RESPIRATORY SYSTEM

Anatomy and Physiology

 Introduction
The respiratory system is composed of the upper and lower respiratory tracts.
Together the two tracts are responsible for ventilation. The upper respiratory tract
warms and filters inspired air so that the lower respiratory tract can accomplish gas
exchange or diffusion.
The essential features of respiration are the transference of :
 Oxygen from the atmosphere to the tissues
 Carbon dioxide from the tissues to the air
 Air Passages
The organs of respiratory system air passages are:
 Nose
 Pharynx
 Larynx
 Trachea
 Bronchi
 Bronchioles
 Upper Respiratory Tract

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 Nose
The nose serves as a passage way for air to pass to and from the lungs. It filters
impurities and humidifies and warms the air as it is inhaled. The nose is composed of
an external and an internal portion

 External Nose
It forms the pyramidal projection in the middle of the face. It presents with the
following features
 Tip(Apex)- It is the lower free end of the nose.
 Root- The upper narrow part attached to the forehead
 Dorsum of the nose- It is formed by a rounded border between the tip and
root of nose along with the adjoining area.
 Nostrils or anterior nares-These are two piriform shaped apertures present
at the bord lower part of the nose.
 Internal Portion of the nose is a hollow cavity separated into the right and left
nasal cavities by a narrow vertical divider, septum. Air entering the nostrils is
deflected upward to the roof of the nose, and it follows a circuitous route before it
reaches the nasopharynx. The air is moistened, warmed to body temperature, and
brought into contact with a sensitive nerves. Some of these nerves detect odors;
others provoke sneezing to expel irritating dust.

Nasal Cavity

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 It is pyramidal in shape. It extends from the nostrils to the posterior nasal apertures
(choanae). The nasal cavity is divided into right and left halves by a median septum.
Boundaries
Each half of the nasal septum has a floor, roof and medial wall and a lateral wall.
 The roof is mainly formed by the cribiform plate of the ethmoid bone. Anteriorly the
roof is formed by the nasal bone and nasal part of the frontal bone. Posteriorly the
roof is contributed by the body of the sphenoid bone.
The floor is formed by the palate, which seperates the nasal cavity from the
oral cavity.
 Median wall- It is a median, osteocartilaginous partition between the two halves of the
nasal cavity. It is covered on either side by mucous membrane.
 Lateral wall- It is irregular, owing to the presence of three shelf like bony projections
called conchae or turbinates. These elevations are called superior, middle and inferior
nasal conchae according to their position on the lateral wall of the nasal cavity.
The superior and middle conchae are parts of the ethmoid bone; the inferior concha is
an independent bone.
 Blood supply
 The nose and sinuses are supplied by the
Ethmoid branches of the internal carotid artery

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 Facial and internal maxillary branches of the external carotid artery.
 The superior part of the nose receives the anterior and posterior ethmoidal arteries - branches
of the ophthalmic artery which itself, is a branch of the internal carotid.
 Venous drainage of the nose and sinuses is via the ophthalmic and facial veins, and the
pterygoid and pharyngeal plexuses.

Paranasal Air Sinuses

These are air-filled extensions of the respiratory part of the nasal cavity into the skull
bones. The sinuses are lined by pseudostratifiedciliar columnar epithelium.
The sinuses are named by their location: frontal, ethmoid, sphenoid, and maxillary
 Frontal air sinus- This large air sinus is situated in the frontal bone.
 Ethmoidal air sinuses- These are the numerous air filled cavities situated
inside the ethmoid bone. They are divided into three- anterior, middle and
posterior.
 Maxillary sinuses- It is the largest among the air sinuses
 Sphenoidal sinuses- It is a cubical cavity within the body of the sphenoid. The
sinus opens into the sphenoethmoidal recess of the nasal cavity.
Functions
 The prominent function of the sinuses is to serve as a resonating
chamber in speech.
 They reduce the weight of the skull
 The inhaled air is warmed and humidified.
 The mucus secreted by the mucous glands helps to trap dust particles
in the inhaled air.
Blood supply
 They are supplied by the branches of both external carotid artery(facial
artery and sphenopalatine branch of maxillary artery) and internal
carotid artery(anterior and posterior ethmoidal branches of ophthalmic
artery)
Nerve Supply
 Paranasal sinuses are supplied by branches of trigeminal nerve.
Pharynx

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 The pharynx  is the part of the throat behind the mouth and nasal cavity, and above
the esophagus and larynx – the tubes going down to the stomach and the lungs. The
pharynx is part of both the respiratory and digestive system. Both systems have
entrances to the pharynx but they are separated from each other by the soft palate.
It is made up of three sections:
1. Nasopharynx
This portion of the pharynx begins at the back of the nasal cavity, situated behind
the nose and above the soft palate. Unlike the other two portions of the pharynx,
the nasopharynx remains open all the time. On each lateral wall is the pharyngeal
opening of the Eustachian (auditory) tube. The nasopharynx functions as an
airway in the respiratory system. Also contained within the nasopharynx are the
adenoids, or pharyngeal tonsils.
2. Oropharynx
The oropharynx is the middle portion of the pharynx, working with both the
respiratory and digestive systems. It opens anteriorly in the mouth and extends
from the soft palate to the hyoid. In each lateral wall is a palatine tonsil; also in
this region are the sublingual tonsils, which are under the tongue. The
oropharynx functions as an airway and as part of the alimentary canal.
3. Laryngopharynx
 The laryngopharynx is the posteriormost inferior region of the pharynx, reaching
from the hyoid to the lower border of the cricoid cartilage; it’s the place where
the respiratory and digestive systems diverge.
Larynx

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 The larynx is a tough, flexible segment of the respiratory tract connecting the pharynx to
the trachea in the neck. It plays a vital role in the respiratory tract by allowing air to pass
through it while keeping food and drink from blocking the airway. The larynx is also the
body’s “voice box” as it contains the vocal folds that produce the sounds of speech and
singing. The major function of the larynx is vocalization, it protects the lower airway
from foreign substances and facilitates coughing.
It is a cartilaginous epithelium lined organ that connects the pharynx and the trachea and
consists of the following:
 Epiglottis- A valve flap of cartilage that covers the opening to the larynx
during swallowing.
 Glottis- The opening between the vocal cords in the larynx
 Thyroid cartilage-the largest of the cartilage structures , part of it forms the
Adam’s apple.
 Cricoid cartilage-The only complete cartilaginous ring in the larynx
 Arytenoid cartilages-Used in vocal cord movementwith the thyroid cartilage
 Vocal cords- ligaments controlled by muscular movements that produce
sounds
Blood supply
Vascular supply for the larynx is derived from the superior and inferior thyroid
arteries. The external carotid artery gives rise to the superior thyroid artery. The
thyrocervical artery, which arises from the anterosuperior surface of the
subclavianartery gives rise to the inferior thyroid artery and two other branches.

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 The venous drainage of the larynx is via the inferior, middle, and superior thyroid
veins. The inferior thyroid veins continue via the subclavian or left brachiocephalic
vein. The middle and superior thyroid veins empty into the internal jugular vein.
Lymphatic drainage of the larynx is accomplished via the deep cervical and
paratracheal nodes medially, and via the pretracheal and pre-laryngeal nodes medially.

