ch 25 Respiratory assessment Flashcards
is gas exchange
respiratory system
transfer of oxygen (O2) and carbon dioxide (CO2) between the atmosphere and blood.
respiratory system
the upper respiratory tract and the lower respiratory tract
respiratory system is divided into 2 parts:
the nose, mouth, pharynx, epiglottis, larynx, and trachea.
upper respiratory tract includes
the nose
Air enters the respiratory tract through
bone and cartilage
nose is made of
divided into 2 nares by the nasal septum
nose
inside of the nose is shaped into 3 passages by projections called
turbinates
increase the surface area of the nasal mucosa that warms and moistens the air as it enters the nose
turbinates
with the pharynx
nasal cavity connects
the nasopharynx, oropharynx, and laryngopharynx
nasal cavity connects with the pharynx.
- It is a tubular passageway that is subdivided into 3 parts:
to protect the lower airway by warming and humidifying air and filtering small particles before air enters the lungs.
nose functions
, found within the mucosa of the upper part of the nasal cavity, is responsible for the sense of smell.
olfactory nerve
Air moves through the oropharynx to the laryngopharynx. It then travels through the epiglottis to the larynx before moving into the trachea.
Route of air through nose to ody
is a small flap behind the tongue that closes over the larynx during swallowing
epiglottis
prevents solids and liquids from entering the lungs.
epiglottis function
are in the larynx
vocal cords location
(the opening between the vocal cords) and into the trachea.
air passes through the glottis
U-Shaped cartilages keep the trachea open but allow the adjacent esophagus to expand for swallowing.
trachea
into the right and left mainstem bronchi at a point called the carina.
trachea bifurcates
is located at the angle of Louis, which is at the level of the 4th and 5th thoracic vertebrae.
carina
this area during suctioning causes vigorous coughing
Stimulation of carnia
Once air passes the carina, it is in the
considered lower respiratory tract
bronchi, bronchioles, alveolar ducts, and alveoli
lower respiratory tract consists
Except for the right and left mainstem bronchi,
all lower airway structures are found within the lungs.
-upper, middle, and lower
right lung is divided into 3 lobes
-upper and lower
left lung into 2 lobes
mainstem bronchi, pulmonary vessels, and nerves enter the lungs through a slit called the
hilus
is shorter, wider, and straighter than the left mainstem bronchus
right mainstem bronchus
is shorter, wider, and straighter than the left mainstem bronchus.
right mainstem bronchus vs left
right mainstem bronchus is shorter, wider, and straighter than the left mainstem bronchus.
aspiration is more likely to occur in the right lung than in the left lung.
several times to form the lobar, segmental, and subsegmental bronchi.Further divisions form the bronchioles.
mainstem bronchi subdivide
the respiratory bronchioles.
most distant bronchioles are
are encircled by smooth muscles that constrict and dilate in response to variousstimuli.
bronchioles
to a decrease or increase in the diameter of the airways caused by contraction or relaxation of these muscles
bronchoconstriction and bronchodilation refer
act as a pathway to conduct gases to and from the alveoli
trachea and bronchi
volume of air in the trachea and bronchi is called the
-This air does not take part in gas exchange.
anatomic dead space (VD)
is about 500mL (in a 150-lb man). Of each 500 mL inhaled, about 150mL is VD.
adults, normal tidal volume (VT), or volume of air exchanged with each breath,
are small sacs in the lungs that are the primary site of gas exchange for O2 and CO2
Alveoli
They allow movement of air from alveolus to alveolus
alveoli are interconnected by pores of Kohn
air movement through these pores and helps move mucus out of the respiratory bronchioles.
Deep breathing promotes
can also move through these pores, spreading infection to previously uninfected areas.
Bacteria (alveoli)
of about 2500 mL with a surface area for gas exchange that is about the size of a tennis court.
Alveoli have a total volume
, where the alveoli come in contact with pulmonary capillaries
Gases are exchanged across the alveolar-capillary membrane
excess fluid fills the interstitial space and alveoli, markedly reducing gas exchange.
pulmonary edema
is a lipoprotein that lowers the surface tension in the alveoli
-prevents alveoli collapse
Surfactant
reduces the amount of pressure needed to inflate the alveoli and makes them less likely to collapse
Surfactant
each person takes a slightly larger breath, termed a sigh, after every 5 or 6 breaths. This sigh stretches the alveoli and promotes surfactant secretion.
sigh
refers to collapsed, airless alveoli.
atelectasis
because of the effects of anesthesia, decreased mobility, and pain, which can alter breathing and lung expansion.
