The respiratory system

The respiratory system
By C Settley

The respiratory system consists of:
• The nose
• Nasopharynx
• Larynx
• Trachea
• Bronchi
• Bronchioles and lung tissue
7/25/2018 Compiled by C Settley 2

• The nose and nasal cavity form the first port of
entrance of air into our body.
• The mouth can be used as a secondary entrance when
needed.
• The pharynx is the throat, which is made of muscles
and extends from the end of the nasal cavity to
the larynx.
• The larynx is the voice box and connects the pharynx to
the trachea (windpipe).
• The epiglottis is a piece of cartilage that covers the
larynx during swallowing to prevent food going down
the trachea, which could make us choke.

• The trachea allows air to pass through to the lungs. It is covered
by the epithelium, made of cells that produce mucus, which traps
germs, dirt and dust to prevent it going to the lungs.
• Epithelial cells have hair-like structures on their surface called cilia.
Cilia push dirt towards the pharynx.
• Towards its end the trachea splits into two branches, the left and
the right bronchus.
• Each bronchus leads to a lung.
• The bronchi keep separating into branches, which in turn separate
into smaller branches, the bronchioles that spread throughout the
lungs.
• The lungs are spongy structures made of many capillaries and
millions of tiny air sacs, each one called alveolus.

Function of mucus
• Protects airways
• Transports foreign material
• Inhaling something that
you are hypersensitive to
irritates the airways, such
as dust or pet dander, your
body will secrete mucus to
protect the lining of the
airway.
Function of cillia
• Tiny hairs called cilia protect
the nasal passageways and
other parts of the
respiratory tract, filtering
out dust and other particles
that enter the nose with the
breathed air.

The respiratory system:
Gas exchange
– Obtaining oxygen & removing carbon dioxide is
referred to as gas exchange.
– The alveoli have several adaptations that allow gas
exchange to take place with the maximum effect:
• 1. They provide a large surface area where gas
exchange can take place.
• 2. Their walls are moist and very thin (one cell thick).
• 3. They have a lot of tiny blood capillaries passing
through them.

The diagram shows the structure of
the alveoli.

Factors affecting gas exchange
• Exercise
– Good for the body.
– The body will need more oxygen coming into the body in
order to keep the body moving during exercise.
– A person breathes faster and deeper with exercise.
– This is the body's way of increasing the amount of oxygen
coming in.
– Breathing deeper increases the amount of oxygen filling
the lungs.
– The respiration also increases due to faster breathing.
– The number of heartbeats in a minute, increases too.
– The heart and lungs work together to get oxygen out to
the body.

– Once oxygen is in the lungs, the heart pumps blood to the lungs for
the blood to release its carbon dioxide and pick up oxygen at the site
of the alveoli.
– The blood goes back into the heart where it gets pumped out to the
rest of the body.
– When the blood gets to the organs of the body, another gas exchange
takes place.
– Oxygen is given to the organs and carbon dioxide is put into the blood.
– Both the respiration and heart rate have to increase in order to supply
the needed oxygen to the body.
– If the respiration rate increased, but the heart rate did not, then the
usual amount of oxygen would get to the body.
– If the heart rate increased and the respiration did not, then
deoxygenated blood (blood without oxygen) would go out to the body
rather than oxygenated blood (blood with oxygen).

• Smoking
– Smoking also affects respiration.
– Active & passive smoking.
– Cigarette smoke damages the alveoli when
inhaled.
– Damaged alveoli are no longer able to participate
in gas exchange.
– This surface area is decreased when alveoli are
damaged by smoking.

