RESPIRATORY ASSESSMENT

LESSON #6

Internet Resources of Interest:

Kansas Continuing Learning Project: for advanced nurse practitioners

http://www2.kumc.edu/kclp

from this site, then go to http://fhsu.edu.nursing/cxr/

A chest x-ray interpretation course

Virtual Hospital: links to pulmonary disease and clinical radiology

http://www.vh.org/Providers/Lectures/icrad

Health Answers: Pulmonary disease and radiology examples

http://www.healthanswers.com/centers/

Online teaching book: main teaching file (select type of case, has case

example with questions and answers (quick cases)

http://rad.washington.edu

Pediatric radiology: (402 diseases in 1596 cases):

http://pediaatricradiology.com

Other sites:

http://www.expertsweb.com

http://www.medmatrix.org

GENERAL CONSIDERATIONS

· Pulmonary disease occurs when the lungs are unable to provide

adequate oxygenation or to eliminate carbon dioxide

· During a 24 hour period, lungs oxygenate more than 5700 liters

of blood with more than 11,400 liters of air in the lungs

EPIDEMIOLOGY

· Estimates of pulmonary disease in the U.S. annually, include over

80,000 deaths from chronic lung disease, over 5 million cases with

pulmonary disability & more than 20 million cases with pulmonary symptoms

· Cancer of the lung is the leading cause of death from cancer in the U.S.,

with the incidence in women increasing over that of men

COMMON RESPIRATORY - PULMONARY DISORDERS

· Asthma

· Chronic Obstructive Pulmonary Disease (Emphysema,

Chronic Bronchitis, Cystic Fibrosis)

· Pneumonia

· Lung Cancer

· Croup Syndromes (although middle airway,

is very common in young children)

ASTHMA

· 5% of adults & 8% of children in the U. S.

· Estimated over 15 million people in the U.S. have asthma

· Incidence has increased 60% during the last decade

· Childhood exposure to damp housing, cigarette smoke &

high levels of allergens has been associated with increased risk

CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)

· Fourth leading cause of death in the U.S.

· Smoking accounts for >90% of the risk for COPD

PNEUMONIA

· Advanced age, immunocompromise, reduced forced expiratory

volume & high alcohol intake are the greatest risk factors in

the general population

· Other risk factors include altered consciousness, smoking, underlying

lung disease, endotracheal intubation malnutrition, airway obstruction

& immobilization

· May be community acquired or nosocomial

LUNG CANCER

· 80% to 90% of lung cancer is caused by smoking, with the rest

caused by air pollution, radiation, radon & industrial exposure

(such as, asbestos, arsenic, sulfur dioxide, formaldehyde, silica,

nickel, airplane glue, coal tar, textile fibers, choromethyl ethers,

chromate, vinyl chlorides)

· Incidence is highest in men >70 years old & women 50 to 60 years old

· Family history of predisposition (first degree relatives have

a 2.5 fold increase in risk

· Risk associated with passive smoking is estimated between 1.4 &

3.0 times the unexposed risk, especially in children

CROUP SYNDROMES: COMMON IN PEDIATRIC POPULATION

· Acute Laryngeotracheobronchitis (LTB) (viral croup),

more common from 3 months to 3 years, low grade fever

· Acute Spasmodic Laryngitis ( “Spasmodic,” “Midnight,”,

“Twilight,” “Allergic” Croup), more common from 1 to 4 years,

low grade or no fever

· Acute Epiglottitis (Supraglottitis, bacterial) Medical Emergency,

occurs from 1 to 8 years of age, “cherry red” epiglottis,

toxic, high fever

· Retropharyngeal Abcess (bacterial, toxic) age 1-3 years &

variable, high fever

· Acute Bacterial Tracheitis (“Membranous Croup), LTB worsens,

despite therapy, age range 1 month to 6 years, toxic, high fever

ASSESSMENT: STRUCTURES & FUNCTION TO CONSIDER

· General Assessment

· Degree of distress, dyspnea or shortness of breath (SOB)

· Cyanosis of skin, nails, mucous membranes

· Evidence of chronic hypoxia, such as clubbing;

or poor growth in children

· Consider General Areas of Airway Assessment

· Upper Airway:

· Nose, mouth, pharynx, ears. (usually associated with URI)

· Adventitious sounds are loud & moist, & refer loudly

to lower airways

· Sounds are heard equally loud with stethoscope over

lung fields, throat, mouth or nasal areas

· Middle Airway:

· Obstruction occurs in trachea & epiglottis area & is

usually most evident with inspiration

· Most common causes are croup syndromes or

foreign body aspiration

· Most common sign is inspiratory stridor

· Lower Airway:

· Adventitious sounds are softer, may be generalized

or localized to a specific area in the lung fields,

or may be inspiratory or expiratory.

