WHAT IS OXYGENATION?

➢ When the air comes into your nose it gets

• A dynamic interaction involving the transport
of Oxygen to all the body parts and the
removal of Carbon dioxide.
ESSENTIAL COMPONENTS OF OXYGENATION:
1. Lungs
2. Heart
3. Blood Vessels
4. Red Blood Cells (RBC)
MAIN PROCESSES OF OXYGENATION:
1. Gas Exchange
2. Gas Transport
3. Gas Carrying Mechanism
WHAT IS RESPIRATORY SYSTEM?
• Respiratory system is the system that helps
you breathe in and out, so oxygen (02) can
be pumped through your body and carbon
dioxide (CO2) can be removed from the
blood stream. You must remember that the
Respiratory system is made up of many
different organs.
ANATOMY OF THE RESPIRATORY SYSTEM
It composed of two (2) divisions which are:
1. UPPER RESPIRATORY TRACT
Consist of:
➢ Nose
➢ Paranasal sinuses
➢ Pharynx, tonsils and adenoids
➢ Larynx
➢ Trachea
filtered by tiny hair and it is moistened by
the mucus that is in your nose.
➢ Your sinuses also help out with your
Respiratory System. They help to moisten
and heat the air that you breath.
➢ Air can also get into your body through your
mouth/oral cavity but air is not filtered as
much when it enters in through your mouth.
NOSE
It composed of two (2) nostrils (nares) that
functions as the openings of air to enter.
Anterior Nares - nostrils or external openings into
the nasal cavities.
Posterior Nares - openings from the nasal cavity
into the nasopharynx.
NASAL SEPTUM
• Partition or walls lined with mucous
membranes that have rich blood supply.
NASAL CAVITY
1. Contains cylindrical passages enclosed by
facial bones.
2. Contains thin body plates in each nostril
which are covered with a mucous
membrane and with many blood vessels.
3. Traps dust and foreign particles.
4. Raises the temperature of cold air before it
enters the lungs.

2. LOWER RESPIRATORY TRACT

Consist of: Angela C.
➢ Nose
➢ Paranasal sinuses
➢ Pharynx, tonsils and adenoids
➢ Larynx
➢ Trachea
THE UPPER RESPIRATORY TRACT
THE NOSE AND THE MOUTH
OLFACTORY RECEPTOR

• Located in the nasal cavity

• Sense of smell
PARANASAL SINUSES
Air-filled spaces inside the bone:
1. Frontal
2. ethmoidal
3. sphenoidal
4. Maxillary

➢ Cavities in the skull

➢ Around the nasal area
➢ Connected to nasal cavity by short ducts
➢ Mucous membranes
➢ Resonance for the voice
MUCOUS MEMBRANE
Produces mucous by Goblet cells in which it helps
to trap dirt and pathogens such as germs or
microorganisms.
CILIA
It is a tiny hair-like structure in nasal cavity.
Internal part: merge with external nose.
Posteriorly, it connects with the pharynx or throat
via two openings called the internal nares.
THREE SECTIONS:
➢ Traps dirt
➢ Traps pathogens NASOPHARYNX – upper portion behind nasal
➢ Trapped particles pushed toward the cavities.
esophagus.
OROPHARYNX – middle section, located behind
Sample image of a Cilia: oral cavity.
LARYNGOPHARNX – located behind the larynx or
bottom section of the pharynx.

THE LOWER RESPIRATORY TRACT

It consists of:

• LUNGS, which contain the bronchial and

alveolar structures needed for gas
exchange.
• PLEURA
• MEDIASTINUM
LARYNX BRONCHIAL AND BRONCHIOLES
It is also known as “voice box”. It is a cartilaginous • It branches from the secondary bronchi and
epithelium-lined organ that connects the pharynx divide into smaller tubes: terminal and
and the trachea. respiratory bronchioles.
• Smallest airways less than 1mm in diameter
• Epiglottis
• Glottis
• Thyroid cartilage
• Cricoid cartilage

• Arytenoid cartilages:
• Vocal cords
TRACHEA
It is the “windpipe”. It is composed of smooth
muscle with C-shaped rings of cartilage at regular
intervals.

• These bronchi tubes split up, like tree

branches, and get smaller and smaller
inside your lungs.
• The air flows past your bronchi tubes and
into your bronchiole. These tubes keep
getting smaller and smaller until they finally
end with small air sacs (called alveoli).

BRONCHIAL TREE

• Secondary or lobar bronchi

• 3 branches on right ; 2 on left
• Tertiary or segmental bronchi
• 10 branches on right; 8 on left
 • Bronchi lined with pseudostratified ciliated
columnar epithelium
• Held open by complete rings of cartilage

ALVEOLI

PRIMARY /MAINSTEM BRONCHI

RIGHT LEFT
• shorter & wider • longer, narrower,
vertical to trachea • branches off at 45
THE ALVEOLI AND CAPILLARY NETWORK
• most frequent route degrees
of aspirated material • Your alveoli are tiny air sacs that fill up with
air/oxygen when you breath in.
• Your alveoli are surrounded by many tiny
LUNGS blood vessels called capillaries.
RIGHT LUNG – it composed of three (3) sections • The walls of your alveoli (and capillaries)
or lobes: are so thin that the oxygen or carbon
dioxide can pass through them, traveling
➢ superior, middle, and inferior right into, or out of your blood stream.
LEFT LUNG – it composed of two (2) lobes: 300 Million, clustered into 15-20, surrounded by
➢ Superior & inferior capillaries, the walls of the alveoli are exceedingly
thin and are only one.
Smaller
TYPES OF ALVEOLI:
➢ Heart lies more to the left side of the chest.
TYPE I - epithelial cells that form the alveolar wall
TYPE II - metabolically active, secrete surfactant

• SURFACTANT – phospholipid that prevents

alveolar collapse/reduces surface tension in
the alveoli.
REMINDER:
TYPE III - alveolar cell macrophages
RIGHT LUNG – 3 LOBES
ANATOMY OF THE RESPIRATORY SYSTEM
LEFT LUNG – 2 LOBES
 RESPIRATORY SYSTEM PHYSIOLOGY
OXYGEN

CARBON DIOXIDE

WHY DO WE NEED TO BREATH?

