NSG210 Hinkle Ch. 17: Assessment of Respiratory Function

Source: Hinkle & Cheever, Brunner & Suddarth’s Medical-Surgical Nursing 15e, Chapter 17, pp. 462-493 (textbooks/HINKLE_MS_CH17.pdf, also in textbooks/exam01/). Week 02 reading; on Exam 1 (background for the COPD and asthma questions). See also nsg210-week-02-summary.

Learning Outcomes

1. Describe upper and lower respiratory tract structure and function; ventilation, diffusion, perfusion, and V/Q imbalance.
2. Perform a comprehensive respiratory assessment.
3. Discriminate normal and abnormal findings by inspection, palpation, percussion, and auscultation.
4. Recognize major symptoms of respiratory dysfunction from history and physical findings.
5. Identify diagnostic tests and nursing implications.

Key terms:

• Ventilation: air movement in and out; respiration: gas exchange between air and blood and between blood and cells
• Pulmonary diffusion: gas moves from high to low concentration; pulmonary perfusion: blood flow through pulmonary vessels
• Physiologic dead space: airway that does not take part in gas exchange (about 150 mL)
• Compliance: force needed to expand the lungs
• Hypoxemia: low arterial oxygen tension; hypoxia: low oxygen supply to tissues
• Dyspnea: subjective uncomfortable breathing; orthopnea: dyspnea lying flat, relieved by sitting or standing
• Tachypnea: abnormally rapid respirations; apnea: temporary cessation of breathing
• Crackles: discontinuous popping on inspiration; wheezes: continuous musical sounds; rhonchi: low-pitched snoring sounds; stridor: high-pitched inspiratory sound over the neck from upper airway obstruction
• Fremitus: palpable vibration of speech; bronchophony, egophony, whispered pectoriloquy: abnormal voice transmission
• Hemoptysis: coughing up blood from the respiratory tract

I. Anatomy

A. Upper airway

• Nose: filters, warms, humidifies; turbinates increase mucosal surface; cilia move mucus to nasopharynx
• Paranasal sinuses (frontal, ethmoid, sphenoid, maxillary): resonating chambers; common infection site
• Pharynx: nasopharynx, oropharynx (palatine tonsils), laryngopharynx; adenoids in nasopharynx roof
• Larynx (“watchdog of the lungs”): epiglottis covers the larynx during swallowing; glottis; thyroid cartilage (Adam’s apple); cricoid cartilage (only complete ring); arytenoids; vocal cords; functions in vocalization, protects lower airway, facilitates cough
• Trachea: C-shaped cartilage rings (incomplete posteriorly); divides into right and left mainstem bronchi

B. Lower airway

• Right lung 3 lobes (upper, middle, lower); left lung 2 lobes (upper, lower)
• Pleura: visceral (covers lung) and parietal (lines chest wall); pleural fluid lubricates
• Mediastinum: heart, thymus, aorta, vena cava, esophagus
• Lobar bronchi (3 right, 2 left), segmental bronchi (10 right, 8 left - basis of postural drainage), subsegmental bronchi
• Bronchioles: no cartilage; patency depends on elastic recoil; cilia sweep mucus toward larynx
• Terminal bronchioles (no mucous glands or cilia) leads to respiratory bronchioles leads to alveolar ducts, sacs, alveoli
• Alveoli: about 300 million; 50-100 square meters
  • Type I cells: 95% of surface, barrier
  • Type II cells: 5%, make type I cells and surfactant (reduces surface tension)
  • Alveolar macrophages: phagocytic defense

II. Physiology

A. Ventilation mechanics

• Inspiration (first third of cycle) requires energy; expiration (last two thirds) is normally passive
• Air flows from high to low pressure: diaphragm and intercostals enlarge thorax, intrathoracic pressure falls below atmospheric
• Airway resistance increased by (Chart 17-1): bronchial smooth muscle contraction (asthma), mucosal thickening (chronic bronchitis), obstruction (mucus, tumor, foreign body), loss of elasticity (emphysema)
• Compliance: increased when lungs lose recoil (emphysema); decreased when lungs are stiff (severe obesity, pneumothorax, hemothorax, pleural effusion, pulmonary edema, atelectasis, fibrosis, ARDS) - more work of breathing

