Respiratory System,
Tracheostomy, Lung Cancer,
Pneumonia, Tuberculosis (TB)
Zoya Minasyan RN, MSN-Edu
Structures and Functions of Respiratory
System
Fig. 26-1. Structures of the respiratory tract. A, Pulmonary functional unit. B, Ciliated mucous membrane.
Structures and Functions of Respiratory
System
Fig. 26-5. A small portion of the respiratory membrane greatly magnified. An extremely thin interstitial layer of
tissue separates the endothelial cell and basement membrane on the capillary side from the epithelial cell and
surfactant layer on the alveolar side of the respiratory membrane. The total thickness of the respiratory
membrane is less than 1⁄5000 of an inch.
Structures and Functions of Respiratory
System
Physiology of Respiration
Ventilation
Compliance
Diffusion
Oxygen-hemoglobin dissociation curve
Mixed venous blood gases
Oximetry
Structures and Functions of Respiratory
System
Arterial blood gases
Table 26-1. Normal Arterial and Venous Blood Gas Values *.
Structures and Functions of Respiratory System
Table 26-3. Critical Values for Pao2 and Spo2 *.
Structures and Functions of Respiratory
System
Control of Respiration
Chemoreceptors
Mechanical receptors
Assessment of Respiratory System
Assessment of Respiratory System
Fig. 26-8. Sequence for examination of the chest. A, Anterior sequence. B, Lateral sequence. C, Posterior
sequence. For palpation, place the palms of the hands in the position designated as “1” on the right and left
sides of the chest. Compare the intensity of vibrations. Continue for all positions in each sequence. For
percussion, tap the chest at each designated position, moving downward from side to side. Compare percussion
sounds at all positions. For auscultation, place the stethoscope at each position and listen to at least one
complete inspiratory and expiratory cycle. Keep in mind that, with a female patient, the breast tissue will
modify the completeness of the anterior examination.
Assessment of Respiratory System
Fig. 26-9. Diagram of percussion areas and sounds in the anterior side of the chest.
Assessment of Respiratory System
Fig. 26-10. Diagram of percussion areas and sounds in the posterior side of the chest. Percussion proceeds
from the lung apices to the lung bases, comparing sounds in opposite areas of the chest.
Assessment of Respiratory System
Fig. 26-11. Normal auscultatory sounds.
Assessment of Respiratory System
Table 26-8. Normal Physical Assessment of the Respiratory System.
Diagnostic Studies of Respiratory
System
Sputum Studies
Skin Tests
Endoscopic Examinations
Bronchoscopy
Diagnostic Studies of Respiratory
System
Fig. 26-12. Fiberoptic bronchoscope. A, The transbronchoscopic balloon-tipped catheter and the flexible
fiberoptic bronchoscope. B, The catheter is introduced into a small airway and the balloon inflated with
1.5 to 2 mL of air to occlude the airway. Bronchoalveolar lavage is performed by injecting and withdrawing
30-mL aliquots of sterile saline solution, gently aspirating after each instillation. Specimens are sent to the
laboratory for analysis.
Sinusitis
Head and Neck Cancer
Tracheostomy
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Definition:
• Surgical incision into the trachea to establish an airway
• Stoma that results from tracheotomy
Indications
– Bypass upper airway obstruction
– Facilitate removal of secretions
– Long-term mechanical ventilation
– Permit oral intake and speech in patient who requires long-term mechanical
ventilation
Advantages
– Less risk of long-term damage to airway
– Increased comfort
– Patient can eat.
– Increased mobility because tube is more secure
Parts of a Tracheostomy Tube
Types of tracheostomy tubes. A, Parts of a tracheostomy tube. B, Tracheostomy tube inserted in airway with inflated
cuff. C, Fenestrated tracheostomy tube with cuff, inner cannula, decannulation plug, and pilot balloon.
D, Tracheostomy tube with foam cuff and obturator (one cuff is deflated on tracheostomy tube).
Tracheostomy Care
• Explain purpose before procedure.
