Respiratory Disorders

Objectives
On completion of this lecture, the learner will be able to:

- Describe the structures and functions of the respiratory tract.

- Describe the etiology, pathophysiology, clinical manifestations,

complications, diagnostic abnormalities, nursing and
collaborative management of patient with respiratory disorder.
 Outline
- Anatomy and physiology of respiratory system.
- Essential functions of respiratory system.
- Assessment of respiratory system.
- Diagnostic Evaluation.
- Common respiratory problems such as COPD, TB, and bronchial asthma.
- Definition.
- Risk factors.
- Diagnostic procedures.
- Signs and symptoms.
- Treatment.
- Nursing intervention.
 Anatomy of respiratory system
- The respiratory tract is the path of air from the nose to the
lungs.
- The respiratory system is divided into two parts:
1. The upper respiratory system which includes the nostrils,
nasal cavity, sinuses, pharynx and larynx.

2. The lower respiratory system which includes the trachea

and the lungs which lie within the thoracic cavity.
2- Sinuses: air-filled cavities within the hollow
bones that surround the nasal passages and
provide resonance during speech.
 3- Pharynx:
- Passage way for the
respiratory and digestive
tracts located behind the
oral and nasal cavities.
- Divided into the:
- Nasopharynx.
- Oropharynx.
- Laryngopharynx.
4. Larynx:
- Located above the trachea, just
below the pharynx at the root of
the tongue; commonly called the
voice box.
- Contains two pairs of vocal
cords.
5. Epiglottis:
- Prevents food from entering the
tracheo-bronchial tree by
closing over the glottis during
swallowing.
 Lower Respiratory Tract
1. Trachea: located in front of the
esophagus, branches into the right and left
mainstem bronchi.
2. Mainstem bronchi:
- The mainstem bronchi divide into
secondary or lobular bronchi that enter
each of the five lobes of the lung.
- The bronchi are lined with cilia, which
propel mucus up and away from the lower
airway to the trachea, where it can be
expectorated or swallowed.
3. Bronchioles:
- Branch from the secondary bronchi and
subdivide into the small terminal and
respiratory bronchioles.
 4. Alveolar ducts and alveoli:
- Alveolar ducts branch from the respiratory
bronchioles.
- Alveolar sacs which arise from the ducts,
contain clusters of alveoli, which are the
basic units of gas exchange.
- Alveolar cells in the walls of the alveoli
secrete surfactant, a phospholipid protein
that reduces the surface tension in the
alveoli; without surfactant, the alveoli
would collapse.
5. Lungs:
- Located in the pleural cavity
in the thorax.
- Extend from just above the
clavicles to the diaphragm, the
major muscle of inspiration.
Accessory muscles of respiration include:

1.The scalene muscles, which elevate the first

two ribs.

2.The sternocleidomastoid muscles, which raise

the sternum.

3.The trapezius and pectoralis muscles, which

fix the shoulders.
 Ventilation
Ventilation is the exchange of air between the external environment
and the alveoli. There are two phases of ventilation:
1. Inspiration.
2. Expiration.
- Air moves by bulk flow from an area of high pressure to low
pressure.
- The body changes the pressure in the alveoli by changing the
volume of the lungs.
- As volume increases, pressure decreases and as volume
decreases; pressure increases.
 The Essential Functions of Respiratory System

- The primary function is gas exchange, which involves delivery

of oxygen to the tissues and removal of carbon dioxide waste.
- Filters and humidifies air that enters the lungs.

- Traps particular matter in the mucus of the airways and propels

it toward the mouth for elimination by coughing or swallowing
(nose and bronchi).
- Transport of oxygen from the blood into cells of the body.
 The Essential Functions of Respiratory
System
Secondary functions of the respiratory system:
1. Facilitates sense of smell.
2. Produces speech.
3. Maintains acid-base balance.
4. Maintains body water levels.
5. Maintains heat balance.
 Assessment of patient with respiratory
disorder

1- health history
2- physical examination
 Health History
Cough.
Sputum (color, quantity).
Hemoptysis.
Dyspnea (SOB).
Wheezing - Crackles.
Cyanosis.
Chest pain with breathing.
 Family History

- The development of lung cancer is thought to be partially based

on genetics.

- A history of certain respiratory diseases (asthma, emphysema) in

a family may increase the risk for development of the disease.

