Respiratory System: Anatomy and Physiology, Assesment, Disorders
Anatomy and Physiology
The number of clients with chronic respiratory problems is increasing. Respiratory disorders are common and rank as the fifth leading cause of death in the
ANATOMY AND PHYSIOLOGY REVIEW
The two purposes of the respiratory system are to provide a source of oxygen for tissue metabolism and to remove carbon dioxide, the major waste product of metabolism. The respiratory system also influences the following functions:
• Acid-base balance
• Speech
• Sense of smell
• Fluid balance
• Thermoregulation
Upper Respiratory Tract
The upper airways consist of the nose, the sinuses, the pharynx (throat), and the larynx (“voice box”).
NOSE AND SINUSES
The nose is the organ of smell, with receptors from cranial nerve I (olfactory) located in the upper areas. This organ is a rigid structure that contains two passages separated in the middle by the septum. The upper one third of the nose is composed of bone; the lower two thirds is composed of cartilage, which allows limited movement. The septum and interior walls of the nasal cavity are lined with mucous membranes that have a rich blood supply. The anterior nares (nostrils or external openings into the nasal cavities) are lined with skin and hair follicles, which help keep foreign particles or organisms from entering the lungs. The posterior nares are openings from the nasal cavity into the nasopharynx.
Three bony projections (turbinates) protrude into the nasal cavities from the walls of the internal portion of the nose. Turbinates increase the total surface area for filtering, heating, and humidifying inspired air before it passes into the nasopharynx. Inspired air entering the nose is first filtered by vibrissae in the nares. Particles not filtered out in the nares are trapped in the mucous layer of the turbinates. These particles are moved by cilia (hairlike projections) to the oropharynx, where they are either swallowed or expectorated. Inspired air is humidified by contact with the mucous membrane and is warmed by exposure to heat from the vascular network.
The paranasal sinuses are air-filled cavities within the bones that surround the nasal passages. Lined with ciliated epithelium, the purposes of the sinuses are to provide resonance during speech and to decrease the weight of the skull.
PHARYNX
The pharynx, or throat, serves as a passageway for both the respiratory and digestive tracts and is located behind the oral and nasal cavities. It is divided into the nasopharynx, the oropharynx, and the laryngopharynx.
The nasopharynx is located behind the nose, above the soft palate. It contains the adenoids and the distal opening of the eustachian tube. The adenoids (pharyngeal tonsils) are an important defense, trapping organisms that enter the nose or mouth. The eustachian tube connects the nasopharynx with the middle ear and opens during swallowing to equalize pressure within the middle ear.
The oropharynx is located behind the mouth, below the nasopharynx. It extends from the soft palate to the base of the tongue and is a shared passageway for breathing and swallowing. The palatine tonsils (also known as faucial tonsils) are located on the lateral borders of the oropharynx. These tonsils also guard the body against invading organisms.
The laryngopharynx is located behind the larynx and extends from the base of the tongue to the esophagus. The laryngopharynx is the critical dividing point where solid foods and fluids are separated from air. At this point, the passageway divides into the larynx and the esophagus.
LARYNX
The larynx is located above the trachea, just below the pharynx at the base of the tongue. It is innervated by the recurrent laryngeal nerves. The larynx is composed of several cartilages. The thyroid cartilage is the largest and is commonly referred to as the Adam’s apple. The cricoid cartilage, which contains the vocal cords, lies below the thyroid cartilage. The cricothyroid membrane is located below the level of the vocal cords and joins the thyroid and cricoid cartilages. This site is used in an emergency for access to the lower airways. In this procedure, called a cricothyroidotomy (or cricothyrotomy), an opening is made between the thyroid and cricoid cartilage and results in a tracheostomy. The two arytenoid cartilages, which attach at the posterior ends of the vocal cords, are used together with the thyroid cartilage in vocal cord movement.
Inside the larynx are two pairs of vocal cords: the false vocal cords and the true vocal cords. The opening between the true vocal cords is the glottis. The epiglottis is a leaf-shaped, elastic structure that is attached along one edge to the top of the larynx. Its hinge-like action prevents food from entering the tracheobronchial tree (aspiration) by closing over the glottis during swallowing. The epiglottis opens during breathing and coughing.
Lower Respiratory Tract
The lower airways consist of the trachea; two mainstem bronchi; lobar, segmental, and subsegmental bronchi; bronchioles; alveolar ducts; and alveoli. The tracheobronchial tree is an inverted treelike structure consisting of muscular, cartilaginous, and elastic tissues. This system of continually branching tubes, which decrease in size from the trachea to the respiratory bronchioles, allows gases to move to and from the pulmonary parenchyma. Gas exchange takes place in the pulmonary parenchyma between the alveoli and the pulmonary capillaries.
TRACHEA
The trachea (windpipe) is located in front of (anterior to) the esophagus. It begins at the lower edge of the cricoid cartilage of the larynx and extends to the level of the fourth or fifth thoracic vertebra. The trachea branches into the right and left mainstem bronchi at the carina.
The trachea is composed of 6 to 10 C-shaped cartilaginous rings. The open portion of the С is the back portion of the trachea and contains smooth muscle that is shared with the esophagus. Low pressure must be maintained in endotracheal and tracheostomy tube cuffs to avoid causing erosion of this posterior wall and to avoid creating a tracheoesophageal fistula (abnormal connection between the trachea and the esophagus).
MAINSTEM BRONCHI
The mainstem, or primary, bronchi begin at the carina. The bronchus is similar in structure to the trachea. The right bronchus is slightly wider, shorter, and more vertical than the left bronchus. Because of the more vertical line of the right bronchus, it can be accidentally intubated when an endotracheal tube is passed. Similarly, when a foreign object is aspirated from the throat, it most often enters the right bronchus.
LOBAR, SEGMENTAL, AND SUBSEGMENTAL BRONCHI
The mainstem bronchi further branch into the five secondary (lobar) bronchi that enter each of the five lobes of the lung. Each lobar bronchus is surrounded by connective tissue, blood vessels, nerves, and lymphatics, and each branches into segmental and subsegmental divisions. The cartilage of these lobar bronchi is ringlike and resists collapse. The bronchi are lined with ciliated, mucus-secreting epithelium. The cilia propel mucus up and away from the lower airway to the trachea, where the mucus is either expectorated or swallowed.
BRONCHIOLES
The bronchioles branch from the secondary bronchi and subdivide into smaller and smaller tubes: the terminal and respiratory bronchioles. These terminal and respiratory tubes are less than
ALVEOLAR DUCTS AND ALVEOLI
Alveolar ducts, which resemble a bunch of grapes, branch from the respiratory bronchioles. Alveolar sacs arise from these ducts. The alveolar sacs contain clusters of alveoli, which are the basic units of gas exchange. A pair of healthy adult lungs contains approximately 300 million alveoli, which are surrounded by pulmonary capillaries. Because these small alveoli are so numerous and share common walls, the surface area for gas exchange in the lungs is extensive. In a healthy adult, this surface area is approximately the size of a tennis court. Acinus is a term used to indicate the structural unit consisting of a respiratory bronchiole, an alveolar duct, and an alveolar sac.
In the walls of the alveoli, specific cells (type II pneumocytes) secrete surfactant, a fatty protein that reduces surface tension in the alveoli. Without sufficient surfactant, atelectasis (collapse of the alveoli) ultimately occurs. In atelectasis, gas exchange is reduced because the alveolar surface area is reduced.
LUNGS
The lungs are sponge-like, elastic, cone-shaped organs located in the pleural cavity in the thorax. The apex (top) of each lung extends above the clavicle; the base (bottom) of each lung lies just above the diaphragm (the major muscle of inspiration). The lungs are composed of millions of alveoli and their related ducts, bronchioles, and bronchi. The right lung, which is larger than the left, is divided into three lobes: upper, middle, and lower. The left lung, which is somewhat narrower than the right lung to make room for the heart, is divided into two lobes.
The hilum is the point at which the primary bronchus, pulmonary blood vessels, nerves, and lymphatics enter each lung. Innervation of the chest wall is via the phrenic (pleura) and intercostal (diaphragm, ribs, and muscles) nerves. Innervation of the bronchi is via the vagus nerve.
The pleura is a continuous smooth membrane composed of two surfaces that totally enclose the lung. The parietal pleura lines the inside of the thoracic cavity and the upper surface of the diaphragm. The visceral pleura covers the lung surfaces, including the major fissures between the lobes. These two surfaces are lubricated by a thin fluid that is produced by the cells lining the pleura. This lubrication allows the surfaces to glide smoothly and painlessly during respirations.
Blood flow through the lungs occurs via two separate systems: bronchial and pulmonary. The bronchial system carries the blood necessary to meet the metabolic demands of the lungs. The bronchial arteries, which arise from the thoracic aorta, are part of the systemic circulation and do not participate in gas exchange.
The pulmonary circulation is composed of a highly vascular capillary network. Oxygen-depleted blood travels from the right ventricle of the heart into the pulmonary artery, which eventually branches into arterioles that form the capillary networks. The capillaries are enmeshed around and through the alveoli, the site of gas exchange. Freshly oxygenated blood travels from the capillaries and through the venules to the pulmonary veins and then to the left atrium. From the left atrium, oxygenated blood flows into the left ventricle, where it is pumped throughout the systemic circulation.
Accessory Muscles of Respiration
Breathing occurs through changes in the size of and pressure within the thoracic cavity. Contraction and relaxation of specific skeletal muscles (and the diaphragm) cause changes in the size and pressure of the thoracic cavity. Accessory muscles of respiration include the scalene muscles, which elevate the first two ribs; the sternocleidomastoid muscles, which raise the sternum; and the trapezius and pectoralis muscles, which fix the shoulders. In addition, various back and abdominal muscles are used when the work of breathing is increased.
Respiratory Changes Associated with Aging
Many changes associated with older clients result from heredity and a lifetime of exposure to environmental stimuli (e.g., cigarette smoke, bacteria, air pollutants, and industrial fumes and irritants). Table 27-1 shows the age-related changes in the partial pressure of arterial oxygen (Pao2).
Respiratory disease is a major cause of acute illness and chronic disability in older clients. Although respiratory functioormally declines with age, there is usually little difficulty with the demands of ordinary activity. However, the sedentary older adult often reports feeling breathless during exercise.
It is difficult to determine which respiratory changes in older adults are related to normal aging and which changes are pathologic and associated with respiratory disease or exposure to pollutants. In addition, age-related disorders of the neuromuscular and cardiovascular systems may cause abnormal respiration, even if the lungs are normal.
The respiratory system is situated in the thorax, and is responsible for gaseous exchange between the circulatory system and the outside world. Air is taken in via the upper airways (the nasal cavity, pharynx and larynx) through the lower airways (trachea, primary bronchi and bronchial tree) and into the small bronchioles and alveoli within the lung tissue.
Move the pointer over the coloured regions of the diagram; the names will appear at the bottom of the screen)
The lungs are divided into lobes; The left lung is composed of the upper lobe, the lower lobe and the lingula (a small remnant next to the apex of the heart), the right lung is composed of the upper, the middle and the lower lobes.
Mechanics of Breathing
To take a breath in, the external intercostal muscles contract, moving the ribcage up and out. The diaphragm moves down at the same time, creating negative pressure within the thorax. The lungs are held to the thoracic wall by thepleural membranes, and so expand outwards as well. This creates negative pressure within the lungs, and so air rushes in through the upper and lower airways.
Expiration is mainly due to the natural elasticity of the lungs, which tend to collapse if they are not held against the thoracic wall. This is the mechanism behind lung collapse if there is air in the pleural space (pneumothorax).
Physiology of Gas Exchange
Each branch of the bronchial tree eventually sub-divides to form very narrow terminal bronchioles, which terminate in the alveoli. There are many millions of alveloi in each lung, and these are the areas responsible for gaseous exchange, presenting a massive surface area for exchange to occur over.
Each alveolus is very closely associated with a network of capillaries containing deoxygenated blood from the pulmonary artery. The capillary and alveolar walls are very thin, allowing rapid exchange of gases by passive diffusion along concentration gradients.
CO2 moves into the alveolus as the concentration is much lower in the alveolus than in the blood, and O2 moves out of the alveolus as the continuous flow of blood through the capillaries prevents saturation of the blood with O2 and allows maximal transfer across the membrane.