• Inform patient and family of inability to speak while inflated cuff is used.
• During insertion, obturator is placed inside outer cannula, with rounded
tip protruding from end to ease insertion.
• After insertion, obturator must be immediately removed to allow airflow.
– Keep obturator near bedside in case of decannulation.
– Suctioning the airway to remove secretions
– Cleaning around stoma
– Changing ties
– Providing inner cannula care
• Some tubes have a removable inner cannula for easier cleaning.
Suctioning Tracheostomy
Suctioning tracheostomy with closed system suction catheter.
Tracheostomy Care
• Tube with inflated cuff is used for risk of
aspiration or in mechanical ventilation.
– Inflate cuff with minimum volume required to
create an airway seal.
– Inflate cuff with air to form seal.
• Excessive cuff pressure can
– Compress tracheal capillaries
– Limit blood flow
– Predispose to tracheal necrosis
Tracheostomy Care
• Deflation
– To remove secretions accumulating above the cuff
– Patient should cough up secretions before deflation to
avoid aspiration.
– Suction mouth and tube.
– Patient should cough and be suctioned again.
– Assess patient’s ability to protect airway from aspiration.
– Remain with patient when cuff is initially deflated, unless
patient can protect against aspiration and breathe without
respiratory distress.
Tracheostomy Care
• Tube of equal or smaller size kept at bedside for emergency reinsertion
• Accidental dislodging
– Immediately replace tube.
– Insert obturator into replacement tube.
– If insertion is successful, obturator is removed immediately for airflow
through the tube.
• If tube cannot be replaced
– Assess level of respiratory distress
– Severe distress may progress to respiratory arrest
– Cover stoma with sterile dressing and ventilate with bag-mask until
help arrives
– The nurse should take care not to dislodge the
tracheostomy tube during the first 5 to 7 days when the
stoma is not mature (healed).
Tracheostomy Care
• Initially should receive humidified air.
• Tube should be changed monthly.
• Patient can be taught to change tube using
clean technique at home.
• When a tracheostomy has been in place for
several months, the healed tract will be well
formed.
Changing Tracheostomy Tube at Home
When a tracheostomy has been in place for several months, the tract will be well formed. The patient can then be
taught to change the tube using a clean technique at home.
Swallowing Dysfunction
• Inflated cuff
– Interferes with normal function of muscles used to swallow
– Evaluate risk of aspiration when cuff deflated
• Techniques to promote speech
– Spontaneously breathing patient may deflate cuff, allowing exhaled air
to flow over vocal cords.
Speaking Tracheostomy Tubes
A, Fenestrated tracheostomy tube with cuff deflated, inner cannula removed, and tracheostomy tube capped to allow
air to pass over the vocal cords. B, Speaking tracheostomy tube. One tube is used for cuff inflation. The second tube is
connected to a source of compressed air or oxygen. When the port on the second tube is occluded, air flows up over
the vocal cords, allowing speech with an inflated cuff.
Speech
• Tracheostomy tubes and valves have been designed to
facilitate speech.
• Fenestrated tube has opening on surface of outer cannula to
permit airflow over vocal cords to allow
– Spontaneous breathing through larynx
– Speech
– Secretion expectoration with tube in place
• Fenestrated tube
– Requires frequent suctioning
– Ability to swallow is determined before use.
– Frequently assess for signs of respiratory distress on first
use.
Passy-Muir Speaking Tracheostomy
Valve
The valve is placed over the hub of the tracheostomy tube after the cuff is deflated. Multiple options are available
and can be used for ventilated and nonventilated patients. The valve contains a one-way valve that allows air to enter
the lungs during inspiration and redirects air upward over the vocal cords into the mouth during expiration.
Lung Cancer
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Most important risk factor in 80% to 90% of all lung cancers is smoking.
– Contains 60 carcinogens that interfere with cell development
• Total number of cigarettes smoked
• Age of smoking onset
• Depth of inhalation
• Tar and nicotine content
• Use of unfiltered cigarettes
Causes a change in bronchial epithelium
Other carcinogens pose risk for developing lung cancer.