PLEURA
A double-walled membrane that encloses the
lungs.
1. Visceral layer covers lung tissue.
2. Parietal layer lines inside of chest wall, &
upper surface of diaphragm.
RESPIRATION CAUSES OF INCREASED AIRWAY
RESISTANCE
It is the whole process of gas exchange between
the atmospheric air and the blood and between the
blood and cells of the body.

• Exchange of 02 (oxygen) & C02 (carbon

dioxide)
VENTILATION
Is a movement of the walls of the thoracic cage and
of its floor, the diaphragm.

• Movement of air in and out of the lungs. LUNG COMPLIANCE

• Fact:10,000 L of air are filtered ,warmed
and humidified daily.
PHYSICAL FACTORS THAT GOVERN AIRFLOW
IN AND OUT OF THE LUNGS:
• are collectively referred to as the mechanics
of ventilation.
• Air pressure variances,
• Airway resistance,
• Lung compliance.
• It is the elasticity and expandability of the
lungs and thoracic structures.
• Compliance is determined by examining the
volume–pressure relationship in the lungs
and the thorax.
• Compliance is normal (1 L/cm H2O) if the
lungs and the thorax easily stretch and
distend when pressure is applied.
INCREASED COMPLIANCE

AIR PRESSURE VARIANCES • The lungs have lost their elastic recoil and
become overdistended (e.g., in
Air flows from a region of higher pressure to a
emphysema).
region of lower pressure.
DECREASED COMPLIANCE
DURING INSPIRATION
• The lungs and the thorax are “stiff.”
• Movements of the diaphragm and
intercostal muscles enlarge the thoracic e.g., morbid obesity, pneumothorax, hemothorax,
cavity and thereby lower the pressure inside pleural effusion, pulmonary edema, atelectasis,
the thorax to a level below that of pulmonary fibrosis, and acute respiratory distress
atmospheric pressure. syndrome (ARDS).
• Air is drawn through the trachea and the
FACTORS THAT DETERMINE LUNG
bronchi into the alveoli.
COMPLIANCE:
DURING EXPIRATION
• The surface tension of the alveoli.
• The diaphragm relaxes and the lungs recoil, • The connective tissue and water content of
resulting in a decrease in the size of the the lungs.
thoracic cavity. • The compliance of the thoracic cavity.
• Alveolar pressure then exceeds
RESPIRATORY DRIVE
atmospheric pressure, and air flows from
the lungs into the atmosphere. Normally we breathe to remove CO2 from the body,
AIRWAY RESISTANCE NOT to get oxygen in.
AUTOMATIC FUNCTION:
• Is determined by the radius, or size of the
airway through which the air is flowing, as Primary drive: increase in arterial CO2
well as by lung volumes and airflow velocity.
Secondary (hypoxic) drive: decrease in arterial
O2
LUNG VOLUMES AND CAPACITIES
Lung volumes are categorized as:

• Tidal volume,
• Inspiratory reserve volume,
• Expiratory reserve volume,
• Residual volume.
Lung capacity is evaluated in terms of:
• Vital capacity,
• Inspiratory capacity,
• Functional residual capacity,
• Total lung capacity.
PRESSURES:
• Atmospheric pressure - outside the body
• Intrapulmonary pressure - inside the lungs
• Intrapleural pressure - intrapleural spaces
EXCHANGE OF O2 AND CO2
• Exchange of O2 and CO2 by passive
process : diffusion
• Gases move from an area of high pressure
to low pressure
• DALTON’S LAW - each gas in a mixture
exerts its own pressure as if all other gases
were not present.
PULMONARY PERFUSION

• It is the actual blood flow through the

pulmonary vasculature.
• The blood is pumped into the lungs by the
right ventricle through the pulmonary artery.
• Normally, about 2% of the blood pumped by
PULMONARY DIFFUSION AND PERFUSION the right ventricle does not perfuse the
alveolar capillaries.
PULMONARY DIFFUSION

• It is the process by which oxygen and

carbon dioxide are exchanged from areas of
high concentration to areas of low
concentration at the air-blood interface.
• alveolar–capillary membrane is ideal for
diffusion
2 PHASES OF PULMONARY VENTILATION
INHALATION
PULMONARY CIRCULATION
It is considered a low-pressure system because the
systolic blood pressure in the pulmonary artery is
20 to 30 mm Hg and the diastolic pressure is 5 to
15 mm Hg.

