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Respiratory Module Contents/Index
- Part I
Introduction
Chronic Obstructive Pulmonary
Disease
Asthma
Chronic Bronchitis
Respiratory Module Part II
Introductory
Material
You all woke up this morning! You thought about eating, dressing, perhaps
walking or driving....
How many of you gave any thought to your breathing?
 | Lung disease is a leading cause of death in the USA. |
| It is the 2nd leading cause of disability. Approximately 30 million people
in the USA have
some sort of lung disease. |
| If you asked an employer what was the major cause of illness among
workers, accounting
for sick days, you would be told that 'respiratory
illness is the overwhelming cause of
days missed at work'! |
People have a certain degree of control over how well their lungs function.
What sorts of behavior
can impair lung function? You will all answer "smoking".
Of course this is true, but Be Creative...
what else can nurses teach
clients about maintaining respiratory health?
1.
2.
3.
4.
5.
The following 3 words are often confused: Your book defines them well.
| Respiration is: |
| Ventilation is: |
| Diffusion is: |
The actual gas exchange occurs in the 300,000,000 alveoli located in our
terminal bronchioles.
It is via the marvelous action of diffusion that we can
live our lives!
Have you ever had difficulty breathing for any reason (choking, asthma,
allergy)? Have you ever
taken care of clients who have severe lung disease and
need to spend all of their energy just
thinking about the act of
breathing/ventilation? Most of us just take breathing for granted....until it
becomes difficult. Then it can become a terrifying experience.
In this module, we will discuss some leading causes of lung disease and also
some of the drugs
used to treat this pathology. Review the following clinical
manifestations of pulmonary alterations (diseases) in your text. Look for them in the
clinical setting. You will be assessing these symptoms
all throughout your
nursing career!
| Dyspnea is: |
| Abnormal Breathing Patterns are: |
| Hypo/Hyper Ventilation is: |
| Cough is: |
| Hemoptysis is: |
| Cyanosis is: |
| Pain with breathing is: |
| Clubbing is: |
| Abnormal Sputum is: |
In order to understand lung pathology, you need to thoroughly review
the Mechanics of Breathing .
Heuther Chapter 25 will offer you a great review..
How well you breathe is directly affected by: 1) major and accessory muscles,
2) alveolar surface tension, 3) elastic properties, and 4) airway
resistance to flow.
1. Major and Accessory Muscles:
(Use your Book!) (See Fig 25-11 in Heuther)
Normally we use our diaphragms and external intercostal muscles to
breathe. How do these work?
What are our accessory muscles called? When do we use them? Why are they used in
some
disease states?
2. Alveolar Surface Tension :
Surface tension occurs any time that a gas and a liquid interface. When
gases like oxygen and
liquids like the moisture inside an alveoli meet,
molecules tend to adhere to each other.
This makes it very hard for the alveoli
to expand and fill with air.
Surface tension therefore could be thought of as a force that would collapse the
alveoli, (make it
hard to expand) if it were not for the presence of a lubricant
called Surfactant.
Surfactant opposes or lowers the pressure of surface tension and
thus prevents the alveoli from collapsing.
Where is this surfactant protein produced?__________________
Ponder...
| How does soap work when we rub it on our hands? Why do we use soap? |
| Call an OB nurse and ask how surfactant is used in the premature infant?
Let us all know on the discussion board. |
| What famous President's, deceased baby
might have lived if born today rather than in 1963? Why?
Put your answer on the discussion board! |
| How does smoking affect surfactant?
Your text has the answer. |
3. Elastic Properties :
Our lungs are full of elastic fibers that allow for expansion during
inspiration and a return to
a resting state upon expiration.
We need a balanced Compliance to breathe in.
We need Elasticity and Recoil to breathe out.
1) Compliance ( during inspiration)
Relates to how easy it is to stretch the alveoli to expand and allow air in
(thus it is the opposite
of elasticity).
Think of a brand new balloon. You try to blow it up and it is very difficult the
first time. It is stiff!
