1.

To be familiarized with the

Respiratory system, its parts
and functions.
2. Overview of the common

Objectives symptoms associated with

respiratory diseases
3. How to properly assess a
patient who are considered
having a respiratory disorder
4. Be able to interpret ABG
results.
Respiratory System
Is composed of the upper and lower respiratory tracts.
Together the two tracts are responsible with ventilation.

The upper respiratory , known as the upper airway, warms

and filters inspired air so that the lower respiratory tract
(lungs) can accomplish gas exchange.

Gas exchange involves delivering oxygen to the tissues

through the bloodstream and expelling waste gases, (CO2)
during expiration.
Upper Respiratory Tract
Upper airway structures consists of nose, sinuses and nasal
passages, pharynx, tonsils and adenoids, larynx and trachea
Nose
This serves as a passageway for air to pass to and from lungs.
It filters impurities and humidifiers and warms the air as it is
inhaled. The nose is composed of an external and an internal
portion. Air entering the nostrils is deflected upward to the
roof of the nose, and it follows a circuitous route before it
reaches the nasopharynx. It comes into contact with a nasal
mucosa that traps practically all the dust and organisms in
the inhaled air. mucus , secreted continuously by goblet cells,
covers the surface of the nasal and is moved back to the
nasopharynx by the action of the celia.
Paranasal Sinuses
These air spaces are connected by a series of ducts that drain
into the nasal cavity. The sinuses are named after its
locations: frontal, ethmoidal, sphenoidal, and maxillary. The
prominent function is they serve as a resonating chamber in
speech. The sinuses are a common site of infection.
Pharynx, Tonsils and Adenoids
The pharynx or throat is a tube like structure that connects the nasal
and the oral cavities to the larynx. It is divided into three regions;
nasal, oral and laryngeal.

The nasopharynx is located posterior to the nose and above the soft
palate.

Laryngopharynx extends from the hyoid bone to the cricoid cartilage.

Adenoids, or pharyngeal tonsils are located in the roof of the

nasopharynx. These links in the chain of lymph nodes guarding the
body from invasion.
Larynx

Major function is vocalization, also protects the lower airway

from foreign substances and facilitates coughing.
● Epiglottis- valve flap cartilage that covers the opening to the larynx
during swallowing
● Glottis- opening between the vocal cords in the larynx
● Thyroid cartilage- the largest cartilage structures
● Criticoid structure- located below the thyroid cartilage
● Arytenoid cartilage- used in vocal movement with thyroid cartilage
● Vocal cords- ligaments controlled by muscles to produce sounds.
Trachea

Also known as “windpipe”, the cartilaginous rings are

incomplete on the posterior surface and give firmness to the
wall of the trachea, preventing it from collapsing. The trachea
serves as the passage between the larynx and the bronchi.
Lower Respiratory tract

These are consists of the lungs, which contains the bronchial

and alveolar structures needed for gas exchange.
Lungs
Are paired elastic structures enclosed in the thoracic cage, which
is an airtight chamber with distensible walls. Ventilation requires
movement of the walls of the thoracic cage and the diaphragm.
The effect of these movements is alternately to increase and
decrease the capacity of the chest.

Inspiration- the capacity of the chest is increased, air enters

through the trachea because of the lowered pressure within and
inflates the lungs

Expiration- when the chest wall returns to its previous position,

the lungs recoil and force air out through the bronchi and
trachea
Pleura

These are serous membrane that lines the lungs(visceral

pleura) and wall of the thorax (parietal pleura). These serves
as lubricants in the thorax and lungs to permit smooth
motion of the lungs within the thoracic cavity with each
breath.
Mediastinum

It is the central compartment of the thoracic cavity, located

between the two pleural sacs. It extends from the sternum to
the vertebral column and contains all the thoracic tissue
outside the lungs.
Lobes

Our lungs are divided into lobes. The right lung has upper,
middle and lower lobes, whereas the left lung consist of
upper and lower lobes. Each lobe is further subdivided into
2-5 segments by fissures, which are extension of the pleura.

Lobes are made of sponge-like tissue that is surrounded by a

membrane called pleura, which separates the lungs from the
chest wall.
Question …….

