Lecture for undergraduate Nursing students

1.  RESPIRATIONS
Refers to the intake of air into the lungs through
Inhalation and the movement of gases from the
lungs to the atmosphere through exhalation.
 Inhalation also called inspiration and Exhalation
called expiration.
 Ventilation is also used to refer to the
movement of air in and out of the lungs.

2. Mechanics and Regulation of Breathing
 During inhalation,
the diaphragm contracts,
the ribs move upward and
outward, and the sternum
moves outward, thus enlarging
the thorax and permitting the lungs to expand.
 During exhalation, the diaphragm relaxes, the ribs
move downward and inward, and the sternum moves
inward, thus decreasing the size of the thorax as the
lungs are compressed. Normal breathing is automatic
and effortless.

3. Respiration control:
Respiration is controlled by:
1) Respiratory centers in the medullamoblongata and
the pons of the brain
2) chemoreceptors located centrally in the medulla and
peripherally in the carotid and aortic bodies.
These centers and receptors respond to changes in the
concentrations of oxygen (O2), carbon dioxide (CO2),
and hydrogen (H+) in the arterial blood.

4.  Factors Affecting Respirations
 Those that increase the rate include:
1. exercise (increases metabolism).
2. stress.
3. increased environmental temperature.
4. Lowered oxygen concentration at increased
altitudes.
 Factors that may decrease the respiratory
rate include:
1. decreased environmental temperature.
2. Certain medications (e.g., narcotics)
3. increased intracranial pressure (ICP).

5.  The depth of respiration
 The depth of a person’s respirations can be
established by watching the movement of the chest.
 Respiratory depth is generally described as:
1. normal
2. Deep
3. shallow.
 Deep respirations are those in which a large volume of
air is inhaled and exhaled, inflating most of the lungs.
 Shallow respirations involve the exchange of a small
volume of air and often the minimal use of lung tissue.

6.  The depth of respiration (con’t)
 During a normal inspiration and expiration, an adult
takes in about 500 mL of air. This volume is called the
tidal volume.
 Body position also affects the amount of air that can
be inhaled. Clients lying on their back have poorer
lung aeration, which predisposes them to the stasis of
fluids and subsequent infection.

7.  The depth of respiration (con’t)
 Certain medications also affect the respiratory depth.
For example, narcotics such as morphine and large
doses of barbiturates such as pentobarbital and
diazepam depress the respiratory centers in the brain,
thereby depressing the respiratory rate and depth.
Abnormalities in the depth of respiration
 Hyperventilation refers to very deep, rapid
respirations
 Hypoventilation refers to very shallow respirations.

8.  Respiratory rhythm refers to the regularity of the
expirations and the inspirations. Respiratory rhythm
can be described as regular or irregular.
 An infant’s respiratory rhythm may be less regular
than an adult’s.

9.  Respiratory quality or character: refers to
those aspects of breathing that are different from
normal, effortless breathing.
 Usually, breathing does not require noticeable effort.
Sometimes, however, clients can breathe only with
substantial effort—this is referred to as labored
breathing.

10.  Sound of breathing
 The sound of breathing is also significant.
 Normal breathing is silent, but a number of abnormal
sounds such as a wheeze are obvious to the nurse’s
ear.
 Many sounds occur as a result of the presence of
fluid in the lungs and are most clearly heard with a
stethoscope.

11.  Variations in Respiration by Age
Normal Ranges/ breath
/minute
Respiration
Average
Age
30-6035Newborn
20-40301 year
15-25205-8 years
15-251910 years
15-2018Teen
12-2016Adult

12.  Altered Breathing Patterns and Sounds
A. Alteration in Rate include:
1. Tachypnea—quick, shallow breaths
2. Bradypnea—abnormally slow breathing
3. Apnea—cessation of breathing temporarily.
4. Respiration Arrest_ cessation of breathing
permanently.
5. Hypernea--- Respirations are labored, increased in
depth, and increased in rate (greater than 20 breaths per
minute). Occurs normally during exercise.

13. B. Alteration in Rhythm include:
1. Cheyne-Stokes breathing—rhythmic waning of
respirations, from very deep to very shallow breathing
and temporary apnea.

14. B. Alteration in Rhythm include: (con’t)
2. Gasping Breathing: gasping also known as
agonal respiration or agonal breathing is an
abnormal pattern of breathing characterized by
shallow, slow (3-4 breath/per minute), labored
breathing and irregular inspirations followed by
irregular pauses.
 Possible causes include:
1. cerebral ischemia
2. extreme hypoxia or even anoxia.
3. accompanying organ failure (e.g. liver
failure and renal failure)

15. 4. septic shock
5. Metabolic Acidosis .
6. Cardiogenic shock
7. Cardiac arrest.
Management of Gasping Breathing
 Gasping Breathing is an extremely serious medical
sign requiring immediate medical attention, as the
condition generally progresses to complete apnea and
heralds death.

