CONCEPT in CONCEPT in OXYGENATIONOXYGENATION

ObjectivesObjectives

Review the structure and function of Review the structure and function of the respiratory function.the respiratory function.

Describe the process of ventilation Describe the process of ventilation and respiration.and respiration.

Explain the role and function of the Explain the role and function of the respiratory system in transporting respiratory system in transporting oxygen and carbon dioxide to and oxygen and carbon dioxide to and from body tissuesfrom body tissues

Identify factors influencing Identify factors influencing respiratory function.respiratory function.

Identify common manifestations of Identify common manifestations of impaired respiratory function impaired respiratory function

Identify and describe nursing Identify and describe nursing measures to promote respiratory measures to promote respiratory function and oxygenation.function and oxygenation.

Explain the use of therapeutic Explain the use of therapeutic measures such as medications, measures such as medications, inhalation therapy, oxygen therapy, inhalation therapy, oxygen therapy, artificial airways and chest drainage artificial airways and chest drainage to promote respiratory functionto promote respiratory function

The concept of The concept of oxygenation is oxygenation is a dynamic one a dynamic one that involves that involves the the transportation transportation of oxygen to of oxygen to blood cells and blood cells and removal of removal of carbon carbon dioxide.dioxide.

When When atmospheric atmospheric oxygen is oxygen is taken into the taken into the lungs, it is lungs, it is picked-up by picked-up by the blood and the blood and transported to transported to the cellular the cellular levels through levels through a network of a network of blood vessels. blood vessels.

The heart The heart functions as functions as the pump that the pump that moves the moves the blood thru the blood thru the lungs where lungs where oxygen and oxygen and carbon dioxide carbon dioxide are exchanged.are exchanged.

The The oxygenated oxygenated blood is then blood is then returned to the returned to the lungs and to lungs and to the body the body tissue and tissue and process process repeats itself.repeats itself.

OXYGENOXYGEN

Clear, odorless gas that constitutes Clear, odorless gas that constitutes approximately 21% of the air we approximately 21% of the air we breathebreathe

Absence of oxygen can lead to Absence of oxygen can lead to DEATH.DEATH.

RESPIRATIONRESPIRATIONThe process of The process of

gas exchange gas exchange between the between the individual and individual and the the environment. environment.

2 COMPONENTS OF 2 COMPONENTS OF RESPIRATIONRESPIRATION

Pulmonary ventilation or breathing; Pulmonary ventilation or breathing; the movement of air between the the movement of air between the atmosphere and the alveoli of the atmosphere and the alveoli of the lunglung

Diffusion of oxygen and carbon Diffusion of oxygen and carbon dioxide between the alveoli and dioxide between the alveoli and pulmonary capillaries. pulmonary capillaries.

STRUCTURE OF STRUCTURE OF RESPIRATORY RESPIRATORY

SYSTEMSYSTEM

UPPER RESPIRATORY SYSTEMUPPER RESPIRATORY SYSTEM

Or the upper tractOr the upper tract Or upper airwayOr upper airway Warms and filters Warms and filters

inspired air so that inspired air so that the lower the lower respiratory tract respiratory tract (the lungs) can (the lungs) can accomplish gas accomplish gas exchange.exchange.

NOSENOSE Composed of external and internal Composed of external and internal

portion.portion. External portion protrudes from the External portion protrudes from the

face and is supported by the nasal face and is supported by the nasal bones and cartilage.bones and cartilage.

Anterior nares (nostrils) are the Anterior nares (nostrils) are the external openings of the nasal external openings of the nasal cavities.cavities.

Internal portion of the nose is a hollow Internal portion of the nose is a hollow cavity separated into left and right cavity separated into left and right nasal cavities by a narrow vertical nasal cavities by a narrow vertical divider, the divider, the SEPTUMSEPTUM..

Each nasal cavity is divided into three Each nasal cavity is divided into three passageways by the projections of the passageways by the projections of the turbinates (CONCHAE) from the turbinates (CONCHAE) from the lateral walls.lateral walls.

Nasal cavities are lined with highly Nasal cavities are lined with highly vascular ciliated mucus membranes vascular ciliated mucus membranes called called NASAL MUCOSANASAL MUCOSA..

The nose serves:The nose serves:– as a passageway for air to pass to and as a passageway for air to pass to and

from the lungsfrom the lungs– Filters impuritiesFilters impurities– Humidifies the airHumidifies the air– Warms the airWarms the air– Responsible for olfaction (smell) Responsible for olfaction (smell)

because olfactory nerves are located in because olfactory nerves are located in nasal mucosanasal mucosa

PARANASAL SINUSESPARANASAL SINUSES Are named by their locationAre named by their location

– FrontalFrontal– EthmoidalEthmoidal– SphenoidalSphenoidal– MaxillaryMaxillary

Its prominent function is to serve as Its prominent function is to serve as a RESONATING CHAMBER IN SPEECH.a RESONATING CHAMBER IN SPEECH.

Common site for infection.Common site for infection. It traps particles.It traps particles.

PHARYNXPHARYNXOr THROATOr THROATTube-like structure that connects Tube-like structure that connects

the nasal and oral cavities to the the nasal and oral cavities to the larynx.larynx.

Functions as the PASSAGEWAY Functions as the PASSAGEWAY FOR THE RESPIRATORY AND FOR THE RESPIRATORY AND DIGESTIVE TRACTSDIGESTIVE TRACTS

LARYNXLARYNXKnown as the “VOICE BOX”Known as the “VOICE BOX”Major function: VOCALIZATIONMajor function: VOCALIZATIONProtects the lower airway from Protects the lower airway from

foreign substances and foreign substances and facilitates coughing.facilitates coughing.

