The document discusses the respiratory system and key respiratory conditions including pneumonia and COPD. It covers the structure and function of the respiratory system including ventilation, gas exchange, and control of breathing. It then discusses specific conditions like COPD and asthma in terms of etiology, pathophysiology, clinical manifestations, diagnosis, and treatment. Pneumonia is also summarized including risk factors, signs and symptoms, diagnostic testing, potential complications, and collaborative care approaches.

1. Structures and Functions of
the Respiratory System

2. ∗Ventilation
∗Diffusion (alveolar-
capillary
membrane)
∗Perfusion
∗Diffusion (capillary-
cellular level)
Gas Exchange

3. Ventilation
Movement of Chest Wall

4. Ventilation
• Depends on volume and pressure changes within
thoracic cavity
• Diaphragm is major muscle of inspiration; also
external intercostal muscles. Contraction increases
diameter of thoracic cavity intrathoracic pressure→ ↓
air flows into respiratory system→
• Expiration is passive process d/t lung elasticity. ↑
intrathoracic pressure air flows out of lungs→
• Accessory muscles

5. Control of Ventilation
∗ Neural control- respiratory center in medulla & pons
∗ Central chemoreceptors – sensitive to pH
∗ Peripheral chemoreceptors- sensitive to paO2
∗ Patients with COPD- hypoxic drive
∗ WOB- amount of effort required for the maintenance
of a given level of ventilation (as WOB s, more↑
energy is expended for adequate ventilation)

6. Factors Influencing
Ventilation
• Airway resistance- opposition to gas flow
• Compliance- distensibility / stretchability
- Dependent on lung elasticity & elastic recoil
of chest wall
- Decreased compliance- lungs difficult to
inflate
- Increased compliance- destruction of
alveolar walls & loss of tissue elasticity

7. Diffusion
Alveolar-Capillary Membrane

8. Oxyhemoglobin Curve

9. Ventilation-Perfusion
• Adequate diffusion depends on balanced ventilation-
perfusion (V/Q) ratio
• Normal lung: V=4L/min; Q= 5L/min (0.8)
• If imbalanced: gas exchange interrupted
- High V/Q= “wasted” or dead-space
ventilation
- Low V/Q= blood “shunted” past area; no
gas exchange occurs

10. V/Q Matching

11. Perfusion

12. Diffusion
Body Tissue-Blood Capillary

13. Progressive, irreversible airflow
limitation
Associated with abnormal
inflammatory response of lungs
to noxious particles or gases
COPD

14. ∗Cigarette smoking
∗Occupational chemicals and dusts
∗Air pollution
∗Infection
∗Heredity- A1-antitrysin deficiency
∗Aging
COPD
EtiologyEtiology

15. ∗ Primary process is inflammation
∗ Inhalation of noxious particles→
inflammatory cells release mediators
(leukotrienes, interleukins, TNF) airways→
become inflammed with increased goblet
cells excess mucus production (bronchitis)→
& structural remodeling to peripheral airways
with d collagen & scar tissue↑
COPD
Pathophysiology

16. ∗ Destruction of lung tissue caused by imbalance
of proteinases/antiproteinases results in
emphysema with loss of attachments &
peripheral airway collapse (Centrilobar-
affects respiratory bronchioles/upper
lobes/mild disease; panlobar- alveolar ducts,
sacs, respiratory bronchioles- lower lobes/AAT
deficiency
COPD
PathophysiologyPathophysiology

17. ∗Air goes into lungs easily but unable
to come out; air trapped in distal
alveoli, causing hyperinflation &
overdistension
∗PV thickens with surface area for↓
gas exchange- V/Q mismatch
COPD
PathophysiologyPathophysiology

19. COPD:
Chronic Bronchitis vs. Emphysema

20. Emphysema

21. Chronic Bronchitis
Blue Bloater versus Pink Puffer

22.  Develop slowly around 50 years of age after history of smoking
 Cough, sputum production, dyspnea
 In late stages, dyspnea at rest
 Wheezing/chest tightness- may vary
 Prolonged I:E, BS, tripod position, pursed-lip breathing,↓
edema
 ↑ A-P diameter of chest
 Advanced- weight loss, anorexia (hypermetabolic state)
 Hypoxemia, possible hypercapnia
 Bluish-red color from polycythemia, cyanosis
COPD
BehaviorsBehaviors

