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Module4

RespiratorySystem

1
1.1

IntroductiontoRespiratorySystem
Definitions

Mainfunctionofrespiratorysystemexchangegasesbetweenbodyandatmosphere Generallyspeaking:respirationrefersto2processes: o Externalrespiration: AbsorptionofOxygen&removalofcarbondioxidefrombodyasawhole o Internalrespiration: UseofOxygenandproductionofcarbondioxidebycellsinbody Totallungcapacity o 6000ml:ForceddeepbreatheVolumeofairinlungafteraforcefulinspiration Tidalvolume o 500ml:Normalbreathingvolumeofairinspire/expireduringeachrespiratorycycle o Normalbreathing1220breathesperminute) Deadairspace o 150ml:Airremaininginpassages Minutevolume o Amountofairthatmovesinandoutofthelungsperminute o TidalVolumexrespiratoryrate(1220bpm)=minutevolume o VT or tidal volume is the amount of air the lungs breathe in one breath, o VE or minute volume is the number of breaths o RR (respiratory rate or f=frequency) breathed in one minute times the tidal volume. o Thus VT x RR = VE. 350ml x 12 breaths per minute = 4,2 L/min.

AnatomyofRespiratorySystem

Maincomponents: ThoracicCage Airpassages Lungs Anddiaphragmdeficiency Upperrespiratorysystem(upperairway): Nose o Nasalcavity Mouth Pharynx(throat) o (comprisedof:Nasopharynx,Oropharynx) Lowerrespiratorysystem(lowerairway): Larynx Trachea Mainbronchi Bronchioles Alveoli(TerminalAirSacs) o Lungs

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2.1 2.1.1 Upperairway Pharynx

RespiratorySystem


2.2 2.2.1

SharebyrespiratoryANDdigestivesystem Liesbetweennoseandoesophagus/larynx o Oesophagusispipethatgoestothestomach Nasopharynx Oropharynx


LowerAirway Larynx

Larynx(voicebox)lieswithinthyroidcartilage(AdamsApple)inneck.Thyroidcartilageeasilylocated inmidlineofneck,belowjawbecauseofitssize Tubularstructureliesanteriortooesophagus ActsasairpassagewayANDspeciallystructuredtocreatesound Arrangementoftinybone,cartilages,musclesandtwovocalcords o Airentersvianosewhereiswarmed/humidifiedandfiltered. o Passesthroughpharynxandlarynxanddownthetracheaintolungs

EPIGLOTTIS Structurewhichprotectsairwayduringswallowing Leaflikestructureflopsovertopreventfoodfromenteringairway


2.2.2 Trachea


2.3

Belowthelarynxistracheawhichissemirigidtube+12.5cminlength Trachea(windpipe)beginsbelowthyroidcartilagecanbefeltinmidlineofneckuntilitdisappears intochest(thoraciccage)atlevelofSternalNotch o SternalNotchisthehollowbetweentwomedialendsofclavicles SupportedbyCshapedringofcartilage o Preventitfromcollapsingwhenairmovesin/outoflungs Tracheaendsatcarinawhereitdividesintotwobronchiwhichenterintolungsanddividesfurther intobronchioles Tracheaalsolinedbymucousmembranecontainingcellswhichsecretemucouscellswithcilia(hair likestructures)tomovesecretionsupwardstopharynx
ThoracicCage

ConsistsofBonesandsofttissue Bonesare: Ribs: 12oneachside(12pairs) Sternum(Breastbone): anteriortowhichtheribsjoin Spine: posteriortowhichoppositeendofeachribjoins Softtissue: consistsofintercostalmuscles

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RespiratorySystem

2.3.1 Lungs


2.3.2

Approximatelysameshapeasthoraciccavity NOTattachedtothoraciccavityhangfreelywithinit o Suspendedbytrachea/arteriesandveinswhichruntoandfromlungsandbyligamentswith theirbaseslyingonthediaphragm Rightlungdividedintothreelobes(Bronchiisshorterthanleft) Leftlungdividedintotwolobes(leftlunggiveswayforheart) Eachlungconsistsofbronchi,bronchiolesandalveoli LungshaveNOmuscletissue


Bronchi


2.3.2.1

Eachmainbronchus(leftandright)passesintocorrespondinglung Rightbronchus:shorterandstraighter Fromeachbronchusnumeroussmallerbronchiaregivenoff Structureofbronchiissimilartotracheaincompleteloopsofcartilagemaintainshapesoftubes Alsolinedwithmucousmembranescontainingciliaandmucouscells


Bronchioles

Smallestbronchialtubesreferredtoasbronchioles
2.3.3 Alveoli(TerminalAirSacs)