• Surface area of the membrane
– The larger the surface area of the membrane the
higher the rate of gas exchange that takes place.
– There is a directly proportional relationship
between surface area and gas exchange because
when the surface area is large more blood and air
are able to circulate hence increasing the rate of
gas exchange.
• E.g. Removal of lung tissue, destruction of lung tissue &
excessive secretions

• Surface area of the membrane

• Concentration gradient
– Each alveolus is surrounded by blood capillaries which ensure a
good blood supply. This is important as the blood is constantly
taking oxygen away and bringing in more carbon dioxide - which
helps to maintain the maximum concentration gradient
between the blood and the air in the alveoli.
– The lung response to acute altitude exposure is mainly
hyperventilation which, together with elevated heart rate, aims
at achieving an adequate supply of oxygen to the tissues.
– E.g. High altitude, obstruction of airways by inflammation or
secretions

• Concentration gradient

• Thickness of the membrane.
– The rate of gaseous exchange process is also affected by the thickness
of the membrane through which the gases have to diffuse.
– A thicker membrane reduces the rate at which gases diffuse from
areas of higher concentration to those of lower concentration.
– Reduced thickness of a membrane can increase the speed at which
gases flow.
• E.g. Pulmonary oedema
– Prolonged mechanical ventilation

• Blood flow through the lungs
– If blood flow is reduced then the rate of diffusion
in the alveoli is reduced.
• E.g. cardiac failure & pulmonary embolisms

Process of breathing
• Inspiration
– During inspiration or inhaling the diaphragm
contracts (tightens) and moves downward.
– This increases the space in the chest cavity, into
which the lungs expand.
– The intercostal muscles between the ribs also help
enlarge the chest cavity.
– They contract to pull the rib cage both upward
and outward during inhalation.

• Expiration
– This happens due to elastic properties of the
lungs, as well as the internal intercostal muscles
which lower the rib cage and decrease thoracic
volume.
– As the thoracic diaphragm relaxes during
exhalation it causes the tissue it has depressed to
rise superiorly and put pressure on the lungs to
expel the air.

Classification of respiratory illnesses
• Infections
– Pneumonia & bronchitis
• Inflammation
– Asthma
• Autoimmune conditions
– Lupus
• Cardiovascular conditions
• Trauma
• Congenital conditions
– Congenital cystic adenomatoid malformations (CCAMs)
form when a baby's lung tissue grows more than normal

On assessment:
Subjective data
• Problems in breathing?
• Describe the situations.
• What do you do to relieve the problem?
• Do you have a cough?
• Describe the cough.
• Sputum ?
• Describe.
• Pain when breathing?
• Describe.
• Where is the pain?

Subjective data
• Family history
• Past medical history
• Incidence of shortness of breath
• Exercise tolerance
• Cough
• Wheezing
• Allergies
• Occupational history
• Smoking and lifestyle habits

Subjective data
Classification of shortness of breath
• Grade 1
– Short of breath on hills or stairs only
• Grade 2
– Walks about 1 km before becoming short of breath
• Grade 3
– Short of breath after walking 100-200 metres
• Grade 4
– Short of breath on slight exertion
• Grade 5
– Dyspnoea at rest

Objective data
• Respiratory - physical assessment- pg. 565
• General clinical signs- pg. 571
• Posterior & anterior chest
– Inspection
– Palpation
– Percussion
– Auscultation
• Video- examination of the lungs
• Breath sounds
• Video- lung sounds

Diagnostic studies
• Sputum
• Chest x ray
• Arterial blood gases
• Pulse oximetry
• Pulmonary function
test

Common respiratory problems
• Cough
– A cough is a common reflex action that
clears the throat of mucus or foreign
irritants.
– Coughing to clear the throat is typically an
infrequent action.
– The presence of illnesses or obstruction
make coughing to occur more frequent.
– In general, a cough that lasts for less than
three weeks is an acute cough.

• Causes of a cough
– Inflammation
• Allergy or infection
– Mechanical pressure
• Tumors
– Chemical factors
• Inhaled impurities e.g. smoke, fumes & gases
– Thermal factors
• Inhalation of very hot or very cold air that
causes coughing

• Nursing assessment of cough
– Obtain history
– Describe onset
– Nature
– Time of day
– Productive?
– Sound

• Nursing interventions of cough
– Physiotherapy
– Percussion
– Vibration
– Postural drainage
– Hydration
– Nutrition
– Support
– Pain relief
– Oral hygiene
– Specific treatment

Vibration
• Hand position for chest
vibrations
– Place patient in optimal postural
drainage position
– Perform firm compressive
vibrations to the chest wall during
expiration .
– Movement sets up course
vibrations in the airways to help
loosen the secretions sticking to
the walls of the airways.
– Vibrations should be avoided over
patients breasts, spine and
sternum to avoid discomfort
– 1-5 minutes of vibration is usually
performed in each selected
position.