postoperative patient is at risk for atelectasis
, lack of surfactant contributes to widespread atelectasis and collapse of lung tissue
acute respiratory distress syndrome (ARDS)
pulmonary and bronchial
lungs have 2 different types of circulation:
provides the lungs with blood that takes part in gas exchange
Pulmonary circulation
receives deoxygenated blood from the right ventricle of the heart and delivers it to pulmonary capillaries that lie directly alongside the alveoli.
pathology of pulmonary artery
starts with the bronchial arteries, which arise from the thoracic aorta
Bronchial circulation
but provides O2 to the bronchi and other lung tissues. Deoxygenated blood returns from the bronchial circulation through the azygos vein into the superior vena cava.1
Bronchial circulation does not take part in gas exchange
is shaped, supported, and protected by 24 ribs (12 on each side
chest wall (description)
which consists of the ribs and sternum, protect the lungs and the heart from injury.
thoracic cage function
is the space in the middle of the thoracic cavity.
mediastinum
It contains the major organs of the chest, including the heart, aorta, and esophagus.
mediastinum consists
chest cavity is lined with a membrane called the
parietal pleura
lungs are lined with a membrane called the
visceral pleura
join to form one continuous membrane.
parietal and visceral pleurae join
does not have any sensory (pain) fibers or nerve endings.
visceral pleura consists
This is why irritation or inflammation of the parietal pleura can cause pain with each breath.
parietal pleura has pain fibers.
is the space between the pleural layers
-Normally this space contains 10 to 20 mL of fluid.
intrapleural space
(1) it provides lubrication, allowing the pleural layers to slide over each other during breathing
(2) it increases unity between the pleural layers. This promotes expansion of the pleurae and lungs during inspiration.
intrapleural space (fluid ) serves 2 purposes:
via lymphatic circulation
Fluid drains from the pleural space
Several pathologic conditions may cause the accumulation of greater amounts of fluid, termed
pathology of pleural effusion.
-Pleural fluid may accumulate because of blockage of lymphatic drainage (e.g., from cancer)
- an imbalance between intravascular and oncotic fluid pressures, as in heart failure. —–Purulent pleural fluid with bacterial infection is called empyema.
cause of pleural effusion.
Purulent pleural fluid with bacterial infection is called
empyema.
is the major muscle of respiration
Diaphragm
, moves downward, and increases intrathoracic volume.
During inspiration the diaphragm contracts
At the same time, the internal intercostals relax and the external intercostal muscles contract. This increases the lateral and anteroposterior (AP) dimension of the chest
During inspiration the diaphragm contracts
, each innervated by the right and left phrenic nerves
diaphragm is made up of 2 hemidiaphragms
the spinal cord between C3 and C5, the 3rd and 5th cervical vertebrae
phrenic nerves arise from
in hemidiaphragm paralysis on the side of the injury. Complete spinal cord injuries above the level of C3 result in total diaphragm paralysis and dependence on a mechanical ventilator.
Injury to the phrenic nerve results
refers to the process of obtaining O2 from the atmospheric air and making it available to the organs and tissues of the body
Oxygenation
by partial pressure of O2 in arterial blood (PaO2), arterial O2 saturation (SaO2)
lungs’ ability to oxygenate arterial blood adequately is evaluated
dissolved O2 and hemoglobin-bound O2
O2 is carried in the blood in 2 forms:
the amount of O2 dissolved in the plasma
PaO2 represents
is the amount of O2 bound to hemoglobin in comparison with the amount of O2 the hemoglobin can carry.
SaO2 (defined)
-Unexplained apprehension
-Unexplained restlessness or irritability
-Unexplained confusion or lethargy (can be early or late)
Early signs of inadequate Oxygen (CNS)
-Combativeness
-Coma
Late signs of inadequate Oxygen (CNS)
-Tachypnea
Dyspnea on exertion
Early signs of inadequate Oxygen (respiratory)
-Dyspnea at rest
-Use of accessory muscles
-Retraction of intercostal spaces on inspiration
-Pause for breath between sentences, words
Late signs of inadequate Oxygen (respiratory)
-Tachycardia
-Mild hypertension
-Dysrhythmias (can be early or late)
Early signs of inadequate Oxygen (cardiovascular)
-Hypotension
-Cyanosis
-Cool, clammy skin
Late signs of inadequate Oxygen (cardiovascular)
-Diaphoresis
-Decreased urine output
-Unexplained fatigue
can be early or late signs of inadequate Oxygen
involves inspiration, or inhalation (movement of air into the lungs), and expiration, or exhalation (movement of air out of the lungs)
Ventilation
from an area of higher pressure (atmospheric) to one of lower pressure (intrathoracic).