· Breath sounds may be decreased of absent

· Changes in fremitus, percussion & egophony may be present

· Retractions or Use of Accessory Muscles:

· Retractions may help indicate degree of respiratory distress

· Infants & young children may have more sub-costal

(sub-xyphoid, sub-sternal) & intercostal retractions

· Older children & adults may have more suprasternal

& supraclavicular retractions

STRUCTURES TO CONSIDER

· Nose

· Inspired air is warmed, filtered & humidified by

upper airway passages

· Obstructions may be due infection, allergy,

polyps or septal deviations

· Obstructions may be manifested by mouth breathing or snoring

· Infants are obligate nose breathers & dyspnea may

result from nasal obstruction

· Trachea & Bronchi

· Bifurcates into right & left bronchus at Angle of Louis, or 2^nd rib level

· Carina – the area of bifurcation, where the right

bronchus is positioned more vertically than the left bronchus

· Right Bronchus – is more susceptible to foreign body aspiration

· Aspiration Pneumonia – usually will be right lower lobe (right lung)

· Bronchioles

· Are no longer supported by cartilage, but are surrounded

by smooth muscle

· Bronchiolar smooth muscle is generally most relaxed (open)

with inspiration & more contracted (closed) with expiration

· Initial spasm of smooth muscle is more apparent with expiration,

but can progress to the inspiratory phase

· Expiratory wheezing is one of the first signs of obstruction

in the bronchioles & alveolar ducts

· Pleural Cavity & Pleura

· Pleurae – are serous membranes that cover the outer lungs

& inner rib cage

· Visceral pleura – covers outer surface of each lung

· Parietal pleura – covers the inner portion of the rib cage & the

upper surface of the diaphram

· Pleural fluid – lubricates the pleurae for smooth lung movements

· Pleural space – potential space between visceral & parietal pleurae

· Disruption of pleura causes painful respirations

· Pleurisy – inflammation of pleurae

· Effusion – fluid collection between pleurae

· Pneumothorax – air between pleurae, causing reduction

in lung expansion

· Hemothorax – blood between pleurae, causing reduction

in lung expansion

· Right & Left Lungs

· Anterior Right Lung – Upper, middle & lower lobes (3 lobes)

· Anterior Left Lung – Upper & lower lobes (2 lobes)

· Posterior Right & Left Lungs – each have upper & lower lobes (2 lobes)

· Expansion & capacity the same, for all practical purposes

EVALUATION: HISTORY

· History is most diagnostic

· Obtain the patient’s baseline function, compared to the present illness

· Example: an individual with chronic bronchitis may cough &

expectorate a cup of mucous per day, and you want to find out how the

cough has changed in amount and character.

· Example: an individual with SOB may usually be able to walk one block

before experiencing SOB, and you want to find out how that has changed

· Example: Any change in chronic cough may be significant

HISTORY: QUALITY OF SYMPTOMS:

MAIN SYMPTOMS OF PULMONARY DISEASE

· Dyspnea (shortness of breath – SOB), may be expressed as “can’t get air”

· Cough (children may vomit with cough)

· Sputum

· Hemoptysis (bloody sputum needs to be distinguished from hematomesis,

or bloody emesis)

· Chest pain – characteristics may distinquish whether the pain is pleuretic

of musculoskeletal in nature

· Wheezing

· Cyanosis

HISTORY: SPUTUM CHARACTERISTICS & ASSOCIATIONS

· Mucoid URI, asthma, tumors, TB, emphysema

· Mucopurulent Pneumonia

· Yellow-green, purulent Bronchiectasis, chronic bronchitis

· Rust-colored Pneumococcal pneumonia (strep. pneumoniae)

· Red current jelly Klebsiella pneumonia

· Foul odor Lung abcess

· Pink blood-tinged strep or staph pneumonia

· Gravel Bronchiolithiasis

· Pink, frothy Pulmonary edema

· Profuse, colorless (Bronchorrhea) – Alveolar cell carinoma

· Bloody Pulmonary emboli, bronchiectasis, abcess, TB,

tumor, cardiac causes, blooding disorders

HISTORY: ASSOCIATED SYMPTOMS

· Examples:

· Post nasal drip: may have AM cough upon awakening, then clear up

· Allergies: may have itchy, watery eyes, seasonal timing

HISTORY: RELIEVING – EXACERBATING FACTORS

· Examples:

· Relief: hot air – cold air, laying down, sitting up, OTCs

· Exacerbate: environmental exposures, exercise, foods, OTCs,

HISTORY: FAMILY HISTORY

· Genetic & Familial Associations

HISTORY: LIFE STYLE ISSUES

· Job, hobbies

· Environmental factors

HISTORY: ASSESSMENT OF FUNCTION – LIMITATIONS

· Establish baseline of usually activities

· Exercise intolerance

HISTORY: SMOKING

· Change in cough, secondary to smoking

· Smoking history: packs/day for how many years

· Pack/Year Smoking History: Packs/day X years of smoking

CHANGE IN COUGH!!

COMMON TERMINOLOGY:

· DYSPNEA:

Subjective, history data

“SOB”

“Can’t get air”

Change in baseline?

· TACHYPNEA:

Objective, physical exam finding

Respirations faster than normal & not exercised induced

General example of resting rates:

NB 30-50/60

Child 20-30 (& not >40)

Adult 8-16/20 (& not >20s – 30s)

· HYPERVENTILATION: Person is using more air than needed (rate or volume)

Consider anxiety vs exercise

Consider brain injury vs hysterical response

Blowing off extra PCO2 can lead to respiratory alkalosis

Normal Arterial Blood Gas (ABG)