• Negative (-) pressure

• Lung expansion
EXPIRATION

• Positive (+) pressure

• Lung recoil, decrease in size

PULMONARY ARTERY PRESSURE is not great
enough to supply blood to the apex of the lung
against the force of gravity.
VENTILATION AND PERFUSION BALANCE AND
IMBALANCE
Adequate gas exchange depends on an adequate
ventilation–perfusion (V./Q.) ratio.
V./Q. imbalance occurs as a result of inadequate
ventilation, inadequate perfusion, or both.
CAUSES OF ALTERED VENTILATION:

• Airway blockages
• Local changes in compliance
• Gravity
4 POSSIBLE (V./Q.) STATES IN THE LUNG:
1. Normal V/Q – 1:1 ratio
2. Low V/Q – <1 shunt unit Q↑ = blood
bypasses alveoli w/out gas exchange:
obstructed airway (shunt)
3. High V/Q - >1 dead space V↑ = blocked
PERFUSION alveoli do not have enough blood supply:
emboli, MI (dead space)
• A process of circulating blood through the
capillary bed. 4. Absent V/Q – 0 silent unit = no V/Q:
pneumothorax, ARDS, imbalance =
Perfusion Requirements: shunting = hypoxia (silent unit).

• Adequate blood volume

• Adequate haemoglobin
• Intact, non-occluded pulmonary capillaries
• Functioning Left Heart

PULMONARY CIRCULATION VENTILATION AND PERFUSION RATIO (V/Q)

Upright position:

• The pulmonary artery pressure is not great

enough to supply blood to the apex of the
lung against the force of gravity.
• Poor blood supply.
Lying down turns to one side:

• More blood passes to the dependent lung.

PERFUSION is also influenced by alveolar
pressure.
V./Q. IMBALANCE
Pulmonary artery pressure, gravity, and alveolar
V./Q. imbalance causes shunting of blood, resulting
pressure determine the PATTERNS OF
in hypoxia (low level of cellular oxygen)
PERFUSION.
Severe hypoxia results when the amount of
shunting exceeds 20%.
Oxygen therapy may eliminate hypoxia. GAS EXCHANGE
VENTILATION AND PERFUSION RATIO RBC AND HEMOGLOBIN

• A single Erythrocyte contains 300 million

hemoglobin molecules.
• One hemoglobin molecule can transport
four oxygen molecules.
• There are more than one billion oxygen
molecules
PARTIAL PRESSURE OF GASES
GASEOUS MIXTURE:

• nitrogen (78.6%)
• oxygen (20.8%)
• with traces of carbon dioxide (0.04%)
• water vapor (0.05%)
• helium
• argon
GAS EXCHANGE
Partial Pressure

• It is the pressure exerted by each type of

gas in a mixture of gases.
The partial pressure of a gas

• It is proportional to the concentration of that

gas in the mixture.
• The total pressure exerted by the gaseous
mixture, whether in the atmosphere or in the
lungs, is equal to the sum of the partial
pressures.
“The total pressure exerted by the gaseous mixture,
whether in the atmosphere or in the lungs, is equal
to the sum of the partial pressures.”
The atmospheric pressure at sea level is about 760
mm Hg.
The partial pressure computation:

• Nitrogen in the atmosphere at sea level is

78.6% of 760, or 597 mm Hg
• Oxygen is 20.8% of 760, or 158 mm Hg
ONCE THE AIR ENTERS THE TRACHEA,
It becomes fully saturated with water vapor.
• Water vapor exerts a pressure of 47 mm
Hg.
• When it fully saturates a mixture of gases at
the body temperature of 37°C (98.6°F).
• Nitrogen and oxygen are responsible for
almost all of the remaining 713 mm Hg
pressure.
ONCE THIS MIXTURE ENTERS THE ALVEOLI,
• It is further diluted by carbon dioxide.
• The water vapor continues to exert a
pressure of 47 mm Hg.
• The remaining 713 mm Hg pressure is now
exerted as follows:
▪ Nitrogen, 569 mm Hg (74.9%);
▪ Oxygen, 104 mm Hg (13.6%);
▪ Carbon dioxide, 40 mm Hg (5.3%).
THE CHANGES IN PARTIAL PRESSURE
FIGURE 20-5 – The changes in Partial pressure
ALVEOLAR GAS EXCHANGE
The loading of oxygen and the unloading of carbon
dioxide in the lungs.
EFFECTS OF PRESSURE ON OXYGEN
TRANSPORT
▪ Oxygen and carbon dioxide are transported
simultaneously, either dissolved in blood or
combined with hemoglobin in red blood
cells.
▪ Large amounts of oxygen can be
transported in the blood because oxygen
combines easily with hemoglobin to form
Oxyhemoglobin.
▪ The volume of oxygen physically dissolved
in the plasma is measured by the partial
pressure of oxygen in the arteries (PaO2).
▪ The higher the PaO2, the greater the
amount of oxygen dissolved.
e.g.,
At a PaO2 of 10 mm Hg, 0.03 mL of oxygen is
dissolved in 100 mL of plasma.
At PaO2 of 20 mm Hg, twice this amount is An increase in these factors shifts the curve to the
dissolved in plasma, and at PaO2 of 100 mm Hg, right, thus less oxygen is picked up in the lungs, but
10 times this amount is dissolved. more oxygen is released to the tissues.
Therefore, the amount of dissolved oxygen is
directly proportional to the partial pressure,
regardless of how high the oxygen pressure
becomes.
OXYHEMOGLOBIN DISSOCIATION CURVE

If PaO2 is unchanged, a decrease in these factors

causes the curve to shift to the left, making the
bond between oxygen and hemoglobin stronger.