Ventilation
In respiratory physiology, ventilation (or ventilation rate) is the rate at which gas enters or leaves the lung. It is categorized under the following definitions:
|
Measurement |
Equation |
Description |
|
Minute ventilation |
tidal volume * respiratory rate[1][2] |
the total volume of gas entering the lungs per minute. |
|
Alveolar ventilation |
(tidal volume – dead space) * respiratory rate [1] |
the volume of gas per unit time that reaches the alveoli, the respiratory portions of the lungs where gas exchange occurs. |
|
Dead space ventilation |
dead space * respiratory rate[3] |
the volume of gas per unit time that does not reach these respiratory portions, but instead remains in the airways (trachea, bronchi, etc.). |
Control
Ventilation occurs under the control of the autonomic nervous system from parts of the brain stem, the medulla oblongata and the pons. This area of the brain forms the respiration regulatory center, a series of interconnected brain cells within the lower and middle brain stem which coordinate respiratory movements. The sections are the pneumotaxic center, the apneustic center, and the dorsal and ventral respiratory groups. This section is especially sensitive during infancy, and the neurons can be destroyed if the infant is dropped and/or shaken violently. The result can be death due to “shaken baby syndrome“.[9]
The breathing rate increases with the concentration of carbon dioxide in the blood, which is detected by peripheral chemoreceptors in the aorta and carotid artery and central chemoreceptors in the medulla. Exercise also increases respiratory rate, due to the action of proprioceptors, the increase in body temperature, the release of epinephrine, and motor impulses originating from the brain.[10] In addition, it can increase due to increased inflation in the lungs, which is detected by stretch receptors.
Inhalation
Inhalation is initiated by the diaphragm and supported by the external intercostal muscles. Normal resting respirations are 10 to 18 breaths per minute, with a time period of 2 seconds. During vigorous inhalation (at rates exceeding 35 breaths per minute), or in approaching respiratory failure, accessory muscles of respiration are recruited for support. These consist ofsternocleidomastoid, platysma, and the scalene muscles of the neck. Pectoral muscles and latissimus dorsi are also accessory muscles.
Under normal conditions, the diaphragm is the primary driver of inhalation. When the diaphragm contracts, the ribcage expands and the contents of the abdomen are moved downward. This results in a larger thoracic volume and negative pressure (with respect to atmospheric pressure) inside the thorax. As the pressure in the chest falls, air moves into the conducting zone. Here, the air is filtered, warmed, and humidified as it flows to the lungs.
During forced inhalation, as when taking a deep breath, the external intercostal muscles and accessory muscles aid in further expanding the thoracic cavity. During inhalation the diaphragm contracts.
Exhalation
Exhalation is generally a passive process; however, active or forced exhalation is achieved by the abdominal and the internal intercostal muscles. During this process air is forced or exhaled out.
The lungs have a natural elasticity: as they recoil from the stretch of inhalation, air flows back out until the pressures in the chest and the atmosphere reach equilibrium.[11]
During forced exhalation, as when blowing out a candle, expiratory muscles including the abdominal muscles and internal intercostal muscles, generate abdominal and thoracic pressure, which forces air out of the lungs.
Gas exchange
The major function of the respiratory system is gas exchange between the external environment and an organism’s circulatory system. In humans and other mammals, this exchange facilitatesoxygenation of the blood with a concomitant removal of carbon dioxide and other gaseous metabolic wastes from the circulation.[12] As gas exchange occurs, the acid-base balance of the body is maintained as part of homeostasis. If proper ventilation is not maintained, two opposing conditions could occur: respiratory acidosis, a life threatening condition, and respiratory alkalosis.
Upon inhalation, gas exchange occurs at the alveoli, the tiny sacs which are the basic functional component of the lungs. The alveolar walls are extremely thin (approx. 0.2 micrometres). These walls are composed of a single layer of epithelial cells (type I and type II epithelial cells) close to the pulmonary capillaries which are composed of a single layer of endothelial cells. The close proximity of these two cell types allows permeability to gases and, hence, gas exchange. This whole mechanism of gas exchange is carried by the simple phenomenon of pressure difference. When the air pressure is high inside the lungs, the air from lungs flow out. When the air pressure is low inside, then air flows into the lungs.
Immune functions
Airway epithelial cells can secrete a variety of molecules that aid in the defense of lungs. Secretory immunoglobulins (IgA), collectins (including Surfactant A and D), defensins and other peptides and proteases, reactive oxygen species, and reactive nitrogen species are all generated by airway epithelial cells. These secretions can act directly as antimicrobials to help keep the airway free of infection. Airway epithelial cells also secrete a variety of chemokines and cytokines that recruit the traditional immune cells and others to site of infections.
Most of the respiratory system is lined with mucous membranes that contain mucosal-associated lymphoid tissue, which produces white blood cells such as lymphocytes.
Metabolic and endocrine functions of the lungs
In addition to their functions in gas exchange, the lungs have a number of metabolic functions. They manufacture surfactant for local use, as noted above. They also contain a fibrinolytic system that lyses clots in the pulmonary vessels. They release a variety of substances that enter the systemic arterial blood and they remove other substances from the systemic venous blood that reach them via the pulmonary artery. Prostaglandins are removed from the circulation, but they are also synthesized in the lungs and released into the blood when lung tissue is stretched. The lungs also activate one hormone; the physiologically inactive decapeptide angiotensin I is converted to the pressor, aldosterone-stimulating octapeptide angiotensin II in the pulmonary circulation. The reaction occurs in other tissues as well, but it is particularly prominent in the lungs. Large amounts of the angiotensin-converting enzyme responsible for this activation are located on the surface of the endothelial cells of the pulmonary capillaries. The converting enzyme also inactivates bradykinin. Circulation time through the pulmonary capillaries is less than one second, yet 70% of the angiotensin I reaching the lungs is converted to angiotensin II in a single trip through the capillaries. Four other peptidases have been identified on the surface of the pulmonary endothelial cells.
Vocalization
The movement of gas through the larynx, pharynx and mouth allows humans to speak, or phonate. Vocalization, or singing, in birds occurs via the syrinx, an organ located at the base of the trachea. The vibration of air flowing across the larynx (vocal cords), in humans, and the syrinx, in birds, results in sound. Because of this, gas movement is extremely vital for communicationpurposes.
Temperature control
Panting in dogs, cats and some other animals provides a means of controlling body temperature. This physiological response is used as a cooling mechanism.
Coughing and sneezing
Irritation of nerves within the nasal passages or airways, can induce coughing and sneezing. These responses cause air to be expelled forcefully from the trachea or nose, respectively. In this manner, irritants caught in the mucus which lines the respiratory tract are expelled or moved to the mouth where they can be swallowed. During coughing, contraction of the smooth muscle narrows the trachea by pulling the ends of the cartilage plates together and by pushing soft tissue out into the lumen. This increases the expired airflow rate to dislodge and remove any irritant particle or mucus.
The respiratory system is the system in the human body that enables us to breathe.
The act of breathing includes: inhaling and exhaling air in the body; the absorption of oxygen from the air in order to produce energy; the discharge of carbon dioxide, which is the byproduct of the process.
The parts of the respiratory system
The respiratory system is divided into two parts:
Upper respiratory tract:
This includes the nose, mouth, and the beginning of the trachea (the section that takes air in and lets it out).
Lower respiratory tract:
This includes the trachea, the bronchi, broncheoli and the lungs (the act of breathing takes place in this part of the system).
The organs of the lower respiratory tract are located in the chest cavity. They are delineated and protected by the ribcage, the chest bone (sternum), and the muscles between the ribs and the diaphragm (that constitute a muscular partition between the chest and the abdominal cavity).
The trachea – the tube connecting the throat to the bronchi.
The act of breathing
The act of breathing has two stages – inhalation and exhalation
· Inhalation – the intake of air into the lungs through expansion of chest volume.
· Exhalation – the expulsion of air from the lungs through contraction of chest volume.
Inhalation and exhalation involves muscles:
1. Rib muscles = the muscles between the ribs in the chest.
2. Diaphragm muscle
Muscle movement – the diaphragm and rib muscles are constantly contracting and relaxing (approximately 16 times per minute), thus causing the chest cavity to increase and decrease.
During inhalation – the muscles contract:
Contraction of the diaphragm muscle – causes the diaphragm to flatten, thus enlarging the chest cavity.
Contraction of the rib muscles – causes the ribs to rise, thus increasing the chest volume.
The chest cavity expands, thus reducing air pressure and causing air to be passively drawn into the lungs. Air passes from the high pressure outside the lungs to the low pressure inside the lungs.
During exhalation – the muscles relax:
The muscles are no longer contracting, they are relaxed.
The diaphragm curves and rises, the ribs descend – and chest volume decreases.
The chest cavity contracts thus increasing air pressure and causing the air in the lungs to be expelled through the upper respiratory tract. Exhalation, too, is passive. Air passes from the high pressure in the lungs to the low pressure in the upper respiratory tract.
Inhalation and exhalation are involuntary and therefore their control requires an effort.
Changes in chest volume during inhalation and exhalation – note that it only shows the movement of the diaphragm, not that of the rib muscles.
What Do We Measure And How Do We Measure It?
The respiratory airways include the respiratory apertures (mouth and nose), the trachea and a branching system of long, flexible tubes (bronchi) that branch of to shorter and narrower tubes (broncheoli) until they end in sacs called the pulmonary alveoli.
The lungs encompass the entire system of tubes branching out from the main bronchi to the alveoli.
Measuring the functioning of the lungs is a medical tool for diagnosing problems in the respiratory system.
Measurements of lung function
2. Air volume (in liters) – lung capacity
· Maximum lung volume is known as TLC (total lung capacity). It can be obtained by maximum strenuous inhalation.
· Essential air volume is the maximum volume utilized by the lungs for inhalation, also known as VC (vital capacity).
· Residual volume (RV) is the volume of air remaining in the lungs after strenuous exhalation when the lungs feel completely empty. Residual volume prevents the broncheoli and the alveoli from sticking together. Residual volume is approximately 1.5 liters (adults).
· The differential between total lung capacity and residual volume is the maximal volume utilized by the lungs in order to breath. It is known as vital capacity(VC). In an adult, the VC is between 3.5 and 4.5 liters.
· Tidal Volume or VT is the volume of air displaced betweeormal inspiration and expiration. In a healthy adult the tidal volume is approximately 500 milliliters.
2. Rate of airflow through the respiratory airways (into and out of the lungs).This measures the effectiveness of airflow.
3. Efficiency of diffusion of oxygen from the pulmonary alveoli into the blood (not dealt with in this unit).
TLC (total lung capacity) of children
Examining lung function
The most common, accessible and efficient method of measuring lung function is by means of a spirometer. Its purpose is to diagnose obstructive diseases of the respiratory system. It produces a diagram (graphic depiction) of the volume of air expired in a given time (liter/minute)
The spirometer shows the rate at which air is expelled from the lungs. It measures the total lung capacity up to the residual volume (this test does not show the rate at which oxygen is absorbed).
If the airways are blocked the rate of the airflow of the lungs decreases. This will show on the diagram and thus indicate that there is a problem in the airways.
The most common obstruction stems from excessive phlegm, or from swelling of the inner wall of the air ways.
The most common problem of blockage of the air ways is asthma. people suffering from asthma it take longer to empty the lungs than healthy people. For example, during the first second of exhalation, only half of the vital air capacity in their lungs is expelled as opposed to 90% in healthy people. The rest is exhaled much later.
A spirometer examination takes only a few seconds. It is completely safe but there is a need for the patient to cooperate in order to obtain accurate results.
Stages of the examination:
1. The patient is asked to inhale as deeply as possible.
2. The patient is asked to exhale strenuously into the spirometer.
3. The patient is asked to continue to expel air for a few seconds, despite the strong urge to breathe in.
4. The test is repeated twice or three times.
Respiratory rate
Children in the upper classes of elementary school breathe about 20 times per minute.
Every breath causes an inhalation of approximately 7 milliliters of air volume per kilogram of body weight.
A child who weighs 30 kilos inhales approximately 210 milliliters of air volume (210X30). In other words, in the duration of a minute some 4200 milliliters of air volume enters and be expelled from the lungs.
Athletes breathe slightly deeper and slower. With every breath they inhale approximately 10 milliliters of air per kilogram. Thus an athletic child who weighs 30 kilos will only breathe 15 times in the duration space of a minute. Each inhalation will require some 300 milliliters of air volume. In the space of a minute 4500 milliliters of air volume will enter and be expelled from the his lungs. We can deduce from this that athletes ventilate their airways in a much more efficient way.
When we are under strain we breathe faster and more deeply. Since the lungs contain a reserve of air, we do not become tired because lack of air (oxygen) is causing respiratory restriction, but because of strain and tiredness in our respiratory and heart muscles.
When we are under emotional stress (before an exam, in distress, or feeling very frightened) we breathe faster, but our breathing is shallower. For example, under stress we inhale 30 times per minute but at a rate of only 4 milliliters per kilo. In other words, overall only 3600 milliliters per minute are passing through our airways, so we feel “short of breath.”
During severe asthma attacks, the breathing of asthma patients is shallower and at a higher rate. Their breathing is thus not very efficient.