B. Lung volumes and capacities (Table 17-1, healthy men; women 20-25% less)

C. Perfusion and V/Q

• Pulmonary circulation is low pressure (systolic 20-30, diastolic 5-15 mm Hg)
• Upright: apex poorly perfused, bases best perfused; side-lying sends more blood to the dependent lung
• About 2% of RV output normally bypasses alveoli (shunt)
• V/Q states (Chart 17-2):
  • Normal ratio about 1:1
  • Low V/Q (shunt): perfusion exceeds ventilation - pneumonia, atelectasis, tumor, mucus plug
  • High V/Q (dead space): ventilation exceeds perfusion - pulmonary embolism, pulmonary infarction, cardiogenic shock
  • Silent unit: neither - pneumothorax, severe ARDS
• Shunting is the main cause of hypoxia after thoracic or abdominal surgery; severe hypoxia when shunt exceeds 20%

D. Gas exchange and transport

• Air: nitrogen 78%, oxygen 21%; atmospheric pressure at sea level about 760 mm Hg
• Alveolar PO2 about 100 mm Hg at sea level
• Oxygen carried mostly bound to hemoglobin (20 mL per 100 mL blood) vs 0.3 mL dissolved
• Hemoglobin 100% saturated at PaO2 of 150; PaO2 100 gives SaO2 97%; PaO2 40 gives SaO2 about 70-75%
• Oxyhemoglobin dissociation curve (Chart 17-4): normal PaO2 over 70; relatively safe 45-70; dangerous under 40
• Right shift (increased CO2, hydrogen ions/acidosis, temperature, 2,3-DPG): less oxygen picked up in lungs, more released to tissues
• Left shift (decreases in those factors): tighter binding, less oxygen released to tissues
• Flat upper curve: PaO2 can fall from 100 to 80 while saturation stays about 94%
• Normal PaO2 80-100 and SaO2 95-98% leaves a 15% margin; at PaO2 40 (SaO2 75%) there is no reserve for stress
• Cardiac output (normal 5 L/min) determines oxygen delivery; tissues use about 250 mL/min (25%)
• CO2: 90% carried by RBCs, 5% dissolved (PCO2 drives movement); arterial PCO2 40 mm Hg; major determinant of acid-base balance

E. Neurologic control

• Phrenic nerve drives respiratory muscles
• Medulla and pons centers control rate and depth; apneustic center (lower pons) promotes deep inspirations; pneumotaxic center (upper pons) controls pattern
• Central chemoreceptors (medulla): respond to pH changes in CSF
• Peripheral chemoreceptors (aortic arch, carotids): respond first to PaO2, then PaCO2 and pH
• Mechanoreceptors: Hering-Breuer reflex - stretch receptors stop inspiration to prevent overdistention
• Proprioceptors in muscles and chest wall: movement increases ventilation (ROM exercises stimulate breathing in immobile patients)
• Baroreceptors: BP changes cause reflex hypo- or hyperventilation

F. Gerontologic changes (Table 17-2)

• Vital capacity and muscle strength peak at 20-25 years
• Fewer cilia, less mucus, weaker cough and gag, decreased antibody response leads to more infections and aspiration
• Alveoli lose elasticity around 50; dead space and residual volume increase; vital capacity, FVC, PaO2 decrease; TLC unchanged
• Calcified costal cartilages, kyphosis, barrel chest, weaker muscles; increased work of breathing
• Older adults can do ADLs but tolerate prolonged activity less

III. Health History

Major symptoms: dyspnea, cough, sputum, chest pain, wheezing, hemoptysis.

