RESPIRATORY BUNDLE

11 pgs.

> Review of the Respiratory System

> Emphysema vs Chronic Bronchitis
> Chronic Obstructive Pulmonary Disease (COPD)
> Asthma
> Acute Respiratory Distress Syndrome
> Pulmonary Embolism
> Pneumonia
> Pneumothorax vs Hemathorax
> Chest Tube
> Oxygen Delivery
 REVIEW OF THE RESPIRATORY SYSTEM

FUNCT ION
> Gas Exchange (oxygen & carbon dioxide)
> Warms & moisturizes air before entering lungs
(matches body temp & humidity level)
> Talk (air passes vocal cords to make sounds)
> Cough & sneeze to rid particles causing irritation
> Helps control body’s pH

3 LOBES 2 LOBES

BREAT HING T ERMS

> Dyspnea: difficult, painful breathing
> Tachypnea: fast breathing
> Bradypnea: very slow breathing
> Apnea: stop breathing for periods of time
> Orthopnea: difficultly breathing when lying
down, but relieved by sitting up (orthopneic
position)
> Hypoventilation: decreased rate & depth
(shallow)
> Hyperventilation: increased rate & depth
> Cheyne-Stokes: variation of decreased &
shallow breathing to rapid + periods of
apnea
> Kussmaul: rapid breathing, gasping &
hungry for air
 EMPHYSEMA vs CHRONIC BRONCHITIS
Both are types of COPD

RISK FACTORS
> YEARS of Smoking! or Second-hand
smoke
> YEARS of Exposure to high polluted
area, Chemical fumes
> AAT deficiency (Emphysema)
> Repeated respiratory infection (Chronic
Bronchitis)

EMPHYSEMA “PINK PUFFER” CHRONIC BRONCHIT IS “BLUE BLOAT ER”

Enlargement of the alveoli & alveolar ducts leading to Severe inflammation & hardening of the bronchi &
damage & loss of elasticity. bronchioles.
> Air trapped in the alveoli ―> unable to exhale
causing lungs to distend ―> poor gas exchange causing SYMPTOMS
lung muscles to suffer from little oxygen ―> loss of > Chronic cough “dry, smoker-like”
elasticity > Coughs sputum (mucus & pus)
> Cyanosis “blue” (hypoxia)
SYMPTOMS > Peripheral edema, Obese “bloated”
> Dyspnea on exertion, SOB (Right- Side HF ―> cor pulmonale)
> Barrel chest “puffed out” > Dyspnea, SOB
> “Pursed-lip breathing” puffing or gasping for air > Crackle or Wheezing lungs sounds
> Hyperventilation > Respiratory acidosis (trapped CO2 & low inhalation of O2)
> Pink, flushed skin
> Clubbed fingers (low oxygen)
> Respiratory acidosis (trapped CO2 & low inhalation
of O2)
> Visible use of accessory muscles
 CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)

Worsening condition of decreased airflow from emphysema and

Pulse Ox Stat for a COPD
chronic bronchitis.
pt. is between 88-93%.
> Usually diagnosed in Middle-age to Old-age people (happens
gradually) This is NORMAL!
> Irreversible “NO CURE” but treatable to relieve symptoms.

