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NCM 112 MIDTERMS by TONS and MADS MIDTERMS COVERAGE: Respiratory and Cardiovascular WEEK 5 - INTRODUCTION TO RESPIRATORY DISORDERS VID: Respiratory System - not transcribed BOOK: CHAP 21 Page 486 RESPIRATORY SYSTEM (More info in Chap 21) A. PRIMARY FUNCTIONS a. Oxygen transport i. O2 is supplied and CO2 is removed ii. Cells are in close contact with capillaries that permit easy passage or exchange of O2 and. iii. Diffuses through membrane of tissue cells, used by mitochondria for cellular respiration. b. Respiration and Ventilation: i. O2 concentration in blood within capillaries of lungs is lower than in the lungs’ air sacs (alveoli) → oxygen diffuses from the alveoli to the blood. ii. CO2 higher concentration in the blood than in alveoli diffuses from the blood into the alveoli. iii. Movement of air in & out of airways (ventilation) c. Pulmonary Diffusion and Perfusion: Works in concert with CV system i. Diffusion: O2 and CO2 are exchanged at air–blood interface. ii. Alveolar–capillary membrane - ideal for diffusion because of its thinness and large surface area. B. SECONDARY FUNCTIONS a. Facilitates sense of smell b. Produces speech c. Maintains acid-base balance d. Maintains body water levels e. Maintains heat balance C. Gas exchange: delivering O2 to tissues through bloodstream, expelling waste gas CO2 during expiration. ANATOMY - Upper and lower respiratory tracts: 2 tracts responsible for ventilation (movement of air in and out of airways). I. UPPER RESPIRATORY TRACT (upper airway)- warms and filters inspired air so that the lower respiratory tract (lungs) can accomplish gas exchange. A. Larynx (voice organ/box) 1. Cartilaginous epithelium lined structure that connects pharynx and trachea. 2. Major function: vocalization. 3. Protects lower airway from foreign substances and facilitates coughing. 4. Consists of the following: a) Epiglottis: valve flap of cartilage that covers opening to larynx during swallowing b) Glottis: (entrance to larynx); opening between the vocal cords in the larynx c) Thyroid cartilage: largest of cartilage structures; part of it forms Adam’s apple d) Cricoid cartilage: the only complete cartilaginous ring in larynx (below thyroid cartilage) e) Arytenoid cartilages: used in vocal cord movement with thyroid cartilage f) Vocal cords: ligaments controlled by muscular movements that produce sounds; located in lumen of larynx B. Nose - passageway for air to pass to and from lungs. 1. Filters impurities and humidifies and warms air as it is inhaled. 2. External portion protrudes from the face and is supported by nasal bones and cartilage. 3. Anterior nares (nostrils): external openings of nasal cavities. 4. Internal portion is hollow cavity separated into right and left nasal cavities by the septum. 5. Each nasal cavity is divided into 3 passageways by projection of turbinates from lateral walls. 6. Turbinate bones conchae, because of their curves, increase mucous membrane surface of nasal passages and slightly obstruct air flowing through them. Air entering nostrils is deflected upward to the roof of the nose comes into contact with large surface of moist, warm, highly vascular, ciliated mucous membrane (nasal mucosa) that traps practically all dust and organisms in inhaled air. 7. Nerves detect odors; others provoke sneezing to expel irritating dust. 8. Mucus, secreted continuously by goblet cells, covers surface of nasal mucosa and is moved back to nasopharynx by action of the cilia C. Sinuses (Paranasal Sinuses) 1. 4 pairs of bony cavities that lined with nasal mucosa and ciliated pseudostratified columnar epithelium connected by series of ducts that drain into nasal cavity. 2. Serve as resonating chamber in speech. 3. Common site of infection. D. Pharynx (throat) 1. Tubelike structure that connects nasal and oral cavities to larynx. 2. Passageway for respiratory & digestive tracts 3. 3 regions: nasal, oral, and laryngeal. a) Nasopharynx: posterior to nose and above soft palate. b) Oropharynx: faucial or palatine tonsils. c) Llaryngopharynx extends from hyoid bone to cricoid cartilage. 4. Adenoids or pharyngeal tonsils a) Roof of nasopharynx b) Important links in chain of lymph nodes guarding from invasion by organisms entering nose and throat 5. Trachea (Part of Upper in Book) - windpipe 1