Postural drainage
• Educate patient:
– Each position should be held for a minimum of five minutes.
– Positions can be done on a bed or on the floor.
– In each position, your chest should be lower than your hips to
allow mucus to drain.
– Use pillows, foam wedges, and other devices to make yourself
as comfortable as possible.
– While in the positions, try to breathe in through your nose and
out through your mouth for longer than you breathe in for
maximum effectiveness.
– Do these positions in the morning to clear mucus that’s built up
overnight or right before bed to prevent coughing during the
night.

Postural drainage
• On your back
– Your chest should be
lower than your hips,
which you can achieve
by lying on a slanted
surface or propping your
hips up about 18 to 20
inches with pillows or
another item.
– This position is best for
draining the bottom
front parts of your lungs

Postural drainage
• On your sides
– With pillows under your
hips, lie on one side so that
your chest is lower than
your hips.
– To clear congestion from
the bottom part of the
right lung, lie on your left
side.
– To clear congestion from
the bottom part of your
left lung, lie on your right
side.

Postural drainage
• On your stomach
– Drape your body over a
stack of pillows or other
object, such as a
beanbag, and rest your
arms by your head, with
your chest lower than
your hips.
– This position is best for
clearing mucus in the
lower back area of the
lungs.

• Sputum
– Is a mixture of saliva and mucus coughed
up from the respiratory tract, typically as a
result of infection or other disease and often
examined microscopically to aid medical
diagnosis.

• Nursing assessment of presence of
sputum
– Evaluate color, consistency, amount,
presence of matter, blood or pus
– Collection
– Time of day sputum is produced

• Nursing interventions of presence of
sputum
– Medications
– Hydration
– Assistance
– Postural drainage
– Collection
– Quantity, colour, amount & odour

• Dyspnoea
– Difficult or laboured breathing; shortness of
breath.
– Dyspnoea is a sign of serious disease of the
airway, lungs, or heart. The onset of
dyspnoea should not be ignored; it is reason
to seek medical attention.

• Causes of dyspnoea
– Cardiac diseases
– Shortness of breath
– Pulmonary embolisms
– Pneumothorax

• Nursing assessment
– History taking
– Duration
– Severity
– Ability to talk
– Respiration rate, heart rate
– Wheezing, stridor or coughing present?
– Onset
– Impact thereof

• Nursing interventions
– Cause should be treated
– Comfortable position
– Oxygen therapy
– Assessment

• Haemoptysis
– Haemoptysis is the coughing up of blood or
blood-stained mucus from the bronchi,
larynx, trachea, or lungs.

• Causes of haemoptysis
– Bronchitis (acute or chronic), the most common
cause of coughing up blood.
– Bronchiectasis.
– Lung cancer or non-malignant lung tumours.
– Use of blood thinners (anticoagulation)
– Pneumonia.
– Pulmonary embolism.
– Congestive heart failure, especially due to mitral
stenosis.
– Tuberculosis.

• Nursing assessment
– History… illnesses/diseases?
– Must be differentiated from hematemesis

• Nursing interventions
– Bed rest
– May be life threatening
– Support
– IV
– Blood specimens
– Oxygen
– Quantity, colour and character
– Emergency equipment (ET tube, etc)
– Patient should be prepared for surgical
intervention if needed

• Cyanosis
– Cyanosis refers to a bluish cast to the skin
and mucous membranes. Peripheral cyanosis
is when there is a bluish discoloration to
your hands or feet. It's usually caused by
low oxygen levels in the red blood cells or
problems getting oxygenated blood in the
body.

