3 Respiratory System

respiratory by Chilot K.
Disorders of the Respiratory system

For 2nd year BSc Students
BY CHILOT K (BSC, MSC, ASSISTANT PROF.)
04/26/2024
Anatomy and physiology overview
 The respiratory system is composed of the upper

and lower respiratory tracts
 Upper airway structures consist of the nose,
sinuses and nasal passages, pharynx, tonsils,
larynx, and trachea.
 Lower respiratory tract consists of the lungs,
which contain the bronchial and alveolar structures
needed for gas exchange.
respiratory by Chilot K. 04/26/2024

Upper respiratory tract
Nose:
 is composed of an external and an internal portion
 The anterior nares (nostrils) are the external
openings of the nasal cavities
 The internal portion of the nose is a hollow cavity
separated into the right and left nasal cavities by a
narrow vertical divider, the septum

Upper respiratory tract cont’d
 The nasal cavities are lined with highly vascular

ciliated mucous membranes called the nasal
mucosa
 It contains fine hairs inside , the cilia
 Function:
 serves as a passageway for air to pass to and from
the lungs
 filters impurities
 humidifies and warms the air as it is inhaled.
Para nasal Sinuses

 Include four pairs of bony cavities
 Named by their location: frontal, maxillary,
ethmoidal and sphenoid
 Function: serve as a resonating chamber in speech

Fig 1: Upper Respiratory Tract…
The para-nasal sinuses

Pharynx, Tonsils, and Adenoids

 Pharynx, or throat, is a tube like structure that connects
the nasal and oral cavities to the larynx
 Functions: a passage way for the respiratory and
digestive tracts
 Adenoids, or pharyngeal tonsils, are located in the roof
of the nasopharynx
 Encircle the throat.
 Function: are important links in the chain of lymph
nodes guarding the body from invasion by organisms
entering the nose and therespiratory
throatby Chilot K. 04/26/2024
Fig 2: The pharynx and other oral structures

Cont---
Larynx
 The larynx, or voice organ, is a cartilaginous
epithelium-lined structure that connects the
pharynx and the trachea.
 The major function of the larynx is vocalization.
 It also protects the lower airway from foreign
substances and facilitates coughing

Cont---
Trachea
 The trachea, or windpipe, is composed of smooth
muscle with C-shaped rings of cartilage at regular
intervals.
 The trachea serves as the passage between the
larynx and the bronchi.

 In general the primary function of upper
respiratory tracts are:
 To warm, humidify, and filter entering air
 To protect the lower airway from foreign material.

ANATOMY OF THE LOWER
RESPIRATORY TRACT
LUNGS
 located within the thoracic cavity and it is
surrounded by ribs & muscles.

 The lungs and wall of the thorax are lined with a
serous membrane called the pleura.

 Two thin membranes: i.e. the visceral pleura
covers the lungs; the parietal pleura lines the

thorax.

LUNGS…
 The space b/n visceral and parietal pleura called
pleural cavity/space.
 The space contains small amount of serous fluid .
 Each lung is divided in to lobes i.e. the left lung
consists of upper and lower lobes and the right lung
upper, middle and lower lobes.

Fig 3. The lobes of the lung

Bronchial tree
Bronchus, Bronchi and Bronchioles

 Bronchus: right and left
 There are several divisions of the bronchi within each
lobe of the lung.
 First are the lobar bronchi (three in the right lung and
two in the left lung).
 Lobar bronchi divide into segmental bronchi (10 on the
right and 8 on the left)
 Segmental bronchi then divide into sub segmental
bronchi.
 The sub segmental bronchi thenbybranch
respiratory into bronchioles,
Chilot K. 04/26/2024
ALVEOLI
 Air sacs
 The lung is made up of about 300 million
alveoli, which are arranged in clusters of 15

to 20.

Fig 4. Respiratory tracts

Functions of the Respiratory System
The respiratory system performs life-

sustaining processes:
Respiration and Ventilation
• Respiration: a process of gas exchange
between the atmospheric air and the blood,
and between the blood and cells of the body.
• Ventilation (air flow in and out of the lungs)

Lung Volumes
 Tidal volume (TV): The volume of air inhaled or exhaled with
each breath in normal respiration, amount (500ml)
 Inspiratory reserve volume (IRV) : The maximum volume of
air that can be inhaled after a normal inhalation (3000ml)
 Expiratory reserve volume (ERV): The maximum volume of
air that can be exhaled forcibly after a normal exhalation
(1,100ml)
 Residual volume(RV) : The volume of air remaining in the
lungs after a maximum exhalation (1,200ml)

Assessment: Physical Examination
Physical Assessment of the Upper

Respiratory Structures
Inspect and palpate nose and sinuses
Assess the pharynx and mouth
Note the position of the trachea by direct
palpation and inspection

Physical Assessment of the Lower
Respiratory Structures
Inspection of Thorax
 musculoskeletal structure, the patient’s nutritional
status, and the respiratory system.

 Chest configuration: normally, the ratio of
anteroposterior diameter to lateral diameter is 1:2.

 But it can change due to different deformities:
 Barrel chest
 Funnel chest (pectus excavatum)
 Pigeon chest (pectus carinatum)
 Kyphosis
 Lordosis
 Scoliosis
 Kyphoscoliosis
Assessment: Physical Examination…
Barrel Chest

Breathing Patterns and Respiratory Rates

 Observing the rate and depth of respiration is a
simple but important aspect of assessment.
 Eupnea: Normal, breathing at 14-24 breaths/minute

 Bradypnea: Slower than normal rate (<12

breaths/minute), with normal depth and
regular rhythm.
 Tachypnea: Rapid, shallow breathing >24

breaths/minute

 Hypoventilation: Shallow, irregular breathing
 Hyperventilation: Increased rate and depth of

breathing (called Kussmaul's respiration if caused by
diabetic ketoacidosis)

 Apnea: Period of cessation of breathing. Time

duration varies.

