Lecture 12 Respiratory System

Question 1

Understanding the Respiratory System

Answer 1

• consists of 2 lungs, conducting airways, and associated BVs
• major function is gas exchange through inhalation and exhalation
• oxygen in the lungs replaces carbon dioxide in blood at alveoli during perfusion and the carbon dioxide is expelled on exhalation
• disease or trauma may interfere with conducting airways, lungs, breathing mechanics, and neurochemical control of ventilation

Question 2

Conducting Airways

Answer 2

• upper airway: nose, mouth, pharynx, larynx-allows airflow and warms, humidifies and filters inspired air
• lower airway: trachea,bronchi, and bronchioles-facilitates gas exchange
• terminal alveoli: air sacs at end of conducting airways-ventilation is ability to move air in and out of lungs
• respiration: supplies oxygen to blood and body tissues and removes carbon dioxide-hypoxemia is deficient oxygenation of arterial blood most common condition caused by pulmonary disease; respiratory alterations or cardiovascular compromise

Question 3

Lungs

Answer 3

-air-filled, sponge like organs divided into lobes (3 on right, 2 on left)

Question 4

Breathing Mechanics

Answer 4

-depends on lung volume and capacity, compliance, and resistance to airflow

Question 5

Neurochemical Control

Answer 5

• respiratory center is located in the lateral medulla oblongata of the brain stem (impulses travel down the phrenic nerves to the diaphragm and then down to the intercostal nerves)
• chemoreceptors and peripheral receptors

Question 6

S&S of Pulmonary Disease

Answer 6

• classifications: acute or chronic; obstructive or restrictive; or infectious or noninfectious
• cough
• dyspnea
• chest pain
• cyanosis
• clubbing: heart and lung diseases that ↓ O2 in the blood-thickening and widening at terminal phalange
• flared nostrils: sign that person is having difficulty breathing
• altered breathing patterns
• hemoptysis

Question 7

SIFTT

Answer 7

• because impairment can result from diseases other than cardiopulmonary conditions, therapists in all settings need expertise in anticipating and detecting pulmonary dysfunction
• clinical observation of the client as he or she breathes is important
• Assessment of the 3 muscle groups (abdominal, intercostal muscles, and the diaphragm) involved in normal ventilatory function may be required

Question 8

Aging and the Pulmonary System

Answer 8

• Increased stiffness of the chest wall as the rib articulations and cartilage ossify and become less flexible
• effects of age are not nearly as influential as smoking in causing a premature decline in lung function and in limiting the ability to exercise
• SIFTT: regular exercise can substantially slow the decline in maximal O2 delivery caused by cardiovascular deconditioning related to age or ↓’d levels of habitual physical activity

Question 9

Acute Respiratory Distress Syndrome (ARDS)

Answer 9

-form of pulmonary edema that can quickly lead to acute respiratory failure
-may follow a direct or indirect lung injury
-can prove fatal within 48 hours; 50 - 70% mortality
-etiology: shock, sepsis, and trauma are the most common causes
-patho: fluid accumulates in the lungs causing them to stiffen, which impairs ventilation and ↓’s oxygenation of the capillary blood look at picture on page 3
-CM: rapid, shallow breathing and dyspnea within hours to days of injury; with progression: hypoxemia; crackles and rhonchi due to fluid accumulation causing
restlessness, apprehension, and tachycardia
-dx: arterial blood gas, chest x-rays, pulse oximetry (O2 saturation)
-tx: intubation and mechanical ventilation to ↑ lung volume

Question 10

Asthma

Answer 10

• chronic reactive airway disorder causing episodic airway obstruction (acute exacerbations) resulting from bronchospasms and ↑’d mucus secretion
• most common chronic disease in adults and children
• RF: overcrowded living conditions with repeated exposure to cigarette smoking, dust, cockroaches, and mold may be contributing factors
• etiology: genetics, environment: extrinsic, intrinsic, occupational asthma
• patho: bronchial linings overreact to various triggers, causing episodic smooth muscle spasms that severely restrict the airways (includes mucous plugging as it progresses)
• CM: beginning there is a sensation of chest constriction, wheezing, nonproductive coughing, dyspnea, prolonged expiration, tachycardia, SOB, and tachypnea; other symptoms may include fatigue, a tickle in the back of the throat accompanied by a cough in an attempt to clear the airways, and nostril flaring; as attack progresses, the cough becomes more productive of a thick, tenacious, mucoid sputum
• acute attack that cannot be altered with routine care is called status asthmaticus
• tx: identifying specific allergens for each individual and avoidance of asthma triggers, combined with the use of two classes of medications; bronchodilators, anti-inflammatories