1. Are lungs of equal size?

2. Why is the right lung have 3 lobes and left only 2?
Bronchi and Bronchioles
1. Lobar bronchi-the structures identified when choosing
the most effective postural drainage position for a
patient. (10 on the right and 8 on the left)
2. Segmental bronchi- these surrounded by connective
tissue that contains arteries, lymphatics and nerves
3. Subsegmental bronchi- branch into bronchioles, their
patency depends on entirely on the elastic recoil of the
surrounding smooth muscle and on alveolar pressure.
Bronchi and Bronchioles

4. Bronchioles- contain submucosal glands, which produce

mucus that covers the inside lining of the airways.

Respiratory
Terminal
Bronchioles
bronchioles
bronchioles

Alveolar Alveolar
Alveoli Sac ducts
Alveoli
Oxygen and carbon dioxide exchange takes place in the
alveoli. Lungs are made up of about 300 million alveoli,
which are arranged in 15-20 clusters.

There are 3 types of alveoli cells

1. Type I- epithelial cells that from the alveolar walls.

2. Type II- metabolically active
3. Type III- macrophages
Function of the Respiratory System

Oxygen transport- oxygen is supplied to and carbon

dioxide is removed from, cells by way of the circulating
blood. Oxygen diffuses from the capillary through the
capillary wall to the interstitial fluid. The movement of
carbon dioxide occurs by diffusion in the opposite
direction- from cell to blood.
Function of the Respiratory System
1. Respiration - gas exchange between the atmospheric air
and the blood and between the blood and cells of the
body.
Function of the Respiratory System
2. Ventilation

physical factors that govern air flow in and out of the lungs
are collectively referred to as the mechanics of ventilation
and include air pressure variances, resistance to air flow, and
lung compliance.
Function of the Respiratory System

3. Air Pressure Variances

Air flows from a region of higher pressure to a region of

lower pressure.
Function of the Respiratory System

4. Airway Resistance

Determined by the radius of the airway through which the air

is flowing. Any process that changes the bronchial diameter
or width affects airway resistance and alters the rate of
airflow for a given pressure gradient during respiration.
Function of the Respiratory System

5. Compliance

Is the elasticity and expandability of the lungs and thoracic

structures. Factors that determine lung compliance are the
surface tension of the alveoli and the connective tissue of
the lungs.
Function of the Respiratory System
6. Lung volume and capacities

Reflects the mechanics of ventilation, is viewed in terms of

lung volume and lung capacities.

Lung volumes are categorized as tidal volume, inspiratory

reserve volume, expiratory reserve vol, and residual vol.

Lung capacity is evaluated in terms of vital capacity,

inspiratory capacity, functional residual capacity and total
lung capacity
Function of the Respiratory System

7. Pulmonary diffusion

The process by which oxygen and carbon dioxide are

exchanged at the air-blood interface. The alveolar-capillary
membrane is ideal for diffusion because of its thinness and
large surface area.
Function of the Respiratory System

8. Pulmonary Perfusion

Is the actual blood flow through the pulmonary circulation.

The blood is pumped into the lungs by the right ventricle
through the pulmonary artery. Is influenced by alveolar
pressure. The pulmonary capillaries are sandwiched between
adjacent alveoli.
Function of the Respiratory System

9. Ventilation and perfusion balance and imbalance

Adequate gas exchange depends on an adequate ventilation-

perfusion ratio. The ventilation-perfusion ratio varies on the
area of the lung.

Imbalance causes shunting of blood, resulting to hypoxia(low

level of cellular oxygen)
Function of the Respiratory System

10. Partial pressure of gasses

This is the pressure of a gas is proportional to the

concentration of that gas in the mixture. The total pressure
exerted by the gaseous mixture, whether in the atmosphere
or in the lungs, is equal to the sum f the partial pressures.
Function of the Respiratory System

11. Effects of pressure on oxygen transport

Oxygen and carbon dioxide are transported simultaneously

either dissolved in blood or combined with hemoglobin in red
blood cells.

