ncm-112-respi-231104121830-0cc8a6b9.pptx

respiratory system

1. Welcome to NCM 112-RESPI Mary Ann G.Andrada , BSN-RN Instructor

2. Anatomic and physiologic overview Respiratory system composed of the upper and lower respiratory tract , this two tracts are responsible for ventilation. *Ventilation-movement of air in and out of the airways. Key function of the Respiratory system is gas exchange. *Gas exchange-involves delivering oxygen to the tissues through the blood stream and expelling waste gases such as carbon dioxide during expiration.

3. Upper Respiratory tract or the upper airway consist of the nose , mouth, pharynx, larynx and trachea. *Key functions are, to warm , humidify and filter the air that we breath. Lower respiratory tract or the lower airway includes the bronchi , bronchioles, alveoli ducts and alveoli. Key function is gas exchange *Alveoli are the functional unit for gas exchange.

4. PLEURA – surround and cushion each of the lungs. Pleural cavity – space between the two layers of the pleura. *Two layers of the Pleura* Parietal Pleura – the outer layer that attached to the chest wall. Visceral Pleura – the inner layer that covers the lungs , blood vessels and bronchi.

5. Blood Flow Deoxygenated blood from the body goes to the right atrium and then to the right ventricle and then to the lungs, where it becomes oxygenated and then is returned to the left atrium. “The blood coming from the right ventricle and it is passing along the alveoli, and this is where diffusion takes place. Oxygen is diffused from the alveoli into the capillaries, and then carbon dioxide moves the opposite direction into the alveoli, where we can in turn breathe out that carbon dioxide, and then the oxygenated blood returns to the left atrium.”

6. Oxygenation and Tissue Perfusion Oxygenation – the delivery of oxygen to the tissues to maintain cellular activity. Tissue perfusion – the volume of blood that flows through a unit quantity of the tissue. Physiology of Oxygenation 4 components: 1.Pulmonary ventilation 2.Alveolar-capillary gas exchange 3.Transport of O2 and CO2 4.Systemic diffusion

7. Factors affecting oxygenation 1.Age 2.Environmental factors 3.Lifestyles Factors 4.Disease Processes 5.Medications 6.Stress

8. Impaired Oxygenation > can be life threatening >mild to severe >Diseases injuries >Frightening , frustrating

9. Respiratory System’s Diagnostic Test and Lab. ABGs , Pulse Oximetry , PFT, Bronchoscopy, Thoracentesis : ABG – an arterial blood gas test measures the level of oxygen and carbon dioxide in your blood as well as the pH balance in your blood. 5 key components of ABG: 1.pH – measures the balance of acids and bases in your blood . Usually range to 7.35 to 7.45 2.PaCO2 – partial pressure of carbon dioxide usually range to 35 to 45 mmHg.

10. 3.HCO3 – Bicarbonate usually 22 and 26 mmHg 4.PaCO2 – partial pressure of oxygen usually 80 to 100 5.SaO2 - oxygen saturation of the arterial blood usually 95 to 100 Pulse Oximetry – SPo2 95 to 100 ( pt.w / COPD below 90) PFT – Pulmonary Function Test are noninvasive tests that show how well the lungs are working. PFT measure:lung volume,capacity,rates of flow and gas exchange

11. Bronchoscopy – insertion of a tube in a pt.airway that allows the visualization of that airway as well as a collection of specimens Nsg.care Pre- procedure:1. NPO for 4 to 8 hrs. 2.Prescribed medication w/c allow for sedation of the pt.during procedure. Post:1.make sure that pt.gag reflex has returned before we provide them anything to eat or drink.

12. 2.Advised the pt . that sore , dry throat , and blood tinged mucus is expected 3 . monitor pt . for complication such as pneumothorax. Thoracentesis – insertion of the needle into the pt.posterior chest to remove fluid or air from the pleural space. Nsg . care : Pre-procedure: 1.let the pt . sit upright and their arms should be supported on their bedside table or on pillows . 2.They need to remain perfectly still during the procedure *advised them not to talk,move or cough during the procedure .