Question 11

SIFTT: Exercised Induced Asthma

Answer 11

• acute, reversible, usually self-terminating, develops 5-15 minutes after strenuous exercise when the person no longer breathes through the nose, warming and humidifying the air, but opens the mouth
• coughing is the most common symptom, but other symptoms include: chest tightness, wheezing, and SOB
• if client has an inhaler available, provide whatever assistance is necessary for that person to self-administer the medication
• problem is rare in activities that require only short bouts of energy (baseball, sprints, gymnastics, skiing) compared with those that involve endurance exercise (soccer, basketball, distance running or biking)

Question 12

Exercise and Medication for Asthma

Answer 12

-take bronchodilators by MDI 20-30 minutes before exercise
-long-term use of inhaled corticosteroids in the management of moderate to severe asthma is associated with ↓’d bone mineral density and associated ↑’d risk of fractures, particularly in high-risk
postmenopausal women

Question 13

Status Asthmaticus

Answer 13

-immediate medical care is recommended for anyone with asthma who is struggling to breathe with no improvement in 15-20 minutes after initial treatment with medications or who is hunched over and unable
to straighten up or resume activity after medication dosage
-presence of blue or gray lips or nail beds is another indication of the need for medical attention

Question 14

Chronic Obstructive Pulmonary Disease

Answer 14

• COPD refers to chronic airflow limitation that is not fully reversible
• most important of these disorders are obstructive bronchitis, emphysema, and chronic asthma
• second leading cause of disability in adults under 65 y/o
• 4th leading cause of death in the US (3rd by 2020)
• COPD is almost always caused by exposure to environmental irritants, this condition rarely occurs in nonsmokers
• patho: In people with COPD, the alveoli don’t work properly d/t damage (aka emphysema) or the bronchi become inflamed (chronic bronchitis)
• CM: SOB, cough, wheezing, sputum; takes longer to breathe out than in
• dx: use of spirometry to measure how much air the lungs can hold and how well the respiration is able to move air into and out of the lungs
• tx: Successful management requires a multifaceted approach that includes smoking cessation, drugs, airway clearance, exercise, etc, goals are to improve oxygenation and decrease carbon dioxide retention
• no cure

Question 15

SIFTT for COPD

Answer 15

• adopt a sedentary lifestyle leading to progressive deconditioning
• pulmonary rehab: programs that include exercise can reduce hospitalizations, ↑ exercise tolerance, ↓ dyspnea, improve skills in using inspiratory muscle training devices, ↑ independence in ADLs, and ↑ sense of well-being and quality of life; UE training, ↓’s metabolic and ventilatory requirements for arm elevation-this type of program may allow clients with COPD to perform sustained UE activities with less dyspnea
• to prevent early airway collapse during exhalation, teach exhalation through pursed lips
• if secretions are thick, urge client to drink fluids throughout the day
• monitor vital signs

Question 16

Chronic Bronchitis

Answer 16

• form of COPD with inflammation of the bronchi
• defined as a condition of productive cough lasting for 3 months per year for at least 2 consecutive years
• distinguishing characteristic is obstruction of airflow caused by mucus
• characterized by inflammation and scarring of the bronchial lining
• irritants such as cigarette smoke, long-term dust inhalation, or air pollution cause mucous hypersecretion and hypertrophy of mucus-producing cells in the large bronchi: the swollen mucous membrane and thick sputum obstruct the airways-Infection ensues with airway collapse
• CM: persistent cough and sputum production results in SOB, prolonged expiration, use of accessory muscles for breathing, and recurrent infection
• ↓’d exercise tolerance, ↓’d alveolar ventilation, and ↑’d partial pressure of arterial CO2-leads to polycythemia and cyanosis, pulmonary HTN, and cor pulmonale
• dx: chest x-rays, pulmonary function tests, ABG, sputum culture
• tx: avoid air pollutants, stop smoking, drugs, pursed-lip breathing