- Exposure to viral or bacterial respiratory infections in the

home increases the risk for development of these conditions.
 Life-style and Health Practices

- Smoking.
- Exposure to certain environmental inhalants.
- Shortness of breath can be a manifestation of stress.
- All medications should be considered to determine if respiratory
problems could be attributed to adverse reactions.
- If the patient is using oxygen or other respiratory therapy at
home.
 Thoracic and Lung Assessment
Objective data: collected through:
Inspection.

Palpation.

Percussion.

Auscultation.
 Diagnostic Tests
Arterial blood gas analysis.
Sputum examination.
Pleural Fluid Analysis “Thoracentesis”.
Chest X-Ray.
CT Scan and MRI
Pulmonary Angiography.
Ventilation-Perfusion Scan.
Bronchoscopy.
Lung Biopsy.
Pulmonary Function Tests “Spirometry”
 Common Chronic Respiratory Disorders

Chronic obstructive pulmonary disease (COPD).

Tuberculosis of the lungs.

Bronchial Asthma.
 COPD
In COPD, less air flows in and out of the airways
because of one or more of the following:
- The walls of the airways become thick and inflamed.

- The airways make more mucus than usual, which

tends to clog / plug / close them.
- The walls between many of the air sacs are destroyed.
- The airways and air sacs lose their elastic quality.
 Two Major Causes of COPD
- Is a term used to describe two related lung diseases:
- Chronic Bronchitis is characterized by:
- Chronic inflammation and excess mucus production.
- Presence of chronic productive cough.

- Emphysema is enlargement and destruction of the

alveoli: is characterized by:
- Damage to the small, sac-like units of the lung that deliver
oxygen into the lung and remove the carbon dioxide.
- Chronic cough.
 COPD Causes
-Smoking.
-Occupational exposure.
-Air pollution.
-Genetic (hereditary) risk: Alpha1 antitrypsin
deficiency is a genetic condition that is
responsible for about 2% of cases of COPD.
Alpha1antitrypsin protects the lungs from
damage.
 COPD Symptoms

- Chronic cough (dry / productive).

- Shortness of breath.
- Limitation of physical activity, exertional dyspnea and
dyspnea on rest.
- Prolonged expiration.
- Wheezing and crackles.
- Chest infection.
 COPD Symptoms

- Barrel chest.
- Use of accessory muscles for breathing.
- Orthopnea.
- Congestion and hyperinflation seen on
chest x-ray.
- ABG levels that indicate hypoxemia.
- Cardiac dysrhythmias.
- Other symptoms of COPD can be more
vague, weight loss, tiredness and ankle
swelling.
 COPD
Diagnostic tests
- Sputum cultures.

- Chest x-ray.

- High-resolution CT.

- Pulmonary function test (spirometry).

- Arterial blood gases test.

- Pulse oximeter.
 Types of COPD
- Mild COPD: no abnormal signs, smokers cough, little or no
breathlessness.
- Moderate COPD: breathlessness with/without wheezing, cough
with/without sputum.
- Severe COPD:
- Breathlessness on any exertion / at rest.
- Wheeze and cough prominent.
- Lung inflation usual.
- Cyanosis, peripheral edema.
- Polycythemia in advanced disease (an increase in the number of red
blood cells).
 COPD Medical management

- Smoking cessation and elimination of environmental pollutants.

- Chest physiotherapy and postural drainage to improve pulmonary
ventilation.
- Proper hydration helps to cough up secretions or tracheal
suctioning when the patient is unable to cough.
- Increase fluids intake to correct loss from diaphoresis and
inaccessible loss of hyperventilation.
- Antibiotics for infection.
- Bronchodilators to relieve bronchospasm, reduce airway
obstruction, and mucosal edema.
- Mucolytic to thin / liquefy secretions.
 COPD Medical management (cont…)
- Corticosteroids : reduces inflammation (NSAIDs).
- Supplemental oxygen remains the cornerstone of modern therapy:
Helps with shortness of breath; with low concentration during
the acute episodes (1-2L/min) as prescribed.
- In asthma adrenaline ( epinephrine) SC if the bronchospasm
not relieved.
- Sedative or tranquilizers to calm the patient.
- Intubations and mechanical ventilation if there is respiratory
failure.
 COPD Medical management (cont…)

- Palliative measure such as regular exercise, good nutrition, flu

and pneumonia vaccines.