13. Management of Patients with Upper Respiratory Tract Disorders Upper airway infections also known as URI’s Rhinitis Viral Rhinitis(Common Cold) Rhinosinusitis Acute Rhinosinusitis Chronic Rhinosinusitis and Recurrent Acute Rhinosinusitis Pharyngitis(Acute and Chronic)

14. Tonsillitis and Adenoiditis Peritonsillar Abscess Laryngitis Obstruction and Trauma of the Upper Respiratory Airway Obstruction During Sleep(OAS) Epistaxis(nosebleed) Nasal Obstruction Fractures of the Nose Laryngeal Obstruction *Cancer of the Larynx*

15. Obstructive Sleep Apnea:

16. Sleep Apnea

17. Potentially serious sleep disorder Breathing repeatedly stops and starts

18. Sleep Stages Light Sleep. - Stage 1 1-5 mins NREM 4-5% of total sleep time is considered normal Increases to 15% by age 70 Restful Sleep. - Stage 2 10-60 mins Deep Sleep. - Delta or Slow Wave Sleep Range of total sleep: 10 - 20% % decreases with age 20-40 mins REM. - Rapid Eye Movement sleep - 20 - 25% total time get body paralysis - atonia mind very active very vivid hallucinatory imagery or dreaming

19. Sleep Architecture . Each NREM - REM couplet is equal to one cycle . Normally go through a sleep cycle every 90 minutes . Go through about 4 - 5 cycles in a good 7 1/2 hour sleep . REM cycles get longer and closer as the length of the sleep gets longer.

20. Sleep Apnea is: Common Dangerous Easily recognized Treatable

21. Sleep Apnea Risk Factors Obesity Increasing age Male gender Anatomic abnormalities of upper airway Family history Alcohol or sedative use Smoking Associated conditions

22. Obstructive Sleep Apnea: Cessation of air flow for greater than 10 Seconds with continued chest and abdominal effort

23. Epidemiology of OSA 85% men Prevalence - 2% in women, 4% in men two thirds are obese

24. Clinical features: Heavy snoring – characteristics Witnessed apnea: Stop breathing while sleeping - then .snort. Choking daytime sleepiness evaluated by Epworth sleepiness score

25. adenotonsillar hypertrophy nasal obstruction hypothyroidism acromegaly Down syndrome sedative use Alcohol Smoking micrognathia retrognathia Obesity Neck circumference vocal cord paralysis Risk factors

26. Sleep Apnea Risk Factors Obesity Increasing age Male gender Anatomic abnormalities of upper airway Family history Alcohol or sedative use Smoking Associated conditions

27. physical exam High blood pressure Nasal obstruction - turbinate hypertrophy, polyposis, septal deviation oral cavity and oropharynx redundant mucosa elongated uvula Macroglossia

28. Types of Sleep Disordered Breathing Apnea Cessation of airflow > 10 seconds Hypopnea Decreased airflow 30% from baseline lasting > 10 seconds associated with > 4% oxyhemoglobin desaturation

29. Apnea Patterns Obstructive Mixed Central Airflow Respiratory effort

30. Respiratory Effort-related Arousals

31. What About “Simple Snoring?” Snoring in pregnancy is associated with increased hypertension and growth retardation, controlling for weight, age, smoking (Franklin, Chest, 2000) Snoring is associated with cognitive decline (Quesnot, J Am Geriatric Soc, 1999) Snoring medical students are more likely to fail exams, controlling for BMI, age, sex (Ficker, Sleep, 1999).

32. SNORING Snoring is a risk factor for cardiovascular disease in women. (Hu, J Am Coll Cardiol 2000). Snoring is a risk for type II diabetes (Al-Delaimy, Am J Epidemiol 2002). Snoring women have faster progression of CAD ( Leineweber C. Sleep 2004)

33. Measures of Sleep Apnea Frequency Apnea Index # apneas per hour of sleep Apnea / Hypopnea Index (AHI) # apneas + hypopneas per hour of sleep Respiratory Disturbance Index # apneas + hypopneas + RERAs per hour of sleep

34. One Definition of Obstructive Sleep Apnea (OSA) CPAP will be covered for adults with sleep-disordered breathing if: Hypertension Stroke Sleepiness Ischemic heart disease Insomnia Mood disorders

