Respiratory System

Normal Breath Sounds

1. Tracheal BS heard at the level of the trachea, characterized as harsh, discontinuous sounds.
2. Bronchial BS heard at the level of the bronchi, characterized as high-pitched.
3. Broncho-vesicular BS heard at the level of the scapula, characterized as medium-pitched.
4. Vesicular BS heard at the level of the lower lobes, characterized as low-pitched.

Abnormal (Adventitious) Breath Sounds

1. Rales indicate elevated moisture in the lungs.
2. Crackles, a more severe (coarse) form of rales indicating accumulation of fluids in the lungs. Often observed in pulmonary edema secondary to heart failure and pneumonia.
3. Rhonchi are sounds continuously created by secretions in the airway.
4. Friction Rub heard from pleurisy and pericarditis, when the pleura rubs against other membranes producing a leather-like scratching.

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Pneumonia

Inflammation involving the lungs. Most commonly caused by Streptococcus pneumoniae in adults. In children aged 6 months to 6 years old, the most common cause is Haemophilus influenzae serotype B.

Risk Factors

1. Being a smoker
2. Air pollution
3. Immunocompromised patients e.g. AIDS patients, chemotherapy, dialysis patients

Symptoms

1. Pathognomonic: rusty sputum, a brownish color created by bacterial (S. pneumoniae) pneumonia. Sputum may still be green in some cases.
2. Dyspnea and Fever
3. Pleuritic Chest Pain, pain onset caused by coughing.

Diagnostic Examination

1. Confirmatory: CXR
2. Sputum Test (Culture and Sensitivity) used for antibiotics.
3. Leukocytosis (normal: 5-10k) indicates bacterial infection.

Medical Management

1. Amoxicillin
2. Azithromycin

Nursing Interventions

1. Dyspnea → Positioning, Oxygen, Suctioning, Deep Breathing and Coughing Exercises, Chest Physiotherapy

Types of Pneumonia

1. Community Acquired Pneumonia (CAP)
2. Hospital Acquired Pneumonia (HAP)
3. Ventilator Acquired Pneumonia (VAP)

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Pulmonary Tuberculosis (Koch’s Disease)

Discovered by Robert Koch, caused by Mycobacterium tuberculosis

Risk Factors

(mn. MOA)

1. Malnutrition
2. Overcrowding
3. Alcoholism
4. Immunocompromised or Ingestion of Infected Unpasteurized Bovine Milk

Symptoms

(mn. PLAN)

1. Productive Cough
2. Low Grade Afternoon Fever, the pathognomonic sign of TB.
3. Anorexia
4. Night Sweats

Diagnostic Examination

1. Screening: Mantoux Test, a PPD sample injected intradermally (skin test). A positive result indicates exposure.
   • Healthy individuals test positive if the skin test returns 10 mm or more.
   • Immunocompromised individuals test positive for 5 mm or more.
2. Confirmatory: Sputum Culture, or GeneXpert (uses sputum sample)
3. Determine Extent of Lesions: CXR (mild, moderately advanced, far advanced)

Medical Management

(mn. RIPES) used for 6 months.

1. Rifampicin: red-orange secretions
   • Contact lenses can be stained if worn by the patients. Recommend the use of eyeglasses.
2. Isoniazin: results in numbness/paresthesia. Requires Pyridoxine (Vitamin B6) to offset numbness.
3. Pyrazinamide: increases uric acid ergo avoided for patients with gouty arthritis
4. Ethambutol: causes optic neuritis; blurring vision. Color discrimination is affected.
5. Streptomycin: IM ANST; (mn. SON) sensorineural hearing loss. The drug is ototxic and nephrotoxic (check creatinine).

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Chronic Obstructive Pulmonary Diseases

Always teach the patient about pursed lip breathing, which prevents air trapping. Exhalation is extended longer than inhalation.

Risk Factors

1. Smoking, Air Pollution

Chronic Bronchitis

Chronic Bronchitis: blue boater; problems with the constriction of airway due to inflammation, which also increases mucus production due to mucus gland growth.

Symptoms

• Coughing for more than three months for two consecutive years.
• INC
• ABG: respiratory acidosis
• Nursing Management: Low inflow O2 (less than 6) to prevent the loss of the hypoxic drive.

Management

(mn. CAMB)

1. Corticosteroids
2. Antimicrobials
3. Mucolytics/Expectorants
4. Bronchodilators: Salbutamol, Ventril; avoid stimulants because of palpitation as a side effect.

• STOP SMOKING

Emphysema

Emphysema: pink puffer; problems with (mn. IBA) inelasticity of alveoli, barrel chest (increased anteroposterior chest diameter due to air trapping), and air trapping. Highly related to smoking.

Risk Factors

1. Smoking
2. Alpha-1 antitypsin deficiency
3. Air Pollution

Signs and Symptoms

1. Productive Cough
2. Dyspnea at rest
3. Rales, Crackles, Rhonchi
4. Barrel Chest d/t Air Trapping

Diagnostic Examination

1. ABG (resp. acidosis)
2. CXR

Management

(mn. FLA, CAMB)

1. Force Fluids
2. Low Inflow O2 (prevent loss of hypoxic drive)
3. Administer medications as ordered
4. Corticosteroids
5. Antibiotics
6. Mucolytics/Expectorants
7. Bronchodilators

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Bronchial Asthma

A reversible inflammatory lung condition due to hypersensitivity to allergens. Bronchoconstriction occurs (treated with bronchodilator)

Risk Factors

1. Family History

Symptoms

1. Cough
2. Dyspnea
3. Wheezing on Expiration (wheezing on inspiration is stridor, often found when choking)

Management

1. High Fowler’s Positioning or Tripod during dyspnea
2. Enforce CBR
3. Administer medications as ordered: bronchodilators (causes palpitation, avoid stimulants e.g. caffeine), steroids (increases (mn. BNG) BP, Na, Glucose, and decreases Potassium. Feed the patient with banana or avocado)
4. Metered Dose Inhaler (MDI), a maintenance drug used to prevent exacerbation.

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Pneumothorax

Pneumothorax is the accumulation of air in the pleural space. The normally negative pressure present in the space becomes positive and acts on the lungs, preventing it from expanding.

Causes

1. Spontaneous pneumothorax
2. COPD (Secondary pneumothorax)
3. Catamenial pneumothorax

Symptoms

1. Dyspnea
2. Dullness
3. Decreased chest expansion
4. Diminished breath sounds
5. Tracheal Deviation towards the unaffected side found in tension pneumothorax.
6. Tension Pneumothorax, where a hole is punctured by a mechanical ventilator into the pleural space.

Diagnostic Examination

1. CXR reveals hyperinflation of the lungs.
2. ABG

Management

1. Thoracentesis may be the primary form of management if mild.
2. If moderate to severe, a CTT (chest tube thoracostomy) may be required.
   • Nursing Management: if a CTT is attached to a water-sealed drainage, monitor fluctuations (should fluctuate, otherwise obstruction or re-expansion of the lungs may have occurred) and bubbling (should be intermittent, an air leak may be present).

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Chest Injuries

Rib Fractures

Resulting from direct blunt chest trauma, often from vehicular accident victims. The pathognomonic sign of rib fractures is pain on the site of injury exacerbated upon inspiration.

• Surgery is not required. Ribs unite spontaneously.
• Maintain high fowler’s and monitor for respiratory depression.

Flail Chest

Resulting from direct blunt chest trauma that damages two or more ribs. The pathognomonic sign is paradoxical breathing, where inhalation reduces chest size and vice versa.