1. Alterations in Respiratory Functioning
Spring 2011

2. Anatomy & Physiology Review
Structures of Upper Respiratory Tract
Pharynx
Larynx
Nose
Sinuses
Structures of Lower Respiratory Tract
Airways
Trachea
Mainstem bronchi
Lobar, segmental, and subsegmental bronchi
Bronchioles
Alveoli

3. Anatomy & Physiology Review
Lungs
Right
Upper lobe
Middle lobe
Lower lobe
Left
Pleura
Parietal pleura
Visceral pleura
Pulmonary circulation

4. Anatomy & Physiology Review
Accessory Muscles of Respiration
Scalene muscles
Lift first 2 ribs
Sternocleidomastoid
Raise sternum
Trapezius & Pectoralis muscles
Fix shoulders
Sometimes abdominal and back muscles

5. Aging & Respiratory Changes
Alveolar surface area decreases
Efficiency of oxygen and carbon dioxide exchange decreases
Elasticity decreases
Chest wall elasticity decreases
Respiratory muscle strength decreases
Diaphragm and intercostals
Ability to cough decreases
Residual volume increases
Vital capacity decreases
Pulmonary blood flow decreases
Effectiveness of cilia decreases

6. Assessment……Patient History
Smoking (pack-years)
Childhood illnesses
Adult illnesses
Vaccinations
Medications / herbals
Allergies
Surgeries upper/lower respiratory system
Hospitalizations
Diagnostics
Chest x-ray, pulmonary function tests, TB test
Recent unplanned weight loss / nutritional status
Night sweats
Sleep disturbances
Recent travel
Occupation
Leisure activities
Family history

7. Assessment……Current Health Problem
Acute versus chronic
Cough
Sputum production
Chest pain
Dyspnea
Shortness of Breath (rest/exertion)
PND
Orthopnea
Onset of problem (when)?
Frequency of problem?
How long it lasts?
Worse over time?
Symptoms?
Interventions / treatments?
What makes it better/worse?

8. Physical Assessment Nose & Sinuses Pharynx, trachea & Larynx
Lungs & Thorax
Inspection
Palpation
Percussion
Auscultation
Normal Breath sounds (normal, increased, diminished, absent)
Bronchial / tubular
Bronchovesicular
Vesicular
Adventitious breath sounds
Crackle
Wheeze
Rhonchus
Pleural friction rub

9. Psychosocial Assessment
Anxiety
Stress
Coping mechanisms / support systems
Family role / structure
Financial concerns
Unemployment
Disability / affect on ADL’s
Strengths

10. Physical Assessment Clubbing Weight loss Unevenly developed muscles
Skin & mucous membrane changes
General appearance
Endurance

11. Diagnostics……Laboratory Tests
RBC
Hemoglobin & Hematocrit
White Blood Cells
Arterial blood gas analysis
Sputum specimens

12. Diagnostics…..Imaging Chest x-rays Computed tomography (CT)
Ventilation & perfusion scanning (V/Q scan)

13. Diagnostics…… noninvasive
Pulse Oximetry
Capnometry & Capnography
Pulmonary Function Tests
Evaluate lung volumes, flow rates, gas exchange, airway resistance
Exercise Testing

14. Diagnostics…….Invasive
Skin tests
Endoscopic Examinations
Bronchoscopy
Laryngoscopy
Mediastinoscopy
Thoracentesis
Aspirate pleural fluid or air from pleural space
Lung Biopsy
Obtain tissue for histologic analysis, culture, or cytologic exam

15. Health Promotion Lifestyle Behaviors Smoking
Environmental/ocupational exposures
Immunizations

16. Pharmacologic Management Oxygen Therapy
Goal of oxygen therapy… to use the lowest fraction of inspired oxygen for an acceptable blood oxygen level without causing harmful side effects
Hazards & Complications
Combusion
Oxygen induced hypoventilation
Oxygen toxicity
Absorption atelectasis
Drying of mucous membranes
Infection

17. Oxygen Therapy Low-flow Systems High-Flow Systems Nasal cannula
Simple facemask
Partial rebreather mask
Non-rebreather mask
High-Flow Systems
Venturi mask
T-piece
Face tent
Aerosol mask
Tacheostomy collar

