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Ventilation, Perfusion, and Respiration

• The respiratory system handles ventilation (air movement).
• The cardiovascular system handles profusion (blood flow).
• Together, they enable external respiration (gas exchange) at the alveolar-capillary level.
• Adequate ventilation and perfusion are essential for gas exchange in the lungs.
• Cellular respiration (gas exchange inside the body) occurs between capillaries and cells, driven by hydrostatic and oncotic pressures.

History - Current Complaints

• Assess current respiratory complaints to gather necessary information for diagnosis and treatment.
• Needs Closer Evaluation: Patients reporting cough, nasal or sinus symptoms, pain, discolored mucus, dyspnea, fatigue, or unexplained weight loss need closer evaluation.
• Needs Emergent Medical Care: Patients who have difficulty speaking, use accessory muscles, head bobbing, pursed lip breathing, adventitious breath sounds, altered mental status, hypoxia, or cyanosis need immediate medical intervention.
• Pediatrics: In children, grunting and retractions are signs of respiratory distress.
• Yellow sputum color may indicate infection.
• White sputum color may indicate inflammation.
• Green sputum color may indicate bacterial infection.
• Bloody sputum color may indicate bleeding.
• Foamy sputum color may indicate pulmonary edema.
• Inquire about the onset, provoking/palliating factors, quality, region/radiation, severity, and timing of symptoms.
• Ask the patient what they think is causing their symptoms to understand their perspective.

Past Medical History

• Gather information about past medical history, including smoking, drug use, allergies, medications, and surgical history.
• Secondhand smoke exposure, feeding habits, and sleeping habits are important in infants and children.
• SUIDI/SIDS, common in infants up to 6 months, is diagnosed by excluding other possibilities.
• Family history, travel, work, and residence can reveal risk factors.
• A thorough history helps determine the need for further evaluation.

Assessment - Inspection

• Assess the patient's general impression, tone, appearance, and mental status.
• Check the patency of the airway, nares, and neck/trachea, making sure to note how they are managing secretions.
• Observe the rate, depth, and effort of breathing, as well as the shape of the thorax.
• Tachycardia can be an early sign of hypoxia.
• Evaluate skin color, turgor, and mucus membranes for signs of respiratory distress such as cyanosis.
• Check nails for clubbing or signs of tobacco staining.
• Infants typically have a neutral to open airway.
• Adults tilt their head back in the absence of trauma, otherwise, perform a jaw tilt maneuver.

Assessment - Palpate

• Palpate the trachea to ensure it is midline.
• Assess the thorax for crepitus, pain, masses, deformities, and expansion.

Assessment -Auscultate

• Auscultate lung sounds to assess respiratory function.
• Upper lobes are best heard anteriorly.
• The right middle lobe and lower lobes are best heard posteriorly.
• Listen to both inspiration and expiration.
• Adventitious lung sounds are generally abnormal, but may be normal with chronic diseases.
• Stridor:
  • High-pitched inspiratory sound caused by upper airway obstruction.
  • Examples include croup, epiglottitis, laryngitis, allergic reactions, foreign body airway obstruction, and vocal cord injuries
  • Can also cause edema from nerve injury after thyroidectomy.
• Rhonchi:
  • Low-pitched, "junky" or snoring sound due to thick mucus in the upper/large airways.
  • Can be heard during inspiration and exhalation, and often clears with coughing.
  • Conditions can include COPD, pneumonia, bronchitis, foreign bodies, and tumors.
  • Reassess after interventions.
• Wheezes:
  • Musical, violin-like sounds in the smaller airways caused by bronchoconstriction, mucosal edema, and excessive mucus production.
  • May only occur during exhalation, both exhalation and inhalation, or just inhalation, depending on severity
  • "Silent Chest" = respiratory arrest.
  • Conditions include asthma, COPD, and allergic reactions.
• Crackles:
  • Fine (soft like hair rubbing together) or coarse (slightly louder popping sound) from recruitment of atelectic alveoli or fluid in the alveoli or terminal bronchioles.
  • Track the location to determine how far up the lungs you can hear them.
  • Monitor if they clear with deep breathing which would indicate atelectasis
  • Conditions include hypoventilation, bronchitis, pneumonia, COPD, pulmonary edema, and congestive heart failure.