This balloon has decreased compliance.( like in
pneumonia or ARDS)
Now think of a balloon that has been inflated for two months and you decide to
let the air out.....
It looks stretched, oversized and very flabby. This
balloon has increased compliance (like a person
with emphysema).
Healthy lungs have a balanced compliance.
2) Elastic Recoil ( during expiration)
Lungs return to the resting state after inspiration due to recoil or relaxation
that relates to the
elasticity of the connective tissue fibers in the alveoli.
Go get a thick rubber band.... Now take in a deep breath as you stretch
the rubber band. (compliance)
Hold that breath...... As you let go of that breath, (and let
the elastic band relax) the elastic recoil
of your lungs will cause
exhalation to occur. This relaxation of your alveoli fibers is called Recoil.
This
is why we passively exhale. Think about it... Do you have to make any effort to
exhale if
you have healthy lungs? It just happens! (thanks to elastic recoil). Was there
any effort involved in allowing the rubber band to relax?
Ponder....
| What happens to Elastic Recoil in emphysema? |
| People who have emphysema will
never reverse their alveolar pathology. Can you
explain why? |
Resistance to Airflow:
Normally resistance to air flow is quite low because healthy airways
are quite wide.
What are three things that could decrease the size of the airway?
1)
2)
3)
What 2 diseases always manifest Airflow Obstruction or Resistance?
1)
2)
With the above basic introductory knowledge, you are now ready to begin
exploring some major respiratory diseases.
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Chronic Obstructive Pulmonary Disease
COPD, sometimes call "obstructive pulmonary disease" is not a disease
in itself but is rather a name for a group of diseases characterized by
chronic and recurrent obstruction of air flow in the pulmonary airways
particularly upon expiration.
This umbrella term encompasses:
1) Asthma (not
always classified as chronic- often intermittent)
2) Chronic Bronchitis
3) Emphysema
The most common cause of COPD is what ?
Other causes might be what ?
Ponder...
Why do persons who smoke pay more for life insurance?
Answer: Study after study tells us that persons who smoke, die, on an average, 10 years
earlier.
This means.... that if the average life span age of a male is 75 years old, the
average life
span age of a
smoking male is 65.
Consider further... if your lucky
'smoking neighbor' lived to be 85, (beat the average age by
10
yrs)
some other very unfortunate smoking male only lived to
be 55. ( according to the law of averages) Food for thought.
Scenario:
Adam, 54 years old is your neighbor. He has smoked for 40 years and has
been diagnosed COPD, He tells you he has heard the physician use words like
'emphysema' and 'chronic bronchitis' when discussing his situation. He
declares that he is throwing his cigarettes away forever! He is tranquil and
relieved about his situation and asks
you for confirmation that once he quits smoking his lungs will return to a
healthy status. As you progress through this module, strive to understand the
pathological process occurring in Adam's lungs.
What indeed is the future status of his lungs? (both IF he does indeed quit smoking or if he decides to continue using tobacco products) How will you
respond to Adam's question?
Quote for the Day: "What Starts out to be a Single
Puff....
Turns out to be ... A Death Sentence" (Tommy
Thompson -Former US Sec of health)
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Asthma (often
called Bronchial Asthma)
Definition: Is a chronic inflammatory disease (occurring in the airways)
Characterized by increased or exaggerated airway responsiveness to a
variety of stimuli, that
result in bronchospasm or airway narrowing
(with obstruction).
Ask a friend who has asthma...What stimuli triggers their asthma attacks?
(or post this question on the discussion site and find out from
fellow students)
How would you define bronchospasm in asthma?
9 -12 million people in the USA have asthma. It is considered the most common
cause of
chronic illness in
children <17 yrs.
It is felt that the disease relates to inherited characteristics reacting
with the environment to
cause bronchospasm.
 Lewis, 5th ed,
Pathophysiology :
Recall how we discussed the Inflammatory Process a few weeks
ago...
This same process happens in asthma.