Thoracic Palpation
 Palpates the thorax for:
 Tenderness
 Masses
 Lesions
 Respiratory excursion (estimation of
thoracic expansion), and
 Vocal fremitus (vibration produced in the
chest by sound generated in the larynx).

Thoracic percussion
 Percussion sets the chest wall and underlying
structures in motion, producing audible and

tactile vibrations.
 To determine whether underlying tissues are
filled with air, fluid, or solid material.

 To estimate the size and location of certain
structures within the thorax ( liver).

Thoracic Auscultation
 Auscultation is useful in assessing the flow of
air through the bronchial tree and in

evaluating the presence of fluid or solid
obstruction in the lung structures.
 Auscultate for normal breath sounds,
adventitious sounds, and voice sounds.

Assessment: Health History…
 Common Signs and Symptoms
The major signs and symptoms of respiratory
disease are:
 Dyspnea (difficult or labored breathing)
 Cough
 Sputum production
 Chest pain
 Wheezing

Assessment: Health History…
 Clubbing of the fingers
 Hemoptysis, and
 Cyanosis.
 These clinical manifestations are related to the
duration and severity of the disease.

Diagnostic Modalities
Diagnostic Tests
 Pulmonary function tests (PFTs): measurements
of lung volumes, ventilatory function, and the
mechanics of breathing, diffusion, and gas
exchange.
 Arterial blood gas studies: measurements of blood
pH and of arterial oxygen tension (PaO2) and
carbon dioxidetension (PaCO2)
Common diagnostic tests for respiratory disorders
 PULSE OXIMETRY: a noninvasive method of

continuously monitoring the oxygen saturation of
hemoglobin
 SPUTUM STUDIES
 to identify pathogenic organisms and to determine
whether malignant cells are present.

IMAGING STUDIES
 Imaging studies, including x-rays, computed
tomography (CT) scans, magnetic resonance
imaging (MRI)

ENDOSCOPIC PROCEDURES
 Bronchoscopy: is the direct inspection and

examination of the larynx, trachea, and bronchi.
 Thoracoscopy: for visualizing thoracic structures.

Upper Respiratory
Tract Disorders
Tonsillitis
Tonsillitis
 It is an inflammation & enlargement of the
tonsil tissue,
 It can be acute or chronic
 Tonsil frequently serve as the site of acute
infection b/c tonsils filter organisms and

protect the respiratory tract from infection.
Acute tonsillitis
 Causative agent:-
 Bacteria: Group A streptococcus/the most common
 Others : staphylococcus, H. influenza and others
 It can be viral in origin
 It is very common up to the age of 15years.
 It can occur at any age but not common in adults.

Cont---
 Predisposing factor
 URTI
 Lowered immunity
 Pollution
 Hot or cold temperatures

Cont---
 Clinical Features
 sore throat,
 dysphagia,
 headaches,
 fever ,
 red and pus or exudates present on the tonsils.

Cont---
 Diagnostic evaluation
 History
 Physical examination / visual inspection/
 Culture & sensitivity

cont---
 Medical Mgt:
 If bacteria:
 First line
 Amoxicillin 500mg PO TID for 7 days OR
 Ampicillin 500mg QID FOR 7days or
 Benz. Penicillin 2.4 Million IU. IM. stat or procaine
penicillin 800, 000 IU IM daily for 5-7 days
 Alternative
 Erytomycin 500 mg every 6 hrs for 5 days
cont---
 If viral only a symptomatic therapy
 Nursing intervention: -
 Analgesics such as paracetamol 500mg Po
PRN
 Tepid sponge
 Bed rest and soft diet
 Warm saline gargles

Cont---
 Complication: -
 Laryngeal edema
 Sinusitis (inflammation of the mucus membrane of
one or more sinuses)
 Acute rhinitis (inflammation of the nasal mucosa)
 Acute otitis media
 Septicemia
 Chronic tonsillitis
 RHD
Chronic tonsillitis
 It is due to recurrent or unresolved acute tonsillitis.

 Etiology:
 similar to acute tonsillitis
 C/M; -
 Mild edema, scaring of the tonsil and pretonsilar abscess.
 Scratching sensation in the throat , cough,
 recurrent pain
 cough
 enlarged cervical lymph node

Cont---
 R/X: -
 Surgery/ tonsillectomy
 Nutritious diet (high liquid and semi liquid
diet for several days, avoid spicy, cold, acidic

or rough foods) & vitamins
 Antibiotic & Analgesics

Pharyngitis
 is a febrile inflammation of the throat.

 Causative agent:-
 Viral organism 70%
 If bacterial: Group A streptococcus is the most
common bacterial organism
 Others:- Mycoplasma pneumoniae, Arcanobacterium
haemolyticum, Neisseria gonorrhea, Chlamydia
pneumoniae
 It can also caused by inhalation of irritant gases or
ingestion of irritant liquid.
. Fig. Pharyngitis

Cont----
 Clinical Features
 Cough
 Enlarged & tender cervical lymph nodes
 Fever, malaise, & sore throat
 Difficulty swallowing.
 Fiery Red pharyngeal membrane & tonsil
 A constant sense of irritation
 Fullness in the throat
 collected Mucus in the throat and can be
expelled by coughingrespiratory by Chilot K. 04/26/2024
Pharyngitis…
 Diagnosis:
 clinical sing & symptoms
 Throat culture
 Differential diagnosis: -
 Tonsillitis
 laryngitis

Cont---
 Medical Rx:
 viral subsides within 10 days if not
complicated,
 Viral pharingitis does not improve with any
chemotherapy
 For bacterial causes
 Ampicillin 500mg po Qid for10 days or
 Erythromycin 500mg PO QID for 10days

Cont---
 For Chronic pharingitis
 Is common in adults who work or live in dust
surrounding, suffer with chronic cough, and

habitually use alcohol or tobacco.
 RX: avoiding the causative agents.