Stridor
• Stridor is a high-pitched, wheezing sound
caused by disrupted airflow. Stridor may also
be called musical breathing or extra thoracic
airway obstruction.
• Airflow is usually disrupted by a blockage in
the larynx (voice box) or trachea (windpipe).
• Stridor affects children more often than
adults.

Causes of stridor
• an object blocking the airway
• swelling in your throat or upper airway
• trauma to the airway, such as a fracture in the neck or an object stuck in the nose
or throat
• neck surgery
• inhaling smoke
• swallowing a harmful substance that causes damage to the airway
• croup, a viral respiratory infection
• vocal cord paralysis
• bronchitis, an inflammation of the airways leading to the lungs
• tonsillitis, an inflammation of the lymph nodes at the back of the mouth and top of
the throat by viruses or bacteria
• epiglottitis, an inflammation of the tissue covering the windpipe caused by the H.
influenza bacterium
• tumours
• abscesses, a collection of pus or fluid
• laryngomalacia

Grading
• Based on the appearance of the stridor in the
respiratory cycle it is divided into the following
grades:
– Grade 1: Inspiratory stridor.
– Grade 2: Expiratory stridor.
– Grade 3: Inspiratory and Expiratory (Biphasic)
stridor, plus pulsus paradoxus.

Diagnosis can be made by the
following investigations:
• X-rays CT scan of the chest
• bronchoscopy to provide a clearer view of the
airway
• laryngoscopy to examine the voice box
• pulse oximetry and arterial blood gases test to
measure the amount of oxygen in the blood

Management of stridor
• Oxygen
• Dexamethasone oral
• Nebulised salbutamol 5mg when required
• Treatment of any infection
• If severe and not improving on conservative
management may need to consider:
• Tracheostomy if upper airway obstruction
• Nebulised adrenaline

Laryngotracheo bronchitis (croup)
• An upper airway infection that blocks
breathing and has a distinctive barking cough.

Causes of
• Croup is usually caused by a virus infection, most
often a parainfluenza virus.
• May be contracted via a virus by breathing
infected respiratory droplets coughed or sneezed
into the air.
• Virus particles in these droplets may also survive
on toys and other surfaces.
• If a child touches a contaminated surface and
then touches his or her eyes, nose or mouth, an
infection may follow.

Clinical features of
• Begins as a typical cold.
• If there is enough inflammation and coughing, a child
will develop a loud barking cough.
• Cough is worse at night
• Further aggravated by crying and coughing, as well as
anxiety and agitation.
• Fever and a hoarse voice.
• Because children have small airways, they are most
susceptible to having more marked symptoms with
croup, particularly children younger than 3 years old.

Clinical features of
• Noisy, high-pitched breathing sounds when
inhaling and exhaling
• Drooling
• Difficulty swallowing
• Breathes at a faster rate than usual
• Struggles to breathe
• Develops blue or grayish skin around the nose,
mouth or fingernails (cyanosis)

Management of
• Croup is often mild and can be managed at
home.
• Corticosteroids: Dexamethasone
• If a child is very young, has certain underlying
medical conditions, or seems very ill, the
doctor may recommend an evaluation before
prescribing any medication.

Management of
• Steroid medicines
– Do not shorten the length of the illness
– Have anti-inflammatory effects
– Likely to reduce the severity of breathing problems.
• Immediate treatment: Epinephrine / adrenalin via
inhalation/ nebuliser
• Home management:
– Mother comfort baby
• Keep child calm
• Crying can make symptoms worse.
• Reassuring caregiver
• Children with noisy breathing should be placed in an upright position.

Chronic obstructive pulmonary
disorders- pg. 602
• A group of lung diseases that block airflow
and make it difficult to breathe.

