RESPIRATORY SYSTEM

OVERVIEW OF THE STRUCTURES AND FUCNTIONS OF THE RESPIRATORY SYSTEM

I. Upper Respiratory System
1. Filtering of air
2. Warming and moistening of air
3. Humidification

A. Nose
- Cartillage
- Right nostril
- Left nostril
- Separated by septum
- Consist of anastomosis of capillaries known as Keissel Rach Plexus (the site of nose bleeding)
B. Pharynx/Throat
- Serves as a muscular passageway for both food and air
C. Larynx
- For phonation (voice production)
- For cough reflex
Glottis
- Opening of larynx
- Opens to allow passage of air
- Closes to allow passage of food going to the esophagus
- The initial sign of complete airway obstruction is the inability to cough

II. Lower Respiratory System

- For gas exchange
A. Trachea/Windpipe
- Consist of cartilaginous rings
- Serves as passageway of air going to the lungs
- Site of tracheostomy
B. Bronchus
- Right main bronchus
- Left main bronchus
C. Lungs
- Right lung (consist of 3 lobes, 10 segments)
- Left lung (consist of 2 lobes, 8 segments)
- Serous membranes
Pleural Cavity
a. Pareital
b. Pleural fluid
c. Visceral
With Pleuritic Friction Rub
a. Pneumonia
b. Pleural effusion
c. Hydrothorax (air and blood in pleural space
Alveoli
- Site of gas exchange (CO2 and O2)
- Diffusion (Dalton’s law of partial pressure of gases)

Respiratory Distress Syndrome

- Decrease oxygen stimulates breathing
- Increase carbon dioxide is a powerful stimulant for breathing

Type II Cells of Alveoli

- Secretes surfactant
- Decrease surface tension
- Prevent collapse of alveoli
- Composed of lecithin and spingomyelin
- L/S ratio to determine lung maturity
- Normal L/S ratio is 2:1
- In premature infants 1:2
- Give oxygen of less 40% in premature to prevent atelectasis and retrolental fibroplasias
- retinopathy/blindness in prematurity
Disorders of Respiratory System
1. PTB/Pulmonary Tuberculosis (Koch’s Disease)
- Infection of lung tissue caused by invasion of mycobacterium tuberculosis or tubercle bacilli
- An acid fast, gram negative, aerobic and easily destroyed by heat or sunlight

A. Precipitating Factors
1. Malnutrition
2. Overcrowded places
3. Alcoholism
4. Over fatigue
5. Ingestion of an infected cattle with mycobacterium bovis
6. Virulence (degree of pathogenecity) of microorganism

B. Mode of Transmission
1. Airborne transmission via droplet nuclei

C. Signs and Symptoms

1. Low grade afternoon fever, night sweats
2. Productive cough (yellowish sputum)
3. Anorexia, generalized body malaise
4. Weight loss
5. Dyspnea
6. Chest pain
7. Hemoptysis (chronic)

D. Diagnostic Procedure
1. Mantoux Test (skin test)
- Purified protein derivative
- DOH 8 – 10 mm induration, 48 – 72 hours
- WHO 10 – 14 mm induration, 48 – 72 hours
- Positive Mantoux test (previous exposure to tubercle bacilli but without active TB)

2. Sputum Acid Fast Bacillus

- Positive to cultured microorganism

3. Chest X-ray
- Reveals pulmonary infiltrates

4. CBC
- Reveals increase WBC

E. Nursing Management
1. Enforce CBR
2. Institute strict respiratory isolation
3. Administer oxygen inhalation
4. Force fluids to liquefy secretions
5. Place client on semi fowlers position to promote expansion of lungs
6. Encourage deep breathing and coughing exercise
7. Nebulize and suction when needed
8. Comfortable and humid environment
9. Institute short course chemotherapy
a. Intensive phase
- INH (Isonicotinic Acid Hydrazide)
- Rifampicin (Rifampin)
- PZA (Pyrazinamide)
- Given everyday simultaneously to prevent resistance
- INH and Rifampicin is given for 4 months, taken before meals to facilitate absorption
- PZA is given for 2 months, taken after meals to facilitate absorption
- Side Effect INH: peripheral neuritis/neuropathy (increase intake of Vitamin B6/Pyridoxine)
- Side Effect Rifampicin: all bodily secretions turn to red orange color
- Side Effect PZA: allergic reaction, hepatotoxicity, nephrotoxicity
- PZA can be replaced by Ethambutol
- Side Effect Ethambutol: optic neuritis