23. Increased A-P Diameter
Barrel-Chest

24. ∗ PFTs ( RV, FEV1)↑ ↓
∗ CXR
∗ ABGs
∗ Sputum C&S if infection suspected
∗ EKG- RV hypertrophy
∗ 6 minute oxy-walk
COPD
DiagnosisDiagnosis

26. Spirometry Results
Stage I Mild FEV1/FVC < 0.70
FEV1 ≥ 80% predicted
Stage II Moderate FEV1/FVC < 0.70
50% ≤ FEV1 < 80% predicted
Stage III Severe FEV1/FVC < 0.70
30% ≤ FEV1 < 50% predicted
Stage IV Very
Severe
FEV1/FVC < 0.70
FEV1 < 30% predicted
OR
FEV1 < 50% predicted PLUS
chronic respiratory failure
COPD – Classification

27. ∗ Cor pulmonale- RV hypertrophy 2º pulmonary
hypertension (late)
∗ Exacerbations of COPD
∗ Acute respiratory failure
∗ Peptic ulcer and gastroesophageal reflux
disease
∗ Depression/anxiety
COPD
ComplicationsComplications

28. ∗ Smoking cessation
∗ Medications- bronchodilators (inhaled & step-wise),
Spriva (LA anticholinergic), ICS
∗ Oxygen therapy
∗ RT- PLB, diphragmatic, cough, CPT, nebulization
therapy
∗ Nutrition- Avoid over/underweight, rest 30” before
eating, 6 small meals, avoid foods that need a great
deal of chewing, avoid exercise 1 hr before meal, take
fluids between meals to avoid stomach distension
COPD- Collaborative Care

29. ∗Ineffective Breathing Pattern
∗Impaired Gas Exchange
∗Ineffective Airway Clearance
∗Imbalanced Nutrition: Less than
Body Requirements
COPD
Nursing Diagnoses

30.  Chronic inflammatory disorder associated with
airway hyperresponsiveness leading to
recurrent episodes (attacks)
 Often reversible airflow limitation
 Prevalence increasing in many countries,
especially in children
Asthma

31. ∗ Airway hyperresponsiveness as a result of
inflammatory process
∗ Airflow limitation leads to hyperventilation
∗ Decreased perfusion & ventilation of alveoli
leads to V/Q mismatch
∗ Untreated inflammation can lead to LT
damage that is irreversible
∗ Chronic inflammation results in airway
remodeling
Asthma
PathophysiologyPathophysiology

34. ∗ Allergens – 40%
∗ Exercise (EIA)
∗ Air pollutants
∗ Occupational factors
∗ Respiratory infections – viral
∗ Chronic sinus and nose problems
∗ Drugs and food additives – ASA, NSAIDs, ß-blockers,
ACEi, dye, sulfiting agents
∗ Gastroesophageal reflux disease (GERD)
∗ Psychological factors- stress
Asthma
Potential TriggersPotential Triggers

35. ∗ Bronchospasm
∗ Plasma exudation
∗ Mucus secretion
∗ AHR
∗ Structural changes
Asthma Inflammation –
Effects

36. ∗ Cough
∗ Chest tightness
∗ Wheeze
∗ Dyspnea
∗ Expiration prolonged -1:3 or 1:4, due to
bronchospasm, edema, and mucus
∗ Feeling of suffocation- upright or slightly bent
forward using accessory muscles
∗ Behaviors of hypoxemia- restlessness, anxiety,
HR & BP, PP↑
Asthma Inflammation
Clinical ManifestationsClinical Manifestations

37. ∗ History and patterns of symptoms
∗ Measurements of lung function
∗ PFTs- usually WNL between attacks; FVC, FEV↓ 1
∗ PEFR- correlates with FEV
∗ Measurement of airway responsiveness
∗ CXR
∗ ABGs
∗ Allergy testing (skin, IgE)
Asthma
DiagnosisDiagnosis

38. ∗ No (or minimal)* daytime symptoms
∗ No limitations of activity
∗ No nocturnal symptoms
∗ No (or minimal) need for rescue medication
∗ Avoid adverse effects from asthma medications
∗ Normal lung function
∗ No exacerbation
∗ Prevent asthma mortality
∗ * Minimal = twice or less per week
Asthma
Therapeutic GoalsTherapeutic Goals