Functions of Organs in Respiratory System
Respiration begins when oxygen enters into the body through the nose and the mouth. The oxygen then travels through the trachea and pharynx where the trachea divides into two bronchi. Here the bronchi are divided into bronchial tubes, in the chest cavity, so air can be directly moved into the lungs.
Nose
The nose is the primary upper respiratory organ in which air enters into and exits from the body. Cilia and mucus line the nasal cavity and traps bacteria and foreign particles that enter in through the nose. In addition, air that passes through the nasal cavity is humidified and moistened.
The nasal septum divides the nose into two narrow nasal cavities: one area is responsible for smell and the other area is responsible for respiration. Within the walls of the nasal cavity there are frontal, nasal, ethmoid, maxillary, and sphenoid bones. Cartilage helps form the shape of the nose.
Pharynx
Besides the nose, air can enter into the lungs through the mouth. The pharynx is a tubular structure, positioned behind the oral and nasal cavities, that allows air to pass from the mouth to the lungs. The pharynx contains three parts: The nasopharynx, which connects the upper part of the throat with the nasal cavity; the oropharynx, positioned between the top of the epiglottis and the soft palate; and the laryngopharynx, located below the epiglottis.
Larynx
From the pharynx, air enters into the larynx, commonly called the voice box. The larynx is part of the upper respiratory tract that has two main functions: a passageway for air to enter into the lungs, and a source of vocalization. The larynx is made up of the hyoid bone and cartilage, which helps regulate the flow of air. The epiglottis is a flap-like cartilage structure contained in the larynx that protects the trachea against food aspiration.
Bronchi
The bronchi allow the passage of air to the lungs. The trachea is made of c-shaped ringed cartilage that divides into the right and left bronchus. The right main bronchus is shorter and wider than the left main bronchus. The right bronchus is subdivided into three lobar bronchi, while the left one is divided into two lobar bronchi.
Lungs
The lungs are spongy, air-filled organs located on both sides of the chest cavity. The left lung is divided into a superior and inferior lobe, and the right lung is subdivided into a superior, middle, and inferior lobe. Pleura, a thin layer of tissue, line the lungs to allow the lungs to expand and contract with ease.
Respiration is the primary function of the lungs, which includes the transfer of oxygen found in the atmosphere into the blood stream and the release of carbon dioxide into the air.
Alveoli
The average adult has about 600 million alveoli, which are tiny grape-like sacs at the end of the respiratory tree. The exchange of oxygen and carbon dioxide gases occurs at the alveolar level. Although effort is required to inflate the alveoli (similar to blowing up a balloon), minimal effort is needed to deflate the alveoli (similar to the deflating of a balloon).
Diaphragm
The diaphragm is a muscular structure located between the thoracic and abdominal cavity. Contraction of the diaphragm causes the chest or thorax cavity to expand, which occurs during inhalation. During exhalation, the release of the diaphragm causes the chest or thorax cavity to contract.
Oxygen saturation
Oxygen saturation is a term referring to the concentration of oxygen in the blood. The human body requires and regulates a very precise and specific balance of oxygen in the blood. Normal blood oxygen levels are considered 95-100 percent. If the level is below 90 percent, it is considered low resulting in hypoxemia. Blood oxygen levels below 80 percent may compromise organ function, such as the brain and heart, and should be promptly addressed. Continued low oxygen levels may lead to respiratory or cardiac arrest. Oxygen therapy may be used to assist in raising blood oxygen levels. Oxygenation occurs when oxygen molecules (O2) enter the tissues of the body. For example, blood is oxygenated in the lungs, where oxygen molecules travel from the air and into the blood. Oxygenation is commonly used to refer to medical oxygen saturation.
In medicine, oxygen saturation (SO2), commonly referred to as “sats”, measures the percentage of hemoglobin binding sites in the bloodstream occupied by oxygen. At low partial pressures of oxygen, most hemoglobin is deoxygenated. At around 90% (the value varies according to the clinical context) oxygen saturation increases according to an oxygen-hemoglobin dissociation curve and approaches 100% at partial oxygen pressures of >10 kPa. A pulse oximeter relies on the light absorption characteristics of saturated hemoglobin to give an indication of oxygen saturation.
Physiology
This balance is maintained for the most part by chemical processes in the body to sustain aerobic metabolism and life. Using the respiratory system, red blood cells, specifically the hemoglobin, gather oxygen in the lungs and distribute it to the rest of the body. The needs of the body’s blood oxygen may fluctuate such as during exercise when more oxygen is required [2] or when living at higher altitudes. A blood cell is said to be “saturated” when carrying a normal amount of oxygen. Both too high and too low levels can have adverse effects on the body.
Measurement
An SaO2 (arterial oxygen saturation) value below 90% causes hypoxemia (which can also be caused by anemia). Hypoxemia due to low SaO is indicated by cyanosis. Oxygen saturation can be measured in different tissues:
· Venous oxygen saturation (SvO2) is measured to see how much oxygen the body consumes. Under clinical treatment, a SvO2 below 60% indicates that the body is in lack of oxygen, andischemic diseases occur. This measurement is often used under treatment with a heart-lung machine (extracorporeal circulation), and can give the perfusionist an idea of how much flow the patient needs to stay healthy.
· Tissue oxygen saturation (StO2) can be measured by near infrared spectroscopy. Although the measurements are still widely discussed, they give an idea of tissue oxygenation in various conditions.
· Peripheral capillary oxygen saturation (SpO2) is an estimation of the oxygen saturation level usually measured with a pulse oximeter device. It can be calculated with the pulse oximetryaccording to the following formula:
Blood circulation: Red = oxygenated (arteries), Blue = deoxygenated (veins)
Medical significance
|
Effects of decreased oxygen saturation[4] |
|
|
SaO2 |
Effect |
|
85% and above |
No evidence of impairment |
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65% and less |
Impaired mental function on average |
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55% and less |
Loss of consciousness on average |
Healthy individuals at sea level usually exhibit oxygen saturation values between 96% and 99%. An SaO2 (arterial oxygen saturation) value below 90% causes hypoxemia (which can also be caused by anemia). Hypoxemia due to low SaO is indicated by cyanosis, but oxygen saturation does not directly reflect tissue oxygenation. The affinity of hemoglobin to oxygen may impair or enhance oxygen release at the tissue level. Oxygen is more readily released to the tissues when pH is decreased, body temperature is increased, arterial partial pressure of carbon dioxide (PaCO2) is increased, and 2,3-DPG levels (a byproduct of glucose metabolism also found in stored blood products) are increased. When the hemoglobin has greater affinity for oxygen, less is available to the tissues. Conditions such as increased pH, decreased temperature, decreased PaCO2, and decreased 2,3-DPG will increase oxygen binding to the hemoglobin and limit its release to the tissue.
Example pulse oximeter
Pulse oximetry is a method used to measure the concentration of oxygen in the blood. A small device that clips to the body (typically a finger but may be other areas), called a pulse oximeter, uses a special light to estimate the amount of oxygen in the blood. The clip attaches to a reading meter by a wire to collect the data. Oxygen levels may also be checked through an arterial blood gas test (ABG), where blood taken from an artery is analysed for oxygen level, carbon dioxide level and acidity.
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Mechanism of Breathing |
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This is the process by which the lungs expand to take in air then contract to expel it. The cycle of respiration, which occurs about 15 times per minute, consists of three phases: Inspiration, Expiration and Pause Proper breathing involves all the muscles of the head, neck, thorax and abdomen, in addition to the involuntary musculature of the larynx, trachea and bronchi.
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Whole body Breathing |
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Most of us breathe in three of four different ways. These ways of breathing can be called high, low, middle or complete breathing. 1. High breathing refers to breathing that takes place primarily in the upper part of the chest and lungs. Also called “calvicular breathing” or “collarbone breathing”, it involves movement of the ribs, collarbone and shoulders. High breathing is naturally shallow and a large percentage of the oxygen fails to reach the alveoli and enter into gaseous exchange. This is the least desirable form of breathing as only the upper lobes of the lungs are used which have only a small air capacity. The upper rib cage is fairly rigid and so not much expansion of the ribs can take place. High breathing is a common cause of digestive, constipation and gynaecological problems. 2. Middle breathing is a way of breathing in which mainly the middle parts of the lungs are filled with air. 3. Low Breathing refers to respiration which takes place primarily in the lower part of the chest and lungs. It consists mainly of the movement of the abdomen in and out and the corresponding movement of the diaphragm. It is sometimes also called “abdominal breathing” and “diaphragmatic breathing.” This type of breath is far superior to high or middle breathing for new reasons: More air is taken in when inhaling due to greater movement of the lungs and the fact that the lower lobes of the lungs have a larger capacity than the upper lobes. The diaphragm acts like a second heart. Its piston-like movements expand the base of the lungs, allowing them to suck in more venous blood. The increase in the venous circulation improves the general circulation. The abdominal organs and the solar plexus, a very important nerve centre, are massaged by and down movements of the diaphragm. 4. Whole Body Breathing involves the entire respiratory system and not only includes the of the lungs used in high, low and middle breathing, but expands the lungs so as to take in more air than the amounts inhaled by each of these three kinds of breathing together when employed in shallow breathing. The complete breath is not just deep breathing; it is the deepest possible breathing. Not only does raise his shoulders, collarbone and ribs, as in high breathing, and also extend his abdomen and lower his diaphragm, as in low breathing, but he does both as much is needed to expand his lungs to their fullest capacity. This type of breathing should only be utilised when doing breathing exercises. The rest of the time it is best to use low breathing by pushing the stomach out slightly when inhaling, and then just letting the stomach fall back to its original position in the exhale. |
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Corrective Breathing |
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“To be wholly alive is to breathe deeply, to move freely, and to feel fully. Breath is the most fundamental, tangible link to life.” Incorrect breathing manifests itself in: Sleeping Disturbances/ Insomnia Anxiety / Irritability / Panic Attacks Confused thinking / Fatigue Allergies Asthma Digestive Problems Elevated blood pressure Back problems, tension and headache Immune System Dysfunction Healthy cells need oxygen. Oxygen is essential for assimilation of nutrients and the detoxification and elimination of waste products. It is the main energy source for our brain function Physiological Benefits include: Relaxes the entire body and nervous system, where tensions and anxieties are held Emotional Benefits include: Clarity of Thought All of these (and much more) are well documented in various western publications both within and outside of the medical community. Many doctors are beginning to recommend breathing exercises to their patients as a means of coping with various health problems. While the jury is still out regarding the absolute mechanism behind the effectiveness of breathing, most researchers believe that the deep relaxation of both mind and body are central to health. |
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Fertility Breathing |
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Fertility Breathing increases oxygen levels to our cells, expands the working capacity of respiratory system and supports the functioning of the endocrine system. Working together with acupuncturists Rangana has developed a unique breathing system incorporating the acupuncture channels. The channels used are those associated with fertility and help to bring energy and blood flow to the centre of the body. Using this method to build on the acupuncture treatments the client is able to practise at home in between sessions. This method is particularly useful through IVF when a good pelvic blood flow is essential. Clients also find it a useful relaxation method. Physiological Benefits include: Helps circulate oxygen around the body Increases ovarian and uterine blood flow Reduces hormonal treatment side effects Helps embryo implantation oxygenating the placenta Regulates the Hypothalamus Pituitary Ovarian (HPO) axis Calms the effects of endometriosis Emotional Benefits include: Increases sense of control over one’s life Enhances quality of life and health Restructures negative thoughts and behaviour patterns Reduces stress |
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Pregnancy Breathing |
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How does it work? In what stage of pregnancy I can start? Visualization will teach you to mentally “see” and affect structures within your body e.g. your muscles, your cervix, your hormones. You will also be taught how to communicate with your baby within your womb. Benefits Creates Space Breathing opens the body, ribcage, abdomen, diaphragm, and spine. Circulation More fluid, diaphragm acts as a lift pump from lower half of body. Extra Oxygen Baby placenta Cleansing 60-70% of toxins released through exhalation. Digestion Massage the abdominal organs Backache At the end of the exhalation the diaphragm releases the lumbar spine, lower ribs open during inhalation touching parts of the spine that needs opening and decompressing. Attention Concentration and focus improved, helps with emotional seesaw of pregnancy and during labour, quietens the mind. Relaxation Slow, deep and rhythmic breathing causes a reduction in the heart rate and relaxation of the muscles. |
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History
Obtaining accurate information from the client is important in determining the type and severity of pulmonary problems.
DEMOGRAPHIC DATA
Age, gender, and race can affect the physical and diagnostic findings related to respiratory function. Many of the diagnostic studies relevant to respiratory disorders (e.g., pulmonary function tests) use these demographic data for determining predicted normal values.
