Chapter 47: Respiratory System

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It's truly remarkable, isn't it?

This constant, almost invisible work our bodies do with every single breathtaking in oxygen, you know, the fuel for life and getting rid of dioxide.

Absolutely fundamental.

It powers everything.

Okay, so let's unpack this today because we are doing a deep dive into the respiratory system.

Exactly.

And our guide for this is going to be a really excellent resource.

The respiratory system chapter from Saunders Comprehensive Review for the NCLE -XPN examination, seventh edition.

It's great for getting a solid handle on everything.

Right, from the basics right up to the clinical side.

From anatomy to assessments, procedures, nursing care, the works.

Precisely.

So, if you're in healthcare needing a refresher or honestly just fascinated by how your body works, our mission here is to give you a clear, engaging picture of the respiratory system.

We'll pull out the key ideas, the assessment techniques, procedures, safety stuff,

all in a way that's easy to follow.

And it all really boils down to two main ideas, doesn't it?

Gas exchange, getting oxygen in and CO2 out and perfusion, getting the blood to the lungs for exchange to happen.

Those are the big ones.

We'll also circle back to that critical thinking scenario from the chapter, start the gunshot wound one, keep it in the back of your mind, we'll connect the dots later.

Sounds like a plan.

So where else to start but the beginning?

Anatomy and physiology, the main job, like we said, oxygen in for metabolism,

CO2 out.

But it does more, right?

Oh, definitely.

Those are the primary functions, life -sustaining, but secondary roles.

Sense of smell, that's respiratory.

Speech production, air, moving over vocal cords, even helps with acid -base balance, water balance and heat balance too.

Wow, quite the multitasker.

Okay, so we usually break it down into upper and lower respiratory tracks.

Let's start at the top.

What's up there?

Upper track involves the nose, the sinuses, the pharynx and the larynx, plus the epiglottis, which is super important.

The nose is step one for air coming in.

It humidifies, warms and filters the air.

Like a little air treatment plant right on your face.

And sinuses, we usually only think about them when they're blocked.

Yeah, they're those air -filled spaces in the skull.

Their main job in respiration, resonance for speech, gives your voice its quality.

Okay, then moving back, we hit the pharynx, the throat area.

Feels like a busy intersection.

It really is.

Shared path for air and food.

You've got the nasopharynx behind the nose, oropharynx behind the mouth, and then the laryngeopharynx, which leads down the larynx and the esophagus.

And just below that, the larynx or voice box.

That's right, houses the vocal cords false and true.

And the opening between the true cords is the glottis.

Crucially, the glottis is key for our cough reflex.

It's like the lungs first line of defense, forcefully kicking out irritants.

A powerful protective mechanism.

And the epiglottis, that little flap.

Think of it as a traffic cop for swallowing.

It folds down over the glottis, making sure food goes down the esophagus, not the trachea.

Prevents you from choking, essentially.

Absolutely crucial.

Okay, let's head down into the lower respiratory tract now, past the larynx and epiglottis.

What do we find?

We start with the trachea, the windpipe, runs down in front of the esophagus, then it splits at a point called the carina into the right and left main stem bronchi.

And there's an important difference between those two bronchi, isn't there?

Yes, definitely.

The right main bronchus is a bit wider, shorter, and it angles downwards more vertically than the left.

So if someone accidentally inhales something, like a small object, it's much more likely to end up in the right bronchus.

Good clinical point to remember.

Definitely.

And these main bronchi branch out further.

They do.

They divide into lobar, or secondary bronchi, one for each lung lobe.

Remember, three lobes on the right, two on the left.

So five lobar bronchi in total.

And all these tubes, down to this point, are lined with cilia.

Ah, the tiny hairs.

Like a little escalator system.

Exactly.

Those cilia beat upwards, moving mucus and trapped particles dust, germs up and out of the lower airways, towards the throat, where you can cough it out or swallow it, constantly cleaning.

Amazing.

What happens after the lobar bronchi?

They keep dividing into smaller tubes called bronchioles, then terminal bronchioles, and finally respiratory bronchioles.

Big difference here.

Bronchioles don't have cartilage in their walls, they stay open because of the elastic recoil of the lung tissue around them.

They depend on the lung itself.

Right.

And another key thing, the terminal bronchioles don't have cilia, and no gas exchange happens there.

They're purely air conductors, leading air to where the action is.

Okay, so just pathways.

Where does the actual gas exchange finally happen?

That happens in the alveolar ducts in the alveoli.

We talk about the olsenus, that's everything beyond the terminal bronchiole.

Respiratory bronchioles, alveolar ducts in the alveoli themselves, the ducts lead to alveolar sacs, which are like clusters of grapes, and each grape is an alveolus.

These tiny air sacs are the basic units for gas exchange.

Super thin walls surrounded by capillaries.

And we can't forget surfactant here.

Those type 2 alveolar cells are crucial.

Absolutely crucial.

These cells secrete surfactant, which is a mix of phospholipids and proteins.

Its job is to reduce surface tension inside the alveoli.

Without enough surfactant, the alveoli would tend to collapse when you exhale, making it incredibly hard work to breathe.

You see that issue in premature babies sometimes.

Exactly.