SYMPTOMS (EMPHYSEMA & CHRONIC BRONCHIT IS) INT ERVENT IONS/CLIENT T EACHING
> Dyspnea on exertion, SOB > Stop Smoking!
> Hypoxemia (LOW O2 in blood), Hypercapnia (High CO2) > High Fowler’s or Orthopneic position (widens lung cavity to
> Dry, productive “sputum” cough (Chronic B.) help with breathing)
> Barrel chest “puffed out” (Emphysema) > Use Inceptive spirometer, Give oxygen (2-3 L/min)
> Use of accessory muscles (Emphysema) > Teach “pursed lip” breathing technique
> Clubbed fingers (Emphysema) > Teach “huff coughing” technique
> Crackle & Wheezing lung sounds (Chronic B.) > Perform chest physiotherapy or “percussions” (loosens mucus
> Cyanosis “blue” mucous membranes & fingers (Chronic B.) trapped in lungs)
> Pink undertone to skin (Emphysema) > Drink plenty fluid (2-3 L/day)
> Low energy > Small, frequent meals (4-6 meals/day)
> Repeated respiratory infection (Chronic B.) > Diet high in calories, protein
> Tripod position (either sits or stand, leans over & place hands > Avoid gassy foods (carbonated drinks & fiber) ―>leads to
on knees or other surfaces to help breathe better) bloating, which puts pressure on lungs
> Oral care (brush teeth) BEFORE eating
DIAGNOST IC LAB T ESTS > Avoid lying down 1 hr AFT ER eating
> ^¦ Hbg > Avoid exercising 1 hr BEFORE & AFT ER eating (conserve
> Hypoxemia (PaO2 less than 80) as much oxygen)
> Hypercapnia (PaCO2 greater than 45) > Avoid drinking water WHILE eating
> Respiratory Acidosis > Check for signs of infection (fever, sputum color & amount)
> Sputum culture & WBC (check for respiratory infection) > Avoid hot, humid & very cold weather
> Stay up-to-date on vaccines
MEDICAT IONS
> Short-acting Bronchodilators (albuterol i.e. rapidly relaxes
bronchioles smooth muscles)
> Long acting Bronchodilators (salmeterol i.e. gradually relaxes
bronchial smooth muscles)
> Glucocorticosteriods (prednisone, fluticasone i.e. reduces
inflammation)
> Anticholinergic (ipratropium i.e. relaxes & dilates bronchial &
reduces mucus)
> Methtlaxanthines (theophylline i.e. relaxes bronchi smooth
muscles/for pt. with severe COPD)
> Phosphodiesterase type 4 inhibitors (roflumilast i.e. decrease
exacerbations in severe COPD w/ Hx of chronic bronchitis)
> Mucolytics
 ASTHMA
Chronic inflammation & tightening of the bronchi &
bronchial airways. T RIGGERS
> Occurs at any age, but generally starts during childhood > Smoke, Air pollution

☐
> Reversible, unlike COPD > Allergies (pollen, dust, grass, cats)
> Strong perfumes
RISK FACTORS > Exercise (take asthma med 30 mins BEFORE
> Allergies (dust, pollen, cats, etc.) exercising)
> Smoking! or Second hand smoke > Stress
> Family Hx of asthma > Meds: NSAIDs, beta blockers, aspirin

> Infection
> GERD

SYMPTOMS
> Dyspnea, SOB
> Use of accessory muscles
> Chest tightness & pain
> Wheezing lung sounds
> Cough, Thick sputum
> Hypoxemia
> Anxiety, Stress

DIAGNOST IC LAB T ESTS

> Hypoxemia (PaO2 less than 80) severe hypercapnia ―> AST HMA AT TACK
> Hypercapnia (PaCO2 greater than 45)
> Pulmonary function test (diagnose asthma & it’s severity)
> Chest x-ray AST HMA AT TACK “status asthmaticus”
> Deadly. Unresponsive to usual asthmatic treatment
INT ERVENT IONS > Medical Emergency & needs to be treated IMMEDIAT ELY!
> High Fowler’s position > SIGNS: Extreme wheezing , Chest tightening, Rapid
> Give oxygen & regularly check pulse ox (Normal O2 breathing, Dyspnea, Respiratory acidosis (severe hypercapnia)
95-100%) > T REAT MENT: Bronchodilators (SHORT ACT ING for FAST
> Assess peak flow meter reading RELEIF), Oxygen, Epinephrine, Steroids, Emergency intubation
> Educate pt. on how to use inhaler devices (MDI)

Measure lungs ability to push air out.

MEDICAT IONS
Peak Flow > Do it 3x and document the HIGHEST score
> Short-acting Bronchodilators (albuterol i.e. rapidly relaxes
Meter out of all 3.
bronchioles smooth muscles)
> The highest score is documented over a 2
> Long acting Bronchodilators (salmeterol i.e. gradually
week period when asthma is controlled.
relaxes bronchial smooth muscles)
- AWESOME! ―> 80-100%
> Anticholinergic (ipratropium i.e. relaxes & dilates bronchial
- Meh.. ―> 60-80%
& reduces mucus)
- OMG! ―> <60% (CALL T HE DOCTOR)
> Methtlaxanthines (theophylline i.e. relaxes bronchi smooth
muscles
> Glucocorticosteriods (prednisone, fluticasone i.e. reduces
inflammation)
 ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS)
Life-threatening lung injury. Damage to the capillary membranes
surrounding the alveoli causing the sacs to build up with fluid
> Surfactant (increases compliance of lungs & reduces airway
resistance) is decreased affecting the alveoli