PERSONAL AND FAMILY HISTORY
Medical History
The nurse asks clients about their own respiratory history and that of their family members. The family history is obtained to consider respiratory disorders with a genetic component, such as cystic fibrosis, some lung cancers, and alpha,-antitrypsin deficiency (one risk factor for emphysema). Clients with asthma often have a family history of allergic symptoms and reactive airways. The nurse assesses for a history of infectious disease, such as tuberculosis, and considers that family members may have similar environmental or occupational exposures.
Smoking History
The nurse questions the client about the use of cigarettes, cigars, pipe tobacco, marijuana, and other controlled substances, and he or she notes whether the client has passive exposure to smoke in the home or workplace. If the client smokes, the nurse asks for how long, how many packs a day, and whether the client has quit smoking (and how long ago). The smoking history is documented in pack-years (number of packs smoked per day multiplied by number of years). Because the client may have guilt or denial about this habit, the nurse assumes a nonjudgmental attitude during the interview.
Smoking induces anatomic changes in the large and peripheral airways, and these changes lead to varying degrees of airway obstruction. Men who continue to smoke experience a more rapid decline in their pulmonary function than do non-smokers. The pulmonary function of clients who have quit smoking for 2 or more years appears to decline less rapidly than in clients who continue to smoke.
Medication Use
The nurse asks about medications taken for breathing problems and about drugs taken for other conditions. For example, a cough can be a side effect of the angiotensin-converting enzyme (ACE) inhibitors. The nurse determines which over-the-counter medications (e.g., cough syrups, antihistamines, decongestants, inhalants, and nasal sprays) the client is using.
The use of home remedies also is assessed. The client is asked about past medication use and the reason for its discontinuation. For example, he or she may have used numerous bronchodilator metered dose inhalers but may prefer one particular drug for relieving breathlessness. In addition, some medications for other conditions can cause permanent changes in pulmonary function. For example, clients may have residual pulmonary fibrosis if they received bleomycin (Blenoxane) as chemotherapy for cancer or amiodarone (Cordarone) for cardiac problems.
Allergies
Information about allergies is important to the respiratory history. The nurse determines whether the client has any known allergies to environmental substances such as foods, dust, molds, pollen, bee stings, trees, grass, animal dander and saliva, or medications. The client is asked to explain a specific allergic response. For example, does he or she wheeze, have trouble breathing, cough, sneeze, or experience rhinitis after exposure to the allergen? Has he or she ever been treated for an allergic response? If the client has received treatment for allergies, the nurse asks about the circumstances leading up to the need for treatment, the type of treatment, and the response to treatment.
Travel and Area of Residence
Travel and area of residence may be relevant for a history of exposure to certain diseases. For example, histoplasmosis, a fungal disease caused by inhalation of contaminated dust, is found in the central United States, the Mississippi and Missouri river valleys, and Central America. Coccidioidomycosis, another fungal disease, is found predominantly in the western and southwestern United States, Mexico, and portions of Central America.
DIET HISTORY
An evaluation of the client’s diet history may reveal allergic reactions to certain foods or preservatives. Signs and symptoms range from rhinitis, chest tightness, weakness, shortness of breath, urticaria, and severe wheezing to loss of consciousness. The nurse documents in a prominent location of the client’s record any known allergies and the specific type of allergic response experienced. The client is asked about his or her usual food intake and whether any symptoms occur with eating. Malnutrition may occur if he or she has difficulty breathing during eating or the food preparation process.
OCCUPATIONAL HISTORY AND SOCIOECONOMIC STATUS
The nurse considers the home, community, and workplace for environmental factors that could cause or contribute to lung disease. Occupational pulmonary diseases include pneumoconiosis, which results from the inhalation of dust (e.g., coal dust, stone dust, silicone dust); toxic lung injury; and hypersensitivity disease (e.g., hypersensitivity to latex). The occupational history includes the exact dates of employment and a brief job description. Exposure to industrial dusts of any type or to the noxious chemicals found in smoke and fumes may cause respiratory disease. Coal miners, stone masons, cotton handlers, welders, potters, plastic and rubber manufacturers, printers, farm workers, and steel foundry workers are among the most susceptible.
The nurse obtains information about the home and living conditions, such as the type of heat used (e.g., gas heater, wood-burning stove, fireplace, and kerosene heater) and exposure to environmental irritants (e.g., noxious fumes, chemicals, animals, birds, and air pollutants). The client is asked about hobbies and leisure activities. Pastimes such as painting, working with ceramics, model airplane building, furniture refinishing, or woodworking may have exposed the client to harmful chemical irritants.
CURRENT HEALTH PROBLEMS
Whether the pulmonary problem is acute or chronic, the chief complaint is likely to include cough, sputum production, chest pain, and shortness of breath at rest or on exertion. During the interview, the nurse explores the history of the present illness, preferably in chronologic order. This analysis of the problem(s) includes the following:
• Onset
• Duration
• Location
• Frequency
• Progressing and radiating patterns
• Quality and number of symptoms
• Aggravating and relieving factors
• Associated signs and symptoms
• Treatments
Cough
Cough is the cardinal sign of respiratory disease. The nurse asks the client how long the cough has persisted (e.g., 1 week, 3 months) and whether it occurs at a specific time of day (e.g., on awakening in the morning, which is common in smokers) or in relation to any physical activity. The nurse determines whether the cough is productive or nonproductive, congested, dry, tickling, or hacking.
Sputum Production
Sputum production is an important symptom associated with coughing. The nurse notes the duration, color, consistency, odor, and amount of sputum. Sputum may be clear, white, tan, gray or, if infection is present, yellow or green.
The nurse describes the consistency of sputum as thin, thick, watery, or frothy. Smokers with chronic bronchitis have mucoid sputum because of chronic stimulation and hypertrophy of the bronchial glands. Voluminous, pink, frothy sputum is characteristic of pulmonary edema. Pneumococcal pneumonia is often associated with rust-colored sputum, and foul-smelling sputum is often found in anaerobic infections such as a lung abscess. Blood in the sputum (hemoptysis) is most commonly noted in clients with chronic bronchitis or bronchogenic carcinoma. Clients with tuberculosis, pulmonary infarction, bronchial adenoma, or lung abscess may expectorate grossly bloody sputum.
Sputum can be quantified by describing its production in terms of measurements such as teaspoon, tablespoon, and cups or fractions of cups. Normally, the tracheobronchial tree can produce up to 3 ounces (90 mL) of sputum per day. The nurse determines whether sputum production is increasing, possibly from external stimuli (e.g., an irritant in the work setting) or an internal cause (e.g., chronic bronchitis or a pulmonary abscess).
Chest Pain
A detailed description of chest pain helps the nurse differentiate pleural, musculoskeletal, cardiac, and gastrointestinal pain. Because the perception of pain is subjective, pain is analyzed in relation to the characteristics described in the history of the present illness. Coughing, deep breathing, or swallowing usually worsens chest wall pain.
Dyspnea
The perception of dyspnea (difficulty in breathing or breathlessness) is subjective and varies among clients. A client’s perception may not be consistent with the severity of the presenting problem. Therefore the nurse determines the type of onset (slow or abrupt), the duration (number of hours, time of day), relieving factors (changes of position, medication use, activity cessation), and evidence of audible sounds (wheezing, crackles, stridor).
The nurse tries to quantify dyspnea by asking whether this symptom interferes with activities of daily living (ADLs) and, if so, how severely. For example, is the client breathless while dressing, showering, shaving, or eating? Does dyspnea on exertion occur after walking one block or climbing one flight of stairs?
The nurse asks about paroxysmal nocturnal dyspnea (PND), which involves intermittent dyspnea during sleep, and about orthopnea, which is demonstrated by a shortness of breath that occurs when lying down but is relieved by sitting up. These two conditions are commonly associated with chronic pulmonary disease and left ventricular failure. In PND, the client has a sudden onset of breathing difficulty that is severe enough to awaken the client from sleep.
Physical Assessment
ASSESSMENT OF THE NOSE AND SINUSES
The nurse inspects the client’s external nose for deformities or tumors and inspects the nostrils for symmetry of size and shape. Nasal flaring may indicate an increased respiratory effort. To observe the interior nose, the nurse asks the client to tilt the head back for a penlight examination. The nurse may use a nasal speculum and nasopharyngeal mirror for a more thorough examination of the nasal cavity.
The nurse inspects for color, swelling, drainage, and bleeding. The mucous membrane of the nose normally appears redder than the oral mucosa, but it may appear pale, engorged, and bluish gray in clients with allergic rhinitis. The nasal septum is checked for evidence of bleeding, perforation, or deviation. Some degree of septal deviation is common in most adults and appears as an S shape, inclining toward one side or the other. A perforated septum is noted if the light shines through the perforation into the opposite nostril; this condition is often found in cocaine users. Nasal polyps, a common cause of obstruction, appear as pale, shiny, gelatinous structures attached to the turbinates.
The nurse occludes one nare at a time to check whether air moves through the nonoccluded side easily. The nose and paranasal sinuses are palpated to detect tenderness or swelling. Only the frontal and maxillary sinuses are readily accessible to clinical examination because the ethmoid and sphenoid sinuses lie deep within the skull. Using the thumbs, the nurse checks for sinus tenderness by pressing upward on the frontal and maxillary areas; both sides are assessed simultaneously. Tenderness in these areas suggests inflammation or acute sinusitis. Tenderness in response to tapping a finger over these areas also indicates inflammation.
Transillumination of the sinuses may be used to detect sinusitis. In a darkened room, the nurse places the bulb of a penlight on the client’s cheek (just under the corner of the eye) and observes for light penetration through the roof of the mouth. Normally, a faint glow of light through the bone outlines the sinus. Transillumination is absent or decreased in sinusitis. However, this test is not conclusive for sinusitis.
ASSESSMENT OF THE PHARYNX, TRACHEA, AND LARYNX
Examination of the pharynx begins with inspection of the external structures of the mouth. To examine the structures of the posterior pharynx, the nurse uses a tongue depressor to press down one side of the tongue at a time (to avoid stimulating the gag reflex). As the client says “ah,” the nurse notes the rise and fall of the soft palate and uvula and observes for color and symmetry, evidence of discharge (postnasal drainage), edema or ulceration, and tonsillar enlargement or inflammation.
The neck is inspected for symmetry, alignment, masses, swelling, bruises, and the use of accessory neck muscles in breathing. Lymph nodes are palpated for size, shape, mobility, consistency, and tenderness. Tender nodes are usually movable and suggest inflammation. Malignant nodes are often hard and are fixed to the surrounding tissue.
The nurse gently palpates the trachea for deviation, mobility, tenderness, and masses. Firm palpation may elicit coughing or gagging. The space on either side of the trachea should be equal. Many pulmonary disorders cause the trachea to deviate from the midline. Tension pneumothorax, large pleural effusion, mediastinal mass, and neck tumors push the trachea away from the affected area, whereas pneumonectomy, fibrosis, and atelectasis cause a pull toward the affected area. Decreased tracheal mobility may occur with carcinoma or fibro-sis of the mediastinum.
The larynx is usually examined by a specialist with a laryngoscope. The nurse may observe an abnormal voice, especially hoarseness, when there are abnormalities of the larynx.
ASSESSMENT OF THE LUNGS AND THORAX
Inspection
Inspection of the chest begins with an assessment of the anterior and posterior thorax. If possible, the client is in a sitting position during the assessment. He or she should be undressed to the waist and draped for privacy and warmth. The chest is observed by comparing one side with the other. The nurse works from the top (apex) and moves downward toward the base while inspecting for discoloration, scars, lesions, masses, and spinal deformities such as kyphosis, scoliosis, and lordosis.
The nurse observes the rate, rhythm, and depth of inspirations as well as the symmetry of chest movement. An impaired movement or unequal expansion may indicate an underlying disease of the lung or the pleura. The nurse observes the type of breathing (e.g., pursed-lip or diaphragmatic breathing) and the use of accessory muscles. In observing respiration, the nurse documents the duration of the inspiratory (I) and expiratory (E) phases. The ratio of these phases (the I/E ratio) is normally 1:2. A prolonged expiratory phase indicates an obstruction of air outflow and is often seen in clients with asthma or chronic obstructive pulmonary disease (COPD).
The nurse examines the shape of the client’s chest and compares the anteroposterior (AP) diameter with the lateral diameter. This ratio normally ranges from 1:2 to approximately 5:7, depending on body build. The ratio increases to 1:1 in clients with emphysema, which results in the typical barrel chest appearance.
Normally, the ribs slope downward. However, clients with air trapping in the lungs caused by chronic asthma or emphysema have little or no slope to the ribs (i.e., the ribs are more horizontal).
The nurse also checks for abnormal retractions of the intercostal spaces during inspiration, which indicate airflow obstruction. These retractions may be due to fibrosis of the underlying lung, severe acute asthma, emphysema, or tracheal or laryngeal obstruction.