18. Noninvasive Positive Pressure Ventilation
Technique uses positive pressure to keep alveoli open and improve gas exchange without intubation
BiPAP (bi-level positive airway pressure)
CPAP (continuous positive airway pressure)
Transtracheal oxygen therapy

19. Home Oxygen Therapy Patient education Methods Safety
Compressed gas in tank or cylinder
Liquid oxygen in a reservoir
Concentrator

20. Bronchodilators
Used for short-term prophylaxis, relief of acute attacks, and long term control (except salmeterol has delayed onset)
Beta2 –adrenergic agonists
Inhaled, short-acting
Albuterol (Proventil, Ventolin)
Inhaled, long-acting
Formoteraol (foradil aerolizer, salmeterol (Serevent)
Oral, long-acting
Albuterol (Proventil, Volmax) terbutaline(Brethine)
Anticholinergics
Ipratropium, inhaled (Atrovent)
Methylxanthines
Theophylline (Theolair SR)
PO or IV
Aminophylline
Theophylline

21. Beta 2 Adrenergic Agonists
ACTION: Activate receptors in bronchial smooth
muscle resulting in bronchodilation
USE: Prevention & treatment of bronchospasm related to asthma, bronchitis, emphysema
ADVERSE nervousness, restlessness, tremor, palpitations,
EFFECTS: arrhythmias, hypertension, hyperglycemia
Nursing Actions: Assess blood pressure, pulse, respiration, lung sounds
Contraindications: cautiously in clients with diabetes, hyperthyroidism, heart disease, hypertension, angina, & on beta-adrenergic blockers.
Pregnancy Category C (animal studies have shown adverse effect)

22. Inhaled Anticholinergics
ACTION: Inhibits cholinergic receptors in bronchial smooth muscle resulting in decreased cnoncentrations of cyclic guanosine monophosphate (cGMP) producing local bronchodilation
USE: Maintenance therapy of reversible airway obstruction due to COPD. Unlabeled use: adjunctive management of bronchospasm caused by asthma.
ADVERSE nervousness, headache, blurred vision, palpitations,
EFFECTS: nausea, dry mouth, hoarseness.
Nursing Actions: assess respiratory status. Not for use in acute attacks of bronchospasm (too slow onset). Rinse mouth after to decrease unpleasant taste.
Contraindications: peanut or soy allergy. Avoid during acute bronchospasm. Cautiously with prostatic hypertrophy, glaucoma, urinary retention
Pregnancy Category B.

23. Methylxanthines
ACTION: Mild bronchodilator resulting in relaxation of bronchial smooth muscle.
USE: Used as maintenance therapy in long term control of chronic asthma/acute exacerbation of asthma or bronchitis (Aminophylline)
ADVERSE anxiety, tachycardia, N&V, tremor
EFFECTS: seizures, arrhythmias
Nursing Actions: Monitor serum levels and adverse effects Use infusion pump to administer. Caffeine increases CNS and cardiac adverse effects. Many potential interactions. Assess BP, pulse, respiratory status.
Contraindications: Heart disease, hypertension, liver/renal dysfunction, diabetes Children & older adults.
Pregnancy Category C

24. Anti-Inflammatory Agents
Used for long-term prophylaxis, not for aborting ongoing asthmatic attacks
Glucocorticoids
Inhaled
beclomethasone dipropionate (AVAR), budesonide (Pulmicort Turbuhaler), fluticasone propionate (Flovent), triamcinolone acetonide (Azmacort)
Oral
Prednisone (Deltasone), prednisolone
Mast cell stabilizers
Cromolyn (inhaled- Intal) and nedocromil (Tilade)
Leukotriene modifiers
Oral: montelukast (Singulair), zafirlukast (Accolate), zileuton (Zyflo)

25. Glucocorticoids
ACTION: Prevent inflammation, suppress airway mucous production, promote responsiveness of beta2 receptors in bronchial tree.
USE: Inhaled: long term prophylaxis. Oral: short term symptoms of asthma after acute attacks or long term chronic asthma bronchitis maintenance.
ADVERSE headache, hoarseness, oropharyngeal
EFFECTS: fungal infections, flu-like syndrome, adrenal suppression
Nursing Actions: Do not abruptly discontinue; Assess blood sugar levels, respiratory status. If used with beta2 agonist use that first then use glucocorticoid(beta2 agonist promotes bronchodilation & enhances absorption of glucocorticoid.
Contraindications: acute attack of asthma, infections, diabetes, glaucoma, immunosuppression, clients who have rece4ived live virus vaccine, on NSAID’s.
Pregnancy Category B (budesonide) C-all others

