Critical Care Nursing

A Holistic Approach
Part 5
Anatomy and Physiology of the
Respiratory System
Chapter 23
Thorax
• Thoracic cage
– Ridged and flexible; protects organs
• Muscles of ventilation
– Diaphragm, external/internal intercostal muscles
• Lungs
• Pleural space
– Parietal pleura, visceral pleura
• Mediastinum
– Contains the heart, esophagus, vessels, thymus

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Airways

• Nasopharynx – warms, filters, and moisturizes

• Oropharynx
• Trachea – passageway, smooth muscle, cricoid cartilage
• Bronchi – right, left, carina (neuronal tissue)
• Bronchioles
• Terminal bronchioles
• Alveoli – gas exchange

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Pulmonary Circulation

• Deoxygenated blood from right ventricle

• Pulmonary artery – arteriole
• Capillaries
– Wrap around every alveoli
– Thin-walled for efficient gas exchange
• Venules
• Pulmonary vein
• Left atrium

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Physiology of Respiration

• Ventilation
– Movement of air between the alveoli and atmosphere
• Diffusion
– Movement of CO2 and O2 between alveoli and
capillaries
• Transport
– Movement of O2 from the alveoli to the cells
– Movement of CO2 from the cells to the alveoli

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Process of Ventilation

• Movement of the diaphragm

• Changes in the transpulmonary pressure
• Lung compliance
• Airway resistance

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Balance of Ventilation to Perfusion

• Alveolar dead space

– Collapsed alveoli from pneumonia or atelectasis
• Shunting
– Anatomical
• Blood moves from the right side to left side of the
heart without being oxygenated
– Physiological
• Blood moved by alveoli without picking up oxygen

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VQ Mismatch

• Physiological shunt
– Low ventilation–perfusion ratio
• Alveolar dead space
– High ventilation–perfusion ratio
• Silent unit
– Both ventilation and perfusion are decreased

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Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition.
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Patient Assessment:
Respiratory System
Chapter 24
History

• Dyspnea
• Chest pain
• Sputum production
• Cough
• Past history
• Family history
• Personal and social history

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Inspection

• Respiratory rate, depth, and pattern of respiration

• Labored breathing, use of accessory muscles
• Cyanosis of skin
• A/P diameter of chest, and patient posture
• Chest expansion
• Chest deformities or scars
• IE ratio
• Clubbing of the fingers

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Palpation

• Tactile fremitus
• Subcutaneous emphysema
• Thoracic expansion
• Trachea

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Percussion

• Audible vibrations
• Tactile vibrations

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Auscultation
• Tracheal breath sounds
– Over trachea, loud and harsh

• Bronchial breath sounds

– Over large airways they are normal; anywhere else they
are not normal

• Bronchovesicular breath sounds

– Medium in pitch; heard over bronchioles

• Vesicular breath sounds

– Heard over distal airway; quiet, low pitched

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Pulse Oximetry
• Reflects the arterial oxygen
saturation of hemoglobin
• Saturations of 93% to 99% are
normal
• Not reliable in patients
– Using vasoconstricting
meds
– With known
dyshemoglobins
(carboxyhemoglobin or
methemoglobin)
– In shock, cardiac arrest
– With severe anemia

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End-Tidal Carbon Dioxide Monitoring

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Arterial Blood Gases

• pH: 7.35–7.45
• PaO2: 80–100 mm Hg
• PaCO2: 35–45 mm Hg
• HCO3: 22–26 mm Hg
• SaO2: 93–99%

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Acid–Base Balance

• Respiratory acidosis
• Respiratory alkalosis
• Metabolic acidosis
• Metabolic alkalosis

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Other Diagnostic Tests

• Chest X-ray
• Ventilation-perfusion scan
• Pulmonary angiogram
• Pulmonary function test (PFT)
• Bronchoscopy
• Thoracentesis
• Sputum culture

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Patient Management:
Respiratory System
Chapter 25
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Pulmonary Toilet

• Cough and deep breathing

• Chest physiotherapy
– Positioning
– “Good lung” down
– Postural drainage
– Percussion or vibration

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Oxygen Delivery Systems

• Nasal cannula
– For children, blow-by
• Simple face mask
• Venturi mask
• Face tent
• Non-rebreather mask

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Artificial Airways
• Nasopharyngeal / Oropharyngeal
– Size by placing device from ear lobe to corner of mouth
• Endotracheal tube
– Uncuffed tubes for children younger than 10 years of age
• Laryngomask airway (LMA)
– Sizes 1,2,3,4, and 5
– Sizes 3 and 4 for most of the population
• Tracheostomies

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Chest Tubes

• Remove air and fluid from

the pleural space
• Re-expand a collapsed lung
• Restore negative pressure to
the pleural space

