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Respiratory 1

  1. General Respiratory Anatomy and Physiology (illustration)
    1. The respiratory system is comprised of the upper airway and lower airway structures.
    2. The upper respiratory system filters, moistens and warms air during inspiration.
    3. The lower respiratory system enables the exchange of gases to regulate serum PaO2, PaCO2 and Ph. 
  2. Upper Respiratory
    1. Nose and sinuses (illustration)
      1. Filters, warms and humidifies air
      2. First defense against foreign particles
      3. Inhalation for deep breathing is to be done via nose
      4. Exhalation is done through the mouth
    2. Pharynx
      1. Behind oral and nasal cavities
      2. Nasopharynx
        1. behind nose
        2. soft palate, adenoids and eustachian tube
      3. Oropharynx
        1. from soft palate to base of tongue
        2. palatine tonsils
      4. Laryngopharynx
        1. base of tongue to esophagus
        2. where food and fluids are separated from air
        3. bifurcation of larynx and esophagus
    3. Larynx (illustration)
      1. Between trachea and pharynx
      2. Commonly called the voice box
      3. Thyroid cartilage - Adam's apple
      4. Cricoid cartilage
        1. contains vocal cords
        2. the only complete ring in the airway
      5. Glottis - opening between vocal cords (illustration)
      6. Epiglottis - covers airway during swallowing (illustration)
  3. Lower Respiratory and Other Structures
    1. Trachea (illustration)
      1. Anterior neck in front of esophagus
      2. Carries air to lungs (illustration)
    2. Mainstem bronchi
      1. Right and left
      2. Right is more vertical, so right middle lobe is more likely to receive aspirate into it with the result of aspiraton pneumonia, which is more commonly found in elderly populations
    3. Conducting airways
      1. Lobar bronchi
        1. surrounded by blood vessels, lymphatics, nerves
        2. lined with ciliated, columnar epithelial cell (illustration)
        3. cilia move mucus or foreign substances up to larger airways
      2. Bronchioles
        1. no cartilage; collapse more easily
        2. no cilia
        3. do not participate in gas exchange
    4. Alveolar ducts and alveoli (illustration)
      1. Lungs contain approximately 300 million alveoli
      2. Alveoli surrounded by capillary network
      3. Gas exchange area (blood takes O2, gives off CO2)
      4. Gas exchange happens at alveolar-capillary membrane (al-cap memb)
      5. Held open by surfactant which decreases surface tension to minimize alveolar collapse
    5. Accessory muscles of respiration
      1. Scalene muscles - elevate first two ribs
      2. Sternocleidomastoid - raise sternum (illustration)
      3. Trapezius and pectoralis - stabilize shoulders
      4. Abdominal muscles - puts power into cough and used most often with chronic respiratory problems and acute severe respiratory distress
  4. Physiology (illustration)
    1. Basic gas-exchange unit of the respiratory system is the alveoli.
    2. Alveolar stretch receptors respond to inspiration by sending signals to inhibit inspiratory neurons in the brain stem to prevent lung over distention.
    3. During expiration stretch receptors stop sending signals to inspiratory neurons and inspiration is ready to start again.
    4. Oxygen and carbon dioxide are exchanged across the alveolar capillary membrane by process of diffusion.
    5. Neural control of respirations is located in the medulla. The respiratory center in the medulla is stimulated by the concentration of carbon dioxide in the blood.
    6. Chemoreceptors, a secondary feedback system, located in the carotid arteries and aortic arch respond to hypoxemia. These chemoreceptors also stimulate the medulla.
    7. Ph regulation
      1. Blood Ph (partial pressure of hydrogen in blood): a decrease in blood Ph stimulates respiration hyperventilation, both through the neurons of the brain's respiratory center and through the chemoreceptors in carotid arteries and aortic arch.
      2. Blood PaCO2 (partial pressure of carbon dioxide in arterial blood): an increase in the PaCO2 results in decreased blood Ph, and stimulates respiration as described above.