35. Sleep Apnea vs Sleep Disorders Prevalence of common sleep disorders Insomnia: 10-30% Sleep Apnea: 5% Narcolepsy: 0.05% Diagnoses of patients presenting to sleep centers (Coleman II, 2000) Sleep apnea: 67.8 Narcolepsy 3.2%

36. 1 2 3 4 5 6 7 8 9 The Upper Airway

37. Pathophysiology of Apnea Wakefulness Sleep

38. Pathophysiology of Sleep Apnea Awake: Small airway + neuromuscular compensation Loss of neuromuscular compensation + Decreased pharyngeal muscle activity Sleep Onset Hyperventilate: connect hypoxia & hypercapnia Airway collapses Pharyngeal muscle activity restored Apnea Arousal from sleep Hypoxia & Hypercapnia Increased ventilatory effort

39. Signs and Symptoms of OSA Excessive daytime sleepiness . Loud snoring . Observed episodes of stopped breathing during sleep. Abrupt awakenings accompanied by gasping or choking. Awakening with a  dry mouth  or sore throat. Morning headache. Difficulty concentrating during the day.

40. Clinical Consequences Cardiovascular Complications Morbidity Mortality Sleep Fragmentation Hypoxia/ Hypercapnia Excessive Daytime Sleepiness Sleep Apnea

41. Consequences: Excessive Daytime Sleepiness Increased motor vehicle crashes Increased work-related accidents Poor job performance Depression Family discord Decreased quality of life

42. Consequences: Cardiovascular Systemic hypertension Cardiac arrhythmias Cardiovascular disease Myocardial ischemia Congestive heart failure Cerebrovascular disease

43. Consequences: Cardiovascular Disease Odds Ratio Cross Sectional Study of Association Between OSA and CVD Adjusted for age, sex, race, BMI, Htn, cigs., chol. 0.5 1 1.5 2 2.5 CAD HF CVA 0 - 1.3 1.4 - 4.4 4.5 - 11.0 > 11.0 AHI Adapted from Shahar E et al. Am J Respir Crit Care Med 2001;163.

44. Risk Factor: Obesity Davies RJ et al. Eur Respir J 1990;3. >4% Arterial saturation dipa h -1 % Predicted normal neck circumference

45. Diagnosis: History Snoring (loud, chronic) Nocturnal gasping and choking Ask bed partner (witnessed apneas) Automobile or work related accidents Personality changes or cognitive problems Risk factors Excessive daytime sleepiness Sleep Apnea: Is Your Patient at Risk? NIH Publication, No 95-3803.

46. Diagnosis: Assessing Daytime Sleepiness Often unrecognized by patient Ask family members Must ask specific questions Fatigue vs. sleepiness Auto crashes or near misses Sleep in inappropriate settings Work Social situations

47. Diagnosis: Physical Examination Upper body obesity / thick neck > 17” males > 16” females Hypertension Obvious upper airway abnormality

48. Exam: Tonsillar Hypertrophy Shepard JW Jr et al. Mayo Clin Proc 1990;65. Oropharynx With Tonsillar Hypertrophy Normal Oropharynx

49. Why Get a Sleep Study? Signs and symptoms poorly predict disease severity Appropriate therapy dependent on severity Failure to treat leads to: Increased morbidity Motor vehicle crashes Mortality Other causes of daytime sleepiness

50. What Test Should be Used? In-laboratory full night polysomnography Split night studies Home diagnostic systems Oximetry to full polysomnography

51. Polysomnography

52. Polysomnogram

53. Diagnostic Conclusions Signs and symptoms Excessive daytime sleepiness Hypertension and other cardiovascular sequelae Sleep study results Apnea / hypopnea frequency Sleep fragmentation Oxyhemoglobin desaturation

54. Treatment Objectives Reduce morbidity and mortality Reduce sleepiness Decrease cardiovascular consequences Improve quality of life

55. Therapeutic Approach Risk counseling Motor vehicle crashes Job-related hazards Judgment impairment Apnea and co-morbidity treatment Behavioral Medical Surgical

56. Behavioral Interventions Encourage patients to: Lose weight Avoid alcohol and sedatives Avoid sleep deprivation Avoid supine sleep position Stop smoking