A. Dyspnea

• Acute disease causes more severe dyspnea than chronic
• Sudden dyspnea in healthy person: pneumothorax, airway obstruction, allergic reaction, MI
• Sudden dyspnea in immobilized patient: PE
• Dyspnea with progressive hypoxemia after trauma, shock, bypass, or massive transfusion: ARDS
• Orthopnea: heart disease, sometimes COPD; dyspnea with expiratory wheeze: COPD
• Noisy breathing: airway narrowing or obstruction; stridor with upper airway blockage
• Ask: associated symptoms, onset, time of day, worse lying flat, exertion level, severity 0-10
• Use a standardized dyspnea scale (0-10) each shift and with changes

B. Cough

• Protective reflex; impaired by muscle weakness, inactivity, NG tube, depressed medulla (anesthesia, brain disorders)
• Causes: asthma, GERD, infection, ACE inhibitors
• At night: left-sided HF or asthma
• Morning with sputum: bronchitis
• Worse supine: postnasal drip
• After eating: aspiration or reflux
• Recent onset: acute infection
• Dry, irritative: viral URI or ACE inhibitor (Concept Mastery Alert: ask about ACE inhibitors with a dry, nonproductive cough)
• High-pitched irritative: laryngotracheitis; brassy: tracheal lesion; severe or changing: bronchogenic carcinoma
• Violent coughing can cause bronchospasm and syncope

C. Sputum

• Profuse purulent (yellow, green, rust) or color change: bacterial infection
• Thin mucoid: viral bronchitis
• Gradual increase: chronic bronchitis, bronchiectasis
• Pink-tinged mucoid: lung tumor
• Profuse frothy pink: pulmonary edema
• Foul-smelling with bad breath: lung abscess, bronchiectasis, anaerobic infection

D. Chest pain

• Lungs and visceral pleura have no pain fibers; parietal pleura does
• Pleuritic pain: sharp, “catches” on inspiration, “like a knife”; patient lies on the affected side to splint; splint with hands when coughing
• Causes: pneumonia, pulmonary infarction, pleurisy, late bronchogenic carcinoma (dull, persistent)
• Assess onset, quality, intensity, radiation, relation to position and breathing phase

E. Wheezing and hemoptysis

• Wheezing: high-pitched musical, on expiration (asthma) or inspiration (bronchitis); bronchoconstriction
• Hemoptysis causes: pulmonary infection, lung cancer, heart or vessel abnormalities, PE or infarction
• Lung blood: bright red, frothy, mixed with sputum; tickle in throat, salty taste, bubbling in chest; alkaline pH (over 7)
• Stomach blood: vomited, dark “coffee ground,” mixed with food; acid pH (under 7)
• Nasopharyngeal blood: preceded by sniffing, blood in nose

F. Past, social, family history

• Immunizations (influenza, pneumonia), allergies, medications
• Psychosocial (Chart 17-6): coping, quality of life, roles, depression, anxiety, support
• Risk factors (Chart 17-7): atypical immune response (asthma), indoor pollutants (smoke, radon), outdoor pollutants, genetics, infection, obesity, family history, smoking and vaping
• Genetic disorders (Chart 17-8): asthma, CF, COPD, alpha1-antitrypsin deficiency, primary ciliary dyskinesia, pulmonary fibrosis, pulmonary hypertension
• Pack-years = packs per day x years smoked; ask when quit
• E-cigarettes contain toxic substances (acrolein, formaldehyde); FDA has not found them safe or effective for quitting; FDA-approved nicotine replacement: gum, patch, lozenge, oral inhaler, nasal spray
• Disparities (Chart 17-9): higher tobacco use in rural and low-income groups; higher asthma death rates in African Americans; lower vaccination rates among older African Americans and Hispanics
• Severe dyspnea: shorten and pace the interview

IV. Physical Assessment

A. General appearance

• Clubbing: spongy nail bed, loss of nail bed angle (180 degrees or more); chronic hypoxia, chronic lung infection, lung cancer, congenital heart disease, endocarditis, IBD
• Cyanosis: very late sign; appears when at least 5 g/dL hemoglobin is unoxygenated; anemic patients rarely show it; polycythemic patients may look cyanotic while oxygenated - unreliable sign
• Central cyanosis: tongue and lips (low arterial oxygen); peripheral cyanosis: fingers, toes, earlobes (vasoconstriction, cold)