2.4

Bronchiolesenteralveoli(airsacs) Thisiswheregaseousexchangetakesplacebetweenoxygenandcarbondioxide Alveoli(Singularalveolus)areairsacsONEcellthick Surroundedbycapillariestoallowoxygenandcarbondioxidetopassthrougheasily


Pleura


2.4.1

Doublelayerofsmoothandslipperytissuecoveringeachlung Pleurahelpsusbreath
VisceralPleura

Innerlayerofpleura Coversoutside(anterior)oflungs
2.4.2 ParietalPleura

Outerlayerofpleura Coversinsideofthoraciccavity

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2.4.3 ParietalFluid

RespiratorySystem

Fluidinspacebetweenvisceralandparietalpleural Preventsfrictionfromoccurring

2.5 Diaphragm

Domeshapedmuscleseparatesthoracicandabdominalstructures Mainmusclesconcernedwithbreathing

3
3.1

Breathing
Introductiontobreathing

Breathinginiscontractingofdiaphragm Breathingoutisrelaxedstateofdiaphragm(conversely) Respirationcontrolledbybrainstem o Informationtransmittedviaspinalcordtomusclesofrespiration:diaphragm,intercostalmuscles Contractionofdiaphragmandintercostalmusclesleadtoinhalationconverselyrelaxationofthose musclesleadstoexhalation Contractionofdiaphragmcontrolledbyphrenicnervewhichoriginatesatcervical3,4,5(C4C5) Automaticstimulustobreatheisinitiatedbycontrolcentreinbrainstemcontinuallymonitorslevels ofcarbondioxideandph.inblood o Stimulusbreatheisinitiatedbyrecognitionofhighcarbondioxidelevelsbychemoreceptors o Chemoreceptorsarefoundinaorticandcarotidbodies
Characteristicsofnormalbreathing

3.2


3.3

Normalrateanddepth 1220bpm Regularbreathingpattern Goodbreathsounds(BOTHSIDESofchest) Equalriseandfall Movementofabdomen


Characteristicsofpoorbreathing

Pulmonaryvesselbecomeobstructed Alveoliaredamaged Airpassagesareobstructed Bloodflowtolungsisobstructed

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3.4

RespiratorySystem

Pleuralspaceisfilled
Signsofabnormalbreathing

Slowerthe8breaths/minORfasterthan24breaths/min Musclesretractions Pale/cyanoticskin(blueishcolouredskin) Cool,damp(clammy)skin Shallow/irregularrespirations Pursedlips Nasalflaring

4
4.1

GaseousExchange
Introductiontogaseousexchange

Atmosphericairmixtureofgases o Resultisdifferentonabsorptionandexcretionbybody

Inspiredair ExpiredAir Oxygen 21.00% 17.00% CarbonDioxide 0.04% 4.00% Nitrogen 79.00% 79.00% 4%(47%)of21%oxygeninhaledisretainedbythebody o WhileamountofcarbondioxideEXPIREDis100timeGREATERthancarbondioxideinhaled Expiredairdiffersfromatmosphericaircontainslessoxygenandmorecarbondioxide o Butwarmedtobodytemperatureandmoistenedbywatervapour
4.2 Inspiration

Whenfreshinhaledair/gasreachesalveolioxygenmovesfromalveoliintoblood(through capillaries) o Capillariesminutebloodvessels Carbondioxidebroughttothelungsbybloodincapillariesmovesacrossalveoli Gaseousexchangeisnowcomplete Bloodbringgasestolungsvenousblood(deoxygenatedblood) Bloodtakinggasesfromlungsarterialblood(oxygenatedblood) Toosculatethelungsistolistentothefourquadrantsofthechest(tolistentothelungs)

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RespiratorySystem

5.1

AirwayObstructions
Lowerairwayobstructionscanbecausebyinfection,foreignbodies,asthma,chronicbronchitisand emphysema
Asthma

Twopredisposingfactorsareallergiesandstress Condition:airwaybecomesnarrowduetovariouscausessuchas: o Bronchospasm o Swelling o Mucousplugging AboveisthePATHOPHYSIOLOGY Pt.canshowsignsofallthreecauses/symptoms o Sometimesnarrowingofairwaysmaygetbetterbyitselforwithspecifictreatment Narrowingofairwaypt.needstoworkhardertobreathein/out.Pt.willcomplainofdyspnea (difficultybreathing)andshortnessofbreath. Airpassingthroughnarrowpassagescausemedicalsounds o SoundcalledWHEEZING Whenairwaysbecomeseverelynarrowthereisalmostnoairmovementin/outwheezingwill stop o ThisiscalledSILENTASTHMATICUS (NEEDIMMEDIATEASSISTANCE)