Some sort of allergen or trigger -> inflammation -> a hyper or excess response
of the airway.
Recall that
1) chemical mediators are released
2) vascular dilation and congestion occur
3) chemotaxis occurs with WBC's arriving
This all results in severe narrowing due to:
Fig 26-8 is terrific- don't miss out
| Thick tenacious mucous- hypersecretion |
| Thickening/edema/swelling of the airway walls |
| Increased contraction of the bronchial muscles->airway constriction
|
Manifestations:
What will the RN assess for in the client? What are the clinical
manifestations that you will see?
1)
2)
3)
4)
5)
Air becomes trapped behind the occluded and narrowed airways-->
hyperinflation of the alveoli
(air sacs).
The client then needs to use accessory muscles to maintain ventilation and
gas exchange.
| Ponder....
What will this client
look like? Can you remember taking care of someone who can't
get enough air? |
Eventually this client will develop dyspnea and fatigue.
The alveoli remain open but they are hyperinflated.
Picture how the upper airways are obstructed (narrowed).
| Ponder ...
What effect will this have
on the exchange of O2 and CO2? Can diffusion occur in the alveoli? |
When asthma cannot be reduced or reversed and the client worsens, a life
threatening asthma condition
called
________________develops.
What is the implication of this?
Teaching Point
As a nurse, working in a community setting, a clinic or an ER, it is
important to teach clients to seek medical attention if their regular
asthma meds are not working. The sooner these clients are seen in a medical
setting, the easier it is to reverse their airway obstruction. How will
you teach this information?
Real life scenario ...I took care of a young man who had an asthma attack.
His bronchodilator wasn't working. So he used it over and over and over-
perhaps 3 - 5 times an hour for a 6
hour period. He entered the medical system when he collapsed
with a cardiac arrest.
How could a bronchodilator induce cardiac arrest? What happens to the heart when
epinephrine (similar to the meds in bronchodilators) flows and
the beta 1 receptors are
being excessively stimulated. If you had the chance to
give advice to
this young man, what
would you teach him about inhaler use?
Treatment for Asthma:
| Eliminate causative agents |
| Education on prevention |
| Medications to 1) reverse bronchospasm and 2) reverse airway inflammation
1. Steroids
2. Bronchodilators
3. Anticholinergics |
Want more info?
1) Asthma &
Allergy Foundation of America
2) WWW flash/movie presentation about Asthma - Highly recommended!
Don't miss it!
http://www.whatsasthma.org/index.html
Return to Content List
CHRONIC BRONCHITIS
This is another form of a disease that we place under an umbrella called COPD.
Very common in our society.
In what populations?
What are the causes of chronic bronchitis?
Definition of of Chronic Bronchitis : 2 parts:
1.Inflammation of both major and small airways. Some irritant like cigarette
smoke has irritated the airway and initiated the inflammatory process.
Recall that this means you will have the classic symptoms of inflammation, even
though you can not see into the airways. 5 symptoms of inflammation are:
2. Edema and Hyperplasia : Increased tissue of bronchial airways ->
causes hypertrophy of mucous secreting glands-> abundant production of thick,
inflammatory exudate/mucous (= the fluid that has escaped from blood vessels and
has been deposited in tissues or on tissue surfaces- usually from
inflammation). This causes
| bronchial narrowing |
| plugging of the airway (It is hard to clear this mucous )
|
To actually have a DX of Chronic Bronchitis you need to meet two specific criteria:
Your textbook describes them as:
1.
2.
Ponder...
Recall our discussion about the SNS and the role of epinephrine (epi) in
times of stress.
Remember that we all have endogenous epi in our bodies. How
does epi affect Beta 1receptors in the heart
and
Beta 2 receptors in the lungs?
What
effect does epi have on the bronchial airway?
Why do we sometimes give epinephrine to persons in severe respiratory
distress?
How would endogenous epi affect a person who is being stressed by exercise ?