Trachea
The trachea or windpipe is composed of smooth muscle with C- shaped rings of
cartilage at regular intervals. The trachea is the tube linking the cricoid cartilage of
the larynx to the bronchi, forming part of the conducting system which transports air
from the external environment to the lungs.
The trachea develops in the second month of development. It is lined with
an epithelium that has goblet cells which produce protective mucins. It begins at the
bottom of the larynx, and ends at the carina, the point where the trachea branches into
left and right main bronchi. The trachea is surrounded by 16-20 rings of hyaline
cartilage; these 'rings' are incomplete and C-shaped.
Carina
The last tracheal ring is thick and broad. From its lower border, a hook like process
curves downwards and backwards between the bronchi. This projection is called the
carina.
Trachea Conditions
 Tracheal stenosis: Inflammation in the trachea can lead to scarring and narrowing of the
windpipe. Surgery or endoscopy may be needed to correct the narrowing (stenosis), if
severe.
 Tracheoesophageal fistula: An abnormal channel forms to connect the trachea and the
esophagus. Passage of swallowed food from the esophagus into the trachea causes serious
lung problems.
 Tracheal foreign body: An object is inhaled (aspirated) and lodges in the trachea or one of
its branches. A procedure called bronchoscopy is usually needed to remove a foreign
body from the trachea.
 Tracheal cancer: Cancer of the trachea is quite rare. Symptoms can include coughing or
difficulty breathing.

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 Tracheomalacia: The trachea is soft and floppy rather than rigid, usually due to a birth
defect. In adults, tracheomalacia is generally caused by injury or by smoking.
 Tracheal obstruction: A tumor or other growth can compress and narrow the trachea,
causing difficulty breathing. A stent or surgery is needed to open the trachea and improve
breathing.
Blood supply
By inferior thyroid artery and bronchial arteries and venous drainage is into inferior
thyroid vein.
Tracheobronchial tree
The air passages between trachea and alveoli are divided about 23 times and form the
tracheobronchial tree. This concept was first introduced by Weibel. The main airway
trachea branches into two bronchi (primary pulmonary bronchus). Each principal
bronchus enters each lung and give rise to many branches called lobar bronchi
(secondary bronchus). Right bronchus give rise to superior, middle and inferior lobar
bronchi while left bronchus give rise to superior and inferior lobar bronchi.
Each lobar bronchus give rise to segmental or tertiary pulmonary bronchi. The
tertiary pulmonary bronchi divide further into successive generations of smaller
bronchi and bronchioles within the parenchyma of the lung. Trachea and the first 16
generations of tracheobronchial tree constitutes the conducting zone where no gas
exchange takes place. The last 7 generations of tracheobronchial tree constitute the
respiratory zone where actual gas exchange takes place. This zone consists of alveolar
ducts, respiratory bronchioles and alveoli.
Lower respiratoty tract
The lower respiratory tract consists of lungs, which consists of bronchial and alveolar
structure needed for gas exchange
Lungs
The lungs are paired elastic structures enclosed in a thoracic cage, which is an air tight
chamber with distensible walls. Each lung is conical in shape; It is enveloped by
double layer serous membrane called as pleura. Each lung is divided into lobes. The
right lung has upper, middle, and lower lobes, whereas left lung has upper and lower
lobes. Each lung has an apex at the upper end, a base resting on the diaphragm and
two surfaces costal and mediastinal.
Lingula of the lung

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 It is a tongue shaped projection of lung below the cardiac notch.
The Left Lung
The human left lung is smaller and narrower that the right lung, and is divided into
two lobes, an upper and a lower, by the oblique fissure.
The right lung

The right lung is divided into three lobes.The upper lobe, middle lobe, and lower lobe.
The Hilium
Above and behind the cardiac impression is a triangular depression named the hilum. The
hilum is the root of the lung where that contains structures that supply the lungs with blood,
lymph fluid, and innervation, such as the pulmonary vein, pulmonary artery, pulmonary
nerves, and lymphatic vessels.

Functions of the lung

 Lung is the organ of exchange of the gases
 Surfactant secreted by pneumocyte-II of alveoli prevents the collapse of
alveoli. It is a complex of phospholipids, proteins, carbohydrates and several
ions(Dipalmitoylphosphatidyl choline). It lowers the surface tension of the
alveoli. This increases the compliance of lungs and reduces the work of
breathing. By reducing the surface tension, surfactant prevents fluid
accumulation in the alveolus and keeps it dry.
Non respiratory functions of lung
 Angiotensin converting Enzyme is present in the pulmonary capillary
endothelium. This converts angiotensin I to angiotensin II, which is
responsible for the maintanence of blood pressure.
 APUD cells or neuroendocrine cells are present in the bronchiolar tree. They
produce various vasoactive substances like VIP and substance P which may
have a role in maintaining tone of bronchioles.
 Lungs contain tissue type plasminogen activator, which converts plasminogen
to plasmin. Thus it has a role in fibrinolytic mechanism of the body.
Defense functions of respiratory system
 Mucus secreted by the goblet cells of upper respiratory tract helps to entrap
foreign particles. The cilia of epithelium beat upwards and push the mucus
towards the nose and exterior.
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  Mucus also contains IgA antibodies that provides local immunity.
 Alveolar macrophages engulf foreign particles and destroy them by
phagocytosis
 Preventing reflexes like cough reflex, sneezing reflex, and bronchoconstriction
reflex helps to clear the passage from inhaled foreign particles.
Pleura
The pleura is a serous membrane lined by a single layer of squamous cells.

There are two layers;

 The outer pleura (parietal pleura) is attached to the chest wall
 Inner pleura (visceral pleura) covers the lungs and adjoining structures, via blood
vessels, bronchi and nerves.
 The thin space between the two pleural layers is known as the pleural cavity and normally
contains a small amount of pleural fluid.
 The parietal pleurae are highly sensitive to pain, while the visceral pleura are not, due to its
lack of sensory innervation. In the current review we will present the anatomy of the pleural
space.

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Pleural cavity- It contains pleural fluid. The intrapleural pressure is -2 mm Hg during
expiration and -6 mm Hg during inspiration. This prevents collapse of lung parenchyma and
also aids in the venous return of body.
Mediastinum
It is in the middle of the thorax, between the pleural sacs that contain the two lungs. It
extends from the sternum to the vertebral column and contain all of the thoracic
tissues outside the lungs(heart, thymus, the aorta and vena cava, and esophagus)
Bronchi and bronchioles
 There are several divisions of the bronchi within each lobe of the lung. First
are lobar bronchi(three in the right and two in the left lung).
 Lobar bronchi divides into segmental bronchi(10 on the right and 8 on the
left); these structures facilitate effective postural drainage in the patient.
 Segmental bronchi then divide into subsegmental bronchi.-contains arteries,
lymphatics and nerves.
 The subsegmental bronchi then branch into bronchioles, which have no
cartilage in their walls.
 The bronchioles contain submucosal glands, which produce mucus that covers
the inside lining of the airways.
 The bronchioles branch into terminal bronchioles, which donot have mucus
glands or cilia.
 Terminal bronchioles become respiratory bronchioles, which are considered to
be the transitional
Alveoli
 An alveolar duct is a tube composed of smooth muscle and connective tissue,
which opens into a cluster of alveoli. An alveolus is one of the many small, grape-
like sacs that are attached to the alveolar ducts.
 An alveolar sac is a cluster of many individual alveoli that are responsible for gas
exchange. An alveolus is approximately 200 μm in diameter with elastic walls that
allow the alveolus to stretch during air intake, which greatly increases the surface
area available for gas exchange.
 The alveolar wall consists of three major cell types: type I alveolar cells, type II
alveolar cells, and alveolar macrophages.