RISK FACTORS ―> Systemic damage that’s Direct

(from lungs) or Indirect (not from lungs)
> Lung trauma
> Aspiration
> Pulmonary infection (pneumonia, tuberculosis)
> Pulmonary embolism
> Near-drowning
> Inhalation of harmful chemicals (smoke, toxic gas)
> CNS damage
> End-stage kidney disease
> Drug overdose
> Blood transfusion
> Sepsis

SYMPTOMS INT ERVENT IONS

> Hypoxemia (low O2 in blood) > Mechanical ventilation! with PEEP or CPAP to avoid
> Dyspnea, High RR (air hunger) alveolar collapse
> High HR > Continuously check ABG levels, Pulse ox, & Lung
> Cyanosis “blue” lips sounds
> Use of accessory muscle > Passive ROM, Turn frequently
> Nasal flaring > Continuously check skin integrity & give oral care
> Bilateral noncardiogenic pulmonary edema (crackle lung sounds) > Suction secretions (give O2 before suctioning to
> Bilateral pulmonary infiltrates prevent hypoxemia)
> Decreased lung volume & compliance > Prevent infection!
> Confusion, Agitation, & Restlessness (low O2 in brain) > Meds: Anesthesia (propofol i.e. sedates pt to
decrease stress & major effort to breathe);
DIAGNOST IC LAB T ESTS Neuromuscular blocking agents (vecuronium i.e.
> Hypoxemia (low O2 level) paralyzes body to improve ventilation because pt uses
> Hypercapnia (high O2 level) major effort to breathe)
> Chest x-ray

Prone (stomach lying) position is the

most effective position to facilitate
ventilation & perfusion, move trapped
secretions, & improve atelectasis
 PULMONARY EMBOLISM
A blood clot (embolism) that becomes lodged in the lung.
PE can also be caused by air, tumor, or amniotic fluid.
> Very common in postoperative pt. (HIGH risk of DVT!)
> A medical emergency b/c risk of sudden death (signs of
PE is sometimes caught late)

RISK FACTORS MOST COMMON.

> Deep Venous Thrombosis (DVT) ―> Embolism travels from leg
> Surgery to lung.
> Long-term immobility
> High platelet count (increased coagulation “blood clot formation”)
> Heart Failure, Atrial Fibrillation
> Smoking
> Obesity, Pregnancy

SYMPTOMS
> Chest pains
> Dyspnea, SOB
> Harsh cough w/ bloody sputum
> Anxiety, Feeling of impending doom PAT IENT EDUCAT ION TO PREVENT ANOT HER DVT
> Hypoxemia > Elevate leg
> Pleural friction rub lung sounds > NO SMOKING!
> High HR & RR, Hypotension > Remain ACT IVE, Perform ROM when sitting
> Petechiae on chest (red dots) > Stay hydrated
> Diaphoresis (excessive sweating) > Compression stockings (promotes blood circulation)
> Cyanosis “blue” skin (deprived of oxygen) > Avoid crossing legs
> Syncope
IF ON WARFARIN
> Antidote = Vitamin K
DIAGNOST IC LAB T ESTS
> Maintain consistent vitamin K intake
> Elevate D-Dimer (indication of a LARGE clot breakdown) (green leafy veggies).
> Too much vitamin K interferes with
INT ERVENT IONS anticoagulant effects of warfarin & will
> Give oxygen cause blood clot formation.
> High Fowler’s position
> Bed rest
> Monitor cardiac, neuro. & respiratory status
> If DVT, do NOT massage leg (causes clot to dislodge & move
towards lungs)
> Meds: Anticoagulants (warfarin, heparin i.e. prevents more clot
formation); Thrombolytic (reteplase, alteplase i.e. dissolves blood clot)
Procedures:
> Embolectomy (surgical removal of clot)
> Vena cava filter (filter insertion in vena cava to stop embolism
from reaching lungs)
 PNEUMONIA

Inflammation of the alveoli sacs caused by a bacterial, viral,

or fungal infection.
> Community-acquired, Hospital-acquired, or Healthcare-acquired
> Ranges from mild to life-threatening.