Cont---
 Complication: -
 Otitis Media
 Mastoditis
 Sinusitis
 Peritonsilar abscess etc

Cont---
 Nursing Intervention:-
 Instruct bed rest during febrile stage of illness.
 Liquid or soft diet.
 Warm saline gargles or irrigation.
 Mouth care can be given.

Laryngitis
 It is an inflammation of the larynx often

occurs as a result of voice abuse, exposure to
dust, chemicals, smoke, & other pollutant.
 Etiology:
- Almost always virus

- Bacterial invasion may be secondary.

Risk factors
 URTI:Laryngitis is usually associated with
acute rhinitis or naso-pharyngitis.
 Vocal misuse and over use
 Irritation / smoking/alcohol
 Seasonal changes /sudden temperature change
 Iatrogenic : intubations and endo-laryngeal
surgery

C/F
 Severe cough
 Pain occurs in severe cases
 Stridor may be present in children
 Edema, exudates, congestion of the larynx
 Hoarseness or complete loss of voice /aphonia

Medical Management
 Resting the voice
 Avoid smoking,
 Bed rest
 Inhaling cool steam
 Treat secondary bacterial infection with
antibiotics.

Cont---
 Potential complication
 Sepsis
 Peritonsillar abscess
 Otitis Media
 Sinusitis

Lower Respiratory Tract Disorders

Bronchitis/Acute tracheo-bronchitis
 Is an acute inflammation of the mucous membranes

of the trachea & the bronchial tree.
 Often follows infections of the URT.
 Causative agents: - often viral but the common
bacterial causes are:-
 Streptococcus pneumaniae
 Haemephilus Influenza
 Mycoplasma pneumonia

Causative agents cont’d
 N.B. Inhalation of physical agents e.g.

(chemical irritants, gases & other air
contaminants) can also causes bronchitis
 Predisposing factors
 Pre- existing URTI
 Irritants

Cont---
 Clinical Manifestations:-
 Initially: dry, irritating cough & expectorates scanty
mucoid sputum
 As the infection progresses: inspiration and
expiration may become noisy (inspiratory stridor
and expiratory wheeze) and cough with more
profuse purulent (thick sputum) may be present
 Fever, headache, and generalized malaise
 In severe cases, blood-streaked sputum
Cont---
 Medical Management
 For cough
 Dextramethorphan hydro-bromide 15-30mg P.O 3
to 4 times a day.
 Alternative
 Codeine phosphate 10 – 20 mg P.O. 3-4 times a
day
 Antibiotic Treatment:-
 when bronchitis is complicated by bacterial
infections. respiratory by Chilot K. 04/26/2024

Cont---
 First line Antibiotics
 Ampicillin 500mg P.O Qid, for 7 days OR
 Amoxicillin 500gm P.O tid, for 7 days
 Alternative Antibiotic:-
 Erythromycin 500mg P.O Qid for 7 days
OR
 Tetracycline 500mg Qid, for 5-7 days
OR
 Cotrimoxazole 480 mg 2 tabs PO BID for 7 days

Cont---
 Nursing Interventions:-
 Encourage frequent coughing to remove
secretions
 Advice bed rest.
 Steam inhalation
 Advice fluid intake to thin the viscous &
tenacious secretions.

Chronic bronchitis
 It is the presence of a productive cough

that lasts 3 months a year for two
consecutive years, in the absence of major
lung disease (WHO).
 Causes: - The major causes are:-
 Cigarette smoking
 Exposure to pollution

Fig. NORMAL BRONCHUS CHRONIC BRONCHITIS

Cont---
 Clinical Manifestations:-
 History of cigarette smoking & frequent respiratory
infection
 A chronic, productive cough in the winter months
(recurrent coughing and sputum production)
 Production of thick, gelatinous sputum ( greater
amount’s produced during super imposed infection)
 Wheezing and dyspnea as disease progresses

Cont---
 Diagnostic Evaluation
 A complete history: occupational history (exposure
to irritating substance ) and personal history
(history of smoking)/number of packs per day
 Physical examination
 Chest x-ray

Cont---
 Medical Management
 Bronchodilators (to relieve bronchospasm &
reduce air way obstruction).

 Postural drainage
 Increase fluid intake
 The patient must stop smoking
 Why not Antibiotics?

PNEUMONIA
 Pneumonia
Vs
Pneumonitis
 Pneumonia is inflammation of the lung parenchyma.
 Pneumonitis is a more general term that describes
an inﬂammatory process in the lung tissue that may
predispose or place the patient at risk for microbial
invasion.
 is the most common cause of death

cont…
 Causes
 It can be caused by wide variety of etiological
agents (infectious or non infectious)
 Bacteria
 Viruses
 Fungi
 chemical (irritant gases), or radiation (>6 weeks of
treatment of lung or breast CA with radiation.)

