1. ASSESSMENT OF THE RESPIRATORY SYSTEM
Respiratory A&P and Assessment
PN 132
ASSESSMENT OF THE RESPIRATORY SYSTEM

2. Objectives
Identify and define the parts and functions of the upper and lower respiratory system
Define common terminology associated with respiratory anatomy, physiology and assessment
Identify components of a complete respiratory assessment

3. Terminology Airway Obstruction Anoxia Apnea Asphyxia
Something blocks the airway
Prevents air from entering or leaving lungs
Anoxia
Absence of oxygen
Apnea
Absence of spontaneous respiration
SAS (sleep apnea)
Asphyxia
Impairment of ventilation and exchange of oxygen and carbon dioxide

4. Terminology Bradypnea Cyanosis Dyspnea Hyperventilation Hypoxia
Abnormally slow rate of respiration <10 bpm
Cyanosis
Bluish discoloration of the skin caused by a lack of adequate oxygen
Dyspnea
SOB, difficult breathing or labored breathing
Hyperventilation
Abnormally rapid deep breathing
Results in decreased levels of CO2 at cellular level
Hypoxia
Decrease levels of oxygen in inspired gases, arterial blood, or tissues
Just short of anoxia -

5. Terminology Kussmaul Respirations Respiratory Failure Tachypnea
Deep and labored breathing
Respiratory Failure
Dangerously low level of oxygen (O2) in the blood OR
Dangerously high level of carbon dioxide (CO2) in the blood
Tachypnea
Abnormally rapid rate of respiration
> 20 respirations per minute

6. The Respiratory System
We cannot live without air.
Millions of cells in our bodies need a
continuous supply of oxygen.

7. Respiratory System Anatomy and Physiology
Respiratory Anatomy Video

8. Structures of the Respiratory System
Upper Respiratory Tract
Nose Pharynx
Mouth
Larynx
Trachea
Lower Respiratory Tract
Bronchial tree
Lungs: alveolar ducts and alveoli
Slide: pg th edition ADH
Respiratory tract infections are mostly caused by bacteria and viruses. (inside the lungs you’ll find atmospheric pressure; outside the lungs (intrapleural space) you’ll find -4mmgh pressure which is then a “negative” pressure being just below atmospheric pressure which helps with lung expansion).

9. Upper Respiratory Tract
Lower Respiratory Tract

10. The Pleurae Multilayered membranes that are serous and moist
Surround and protect each lung
Parietal Pleura: outer layer of the pleura
Lines the thoracic cavity and forms the sac containing each lung.
Visceral Pleura: inner layer of pleura
Closely surrounds the lung tissue.

11. The Pleural Space The space between the folds of the pleural membranes
Contains lubricating fluid
Prevents friction during respiration.
Airtight vacuum
Contains negative pressure
Keeps the lungs inflated.
Highlight this information

12. The Diaphragm
Muscle that separates the thoracic cavity from the abdomen
Contracts and Relaxes
Phrenic nerve
Stimulates diaphragm
to contract during
respiration.

13. External Respiration BREATHING
exchange of oxygen and carbon dioxide between the environment and the lungs (ventilation) and…
Between the alveolus and the alveolar capillaries (which are IN the lungs)
External respiration: breathing creates: ventilation AND gas exchange. Breathing is : voluntary and non-voluntary (brainstem control); External respiration is the act of breathing plus the exchange of oxygen and co2 at the alveolar and capillary level. External respiration: gas exchange plus voice production, active and passive processes, voluntary and involuntary, environment and body, mechanical process.

14. Internal Respiration Exchange of oxygen and carbon dioxide
cellular level
AKA internal respiration
Internal Respiration: Involves cellular metabolism. Cellular metabolism uses aerobic (utilizing oxygen) and anerobic (without oxygen which then leads to production of lactate/lactic acid) metabolic processes that take place in the cell. Involuntary, active(requires energy therefore uses oxygen to produce energy), NOT passive, produces energy (ATP) and waste products (CO2 and H2O). This is a chemical process at the cellular level (not external involving environmental contact). Oxygen →cell→food/glucose, a.a (amino acids). and f.a.(fatty acids)→breaks down into Energy (34 ATP) + waste products (CO2 and H2O).
Protein→A.A.s→Ammonia (NH3) a source of nitrogen for all A.A.s [FYI: N2=nitrogen in the atmosphere].

15. CELLULAR RESPIRATION
Exchange of gases within the cells of body organs and tissues.
Oxygen passes from the bloodstream into the tissue cells as carbon dioxide passes from the tissue cells back into the blood stream.
Internal Respiration involves (same as) Cellular Respiration: Exchange of gases between vessels and tissues. Oxygen→travels through the artery→to the cell→In the cell glucose is broken down (C6H12O6) →6CO2 + 6H2O = 36ATP(produced energy) + CO2 and H2O. The CO2 of which then goes to the veins back to the heart→Lungs (to be breathed off).

