Definition: Abnormal and Permanent enlargement of gas exchange airways
accompanied by the destruction of alveolar walls.
If we could see inside the lungs, we would see permanent stretching and
enlargement of the
A unit of 3 things
|1. Respiratory Bronchioles
2. Alveolar Ducts
|These together make up the gas exchange airway system
Recall from anatomy that the actual gas exchange takes place in the
respiratory bronchioles, alveolar ducts and alveoli.
Your book calls these the Acini. (plural of acinus.
I often use the word alveoli but in the strict sense, I mean the acini).
(mentioned in Module I) is now 66 years old. He has been on O2 at home for 6
You occasionally see him at the grocery store, walking slowly, carrying his oxygen tank
His wife is with him to do the lifting and the heavy work. Adam may have a
variety of diagnoses
but a very good bet is that he has emphysema. He walks
slowly and appears SOB. He tells you
that he rarely goes out of the house
as it is just too much effort. Mostly he sits in his chair and
reads or watches
TV. His wife is with him and she secretly tells you that she is getting
out as she has "to do everything at home these days".
This is what an RN should realize is occurring in Adam's lungs if he has
|Permanent stretching/ enlargement of his alveoli|
|Loss of elasticity/recoil with abnormal dilation of the air spaces|
|Alveolar walls are destroyed and the connective tissue support in the
lower airways breaks down.|
|Hyperinflation occurs. Lung sacs are permanently over inflated.|
|Appears to be the end stage of a process that has progressed slowly for
|Obstruction relates to actual changes in the lung tissue itself, (verses
mucous and inflammation of |
When did this disease process begin for Adam?
At what point does a client become aware that he/she has emphysema?
Early or late in the disease state?
If a friend with emphysema seems to be coughing productively, month after
month, what additional diagnoses might you suspect?
2 Major Causes of Emphysema:
1) Major cause is :__________________What percent of the time?
2) Deficiency of alpha antitrypsin (we normally have enough of
Enzymes called proteases, have the potential to
destroy the walls and elasticity of the alveoli.
Normally the lung is protected from this process by an anti
protease enzyme called alpha 1 antitrypsin.
In emphysema (1-2% of cases) there is a genetic imbalance between
the two enzymes.
Deficiency of alpha antitrypsin --> destruction of the alveoli
This is a genetic disorder - an inherited recessive trait so both
parents have to have the defective gene.
It is particularly important that these persons not smoke. Why?
Manifestations of Emphysema:
(7 of the more
|1) Dyspnea: Have you ever seen people with COPD huff and puff with
any activity? |
Realize that it can be a major focus just to get
Sometimes they can't even complete a sentence without
having to stop
mid sentence and catch their breath.
this in the clinical setting)
|2) Orthopnea: The preferred position is a 'sitting up
straight' position which stabilizes chest structures and allows maximum
chest expansion. Many of you have seen these clients
sitting on the
edge of the bed with their arms forward on the bedside table
Now, each of you - try bending over in your chair and see how much harder
it is to breathe? This
is why these people insist of being upright. What
happens when we try to help them lie flat?
|3) Increased use of accessory muscles: Air flow 'IN' is still
possible. Thus the person will work
hard to breathe. You will see the
accessory muscles hard at work. (This is easy to see in a
setting. Watch for it. Look at the chest, abdominal and neck muscles
moving visibly with each breath).|
During inspiration, the airways are pulled open, allowing air to
move past any obstruction.
|4) Prolonged Expiration : The airway has
collapsed or narrowed and this traps the air in
the distal spaces.
Don't miss Figure 26 - 11. The picture tells it all!|
It will require a focused effort to get the
We teach these clients to breathe out
through pursed lips (take a deep breath in and then
let it out very slowly over 6- 8 seconds,
through lips that are almost closed. Try this - it
works by slowing expiration and thus preventing/decreasing the collapse of the lung air
sacs and airways.
|5) Struggle to Maintain Normal Arterial Blood Gas Values:|
(This section is long- It's IMPORTANT!)
Eventually the client will tire and decompensate --> hypercapnia & Hypoxemia.
The client eventually, over years, becomes exhausted.
Lets draw a sample of arterial blood from an artery (Ouch!)....
and then lets:
Put an O2 sat meter on a finger (No Pain - wow) and see how saturated the
red blood cells are with O2 as they travel through the finger.
Lets look at the values..
|Arterial 02 =
||PO2 is below 80, often down to 50 -60
|O2 saturation = 96 - 100 %
||O2 saturation hovers about 90 as a baseline
|PCO2 = 35 - 45
||PCO2 = > 45
|HCO3 = 22-26
||(variable depending upon compensation)
Through the use of an INC breathing rate, and use of accessory muscles,
emphysema clients can
initially compensate and maintain near normal gas levels.