B. Upper respiratory structures

• Nose: lesions, symmetry; mucosa redder than oral mucosa; pale and swollen in allergic rhinitis; swollen and red with colds; septal deviation, perforation; polyps (gray, gelatinous, movable)
• Sinuses: palpate frontal and maxillary for tenderness (inflammation); transillumination - no glow suggests fluid or pus
• Mouth and pharynx: color, symmetry, exudate, ulceration, enlargement; press tongue blade beyond midpoint
• Trachea: palpate just above sternal notch; normally midline; deviated by neck or mediastinal masses, pneumothorax, pleural effusion

C. Inspection of the thorax

• Position: sitting, arms crossed with hands on opposite shoulders (separates scapulae); or roll side to side if supine
• Landmarks (Chart 17-10): angle of Louis marks the second rib; C7 (vertebra prominens) posteriorly; midsternal, midclavicular, anterior axillary, midaxillary, posterior axillary, scapular, vertebral lines; upper lobes dominate anteriorly, lower lobes posteriorly; right middle lobe not heard posteriorly
• Normal AP to lateral ratio 1:2
• Barrel chest: increased AP diameter; aging, emphysema, COPD; ribs widely spaced, intercostal bulging on expiration
• Funnel chest (pectus excavatum): depressed lower sternum; can compress heart (murmurs); rickets, Marfan
• Pigeon chest (pectus carinatum): anterior sternum displacement; rickets, Marfan, kyphoscoliosis
• Kyphoscoliosis: elevated scapula, S-shaped spine; limits lung expansion; osteoporosis

Breathing patterns (Table 17-3):

• Eupnea: normal 12-20/min
• Bradypnea: under 10, regular; increased ICP, brain injury, drug overdose
• Tachypnea: over 24, shallow; pneumonia, pulmonary edema, metabolic acidosis, sepsis, pain, rib fracture
• Hypoventilation: shallow, irregular
• Hyperpnea: increased depth
• Hyperventilation: increased rate and depth lowering PaCO2; exertion, anxiety, metabolic acidosis; Kussmaul respiration with DKA or kidney failure
• Apnea: cessation; life threatening if sustained
• Cheyne-Stokes: regular cycle of increasing then decreasing rate and depth followed by apnea (about 20 seconds); time the apnea; HF, respiratory center damage
• Biot’s (ataxic): 3-4 normal breaths followed by irregular apnea of 10-60 seconds; drug overdose, brain injury at the medulla
• Obstructive: prolonged expiration; asthma, COPD, bronchitis
• Concept Mastery Alert: Cheyne-Stokes is a regular waxing and waning pattern with apnea; Biot’s is irregular apnea between normal breaths

Other inspection:

• Slight intercostal retraction normal in thin people
• Bulging on expiration: expiratory obstruction (emphysema)
• Marked asymmetric retraction on inspiration: branch obstruction
• Asymmetric bulging: increased pressure in a hemithorax (pneumothorax, pleural effusion)
• Accessory muscles: sternocleidomastoid, scalene, trapezius on inspiration; abdominal and internal intercostals on expiration

D. Palpation

• Tenderness, masses, lesions with fingertips or ball of hand
• Respiratory excursion: thumbs at costal margin anteriorly or at T9-T10 posteriorly, slide medially to raise skin fold, patient breathes deeply; normally symmetric; decreased with fibrosis; asymmetric with splinting (pleurisy, rib fractures, trauma) or unilateral bronchial obstruction
• Tactile fremitus: patient says “ninety-nine”; palmar or ulnar surface; compare sides; avoid bone
  • Greater in men (deeper voice), on the right, over large bronchi; less over heart, with thick chest wall or obesity
  • Increased with consolidation (pneumonia) - solid tissue conducts sound
  • Decreased or absent with air (emphysema, pneumothorax) or fluid (effusion)