Consists of:Consists of:– Epiglottis – covers the opening to the Epiglottis – covers the opening to the

larynx during swallowinglarynx during swallowing– Glottis – opening between the vocal Glottis – opening between the vocal

cords in the larynxcords in the larynx– Thyroid cartilage – largest of the Thyroid cartilage – largest of the

cartilage structures, forms the ADAM’S cartilage structures, forms the ADAM’S APPLEAPPLE

– Vocal cords – ligaments controlled by Vocal cords – ligaments controlled by muscular movements that produce muscular movements that produce soundssounds

TRACHEATRACHEA

Or “WINDPIPE”Or “WINDPIPE” Serves as the passage between the Serves as the passage between the

larynx and the bronchilarynx and the bronchi

LOWER RESPIRATORY LOWER RESPIRATORY SYSTEMSYSTEM

LUNGSLUNGS Paired elastic Paired elastic

structures structures enclosed in enclosed in thoracic cagethoracic cage

Composed of 3 Composed of 3 lobes on right lobes on right side and 2 lobes side and 2 lobes on left sideon left side

Covered by Covered by PLEURA PLEURA

PLEURAPLEURA Serous Serous

membrane that membrane that lines the lungs lines the lungs and wall of and wall of thoraxthorax

Visceral pleura-Visceral pleura- covers the lungscovers the lungs

Parietal pleura-Parietal pleura- lines the thoraxlines the thorax

PLEURAL FLUIDPLEURAL FLUID Serves to Serves to

lubricate the lubricate the thorax and lungs thorax and lungs and permit and permit smooth motion smooth motion of the lungs of the lungs within the within the thoracic cavity thoracic cavity with each with each breath.breath.

BRONCHI and BRONCHI and BRONCHIOLESBRONCHIOLES

They are formed They are formed by branching if by branching if tracheatrachea

Right main Right main bronchus – bronchus – larger and more larger and more vertical than leftvertical than left

Bronchioles Bronchioles branch into branch into terminal terminal bronchioles bronchioles which end in which end in alveolialveoli

ALVEOLIALVEOLI Arranged in Arranged in

clustersclusters Site for GAS Site for GAS

EXCHANGEEXCHANGE SURFACTANT- SURFACTANT-

reduces surface reduces surface tension to keep tension to keep alveoli from alveoli from collapsingcollapsing

FUNCTION OF THE FUNCTION OF THE RESPIRATORY SYSTEMRESPIRATORY SYSTEM

The cells of the body derive energy The cells of the body derive energy they need from the oxidation of they need from the oxidation of carbohydrates, fats and proteins.carbohydrates, fats and proteins.

Certain vital tissues, such as those of Certain vital tissues, such as those of the brain and heart, cannot survive the brain and heart, cannot survive for long without a continuing supply for long without a continuing supply of oxygen.of oxygen.

As a result of oxidation in the body As a result of oxidation in the body tissues, carbon dioxide is produced tissues, carbon dioxide is produced and must be removed from cells to and must be removed from cells to prevent build-up of acid wastes.prevent build-up of acid wastes.

Therefore, the respiratory Therefore, the respiratory system performs these functions system performs these functions to facilitate life-sustaining to facilitate life-sustaining processes.processes.

OXYGEN TRANSPORTOXYGEN TRANSPORT

Oxygen is supplied to, and Oxygen is supplied to, and carbon dioxide is removed from, carbon dioxide is removed from, cells by way of circulating blood.cells by way of circulating blood.

Cells are in close contact with Cells are in close contact with capillaries, whose thin walls capillaries, whose thin walls permit easy passage or permit easy passage or exchange of oxygen and carbon exchange of oxygen and carbon dioxide.dioxide.

Oxygen diffuses from the capillary Oxygen diffuses from the capillary through the capillary wall to the through the capillary wall to the interstitial fluid.interstitial fluid.

At this point, it diffuses through the At this point, it diffuses through the membrane of tissue cells, where it is membrane of tissue cells, where it is used by mitochondria for cellular used by mitochondria for cellular respiration. respiration.

The movement of carbon dioxide The movement of carbon dioxide occurs by diffusion in the opposite occurs by diffusion in the opposite direction – from cell to blood.direction – from cell to blood.

RESPIRATIONRESPIRATIONThe whole process of gas The whole process of gas

exchange between the exchange between the atmospheric air and the blood atmospheric air and the blood and between the blood and cells and between the blood and cells of the bodyof the body

After tissue capillary exchanges, After tissue capillary exchanges, blood enters the systemic veins blood enters the systemic veins (where it is called VENOUS (where it is called VENOUS BLOOD)BLOOD)

The oxygen concentration in The oxygen concentration in blood within the capillaries of the blood within the capillaries of the lungs is lower that in the lungs’ lungs is lower that in the lungs’ air sacs (alveoli). Therefore, air sacs (alveoli). Therefore, oxygen diffuses from the alveoli oxygen diffuses from the alveoli to the blood.to the blood.

Carbon dioxide, which has the Carbon dioxide, which has the higher concentration in the blood higher concentration in the blood than in the alveoli, diffuses from than in the alveoli, diffuses from the blood into the alveoli.the blood into the alveoli.

Movement of air in and out of the Movement of air in and out of the airways (ventilation) continually airways (ventilation) continually replenishes the oxygen and replenishes the oxygen and removes the carbon dioxide from removes the carbon dioxide from the airways in the lung.the airways in the lung.

VENTILATIONVENTILATION Movement of air in and out of the Movement of air in and out of the

lungslungs Adequate ventilation depends on Adequate ventilation depends on

several factors:several factors:– Clear airwaysClear airways– An intact CNS and respiratory centerAn intact CNS and respiratory center– An intact thoracic cavity capable of An intact thoracic cavity capable of

expanding and contractingexpanding and contracting– Adequate pulmonary compliance and Adequate pulmonary compliance and

recoilrecoil

2 PHASES:2 PHASES:– Inspiration Inspiration – involves the contraction – involves the contraction

and descent of the chest is increased and descent of the chest is increased and the pressure in the air passages and and the pressure in the air passages and alveoli decreases, secreting sub-alveoli decreases, secreting sub-atmospheric pressure so that air goes atmospheric pressure so that air goes into the respiratory area until the into the respiratory area until the pressure gradient is equalized.pressure gradient is equalized.

– ExpirationExpiration – a passive process that – a passive process that results in the expulsion of air when the results in the expulsion of air when the components of the thoracic cage relax.components of the thoracic cage relax.