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  A type I alveolar cell is a squamous epithelial cell of the alveoli, which constitute
up to 97 percent of the alveolar surface area.
 A type II alveolar cell is interspersed among the type I cells and
secretes pulmonary surfactant, a substance composed of phospholipids and
proteins that reduces the surface tension of the alveoli.
 Alveolar macrophage, a phagocytic cell of the immune system that removes debris
and pathogens that have reached the alveoli.

 Physiology of Respiration
At rest, a human breathes about 12-20 breathes per minute, 500ml of air is taken in
each breath which equals to 6-8 liters of air in 1 minute. The major function of the
respiratory system is to supply the body with oxygen and to dispose of carbon
dioxide. To do this, at least four distinct events, collectively called respiration, must
occur.
Respiration
 Pulmonary ventilation. Air must move into and out of the lungs so that gasses in
the air sacs are continuously refreshed, and this process is commonly called
breathing.
 External respiration. Gas exchange between the pulmonary blood and alveoli must
take place.
 Respiratory gas transport. Oxygen and carbon dioxide must be transported to and
from the lungs and tissue cells of the body via the bloodstream.
 Internal respiration. At systemic capillaries, gas exchanges must be made between
the blood and tissue cells.
Mechanics of Breathing
 Rule. Volume changes lead to pressure changes, which lead to the flow of gases
to equalize pressure.
 Inspiration. Air is flowing into the lungs; chest is expanded laterally, the rib cage
is elevated, and the diaphragm is depressed and flattened; lungs are stretched to the
larger thoracic volume, causing the intrapulmonary pressure to fall and air to flow
into the lungs.

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  Expiration. Air is leaving the lungs; the chest is depressed and the lateral
dimension is reduced, the rib cage is descended, and the diaphragm is elevated and
dome-shaped; lungs recoil to a smaller volume, intrapulmonary pressure rises, and
air flows out of the lung.
 Intrapulmonary volume. Intrapulmonary volume is the volume within the lungs.
 Intrapleural pressure. The normal pressure within the pleural space, the
intrapleural pressure, is always negative, and this is the major factor preventing the
collapse of the lungs.
 Non respiratory air movements. Non respiratory movements are a result of reflex
activity, but some may be produced voluntarily such as cough, sneeze, crying,
laughing, hiccups, and yawn.
Lung Volumes and capacities
Lung function which reflects the mechanics of ventilation is viewed in terms of
lung volumes and capacities.
Lung volumes are categorized as tidal volume, inspiratory reserve volume,
expiratory reserve volume,and residual volume.
Lung capacities are vital capacity, inspiratory capacity, functional residual
capacity, and total lug capacity
 Tidal volume. Normal quiet breathing moves approximately 500 ml of air into and
out of the lungs with each breath. The volume of air inhaled and exhaled in each
breath is referred to as tidal volume.
 Inspiratory reserve volume. The amount of air that can be taken in forcibly over
the tidal volume is the inspiratory reserve volume, which is normally between
2100 ml to 3200 ml. The maximum volume of air that can be inhaled after a
normal inhalation
 Expiratory reserve volume. The amount of air that can be forcibly exhaled after a
tidal expiration, the expiratory reserve volume, is approximately 1200 ml.
 Residual volume. The volume of air remaining in the lungs after a maximum
exhalation .Even after the most strenuous expiration, about 1200 ml of air still
remains in the lungs and it cannot be voluntarily expelled; this is called residual
volume, and it is important because it allows gas exchange to go on continuously
even between breaths and helps to keep the alveoli inflated.

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 Vital capacity. The total amount of exchangeable air is typically around 4800 ml in
healthy young men, and this respiratory capacity is the vital capacity, which is the
sum of the tidal volume, inspiratory reserve volume, and the expiratory reserve
volume.
 Dead space volume. Much of the air that enters the respiratory tract remains in the
conducting zone passageways and never reaches the alveoli; this is called the dead
space volume and during a normal tidal breath, it amounts to about 150 ml.
 Functional volume. The functional volume, which is the air that actually reaches
the respiratory zone and contributes to gas exchange, is about 350 ml.
 Total Lung capacity- The volume of air in the lungs after a maximum inspiration.
TLC-=TV+IRV+ERV+RV. Decreased with restrictive diseases such as atelectasis
and pneumonia and increased with COPD.
 Inspiratory capacity- The maximum volume of air remaining in the lungs after a
normal expiration. IC=TV+IRV. Normal=3500 ml. Decreased in restrictive
diseases or in obesity.

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Control of Respiration

Neural Regulation
 Phrenic and intercostal nerves. These two nerves regulate the activity of the
respiratory muscles, the diaphragm, and external intercostals.
 Medulla and pons. Neural centers that control respiratory rhythm and depth are
located mainly in the medulla and pons; the medulla, which sets the basic rhythm
of breathing, contains a pacemaker, or self-exciting inspiratory center, and an
expiratory center that inhibits the pacemaker in a rhythmic way; pons

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 centersappear to smooth out the basic rhythm of inspiration and expiration set by
the medulla.
 Eupnea. The normal respiratory rate is referred to as eupnea, and it is
maintained at a rate of 12 to 20 respirations/minute.
 Hyperpnea. During exercise, we breathe more vigorously and deeply because
the brain centers send more impulses to the respiratory muscles, and this
respiratory pattern is called hyperpnea.
Non-neural Factors Influencing Respiratory Rate and Depth
 Physical factors. Although the medulla’s respiratory centers set the basic
rhythm of breathing, there is no question that physical factors such as talking,
coughing, and exercising can modify both the rate and depth of breathing, as well
as an increased body temperature, which increases the rate of breathing.
 Volition (conscious control). Voluntary control of breathing is limited, and the
respiratory centers will simply ignore messages from the cortex (our wishes) when
the oxygen supply in the blood is getting low or blood pH is falling.
 Emotional factors. Emotional factors also modify the rate and depth of
breathing through reflexes initiated by emotional stimuli acting through centers in
thehypothalamus.
 Chemical factors. The most important factors that modify respiratory rate and
depth are chemical- the levels of carbon dioxide and oxygen in the blood;
increased levels of carbon dioxide and decreased blood pH are the most important
stimuli leading to an increase in the rate and depth of breathing, while a decrease
in oxygen levels become important stimuli when the levels are dangerously low.
 Hyperventilation. Hyperventilation blows off more carbon dioxide and
decreases the amount of carbonic acid, which returns blood pH to normal range
when carbon dioxide or other sources of acids begin to accumulate in the blood.
 Hypoventilation. Hypoventilation or extremely slow or shallow breathing
allows carbon dioxide to accumulate in the blood and brings blood pH back into
normal range when blood starts to become slightly alkaline.
 Ventilation