E. Percussion (Table 17-4)

• Flatness: soft, high, short; thigh; large pleural effusion
• Dullness: medium; liver; lobar pneumonia
• Resonance: loud, low, long; normal lung; simple chronic bronchitis
• Hyperresonance: very loud, lower, longer; none normally; emphysema, pneumothorax
• Tympany: loud, high, musical; gastric air bubble; large pneumothorax
• Technique: middle finger of nondominant hand on chest, strike distal joint with dominant middle finger; 5-6 cm intervals; posterior from shoulder tops (5 cm apical resonance) down; do not percuss bone
• Normal dullness left of sternum at third to fifth intercostal spaces (heart) and at right costal margin (liver)
• Diaphragmatic excursion: mark dullness at full inspiration and full expiration at midscapular line; normal 5-7 cm (up to 8-10 cm in tall young men); right diaphragm about 2 cm higher (liver); decreased with pleural effusion; high diaphragm with atelectasis, paralysis, pregnancy

F. Auscultation

• Diaphragm firmly on bare skin; patient breathes slowly and deeply through mouth; apices to bases and midaxillary lines; two full breaths per site; rest periodically to avoid hyperventilation

Normal breath sounds (Table 17-5):

• Vesicular: soft, low; inspiration longer than expiration; most of the lung fields
• Bronchovesicular: intermediate; equal; first and second interspaces anteriorly and between scapulae
• Bronchial: loud, high; expiration longer; over manubrium
• Tracheal: very loud, high; equal; over trachea in the neck
• Diminished or absent with obstruction (atelectasis), fluid (effusion), tissue (obesity); emphysema faint with prolonged expiration
• Bronchial or bronchovesicular sounds over peripheral lung mean consolidation (pneumonia, HF)

Adventitious sounds (Table 17-6):

• Crackles: discontinuous popping, mostly inspiratory; fluid or delayed reopening of collapsed alveoli; HF, fibrosis
  • Coarse: early inspiration and expiration, large bronchi, not positional; obstructive disease
  • Fine: mid-late inspiration, like hair rubbed together, alveoli, dependent areas, may change with position; interstitial pneumonia, fibrosis; early inspiratory fine crackles with bronchitis or pneumonia
• Wheezes: continuous, high-pitched, musical; mostly expiratory; narrowed airway; chronic bronchitis, bronchiectasis
• Rhonchi: deep, low-pitched, snoring; mostly expiratory; may clear with cough; secretions or tumor
• Pleural friction rub: low-pitched grating, like leather rubbing; inspiration and expiration; may stop with breath-holding; not cleared by cough; best in axillae and bases; pleural inflammation
• Stridor: continuous high-pitched over the neck; upper airway narrowing - immediate intervention

Voice sounds (patient says “ninety-nine” or “eee”):

• Normally faint and indistinct
• Bronchophony: louder, clearer than normal
• Egophony: “E” sounds like “A”
• Whispered pectoriloquy: whispers heard clearly
• All indicate increased density (pneumonia, pulmonary edema)

G. Findings in common disorders (Table 17-7)

H. Acutely or critically ill patient

• Check ventilator settings and that alarms are on; patient-ventilator synchrony; agitation, nasal flaring, accessory muscle use, paradoxical chest-abdomen movement
• HOB elevated to prevent aspiration (especially with tube feeds); prone positioning for refractory hypoxemia in ARDS
• Lethargy and somnolence may mean rising CO2 even if sedated
• Turn patient to auscultate dependent areas (atelectasis, effusion)
• Bedside tests: RR, ETCO2, tidal volume, minute ventilation, vital capacity, inspiratory force, compliance - important after chest or abdominal surgery, prolonged anesthesia, preexisting lung disease, older or obese patients
• Low tidal volumes from obesity, distention, pain, sedation, overdose lead to atelectasis
• Quality and Safety Nursing Alert: do not rely on visual inspection of chest movement; the patient may be moving only dead-space air; use auscultation and pulse oximetry
• Minute ventilation = tidal volume x RR; falls with hypoventilation (PaCO2 rises)
• Quality and Safety Nursing Alert: vital capacity under 10 mL/kg means the patient cannot sustain spontaneous breathing - needs respiratory assistance (normal VC is about twice tidal volume)
• FEV1 normally at least 80% of VC; FEV1/FVC under 85% suggests obstruction; proportional reduction suggests restriction
• Inspiratory force: normal about 100 cm H2O negative pressure; under 25 cm H2O after 15 seconds of occlusion usually means mechanical ventilation needed