b. Standard phase
- Injection of streptomycin (aminoglycoside)
- Kanamycin
- Amikacin
- Neomycin
- Gentamycin
- Side Effect:
- Ototoxicity damage to the 8th cranial nerve resulting to tinnitus leading to hearing loss
- Nephrotoxicity check for BUN and Creatinine
- Give aspirin if there is fever
- Side Effect: tinnitus, dyspepsia, heartburn
10. Provide increase carbohydrates, protein, vitamin C and calories
11. Provide client health teaching and discharge planning
a. Avoidance of precipitating factors
b. Prevent complications (atelectasis, military tuberculosis)
PTB
- Bones (potts)
- Meninges
- Eyes
- Skin
- Adrenal gland
c. Strict compliance to medications
d. Importance of follow up care

PNEUMONIA
Inflammation of the lung parenchyma leading to pulmonary consolidation as the alveoli is filled with
exudates

A. Etiologic Agents
1. Streptococcus Pneumonae – causing pneumococal pneumonia
2. Hemophylus Influenzae – causing broncho pneumonia
3. Diplococcus Pneumoniae
4. Klebsella Pneumoniae
5. Escherichia Pneumoniae
6. Pseudomonas

B. High Risk Groups

1. Children below 5 years old
2. Elderly

C. Predisposing Factors
1. Smoking
2. Air pollution
3. Immuno compromised
a. AIDS
- Pneumocystic carini pneumonia
- Drug of choice is Retrovir
b. Bronchogenic Cancer
- Initial sign is non productive cough
- Chest x-ray confirms lung cancer
4. Related to prolonged immobility (CVA clients), causing hypostatic pneumonia
5. Aspiration of food causing aspiration pneumonia

D. Signs and Symptoms

1. Productive cough with greenish to rusty sputum
2. Dyspnea with prolong expiratory grunt
3. Fever, chills, anorexia and general body malaise
4. Weight loss
5. Rales/crackles
6. Bronchial wheezing
7. Cyanosis
8. Pleuritic friction rub
9. Chest pain
10. Abdominal distention leading to paralytic ileus (absence of peristalsis)

E. Diagnostic Procedure
1. Sputum Gram Staining and Culture Sensitivity – positive to cultured microorganisms
2. Chest x-ray – reveals pulmonary consolidation
3. ABG analysis – reveals decrease PO2
4. CBC – reveals increase WBC, erythrocyte sedimentation rate is increased

F. Nursing Management
1. Enforce CBR
2. Administer oxygen inhalation low inflow
3. Administer medications as ordered
Broad Spectrum Antibiotic
a. Penicillin
b. Tetracycline
c. Microlides (Zethromax)
- Azethromycin (Side Effect: Ototoxicity)
- Antipyretics
- Mucolytics/Expectorants
- Analgesics
4. Force fluid
5. Place on semi fowlers position
6. Institute pulmonary toilet (tends to promote expectoration)
- Deep breathing exercises
- Coughing exercises
- Chest physiotherapy
- Turning and reposition
7. Nebulize and suction as needed
8. Assist in postural drainage
- Drain uppermost area of lungs
- Placed on various position
Nursing Management for Postural Drainage
a. Best done before meals or 2 – 3 hours to prevent gastro esophageal reflux
b. Monitor vital signs
c. Encourage client deep breathing exercises
d. Administer bronchodilators 15 – 30 minutes before procedure
e. Stop if client cannot tolerate procedure
f. Provide oral care after procedure
g. Contraindicated with
- Unstable vital signs
- Hemoptysis
- Clients with increase intra ocular pressure (Normal IOP 12 – 21 mmHg)
- Increase ICP
9. Provide increase carbohydrates, calories, protein and vitamin C
10. Health teaching and discharge planning
a. Avoid smoking
b. Prevent complications
- Atelectasis
- Meningitis (nerve deafness, hydrocephalus)
c. Regular adherence to medications
d. Importance of follow up care