Gas(o2 & Co2) flows
occurs, neck and shoulder muscles, as well as other accessory muscles of respiration, can aid the effort
dyspnea (shortness of breath)
is passive
expiration
is the tendency for the lungs to return to their original size after being stretched or expanded.
Elastic recoil
is due to the elastin fibers found in the alveolar walls and surrounding the bronchioles and capillaries.
elasticity of lung tissue
allows the chest to passively decrease in size (volume). When intrathoracic pressure rises, air moves out of the lun
elastic recoil of the chest wall and lungs
expiration to become an active, labored process
Exacerbations of asthma or chronic obstructive pulmonary disease (COPD) cause
Abdominal, intercostal, and accessory muscles (e.g., scalene, trapezius) help expel air during labored breathing.
body parts help expel air during labored breathing
is a measure of the ease of expansion of the lungs
Compliance (distensibility)
-This is a product of the elasticity of the lungs and elastic recoil of the chest wall
Compliance (distensibility)
, it is harder for the lungs to inflate
compliance is decreased
when there is destruction of alveolar walls and loss of tissue elasticity, as in COPD.
Compliance increases
occurs with conditions that increase fluid in the lungs (e.g., pulmonary edema, ARDS, pneumonia), make lung tissue less elastic or distensible (e.g., pulmonary fibrosis, sarcoidosis), or restrict lung movement (e.g., pleural effusion)
cause of compliance when it’s decreased
refers to any obstacle to airflow during inspiration and/or expiration
resistance
is changes in the diameter (size) of the airways
main factor affecting airway resistance
patient with an acute asthma attack has narrowed airways, resulting in
- presence of secretions in the bronchi
example of increased resistance.
decreases resistance by increasing the diameter of the bronchi, promoting air entry.
bronchodilators
Changes in compliance and/or resistance can seriously
affect both oxygenation and ventilation.
responds to chemical and mechanical signals
Located in the brainstem, the respiratory center (the medulla)
sends impulses to the respiratory muscles through the spinal cord and phrenic nerves.
medulla (function)
is a receptor that responds to a change in the chemical composition (PaCO2 and pH) of the fluid around it
chemoreceptor
are found in the medulla.
Central chemoreceptors (located)
They respond to changes in the hydrogen ion (H+) concentration.
-An increase in the H+ concentration (acidosis) causes the medulla to increase the respiratory rate and VT.
-A decrease in H+ concentration (alkalosis) has the opposite effect.
Central chemoreceptors (function)
causes the medulla to increase the respiratory rate and VT.
An increase in the H+ concentration (acidosis) // chemoreceptors
has the opposite effect
A decrease in H+ concentration (alkalosis) // chemoreceptors
primarily by their effect on the pH of the cerebrospinal fluid.
Changes in PaCO2 regulate ventilation
This lowers the cerebrospinal fluid pH and stimulates an increase in respiratory rate.
PaCO2 level is increased, more CO2 is available to combine with H2O and form carbonic acid (H2CO3).
are found in the carotid bodies at the bifurcation of the common carotid arteries and in the aortic bodies above and below the aortic arch.
Peripheral chemoreceptors
and may result in chronically elevated PaCO2 levels.
- largely because of a hypoxic drive from the peripheral chemoreceptors
COPD change lung function
are found in the conducting upper airways, chest wall, diaphragm, and capillaries of the alveoli.
Mechanical receptors (location)
They are stimulated by a variety of physiologic factors, such as irritants, muscle stretching, and alveolar wall distortion.
Mechanical receptors (stimulated)
are irritant, stretch, and juxtacapillary (J) receptors
3 major types of mechanical receptors
are found in the conducting airways.
Irritant receptors (location)//(type of mechanical receptors)
sensitive to inhaled particles and aerosols and, when stimulated, initiate the cough reflex.
Irritant receptors (effect)//(type of mechanical receptors)
, in the smooth muscle of the airways, aid in the control of respiration.
Signals from stretch receptors//(type of mechanical receptors)
lungs inflate, stretch receptors activate the inspiratory center to inhibit further lung expansion. This is called the Hering-Breuer reflex, and it prevents overdistention of the lungs.
stretch receptors (function)// (type of mechanical receptors)
prevents overdistention of the lungs.
Hering-Breuer reflex (from stretch receptor)
found in the capillaries of the alveoli, occurs with increased pulmonary capillary pressure. This causes rapid, shallow respiration (tachypnea) seen in pulmonary edema
Stimulation of J receptors//(type of mechanical receptors)
are efficient in protecting the lungs from inhaled particles, microorganisms, and toxic gases
Respiratory defense mechanisms
air filtration, mucociliary clearance system, cough reflex, reflex bronchoconstriction, and alveolar macrophages.