39. ∗ Suppress inflammation
∗ Reverse inflammation
∗ Treat bronchoconstriction
∗ Stop exposure to risk factors that sensitized
the airway
Asthma
Collaborative ManagementCollaborative Management

40.  Antiinflammatory Agents
 Corticosteroids- suppress inflammatory response.
Reduce bronchial hyperresponsiveness & mucus
production, B2 receptors↑
∗ Inhaled – preferred route to minimize systemic side effects
∗ Teaching
∗ Monitor for oral candidiasis
∗ Systemic – many systemic effects – monitor blood glucose
∗ Mast cell stabilizers- NSAID ; inhibit release of mediators
from mast cells & suppress other inflammatory cells
(Intal, Tilade)
Asthma
MedicationsMedications

41.  Antiinflammatory Agents
 Leukotriene modifiers
 Block action of leukotrienes
 Accolate, Singulair, Zyflo)
 Not for acute asthma attacks
 Monclonal Ab to IgE
 ↓ circulating IgE
 Prevents IgE from attaching to mast cells, thus preventing
the release of chemical mediators
 For asthma not controlled by corticosteroids
 Xolair SQ
Asthma
MedicationsMedications

42.  Bronchodilators
 B-agonists- SA for acute bronchospasm & to
prevent exercised induced asthma (EIA)
(Proventil, Alupent); LA for LT control
 Combination ICS + LA B-agonist (Advair)
 Methylxanthines- Theophylline: alternative
bronchodilator if other agents ineffective.
Narrow margin of safety & high incidence of
interaction with other medications
 Anticholinergics- block bronchoconstriction .
Additive effect with B-agonists (Atrovent)
Asthma
MedicationsMedications

43.  Name/dosage/route/schedule/purpose/SE
 Majority administered by inhalation (MDI, DPI,
nebulizers)
 Spacer + MDI- for poor coordination
 Care of MDI- rinse with warm H2O 2x/week
 Potential for overuse
 Poor adherence with asthma therapy is challenge
for LT management
 Avoid OTC medications
Asthma
Patient Teaching- MedicationsPatient Teaching- Medications

44.  GINA- decrease asthma morbidity/mortality &
improve the management of asthma worldwide
 Education is cornerstone
 Mild Intermittent/Persistent: avoid triggers,
premedicate before exercise, SA or LA Beta
agonists, ICS, leukotriene blockers
 Acute episode: Oxygen to keep O2Sat>90%, ABGs,
MDI B-agonist; if severe- anticholinergic nebulized
w/B agonist, systemic corticosteroids
Asthma
Collaborative CareCollaborative Care

45. ∗Ineffective Airway Clearance
∗Impaired Gas Exchange
∗Anxiety
∗Deficient Knowledge
Asthma
Nursing Diagnoses

46. ∗ HAP- pneumonia occurring 48 hours or longer after
admission
∗ VAP- pneumonia occurring 48-72 hours after ET
intubation
∗ HCAP- hospitalized for 2 or more days within 90 days
of infection; resided in LTC facility; received IV therapy
or wound care within past 30 days of current
infection; attended a hospital or dialysis clinic
∗ Aspiration pneumonia- abnormal entry of secretions
into lower airway
Pneumonia

47. ∗ Congestion
∗ Fluid enters alveoli; organisms multiply & infection spreads
∗ Red hapatization
∗ Massive capillary vasodilation; alveoli filled with organisms,
neutrophils, RBCs, & fibrin
∗ Gray hepatization
∗ Blood flow decreases & leukocytes & fibrin consolidate in
affected part
∗ Resolution
∗ Resolution & healing; exudate processed by macrophages
Pneumonia
PathophysiologyPathophysiology

48. Pneumonia
Risk FactorsRisk Factors
∗ Aging
∗ Air pollution
∗ Altered LOC
∗ Altered oral normal flora
secondary to antibiotics
∗ Prolonged immobility
∗ Chronic diseases
∗ Debilitating illness
∗ Immunocompromised state
∗ Inhalation or aspiration of
noxious substances
∗ NG tube feedings
∗ Malnutrition
∗ Resident of Long-term care
∗ Smoking
∗ Tracheal intubation
∗ Upper respiratory tract
infection