– Polycyclic aromatic hydrocarbons
– Arsenic
– Air pollution
Etiology
• Environmental tobacco smoke (ETS) inhaled by
nonsmokers poses 35% increased risk of
developing lung cancer.
• Children are more vulnerable to ETS than
adults.
Lung Cancer
Lung cancer (peripheral adenocarcinoma). The tumor shows prominent black pigmentation, scar.
Lung Carcinoma
The gray-white tumor tissue is infiltrating the lung. Histologically this tumor was
identified as a squamous cell carcinoma.
Pathophysiology
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Lung cancers metastasize by
– Direct extension
– Blood circulation
– Lymph system
Common sites for metastatic growth
– Liver
– Brain
– Bones
– Scalene lymph nodes
– Adrenal glands
Clinical Manifestations
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Pneumonitis
Persistent cough with sputum (most common)
Hemoptysis
Chest pain
Dyspnea
Later manifestations
– Anorexia
– Fatigue
– Nausea/vomiting
– Hoarse voice
– Unilateral paralysis of diaphragm
– Dysphagia
– Superior vena cava obstruction
Diagnostic Studies
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Chest x-ray
CT scan
Magnetic resonance imaging (MRI)
Diagnosis identified by malignant cells
Diagnostic Studies
• Sputum specimens obtained for cytologic studies
– Fiberoptic bronchoscope
– Video-assisted thoracoscopy (VATS)
– Pulmonary angiography
• Chemotherapy
• Radiation therapy
– Used as curative therapy, palliative therapy, or adjuvant
therapy
– Primary therapy for those unable to tolerate surgery
– Some cancer cells are more radiosensitive than others.
– Stereotactic radiotherapy
Nursing Management
Nursing Diagnoses
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Ineffective airway clearance
Anxiety
Acute pain
Imbalanced nutrition: Less than body
requirements
• Ineffective health maintenance
• Ineffective breathing pattern
Nursing Management: Nursing Implementation
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Health promotion
– Avoid smoking.
– Promote smoking cessation programs.
– Support education and smoking policies.
Acute intervention
– Offer support during diagnostic evaluation.
– Monitor for side effects.
– Provide comfort.
– Teach methods to reduce pain.
Educate indications for hospitalization. Ambulatory and home care
– Follow up carefully for manifestations of metastasis.
– Educate patient on signs and symptoms of hemoptysis, dysphagia, chest
pain, and hoarseness.
– May need information about hospice
– http://www.cdc.gov/tobacco/quit_smoking/cessation
/index.htm
Pneumonia
• Acute inflammation of lung caused by microbial organism
• Discovery of sulfa drugs and penicillin decreased morbidity and mortality
rates.
• Likely to result when defense mechanisms become overwhelmed
• ↓ Cough and epiglottal reflexes may allow aspiration
• Mucociliary mechanism impaired by
– Pollution
– Cigarette smoking
– Upper respiratory infections
– Tracheal intubation
– Aging
Etiology
• Three ways organisms reach lungs:
– Aspiration from nasopharynx or oropharynx
– Inhalation of microbes such as Mycoplasma
pneumoniae
– Hematogenous spread from primary infection
elsewhere in body
Types of Pneumonia
• Community-acquired pneumonia
– Lower respiratory infection of lung
– Onset in community or during first
2 days of hospitalization
– Highest incidence in midwinter
– Smoking- important risk factor
Types of Pneumonia
• Organisms implicated
– Streptococcus pneumoniae
– Haemophilus influenzae
– Legionella
– Mycoplasma
– Chlamydia
Types of Pneumonia
• HAP: Hospital-acquired pneumonia.
• VAP: Ventilator-associated pneumonia.