Respiratory defense mechanisms include
filter inspired air
Nasal hairs ( air filtration)
the abrupt changes in direction of airflow that occur as air moves through the nasopharynx and larynx increase air turbulence.
-causes particles and bacteria to contact the mucosa lining these structures.
-particles (greater than 5 μm) are less dangerous
abrupt changes in direction of airflow ( air filtration )
velocity of airflow slows greatly after it passes the larynx, facilitating the deposition of smaller particles (1 to 5 μm). They settle out the way that sand does in a river, a process termed sedimentation.
- smaller particles (1 to 5 μm)
velocity of airflow slows greatly after it passes the larynx,( air filtration ) aka sedimentation.
e are too small to settle in this manner and are deposited in the alveoli. An example of small particles that can build up is coal dust, which can lead to pneumoconiosis
Particles less than 1 μm in siz (dangerous)
Below the larynx, the mucociliary clearance system, also called the
mucociliary escalator
, is responsible for the movement of mucus.
mucociliary escalator (function)
continually secrete mucus at a rate of about 100 mL/day. This mucus forms a blanket that contains the impacted particles and debris from distal lung areas
Goblet cells and submucosal glands
helps protect against bacteria and viruses.
Secretory immunoglobulin A (IgA) in the mucus
cover the airways from the level of the trachea to the respiratory bronchioles
Cilia
about 200 cilia. They beat rhythmically about 1000 times per minute in the large airways, moving mucus toward the mouth.
-We normally swallow the mucus without noticing.
Each ciliated cell has
the tracheobronchial tree. As a result, we remove particles that penetrate more deeply into the airways less rapidly.
ciliary beat is slower further down
Dehydration, smoking, inhalation of high O2 concentrations, infection, and drugs, such as atropine, anesthetics, alcohol, or cocaine,
causes of impair ciliary action
Patients with COPD and cystic fibrosis often have repeated lower respiratory tract infections. These conditions are associated with destroyed cilia, resulting in impaired secretion clearance, a chronic productive cough, and chronic colonization by bacteria. These lead to frequent respiratory tract infections.
conditions are associated with destroyed cilia,
is a protective reflex that clears the airway by a high-pressure, high-velocity flow of air. It is a backup for mucociliary clearance, especially when this clearance mechanism is overwhelmed or ineffective.
cough
especially when this clearance mechanism is overwhelmed or ineffective. =COUGH
backup for mucociliary clearance,
Coughing is effective in removing secretions only above the subsegmental level (large or main airways)
Coughing is effective in removing secretions ONLY above the subsegmental level
Secretions below this level must be moved upward by the mucociliary mechanism before we can remove them by coughing.
Secretions below subsegmental level
another defense mechanism
Reflex bronchoconstriction is
response to the inhalation of large amounts of irritating substances (e.g., dusts, aerosols), the bronchi constrict to prevent entry of the irritants
Reflex bronchoconstriction (function)
, such as a person with asthma, may have bronchoconstriction after inhalation of triggers, such as cold air, perfume, or other strong odors.
hyperreactive airways ex asthma
Because there are no ciliated cells below the level of the respiratory bronchioles, the primary defense mechanism at the alveolar level is
alveolar macrophages
rapidly phagocytize inhaled foreign particles, such as bacteria. The debris is moved to the level of the bronchioles for removal by the cilia or removed from the lungs by the lymphatic system.
Alveolar macrophages
tend to remain in the lungs for indefinite periods and can stimulate inflammatory responses
Particles (e.g., coal dust, silica) that cannot be adequately phagocytized
Because alveolar macrophage activity is impaired by cigarette smoke, the smoker who is employed in an occupation with heavy dust exposure (e.g., mining, foundries) is at an especially
high risk for lung disease
can be divided into alterations in structure, defense mechanisms, and respiratory control
Age-related changes in the respiratory system
Structural changes include calcification of the costal cartilages, which can interfere with chest expansion. The outward curvature of the spine is marked, especially with osteoporosis, and the lumbar curve flattens
Structural changes in elder
chest may appear barrel shaped, and
chest shape elder
the older person may need to use accessory muscles to breathe. Respiratory muscle strength progressively declines after age 50. Overall, the
lungs in the older adult are harder to inflate.