HISTOPLASMOSIS
Acute fungal infection caused by inhalation of contaminated dust or particles with histoplasma capsulatum
derived from birds manure

A. Signs and Symptoms

PTB or Pneumonia like
1. Productive cough
2. Dyspnea
3. Fever, chills, anorexia, general body malaise
4. Cyanosis
5. Hemoptysis
6. Chest and joint pains

B. Diagnostic Procedures
1. Histoplasmin Skin Test – positive
2. ABG analysis PO2 decrease

C. Nursing Management
1. Enforce CBR
2. Administer oxygen inhalation
3. Administer medications as ordered
a. Antifungal
- Amphotericin B
- Fungizone (Nephrotoxicity, check for BUN and Creatinine, Hypokalemia)
b. Steroids
c. Mucolytics
d. Antipyretics
4. Force fluids to liquefy secretions
5. Nebulize and suction as needed
6. Prevent complications – bronchiectasis
7. Prevent the spread of infection by spraying of breeding places

COPD (Chronic Obstructive Pulmonary/Lung Disease)

Chronic Bronchitis
Inflammation of bronchus resulting to hypertrophy or hyperplasia of goblet mucous producing cells leading
to narrowing of smaller airways

A. Predisposing Factors
1. Smoking
2. Air pollution
B. Signs and Symptoms
1. Productive cough (consistent to all COPD)
2. Dyspnea on exertion
3. Prolonged expiratory grunt
4. Anorexia and generalized body malaise
5. Scattered rales/ronchi
6. Cyanosis
7. Pulmonary hypertension
a. Peripheral edema
b. Cor Pulmonale (right ventricular hypertrophy)
C. Diagnostic Procedure
ABG analysis – reveals PO2 decrease (hypoxemia), PCO2 increase, pH decrease

Bronchial Asthma
Reversible inflammatory lung condition due to hypersensitivity to allergens leading to narrowing of smaller
airways

A. Predisposing Factors (Depending on Types)

1. Extrinsic Asthma ( Atopic/ Allergic )
Causes
a. Pollen
b. Dust
c. Fumes
d. Smoke
e. Gases
f. Danders
g. Furs
h. Lints

2. Intrinsic Asthma (Non atopic/Non allergic)

Causes
a. Hereditary
b. Drugs (aspirin, penicillin, beta blocker)
c. Foods (seafoods, eggs, milk, chocolates, chicken
d. Food additives (nitrates)
e. Sudden change in temperature, air pressure and humidity
f. Physical and emotional stress

3. Mixed Type  90 – 95%

B. Signs and Symptoms

1. Cough that is non productive
2. Dyspnea
3. Wheezing on expiration
4. Cyanosis
5. Mild Stress/apprehension
6. Tachycardia, palpitations
7. Diaphoresis

C. Diagnostic Procedure
1. Pulmonary Function Test
- Incentive spirometer reveals decrease vital lung capacity
2. ABG analysis – PO2 decrease
- Before ABG test for positive Allens Test, apply direct pressure to ulnar and radial artery to determine
presence of collateral circulation