The volume of oxygen dissolved in the plasma is measured by

the partial pressure of oxygen in the arteries. The higher the
partial pressure of arterial carbon dioxide the greater the
amount of oxygen dissolved.
Function of the Respiratory System

12. Oxyhemoglobin dissociation curve

Is the relationship between the partial pressure of oxygen

and the percentage of saturation of oxygen. The percentage
of the saturation can be affected by carbon dioxide,
hydrogen ion concentration, temperature and
diphosphoglycerate.
Function of the Respiratory System

13. Carbon dioxide transport

At the same time that the oxygen diffuses from the blood
into the tissue, carbon dioxide diffuses from the tissue cells
to blood and is transported to the lungs for excretion.
Function of the Respiratory System
13. Neurologic control of ventilation

Resting respiration is the result of cyclic excitation of the

respiratory muscle by the phrenic nerve.
Common Symptoms
Dyspnea

Most common symptom for pulmonary and cardiac disorders.

The right ventricle of the heart is affected ultimately by the
lung disease because it must pump blood through the lungs
against greater resistance.

In general, acute disease of the lungs produce a more severe

grade of dyspnea than do chronic diseases. Sudden dyspnea
in a healthy person may indicate pneumothorax.
Dyspnea

The circumstances that produces he dyspnea must be

determined. It is essentially important to assess the patient’s
rating of the intensity of breathlessness, the effort required
to breathe, and the severity of the breathlessness or
dyspnea.
Cough

Is a reflex that protects the lungs from the accumulation of

secretions or the inhalation of foreign bodies. Cough results
from irritation of the mucous membranes anywhere in the
respiratory tract. The stimulus that produces a cough may
arise from an infectious process or from airborne irritant.
Cough
Dry, irritant cough- URTI

Irritative, high pitched cough- laryngotracheitis

Brassy cough-the result of tracheal lesion

Severe or changing cough- bronchogenic carcinoma

Cough at night- left sided heart failure or bronchial asthma

Cough in the morning with sputum- bronchitis

Sputum production
This is the reaction of the lungs to any constant recurring
irritant. It may also be associated with nasal discharge.

Purulent sputum( thick, yellow,green or rust-colored)-

common sign of bacterial infection

Thin mucoid- viral bronchitis

pink -tinged - suggest tumor

Profused, frothy pink material, often welling up the throat -

pulmonary edema

Foul-smelling- lung abcess

Chest pain

May be associated with pulmonary or cardiac disease. Chest

pain associated with pulmonary conditions may be sharp,
stabbing and intermittent, or it may be dull aching and
persistent.

It may occur with pneumonia, pulmonary embolism with lung

infection, pleurisy or late symptom of bronchogenic
carcinoma
Wheezing
A high pitched, musical sound heard mainly on expiration or
inspiration. It is often the major finding in a patient with
bronchoconstriction or airway narrowing.

Rhonchi- low pitched continuous sound heard over the lungs

in partial airway obstruction
Hemoptysis
Expectoration of blood from respiratory tract. Onset is
usually sudden and it may be intermittent or continuous.

Most common causes:

● Pulmonary infection
● Carcinoma
● Abnormalities of the heart or blood vessels
● Pulmonary artery or vein abnormalities
● Pulmonary embolism
Hemoptysis
● Bloody sputum from the nose or nasopharynx is usually
preceded by considerable sniffing, with blood possibly
appearing in the nose.
● Blood from the lungs is usually bright red, frothy and
mixed with sputum. Initial symptoms include a tickling
sensation in the throat, a salty taste, burning or bubbling
sensation in the chest and perhaps chest pain, in which
case the patients tends to splint the bleeding side.
● If the hemorrhage is in the stomach, the blood is
vomited (hematemesis) rather than coughed up.
Physical Assessment of
Respiratory System
Clubbing of the fingers

Is a sign of lung disease that is found in patients with chronic

hypoxic conditions, chronic lung infections, or malignancies
of the lungs.
Cyanosis

Bluish coloring of the skin, is a very late indicator of hypoxia.

