Respiratory Assessment: Ventilation and Perfusion

• Ventilation involves air movement into and out of the lungs through inspiration and expiration.
• Ventilation is driven by the diaphragm and intercostal muscles.
• Perfusion is the delivery of oxygenated blood to tissues with the removal of carbon dioxide.
• Respiration is the biochemical exchange of gases occurring at the alveolar and cellular levels.

History Taking: Assessment Questions

• Focused assessment questions need to be included when assessing a person's respiratory condition.
• Current complaints include shortness of breath (dyspnea), wheezing, chest tightness, persistent cough, sputum production, fatigue, and recent infections.
• The OPQRST framework should be used when assessing signs and symptoms.
• "O" in OPQRST refers to the onset of the symptoms, whether gradual or sudden.
• "P" refers to factors that make the symptoms better or worse, such as exertion, lying flat, or environmental triggers.
• "Q" refers to describing the symptoms, such as sharp pain, tightness, or productive or dry cough.
• "R" refers to the location of the discomfort and whether it radiates.
• "S" refers to rating the severity of symptoms on a scale from 0-10.
• "T" refers to whether the symptoms are constant or intermittent, and if they worsen at a certain time of day.
• "U" refers to what the patient thinks is causing the symptoms.
• Past medical history includes chronic respiratory illnesses such as asthma, COPD, pneumonia, CHF, cystic fibrosis, and tuberculosis.
• Include previous hospitalizations or the need for oxygen therapy in the past medical history.
• Smoking and drug use includes pack-year history (cigarettes per day x years smoking).
• Vaping, illicit drug use, especially inhaled substances like marijuana, methamphetamines, and crack cocaine, needs to be included in the history taking.
• Allergies: Note environmental, food, and medication allergies that might exacerbate an individuals respiratory conditions.
• Medications: Bronchodilators (Albuterol, Ipratropium).
• Medications: Corticosteroids (Prednisone, Fluticasone).
• Medications: Leukotriene receptor antagonists (Montelukast).
• Family history includes a history of asthma, COPD, lung cancer, or genetic disorders like cystic fibrosis.
• Travel, work, and exposures include recent travel to areas endemic for tuberculosis or fungal infections.
• Travel, work, and exposures include occupational exposure to dust, chemicals, or irritants.

Assessment (Physical Exam)

• Inspection: Assess the general appearance for signs of respiratory distress, such as nasal flaring, accessory muscle use, or tripod positioning.
• Inspection: Note any cyanosis, differentiating between central (lips, tongue) and peripheral (fingers, toes) cyanosis.
• Inspection: Look for nail clubbing, which indicates chronic hypoxia.
• Inspection: Note the shape of the thorax, such as barrel chest (COPD), kyphosis, or scoliosis.
• Palpation: Check for tracheal deviation, which could indicate pneumothorax or pleural effusion.
• Palpation: Assess tactile fremitus, which is increased in pneumonia and decreased in pleural effusion.
• Percussion: Hyperresonance indicates pneumothorax or emphysema.
• Percussion: Dullness indicates pleural effusion or pneumonia.
• Auscultation: Crackles (rales) indicate fluid overload, pneumonia, or CHF.
• Auscultation: Wheezing indicates bronchospasm, associated with asthma or COPD.
• Auscultation: Stridor indicates upper airway obstruction.
• Auscultation: Absent breath sounds indicate pneumothorax or pleural effusion.

Diagnostic Testing

• Pulse Oximetry measures oxygen saturation (SpO2).
• Pulse oximetry can be unreliable in anemic patients, and carbon monoxide poisoning needs to be accounted for.
• Capnography (End-Tidal CO2 Monitoring) is used in patients on ventilators or post-surgery.
• Arterial Blood Gases (ABGs) assess oxygenation, ventilation, and acid-base status.
• Normal ABG values: pH: 7.35-7.45.
• Normal ABG values: PaCO2: 35-45 mmHg.
• Normal ABG values: HCO3: 22-26 mEq/L.
• Normal ABG values: PaO2: 80-100 mmHg.
• Chest X-ray (CXR): Pneumonia leads to Consolidation.
• Chest X-ray (CXR): CHF leads to Pulmonary edema, enlarged heart.
• Chest X-ray (CXR): Pneumothorax leads to absent lung markings.
• Sputum Culture identifies bacterial, fungal, or viral infections.
• It's important to ensure the proper sputum collection technique
• Pulmonary Function Tests (PFTs): Obstructive diseases (asthma, COPD) will have a Decreased FEV1/FVC ratio.
• Pulmonary Function Tests (PFTs): Restrictive diseases (fibrosis, scoliosis) will have a Decreased lung volume.

Respiratory Interventions

• Oxygen Therapy: Nasal Cannula (1–6 L/min) is good for use with Mild hypoxia.
• Oxygen Therapy: Non-Rebreather Mask (10–15 L/min) is good for Severe hypoxia.
• Oxygen Therapy: Venturi Mask delivers a Specific FiO2 in COPD.
• BİPAP/CPAP provides Non-invasive ventilation.
• Intubation and Mechanical Ventilation occur with Severe respiratory failure.
• Medications & Treatments includes bronchodilators.
• Short-acting beta-agonists (SABAs) like Albuterol, is used as a rescue inhaler.
• Long-acting beta-agonists (LABAs) like Salmeterol, is for maintenance.
• Corticosteroids include Inhaled Fluticasone.
• Corticosteroids include Oral/IV Prednisone or methylprednisolone for exacerbations.
• Mucolytics like Acetylcysteine are used with Cystic Fibrosis and chronic bronchitis.
• Antibiotics are used to treat Pneumonia, with bacterial exacerbations of COPD.
• Anticoagulants are used to treat Pulmonary embolism.

Chest Tube Management

• Monitor drainage: Normal output is <100 mL/hr.
• Water seal chamber: Continuous bubbling indicates a leak.
• Keep tubing free of kinks.
• Never clamp chest tube without an order.

Common Respiratory Conditions

• Asthma triggers include: Allergens, cold air, and exercise.
• Asthma management involves: Rescue (Albuterol) + Controller (ICS, LABA).
• Asthma complication: Status asthmaticus (severe attack unresponsive to meds).
• COPD involves Chronic bronchitis + emphysema.
• COPD oxygen therapy goal: SpO2 88-92%.
• COPD patients are often found in a tripod positioning, with pursed-lip breathing.
• COPD exacerbations are treated with bronchodilators, steroids, and antibiotics.
• Pneumonia can either be Community-acquired or hospital-acquired (HAP).
• Pneumonia treatment: Antibiotics, oxygen, hydration, and incentive spirometry.
• Pulmonary Embolism symptoms include Sudden dyspnea, chest pain, and tachycardia.
• Pulmonary Embolism can be diagnosed with a CT angiogram and D-dimer.
• Pulmonary Embolism Treatment: Anticoagulation (heparin, warfarin, DOACs).
• Cystic Fibrosis is characterized by Thick mucus production affecting the lungs and pancreas.
• Cystic Fibrosis management includes Chest physiotherapy, pancreatic enzymes, and nebulized saline.
• Tuberculosis symptoms include Night sweats, weight loss, and hemoptysis.
• Tuberculosis isolation requires: Airborne precautions (N95 mask).
• Tuberculosis treatment: RIPE therapy (Rifampin, Isoniazid, Pyrazinamide, Ethambutol).

Understand ventilation, perfusion, and respiration in respiratory assessment. Focused questions, including OPQRST (onset, provocation, quality, region/radiation, severity, and timing), guide sign/symptom evaluation. Key factors include dyspnea, wheezing, cough, and recent infections.