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 Ventilation requires movement of the walls of the thoracic cage and its floor, the diaphragm.
The effect of these movements is alternately to increase and decrease the capacity of the
chest. When the capacity of the chest is increased, air enters through the trachea (inspiration)
and moves into the bronchi, bronchioles and alveoli and inflates the lung. When thechest wall
and diaphragm returns to their previous position (expiration), the lungs recoil and force the
air out through the bronchi and the trachea. The inspiratory phase normally requires energy
and the expiration is normally passive, requiring very little energy.
The physical factors that govern air inflow in and out of the lungs are collectively referred to
as mechanics of ventilation and it includes air pressure variances, resistance to airflow, and
lung compliance.
 Air pressure variances-Air flows from a region of higher pressure to a region of lower
pressure. During inspiration, movements of the diaphragm and intercoastal muscles enlarge
the thoracic cavity and thereby lower the pressure inside the thorax to a level below that of
atmospheric pressure.As a result air is drawn through the trachea and bronchi into the
alveoli. During expiration, there is a decrease in size of thoracic cavity. The alveolar pressure
exceeds the atmospheric pressure, and air flows from the lungs into the atmosphere

 Airway resistance- Any process that changes the bronchial diameter or width affects airway
resistance and alters the rate of airflow for a given pressure gradient during inspiration. With
increased resistance, greater than normal respiratory effort is required to achieve normal
levels of ventilation.

 Compliance- It is the elasticity and expandability of the lungs and thoracic structures.
Factors that determine lung compliance are the surface tension of the alveoli, the connective
tissue and water content of the lungs, and the compliance of the thoracic cavity. Compliance
is normal if the lungs and the thoracic cavity easily stretch and distend when pressure is
applied. Increased compliance occurs when lungs have lost their elastic coil and becomes
overdistended(emphysema). Decreased compliance occurs if the lungs and thorax are stiff.

 Normal and Altered Breathing Patterns

Eupnea is the term for the normal respiratory rate for an individual at rest. Several other
terms describe abnormal breathing patterns that are indicative of symptoms of many diseases,
many of which aren’t mainly respiratory diseases. Some of the more common terms for
altered breathing patterns include:
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 Dyspnea: commonly called shortness of breath. It describes dramatically decreased
tidal volume and sometimes increased respiratory rate, leading to a sensation of
breathlessness. It is a common symptom of anxiety attacks, pulmonary embolisms, heart
attacks, and emphysema, among other things.
 Hypernea: refers to increased volume of air cycled to meet the body’s metabolic
needs, which may or may not involve a change in frequency of breathing. It is a symptom of
exercise and adjustment to high altitude, which are generally not problematic, but can also be
seen in those with anemia or septic shock, which is problematic.
 Tachypnea: describes increased respiratory rate. Often a symptom of carbon
monoxide poisoning or pnuemonia.
 Bradypnea: describes decreased respiratory rate. Often a symptom of hypertension,
heart arryhmias, or slow metabolic rate from hypothyroidism.
 Apnea: Transient stopped breathing that begins again soon afterwards. It is the main
symptom of sleep apnea, in which breathing temporarily stops during sleep.
 Physiology of gas exchange
Each branch of the bronchial tree eventually sub-divides to form very narrow terminal
bronchioles, which terminate in the alveoli. There are many millions of alveloi in each lung,
and these are the areas responsible for gaseous exchange, presenting a massive surface area
for exchange to occur over.
Each alveolus is very closely associated with a network of capillaries containing
deoxygenated blood from the pulmonary artery. The capillary and alveolar walls are very
thin, allowing rapid exchange of gases by passive diffusion along concentration gradients. 
CO2 moves into the alveolus as the concentration is much lower in the alveolus than in the
blood, and O2 moves out of the alveolus as the continuous flow of blood through the
capillaries prevents saturation of the blood with O2 and allows maximal transfer across the
membrane.
 Pulmonary diffusion and perfusion
Pulmonary diffusion is a process by which oxygen and carbondioxide are exchanged from
areas of high concentration to areas of low concentration at the air blood interface. The
alveolar capillary membrane is ideal for diffusion because of its thinness and large surface
area. In the normal healthy adult, oxygen and carbondioxide travel across the alveolar
capillary membrane without difficulty as a result of differences in gas concentrations in
alveoli and capillaries.

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 Pulmonary perfusion is the actual blood flow through the pulmonary vasculature. The blood
is pumped into the lungs by the right ventricles through the pulmonary artery. The pulmonary
artery divides into right and left branches to supply both lungs. The pulmonary circulation is
considered as low pressure system because the systolic blood pressure in the pulmonary
artery is 20-30 mm Hg and the diastolic pressure is 5-15 mm Hg. Because of these low
pressures, the pulmonary vasculature normally can vary its capacity to accommodate the
blood flow it receives. Perfusion is also influenced alveolar pressure, pulmonary artery
pressure and gravity
 Ventilation and perfusion balance and imbalance
Adequate gas exchange depends on an adequate ventilation perfusion (V/Q) ratio. Airway
blockages, local changes in compliance and gravity may alter ventilation. V/Q imbalance
occurs as a result of inadequate ventilation, inadequate perfusion or both. There are 4 possible
V/Q states in the lung;
 normal V/Q ratio- In a healthy lung, a give amount of blood passes an alveolus and is
matched with an equal amount of gas. Ratio is1:1
 Low V/Q ratio(shunt)- When perfusion exceeds ventilation a shunt exists.Blood bypasses the
alveoli without gas exchange occurring. Due to obstruction of the distal airways
(Pneumonia, mucus plug)
 high V/Q ratio(dead space) – When ventilation exceeds perfusion, dead space results. The
alveoli donot have an adequate blood supply for gas exchange to occur. Eg:Pulmonary
emboli, cardiogenic shock
 Absence of ventilation and perfusion(silent unit)- It occurs when there is absence of both
ventilation and perfusion or with limited ventilation and perfusion eg: Pneumothorax
V/Q imbalances causes shunting of blood, resulting in hypoxia. Supplemental o2 may
eliminate hypoxia, depending on the type of V/Q imbalance.
Partial pressure of gases
 Effect of pressure on oxygen transport
Oxygen and carbondioxide transported simultaneously either dissolved in blood or combined
with haemoglobin in RBCs.Each 100 ml of normal arterial blood carries 0.3 ml of oxygen
physically dissolved in plasma and 20 ml of oxygen in combination with haemoglobin. Large
amounts of oxygen can be transported in the blood because oxygen combines easily with hb
to form oxyhemoglobin.
o O2+ Hgb= HgbO2

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 The volume of air physically dissolved in the plasma is measured by the partial pressure of
oxygen in the arteries(PaO2). The higher the PaO2, the greater the amount of oxygen is
dissolved.
When the Pao2 is150 mm of Hg, haemoglobin is 100% saturated and doesnot combine with
any additional oxygen. If PaO2 is less than 150 mm of Hg, the percentage of haemoglobin
saturated with oxygen decreases.
 Oxyhemoglobin dissociation curve
It shows the relationship between the partial pressure of oxygen(PaO 2) and the percentage of
saturation of oxygen(SaO2). The percentage of saturation can be affected by carbon dioxide,
hydrogen ion concentration, and 2,3diphosphoglycerate. An increase in these factors shifts
the curve to the right, thus less oxygen is picked up in the lungs, but more oxygen is released
to the tissues. A decrease in these factors causes the curve to shift to the left, making the bond
between oxygen and haemoglobin stronger. It is sigmoidal in shape.

