Abnormal Breathing patterns

Respiratory Disorders

2010 Medical-Surgical Certification

Review

Changes in the rate, depth, regularity, effort

Patterns of breathing
Kussmaul respirations (hyperpnea)
Labored
Restrictive panting
Cheyne-Stokes respirations

Hypoventilation

Inadequate alveolar ventilation to remove

CO2
PaCO2 increases greater than 44 mm Hg.
(Hypercapnia)
May result in somnolence or disorientation

Hyperventilation

Hemoptysis

Alveolar ventilation that exceeds metabolic demands

PaCO2 decreases to less than 36 mm Hg.
(Hypocapnia)
May occur with head injury, anxiety, conditions of
inadequate O2 in the blood

Cyanosis

Coughing up blood
Usually BRB, alkaline pH, mixed with frothy
sputum
Indicates a localized abnormality; infection or
inflammation

Cyanosis

Reflective of decreased PaO2, decrease C.O.,

cold, anxiety, cardiac right to left shunt
Central cyanosis- decreased O2 saturation of Hgb.
In the arterial blood, best seen in bucccal
membranes
Peripheral cyanosis best seen in the nail beds

Cyanosis can be caused by :

A. decreased blood Ph
B. pulmonary left-to-right shunts
C. cardiac left-to-right shunts
D. cold environments

Clubbing

Causes of Hypoxemia

Hypoventilation
ARDS
Pulmonary embolism
Pneumonia
Pulmonary edema/CHF
Interstitial pneumonitis/fibrosis
Mechanical obstruction
Hypovolemic shock
Abnormal hemoglobin
Low atmospheric oxygen content
High altitude
Smoke inhalation
CO poisoning

Reflection of inadequate
oxygenation
Worsens with time

Hypoxemia Signs and Symptoms

Tachypnea
ABG with PaO2 < 60
mmHg
Tachycardia, HTN
Confusion, delirium

Speaking in short,
staccato sentences
Increased work of
breathing and use of
accessory muscles
Decreased LOC
Pallor
Cyanosis
Anxiety
Fear

Interventions

Administer oxygen!
Monitor VS, cardiac and respiratory status
for changes
Diagnostic studies:

Causes of Hypercapnia

Arterial blood gas

Basic labs: electrolyte panel, coag panel, CBC,
cardiac enzymes, cultures if indicated
Chest x-ray, ECG

ARDS
Pulmonary embolism
Pneumothorax
COPD

Asthma

Neuromuscular

Spinal cord injury

CNS dysfunction

Chemical depression

Morbid obesity
Kyphoscoliosis

Pulmonary edema

Antibiotics if indicated

Headache
Drowsiness, confusion, decreased LOC
Blurred vision
Seizures
Flushing of skin
Hypotension and bradycardia if severely acidotic

CVA, meningitis
Opioids, sedatives

Interventions

Hypercapnia Signs and Symptoms

MS, myesthenia gravis

Ventilate patient!
Monitor VS, cardiac and respiratory status
for changes
Diagnostic studies:

Arterial blood gas

Basic labs: electrolytes, CBC
Chest x-ray

Bronchodilators, reversal agent depending

on cause
Anticipate NIPPV or MV if severe

Pulmonary Embolism

Particulate matter

Blood clots are the most common (DVT)

Also fat, oil, air, tumor cells, amniotic fluid, foreign
objects (catheter tips, injected particles), or septic
emboli

Enters into systemic venous circulation

Lodges in the pulmonary vasculature
Obstructs blood flow hypoxemia

Risk Factors:

History of thromboembolic
disease
Prolonged anesthesia or
surgery
Surgery to the lower
extremities or hip
Immobilization
Estrogen therapy
Major trauma

Pregnancy (especially postpartum)

Congestive heart failure
Malignancy
Obesity
Hypercoagulability
Smoking
CHF
Stroke

Signs and Symptoms

Sudden onset of dyspnea

Pleuritic chest pain
Apprehension or feeling of impending doom
Cough, hemoptysis from pulmonary infarction
Tachypnea
Crackles
Pleural friction rub, abnormal heart sounds
Tachycardia, non-specific ECG changes
Diaphoresis
Low grade fever
Petechiae over chest and axillae

Treatment

Monitor VS, cardiac and respiratory status for changes

Oxygen, IV access
Diagnostic studies:

ABG identify degree of hypoxemia

CBC & coag panel
ECG
Chest x-ray, V/Q scan, CT angiogram

Medical Management

Anticoagulation

Surgery

In emergencies transfer to ICU, intubation, mechanical

ventilation
Anticoagulation and/or surgery

Heparin 5,000-10,000 unit bolus followed by a continuous

infusion, goal PTT is 1.5 2 times normal
Thrombolytic agents lyse clots but patient is at risk for
bleeding
Coumadin oral dosing to goal of INR 2-3

Embolectomy used when thrombolytic therapy is

contraindicated in patient with large or multiple PEs with shock,
mortality as high as 50%
Inferior vena cava filter placement

Thoracic injuries

Fractures
Flail chest
Pneumothorax
Tension pneumothorax

Flail Chest

Flail Chest

Fracture of several consecutive ribs or the fracture of the

sternum with ribs
Instability of the chest wall

Inspiration: chest wall moves inward

Expiration: chest wall moves outward

Flail Chest

Cyanosis
Hypercapnia, hypoxemia
Pain with inspiration
Paradoxical movement of the flail segment
Nursing interventions