We call these persons "Pink Puffers". (These are
the clients who look pretty good when you assess them.
They are working hard to
breathe. They hold their O2 sats above 90 % and seem to be breathing fairly well
at this stage.
What will happen if they keep on smoking?)
As the disease progresses, and as we see them work harder to breathe -->
and blood gas values will be lower. We call
them "Blue Bloaters". (Look at their color. It will
perhaps gray. They are worn out and just can't maintain adequate
Scenario :Lets take another look at
Adam carrying the O2 tank in the grocery store.
assume he does have emphysema. He probably lives with an O2
saturation of 88- 90. (with
the help of O2) His PO2
is less than 80. He probably never reaches a normal 02 level.
he has learned to live with these low values. He has adjusted to a life
with less O2 and more
CO2 on board. He isn't out shoveling snow and he couldn't
walk around the Mall of America...
but with help he can manage to survive in a
Major Point here: The goal of the RN isn't going to be to 'cure'. The damage
has been done and
as far as we know, it is still irreversible in this day and age.
Our goal is to help these clients maintain their baseline ABG's.
We also try to offer support and encourage healthy living.
You WILL encounter many many individuals who are admitted with COPD.
They are ill and
you will do your best to help them return to their baseline
status. As they leave the medical
setting, you hear them admit that they plan to
continue smoking. You will need to
communicate professionally and non
judgmentally. Take some time to think about how
you will respond to these
RN's Need to Understand the Oxyhemoglobin
Curve that you see below or Fig 25-17 in H&M
Heuther &McCance - permission received
||An O2 sat of 90 % = a PO2 of 60
- Remember This Important Point
Look at the curve. Note that O2 Sat is on the vertical . PO2 Blood gas value
is horizontal (across).
Remember that _____ is a normal O2 saturation
Follow the 90 % O2 sat across and see that it merges with a PO2 of 60.
You will feel rotten if you suddenly have a PO2 of 60. (= O2 sat of 90)
Have you ever heard a nurse read a sat of 90% and say to the client "You're
Don't fall into this trap.
Remember Adam in the grocery store, carrying the O2 tank has an O2 sat of 89
or 90 %!
Do you want to live like Adam? We can't do much for Adam. 89 or 90% is the best
he can ever
achieve by himself. Why is this so?
A 90 % O2 sat (= PO2 of 60) means that you are receiving adequate but not
optimal O2 saturation.
Unless there is a reason ( like pneumonia, pneumothorax, chest surgery, COPD,
etc) you should be very very concerned if your client has an O2 sat of only 90
%. You should be asking yourself what is going on to make it be this low. This
is the minimal amount that you can tolerate and not have a need for O2
If you love your mother.... you won't want her to have an O2 sat of 90!!!!
Check it out. Find out why your client's O2 sats are below the normal 96 % . Assess for
One more important concept about Blood Gas Values...........Hang on -
this is important.
Why do we breathe? What makes it all happen?
Your text explains chemoreceptors so well. Don't miss it!
(Fig 25 -10)
1) Where are they located?
2) How does the SNS (sympathetic nervous system) and the
PSNS affect our breathing?
Read in your book about chemoreceptors in the respiratory center.
The 'impetus to breathe' or you might say the 'driving force' is due to 2
1. Decreased O2
2. Increased CO2
Healthy persons take a breath if the chemoreceptors sense too much CO2 in the
body or too little O2 in the body.
This means you and me!
Persons with COPD have gradually lost the impetus to breathe related to
Consider how they have lived with a gradual build up of CO2 for many
They are used to hypercapnia and it no longer stimulates a breath.........
These persons take a breath because their body says " Hey, I don't have
enough O2, I had better take a breath!"
What will happen if you turn the O2 up too far on a person with COPD?
What level of O2 saturation do we try to get a person with COPD up to ?
Let's say you are taking care of the president of the USA ( you like this
fellow!) and he does not smoke.
What level of O2 saturation do you want him or her (
someday it might be a woman) to attain ?
Ask on the discussion board if this is confusing to
Real life scenario: Happens all the time.......
You are working in the ER. A person arrives very SOB. No one knows this
client. The ambulance crew
viewed the SOB and turned the O2 up to 8
liters. The RN turns the O2 down to 5 liters
to maintain an O2 sat of 92
%.The staff begins assessing. ABG's are drawn and sent to the lab.
client is lethargic and slows down his/her breathing. You get a little history
and find that
this client has longstanding COPD. Breathing becomes more
shallow. ABG's show that the
PCO2 is abnormally high at 49. The PO2 is low at
58. The physician looks at the ABG's and
says to turn the O2 down to 1 - 2
L/min. WHY? It might sound the opposite of what you
What has happened here? This is complex but deals with the fact that this client
has COPD and
no longer has the stimulus to breath because of too much CO2. The
only reason that this client
is breathing is because chemoreceptors sense too
little O2. You have just suddenly given this
client lots of O2. The
chemoreceptors say: "Ah this is cool! I've got all the O2 I need. No reason
for me to initiate many breaths! I haven't had it this good for a looooong time!"