THE UNUSUAL SHAPE OF THE

OXYHEMOGLOBIN DISSOCIATION CURVE IS A
DISTINCT ADVANTAGE TO THE PATIENT FOR
TWO REASONS:
The relationship between the partial pressure of
1. If the PaO2 decreases from 100 to 80 mm
oxygen (PaO2) and the percentage of saturation of
Hg as a result of lung disease or heart
oxygen (SaO2).
disease, the hemoglobin of the arterial
FACTORS THAT CAN AFFECT THE OXYGEN blood remains almost maximally saturated
SATURATION: (94%), and the tissues do not suffer from
hypoxia.
▪ Carbon dioxide 2. When the arterial blood passes into tissue
▪ Hydrogen ion concentration capillaries and is exposed to the tissue
▪ Temperature tension of oxygen (about 40 mm Hg),
▪ 2,3 – diphosphoglycerate hemoglobin gives up large quantities of
INTERPRETATION oxygen for use by the tissues.
CARBON DIOXIDE TRANSPORT
▪ At the same time that oxygen diffuses from
the blood into the tissues, carbon dioxide
diffuses from tissue cells to blood and is
transported to the lungs for excretion.
▪ The amount of carbon dioxide in transit is
one of the major determinants of the acid–
base balance of the body.
▪ Normally, only 6% of the venous carbon
dioxide is removed in the lungs and enough
remains in the arterial blood to exert a
pressure of 40 mm Hg.
▪ Most of the carbon dioxide (90%) is carried
by RBC; the small portion (5%) that remains
dissolved in the plasma (partial pressure of
carbon dioxide [PCO2])
▪ Hypoxemic drive
CARBON DIOXIDE TRANSPORT IN BLOOD
NEUROLOGIC CONTROL OF VENTILATION
▪ Resting respiration is the result of cyclic
excitation of the respiratory muscles by
the phrenic nerve.
▪ The rhythm of breathing is controlled by
respiratory centers in the brain.
▪ The inspiratory and expiratory centers in
the medulla oblongata.
▪ Pons control the rate and depth of
ventilation to meet the body’s metabolic
demands.
▪ The apneustic center in the lower pons
stimulates the inspiratory medullary
center to promote deep, prolonged
inspirations.
▪ The pneumotaxic center in the upper
pons is thought to control the pattern of
respirations.
RECEPTOR SITES ASSIST IN THE BRAIN’S
CONTROL OF RESPIRATORY FUNCTION:
1. The center chemoreceptors
• Located in the medulla, respond to
chemical changes in the cerebrospinal
fluid, which result from chemical
changes in the blood.
• Respond to an increase or decrease in
the pH and convey a message to the
lungs to change the depth and the rate
of ventilation to correct the imbalance.
2. The peripheral chemoreceptors
• Located in the aortic arch and the
carotid arteries and respond first to
changes in PaO2, then to partial
pressure of carbon dioxide (PaCO2) and
pH.
3. The Mechanoreceptors
• In the lunch include stretch, irritant, and
juxtacapillary receptors, and respond to
changes in resistance by altering
breathing patterns to support optimal
lung function.
• E.g., the Hering-Breuer reflex is
activated by stretch receptors in the
alveoli.
4. The proprioceptors
• In the muscles and chest wall respond
to body movements, causing an
increase in ventilation.
Medulla Rhythmicity Area:
Two groups of neurons in medulla
1. Dorsal respiratory group
• Basic rhythm of breathing
• Inspiration – 2
seconds
• Expiration – 3
seconds
• Inspiratory area
has
autorhythmicity
2. Ventral
respiratory group
• Inactivity during
 normal breathing decreased pH (increased H+). Increased CO2
• During high ventilation, inspiratory called hypercapnia.
center stimulates increased inspiratory 1. Central: located in the brainstem, medulla
movements • ↑ OH in CSF
• Expiratory center causes contractions of • ↑ Arterial PCO2 =
expiratory muscles change of pH in
CSF = ↑ depth &
rate of RR =
decreased pCO2
2. Peripheral: located
in aorta & carotid
arteries carotid &
aortic bodies
sensitive to )2
changes. Sends signal to medulla – vagal
nerve stimulation = ↑ rate of inspiration
CONTROL MECHANISM OF RESPIRATION
Neural
DEPTH AND RATE OF BREATHING: PCO2
1. Cerebral cortex – voluntary, works for a
short time, allows for voluntary ventilation,
such as during states of crying, laughing,
singing and talking
2. Pons:
• Apneustic center – stimulates neurons
to promote inspiration
• Pneumotaxic center – inhibits
apneustic & inhibits inspiration
3. Medulla – major brain area that controls
rhythm if respiration, stimulation to initiate
ventilation
4. Spinal Cord – facilitates maintenance of
respiratory center, assists by relaying the CONTROL MECHANISMS OF RESPIRATION
information from the brain to the muscles of • Hering-Bruer Reflex – stretch receptors in
ventilation lung tissue which assist in maintaining
respiratory rhythm and prevent
PNEUMOTAXIC AREA OF PONS: overstretching of the lungs.
• Coordinates transition between inspiration • Mechanoreceptors – include stretch,
and expiration irritant & juxtareceptors.
• When more active, breathing is quicker • Blood pressure increases and decreases
• Impulses inhibit inspiratory center before – indirectly proportional to breathing rates
lungs over inflate as a short-term homeostatic mechanism
• Stretch receptors send signals through • Limbic system stimulation – increased
vagus nerve to pneumotaxic area emotions and anxiety
• Inflation or Hering-Breuer reflex • Temperature
• Pain
CHEMORECEPTORS • Stretching of anal sphincter
Note: the aortic and carotid bodies have
chemoreceptors that detect (via the
glossopharyngeal IX and vagus X cranial
nerves) increased CO@, decreased O2 and