NCM 112 MIDTERMS by TONS and MADS f) Sudden dyspnea in healthy px: acute respiratory obstruction, pneumothorax, allergic reaction, or MI. (1) In immobilized patients, sudden dyspnea → pulmonary embolism. g) ARDS: Dyspnea and tachypnea with progressive hypoxemia from lung trauma, shock, cardiopulmonary bypass, or multiple blood transfusions. h) Heart disease/COPD: Orthopnea (inability to breathe easily except upright position) (1) COPD: Dyspnea w/ expiratory wheeze i) Noisy breathing from narrowing of airway or localized obstruction of major bronchus by tumor or foreign body. (1) Stridor: High-pitched sound heard (usually inspiration; partially blocked upper airway) (2) Asthma: Inspiratory and expiratory wheezing if no HF. j) Ask: (1) How much exertion triggers SOB? Does it occur at rest? With exercise? Running? Climbing stairs? (2) Is there an associated cough? (3) Is SOB related to other symptoms? (4) Was onset of SOB sudden/gradual? (5) What time of day/night SOB occur? (6) Is SOB worse when laying flat? (7) Is SOB worse while walking? If so, when walking how far? How fast? (8) How severe is SOB? Ccale of 1-10, if 1 is breathing w/o any effort and 10 is breathing difficult as it could be, how hard is it to breathe? k) Visual analogue or other scales to assess changes in severity of dyspnea 2. Cough - reflex; protects lungs from accumulation of secretions or inhalation of foreign bodies. a) Presence/absence: diagnostic clue (some disorders cause or suppress coughing ) b) Reflex impaired by weakness or paralysis of respiratory muscles, NGT, prolonged inactivity, depressed function of medullary centers (anesthesia, brain disorders). c) Irritation of mucous membranes anywhere in respiratory tract → COUGH d) Stimulus that produces cough: infectious process or airborne irritant (smoke, smog, dust, gas) e) Persistent frequent cough → exhausting, pain. f) May indicate serious pulmonary disease, cardiac disease, medication reactions (amiodarone, ACE inhibitors, smoking, GERD) g) To determine cause, describe the cough: (1) Dry, irritative cough: URTI viral or side effect of ACE inhibitor. (2) Irritative high-pitched cough: laryngotracheitis (3) Brassy cough: tracheal lesion (4) Severe or changing cough: bronchogenic carcinoma. (5) Pleuritic chest pain w/ coughing: pleural/chest wall (musculoskeletal) involvement. h)Inquire about onset & time of coughing. (1) Coughing at night: onset of left-sided HF or bronchial asthma. (2) Cough in morning with sputum production: bronchitis. (3) Cough worsens when supine: postnasal drip (rhinosinusitis). (4) Coughing after food intake: aspiration in tracheobronchial tree. (5) Cough of recent onset: acute infection. i) Persistent cough → embarrassment, exhaustion, inability to sleep, and pain. j) Violent coughing → bronchial spasm, obstruction, further irritation of bronchi → syncope (fainting). k) Severe repeated nonproductive uncontrolled cough → exhausting harmful. 3. Sputum Production a) coughs long enough → produces sputum. b)reaction of lungs to constantly recurring irritants. c) may be associated w/ nasal discharge. d) Nature of sputum is indicative of its cause. (1) Profuse purulent (thick, yellow, green, or rust-colored) or change in color: bacterial infection. (2) Thin mucoid: viral bronchitis (3) Gradual increase of sputum: chronic bronchitis or bronchiectasis (4) Pink Tinged mucoid: lung tumor. (5) Profuse, frothy, pink material, often welling up into throat: pulmonary edema. (6) Foul-smelling sputum & bad breath: lung abscess, bronchiectasis, or infection caused by fusospirochetal or other anaerobic organisms. 4. Chest Pain or Discomfort a) If associated with pulmonary conditions: (1) Sharp, stabbing, intermittent; or (2) Dull, aching, and persistent. b) Pain usually on the side where pathologic process is located, but may be referred elsewhere (neck, back, or abdomen) c) May occur with pneumonia, pulmonary embolism with lung infarction, pleurisy, or late symptom of bronchogenic carcinoma. d) Carcinoma: pain dull & persistent because cancer invaded chest wall, mediastinum, or spine. e) Lung disease does not always cause thoracic pain because lungs and visceral pleura lack sensory nerves and insensitive to pain stimuli. (1) Parietal pleura has rich supply of sensory nerves stimulated by inflammation & stretching of membrane → Pleuritic pain (sharp and seems to “catch” on inspiration) “like the stabbing of a knife.” 3
