OVERVIEW OF RESPIRATORY SYSTEM:

I. Upper respiratory tract:

Fx:
1. Filtering of air
2. Warming & moistening
3. Humidification
a. Nose – cartilage
- Parts: Rt nostril separated by septum
Lt nostril

- Consists of anastomosis of capillaries –

Kessel – Bach Plexus – site of epistaxis
b. Pharynx (throat) – muscular passageway for air& food
Branches:
1. Oropharynx
2. Nasopharynx
3. Layngopharynx

c. Larynx – voice box

Fx:
1. For phonation
2. Cough reflex

Glottis – opening
Opens to allow passage of air
Closes to allow passage of food

II. Lower Rt – Fx for gas exchange

a. Trachea – windpipe
- has cartillagenous rings
- site for permanent/ artificial a/w – tracheostomy
- Passageway bet. Larynx and bronchi
b. Bronchus – R & L main bronchus
c. Lungs – R – 3 lobes = 10 segments
L – 2 lobes – 8 segments
Visceral pleura – covers lungs
Parietal pleura – covers thorax

Bronchi – bronchioles – teminal bronchioles – resp bronchioles - *tracheobronchial tree 150ml of air

Post pneumonectomy - position affected side to promote expansion of lungs

Post segmental lobectomy – position unaffected side to promote drainage

Lungs – covered by pleural cavity, parietal lobe & visceral lobe

Alveoli – acinar cells
- site of gas exchange (O2 & CO2)
- diffusion: Daltons law of partial pressure of gases
- 300 million/15 to 20 clusters
Type I alveolar cells are
epithelial cells that form the alveolar walls. Type II alveolar cells
are metabolically active. These cells secrete surfactant, a phospholipid
that lines the inner surface and prevents alveolar collapse.
Type III alveolar cell macrophages are large phagocytic cells
that ingest foreign matter (eg, mucus, bacteria) and act as an important
- defense mechanism.
Ventilation – movement of air in & out of lungs
*movement of the walls of thoracic cage and diaphragm
Respiration – movement of air into cells
*gas xchange bet atmospheric air and blood and bet bet blood and cells

Type II cells of alveoli – secretes surfactant

Surfactant - decrease surface tension of alveoli

Lecithin & spinogometer

L/S ratio 2:1 – indicator of lung maturity

If 1:2 – adm O2 - < 40% Concentration to prevent atelectasis & retinopathy or blindness.

I. PNEUMONIA – inflammation of lung parenchyma leading to pulmonary consolidation as alveoli is filled

with exudates.

Etiologic agents:
1. Streptococcus pneumoniae (pnemococcal pneumonia)
2. Hemophilus pneumoniae(Bronchopneumonia)
3. Escherichia coli
4. Klebsiella P.
5. Diplococcus P.

High risk elderly & children below 5 yo

Predisposing factors:
1. Smoking
2. Air pollution
3. Immuno-compromised
a. AIDS – PLP
b. Bronchogenic CA - Non-productive to productive cough
4. Prolonged immobility – CVA- hypostatic pneumonia
5. Aspiration of food
6. Over fatigue

S/Sx:
1. Productive cough – pathognomonic: greenish to rusty sputum
2. Dyspnea with prolonged respiratory grunt
3. Fever, chills, anorexia, gen body malaise
4. Wt loss
5. Pleuritic friction rub
6. Rales/ crackles
7. Cyanosis
8. Abdominal distension leading to paralytic ileus

Sputum exam – could confirm presence of TB & pneumonia

Dx:
1. Sputum GSCS- gram staining & culture sensitivity - Reveals (+) cultured microorganism.
2. CXR – pulmo consolidation
3. CBC – increase WBC
Erythrocyte sedimentation rate
4. ABG – PO2 decrease