26. Mast Cell Stabilizers
ACTION: Prevent release of histamine and substance of anaphylaxis.
USE: Prophylaxis of allergic disorders (rhinitis & asthma) Prevention of exercise induced bronchospasm.
ADVERSE nasal irritation, irritation of throat & trachea, EFFECTS: hoarseness, unpleasant taste, anaphylaxis
Nursing Actions: Advise to take 15 minutes before exercise or exposure to allergen. Prophylaxis may take several weeks for full therapeutic effects. Not for acute attacks. Rinse mouth after use to minimize irritation/hoarseness
Contraindications: Cautiously in children, CAD, dysrhytmias, liver/kidney impairment.
Pregnancy Category B

27. Leukotriene Modifiers
ACTION: Antagonizes effects of leukotrienes resulting in suppression of inflammation, bronchoconstriction, airway edema, & mucus production.
USE: Prevention & chronic treatment of asthma; manage seasonal allergic rhinitis
ADVERSE headache, fatigue, cough, nausea, increased EFFECTS: liver enzymes
Nursing Action: Assess respiratory function, allergy symptoms, monitor liver enzymess:
Contraindications: Acute attacks of asthma, liver impairment; Use carefully with warfarin & Theophylline; do not give with food
Pregnancy Category B

28. Antitussives…opioids vs. nonopioid
codeine and hydrocodone suppress cough reflex center in CNS (medulla)
Contraindicated with alcohol use, CNS depression, impaired renal/liver function, BPH, Addison’s disease, COPD
Adverse Effects include sedation, nausea, constipation, potential for abuse
Nonopioid
less effective than opioids
Dextromethorphan works in same way as opioids
Contraindications: hyperthyroidism, cardiac/vessel disease, hypertension, glaucoma, MAOIs in past 14 days
Adverse Effects include dizziness, drowsiness, & nausea
Benzonatate (Tessalon Perles) suppresses cough reflex by anesthetizing stretch receptor cells in respiratory tract preventing reflex stimulation of medullary cough center
Contraindications: None
Adverse Effects include headache, sedation, nausea, constipation, pruritus

29. Decongestants
Indications: nasal congestion associated with acute/chronic rhinitis, common cold, sinusitis, hay fever
Contraindications: narrow angle glaucoma, hypertension, diabetes, prostatitis, hyperthyroidism, CAD Adverse Effects: nervousness, insomnia, palpitations, tremor, rebound congestion. Nasal steroids may cause localized mucosal irritation/dryness.
Adrenergics (sympathomimetics)
Constrict small arterioles in upper respiratory tract (esp. sinuses) to relieve nasal stuffiness
Ephedrine, oxymetazoline (Afrin), xylometazoline (Nasolin, Sudafed), naphazoline (Privine)
Anticholinergics (parasympatholytics)
Corticosteroids (intranasal steroids)
Beclomethasone dipropionate (Beconase), budesonide (Rhinocort), fluticasone (Flonase), triamcinolone (Nasacort)

30. Antihistamines
Indications: nasal allergies, seasonal hay fever, symptoms of common cold such as sneezing/runny nose.
Action: Bind to histamine receptors; prevent action of histamine.
Contraindications: narrow angle glaucoma, cardiac / kidney disease, hypertension, asthma, COPD, PUD, seizure disorders, BPH
Adverse Effects: drowsiness, dry mouth, changes in vision, difficulty urinating, constipation.
Non-sedating antihistamines
Loratadine (Claritin) , fexofenadine (Allegra)
Traditional antihistamines
Diphenhydramine (Benadryl), chlorpheniramine (Chlor-trimeton), brompheniramine (Dimetapp)
Hydroxyzine (Vistaril), promethazine (Phenergan), dimenhydrinate (Dramamine)

