Overview of the system

Respiratory System
The major function of the respiratory system is to supply the body with oxygen and to
dispose of carbon dioxide. There are four distinct events collectively called respiration
must occur:

1. Pulmonary ventilation. Air must move into and out of the lungs so that the gases
in the air sacs (alveoli) of the lungs are continuously changed and refreshed. This
process of pulmonary ventilation is commonly called breathing.
2. External respiration. Gas change between the pulmonary blood and alveoli must
take place. It is a gas exchange between the blood and body exterior.
3. Respiratory Gas transport. Oxygen and carbon dioxide must be transported to
and from the lungs and tissue cells of the body via the bloodstream.
4. Internal respiration. At systemic capillaries, gas exchanges must be made
between the blood and tissue cells. In internal respiration, gas exchanges are
occurring between the blood and cells inside the body.
The respiratory system consists of the organs that exchange these gases . These
organs are the nose, pharynx, larynx, trachea, and lungs.

Nose– is formed by a framework of cartilage and bone covered with skin and
lined internally with mucous membrane. On the undersurface of the nose is formed by the
nasal bones that help support the external nose and hold it in a fixed position.

Pharynx- also called the throat. It is a tube approximately 5 inches long. Its walls
are made of skeletal muscle lined with mucous membrane. The pharynx is a passageway
for both air and food and forms a resonating chamber fro speech sounds.

Larynx or Voice Box- it is very short passageway that connects the pharynx with
trachea. Its walls are supported by nine pieces of cartilage.

Trachea- also referred to as the wind pipe. It is a tubular passageway for air
approximately 4.5 inches in length and about 1 inch in diameter. The tracheal epithelium
is pseudostratified , ciliated columnar cells with goblet cells and basal cells.

Lungs- are paired, cone-shaped organs located in and filling the pleural divisions
of the thoracic cavity. The apex of the lungs is about 4 cm above the first rib, and the base
of the lungs rests on the diaphragm.

CHRONIC OBSTRUVTIVE PULMONARY DISEASE

Chronic Obstructive Pulmonary Disease (COPD) is a disease state characterized

by airflow limitation that is not fully reversible. COPD may include diseases that cause
airflow obstruction(eg, emphysema, chronic bronchitis) or a combination of these
disorders. Theses diseases have certain features in common: 1. Patients almost always
have a history of smoking; 2. dyspnea, labored breathing, 3. coughing and frequent
pulmonary infections are common; 4. most COPD victims are hypoxic, retain carbon
dioxide and have respiratory acidosis.

Chronic Bronchitis, the mucosa of the lower respiratory passages becomes

severely inflamed and produces excessive amounts of mucous. The pooled mucus impairs
ventilation and gas exchange and dramatically increases the risk of lung infections.
In Emphysema, the alveoli enlarge as the walls of adjacent chambers break
through, and chronic inflammation promotes fibrosis of the lungs. As the lungs become
less elastic, the airways collapse during expiration and obstruct outflow of air. As a result,
these patients use an incredible amount of energy to exhale, and they are always
exhausted. Because air is retained in the lungs, oxygen exchange is surprisingly efficient,
and cyanosis does not usually appear until late in the disease.

PATHOPHYSIOLOGY

In COPD, the airflow limitation is both progressive and associated with an

abnormal inflammatory response of the lungs to noxious particles or gases. The
inflammatory response occurs throughout the airways, parenchyma, and pulmonary
vasculature. Over time, this injury-snd-repair process causes scar tissue formation and
narrowing of the airway lumen.
Early in the course of COPD, the inflammatory response causes pulmonary
vasculature changes that are characterized by thickening of the vessel wall. These
changes may occur as a result of exposure to cigarette smoke or use of tobacco products
or as a result of the release of inflammatory mediators.

CLINICAL MANIFESTATIONS

COPD is characterized by three primary symptoms: cough, sputum production,

and dyspnea on exertion. These symptoms worsen over time. Chronic cough and sputum
production often precede the development of airflow limitation by many years. Weight
loss is common because dyspnea interferes with eating, and the work of breathing is
energy-depleting. Often patient cannot participate in even mild exercise because of
dyspnea. The patient with COPD is at risk for respiratory insufficiency and respiratory
infections, which in turn increase the risk for acute and chronic respiratory failure.

MEDICAL MANAGEMENT

RISK REDUCTION
Smoking cessation is the most effective intervention to prevent COPD its
progression. Nurses play a key role in promoting smoking cessation and educating
patients about ways to do so. Patients diagnosed with COPD who continue to smoke must
be encourage ad assisted to quit. Factors associated with continued smoking vary among
patients and may include the strength of nicotine addiction, continued exposure to
smoking-associated stimuli, stress, depression and habit.
 Because there are multiple factors associated with continued smoking, successful
cessation often requires multiple strategies. The health care provider should promote
cessation by explaining the risk of smoking and personalizing the “at risk” message to the
patient. Smoking cessation can begin in a variety of health care settings like the
outpatient clinic, pulmonary rehabilitation, community, hospital, and the patient’s home.
Regardless of the setting, the nurse has the opportunity to teach the patient about the risks
of smoking and the benefits of smoking cessation.