The oxyhemoglobin dissociation curve is marked to show three oxygen levels:

1. Normal levels- PaO2> 70 mm Hg
2. Relatively safe levels –PaO2 45-70 mm Hg
3. Dangerous levels- PaO2< 40 mmHg

 Carbon dioxide Transport

20
 At the same time that oxygen diffuses from the blood into the tissues, carbon dioxide diffuses
from tissue cells to blood and is transported to the lungs for excretion. The amount of carbon
dioxide in transit is one of the major determinants of the acid base balance of the body.
Normally, only 6% of the venous carbon dioxide is removed in the lungs and enough remains
in the arterial blood to exert a pressure of 40 mm Hg.
Respiratory Assessment
 Health History
The health history initially focuses on the patient’s presenting problem and associated
symptoms. Common symptoms of respiratory disease are dyspnea, cough, sputum
production, chest pain, wheezing and hemoptysis.
 Dyspnea
It is a subjective of difficult or labored breathing, breathlessness, shortness of breath.
 Cough
 Sputum Production
 Chest Pain
 Wheezing
 Hemoptysis

 Past health, Social and Family history

Smoking history- At what age smoking started? How many packs per day smoke now? For
how long? Have ever tried for quit smoking? What activities associate smoking? Are they
living with a smoker?
Environmental exposure- Where do they work? Pollution exposure?
Farmers may be at risk of grain or pesticide inhalation
Coal miners are at risk of pneumoconiosis

 Physical Assessment

 General Appearance
The Patient’s general appearance may give clues to respiratory status.
 Clubbing of the fingers

21
 It is a change in the normal nail bed. It appears as sponginess of the nail bed and loss of the
nail bed angle. It is a sign of lung disease that is found in patients with chronic hypoxic
conditions, chronic lung infections, or malignancies of the lung.
 Cyanosis
It is a bluish colouring of the skin, is a very late indicator of hypoxia. The presence or
absence of hypoxia is determined by the amount of unoxygenated haemoglobin in the blood.
Assessment of cyanosis is affected by room lighting, the patient’s skin colour and the
distance of the blood vessels from the surface of the skin. In the presence of a pulmonary
condition, central cyanosis is assessed by observing the colour of the tongue and lips. This
indicates a decrease in oxygen tension in the blood. Peripheral cyanosis results from
decreased blood flow to the body’s periphery(fingers, toes or ear lobes).
 Upper respiratory structures
 Nose and sinuses
 Inspect the external nose for lesions, asymmetry or inflammation.
 Ask the patient to tilt the head backward and examine the internal structures
of the nose, the mucosa for color, swelling, exudate or bleeding. Mucosa
appears swollen and hyperemic if patient has common cold and appears pale
and swollen if the patient has allergic rhinitis
 Inspect the septum for deviation, perforation or bleeding.
 Inspect the inferior and middle turbinates. In chronic rhinitis, nasal polyps
may develop between the inferior and middle turbinates; they are
distinguished by their gray appearance.
 Palpate the frontal and maxillary sinuses for tenderness.
 Mouth and pharynx
 Ask the patient to open the mouth wide and inspect the anterior and posterior
pillars, tonsils, uvula and posterior pharynx for color, symmetry and evidence
of exudate, ulceration and enlargement
 Trachea
 Palpate for the position and mobility of the trachea. This is performed by
placing the thumb and the index finger of one hand on either side of the
trachea just above the sternal notch. Normally the trachea is in midline, it may
be deviated by masses in the neck or mediastinum or due to any pulmonary
disorders such as a pneumothorax or pleural effusion.

22
 Lower respiratory structures and breathing
It includes inspection, palpation, percussion and auscultation.
 Positioning
The patient should be in a sitting position with arms crossed in front of the chest and
hands placed on the opposite shoulders. If the patient is unable to sit place the patient
in supine to assess anterior thorax and roll the patient from side to side to complete
posterior examination.
 Thoracic inspection
 Chest configuration
Normally, the ratio of the anteroposterior diameter to the lateral diameter is 1:2
 Barrel chest
It occurs as a result of overinflation of the lungs, which increases the
anteroposterior diameter of the thorax. It occurs with ageing and is a hallmark
sign of emphysema and COPD.
 Funnel chest(pectusexcavatum)
It occurs when there is a depression in the lowerportion of the sternum. It may
occur with rickets or Marfan syndrome, or rickets.
 Pigeon chest(Pectuscarinatum)
It occurs as a result of the anterior displacement of the sternum, which also
increases anteroposterior diameter. It may occurs with rickets, Marfan
syndrome, or severe kyphoscoliosis.
 Kyphoscoliosis
It is characterized by elevation of the scapula and a corresponding S shaped
spine. It may occur with osteoporosis, and other skeletal disorders that affect
the thorax.
 Breathing Patterns and respiratory rates
The normal adult who is resting comfortably takes 14-20 breaths per minute. The
normal pattern is described as eupnea.

23
  Use of accessory muscles
Observe for the use of accessory muscles, such as the sternocleidomastoid,
scalene and trapezius muscles during inspiration and the abdominal and internal
intercoastal muscles during expiration.
 Thoracic palpation
Palpate the thorax for tenderness, masses, lesions, respiratory excursion and vocal
fremitus
 Respiratory excursion
 It is an estimation of thoracic expansion and may disclose significant
information about the thoracic movement during breathing.
 Place the thumb anteriorly along the coastal margin of the chest wall and
posteriorly adjacent to the spinal column at the level of 10th rib
 Decreased chest excursion may be caused by chronic fibrotic disease
 Asymmetric excursion may be due to splinting secondary to pleurisy,
fractured ribs, trauma or unilateral bronchial obstruction
 Tactile fremitus
 It describes vibrations of the chest wall that result from speech detected on
palpation.

24
  Air doesnot conduct sound well; whereas a solid substance such as tissue
does.
 A patient with emphysema exhibit almost no tactile fremitus
 A patient with consolidation of a lobe of the lung from pneumonia has
increased tactile fremitus.
 Thoracic percussion
Percussion produces audible and tactile vibration and allows the nurse to determine
whether underlying tissues are filled with air, fluid, or solid material. Percussion is also
used to estimate the size and location of certain structures within the thorax

 Diaphragmatic excursion
 The normal resonance of the lung stops at the diaphragm.
 The position of the diaphragm is different during inspiration and expiration
 Instruct the patient to take deep breath and hold it while the maximal
descent of the diaphragm is percussed.
 Maximal excursion of the diaphragm is 8-10cm in healthy tall young men,
but for most people it is usually 5-7cm.

25
  Normally diaphragm is 2cm higher on the right because of the location of
the liver.
 Decreased diaphragmatic excursion may occur with pleural effusion
 Thoracic Auscultation
Assessment helps the nurse assess the flow of air through the bronchial tree and evaluate
the presence of fluid or solid obstruction in the lung.
 Breath sounds
Normal breath sounds are distinguished by their location over a specific area of
the lung and are identified as vesicular, bronchovesicular and bronchial breath
sounds
The location, quality and intensity of breath sounds are determined during
auscultation.