The presence or absence of cyanosis is determined by the
amount of unoxygenated hemoglobin in the blood.
Nose and Sinuses
Inspect the external nose for any lesions, asymmetry or
inflammation and then ask patient to tilt the head backward
gently. Inspect the mucosa for color, swelling, exudate or
bleeding. Inspect also for septal deviation perforation or
bleeding. Inspect as well the inferior and middle turbinates.
Chronic rhinitis, nasal polyps may develop between the
inferior and middle turbinates.
Mouth and Pharynx

Instruct patient to open mouth wide and take a deep breath.

Usually it flattens the posterior tongue and briefly allows full
view of the anterior and posterior pillars, tonsils, uvula and
posterior pharynx. Check for structure, color, symmetry and
evidence of exudate, ulceration or enlargement.
Trachea

During direct palpation the position and mobility of trachea is

being noted. This is performed by placing the thumb and
index finger of one hand on either side of the trachea just
above the sternal notch. The trachea is normally in the
midline as it enters the thoracic inlet behind the sternum, but
it may be deviated by masses in the neck or mediatinum.
Thoracic Inspection

Inspection of the thorax provides information about the

musculoskeletal structure, the patient's’ nutritional status,
and the respiratory system. Inspect for the skin over the
thorax, the color, and turgor and evidence of loss of
subcutaneous tissue.
Chest Configuration
Barrel chest- occurs as a result of over inflation of the lungs,
seen in patient with emphysema.
Chest Configuration
Funnel chest (pectus excavatum)- occurs when there is
depression in the lower portion of the sternum. Most seen on
patients with rickets or Marfan’s syndrome.
Chest Configuration
Pigeon chest (pectus carinatum)- result from a displacement
of the sternum. There is an increase in the anteroposterior
diameter.
 Chest Configuration
Kyphoscoliosis- characterized by elevation of the scapula and
a corresponding S-shaped spine. This limits the lung
expansion within the thorax. It may occur with osteoporosis
and other skeletal disorders that affect the thorax.
Breathing patterns and Respiratory
Rates
Respiratory rhythms and their deviation from normal are
important observations that the nurse reports and
documents. Temporary pauses of breathing, or apnea, may be
noted. When apneas occur repeatedly during sleep,
secondary to transient upper airway blockage, the condition
is called Obstructive sleep apnea.
Thoracic Palpitation

Palpate the thorax for tenderness, masses, lesions,

respiratory excursion, and vocal fremitus.
Respiratory Excursion

Is an estimation of thoracic expansion and may disclose

significant information about thoracic movement during
breathing.
Respiratory Excursion

Must observe the movement of the thumb during inspiration

and expiration. Normally this movement is symmetric

Decrease chest excursion may be caused by chronic fibrotic

disease

Asymmetric excursion may be due to splinting secondary

pleurisy, fractured ribs, trauma, or unilateral bronchial
obstruction.
Tactile fremitus
Sound generated by the larynx travels distally
along the bronchial tree to set the chest wall un
resonant motion. The detection of the resulting
vibration on the chest wall by touch is called tactile
fremitus.

normally , fremitus most prominent between

scapula and decreases as you go down.
Thoracic Percussion

It is used to determine whether underlying tissues are filled

with air, fluid or solid material. It is also used to estimate the
size and location of certain structures within the thorax.
Diaphragmatic Excursion
The normal resonance of the lungs stops at the diaphragm, the
position of the diaphragm is different during inspiration and
expiration.

To assess, instruct the patient to take a deep breath and hold it while
the maximum descent of the diaphragm is percussed. The point at
which the percussion note at the midscapular line changes from
resonance to dullness is marked with a pen. The patient is then
instructed to exhale fully and hold it while the nurse percusses
downward to the dullness of the diaphragm, this point is marked.
The distance between two markings indicates the range of motion of
the diaphragm. Maximum excursion of the diaphragm may be as
much as 8 to 10 cm for tall young men or 5 to 7 cm for most people.
Thoracic Auscultation

Auscultation of posterior, anterior and lateral thorax is also

included. It is used to assess the flow of air through the
bronchial tree and in evaluating the presence of fluid or solid
obstruction in the lung.