16. Pulmonary Circulation
Superior Vena Cava
Pulmonary Arteries
Right Lung
Left Lung
Pulmonary Veins
Inferior Vena Cava
Aorta

17. Respiratory System Function
To exchange carbon dioxide (CO2) and oxygen (O2)
To make oxygen (O2) available to the blood stream
So that it can be picked up and used by the cells of organs and tissues in the body
To remove carbon dioxide (CO2) waste from the blood stream
2 seconds =inspiration of 21% oxygen. 3 seconds = expiration (16% oxygen and 3.5% CO2) (interesting note: 37% oxygen total then is involved in the “exchange” per breathe is it not? And the difference of 21%-16% is 5% oxygen being taken in per breath). Range of normal adult respiratory rate is 14-20bpm (txtbook pg 378);

18. Respiratory Assessment
Peripheral chemoreceptors (outside the CNS) = carotid and aortic bodies have chemoreceptors which signal the brainstem (nervous system). Carbonic Acid (dissolved CO2) is chemical stimulant for respiration regulation.l *main stimulator to breathe. Central chemoreceptors (brain and spinal cord) respond to CO2 and pH in CSF. CO2 in blood to get into CSF must cross blood brain barrier (BBB) thus central response time is slower. Peripheral chemorecetors sense levels of oxygen, CO2 and pH within the blood therefore increasing or decreasing breathing depth and rate.
Respiratory Assessment

19. Respiratory Assessment
The respiratory assessment is always included in a patient’s physical exam.
Individuals require more extensive data-gathering
- chronic lung conditions
- allergic reactions
- trauma
- recent surgery, etc.

20. Lung Assessment

21. Lung Assessment OBJECTIVE SUBJECTIVE What you see and hear
What the patient tells you

22. Subjective Assessment
Ask the patient to describe any symptoms he/she is experiencing
- shortness of breath
- difficulty breathing
- cough
- orthopnea
- pain with inspiration
- wheezing, etc.

23. Subjective Assessment
Data must include details such as
- onset
- duration
- precipitating factors
- measures that relieve the symptoms
- these may be medications, positioning,
oxygen, alternative measures, etc.

24. Subjective Assessment
Cough
If present, ask for details
Productive/Non-productive
Frequency/sound
If productive, ask for
Color
Amount
Tenacity
Use quotes from the patient whenever possible!

25. Productive and Non-Productive Cough

26. Objective Assessment Observe the patient
Facial expressions when breathing
Chest movement
Quality of respirations
- rate, rhythm, depth
Normal Range = breaths per minute

27. Objective Assessment Observe for - flaring nostrils
- color of lips and nailbeds
- anxiety on the patient’s face
- skin color and turgor
- equality of breathing on both lungs
- retractions
- Dyspnea
- Orthopnea

28. Dyspnea = Difficulty Breathing
Dyspnea and Orthopnea
Dyspnea = Difficulty Breathing

29. Flaring Nostrils

30. Lip Cyanosis

31. Cyanosis of the Nail Beds

32. Lung Auscultation 1-7 ribs (sternum) 8-10 (costal cartilage)
11-12 (floating ribs-free anterior tips)

33. Auscultation Be sure to warm your stethoscope!! Listening for sounds
Auscultate ALL lung fields
Both anteriorly and posteriorly
C7 (posterior) big notch that sticks out (feel it)
T1-T12; T1-T4 (upper lobes posterior); T4-T12 (lower lobes posterior)
Anterior: RUL: T1-T4; RML: T4-T6; LUL: T1-T6; LLL: T6-T12
Be sure to warm your stethoscope!!

34. Anterior and Posterior Lung Auscultation

35. B = Bronchial
BV = Bronchial Vesicular
V = Vesicular

36. Lung Auscultation
The nurse notes the presence of any adventitious sounds (abnormal breath sounds)
- wheezes
- crackles
- pleural friction rub
- absence of breath sounds

37. Normal Breath Sounds Listen:

38. Adventitious Breath Sounds
Abnormal sounds superimposed on breath sounds
Includes:
Crackles (“rales”)
Sibilant Wheezes (“wheezes”)
Sonorous Wheezes (“rhonchi”)
Pleural Friction Rubs
Pleural friction rub also sounds like a loudly purring kitty.  Another description is leather rubbing together (if you ride horses the saddle/sturrup makes sounds when you mount—you would relate to it).
www. Rnceus.com/bs/bsendins.html
Crackles: End inspiration (small bronchioles and/or alveolar sacs pop open; causes: atelectasis, CHF, Pulmonary Fibrosis. Atelectasis =collapsed airless airways/sound is usually heart posteriorly and is quiet end-insp crackles. People with CT sites, restrictive disease (obesity, fx ribs, later stages of pregnancy) Note: after takes many deep breathes crackles sounds decrease.
Crepitant (fine) crackles (fluid overload, CHF), sounds decrease with diuresis. Hydrostatic pressure is gravity specific therefore auscultated in bases and shifts according to pt position.
(excessive fluid pressure within the capillaries of alveoli; fluid has not leaked into the lungs yet.)
FINE: end of inspiration (alveoli, bronchioles), medium or coarse(rhonchi) sounds like opening a velcro fastener; Remember: “Rhonchi in the Bronchi”