NURSING MANAGEMENT

The nurse plays a key role in identifying potential candidates for pulmonary rehabilitation
and in facilitating and reinforcing the material learned in the rehabilitation program.
However, the nurse can be instrumental in teaching the patient and family as well as
facilitating specific services for the patient.

PATIENT EDUCATION

Patient education is a major component of pulmonary rehabilitation and includes a wide

variety of topics. Depending on the length and program , topics may include normal
anatomy and physiology of the lung, pathophysiology and changes with COPD,
medications and home oxygen therapy, nutrition, respiratory therapy treatments,
symptom alleviation and smoking cessation.

BREATHING EXERCISES. The breathing pattern of most people with COPD is shallow,
rapid, and inefficient; the more severe the disease, the more inefficient the breathing
pattern. With practice, this type of upper chest breathing can be changed to diaphragmatic
breathing, which reduces the respiratory rate, increases alveolar ventilation, and
sometimes helps expel air as much air as possible during expiration. Pursed lip breathing
helps slow expiration, prevents collapse of small airways, and helps the patient to control
the rate and depth of respiration.

INSPIRATORY MUSCLE TRAINING. Once the patient masters diaphragmatic

breathing, a program of inspiratory muscle training may be prescribed to help strengthen
the muscle used in breathing. This program requires that the patient breathe against
resistance for 10-15 minutes everyday.

ACTIVITY PACING
A patient with COPD has decreased exercise tolerance during specific periods of the day.
This is especially true on arising in the morning, because bronchial secretions collect in
the lungs during the night while the person is lying down. The patient has difficulty
bathing or dressing. Activities requiring the arms to be supported above the level of the
thorax may produced fatigue or respiratory distress but may be tolerated better after the
patient has been up and moving around for an hour or more.

SELF CARE ACTIVITIES

As gas exchange, airway clearance, and the breathing pattern improve, the patient is
encouraged to assume increase participation in the self-care activities. The patient is
taught to coordinate diaphragmatic breathing with activities such as walking, bathing,
bending, or climbing stairs. The patient should bathe, dress, and take short walks, resting
as needed to avoid fatigue and excessive dyspnea. Fluids should always be readily
available, and the patient should begin to drink fluids without having to be reminded. If
postural drainage is to be done at home, the nurse instructs and supervises the patient
before discharge or in the outpatient setting.

PHYSICAL CONDITIONING
Physical conditioning techniques include breathing exercises and general exercises
intended to conserve energy and increase pulmonary ventilation. There is a close
relationship between physical fitness and respiratory fitness. Graded exercises and
physical conditioning programs using treadmills, stationary bicycles, and measured level-
walks can improve symptoms and increase work capacity and exercise tolerance. Any
physical activity that can be done regularly is helpful. Light weight portable oxygen
systems are available for ambulatory patients who require oxygen therapy during
physical activity.

OXYGEN THERAPY
Oxygen supplied to the home comes in compressed gas, liquid, or concentrator systems.
Portable oxygen systems allow the patient to exercise, work and travel. To help the
patient adhere to the oxygen prescription, the nurse explains the proper flow rate and
required number of hours for oxygen use as well as the dangers of our arbitrary changes
in flow rates or duration of therapy. The nurse cautions the patient that smoking with or
near oxygen is extremely dangerous. The nurse also reassures the patient that oxygen is
not addictive and explains the need for regular evaluations of blood oxygenation by pulse
oximetry or arterial blood gas analysis.

NUTRITIONAL THERAPY
Nutritional assessment and counseling are important aspects in the rehabilitation process
for the patient with COPD. Approximately 25% of patients with COPD are
undernourished. A thorough assessment of caloric needs and counseling about meal
planning and supplementation are part of the rehabilitation process.

COPING MEASURE.
Any factors that interferes with normal breathing quite naturally induces anxiety,
depression and changes in behavior. Many patients find the slightest exertion exhausting.
Constant shortness of breath and fatigue may make the patient irritable and apprehensive
to the point of panic. Restricted activity (and reversal of family roles due to loss of
employment), the frustration of having to work to breathe, and the realization that the
disease is prolonged and unrelenting because the patient to react with anger, depression
and demanding behavior. Sexual function may be compromised, which also diminishes
self-esteem. In addition, the nurse needs to provide education as support to the
spouse/significant other and family because the care giver role in end-stage COPD can be
difficult.
 References:
th
Medical-Surgical Nursing 10 edition; Suzanne C. Smeltzer, Brenda Bare
Human Anatomy & Physiology in Health and Diseases 3rd edition by Shirley Burke
Fundamentals of Anatomy and Physiology 2nd edition by Donald C. Rizzo
Essentials of Human Anatomy and Physiology by Elaine M. Marieb