31. Expectorants / Mucolytics
Enhance flow of secretions in respiratory passages
Used for pulmonary disorders with large amounts of secretions
Antidote for acetaminophen poisoning
Acetylcysteine (Mucomyst)
Smells like rotten eggs
Dilute with fruit juice
Expectorants
Break down and thin secretions
Guaifenesin (Mucinex)

32. Influenza Medications
Antiviral Agents
Most effective if started with hours of first symptoms
Treatment of influenza A
Amantadine (Dymmetrel), rimantadine (Flumadine),
Treatment of influenza B
Ribavirin (Virazole)
Treatment of both A & B
Zanamivir (Relenza), oseltamivir (Tamiflu)
Adverse Effects: bronchospasm; vary significantly by drug
Contraindications: COPD, asthma
Pregnancy Category C

33. Thoracic Surgery Segmental resection (segmentectomy) Wedge resection
Lung resection that includes bronchus, pulmonary artery & vein, tissue of involved lung
Wedge resection
Remove peripheral portion of small localized areas of tissue
Lobectomy
Removal of entire lung lobe
Pneumonectomy
Removal of entire lung (cancer, absceses, TB)
No chest tube required

34. Preoperative Care Relieve anxiety Promote patient participation
Encourage expression of fears / concerns
Reinforce surgeon’s explanation
Educate what to expect after surgery

35. Post Operative Care Maintain patent airway Ensure adequate ventilation
Prevent complications
Assess for adequacy of ventilation & gas exchange
Maintain closed chest drainage system / chest tube(s)
Manage pain (pain causes guarding & hypoventilation)
Encourage IS q hour W/A, cough, & DB with splinting
Incision care

36. Laryngectomy / Radical Neck Disection
Partial
Hemilaryngectomy or supraglottic laryngectomy
Partial voice conservation laryngectomies
Tracheostomy usually temporary
Total
Tracheostomy permanent
Total voice loss
Cord stripping, cordectomy,
Nodal Neck resection
Removal of lymph nodes, sternocleidomastoid muscle, jugular vein, 11th cranial nerve (shoulder drop), & surrounding soft tissue
Post Operative Priorities
Airway maintenance and ventilation
Provide alternate form of communication

37. Nasal & Sinus Surgery Rhinoplasty (cosmetic, fractures)
Nasoseptoplasty (nasal septum deviation)
Post Operative Care
Observe for edema or bleeding
Assess vital signs
Assess frequency of swallowing
Semi-Fowlers position and move slowly
Cool compresses on nose, eyes, or face
Limit valsalva maneuvers
No blowing nose

38. Tonsillectomy & Adenoidectomy
For recurrent acute infections, chronic infections, peritonsillar abscess, or enlarged tonsils or adenoids that obstruct airway
Postoperatively
Assess for airway clearance
Provide pain relief
Monitor for bleeding

39. Respiratory Interventions
Chest Physiotherapy
Nebulizer/Updrafts
Humidification
Incentive Spirometry
Cough & deep breathe

40. Principles of Mechanical Ventilation
To support & maintain gas exchange and
decrease the work of breathing
Be concerned with patient first and ventilator second
Nursing priorities
Monitoring and evaluating patient responses
Managing ventilator system safely
Preventing complication

41. Tracheostomy / Trach Care
Tracheotomy
Surgical incision into trachea
Tracheostomy
Stoma or opening resulting from tracheotomy
Temporary or permanent
Tube is secured in place with sutures and ties/velcro
Postop care
Assess respiratory system for
Patent airway
Bilateral breath sounds
Complications

42. Complications of Tracheostomy
Tube obstruction
Tube dislodgment
Pneumothorax
Subcutaneous emphysema
Bleeding
Infection
Tracheomalacia
Tracheal stenosis
Tracheoesophageal fistula

43. Types of Tracheostomy Tubes
Plastic or metal
Multiple sizes
Inner cannula may be disposable or reusable
Cuffed tube vs. noncuffed tube
Fenestrated tube

44. Caring for Patients with Trach
Prevent tissue damage
Cuff pressing against tracheal mucosa
Check cuff pressure per policy for appropriate inflation
Stabilize the tube to minimize movement
Suction only when needed
Prevent and treat malnutrition, dehydration
Warm and humidify air
keep secretions thinned and moist