RISK FACTORS
> Bacteria (staphylococcus, streptococcus, klebsiella)
Virus (influenza)
> Aspirating food, drink, or vomit
> Postoperative
> Immobility
> Smoking
> COPD, Asthma

SYMPTOMS INT ERVENT IONS

> Dyspnea on expiration, SOB > Use incentive spirometer, Give oxygen
> Mild or High Fever > Drink plenty fluids (2-3 L/day)
> Chest pain > Assess lung sounds, RR, & pulse ox (95-100%)
> Cough, Thick sputum “mucus” > Cough & deep breathing exercise
> Fatigue, Confusion > Suction excess mucus
> Crackle & Wheezing lung sounds > Turn frequently
> Hypercapnia (high CO2), Hypoxemia (low O2) > Meds: Antibiotics (macrolides i.e. rid bacterial
> Respiratory acidosis (CO2 retention) infection); or Antiviral (oseltamivir i.e. rid viral
> High HR & RR, Hypotension infection); Antipyretic (acetaminophen i.e. rid fever)
> Body aching
> Cyanosis “blue” skin (deprived of O2) PREVENT PNEUMONIA
> Up-to-date vaccines (influenza)
DIAGNOST IC LAB T ESTS > Use good hand hygiene
> ^¦ WBC
> Hypoxemia (PaO2 less than 80)
> Hypercapnia (PaCO2 greater than 45)
> Sputum culture
> Chest x-ray
 g
PNEUMOTHORAX & HEMOTHORAX
Trapped air (pneumothorax), fluid (pleural effusion) or blood (hemothorax)
in the pleural cavity that puts pressure on the lung & cause a collapsed
lung.
> Collapsed lung can be either PART IAL or COMPLET E
> Three types of Pneumothorax: Closed, Open, & Tension
> Accumulation of air, fluid, or blood shifts the mediastinum leading to a
collapsed lung.
> Leads to death if not treated IMMEDIAT ELY!

RISK FACTORS
PNEUMOT HORAX HEMOT HORAX
Pneumothorax & Hemothorax
> Chest trauma (blunt force or penetration)
> Chest surgery complication
> Clogged chest tube Penetration
> Spontaneous (rupture of a defect lung due to decreased (stabbing)
elasticity & thickening alveoli)
Pleural Effusion
> Heart Failure, Liver or Kidney Disease Tear
(rib fracture tearing
> Cancer
into lung)
> Infection (pneumonia, tuberculosis)
> Autoimmune Disorder (lupus, rheumatoid arthritis)

SYMPTOMS
> Severe dyspnea
> Sharp chest pain during inhalation
> Asymmetrical chest (mediastinal shift)
> Absent breath sounds in affected side
> Hypoxemia
Severe complication w/
> Nasal flaring closed or open
> Weak pulse, Hypotension pneumothorax
> Cyanosis “blue” skin
> Anxiety, Confusion

DIAGNOST IC LAB T ESTS INT ERVENT IONS

> Hypoxemia (PaO2 less than 80) > Give oxygen
^¦ ^¦ > High Fowler’s position
> Hbg & Hct (Hemathorax)
> Chest X-ray > Teach deep breathing technique (expands lung cavity)
> CT scan > Assess chest movement, breath sounds, & vital signs,
> Thoracentesis (Hemathorax) confirms blood in cavity especially Pulse ox, RR, BP, & HR
> Closely monitor chest tube (suction, tubing, drainage)
COMPLICAT IONS > Meds: Opioid analgesic IV (morphine, fentanyl i.e. relieves pain)
> Decreased cardiac output Procedure:
> Respiratory failure > Chest tube (inserted in pleural cavity to facilitate drainage,
reestablish lung expansion & negative pressure)
 CHEST TUBE

Tube inserted into the chest to drain air, fluid, or blood from
the pleural cavity (space between the lungs & chest wall)
> Three Chambers: Suction Control Chamber, Water Seal
Chamber, & Drainage Collection Chamber