57. Weight Loss Should be prescribed for all obese patients Can be curative but has low success rate Other treatment is required until optimal weight loss is achieved

58. Sleep-Position Training

59. Medical Interventions Positive airway pressure Continuous positive airway pressure (CPAP) Bi-level positive airway pressure Oral appliances Other (limited role) Medications Oxygen

60. Positive Airway Pressure

61. Positive Airway Pressure

62. Positive Airway Pressure: Problems Patient Acceptance Claustrophobia Aerophagia Chest Discomfort Mask Discomfort

63. CPAP for OSA: Benefits Improved cognitive function Improved quality of life Reduced daytime sleepiness Reduced risk of automobile accidents Reduced health care costs Reduced blood pressure Reduced cardiac arrhythmias Improved glucose tolerance Reduced mortality rate Reversal of impotence

64. CPAP Compliance Patient report: 75% Objectively measured use > 4 hrs for > 5 nights / week: 46% Asthma-medicine compliance: 30%

65. Strategies to Improve Compliance Patient Education Frequent and early follow-up Machine-patient interfaces Masks Nasal pillows Chin straps Humidifiers Ramp Desensitization Pressure relief CPAP or Bi-level pressure

66. CPAP Masks

67. Oral Appliances Indications Snoring and apnea (not severe) Efficacy Variable with 52% of patients with AHI<10/hr on treatment Side effects TMJ discomfort, dental misalignment, and salivation

68. Oral Appliances Variables that Effect Efficacy Severity of OSA: higher success with mild to moderate disease (AHI <30-40) Degree of protrusion: more effective with increased protrusion Positionality of SDB: more effective in patients with supine-dependent OSA BMI: more effective in patients with lower BMI Sleep 2006;29:244

69. Oral Appliance: Mechanics

70. Supplemental Oxygen Not a primary treatment for sleep apnea Does not improve daytime sleepiness May prolong apneas Reduces oxygen desaturation during apneas Reduces arrhythmias

71. Pharmacologic Treatment Limited Role Protriptyline or fluoxetine Decongestants Nasal steroids Antihistamines Other

72. Surgical Alternatives Reconstruct upper airway Uvulopalatopharyngoplasty (UPPP) Radiofrequency tissue volume reduction Genioglossal advancement Nasal reconstruction Tonsillectomy Bypass upper airway Tracheostomy

73. Uvulopalatopharyngoplasty (UPPP) Usually eliminates snoring No accurate method to predict surgical success Follow-up sleep study required

74. Uvulopalatopharyngoplasty (UPPP)

75. Primary Care Management Risk counseling Behavior modification Monitor symptoms and compliance Monitor weight and blood pressure Ask about recurrence of symptoms Evaluate CPAP use and side effects Sleep Apnea: Is Your Patient at Risk? NIH Publication No.95-3803.

76. Primary Care Management Reasons for lack of improvement Noncompliance Alcohol and sedative use Depression Poor sleep habits Nonapneic sleep disorder Persistent or recurrent symptoms Consider referral to sleep specialist

77. Portable Monitoring (or oximetry) is to in-lab PSG as… CXR is to CT scan (lung cancer) Pre-post spirometry is to methacholine challenge (asthma) Fasting glucose is to oral glucose challenge test (diabetes)

78. Oral Appliances (Kushida C, Sleep 2006) Indicated for patients with mild-to-moderate obstructive sleep apnea who prefer oral appliances to CPAP do not respond to CPAP are not appropriate candidates for CPAP fail treatment attempts with CPAP ( Kushida Sleep 2006) Not as effective as CPAP Lower blood pressure 3-4 mmHg (Otsuka Sleep Breath 2006) Outperformed surgery in the only head-to-head trial. Preferred to CPAP in head-to-head trials.

79. Sleep Apnea Questions?

80. Nursing Diagnosis Ineffective Breathing Pattern. Impaired Gas Exchange.

81. Nursing Interventions Assess the frequency and pattern of breathing; Observe presence of apnea and changes in the heart rate. Persons with apnea have periods of cessation of breathing over 15-20 seconds accompanied by bradycardia. Assess skin,  nail  beds, skin, mucous membranes for pallor or cyanosis. Reveals presence of hypoxemia causing cyanosis from an uneven distribution of gases and  blood  in the  l lungs , and alveolar hypoventilation caused by airway obstruction and absence of chest wall movement.