Teaching coughing, deep breathing

Pain medication
Suction
Splint

Pneumothorax

Injury allows accumulation of air or blood in the

pleural space
Increase in intra-thoracic pressure
Lung doesnt fully inflate
Air and blood collect in the pleural space it is a
hemopneumothorax

Hemothorax

Pneumothorax

Asymmetrical lung
expansion
Chest pain, crepitus
Decreased, absent breath
sounds
Mediastinal shift

Tension Pneumothorax

Nursing Interventions

Oxygen
Coughing and deep
breathing

Air continues to leak into the pleural space with no escape

Increasing pressure shift to the unaffected side

Emergency situation

Compromises heart and lung function

Tension Pneumothorax

Asymmetrical lung expansion, tracheal deviation

Cyanosis, tachycardia
Decreased or absent breath sounds
Distended neck veins
Severe chest pain
Nursing:

O2; chest tube management

Frequent position changes
Pain management

Obstructive Pulmonary Disorders

(COPD)

Treatment

Insertion of a chest tube

Apex of the chest

Facilitates air or fluid evacuation

drains air (air rises)

drains fluid (gravity pools fluid)

Asthma

Asthma ( to a certain extent)

Chronic Bronchitis
Emphysema

Lower chest

Pulmonary Disorders:
Obstructive Pulmonary Disease: Asthma

Accessory muscle use

Clear, viscous sputum
Nonproductive cough
Decrease activity tolerance
Dyspnea, hyperventilation
Hyperresonance, decreased breath sounds

Asthma

Airway response to stimuli

Widespread airway constriction

Smooth muscle spasm in the airways

Bronchial mucosa narrowing Air trapped
Airways become occluded by secretions
Lungs hyper inflate

Asthma diagnosis/treatment

CXR
Bronchodilators
Steroids
Treatment for exacerbations

Allergens, drugs, viral infections, genetics, stress

Chronic Bronchitis

Asthma: Evaluation and Treatment

Spirometry
Arterial Blood Gases
Removal from the offending stimulus
Inflamed corticosteroids
Brochodilators
Bronchospasm inhibitors

From lung irritants

Air pollution, smoking

Increased bronchial
mucus production, goblet
cell hyperplasia
Increased sputum
production, cilia damage
Epithelial metaplasia

Results:

Bronchial edema,
Bronchospasms,
Impaired clearance and
ventilation, small airway
blockage
Decreased airflow,
secondary infections

As the disease progress:

pulmonary hypertension,
cor pulmonale

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Chronic Bronchitis symptoms

Emphysema

Accessory muscle use

Bronchospasms
Chronic thick productive
coughs
Cyanosis, Dyspnea
Heart failure

Lung parenchyma disease

Changes in alveolar walls,

enlargement
Associated with smoking, air
pollution

Impaired ventilation

Impaired diffusion due to:

Distal air spaces enlarge, loss of

capillary membranes, pulmonary
vasoconstriction

Impaired perfusion

Emphysema

Decreased lung elasticity,

collapsed airway upon
exhalation, trapped air

Loss of pulmonary vasculature,

pulmonary hypertension

Air trapping in emphysema

Accessory muscle use

Characteristic patient
position Tripod
Fatigue, decreased
activity tolerance
Pursed lip breathing
Lung hyperesonance,
wheezes

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Emphysema differs from chronic

bronchitis in that:

Nursing for patients with Emphysema

Administer Oxygen
Encourage activity
Adequate liquid intake
Teach signs of pneumonia
Influenza vaccines

A. emphysema obstruction results from mucus

production and inflammation
B. emphysema obstruction results from changes in
lung tissues
C. chronic bronchitis obstruction results from
changes in the lung tissue
D. there are no visual differences between the two
conditions

Acute Respiratory Distress Syndrome

ARDS

Oxygen-Carbon
Dioxide balance
cannot be
maintained
Unknown
Etiology

Acute Respiratory Failure (ARDS)

Etiology:

Shock
Trauma
Serious nervous system
injury
Pancreatitis
Fat & amniotic fluid
emboli
Pulmonary infections
Sepsis

Inhalation of toxic gases

Pulmonary aspiration
Drug ingestion
Hemolytic disorders
Multiple blood transfusions
Cardiopulmonary bypass
Near-drowning

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ARDS

ARDS Pathophysiology

Capillaries leak Decreased blood flow to the

lung Platelet aggregation
Inflammation Alveolar edema Pulmonary
edema
Decreased lung compliance Patches of
atelectasis
Patient hyperventilates causing hypocapnia and
hypoxemia

ARDS Nursing Interventions

Bed rest, prone

Oxygen
Chest physiotherapy
Suction
Pain management
Fluid I and O
Frequent repositioning to mobilize secretions
Calorie intake

Geriatric Considerations

Skeletal changes

Increase in AP diameter:

Decreased:

Kyphoscoliosis, Barrel chest

Chest wall compliance
Alveoli elasticity
Pulmonary capillary network
Muscle strength; ability to form a cough
Dry mucous membranes
Expansion of chest wall

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Increased AP diameter

Kyphosis

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