With the use of stethoscope, place it against the chest wall

as the patient breathes slowly and deeply through the
mouth.
Adventitious Sounds

An abnormal condition that affects the bronchial tree and

alveoli may produce adventitious sounds. It is divided into
two categories: noncontinuous sunds (crackles) and
continuous sounds ( wheezes).
Tidal Volume

Referred to as the volume of each breath. A spirometer is an

instrument that can be used at the bedside to measure
volumes.
Minute ventilation

Respiratory rates and tidal volume alone are unrealible

indicators of adequate ventilation, because both can vary
widely from breath to breath.
Vital Capacity

The maximum amount of air a person can expel after a

maximum inhalation. The normal value depends on the
patient’s age, gender, body build and weight.
Inspiratory Force

Evaluates the effort the patient is making during inspiration.

It does not require patient cooperatin and therefore is a
useful measurement in the unconscious patient. Equipment
used for measurement includes a manometer that measures
negative pressure and adapters that are connected to an
anesthesia mask or a cuffed endotracheal tube.
Diagnostic evaluation
Pulmonary Function Test (PFTs)

Used in patients with chronic respiratory disorders. They are

performed to assess respiratory function and to determine
the extent of dysfunction. Such test include measurements
of lung volumes, ventilatory function and the mechanics of
breathing, diffusion and gas exchange.
Arterial Blood Gas Studies

Measures the pH and arterial oxygen and carbon dioxide

tensions are obtained when managing patients with
respiratory problems and adjusting oxygen therapy as
needed.
Pulse Oximeter
A noninvasive method of monitoring the oxygen saturation of
hemoglobin. Normal SpO2 value is 95%-100%. Less than
85% may indicate that the tissue are not receiving enough
oxygen and further evaluation is needed.
cultures

Throat cultures may be performed to identify organisms

responsible for pharyngitis. Throat culture may also assist in
identifying organisms responsible for infection or the lower
respiratory tract.
Sputum studies

Obtained for analysis to identify pathogenic organisms and

to determine whether malignant cells are present. Periodic
sputum examinations may be necessary for patients receiving
antibiotics, corticosteroids and immunosuppressive
medication for prolonged periods, because this agents are
associated with opportunistic infections.
Imaging studies
Chest X-Ray
Densities produced by fluid, tumors, foreign bodies and other
pathologic conditions can be detected by x-ray examination.
Chest x-ray are usually taken after a full inspiration because
the lungs are best visualized when they are well aerated.
Computed Tomography
The image produced provide a cross-sectional view of the
chest. CT can distinguish fine tissue density rather that x-ray.
CT may be used to define pulmonary nodules and small
tumors adjacent to pleural surfaces that are not visible on
routine CXR and to demonstrate mediastinal abnormalities
and hilar adenopathy.
Magnetic Resonance Imaging
Magnetic fields and radiofrequency signal are used. MRI
yields a much more detailed diagnostic image that CT
because it visualizes soft tissue. MRI are used to
characterized pulmonary nodules, to help stage bronchogenic
carcinoma, and to evaluate inflammatory activity in
interstitial lung disease, acute pulmonary embolism, and
chronic thrombotic pulmonary hypertension
Fluoroscopic studies

It is used to assist with invasive procedures, such as a chest

needle biopsy or transbronchial biopsy, that are performed to
identify lesions. It may also be used to study movement of
the chest wall, mediastinum, heart and diaphragm.
Pulmonary Angiography

Commonly used to investigate thromboembolic disease of

the lungs, such as pulmonary emboli and congenital
abnormalities of the pulmonary vascular tree. It involves
rapid injection of a radiopaque agent into the vasculature of
the lungs for radiographic study of the pulmonary vessel.
Radioisotope Diagnostic procedures
(lung scans)
V/Q, Gallium scan and Positron Emission Tomography (PET)
are used to assess the normal lung functioning, pulmonary
vascular supply and gas exchange.
Endoscopic procedures
Bronchoscopy

Direct inspection and examination of the larynx, trachea, and

bronchi through either flexible fiberoptic bronchoscope or a
rigid bronchoscope.
Thoracoscopy

Is a diagnostic procedure in which the pleural cavity is

examined with an endoscope.
Thoracentesis

A thin layer of pleural fluid normally remains in the pleural

space. An accumulation of pleural fluid may occur with some
disorders.
Biopsy

1. Pleural biopsy
2. Lung biopsy
3. Lymph node biopsy