Mode of transmission
 Pathogens can be introduced in to the lungs

and cause pneumonia in 3 different routes i.e.
 inhalation: commonest
 aspiration and
 circulatory / hematogeneous spread

Classification of pneumonia
A) According to the causative agents / Etiologic classification

 bacterial pneumonia
 are the most common
 can be – gram negative or gram positive bacteria
Gram positive Gram negative
 Streptoccocus pneumoniae - E. coli
 Staphylococcus aureus - pseudomonas
- Klebsiella

Cont---
 Viral pneumonia :
 Influenza virus type A (is the most common)
 cytomegalovirus (in immune compromised pt)
 fungal pneumonia:
 pneumocystis carinii pneumonia (PCP) (common in
in immune compromised pt
 histoplasma capsulatum (histoplasmosis)

Cont---
B) by anatomical dissemination/ Radio logic /Anatomic/ Classification
 Lobar pneumonia :
 Pneumonia affecting one or more lobes of the lung Broncho Pneumonia
 It is distributed in a fashion, having originated in one or more localized
areas with in the bronchi & extending to the adjacent surrounding lung
parenchyma
 It is more common than lobar pneumonia

Bronchopneumonia Lobar pneumonia
Cont---
C) by the area or setting the diseases acquired
 Community Acquired pneumonia / CAP/
 Pneumonia that occurred in the community or is diagnosed
with in 48 hrs after admission to the hospital.

 Causative agent are: -
 streptococcus pneumonia / 50 – 60% /
 staphylococcus aureus
 H. influenza

Cont---
 Hospital Acquired /nosocomial / pneumonia
 The onset of pneumonia symptoms more than 48 hours after
admission (mostly5-7 days of hospitalization) or before 72
hours after discharge in patients with no evidence of infection
at the time of admission.
 Causative agents: multi resistant bacteria
 Staph. auerus
 Pseudomonas spp.
 Gram negative enteric bacilli / E. coli/

Cont---
D) On the basis of clinical presentation / Clinical
classification
 Typical pneumonia
 Pneumonia with sever manifestations
 Usually caused by bacteria
 Atypical pneumonia
 Produce less striking symptoms and physical findings
than typical pneumonia

Typical pneumonia Atypical pneumonia
Abrupt onset of fever, Chills generally no fever
Productive Cough (prulent sputum dry cough (mucoid sputum
dullness, cracles and bronchial breath few scattered wheezes and cracles
sounds
patchy infiltrate and small pleural chest x ray shows minimal or no

effusion in some pts infiltration.
Elevation of WBC WBC commonly < 10,000u/l
Sever/pleuritic type of chest pain Minimal
Grunting , nasal flaring and use of Often No

accessory muscles.
Cont---
 Clinical Features of pneumonia
 Cough : - first dry then rusty sputum / purulent/ after 24 hours
 Fever-
 Pleurtic chest pain / aggravated by inspiration /
 Tachycardia
 Bronchial breath sound, dullness & some times
crackle/crepitation

Cont---
 DX:
 hx and P/E:
 WBC & differential count
 Sputum gram stain
 Chest x – ray

Cont---
 Markers of severe pneumonia
 Respiration rate greater than 30/ min
 more than or equal to two lobe is involved
 Cyanosis and Hypotension
 Confusion

Cont---
 Managements
 General Management: -
 Bed rest
 Analgesics
 O2 administration
 Antipyretics(for reduce fever)
 Fluid mgt

Cont---
 Specific Management: -
 Community acquired ambulatory pts /mild
pneumonia
 Amoxicillin 500mg po. Tid 7 days OR
 Erytromycine 500 mg PO QID for 5-7 days or
 Ampicillin 500mg po. Qid for 7 days
 Alternative
 Procaine penicillin 800,000IU IM daily for 5-7
days.
Cont---
 Community acquired hospitalized pts/ For
severe CAP
 Admit the patient
 Crystalline penicillin 150,000 – 250.000 lu/ kg/ 24
hours, divided in to 6 doses. Or benzyl penicillin IV
2 million IU 6 hrly for 7-10 days
Plus
Cont---
 Gentamycine 5-7 mg/kg IV daily divided doses for
7 days OR
 Doxycycline 200mg PO immediately
followed by 100mg BID for 7-20 days OR
 Erytromycine 500mg PO every 6hrs for 7-10
days

Cont---
 Hospital acquired pneumonia
 Cloxacillin 1-2gm IV every 6 hrs for 7 days plus
Gentamycin (5-7mg/kg) 80mg iv / Im tid for 7 – 10
days or
 3rd generation Cephalosporin e.g. Ceftazidime 1gm IV
every 8 hrs or Ceftriaxione 1-2gm IV/IM BID for 7days
plus either Gentamycine or Ciprofloxacillin 500mg PO
/IV BID for 7 days.
 Aspiration pneumonia
 Metronidazole 500mg po tid
 Amoxicillin 500mg po / respiratory
Iv tid by Chilot K. 04/26/2024
Pneumonia…
o Complications
• Pulmonary effusion
• Empyema (Lung abscess)
• Lobar collapse
• Sepsis

Pneumonia…
o Complications
• Pulmonary effusion
• Empyoma (Lung abscess)
• Lobar collapse
• Sepsis

Nursing Intervention
 Maintain a patent airway and adequate
oxygenation
 Obtain sputum specimens as needed
 Use suction if the patient can’t produce a
specimen
 perform chest physiotherapy
 Provide a high calorie, high protein diet of soft
foods
 To prevent aspiration during nasogastric tube
feedings, check the position of tube, and
administer feedings slowly
Nursing Intervention…
 To control the spread of infection, dispose
secretions properly
 Provide a quiet, calm environment, with frequent
rest periods
 Monitor the patient’s ABC levels, especially if he’s
hypoxic
 Assess the patient’s respiratory status. Auscultate
breath sounds at least every 4 hours
 Monitor fluid intake and output
 Evaluate the effectiveness of administered
medications
 Explain all procedures respiratory
to thebypatient and family
Chilot K. 04/26/2024
Quize 1 (5%)
 1. define pneumonia 1point

