that conserves O2 & required high liter
flow to achieve concentration of 40%-60%. It does not deliver accurate Fraction
 of Inspired O2 to the client. The bag should not deflate during inspiration.
Rebreathing bags conserves oxygen by having the client rebreathe his or her own
exhaled air.

 Non-Rebreather Mask –
 A low-flow system that delivers the highest O2 concentration of 95-100% by
means other than intubation or mechanical ventilation at liter flows of
 10-15 Lpm
 The pt breathes only the source of gas from the bag
 One-way valves on the mask & between the reservoir bag & mask prevent the room
air & the pt’s exhaled air from entering the bag
 To prevent CO2 build up, the nonrebreather bag must not totally deflate during
inspiration

 Venturi Mask –
 A high flow system that delivers precise oxygen concentrations
 Often used for pts with COPD
 O2 concentration vary from 24%, 40% to 50% depending on the brand at liter
flow of 4 to 10 liters per minute
 Designed with a wide-bore tubing & various color-coded jet adapters
 Each color code corresponds to a precise oxygen concentration & a specific liter
flow

 Face Tent
o Can replace mask when mask is poorly tolerated by the patients
o When the face tent alone is used to supply O2, the concentration of O2 varies so it is often
used with a venturi system
o Frequently inspect the pt’s facial skin for dampness or chafing; dry & treat as needed;

 CHEST TUBE DRAINAGE (pleur evac – in the states)

 Purpose:
 1. to remove air, fluids & exudates from lungs;
 2. to facilitate reexpansion of lungs;
 3. restore negative intrapleural pressure;
 4. also done for recurrence of fluid accumulation in the pleural space after thoracentesis

 Principle: Gravity (for draining) & Water Seal (creates vacuum and maintains negative
pressure; gas & air will be dissolved in the water & will just evaporate thru the vent)

CHEST TUBE INSERTION:

 2-3 ICS (evacuation of air) and

 8-9 ICS (evacuation of fluid)

TYPES OF CHEST TUBE SYSTEMS:

 One bottle system: bottle serves as both collection chamber & water seal

 Two bottle system: one bottle serves as collection chamber, the other as the water seal as vent
where it just evaporates

 Three bottle system: (same principle with Pleur-Evac) **BQ**

1- Drainage or collecting bottle connected to chest tube
2 – Water seal bottle containing 300cc of sterile H2O or NSS (has two tubes: 1 long
tube – 2-3 cm. submerged in water; 1 short tube connected to next bottle)
3 – Suction control (has three tubes: 1 long tube submerged in H2O – 10-20cc; 1 short
tube connected to water seal bottle; 1 short tube connected to suction
 GEN. PRINCIPLES IN CHEST TUBE MGT. BQ*
1. Water Seal Bottle – intermittent bubbling, tidaling; coincides with inspiration;
if continuous there is a leak (apply pressure on stoma with vasilinized sterile
gauze,
2. go to collection tube & pinch,
3. notify DR; change system –
4. clamp no more than 1 minute before reinsertion.
IF BUBBLE IS CONTINUOUS – MEANS LEAKAGE

2. After 1-4 days: system stops – there is obstruction, usually blood clots,
MGT: milk or strip tubing & apply on&off pressure

3. After several days: system stops – negative pressure now achieved; lung has
reexpanded

(auscultate lungs for N breath sounds, confirmed by Xray; DR orders removal of chest tube;

*At b/s during removal – sterile gloves, dressing set,, 2 sets of vasilinized gauze & plaster,
]give analgesic before removal; teach pt to hold breath & bear down (valsalva maneuver)
on removal of tubes – to prevent entry of positive air

4. If chest tube is accidentally pulled out - @ b/s rubber tipped clamps but never clamp
over an extended period of time unless with DR’s order – may ↑ pressure and lead to
tension pneumothorax

5. If bottle accidentally broken - @b/s extra bottle of sterile H2O – submerge distal end to
H20

 MECHANICAL VENTILATION
 Ventilation is performed by mechanical means in individuals who are unable to maintain
normal level of oxygen & carbon dioxide in the blood

 Usually used with endotracheal or tracheostomy intubations

 Indicated for pts:

 with COPD
 who are obese
 with severe neurologic depression
 with thoracic trauma
 with Acute Respiratory Distress Syndrome
 who have undergone thoracic or open-heart surgery (are likely to be maintained on
mechanical ventilation post-op)
 with apnea that is not readily reversible

 Guide in deciding to place pt on a mechanical ventilator:

 PaO2 <50mmHg with pH<7.25
 PaO2 <50mmHg with FiO2 >0.60
 Respiratory Rate of >35/min (N=12-20)
 Vital capacity is < 2 times tidal volume

 Classification of Ventilators:
 NEGATIVE-PRESSURE VENTILATORS
 Exert a negative pressure on the external chest
 Physiologically, similar to spontaneous ventilation by decreasing intrathoracic pressure
during pressure to allow air to flow into the lungs to fill its volume
 Used mainly for in chronic respiratory failure associated with neuromuscular
conditions (poliomyelitis, muscular dystrophy, ALS, MG)
 Inappropriate to use in unstable or complex patients whose condition requires frequent
ventilator changes
  Are simple to use & do not require intubation of the airway
 Especially adaptable for home use

 POSITIVE-PRESSURE VENTILATORS
 Inflate the lungs by exerting positive pressure on the airway forcing the alveoli to
expand during inspiration; expiration occurs passively
 Endotracheal intubation or tracheostomy is necessary in most cases
 Widely used in hospital settings & increasingly used in the home for patients with
primary lung disease

