Week 11 respiratory

Respiratory Function

Learning Objectives1. Describe anatomic changes in the lungs

resulting from the normal aging process.2. Describe age related changes in ventilation.3. List nursing diagnoses for older adults with

respiratory diseases.4. Identify nursing interventions and outcomes

for older adults with various respiratory alterations.

5. Discuss smoking cessation methods and interventions.

6. Identify risk factors for the development of tuberculosis in older adults.

7. List the benefits of pulmonary rehabilitation for older adults with chronic obstructive pulmonary disease.

Respiratory System Components

Lungs Airways leading to the lungs Blood vessels serving the lungs Chest wall

Gerontological NursingBy Patricia Tabloski

Normal Aging ChangesDifferentiating normal aging changes

from disease-related changes is difficult.

Lung structure and function with normal aging include Stiffening of elastin + collagen

connective tissue supporting the lungs Altered alveolar shape increased

alveolar diameter Decreased alveolar surface area

available for gas exchange Increased chest wall stiffness

Thoracic cageThe ribs become less mobile and

the compliance of the chest wall decreases

Osteoporosis and calcification of the costal cartilage

Kyphosis or Scoliosis degeneration of the intervertebral => shorter thorax with an increased AP diameter

Respiratory musclesRespiratory muscles weaken =>

Inspiratory and expiratory forces are decreased

The diaphragm does not lose mass with aging but it may flatten and become less efficient specially in patients with COPD

Older adults use the less efficient accessory muscles of respiration such as the abdominals, sternocleidomastoid and trapezius muscle

Breathing patterns

More dependent on intraabdominal pressure changes and positioning

Normal rate of 16 to 25 breaths/min

Decrease in tidal volume (Vt)Alveoli at the base of the lungs are

underventilated => hypoxemia and hypercarbia

Lung ParenchymaProgressive loss of elastic recoil

of the lung parenchyma and conducting airways => respiratory system compliance decreases

Lung becomes less elastic as collagenic substances surrounding the alveoli and alveolar ducts stiffen and form cross linkages

Lung CapacityTotal lung capacity (TLC) changes

little with ageVital capacity (VC) is decreasedRate of reduction of VC is greater in

older men than in older womenDecreased compliance of the thorax

accounts for the increase in residual volume (RV) and expiratory reserve volume (ERV).

Lung CapacityInspiratory capacity of older

adults is affected by the decreased ability to take a deep breath

Functional dead space ventilation in increased from one third to as much as one half of each breath

AirwayAffected by four factors:(1) Size of the airway(2) Resistance in the airway(3) Muscle strength(4) Elastic recoil.When measured in the older

client, all of these indices are decreased

Early airway closure is seen in older clients

AlveoliAlveoli decrease in number Progressive loss of the

intraalveolar septum

Alveoli enlarge because of dilation of the proximal bronchioles

Immune systemDecrease in the number and

effectiveness of cilia => increased difficulty in clearing secretions and increased risk for the development of respiratory tract infections

Alveolar macrophage activity is defective

Decreased IgA

Gas Exchange

PaO2 falls at a rate of 4 mmHg per decade of life.

A normal PaO2 for a 70 year old is between 75 and 80 mmHg. “70 at 70”

Fall in PaO2 is most likely caused by an increased closing volume during tidal breathing.

Cardiovascular Changes Affecting the Pulmonary System

Increased stiffness of heart + blood vessels vessels less compliant to increased blood flow demands

Impaired diastolic filling diastolic dysfunction Increased left ventricular afterload systolic

dysfunction Decreased cardiac output with rest and

exercise oxygen-carrying capacity(hemoglobin x 1.34) of

the blood is reduced with age The arterial pH of the older person remains

within normal adult range of 7.35 to 7.45 less increase in heart rate and a lower response

to increasing carbon dioxide

Normal Aging of Immune Function Can Affect Pulmonary Function

Decrease in the nature + quantity of antibodies produced

Cilia less effective in removing debris more foreign bodies in lungs

Decreased antibody production after immunization

Use of medications suppress immune function

Neurological Changes of Aging and the Respiratory SystemNeuron loss in the brain and

central nervous system Increased reaction time Decreased response to multiple

complex stimuli Impaired ability to adapt and interact

with the environment

Changes That Affect Pulmonary Function Loss of muscle tone

Exacerbated by deconditioning + sedentary lifestyle

Increased thoracic rigidity Osteoporotic changes to the spine

(kyphosis)

Changes That Affect Pulmonary Function Medication use

Fatigue Depressed cough reflex Insomnia Dehydration Bronchospasm

Changes Affect Pulmonary Function Diagnosis of neurological disease or

impairment Dementia Parkinson’s disease Stroke or CVA

Increased anteroposterior diameter of thorax barrel chest appearance

FACTORS AFFECTING LUNG FUNCTION

Exercise and Immobility

Exercise has a positive effect on the respiratory and cardiovascular systems

Smoking Smoking has long been known to damage

the lungs. Recently prolonged exposure to

secondhand smoke has been shown to damage the lungs of nonsmokers.

Heavy smokers may demonstrate a ninefold increase in the reduction of Forced Expiratory Volume over normal expected reductions.