• HCAP: Health care–associated pneumonia: newonset pneumonia in a patient who
• was hospitalized in an acute care hospital for ≥2
days within 90 days of the infection;
• resided in a long-term care facility;
• received recent intravenous antibiotic therapy,
chemotherapy, or wound care within the past
30 days of the current infection; or
• attended a hospital or hemodialysis clinic.
Types of Pneumonia
• Risk factors for HAP
– Immunosuppressive therapy
– General debility
– Endotracheal intubation
• Treatment is based on
– Known risk factors
– Severity of illness
Types of Pneumonia
• Aspiration pneumonia
– Occurring from abnormal entry of secretions into
lower airway
– Usually with history of loss of consciousness
• Gag and cough reflexes suppressed
– Forms of aspiration pneumonia
• Mechanical obstruction
• Chemical injury
• Bacterial infection
Types of Pneumonia
• Opportunistic pneumonia
– Patients at risk
• Severe protein-calorie malnutrition
• Immune deficiencies
• Chemotherapy/radiation recipients
• Long-term corticosteroid therapy
• Causes of opportunistic pneumonia
– Bacterial and viral causative agents
– Pneumocystis jiroveci (PCP)
– Cytomegalovirus
– Fungi
Types of Pneumonia
• Clinical manifestations of PCP (Pneumocystis
jiroveci)
– Fever
– Tachypnea
– Tachycardia
– Dyspnea
– Nonproductive cough
– Hypoxemia
Pathophysiology
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Stage 1: Congestion from outpouring of fluid to alveoli
– Organisms multiply.
– Infection spreads.
– Interferes with lung function
Stage 2:
– Red hepatization
• Massive dilation of capillaries
• Alveoli fill with organisms, neutrophils, RBCs, and fibrin.
• Causes lungs to appear red and granular, similar to liver
– Gray hepatization
– ↓ Blood flow
– Leukocyte and fibrin consolidate in affected part of lung.
Resolution
– Resolution and healing if no complications
– Exudate lysed and processed by macrophages
– Tissue restored
Pathophysiologic Course of Pneumococcal Pneumonia
Clinical Manifestations
• CAP symptoms(care associated Pneumonia)
– Sudden onset of fever
– Shaking chills
– Shortness of breath
– Cough productive of purulent sputum
– Pleuritic chest pain
Clinical Manifestations
• Physical examination findings
– Dullness to percussion
– ↑ Fremitusa (vibration or tremor, resulting from a physical action
such as speaking or coughing, felt by hand and used to assess whether
the chest is affected by disease)
– Bronchial breath sounds
– Crackles
– Related to infection with S. pneumoniae and H. influenzae.
• Initial manifestations are highly variable in viral pneumonia.
– Primary pneumonia can be caused by influenza viral infection.
– Can be a complication of systemic viral disease
Complications
• Pleurisy (inflammation of the membrane pleura surrounding the lungs,
usually involving painful breathing, coughing, and the buildup of fluid in
the pleural cavity)
• Pleural effusion (a thin transparent membrane that lines the chest wall
and doubles back to cover the lungs, thereby forming a continuous sac
enclosing the narrow pleural cavity. The inner faces of the cavity are
lubricated by fluid to ease breathing) movements.
• Usually is sterile and reabsorbed in 1 to 2 weeks or requires a
thoracentesis (surgical procedure in which a needle is inserted through
the chest wall in order to withdraw fluid, blood, or air)
• Atelectasis
– Usually clears with cough and deep breathing
• Bacteremia
– Bacterial infection in the blood
Complications
• Lung abscess
– Seen when caused by S. aureus and
gram-negative pneumonias
• Pericarditis
– Spread of microorganism to heart
• Meningitis
– Patient who is disoriented, confused, or
somnolent should have lumbar puncture.
• Endocarditis
– Microorganisms attack endocardium and heart
valves.
