The respiratory process begins with the nose down to the trachea (upper respiratory tract), and to the bronchi, bronchioles, and alveolar sacs (lower respiratory tract). It is responsible for the intake of oxygen to sustain life, and for the removal of carbon dioxide as waste. Alterations in its function, whether restrictive or obstructive, can become life-threatening if unmanaged.
Monitoring
| Normal Breath Sound | Description | Found At |
|---|---|---|
| Tracheal | Harsh breath sounds | Level of the trachea |
| Bronchial | High-pitched breath sounds | Level of the bronchi |
| Bronchovesicular | Medium-pitched breath sounds | Level of the scapula (mid-lung field) |
| Vesicular | Low-pitched breath sounds | Level of the lower lobes of the lung |
| Abnormal Breath Sound | Description | Found In |
|---|---|---|
| Rales | Discrete, non-continuous breath sounds produced by moisture of the tracheobronchial tree. Heart best during inspiration. | |
| Crackles | A coarse form of rales, indicating the presence of fluid in the lungs | Pulmonary edema Pneumonia Inflammation |
| Ronchi | ”Popping” breath sounds produced by secretions obstructing the airway | |
| Wheezes | Continuous, musical breath sounds - Wheezes on inspiration: stridor - Wheezes on expiration: asthma | Asthma Bronchoconstriction |
| Friction Rub | Crackling, grating sounds originating from inflamed pleura. | Pericarditis Pleurisy |
Review: Reading ABGs
Find the type of acid-base imbalance, and its classification:
- pH: 7.35 - 7.45. Lower than normal is acidosis, higher is alkalosis.
- CO₂: 35 - 45. Lower than normal is alkalosis, higher is acidosis.
- HCO₃-: 22 - 26. Lower than normal is acidosis, higher is alkalosis.
- Whichever of the CO₂ (respiratory) and HCO₃- (metabolic) readings agree with the pH deviation is the result. If both agree, it is combined or mixed.
Find the level of compensation achieved:
- Fully Compensated: read the pH. If it is normal, full compensation is achieved. Identify which region the pH is closer to even in the normal range. Determine the match from CO2 or HCO3 to differentiate respiratory from metabolic pH imbalance.
- Partially Compensated: read the pH. If none of the values are normal, compensation is partial. Same rules as before are observed.
- Uncompensated: if one of CO₂ or HCO₃- is normal, but the pH is abnormal, no compensation has been achieved.
Pneumonia
The inflammation of the lungs. Most commonly caused by Streptococcus pneumoniae in adults. In children aged 6 months to 6 years old, the most common cause is Haemophilus influenzae serotype B.
- Etiological/Risk Factors: smoking, air pollution, immunocompromisation (e.g., AIDS, chemotherapy, dialysis patients).
- Clinical Manifestations: green to rusty sputum (pathognomonic), dyspnea, fever, pleuritic chest pain (pain upon coughing/breathing), rales, crackles.
- Diagnostic Evaluation: CXR (confirmatory), CBC (elevated WBC), Sputum GS/CS
- Management: oxygen therapy, force fluids (liquefy secretions), nebulize, suctioning as necessary
- Drug of choice: amoxicillin; alternatively, azithromycin
- Nursing Interventions: positioning, deep breathing and coughing exercises, CPT
Types of Pneumonia
- Community Acquired Pneumonia (CAP)
- Hospital Acquired Pneumonia (HAP)
- Ventilator Acquired Pneumonia (VAP)
Pulmonary Tuberculosis
Discovered by Robert Koch, giving it the name “Koch’s disease”. It is caused by Mycobacterium tuberculosis
- Risk Factors: (mn. MOAI, as in this guy 👉 🗿)
- Malnutrition
- Overcrowding
- Alcoholism
- Immunocompromised or Ingestion of Infected Unpasteurized Bovine Milk
- Clinical Manifestations: (mn. PLAN)
- Productive Cough
- Low Grade Afternoon Fever, the pathognomonic sign of TB.
- Anorexia, Weight Loss
- Night Sweats
- Diagnostic Examination:
- Screening: Mantoux Test, a PPD sample injected intradermally (skin test). A positive result indicates exposure.
- Healthy (low-risk) individuals test positive if the skin test returns an induration of 10 mm or more.
- Immunocompromised (high-risk) individuals test positive with only 5 mm or more.
- Confirmatory: Sputum Culture, or GeneXpert (uses sputum sample, faster)
- Determine Extent of Lesions: CXR (mild, moderately advanced, far advanced)
- Screening: Mantoux Test, a PPD sample injected intradermally (skin test). A positive result indicates exposure.
- Medical Management: (mn. RIPES) used for 6 months.