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5.1.1 ClinicalpictureofAsthma

RespiratorySystem

Difficultyinexpiration(breathingOUTistheproblem) o Pursedlips o Signsofcyanosis o Difficultinspeech o Cough BarrelChest o Hyperresonant(highpitchedsound) o Wheezingthensilentchest o Tachypnea(fastbreathing) Accessorymuscleuse o Pt.willbesittinginthetripodposition o Usingstomachmusclestobreath o Usingneckmusclestobreath DecreasedLOC(lackofconsciousness) o Agitation o Restlessness Tachycardia(heartbeatsover120bpm)
TreatmentandManagement

5.1.2

Aimisto: o Oxygenate o Bronchodilate o Stopreaction History: o Howlonghastheattacklasted o Whatmedicationwastaken Airway:Mostimportant o MAINTAINAIRWAY Breathing: o Nebulisedoxygen o Backupearly(ifneeded) Partialrebreathermask Nebulizer(+40%@46L/min) Partialrebreathermask Circulation: o Monitorgradeoftachycardia(fastheartbeatabove120bpm) Assess: o Severity o VitalsincludingHGT Reassesspt.continuously: o TransportASAP o RememberBackupearly(ifneeded)!!!!!!!!!!!

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5.2 Anaphylaxis

RespiratorySystem


5.2.1

Donotsufferfromasthmamaysuffersevereallergicreaction Allergensubstancepeoplearesensitivetomaycauseallergicreactionoranaphylaxis
Signsandsymptoms


5.2.2

Airwayswelling Dilationofbloodvessels Hypotension(lowbloodpressure) Widespreaditching


TreatmentandManagement

5.3

SameasAsthma
PulmonaryOedema


5.3.1

OccurswhenLEFTsideofHEARTcannotremovebloodasfastasRIGHTsidedeliversblood Fluidbuildsupinalveoliandlungtissuebetweenalveoliandpulmonarycapillaries Oedemabeginstointerferewithgaseousexchange


Signsandsymptoms


5.3.2

Dyspnea(difficultybreathing)withshallowandrapidrespirations Frothypinksputum HistoryofCongestiveHeartFailure


TreatmentandManagement


5.4

ABC Oxygen VitalSigns Transportincomfortablepositionforpt. Callforbackup(ifneeded)


ChronicObstructivePulmonaryDisease

MayresultfromdirectlungandairwaydamagefrominfectionORinhalationoftoxicsubstanceALSO calledCOLD COLD:ChronicObstructiveLungDisease o Emphysema o Chronicbronchitis o Asthma


TreatmentandManagement

5.4.1

ABC Oxygen VitalSigns Transportincomfortablepositionforpt. Callforbackup(ifneeded) ReassurepatientEMOTIONALsupport

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5.5 Emphysema

RespiratorySystem

Causebydistensionanddestructionofalveoli(normalresultofdisease) Causesdecreaseinsurfaceareaavailableforgaseousexchange Resultsinloweroxygenintakeandcarbondioxidereleasefromblood NORMALpersonstimulustobreathecontrolledbyincreaseincarbondioxidelevelsinblood Emphysemapatientsrelyondecreasedlevelsonoxygenasstimulustobreathe o Forthisreasonemphysemapt.needtobecloselymonitoredwhenapplyinghighconcentrations ofoxygenpt.maylosestimulustobreatheandbecomeepneic. o NEVERwithholdoxygenfromthesept.


Signsandsymptoms

5.5.1


5.5.2

Dyspnea(difficultybreathing) Barrelchest Hypoxia(pt.notnormallycyanoticpinkpuffer) Respiratoryfailure


TreatmentandManagement


5.6

ABC Oxygen VitalSigns Transportincomfortablepositionforpt. Callforbackup(ifneeded) ReassurepatientEMOTIONALsupport


SpontaneousPneumothorax

Surfaceoflungisdisruptedairescapesintopleuralspaceeffectselasticityoflungtissue Pneumothoraxmostcommonlycausebytraumacanalsobecausebymedicalcondition Mayoccurinpt.withchroniclunginfection&pt.bornwithweakareasinlungs Asthmaandemphysemapt.highriskofspontaneouspneumothorax o Occurringwhenweakenedpotionoflungruptureswhilstcoughing Causesdecreaseinsurfaceareaavailableforgaseousexchange Resultsinloweroxygenintakeandcarbondioxidereleasefromblood NORMALpersonstimulustobreathecontrolledbyincreaseincarbondioxidelevelsinblood Emphysemapatientsrelyondecreasedlevelsonoxygenasstimulustobreathe o Forthisreasonemphysemapt.needtobecloselymonitoredwhenapplyinghighconcentrations ofoxygenpt.maylosestimulustobreatheandbecomeepneic. o NEVERwithholdoxygenfromthesept.
Signsandsymptoms