GERONTOLOGIC CONSIDERATIONS
A gradual decline in respiratory function begins
in early to middle adulthood and affects the
structure and function of the respiratory system.
Changes in vital capacity and strength of the
respiratory muscles:
• 20 and 25 years of age – peak of vital capacity
• 40 years and older – reduce the surface area
for gas exchange
• 50 years of age – the alveoli begin to lose
elasticity
o Decrease in vital capacity
These changes result in a decreased diffusion
capacity for oxygen with increasing age, producing
lower oxygen levels in the arterial circulation.
Older adults have a decreased ability to rapidly
move air in and out of the lungs.
PULMONARY VOLUMES
Values determined by using a spirometer
TIDAL VOLUME (TV) – air moved by one
respiration, an average of 500ml is moved into
and out of the respiratory tree in relaxed
breathing. Of the 500ml, 150ml do not reach the
alveoli, coming to lie in anatomic dead space.
INSPIRATORY RESERVE VOLUME (IRV) – a
deep breath, iar that can be inspired forcibly
beyond the tidal volume (2100-3200ml)
EXPIRATORY RESERVE VOLUME (ERV) –
exhaling vigorously forces out 1200 ml air in
addition to the tidal volume. After expiration
1200ml of air remains in the ling as a residual
volume
RESIDUAL VOLUME (RV) – amount of air left in
alveoli after forced expiration that keeps them
inflated or air left in the lungs after maximal
expiration (1200ml)
Respiratory Capacities
Four additional measurements – values determined
by adding two or more of the respiratory
volumes:
1. Vital capacity – maximum amount of air
that can be expired after taking the deepest
breath possible (VC = TV + IRV + ERV)
approximately 600ml
2. Inspiratory capacity – maximum volume of
air that can be inhaled following exhalation
of residing tidal volume (IC = TV + IRV)
3. Functional residual capacity – voume air
remaining in the lings following exhalation of
resting volume (FRC = ERV +RV)
4. Total lung capacity – sums of all volumes
or total volume of air that the lungs can hold
(TLC = VC + RV)
FACTORS MAINTAINING ADEQUATE
VENTILATION
1. Clear airways
2. Intact CNS & Respiratory center
3. Intact thoracic cavity capable of expanding
and contracting
4. Adequate pulmonary compliance and recoil
LUNG DEFENSE MECAHNISM
1. Muco-cillary escalator (respiratory
blanket)
 2. Alveolar macrophages – phagocytes in A – Associated S/Sx
alveoli of the lungs COMMON SYMPTOMS
3. Structural architecture – traps air The major signs and symptoms of respiratory
particles, humidifies and filters disease:
4. IgG – monitor surveillance ✓ Dyspnea
5. Thoracic cage – protect structures of lung o Is a multidimensional
symptom common to many
FACTORS AFFECTING RESPIRATORY pulmonary and cardiac
FUNCTION disorders, particularly when
1. AGE there is decreased lung
• Birth – fluid lungs, gradually expands compliance or increased
reach full inflation by 2 weeks airway resistance.
• Elderly – wall is more rigid & less elastic o Subjective feeling of difficult
decreased cough reflex & cilia drier or labored breathing,
mucous membranes breathlessness, shortness of
Ex. Osteoporosis = inadequate breath
expansion of lungs Causes of Dyspnea:
2. ENVIRONMENT o Allergic reactions
• Altitude, heat, cold and pollution o Anemia
3. LIFESTYLE o Neurologic or neuromuscular
• Exercise - ↑ rate & depth of O2 = ↑ disorders
supply o Trauma
• Sedentary – lack alveolar expansion ; o Advanced disease
less able to response to respiratory o Common at the end of life
stressors o Can also occur after exercise
4. HEALTH STATUS in people without disease
• Adverse effects pf respiratory diseases In immobilized patients, sudden
5. MEDICATION dyspnea may denote pulmonary
• Sedative-hypnotics, narcotics, embolism (PE)
barbiturates, anti-anxiety drugs Dyspnea and Tachycardia
6. STRESS o Abnormally rapid respirations
o Accompanied by progressive
• Psychological & physiological
hypoxemia (low blood
oxygen level)
ASSESSMENT
Causes of Hypoxemia:
o Lung trauma
1. HEALTH HISTORY
o Shock
✓ Chief Complaints
o Cardiopulmonary bypass, or
✓ Heredofamilial diseases
multiple blood transfusions
✓ Lifestyle; habits: smoking, exercise,
may signal ARDS
diet, metal status, fatigue, syncope
Orthopnea
and fainting, BP, Pain (use
o Is shortness of breath when
COLDPSA)
lying flat
The nurse should explore:
o Relieved by sitting or
O – Onset
standing
L – Location
o May be found in patients
D – Duration
with heart disease
C – Character
o Occasionally in patients
A – Aggravating and Alleviating Factors
with chronic obstructive
R - Relieving Radiating Factors
T – Timing if the presenting problem
 pulmonary disease
(COPD)
Stridor
o A high -pitched sound
heard
o Usually on inspiration
o When someone
breathing through
partially blocked upper
airway dyspnea with an
expiratory wheeze occurs
with COPD
To determine the cause of dyspnea
The nurse should ask the following
questions:
o Is the shortness of breath
related to other symptoms?
Is a cough present?
o Was the onset of shortness
of breath sudden or gradual?
o At what time of day or night
does the shortness of breath
occur?
