Assessment of the Respiratory System

1. Assessment of the Respiratory System Irene Owens MSN, FNP-BC

2. Anatomy and Physiology Review • Upper respiratory tract • Lower respiratory tract • Lungs • Accessory muscles of respiration • Respiratory changes associated with aging

3. Assessment Techniques • Collect history of client data on family, personal, smoking, drug use, allergies, travel, place of residence, dietary history, occupational history, and socioeconomic level. • Assess current health problems such as cough, sputum production, chest pain, and dyspnea.

4. Physical Assessment • Assessment of the nose and sinuses • Assessment of the pharynx, trachea, and larynx • Assessment of the lungs and thorax • Inspection • Palpation, check fremitus • Percussion • Auscultation

5. Breath Sounds • Normal breath sounds include bronchial, bronchovesicular, and vesicular. • Adventitious breath sounds include: • Crackle • Wheeze • Rhonchus • Pleural friction rub

6. Other Assessments • Voice sounds • Bronchophony • Whispered pectoriloquy • Egophony • Skin and mucous membranes • General appearance • Endurance

7. Psychosocial Assessment • Some respiratory problems may be worsened by stress. • Chronic respiratory disease may cause changes in family roles, social isolation, and financial problems due to unemployment or disability. • Discuss coping mechanisms and offer access to support systems.

8. Laboratory Tests • Blood tests • Sputum tests • Radiographic examinations including standard chest x-rays, digital chest radiography, CT • Ventilation and perfusion scanning • Pulse oximetry

9. Pulmonary Function Testing • These tests evaluate lung volumes and capacities, flow rates, diffusion capacity, gas exchange, airway resistance, and distribution of ventilation. • Client preparation • Procedure for performing tests at the bedside

10. Other Testing and Follow-Up Care • Exercise testing • Skin testing

11. Other Invasive Diagnostic Tests • Endoscopic examinations • Thoracentesis: aspiration of pleural fluid or air from the pleural space • Client preparation for stinging sensation and feeling of pressure • Correct position • Motionless client • Follow-up assessment for complications

12. Lung Biopsy • Performed to obtain tissue for histologic analysis, culture, or cytologic examination • Client preparation • May be performed in client’s room (Continued)

13. Lung Biopsy (Continued) • Follow-up care: • Assess vital signs and breath sounds at least every 4 hours for 24 hours. • Assess for respiratory distress. • Report reduced or absent breath sounds immediately. • Monitor for hemoptysis.

14. Interventions for Clients Requiring Oxygen Therapy

15. Oxygen Therapy • Hypoxemia: low levels of oxygen in the blood • Hypoxia: decreased tissue oxygenation • Goal of oxygen therapy: to use the lowest fraction of inspired oxygen for an acceptable blood oxygen level without causing harmful side effects

16. Hazards and Complications of Oxygen Therapy • Combustion • Oxygen-induced hypoventilation • Oxygen toxicity • Absorption atelectasis • Drying of mucous membranes • Infection

17. Low-Flow Oxygen Delivery Systems • Nasal cannula • Simple face mask • Partial rebreather mask • Non-rebreather mask

18. High-Flow Oxygen Delivery Systems • Venturi mask • Face tent • Aerosol mask • Tracheostomy collar • T-piece

19. Noninvasive Positive-Pressure Ventilation • BiPAP cycling machine delivers a set inspiratory positive airway pressure each time the client begins to inspire. At exhalation, it delivers a lower set end-expiratory pressure. Together the two pressures improve tidal volume. • Technique uses positive pressure to keep alveoli open and improve gas exchange without airway intubation.

20. Continuous Nasal Positive Airway Pressure • Technique delivers a set positive airway pressure throughout each cycle of inhalation and exhalation. • Effect is to open collapsed alveoli. • Clients who may benefit include those with atelectasis after surgery or cardiac-induced pulmonary edema; it may be used for sleep apnea.

21. Transtracheal Oxygen Delivery • Used for long-term delivery of oxygen directly into the lungs • Avoids the irritation that nasal prongs cause and is more comfortable • Flow rate prescribed for rest and for activity

22. Home Oxygen Therapy • Criteria for home oxygen therapy equipment • Client education for use • Compressed gas in a tank or cylinder • Liquid oxygen in a reservoir • Oxygen concentrator

23. Interventions for Clients with Noninfectious Problems of the Upper Respiratory Tract

24. Fracture of the Nose • Displacement of either the bone or cartilage of the nose can cause airway obstruction or cosmetic deformity and is a potential source of infection. • Cerebrospinal fluid could indicate skull fracture. • Interventions: • Rhinoplasty • Nasoseptoplasty

25. Epistaxis • Nosebleed is a common problem. • Interventions if nosebleed does not respond to emergency care: • Affected capillaries are cauterized with silver nitrate or electrocautery and the nose is packed. • Posterior nasal bleeding is an emergency. (Continued)

26. Epistaxis (Continued) • Assess for respiratory distress and for tolerance of packing or tubes. • Administer humidification, oxygen, bedrest, antibiotics, pain medications.