The important questions here are:
1) Why do you turn down the O2? Will this perhaps cause the client to breath
2) What will happen to the PO2 level when you turn down the O2 level?
If you know an ER nurse or physician, discuss this with him or her.
Be very aware that high concentrations of O2 can suppress the oxygen
which provide the main stimulus for breathing in clients with COPD. Often we
them stop breathing all together, but we see a decrease in the effort their
brain makes in
sending the stimulus to breathe.
If you are confused, post your questions and ask for help. This
is a very difficult but important concept for RN's to understand.
|6) Eating Can be difficult --> reduced weight|
Why do you suppose this might happen?
|7) Barrel Chested Configuration|
Go look at your chest dimensions in a mirror.
Normally, people are twice as wide as they are deep.
In extensive COPD, the lungs become hyperinflated from chronic air
The chest becomes round like a barrel! It is just as wide as it is deep!
What has happened to recoil after emphysema begins? ________________
Why would this contribute to hyperinflation? __________________________
Want More Information?
MedLine Plus: COPD
Click on hyperlink and under search, type 'COPD' for further information
General Ideas for Treatment for chronic Bronchitis
Think of some ways that you might treat these clients.
(Add to this list as you progress through the module)
Late Stages of COPD
Chapter 26 in H&M
1. Pulmonary Hypertension
This means the elevation of arterial blood pressure in
the pulmonary arteries.
Is this a primary or a secondary condition if it occurs
along with COPD? ______________
How rapidly does it progress?
How is it similar to right sided heart failure? Why?
What is the survival rate?
2. Cor Pulmonale
Look at the words : 'cor' refers to heart. 'Pulmonale' refers
It is the heart and lungs failing together.
This occurs secondary to what?__________________________
3. Recurrent Respiratory Infections
Why do you suppose these occur?
4. Chronic Respiratory Failure
Do you know anyone in the "50/50 club"?
This means they are in a state of respiratory failure
1) Hypercapnia (increased CO2 in the blood > 50 mg
2) Hypoxemia (lack of adequate O2 in the blood < 50 mg
The tissues are not receiving the O2 they need
This eventually leads to death.
If a healthy person suddenly becomes ill and has
blood gases that indicate respiratory failure, what piece of
equipment will be needed in order to
What might be the personal decision of a person who has
longstanding COPD regarding a ventilator?
Has anyone in the class worked at
Bethesda hospital with the long term vent clients? Have you any insights for us?
(Please share via the discussion board.)
It is very hard to wean a COPD
client off of a ventilator. Can you reason why this would be?
Talk to an RN at Bethesda or in an ICCU about this
A rule of thumb for me: If the client is in the
50/50 club, he/she is in respiratory failure and I had better be very aware of the options for
this client- Quickly!.
Now take a look at Figure 26-10 in H&M. Can you understand this now?
If not ask for help.
Return to Content List
Selected Respiratory Drugs
Several drugs are used frequently and effectively to relieve respiratory
This is a great time to stop and study the respiratory pharmacology module.
It is located on the content page.
Return to Content List
Definition: An acute infection of the parenchymal structures of the
(parenchymal = the essential or functional elements of an organ)
Thus, in the lung, this would mean the lower respiratory track : the alveoli, alveoli duct and
where the gases
are actually exchanged.
1 - 4 million cases annually in the USA
is a leading cause of death in the USA
Usually caused by infectious agents like bacteria and viruses.
May also be noninfectious - aspirate your tube feeding, inhale fumes, reflux of
gastric juices from stomach -->lungs.
Ponder... How can RN's help to prevent pneumonia?
Remember, the lung should be sterile below the larynx.
Students ask... what about all the germs that we inhale.... don't they interfere
with the sterility
of the lungs....good question!
Go back to your A & P.
What are the natural defenses that strive to keep the lung sterile?
When these defenses fail, infections like pneumonia can occur down in the
Pathogens multiply, stimulate the full inflammatory response, the acini fill
with mucous and
debris,---> serious interruptions in diffusion across the
alveolar capillary membrane.
Ponder... What will the RN be assessing for? What might you expect to see?
Susceptibility to pneumonia INC with:
1) Loss of cough reflex. Picture an elderly, weakened client, lying in bed with
an NG in place, and no ability to cough effectively. How about a seriously
ill client with an ET (endotracheal) tube? Please be very aware that any time a tube
is placed into the lungs or stomach, there is an increased chance for aspiration of
2) Damage to the ciliated endothelium that lines the respiratory track.