USES
> Post-Op Thoracic Surgery
> Pneumothorax (collapsed lung due to accumulation of air in
pleural cavity)
> Hemothorax (collapsed lung due to accumulation of blood in
pleural cavity)
> Pleural Effusion (collapsed lung due to accumulation of fluid
in pleural cavity) — normally, a small amount of fluid is in the
lung pleural cavity & acts as a lubricant to help the lungs
moves easily as we breath. BUT with pleural effusion,
abnormal amount of fluid accumulates

A. Suction Control Chamber

> Gentle & Continuous bubbling is GOOD! (suction is working just fine)
> Vigorous bubbling is BAD!
> Check water level & if TOO LOW, add more water (prescribed amount is approx. 20 cm for adults)

B & C. Water Seal Chamber & Air Leak Monitor

Allows fluid, air, & blood to drain from pleural cavity & prevent air from entering the pleural cavity
> Add ST ERILE FLUID to keep it at 2 cm (minimum amount required to function)
> Tidaling (steady up & down movement with each breath pt. takes) is a GOOD sign!
> If tidaling STOPS, it’s either good or bad
- Good: lung re-expanded & chest tube can be removed
- Bad: an obstruction inside the chest tubing (blood clot, tube kink or loop)
- So if tidaling STOPS, assess the pt. FIRST (auscultate lung sounds), then the device (check for obstructions)
> Continuous bubbling indicates AIR LEAK in the stystem! (Notify HCP or both HCP & RN if you are a LPN/LVN)
> Intermittent bubbling is NORMAL, especially when pt. coughs

D. Drainage Collection Chamber:

> Assess drainage amount & color hourly for the first 24 hours, then every 8 hours
> Report drainage amount > 100 mL/hr or BRIGHT, RED blood (especially if in excess amount) — Old, dark blood is NORMAL
> Report cloudy blood
> Document findings clearly & regularly
 CHEST TUBE CONTINUED…
NURSING CONSIDERAT IONS
> Chest X-ray to verify placement of chest tube
> Keep drainage device BELOW pts. chest level (AVOID fluid or blood back-flow into pleural cavity)
> Keep tubing free of kinks & check for obstructions
> Regularly monitor chest tube insertion site for redness, pain, infection, & crepitus (crackling sound
that indicates subcutaneous emphysema)
> Assess occlusive, sterile dressing at the chest tube insertion site
> Assess respiratory status & lung sounds every 2-4 hrs. (especially for DIMINISHED lung sounds)
> Cough & Deep breathing technique every 2 hours
> Turn frequently to promote drainage & ventilation, Semi-Fowler or High-Fowler position
> DO NOT strip “milk” or clamp tubing (unless specifically prescribed)
> Palpate chest tube insertion site for subcutaneous emphysema (air trapped in tissue beneath the
skin that grows in size, makes a crackling sound “rice crispy treat”)
> Keep sterile water, clamp, & sterile occlusive dressing at bedside AT ALL T IMES
ACCIDENTAL DISLODGE FROM PT.
> Tell pt. to exhale & cough IMMEDIAT ELY & as much as possible
> QUICKLY cover area with sterile occlusive dressing, only taping 3 SIDES (allows air to escape, while
preventing air from entering)
DRAINAGE DEVICE BROKEN
All these measures are
> If LPN/LVN, notify RN & HCP
> Insert end of tubing in 1-2 in of sterile water until broken device is replaced taken to prevent
T ENSION PNEUMOT HORAX
REMOVAL OF CHEST T UBE
> Pre-medicate with analgesic 30 mins before removal (if prescribed)
> Tell pt. to take deep breath, exhale, & bear down (Valsalva maneuver) during chest tube removal —
prevents air entering pleural cavity
> Check respiratory status, lung sounds, equal/non-equal chest rises, & drainage
> Chest X-ray to assess lung re-expansion & check for recurrent pneumothorax/hemothorax

Tubes are clamped as prescribed & for certain reasons:

- Air leakage
tubes should be clamped for
- During drainage device change
ONLY A FEW SECONDS
- Before chest tube removal (risk of tension pneumothorax)
 É
OXYGEN DELIVERY
NASAL FLOW RAT E: 1-6 L/min FLOW RAT E: 5-8 L/min
SIMPLE
FiO2: 24%-44% FiO2: 40%-60%
CANNULA INDICAT IONS: Chronic airflow limitation, Long-term use, FACE MASK INDICAT IONS: Emergency situation, Short-term use,
Inexpensive Inexpensive
NURSE CONSIDERAT IONS: NURSING CONSIDERAT IONS:
> Easily dislodges, Be sure the prongs fit properly & the > Short-term use
openings are facing the nasals > Be sure it properly fits around nose & mouth
> Continuously check for patent, non-clogged nasals & nasal > NOT best used for pts with anxiety or
prongs claustrophobia (can feel warm & confining if too tight)
> Assess nasal mucosa for irritation & drying caused by > Adjust straps for comfortable fit
high flow rate (4 L/min & greater) or extended use — > Assess for moisture collection & skin breakdown
apply water-soluble gel to nasals > Closely watch high risk aspirating pts
> Add humidifier as prescribed (used for flow rates 3 L/min > Remove to eat, use nasal cannula
& greater

PART IAL FLOW RAT E: 6-10 L/min NON FLOW RAT E: 10-15 L/min
FiO2: 40%-60% FiO2: 60%-100%
REBREAT HER REBREAT HER
INDICAT IONS: Pts. needing to raise O2 INDICAT IONS: Deteriorating respiratory pts. who may
concentration (NOT best for COPD pts.) require intubation, Delivers high O2 concentration w/o
NURSING CONSIDERAT IONS: intubation
> Adjust O2 flow rate to keep reservoir bag 2/3 NURSING CONSIDERAT IONS:
full during inhalation & to AVOID deflation of the > Be sure valves open during exhalation & closes
reservoir bag (can cause lose of O2 & CO2 during inhalation
buildup) > Hourly data collection of the valve & flaps
> Make sure reservoir bag doesn’t twist or kink > Adjust O2 flow rate to keep reservoir inflated
> Be sure it properly fits around nose & mouth > Make sure reservoir bag doesn’t twist or kink or
> NOT best used for pts with anxiety or that the O2 source doesn’t disconnect; otherwise, the
claustrophobia (can feel warm & confining if too pt. will suffocate
ONE WAY VALVE
tight) > Be sure it properly fits around nose & mouth
(so that the pt.
> Adjust straps for comfortable fit doesn t rebreather > NOT best used for pts with anxiety or
> Assess for moisture collection & skin breakdown exhaled air) claustrophobia (can feel warm & confining if too tight)
NO > Closely watch high risk aspirating pts > Adjust straps for comfortable fit
VALVE > Remove to eat, use nasal cannula > Assess for moisture collection & skin breakdown
> Closely watch high risk aspirating pts
> Remove to eat, use nasal cannula

VENT URI FLOW RAT E: 4-10 L/min FACE T ENT/ FLOW RAT E: 10 L/min
FiO2: 24%-60% FiO2: 24%-100%
REBREAT HER AEROSOL
INDICAT IONS: Chronic lung diseases (COPD), Delivers INDICAT IONS: Facial trauma or burn pts, Delivers
high, accurate O2 concentration & consistent FiO2
MASK high O2 concentration
NURSING CONSIDERAT IONS: NURSING CONSIDERAT IONS:
> Air entrapment port for adapter should remain open > Fits loosely & tolerated better than a face mask
& uncovered > Be sure aerosol mist leaves from vents during
> Different adapters (color & size) deliver different inhalation & exhalation
rates & FiO2 > It gives off high humidity, so continuously monitor
> Check tubing for kinks to AVOID FiO2 alterations humidity level
> Assess flow rate (flow rate < 10 L/min can lead to > Be sure adequate water is in humidifier
over-oxygenation & is harmful) canister
> Be sure it properly fits around nose & mouth > Regularly empty moisture collection from the
> Assess nasal mucosa for irritation & drying, moisture tubing
collection, & skin breakdown
> Remove to eat, use nasal cannula
> Humidity NOT required

BE AWARE! Flow rate & FiO2 ranges will slightly vary between textbooks, online sources, & any medical facility you may work at