Diagnostic Tests
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History
Physical examination
Chest x-ray
Gram stain of sputum
Sputum culture and sensitivity
Pulse oximetry or ABGs
CBC, differential, chemistries
Blood cultures
Collaborative Care
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Antibiotic therapy
Oxygen for hypoxemia
Analgesics for chest pain
Antipyretics
Fluid intake at least 3 L per day
Caloric intake at least 1500 per day, IV
Pneumococcal vaccine
– Indicated for those at risk
• Chronic illness such as heart and lung disease, diabetes
mellitus
• Recovering from severe illness
• 65 or older
• In long-term care facility
Nursing Assessment
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History
– Lung cancer
– COPD
– Diabetes mellitus
– Debilitating disease
– Malnutrition
– AIDS
– Use of antibiotics, corticosteroids,
chemotherapy, immunosuppressants
– Recent abdominal or thoracic surgery
– Smoking
– Alcoholism
– Respiratory infections
– Prolonged bed rest
– Dyspnea
– Nasal congestion
– Pain with breathing
– Sore throat
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Muscle ache
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Fever
Restlessness
Tachypnea
Asymmetric chest movements
Use of accessory muscles
Crackles
Green or yellow sputum
Tachycardia
Changes in mental status
Leukocytosis
Abnormal ABGs
Pleural effusion
Pneumothorax on x-ray
Nursing Diagnoses
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Ineffective breathing pattern
Ineffective airway clearance
Acute pain
Imbalanced nutrition: Less than body
requirements
• Activity intolerance
Planning
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Clear breath sounds
Normal breathing patterns
No signs of hypoxia
Normal chest x-ray
No complications related to pneumonia
Nursing Implementation
• Teach nutrition, hygiene, rest, regular exercise to maintain natural
resistance.
• Prompt treatment of URIs
• Strict asepsis
• Encourage those at risk to obtain influenza and pneumococcal
vaccinations.
• Reposition patient every 2 hours.
• Elevate head of bed 30 to 45 degrees for patients with feeding tube.
• Assist patients at risk for aspiration with eating, drinking, and taking
medications.
• Assist immobile patients with turning and deep breathing.
• Emphasize need to take course of medication(s).
• Teach drug–drug interactions.
Evaluation
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Dyspnea not present
SpO2 ≥ 95
Free of adventitious breath sounds
Clear sputum from airway
Reports pain control
Verbalizes causal factors
Adequate fluid and caloric intake
Performs activities of daily living
Tuberculosis (TB)
• Infectious disease caused by
Mycobacterium tuberculosis
TB Involves
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Lungs
Larynx
Kidneys
Meninges
 Bones
 Adrenal glands
 Lymph nodes
Etiology and Pathophysiology
• Spread via airborne droplets when infected
person
– Coughs
– Speaks
– Sneezes
– Sings
– Transmission requires close, frequent, or
prolonged exposure.
Etiology and Pathophysiology
• Spread
– Inhaled bacilli pass down bronchial system and
implant themselves on bronchioles or alveoli.
– Multiply with no initial resistance
– Replicates slowly and spreads via the lymphatic
system
• If cellular immune system is activated
– Tissue granuloma forms
– The bacteria are contained, preventing replication
and spread of disease
Etiology and Pathophysiology
• Favorable environments for growth:
– Upper lobes of lungs
– Kidneys
– Epiphyses of bone
– Cerebral cortex
– Adrenal glands
Clinical Manifestations
 Fatigue
 Malaise
 Anorexia
 Weight loss
 Low-grade fevers
 Night sweat
Clinical Manifestations
• Cough becomes frequent.
– Hemoptysis is not common and is usually
associated with advanced disease.
– Acute symptoms (generalized flu symptoms)
• High fever
• Chills
• Pleuritic pain
• Productive cough
Complications
• Miliary TB
– Large numbers of organisms invade the bloodstream and
spread to all organs.
• Acute or chronic symptoms
• Pleural effusion
– Caused by bacteria in pleural space
– Inflammatory reaction with plural exudates of protein-rich
fluid
• TB pneumonia
– Large amounts of bacilli discharging from granulomas into
lung or lymph nodes
• Other organ involvement
– CNS—Meninges
– Bone and joint tissue
– Kidneys
Diagnostic Studies
• Skin testing
– Intradermal administration of tuberculin
• Induration at injection site indicates exposure.