Chest wall stiffening
Costal cartilage calcification
↑ Anteroposterior diameter
↓ Elastic recoil
↓ Chest wall compliance
↓ Functioning alveoli
↓ Respiratory muscle strength
Changes in structure of elder
↓ Cell-mediated immunity
↓ Specific antibodies
↓ Cilia function
↓ Cough force
↓ Alveolar macrophage function
↓ Sensation in pharynx
Changes in defense mechanism of elder
↓ Response to hypoxemia
↓ Response to hypercapnia
Changes in Respiratory Control of elder
dyspnea can occur if their activity exceeds their normal exercise.
older adults have less tolerance for exertion
because of a decline in both cell-mediated and humoral immunity (ability to produce antibodies).
older adults, respiratory defense mechanisms are less effective
for aspiration.
older adult is at greater risk
resulting in a more gradual response to changes in blood O2 or CO2 level.
aging process alters respiratory control,
if respiratory distress is severe, only obtain pertinent information and defer a thorough assessment until the patient’s condition stabilizes.
physical assessment= if respiratory distress is severe
lower respiratory problems, such as asthma, COPD, pneumonia, and tuberculosis (TB).
ask about lower history problems
such as medications, pollen, smoke, mold, or pet exposure.
Ask the patient with allergies about possible precipitating factors or triggers,
such as runny nose, wheezing, scratchy throat, or chest tightness.
Record the characteristics and severity of the allergic reaction, example
Determine the frequency of asthma exacerbations.
frequency of asthma
. Cough is a common side effect
effect of angiotensin-converting enzyme (ACE) inhibitors.
, dyspnea and decreased exercise tolerance may occur very quickly.
effect of upper respiratory tract infection is superimposed on a chronic problem
in the presence of mold, or with changes in temperature or air pollution.
asthma, symptoms may occur or worsen during exercise,
occurs with secretions
loose-sounding cough
may mean an airway irritation or obstruction.
dry, hacking cough
suggests upper airway obstruction from inhibited vocal cord movement due to subglottic edema.
harsh, barky cough
amount, color, consistency, and odor
-Quantify the amount of sputum per day.
If the patient has a productive cough, evaluate the following characteristics of sputum:
clear or slightly whitish.
Sputum is normally
is usually clear to gray with occasional specks of brown.
If a patient is a cigarette smoker, the sputum
may have clear, whitish, or slightly yellow sputum, especially in the morning on rising.
patient with COPD sputum
suspect pulmonary complications
If the patient reports any change from baseline color of sputum
any changes in consistency of sputum to thick, thin, or frothy and pink tinged.
sputum may indicate dehydration, postnasal drip or sinus drainage, or possible pulmonary edema
suggests an infectious process.
foul odor or exceptionally bad breath or taste in the mouth
spitting or coughing up blood
hemoptysis
(vomiting blood).
hematemesis
such as pneumonia, TB, lung cancer, and severe bronchiectasis.
Hemoptysis occurs with a variety of conditions
are musical sounds that can be audible
wheezes
some degree of airway obstruction, such as asthma, foreign body aspiration, and emphysema.
Wheezing indicates
Respiratory problems that have a strong genetic link
is the most important risk factor for COPD and lung cancer.
Smoking
Do this by multiplying the number of cigarettes smoked per day by the number of years smoked
Quantify smoking habits in pack-years
prior residence in China, India, Africa, the former Soviet Republics, Latin America, or any developing country.
Risk factors for TB include
exposure to people with high rates of TB transmission, such as the homeless, injection drug users, and people with HIV infection
other Risk factors for TB include
those exposed to bird and rodent feces or polluted water, those working closely with the soil, and immunocompromised patients.
Risk factors for fungal lung infections include
can be a symptom of respiratory disease
Weight loss (resp disease)
are common in patients with COPD, lung cancer, TB, and chronic severe infection (bronchiectasis)
Anorexia, weight loss, and chronic malnutrition
Determine if weight loss was intentional, and, if not, if food intake is changed by anorexia (from medications), fatigue (from hypoxemia, increased work of breathing), or feeling full quickly (from lung hyperinflation).
cause of weight loss
can cause sputum to thicken and obstruct the airway
Dehydration (effect airway)
from fluid retention may impair gas exchange.
Rapid weight gain ( (effect airway)
of limited mobility, which can cause constipation.
Dyspnea can be the cause
leading to atelectasis or pneumonia.
Immobility and sedentary habits are risk factors for hypoventilation
with chest tightness, wheezing, or coughing. This suggests a need for adjunct therapy or other medication changes
patient with asthma or COPD may awaken (symptoms)
and may cause sleep apnea
Excess weight interferes with normal ventilation
while awake or asleep
Extremely obese persons may hypoventilate
snoring, insomnia, abrupt awakenings, daytime drowsiness, and early morning headaches.
Manifestations of sleep apnea include
of TB.
