Respiratory System Anatomy and Processes

Respiratory System

• The aim is to perform necessary nursing practices regarding the respiratory system.
• Purposes include applying appropriate nursing interventions for diagnosis and treatment.

Lung Location and Anatomy

• The lungs occupy the thoracic cavity except for the mediastinum, which houses the heart, great blood vessels, bronchi, esophagus and other organs.
• The surface of each lung is covered with a visceral serosa called the visceral pleura.
• The walls of the thoracic cavity are lined by the parietal pleura.
• There exists a negative pressure between both pleurae.
• Surfactant is secreted by the epithelium, covering alveoli and preventing lung collapse.

Respiratory Processes

• Respiration involves the following processes: ventilation, diffusion, perfusion, and regulation.
• Ventilation includes inspirations (air moves in) and expiration - air is pushed out.
• Ventilation depends on the elasticity of the lungs.
• External air is pulled into the lungs due to an increase in intrapulmonary volume.
• Forced expiration occurs mostly by contracting internal intercostal muscles to depress the rib cage.

Diffusion and Perfusion

• Diffusion is the spontaneous movement of gases without energy, between gas in the alveoli and blood in capillaries.
• Perfusion occurs as the cardiovascular system pumps blood throughout the lungs.
• Diffusion and perfusion are assessed by measuring the level of oxygen in the blood.
• The combination of hemoglobin with oxygen is expressed as % saturation, generally between 95% and 100%.

Respiratory Mechanism

• It begins with warming and moistening air in the mouth or nasal cavity.
• Air flows through the pharynx, larynx, and trachea to the bronchi.
• Air flows from the bronchi to bronchioles in the lungs, reaching the alveoli, the farthest air sacs.
• Oxygen and carbon dioxide are exchanged in the alveoli.
• Oxygen participates in the circulation depending on Hgb in the erythrocyte and is given to the cells depending on the body's needs
• Carbon dioxide separates from erythrocytes, passes through capillary membrane pores to alveoli as oxygen leaves the alveoli and enters the blood

Regulation and Factors Affecting Oxygenation

• Respiration is regulated by the respiratory center in the medulla oblongata and pons
• Factors affecting oxygenation include health status, age, lifestyle, and environmental factors.

Factors related to health status

• Blood diseases like anemia.
• Myocardial muscle contraction problems.
• Increased metabolic rate due to exercise, infection, fever, pregnancy, and wound healing.
• Musculoskeletal disorders like costa fractures and kyphosis.
• Carbon monoxide (CO) poisoning reduces oxygen transport capacity.
• Chronic diseases.

Age-Related Factors

• Oxygen requirement is increased in premature infants.
• Oxygen requirements are decreased in the elderly.

Factors related to lifestyle

• Inadequate and unbalanced nutrition and obesity.
• Exercise.
• Drug use
• Anxiety.

Drug use

• Drug (narcotic) overuse suppresses the respiratory center resulting in decreased respiratory depth and rate and consequently reduced oxygen intake.

Environmental Factors

• Polluted air.
• High altitude places; Oxygen concentration in the atmosphere is low.

Examination of the Chest

• Involves inspection using the eyes, palpation using the hands, and auscultation using a stethoscope.

Inspection

• Assessment includes, position of the patient, size, shape and symmetry of the chest.
• Assess for thoracic deformities such as bilateral or unilateral issues.
• Status of the skin including colour, turgor.
• Assess muscular development and look for vascular anomolies.
• Also look at respiratory rate and rhythm, including frequency, regularity, and duration of breathing.

Respiratory Rate

• Eupnea is considered natural or normal breathing
• Bradypnea involves an abnormal slowing of respiration resulting from conditions such as a central nervous system disease or drugs
• Tachypnea involves an abnormal increase of breathing frequency resulting from things like severe pain, chronic pulmonary or cardiac diseases, and anxiety.

Abnormal Breathing Patterns

• Dyspnea is hard breathing
• Apnea : Temporary cessation of breathing
• Hyperpnea : Increased depth of breathing (metabolic acidosis)
• Use of accessory muscles during respiration: (diseases with dyspnea)

Thoracic Deformities

• Pectus excavatum/ Funnel Chest, abnormality of connective tissue causing a depression of the sternum.
• Pectus carinatum(pigeon chest): sternum is raised
• Barrel chest isn't a disease, but suggests an underlying condition.

Auscultation

• With breath sounds produced as air moves through the tracheobronchial tree
• Turbulent air flow in large airways creates vibrations transmitted to the chest wall.
• Stethoscope must contact the skin.
• Listening through clothing is unacceptable.