26
 Adventitious sounds
Adventitious breath sounds are abnormal soundsthat are heard over a patient's lungs
and airways. Thesesounds include abnormal sounds such as fine and coarse crackles
(crackles are also called rales), wheezes (sometimes called rhonchi), pleural rubs and
stridor.

 Voice sounds
The sound heard through the stethoscope as the patient speaks is known as vocal
resonance. With normal physiology the sounds are faint and indistinct. Pathology
that increases lung density, such as pneumonia and pulmonary edema, alters this
normal physiologic response and may result in the following sounds;
 Bronchophony- describes vocal resonance that is more intense and clearer
than normal.
 Egophony- describes voice sounds that are distorted. It is best appreciated
by having the patient repeat the letter E. The sound distortion produced by
consolidation transforms the sound into a clearly heard A rather than E.
 Whisphered pectoriloquy- describes the ability to clearly and distinctly
hear whisphered sounds that should not normally be heard.

27
 Diagnostic Evaluation
The nurse should educate the patient on the purpose of the studies, what to expect, and
any possible side effects related to these examinations prior to testing
 Pulmonary function tests
Pulmonary function tests (PFTs) are noninvasive tests that show how well the lungs are
working. The tests measure lung volume, capacity, rates of flow, and gas exchange. This
information can help your healthcare provider diagnose and decide the treatment of certain
lung disorders. They are used to assess the respiratory function and to determine the extent of
dysfunction, response to therapy, and as screening therapy in potentially hazardous industries
such as coal mining and also used before surgery to screen patients who are scheduled for
thoracic and upper abdominal surgical procedures.
There are 2 types of disorders that cause problems with air moving in and out of the lungs:
 Obstructive. This is when air has trouble flowing out of the lungs due to airway
resistance. This causes a decreased flow of air.
 Restrictive. This is when the lung tissue and/or chest muscles can’t expand enough.
This creates problems with air flow, mostly due to lower lung volumes.
PFT can be generally performed by a technician using a spirometer that has a volume
collecting device attached to a recorder that demonstrates volume and time simultaneously.
Term used Symbol Description Remarks
Forced vital FVC Vital capacity Forced vital
capacity performed with a capacity is often
maximally forced reduced in
expiratory effort chronic
pulmonary
disease because
of air trapping
Forced FEVt(FEV1) Volume of air A valuable clue
expiratory exhaled in the to the severity of
volume specified time during the expiratory
the performance of airflow
forced vital capacity; obstruction.
FEV1 is the volume
exhaled in 1 second

28
 Ratio of forced FEVt/FEV% Fevt expressed as a Another way of
expiratory percentage of the expressing the
volume to forced forced vital capacity presence or
vital capacity absence of
airway
obstruction

Forced FEF200-1200 Mean forced An indicator of

expiratory flow expiratory flow large airway
between 200 and obstruction
1200 mL of the FVC
Forced mid FEF25-75% Mean forced Slowed in small
expiratory flow expiratory flow airway
during the middle obstruction
half of the FVC
Forced end FEF75-85% Mean forced Slowed in
expiratory flow expiratory flow obstruction of
during the terminal smallest airways
portion of the FVC
Maximal MVV Volume of air An important
voluntary expired in a specific factor in
ventilation period (12 seconds) exercise
during repetitive tolerance
maximal effort

 Arterial blood gas studies

An arterial blood gas (ABG) test measures the acidity (pH) and the levels of oxygen and
carbon dioxide in the blood from an artery. This test is used to check how well the lungs are
able to move oxygen into the blood and remove carbon dioxide from the blood. An ABG test
uses blood drawn from an artery, where the oxygen and carbon dioxide levels can be
measured before they enter body. An ABG measures:
 Partial pressure of oxygen (PaO2 tissues). This measures the pressure of oxygen
dissolved in the blood and how well oxygen is able to move from the airspace of the
lungs into the blood. PaO2: 11-13 kPa || 82.5 – 97.5 mmHg
 Partial pressure of carbon dioxide (PaCO2). This measures the pressure of carbon
dioxide dissolved in the blood and how well carbon dioxide is able to move out of the
body. PaCo2: 35-45 mm Hg
 pH. The pH measures hydrogen ions (H+) in blood. The pH of blood is usually between
7.35 and 7.45. A pH of less than 7.0 is called acid and a pH greater than 7.0 is called
basic (alkaline). So blood is slightly basic.
 Bicarbonate (HCO3). Bicarbonate is a chemical (buffer) that keeps the pH of blood
from becoming too acidic or too basic. Normal range is  22-26 mEq/L
 Oxygen content (O2CT) and oxygen saturation (O2Sat) values. O2 content measures
the amount of oxygen in the blood. Oxygen saturation measures how much of
the hemoglobin in the red blood cells is carrying oxygen (O2).

29
  Interpretation of results
Acidosis Respiratory pH ↓  PaCO2  ↑
Acidosis Metabolic& pH ↓ PaCO2  ↓
Alkalosis Respiratory pH ↑ PaCO2  ↓
Alkalosis Metabolic pH ↑ PaCO2   ↑

 Venous blood gas studies

It provides additional data on oxygen delivery and consumption. VBG levels reflect the
balance between the amount of oxygen used by tissues and organs and the amount of
oxygen returning to the right side of the heart in the blood.
 Pulse oximetry
Pulse oximetry is a test used to measure the oxygen level (oxygen saturation) of the blood. It
is an easy, painless measure of how well oxygen is being sent to parts of the body furthest
from your heart, such as the arms and legs. A clip-like device called a probe is placed on a
body part, such as a finger or ear lobe. The probe uses light to measure how much oxygen is
in the blood. This information helps the healthcare provider decide if a person needs extra
oxygen.
Normal arterial oxygen is approximately 75 to 100 millimeters of mercury (mm
Hg).Values under 60 mm Hg usually indicate the need for supplemental oxygen. Normal
pulse oximeter readings usually range from 95 to 100 percent. Values under 90 percent are
considered low.

Working principle
 The oximeter utilizes an electronic processor and a pair of small light-emitting
diodes (LEDs) facing a photodiode through a translucent part of the patient's body,
usually a fingertip or an earlobe.
 One LED is red, with wavelength of 660 nm, and the other is infrared with a
wavelength of 940 nm.
 Absorption of light at these wavelengths differs significantly between blood loaded
with oxygen and blood lacking oxygen.
 Oxygenated hemoglobin absorbs more infrared light and allows more red light to
pass through.
 Deoxygenated hemoglobin allows more infrared light to pass through and absorbs
more red light.
 An important tool for any SpO2 reading is plethysmography tracings or "pleth" which
is a measure of volumetric changes associated with pulsatile arterial blood flow. 

 Cultures
Throat, nasal and nasopharyngeal cultures can identify pathogens responsible for
respiratory infections, such as pharyngitis. Throat cultures are performed in adults with
severe or ongoing sore throats accompanied by fever and lymph node enlargement and
are most useful in detecting streptococcal infection. Other sources of infection, such as
Staphylococcus aureus or influenza are detected via nasal or nasopharyngeal cultures.

30
 Ideally all cultures should be obtained prior to antibiotic therapy. Results usually take
between 48-72 hours, with preliminary reports available usually within 24 hours.
Cultures may be repeated to assess a patient’s response to therapy.