This important filter for pathogens is damaged by cigarette smoke.
This is just one of many reasons why a person who smokes can more
easily become ill.
3) Decreased resistance to infection: This would include:
The young and the very old
Persons with decreased immunity for a variety of reasons.
Persons with heart and lung problems
Pathophysiology: What is happening?
Involves the alveoli, alveolar ducts and interstitial spaces
around the alveoli.
What does interstitial mean?
An organism enters --> causes an inflammatory process-->signs of inflammation.
What would the inside of the lungs look like if inflammation occurred? ( what
are the 5
The inflammatory process produces an exudate (or secretion/mucous) -->
edema of the tissue.
What a great medium for organisms to multiply and spread to adjacent portions of
Classifications: Done in many different
Lobar verses Broncho
1. Lobar Pneumonia - starts in ONE area and may fill (consolidate) an
If a lung is consolidated, it usually means it is filled (solid) with
Can any diffusion occur here?
What happens to the client?
2. Bronchopneumonia - most common.
Inflammation starts simultaneously in
several areas, producing patchy, diffuse areas of consolidation.
Bacterial verses Viral (this method not widely
used any more)
1. Pneumococcal /Bacterial (same as streptococcal) causes about 90 % of Pneumococcal disease.
2. Viral is less severe. Usually self limiting. No drug treatment available.
Community Acquired verses Hospital Acquired
1. Community Acquired: The organisms are found in the community rather than a hospital.
Usually found in an immunocompromised person
Frequently associated with an upper respiratory infection
Lower mortality rate than hospital acquired --> < 5%
Most common is pneumococcal pneumonia (= streptococcal).
This is the type that the pneumococcal pneumonia vaccine
Who should get this vaccine?
How often do you need the vaccine?
Is it dangerous?
Need more information? Click Here. Pneumonia
2. Hospital Acquired:
Usually a nosocomial infection. What does nosocomial
You will hear and use this word often in your work.
This type usually occurs 72 hours or more after
Is the 2nd most common cause of hospital acquired infections.
(What is the Most common cause of hospital acquired
Mortality is high - 50 - 70 %
Most caused by bacteria but of a different type.
Ex = klebsiella, E coli and pseudomonas ( no
need to memorize)
You are working in an urgent care setting. A 42 year old woman arrives in a
lethargic condition. She tells you she "just feels rotten". She has 4 children, works full time, admits to a lack of
sleep, poor eating habits, and a general feeling of being overwhelmed with her
life responsibilities. After lab and x ray are completed, she is diagnosed with pneumococcal pneumonia. What might you expect to see during your assessment?
Might she present with?
|Fever? How high?|
|Malaise? What does this mean?|
|Dyspnea and Tachypnea? Why?|
|Cough? Will it be productive?|
|What will the breath sounds be?|
|Will there be chest pain?|
|What else have you heard about pneumonia?|
As you seek these answers, look in your book, ask health professionals and
ask your clients and friends who have had pneumonia. Be curious.
Don't assume that symptoms are always the same with each client with pneumonia.
Return to Content List
A new name for this is Pneumocystis Jaroveci.
You may still see it referred to as Pneumocystis Carinii Pneumonia (PCP).
Atypical type of pneumonia. Found in persons with impaired immune systems.
Thought to be caused probably by a fungus or maybe a parasite. (Texts
differ - Remains a
Most Americans develop antibodies to PCP in early childhood. It is
actually a very common organism.
A healthy immune system controls PCP. Our immune systems prevent us from
developing this disease.
However, PCP can become active in in persons
with impaired immune systems.
Major initial sx are SOB, fever, fatigue and dry cough.
Sometimes treated prophylactically with meds such as septra and
pentamidine, although this is not always the case
since the advent of better antiviral therapy.
Prophylactic treatment would start when the person has a T cell count < 200.
Why is the 200 count significant?
What type of client's have T cell counts < 200?
Whereas this used to be a major cause of death in AIDS, it is now very
preventable with good antiviral therapy and appropriate treatment with meds.
Want more information
Return to Content List
End of the Respiratory Module.
1) Complete the Respiratory Case study and submit to your instructor.
Complete the Self Evaluation as many times as needed.
Contribute to your discussion group as per the schedule.
All through your nursing career, you will discover that RN's are frequently
involved in assessment of respiratory problems. Critical thinking, competent
teaching of clients and a good plan of action can save lives and improve
the quality of life for your clients, friends and family. As you put the
knowledge gained in this module to work in the clinical setting, you will
realize how YOU can make a difference.
Go out and be the Best you can BE!
Great Achievement !
This was a loooong module and you have just won first
place for persistence!
You deserve to take some time to do something holistic for yourself!