Respiratory System

Muamar Aldalaeen, RN,

MBA,HCRM,CIC,IPM, MSN,
.PhD
Haneen AlNuaimi, MSN

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 Pulmonary Embolism
• Obstruction of a pulmonary artery or one of it’s branches by a
bloodborn substance.

• These materials may include: amniotic fluid, fat, air, migrated

tumor cells, ca, emboli.

• Lower lobes affected more than the higher lobe because of

sluggish blood flow

• Deep vein thrombosis is a common cause of pulmonary

embolism.
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 Pathophysiology
• A cascade of events begins the process of
thromboembolus development.

• Virchow’s triad of factors, which include

venous stasis, hypercoagulability, and vascular
endothelium damage, has long been believed
to contribute to venous thromboembolism.
 Pulmonary Embolism
• Origin of P.E:
• 1-DVT: venous stasis, vein wall damage,
hypercoagubility

• 2-Fat embolism: Fracture of femur,

orthopedic surgery

• 3-Air embolism: I.V catheter, chest

wound, C.V abdominal surgery
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 Pulmonary Embolism
• 4-Amniotic Fluid: placental tissue, fluid clots

• 5-Septic embolism: massive infection and

endocarditis

• 6-Rt. Heart cells: A.F, prosthetic valve,

central lines

• 7-Tumor cells
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 Pathopysiology
• Respiratory dead space within the pulmonary
system occurs when the alveoli are ventilated
but not perfused by the blood that normally
flows through the pulmonary arteries and
capillaries.

• This produces areas of mismatched ventila-

tion and perfusion
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• As a result, well-ventilated alveoli are
underperfused, and gas exchange is
compromised

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• Pulmonary vascular constriction resulting from
decreased carbon dioxide, which is normally
present in pulmonary arterial blood.

• Blood flow is shunted from the underperfused

alveoli to alveoli that are being perfused.
• This causes a state where perfusion is now
greater than normal ventilation.

• When this occurs, a percentage of the blood

will not be perfused and will return to the left
side of the heart without having experienced
gas exchange, leading to hypoxemia.
• Direct physiologic pulmonary changes to
adapt to the decreased gas exchange include:
• Increased minute ventilation
• Decreased vital capacity
• Increased airway resistance,
• Decreased diffusing capacity
 Pulmonary Embolism
• The severity of hemodynamic change in pulmonary
embolism depends on the size of the embolus and
degree of pulmonary vascular obstruction as well as
on the preexist-ing status of the cardiopulmonary
system.

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 Pulmonary Embolism
• In patients with no previous cardiopulmonary disease,
there is a relationship between the degree of
pulmonary artery obstruction and the pulmonary
artery pressure.

• Increased right ventricular after-load results from

obstruction of the pulmonary vascular bed by
embolism

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• In patients with no preexisting
cardiopulmonary disease, obstruction of less
than 20% of the pulmonary vascular bed
produces compensatory events that minimize
adverse hemodynamic consequences.

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• When the degree of pulmonary vascular
obstruction exceeds 30% to 40%, increases in
pulmonary artery pressure occur, followed by
modest increases in right atrial pressure.

• As the degree of pulmonary artery obstruction

exceeds 50% to 60%, compensatory
mechanisms are overcome, producing
decreased C.C and increased right atrial
pressure 14
• Patients with preexisting cardiopulmonary
disease have degrees of pulmonary
hypertension that are disproportionate to the
degree of embolic obstruction.

• Severe pulmonary hypertension may develop

from a relatively small reduction of pulmonary
blood flow
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 Risk Factors for
Thromboembolism
• Cancer
• Major surgery or truama
• Prolonged immobalization
• Preganacy
• Inhereited blood clotting disorders
• AF
• HF
• Obesity and smoking
 Pulmonary Embolism
• Clinical Manifestations
1.Dyspnea the most frequent symptom
2.Tachypnea the most frequent sign: decreased CO2
3.Sudden & pluratic chest pain
4.Fever, cough, anxiety & homeostasis
5.Apprehension, Diaphoresis & syncope

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 S/S small embolus
• Dyspnea, tachypnea, tachcardia

• Chest pain, mild fever, hypoxemia

• Apprehension, cough, diaphoresis

• Decreased breath sounds of affected area

• Rales, wheezing
 S/S large embolus
• Cynosis, restlessness, anxiety
• Confusion, hypotension
• Cold clammy skin
• Decreased U.O
• Pleuritic chest pain associated with Pul.
Infarction
• Hemoptysis associated with Pul. Infarction
 Diagnosis
• 1-X-ray
• 2-ECG
• 3-ABGs
• 4-V/Q sacn

• X-ray shows infiltration, atelectasis, elevation

diaphram and pleural effusion

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 Pulmonary Embolism
• Medical Management
1. Emergency Management
2. Nasal O2
3. IV infusion for Medication
4. Perfusion Scan
5. ABGs & ECG monitoring
6. Small dose of Morphine
7. Intubation & mechanical Ventilation

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 Pulmonary Embolism
Pharmacologic Management
1. Anticoagulant therapy
1. heparin 5000-10000 bolus then 18u/kg/hrs
2. warfarin for three months
3. Thrombolytic therapy (STK , Actylase (TPA))
2. Surgical Management (Surgical Embolectomy)

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 Pulmonary Embolism
• Nursing Management
1.Preventing thrombus formation
2.Monitoring thrombolytic therapy
3.Providing post operative nursing care
4.Managing O2 therapy
5.Preventing anxiety
6.Monitor for complications