 Sputum studies
 Sputum is obtained for analysis to identify pathogenic organisms and to determine
whether malignant cells are present.
 Sputum samples ideally are obtained early in the morning before the patient has
had anything to eat or drink.
 The patient is instructed to rinse the mouth , after taking few deep breaths, the
patient coughs deeply and expectorates sputum into a sterile container.
 Other methods of collecting sputum include endotracheal or transtracheal
aspiration or bronchoscopic removal.

 Imaging studies
It includes X rays, computed tomography, magnetic resonance imaging, and radioisotope
or nuclear scanning.
 Chest X-Ray
 The normal pulmonary tissue is translucent because it consists of mostly
air and gases;therefore, densities produced by fluids, tumours, foreign
bodies and other pathologic conditions can be detected by X-Ray
examination.
 The routine chest x-ray consists of two views; posteroanterior projection
and lateral projection.
 The patient should be asked to wear a gown, remove metal objects from
the chest.
 Patients need to be able to take a deep breath and hold it without
discomfort during x ray
 X rays are contra indicated during pregnancy.

 Computed tomography
 A CT is an imaging method in which the lungs are scanned in a successive
layers by a narrow beamed x-ray.
 CT scan can distinguish fine tissue density.
 It may be used to define pulmonary nodules and small tumours adjacent to
pleural surfaces that are not visible on chest x-ray.
 Contrast agents may be used. If contrast dye is needed, patients will need
to stay NPO for 4 hours prior to the examination. Also the nurse should
assess for any allergies to the contrast agent.
 Advancements in CT scanning technology referred to as multi detection,
spiral or helical CT, enable the chest to scan quickly, while generating an
extensive number of images that can generate a 3D analysis.

31
  Contraindications include allergy to dye, pregnancy, claustrophobia, and
morbid obesity, whereas potential complications include acute kidney
injury and acidosis secondary to contrast.
 HRCT
 High-resolution computed tomography (HRCT) is a type of computed
tomography (CT) with specific techniques to enhance image resolution. It is
used in the diagnosis of various health problems, though most commonly for
lung disease, by assessing the lung parenchyma.
 HRCT is used for diagnosis and assessment of interstitial lung disease, such
as pulmonary fibrosis, and other generalized lung diseases such
as emphysema and bronchiectasis.
 Intravenous contrast agents are not used for HRCT[3] as the lung inherently has
very high contrast (soft tissue against air).
  HRCT does not image the whole lungs (by using widely spaced thin sections),
it is unsuitable for the assessment of lung cancer or other localised lung
diseases. 
 HRCT is performed using a conventional CT scanner. However, imaging
parameters are chosen so as to maximize spatial resolution: [1] a narrow slice
width is used (usually 1–2 mm), a high spatial resolution image reconstruction
algorithm is used, field of view is minimized
 Depending on the suspected diagnosis, the scan may be performed in
both inspiration and expiration. The patient may also lie prone rather than the
more usual supine .

 Magnetic resonance imaging

 MRI is similar to CT except that magnetic fields and radiofrequency signals
are used instead of radiation.
 A magnetic resonance imaging (MRI) scan is a painless procedure that lasts
15 to 90 minutes, depending on the size of the area being scanned and the
number of images being taken.
 MRI scans of the brain or chest areas don’t usually require any special dietary
preparation.
 It is used to characterize pulmonary nodules, to help stage the carcinoma ant
to evaluate Inflammatory activity in interstitial lung disease, etc
 Contraindications include morbid obesity, claustrophobia, implanted metal
devices, confusion and agitation.
 Gadolinium based contast agents used during MRI may potentially lead to
nephrogenic systemic fibrosis in patients with reduced kidney function
Nursing Interventions
 Instruct patient to remove all metal objects such as hearing aids, hair clips,
medication patches, etc
 Instruct the patient to lie flat and remain still during the procedure.

32
  Patients should be notified that they will hear a loud humming or
thumping noise. Ear plugs are typically offered to patients to minimize
this noise
 If contrast dye is using patient should remain NPO pre- examination.
 Fluroscopic studies
 It allows live X-Ray images to be generated via a camera to a video screen.
 It is used to assist with invasive procedures such as chest needle biopsy or
transbronchial biopsy that are performed to identify lesion.
 It als may be used to study the movement of the chest wall, mediastinum,
heart and diaphragm to detect diaphragm paralysis and to locate lung masses.

 Pulmonary angiography
 It is used to detect congenital abnormalities of the pulmonary vascular tree,
and less frequently pulmonary edema.
 To visualize the pulmonary vessels, a radio opaque dye is injected through a
catheter, which has been initially inserted into a vein(jugular, subclavian,
brachial, and femoral) and then threaded into the pulmonary artery.
 Contraindicatons include allergy to the dye, pregnancy and bleeding
abnormalities, whereas potential complications include acute kidney injury,
acidosis, cardiac dysrhythmias, and bleeding.
Nursing Intervention
 Prior to the procedure the nurse should verify that the informed consent has
been obtained.
 Assess for any known allergies, anticoagulation status and renal function.
Patient should be kept NPO for 6-8 hours before the procedure Pre
medications such as antianxiety, antihistamines and secretion reducing agents
are given.
 Monitor vital signs, level of consciousness, o 2 saturation, vascular access site
for bleeding, hematoma.
 Radioisotope diagnostic procedures(Lung scan)
 Several types of lung scans-V/Q scan, gallium scan, and positron emission
tomography are performed to assess normal lung functioning, pulmonary
vascular supply and gas exchange
A ventilation–perfusion (VQ) scan
 It  is a nuclear medicinescan that uses radioactive material
(radiopharmaceutical) to examine airflow (ventilation) and blood flow
(perfusion) in the lungs. The aim of thescan is to look for evidence of any
blood clot in the lungs, called pulmonary embolism (PE).
  There is no preparation for a VQ scan other than having had a recent chest x
ray. The test will take about an hour. For each scan, you will need to lie very
still on a table as the table moves under the scanner and pictures are taken of
your lungs. Before each scan, you will need to hold your breath for a few
seconds

33
  Before the ventilation scan,the patient should wear a breathing mask and will
breathe in a small amount of a radioisotope gas mixed with oxygen. Before
the perfusion scan, the technician will inject a small amount of radioisotope
into a vein. The scanner detects the energy that the radioisotopes release
inside your body and uses the energy to make pictures of your lungs.
Gallium scan
 It is a radioisotope lung scan used to detect inflammatory conditions,
abscesses, adhesions, and the presence, location and size of tumours,
 Gallium is injected IV and the scans are obtained at intervals(6, 24 and 48
hours)
PET scan
 PET is a radioisotope study with advanced diagnostic capabilities that is used
to evaluate lung nodules for malignancy
 It can detect and display metabolic changes in tissue, distinguish normal
tissue from diseased tissue, viable from dead tissue, show regional blood
flow.
 The nurse should instruct the patient to avoid caffeine, alcohol and tobacco
for 24hours prior to the scan and abstain from foods and fluids for 4 hours
prior to the scan.
 Endoscopic Procedures
 Bronchoscopy
 It is the direct inspection and examination of the larynx, trachea and bronchi
through either a flexible fiberoptic bronchoscope.
 The purposes of diagnostic bronchoscopy are
1. To visualize tissues and determine the nature, location and extent of
the pathologic process
2. To collect secretions for analysis and to obtain a tissue sample for
diagnosis
3. To determine whether a tumour can be resected surgically.
 The purposes of therapeutic bronchoscopy are
1. To remove foreign bodies or secretion from the tracheobronchial tree
2. Control bleeding
3. Treat postoperative atelectasis
4. Destroy and excise lesions
 Possible complications include a reaction to the local anaesthetic, over
sedation, prolonged fever, infection, aspiration, vasovagal response, bleeding
 Informed consent should be obtained before the procedure
 Kept NPO 4-8 hours prior to the procedure.
 Administer pre medications such as atropine and a sedative to inhibit vagal
stimulation
 Patient should remove dentures and oral prostheses. A local anaesthetic such
as lignocaine is normally sprayed on the pharynx.
 After the procedure patient should kept NPO until cough reflex returns.