Classification of Chronic obstructive
pulmonary disorders- pg. 602
Inflammatory conditions Asthma
Obstructive conditions Chronic bronchitis &
Emphysema
Infective conditions Bronchiectasis

Signs & symptoms of Chronic
obstructive pulmonary disorders
• Shortness of breath
• Wheezing
• Chest tightness
• Having to clear your throat first thing in the morning, due
to excess mucus in your lungs
• A chronic cough that may produce mucus (sputum) that
may be clear, white, yellow or greenish
• Blueness of the lips or fingernail beds (cyanosis)
• Frequent respiratory infections
• Lack of energy
• Unintended weight loss (in later stages)
• Swelling in ankles, feet or legs

Causes of airway obstruction
• Emphysema.
– This lung disease causes
destruction of the fragile
walls and elastic fibers of
the alveoli.
– Small airways collapse
when the patient
exhales, impairing
airflow out of the lungs.

Causes of airway obstruction
• Chronic bronchitis.
– In this condition, the
bronchial tubes become
inflamed and narrowed
and the lungs produce
more mucus, which can
further block the
narrowed tubes.
– The patient develops a
chronic cough trying to
clear the airways.

Risk factors for Chronic obstructive
pulmonary disorders-
pg. 603
• Exposure to tobacco smoke.
– The most significant risk factor for COPD is long-term
cigarette smoking.
– The more years a person smoke and the amount-the
greater the risk.
– Pipe smokers, cigar smokers and marijuana smokers
– 2nd hand smokers
• People with asthma who smoke.
– The combination of asthma, a chronic inflammatory airway
disease, and smoking increases the risk of COPD even
more.
• Occupational exposure to dusts and chemicals.
– Long-term exposure to chemical fumes, vapors and dusts
in the workplace can irritate and inflame the lungs.

Risk factors for Chronic obstructive
pulmonary disorders-
pg. 603
• Exposure to fumes from burning fuel.
– In the developing world, people exposed to fumes
from burning fuel for cooking and heating in
poorly ventilated homes are at higher risk of
developing COPD.
• Age.
– COPD develops slowly over years, so most people
are at least 40 years old when symptoms begin.
• Genetics.
– More susceptible.

CHRONIC BRONCHITIS -pg. 608
• Bronchitis is an inflammation of the bronchial
tubes, the airways that carry air to your lungs.
• It causes a cough that often brings up mucus.
• It can also cause shortness of breath,
wheezing, a low fever, and chest tightness.
• There are two main types of bronchitis: acute
and chronic.

EMPHYSEMA- pg. 608
• Block airflow and make it difficult to breathe.
• Damage to the lungs from COPD can't be
reversed.
• Symptoms include shortness of breath,
wheezing or a chronic cough.
• Rescue inhalers and inhaled or oral steroids
can help control symptoms and minimise
further damage.

Emphysema & Bronchitis
• VIDEO- Emphysema & Bronchitis

Assessment & common findings
of COPD- pg. 608
• Chronic hypoxaemia
• Reduced pulmonary airflow
• Forced expiratory volume and peak flow are
reduced
• Dyspnoea, tiredness and activity intolerance
• Chronic bronchitis: may exhibit carbon dioxide
retention and some degree of cardia involvement
& cyanosis and clubbing
• Emphysema: chest x ray shows hyperinflation and
the lungs are transparent

DEFINITIONS
• Hypoxia
– Deficiency in the amount of oxygen reaching the
tissues.
• Hypoxaemia
– Abnormally low level of oxygen in the blood.
– More specifically, it is oxygen deficiency in arterial
blood.
– Causes hypoxia.
• Hyperinflation
– Occur when air gets trapped in the lungs and causes
them to overinflate

Respiratory acidosis vs
Respiratory alkalosis
• Acidosis refers to an excess of acid in the blood
that causes the pH to fall below 7.35
• Alkalosis refers to an excess of base in the blood
that causes the pH to rise above 7.45.
– acids and bases have been defined differently by three
sets of theories. One is the Arrhenius definition, which
revolves around the idea that acids are substances
that ionize (break off) in an aqueous solution to
produce hydrogen (H+) ions while bases produce
hydroxide (OH-) ions in solution.