Nsg Mgt:
1. Enforce CBR
2. Strict respiratory isolation
3. Meds:
a.) Broad spectrum antibiotics
Penicillin or tetracycline
Macrolides – ex azythromycin (zythromax)
b.) Anti pyretics
c.) Mucolytics or expectorants
4. Force fluids – 2 to 3 L/day
5. Institute pulmonary toilet-
a.) Deep breathing exercise
b.) Coughing exercise
c.) Chest physiotherapy – cupping
d.) Turning & reposition - Promote expectoration of secretions
6. Semi-fowler
7. Nebulize & suction
8. Comfy & humid environment
9. Diet: increase CHO or calories, CHON & vit C
10. Postural drainage - To drain secretions using gravity
Mgt for postural drainage:
a.) Best done before meals or 2 – 4 hrs after meals to prevent Gastroesophageal Reflux
b.) Monitor VS & breath sounds
Normal breath sound – bronchovesicular
c.) Deep breathing exercises
d.) Adm bronchodilators 15 – 30 min before procedure
e.) Stop if pt can’t tolerate procedure
f.) Provide oral care – it may alter taste sensation
g.) C/I – pt with unstable VS & hemoptysis, increase ICP, increase IOP (glaucoma)
Normal IOP – 12 – 21 mmHg
11. HT:
a.) Avoidance of precipitating factors
b.) Complication: Atelectacies & meningitis
c.) Compliance to meds

PULMONARY TUBERCULOSIS (KOCH DSE) - Inflammation of lung tissue caused by invasion of

mycobacterium TB or tubercle bacilli or acid fast bacilli – gram (+) aerobic, motile & easily destroyed by heat or
sunlight.

Predisposing factors:
1. Malnutrition
2. Overcrowding
3. Alcoholism
4. Ingestion of infected cattle (mycobacterium BOVIS)
5. Virulence
6. Over fatigue

S/Sx:
 1. Productive cough – yellowish
2. Low fever
3. Night sweats
4. Dyspnea
5. Anorexia, general body malaise, wt loss
6. Chest/ back pain
7. Hempotysis

Diagnosis:
1. Skin test – mantoux test – infection of Purified CHON Derivative PPD
DOH – 8-10 mm induration
WHO – 10-14 mm induration
Result within 48 – 72h
(+) Mantoux test – previous exposure to tubercle bacilli

Mode of transmission – droplet infection

2. Sputum AFB – (+) to cultured microorganism
3. CXR – pulmonary infiltrate caseosis necrosis
4. CBC – increase WBC

Nursing Mgt:
1. CBR
2. Strict resp isolation
3. O2 inhalation
4. Semi fowler
5. Force fluid to liquefy secretions
6. DBCE
7. Nebulize & suction
8. Comfy & humid environment
9. Diet – increase CHO & calories, CHON, Vit, minerals
10. Short course chemotherapy

- Intensive phase

INH – isoniazide - give before meals for absorption

Rifampicin - given within 4 months, given simultaneously to prevent
resistance
-S/E: peripheral neutitis – vit B6
Rifampicin -All body secretions turn to red orange color urine, stool, saliva,
sweat & tears.

PZA – Pyrazinamide – given 2 mos/ after meals. S/E: allergic rxn, nephrotoxicity & hepatoxicity

Standard regimen
1. Injection of streptomycin – aminoglycoside
Ex. Kanamycin, gentamycin, neomycin
S/E:
a.) Ototoxicity – damage CN # 8 – tinnitus – hearing loss
b.) Nephrotoxicicity – monitor BUN & Crea
HT:
a.) Avoid pred factors
b.) Complications:
1.) Atelectasis
 2.) Miliary TB – spread of Tb to other system
c.) Compliance to meds
- Religiously take meds

HISTOPLASMOSIS- acute fungal infection caused by inhalation of contaminated dust with histoplasma
capsulatum transmitted to birds manure.
S/Sx: Same as pneumonia & PTB – like
1. Productive cough
2. Dyspnea
3. Chest & joint pains
4. Cyanosis
5. Anorexia, gen body malaise, wt loss
6. Hemoptysis

Dx:
1. Histoplasmin skin test = (+)
2. ABG – pO2 decrease

Nsg Mgt:
1. CBR
2. Meds:
a.) Anti fungal agents
Amphotericin B (Fungizone)
S/E :
a.) Nephrotoxcicity check BUN
b.) Hypokalemia
b.)Corticosteroids
c.) Mucolytic/ or expectorants
3. O2 – force fluids
4. Nebulize, suction
5. Complications:
a.) Atelectasis
b.) Bronchiectasis COPD
6. Prevent spread of histoplasmosis:
a.) Spray breading places or kill the bird.