Diagnostics

• Pulse oximetry:
  • Estimates oxygen binding to hemoglobin, dependent on adequate ventilation and perfusion.
  • Inaccurate if the patient has nail polish.
• Capnography, Capnometry:
  • Measure exhaled CO2.
• VBGs and ABGs:
  • Respiratory acidosis caused by COPD, late-stage pneumonia, ARDS, hypoventilation and/or respiratory failure.
  • Respiratory alkalosis is caused by hyperventilation, early asthma or pneumonia, and anxiety.
  • Blood gases are more accurate but invasive.
  • Perform Allen's test before radial artery puncture to ensure hand blood flow; apply pressure to puncture site for several minutes to prevent bleeding.
• Sputum analysis:
  • Can confirm infection, organism, and sensitivity.
• Chest x-ray:
  • Can identify problems with the heart, lungs, and pleural space, masses, fluid or air collections in the pleural space, pneumonia, atelectasis, and TB infections.
• Pulmonary Function Test:
  • Evaluates lung function to determine if diseases like COPD are stabilizing or progressing.
• UA: Urine struck pneumonia antigen test
  • Identifies strep infections by detecting antigens floating in the bloodstream.

Diagnostics - Procedures

• Thoracentesis (Awake):
  • Involves local anesthetic and patient positioning/reassurance.
  • Assess vital signs and lung sounds throughout procedure.
  • Risks include pain, bleeding, infection, hypotension and pneumothorax.
• Bronchoscopy:
  • Flexible: Moderate sedation.
  • Rigid: Requires general anesthesia and awareness of the gag reflex prior to oral intake.
• Lung Biopsy:
  • Percutaneous: requires moderate sedation.
  • Open: Needs general anesthesia and a chest tube afterward.

Chest Tube Management

• Chest tube management includes maintaining a closed system and keeping the collection system below the level of the chest.
• Air Vent:
  • Not defined in text
• Water Seal:
  • Not defined in text
• Drainage Canister:
  • Not defined in text
• Suction:
  • Not defined in text
• Frequent respiratory assessment (every 2 to 4 hours):
  • Monitor respiratory status and chest tube function.
• Check tubes for kinks or loops, which can impede drainage.
• Check the water seal chamber for bubbling on exhalation, indicating lung reinflation; tidaling/fluctuation decreases as pleura heals.
• Continuous bubbling indicates an air leak- check tubing and connections first.
• Measure drainage as part of intake and output monitoring.
• Keep the water level in the water seal chamber full.
• Never clamp the chest tube.
• Assist with position changes, ambulation, pain management and encourage coughing and deep breathing.
• Apply occlusive dressing after removal.
• For hemothorax:
  • Monitor H&H and WBC.
  • If removed, cover hole and call for help.

Airway Management

• Problems in respiratory patients can be divided into airway, breathing, and circulation/perfusion issues.
• Ensure the Airway Is Open via assessment and management:
  • Position: If the patient can't maintain their airway, use a head-tilt, chin-lift, or jaw-thrust maneuver.
  • If the tongue is obstructing the airway due to altered mental status, consider an oral airway (no gag reflex) or nasal airway (gag reflex).
  • Determine if long-term airway management and an ET tube are necessary.
• Airway Adjuncts:
  • BIPAP, CPAP, and APAP support patients with intermittent airway obstruction or who require increased airway pressures.
  • Masks and straps must fit snugly to avoid leaks.
  • These devices can cause anxiety, so use relaxation techniques or benzodiazepines; humidify the air to prevent drying.
  • Suction if needed.
  • FBAO maneuvers if appropriate, but if there are adventitious sounds, the airway is likely not patent.
• Adventitious sounds:
  • Snoring indicates a partial obstruction by the tongue; positioning or an OPA can help.
  • Gurgling indicates secretions; remove thick secretions with a finger sweep and suction thin secretions with a yankauer. Follow with oxygenation and continued assessment.
  • Stridor suggests foreign body, infection, or inflammation at the glottis; encourage coughing if possible; if not, use back blows/chest thrusts for infants and abdominal thrusts for older children/adults/CPR for the unresponsive victim.
  • Only sweep out objects that are visible in the mouth
• Airway Maintenance:
  • Address mucus, mucus plugs, and secretions with hydration, suction, mucolytics, TCDB, and chest PT.
• Tracheostomy Care:
  • Care includes managing the inner cannula, stoma, dressing, and ties.
  • Document care given.
• URI & Infections:
  • URI typically caused by a virus.
  • Rhinitis/ Rhinosinusitis
    • Can be allergic or viral
      • Treat with intranasal steroids, antihistamines, decongestants, or saline.
    • Acute Bacterial Rhinosinusitis:
      • Treat with antibiotics if symptoms persist beyond 10 days or worsen after 5-6 days.
  • Pharyngitis:
    • Can be viral or bacterial (strep throat)
  • Tonsillitis
    • Often inflamed with pharyngitis and composed of lymphatic tissue.
    • May require tonsillectomy; monitor for airway, gag reflex, and bleeding post-op.