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Pneumothorax/Hemothorax
• When parietal or visceral pleura is branches
and the pleural space exposed to positive
atmospheric pressure

• Air or blood accumulated in chest cavity

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Pneumothorax/Hemothorax
• Traumatic disorders of the respiratory tract where in
the underlying lung tissue is compressed and
eventually collapses.
• Types
1.Simple Pnuemothrax
2.Traumatic Pneumothorax
3.Tension

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Pneumothorax/Hemothorax
• Simple: spontaneous: air enters the pleural
space

• May occur in health

• COPD

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 Pneumothorax/Hemothorax
• Traumatic: laceration in the lung or from wound in the
chest wall

• Rib fractures, stab wound, invasive thoracic procedure

• May lead to hemothorax

• Open pneumothorax: air in and out in each breath: lung collapse

and shift of heart and great vessels to opposite site during
inspiration and to the injured site during expiration
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Pneumothorax/Hemothorax
• Tension pneumothorax: air enter during
inspiration and cannot escape during
expiration.

• One way valve occurs.

• Positive pressure occur and lung collapse, shift

of heart and vessels to the unaffected side
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 Pneumothorax/Hemothorax
• Clinical Manifestations
1.Sudden pluratic pain
2.Anxious patient , dyspnea & air hunger
3.Increase use of accessory muscles
4.Central cyanosis
5.Tympanic sound in percussion
6.Absent of breath sound & tactile fremetus
7.Agitation Diaphoresis & hypotension

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Pneumothorax/Hemothorax
• Medical Management
1.High concentration supplemental O2
2.Chest tube for drainage
3.In emergency any thing may be used to fill the
chest wound
4.Heavy dressing
5.Needle aspiration thoracenthesis
6.Connecting chest tube to water seal drainage
7.An emergency thoractomy may also performed

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 Pulmonary Edema
• Abnormal accumulation of fluid in the lung tissue,
the alveolar space or both. It a sever life-threatening
condition

• Causes:
• 1-LVF
• 2-Hypervolemia
• 3-Sudden increased of the pressure in the pulmonary
circulation
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 Pulmonary Edema
• 3-Flash pulmonary edema: one lung is removed
surgically, the cardiac output goes to the another lung

• 4-Re-expansion lung: result from rapid inflation of the

lung after removal of air from lung after pneumothorax
• 5-Injury to lung tissues as ARDS
• 6-Hypertension
• 7-Aspiration
• 8-High altitude P.E
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 Pulmonary Edema
• Clinical manifestations:
• Dyspnea, orthopnea and air hunger
• Central cyanosis
• Anxious and agitated patient
• Foamy-forthy sputum
• Confusion
• Decreased O2 sat
• Impairment in ABGs
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 Pulmonary Edema
• Diagnosis:
• Crackles and increased RR
• Chest X-ray; interstitial marking
• Decreased O2 sat
• ABGs: arterial hypoxemia

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 Pulmonary Edema
• Management:
• 1-Treatment of the underlying cause

• 2-Improving LVF if it is cardiac origin by

vasodilators, inotropic agents, lasix, morphine
and O2 therapy

• 3-Treat hypertension
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 Chest Tube
• It is used in the treatment of pneum, hemothorax.

• _ve pressure inside the pleural cavity

• The chest tube may be inserted to the Rt., lt, pleural

space and to mediastinum to remove air, or fluid

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Dr. Murad Alkhalaileh 38
 Chest Tube
• Types of drainage system:

• 1-Traditional water seal (Wet suction): collection chamber,

suction and water chamber:
• Sterile water installed into water seal and suction chamber: water
acts as a seal and keeps the air from being back to patients
• Has positive-negative pressure release valve
• Additional suction can be added by connecting system to a
suction source
• The degree of suction is determined by amount of water in the
suction control chamber (20 cm)
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 Chest Tube
• 2-Dry suction water seal: Collection, water and
suction chamber
• Sterile water installed into water seal chamber up to
20cm level
• Has positive-negative pressure release valve
• Suction pressure is set with a regulator
• Quieter than the water seal system

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 Chest Tube
• 3-Dry suction: Has a one way mechanical valve that
allow the air to leave the chest and prevent air from
moving back into the chest.

• Ne need to fill suction chamber with water.

• Used in emergency

• Works even it knocked, used during pt ambulation

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 Chest Tube
• Equipments:
• Chest tube insertion tray: chest tube, scalpel, gloves
• Antseptic solution
• Local anesthetic agent
• Chest drainage system
• Adhesive tap

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 Chest Tube
• Some actions:
• 1-Be sure that the tubing does not knik, loop or interfere
with patients movement

• Provide adequate analgesia

• Change position of patient Q 1.5-2 hours

• Gently milk the tubing into the direction of the drainage

system
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 Chest Tube
• Make sure there is fluctuation of the fluid level in the
water seal chamber, if no fluctuation:
• A-Lung expansion
• B-tube obstruction
• C-Suction system not working

• Encourage patient to take deep breathing and cough

at regular intervals

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 Chest Tube
• The drainage system should be always under patient
level

• Do not use clamping during disconnection of the

drainage system

• During removal: the chest tube is clamped, then

removed, apply 4X4 gauze

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 Chest Tube
• Monitor the color, amount and consistency of the
fluid

• Keep suction at prescribed level

• Keep air vent is open when suction is off

• Monitor O2 sat, V/S, breathing sounds, surgical

dressing, ECG, skin color, capillary refill
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