16. B. Alteration in Rhythm include: (con’t)
3. Kussmaul breathing is a deep and labored
breathing pattern often associated with
severe metabolic acidosis, particularly diabetic
kitoacidosis (DKA) but also Kidney Failure.
 It is a form of hyperventilation, which is any
breathing pattern that reduces carbon dioxide in
the blood due to increased rate or depth of
respiration.

17. B. Alteration in Rhythm include:(con’t)
4. Ease or Effort
A. Dyspnea— difficult and labored breathing during
which the individual has a persistent, unsatisfied need
for air and feels distressed.
B. Orthopnea— ability to breathe only in upright sitting
or standing positions.

18. C. Alteration in breath sounds include: (con’t)
A. Audible Without Amplification
1. Stridor— a shrill, harsh sound heard during
inspiration with laryngeal obstruction.
2. Stertor— snoring or sonorous respiration, usually due
to a partial obstruction of the upper airway.
3. Wheeze—continuous, high-pitched musical squeak or
whistling sound occurring on expiration and sometimes
on inspiration when air moves through a narrowed or
partially obstructed airway.

19. C. Alteration in breath sounds include: (con’t)
B. Crackles, crepitations, or rales are the clicking,
rattling, or crackling noises that may be made by one
or both lungs of a human with a respiratory
disease during inhalation. They are often heard only
with a stethoscope ("on auscultation").
Types
A. Bilateral crackles refers to the presence of crackles
in both lungs.
B. Basal or basilar crackles are crackles apparently
originating in or near the base of the lung.
C. Bibasal or bibasilar crackles refer to crackles at the
bases of both the left and right lungs.
D. Bilateral basal crackles also refers to the presence

20. C. Alteration in breath sounds : (con’t)
 Crackles are caused alveoli collapsed by fluid,
exudate, or lack of aeration during expiration.
 Crackles can be heard in patients with:
1. Pneumonia
2. Atelectasis
3. Pulmonary fibrosis
4. acute bronchitis
5. post thoracotomy
6. metastasis ablation
7. Pulmonary edema secondary to left-
sided Congestive Heart Failure (CHF)

21. D. Alteration in respiration: Secretions and
Coughing
1. Hemoptysis— the presence of blood in the sputum
2. Productive cough— a cough accompanied by
expectorated secretions.
3. Nonproductive cough— a dry, harsh cough without
secretions.

22.  Phrenic nerve & Respiration
 The phrenic nerve is a twin nerve, with one on the left
side and one on the right of the diaphragm. The
phrenic nerve begins in the brain and then continues
down to the first few cervical vertebrae of the spine.
 The phrenic nerve controls the diaphragm muscle,
which controls the breathing process.
 When the phrenic nerve is damaged, it can prevent
the normal breathing processes and impact health.
Fortunately, treatments exist to remedy the condition.

23.  Phrenic nerve & Respiration (con’t)
Causes of Phrenic Nerve Damage
1. Physical trauma that causes spinal cord injury: nerve impulses
can be disrupted especially if the injury occurs above the third
vertebrae. If the injury is lower in the spine, breathing is usually
not impacted.
2. Surgical complications or trauma: Up to 10% of cases of
phrenic nerve damage are caused by operative trauma, damage
can unintentionally occur during heart or abdominal surgery.

24. symptoms of Phrenic Nerve Damage
1. the symptoms are varied, depending on whether the
left or right nerve is damaged. If only one is damaged,
the patient will continue to breathe, although it will be
labored. If both nerves are damaged, it becomes
medically urgent, as patient can no longer breathe on
own.
2. Hiccups.
3. Diaphragm paralysis, which prevents the patient from
being able to regulate breathing on his or her own

25. Treatment for Phrenic Nerve Damage and Diaphragm
Paralysis
 Fortunately, treatment exists for damage.
 patients get a pacemaker to normalize the heartbeat as well as
phrenic nerve damage.
 The pacemaker works by stimulating the phrenic nerve. The
stimulator is surgically implanted with the surgeon placing an
electrode next to the phrenic nerve.
 Patients can receive one or two implants, depending on
whether one or both nerves are damaged. Next, the surgeon
implants a receiver just under the skin. The receivers convert
the radio waves into stimulating pulses, causing the diaphragm
to contract.

26. The Diaphragmatic pacemaker