Respiratory distress syndrome in preemies is often due to insufficient surfactant.

Really highlights how important it is.

Okay, so the lungs themselves, they sit in the pleural cavity stretched from the collarbones down to the diaphragm.

Right lung, three lobes, left lung, two.

And they get nerve signals from a few places.

The phrenic nerve is key, it controls the diaphragm.

The vagus nerve and thoracic nerves are also involved.

The lungs are wrapped in the pleura, a double layer.

The outer layer, the parietal pleura, lines the chest cavity.

The inner layer, visceral pleura, covers the lungs directly.

And there's that space between them, the pleural space.

With fluid.

Right, the pleural space normally has just a thin film of pleural fluid.

It acts like a lubricant, letting the layers slide smoothly past each other as the expand and contract.

Pain -free movement.

And the lungs have a huge blood supply via the pulmonary circulation for that gas exchange.

And when we need to breathe harder, we use more than just the diaphragm, right?

Those accessory muscles.

Precisely.

If you're working hard or having trouble breathing, other muscles jump in.

Scalenes and sternocleidomastoids in the neck help lift the ribs and sternum.

Trapezius and pectoralis muscles in the chest and back help stabilize things.

They all pitch in.

Okay, let's put it all together.

The respiratory process itself.

Inspiration breathing in.

How does that start?

Inspiration starts with the diaphragm contracting and pulling downwards.

That increases the volume inside your chest cavity.

Basic physics.

Bigger volume means lower pressure inside the lungs compared to the air outside.

So air moves from high pressure outside to low pressure inside.

Exactly.

Air rushes in down through the airways to the alveoli, like a vacuum cleaner almost.

And once the air hits the alveoli, that's where the exchange happens.

That's the spot.

Oxygen crosses the thin alveolar walls into the capillaries, grabs onto hemoglobin and red blood cells, and gets shipped off to the modi tissues.

At the same time, carbon dioxide, the waste product, moves from the blood into the alveoli.

To be breathed out.

Which brings us to expiration.

Right.

For expiration, the diaphragm and intercostal muscles relax.

The lungs are naturally elastic, so they recoil, making the chest cavity smaller.

Smaller volume means higher pressure inside than outside.

So the air gets pushed out.

Yep.

Air rich in CO2 and water vapor flows back up the airways and out.

You mentioned earlier that effective gas exchange needs ventilation and profusion matching.

Can you break that down a bit?

Why is that match so important?

Sure.

Ventilation is getting air into the alveoli.

Profusion is getting blood to the capillaries around those alveoli.

For efficient gas exchange, you need both to be well matched in the same areas If you have good airflow but poor blood flow, or vice versa in one part of the lung, you get a VQ mismatch, and gas exchange suffers.

It's a really key concept for understanding lung diseases.

Makes total sense.

Yeah.

You need air and blood in the same place at the same time.

Okay, great foundation on AMP.

Now, how do we figure out if something's wrong?

Let's talk diagnostic tests.

The chapter kicks off with risk factors, right?

Box 47 to 1.

Yes, it lists quite a few.

Things like allergies, previous chest injuries, living in crowded conditions, exposure to pollutants or chemicals,

family history of respiratory infections, frequent respiratory illnesses themselves,

even things like scoliosis where you live, recent travel, and of course smoking is a huge one.

Knowing these helps identify people at higher risk.

Okay, then a super common starting point.

Yeah.

The chest x -ray or radiograph.

What can that show us?

A chest x -ray gives a good overall picture of the lungs and structures in the chest.

It can show things like pneumonia, consolidation,

fluid buildup, plural effusion, masses, collapsed lung areas.

Beforehand, you need to make sure the patient removes metal objects like jewelry from the chest and check if they can hold their breath for a moment for a clearer image.

Any specific post -procedure care?

Usually minimal, just help them get dressed.

But a critical point,

always ask female clients about potential pregnancy before any x -ray, radiation risk.

Got it.

Another common test is getting a sputum specimen.

Why analyze lung secretions?

Sputum analysis is vital for finding out what's causing an infection bacteria, fungi, or if there are abnormal cells like cancer cells, you can get the sample by having the patient cough it up or sometimes through suctioning.

The chapter has a good priority nursing actions box on suctioning technique.

Right, I see that.

What are some key takeaways from the suctioning guidelines?

Well, things like explaining the procedure, proper positioning,

strict sterile technique if you're going deep into the trachea, using appropriate PPE,

hyper -oxygenating the patient before and after suctioning is crucial to prevent oxygen levels from dropping too low, and always listen to lung sounds before and after to see if it helped.

Document everything.

And for just coughing up a sample.

Any tips for getting a good one?

Yeah, definitely.

Best time is usually first thing in the morning.

Have the patient rinse their mouth with water first, just water to avoid contaminating it with mouth bacteria.

Aim for about 15 mL.

Needs to be a deep cough from the chest, not just spit.

And importantly, if it's for culture, get the sample before starting antibiotics.

Good point, and after collection.

Get it to the lab quickly if it's for culture, offer mouth care afterwards, and always remember informed consent for invasive things and monitoring vital signs.

Okay, moving to more invasive views.

Laryngoscopy and bronchoscopy.

Looking inside the airways directly.