27. Nasal Polyps • Benign, grapelike clusters of mucous membranes and connective tissue • May obstruct nasal breathing, change character of nasal discharge, and change speech quality • Surgery: treatment of choice

28. Cancer of the Nose and Sinuses • Cancer of the nose and sinuses is rare and can be benign or malignant. • Onset is slow and manifestations resemble sinusitis. • Local lymph enlargement often occurs on the side with tumor mass. • Radiation therapy is the main treatment; surgery is also used.

29. Facial Trauma • Le Fort I nasoethmoid complex fracture • Le Fort II maxillary and nasoethmoid complex fracture • Le Fort III combination of I and II plus an orbital-zygoma fracture, often called craniofacial disjunction • First assessment: airway

30. http://en.wikipedia.org/wiki/Le_Fort_fracture_of_skull

31. Facial Trauma Interventions • Anticipate the need for emergency intubation, tracheotomy, and cricothyroidotomy. • Control hemorrhage. • Assess for extent of injury. • Treat shock. • Stabilize the fracture segment.

32. Obstructive Sleep Apnea • Breathing disruption during sleep that lasts at least 10 seconds and occurs a minimum of five times in an hour • Excessive daytime sleepiness, inability to concentrate, and irritability • Nonsurgical management and change of sleep position • Surgical management: uvulopalatopharyngoplasty

33. Disorders of the Larynx • Vocal cord paralysis • Vocal cord nodules and polyps • Laryngeal trauma

34. Interventions for Clients with Noninfectious Problems of the Lower Respiratory Tract

35. Chronic Airflow Limitation • Chronic lung diseases of chronic airflow limitation include: • Asthma • Chronic bronchitis • Pulmonary emphysema • Chronic obstructive pulmonary disease includes emphysema and chronic bronchitis characterized by bronchospasm and dyspnea.

36. Asthma • Intermittent and reversible airflow obstruction affects only the airways, not the alveoli. • Airway obstruction occurs due to inflammation and airway hyperresponsiveness.

37. Aspirin and Other NonsteroidalAnti-Inflammatory Drugs • Incidence of asthma symptoms after taking aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) • However, response not a true allergy • Results from increased production of leukotriene when other inflammatory pathways are suppressed

38. CollaborativeManagement • Assessment • History • Physical assessment and clinical manifestations: • No manifestations between attacks • Audible wheeze and increased respiratory rate • Use of accessory muscles • “Barrel chest” from air trapping

39. Laboratory Assessment • Assess arterial blood gas level. • Arterial oxygen level may decrease in acute asthma attack. • Arterial carbon dioxide level may decrease early in the attack and increase later indicating poor gas exchange. (Continued)

40. Laboratory Assessment(Continued) • Atopic asthma with elevated serum eosinophil count and immunoglobulin E levels • Sputum with eosinophils and mucous plugs with shed epithelial cells

41. Pulmonary Function Tests • The most accurate measures for asthma are pulmonary function tests using spirometry including: • Forced vital capacity (FVC) • Forced expiratory volume in the first second (FEV1) • Peak expiratory rate flow (PERF) • Chest x-rays to rule out other causes

42. Interventions • Client education: asthma is often an intermittent disease; with guided self-care, clients can co-manage this disease, increasing symptom-free periods and decreasing the number and severity of attacks. • Peak flow meter can be used twice daily by client. • Drug therapy plan is specific.

43. Drug Therapy • Pharmacologic management of asthma can involve the use of: • Bronchodilators • Beta2 agonists • Short-acting beta2 agonists • Long-acting beta2 agonists • Cholinergic antagonists (Continued)

44. Drug Therapy (Continued) • Methylxanthines • Anti-inflammatory agents • Corticosteroids • Inhaled anti-inflammatory agents • Mast cell stabilizers • Monoclonal antibodies • Leukotriene agonists

45. Other Treatments for Asthma • Exercise and activity is a recommended therapy that promotes ventilation and perfusion. • Oxygen therapy is delivered via mask, nasal cannula, or endotracheal tube in acute asthma attack.

46. Emphysema • In pulmonary emphysema, loss of lung elasticity and hyperinflation of the lung • Dyspnea and the need for an increased respiratory rate • Air trapping, loss of elastic recoil in the alveolar walls, overstretching and enlargement of the alveoli into bullae, and collapse of small airways (bronchioles)

47. Classification of Emphysema • Panlobular: destruction of the entire alveolus • Centrilobular: openings occurring in the bronchioles that allow spaces to develop as tissue walls break down • Paraseptal: confined to the alveolar ducts and alveolar sacs

48. Chronic Bronchitis • Inflammation of the bronchi and bronchioles caused by chronic exposure to irritants, especially tobacco smoke • Inflammation, vasodilation, congestion, mucosal edema, and bronchospasm • Affects only the airways, not the alveoli • Production of large amounts of thick mucus

49. Complications • Chronic bronchitis • Hypoxemia and acidosis • Respiratory infections • Cardiac failure, especially cor pulmonale • Cardiac dysrhythmias

50. Physical Assessment and Clinical Manifestations • Unplanned weight loss; loss of muscle mass in the extremities; enlarged neck muscles; slow moving, slightly stooped posture; sits with forward-bend • Respiratory changes • Cardiac changes