Management (non pharmacological)
of COPD- pg. 608
• Breathing exercises:
– Pursed lip breathing
• Exhaling through tightly pressed (pursed) lips and
inhaling through the nose with the mouth closed.
• Helps to keep the airways open during expiration
– Diaphragmatic breathing
• Improves ventilation and
slows respiratory rate
– Effective coughing
• Loosens up secretions which improves blood flow

Management (pharmacological)
of COPD- pg. 608
• Bronchodilators
– Ipratropuim bromide
• Steroids
• Antibiotics
• Oxygen supplementation

Essential health information
of COPD- pg. 608
• Stop smoking
• Regular exercise
• Balanced lifestyle
• Care for home nebulisers
• Use meds correctly
• Consult physiotherapist
• Steam inhalations
• Avoid environmental irritants
• Avoid infection
• Seek medical attention promptly
• Avoid extreme weather and temperatures

COPD
• Video- Management and treatment of COPD

General nursing care for Chronic
obstructive pulmonary disorders-
pg. 603
• Nursing Diagnosis: Impaired Gas Exchange
• OUTCOMES: Patient will:
– Demonstrate improved ventilation and oxygenation.
– Exhibit arterial blood and pH levels at patient’s baseline.
• NURSING INTERVENTIONS:
– The nurse monitors indications of hypoxemia, respiratory
acidosis, and respiratory alkalosis.
– Hypoxemia and hypercapnia often occur simultaneously,
and the signs and symptoms are similar. These include
headache, irritability, confusion, increasing somnolence,
asterixis (flapping tremors of extremities), cardiac
dysrhythmias, and tachycardia.

pg. 603
• Morning headache is a frequent sign of
hypercapnia. If hypocapnia is developing,
tachypnea, tingling of the extremities, muscular
weakness, and spasm are often present.
• Worsening of condition
• The nurse is in a key role to assess the need for
supplemental oxygen, to assess the response to
therapy and acceptance of therapy.

pg. 603
• It is important for the nurse to educate the
patient and family on the following points:
– Oxygen & its adjustments
– Oxygen dries the nose membranes.
– If humidification is used, the amount of water in the
humidifier bottle must be checked every 6 to 8 hours
and refilled as needed with sterile or distilled water.
– Monitor oxygen source.
– Safety precautions must always be observed. Oxygen
is not flammable itself, but it supports combustion.
• Inform medical practitioner of changes in clinical
manifestations

pg. 603
• Nursing Diagnosis: Ineffective Airway
Clearance
– Demonstrate adequate airway clearance.
– Use effective methods of coughing.
– Use Broncho active medications, including
inhalers, nebulizers, and humidifiers appropriately.

pg. 603
– Clearing of the airways is of utmost importance in
meeting tissue demands for increased oxygen
during periods of rest and increased activity.
– The nurse should teach the patient effective
coughing manoeuvres of sitting upright and using
the huff coughing technique.
– To thin secretions, a fluid intake of 3 to 4 L should
be encouraged unless otherwise indicated.

pg. 603
• Nursing Diagnosis: Ineffective Breathing
Pattern
– Demonstrate effective breathing pattern.
– Controlled breathing techniques (pursed-lip
breathing), and diaphragmatic breathing
(abdominal muscle breathing).
– Demonstrate respiratory rate within near-normal
limits.

pg. 603
• NURSING INTERVENTIONS
– The nurse encourages the patient to use controlled
breathing techniques, including pursed-lip breathing,
the forward-leaning position, and abdominal breathing,
to control dyspnoea and anxiety.

pg. 603
• Nursing Diagnosis: Activity Intolerance
– Maintain or work toward an optimal activity
level.
– Pace activities.
– Plan for simplification of activities.
– Participate in planned muscle-conditioning
program.

pg. 603
– Avoid physical exertion.
– Exercise training
• improves aerobic capacity
• Endurance
• Strength
• functional performance in day-to-day life
• reduces breathlessness and fatigue during
exertion.