5.6.1


5.6.2

Dyspnea(difficultybreathing) Chestpain Decreasedairentryintoinjuredside


TreatmentandManagement

ABC Oxygen VitalSigns Transportincomfortablepositionforpt. Callforbackup(ifneeded)

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5.7 Hyperventilation

RespiratorySystem


5.7.1

Normallyfoundinpt.whoareanxious/hystericalincreasedrespiratoryrate Maycomplainoffatigue/nervousness/dizziness/tingling/numbnessaroundmouth,hands,feet, chestanddyspnea. Respirationdeepandrapid Maymanifestwithcontortionsofthehand(carpalspasmsflexedpositionwiththumbdrawninto thepalm) Hyperventilationresultsfromexcesscarbondioxidebeingblownoff o Excesslossofcarbondioxidechangesbodychemistry Sincedecreaseincarbondioxideprimarystimulustobreatheislostpt.maybecomeapneic


TreatmentandManagement

ABC Oxygen VitalSigns Transportincomfortablepositionforpt. Callforbackup(ifneeded) ReassurepatientEMOTIONALsupport

ChestInjuries

Typesofchestinjuriesinclude: OpenChestinjuries Closechestinjuries Ribfractures Flailchest Contusionofthelung Penetratinginjuries SimplePneumothorax TensionPneumothorax


6.1 OpenChestinjury


6.2

Ifchestwallhasbeenpenetratedbybullet,knifeetc.(openchestinjury) Traumapt. Ifpt.hassufferedsevereblowtothoraxandribshasfracturedbadlybonesmaylaceratechestwall andskinfrominside Heart,lungsandothervitalstructures/organsmaybedamaged


Penetratinginjuries

Oftenresultinsuckingchestwounds o Causeairtoentrepleuralspace(pneumothorax)/bleedingintopleuralspace(haemothorax) o Sometimesassociatedwithfractures o PneumothoraxAirinpleuralspace o Haemothoraxbleedinginpleuralspace Traumatochestmorefrequentlycausescombinationofbothairandbloodinpleuralspace o Thisiscalled:PNEUMOHAEMOTHORAX

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6.2.1 TreatmentandManagement

RespiratorySystem


6.3

ABC Oxygen Sealopenwoundsusesemiocclusivedressing o Sidefacingthefloorshouldbeopentoallowdrainage(gravitationpull) NEVERremovepenetratingobject(iftheobjectisstillimpaled) VitalSigns SecondarySurvey Transport Callforbackup(ifneeded)


ClosedChestinjury


6.3.1

Noassociateopenwound Chestcompressedandseverelybruised Underlyingstructuresmaybeinjured


SignsandSymptoms


6.3.2

Oneormoremayoccur Painatsiteofinjury Dyspnea Haemoptysis(coughingupblood) Cyanosis Rapid,weakpulseandhypotension(shock) Abnormalexpansionofoneorbothsideofchestonaspiratione.g.tensionpneumothorax Paradoxicalchestmovement(flailchest)


TreatmentandManagement


6.4

ABC Oxygen Sealopenwoundspromptlynomatterhowsmall o Usesemiocclusivedressing Sidefacingthefloorshouldbeopentoallowdrainage(gravitationpull) VitalSigns Controlexternalbleeding Transportincomfortablepositionforpt. Callforbackup(ifneeded)


RibfracturesSimpleribfracture

6.4.1

Mostcommoninjuriesfoundintraumasituation
SignsandSymptoms


6.4.2

Greatdealofpain Pain/tendernessatsiteofinjury Dyspnea Alwayschestpossiblepneumothoraxwilloccuriftheendoffractureribhaspenetratedthelung


TreatmentandManagement

ABC Oxygen VitalSigns SecondarySurvey

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6.5

RespiratorySystem

Encouragept.tobreathenormally Splintinjuredsideusingpt.armorhandforsupport Transport Callforbackup(ifneeded)


RibfracturesFlailchest

6.5.1

Flailchestwhen2/3ormoreribsarefracturein2/3ormoreplaces Createsflailsegmentwhichproduceparadoxicalbreathing o Oninhalationflailsectionmovesinwards o Onexhalationflailsectionmovesoutwards Flailsectiondependingonseveritycaninterferewithventilationofthelungsthereforegaseous exchange