82. Nursing Interventions Provide tactile stimulation by applying gentle rub in the soles of feet or chest wall Indicated for mild and intermittent episodes of apnea to stimulate spontaneous breathing. Administer  methylxanthines (e.g., (theophylline) as prescribed. Used as a smooth  muscle  relaxant and a cardiac muscle and central  nervous system  stimulant. Use of Nasal Continuous positive airway pressure (CPAP). Indicated when the infant remains to have episodes of apnea despite producing a therapeutic level of methylxanthine .

83. Nursing Interventions for Impaired Gas Exchange Assess respiratory rate, depth, and ease, periods of apnea. Assess for skin color and perfusion. Assess for changes in consciousness, the presence of irritability and somnolence.

84. Nursing Interventions for Impaired Gas Exchange Assess for changes in consciousness, the presence of irritability and somnolence. Monitor ABG levels and oxygen saturation. Monitor chest- Xray studies for further evaluation.

85. Nursing Interventions for Impaired Gas Exchange Administer continuous nasal airflow or CPAP via a nasal mask, or a face mask. Administer methylxanthines as indicated.

86. Management of Patients with Chest and Lower Respiratory Disorder Atelectasis Respiratory Infection: >Acute Tracheobronchitis >Pneumonia >Pulmonary Tuberculosis >Lung Abscess

87. PLEURAL CONDITIONS – are disorders that involve the membranes covering the lungs(visceral pleura)and the surface of the chest wall(parietal pleura)or disorders affecting the pleural space, Pleurisy Pleural Effusion Empyema Chronic Obstructive Pulmonary Disease >Chronic Bronchitis >Bronchiectasis > Emphysema,Asthma ,status asthmaticus

88. Pulmonary Arterial Hypertension Pulmonary Heart Disease( Cor Pulmonale ) Pulmonary Embolism Sarcoidosis Occupational lung Diseases:Pneumoconioses Chest Tumors Lung Cancer(Bronchogenic Carcinoma) Tumors of the Mediastinum

89. Chest Trauma Blunt Trauma Sternal and Rib Fractures Flail Chest Pulmonary Contusion Penetrating Trauma:Gunshot and Stab Wounds Pneumothorax Cardiac Temponade Subcutaneous Emphysema

90. Management of Patients with Chronic Pulmonary Disease COPD:Chronic Bronchitis and Emphysema Bronchiectasis Asthma Status Asthmaticus Cystic Fibrosis

91. Pleural Condition Pleural Condition - disorders that involve the membranes covering the lungs(visceral pleura)and the surface of the chest wall(parietal pleura)or disorders affecting the pleural space. Pleurisy( pleuritis )-inflammation of both layers of the pleura(parietal and visceral) May develop in conjuction with pneumonia , or URT’sTB or collagen disease , after trauma to the chest , pulmonary infarction , or PE in pt , with primary or metastatic cancer and after thoracotomy.

92. Note: The parietal pleura has nerve endings and the visceral pleura does not When the inflamed pleural membranes , rub together during respiration(intensified on inspiration),the result is “severe sharp , knifelike pain.” Clinical Manifestation: >sharp chest pain when breathing deeply – most common symptom of pleurisy . Pleuritic pain is limited in distribution rather than diffuse, it usually occur on one side.

93. >pain may be worse when you cough , sneeze or move around – may be relieved by taking shallow breaths >Pain may be localized or radiate to the shoulder or abdomen >as fluid develops the pain decreases. Assessment and Diagnostic Findings: In early period ,when little fluid has accumulated pleural friction rub can be heard with the stethoscope , only to disappear later as more fluid accumulate and seperates the inflamed pleural surfaces

94. Diagnostic Test: Chest x-rays Sputum analysis Thoracentesis – to obtain a specimen of pleural fluid for examination Pleural biopsy – less common MEDICAL MANAGEMENT: Note : The objectives of treatment are to discover the underlying condition causing the pleurisy and to relieve the pain.