Exactly.

Laryngoscopy looks at the larynx voice box.

Brongoscopy uses a flexible scope to look deeper into the larynx, trachea, and larger bronchi.

Beforehand, the patient needs to be MPO nothing by mouth for a set time, check their coagulation studies for bleeding risk, remove dentures, eyeglasses, have suction ready, 4D access is needed for sedation, and emergency equipment must be right there.

And post -procedure care.

What are the priorities?

Semi -fowler's position, usually.

Big thing is monitoring for the return of the gag reflex.

Keep them MPO until it's back to prevent aspiration.

Watch their sputum for blood.

Keep a close eye on respiratory status, especially with sedation.

And be alert for complications like bronchospasm or even perforation.

Look for crepitus under the skin, dysrhythmias, bleeding, low oxygen, signs of pneumothorax.

Report any of those immediately.

The chapter also mentions EBS endobronchial ultrasound.

How's that different?

EBS is bronchoscopy plus ultrasound.

The scope has an ultrasound probe on the end, so you can see through the airway wall to look at nearby lymph nodes and lung tissue.

It's really good for guiding biopsies of things that are harder to reach, especially for diagnosing and staging lung cancer or finding infections or inflammatory diseases like sarcoenosis.

Post -procedure monitoring is similar.

Watch for bleeding, respiratory distress.

Pulmonary angiography sounds like it focuses on the lungs' blood vessels.

That's exactly it.

It's an x -ray procedure using contrast dye.

A catheter is threaded through a vein, usually in the arm or groin, up into the pulmonary artery.

Then contrast dye is injected, and they take x -ray images, fluoroscopy, to see the blood flow.

Great for diagnosing pulmonary embolism, blood clots, or other vascular issues in the lungs.

What are the pre -procedure checks for that?

Big one is allergies, iodine, seafood, contrast dyes, NPO status again, check coagulation, Fourier access needed.

Often sedation is given, so they need to lie still.

Warn them they might feel a flush, an urge to cough, maybe nausea or salty taste when the dye goes in.

And again, emergency gear ready.

And specific post -procedure care.

Yes.

Avoid BP checks on the arm used for injection for 24 hours.

Monitor the circulation in that limb, closely pulses, color, temp, sensation.

Check the insertion site for bleeding or hematoma.

And watch for any delayed reaction to the dye.

Okay.

Thoracentesis that's removing fluid or air from the pleural space.

Correct.

A needle is inserted through the chest wall into that space between the lung and chest wall linings.

Pre -procedure, maybe an ultrasound or x -ray to guide placement.

Check coagulation studies.

Positioning is key.

Usually sitting up, leaning forward over a table, or lying on the unaffected side with the head of the bed up.

Crucial instruction.

Tell the patient not to cough, breathe deeply, or move suddenly during the procedure to avoid lung injury.

And afterwards, what do we monitor?

Respiratory status is number one rate, depth, oxygen sats, distress signs.

Check the puncture site dressing for bleeding or crepitus, that crackling sound indicating air leakage.

Watch closely for complications like pneumothorax, air embolism, pulmonary edema.

Report issues immediately.

Pulmonary function tests, PFTs.

Sounds like a broad assessment of lung function.

It is.

PFTs are non -invasive tests measuring lung mechanics, gas exchangeability, and checking for acid base issues.

Includes things like spirometry, how much and how fast you can breathe out lung volumes, and often arterial blood gases, ABGs.

Anything special before PFTs.

Check medications.

Some analgesics might affect breathing.

May need to hold bronchodilators beforehand.

Check with the provider.

Have them empty their bladder, wear loose clothes, remove dentures.

No smoking or heavy meals for four, six hours prior.

Afterwards, they can usually resume diet and any held meds.

Lung biopsy is getting actual tissue samples.

Can be done during bronchoscopy or as open surgery?

Yes.

Transbronchial biopsy happens via bronchoscopy using forceps or a needle.

Less invasive.

Open lung biopsy is a surgical procedure in the OR needing a chest incision.

Pre -procedure, NPO.

For transbronchial, explain about local anesthetic for the throat, maybe feeling pressure.

Analgesics sedatives often given for both.

Post -procedure.

Check the dressing site for bleeding drainage.

Monitor very closely for respiratory distress, pneumothorax, air emboli.

Report immediately.

Often a post -biopsy chest x -ray is done to check for pneumothorax.

Spiral CT scans seem really important now, especially for suspected PEs.

Absolutely.

Spiral or helical CT gives detailed cross -sectional images of the pulmonary arteries.

Usually involves 5e contrast eye.

It's often the go -to test for diagnosing pulmonary embolism.

If contrast is contraindicated, then a VQ scan might be used instead.

The scanner spins around you, gathering lots of data quickly to create 3D images.

And the VQ scan you just mentioned, ventilation perfusion scan.

What does that show?

VQ scan looks at two things.

Perfusion, blood flow, and ventilation airflow in the lungs.

For perfusion, a radioactive tracer is injected 5e and they scan how it flows through lung vessels.

For ventilation, you might inhale a radioactive gas and they scan its distribution.

Comparing the two scans helps find mismatches, areas getting air but no blood, or blood but no air which is classic for a PE.