Palpation
Palpation of the chest occurs after inspection. Palpation allows the nurse to assess respiratory movement symmetry and observable abnormalities, to identify areas of tenderness, and to elicit vocal or tactile fremitus (vibration).
The nurse assesses thoracic expansion by placing the thumbs posteriorly on the spine at the level of the ninth ribs and extending the fingers laterally around the rib cage. As the client inhales, both sides of the chest should move upward and outward together in one symmetric movement, and the nurse’s thumbs move apart. On exhalation, the thumbs should come back together as they return to the midline. Decreased movement on one side (unilateral or unequal expansion) may be a result of pain, trauma, or pneumothorax (air in the pleural cavity). Respiratory lag or slowed movement on one side may indicate the presence of a pulmonary mass, pleural fibrosis, atelectasis, pneumonia, or a lung abscess.
The nurse palpates any abnormalities found on inspection (e.g., masses, lesions, bruises, and swelling). The nurse also palpates for tenderness, particularly if the client has reported pain. Crepitus (subcutaneous emphysema) is felt as a crackling sensation beneath the fingertips and should be documented, especially if it occurs around a wound site or if a pneumothorax is suspected. Crepitus indicates that air is trapped within the tissues.
Tactile (vocal) fremitus is a vibration of the chest wall produced when the client speaks. This vibration can be palpated on the chest wall. To elicit tactile fremitus, the nurse places the palm or the base of the fingers against the client’s chest wall and instructs him or her to say the number 99. Using the same hand and moving from the apices to the bases, the nurse compares vibrations from one side of the chest with those from the other side. Palpable vibrations are transmitted from the tracheobronchial tree, along the solid surface of chest wall, and to the nurse’s hand.
The nurse notes the symmetry of the vibrations and areas of enhanced, diminished, or absent fremitus. Fremitus is decreased if the transmission of sound waves from the larynx to the chest wall is slowed. This situation can occur when the pleural space is filled with air (pneumothorax) or fluid (pleural effusion) or when the bronchus is obstructed. Fremitus is increased over large bronchi because of their proximity to the chest wall. Disease processes such as pneumonia and abscesses increase the density of the thorax and enhance transmission of the vibrations.
Percussion
The nurse uses percussion to assess for pulmonary resonance, the boundaries of organs, and diaphragmatic excursion. Percussion involves tapping the chest wall, which sets the underlying tissues into motion and produces audible sounds. The nurse places the distal joint of the middle finger of the less dominant hand firmly over the intercostal space to be percussed. No other part of the nurse’s hand touches the client’s chest wall because doing so absorbs the vibrations. The middle finger of the dominant hand then delivers quick, sharp strikes to the distal joint of the positioned finger. The nurse maintains a loose, relaxed wrist while delivering the taps with the tip of the finger, not the finger pad. This technique is repeated two or three times to determine the intensity, pitch, quality, and duration of the sound produced. Long fingernails limit the ability to percuss.
Percussion produces five distinguishable notes. These sounds assist the nurse in determining the density of the underlying structures (i.e., whether the lung tissue contains air or fluid or is solid). Percussion of the thorax is performed over the intercostal spaces because percussing the sternum, ribs, or scapulae yields sound indicating solid bone. Percussion penetrates only 2 to 3 inches (5 to 7 cm), and therefore deeper lesions are not detected with this technique.
Percussion begins with the client sitting in an upright position. The nurse assesses the posterior thorax first and proceeds systematically, beginning at the apex and working toward the base. The apex of the lung extends anteriorly approximately ¾ to 1 ½ inches (2 to 4 cm) above the clavicle. Posteriorly, there is approximately a 2-inch (5-cm) width of lung tissue at the apex.
The nurse assesses diaphragmatic excursion by instructing the client to “take a deep breath and hold it” while percussing downward until dullness is noted at the lower border of the lung. Normal resonance of the lung stops at the diaphragm, where the sound becomes dull; this site is marked. The nurse repeats the process after instructing the client to “let out all your breath and hold.” The difference between the two markings or sounds is the diaphragmatic excursion, which may range from 1 to 2 inches (3 to 5 cm). The diaphragm is normally higher on the right because of the location of the liver. Diaphragmatic excursion may be decreased or absent in clients with pleurisy, diaphragm paralysis, or emphysema.
The nurse continues to assess the thorax with percussion of the anterior and lateral chest. The percussion note changes from resonance of the normal lung to dullness at the borders of the heart and liver. The presence of fluid or solid material is indicated by a dull percussioote over lung tissue (as occurs with pneumonia, pleural effusion, fibrosis, atelectasis, and tumors).
Auscultation
Auscultation includes listening for normal breath sounds, adventitious sounds, and voice sounds. Auscultation provides information about the flow of air through the tracheo-bronchial tree and helps the listener to identify fluid, mucus, or obstruction in the respiratory system. The diaphragm of the stethoscope is designed to detect high-pitched sounds.
Auscultation begins with the client sitting in an upright position. With the stethoscope pressed firmly against the client’s chest wall (clothing can distort or muffle sounds), the nurse instructs him or her to breathe slowly and deeply through an open mouth. (Breathing through the nose would set up turbulent sounds that are transmitted to the lungs.) A systematic approach is used, beginning at the apices and moving down through the intercostal spaces to the bases. Listening over bony structures is avoided while auscultating the thorax posteriorly, laterally, and anteriorly. The nurse listens to a full respiratory cycle, noting the quality and intensity of the breath sounds. The client is observed for signs of lightheadedness or dizziness caused by hyperventilation during auscultation. If these symptoms occur, the client is told to breathe normally for a few minutes.
NORMAL BREATH SOUNDS
Normal breath sounds are produced as air vibrates while passing through the respiratory passages from the larynx to the alveoli. Breath sounds are identified by their location, intensity, pitch, and duration within the respiratory cycle (e.g., early or late inspiration and expiration). Normal breath sounds are known as bronchial or tubular (harsh hollow sounds heard over the trachea and mainstem bronchi), bronchovesicular (heard over the branching bronchi), and vesicular (a soft rustling sound heard in the periphery over small bronchioles). The nurse describes these sounds as normal, increased, decreased (diminished), or absent.
When bronchial breath sounds are heard peripherally, they are abnormal. This increased sound occurs when centrally generated bronchial sounds are transmitted to an area of increased density, such as in clients with atelectasis, tumor, or pneumonia. When audible in an abnormal location, bronchovesicular breath sounds may indicate normal aging or an abnormality such as pulmonary consolidation and chronic airway disease.
ADVENTITIOUS BREATH SOUNDS
Adventitious sounds are additional breath sounds superimposed oormal sounds, and they indicate pathologic changes in the tracheobronchial tree. Table 27-6 classifies and describes adventitious sounds: crackle, wheeze, rhonchus, and pleural friction rub. Adventitious sounds vary in pitch, intensity, duration, and the phase of the respiratory cycle in which they occur. The nurse documents exactly what is heard on auscultation.
VOICE SOUNDS
If the nurse discovers abnormalities during the physical assessment of the lungs and thorax, the client is assessed for vocal resonance. Auscultation of voice sounds through the normally air-filled lung produces a muffled, unclear sound because sound vibrations travel poorly through air. Vocal resonance is increased when the sound must travel through a solid or liquid medium, as it does in clients with a consolidated area of the lung, pneumonia, atelectasis, pleural effusion, tumor, or abscess.
BRONCHOPHONY. Bronchophony is the abnormally loud and clear transmission of voice sounds through an area of increased density. For assessment of bronchophony, the client repeats the number 99 while the nurse systematically auscultates the thorax.
WHISPERED PECTORILOQUY. Whispered pectoriloquy is the enhanced voice heard through the chest wall. It is much more sensitive than bronchophony and is perceived by having the client whisper the number sequence one, two, three. Whispered words normally sound faint and indistinct. If they are heard loudly and distinctly, the nurse suspects consolidation of lung tissue.
EGOPHONY. Egophony is another form of abnormally enhanced vocal resonance and has a high-pitched, bleating, nasal quality. The nurse auscultates the thorax while the client repeats the letter E. Egophony exists when this letter is heard as a flat, nasal sound of A through the stethoscope. This abnormal sound indicates an area of consolidation, pleural effusion, or abscess.
OTHER INDICATORS OF RESPIRATORY ADEQUACY
The nurse evaluates additional indicators of respiratory adequacy because gas exchange affects all body systems. Some indicators (e.g., cyanosis) indicate immediate oxygenation problems. Other changes (e.g., clubbing, weight loss, unevenly developed muscles) reflect a more long-standing oxygenation problem.
Skin and Mucous Membranes
The skin and mucous membranes are assessed for the presence of pallor or cyanosis, which could indicate inadequate ventilation. Areas to assess include the nail beds and the mucous membranes of the oral cavity. The fingers are examined for clubbing, which would indicate hypoxia of long duration.
General Appearance
The nurse observes the client for muscle development and general body build. Long-term respiratory problems are often associated with an inability to maintain body weight and a loss of general muscle mass. Arms and legs may appear thin or poorly muscled. The muscles of the neck and chest may be hypertrophied, especially in the client with chronic obstructive pulmonary disease (COPD).
Endurance
The nurse observes how easily the client moves and whether he or she is short of breath while resting or becomes short of breath when walking 10 to 20 steps. As the client speaks, the nurse observes how often he or she pauses for breath between words.
Psychosocial Assessment
The nurse assesses aspects of the client’s lifestyle that may significantly affect respiratory function. Some respiratory conditions may be worsened by stress. The nurse asks about present life stresses and usual coping mechanisms.
Chronic respiratory illnesses may cause changes in family roles and relationships, social isolation, financial problems, and unemployment or disability. By discussing coping mechanisms, the nurse assesses the client’s reaction to these psychosocial stressors and discovers strengths and ineffective behaviors. For example, the client may react to stress with dependence on family members, withdrawal, or noncompliance with interventions. After completing the psychosocial assessment, the nurse assists the client in determining the support systems available to help cope with respiratory impairment.
Diagnostic Assessment
I LABORATORY TESTS
Blood Tests
A red blood cell count provides data regarding the transport of oxygen from the lungs. A hemoglobin deficiency directly affects tissue oxygenation because hemoglobin transports oxygen to the cells and could cause hypoxemia.
Arterial blood gas (ABG) analysis assesses oxygenation (partial pressure of arterial oxygen [Pao2]), alveolar ventilation (partial pressure of arterial carbon dioxide [Paco2]), and acid-base balance. Blood gas studies provide valuable information for monitoring treatment results, adjusting oxygen therapy, and evaluating the client’s responses to treatment and therapy, such as during weaning from mechanical ventilation.
Sputum Tests
Sputum specimens obtained by expectoration or tracheal suctioning assist in the identification of pathogenic organisms or abnormal cells, such as in a malignancy or a hypersensitivity state. Sputum culture and sensitivity analyses identify bacterial infection with either gram-negative or gram-positive organisms and determine the vulnerability to specific antibiotics. Cytologic examination is performed on sputum to help diagnose malignant lesions by identifying cancer cells. Benign conditions, such as a hypersensitivity state, may also be identified by cytologic testing. Eosinophils and Curschmann’s spirals (a mucous form) are often found by cytologic study in clients with allergic asthma.
RADIOGRAPHIC EXAMINATIONS
Standard Radiography
Chest x-ray examinations are performed for clients with respiratory tract disorders to evaluate the present status of the chest and to provide a baseline for comparison with future changes. Standard chest x-ray examinations are performed from posteroanterior (PA; back to front) and left lateral (LL) projections. Portable chest x-ray studies (taken anteroposterior [AP], front to back) cost more, and the films produced are of lower quality and are more difficult for the radiologist to interpret. Consecutive, 10-mm cross-sectional views of the thorax and produces a three-dimensional assessment of the lungs and thorax.
Fat, cystic, and solid tissue can be distinguished with CT. By adding an intravenously injected contrast agent, vessels and other soft tissue structures can be identified. CT is especially valuable in studying the mediastinum, hilar region, and pleural space. The newer high-resolution CT (HRCT) uses 1.5- to 2-mm “slices” to assist in assessing bronchial abnormalities, interstitial disease, and emphysema. Nursing interventions for the client undergoing CT include education about the procedure and determination of the client’s sensitivity to the contrast medium (very important for anaphylaxis prevention).
Ventilation and Perfusion Scanning
A ventilation and perfusion scan (V/Q scan) identifies the areas of the lung being ventilated and the distribution of pulmonary blood. It is used primarily to support or rule out a diagnosis of pulmonary embolism.
To perform the study, the physician first injects a radionuclide with the client in a supine position and then takes six perfusion views: anterior, posterior, right and left lateral, and two obliques. If the perfusion scan is normal, there is no reason to continue with the ventilation scan. Otherwise, the client inhales a radioactive gas or radioaerosol, and the lung is scanned continuously—as the gas makes its way into the lungs (the “wash-in” phase), once the gas has reached equilibrium within the lungs, and then while the gas is leaving the lungs (the “wash-out” phase).