Physical factors that govern the air Physical factors that govern the air flow in and out of the lungs are flow in and out of the lungs are collectively referred to as the collectively referred to as the mechanics of ventilation and mechanics of ventilation and includesincludes– Muscle structureMuscle structure– Interpleural pressureInterpleural pressure– Lung complianceLung compliance– Airway resistanceAirway resistance

MUSCLE STRUCTUREMUSCLE STRUCTURE

Muscle bundles that influence Muscle bundles that influence respiration:respiration:– Intercostal musclesIntercostal muscles– Anterior neck muscles such as Anterior neck muscles such as

Scalene, sternocleidomastoidScalene, sternocleidomastoid– Muscles of abdomenMuscles of abdomen

INTRAPLEURAL PRESSUREINTRAPLEURAL PRESSURE

Pressure in the pleural cavity Pressure in the pleural cavity surrounding the lungssurrounding the lungs

Always slightly Always slightly negativenegative in relation to in relation to atmospheric pressureatmospheric pressure

INTRAPULMONARY PRESSURE INTRAPULMONARY PRESSURE (pressure within the lungs)(pressure within the lungs)

LUNG COMPLIANCELUNG COMPLIANCE Is the measure of the elasticity, Is the measure of the elasticity,

expandability and distensibility of the expandability and distensibility of the lungs and thoracic structureslungs and thoracic structures

Factors that determine lung Factors that determine lung compliance are the SURFACE compliance are the SURFACE TENSION of the ALVEOLI (normally TENSION of the ALVEOLI (normally low with the presence of surfactant) low with the presence of surfactant) and the connective tissue (collagen and the connective tissue (collagen and elastin) of the lungs. and elastin) of the lungs.

Determined by examining the Determined by examining the volume-pressure relationship in the volume-pressure relationship in the lungs and the thorax.lungs and the thorax.

NORMALLY, the lungs and thorax NORMALLY, the lungs and thorax easily stretch and distend when easily stretch and distend when pressure is applied. pressure is applied.

HIGH or increased compliance occurs HIGH or increased compliance occurs when the lungs have lost their when the lungs have lost their elasticity and the thorax is elasticity and the thorax is overdistended.overdistended.

When lungs and thorax are “stiff”, When lungs and thorax are “stiff”, there is LOW or decreased there is LOW or decreased compliance. compliance.

Conditions associated with this Conditions associated with this include pneumothorax, hemothorax, include pneumothorax, hemothorax, pleural effusion, pulmonary edema, pleural effusion, pulmonary edema, atelectasis, pulmonary fibrosis and atelectasis, pulmonary fibrosis and ARDS.ARDS.

AIRWAY RESISTANCEAIRWAY RESISTANCE Refers to the relationship between Refers to the relationship between

airflow and pleural pressureairflow and pleural pressure

REQUIREMENTS FOR REQUIREMENTS FOR EFFECTIVE VENTILATIONEFFECTIVE VENTILATION

Patent airwayPatent airwayElastic, expansible lungs and Elastic, expansible lungs and

tracheo-bronchial treetracheo-bronchial treeAdequate musculo-skeletal Adequate musculo-skeletal

apparatus of chest wallapparatus of chest wall

FACTORS AFFECTING FACTORS AFFECTING RESPIRATORY RESPIRATORY

FUNCTIONFUNCTION

AGEAGE At birth, fluid-filled lungs drain, At birth, fluid-filled lungs drain,

partial pressure of carbon dioxide partial pressure of carbon dioxide rises, neonate takes a first breath.rises, neonate takes a first breath.

Lungs reaches full inflation by 2 Lungs reaches full inflation by 2 weeks of ageweeks of age

Changes of aging that affect the Changes of aging that affect the respiratory system are infection, respiratory system are infection, physical or emotional stress, surgery, physical or emotional stress, surgery, anesthesia and other proceduresanesthesia and other procedures

Respiratory rates are HIGHEST and Respiratory rates are HIGHEST and mist variable in NEWBORNS.mist variable in NEWBORNS.

Because of rib cage structure, infants Because of rib cage structure, infants rely almost exclusively on rely almost exclusively on DIAPHRAGMATIC MOVEMENT for DIAPHRAGMATIC MOVEMENT for breathing. breathing.

Changes in ElderlyChanges in Elderly

Chest wall and airways become more Chest wall and airways become more rigid and less elasticrigid and less elastic

The amount of exchanged air is The amount of exchanged air is decreaseddecreased

The cough reflex and cilia action are The cough reflex and cilia action are decreaseddecreased

Mucus membranes become drier and Mucus membranes become drier and more fragilemore fragile

Decrease in muscle strength and Decrease in muscle strength and enduranceendurance

If osteoporosis is present, adequate If osteoporosis is present, adequate lung expansion may be lung expansion may be compromised.compromised.

A decrease in efficiency on the A decrease in efficiency on the immune system occurs.immune system occurs.

Gastroesophageal reflux diseaseGastroesophageal reflux disease is is more common in older adults and more common in older adults and increases the risk of aspiration. The increases the risk of aspiration. The aspiration of stomach contents into aspiration of stomach contents into the lungs often causes the lungs often causes bronchospasm by setting up an bronchospasm by setting up an inflammatory response. inflammatory response.

ENVIRONMENTENVIRONMENT

LIFESTYLELIFESTYLE

HEALTH STATUSHEALTH STATUS

MEDICATIONSMEDICATIONS

STRESSSTRESS

PHYSICAL ASSESSMENTPHYSICAL ASSESSMENTandand

HEALTH HISTORYHEALTH HISTORY

The health history focuses on the physical The health history focuses on the physical and functional problems of the patient and and functional problems of the patient and the effect on these problems on his or her the effect on these problems on his or her life.life.

Reason patient is seeking health care is Reason patient is seeking health care is often related to:often related to:– DyspneaDyspnea– PainPain– Accumulation of mucusAccumulation of mucus– WheezingWheezing– HemoptysisHemoptysis– Edema of ankles and feetEdema of ankles and feet– CoughCough– Fatigue and weaknessFatigue and weakness

SUBJECTIVE DATASUBJECTIVE DATA

ASSESSMENT INTERVIEWASSESSMENT INTERVIEW– Have you noticed any changes in your Have you noticed any changes in your

breathing pattern?breathing pattern?– If so, which of your activities might If so, which of your activities might

cause these symptoms?cause these symptoms?– How many pillows do you use to sleep at How many pillows do you use to sleep at

night?night?– Have you had any medical conditions Have you had any medical conditions

experienced before?experienced before?

How frequently have these occurred? How frequently have these occurred? How long did they last? And how How long did they last? And how were they treated?were they treated?

Do you smoke? If so, how much? Do you smoke? If so, how much? Does any of our family member Does any of our family member

smoke?smoke? Do you use alcohol? If so, how many Do you use alcohol? If so, how many

drinks do you usually have per day or drinks do you usually have per day or per weekper week

Describe your exercise patterns.Describe your exercise patterns.

How often and how much do you How often and how much do you cough?cough?

Is it productive, accompanied by Is it productive, accompanied by sputum or non productive cough?sputum or non productive cough?