Pre -imposed procedure for VQ.

Pre -check allergies again, dye, iodine, seafood.

Remove chest jewelry.

Review breathing instructions for the ventilation part.

4V access.

Sedation if ordered.

Emergency gear ready.

Post.

Monitor for any rare reaction to the tracer.

Reassure them the radioactivity clears pretty quickly, usually within about 8 hours.

Skin tests are also mentioned for some infectious respiratory diseases.

Right, like the tuberculin skin test or TST for TB.

A small amount of antigen is injected just under the skin.

If you've been exposed to that organism, you might get an immune reaction, a raised hard area called induration.

Box 47 -2 covers the general technique.

Key things are checking for past reactions, using a good site, inner forearm usually, marking it, documenting carefully.

Don't scratch or wash it.

The reaction is read after a specific time, usually 48 -72 hours, measuring the induration size in millimeters.

Interpretation depends on the size and the person's risk factors.

And we can't forget ABGs and pulse oximetry for direct oxygenation info.

Definitely not.

ABGs, arterial blood gases, covered more in chapter 9, measure oxygen, CO2, and pH, an arterial blood vital for assessing gas exchange and acid -base status.

Remember not deception right before drawing an ABG.

It can skew the results.

Pulse oximetry, chapter 10, is the non -invasive clip on the finger or earlobe, giving a continuous estimate of oxygen saturation, PO2.

Lastly for diagnostics, the D -dimer test.

How does that fit in?

D -dimer is a blood test measuring a fragment produced when blood clots break down.

It's not specific to the lungs, but a high level suggests clotting might be happening somewhere.

So it's often used as a screening tool to help rule out conditions like DVT or PE.

If it's normal, a PE is less likely.

If it's elevated, it doesn't confirm a PE, but it means further investigation like CT scan is usually needed.

Normal is typically 250 NGML DDU or a 0 .5 mgmL FEU.

Wow, that's a lot of diagnostic tools.

Okay, so we find a problem.

What are the treatments?

Let's start with breathing retraining.

Right.

Box 47 .3 talks about techniques like pursed lip breathing and diaphragmatic breathing.

The goal is to make breathing more efficient, use less effort, reduce fatigue, and get rid of CO2 better.

Pursed lip breathing, inhale through the nose, exhale slowly through pursed lips, like whistling helps keep airways open longer.

Creates some back pressure.

Exactly.

Diaphragmatic or belly breathing focuses on using the diaphragm muscle instead of the chest muscles.

Put one hand on your chest, one on your belly hand should rise when you inhale.

There's also huff coughing, which helps clear mucus without as much effort.

Chest physiotherapy or CPT, that's for helping clear secretions too, right?

Yes.

CPT uses percussion, clapping on the chest, vibration, shaking motion during exhale, and postural drainage, using gravity by positioning the patient.

Box 47 .4 details it.

Usually done before meals or a few hours after.

Stop if painful.

Maybe give a bronchodilator beforehand.

Protect the skin with a towel.

Position for specific lung segments, percuss, vibrate, let them rest in position to drain.

Repeat.

Monitor tolerance.

Dispose of sputum.

Provide oral care.

Important are the contraindications too, like unstable vitals, increased ICP, active bronchospasm, certain fractures, recent incisions.

Instead of spirometry, that little device we often see post -op patients using.

Yep.

Box 47 .5.

It encourages slow, deep breaths to inflate the lungs fully and prevent atelectasis or lung collapse.

You can instruct the patient to sit up, seal their lips around the mouthpiece, inhale slowly and deeply to raise the indicator or piston.

Hold for about five seconds, then exhale slowly.

Repeat maybe 10 times an hour while awake.

Oxygen therapy is fundamental.

Table 47 .1 shows different delivery systems.

Can we quickly walk through the main ones?

Sure.

Nasal cannula, low flow, common for chronic conditions, long -term use.

Nasal high flow, Box 47 .6.

Higher flows, heated, humidified for moderate hypoxemia.

Simple face mask, short -term emergencies.

Venturi mask delivers precise oxygen percentage.

Crucial in acute respiratory failure risk.

Partial rebreather.

Higher O2 concentration, but maybe not for COPD.

Non -rebreather mask.

Highest O2 concentration without intubation for deteriorating patients.

Trecheostomy collar T -bar for patients with tracts or tubes needing humidified O2.

Face tent, loose fit.

Good for facial trauma burns.

And then there's CTAP and BiPAP.

How do they help?

Both provide positive airway pressure non -invasively.

CPAP gives one constant pressure level during both inhale and exhale.

Great for sleep apnea, sometimes COPD exacerbations.

BiPAP gives two levels.

Higher pressure on inhalation, lower on exhalation.

Often used if CPAP isn't enough or more breathing support is needed.

Both basically work by splinting the airways open and improving oxygenation.

Important general nursing points when giving oxygen.

Always assess the patient first color.

O2SATs, vitals, breathing effort.

Post the oxygen and use sign.

Check history for chronic lung disease.

Their breathing drive might be different.

Humidify if needed, especially at higher flows.

Follow system specific guidelines.

And be cautious with high flow rates for patients with chronic CO2 retention hypercapnia.