Upper Airway Disorders

• Obstructive Sleep Apnea:
  • Managed with CPAP, weight loss, or surgery.
• Laryngitis:
  • Treatment includes smoking cessation, URI management, GERD management, and screening for cancer.
• Laryngeal Cancer:
  • Risk factors include smoking, tobacco use, toxin exposures, and GERD.
  • Hoarseness lasting more than 2 weeks may be indicative.

Croup and Related Syndromes

• Laryngotracheobronchitis:
  • Characterized by a brassy or barking cough and often presenting with stridor.
  • Managed with supportive care, hydration, steroids, and nebulized treatments.
• Bronchiolitis and RSV:
  • Viral inflammation that leads to wheezing and dyspnea.
  • Treated with vaccine and/or antiviral medications.
• Acute Epiglottitis:
  • Characterized by tripod positioning, sniffing position, drooling, and muffled voice.
  • Typically bacterial in origin, with acute onset.
  • Requires antibiotics and avoiding ANYTHING IN THE MOUTH, as it can cause laryngospasm and airway obstruction

Influenza

• Influenza is a viral infection of the respiratory tract, spread through droplets - Use PRECAUTIONS!
• Antiviral agents may be started within 24-48 hours of symptom onset to shorten the illness duration by 1 day.
• Biggest concern is development of a secondary infection, especially in elderly, young, and immunocompromised patients.
• Monitor for pneumonia symptoms, such as lingering cough, nighttime cough, fever after feeling better, and lack of energy/appetite after initial improvement.

Breathing Assessment & Management:

• Respiration and Gas Exchange:
  • Lower airway disorders disrupt processes below the glottis, including alveolar ventilation and respiration/gas exchange.
• Assessment and Management:
  • Rate- Is the rate too fast or slow for the patient's age?
    • Consider current conditions such as pain, fear, fever, sleep/activity, and medications.
  • Depth- Is breathing deep, shallow, or normal?
    • Determine if it is constant or fluctuating.
  • Effort- Is the effort normal, increased, or decreased?
  • Adventitious sounds- Are there abnormal sounds?
    • Lower airway disorders impact airflow below the glottis, alveolar ventilation, and respiration (gas exchange).

Asthma

• Asthma is a "intermittent and reversible" airway obstruction due to an immune response.
• Inflammation/edema, bronchoconstriction, and mucus production all decrease the internal diameter of the airways, causing air trapping, prolonged expiratory phase, and wheezing.
• Inflammatory response: cumulative from exposures of the past 7 of days, exacerbated quickly by:
  • Cigarette smoke, mold, pollen, animal dander, roaches, air pollutants, occupational irritants, and dust
• Viral infections (bacterial too), and allergic responses cause inflammation and edema and a potential asthma attack.
• Nasal polyps are part of the allergic Triad: "Allergic Triad" = asthma, aspirin allergy, and nasal polyps
• Emotional responses, as well as food and drug allergies can also trigger an asthma attack.
• Daily control mediations, coupled with a rescue inhaler (SABA) for exacerbated symptoms. Ensure they know how to use them.

Chronic Bronchitis & Emphysema - Chronic Bronchitis

• Chronic inflammation of bronchi and goblet cells causes narrowing/thickening of airways/mucous production.