- All COPD guidelines recommend yearly influenza vaccination.

- Annual flu vaccine: reduces risk of flu and its complications.
- Pneumonia vaccine: reduces risk of common cause of
pneumonia.
 COPD Nursing intervention (cont…)
Assessment: (2) Physical examination
- Observe for clubbing.
- The use of pursed lips breathing and chest movement.
- Distended neck vein on expiration.
- The presence of barrel chest.
- Observe for abdominal breathing.
- Hyperresonance in percussion.
- Auscultate the chest and listen for musical wheezes
characteristics of chronic bronchitis.
 Nursing diagnosis
– Ineffective breathing pattern related to increase need of O2.
– Ineffective airway clearance related to excessive accumulation of
secretions.
– Impaired gas exchange related to impaired expiration and co2
retention.
– Sleep pattern disturbance related to dyspnea.
– Activity intolerance related to inadequate oxygenation.
– High risk for ineffective individual coping related to chronic disease, its
effects and its treatment
– High risk for altered health maintenance related to insufficient knowledge of
prevention, identification and treatment of respiratory complication of
COPD.
 Nursing Intervention for COPD
- Monitor:
- Vital signs.
- Color, amount and consistency of sputum.
- Weight.
- Pulse oximetry.
- Position: Place the patient in a fowler’s position and leaning
forward to aid in breathing.
- Bed rest was recommended in order to decrease tissue oxygen
need.
- Instruct the patient in diaphragmatic or abdominal breathing
techniques and pursed-lip breathing techniques.
 Nursing Intervention for COPD

- Encourage fluid intake up to 3000 ml / day to keep secretions thin,

unless contraindicated.
- Allow activity as tolerated.
- Encourage small frequent meals to maintain nutrition and prevent
dyspnea.
- Provide a high-calorie, high protein diet with supplements.
- Suction fluids from the lungs to clear the airway and prevent
infection.
 Patient Education for COPD
To prevent irritation andinfection of the airways, instruct the patient to Avoid:
- Exposure to cigarette, pipe, and cigarsmoke as well as to dusts and
powders.
- Exposure to individuals with infections.
- Crowds areas during cold and flu season.
- Extremes in temperature “Stay indoors when temperature and humidity are
both high.
- Eating gas – producing foods, spicy foods and extremely hot or cold foods.
- Powerful odors.
- Use of aerosol sprays.
 Patient Education for COPD cont.,
- Use medications and inhalers as prescribed.
- Use oxygen therapy as prescribed.
- Adhere to activity limitations, alternating rest periods with activity.
- Meet nutritional requirements.
- Recognize the signs and symptoms of respiratory infections and
hypoxia.
- Use air conditioning to help decrease pollutants and control
temperature.
- Stay indoors when the pollen count is high.
- Obtain immunization against influenza and streptococcal
pneumonia.
 Chronic
Bronchitis
 Chronic Bronchitis

- defined as the presence of cough and sputum production

for at least 3 months in each of 2 consecutive years ; is a
category of COPD.
- Characterized by chronic inflammation.
- The most important cause is recurrent irritation of the
bronchial mucosa by inhaled substances, as occurs in
cigarette smokers.
Irritation, inflammation, excess mucus production, and potential smooth muscle
constriction (bronchospasm).
Chronic bronchitis
 Medical management of Chronic
Bronchitis
the objective of treatment are to keep the bronchioles opened and
functioning.
1. Antibiotics therapy for recurrent infection.
2. Bronchodilators.
3. Postural drainage and chest percussion.
4. Hydration and fluid intake.
5. Corticosteroid may be used.
6. Stop smoking.
Emphysema
 Emphysema
- “Emphysema” is a pathological term
that describes an abnormal distention
of the air spaces beyond the terminal
bronchioles, with destruction of the
walls of the alveoli; is a category of
COPD.
- In emphysema, impaired gas exchange
(oxygen, carbon dioxide) results from
destruction of the walls of over
distended alveoli.
Emphysema
 Emphysema

- The person tends to lean forward

and uses the accessory muscles of
respiration to breathe, forcing the
shoulder girdle upward and causing
the supraclavicular fossae to retract on
inspiration “Tripod Position”.
 Complications