Usually keep it low, like 1 ,2 -elmin via cannula per order because low O2 might be their main stimulus to breathe.

Sometimes though, all that is enough and mechanical ventilation is needed.

Right.

Mechanical ventilation takes over or assists breathing when the patient can't adequately ventilate or oxygenate themselves.

Various types, various modes.

First rule of nursing care.

Always assess the client first, then the ventilator.

And always have a resuscitation bag and boot bag with oxygen ready at the bedside.

Always.

What are the essential nursing interventions for a ventilated patient?

Monitor vitals, lung sounds, respiratory status constantly.

Their spontaneous rate shouldn't be less than the vent setting.

Check skin color, chest expansion symmetry, frequent pulse ox and ABGs.

Assess need for suctioning note secretion characteristics.

Double check ventilator settings against orders.

Monitor the humidifier.

Ensure alarms are on and set correctly.

What if an alarm goes off and you don't immediately know why?

First thing, disconnect the patient from the vent and manually ventilate them with the resuscitation bag while someone else figures out the ventilator issue.

Also, empty water condensation from tubing regularly.

Turn the patient Q2 etch, get them up if possible.

Keep emergency equipment nearby.

Chapter 18 has more on tube care.

Table 47 -2 lists ventilator controls.

What are some key ones?

Tidal volume, VT.

Air volume per breath.

Rate F, breaths per minute.

FiO2, oxygen percentage.

Peak airway pressure, PAP.

Highest pressure during inhale, PEEP.

Positive end expiratory pressure keeps alveoli open at end of exhale.

CPAP.

Continuous positive pressure.

Pressure support.

Help spontaneous breaths.

Ventilator alarms are critical.

Box 47 -7 lists causes.

High pressure versus low pressure.

High pressure usually means increased resistance.

Could be secretions, wheezing bronchospasm, kinked or blocked tube, water in tubing, patient biting tube, coughing, gagging, or fighting the ventilator.

Low pressure usually means a leak or disconnection, tubing disconnected,

cuff leak around the tube, or maybe the patient stopped breathing if they were to stop breathing.

Alarm fatigue and fatigue are big issues.

Huge.

Nurses must respond promptly.

Assess the patient first.

Alarm fatigue getting desensitized is dangerous.

The Joint Commission highlights this.

Facilities need policies, proper settings, staff education.

Key takeaway.

Never ever turn off alarms except maybe very briefly during specific troubleshooting by trained personnel.

What are potential complications of mechanical ventilation?

Several.

Hypotension from increased chest pressure affecting heart return, lung injury like pneumothorax or subcutaneous emphysema, GI stress ulcers, malnutrition, infection, especially ventilator associated pneumonia, BAP, muscle deconditioning, ventilator dependence, or difficulty weaning.

And weaning is the goal getting them off the ventilator.

Exactly.

It's a gradual process of reducing support as their own breathing strength returns, aiming for spontaneous breathing.

Okay, let's shift to chest injuries.

Rib fracture is pretty common from blunt trauma.

Yes.

Risk is injury to underlying structures, pneumothorax, lung contusion.

Main symptom is pain, especially with breathing or movement, tenderness over the site.

They often take shallow breaths, splint the area, x -ray confirms.

Treatment is usually supportive.

Pain meds are key so they can breathe deeply and cough.

High fowler's position.

Teach self -splinting for coughs.

Severe pain might need an intercostal nerve block.

Flailed chest is more serious.

What's happening there?

Very serious.

Multiple ribs broken in multiple places, so a segment of the chest wall detaches and moves paradoxically.

Sex sin on inspiration, bulges out on expiration, messes up breathing mechanics badly.

Often other injuries too.

See severe pain, dyspnea, cyanosis, rapid heart rate, low BP, shallow breathing, diminished sounds, interventions.

Fowler's, humidified O2, monitor closely, pain control, bed rest.

High risk of respiratory failure so often need intubation and ventilation.

Pulmonary contusion, basically a bruised lung.

Yes.

Bleeding and swelling into the lung tissue and alveoli makes the lungs stiff, impairs gas exchange.

Major complication risk is ARDS.

Look for dyspnea, low O2, increased secretions, maybe coughing blood, restlessness, abnormal breath sounds like crackle sweezes, management,

maintain airway, ventilation, maybe mechanical.

Fowler's O2, monitor distress, limit activity.

Pneumothorax, air in the pleural space.

Different types, spontaneous, open, tension.

Right.

Air gets between the lung and chest wall, increases pressure, lung can collapse, spontaneous, often from a ruptured blood, no obvious injury.

Open, penetrating chest wound allows air in, sucking chest wound, tension.

Air gets in but can't get out, pressure builds rapidly, pushes heart and vessels over, mediastinal shift, cuts off blood return.

Life -threatening emergency, usually diagnosed by chest x -ray.

Signs and symptoms listed in box 47 to 8.

What are some key ones?

Absent breath sounds on affected side, cyanosis, unequal chest movement, dyspnea, low BP, sharp chest pain, maybe subcutaneous emphysema, crackles under skin, sucking sound with open wound, rapid heart rate breathing.

Tension pneumo adds tracheal deviation away from affected side.

Immediate interventions for pneumothorax.

For an open wound, cover immediately with a non -porous dressing taped on three sides.