Normal Breath Sounds

• Tracheal sounds are heard over the trachea; the sounds are harsh and like air blown through a pipe.
• Bronchial sounds are present over the large airways in the anterior chest near the second and third intercostal spaces.
• Bronchovesicular sounds are heard in the posterior chest between the scapulae and in the center part of the anterior chest.
• Vesicular sounds are soft, blowing, or rustling sounds normally heard throughout most of the lung fields.

Abnormal Breath Sounds

• Rales involve small clicking, bubbling, or rattling sounds during inhalation.
• Rhonchi sounds resemble snoring.
• Stridor sounds are wheeze-like, heard when a person breathes.
• Wheezing is high-pitched sounds produced by narrowed airways.
• Pleural friction sounds result from the inflammation of the pleura

Changes in Respiratory Function

• Tachypnea: Respiratory rate is more than 24/min
• Bradypnea: Respiratory rate is less than 10/min
• Hyperventilation: increased rate and depth of breathing
• Hypoventilation : decreased rate and depth of breathing irregular

Anoxia, Hypoxia, Dyspnea and Cyanosis Defined

• Anoxia: Absence of oxygen
• Hypoxia: Cells and tissues cannot get enough oxygen
• Dyspnea: Difficult breathing
• Cyanosis: Bluish or purplish discolouration of the skin or mucous membranes, having low oxygen saturation, can be observed from the lips, ear lobes, nails and oral mucosa.

Diagnostic Procedures

• Tests measuring oxygenation and ventilation adequacy.
• Respiratory Function Tests -SFT.
• Arterial Blood Gas Measurement.
• Blood Analysis.
• Tests evaluating respiratory system structure, such as X-rays, bronchoscopy, Lung Scan.
• Tests determining respiratory tract infection and the presence of abnormal cells, which include throat culture, sputum culture, and thoracentesis.

Respiratory Function Tests

• Determining the lungs' ability to exchange O2 and CO2.
• Lung volumes are measured by Spirometry.
• PH Normal values: 7.35-7.45
• PO2 Normal values: 80-100 mm Hg
• PaCO2 Normal values: 35-45 mm Hg
• Analysis - Erythrocyte, Hemoglobin, and Hematocrit testing are performed.

Purposes of Respiratory System Applications

• To use the lungs with maximum capacity.
• To throw pulmonary secretions.
• To provide airway opening.
• To provide tissue oxygenation.
• To improve Cardio-Pulmonary function.

Lung Capacity Interventions

• To maximize lung capacity, interventions include positioning, breathing exercises, assisted breathing devices, mechanical ventilator, and chest tube usage.

Positioning

• In immobile patients, secretion accumulates in the lungs and airways.
• The chest wall cannot expand sufficiently.
• Positioning options include are Right Lateral, Semifowler, Left Lateral, Supine
• Position should be changed at least once every 2 HOURS

Breathing Exercises

• Interventions: Deep breathing exercise, Coughing exercise, and Extension of expiration.

Deep breathing exercise

• On the bed, the knees should be slightly bent
• The patients hands must be under the costas, so they can feel the diaphragm
• Take breath deep from the nose, hold it.
• Exhale leaving the mouth open and slowly (like whistling)
• The process is repeated 5-10 times.

Cough exercise

• Involves performing 3 deep breathing exercises, after which a deep breath is taken.
• Intermittently cough with force during the process.
• Repeat the process 3-5 times

Extension of expiration/ Pursed-lip Breathing

• The patient must sit In fowler position
• Breathe deeply then purse your lips, followed by slowly leaving air, counting up to 4.

Assisted Breathing Devices: Triflow

• It provides increase inspiration.
• Especially helps in the post-op period
• Provides visual notification to the patient
• As each breath moves, the balls move up

Mechanical Ventilation

• It provides the respiratory function artificially with the help of a device.
• Applying a tube that will not be aspirated.

Chest Tube

• It is a system that allows one-way discharge of fluid or air from the pleural cavity with a closed drainage system.

Removal of Pulmonary Secretions

• Includes, hydration, nebulization, moistening/humidification, and postural drainage.

Hydration

• Deliver Sufficient fluid to the patient; 1500-2000 cc fluid / day, unless restricted.
• Softens secretions within the lungs.

Moistening/ Humidification

• Providing heat and humidity to facilitates easier removal of secretions from airways/ mucous membranes.

Nebulization

• Facilitates secretion removal by using bronchodilators and mucolytic drugs.
• The drug is mixed with water and inhaled, and after nebulization, the mouth MUST be rinsed.

Postural Drainage

• It involves getting in positions that makes it easier for mucus to drain.
• It can be aided by the use of Bronchodilators, Steam, and Oxygen.
• Cupping hands can help with chest percussions.