COPD – Chronic Obstructive Pulmonary Disease

1. Chronic bronchitis
2. Bronchial asthma
3. Bronchiectasis
4. Pulmonary emphysema – terminal stage

CHRONIC BRONCHITIS - called BLUE BLOATERS inflammation of bronchus due to hypertrophy or

hyperplasia of goblet mucus producing cells leading to narrowing of smaller airways.

Predisposing factors:
1. Smoking – all COPD types
2. Air pollution
S/Sx:
 1. Prod cough
2. Dyspnea on exertion
3. Prolonged expiratory grunt
4. Scattered rales/ rhonchi
5. Cyanosis
6. Pulmo HPN – a.)Leading to peripheral edema
b.) Cor pulmonary – respiratory in origin
7. Anorexia, gen body malaise

Dx:
1. ABG
PO2 PCO2 Resp acidosis

Hypoxemia – causing cyanosis

Nsg Mgt:
(Same as emphysema)

2.) BRONCHIAL ASTHMA- reversible inflammation lung condition due to hyerpsensitivity leading to
narrowing of smaller airway.
Predisposing factor:
1. Extrinsic Asthma – called Atropic/ allergic asthma
a.) Pallor
b.) Dust
c.) Gases
d.) Smoke
e.) Dander
f.) Lints

2. Intrinsic Asthma-
Cause:
Herediatary
Drugs – aspirin, penicillin, b blockers
Food additives – nitrites
Foods – seafood, chicken, eggs, chocolates, milk
Physical/ emotional stress
Sudden change of temp, humidity &air pressure
3. mixed type: combi of both ext & intr. Asthma
90% cause of asthma

S/Sx:
1. C – cough – non productive to productive
2. D – dyspnea
3. W – wheezing on expiration
4. Cyanosis
5. Mild apprehension & restlessness
6. Tachycardia & palpitation
7. Diaphoresis
Dx:
1. Pulmo function test – decrease lung capacity
2. ABG – PO2 decrease

Nsg Mgt:
1. CBR – all COPD
2. Meds-
a.) Bronchodilator through inhalation or metered dose inhaled / pump. Give 1st before corticosteroids
 b.) Corticosteroids – due inflammatory. Given 10 min after adm bronchodilator
c.) Mucolytic/ expectorant
d.) Mucomist – at bedside put suction machine.
e.) Antihistamine
3. Force fluid
4. O2 – all COPD low inflow to prevent resp distress
5. Nebulize & suction
6. Semifowler – all COPD except emphysema due late stage
7. HT
a.) Avoid pred factors
b.) Complications:
- Status astmaticus- give epinephrine & bronchodilators
- Emphysema
c.) Adherence to med

BRONCHIECTASIS – abnormal permanent dilation of bronchus resulting to destruction of muscular & elastic
tissues of alveoli.

Predisposing factors:
1. Recurrent upper & lower RI
2. Congenital anomalies
3. Tumors
4. Trauma
S/Sx:
1. Productive cough
2. Dyspnea
3. Anorexia, gen body malaise- all energy are used to increase respiration.
4. Cyanosis
5. Hemoptisis

Dx:
1. ABG – PO2 decrease
2. Bronchoscopy – direct visualization of bronchus using fiberscope.
Nsg Mgt: before bronchoscopy
1. Consent, explain procedure – MD/ lab explain RN
2. NPO
3. Monitor VS
Nsg Mgt after bronchoscopy
1. Feeding after return of gag reflex
2. Instruct client to avoid talking, smoking or coughing
3. Monitor signs of frank or gross bleeding
4. Monitor of laryngeal spasm
- DOB
- Prepare at bedside tracheostomy set

Mgt: same as emphysema except Surgery

Pneumonectomy – removal of affected lung
Segmental lobectomy – position of pt – unaffected side

PULMONARY EMPHYSEMA – irreversible terminal stage of COPD

- Characterized by inelasticity of alveolar wall leading to air trapping, leading to maldistribution of gases.
 - Body will compensate over distension of thoracic cavity
- Barrel chest
Predisposing factor:
1. Smoking
2. Allergy
3. Air pollution
4. High risk – elderly
5. Hereditary - a 1 anti trypsin to release elastase for recoil of alveoli.