45. Tracheostomy Care Keeps tube free of secretions
Maintains patent airway
Provides wound care
First assess patient (chart 30-5)
See Best Practice for Tracheostomy Care (chart 30-4)

46. Suctioning Maintains patent airway / promotes gas exchange
Assess need for suctioning
Audible or noisy secretions, crackles, or wheezes
Patient request for suctioning
Hyperoxygenate patient for 30 seconds to 3 minutes to prevent hypoxemia
Lubricate with sterile water or saline and insert a 12–14 fr catheter for adults (without suction)
Withdraw catheter 1-2cm and begin to apply suction intermittently with a twirling motion
Never suction longer than seconds
Hyperoxygenate for 1-5 minutes until HR and O2 sat WNL

47. Chest Tubes
A drain place in pleural space to restore intrapleural pressure and allows re-expansion of the lung
Prevents air and fluid from returning to the chest
Nursing Priorities
Ensure integrity of the system
Promote comfort
Ensure chest tube patency
Prevent complications

48. Chest Tubes Chamber One Chamber Two Chamber Three
Collects fluid draining from the patient
Fluid must never fill to level of tube from patient or tube connecting to chamber two
Chamber Two
Is the water seal that prevents air from entering the patient’s pleural space; a one way valve
Bubbling indicates air drainage from patient when patient exhales, coughs or sneezes
Excessive bubbling may indicate air leak (notify MD if bubbling occurs continuously in water seal chamber)
Rise of 2-4 inches during inhalation and fall during exhalation are normal; absence of tidaling may indicate tube obstruction, no more air is leaking into pleural space
Chamber Three
Suction control

49. Chest Tubes Best Practices
Ensure sterility and patency of system
Tape tubing junctions to prevent accidental disconnects
Keep occlusive dressing at chest tube insertion site
Keep sterile gauze at bedside to cover insertion site immediately if tube becomes dislodged
Keep padded clamps at bedside
Position tubing to prevent kinks and loops which can block drainage
Keep manipulation of tube to minimum (gentle milking)
Assess respiratory status and document amount and type of drainage hourly first 24 hours then at least every 8 hours or per policy (notify MD if exceeds 100mL/hr/

50. Epistaxis Patho: Anterior vs. Posterior
Dryness – crust removal with nose blowing / picking / rubbing
Trauma – direct blows, nasogastric suctioning
Systemic – (less common); HTN, bleeding disorders, cocaine use, tumor
Anterior vs. Posterior
Anterior more common
Posterior bleeds more difficult to control and need emergency intervention

51. Epistaxis Assessment History Inspection and documentation
Number, causes and duration or prior nosebleeds
Inspection and documentation
Amount & color of blood
V.S.
Interventions- Anterior nose bleeds
Upright position / leaning forward
Keep calm & quiet
Compress nose with index finger & thumb for 5-10 min
ice / cool compresses to nose & face
Pack loosely with gauze or nasal tampons
Not blowing nose!
Interventions- Posterior nose bleeds (usually at hospital)
Cautery (silver nitrite, electrocautery)
Packing
Balloon or tampon
Assess for respiratory distress and tolerance of packing
Bedrest , pain management
Humidity / oxygen
Packing usually removed 1-5 days later

52. Epistaxis Patient / Family Teaching Petroleum jelly to nares
Nasal saline sprays and humidifiers
Avoid vigorous nose blowing / picking
Avoid ASA, NSAIDs, strenuous exercise / lifting

53. Facial Trauma Dx: CT head, face & cervical spine
Patho: Described by specific bones involved (mandibular, maxillary, orbital, nasal)
Assess: #1 Airway
For obstruction (stridor, SOB, dyspnea, hypoxia, hypercarbia, cyanosis, loss of consciousness)
#2 Site of trauma
Edema, facial asymmetry, pain, leakage of spinal fluid from ears/nose, vision & eye movement, extensive bruising behind ears “battle sign”
Dx: CT head, face & cervical spine

54. Facial Trauma Interventions: Establish & maintain airway
Prepare for possible intubation / trach
Control bleeding
Assess for extent of injury
May require surgical repair / fixation of fracture
Jaw wiring
Teach patient to keep wire cutter available at all times
Titaneum plates
BoneSource
Teach oral care with Water Pik, soft / liquid diet restrictions (collaborate with nutritionist) , f/u with dentist