Let's air out but not in, give oxygen, Fowler's position.

Prepare for chest tube insertion, that's the definitive treatment usually.

Monitor the chest tube system, watch for subcutaneous emphysema.

Remember, head elevated helps most respiratory patients.

Okay, moving to acute respiratory failure, ARF.

What defines this?

ARF means the lungs can't maintain adequate gas exchange, either can't get enough oxygen into the blood, hypoxemic failure, PO2 -60, or can't remove enough CO2, hypercapnic failure, PACR250 with acidosis, or often both.

Compensatory mechanisms have failed, caused by lung issues, chest wall problems, brain control issues, or muscle weakness.

What are the signs suggesting ARF?

Dysmia, headache, restlessness, confusion, decreased consciousness, tachycardia, hypertension initially, dysrhythmias, changes in breathing pattern, abnormal lung sounds.

Nursing priorities for ARF.

Identify and treat the underlying cause.

Give oxygen to keep PO2 -60 -70, Fowler's position.

Encourage deep breathing if possible.

Maybe bronchodilators.

Prepare for mechanical ventilation if oxygen alone isn't working.

Acute respiratory distress syndrome, ARDS, a severe complication of ARF.

Yes, ARDS is a severe form of respiratory failure from diffuse lung injury.

The key is widespread damage to the alveolar capillary membrane, making it leaky.

Fluid floods the interstitial space and alveoli.

Lungs get heavy, stiff, decreased compliance.

Hallmark.

Severe hypoxemia that doesn't respond well to high levels of oxygen.

Refractory hypoxemia.

Chest x -ray shows bilateral infiltrates, whiteout, many causes, sepsis, trauma, shock, aspiration, burns, etc.

T -indicators of ARDS.

Cypnea, severe dysmia, decreased breath sounds, worsening ABGs, refractory hypoxemia, decreased lung compliance, those bilateral infiltrates on x -ray.

Management involved.

Treat the underlying cause.

Oxygen, Fowler's, often fluid restriction.

Respiratory treatments.

Maybe diuretics, anticoagulants, corticoceroids.

Frequently requires intubation and mechanical ventilation, often with higher PEEP levels.

The chapter then points to asthma, chapter 32, and gets into chronic obstructive pulmonary disease, COPD.

Very common.

Very.

COPD is chronic progressive airflow limitation, usually from emphysema and or chronic bronchitis, caused by an abnormal inflammatory response, typically to cigarette smoke.

Leads to lung damage, pulmonary insufficiency, potentially pulmonary hypertension, and core pulmonal right heart failure from lung disease.

What are the classic COPD signs and symptoms?

Chronic cough, often with sputum.

Exertional dysmia, wheezing, crackles, weight loss, especially emphysema.

Barrel chest, emphysema, using accessory muscles, prolonged expiration, maybe orthopnea, dysrhythmias.

X -ray might show hyperinflation.

ABGs show chronic respiratory acidosis, hypoxemia.

PFTs show decreased vital capacity, obstruction.

Nursing interventions are pretty comprehensive for COPD.

Yes.

Monitor vitals, O2 sats.

Low flow O2, 1 to 2 lm in, if ordered.

Monitor response carefully.

Pulse ox, ABGs.

Respiratory treatments, bronchodilators, maybe CPT.

Teach diaphragmatic pursed lip breathing, record sputum characteristics, suction if needed, monitor weight, small frequent high calorie protein meals, maybe supplements, fluids up to 3L day unless contraindicated, to thin secretions.

Fowler's lean forward position helps breathing.

Balance activity rest, medications.

Bronchodilators, maybe corticosteroids for exacerbations, mucolytics, antibiotics for infections.

Client education, box 47 to 9, is huge for self -management.

Severe acute respiratory syndrome is mentioned briefly.

Yes, caused by a coronavirus.

Presents with fever, aches, mild respiratory symptoms, then dry cough dyspnea after 2 to 7 days.

Spread by close contact secretions.

Prevention focuses on avoiding contact, travel advisories during outbreaks, hand washing.

Pneumonia, common lung infection.

What's happening pathologically?

Infection of lung tissue, interstitium, alveoli, bronchioles.

Causes inflammation, edema, exudate fills alveoli.

Lungs get stiff, compliance decreases, gas exchange is impaired leading to hypoxemia.

Can be community acquired or hospital acquired.

X -ray shows consolidation infiltrates.

Sputum culture IDs the bug.

WBC count and ESR usually elevated.

Typical signs of pneumonia.

Chills, fever, pleuritic chest pain, sharp, worse with breathing.

Tachypnea, runchy wheezes, using accessory muscles, maybe confusion, especially older adults.

Productive cough with sputum.

Nursing care focuses on respiratory support and fighting the infection.

Exactly.

Oxygen.

Monitor respiratory status closely.

Distress, cyanosis.

Encourage cough deep breath, incentive spinometry, semifowlers.

Change position, ambulatus tolerated, CPT suction if needed.

Monitor OT sats, record sputum.

Nutrition, hydration are important.

High calorie protein, fluids.

Balance rest activity.

Antibiotics are key for bacterial pneumonia.

Also antipyretics, bronchodilators, maybe cough meds.