 TYPES OF POSITIVE-PRESSURE VENTILATORS:

1. Pressure-Cycled Ventilator: pushes air into the lungs until a predetermined
pressure is reached within the tracheobronchial tree; expiration occurs by passive
relaxation of the diaphragm
2. Volume-Cycled Ventilator: most popular type & safest for intubated adults &
older children; delivers air into the lungs until a certain predetermined tidal volume
is reached before terminating inspiration
3. Time-Cycled Ventilator: terminate inspiration after a preset time; tidal volume is
regulated by adjusting length of inspiration & flow rate of pressurized gas; rarely
used for adults but used in newborns & infants

 Modes of Mechanical Ventilation

 Assist/Control Mode: pt’s inspiratory effort triggers the ventilator which then delivers
breath; may be set to deliver breath automatically if pt does not trigger it; the same tidal
volume is delivered with each breath
 Intermittent Mandatory Ventilation (IMV): pt may breathe at own rate; IMV breaths are
delivered under positive pressure however all respirations taken by the pt are delivered in
ambient pressure & tidal volume is of pt’s own determination
 Positive End Expiratory Pressure (PEEP): ventilator delivers additional positive
pressure at the end of expiration which maintains the alveoli in the expanded state
o If the patient is intubated and receiving mechanical ventilation with PEEP, several
considerations must be addressed.
 o PEEP, which causes increased end-expiratory pressure, is an unnatural pattern of
breathing and feels strange to the patient.
o The patient may be anxious and “fight” the ventilator. Nursing assessment is important
to assess for problems with ventilation that may be causing the anxiety reaction: tube
blockage by kinking or retained secretions; other acute respiratory problems (eg,
pneumothorax, pain); a sudden drop in the oxygen level; the patient’s level of dyspnea;
or ventilator malfunction.
o In some cases, sedation may be required to decrease the patient’s oxygen consumption,
allow the ventilator to provide full support of ventilation, and decrease the patient’s
anxiety.
o Possible sedatives are lorazepam (Ativan), midazolam (Versed), haloperidol (Haldol),
propofol (Diprivan),

 Controlled Mandatory Ventilation (CMV): all breaths are initiated by the ventilator as
there is no pressure sensed by the machine. Same tidal volume is delivered with each
breath
 Continuous Positive Airway Pressure (CPAP): achieves same result as PEEP except
CPAP is used on pts who are in a T-piece

 Troubleshooting Ventilator Problems **BQ**

PROBLEM CAUSE SOLUTION

↑ in peak airway (OBSTRUCTION) Suction airway for secretions
pressure (HIGH -Coughing or plugged airway Decrease sensitivity
PRESSURE ALARM) tube Manually ventilate the pt
Patient “bucking” ventilator Assess for hypoxia or
Decreasing lung compliance bronchospasm
Sedate only if necessary
Check tubing; reposition pt;
-Tubing kinked insert oral airway if necessary
Manually ventilate patient;
-Pneumothorax notify DR
-Atelectasis or Clear secretions
Bronchospasm
↓ in pressure or loss of -Leak in ventilator or tubing; Check entire ventilator circuit
volume (LOW PRESSURE for patency; correct leak
ALARM) -cuff on tube;

-humidifier not tight

 Nursing Interventions:
 Auscultate breath sounds q2hours
 Monitor ABGs
 Promote optimal gas exchange:
 Administer analgesic agents to relieve pain
 Reposition q2hours to diminish pulmonary effects of immobility
 Monitor for adequate fluid balance (assess peripheral edema, monitor I&O & daily
weights
 Promote effective airway clearance:
 Auscultate lungs q2-4 hours to assess presence of secretions
 Clear airway of secretions (suctioning, chest physiotherapy, position changes)
 Administration of brochodilators & mucolytic agents as ordered
 Prevent trauma & infection
 Perform tracheostomy care at least q8hours
 Ventilator circuit & in-line suction tubing is replaced periodically
 Perform oral hygiene
  Position pt with head elevated above the stomach
 Administer anti-ulcer medications (Sucralfate) to prevent stress ulcer
 Monitor potential complications
 Alterations in cardiac functions
 Assess for adequate volume status by measuring HR, BP, urine output
 Notify DR ASAP if values are abnormal

 Barotrauma & pneumothorax

 Notify DR ASAP
 Prepare patient for chest tube insertion
 Avoid high pressure settings for pts with COPD & ARDS or history or pneumothorax

 Pulmonary infection
 Use meticulous aseptic technique
 Provide frequent mouth care
 Optimize nutritional status

 Criteria for weaning patient from the ventilator:

 Vital Capacity: the amount of air expired after maximum inspiration; used to assess the pt’s
ability to deep breathe; should be 10-25mL/kg
 Maximum Inspiratory Pressure (MIP): used to assess the patient’s respiratory muscle
strength. AKA negative inspiratory pressure & should be at least
-20cmH2O
 Tidal Volume: volume of air that is inhaled or exhaled from the lungs during an effortless
breath; normally 7-9mL/kg
 Minute Ventilation: equal to RR x Tidal Volume; Normal – 6L/min
 Rapid/Shallow Breathing Index: used to assess the breathing pattern; calculated by dividing
RR to Tidal Volume; Normal Index – below 100 breaths/min/L
 Other Measurements: PaO2 >60mmHg; stable VS & ABGs