55. Laryngeal Trauma Patho: crushing / direct blow, fracture,
prolonged ET tube
S&S: dyspnea, aphonia, hoarseness, subcutaneous emphysema, hemoptysis
DX: MD visualize with laryngoscopy
Interventions:
Assess airway (be prepared for intubation)
Monitor VS
Humidified oxygen
Watch for respiratory distress
Tachypnea, nasal flaring, anxiety, sternal retraction, SOB, dyspnea, low O2 sat, stridor
Surgery may be necessary for some

56. Neck Trauma Patho: knife, gunshot, accident, traumatic blow Priority:
Assess and maintain airway
Assess for involvement of multiple systems
Neuro – mental status, sensory & motor function
Cervical spine injury – neck precautions
Esophagus injury – chest pain, oral bleeding
Carotid artery injury – obvious bleeding, Sx of stroke, VS’s.

57. Head & Neck Cancer
Patho: squamous cell of mucosa, salivary glands, thyroid or other structures; curable if treated early
Risk Factors: (info to gather in history)
Smoking in pack years & alcohol use
voice abuse
chronic laryngitis
industrial chemicals
hardwood dust
poor oral hygiene
GERD

58. Head & Neck Cancer Warning signs Pain Lump in mouth, throat or neck
Difficulty swallowing
Oral lesions or persistent sore throat
Oral bleeding
Numbnness of mouth, lips, or face
Change in fit of dentrues
Burning sensation when drinking acidic / hot fluids
Hoarseness or change in voice quality
Shortness of breath
Anorexia & weight loss
Table 31-1

59. Head & Neck Cancer Diagnostics Physical exam
CBC, bleeding times, chemistries
Xrays, CT, MRI, PET scan, Nuclear Imaging
Bone scans
Panendoscopy (laryngoscopy, nasopharyngoscopy, esophagoscopy, bronchoscopy)
Biopsy & tumor staging
Physical exam
Inspect & palpate head/neck for tumor, enlarged lymph nodes

60. Head & Neck Cancer Treatment Surgery Radiation Chemotherapy
Laryngectomy (total or partial)
Tracheotomy
Cordectomy
Post operative care
Assess & maintain airway, VS, comfort, nutrition, speech therapy or alternative forms of communication (artificial larynx)
Post operative complications
Airway obstruction, hemorrhage, wound breakdown, tumor recurrence
Radiation
Skin problems, hoarseness, dysphagia, xerostomia, sore throat
Chemotherapy

61. Asthma
Patho: intermittant & reversible airflow obstruction; affects only airways
Obstruction due to
Inflammation
Allergens, irritants, airborne particles / organisms, ASA, NSAID’s
Airway hyperresponsiveness (twitchy airways)
Exercise, URI, unknown factors
May have both

62. Asthma Assessment: Step System Family history
History of dyspnea, chest tightness, coughing, wheezing, increased mucous
Are symptoms continuous, seasonal, associated with specific activities / exposures
Associated symptoms
Rhinitis, rash, pruiritis
Physical exam
Audible wheeze, increased respiratory rate, coughing, accessory muscles, retractions, labored breathing, cyanosis, hypoxemia, tacchycardia
Step System
Classification of asthma r/t frequency and severity of symptoms and response to drugs (chart 32-2)

63. Asthma Diagnostics Intervention goals Drug Therapy
ABG’s (decreased PaO2)
Increased eosinophils and IgE (if allergic)
PFT’s (decreased FEV1 or PEF)
Intervention goals
Improve airflow
Relieve symptoms
Prevent episodes
Drug Therapy
Preventative therapy drugs
Anti-inflammatories
Leukotriene antagonist
Inhaled corticosteroid
Inhaled cromolyn
Bronchodilators
Rescue drugs – use during acute attack

64. Asthma Patient education Drug therapy
Use bronchodilators 30 mins before exercise
Sequence of using inhalers
Lifestyle management
Stop smoking
Avoid triggers
Self assess respiratory status
Peak flow meter BID (green-80% or above, yellow-50-80%, red-50% of personal best)
When to seek emergency care
Cyanosis
Difficulty breathing walking or talking
Retractions / nasal flaring
Failure of drugs to control symptoms
Peak expiratory rate declining or below 50% below baseline