o Is the shortness of breath
worse when lying flat?
o How much exertion triggers
shortness of breath? Does it
occur with exercise?
o Climbing stair? At rest?
o How severe is the shortness
of breath? On a scale of 1 to
10
The modifies Borg scale is a type of
numeric rating scale
The patient is asked to self-rate the difficulty
breathing is causing him/her at the
present time.
- 0 corresponding to no
difficulty at all to
- 10 corresponding to
maximal breathing
difficulty
The modified Borg Scale – is a type of
numeric rating scale
✓ Cough
o is a reflex that protects the
lungs form the accumulation
of secretions or the inhalation
of foreign bodies.
o Results from irritation or
is inflammation of the mucous
a membranes anywhere in the
respiratory tract and is
associated with multiple
pulmonary disorders
Cough Reflex
o Is stimulated by mucus, pus,
blood, or an airborne irritant,
such as smoke or a gas.
Common causes of cough:
o Asthma
o Gastrointestinal reflux
disease
o Infection
o Side effects of medications,
such as angiotensin-
converting enzyme (ACE)
inhibitors
Onset and time of Cough:
o Coughing at night may
indicate the onset of left-
sided heart failure or
bronchial asthma
o A cough in the morning with
sputum production may
indicate bronchitis
o A cough that worsens when
the patient is in supine
suggests postnasal drip
(rhinosinusitis).
o Coughing after food intake
may indicate aspiration of
material into the
tracheobronchial tree
o A cough of recent onset is
usually from an acute
infection
Character of the cough and
associated symptoms:
o A dry, irritative cough is
characteristic of an upper
respiratory tract infection of
viral origin. (it may be a side
 effect of ACE inhibitor o Profuse, frothy, pink material,
therapy) often welling up into the
o An irritative, high-pitched throat, may indicate
cough can be caused by pulmonary edema
laryngotracheitis o Foul-smelling sputum and
o A brassy cough is the result bad breath point to the
of a tracheal lesion. presence of lung abscess,
o A severe or changing cough bronchiectasis, or an
may indicate bronchogenic infection caused by
carcinoma fusospirochetes or other
o A Violent coughing causes anaerobic organisms.
bronchial spasm, obstruction, ✓ Chest pain
and further irritation of the o may be associated with
bronchi and may result in pulmonary, cardiac,
syncope (fainting) gastrointestinal, or
Concept Mastery Alert musculoskeletal disease or
A nurse interviewing a patient who anxiety
says he has dry, irritating cough that Characteristics:
is not “bringing anything up” should ✓ Sharp
ask whether he is taking ACE ✓ Stabbing
inhibitors ✓ Intermittent
Cough reflex may be impaired by: ✓ Dull
o weakness or paralysis of the ✓ Aching
respiratory muscles ✓ Persistent
o prolonged inactivity Disorders associated with Chest
o presence of nasogastric tube pain:
o depressed function of the o Pneumonia
brain’s medullary centers o Pulmonary infarction
(e.g., anesthesia, brain o Pleurisy
disorders). o As a late symptom of
✓ Sputum production bronchogenic carcinoma
o is the reaction of the lungs to Pleuritic pain
any constantly recurring o from irritation of the parietal
irritant and often results from pleura is sharp and seems to
persistent coughing. “catch” on inspiration.
Sputum Production o patients often describe it as
Nature of sputum: being “like the stabbing of a
o A profuse amount of purulent knife.”
sputum (thick and yellow, o Patients are more
green, or rust colored) is a comfortable when they lay on
common sign of a bacterial the affected side
infection ✓ Wheezing
o Thin, mucoid sputum results o a high-pitched, musical
from viral bronchitis sound heard on either
o A gradual increase of sputum expiration (asthma) or
over time may occur with inspiration (bronchitis)
chronic bronchitis or o bronchoconstriction or airway
bronchiectasis narrowing
o Pink-tinged mucoid sputum Rhonchi
suggests a lung tumor
 o are low-pitched continuous
sounds heard over the lungs
in partial airway obstruction
✓ Hemoptysis
o is the expectoration of blood
from the respiratory tract.
The most common causes are:
o Pulmonary infection
o Carcinoma of the lung
o Abnormalities of the heart or
blood vessels
o Pulmonary artery or vein
abnormalities
o PE or infarction
Following points should be
considered to assess bleeding:
o Bloody sputum from the nose
or the nasopharynx is usually
preceded by considerable
sniffing, with blood possibly
appearing in the nose
o Blood from the lung is usually
bright red, frothy, and mixed
with sputum
o Blood (dark) from the
stomach is vomited rather
than expectorated. (may be
mixed with food) “coffee
ground emesis”
PAST HEALTH, SOCIAL, AND FAMILY HISTORY
• Focus on the patient’s health, personal, and
social hostory, and the family health history.
Specific questions asked:
• Childhood illnesses
• Immunizations
• Medical conditions
• Injuries
• Hospitalizations
• Surgeries
• Allergies
PERSONAL AND SOCIAL HISTORY
Issues such as:
• Diet
• Exercise
• Recreational habits
• Religion
• Psychosocial factors
Respiratory Disorders
Various conditions that affect gas exchange and