- Rifampicin: red-orange secretions
- Contact lenses can be stained if worn by the patients. Recommend the use of eyeglasses.
- Isoniazin: results in numbness/paresthesia. Requires Pyridoxine (Vitamin B6) to offset numbness.
- Pyrazinamide: increases uric acid— avoided for patients with gouty arthritis.
- Ethambutol: causes optic neuritis; blurring vision. Color discrimination (red-green) is affected.
- Streptomycin: IM ANST; (mn. SON) sensorineural hearing loss. The drug is ototoxic and nephrotoxic (check creatinine).
- Rifampicin: red-orange secretions
COPD
Patient Teaching
- The two universal risk factors for COPD is smoking and air pollution. This is applicable to both chronic bronchitis and emphysema. Let the patient make lifestyle changes to avoid these risk factors.
- Always teach the patient about pursed lip breathing, which prevents air trapping. In this type of breathing, exhalation lasts longer than inhalation.
Chronic Bronchitis
Blue boater; problems with the constriction of airway due to inflammation, which also increases mucus production due to mucus gland growth.
- Clinical Manifestations: chronic coughing— more than three months in two consecutive years.
- ABG: respiratory acidosis
- Nursing Management:
- Low inflow O2 (less than 6) to prevent the loss of hypoxic drive.
- Management: (mn. CAMB)
- Corticosteroids (as an antiinflammatory)
- Antimicrobials (if pneumonia occurs)
- Mucolytics/Expectorants
- Bronchodilators: Salbutamol, Ventril; avoid stimulants because of palpitation as a side effect.
Emphysema
Pink puffer; problems with (mn. IBA) inelasticity of alveoli, barrel chest (increased anteroposterior chest diameter due to air trapping), and air trapping. Highly related to smoking.
- Risk Factors: smoking, alpha-1 antitypsin deficiency, air pollution
- Clinical Manifestations:
- Productive Cough
- Dyspnea at rest
- Rales, Crackles, Rhonchi
- Barrel Chest d/t Air Trapping
- Diagnostic Examination: ABG, also respiratory acidosis; CXR (overinflation)
- Management: (mn. FLA, CAMB) (i have no idea how this )
- Force Fluids
- Low Inflow O2 (prevent loss of hypoxic drive)
- Administer medications as ordered
- Corticosteroids
- Antibiotics: if pneumonia occurs
- Mucolytics/Expectorants
- Bronchodilators
Bronchial Asthma
(this wasn’t covered the other day) A reversible inflammatory lung condition due to hypersensitivity to allergens. Bronchoconstriction occurs, restricting breathing.
- Risk Factors: Family History
- Clinical Manifestations: (triad for asthma)
- Cough
- Dyspnea
- Wheezing on Expiration
- Management:
- High Fowler’s Positioning or Tripod during dyspnea
- Enforce complete bed rest
- Administer medications as ordered: bronchodilators (causes palpitation, avoid stimulants e.g. caffeine), steroids (increases (mn. BNG) BP, Na, Glucose, and decreases Potassium. Feed the patient with banana or avocado)
- Metered Dose Inhaler (MDI) with a maintenance drug used to prevent exacerbation.
Pneumothorax
Pneumothorax is the accumulation of air in the pleural space. The normally negative pressure present in the space becomes positive and acts on the lungs, preventing it from expanding.
- Etiology:
- Spontaneous pneumothorax
- COPD (Secondary pneumothorax)
- Catamenial pneumothorax
- Clinical Manifestations:
- Dyspnea
- Dullness
- Decreased chest expansion
- Diminished breath sounds
- Tracheal Deviation (pathognomonic) towards the unaffected side found in tension pneumothorax.
- Tension Pneumothorax, where a hole is punctured by a mechanical ventilator into the pleural space.
- Diagnostic Examination: CXR reveals inflation of the pleura. ABG reveals respiratory acidosis.
- Management:
- Thoracentesis may be the primary form of management if mild.
- If moderate to severe, a CTT (chest tube thoracostomy) may be required.
- Nursing Management: if a CTT is attached to a water-sealed drainage, monitor fluctuations (should fluctuate, otherwise obstruction or re-expansion of the lungs may have occurred) and bubbling (should be intermittent, otherwise an air leak may be present).
Chest Injuries
(also wasn’t discussed the other day)
- Rib Fractures resulting from direct blunt chest trauma, often from vehicular accident victims. The pathognomonic sign of rib fractures is pain on the site of injury exacerbated upon inspiration.
- Management: surgery is not required. Ribs unite spontaneously.
- Maintain high fowler’s and monitor for respiratory depression.
- Flail Chest resulting from direct blunt chest trauma that damages two or more ribs. The pathognomonic sign is paradoxical breathing, where inhalation reduces chest size and vice versa.