- Serious complications associated with this condition (Respiratory

acidosis).
- Congestion, dependent edema, distended neck veins or pain in the
region of the liver suggests the development of cardiac failure.
- Impaired gas exchange (Hypoxemia and Hypercapnia).
- Right-sided heart failure (Cor pulmonale).
Difference between emphysema and chronic
bronchitis
Bronchial
Asthma
 Bronchial Asthma
- Asthma is a chronic inflammatory disorders of the airways
that causes varying degrees of obstruction in the airways.
- It is characterized by 3 airway problems:
- Reversible obstruction, caused by increased reaction of
the airways to various stimuli (triggers) and
inflammation.
- It is not an emotional or psychological disease.
- It can be life-threatening if not properly managed.
 Bronchial Asthma
- The narrowing that results from spasm of the muscles is
called bronchospasm.
- Generally, bronchospasm in asthma is reversible and
subsides spontaneously or with the use of bronchodilators
(medications that relax the muscles surrounding the
airways).
- Asthma is marked by airway inflammation and hyper-
responsiveness to a variety of stimuli or triggers “Atopic
Disease - allergic”.
 Etiology: Asthma Triggers
Cause of asthma is unknown but many factors play a part:
- Genetic factors: Asthma tends to run in the family.
- Environmental factors: animal dander, dust, perfumes, pollen,
smoke, fireplaces, sudden weather changes.
- Physiological factors: gastroesophageal reflux disease, hormonal
changes, sinusitis, stress and viral upper respiratory infection.
- Medications: NSAID, Beta-adrenergic blockers and aspirin.
- Occupational Exposure factors: (wood and vegetable dusts,
industrial chemicals, gases and plastics).
- Food additives: (beer, wine, dried fruit).
 Clinical Manifestation
The most commons symptoms are:
- A wheezing sound when the
patient breathe that may be
triggered by a cold; the most
common symptom of asthma.
- Chronic cough that is worse with
cold or dusty environments.
- Difficulty in breathing that comes
and goes.
- Chest tightness aggravated by cold
weather or after exercise.
 Clinical Manifestation
- Restlessness.
- Pursed lips.
- Absent or diminished lung sounds.
- Hyperresonance.
- Use of accessory muscles for breathing.
- Tachypnea.
- Prolonged expiratory time.
- Tachycardia .
- Diaphoresis.
- Cyanosis.
- Decreased oxygen saturation.
 Diagnosis
- The spirometer test.
- In addition, a substance known as methacholine (known to induce
airway narrowing), may be used to determine if the airways are
hyperresponsive (typical of asthmatics).
- Bronchodilator Reversibility Testing: Relaxing tightened muscles
around the airways and opening up airways quickly to ease
breathing.
- Chest X-ray.
- Arterial Blood Gas
 Medical Management of Asthmatic Patient
- Position the patient in a high fowler’s position or sitting to aid in
breathing.
- Limit exposure triggering agents.
- Monitor vital signs and pulse oximetry.
- Record the color, amount, and consistency of sputum.
- Auscultate lung sounds before, during and after treatments.
- Stay with the patient to decrease anxiety.
- Administer:
- Oxygen as prescribed.
- Bronchodilators, corticosteroids as prescribed.
- Medications such as: inhaled corticosteroids “Have an anti-inflammatory
effect”, inhaled beta2 adrenergic agonist, and cromolyn sodium.
 Patient education: Asthma

Instruct the patients on:

- The intermittent nature of symptoms and need for long-
term management.
- Identify possible triggers and measures to prevent episodes.
- Management of medication and proper administration.
- Teach the patient what to do if an asthma episodes occurs.
 Patient education: Asthma
Discharge instructions: Using an inhaler
 Tuberculosis: TB

-Highly communicable/infectious disease

caused by a bacteria called mycobacterium
tuberculosis.
- This germ enters the body through the air
(usually that which has been coughed out
by someone who is an infectious case of
tuberculosis) that the patient breathe and
causes an infection usually in the lung.
 Risk factors for tuberculosis
- Child younger than 5 years of age; Older patients.
- Substance abuse.
- CRF; DM.
- Immunosuppression from steroids or cancers.
- Drinking unpasteurized milk if the cow infected.
- Homeless individuals or those from a lower socioeconomic group.
- Frequent contact with an untreated or undiagnosied individual.
- Individuals living in crowded areas.
- Individuals with malnutrition, infection, immune dysfunction or human
immunodeficiency virus infection (HIV).
- Immigrants from parts of the world with endemic TB.
Clinical Manifestations
 Complications
Without treatment, tuberculosis can be fatal. Untreated active disease
typically affects the lungs, but it can affect other parts of the body as:
• Joint damage.
• Swelling of the membranes that cover the brain (meningitis).
• Liver or kidney problems.
Scenario
Complete the following
Read carefully the following clinical scenario, then answer all related
questions:

Mr. Ahmed, 66 years - old male, diagnosed with COPD 6 years ago and
diabetes 2 years ago. He was admitted to the hospital with dyspnea
(grade III) and cyanosed lips and fingertips, capillary refill 5 seconds. his
chief complains that “I cannot breathe well”. Mr. Ahmed vital data: BP
140/90 mmHg, P. 100 b/min, R. 30 br/min.
 Based on the previous data answer the following questions:

A- Discuss what would be included in a health history for Mr. Ahmed’s condition.
- Biographical data: A 66 years -old male.
- Chief complaint: inability to breath well.
- History of current illness: no details history related to onset, duration, signs and symptoms and how
to manage before hospitalization.
- Past history: COPD 6 years ago, and diabetes 2 years ago. No other past history related to surgical
history. Past history in the given situation related to common precipitating factors for COPD.
- No history related to current medications, allergies, habits.
- No family history.
- No social history related to nutrition, social activity, sleep pattern, occupation, smoking, …so on.
- No history related to review of system (general status, abdomen, skin / hair / nail, peripheral vascular,
chest and thorax and genital area).
Describing all physical examination techniques could be done for Mr. Ahmed and expected abnormal
findings; using the following format
Finding
Examination technique
(Normal / Abnormal)
General survey: Observe physical and sexual development: Barrel chest.
Observe skin and color: cyanosis, and may swelling of lower extremities.
Observe hygiene and dress: may be poor hygiene and appropriate to weather.
Observe posture and gait: Use of accessory muscles for breathing.
Observe body build: Weight gain related to ascites and swelling of lower extremities.
Assesses level of consciousness: may be confused and inability to concentrate.
Observe comfort level: breathing pattern indicates distress / shortness of breath.
Observe behavior: anxious.
Observe speech: He speaks with difficulty, quickly becoming breathless related to
dyspnea.
Observe facial expressions: may be sad and anxious with poor eye contact.
Vital signs: Bp 140/90 mmHg, P. 100 b/min, R. 30 br/min. Temperature within normal.
No data related to patient’s weight.
Skin, Hair, Nails: Skin cyanosed.
Hair: dry.
clubbing fingers, cyanosed.
Capillary refill more than 2 seconds.

Head and Neck: Ears, and throat normal.

Central cyanosis.
Patients may be use of accessory muscles during respiration.
Distended neck veins.
Pursued lips.
Chest: - Barrel chest.
- Use of accessory muscles for breathing.
- Orthopnea.
- Congestion and hyperinflation seen on chest x-ray.
- Chronic cough (dry / productive).
- Shortness of breath.
- Limitation of physical activity, exertional dyspnea and dyspnea on rest.
- Prolonged expiration.
- Wheezing and crackles.
- Chest infection.
Cardiovascular: Jugular venous distention.
Ankles Edema.
ABG levels that indicate hypoxemia.
Cardiac dysrhythmias.
Core pulomnale.

Abdomen: Bowel sounds 4 quadrants normal.

Genitalia: -
Extremities: Ankles Edema.
Nail beds minimally cyanotic, clubbing nails.

Neurologic: Anxious.
No localized or sensory deficits. Declining cognitive function: including memory and
attention deficits.
Initial laboratory data: ABG, CT chest, CXR, Reparatory function, sputum culture, cardiac enzymes, CBC
Nursing Care Plan
Nursing diagnoses Objectives Intervention
 REFERENCES
- The World Health Organization
http://www.who.int/mediacentre/factsheets/fs315/en/
- The COPD Foundation http://www.copdfoundation.org/
- The US Department of Health and Human Services
http://www.nhlbi.nih.gov/health/dci/Diseases/Copd/Copd_WhatIs
.html
- National Heart Lung and Blood Institute
http://www.nhlbi.nih.gov/health/public/lung/other/copd_breathe. htm
- Center for Disease Control and Prevention http://www.cdc.gov/