Question 17

Emphysema

Answer 17

• form of COPD defined as the abnormal, permanent enlargement of the acini (where the alveoli are located) along with destruction of alveolar walls
• pathologic accumulation of air in tissues, particularly in the lungs
• distinguishing characteristic is limited airflow caused by lack of elastic recoil
• cigarette smoking is the major etiologic factor and has been shown to ↑ the numbers of alveolar macrophages and neutrophils in the lungs
• destruction of elastin protein in the lung that normally maintains the strength of the alveolar walls leads to permanent enlargement of the acini
• obstruction results from changes in lung tissues, rather than from mucous production
• enlargement of the spaces destroys the alveolar walls, which results in a breakdown of elasticity and the loss of fibrous and muscle tissue, making the lungs less compliant
• CM: at first symptoms may be apparent only during physical exertion, but eventually marked exertional dyspnea progresses to dyspnea at rest, ↑’d effort to exhale trapped air, cough is uncommon, client is often thin, has tachypnea with prolonged expiration, and must use accessory muscles for ventilation, barrel chest, anxiety with fear of dyspnea
• dx: chest x-rays, pulmonary function tests, ABG, pulse oximetry
• tx: quitting smoking is the most effective way of preventing lung function decline-caused by emphysema, Pursed-lip breathing (causes resistance to outflow and maintains intrabronchial pressure)

Question 18

Cor Pulmonale

Answer 18

• right sided heart failure-enlargement of RV due to high blood pressure in lungs usually caused by chronic lung disease
• causes ~25% of all heart failure, about 85% of patients with cor pulmonale have COPD, most common in smokers and in middle-age and elderly men
• pulmonary diseases, chest wall abnormalities, neuromuscular disorders
• chronic productive cough, exertional dyspnea, wheezing, fatigue and weakness
• other symptoms as compensation fails: dyspnea at rest, tachypnea, orthopnea, dependent edema, distended neck veins, hepatomegaly, tachycardia, ↓’d CO, weight gain
• dx: Pulmonary artery catheterization, echocardiography, chest x-rays, pulse oximetry, ECG, pulmonary function tests
• tx: bed rest, drug therapy, chest PT, mechanical ventilation, diet

Question 19

Pneumonia

Answer 19

• acute infection of the lung parenchyma impairing gas exchange
• can be caused by…
• bacterial, viral, or protozoa
• inhalation of toxic or caustic chemicals, smoke, dusts or gases
• aspiration of food, fluids or vomitus into the bronchi
• 30% of pneumonias are bacterial
• leading cause of death from infectious disease
• viral pneumonia, accounts for nearly ½ of all cases
• aspiration: although any region may be affected, the right side, especially the right upper lobe in the supine person, is commonly affected
• fungal: primarily affect immunocompromised individuals
• viral: destroys ciliated epithelial cells and invades goblet cells and bronchial mucous glands
• bacterial: lung parenchyma, especially the alveoli in the lower lobes, is the most common site of bacterial pneumonia
• in bacterial pneumonia an infection triggers alveolar inflammation and edema…produces area of decreased ventilation with normal perfusion…capillaries become engorged with blood, causing stasis…as the membrane breaks down, alveoli fill with blood and exudates, resulting in atelectasis…
• in viral pneumonia the virus attacks bronchial epithelial cells, mucus glands, and goblet cells causing inflammation
• CM: sudden and sharp pleuritic chest pain, hacking, productive cough with rust-colored or green, purulent sputum; other S&S: dyspnea, tachypnea, malaise, fever, chills and ↓’d breath sounds; if the infection develops slowly with a fever so low as to be unnoticeable the person may have what is referred to as “walking pneumonia”
• dx: sputum culture, chest x-rays, pulse oximetry, WBC count, ABG
• tx: antibiotics, airway clearance techniques, antifungal drugs, viral treated symptomatically, bed rest

Question 20

SIFTT for Pneumonia

Answer 20

-standard precautions for clients with pneumonia
-adequate hydration and pulmonary hygiene, including deep breathing, coughing, and chest therapy
-preventive measures are important and include early ambulation in postoperative clients and postpartal women unless contraindicated
-caretakers should be instructed in breathing exercises and a positional rotation program with frequent positional changes to prevent secretions from
accumulating in dependent positions and to optimize ventilation/perfusion