 2. write at least 4 clinical feature of pneumonia 1 point(each
0.25 point)
 3. discuss the classification of pneumonia 2point
 4. write nursing intervention for pneumonia 1. point
 5. Bonus discuss the determinants of health?(1 point)

Atelectasis
 Refers to closure or collapse of alveoli and
often is described in relation to x-ray ﬁndings and
clinical signs and symptoms.
 Could be acute or chronic
 May cover a broad range of pathophysiologic
changes, from micro-atelectasis (which is not
detectable on chest x-ray) to macro-atelectasis
with loss of segmental, lobar, or overall lung
volume. respiratory by Chilot K. 04/26/2024
Atelectasis…
o Causes
• Obstruction of a bronchus by wide variety of
diseases e.g. pneumonia, asthma, foreign body,
or a plug of thick exudates.
• Post operative complication (24-72hrs after
operation) most common cause
• Also result from pressure in the thorax caused by
pleural effusion, pneumothorax, etc.
Atelectasis…
o Risk factors oClinical Manifestations
• Respiratory
depression (opioids, Insidious onset of
sedatives, and • Marked and increasing
abdominal distention) dyspnea
• Post operative
• Cough
• Cyanosis
patients, bedridden
• Pleural pain
patients
• Sputum production
• Pleural effusion,
pneumothorax. • Tachycardia and
• Fever
Atelectasis…
o Management
• Aspirate the plural effusion and pneumothorax
• Force the patient to cough and hyperventilate
• Mechanical ventilation may be necessary
• Remove the causes (removal of bronchial obstruction)
o Prevention
• Keep postoperative patients on their side
• Encouraging coughing and deep breathing exercise
• Frequent change of position
• Postural drainage
Pulmonary Emphysema
 It is pathology of the alveoli that describes an
abnormal distention of the airspaces beyond
the terminal bronchioles and destruction of the
walls of the alveoli.
 Oxygen and carbon dioxide exchange impairs.
 It is the end stage of a process that progresses
slowly for many years.
Pulmonary Emphysema…
o Etiology
 No clear causes but some factors may facilitate
the development of emphysema
o Predisposing Causes:
• Cigarette smoking (active or passive): (major
cause)
• Occupational exposure
• Air pollution
• Infection respiratory by Chilot K. 04/26/2024
Typical posture of a
person with chronic
obstructive
pulmonary disease
(COPD): primarily
emphysema.

o Types
 Both types may occur in the same patient.
1. Panlobular (Panacinar) emphysema (PLE)

• There is destruction of the respiratory bronchiole,
alveolar duct and alveoli.
• A hyper-inflated (hyper-expanded) chest, marked
dyspnea on exertion, and weight loss typically occur

2. Centrilobular (Centroacinar) emphysema

(CLE)
• Pathologic changes take place mainly in the center of
the secondary lobule, preserving the peripheral
portions of the acinus.
• Frequently, there is a derangement of ventilation–
perfusion ratio, producing chronic hypoxemia,
hypercapnia, polycythemia, peripheral edema, and
episodes of Rt. sided H.F

Panlobular emphysema (PLE)
Centrilobular emphysema (CLE)
Normal

o Clinical Manifestations
The onset is insidious
• Dyspnea (main symptom)
• History of cigarette smoking & chronic cough
• Wheezing
• Tachypnea
• Exacerbated with a respiratory infection.

• Hyper-resonant on percussion
• Anorexia, weight loss, and weakness
Diagnosis
• Hx and P/E
• Chest x-ray
• Arterial blood gas measurements

Management
1. Risk Reduction
• Smoking cessation is the single most cost-
effective intervention to reduce the risk of
developing COPD & to stop its progression.
2. Bronchodilators
• Aminophylline 5mg/kg by slow IV push over 5
minutes
• Theophedrin 1 tab PO TID
3. Aerosol
• Salbutamol aerosol inhalation 2 puff 3-4x/day
• Beta2-agonists, Corticosteroids
4. Treatment of infection
• They are susceptible to lung infections & must
be treated at the earliest signs of infection
• Treat the most common organisms (S.
pneumonia and H. influenza).
- Ampicillin 500mg PO QID for 7 - 10 days or
- Amoxicillin 500mg PO TID for 7 - 10 days or
- Co-trimoxazole 960mg PO BID for 7 days
5. Oxygenation administration.

Asthma
 chronic inflammatory disease of airways characterized by
increased responsiveness of the tracheobronchial tree to a
multiplicity of stimuli. Results:
 Contraction of muscles surrounding the bronchi
 Vascular congestion/Swelling of membranes
 Increased mucus production .
airway obstruction

Cont---
 When asthma and bronchitis occur together,
the obstruction is compounded and is called
chronic asthmatic bronchitis. ‘’The pt
fighting for air.’’
 If asthma becomes sever , prolonged
/persistent and not respond to conventional

therapy it is known as status asthmaticus.
 Asthma can begin at any age.