      3. Blood PaO2 (partial pressure of oxygen in arterial blood): a decrease in the PaO2 results in a decreased blood Ph, stimulating respiration as described above.
      4. When arterial Ph rises or the arterial PaCO2 falls, hypoventilation occurs.
  5. Disorders of the Upper Respiratory System
    1. Allergic rhinitis (hay fever) - sensitivity to allergens with whitish or clear nasal discharge
    2. Sinusitis (illustration)
      1. Medical condition
        1. inflammation of mucus membranes in the sinuses
        2. may be followed by infection with a yellowish-green discharge
      2. Management
        1. treatment with antibiotics, decongestants, antihistamines
        2. surgery to drain and open sinuses
        3. antral irrigation (sinus irrigation)
        4. Caldwell-Luc procedure
    3. Upper airway obstruction (choking)
      1. Findings
        1. stridor (harsh, vibrating breath)
        2. no sound of air
        3. both hands of client around the throat
        4. management: emergency treatment (illustration)
          1. Heimlich maneuver
          2. cricothyrotomy (cut cricoid cartilage)
          3. tracheotomy/tracheostomy
    4. Pharyngitis
      1. Inflammation of mucous membranes of pharynx
      2. Bacterial, viral, environmental causes
      3. Treat findings; if culture shows bacteria, use antibiotics
    5. Tonsillitis
      1. Inflammation and/or infection of tonsils
      2. Acute form is usually bacterial
      3. Treat findings; if culture shows bacteria, use antibiotics
    6. Peritonsillar abscess
      1. Complication of acute tonsillitis
      2. Infection spreads to surrounding tissue
      3. If swelling is massive, can endanger airway
      4. Treat findings; if culture shows bacteria, use antibiotics
    7. Vocal cord disorders
      1. Laryngitis
        1. inflammation of vocal cords and surrounding mucous membranes
        2. cause: something irritates the larynx
        3. occurs in viral and bacterial infections
        4. in children, called croup(larynx blocked by edema, spasm or both)
        5. treat findings, rest voice, remove irritants, gargle with warm salt water
      2. Vocal cord paralysis
        1. injury, trauma or disease of larynx, laryngeal nerves or vagus nerve
        2. may result as a complication after thyroidectomy surgery
        3. assess how well client can protect airway
        4. can sometimes be surgically treated with Teflon injection
    8. Cancer of the larynx
      1. Etiology
        1. most tumors of the larynx are squamous cell carcinoma
        2. more common among men, age 50 to 65
        3. cigarette smoking and alcohol consumption are related
      2. Findings
        1. persistent sore throat
        2. dyspnea
        3. dysphagia
        4. increasing persistent hoarseness
        5. weight loss
        6. enlarged cervical lymph nodes
      3. Management
        1. radiation therapy
        2. chemotherapy
        3. surgery: removal of all or part of larynx to treat cancer

                                             i.    total laryngectomy: no voice, permanent stoma in neck with no risk of aspiration from oral cavity

          1. radical neck dissection: when cancer has metastasized to surrounding tissues
      1. Nursing interventions
        1. arrange for clients with larnygectomies to meet with members of support groups
        2. establish a method for communication before surgery
        3. maintain airway; have suction equipment at bedside
        4. observe for signs of hemorrhage or infection
        5. teach about trach and stoma care
        6. assist with period of grieving
  1. Disorders of Lower Respiratory System (LRS): Obstructive
    1. General facts: process in chronic obstructive pulmonary diseases
      1. Block airflow out of lungs
      2. Trap air, with impairment of gas exchange
      3. Increase the work of breathing
    2. Emphysema
      1. Destroys alveoli
      2. Narrows and collapses small airways
      3. Overall lung loses elasticity
      4. Traps air
      5. As alveolar walls die, there is less surface for vital gas exchange
    3. Chronic bronchitis
      1. Definition
        1. inflammatory response in the lung
        2. affects few alveoli, mostly airways
      2. Findings
        1. lungs chronically produce fluids
        2. inflammation and mucus narrow the airways