pg. 603
• Nursing Diagnosis: Imbalanced Nutrition: Less
Than Body Requirements
– Maintain optimal weight for height, age, and
gender.

pg. 603
– Nutrition
– Appetite
– Balanced diet

pg. 603
• Nursing Diagnosis: Risk for Infection
– Remain free from infection.
– Exhibit sputum at baseline in color, amount,
and consistency.
– Inform health care provider if signs of infection
occur.

pg. 603
• Isolation
• Educate
• Infection

pg. 603
• Nursing Diagnosis: Ineffective Coping (Individual and
Family)
– Identify own coping mechanisms, both effective and ineffective.
– Identify stressors, threats to role.
– Use effective coping mechanisms (discussion with
family, health care providers).
– Set realistic personal goals.
– Participate in therapeutic regimens.
– State names and telephone numbers of appropriate
community support services, such as home health
provider

pg. 603
• Persons who are short of breath are usually anxious and
frightened therefore the nurse should encourage the
patient to talk about anxiety and fears with family members
and health care professionals.
• The nurse should foster a realistic assessment of abilities
and limitations, with a focus on those activities the patient
is still able to do.
• Positive body responses should be stressed .
• Vocational rehabilitation may be an option for some
patients

Asthma- pg. 604
• A condition in which a person's airways
become inflamed, narrow and swell and
produce extra mucus, which makes it difficult
to breathe.

Causes of asthma- pg. 604
• Airborne substances, such as pollen, dust mites, mold
spores, pet dander or particles of cockroach waste
• Respiratory infections, such as the common cold
• Physical activity (exercise-induced asthma)
• Cold air
• Air pollutants and irritants, such as smoke
• Certain medications, including beta blockers, aspirin,
ibuprofen (Advil, Motrin IB, others) and naproxen (Aleve)
• Strong emotions and stress
• Gastroesophageal reflux disease (GERD), a condition in
which stomach acids back up into your throat

Classification of asthma- pg. 604
INTERMITTENT CHRONIC PERSISTENT
MILD MILD MODERATE SEVERE
I II III IV
Daytime symptoms
(cough, tight chest
and wheeze)
< 1 month
Daytime symptoms
(cough, tight chest
and wheeze)
3-4/week
Daytime symptoms
(cough, tight chest
and wheeze)
>4 /week
Daytime symptoms
(cough, tight chest
and wheeze)
continuous
Night symptoms
(cough, tight chest,
wheeze and night
wakening)
< 1 month
Night symptoms
wheeze and night
wakening)
2-4/month
Night symptoms
wheeze and night
wakening)
>4 /month
Night symptoms
wheeze and night
wakening)
frequent

Pathophysiology of asthma- pg. 604
• Exposure to stimulus
• Immune cells are activated
• They release chemical mediators that cause constriction of
bronchial smooth muscle
• And increase capillary permeability in the airways
• Then produces bronchospasm (narrowing of the bronchi)
• Repeated exposure produces a chronic inflammatory reaction in the
lungs
• Which is characterised by thickened mucus membrane and
production of thick secretions
• Bronchoconstriction (constriction of the airways in the lungs due to
the tightening of surrounding smooth muscle, with consequent
coughing, wheezing, and shortness of breath)

Pathophysiology of asthma- pg. 604
• Vascular congestion (engorgement of an entity, such as
the blood vessels of the erectile tissues, with blood)
• Oedema of mucous membrane
• Ventilation and oxygenation are reduced
• Reduction in airflow
• Air is trapped in alveoli because the bronchospasm is
more pronounced on expiration than on inspiration
• Lungs become hyper inflated
• During an attack there is a marked
ventilation/perfusion mismatch and consequent
alterations in arterial blood gas