Chronic Bronchitis & Emphysema - Emphysema

• Damage to the alveolar walls results in loss of elasticity/decreased gas exchange; patients will commonly have air trapping
• Treatment: Bronchodilators, mucolytics, steroidal anti-inflammatories, and O2 to normal (mental status). Those with hypoxic drive can lose their respiratory drive if put on O2; so if needed, give, but be prepared to ventilate if they start hypoventilating.
• Monitor for signs/symptoms of hypoxia:
  • Bronchodilators (albuterol, etc) are given for hypoxia, stimulating the SNS. Therefore, if a patient's HR is high, it will likely lower, but if used daily, it can initially experience an uptick in HR.
  • Look for increased work of breathing, decreased word count, accessory muscle use, positioning, pursed lip breathing, and changes in skin color and condition.
• Monitor for signs and symptoms of pneumonia or infection:
  • Loss of appetite, back pain, fever or chills, increasing SOB, a change in sputum from white to yellow, or an increased productive cough.
  • Need to be seen quickly due to risk for impaired gas exchange.

Cystic Fibrosis

• Autosomal recessive genetic disorder:
  • Impairs chloride transport = difficult respiration, glands in respiratory tract, pancreas, and reproductive parts of the body
  • The person with CF has salty skin/sweat, frequent constipation, bulky frothy foul-smelling stools (steatorrhea), and infants are prone to meconium ileus. The thick GI secretions plug up the pancreas causing failure and requiring enzyme replacement therapy. The respiratory secretions are difficult to clear, leading to an increased risk of infection.
• Treatment:
  • Postural draining with vibrations and the person must get antibiotics

Lung Cancer

• Commonly caused by smoking
• Biopsy to determine type -Small cell is deadliest
• Treatment -Smoking cessation, surgery, radiation, chemo

Pneumonia

Treatment:

• Comfort, rest, VS, respiratory isolation
• Cluster care
• Humidified O2, Hydration, and antipyretics with analgesics coupled with antibiotics and bronchodilators.
• Monitor respiratory

Tuberculosis

Central appetite loss fatigue lungs : chest pain coughing up blood productive

Tuberculosis

• Main symptoms include: Symptoms Of Pulmonary Tuberculosis Central: Appetite or Fatigue Lungs: cough/coughing up blood and chest pain also includes skin as night sweats
• PPD or QuantiFERON gold blood testing (if positive confirm with ppd then cxr)
  • Confirm with chest x-ray
  • Treatment based on risk and ppd size
  • 4-medications for 2 and 2 for 4 months It must be taken seriously to prevent resistant Tb .
• Discuss liver complications, monitor blood work, rifampin turns secretions red-orange, we are attempting to. monitor

Circulation Perfusion:

• The conditions will have an impact on blood flow that will have an impact on respiration
• pulmonary embolus will have chest pain shortness of breath, there are nonspecific T wave changes

ARDS:

• Pulmonary inflammation and edema
  • Overwhelming Inflammatory Response
• Massive fluids shift into the alveolus hypoxia
  • hypoxia despite Oxygenation / or ventilation
• Most commonly related to sepsis and overdose, aspiration etc treatment includes antibiotics to treat any infections, and steroids to decrease inflammation. paralytics and sedation

COVID-19:

• the noble corona virus that emerged in 2019 is what is called Covid19
• the viruses bind and have an affinity with ace2 level in humans, this enzyme expressed in type 2 in alvelor cells
• this condition will currently have occur with chronic pulmonary disease, so the healthier you are the less likely you will have severe issues
• the infection leads to imflamation the pt runs risk for ARDS like failure

Circulation

• Labs monitor and include: ABGs, D-Dimer, CRP (inflammatory markers), and WBCs, AST / ALT, Lactate Serum iron levels are indicators of severity of disease.
• Remdesivir is the antiviral administered for 4 to 10 days.

Chest trauma:

• pain medication is given, it is very critical to have good pain control and if unable breathing.
  • flail chest is 3 or more ribs and 2 or more places decreases intrathoracic pressure
  • Pneumothorax - air in plural space - hemo
  • If hemothorax monitor H&H for decrease blood loss tension pneumothorax in a picture increases compressions causes mediastinum to narrow.