Question 21

Pneumothorax

Answer 21

• accumulation of air or gas in the pleural cavity caused by a defect in the visceral pleura or chest wall that leads to partial or complete lung collapse
• classified as either traumatic or spontaneous
• common, especially with trauma or after medical procedure
• patho: when amount of air between the visceral and parietal pleurae ↑’s, ↑’ing tension in the pleural cavity can cause the lung to progressively collapse
• in some cases, venous return to the heart in impeded, resulting in tension pneumothorax
• both air and blood into the pleural space, hemopneumothorax
• traumatic pneumothorax: may be classified as open (sucking chest wound–results in positive pressure in the pleural cavity, thereby collapsing lung) or closed (blunt or penetrating trauma–↑’d pressure in pleural space, thereby preventing lung expansion)
• spontaneous pneumothorax: closed and may be classified as primary (idiopathic) or secondary (related to a specific disease)
• tension pneumothorax: progressive build-up of pressure in the pleural space pushes the mediastinum to the opposite hemithorax, and obstructs venous return-leads to circulatory instability - may result in cardiac arrest-air accumulates intrapleurally and can’t escape…intrapleural pressure rises, collapsing the ipsilateral lung
• mediastinum is central compartment of thoracic cavity containing the heart, the esophagus the trachea, the phrenic and cardiac nerves, the thoracic duct, the thymus, and the lymph nodes of the central chest
• closed: Sudden, sharp, pleuritic pain exacerbated by chest movement, breathing, and coughing; asymmetric chest wall movement; SOB; cyanosis; respiratory distress
• open: S&S of closed; absent breath sounds on affected side; chest rigidity on affected side; tachycardia; crackling beneath skin on palpation
• tension: ↓’d CO, hypotension; compensatory tachycardia; tachypnea; lung collapse; mediastinal shift; cardiac arrest
• dx: chest x-rays, pulse oximetry, ABG
• tx: oxygen administration, aspiration of air, bed rest, thoracostomy tube insertion (to try to re-expand lung)

Question 22

Pulmonary Edema

Answer 22

-excessive fluid in the lungs that may accumulate in the interstitial tissue, in the air spaces (alveoli), or in both
-common complication of many disease processes
-most cases of pulmonary edema are due to left ventricular failure, acute hypertension, or mitral valve disease
-patho: pulmonary vasculature fills with fluid that leaks into the alveolar spaces
-normally, there is a balance among lymphatic drainage, capillary hydrostatic pressure, capillary oncotic pressure, and capillary permeability
-result of: fluid overload, ↓’d serum and albumin, lymphatic obstruction, disruption of capillary permeability
-left-sided heart failure leads to right-sided failure (and vice versa), so both pulmonary and peripheral edema may exist simultaneously
-decreases function of left ventricle causes blood to pool there and in the left atrium…eventually blood backs up into pulmonary veins and capillaries; increasing capillary hydrostatic pressure pushes fluid into the interstitial spaces and alveoli, impairing gas exchange
-early stages: DOE, orthopnea, cough, mild tachypnea, increased BP, crackles, JVD
-late stages: labored breathing, bloody sputum, tachycardia, diaphoresis, cyanosis,
falling BP, cold clammy skin, more diffuse crackles, arrhythmias
-dx: ABG analysis shows hypoxia, chest x-rays, pulse oximetry, ECG
-tx: O2 administration, assisted ventilation, drugs, diuretics
-SIFTT: symptoms of pulmonary edema that may come to the therapist’s attention include engorged neck and hand veins, pitting edema of the extremities, and paroxysmal nocturnal dyspnea or orthopnea

Question 23

Pulmonary Embolism and Infarct

Answer 23

-obstruction of the pulmonary blood supply by a dislodged thrombus, heart valve growths, or a foreign substance
-most common cause of sudden death in the hospitalized population
-most common cause of PE is DVT originating in the proximal deep venous system of the lower legs
-patho: trauma, clot dissolution, sudden muscle spasm, intravascular changes can cause the thrombus to loosen and forms an embolus, By occluding the pulmonary artery, the embolus prevents alveoli from
producing enough surfactant to maintain alveolar integrity –> alveoli collapse and atelectasis develops
-CM: first symptom is usually dyspnea, accompanied by angina or pleuritic pain; feeling of impending doom, tachycardia, low grade fever, cyanosis, pleural
effusion, leg edema, jugular vein distention
-dx: ABG, Chest x-rays, pulmonary angiography, pulse oximetry, ECG
-prevention and tx: Anticoagulants, low-molecular weight (LMW) heparin is the most common agent for prophylaxis because it prolongs the clotting time
and allows the body time to resolve the existing clot
-surgical implantation of a filter in the vena cava may be used to prevent PE by filtering the blood and preventing clots from moving
-SIFTT: frequent changing of position, exercise, and early ambulation are necessary to prevent thrombosis and embolism; the legs should not be massaged to relieve muscle cramps, especially when the pain is located in the calf and the person has not been up and about