Night sweats may be a sign
hypoxia can cause neurologic symptoms, ask the patient about apprehension, restlessness, irritability, and memory changes.
indicate inadequate cerebral oxygenation
pleurisy, fractured ribs, and costochondritis .
cause chest pain
Hobbies, such as woodworking (sawdust) or pottery (silica), and animal exposure (allergies) can
work environments cause respiratory problems.
Because of hyperreactive airways, exposure to fumes, smoke, and other chemicals may
trigger an attack in the patient with asthma.
perform good pulmonary hygiene (bronchodilators, coughing, deep breathing) before intimacy. They may need to use O2 therapy equipment during intercourse just like they would with any strenuous physical activity.
strategies improving sexual activity
Check each nare for air patency with respiration while briefly occluding the other nare. Tilt the patient’s head backward and push the tip of the nose upward
how to assess pts nose
mucous membrane should be pink and moist, with no evidence of edema (bogginess), exudate, or bleeding.
-Some septal deviation is normal in an adult.
Normal nose observation description
, which are abnormal, fingerlike projections of swollen nasal mucosa. Polyps may result from long-term irritation of the mucosa (e.g., from allergies)
turbinates for polyps (definition)
could occur with a foreign body.
Purulent and malodorous discharge (nose)
could be related to allergies or from cerebrospinal fluid.
Watery discharge (nose)
could be from trauma or dryness.
Bloody discharge (nose)
could mean an infection
Thick mucosal discharge (nose)
should be smooth and moist, with no evidence of exudate, ulcerations, swelling, or postnasal drip.
normal pharynx
that cranial nerves IX (glossopharyngeal) and X (vagus) are intact and that the airway is protected.
normal response (gagging) means
while the patient is sitting erect with the neck slightly flexed
how to Palpate the lymph nodes
Tender, hard, or fixed nodes
abnormal feeling of node
small, mobile, nontender nodes (shotty nodes)
normal feeling of lymph node
in a well-lit, warm room with measures taken to ensure the patient’s privacy
Chest examination is best done (environment)
It is best to begin on the posterior chest, particularly with female patients
chest examination best done on
, ask the patient to lean forward with arms folded. This position moves the scapulae away from the spine, exposing more of the area you need to examine.
assessing the posterior chest
have the patient sit upright or position the patient supine with the head of the bed elevated to 30 degrees (semi-Fowler’s position)
assessing the anterior chest,
should be less than the side-to-side or transverse diameter
-AP ratio is 1:2.
anterior-posterior (AP) diameter normal
(e.g., barrel chest) may be due to normal aging or result from lung hyperinflation.
increase in (anterior-posterior) AP diameter cause
(e.g., pectus carinatum [a prominent protrusion of the sternum]) and pectus excavatum (an indentation of the lower sternum above the xiphoid process)
abnormalities in the sternum
include kyphosis, scoliosis, and kyphoscoliosis.
Spinal curvatures that affect breathing
Inspiration (I) should take half as long as expiration (E) (I/E ratio = 1:2)
Inspiration duration vs expiration normally
rapid, deep breathing
Kussmaul
abnormal respirations characterized by alternating periods of apnea and deep, rapid breathing
Cheyne-Stokes (like dog)
irregular breathing with apnea every 4 to 5 cycles respirations.
Biot’s (increase Co2-sound like running fast)
, a late sign of hypoxemia, is best seen in light-skinned patients as a bluish tinge to the mucous membranes, lips, and palms of the hands.
Cyanosis ( best seen in light-skinned patients )
may be seen as a gray or white discoloration in the conjunctivae or around the mouth.
In dark-skinned persons, cyanosis
include hypoxemia or decreased cardiac output.
Causes of cyanosis
increase in the angle between the base of the nail and the fingernail to 180 degrees or more
Clubbing
occurs away from the side of a tension pneumothorax or a neck mass, but toward the side of a pneumonectomy or lobar atelectasis.
Tracheal deviation
occurs when air entry is limited by conditions involving the lung (e.g., atelectasis, pneumothorax) or the chest wall (e.g., incisional pain)
Unequal expansion
occurs in conditions that produce a hyperinflated or barrel chest or in neuromuscular diseases (e.g., amyotrophic lateral sclerosis, spinal cord lesions)
Equal but decreased expansion in chest
over a pleural effusion, an atelectasis, or a pneumothorax.
chest Movement may be absent or unequal due to
is the vibration of the chest wall made by vocalization.
Fremitus
is most intense by the sternum and between the scapulae because these areas are closest to the major bronchi
Tactile fremitus
occurs when the lung becomes filled with fluid or is denser.