V. Diagnostic Evaluation

A. Pulmonary function tests (Table 17-8)

• For chronic disease, occupational screening, preop screening (thoracic and upper abdominal surgery, obesity)
• FVC: often reduced in COPD (air trapping)
• FEV1: severity of expiratory obstruction
• FEV1/FVC: presence of obstruction
• FEF 25-75%: slowed in small airway obstruction
• Maximal voluntary ventilation: exercise tolerance
• Interpreted against height, weight, age, gender, ethnicity; may miss early localized changes
• Home peak flow monitoring

B. Blood gases and oximetry

• ABG: radial, brachial, femoral, or arterial line; complications pain, infection, hematoma, hemorrhage
• VBG: oxygen balance; SvO2 (pulmonary artery catheter) or ScvO2 (central line in SVC)
• Pulse oximetry: normal SpO2 over 95%; under 90% needs evaluation; does not measure PaO2, ventilation, or hyperoxemia; unreliable with hypothermia, hemodynamic instability, low perfusion, vasoconstriction, motion, dark skin, nail polish - get ABG
• ETCO2 (capnometry number, capnography waveform): early sign of respiratory depression; standard for anesthesia and procedural sedation; most reliable confirmation of ET tube in the trachea (colorimetric detector does not change color with esophageal intubation); confirms ROSC; false results with bag-mask ventilation, sodium bicarbonate, carbonated drinks, antacids

C. Cultures and sputum

• Throat, nasal, nasopharyngeal cultures before antibiotics; rapid strep in 15 minutes; cultures take 48-72 hours
• Sputum: early morning before eating or drinking; clear nose and throat, rinse mouth (not spit saliva); deep breaths then deep cough into sterile container; induced with hypertonic aerosol if needed; send promptly

D. Imaging

• Chest x-ray: PA and lateral views at full inspiration; no fasting; remove metal; lead shield; contraindicated in pregnancy
• CT: fine tissue density, nodules, mediastinum; contrast contraindicated with kidney impairment, iodine or shellfish allergy, pregnancy; hold metformin day of test (lactic acidosis); NPO 4 hours if contrast; lie still under 30 minutes
• Pulmonary angiography and CT pulmonary angiography (PE): consent, allergies, anticoagulation and renal function, NPO 4 hours; warm flush or chest pain with dye; immobilize punctured extremity; watch for PVCs (catheter in RV); monitor VS, SpO2, site for bleeding, neurovascular checks; cold compresses
• MRI: better tissue distinction; contraindicated with severe obesity, claustrophobia, agitation, unsafe metal implants; gadolinium can cause nephrogenic systemic fibrosis with poor kidney function; remove metal, hearing aids, foil patches; lie still 30-90 minutes; loud noise, earplugs
• Fluoroscopy: guides biopsies, assesses diaphragm movement
• Lung scans (contraindicated in pregnancy):
  • V/Q scan: perfusion (IV isotope) then ventilation (inhaled gas); ventilation without perfusion indicates PE; chest x-ray first; no radiation precautions
  • Gallium scan: inflammation, abscess, tumor staging; scans at 6, 24, 48 hours
  • PET: evaluates nodules for malignancy; no caffeine, alcohol, tobacco 24 hours; NPO 4 hours; empty bladder; fluids afterward

E. Endoscopic procedures

Bronchoscopy:

• Diagnostic (visualize, collect secretions and tissue, assess resectability, find hemoptysis source) and therapeutic (remove foreign bodies or secretions, control bleeding, treat atelectasis, excise lesions, brachytherapy, stents)
• Flexible fiberoptic (bedside, through ET tube) or rigid (OR; foreign bodies, massive hemoptysis)
• Complications: anesthetic reaction, oversedation, fever, infection, aspiration, vasovagal response, laryngospasm, bronchospasm, hypoxemia, pneumothorax, bleeding
• Before: consent; NPO 4-8 hours; remove dentures; atropine and sedative or opioid as prescribed; topical lidocaine
• After: NPO until cough reflex returns, then ice chips and fluids; watch older adults for confusion from lidocaine; monitor for hypoxia, hypotension, tachycardia, arrhythmias, hemoptysis, dyspnea; small blood-tinged sputum and fever in first 24 hours expected; report dyspnea or bleeding
• Quality and Safety Nursing Alert: sedation in respiratory insufficiency may precipitate respiratory arrest