SignsandSymptoms

Paradoxicalmovement Createsflailsegmentwhichproduceparadoxicalbreathing o Oninhalationflailsectionmovesinwards o Onexhalationflailsectionmovesoutwards


TreatmentandManagement

6.5.2


6.6

ABC Oxygen AssistwithventilationwithBVMifneeded(b/p/mbelow6) Beawareofpossibledamagetounderlyingstructures/organs VitalSigns SecondarySurvey Encouragept.tobreathenormally Splintinjuredsideusingpt.armorhandforsupport Transport Callforbackup(ifneeded)
ContusionoftheLung


6.7

Iflungreceivesseverebloge.g.MVAsteeringwheel Bleedingintothelungsubstanceandalveolioccursandcaninterferewithgaseousexchange Severecasesmaypresentrespiratorydistress


SimplePneumothorax

PotentialSpacebetweentwopleurallayersbecomesactualspace(fillswithair) o Whenairescapesfromlungorfromsuckingwound CanResultfromopenorcloseinjury Airinpleuralspacecauseslungtocollapsecausesdecreaseingaseousexchangeanddyspnea Closepneumothoraxcommonlycausebyfracturedrib/spushinginwardafterbluntchesttrauma Openpneumothoraxusuallyresultofpenetratingchestinjury o Causepleuralspacetobeexposedinjuredlungandatmosphere o Airwillbedrawnintopleuralspacefromlungandatmosphere


SignsandSymptoms

6.7.1

Decreasedairentryoninjuredside Decreasedexpansionofchestwall Distendedneckveins Hyperresonant(highpitchednoisewheezingsound)

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6.7.2 TreatmentandManagement

RespiratorySystem


6.8

ABC Oxygen Sealanysuckingwoundswithsemiocclusivedressing AssistwithventilationwithBVMifneeded(b/p/mbelow6) Beawareofpossibledamagetounderlyingstructures/organs VitalSigns SecondarySurvey Transport Callforbackup(ifneeded)


TensionPneumothorax

Untreatedpneumothoraxmaydevelopintotensionpneumothorax Airinpleuralcavitycannotescapeandasmoreairentersthisspacelungbecomesmore compressed o Pressurebuildsupcollapsinginjuredlung o EventuallycausingcompressiononhealthlungandMYOCARDIUM(heartmuscle) Airtrappedwithinpleuralspaceattemptstoforceitswayout o Aircollectsundertheskincausingbubblingandcracklingsensationwhenpalpated ConditionknownasSubcutaneousemphysema Alsoasignoftensionphneumothorax


SignsandSymptoms

6.8.1


6.8.2

Decreasedorabsentairentryoninjuredside Reducedchestmovement Trachealdeviation Distendedneckveins Hyperresonant(highpitchednoisewheezingsound) Centralandperipheralcyanosis Tachycardia Hypotensionor(Reducesbloodpressure) Coldandclammyskin Subcutaneousemphysema
TreatmentandManagement

ABC Oxygen Sealanysuckingwoundswithsemiocclusivedressing AssistwithventilationwithBVMifneeded(b/p/mbelow6) Beawareofpossibledamagetounderlyingstructures/organs VitalSigns SecondarySurvey Transport Callforbackup(ifneeded)

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RespiratorySystem

AirwayManagement

Comprisesof: Suctioning Oxygenmasksandoxygenattached BVMwithreservoirandoxygenattached


7.1 Suctioning

SuctioningTechnique Turnpt.intolateralposition Checksuctionunitturniton Selectandmeasurepropercatheter(YankeurSuctionCatheter)tobeused Openpt.mouthandinserttip SuctionONLYasyouwithdrawthecatheter NEVERsuctionlongerthan20seconds


7.2 ArtificialVentilation

OneortwopersonBVMVentilationNOCOMPRESSION Advancedairway 1Ventilation Adult 1Breath Child 1Breath Infant 1Breath Child: 3secondsages5,6,7 5Secondsages12,13,14 Infants:ONEmonthandolder
7.2.1 BVM

68Seconds 56Seconds 35Seconds 35Seconds


7.2.2

Candelivermorethan90%oxygen DeliversLESStidalvolumethanmouthtomask Requirespracticetobeproficient Maybeusedinadvancedairwaymanagement


OropharyngealTube

Isonlyusedinunconsciouspt. o Canonlybeusedwhenpt.doesNOThaveagagreflex Selectpropersizebymeasuringfromcornerofmouthtoangleofjaw Inserttofollownaturalcurvaturesoflangerestsjustoutsidept.lips Preventtonguefrombeingpushposteriorduringinsertion(thiswillcauseairwayobstruction) Oropharyngealtubeinsertedtopreventtonguefromfallingbackandobstructingairway

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