respiratory function are influenced by genetic
factors. Some are known to have a direct
inherited pathway while others have a strong
familial association, but the exact inheritance
pattern is not entirely clear. The following are
examples of respiratory disorders with a known
or associated familial component:
• Asthma
• Cystic fibrosis
• Chronic obstructive pulmonary disease
• Alpha-1 antitrypsin deficiency
• Primary ciliary dyskinesia
• Pulmonary fibrosis
• Pulmonary hypertension
• Tuberous sclerosis
Family History Assessment Specific to Genetic
Respiratory Disorders
• Assess family history for three generations
for family members with histories of
respiratory impairment
• Assess family history for individuals with
early-onset chronic pulmonary disease and
family history of hepatic disease in infants
(clinical symptoms of alpha-1 deficiency)
• Inquire about family history of cystic fibrosis,
an autosomal recessive inherited respiratory
disorder
Patient Assessment Specific to Genetic
Respiratory Disorders
• Assess for symptoms such as changes
in repiratory status and triggers that
precede changes on respiratory function
• Frequency of respiratory tract infections
or sinus infections
• Determine exposure to environmental
risk (e.g. radon, asbestos)
occupational exposure (e.g., coal miner,
sandblaster, painter)
• Determine presence of secondary risk
factors (e.g., smoking or exposure or
secondhand smoke)
• Assess for:
• Clubbing fingers
• Skin color in general or the presence
of white patches on the skin
• Presence of angiofibromas or ungual
fibromas (seen with primary ciliary
dyskinesia)
• Assess for presence and frequency of:
• Wheezing or coughing
• Mucous production (frequency,
amount, and characteristics of the
mucous)
• Mucosal edema
• Assess for multisystem effects
(gastrointestinal disorders, pancreatic
insufficiency, liver, or kidney disorders)
PHYSICAL ASSESSMENT OF THE
RESPIRATORY SYSTEM
GENERAL APPEARANCE
✓ Clubbed Finger
o Is a change in the normal nail
bed
oIt appears as sponginess of
the nail bed and loss of the
nail bed angle.
o It is a sign of lung disease
that is found in patients with
chronic hypoxic conditions,
chronic lung infections, or
malignancies of the lung/s
o congenital heart disease and
other chronic infections or
inflammatory conditions,
such as endocarditis or
inflammatory bowel disease
✓ Cyanosis
o a bluish coloring of the skin,
is a very late indicator of
hypoxia
o appears when there is at
least 5 g/dL of unoxygenated
hemoglobin
UPPER RESPIRATORY STRUCTURES
or ✓ Nose and Sinuses
o Inspect the external nose for lesions,
asymmetry, or inflammation and
then asks the patient to tilt the head
backward.
o Gently pushing the tip of the nose
upward, the nurse examines the
internal structures of the nose,
inspecting the mucosa for color,
swelling, exudate, or bleeding.
o The nurse inspects the septum for
deviation, perforation, or bleeding
The nurse may palpate the frontal and
maxillary sinuses for tenderness
 The frontal and o Check for deviations and
maxillary sinuses displacements
can be inspected
by LOWER RESPIRATORY STRUCTURES AND
transillumination BREATHING
(passing a strong
Assessment of the lower respiratory structures
light through a
includes:
bony area, such
as the sinuses, to 1. Inspection
inspect the 2. Palpation
cavity). 3. Percussion
4. Auscultation
✓ Mouth and Pharynx
o instruct The patient should be positioned as necessary prior
the to the assessment
patient to
open the ✓ Positioning
mouth o The patient
wide and should be in a
take a sitting
deep position with
breath. arms crossed
o Usually, in front of the
this chest and
flattens hands placed
the posterior tongue and briefly on the opposite shoulders to assess
allows a full view of the anterior and the posterior thorax and the lungs.
posterior pillars, tonsils, uvula, and ✓ Thoracic Inspection
posterior pharynx o to provide information about the
o inspect these structures for color, respiratory system, the
symmetry, and evidence of exudate, musculoskeletal structure, and the
ulceration, or enlargement. patient’s nutritional status.
o to visualize the pharynx, use a o Observe the skin over the thorax for
tongue blade color and turgor and for evidence of
✓ Trachea loss of subcutaneous tissue.
o The o It is important to note asymmetry if
position present
and Locating Thoracic Landmarks
mobility of With respect to the thorax, location
the is defined both horizontally and vertically.
trachea With respect to the lungs, location is defined
are noted by lobe.
by direct
palpation. Horizontal reference points
o This is
performed
by placing the thumb and the index
finger of one hand on either side of
the trachea just above the sternal
notch.
 ✓ CHEST CONFIGURATION
o Normally, the ratio of the
anteroposterior diameter to the
lateral diameter is 1:2
Four main deformities of the chest
associated with respiratory disease
1. Barrel Chest
a. occurs as a result of over
inflation of the lungs,
which increases the
anteroposterior diameter
of the thorax.
b. a hallmark sign of
emphysema and COPD