Postural Drainage Contraindications

• Hemorrhage disorder, osteoporosis, and rib fracture are contraindications.

Maintaining an Open Airway

• Can be achieved with cough exercises, aspiration, airway applications, and tracheostomy.

Cough Exercises

• Remove secretions by coughing.
• Conduct with deep breathing exercises
• If sputum is too much, it is done every in a 2-3 hours at night

Aspiration

• If the secretion is not removed with cough, then aspiration is done.

Aspiration Techniques

• Orafarengeal and nasopharyngeal
• Orotrakeal and Nasotrakeal
• Endotracheal

Aspiration Indications

• Expression of the Patient, Wheezing, Cough, Presence of Secretion, Tachypnea, Hyperventilation, Cyanosis
• Tachycardia, Rhythm Problems, Increased Blood Pressure, Sweating, Unrest

Basic Aspiration Rules

• The aspiration catheter is for single use only.
• Aspiration is done in accordance with aseptic technique, and is applied- wash.
• The aspiration process does not take longer than 15 seconds.
• There should be 20-30 seconds between two applications.
• The mouth secretions must be cleaned
• It is not aspirated more than 3 times at a time.
• Use sterile equipment and gentle approach for the patient

Aspiration Pressure

• Adult: 100-120 mmHg / Probe no: 12-14
• In children: 50-100 mmHg / Probe no: 8-10
• In newborns: 40-60 mmHg / Probe no: 6
• too much negative pressure causes pneumothorax

Aspiration tools

• Required equipment, Aspirator, Aspirator probe, Sterile gloves, Ambu, Oxygen source, Airway, Sterile water
• An aspirator also requires a pressure monometer

Oropharyngeal / Nasopharyngeal Aspiration

• The patient is informed and placed in a semi-Fowler position with head turned to the side.
• Use hand hygiene and gloves.
• Use a sterile hand
• Turn up the head.
• The aspirator is opened and the mouth is aspirated slowly, including the pharynx,
• If there is a problem in the mouth, aspiration is performed from the nose to the pharynx.

Orotracheal and Nasotracheal Aspiration

• Conducted through the mouth or nose.
• Nose is more preferred.
• The catheter is extended up to the trachea.
• If orotracheal aspiration is to be done, an airway is placed
• The process: Patient needs oxygen, requires, a set time.

Precautions related to aspiration

• The aspiration catheter is handled in accordance with the aseptic technique.
• The pressure should be carefully monitored.
• Ensure it is a tube

Airway tools

• Oral, Endotracheal, Nasotracheal, and Tracheostomy tube

Oral Airway

• Is a medical device, used to maintain or open the existing airway.

Function of Oral Airways

• Prevents the tongue from covering the epiglottis, which would prevent breathing.
• Provides sudden respiratory support such as keeping an airway open and ventilation
• Used mainly in emergency situations or short term scenarios.

The following are scenarios to be considered;

• Consciousness if their level is descernding.
• mechanical ventilator connected.

Inserting an Oral Airway

• In an unconscious patient, place them in the supine position with neck extended.
• Insert the airway into the mouth at a downward slope.
• Rotate to turn the airway to be inside the mouth.
• Ensure that teeth are protected, if the airway is inserted the wrong way, harm can be caused
• Check respiration.

Tracheostomy Tubes

• These are placed to maintain air way or support the functions of pulmonary sections.
• Tracheostomy, an operative procedure, creates a surgical airway.
• A tube is placed through an opening that provides an airway and removes secretions from the lungs.
• In patients with tracheostomy sites, its useful to do the following, perfrom regular dressings to prevent/ control infections and follow surgical asepsis.

Tracheostomy indication

• Bypass an obstructed upper airway.
• Enable cleaning to remove secretions from the airway.
• Aid delivering more easily, and more safely, oxygen to the lungs.

Applying Oxygen Therapy

• Treatment must be given at the levels set by doctors, including: - Following appropriate sterilzation of material and use appropriate air way.
• Ensure material is clean, and water has no contamination.
• Frequent observation of skin around tubing around sites for irration

Care guidelines for the application area

• Check the patient at equal intervals in order to avoid suffocation.
• Use flow meter to regulate treatment.
• Clean the areas with appropriate and high standards
• Keep area around and tubing clear from source for fire
• No smoking, or use of high heat devices.

Oxygen Mask Considerations

• The 60/ 100% rule can occur with high oxygen toxicity levels causing CO2 to build up creating physical decline and even potential death
• Blindness in new born.

Indications of Oxygen Toxicity

• Trouble behind the sternum.
• Nausea and vomiting.
• Lethargy in the extremities.
• Weakness.
• Confusion
• Therefore constant monitoring is very important