Increased fremitus
This happens with pneumonia, lung tumors, thick bronchial secretions, and above a pleural effusion (the lung is compressed upward).
condition with voice that moves through a dense tissue or fluid, you can feel that the vibration is increased.
if the hand is farther from the lung (e.g., pleural effusion) or the lung is hyperinflated (e.g., barrel chest)
Fremitus is decreased
may occur with pneumothorax or atelectasis
Absent fremitus
is harder to palpate for fremitus because of the large muscles and breast tissue
anterior of the chest
is used to assess the density or aeration of the lungs
Percussion
area over lung tissue should be resonant, except for the area of cardiac dullness
anterior chest resonant
over lung tissue to the level of the diaphragm
posterior chest should be resonant
should proceed from the lung apices to the bases, comparing opposite areas of the chest
Auscultation begin
or you think the patient will tire easily, start at the bases
If the patient is in mild respiratory distress (start from base)
are bronchial, bronchovesicular, and vesicular.
3 normal breath sounds
are loud, high-pitched sounds that resemble air blowing through a hollow pipe
Bronchial sounds
have an inspiratory to expiratory (I/E) ratio of 2:3, with a gap between inspiration and expiration
Bronchial sounds
have a medium pitch and intensity.
Bronchovesicular sounds
best heard anteriorly between the first and second intercostal space and posteriorly between the scapulae.
- have a 1:1 ratio, with inspiration equal to expiration.
Bronchovesicular sounds
are relatively soft, low-pitched, gentle, rustling sounds.
-They are heard over all lung areas except the major bronchi.
- 3:1 ratio, with inspiration 3 times longer than expiration.
Vesicular sounds
normal and abnormal (adventitious).
classify breath sounds into 2 main categories:
crackles (fine and coarse), wheezes, stridor, and pleural friction rub
Adventitious breath sounds include
is used to evaluate the status of previously identified respiratory problems and to monitor for signs of new problems.
focused assessment
-Arterial blood gases
-Chest x-ray
-Hemoglobin
-Hematocrit
objective Diagnostic
Interstitial edema
early pulmonary edema
alveolar filling
pneumonia
loss of lung volume (alveoli deflate)
atelectasis
(1) pulse oximetry and (2) analysis of arterial blood gases (ABGs)
Two methods are used to assess the efficiency of gas transfer in the lung and tissue oxygenation:
patient with impaired cardiac output or hemodynamic instability (e.g., altered level of consciousness, changes in heart rate and rhythm, low BP) may have inadequate tissue O2 delivery and/or abnormal O2 consumption.
evaluate a mixed venous blood gas.
Values obtained by pulse oximetry are less accurate if the SpO2 is less than 70%
-may display a value that is ±4% of the actual value
less accurate value of pulse Ox
hemoglobin variants (e.g., carboxyhemoglobin, methemoglobin) are present
Pulse oximetry is inaccurate if
motion, low perfusion, anemia, cold extremities, bright fluorescent lights, intravascular dyes, thick acrylic nails, and dark skin color.
Other factors that can alter the accuracy of pulse oximetry include
, obtain an ABG analysis to verify the values.
if there is doubt about the accuracy of the SpO2 reading
are obtained to determine oxygenation status and acid-base balance.
ABGs (function)
measurement of the PaO2, PaCO2 (the partial pressure of CO2 in arterial blood), acidity (pH), bicarbonate (HCO3−), and SaO2
ABG analysis includes
can be obtained by arterial puncture or from an arterial catheter, which is usually inserted into the radial or femoral artery.
Blood for ABG analysis
arterial catheter permits ABG sampling without repeated arterial punctures.
arterial catheter vs arterial puncture
Sensor may be attached to an adaptor on endotracheal or tracheostomy tube. A nasal cannula with a sidestream capnometer can be used in patients without an artificial airway.
how to measure End-tidal CO2(PetCO2) (capnography)
is 2–5 mm (dead space)
-if it increases= pulmonary embolism
Normal difference between PaCO2 and PetCO2
transcutaneous CO2 (PtCO2) and end-tidal CO2 (PetCO2) capnography
CO2 can be monitored using
is a noninvasive method of estimating arterial pressure of CO2 (PaCO2) using an electrode placed on the skin
Transcutaneous measurement of CO2
is the noninvasive measurement of alveolar CO2 during exhalation when CO2 concentration is at its peak
PetCO2
is a flow-directed catheter
pulmonary artery (PA) catheter
Blood drawn from a PA catheter is called a
mixed venous blood gas (SvO2)
(1) it consists of venous blood that has returned to the right side of the heart from all parts of the body and (2) it samples blood just before blood enters the lungs to be oxygenated. Normal SvO2 is 60% to 80%.
mixed venous blood gas (SvO2) (function)
intermittently by obtaining a blood sample from the PA catheter or continuously via a fiberoptic sensor as part of a specific central line with SpO2 monitoring capability.