S/Sx:
1. Productive cough
2. Dyspnea at rest – due terminal
3. Anorexia & gen body malaise
4. Rales/ rhonchi
5. Bronchial wheezing
6. Decrease tactile fremitus (should have vibration)– palpation – “99”. Decreased - with air or fluid
7. Resonance to hyperresonance – percussion
8. Decreased or diminished breath sounds
9. Pathognomonic: barrel chest – increase post/ anterior diameter of chest
10. Purse lip breathing – to eliminated PCO2
11. Flaring of alai nares

Diagnosis:
1. Pulmonary function test – decrease vital lung capacity
2. ABG –
a.) Panlobular / centrolobular emphysema
pCO2 increase
pO2 decrease – hypoxema resp acidosis Blue bloaters
b.) Panacinar/ Centracinar
pCO2 decrease
pO2 increase – hyperaxemia resp alkalosis Pink puffers
Nursing Mgt:
1. CBR
2. Meds –
a.) Bronchodilators
b.) Corticosteroids
c.) Antimicrobial agents
d.) Mucolytics/ expectorants
3. O2 – Low inflow
4. Force fluids
5. High fowlers
6. Neb & suction
7. Institute
P – posture
E – end
E – expiratory to prevent collapse of alveoli
P – pressure
8. HT
a.) Avoid smoking
b.) Prevent complications
1.) Cor pulmonary – R ventricular hypertrophy
2.) CO2 narcosis – lead to coma
3.) Atelectasis
4.) Pneumothorax – air in pleural space
9. Adherence to meds
RESTRICTIVE LUNG DISORDER
PNEUMOTHORAX – partial / or complete collapse of lungs due to entry or air in pleural space.
Types:
1. Spontaneous pneumothorax – entry of air in pleural space without obvious cause.
Eg. rupture of bleb (alveoli filled sacs) in pt with inflammed lung conditions
Eg. open pneumothorax – air enters pleural space through an opening in chest wall
-Stab/ gun shot wound
2. Tension Pneumothorax – air enters plural space with @ inspiration & can’t escape leading to over
distension of thoracic cavity resulting to shifting of mediastinum content to unaffected side.
Eg. flail chest – “paradoxical breathing”

Predisposing factors:
1.Chest trauma
2.Inflammatory lung conditions
3.Tumor
S/Sx:
1. Sudden sharp chest pain
2. Dyspnea
3. Cyanosis
4. Diminished breath sound of affected lung
5. Cool moist skin
6. Mild restlessness/ apprehension
7. Resonance to hyper resonance
Diagnosis:
1. ABG – pO2 decrease –
2. CXR – confirms pneumothorax
Nursing Mgt:
1. Endotracheal intubation
2. Thoracenthesis
3. Meds – Morphine SO4
- Anti microbial agents
4. Assist in test tube thoracotomy
Nursing Mgt if pt is on CPT attached to H2O drainage
1. Maintain strict aseptic technique
2. DBE
3. At bedside
a.) Petroleum gauze pad if dislodged Hemostan
b.) If with air leakage – clamp
c.) Extra bottle
4. Meds – Morphine SO4
Antimicrobial
5. Monitor & assess for oscillation fluctuations or bubbling
a.) If (+) to intermittent bubbling means normal or intact
- H2O rises upon inspiration
- H2o goes down upon expiration
b.) If (+) to continuous, remittent bubbling
1. Check for air leakage
2. Clamp towards chest tube
3. Notify MD
c.) If (-) to bubbling
1. Check for loop, clots, and kink
2. Milk towards H2O seal
 3. Indicates re-expansion of lungs
When will MD remove chest tube:
1. If (-) fluctuations
2. (+) Breath sounds
3. CXR – full expansion of lungs

Nursing Mgt of removal of chest tube

1. DBE
2. Instruct to perform Valsalva maneuver for easy removal, to prevent entry of air in pleural space.
3. Apply vaselinated air occlusive dressing
- Maintain dressing dry & intact