Question 24

Severe Acute Respiratory Syndrome (SARS)

Answer 24

• viral respiratory tract infection that can progress to pneumonia and eventually death
• caused by coronavirus and spread via respiratory droplets
• patho: virus incubates for 2-10 days; spread by close person-to-person contact: infected droplets deposited on mucous membranes of mouth, nose, eyes
• virion attaches to receptors and releases enzymes that weakens the membrane and enable the virion to penetrate the cell, virion removes the protein coating that protects its genetic material, replicates, and matures and then escapes from the cell by budding from plasma membrane…the infection then spreads to other cells
• CM: begins with high fever, chills, achiness, develop respiratory symptoms 4-7 days after onset of fever (dry cough, SOB, pneumonia, etc.)
• dx: patient hx, chest x-rays, cell culture test, serum test for Abs
• tx: oxygen support, antiviral drugs

Question 25

Tuberculosis

Answer 25

• TB (formerly known as consumption), is an infectious, inflammatory, systemic disease that affects the lungs and may involve lymph nodes and other organs
• afflicts 3.8/100,000 people in US, 43.5% ↑ over past 10 years
• highest in people who live in crowded, poorly ventilated, unsanitary conditions
• causative agent is tubercle bacillus
• transmitted by inhalation of infected airborne particles, which are produced when the infected persons sneeze, laugh, speak, sing or cough
• patho: pulmonary infiltrates accumulate, cavities develop, and masses of granulated tissue form within the lungs leading to respiratory failure
• CM: most symptoms are associated with TB do not appear in the early, most curable stage of the disease, but a skin test administered would be positive
• often symptoms delayed until 1 year or more after exposure to the bacilli
• fatigue, cough, fever, night sweats, anorexia, weight loss, chest pain, crackles, wheezes, sputum production, hemoptysis
• dx: chest x-rays, skin test, stains and sputum cultures, CT or MRI, bronchoscopy; in the case of someone with known TB, the skin test will always be positive, requiring periodic screening with chest x-ray studies
• prognosis: greatest number of deaths from any one single infectious agent; untreated, TB is 50% to 80% fatal, and the median time period to death is 2½ years
• tx: daily doses of isoniazid or rifampin for 9 months

Question 26

SIFTT for Tuberculosis

Answer 26

• isolation measures must be taken both in the acute care setting and in outpatient areas
• clients should be cared for in negative-pressure isolation rooms
• treatment will yield a “cure” if the appropriate pharmacologic intervention is followed for the full course prescribed, usually a minimum of 6 months: a cure simply means the active TB will not likely recur, but the person can be re-exposed and re-infected
• TB bacterium must be inhaled and cannot be transmitted by physical contact with extrapulmonary sites unless the organism is expelled, aerosolized, and then inhaled

Question 27

Upper Respiratory Tract Infection

Answer 27

• An acute, usually afebrile viral infection that causes inflammation of the upper respiratory tract (aka, the common cold)
• patho: upper respiratory tract infection, which triggers infiltration of mucus membranes by inflammatory cells
• CM: pharyngitis, nasal congestion, rhinitis, sneezing, HA, watery eyes, lethargy

Question 28

Parenchymal Disorders: Atelectasis

Answer 28

• collapse of normally expanded and aerated lung tissue at any structural level
• if a bronchus is obstructed, atelectasis occurs as air in the alveoli is slowly absorbed into the bloodstream which subsequent collapse of the alveoli
• failure to breathe deeply postoperatively can lead to atelectasis
• SIFTT: one of the underlying goals of acute care therapy is to prevent atelectasis in the high-risk client; frequent, gentle position changes, deep breathing, coughing, and early ambulation; to minimize postoperative pain during deep-breathing and coughing exercises, teach the client to hold a pillow tightly over the incision

Question 29

Disorders of Pleural Space: Pleurisy

Answer 29

• pleuritis, inflammation of the pleura caused by infection, injury or tumor
• CM: sharp, sticking chest pain that is worse on inspiration, coughing, sneezing, or movement associated with deep inspiration, on auscultation, a pleural rub can be heard

Question 30

Disorders of Pleural Space: Plural Effusion

Answer 30

• collection of flid in pleural space
• SIFTT: after transthoracic aspiration, encouraged deep-breathing exercises to promote lung expansion and watch for respiratory distress or pneumothorax