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Reasons for a Chest Tube

• Hemothorax
• Pneumothorax
• Tension pneumothorax or hemothorax
• Fistula

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Pharmacological Interventions

• Bronchodilators
• Anti-inflammatory agents
• Antibiotics
• Sedative agents

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50/50 Rule of Respiratory Failure

• pH less than 7.25

• PaCO2 greater than 50 mm Hg
• PaO2 less than 50 mm Hg

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Mechanical Ventilators

• Negative–pressure
ventilator
• Positive–pressure
ventilator
• Pressure ventilator
• High-frequency ventilator

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Modes of Ventilation

• Assist-control
• Synchronized intermittent mandatory ventilation (SIMV)
• Pressure-support
• Pressure-controlled ventilation
• Volume-guaranteed pressure option
• Continuous positive airway pressure (CPAP)
• Positive end-expiratory pressure (PEEP)

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Ventilator Settings

• FiO2
• Respiratory rate
• Tidal volume
• Peak flow
• Pressure limit
• PEEP
• Sensitivity

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Complications

• Aspiration
• Barotrauma
• Ventilator–associated Pneumonia (VAP)
• Decreased cardiac output

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Common Respiratory Disorders
Chapter 26
Pneumonia

• Community-acquired pneumonia
• Hospital-acquired pneumonia
• Bacteria
• Viruses
• Mycoplasma
• Fungi
• Chemical

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 Pneumonia
is an inflammatory response
to the uncontrolled
multiplication of
microorganisms invading the
lower respiratory tract.

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Pneumonia

• Studies
– CXR, sputum culture, bronchoalveolar lavage
• Management
– Antibiotics, oxygen, pulmonary toilet
• Supportive care
– Nutrition, hydration, rest
• Prevention
– Pneumococcal and influenza vaccines

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Pleural Effusion

• Accumulation of pleural fluid secondary to increased fluid

formation
– Increased capillary permeability
– Deceased colloid osmotic pressure of the blood
– Increased intrapleural negative pressure
– Impaired lymphatic drainage
– Increased pressure in the capillaries or lymphatics

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Assessment of Pleural Fluid

• H/P finding
– Shortness of breath, chest pain
– Tachypnea, hypoxemia, pleural rub
• Diagnostic studies
– CXR – lateral decubitus
– Thoracentesis

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Pneumothorax

• Sudden onset of pleuritic chest pain

– Dyspnea, shortness of breath, increased work of
breathing
• Diagnostic test
– CXR
• Management
– Oxygen
– Possible placement of chest tube

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Pulmonary Embolism

• Part of a deep vein thrombosis that has traveled and

lodged in the pulmonary arteries
• Severity depends on the extent of occlusion
• Mismatch of ventilation and perfusion
• Testing
– VQ scan or a pulmonary angiogram
• Management
– Anticoagulation

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COPD

• History
– Exposure to risk factors, comorbidities, current
medical treatment (beta blockers)
• Tests
– Spirometry, ABGs
• Management
– Oxygen, education, drug therapy, nutrition, exercise,
surgical intervention

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Asthma

• A chronic inflammatory disease of the airways

• Airway hyperresponsiveness
• Variable airway obstruction
• Resolves spontaneously or after using a bronchodilator

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Asthma

• Testing
– Spirometry
– Pulmonary function testing
• Management
– Education, prevent exacerbation, optimize
pharmacotherapy

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Acute Respiratory Failure

• A sudden and life–threatening deterioration in gas

exchange
• Type I – Acute hypoxemic respiratory failure
• Type II - Acute hypercapnic respiratory failure
• Type III – Combined hypoxemic and hypercapnic failure

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Acute Respiratory Failure

• Tests
– ABGs, CXR, PFTs, CT, thoracentesis
• Management
– Correction of gases, oxygen therapy
– Reversal of any narcotics
– Possible mechanical ventilation

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Acute Respiratory Distress
Syndrome
Chapter 27
ARDS

• Complex clinical syndrome

• Acute hypoxic injury
• Caused by direct or indirect pulmonary injury
– Direct injury - aspiration, pulmonary infection, near
drowning, thoracic trauma or toxic inhalation
– Indirect injury – shock, sepsis, hypothermia, DIC,
multiple transfusion eclampsia, pancreatitis, burns

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Phases of ARDS

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Diagnostic Studies

• Blood cultures
• Bronchoalveolar lavage – detection of interleukin-1 and
tumor necrosis factor-
• Blood gas
• CXR
• Lung compliance, airway resistance, and pressure

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Copyright © 2005 Lippincott Williams & Wilkins. Instructor's Resource CD-ROM to Accompany Critical Care Nursing: A Holistic Approach, eighth edition.