When is the sputum produced?When is the sputum produced? What is the amount, color, thickness, What is the amount, color, thickness,

odor?odor? Is it tinged with blood?Is it tinged with blood? Ask for any occurrence of chest pain, Ask for any occurrence of chest pain,

risk factors and medication historyrisk factors and medication history

OBJECTIVE DATAOBJECTIVE DATA

Major signs and symptoms of Major signs and symptoms of respiratory disease are:respiratory disease are:– DyspneaDyspnea– CoughCough– Sputum productionSputum production– Chest painChest pain– WheezingWheezing– Clubbing of the fingersClubbing of the fingers– HemoptysisHemoptysis– Cyanosis Cyanosis

DYSPNEADYSPNEA Difficult or labored breathingDifficult or labored breathing Shortness of breathShortness of breath A common symptom to many A common symptom to many

pulmonary and cardiac disorders.pulmonary and cardiac disorders. Right ventricle of the heart will be Right ventricle of the heart will be

affected ultimately by lung disease affected ultimately by lung disease because it must pump blood through because it must pump blood through the lungs against greater resistance.the lungs against greater resistance.

Clinical SignificanceClinical Significance Sudden dyspnea in HEALTHY PERSON Sudden dyspnea in HEALTHY PERSON

may indicate may indicate pneumothoraxpneumothorax or or ARDS.ARDS. In IMMOBILIZED PATIENTS, sudden In IMMOBILIZED PATIENTS, sudden

dyspnea may denote dyspnea may denote pulmonary pulmonary embolism.embolism.

ORTHOPNEA (inability to breathe ORTHOPNEA (inability to breathe easily except in an upright position) easily except in an upright position) may be found in patients with COPDmay be found in patients with COPD

NOISY BREATHING may result from a NOISY BREATHING may result from a narrowing of the airway or localized narrowing of the airway or localized obstruction of a major bronchus by a obstruction of a major bronchus by a tumor or foreign body.tumor or foreign body.

Wheezing usually signifies asthma.Wheezing usually signifies asthma.

Relief MeasuresRelief Measures

The management of dyspnea is The management of dyspnea is aimed at identifying and correcting aimed at identifying and correcting its cause. its cause.

Relief of the symptom sometimes is Relief of the symptom sometimes is achieved by placing the patient at achieved by placing the patient at rest with the head elevated (high rest with the head elevated (high Fowler’s position).Fowler’s position).

In severe cases, administering In severe cases, administering oxygen.oxygen.

COUGHCOUGH Results from irritation of the mucus Results from irritation of the mucus

membranes anywhere in the membranes anywhere in the respiratory tract. respiratory tract.

Patient’s chief protection against the Patient’s chief protection against the accumulation of secretions in the accumulation of secretions in the bronchi and bronchioles.bronchi and bronchioles.

Clinical SignificanceClinical Significance

May indicate serious pulmonary May indicate serious pulmonary diseases.diseases.

The nurse needs to evaluate the The nurse needs to evaluate the character of the cough – character of the cough – dry, dry, hacking, brassy, wheezing, loose hacking, brassy, wheezing, loose or severe.or severe.

Time of coughing is also noted.Time of coughing is also noted.

DRY & IRRITANT COUGH – DRY & IRRITANT COUGH – characteristic of an upper characteristic of an upper respiratory tract infection of viral respiratory tract infection of viral origin. origin.

LARYNGOTRACHEITIS – causes LARYNGOTRACHEITIS – causes an irritative, high-pitched cough.an irritative, high-pitched cough.

TRACHEAL LESIONS – produce a TRACHEAL LESIONS – produce a brassy coughbrassy cough

BRONCHOGENIC CARCINOMA – BRONCHOGENIC CARCINOMA – severe and changing coughsevere and changing cough

TRACHEAL LESIONSTRACHEAL LESIONS

Coughing at NIGHT may herald Coughing at NIGHT may herald the onset of the onset of LEFT-SIDED LEFT-SIDED HEART FAILUREHEART FAILURE or or BRONCHIAL BRONCHIAL ASTHMA. ASTHMA.

Cough in MORNING WITH Cough in MORNING WITH SPUTUM PRODUCTION may SPUTUM PRODUCTION may indicate indicate BRONCHITIS.BRONCHITIS.

BRONCHIAL ASTHMABRONCHIAL ASTHMA

BRONCHITISBRONCHITIS

A cough that worsens when A cough that worsens when the patient is SUPINE the patient is SUPINE suggests suggests SINUSITIS SINUSITIS (postnasal drip).(postnasal drip).

Coughing AFTER food intake Coughing AFTER food intake may indicate may indicate aspirationaspiration of of material into tracheo-material into tracheo-bronchial tree.bronchial tree.

SPUTUM PRODUCTIONSPUTUM PRODUCTIONThe The color of sputum or color of sputum or

phlegmphlegm, which is the mucus and , which is the mucus and sometimes pus discharge sometimes pus discharge expectorated from the expectorated from the respiratory tract, is often an respiratory tract, is often an indication of the type of indication of the type of respiratory disease that gives respiratory disease that gives rise to sputum production. rise to sputum production.

By examining the type of sputum By examining the type of sputum and noting the color as well as and noting the color as well as the presenting signs and the presenting signs and symptoms, a differential symptoms, a differential diagnosis may be reached prior diagnosis may be reached prior to laboratory tests and to laboratory tests and examination (sputum culture). examination (sputum culture).

A thorough case history and A thorough case history and complete physical examination is complete physical examination is also necessary.also necessary.

Meaning of Different Meaning of Different Sputum ColorsSputum Colors

CLEAR, WHITE, GRAY SPUTUMCLEAR, WHITE, GRAY SPUTUM

Clear sputumClear sputum is considered as  is considered as normalnormal, however, there are many , however, there are many conditions that may cause excessive conditions that may cause excessive sputum production. sputum production.

A profuse amount of clear sputum A profuse amount of clear sputum should therefore be considered as should therefore be considered as abnormal.abnormal.

Pulmonary edemaPulmonary edema ( (fluid in the lungs) – clear, white or pink frothy sputum) – clear, white or pink frothy sputum

Viral respiratory tract infectionsViral respiratory tract infections –  – clear to white (acute)clear to white (acute)

Chronic bronchitisChronic bronchitis (COPD) – clear to  (COPD) – clear to graygray

AsthmaAsthma – white to yellow (thick) – white to yellow (thick)

CHRONIC BRONCHITISCHRONIC BRONCHITIS

CHRONIC BRONCHITISCHRONIC BRONCHITIS

YELLOW SPUTUMYELLOW SPUTUMYellow colored sputumYellow colored sputum is due  is due

to the presence of white blood to the presence of white blood cells, particularly neutrophils and cells, particularly neutrophils and eosinophils. eosinophils.