Vertical Reference Points

2. Funnel Chest (Pectus

Excavatum)
a. occurs when there is a
depression in the lower
portion of the sternum.
This may compress the
heart and great vessels,
resulting in murmurs.
Funnel chest may occur
with rickets or Marfan
syndrome.
LOBES OF THE LUNGS

3. Pigeon Chest (Pectus
Carinatum)
a. Occurs as a result of the
anterior displacement of
the sternum.
b. Which also increases the
anteroposterior diameter.
c. May occur with rickets,
Marfan syndrome, or
severe kyphoscoliosis
4. Kyphoscoliosis
a. Is characterized by
elevation of the scapula
and a corresponding S-
shaped spine.
b. Occur with osteoporosis
and other skeletal
disorders that affect the
thorax
Breathing Patterns and Respiratory Rates
• Observing the rate and depth of respiration
is a simple but important aspect of
assessment.
• The normal adult who is resting comfortably
takes 14 to 20 breaths per minute.
• Normal pattern is described as eupnea
Rate and Depth of respiration
Eupnea
o Normal, breathing at 14-20 breaths/min
Bradypnea
o Slower than normal rate (<10 bpm), with
normal depth and regular rhythm
o Associated with increased intracranial
pressure, brain injury, and drug overdose
Tachypnea
o Rapid, shallow breathing (>24bpm)
o Associated with pneumonia, pulmonary
edema. Metabolic acidosis, septicemia,
severe pain or rib fracture
Hypoventilation
o Shallow, irregular breathing
Hyperpnea
o Increased depth of respiration
Hyperventilation
o Increased rate and depth of breathing that
result in decreased PaCO2 level
o Inspiration and expiration nearly equal in
duration
o Associated with exertion, anxiety, and
metabolic acidosis
o Called Kussmaul’s respiration if associated
with diabetic ketoacidosis or renal origin
Apnea
o Period of cessation of breathing; time
duration varies; apnea may occur briefly
during other breathing disorders, such as
with sleep apnea; life-threatening if
sustained
Cheyne-Stokes
 o Regular where the rate and depth of Thoracic Palpation
breathing increase, then decrease until Palpate the thorax for:
apnea (usually about 20 sec) occurs o Tenderness
o Duration of apnea may vary and o Masses
progressively lengthen; therefore, it is timed o Lesions
and reported. o Respiratory excursion
o Associated with heart failure and damage to o Vocal fremitus
the respiratory center (drug induced, tumor, Respiratory Excursion
trauma) is an estimation of thoracic expansion and may
Biot’s respiration disclose significant information about thoracic
movement during breathing
o assess the patient for range and
symmetry of excursion.
o Periods of normal breathing (3-4 breaths),
For Anterior Assessment
followed by a varying period of apnea
o Place the thumbs
(usually 10-60 sec)
along the costal
o Also called ataxic breathing; associated with
margin of the
complete irregularity
chest wall and
o Associated with respiratory depression
instruct the
resulting from drug overdose and brain
patient to inhale
injury, normally at the level of the medulla
deeply.
Obstructive
o Observe
movement of the
thumbs during
o Prolonged expiratory phase of respiration inspiration and expiration.
o Associated with airway narrowing and seen o This movement is normally symmetric.
in asthma, chronic obstructive pulmonary For Posterior assessment
disease, and bronchitis o place the thumbs
Concept Mastery Alert adjacent to the
There are subtle differences between Cheyne- spinal column at
stokes and Biot’s respiration patterns. Between the level of the 9th
regularly cycled period of apnea, Cheyne- or 10th rib
Stokes respirations demonstrate a regular
pattern with the rate and depth pf breathing o Decreased chest
increasing and then decreasing. In Biot’s excursion may be caused by chronic
respiration, irregularly cycled periods of apnea fibrotic disease.
are interspersed with cycles of normal rate and o Asymmetric excursion may be due to
depth. splinting secondary to pleurisy, fractured
ribs, trauma, or unilateral bronchial
USE OF ACCESSORY MUSCLES obstruction
Observe the ff: Tactile Fremitus
During inspiration: describes vibrations of the chest wall that result
o Sternocleidomastoid from speech detected on palpation
o Scalene o Normally, sounds generated by the
o Trapezius muscles larynx travel distally along the bronchial
During expiration: tree to set the chest wall in resonant
o Abdominal motion.
o Internal intercostal muscles o This is most pronounced with consonant
sounds.
 o The patient is asked to repeat “ninety- concludes with percussion of each lateral
nine” or “one, one, one” as the nurse’s chest wall
hands move down the patient’s thorax o To perform
o The vibrations are detected with the percussion, the
palmar surfaces of the hands, or the middle finger of the
ulnar aspect of the extended hands, on nondominant hand is
the thorax firmly placed against
o The hand or the area of the chest
hands are wall to be percussed.
moved in o The distal
sequence interphalangeal joint
down the of this finger is struck with the tip of the
thorax. middle finger of the dominant hand.
o Corresponding o Bony structures (scapulae or ribs) are not
areas of the percussed
thorax are o To perform
compared. percussion over the
Bony areas anterior chest.
are not assessed. o Begin in the
Thoracic Percussion supraclavicular area
Percussion and proceeds
produces audible and tactile vibration and downward, from one
allows the nurse to determine whether intercostal space to
underlying tissues are filled with air, fluid, or the next
solid material
o Healthy lung tissue is resonant. Diaphragmatic Excursion
o Dullness over the lung occurs when air-
o To assess the position and motion of the
filled lung tissue is replaced by fluid or
diaphragm, instruct the patient to take a
solid tissue
deep breath and hold it while the maximal
descent of the diaphragm is percussed
Thoracic Auscultation
o auscultation of
the anterior,
posterior, and
lateral thorax.
o auscultate for
normal breath
sounds,
adventitious
Percussion usually begins with the posterior thorax. sounds, and
o patient in a sitting voice sounds.
position, symmetric o listen to two full inspirations and expirations
areas of the lungs at each anatomic location for valid
are percussed at 5- interpretation of the sound heard
cm intervals.
o This progression
starts at the apex of
each lung and