NCM 112 MIDTERMS by TONS and MADS (2) Lay on affected side because this splints chest wall, limits expansion and contraction of lung, reduces friction between injured or diseased pleurae (Pain associated with cough reduced manually by splinting rib cage.) f) Assess quality, intensity, radiation of pain & identify & explore precipitating factors & relationship to patient’s position, inspiratory and expiratory phases 5. Wheezing a) high-pitched musical sound on expiration (asthma) or inspiration (bronchitis). b) often major finding in bronchoconstriction c) Rhonchi - low pitched continuous sounds heard over lungs in partial airway obstruction. d) Depending on location and severity, heard w/ or w/o stethoscope. 6. Hemoptysis - expectoration of blood from the respiratory tract a) symptom of both pulmonary and cardiac disorders. b) onset is usually sudden, and it may be intermittent or continuous. c) Signs, which vary from blood-stained sputum to a large, sudden hemorrhage, always merit investigation. d) Most common causes: (1) Pulmonary infection (2) Carcinoma of the lung (3) Abnormalities of heart or blood vessels (4) Pulmonary artery or vein abnormalities (5) Pulmonary embolism and infarction e) Diagnostic to determine cause: (1) chest x-ray (2) chest angiography (3) bronchoscopy. (4) history and physical examination to identify underlying disorder, irrespective of whether bleeding involved small amount of blood in sputum or massive hemorrhage. f) Amount of blood produced is not always proportional to seriousness of cause. (1) Determine source of bleeding: gums, nasopharynx, lungs, stomach. g) When documenting, consider: (1) Bloody sputum from nose or nasopharynx is usually preceded by considerable sniffing, with blood possibly appearing in the nose. (2) Blood from lung is usually bright red, frothy, and mixed with sputum. Initial symptoms include tickling sensation in throat, salty taste, burning or bubbling sensation in chest, chest pain (patient tends to splint bleeding side) (a) The term hemoptysis is reserved for coughing up of blood arising from pulmonary hemorrhage. This blood has an alkaline pH>7.0. (3) If hemorrhage is in stomach, blood is vomited (hematemesis) (4) Blood that has been in contact with gastric juice is dark “coffee ground emesis.”; blood is acid pH (<7.0). F. Past Health, Family, and Social History 1. Brief history of events and conditions that could affect current health status. 2. Childhood illnesses, immunizations, chronic medical conditions, injuries, hospitalizations, surgeries, allergies, current medications (OTC and herbal remedies). 3. Smoking history (including exposure to second-hand smoke) a) Expressed in pack-years: number of packs of cigarettes smoked per day times the number of years smoked. b) Find out if and when the patient quit smoking or is still smoking. 4. Risk factors and genetic factors . 5. Psychosocial factors: anxiety, role changes, family relationships, financial problems, employment status, and strategies to cope 6. Many respiratory diseases are chronic and progressively debilitating and disabling. RISK FACTORS FOR RESPIRATORY DISEASE ● Use of chewing tobacco ● Allergies ● Frequent respiratory illnesses ● Chest injury ● Surgery ● Exposure to chemicals & environmental pollutants ● Family history of infectious disease ● Geographic residence & travel to foreign countries ● Smoking (single most important contributor to lung disease) ● Exposure to secondhand smoke ● Genetic makeup ● Personal or family history of lung disease ● Exposure to allergens and environmental pollutants ● Exposure to certain recreational and occupational hazards II. Physical Assessment of the Respiratory System A. General Appearance. 1. Clubbing of the Fingers a) Sign of lung disease, chronic hypoxic conditions, chronic lung infections, or malignancies of the lung b) May be manifested initially as sponginess of nail bed and loss of nail bed angle 2. Cyanosis a) Bluish coloring of the skin b) Very late indicator of hypoxia (determined by amount of unoxygenated hemoglobin) c) Appears <5 g/dL of unoxygenated HGB (reducing the effective circulating hemoglobin to 2⁄3 of the normal level) d) 15 g/dL does not demonstrate cyanosis. e) Cyanosis is not a reliable sign of hypoxia. (1) Anemia rarely manifests cyanosis 4