Cont---
Types of asthma
A) Extrinsic/ Allergic asthma
 is result from hyper sensitization of the
bronchial mucosa by tissue specific
antibodies .
 It is caused by known allergen: dust, pollens,
mold, etc.
 Most of the allergens are airborne & seasonal

cont---
 Usually seen in persons with family history of
allergy and its onset occurs during child hood
or adolescence.
 Persons with allergic asthma may also have
past medical history of eczema or allergic

rhinitis.
 It is more common

Cont---
B) Intrinsic / non allergic/ Idiopathic asthma
 It is not related to a specific allergens.
 Aggravating factors include common cold,
other respiratory tract infections, exercise,

emotions, & environmental pollutants.
 NSAID drugs like aspirin, ibuprofen and
indomethacin may be a factor.

Cont---
C) Mixed asthma
 It is the most common form of asthma
 It has the characteristics of both allergic &
idiopathic asthma.

Pathophysiology
 Initially allergens encounter => allergens stimulate plasma cells to produce
antigen specific antibody/ IgE => that binds to mast cells in air ways/ lungs.
 Re-exposure to the antigen results in the antigen binding to the antibody,
/antigen antibody reaction causing the release of mast cell products called
inflammatory mediators like - histamine, prostaglandin, and bradykinin =>
results in bronchospasm, membrane swelling and excessive mucus production
=> obstruction

Phatophysiology cont’d
 In non allergic forms w/n nerve endings in the
airways are stimulated by factors like infection, cold
air, exercise, smoking etc, large amount of acetyl
choline (Ach) is released => Ach results in broncho-
constriction and production of mediators =>
bronchospasm, membrane swelling and excessive
mucus production => obstruction.

Phatophysiology cont’d
 The obstruction is caused by one or more of the

following:-
 Contraction of muscles surrounding the bronchi
 Swelling of membranes that line the bronchi
 Filling of the bronchi with thick mucus.

C/M
 The common symptoms of asthma are cough, Dyspnea and
Wheezing
 Expiration is more strenuous and prolonged than inspiration
 Asthma attacks often occur at night or early in the morning
 Patients prefer sitting position during the attack
 The total attack may last 30 minutes to several hours and
subside spontaneously.

Cont---
 Other symptoms include
 Chest tightness
 Diaphoresis
 Late signs of poor oxygenation
 Tachycardia and Widened pulse pressure
 Hypoxemia
 Cyanosis

Dx
 Complete history /Personal & or family
history of allergic disease & P/E
 Chest x – ray :- over inflated lung
 Sputum & blood study (IgE )

Treatment
 Acute asthma attacks RX
 Administer oxygen by mask ( up to 6 liters/ min)
 Rehydrate the patient
 Drugs Rx
 Broncho dilators e.g. Salbutamol,
 Anticholinergic, e.g. atropine and methyl nitrate
 Corticosteroids e.g. pridinsolone

Cont---
 Initial Rx:-
A/ First line
 Salbutamol 2 puff/200mcgm & repeat after 20 minute
for the first hour

OR
 Aminophylline, 5mg/kg slow iv push over 5 minutes.
The same dose could be repeated after 30 minutes.

B/ Alternative
 Adrenaline, 0.5ml Sc. Repeat after 30 minute to 1
hour if patient doesn’t respond.

Cont---
 If response to initial therapy is poor, give the
following
 Aminophylline drip loading dose 3-5 mg/kg in
dextrose & water over 20 minutes. Then
maintenance dose 0.6mg/kg/ hour in 5% D/W.
Plus
 Hydrocortisone, I.v 200mg stat and/or
Prednisolone, 40 – 60mg po in divide dose
immediately after hydrocortisone for 5 – 7 days.
Cont---
 RX of chronic asthma
 Intermittent Asthma
 First Line: - salbutamol, inhalation 2 puff, 3
times a week
 Alternative: - ephedrine 1 tab 3 times per
day + theophyline 100mg 2-3 times per day.

Cont---
 Persistent Asthma
 First Line: - salbutamol inhalation 2 puff 3 times/ day
OR
 ephedrine 100mg TID Plus Beclomethasone 200mcg
inhalation puff daily for two weeks and reduce to 100mcg
if symptom improves.
OR
 Prednisalone, 0.5mg, po/ day.

Potential Complications
 Airway obstruction
 Status asthmaticus
 Respiratory failure
 Pneumonia
 Atelectasis
 Dehydration
Tuberculosis /TB
 TB is an infectious diseases which primarily

affects the lung (85%).
 it may also transmitted to other parts of the body
i.e. pleura, spine, Meninges, kidneys, bones,
lymph nodes etc.

Etiology
 Myco bacterium tuberculosis (Mb TB):
commonest.
 Other mycobacterium
 M. africanum( seen in western Africa)
 M. bovis( <1%, bovin TB)
 M.avium
Transmission
 via air born (inhalation)
 Consumption of raw milk containing M. bovis.

Cont---
 Risk factors
 close contact with someone who has active TB
 immune compromised persons e.g. HIV/AIDS, DM
 Poverty, mal-nutrition, pregnancy, alcohol, drugs, tobacco….
 person living in overcrowded substandard housing
 health care workers
 age

Natural history
 In the great majority (90-95%) of persons infected
with M.TB , but the immunological defense either
kills or suppressed the inhaled bacteria. If reactivated
latent TB.
 Only about 5-10% of persons ( primary infection)
develop Active TB.
 IP: 4-16 weeks after infection

Tuberculosis…
o Classification of TB
1. Anatomical site of TB disease
2. Bacteriological results
3. History of previous treatment
Tuberculin skin test

1. Anatomical site of TB disease
 Pulmonary tuberculosis (PTB): refers to a case

of TB involving the lung.
 Extra pulmonary tuberculosis (PTB): refers to a
case of TB involving organs other than the lungs
such as pleura, Meninges or intestine.