D. Nursing Management
1. Enforce CBR
2. Oxygen inhalation, with low inflow of 2 – 3 L/min
3. Administer medications as ordered
a. Bronchodilators – given via inhalation or metered dose inhalaer or MDI for 5 minutes
b. Steroids – decrease inflammation
c. Mucomysts (acetylceisteine)
d. Mucolytics/expectorants
e. Anti histamine
4. Force fluids
5. Semi fowlers position
6. Nebulize and suction when needed
7. Provide client health teachings and discharge planning concerning
a. Avoidance of precipitating factor
b. Prevent complications
- Emphysema
- Status Asthmaticus (give drug of choice)
- Epinephrine
- Steroids
- Bronchodilators
c. Regular adherence to medications to prevent development of status asthmaticus
d. Importance of follow up care
BRONCHIECTASIS
Abnormal permanent dilation of bronchus leading to destruction of muscular and elastic tissues of alveoli

A. Predisposing Factors
1. Recurrent lower respiratory tract infections
2. Chest trauma
3. Congenital defects
4. Related to presence of tumor

B. Signs and Symptoms

1. Productive cough
2. Dyspnea
3. Cyanosis
4. Anorexia and generalized body malaise
5. Hemoptysis (only COPD with sign)

C. Diagnostic Procedure
1. ABG – PO2 decrease
2. Bronchoscopy – direct visualization of bronchus using fiberscope

Nursing Management PRE Bronchoscopy

1. Secure inform consent and explain procedure to client
2. Maintain NPO 6 – 8 hours prior to procedure
3. Monitor vital signs and breath sound

POST Bronchoscopy
1. Feeding initiated upon return of gag reflex
2. Avoid talking, coughing and smoking, may cause irritation
3. Monitor for signs of gross
4. Monitor for signs of laryngeal spasm – prepare tracheostomy set

D. Treatment
1. Surgery (pneumonectomy , 1 lung is removed and position on affected side)
2. Segmental Wedge Lobectomy (promote re expansion of lungs)
- Unaffected lobectomy facilitate drainage
EMPHYSEMA
Irreversible terminal stage of COPD characterized by
a. Inelasticity of alveoli
b. Air trapping
c. Maldistribution of gases
d. Over distention of thoracic cavity (barrel chest)

A. Predisposing Factors
1. Smoking
2. Air pollution
3. Allergy
4. High risk: elderly
5. Hereditary – it involves deficiency of ALPHA-1 ANTI TRYPSIN (needed to form Elastase, for recoil of
alveoli)

B. Signs and Symptoms

1. Productive cough
2. Dyspnea at rest
3. Prolong expiratory grunt
4. Anorexia and generalized body malaise
5. Resonance to hyperresonance
6. Decrease tactile fremitus
7. Decrease or diminished breath sounds
8. Rales or ronchi
9. Bronchial wheezing
10. Barrel chest
11. Flaring of alai nares
12. Purse lip breathing to eliminates excess CO2 (compensatory mechanism)

C. Diagnostic Procedure
1. Pulmonary Function Test – reveals decrease vital lung capacity
2. ABG analysis reveals
a. Panlobular/ centrilobular
- Decrease PO2 (hypoxemia leading to chronic bronchitis, “Blue Bloaters”)
 - Decrease ph
- Increase PCO2
- Respiratory acidosis
b. Panacinar/ centriacinar
- Increase PO2 (hyperaxemia, “Pink Puffers”)
- Decrease PCO2
- Increase ph
- Respiratory alkalosis

D. Nursing Management
1. Enforce CBR
2. Administer oxygen inhalation via low inflow
3. Administer medications as ordered
a. Bronchodilators
b. Steroids
c. Antibiotics
d. Mucolytics/expectorants
4. High fowlers position
5. Force fluids
6. Institute pulmonary toilet
7. Nebulize and suction when needed
8. Institute PEEP (positive end expiratory pressure) in mechanical ventilation promotes maximum alveolar
lung expansion
9. Provide comfortable and humid environment
10. Provide high carbohydrates, protein, calories, vitamins and minerals
11. Health teachings and discharge planning concerning
a. Avoid smoking
b. Prevent complications
- Atelectasis
- Cor Pulmonale
- CO2 narcosis may lead to coma
- Pneumothorax
c. Strict compliance to medication
d. Importance of follow up care