Evaluation/ Epidemiology:
Is a major health problem associated with smoking and air pollutants.
Anyone who smokes will experience :
| Broncho constriction |
| Paralysis of Ciliary Activity |
| Inactivation of surfactant |
Repeated exposure to irritants over the years causes the inflammatory
response which then
provokes mucous and coughing
The lungs normal defense system/ immune response is impaired.
Manifestations of Chronic Bronchitis - (What you as the RN will be assessing)
Table 26-2 is a great assist
1. Hypoxemia : DEC O2 in the blood. Occurs when the O2 can't diffuse
into the blood through the alveoli.
How low would your O2 level be in hypoxemia?
__________
Review the normal arterial blood gas values!
2. Hypercapnia :INC CO2 in the blood. Has to be caused by hypoventilation of
alveoli.
O2 and CO2 are not diffusing properly. CO2 is too high in the
blood.
What level is too high for CO2 in the blood ?
__________
3. Breathing becomes more labored :(as the disease progresses), even at rest.
SOB (shortness of breath) will be progressive--> gradual
lower exercise tolerance.
Why does this happen?
Expiration will be prolonged. It is hard to get all the air
out.
Look at your clients... You will see this
along with dyspnea.
4. Rhonchi: May be heard due to the presence of mucous (exudate) moving
around.
Scenario:
You
are caring for an elderly client who cannot cough out secretions (for any number
of reasons).
You listen to the lungs and you hear this 'noise'
as the client breathes in, and again the same sound as
the client breathes out. It is very course and loud.
It drowns out any other sounds you might be listening
for.
This is probably rhonchi (= the mucous moving
around in the airway instead of being coughed out).
Sometimes you can get your client to give a
good cough.
Suggest that the client cough... and if you are successful
you might even get to see all the rhonchi gunk
coughed up into the kleenex that you quickly grab and
give to the
client.
Yuck... but great for the client!
If you have healthy lungs, what do YOU do if you have excess
mucous?
Listen to your own lungs. Why don't you have rhonchi?
Listen in a classroom or a public gathering.. There will be
intermittent coughing and clearing of throats as
we normally clear our airways in our healthy bodies.
5. Clubbing of fingers:
Enlargement of the distal ends of the fingers.
Always means the presence of some chronic lung
disease. (Fig 26-1 H&M can't be missed!)
Normally the angle between the nail and finger is 160
degrees. (Look at your fingers)
In the first stages of clubbing you lose the little dip
between your nail and the
tissue of your finger.
In late clubbing the nail bed becomes swollen and spongy and the angle
exceeds 180 degrees.
6. Cyanosis: = Blue! = a late sign.
The client with chronic bronchitis has an imbalance between
ventilation and perfusion.
They are working hard to breathe (ventilating) but they aren't
perfusing their tissues with oxygenated blood.
Thus they have poor color. Where do
you see the first signs of hypoxemia in your clients?
7. Secondary Polycythemia: This is a physiological response to the hypoxia of
chronic bronchitis.
(See your text- polycythemia)
Can you explain how the body is trying to adapt to the low O2
by making more RBC's?
8. Cough: Is a major manifestation. This is also a big part of the diagnosis.
The next time you take care of a client with chronic
bronchitis, ask them how long they have been coughing?
Treatment:
Nurses need to clearly understand that chronic bronchitis is irreversible.
Bronchodilators, expectorants and chest physiology are used PRN
The disease is progressive in nature. The tissue damage cannot be reversed.
90 % of persons with chronic bronchitis are smokers.
What happens if a client is able to stop smoking after signs of chronic
bronchitis are present?
What happens if a person stops smoking before the signs of chronic bronchitis
manifest themselves?
How would you teach friends, neighbors, clients. etc about chronic
bronchitis?
Want more info?
American Lung Association
Return to Content List
This is the end of the Respiratory Module Part I.
Hang in there and surge ahead to Part II.
More great info is just ahead!
Proceed onto Part II of the Respiratory Module.
05/26/2008 |