• Sensitivity remains for life, and individual should not be
tested again.
– Response ↓ in immune compromised patients
• Reactions ≥5 mm considered positive
• Two-step testing recommended for health care workers
getting repeated testing and those with decreased
response to allergens.
Skin testing
• The test is administered by injecting 0.1 mL of
PPD (Purified protein derivative) intradermally on
the dorsal surface of the forearm.
• The test is read by inspection and palpation 48 to
72 hours later for the presence or absence of
induration.
• The indurated area (if present) is measured and
recorded in millimeters with 0 for no induration.
• The reaction occurs 2 to 12 weeks after initial
exposure to the organisms.
Diagnostic Studies
• Chest x-ray
– Cannot make diagnosis solely on x-ray
– Upper lobe infiltrates, cavitary infiltrates, and lymph node
involvement suggest TB.
• Bacteriologic studies
– Stained sputum smears examined for
acid-fast bacilli
– Required for diagnosis
– On different days, three consecutive sputum samples
– Could also be collected from
• Gastric washings
• CSF
• Fluid from an abscess or effusion
Diagnostic Studies
• QuantiFERON-TB (QFT)
– Rapid blood test (few hours)
– Does not replace cultures
Sputum Cultures
– On different days, three consecutive sputum
samples
– Could also be collected from
» Gastric washings
» CSF
» Fluid from an abscess or effusion
Collaborative Care
• Hospitalization not necessary for most
patients
• Drug therapy used to prevent or treat active
disease
Drug Therapy
• Active disease
– Four drugs are used in initial phase for maximum
effectiveness.
• Treatment is aggressive to combat resistant strains of
TB.
•In most circumstances, the treatment regimen for patients
with previously untreated TB consists of a 2-month initial
phase with four-drug therapy (INH isonicotinylhydrazine,
rifampin [Rifadin], pyrazinamide [PZA], and ethambutol).
•If drug susceptibility test results indicate that bacteria are
susceptible to all drugs, ethambutol may be discontinued.
Drug Therapy
• Directly observed therapy (DOT)
– Noncompliance is major factor in multidrug
resistance and treatment failures.
– Requires watching patient swallow drugs
Drug Therapy
• Active disease
– Patients should be taught about side effects and when to
seek medical attention.
– Liver function should be monitored.
• Latent TB infection
– Usually treated with INH for 6 to 9 months
– HIV patients should take INH for 9 months.
• Vaccine
– Bacille Calmette-Guérin (BCG) vaccine to prevent TB is
currently in use in many parts of the world.
– In United States, not recommended
– Can result in positive PPD (Purified protein derivative)
reaction
Nursing Assessment
• Assess for
– Productive cough
– Night sweats
– Afternoon temperature elevation
– Weight loss
– Pleuritic chest pain
– Crackles over apices of lungs
Nursing Diagnoses
• Ineffective breathing pattern
• Imbalanced nutrition: Less than body
requirements
• Noncompliance
• Ineffective health maintenance
• Activity intolerance
Planning
• Goals
– Comply with therapeutic regimen.
– Have no recurrence of disease.
– Have normal pulmonary function.
– Take appropriate measures to prevent spread of
disease.
Nursing Implementation
Selective screening programs in high-risk groups to
detect TB
Identify contacts of patient with TB.
• Acute intervention
– Airborne isolation
– Appropriate drug therapy
– Immediate medical workup
Nursing Implementation
• Teach patient
– Cover nose and mouth with tissue when coughing,
sneezing, or producing sputum
– Hand washing after handling sputum-soiled
tissues
• Ambulatory and home care
– Ensure that patient can adhere to treatment.
– Teach symptoms of recurrence.
Evaluation
• Expected outcomes
– Complete resolution of disease
– Normal pulmonary function
– Absence of any complications
– No transmission of TB