The nurse teaches the client about the procedure and explains that the radioactive substance clears from the body in approximately 8 hours.
OTHER NONINVASIVE DIAGNOSTIC TESTS
Pulse Oximetry
Pulse oximetry identifies hemoglobin saturation. Usually hemoglobin is almost 100% saturated with oxygen. The pulse oximeter uses a wave of infrared light and a sensor placed on the client’s finger, toe, nose, earlobe, or forehead. Ideal normal pulse oximetry values are 95% to 100%; values may be a little lower in older clients and in clients with dark skin. To avoid confusion with the Pao2 values from arterial blood gases, pulse oximetry readings are recorded as the Sao2 (arterial oxygen saturation), or Spo2.
A pulse oximetry reading can alert the nurse to desaturation before clinical signs occur (e.g., dusky skin, pale mucosa, and nail beds). The nurse considers client movement, hypothermia, decreased peripheral blood flow, ambient light (sunlight, infrared lamps), decreased hemoglobin, edema, and fingernail polish as possible causes for low readings. Covering the sensor or changing its positioning could yield better accuracy if too much ambient light is present.
Results lower than 91% (and certainly below 86%) constitute an emergency and necessitate immediate treatment. When the Sao2 is below 85%, the tissues of the body have a difficult time becoming oxygenated. An Sao2 of less than 70% is usually life threatening, but in some cases values below 80% may be life threatening. Pulse oximetry is less accurate at lower values.
Pulmonary Function Tests
Pulmonary function tests (PFTs) evaluate lung function and dysfunction and include studies such as lung volumes and capacities, flow rates, diffusion capacity, gas exchange, airway resistance, and distribution of ventilation. The physician interprets the results by comparing the client’s data with normal findings predicted according to age, gender, race, height, weight, and smoking status.
PFTs are useful in screening clients for pulmonary disease even before the onset of signs or symptoms. Serial testing provides objective data that may be used as a guide to treatment (e.g., changes in pulmonary function can support a decision to continue, change, or discontinue a specific therapy). Preoperative evaluation with PFTs may identify the client at risk for postoperative pulmonary complications. One of the most common reasons for performing such tests is to determine the cause of dyspnea. When performed while the client exercises, PFTs help to determine whether dyspnea is caused by pulmonary or cardiac dysfunction or by muscle deconditioning. These tests are also useful for determining the effect of the client’s occupation on pulmonary function and for evaluating any related disability for legal purposes.
CLIENT PREPARATION. The nurse prepares the client for PFTs by explaining the purpose of the tests for planning care. He or she is advised not to smoke for 6 to 8 hours before testing. According to institutional policy and procedure, bronchodilator medication is withheld for 4 to 6 hours before the test. The client with respiratory impairment often fears further breathlessness and is usually anxious before these “breathing” tests. The nurse helps to reduce apprehension by describing what will be experienced during and after the testing.
PROCEDURE. PFTs can be performed at the bedside or in the respiratory laboratory. The client is asked to breathe through the mouth only. A nose clip may be used to prevent air from escaping. The client performs different breathing maneuvers while measurements are obtained.
FOLLOW-UP CARE. Because numerous breathing maneuvers are performed during PFTs, the nurse observes for increased dyspnea or bronchospasm after such studies. The nurse documents whether bronchodilator medication was administered during testing and alters the client’s medication schedule as indicated.
Exercise Testing
Exercise, or activity in general, increases metabolism and gas transport as energy is generated. These tests are performed on a treadmill or bicycle or by a self-paced 12-minute walking test. The normal client’s exercise is limited by hemodynamic factors, whereas the pulmonary client is limited by ventilatory capacity, pulmonary gas exchange compromise, or both. The nurse explains exercise testing and assures the client of close monitoring by trained professionals throughout the test.
Skin Tests
Skin tests are used in combination with other diagnostic data to identify various infectious diseases (e.g., tuberculosis), viral diseases (e.g., mononucleosis and mumps), and fungal diseases (e.g., coccidioidomycosis and histoplasmosis). The presence of allergic hypersensitivity and the status of the immune system can be demonstrated through skin testing. Exposure to the allergen or organism used in testing produces a specific reaction (delayed hypersensitivity reaction) of the client’s immune system.
Magnetic Resonance Imaging
Magnetic resonance imaging (MRI) is used in the diagnosis of respiratory system disorders to provide information about the type and condition of the tissues being imaged along any plane inside the body: vertically, horizontally, and diagonally. This costly procedure requires little client preparation other than the removal of all metal objects. Because of the powerful magnets used in MRI, clients with pacemakers, aneurysm clips, inner-ear implants, cardiac valves, or any other metallic foreign objects in the body are not candidates for MRI.
The nurse informs the client of possible claustrophobia and discomfort from lying on a hard, cool table inside the magnet’s small cylinder. The nurse instructs the client in the use of relaxation techniques and imagery to help decrease these sensations. Sedation may be necessary in some cases. The nurse explains that the noises heard during the examination are the natural, rhythmic sounds of radiofrequency pulses. These noises may range from barely audible to noticeable.
OTHER INVASIVE DIAGNOSTIC TESTS
Endoscopic Examinations
Endoscopic diagnostic studies to assess respiratory disorders include bronchoscopy, laryngoscopy, and mediastinoscopy. The most common complications are those related to the medications and bleeding.
Thoracentesis
Thoracentesis is used for diagnosis or treatment and involves the aspiration of pleural fluid or air from the pleural space. Microscopic examination of the pleural fluid helps in making a diagnosis. Pleural fluid may be drained to relieve pulmonary compression and the resultant respiratory distress caused by cancer, empyema, pleurisy, or tuberculosis. Thoracentesis is often followed by pleural biopsy to assist in further assessment of the parietal pleura. Thoracentesis also allows the instillation of medications into the pleural space.
CLIENT PREPARATION. Adequate client preparation is essential before thoracentesis to ensure cooperation during the procedure and to prevent complications. The nurse tells the client to expect a stinging sensation from the local anesthetic agent and a feeling of pressure when the needle is inserted. The nurse reinforces the importance of not moving during the procedure (avoiding coughing, deep breathing, or sudden movement) to avoid puncture of the visceral pleura or lung.
These positions widen the intercostal spaces and permit easy access to the pleural fluid. The nurse properly positions and physically supports the client. Pillows are used to make the client comfortable and to provide physical support.
Before the procedure, the nurse checks the client’s history for hypersensitivity to local anesthetic agents and checks to make sure the client has signed an informed consent. The entire chest or back is exposed, and the aspiration site is shaved if necessary. The actual site depends on the volume and location of the effusion, which are determined by radiography and physical examination procedures such as percussion.
PROCEDURE. Thoracentesis is usually performed at the bedside, although ultrasonography or computed tomography may be used to guide it. After draping the client and cleaning the skin with a germicidal solution, the physician uses aseptic technique and injects a local anesthetic agent into the selected intercostal space. The nurse keeps the client informed of the procedure while observing for shock, pain, nausea, pallor, diaphoresis, cyanosis, tachypnea, and dyspnea.
The physician advances the short 18- to 25-gauge thoracentesis needle (with an attached syringe) into the pleural space. Gentle suction is applied as the fluid in the pleural space is slowly aspirated. A vacuum collection bottle is sometimes necessary to remove larger volumes of fluid. To prevent re-expansion pulmonary edema, usually no more than 1000 mL of fluid is removed at one time. If a pleural biopsy is to be performed, a second, larger needle with a cutting edge and collection chamber is used. After the physician withdraws the needle, pressure is applied to the puncture site, and a small sterile dressing is applied.
FOLLOW-UP CARE. After thoracentesis, the physician orders a chest x-ray study to rule out possible pneumothorax and subsequent mediastinal shift (shift of center thoracic structure toward one side). The nurse monitors the client’s vital signs and auscultates breath sounds while noting absent or diminished sounds on the affected side. The puncture site and dressing are observed for leakage or bleeding. The nurse also assesses for other complications, such as reaccumulation of fluid in the pleural space, subcutaneous emphysema, pyrogenic infection, and tension pneumothorax. The client is encouraged to breathe deeply to promote reexpansion of the lung. The nurse documents the procedure, including the client’s tolerance, the volume and character of the fluid removed, any specimens sent to the laboratory, the location of the puncture site, and respiratory assessment findings before, during, and after the procedure.
Lung Biopsy
A lung biopsy is performed to obtain tissue for histologic analysis, culture, or cytologic examination. The physician uses tissue samples to make a definite diagnosis regarding the type of malignancy, infection, inflammation, or lung disease. Biopsy procedures include transbronchial biopsy (TBB) and transbronchial needle aspiration (TBNA), both of which are performed during bronchoscopy; transthoracic needle aspiration (percutaneous approach for areas not accessible by bronchoscopy); and open lung biopsy (in the operating room).
CLIENT PREPARATION. The client may have predetermined ideas about the outcome of the biopsy and may closely associate the terms biopsy and cancer. Therefore the nurse explains what to expect before and after the procedure and explores the client’s feelings and fears. To reduce discomfort and anxiety, the physician may prescribe an analgesic or sedative before the procedure. The nurse informs the client undergoing percutaneous biopsy that discomfort is minimized with a local anesthetic agent but that a sensation of pressure may be experienced during needle insertion and tissue aspiration. Open lung biopsy is usually performed in the operating room with the client under general anesthesia, and the usual preoperative preparations apply.
PROCEDURE. Percutaneous lung biopsy may be performed in the client’s room or in the radiology department after an informed consent has been obtained. Fluoroscopy, CT, or ultrasonography is often used to better visualize the area undergoing biopsy and to guide the procedure. Positioning of the client is similar to that for thoracentesis. The physician cleans the skin with an antibacterial agent and administers a local anesthetic agent. Under sterile conditions, the physician inserts a spinal-type 18- to 22-gauge needle through the skin into the desired area (e.g., tissue, nodule, or lymph node) and obtains the tissue needed for microscopic examination. The nurse applies a dressing after the procedure.
An open lung biopsy is performed in the operating room. The client undergoes a thoracotomy where lung tissue is exposed. At least two tissue specimens are taken (usually from an upper lobe and a lower lobe site). The surgeon places a chest tube to remove air and fluid so the lung can reinflate and then closes the chest.
FOLLOW-UP CARE. The nurse monitors the client’s vital signs and breath sounds every 4 hours for 24 hours and assesses for signs of respiratory distress (e.g., dyspnea, pallor, diaphoresis, and tachypnea). Pneumothorax is a serious complication of needle biopsy and open lung biopsy, and therefore it is important for the nurse to report untoward signs and symptoms promptly. The nurse also monitors for hemoptysis (which may be scant and transient) or, in rare cases, for frank bleeding from vascular or lung trauma.
Signs of Respiratory Distress
Learning the signs of respiratory distress
People having difficulty breathing often show signs that they are not getting enough oxygen, indicating respiratory distress. Below is a list of some of the signs that may indicate that a person is not getting enough oxygen. It is important to learn the symptoms of respiratory distress to know how to respond appropriately. Always consult your doctor for a diagnosis.
· Breathing rate
An increase in the number of breaths per minute may indicate that a person is having trouble breathing or not getting enough oxygen.
· Color changes
A bluish color seen around the mouth, on the inside of the lips, or on the fingernails may occur when a person is not getting as much oxygen as needed. The color of the skin may also appear pale or gray.
· Grunting
A grunting sound can be heard each time the person exhales. This grunting is the body’s way of trying to keep air in the lungs so they will stay open.
· Nose flaring
The openings of the nose spreading open while breathing may indicate that a person is having to work harder to breathe.
· Retractions
The chest appears to sink in just below the neck and/or under the breastbone with each breath–one way of trying to bring more air into the lungs.
· Sweating
There may be increased sweat on the head, but the skin does not feel warm to the touch. More often, the skin may feel cool or clammy. This may happen when the breathing rate is very fast.
· Wheezing
A tight, whistling or musical sound heard with each breath may indicate that the air passages may be smaller (tighter), making it harder to breathe.
Persons who are having a difficult time breathing often show signs that they are not getting enough oxygen, indicating respiratory distress. Below is a list of some of the signs that may indicate that a person is not getting enough oxygen. It is important to learn the symptoms of respiratory distress to know how to respond appropriately. Always consult your physician for a diagnosis.
· breathing rate
An increase in the number of breaths per minute may indicate that a person is having trouble breathing or not getting enough oxygen.
· color changes
A bluish color seen around the mouth, on the inside of the lips, or on the fingernails may occur when a person is not getting as much oxygen as needed. The color of the skin may also appear pale or gray.