34
  A small amount of blood tinged sputum and fever may be expected within
the first 24 hours.
 Thoracoscopy
 It is a diagnostic procedure in which plueral cavity is examined with an
endoscope and fluid and tissues can be obtained for analysis.
 It is performed under anaesthesia, where small incisions are made in the
plueral cavity.
 The fiberopticmediastinoscope is inserted into the plueral cavity, any fluid
present is aspirated and plueral cavity is examined.
 After the procedure, chest tube may be inserted to facilitate the re-expansion
of the lung.
 This procedure is primarily indicated in plueral effusion, plueral disease and
tumor staging.
 Patient should be kept NPO prior to the procedure and obtain informed
consent prior to the procedure.
 Video assisted thoracoscopy
 Video-assisted thoracoscopic surgery (VATS) is minimally invasive thoracic
surgery that does not use a formal thoracotomy incision.
 VATS provides adequate visualization despite limited access to the thorax,
allowing the procedure to be performed in patients who are debilitated or have
marginal pulmonary reserve. [1]
 VATS is principally employed in the management of pulmonary, mediastinal,
and pleural pathology.
 Its main benefit has been the avoidance of a thoracotomy incision, which
allows a shorter operating time, less postoperative morbidity, and earlier return
to normal activity than can be achieved with thoracotomy
 During a video-assisted thoracoscopic surgery procedure, a tiny camera
(thoracoscope) and surgical instruments are inserted into your chest through
small incisions in your chest wall. The thoracoscope transmits images of the
inside of your chest onto a video monitor, guiding the surgeon in performing
the procedure
 Stop taking certain medications like blood thinners
 Stop smoking
 Exercise daily,Do breathing exercises measured with a machine called a
spirometer
 NPO from midnight
 Thoracentesis
 Thoracentesis, also known as thoracocentesis or pleural tap, is an invasive
procedure to remove fluid or air from the pleural space for diagnostic or
therapeutic purposes.
 A cannula, or hollow needle, is carefully introduced into the thorax, generally
after administration of local anesthesia. 
  It typically takes 10 to 15 minutes, but it can take longer if there’s a lot of
fluid in the pleural space.

35
 Procedure
 It is most comfortable to make the patient sit in a chair.
 He should lean forward on a pillow.
 A nurse can stand in front of the patient and hold the patient's hand.
 The ideal interspace is the 7th, 8th or 9th space, midway between the
posterior axillary line and midline. This site avoids possible accidental
puncture of the liver, spleen, diaphragm and descending aorta
 Studies of plueral fluid include Gram stain culture and sensitivity, acid fast
staining and culture, differential cell count, pH, total protein, cytology,etc
 Biopsy 
It is the excision of a small amount of tissue- may be performed to permit examination of
cells from the upper and lower respiratory structures and adjacent lymph nodes
 Pleural biopsy
 It is accomplished by needle biopsy of pleura, thoracoscopy or pleuroscopy
 A visual exploration through a fiberopticpleuroscope inserted into the pleural
space or through a thoracotomy.
 It is performed when there is pleural exudate of undetermined origin.
 Lung biopsy procedures
  A lung biopsy is a procedure in which samples of lungtissue are removed
(with a special biopsy needle or during surgery) to determine if lung disease
or cancer is present.
 A lung biopsy may be performed using either a closed or an open method.
Closed methods are performed through the skin or through the trachea
(windpipe). An open biopsy is performed in the operating room under general
anesthesia.
 The various biopsy procedures include:
o Needle biopsy. After a local anesthetic is given and a needle that is guided
through the chest wall into a suspicious area with computed tomography (CT
or CAT scan) or fluoroscopy  to obtain a tissue sample
o Transbronchial biopsy. This type of biopsy is performed through a
fiberopticbronchoscope through the main airways of the lungs.
o Thoracoscopic biopsy. After a general anesthetic is given, an endoscope is
inserted through the chest wall into the chest cavity. This procedure may be
referred to as video-assisted thoracic surgery (VATS) biopsy

36
 o Open biopsy. After a general anesthetic is given, the doctor makes an incision
in the skin on the chest and surgically removes a piece of lung tissue.
 Patient should kept NPO for 8 hours prior to the surgery.
  A chest X-ray may be performed immediately after the biopsy and repeated
in a few hours.
 Lymph node biopsy
 Lymph node biopsy is a test in which a lymph node or a piece of a lymph
node is removed for examination under a microscope.
 The scalene nodes which are enmeshed in the deep cervical pad of fat
overlying the scalenus anterior muscle, drain the lungs and mediastinum . If
these nodes are palpable on physical examination, a scalene node biopsy is
performed to detect spread of pulmonary disease to the lymph nodes.
 Mediastinoscopy is a procedure that enables visualization of the contents of
the mediastinum, usually for the purpose of obtaining a biopsy.
 The mediastinum is explored, and biopsies are performed on any lymph nodes
found.
 Chest tube drainage is required after the procedure.
 Post procedure care focuses on providing adequate oxygenation, monitor for
bleeding, and providing pain relief.
 The patient may be discharged a few hours after the chest drainage system is
removed.
Conclusion
The respiratory system consists of all the organs involved in breathing. These include the
nose, pharynx, larynx, trachea, bronchi and lungs. Air is taken in via the upper airways (the
nasal cavity, pharynx and larynx) through the lower airways (trachea, primary bronchi and
bronchial tree) and into the small bronchioles and alveoli within the lung tissue.
The Respiratory System is vital to every human being. Without it, we would cease to live
outside of the womb. Alterations in respiratory status have been identified as important
predictors of clinical deterioration in hospitalized patients. To differentiate between normal
and abnormal assessment findings and recognize subtle changes that may negatively impact
patient outcomes, nurses require an understanding of respiratory function and the significance
of abnormal diagnostic test results.
Bibliography
1. Chintamani, “Lewis’s Medical Surgical Nursing”; South Asian edition; Elsevier publications
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2. Jarvis, “ Physical Examination and health assessment”; fifth edition, Elsevier publications.
Page no:438- 480
3. Brunner and Suddarth’s,” Textbook of Medical and Surgical Nursing”; Volume 1, South
Asian edition, Wolters Kluwer Publications.
Page no:306-334
4. www.opentextbc.ca/ anatomy and physiology/ organs and structures of respiratory system.
5. P R Ashalatha and G Deepa, “Textbook of Anatomy and Physiology for nurses”, 4th edition ,
Elsevier publications

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