95. Cont. As the underlying disease(pneumonia , infection)is treated the pleuritic inflammation usually resolve. At the same time it is necessary to monitor for signs and symptoms of pleural effusion , such as shortness of breath , pain, assumption of a position that decreases pain and decreased chest wall excursion Prescribed analgesic agents and tropical application of heat or cold provide asymptomatic relief.

96. c ont. > Indomethacin (Indocin) a non steroidal , anti inflammatory agent may provide pain relief while allowing the pt , to take deep breaths and cough more effectively. *If the pain is severe , an intercostal block may be required* NURSING MANAGEMENT 1.Turning frequently onto the affected side to splint the chest wall and reduce the stretching of the pleura.

97. Cont . Bronchogenic carcinoma – most common malignancy associated with a pleural effusion. Pathophysiology: In certain disorder fluid may accumulate in the pleural space to a point at which it becomes clinically evident . T his almost always has pathologic significance . The effusion can be a relatively clear fluid or it can be bloody or purulent . An effusion of clear fluid may be transudate or an exudate.

98. Teach the pt.to use the hands or a pillow to splint the rib cage while coughing. PLEURAL EFFUSION Pleural effusion – a collection of fluid in the pleural space is rarely a primary disease process ; it is usually a secondary to other disease. Pleural effusion - may be a complication of heart disease , TB, pneumonia, pulmonary infection (particularly viral infection ), nephrotic syndrome , connective tissue disease , pulmonary embolus and neoplastic tumors.

99. cont. Transudate (filtrate of plasma that moves across intact capillary walls)occurs when factors influencing the formulation and reabsorption of pleural fluid are altered,usually by imbalances in hydrostatic or oncotic pressures. The finding of a transudative effusion generally implies that the pleural membranes are not a diseased,but commonly results from heart failure. An Exudate(extravasation of fluid into tissue or cavity)usually results

100. Cont . f rom inflammation by bacterial products or tumor involving the pleural spaces. Clinical Manifestation : *Usually the clinical manifestations are caused by the underlying disease . Pneumonia causes fever , chills, and pleuritic pain , whereas a malignant effusion may result in dyspnea . D ifficulty lying flat and coughing.

101. Cont. The severity of symptoms is determined by the size of the effusion,the speed of its formation and the underlying lung disease. A large pleural effusion causes dyspnea(shortness of breath). A small to moderate pleural effusion causes minimal or no dyspnea. *the severity of the symptoms assessed depends on the time course of the development of the pleural effusion.

102. Assessment and Diagnostic Findings: Assessment of the area of the pleural effusion reveals , decreased or absent breath sounds , decreased fremitus , and a dull , flat sound when percussed. In an extremely large pleural effusion , the assessment reveals a pt. in acute respiratory distress Tracheal deviation away from the affected side may also be noted *Physical exam ., chest x-ray, chest ct . scan and thoracentesis confirm the presence of fluid.

103. *In some instances a lateral decubitus x-ray is obtained . ” the pt . lies on the affected side in a side-lying position .” A pleural effusion can be diagnosed bec . T his position allows for the “layering out of the fluid ” and an air fluid line is visible. Pleural fluid is analyzed by bacterial culture , Gram’s Stain ,acid – fasr bacillus stain(for TB)red and white blood cells count, chemistry studies(glucose amylase , lactic dehydrogenase , protein) cytologic analysis for malignant cells , and ph , and also pleural biopsy may be performed.

104. Medical Mgt : “the objective of tax. are to discover the underlying cause to prevent the reaccumulation of fluid and to relieve discomfort and dyspnea. Specific tx.is directed at the underlying cause Thoracentesis is performed to removed fluid. If the underlying cause is a malignancy, the effusion tends to recur within a few days or weeks Repeated thoracentesis result in pain , depletion of protein and electrolytes and sometimes pneumothorax.

105. Nursing Mgt.: Implement the medical regimen , prepares and position the pt . for thoracentesis , and offer support throughout the procedure. Pain mgt.is priority , the nurse assists the pt.to assume positions that are the least painful Frequent turning and ambulation are important to facilitate drainage Administers analgesic as prescribed and as needed Monitor the system’s function and monitor and record the amount of drainage .