2. Bacteriologic classification
a. Smear-positive pulmonary TB (PTB+):

A patient with at least two initial sputum smear
examinations positive for acid fast bacilli (AFB) by
direct microscopy
or
A patient with one initial smear examination

positive for AFB by direct microscopy and culture
positive
or
or
A patient with one initial smear examination positive

for AFB by direct microscopy and x-ray
abnormalities
b. Smear-negative pulmonary TB (PTB-):

A patient having symptoms suggestive of TB with 3
initial sputum smear examinations negative for AFB
by direct microscopy and
Failure to respond to a course of broad spectrum

antibiotics respiratory by Chilot K. 04/26/2024
OR
Again three negative smear examinations by direct

microscopy
and
Radiological abnormalities consistent with

pulmonary tuberculosis
or
three initial smear examinations negative by

direct microscopy, but culture positive for MTB
3. Based on history of previous treatment
 New patient: have never had treatment for TB,
or have taken anti-TB drugs for less than 4
weeks. May have positive or negative bacteriology
and disease at any anatomical site.
 Previously treated patient: have received 4
weeks or more of anti-TB drugs in the past, may
have disease at any anatomical site.

C/M of PTB
 General symptoms  Pulmonary
 Fever symptoms
 Night sweating  Cough (usually
 weight loss productive)
 Fatigue
 Chest pain
 loss of appetite/anorexia
 Dyspnea
 Hemoptysis

C/ms of Extra pulmonary TB (EPTB
 C/M of EPTB depends on site of involvement

e.g.
 TB lymphadenitis: slowly developing and painless
enlargement of lymph nodes eventually drainage of
pus.
 TB meningitis: headache, fever, vomiting, neck
stiffness, mental status change.
 Intestinal TB: loss of apatite and weight ,
abdominal pain, diarrheal, fluid in the abdominal
cavity (ascites)
o Diagnostic Methods
 Sputum/ AFB
 Chest X-ray
 TB skin test
 Culture

Treatment
o First line essential anti TB drugs in Ethiopia

1. Rifampicin (R)
2. Ethambutol (E)
3. Isoniazid (H/INH)
4. Pyrazinamide (Z)
5. Streptomycin (S)

 Drugs available as single drug:
• E-400mg, INH-300mg S-1gm
 Drugs available in fixed dose combination
(FDC)
• RHZE-150/75/400/275mg
• RHZ-150/75/400mg
• RH-150/75mg
• EH-400/150mg
o Phases of Chemotherapy
 Intensive (initial) phase:
 DOT therapy
 It renders the patient non-infectious by rapidly
reducing the load of bacilli in the sputum, usually
within 2-3 weeks

for new cases
 combination of 4 drugs for the first 2 months
for re-treatment cases

 combination of 5 five drugs for the first 2
months followed by 4 drugs for the next 1
months.
 Continuation phase: important for ensuring cure or
completion of the treatment.
 For new cases Requires treatment with a
combination of two drugs, to be taken for 4
months
 For re-treatment cases
 Treatment with a combination of three drugs for 5
months.

o Standard TB treatment regimen
1. New patient regimen: 2RHZE/4RH
2. Previously treated
 Previously treated TB cases will be re-treated
with 2S(RHZE)/1(RHZE)/5(RH)E.

Tuberculosis…
o TB Treatment Outcomes
 Cured
 Treatment completed
 Treatment failure
 Died
 Lost to follow-up
 Transfer out

o Drug resistant TB
 Drug-resistant TB is a man-made problem,
largely being the consequence of human error
as a result of individual or combination of factors
related to:
 Management of drug supply
 Patientmanagement
 Prescription of chemotherapy
 Patient adherence and

 Poor infection control practice.

o Case Definitions
 Mono-resistance: resistance to one first line
anti-TB drug.
 Poly-resistance: resistance to more than one first
line anti-TB drugs, but not to both isoniazid and
rifampicin.
 Multi drug-resistant (MRD): resistance to at least
isoniazid and rifampicin, the two most powerful
anti-TB drugs. respiratory by Chilot K. 04/26/2024
 Extensively drug resistant tuberculosis
(XDR-TB): resistant to INH and R (i.e. MDR) as
well as any fluoroquinolone (Moxifloxacin (Mfx),
Ganifloxacin (Gfx)), and any of the second line
injectable Anti-TB drugs (capreomycin,
kanamycin and amikaccin)

Tuberculosis…
o Risk Factors for MDR-TB

• Previous exposure to anti-TB treatment
• Exposure to a known MDR-TB case
• History of using poor or unknown quality TB drugs
• Co-morbid conditions associated with mal-absorption
• HIV/AIDS

PLEURAL EFFUSION
 is an accumulation of fluid in the pleural space.
 Normally the space contains only 10-20ml of fluid as
lubricant for plural space.
 can be clear fluid, exudates bloody or pus.
 Causes;
 Increase capillary permeability (e.g. infections
pneumonia, TB , lung CA or trauma)
 Impair lymphatic function (e.g. lymphatic obstruction
due to tumor)
 Increase systemic hydrostatic pressure (e.g. heart
failure) respiratory by Chilot K. 04/26/2024
Cont---
 Clinical manifestations
 The size of effusion will determine the severity of the
symptom.
 If the effusion is small its presence may be discovered
only on chest x-rays and dyspnea may not be present.
 In large effusion lung expansion may be restricted
 Dyspnea with exertion
 Dry non-productive cough caused by bronchial irritation
 Decreased or absent tactile fremitus
 Percussion notes may be respiratory
dull by Chilot K. 04/26/2024
Cont---
 Diagnosis
 chest x ray
 plural fluid analysis of for
 WBC
 RBC
 Malignant cells
 Microorganisms