· grunting
A grunting sound can be heard each time the person exhales. This grunting is the body’s way of trying to keep air in the lungs so they will stay open.
· nose flaring
The openings of the nose spreading open while breathing may indicate that a person is having to work harder to breathe.
· retractions
The chest appears to sink in just below the neck and/or under the breastbone with each breath – one way of trying to bring more air into the lungs.
· sweating
There may be increased sweat on the head, but the skin does not feel warm to the touch. More often, the skin may feel cool or clammy. This may happen when the breathing rate is very fast.
· wheezing
A tight, whistling or musical sound heard with each breath may indicate that the air passages may be smaller, making it more difficult to breathe.
There are many types of lung problems that require clinical care by a physician or other healthcare professional. Listed below are some of the conditions, for which we have provided a brief overview.
If you cannot find the condition in which you are interested, please visit the page in this Web site for an Internet/World Wide Web address that may contain additional information on that topic.
Chronic Obstructive Pulmonary Disease
Chronic Obstructive Pulmonary Disease or COPD is a very common disease that effects more than 12 million individuals in the United States. It is the fourth leading cause of death. COPD is a term used to describe patients with emphysema,chronic bronchitis or a combination of both.
Symptoms of COPD include:
· Shortness of breath with activity or while resting
· Wheezing
· Chest tightness
· A daily or almost daily cough cough that produces mucus
Asthma
What is asthma?
Asthma is a chronic, inflammatory lung disease involving recurrent breathing problems. The characteristics of asthma are three airway problems:
· obstruction
· inflammation
· hyper-responsiveness
What are the symptoms of asthma?
The following are the most common symptoms for asthma. However, each individual may experience symptoms differently.
In some cases, the only symptom is a chronic cough, especially at night, or coughing or wheezing that occurs only with exercise. Some people think they have recurrent bronchitis, since respiratory infections usually settle in the chest in a person predisposed to asthma.
Asthma may resemble other respiratory problems such as emphysema, bronchitis, and lower respiratory infections. If it is not detected, many people with asthma do not know they have it. Consult your physician for a diagnosis.
What causes asthma?
The basic cause of the lung abnormality in asthma is not yet known, although healthcare professionals have established that it is a special type of inflammation of the airway that leads to the following:
· contraction of airway muscles
· mucus production
· swelling in the airways
It is important to know that asthma is not caused by emotional factors – as commonly believed years ago. Emotional anxiety and nervous stress can cause fatigue, which may affect the immune system and increase asthma symptoms, or aggravate an attack. However, these reactions are considered to be more of an effect than a cause.
What happens during an asthma attack?
Persons with asthma have acute episodes when the air passages in their lungs get narrower, and breathing becomes more difficult. These problems are caused by an oversensitivity of the lungs and airways.
· Lungs and airways overreact to certain triggers and become inflamed and clogged.
· Breathing becomes harder and may hurt.
· There may be coughing.
· There may be a wheezing or whistling sound, which is typical of asthma. Wheezing occurs because:
· muscles that surround the airways tighten, and the inner lining of the airways swells and pushes inward.
· membranes that line the airways secrete extra mucus.
· the mucus can form plugs that further block the air passages.
· the rush of air through the narrowed airways produces the wheezing sounds.
What are the risk factors for an asthma attack?
Although anyone may have an asthma attack, it most commonly occurs in:
· children and adolescents ages 5 to 17 years
· adults older than 65
· people living in urban communities
Other factors include:
· family history of asthma
· personal medical history of allergies
How is asthma diagnosed?
To diagnose asthma and distinguish it from other lung disorders, physicians rely on a combination of medical history, physical examination, and laboratory tests, which may include:
·
spirometry – a spirometer is a device used by your physician that assesses lung function. Spirometry, the evaluation of lung function with a spirometer, is one of the simplest, most common pulmonary function tests and may be necessary for any/all of the following reasons:
· to determine how well the lungs receive, hold, and utilize air
· to monitor a lung disease
· to monitor the effectiveness of treatment
· to determine the severity of a lung disease
· to determine whether the lung disease is restrictive (decreased airflow) or obstructive (disruption of airflow)
· peak flow monitoring (PFM) – a device used to measure the fastest speed in which a person can blow air out of the lungs. During an asthma or other respiratory flare up, the large airways in the lungs slowly begin to narrow. This will slow the speed of air leaving the lungs and can be measured by a PFM. This measurement is very important in evaluating how well or how poorly the disease is being controlled.
· chest x-rays – a diagnostic test which uses invisible electromagnetic energy beams to produce images of internal tissues, bones, and organs onto film.
· blood tests – to analyze the amount of carbon dioxide and oxygen in the blood.
· allergy tests
Treatment for asthma:
Specific treatment for asthma will be determined by your physician based on:
· your age, overall health, and medical history
· extent of the disease
· your tolerance for specific medications, procedures, or therapies
· expectations for the course of the disease
· your opinion or preference
As of yet, there is no cure for asthma. However, it can often be controlled with prescription medications that may help to prevent or relieve symptoms, and by learning ways to manage episodes.
Managing asthma:
People with asthma can learn to identify and avoid the things that trigger an episode, and educate themselves about medications and other asthma management strategies.
According to the Guidelines for the Diagnosis and Management of Asthma, published by the National Heart, Lung, and Blood Institute:
· Asthma is a chronic disease. It has to be cared for all the time – not just when symptoms are present.
· The four parts of continually managing asthma are:
· Identify and minimize contact with asthma triggers.
· Understand and take medications as prescribed.
· Monitor asthma to recognize signs when it is getting worse.
· Know what to do when asthma gets worse.
· Working with a healthcare professional is the best way to take care of asthma.
· The more information a person with asthma has, the better asthma can be controlled.
Four components of asthma treatment:
1. The use of objective measures of lung function- spirometry, peak flow expiratory flow rate – to access the severity of asthma, and to monitor the course of treatment.
2. The use of medication therapy designed to reverse and prevent the airway inflammation component of asthma, as well as to treat the narrowing airways.
3. The use of environmental control measures to avoid or eliminate factors that induce or trigger asthma flare-ups, including the consideration of immunotherapy.
4. Patient education that includes a partnership among the patient, family members, and the physician.
Chronic Bronchitis
Chronic Bronchitis
Click Image to Enlarge
What is chronic bronchitis?
Chronic bronchitis is a long-term inflammation of the bronchi, which results in increased production of mucus, as well as other changes.
To be classified as chronic bronchitis:
· cough and expectoration must occur most days for at least three months per year, for two years in a row.
· other causes of symptoms, such as tuberculosis or other lung diseases, must be excluded.
What are the symptoms of chronic bronchitis?
The following are the most common symptoms for chronic bronchitis. However, each individual may experience symptoms differently. Symptoms may include:
· cough
· expectoration (spitting out) of mucus
Chronic bronchitis may cause:
· frequent and severe respiratory infections
· narrowing and plugging of the breathing tubes (bronchi)
· difficult breathing
· disability
Other symptoms may include:
· lips and skin may appear blue
· abnormal lung signs
· swelling of the feet
· heart failure
The symptoms of chronic bronchitis may resemble other lung conditions or medical problems. Consult your physician for a diagnosis.
What are the causes of chronic bronchitis?
In acute bronchitis, bacteria or viruses may be the cause, but in chronic bronchitis there is no specific organism recognized as the cause of the disease.
Cigarette smoking is cited as the most common contributor to chronic bronchitis, followed by:
· bacterial or viral infections
· environmental pollution (chemical fumes, dust, and other substances)
Chronic bronchitis is often associated with other pulmonary diseases such as:
· pulmonary emphysema
· pulmonary fibrosis
· asthma
· tuberculosis
· sinusitis
· upper respiratory infections
How is chronic bronchitis diagnosed?
In addition to a complete medical history and physical examination, your physician may request the following:
· pulmonary function tests – diagnostic tests that help to measure the lungs’ ability to exchange oxygen and carbon dioxide appropriately. The tests are usually performed with special machines that the person must breathe into, and may include the following:
· spirometry – a spirometer is a device used by your physician that assesses lung function. Spirometry, the evaluation of lung function with a spirometer, is one of the simplest, most common pulmonary function tests and may be necessary for any/all of the following reasons:
· to determine how well the lungs receive, hold, and utilize air
· to monitor a lung disease
· to monitor the effectiveness of treatment
· to determine the severity of a lung disease
· to determine whether the lung disease is restrictive (decreased airflow) or obstructive (disruption of airflow)
· peak flow monitoring (PFM) – a device used to measure the fastest speed in which a person can blow air out of the lungs. During an asthma or other respiratory flare up, the large airways in the lungs slowly begin to narrow. This will slow the speed of air leaving the lungs and can be measured by a PFM. This measurement is very important in evaluating how well or how poorly the disease is being controlled.
· arterial blood gas (ABG) – a blood test that is used to evaluate the lungs’ ability to provide blood with oxygen and remove carbon dioxide, and to measure the pH (acidity) of the blood.
· pulse oximetry – an oximeter is a small machine that measures the amount of oxygen in the blood. To obtain this measurement, a small sensor (like a Band-Aid) is taped onto a finger or toe. When the machine is on, a small red light can be seen in the sensor. The sensor is painless and the red light does not get hot.
· x-ray – a diagnostic test which uses invisible electromagnetic energy beams to produce images of internal tissues, bones, and organs onto film.
· computed tomography scan (Also called a CT or CAT scan.) – a diagnostic imaging procedure that uses a combination of x-rays and computer technology to produce cross-sectional images (often called slices), both horizontally and vertically, of the body. A CT scan shows detailed images of any part of the body, including the bones, muscles, fat, and organs. CT scans are more detailed than general x-rays.
Treatment for chronic bronchitis:
Specific treatment for chronic bronchitis will be determined by your physician based on:
· your age, overall health, and medical history
· extent of the disease
· your tolerance for specific medications, procedures, or therapies
· expectations for the course of the disease
· your opinion or preference
Treatment may include:
· oral medications
· bronchodilators for inhaled medications
· oxygen supplementation from portable containers
· lung reduction surgery to remove damaged area of lung
· lung transplantation
What is Chronic Obstructive Pulmonary Disease (COPD)?
COPD is a term that refers to a large group of lung diseases which can interfere with normal breathing. More than 12 million Americans have COPD, and an additional 12 million may have impaired lung function, suggesting it may be significantly under-reported. As many as 24 million people may be affected. The two most common conditions of COPD are chronic bronchitis and emphysema.
The causes of COPD are not fully understood. It is generally agreed that the most important cause of chronic bronchitis and emphysema is cigarette smoking. Causes such as air pollution and occupational exposures may play a role, especially when combined with cigarette smoking. Heredity also plays a contributing role in some patients’ emphysema, and is especially important in a rare form – due to alpha 1 anti-trypsin deficiency.
Patients with chronic bronchitis usually have a cough and sputum production for many years before they develop shortness of breath.
Patients with emphysema usually have shortness of breath and develop a cough and sputum during a respiratory infection, or in the later stages of the illness.
Pulmonary Emphysema
What is pulmonary emphysema?
Emphysema is a chronic lung condition in which alveoli, or air sacs, may be:
· destroyed
· narrowed
· collapsed
· stretched
· over-inflated
Over-inflation of the air-sacs is a result of a breakdown of the walls of the alveoli, and causes a decrease in respiratory function and breathlessness. Damage to the air sacs is irreversible and results in permanent “holes” in the tissues of the lower lungs.
What are the symptoms of pulmonary emphysema?
The following are the most common symptoms for pulmonary emphysema. However, each individual may experience symptoms differently.
Early symptoms of pulmonary emphysema may include:
· shortness of breath
· cough
Other symptoms may include:
· fatigue
· anxiety
· sleep problems
· heart problems
· weight loss
· depression
The symptoms of pulmonary emphysema may resemble other lung conditions or medical problems. Consult your physician for a diagnosis.
What are the causes of pulmonary emphysema?
Emphysema does not develop suddenly, but occurs very gradually. The lung has a system of elastic fibers that allow the lungs to expand and contract. Pulmonary emphysema occurs when a breakdown in the chemical balance that protects the lungs against the destruction of the elastic fibers occurs.
There are a number of reasons for the breakdown in chemical balance:
· smoking
· exposure to air pollution (chemical fumes, dust, and other substances)
· irritating fumes and dusts on the job
· a rare, inherited form of the disease called alpha 1-antitrypsin (AAT) deficiency-related pulmonary emphysema, or early onset pulmonary emphysema
How is pulmonary emphysema diagnosed?