SvO2 can be monitored
in cardiac output or tissue O2 delivery.
Changes in SvO2 provide an early warning of a change
that less O2 is being delivered to the tissues or that more O2 is being consumed.
A decrease in SvO2 suggests
expectoration, tracheal suction, or bronchoscopy.
obtain a sputum sample by
if pt is unable to expectorate spontaneously, sputum may be collected by inhaling an irritating aerosol, usually hypertonic saline. This is called
sputum induction
that the patient has been exposed to the antigen. It does not mean that the patient has TB
a positive result on a TB skin test means
either no exposure or a depression of cell-mediated immunity, which occurs in HIV infection.
negative TB result means
be sure that the injection is intradermal and not subcutaneous
prevent a false-negative reaction, (TB)
is a procedure in which the bronchi are visualized through a fiberoptic tube
Bronchoscopy
diagnostic purposes (obtain biopsy specimens) and for treatment (e.g., to remove mucous plugs, foreign bodies).
Bronchoscopy may be used for
Laser therapy, electrocautery, cryotherapy, and stents may be placed through a bronchoscope to
ways to achieve patency of an airway that has been partially or nearly fully obstructed by tumors
can be done in an outpatient procedure room, in a surgical suite, or at the bedside in the critical care unit or on a medical-surgical unit.
Bronchoscopy performed (environement)
patient may be positioned supine, in low-Fowler’s, or even be seated.
position of patient during Bronchoscopy
HCP inserts the bronchoscope through the nose or mouth. Depending on the approach, the nasopharynx or oropharynx is anesthetized with local anesthetic spray.
insertion of bronchoscopy
is coated with water-soluble lubricant and inserted down into the airways. Small amounts (30 mL) of sterile saline may be injected through the scope and withdrawn and examined for cells, a technique termed bronchoalveolar lavage (BAL)
bronchoscope (how its used)/ termed bronchoalveolar lavage (BAL)
Bronchoscopy can be done through the endotracheal tube of a mechanically ventilated patient.
Bronchoscopy can be done through the endotracheal tube
(1) transbronchially, (2) percutaneously or via transthoracic needle aspiration (TTNA), (3) by video-assisted thoracic surgery (VATS), or (4) as an open lung biopsy
Lung biopsy may be done
is to obtain tissue, cells, and/or fluid for evaluation.
purpose of a lung biopsy
involves passing a forceps or needle through the bronchoscope for a specimen.
Transbronchial biopsy (lung biopsy)
is used to distinguish infection and rejection in lung transplant recipients.
A combination of transbronchial lung biopsy and BAL
involves inserting a needle through the chest wall, usually under bedside ultrasound or CT guidance. Because of the risk for a pneumothorax, a chest x-ray is done after TTNA.
percutaneous or TTNA biopsy
a rigid scope with a lens is passed through a trocar placed into the pleura via 1 or 2 small incisions in the thoracic cavity. The HCP views the lesions in the pleura or peripheral lung on a monitor directly via the scope and can obtain biopsy specimens. A chest tube is kept in place until the lung expands. VATS is much less invasive than open lung biopsy. It is associated with shorter hospital stays and reduced mortality.13 It is ideal for pleural biopsy and resecting lung nodules.
VATS, (lung biopsy)
is used when other procedures cannot diagnose pulmonary disease. With the patient under anesthesia, the chest is opened with a thoracotomy incision and a biopsy specimen is obtained. Postprocedure care is the same as after thoracotomy
open lung biopsy
is the insertion of a large-bore needle through the chest wall into the pleural space to obtain specimens for diagnostic evaluation, remove pleural fluid, or instill medication
Thoracentesis
patient is positioned sitting upright, leaning on an overbed table with feet supported. The skin is cleansed and a local anesthetic (lidocaine) is injected subcutaneously. A percutaneous catheter may be left in to allow further drainage of fluid
Thoracentesis procedure
measure lung volumes and airflow.
Pulmonary function tests (PFTs)
can diagnose pulmonary disease, monitor disease progression, assess response to bronchodilators, and evaluate disability.
results of PFTs (Pulmonary function tests)
Airflow measurement is obtained by trained personnel using a spirometer.
Pulmonary function tests Airflow measurement
are 80% to 120% of the predicted valu
Pulmonary function test normal value
Volume of air inhaled and exhaled with each breath. Only a small proportion of total capacity of lungs
Tidal volume (Vt)
may be used to monitor lung function in people with asthma, cystic fibrosis, or COPD, as well as before and after lung transplantation or other thoracic surgeries
Home spirometry
changes can warn of early lung transplant rejection or infection.
Spirometry