These cells are often present in These cells are often present in chronic inflammation, allergic chronic inflammation, allergic and infectious causes. and infectious causes.

With With INFECTIONSINFECTIONS, it is often in , it is often in the acute setting that the acute setting that yellow yellow sputumsputum is evident due to the  is evident due to the presence of  live presence of  live neutrophilsneutrophils. .

With With ALLERGIC CONDITIONSALLERGIC CONDITIONS, , particularly airway particularly airway hypersensitivity, the hypersensitivity, the yellowish yellowish sputumsputum is due to the presence  is due to the presence of of eosinophilseosinophils..

Acute bronchitisAcute bronchitis – white to  – white to yellowyellow

Acute pneumoniaAcute pneumonia – white to  – white to yellowyellow

AsthmaAsthma – white to yellow (thick) – white to yellow (thick)

GREEN SPUTUMGREEN SPUTUMGreen mucus is indicative of a  is indicative of a

long-standing, possibly chronic, long-standing, possibly chronic, infection.infection.

The color is a result of the The color is a result of the breakdown of neutrophils and breakdown of neutrophils and the release of verdoperioxidase / the release of verdoperioxidase / myeloperioxidase, an enzyme myeloperioxidase, an enzyme that is present within these cells. that is present within these cells.

It may also be seen in long standing It may also be seen in long standing non-infectious inflammatory non-infectious inflammatory conditions. conditions.

With With infectionsinfections, the , the green green sputumsputum will be  will be more purulentmore purulent (large (large amounts of pus).amounts of pus).

While in While in non-infectious inflammatory non-infectious inflammatory conditionsconditions, the , the green sputumgreen sputum will  will be more be more mucoidmucoid (large amounts of (large amounts of mucus).mucus).

PneumoniaPneumonia – white, yellow or green – white, yellow or green Lung abscessLung abscess – green, sudden  – green, sudden

accumulation of large amount of accumulation of large amount of sputum if the abscess rupturessputum if the abscess ruptures

Chronic bronchitisChronic bronchitis – clear, grey to  – clear, grey to green (infection)green (infection)

BronchiectasisBronchiectasis, , cystic fibrosiscystic fibrosis –  – greengreen

LUNG ABCESSLUNG ABCESS

BRONCHIECTASISBRONCHIECTASIS

BROWN, BLACK SPUTUMBROWN, BLACK SPUTUM Brown or black sputumBrown or black sputum is an  is an

indication of ‘indication of ‘old bloodold blood’ and the color ’ and the color may be due to the breakdown of may be due to the breakdown of red blood cells thereby releasing  thereby releasing hemosiderin (from hemoglobin).hemosiderin (from hemoglobin).

Certain organic and Certain organic and non-organic non-organic dustsdusts may also cause may also cause a a brownbrown to  to black black discoloration of discoloration of the sputum.the sputum.

Chronic bronchitisChronic bronchitis – green,  – green, yellow, brown (infection)yellow, brown (infection)

Chronic pneumoniaChronic pneumonia – white,  – white, yellow, green to brownyellow, green to brown

Coal worker’s Coal worker’s pneumoconiosispneumoconiosis – brown to  – brown to blackblack

TuberculosisTuberculosis – red to brown or  – red to brown or blackblack

Lung canceLung cancer – red to brown to r – red to brown to blackblack

COAL WORKER’S PNEUMOCONIOSISCOAL WORKER’S PNEUMOCONIOSIS SIMPLE COAL WORKER’S SIMPLE COAL WORKER’S

PNEUMOCONIOSISPNEUMOCONIOSIS PROGRESSIVE FIBROSIS PROGRESSIVE FIBROSIS

COAL WORKER’S COAL WORKER’S PNEUMOCONIOSISPNEUMOCONIOSIS

RED, PINK RUST-COLORED RED, PINK RUST-COLORED SPUTUMSPUTUM

Red sputumRed sputum is usually an  is usually an indication of whole blood that is indication of whole blood that is more profuse than bleeding in more profuse than bleeding in pink colored sputum. pink colored sputum.

It may completely discolor the It may completely discolor the mucus or appear as streaks or mucus or appear as streaks or spots. spots. 

Pink sputum Pink sputum is also a sign of is also a sign of bleeding but usually of smaller bleeding but usually of smaller quantities that may stain or streak quantities that may stain or streak the sputum. the sputum.

Rust colored sputumRust colored sputum is also due to is also due to the bleeding although the clotting the bleeding although the clotting process may have commenced and process may have commenced and the the red blood cellsred blood cells may have  may have broken down.broken down.

Pneumococcal pneumoniaPneumococcal pneumonia –  – rusty-redrusty-red

Lung cancer Lung cancer - pink to red - pink to red (frothy) progressing to brown or (frothy) progressing to brown or blackblack

TuberculosisTuberculosis – bright red  – bright red streaks progressing to fully red streaks progressing to fully red sputum (hemoptysis)sputum (hemoptysis)

Pulmonary embolismPulmonary embolism – bright  – bright red blood (acute)red blood (acute)

LUNG CANCERLUNG CANCER

Meaning Of Different Meaning Of Different Types Of SputumTypes Of Sputum

CLEAR SPUTUMCLEAR SPUTUM slightly sticky and a bit viscous (thicker slightly sticky and a bit viscous (thicker

than water) is accepted as normal sputum. than water) is accepted as normal sputum. It is produced and secreted in moderate It is produced and secreted in moderate

amounts to moisten the respiratory tract amounts to moisten the respiratory tract and trap dust and microorganisms and trap dust and microorganisms (mucus) and lubricate the mouth and aid (mucus) and lubricate the mouth and aid with chewing, swallowing and digestion with chewing, swallowing and digestion (saliva). (saliva).

While any expectorated sputum is While any expectorated sputum is considered to be abnormal,  small considered to be abnormal,  small amounts of sputum can be coughed up or amounts of sputum can be coughed up or spat out with effort even in the absence of spat out with effort even in the absence of any respiratory pathology.any respiratory pathology.

However, in certain conditions, However, in certain conditions, particularly related to irritation of the particularly related to irritation of the respiratory tract, the amount of respiratory tract, the amount of sputum may become excessive. sputum may become excessive.