In addition to a complete medical history and physical examination, the physician may request the following:
· pulmonary function tests – diagnostic tests that help to measure the lungs’ ability to exchange oxygen and carbon dioxide appropriately. The tests are usually performed with special machines into which the person must breathe, and may include the following:
·
·
spirometry – a spirometer is a device used by your physician that assesses lung function. Spirometry, the evaluation of lung function with a spirometer, is one of the simplest, most common pulmonary function tests and may be necessary for any/all of the following reasons:
· to determine how well the lungs receive, hold, and utilize air
· to monitor a lung disease
· to monitor the effectiveness of treatment
· to determine the severity of a lung disease
· to determine whether the lung disease is restrictive (decreased airflow) or obstructive (disruption of airflow)
· peak flow monitoring (PFM) – a device used to measure the fastest speed in which a person can blow air out of the lungs. During an asthma or other respiratory flare up, the large airways in the lungs slowly begin to narrow. This will slow the speed of air leaving the lungs and can be measured by a PFM. This measurement is very important in evaluating how well or how poorly the disease is being controlled.
· blood tests – to analyze the amount of carbon dioxide and oxygen in the blood.
· chest x-ray – a diagnostic test which uses invisible electromagnetic energy beams to produce images of internal tissues, bones, and organs onto film.
· sputum culture – a diagnostic test performed on the material that is coughed up from the lungs and into the mouth. A sputum culture is often performed to determine if an infection is present.
· electrocardiogram (ECG or EKG) – a test that records the electrical activity of the heart, shows abnormal rhythms (arrhythmias or dysrhythmias), and detects heart muscle damage.
Treatment for pulmonary emphysema:
Specific treatment for pulmonary emphysema will be determined by your physician based on:
· your age, overall health, and medical history
· extent of the disease
· your tolerance for specific medications, procedures, or therapies
· expectations for the course of the disease
· your opinion or preference
The goal of treatment for people with pulmonary emphysema is to live more comfortably with the disease by providing relief of symptoms and preventing progression of the disease with minimal side effects. Treatment may include:
· quitting smoking – the single most important factor for maintaining healthy lungs
· antibiotics for bacterial infections
· oral medications
· bronchodilators and other inhaled medications
· exercise – including breathing exercises to strengthen the muscles used in breathing as part of a pulmonary rehabilitation program to condition the rest of the body
· oxygen supplementation from portable containers
· lung reduction surgery to remove damaged area of the lung
· lung transplantation
Acute Bronchitis
What is acute bronchitis?
Bronchitis is an inflammation of the breathing tubes (airways) that are called bronchi, which causes increased production of mucus and other changes. Although there are several different types of bronchitis, the two most common are acute and chronic.
Acute bronchitis is the inflammation of mucous membranes of the bronchial tubes.
What causes acute bronchitis?
Acute bronchitis is usually caused by infectious agents such as bacteria or viruses. It may also be caused by physical or chemical agents–dusts, allergens, strong fumes–and those from chemical cleaning compounds, or tobacco smoke. Acute asthmatic bronchitis may happen as the result of an asthma attack, or it may be the cause of an asthma attack.
Acute bronchitis is usually a mild, and self-limiting condition, with complete healing and return to function.
Acute bronchitis may follow the common cold or other viral infections in the upper respiratory tract. It may also occur in people with chronic sinusitis, allergies, or those with enlarged tonsils and adenoids. It can be serious in people with pulmonary or cardiac diseases. Pneumonia is a complication that can follow bronchitis.
What are the symptoms acute bronchitis?
The following are the most common symptoms for acute bronchitis. However, each individual may experience symptoms differently. Symptoms may include:
· Runny nose
· Malaise
· Chills
· Slight fever
· Back and muscle pain
· Sore throat
· Wheezing
· Early–dry, nonproductive cough
· Later–abundant mucus-filled cough
· Shortness of breath
The symptoms of acute bronchitis may resemble other conditions or medical problems. Consult your doctor for a diagnosis.
How is acute bronchitis diagnosed?
Acute bronchitis is usually diagnosed by completing a medical history and physical examination. Many tests may be ordered to rule out other diseases, such as pneumonia or asthma. The following tests may be ordered to help confirm a diagnosis:
· Chest X-rays—diagnostic tests which uses invisible electromagnetic energy beams to produce images of internal tissues, bones, and organs onto film.
· Arterial blood gas–to analyze the amount of carbon dioxide and oxygen in the blood.
· Pulse oximetry—an oximeter is a small machine that measures the amount of oxygen in the blood. To obtain this measurement, a small sensor (like a Band-Aid) is taped onto a finger or toe. When the machine is on, a small red light can be seen in the sensor. The sensor is painless and the red light does not get hot.
· Cultures of nasal discharge and sputum—a test used to find and identify the microorganism causing an infection.
· Lung (pulmonary function) tests—diagnostic tests that help to measure the ability of the lungs to exchange oxygen and carbon dioxide appropriately. The tests are usually performed with special machines that a person must breathe into.
Treatment for acute bronchitis
Specific treatment for acute bronchitis will be determined by your doctor based on:
· Your age, overall health, and medical history
· Extent of the disease
· Your tolerance for specific medications, procedures, or therapies
· Expectations for the course of the disease
· Your opinion or preference
In most cases, antibiotic treatment is not necessary to treat acute bronchitis, since most of the infections are caused by viruses. If the condition has progressed to pneumonia, then antibiotics may be appropriate. Most of the treatment is designed to address the symptoms, and may include:
· Analgesics, such as acetaminophen for fever and discomfort
· Cough medicine
· Increased fluid intake
· Increase in humidity
· Smoking cessation
Antihistamines should be avoided in most cases because they dry up the secretions and can make the cough worse.
Pneumonia
What is pneumonia?
Pneumonia is an inflammation of the lungs caused by bacteria, viruses, or chemical irritants. It is a serious infection or inflammation in which the air sacs fill with pus and other liquid.
· Lobar pneumonia affects one or more sections (lobes) of the lungs.
· Bronchial pneumonia (or bronchopneumonia) affects patches throughout both lungs.
What are the different types of pneumonia?
The main types of pneumonia are:
· Bacterial pneumonia is caused by various bacteria. The Streptococcus pneumoniae is the most common bacterium that causes bacterial pneumonia.
It usually occurs when the body is weakened in some way, such as illness, malnutrition, old age, or impaired immunity, and the bacteria are able to work their way into the lungs. Bacterial pneumonia can affect all ages, but those at greater risk include the following:
· persons who abuse alcohol
· persons who are debilitated
· post-operative patients
· persons with respiratory diseases or viral infections
· persons who have weakened immune systems
The symptoms of bacterial pneumonia include:
· shaking, chills
· chattering teeth
· severe chest pain
· high temperature
· heavy perspiring
· rapid pulse
· rapid breathing
· bluish color to lips and nailbeds
· confused mental state or delirium
· cough that produces rust-colored or greenish mucus
· Viral pneumonia is caused by various viruses, and is the cause of half of all cases of pneumonia.
Early symptoms of viral pneumonia are the same as those of bacterial pneumonia, which may be followed by increasing breathlessness and a worsening of the cough.
Viral pneumonias may make a person susceptible to bacterial pneumonia.
· Mycoplasma pneumonia has somewhat different symptoms and physical signs. It is caused by mycoplasmas, the smallest free-living agents of disease in humankind, which have the characteristics of both bacteria and viruses, but which are not classified as either. They generally cause a mild, widespread pneumonia that affects all age groups.
Symptoms include a severe cough that may produce some mucus.
· Other less common pneumonias may be caused by the inhaling of food, liquid, gases or dust, or by fungi.
How is pneumonia diagnosed?
Diagnosis is usually made based on the season and the extent of the illness. Based on these factors, your physician may diagnose simply on a thorough history and physical examination, but may include the following tests to confirm the diagnosis:
· chest x ray – a diagnostic test which uses invisible electromagnetic energy beams to produce images of internal tissues, bones, and organs onto film.
· blood tests – to analyze the amount of carbon dioxide and oxygen in the blood.
· sputum culture – a diagnostic test performed on the material that is coughed up from the lungs and into the mouth. A sputum culture is often performed to determine if an infection is present.
· pulse oximetry – an oximeter is a small machine that measures the amount of oxygen in the blood. To obtain this measurement, a small sensor (like a Band-Aid) is taped onto a finger or toe. When the machine is on, a small red light can be seen in the sensor. The sensor is painless and the red light does not get hot.
· chest CT scan – a test that takes images of the structure in the chest
· bronchoscopy – a procedure used to look inside the airways of the lungs
· pleural fluid culture– a culture of fluid sample taken from the pleural space (space between the lungs and chest wall) to identify the bacteria that cause pneumonia
Treatment for pneumonia:
Specific treatment will be determined by your physician based on:
· your age, overall health, and medical history
· extent of the disease
· your tolerance for specific medications, procedures, or therapies
· expectations for the course of the disease
· your opinion or preference
Treatment may include antibiotics for bacterial pneumonia. Antibiotics may also speed recovery from mycoplasma pneumonia and some special cases. There is no clearly effective treatment for viral pneumonia, which usually heals on its own.
Other treatment may include appropriate diet, oxygen therapy, pain medication, and medication for cough.
Tuberculosis
Tuberculosis
What is tuberculosis?
Tuberculosis (TB) is a chronic bacterial infection that usually infects the lungs, although other organs are sometimes involved. TB is primarily an airborne disease.
There is a difference between being infected with the TB bacterium and having active tuberculosis disease.
There are three important ways to describe the stages of TB. They are as follows:
1. Exposure: This occurs when a person has been in contact, or exposed to, another person who is thought to have or does have TB. The exposed person will have a negative skin test, and normal chest x-ray, and no signs or symptoms of the disease.
2. Latent TB infection: This occurs when a person has the TB bacteria in his/her body, but does not have symptoms of the disease. This person would have a positive skin test, but a normal chest x-ray.
3. TB disease: This describes the person that has signs and symptoms of an active infection. The person would have a positive skin test and a positive chest x-ray.
The predominant TB bacterium is Mycobacterium tuberculosis (M. tuberculosis). Several people infected with M. tuberculosis never develop active TB. However, in people with weakened immune systems, especially those with HIV (human immunodeficiency virus), TB organisms can overcome the body’s defenses, multiply, and cause an active disease.
Who is at risk for developing TB?
TB affects all ages, races, income levels, and both genders. Those at higher risk include the following:
· people who live or work with others who have TB
· medically underserved populations
· homeless people
· people from other countries where TB is prevalent
· people in group settings, such as nursing homes
· people who abuse alcohol
· people who use intravenous drugs
· people with impaired immune systems
· the elderly
· healthcare workers who come in contact with high-risk populations
What are the symptoms of TB?
The following are the most common symptoms for TB. However, each individual may experience symptoms differently.
· cough that will not go away
· fatigue
· loss of appetite
· loss of weight
· fever
· coughing blood
· night perspiring
The symptoms of TB may resemble other lung conditions or medical problems. Consult a physician for a diagnosis.
What causes TB?
The TB bacterium is spread through the air when an infected person coughs, sneezes, speaks, sings, or laughs; however, repeated exposure to the germs is usually necessary before a person will become infected. It is not likely to be transmitted through personal items, such as clothing, bedding, a drinking glass, eating utensils, a handshake, a toilet, or other items that a person with TB has touched. Adequate ventilation is the most important measure to prevent the transmission of TB.
How is TB diagnosed?
TB is diagnosed with a TB skin test. In this test, a small amount of testing material is injected into the top layer of the skin. If a certain size bump develops within two or three days, the test may be positive for tuberculosis infection. Additional tests to determine if a person has TB disease include x-rays and sputum tests.
TB skin tests are suggested for those:
· in high-risk categories.
· who live or work in close contact with people who are at high-risk.
· who have never had a TB skin test.
Recommendations for skin testing in children, from the American Academy of Pediatrics are as follows:
Immediate testing:
· If the child is thought to have been exposed in the last 5 years.
· If the child has an x-ray that looks like TB.
· If the child has any symptoms of TB.
· A child who is coming from countries where TB is prevalent.
Yearly skin testing:
· Children with HIV.
· Children who are in jail.
Testing every 2 to 3 years:
· Children who are exposed to high-risk people.
Consider testing in children from ages 4 to 6 and 11 to 16 if:
· A child’s parent has come from a high-risk country.
· A child has traveled to high-risk areas.
· Children who live in densely populated areas.
Treatment for tuberculosis:
Specific treatment will be determined by your physician based on:
· your age, overall health, and medical history
· extent of the disease
· your tolerance for specific medications, procedures, or therapies
· expectations for the course of the disease
· your opinion or preference
Treatment may include:
· short-term hospitalization
· medications – isoniazid, rifampin, pyrazinamide, ethambutol, or streptomycin, may be prescribed for a period of time up to six months or more for the medication to be effective. Patients usually begin to improve within a few weeks of the start of treatment. After two weeks of treatment with the correct medications, the patient is not usually contagious, provided that treatment is carried through to the end, as prescribed by a physician.