Crucial infection control, hand washing, disposal of secretions.

Patient education on rest, meds, follow -up prevention, vaccines like pneumococcal.

Influenza, the flu, very contagious viral illness.

Yes, types A, B, C.

Annual vaccine is key, especially for high risk groups.

Over 50 chronic illness, immunocompromised healthcare workers.

Contraindicated of severe egg allergy.

Prevention.

Avoid sick people, wash hands, disinfect surfaces.

Chapter mentions Avian H5N1 and Swine H1N1, flu briefly too.

Flu symptoms.

Usually acute onset.

Fever, muscle aches, headache, fatigue, weakness, anorexia, sore throat, cough, runny nose.

Interventions are mostly supportive.

Correct.

Rest.

Fluids.

Monitor lung sounds.

Antipyretics for fever, maybe antitussives for cough.

Antivirals might be used if started early.

Legionnaires' disease bacterial from contaminated water sources.

Right.

Legionella and pneumophila.

Found in things like cooling towers, hot tubs, showers warm, stagnant water systems.

Not spread person to person.

Risk higher with other health issues.

Symptoms start flu -like.

High fevel, chills, aches.

Then dry cough, sometimes diarrhea.

Treated with antibiotics.

Supportive care.

Plural effusion fluid in the plural space again.

Causes.

Can be caused by many things.

Heart failure, pneumonia, TB, cancer, PE, inflammation.

Anything disrupting normal fluid balance there.

Signs suggesting plural effusion.

Pluridic pain.

Sharp, worse with inhale.

Progressive dyspnea.

Decreased chest movement on affected side.

Dry cough.

Tachycardia.

Maybe fever.

Decreased absent breath sounds over the fluid.

X -ray confirms.

Shows fluid level may be mediastinal shift if large.

250 millitell.

Management.

Treat the underlying cause.

Monitor breath sounds.

Fowlers.

Encourage cough deep breath, if not too painful.

Thoracentesis to drain fluid for relief and diagnosis.

For recurrent ones, maybe pleurectomy.

Stripping pleura.

Or pleuridesis.

Instilling irritant to scar space shut.

MPM plus in the plural space.

Thick, opaque, often foul smelling pus.

Usually from lung infection abscess spreading or after surgery trauma introducing bacteria.

Treatment.

Control infection.

Drain the pus.

Re -expand the lung.

Signs of MPMA.

Recent infection trauma history.

Just pain, cough, dyspnea, anorexia weight loss, malaise, fever, chills, night sweats.

Extrathoracentesis shows pus exudate.

Interventions for MPMA.

Monitor breath sounds.

Semi -high fowlers.

Encourage cough deep breath.

Antibiotics.

Teach chest splinting.

Assist with thoracentesis chest tube for drainage.

If pleura gets really thick, might need decortication surgery to remove the inflammatory peel.

Pleurisy.

Inflammation of the pleural layers themselves.

Exactly.

Often from pneumonia or pulmonary infarction.

Inflamed layers rub together causing pain.

Usually one -sided lower chest.

Key findings for pleurisy.

Sharp knife -like pain.

Worse with deep breath cough.

Maybe dyspnea because breathing hurts.

Classic sign.

Plural friction rub herd with stethoscope.

A grating sound.

Treat the cause.

Monitor lung sounds.

Pain meds.

Hot cold applications.

Encourage gentle cough deep breath.

Lying on the affected side can sometimes help splint it and reduce pain.

Pulmonary embolism.

PE.

A clot traveling to the lungs.

Very serious.

Extremely serious.

Usually starts as DVT in the legs.

Breaks off.

Travels to pulmonary artery.

Blocks blood flow.

Risk factors.

Immobility, surgery, obesity, pregnancy, heart failure, age, history of clots.

Fat emboli can happen after long bone fractures.

Prevention is key.

D -dimer can help rule it out, but CT pulmonary angiography is usually diagnostic.

Box 4710 lists sign symptoms.

And the priority nursing actions for suspected PE are critical?

Absolutely time critical.

Notify rapid response provider immediately.

Reassure patient.

Elevate head of bed.

Prepare for oxygen.

Monitor vital slung sounds.

Prepare for AVGs, anticoagulants, heparin.

Document everything.

Watch for sudden dyspnea, apprehension, impending doom feeling, cough, hemoptysis, tachypnea, crackles, maybe petechio, falling O2 sats.

Act fast.

Okay, the chapter then points to other sections for lung glandular cancer CH41 and carbon monoxide poisoning C29.

Let's look at hisoplasmosis.

Fungal lung infection from histoplasma capsuletum spores inhaled from contaminated soil, often with bird bat droppings.

Symptoms can mimic pneumonia.

Positive skin test agglutination test.

Maybe enlarged spleen liver.

Interventions.

O2.

Monitor breath sounds, supportive meds, antimedics, antihistamines, etc.

Antifungals are primary treatment.

Encourage cough deep breath.

Monitor vitals.

Watch for kidney toxicity from antifungals.

Teach prevention like wetting down soil before sweeping.

Thoracoidosis involves granulomas, unknown cause.

Inflammatory granulomas often in lung slump nodes.

Cause unknown may be linked to Epstein bar.