39. Adventitious Breath Sounds
Crackles:
- common on inspiration
- interrupted crackling/bubbling
sounds
- brief, not continuous
- can be fine, medium or coarse
Crackles fine, medium, course→thicker the mucous→more course. Course crackles begin in the Rhonchi and occur during early inspiration and may extend into first part of expiration. The inhaled air collides with secretions in the trachea and large bronchi.
Subcrepitant: increasing in severity of pulmonary edema (when fluid leaks into the lungs therefore increased pressure) crackles may be heart on expiration as well.
Fibrotic crackles (scar tissue)—results in decreased lung compliance; sounds are of collapsed bronchioles and alveoli “popping open;” slightly louder and sharper than previous crackles.
TB results in a creptitant crackle (if located in upper lung field may indicate a pulmonary tubercle). NOTE: Crepitant is not the same as crepitus (S.Q. emphysema; heard when a stethescope is first placed on skin containing SQ air.) however sounds similar to crackling sound (but louder).
Diffuse interstitual fibroses sounds artificial like cellephane.

40. Adventitious Breath Sounds
Crackles
- Occurs when air is forced through respiratory
passages narrowed by fluid, mucous,
etc.
- Inflammation or infection of the small bronchi,
bronchioles, and alveoli
- To simulate the sound of Crackles
Take a few strands of hair between your fingers
Hold it up to your ear
Rub back and forth
ATELECTASIS: an abnormal condition characterized by the collapse of lung tissue, preventing the respiratory exchange of carbon dioxide and oxygen, occurs from occlusion or air to a portion of the lung.

41. Adventitious Breath Sounds
Wheezes:
Sibilant:
- Musical, high-pitched, whistling
sounds.
- Caused by rapid movement of air
through narrowed bronchioles.
- May occur during inspiration or
expiration
- The sound may consist of one or several notes
Often heard continuously through both inspiration and expiration and have a musical quality (ex: acute asthma attack); asthma involves narrow airways (due to spams) which sounds like a harmonica or a “seal” . Sibilant wheeze most commonly heard during expiration but also can be heard during inspiration.
Way to remember: “Sibilant” wheezes (babies, children have higher pitch sound)

42. Adventitious Breath Sounds
Wheezes
Sonorous:
- Low-pitched, loud, snoring
sounds.
- Can be heard at any point of
inspiration or expiration.
- May be continuous
Remember: “Sonorous” sounds like “snore”; Rhonchi are in the Bronchi= sonorous wheezes. Caused by secretions in large airways (ex: bronchitis; crackling bubbling sounds may clear somewhat with coughing.) The mechanism that causes sonorous wheezes is that there is a narrowing of the large airways or an obstruction of the bronchus.  LOUD—Bronchus---SNORE; A narrowing of the Large Airways. If secretions are in the bronchi then it may clear up with a good cough. Most commonly heard upon expiration but also is heard on inspiration.

43. Adventitious Breath Sounds
Listen…..

44. Adventitious Breath Sounds
Pleural Friction Rub
Low-pitched grating or creaking sounds
Heard during both inspiration and expiration
Sound does not originate in the lungs
outside the lung fields
Inflamed pleural surfaces rubbing together during respiration
 Usually indicates Pleurisy
Note if the chest expands equally on both sides. Why? Chest expansion on one side only may indicate serious pulmonary compilations. Note retractions of the chest wall between the ribs and under the clavicle during inspiration.

45. Adventitious Breath Sounds
Pleural Friction Rub
This sound occurs when inflamed pleural surfaces rub together during respiration.
Listen…..

46. Summary
Defined common terminology associated with respiratory assessment and diagnostic testing
Identified components of a complete respiratory assessment
Identified methods for common respiratory diagnostic testing

47. Assignment Read/Review: PowerPoint Handout Student Handouts
AHN – Chapter 9 Pp

48. Next Class Respiratory Diagnostics and Labs Understanding ABGs
Look Over
AHN – Chapter 9 Pp

49. QUESTIONS?
Wheezes: Loud inspiratory Rhonchi=stridor (extrathoracic obstruction ex: Croup)
Expiratory Rhonchi= ______obstruction to the intrathoracic airways.
Diffuse Rhonchi (generalized obstruction)= suggests disease (asthma, COPD)