49. ∗ Usually sudden onset
∗ Fever, shaking chills, SOB, cough w/purulent sputum,
pleuritic CP
∗ Elderly/debilitated- confusion or stupor
Pneumonia
BehaviorsBehaviors

50. ∗ Pleuritis
∗ Pleural effusion- 40% of hospitalized patients
∗ Atelectasis
∗ Bacteremia
∗ Lung abscess
∗ Empyema
∗ Pericarditis
Pneumonia- Complications

51. ∗ CXR
∗ Sputum C&S
∗ Blood cultures
∗ ABGs
∗ Leukocytosis
Pneumonia
Diagnostic StudiesDiagnostic Studies

52. Pleural Effusion

53. Pneumonia

54. ∗ Prompt treatment with antibiotics
∗ Oxygen, analgesics, antipyretics
∗ Influenza vaccine
∗ Pneumococcal vaccine
∗ Nutrition
∗ PSI – Pneumonia Patient Outcomes Research
Team Severity Index
∗ Determine whether to treat at home or in
hospital
Pneumonia
Collaborative CareCollaborative Care

55. ∗ Fever in any hospitalized patient
∗ Pain
∗ Tachypnea
∗ Use of accessory muscles
∗ Rapid, bounding pulse
∗ Relative bradycardia
∗ Coughing
∗ Purulent sputum
Pneumonia
Nursing AssessmentNursing Assessment

56. ∗ Consolidation
∗ Auscultation
∗ Bronchial breathing
∗ Bronchovesicular rhonchi
∗ Crackles
∗ Fremetis
∗ Egophony
∗ Whispered pectroloquy
Pneumonia
Nursing AssessmentNursing Assessment

57. ∗ Ineffective airway clearance RT copious
tracheobronchial secretions
∗ Activity intolerance RT altered respiratory
function
∗ Risk for fluid volume deficit RT fever and
dyspnea
∗ Knowledge deficit about the treatment
regimen and preventive health measures
Pneumonia
Nursing DiagnosesNursing Diagnoses

58. ∗ Hypotension and shock
∗ Respiratory failure
∗ Atelectasis
∗ Pleural effusion
∗ Delerium
∗ Superinfection
Pneumonia
Potential ProblemsPotential Problems

59. ∗ Improving airway patency
∗ Conserving energy – rest
∗ Maintaining proper fluid balance
∗ Patient understanding of treatment and
prevention
∗ Prevention of complications
Pneumonia
Nursing GoalsNursing Goals

60. ∗ Improving airway patency
∗ Removing secretions – coughing vs. suctioning
∗ Adequate hydration loosens secretions
∗ Air humidification to loosen secretions and improve
ventilation
∗ Chest physiotherapy – loosens and mobilizes
secretions
Pneumonia
Nursing InterventionsNursing Interventions

61. ∗ Promoting rest and conserving energy
∗ Bedrest with frequent changes of position
∗ Energy conservation
∗ Sedatives to decrease work of breathing and energy
expenditure unless contraindicated
∗ Promoting fluid intake
∗ Dehydration is possible RT insensible fluid losses
through respiratory tract
∗ If not contraindicated, increase fluid intake to 2
liters/day
Pneumonia
Nursing InterventionsNursing Interventions

62. ∗ Patient education and home care considerations
∗ Increase activities as tolerated – fatigue and weakness may be
prolonged
∗ Breathing exercises to clear the lungs should be taught
∗ Smoking cessation if indicated – smoking destroys tracheobronchial
ciliary action, which is the first line of defense for the lungs.
Smoking also irritates the mucus cells of the bronchi and inhibits
the function of alvolar macrophages
∗ Patient is encouraged to get influenza vaccine because influenza
increases risk for secondary bacterial infections
∗ Staphylococcus
∗ H. influenzae
∗ S. pneumonae
∗ Encouraged to get Pneumovax against S. pneumonae
Pneumonia
Nursing InterventionsNursing Interventions

63. ∗ Oxygenation assessment (ABGs, oximetry)
∗ Pneumococcal vaccine (>65yo; prior to DC)
∗ BC performed within 24h prior to after hospital
arrival
∗ BC before first antibiotic
∗ Adult smoking cessation advice
∗ Antibiotic timing- within 4 hours of arriving to
hospital
∗ Influenza vaccine
Pneumonia- Core Measures