In these pathological cases, the In these pathological cases, the color, texture and even odor of the color, texture and even odor of the sputum may change. sputum may change.

These variations may give an These variations may give an indication of the possible cause.indication of the possible cause.

SEROUSSEROUS NormalNormal, , clear sputumclear sputum is a serous is a serous

discharge.discharge. Large amounts of clear, frothy or Large amounts of clear, frothy or

pink sputum that is of a similar pink sputum that is of a similar consistency as normal sputum may consistency as normal sputum may be a sign of be a sign of pulmonary edemapulmonary edema, which , which is an accumulation of is an accumulation of fluid in the lungs. .

If it extremely profuse and lasting for If it extremely profuse and lasting for weeks or months, then it may be due weeks or months, then it may be due to to lung cancer.lung cancer.

Frothy Frothy sputumsputum is caused by is caused by surfactant in the lung alveoli surfactant in the lung alveoli which reduces the surface which reduces the surface tension of the sputum. tension of the sputum.

It indicates that the sputum had It indicates that the sputum had contact with the lung alveoli or contact with the lung alveoli or originated from this site.originated from this site.

MUCOPURULENTMUCOPURULENTMucoid, mucopurulent or Mucoid, mucopurulent or

purulent sputum is purulent sputum is thickerthicker and and often more often more stickysticky than normal than normal sputum. sputum.

This is partly due to the greater This is partly due to the greater mucus production coupled with mucus production coupled with pus in the purulent types.pus in the purulent types.

Mucoid sputum is a sign of non-Mucoid sputum is a sign of non-infectious airway disease like chronic infectious airway disease like chronic bronchitis (COPD) and asthma or bronchitis (COPD) and asthma or may occur in the early stages of may occur in the early stages of infection. infection.

Mucopurulent sputum is an indication Mucopurulent sputum is an indication of infection of the respiratory tract, of infection of the respiratory tract, particularly of the bronchi or lungs – particularly of the bronchi or lungs – acute bronchitis and pneumonia.acute bronchitis and pneumonia.

BLOOD-STAINEDBLOOD-STAINEDSputum may be blood stained Sputum may be blood stained

where the normal sticky or where the normal sticky or mucopurulent thick consistency mucopurulent thick consistency becomes thinner due to the becomes thinner due to the presence of varying amounts of presence of varying amounts of blood. blood.

In severe cases involving the In severe cases involving the coughing up of large amounts of coughing up of large amounts of blood (hemoptysis), the consistency blood (hemoptysis), the consistency of the sputum may be the same of the sputum may be the same viscosity as blood and little or no viscosity as blood and little or no sputum may be visible. Blood stained sputum may be visible. Blood stained sputum may be due to tuberculosis, sputum may be due to tuberculosis, bronchiectasis, pulmonary embolism bronchiectasis, pulmonary embolism or lung cancer.or lung cancer.

CHEST PAINCHEST PAINMay be associated with May be associated with

pulmonary or cardiac diseases.pulmonary or cardiac diseases.Chest pain associated with Chest pain associated with

pulmonary conditions may be pulmonary conditions may be SHARP, STABBING and SHARP, STABBING and INTERMITTENTINTERMITTENT

May be DULL, ACHING, May be DULL, ACHING, PERSISTENTPERSISTENT

May occur with May occur with PNEUMONIAPNEUMONIA, , PULMONARY EMBOLISM with PULMONARY EMBOLISM with LUNG INFARACTIONLUNG INFARACTION, , PLEURISYPLEURISY

LATE SYMPTOM – bronchogenic LATE SYMPTOM – bronchogenic carcinomacarcinoma

CARCINOMA – pain may be dull CARCINOMA – pain may be dull and persistent because the and persistent because the carcinoma has invaded the chest carcinoma has invaded the chest wall, mediastinum or spinewall, mediastinum or spine

The nurse assesses the quality, The nurse assesses the quality, intensity and radiation of pain.intensity and radiation of pain.

Identifies and explores Identifies and explores precipitating factors, along with precipitating factors, along with the relationship of the patient’s the relationship of the patient’s position. position.

Relief Measures Relief Measures

Analgesic medications may be Analgesic medications may be effective in relieving chest pain.effective in relieving chest pain.

Non-steroidal anti-inflammatory Non-steroidal anti-inflammatory drugs (NSAIDs) used for pleuritic pain drugs (NSAIDs) used for pleuritic pain

WHEEZINGWHEEZING A high-pitched, musical sound heard A high-pitched, musical sound heard

mainly on expiration.mainly on expiration. Major finding in a patient with Major finding in a patient with

bronchoconstriction or airway bronchoconstriction or airway narrowing.narrowing.

Can be heard with or without a Can be heard with or without a stethoscope, depending on locationstethoscope, depending on location

Relief Measures Relief Measures

Oral or inhalant Oral or inhalant bronchodilator bronchodilator medications medications reverse reverse wheezing in wheezing in most instances.most instances.

CLUBBING OF FINGERSCLUBBING OF FINGERS A sign of lung A sign of lung

disease found in disease found in patients with patients with chronic hypoxic chronic hypoxic conditions, conditions, chronic lung chronic lung infections and infections and malignancies of malignancies of the lung.the lung.

Manifested Manifested initially as initially as sponginess of sponginess of the nail-bed the nail-bed and loss of and loss of the nail-bed the nail-bed angle.angle.

HEMOPTYSISHEMOPTYSISExpectoration of blood from the Expectoration of blood from the

respiratory tractrespiratory tractSymptom of both pulmonary and Symptom of both pulmonary and

cardiac disorders. cardiac disorders. Its onset is usually sudden, may Its onset is usually sudden, may

be intermittent or continuous. be intermittent or continuous. The amount of blood produced is The amount of blood produced is

not always proportional to the not always proportional to the seriousness of the cause.seriousness of the cause.

Diagnostic EvaluationDiagnostic Evaluation

Chest angiographyChest angiography Chest x-rayChest x-ray BronchoscopyBronchoscopy

Points to consider when Points to consider when documenting bleeding episode:documenting bleeding episode:

Bloody sputum from the nose Bloody sputum from the nose or the nasopharynx is usually or the nasopharynx is usually preceded by considerable preceded by considerable sniffing, with blood possibly sniffing, with blood possibly appearing on the nose.appearing on the nose.

Blood from the lung is usually bright Blood from the lung is usually bright red, frothy, mixed with sputum.red, frothy, mixed with sputum.

