Respiratory

• What is the Respiratory System responsible for?

  The system responsible for breathing and gas exchange in the body
• What does the Respiratory System include?

  • Structure and functions of the airways, alveoli, lungs, and pleura
  • Mechanics of breathing
• The two main functions of the respiratory system are:

  1. Oxygenate the blood
  2. Remove carbon dioxide
• Pleura


  The thin membrane that covers the lungs and lines the inside of the chest cavity
• Breathing


  The process of moving air in and out of the lungs to facilitate gas exchange
• Respiratory Failure


  A condition where the respiratory system fails to maintain adequate gas exchange
• Types of Respiratory Failure

  • Type 1
  • Type 2
• Anatomy of ribs

  • 12 pairs connect in the anterior thorax to the vertebral bodies of the spinal column
  • The first 7 pairs of ribs are attached to the sternum or breastbone by cartilage
  • The lower 5 ribs do not attach to the sternum
  • The 8th, 9th, and 10th ribs are attached to each other by costal cartilage
  • The 11th and 12th ribs, known as "floating ribs," are not attached in any way to the sternum
• Type 1 Respiratory Failure

  Caused by a failure to oxygenate the blood (low PaO2) with a low PaCO2
• Other terms used to document locations for chest physical assessment

  • Supraclavicular - above the clavicles
  • Infraclavicular - below the clavicles
  • Interscapular - between the scapulae
  • Infrascapular - below the scapulae
  • Bases of the lungs - the lowermost portions
  • Upper, middle, and lower lung fields
• Type 2 Respiratory Failure


  Caused by a failure to eliminate carbon dioxide (high PaCO2)
• Continuous Positive Airway Pressure (CPAP)

  • Continuous pressure applied through the whole of the respiratory cycle
  • Improves lung expansion
  • Recruits alveoli
  • Improve V/Q matching
  • Facilitates the exchange of gases
  • Keeps air in the alveoli- increases FRC
  • Decreases work of breathing
  • Reduce inspiratory effort by preventing atelectasis
• Non-Invasive Ventilation (NIV)


  • Bi-Level pressure (inspiration and expiration)
  • Increases tidal volume
  • Increases minute volume
  • Reduce respiratory rate
• Review of Systems (ROS) for Respiratory Assessment

  • Pulmonary
  • Cardiac
  • Skin
  • General
• Objective Information: Physical Examination

  1. Preparation

  2. Respiratory Assessment

  3. Observations
• Absolute Exclusions to NIV (BTS 2016)

  • Severe facial deformity
  • Fixed upper airway obstruction
  • Facial burns
• Yellow Nail Syndrome


  Yellow nails that lack a cuticle, grow slowly, and are loose or detached, associated with lung disorders / lymphedema
• Causes of Type 2 Respiratory Failure

  1. Shunt or deadspace
  2. Pneumonia
  3. Pulmonary odema
• Normal values for ABG

  pH 7.35-7.45kPa

  pCO2 4.5-6.0kPa

  pO2 10-14kPa

  HCO3 22-26 mmol/l

  Base Excess -2 - +2 mmol/l
• Processes of internal respiration

  Two distinct processes: 1) Exchange of gases between the bloodstream and tissues, 2) Cellular respiration - the process by which cells utilize oxygen to perform basic metabolic functions
• Cellular respiration


  1. Glycolysis

  2. Krebs cycle

  3. Oxidative phosphorylation
• Cellular respiration is the metabolic process by which an organism obtains energy through the reaction of oxygen with glucose to produce water, carbon dioxide and ATP
• Carbon dioxide is a waste product of cellular respiration that comes from the carbon in glucose and the oxygen used in cellular respiration
• Factors influencing tissue gas exchange

  • Partial pressure gradients between the blood and the tissues
  • Blood perfusion of those tissues
  • Surface areas of those tissues
• Cellular respiration can occur anaerobically without oxygen, such as through lactic acid fermentation, but this is very inefficient compared to aerobic respiration
• Sounds of lung auscultation

  Vesicular breathing = normal breathing, no issues

  Inspiratory stridor= upper airway obstruction

  Wheeze= asthma and/or COPD

  Coarse crackles= pneumonia and/or pulmonary odema

  Fine crackles= pulmonary fibrosis
• T1 - T11 are which nerves and who do they innervate?

  Intercostal nerves which innervate the external intercostals
• What is Functional Residual Capacity?

  The volume remaining in the lungs after a normal, passive exhalation (usually around 3L)
• Functions of the pleura


  Protects and cushions the lungs
• Label the pleura

  A) Parietal

  B) Visceral

  C) Pleural

  
• Types of spontaneous pneumothorax

  1. Primary - characterised by having no clear cause or no underlying lung pathology
  2. Secondary - Non-spontaneous or complicated. Can occur as a result of an underlying lung pathology such as COPD, asthma or whooping cough.
• Tension vs non-tension pneumothorax

  Tension - Caused by excessive pressure build up around the lung due to a breach in the lung surface which will let air into the pleural cavity during inspiration but will not allow air to escape during expiration

  Non-tension- Less severe, no air enters the pleural space therefore no air is pressing on the organs
• Sepsis 6 bundle

  1. Oxygen
  2. Cultures
  3. Anti-biotics
  4. Fluids
  5. Lactate measurement
  6. Urine output monitoring
• What does IPPA stand for?


  Inspection, palpation, percussion and auscultation
• Definition of shunt

  Good perfusion without ventilation of alveoli
• Definition of deadspace

  Good ventilation without perfusion
• Definition of silent unit

  A lack of both ventilation and perfusion
• Define V Q mismatch

  Happens when part of the lung receives oxygen without blood flow or blood flow without oxygen
• What is empyema?

  A collection of pus within the pleural cavity, usually associated with pneumonia but sometimes as a result of thoracic trauma or thoracic surgery
• Pressure modes of ventilation

  The ventilator delivers a flow of air to the lung until the pressure generated in the ventilator circuit reaches the pressure limit set on the ventilator. The patient's airway therefore determines the volume of each breath