Higher incidence in African Americans, young adults.

Symptoms.

Night sweats, fever, weight loss, cough, skin nodules, arthritis, feeding test positive, treatment, corticosteroids for symptoms.

Monitor temp, push fluids, rest, small nutritious meals.

Occupational lung diseases from workplace exposures.

Yes.

Fumes, dusts, vapors, allergens can be acute like asthma or chronic like pneumoconiosis, silicosis, black lung or fibrosis, asbestosis, telcosis or allergic alveolitis farmer's lung.

Symptoms vary.

Interventions.

Prevention with protective gear is key.

Treatment is symptom based.

And finally, tuberculosis.

PB.

Highly communicable.

Caused by mycobacterium tuberculosis.

Airborne transmission.

Primarily affects lungs, upper lobes, but can spread.

Forms tubercles, granulomas.

Insidious onset.

Risk of multidrug resistant TB, MDR -TB, if not treated properly.

Goals.

Prevent spread, control symptoms, prevent progression.

Box 4711 lists risk factors.

How is it spread and how does it progress?

Spread via airborne droplets when someone with active pulmonary TB coughs, sneezes, talks.

Close contact tracing is vital.

Risk decreases after two, three weeks of effective meds.

Initial infection can be contained by immune system, latent TB, or progress to active disease, necrosis, cavitation, potential spread if immune system fails or later weakens.

Key history and assessment findings for TB.

History.

Exposure.

Origin trial.

Recent food -like illness.

Previous positive test.

BCG vaccine.

BCG can cause positive TST.

Needs x -ray.

Manifestations.

Often late.

Fatigue.

Lethargy.

Anorexia.

Weight loss.

Low fever.

Chills.

Night sweats.

Persistent cough.

Maybe bloody sputum.

Chest tightness pain.

Physical exam.

Often not revealing early.

Chest x -ray is suggestive.

Infiltrate.

Descalcification.

Upper lobes.

Active disease shows caseation inflammation.

Advanced.

Dullness.

Abnormal breath sounds.

Quantiferon TB gold blood test is rapid sensitive.

Sputum culture for AFB confirms active diagnosis.

TST.

Skin test.

Indicates exposure, latent infection, not necessarily active disease.

Positive TST always needs chest x -ray follow -up.

Interpretation based on in -duration size and risk factors.

Table 47 -3.

What about infection control for hospitalized TB patients?

Yeah.

Strict airborne isolation.

Negative pressure room.

Door closed.

Special ventilation.

Staff wear fitted.

N95 respirator masks.

Maybe gowns.

Meticulous hand hygiene.

Patient wears surgical mask if leaving room.

Isolation usually continues until no longer infectious.

Approx.

2 -3 weeks meds.

Clinical improvement.

Negative smears.

Client education.

Box 47 -12 on meds.

Preventing spread.

Side effects is crucial.

The chapter wraps up by revisiting that critical thinking scenario, the tension pneumothorax.

Key takeaways.

Right.

Likely the gunshot wound led to air entering the chest but not escaping.

Maybe due to an occlusive dressing.

Signs.

Cyanosis.

Air hunger.

Agitation.

Tracheal shift away from affected side.

Subcutaneous emphysema.

Neck vein distension.

Hyperresonance.

Immediate action.

Release the dressing.

Call for help.

RN provider.

It's an emergency.

Needle decompression might be needed.

Then a chest tube.

And the practice questions reinforce these concepts.

Like Q491.

Best position for emphysema dyspnea.

Sitting up.

Leaning forward on a table.

Yes.

That tripod position helps use accessory muscles more effectively.

Q492.

Confirming TV diagnosis.

Sputum culture for m -tuberculosis.

Correct.

That's the definitive test.

Q493.

Finding to report immediately after bronchoscopy biopsy.

Bronchospasm.

Absolutely.

That's an acute airway emergency.

Q495.

Purpose of pursed lip breathing.

Promote CO2 elimination.

By keeping airways open longer during exhalation.

And Q505.

Oxygen flow rate concern for emphysema.

Exceeding 2 lmin.

Right.

Due to the risk of suppressing the hypoxic drive to breathe in chronic CO2 retainers.

Needs careful monitoring if higher rates are used.

Well that really brings us to the end of an incredibly thorough deep dive into the respiratory system.

All guided by that comprehensive chapter in Saunders.

We've covered so much ground.

We really have.

From basic ANP through diagnostics, treatments like oxygen in vents, injuries, acute and chronic conditions like ARF, ARDS, COPD,

infections like pneumonia, flu, TB, plural issues, PE.

The list goes on.

And really highlighting the nurse's role throughout assessment, intervention, safety, education.

Definitely.

It underscores how vital nursing care is for patients with any respiratory issue.

It just shows what an intricate, delicate system it is.

And how many ways it can be challenged.

We really hope this deep dive has given you, our listener, a much stronger foundation and clearer understanding of respiratory care.

We hope it equips you with confidence.

Whether you're studying, practicing, or just curious.

Maybe it leaves you thinking about that constant, quiet work of breathing.

And just how remarkable it is when everything works in balance.

Indeed.

Thank you so much for joining us on this journey through the respiratory system.

We hope the information was valuable and truly insightful for your learning.