Thoracoscopy (including VATS):

• OR under anesthesia; small incisions; inspect pleura, aspirate fluid, biopsy; chest tube may follow
• For pleural effusion, pleural disease, tumor staging, empyema, pneumothorax
• Nursing: consent, NPO; postop VS, pain, respiratory status, bleeding, infection; dyspnea may mean pneumothorax; monitor chest tube

Thoracentesis:

• Aspiration of pleural fluid or air for diagnosis or therapy, biopsy, or instilling medication
• Fluid studies: Gram stain, culture, acid-fast, cell count, cytology, pH, protein, LDH, glucose, amylase, triglycerides, tumor markers

F. Biopsy

• Lung biopsy (interstitial disease, cancer, infection, sarcoidosis): transbronchial brushing, needle aspiration, transbronchial forceps biopsy, percutaneous needle biopsy under fluoroscopy or CT (patient holds breath mid-expiration)
• Complications: pneumothorax, pulmonary hemorrhage, empyema
• Teach to report pain, dyspnea, bleeding, redness, purulent drainage; address anxiety about results
• Pleural biopsy: exudate of unknown origin, TB, fungi
• Lymph node biopsy: scalene nodes; mediastinoscopy (suprasternal incision) and anterior mediastinotomy (chest tube needed) for staging; postprocedure oxygenation, bleeding, pain

High-Yield Numbers

• Normal RR 12-20; bradypnea under 10; tachypnea over 24
• Tidal volume 500 mL (5-10 mL/kg); VC 4600; TLC 5800; RV 1200; FRC 2300; dead space about 150 mL
• Alveoli about 300 million; type I cells 95% of surface
• Pulmonary artery pressure 20-30/5-15 mm Hg
• Shunt over 20% causes severe hypoxia
• Air: nitrogen 78%, oxygen 21%; sea level 760 mm Hg; alveolar PO2 about 100
• PaO2 80-100, SaO2 95-98%; PaO2 under 40 dangerous; PaO2 40 gives SaO2 about 75%
• Arterial PCO2 40 mm Hg
• Cyanosis needs at least 5 g/dL unoxygenated hemoglobin
• AP:lateral 1:2; diaphragmatic excursion 5-7 cm; right side about 2 cm higher
• Cheyne-Stokes apnea about 20 seconds; Biot’s apnea 10-60 seconds
• SpO2 over 95% normal, under 90% needs evaluation
• VC under 10 mL/kg needs ventilatory support; inspiratory force under 25 cm H2O needs ventilation
• FEV1 at least 80% of VC; FEV1/FVC under 85% suggests obstruction
• Bronchoscopy NPO 4-8 hours; CT contrast and angiography NPO 4 hours; PET NPO 4 hours and no caffeine 24 hours
• Lung blood pH over 7; stomach blood pH under 7
• Cultures 48-72 hours; rapid strep 15 minutes

Priority Nursing Actions and Red Flags

• Stridor: upper airway obstruction - emergency
• Sudden dyspnea: consider pneumothorax, PE, MI, allergic reaction
• Tracheal deviation away from affected side with hyperresonance and absent breath sounds: tension pneumothorax
• Lethargy or somnolence: rising CO2
• Cyanosis is a late, unreliable sign; act on earlier signs (restlessness, tachypnea, tachycardia)
• Dry cough on an ACE inhibitor: ask about the medication
• Frothy pink sputum: pulmonary edema
• After bronchoscopy: nothing by mouth until cough and gag return
• Sedation in respiratory insufficiency can cause arrest
• Confirm ET tube placement with ETCO2
• Do not rely on visual chest movement alone; auscultate and check SpO2
• Contrast studies: check allergies, kidney function, hold metformin
• Remove metal and foil-backed patches before MRI

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