Initial symptoms include a tickling Initial symptoms include a tickling sensation in the throat, a salty taste, sensation in the throat, a salty taste, a burning or bubbling sensation in a burning or bubbling sensation in the chest and perhaps chest pain.the chest and perhaps chest pain.

The term “hemoptysis” is reserved The term “hemoptysis” is reserved for the coughing up of blood arising for the coughing up of blood arising from a pulmonary hemorrhage.from a pulmonary hemorrhage.

This blood has an alkaline pH This blood has an alkaline pH (greater than 7.0)(greater than 7.0)

If the hemorrhage is in the If the hemorrhage is in the stomach, the blood is vomited stomach, the blood is vomited (hematemesis) rather than (hematemesis) rather than coughed up.coughed up.

Blood that has been in contact Blood that has been in contact with gastric juice is sometimes with gastric juice is sometimes so dark that it is referred to as so dark that it is referred to as ““coffee groundscoffee grounds”. This blood has ”. This blood has an acid pH (less than 7.0). an acid pH (less than 7.0).

CYANOSISCYANOSISBluish discoloration of the skinBluish discoloration of the skinVERY LATE indicator of hypoxia.VERY LATE indicator of hypoxia.Assessment of cyanosis is Assessment of cyanosis is

affected by affected by room lightingroom lighting, the , the patient’s skin colorpatient’s skin color and the and the distance of the blood vessels distance of the blood vessels from the surface of the skinfrom the surface of the skin. .

In pulmonary condition, central In pulmonary condition, central cyanosis is assessed by observing cyanosis is assessed by observing the color of the tongue and lips. the color of the tongue and lips.

This indicates a decrease in This indicates a decrease in oxygen tension in the blood. oxygen tension in the blood.

Peripheral cyanosis results from Peripheral cyanosis results from decreased blood flow to a certain decreased blood flow to a certain area of the body, as in area of the body, as in vasoconstriction of the nailbeds or vasoconstriction of the nailbeds or earlobes from exposure to cold, earlobes from exposure to cold, and DOES NOT necessarily indicate and DOES NOT necessarily indicate a central systemic problem. a central systemic problem.

Physical Assessment of Physical Assessment of Lower Respiratory Structure Lower Respiratory Structure

and and Breathing PatternsBreathing Patterns

CHEST CONFIGURATIONCHEST CONFIGURATION Normally, the ratio of the Normally, the ratio of the

anteroposterior diameter to the anteroposterior diameter to the lateral diameter is 1:2.lateral diameter is 1:2.

There are four main deformities of the There are four main deformities of the chest associated with respiratory chest associated with respiratory disease that alter this relationship:disease that alter this relationship:– Barrel chestBarrel chest– Funnel chest (pectus excavatum)Funnel chest (pectus excavatum)– Pigeon chest (pectus carinatum)Pigeon chest (pectus carinatum)– kyphoscoliosiskyphoscoliosis

BARREL CHESTBARREL CHEST Due to over-Due to over-

inflation of the inflation of the lungs. lungs.

There is an There is an increase in the increase in the anteroposterior anteroposterior diameter of the diameter of the thorax. thorax.

In patient with In patient with emphysema, the emphysema, the ribs are more ribs are more widely spaced widely spaced and the and the intercostal intercostal spaces tend to spaces tend to bulge on bulge on expiration.expiration.

The appearance The appearance of the patient with of the patient with advanced advanced emphysema is emphysema is thus quite thus quite characteristic and characteristic and often allows the often allows the observer to detect observer to detect its presence its presence easily, even from easily, even from a distance. a distance.

FUNNEL CHEST FUNNEL CHEST (Pectus excavatum)(Pectus excavatum)

Occurs when Occurs when there is a there is a depression in the depression in the lower portion of lower portion of the sternum. the sternum.

This may This may compress the compress the heart and great heart and great vessels resulting vessels resulting in in MURMURSMURMURS..

Funnel chest Funnel chest may occur may occur with rickets or with rickets or Marfan’s Marfan’s syndrome.syndrome.

PIGEON CHEST PIGEON CHEST ( Pectus carinatum)( Pectus carinatum)

Occurs as a Occurs as a result of result of displacement displacement of sternum.of sternum.

KYPHOSCOLIOSISKYPHOSCOLIOSIS

Characterized by Characterized by elevation of the elevation of the scapula and scapula and corresponding S-corresponding S-shaped spine.shaped spine.

This deformity This deformity limits lung limits lung expansion within expansion within the thorax.the thorax.

It may also occur It may also occur with osteoporosis with osteoporosis and other skeletal and other skeletal disorders that disorders that affect the thorax. affect the thorax.

NORMAL BREATH SOUNDSNORMAL BREATH SOUNDS

Distinguished by their location over a Distinguished by their location over a specific area of the lung:specific area of the lung:– VesicularVesicular– BronchovesicularBronchovesicular– Bronchial (Tubular)Bronchial (Tubular)– Tracheal Tracheal

The The LOCATIONLOCATION, , QUAILITYQUAILITY and and INTENSITYINTENSITY of breath sounds are of breath sounds are determined during auscultation. determined during auscultation.

Adventitious Adventitious SoundsSounds

-Discrete, Noncontinuous SoundDiscrete, Noncontinuous Sound-Continuous Musical Sound Continuous Musical Sound (Wheezes)(Wheezes)-Friction RubsFriction Rubs

DISCRETE, DISCRETE, NONCONTINUOUS SOUNDNONCONTINUOUS SOUND

CRACKLESCRACKLES Formerly referred to as RALESFormerly referred to as RALES Result form delayed opening of Result form delayed opening of

deflated airways.deflated airways. Friction rubs result from Friction rubs result from

inflammation of the pleural surfaces inflammation of the pleural surfaces that induces a crackling, grating that induces a crackling, grating sound usually heard in inspiration sound usually heard in inspiration and expiration.and expiration.

May or may not be cleared by May or may not be cleared by coughingcoughing

Reflect underlying Reflect underlying inflammation or inflammation or congestioncongestion

Present in conditions as pneumonia, Present in conditions as pneumonia, bronchitis, heart failure, bronchitis, heart failure, bronchiectasis, and pulmonary bronchiectasis, and pulmonary fibrosisfibrosis

Fine CracklesFine CracklesUsually audible at the end of Usually audible at the end of

inspiration and originate from inspiration and originate from alveolialveoli

Sound is like rubbing several Sound is like rubbing several pieces of hair next to one’s ear.pieces of hair next to one’s ear.