• Video- how does asthma work

Assessment and common findings
of asthma- pg. 604
• Shortness of breath
• Chest tightness or pain
• Trouble sleeping caused by shortness of breath, coughing or wheezing
• A whistling or wheezing sound when exhaling (wheezing is a common sign of
asthma in children)
• Coughing or wheezing attacks that are worsened by a respiratory virus, such as a
cold or the flu
• Signs that your asthma is probably worsening include:
– Asthma signs and symptoms that are more frequent and bothersome
– Increasing difficulty breathing (measurable with a peak flow meter, a device used to check
how well your lungs are working)
– The need to use a quick-relief inhaler more often
• For some people, asthma signs and symptoms flare up in certain situations:
– Exercise-induced asthma, which may be worse when the air is cold and dry
– Occupational asthma, triggered by workplace irritants such as chemical fumes, gases or dust
– Allergy-induced asthma, triggered by airborne substances, such as pollen, mold spores,
cockroach waste or particles of skin and dried saliva shed by pets (pet dander)

Management of asthma- pg. 604
• Avoid environmental triggers
– dust mites
– cockroach allergens
– irritant effects of environmental tobacco smoke
• Stress management

Pharmacological Management of
asthma- pg. 604
• Disease modifiers (CONTROLLER DRUGS)
• Inhaled glucocorticosteroids
– E.g. budesonide
• Safe for long term use
• Suppresses inflammatory response in bronchial tree.
• Use as prescribed, even when feeling fine.

Pharmacological Management of
asthma- pg. 604
• Bronchodilators (RELIEVER DRUGS) cause the
following:
•  relaxation of bronchial smooth muscle.
•  Broncho dilatation facilitation.
• Indicated for short term use.
• E.g. Salbutamol

Correct use of inhaler- pg. 606
• Shake the container thoroughly before use
• Breathe out completely
• Close lips firmly around the mouthpiece
• Depress the vial and breathe in at the same
time
• Inhale as deeply as possible

Spacer- pg. 606
• A spacer is a holding chamber usually made of
plastic and shaped like a football or tube. It
makes it easier to take asthma or COPD
medication from the type of puffer called an
MDI (metered dose inhaler).

Status asthmaticus- pg. 607
• Status asthmaticus is considered a medical
emergency.
• It is the extreme form of an asthma
exacerbation that can result in hypoxemia,
hypercarbia, and secondary respiratory failure.

Status asthmaticus
treatment- pg. 607
• Inhaled beta adrenergic agents such as
salbutamol
• Sometimes it is more effective to nebulise the
drugs as severe dyspnoea may make it difficult
to use inhalers properly
• A nebuliser is a device that converts liquid into
aerosol droplets suitable for inhalation

Status asthmaticus- pg. 607
• Can continue with inhalers after stabilised
• Tablets can be used as adjunct to therapy
• IV aminophylline can be used to treat acute
bronchospasm
• Large doses of intravenous steroids
• Monitor vital signs
• Oxygen therapy
• Mechanical ventilation if needed
• Psychological support

Managing asthma attacks at home-
pg. 607
• Patient must be taught to recognise the attack
• Immediately take a dose of an inhaled short
acting beta receptor agent
• Oral corticosteroids
• Continue meds
• Nearest clinic if no improvement

Monitoring the patient’s response-
pg. 607
• Lung function
• Peak flow rate
– Peak Inspiratory Flow Rate (PIFR) is defined by the
fastest flow rate noted during the inspiratory
cycle.
– Inhaled medication plays an important role in the
treatment of chronic obstructive pulmonary
disease (COPD), with dry powder inhalers (DPIs)
increasingly replacing metered dose inhalers
(MDIs).

Monitoring the patient’s response-
pg. 607

Essential health information- pg. 607
• Patient should understand care regime
• Emphasise importance of compliance
• Side effects of medication should be explained
• Advise patient to avoid irritants
• Stress the importance of seeking medical care
for infections, etc.
• Explore stress management
• Advise patient to avoid extremes of weather

Reference list
• https://www.healthline.com/symptom/stridor
• http//www.handbook.ggcmedicines.org.uk/gu
idelines/respiratory-system/management-of-
stridor/
• https://www.medicalnewstoday.com/articles/
155932.php
• https://roho.4senses.co/pulmonary-function-
tests/

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