Cont---
 Management
 Thoracenthesis
 Water seal chest drainage

Empyema
 It is a collection of purulent liquid / pus/ in the pleural
cavity.
 Cause
 It occurs as result of pneumonia or injury to the chest.
 It may also occur if the lung abscess extends through to
pleural cavity.
 C/M: -
 Fever, anorexia, & weight loss
 Night sweating
 Chest pain
 Dyspnea
Cont---
 Dx:
 History & physical examination
 On auscultation absence of breath sounds
 On percussion – dullness
 Chest x ray
 Pleural fluid analysis

Cont---
 Medical Mx: -
 Thoracentesis: - if fluid is not too thick
 chest drainage tube
 Antibiotic

Pulmonary Embolism
 Thrombosis : is a formation of solid mass with in

the blood vascular system.
 The solid mass formed is called thrombus
 The thrombus may break off the wall of the vein
and known as embolism, / is any mass lying free in

the circulation.
 Pulmonary embolism refers to the obstruction of
one or more pulmonary arteries by a thrombus.

 Is usually a post operative complication.

Cont---
 Risk Factors
1. Venous stasis / slowing of blood flow in
veins/ which may be due to:-
 Prolonged immobilization / post operative/
 Prolonged period of sitting
 Varicose veins

Cont---
2. Hypercoagulability / due to release of tissue
thromboplastin often injury / surgery/ due to:-
-Injury
-Tumor
- Increased platelet count
3. Venous Endothelial Disease such as:-
- Thrombophlebitis

Cont---
4. Certain disease states such as:-
- Trauma
- Postoperative / postpartum period
5. Other pre disposing factors include:-
- Pregnancy
- Oral contraceptive use ???

Cont---
 C/M: - May be non specific
 Chest pain is the commonest symptom
 Sudden onset of dyspnea is the second most
common symptom
 Tachypnea & Haemoptysis
 Tachycardia / rapid & weak pulse/
 Cough & diaphoresis
 Syncope & sudden death

Cont---
 N.B. Multiple small emboli can lodge in the terminal
pulmonary arterioles, producing multiple small
infarctions of the lungs
 Diagnostic evaluation
 Chest x – ray
 Pulmonary angiography
 Mgt
 Surgery
 Pharmacology (anticoagulants/thombolisin therapy)

respiratory by Chilot K.
Questions?
04/26/2024
Group Assignment
o Group 1
o Care of patients with
 Postural drainage
 Water seal drainage
 Tracheostomy
 Thoracentesis
Group Assignment…
Group 2
 Nursing process for patient with
chronic obstructive pulmonary

disease / COPD/

Group Assignment…
Group 3
 Lung abscess
 Pneumothorax
 Cor pulmonale
 Pleurisy/pleuritis

3 Respiratory System

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respiratory by Chilot K.

Disorders of the Respiratory system

BY CHILOT K (BSC, MSC, ASSISTANT PROF.)

 The respiratory system is composed of the upper

respiratory by Chilot K. 04/26/2024

respiratory by Chilot K. 04/26/2024

 The nasal cavities are lined with highly vascular

Para nasal Sinuses

respiratory by Chilot K. 04/26/2024

The para-nasal sinuses

Pharynx, Tonsils, and Adenoids

respiratory by Chilot K. 04/26/2024

respiratory by Chilot K. 04/26/2024

respiratory by Chilot K. 04/26/2024

respiratory by Chilot K. 04/26/2024

surrounded by ribs & muscles.

serous membrane called the pleura.

covers the lungs; the parietal pleura lines the

respiratory by Chilot K. 04/26/2024

respiratory by Chilot K. 04/26/2024

respiratory by Chilot K. 04/26/2024

Bronchus, Bronchi and Bronchioles

alveoli, which are arranged in clusters of 15

respiratory by Chilot K. 04/26/2024

respiratory by Chilot K. 04/26/2024

The respiratory system performs life-

respiratory by Chilot K. 04/26/2024

respiratory by Chilot K. 04/26/2024

Physical Assessment of the Upper

respiratory by Chilot K. 04/26/2024

status, and the respiratory system.

anteroposterior diameter to lateral diameter is 1:2.

respiratory by Chilot K. 04/26/2024

respiratory by Chilot K. 04/26/2024

Breathing Patterns and Respiratory Rates

respiratory by Chilot K. 04/26/2024

 Bradypnea: Slower than normal rate (<12

 Tachypnea: Rapid, shallow breathing >24

respiratory by Chilot K. 04/26/2024

 Hypoventilation: Shallow, irregular breathing

 Hyperventilation: Increased rate and depth of

respiratory by Chilot K. 04/26/2024

 Apnea: Period of cessation of breathing. Time

respiratory by Chilot K. 04/26/2024

respiratory by Chilot K. 04/26/2024

structures in motion, producing audible and

filled with air, fluid, or solid material.

structures within the thorax ( liver).

respiratory by Chilot K. 04/26/2024

air through the bronchial tree and in

adventitious sounds, and voice sounds.

respiratory by Chilot K. 04/26/2024

respiratory by Chilot K. 04/26/2024

duration and severity of the disease.

respiratory by Chilot K. 04/26/2024

 PULSE OXIMETRY: a noninvasive method of

respiratory by Chilot K. 04/26/2024

respiratory by Chilot K. 04/26/2024

 Bronchoscopy: is the direct inspection and