Coarse CracklesCoarse Crackles

A gross, moist sound produced in A gross, moist sound produced in the large bronchi and are audible the large bronchi and are audible in early and mid-inspiration.in early and mid-inspiration.

CONTINUOUS SOUNDS CONTINUOUS SOUNDS (Wheezes)(Wheezes)

Sibilant WheezesSibilant Wheezes

Caused by air Caused by air passing thru passing thru narrowed narrowed tracheo-tracheo-bronchial treebronchial tree

Found in Found in asthma or asthma or airway airway obstructionobstruction

Originate in Originate in brochi and brochi and bronchiolesbronchioles

““Whistling” soundWhistling” sound Musical noise Musical noise

during inspiration during inspiration or expirationor expiration

Louder during Louder during expirationexpiration

May be cleared May be cleared with coughingwith coughing

Sonorous Wheezes Sonorous Wheezes

Called “GURGLES” or Called “GURGLES” or “RONCHI SOUNDS”“RONCHI SOUNDS”

Deep, low-pitched rumbling Deep, low-pitched rumbling sound heard primarily during sound heard primarily during expiration.expiration.

Caused by the movement of air Caused by the movement of air through the airways that are through the airways that are partially obstructed or narrowed partially obstructed or narrowed airwaysairways

Such as in Such as in tumorstumors or or mucosal mucosal swellingswelling

Friction RubsFriction Rubs

Pleural Friction RubsPleural Friction Rubs

Harsh, crackling sound, like Harsh, crackling sound, like two pieces of leather rubbed two pieces of leather rubbed togethertogether

Heard during inspiration Heard during inspiration alone or during both alone or during both inspiration and expiration.inspiration and expiration.

May subside when patient May subside when patient holds breath.holds breath.

Coughing will NOT clear Coughing will NOT clear soundsound

It is secondary to It is secondary to inflammation and loss of inflammation and loss of lubricating pleural fluid. lubricating pleural fluid.

VOICE SOUNDSVOICE SOUNDS

Vocal resonance Vocal resonance – The sound heard through the The sound heard through the

stethoscope as the patient stethoscope as the patient speaksspeaks

The vibrations produced in The vibrations produced in the larynx are transmitted to the larynx are transmitted to the chest wall as they pass the chest wall as they pass through the bronchi and through the bronchi and alveolar tissue.alveolar tissue.

Voice sounds are assessed by Voice sounds are assessed by the having the patient repeat the having the patient repeat “ninety-nine” or “eee” while “ninety-nine” or “eee” while the nurse listens with the the nurse listens with the stethoscope in corresponding stethoscope in corresponding areas of the chest. areas of the chest.

BRONCHOPHONYBRONCHOPHONY– Describes vocal resonance that is more Describes vocal resonance that is more

INTENSE and CLEARER than normal.INTENSE and CLEARER than normal. EGOPHONYEGOPHONY

– Describes the voice sounds that are Describes the voice sounds that are distorted.distorted.

– Best appreciated by having the patient Best appreciated by having the patient repeat the letter “E”repeat the letter “E”

– The distortion produced by consolidation The distortion produced by consolidation transforms the sounds into a clearly transforms the sounds into a clearly heard “A” rather than “E”heard “A” rather than “E”

BREATHING PATTERNS BREATHING PATTERNS and and

RESPIRATORY RATESRESPIRATORY RATES

EUPNEAEUPNEA

Normal, easy, quiet breathingNormal, easy, quiet breathingRespirations are regular in Respirations are regular in

depth and rhythmdepth and rhythm

DYSPNEADYSPNEATYPES:TYPES:

– OrthopneaOrthopnea – shortness of – shortness of breath when lying downbreath when lying down

– Paroxysmal nocturnal dyspneaParoxysmal nocturnal dyspnea – sudden dyspnea at night – sudden dyspnea at night while lying downwhile lying down

APNEAAPNEA Varying periods of cessation of Varying periods of cessation of

breathingbreathing May occur briefly during other May occur briefly during other

disorders, such as with sleep apneadisorders, such as with sleep apnea This can be life-threatening is This can be life-threatening is

sustained.sustained.

BRADYPNEABRADYPNEA Slow breathingSlow breathing Slower than normal rate (<10 Slower than normal rate (<10

breaths per minute), with normal breaths per minute), with normal depth and rhythmdepth and rhythm

TACHYPNEATACHYPNEA Rapid, shallow breathingRapid, shallow breathing >24 breaths per minute>24 breaths per minute

BIOT’S RESPIRATIONBIOT’S RESPIRATION Cluster breathingCluster breathing Cycles of breaths that vary in depth Cycles of breaths that vary in depth

and have varying periods of apnea.and have varying periods of apnea. Periods of normal breathing (3-4 Periods of normal breathing (3-4

breaths) followed by a varying period breaths) followed by a varying period of apnea (usually 10 seconds to 1 of apnea (usually 10 seconds to 1 minute)minute)

Seen in some central nervous system Seen in some central nervous system disorder.disorder.

CHEYNE-STOKES CHEYNE-STOKES Regular cycle where the rate and Regular cycle where the rate and

depth of breathing increase, then depth of breathing increase, then decrease until apnea (usually 20 decrease until apnea (usually 20 seconds) occurs.seconds) occurs.

Characterized by rhythmic and Characterized by rhythmic and waning of depth of respirationwaning of depth of respiration

Seen typically in severe heart failure Seen typically in severe heart failure and coma caused by neurologic and coma caused by neurologic disorder.disorder.

Near death breathing patternNear death breathing pattern

KUSSMAUL’S BREATHINGKUSSMAUL’S BREATHING

Or Or hyperventilationhyperventilation Or Or polypneapolypnea Marked by increase in rate and depthMarked by increase in rate and depth Associated with severe diabetic Associated with severe diabetic

acidosis or renal originacidosis or renal origin

HYPOVENTILATIONHYPOVENTILATION Or Or oligopneaoligopnea Abnormally low amount of air that Abnormally low amount of air that

enters the lungsenters the lungs Shallow, irregular breathingShallow, irregular breathing

Cogwheel or Waxy respirationCogwheel or Waxy respiration Jerky breathing patternJerky breathing patternRespiratory and expiratory Respiratory and expiratory

sounds are clearly split into two sounds are clearly split into two or more sounds. or more sounds.

INTERRUPTEDINTERRUPTED

ORTHOPNEAORTHOPNEA

Inability to breath except Inability to breath except when the trunk is in upright when the trunk is in upright positionposition