Cilia, which are paralyzed by nicotine, are unable to clean the lungs

Smoking

Cigarette smoking causes bronchoconstriction, increased airway resistance and increased closing volumes

Smoking interferes with gas exchange because the carbon monoxide byproduct competes with oxygen for the hemoglobin molecule

Smoking Cessation Smoking cessation is imperative. The five

components of smoking cessation consist of THE 5 AS: ASK, ADVISE, ASSESS, ASSIST AND ARRANGE.

NEW TREATMENTS : bupropion hydrochloride, nicotine gum,

nicotine patches and nicotine inhalation systems.

Bupropion hydrochloride given for 3 days at 150 mg per day and then increased to 150 mg twice a day with doses 8 hours apart and the first dose in the morning. Older clients are encouraged to smoke during the first week of treatment and to set a quit smoking date before the end of the first 14 days treatment

Obesity Obesity results in a decrease in chest wall

compliance.

In older clients with already decreased chest wall mobility and stiffening of the chest, added weight greatly reduces pulmonary functions and increases breathlessness.

Ventilation at the bases of the lungs may be diminished because of the clients inability to take a deep breath

Sleep

Increased sleep time of older adults increases the risk of aspiration and oxygen desaturation during sleep

Anesthesia and Surgery An older client undergoing surgery has an

increased risk of aspiration as a result of loss of laryngeal reflexes.

If surgery is an emergency, risk in increased because of the older clients delayed gastric emptying and the potential for a full stomach.

Incisions, pain and decreased postoperative deep breathing increase the older clients chance of developing postoperative atelectasis.

Anesthesia and Surgery Subsequent immobility decreases ventilation

and effective airway clearance. Hypovolemia contributes to thickened

secretions. Because older clients have a less effective

cough, a painful incision further diminishes the likelihood of effective airway clearance.

Promotion of deep breathing, adequate hydration, frequents position changes and early mobilization will decrease the risk of developing atelectasis

Common Respiratory Symptomselevated respiratory rate of 16 to 25

breaths/min Abnormal breathing patterns in older

clients can be indicative of other metabolic and respiratory illnesses

change in the mental status – 1st sign

responses to hypoxemia and hypercapnia are blunted

Common Respiratory Symptoms Dyspnea is a perception of breathlessness Older clients most often describe their

breathlessness as a sensation of an inability to get enough air, or a choking or smothering feeling.

associated with an acute respiratory or cardiac illness

most common complaint in older clients with pulmonary disease.

older clients usually do not complain of dyspnea until it begins to interfere with their activities of daily living (ADLs)

Common Respiratory Symptoms

cough mechanism Causes of coughing in older clients include

postnasal drip, chronic bronchitis, acute respiratory tract infections, aspiration, gastroesophageal reflux, congestive heart failure (CHF), interstitial lung disease, cancer and angiotensin-converting enzyme inhibitor medications for hypertension and CHF.

recommend cough suppressants with caution Suppression of the cough and depression of

any respiratory function could lead to retention of pulmonary secretions, plugged airways and atelectasis.

ChronicObstructivePulmonaryDisease

COPD characterized by airway obstruction and

decreased expiratory flow rate The 2 reversible components in COPD

are airway diameter and expiratory flow rate

Emphysema, chronis bronchitis, and bronchiectasis are often referred to as COPD

progressive and ultimately fatal disease more than two times high in men as in

women between the ages of 65 and 74 and three times as high between ages of 75 nad 84

COPD Rick factors for COPD include: age, male gender, reduced lung function,

air pollution, exposure to secondhand smoke, familial allergies, poor nutrition, and alcohol intake.

COPD is often a comorbid factor in deaths from pneumonia and influenza, and it accounts for increased physician visits.

COPDSymptoms:

Depending on whether emphysema or chronic bronchitis is the predominant factor.

Symptoms include dyspnea (especially on exertion), cough, sputum production, weight loss, and fatigue.

Diagnosis is based on client history and alterations in the PFTs.

Diagnostic Tests and Procedures history exposure to tobacco smoke;

occupational dusts and chemical; smoke from home cooking and heating fuels; and progressive dyspnea, chronic cough, and chornic sputum production, usually in the morning.

PFTs or simple spirometry is used for the initial diagnosis of airflow obstruction.

A resting ABG measurement a standard baseline posteroanterior chest x-

ray study are also obtained. The blood hemoglobin level is staged based

in the percent if the predicted value of FEV₁.

Treatment Focused on symptoms management through

education smoking cessation healthy lifestyle Proper nutrition

Pharmacotherapy Beta₂ Agonists - albuterol (Proventil, Ventolin),

metaproterenol sulfate (Alupent, Metaprel), and pirbuterol acetate (Maxair). Thru MDI

Anticholinergics - ipratropium bromide or oxitroprium bromide

Steroids Oxygen Therapy Antibiotics Surgical Options- bullectomy, removing the bullae

Nursing ManagementASSESSMENT Assessing their ADLs, quantifying

breathlessness on a scale of 1 to 10, and identifying environmental and social factors

Precipitating factors Physical assessment includes assessment

of the shape and symmtery of the chest; respiratory rate and pattern; body position; use of accessory muscles of respiration; color, temperature, and appearance of extremities; and sputum color, amount, consistency, and odor.

Nursing Management Assess cyanosis in darkly pigmented older

adults, the nurse shouls examine the client with favorable lighting conditions (e.g., use overbed light or natural sunlight).

The lips, nail beds, circumoral region, cheek bones and earlobes.

Changes in level of consciousness, increased respiratory rate, use of accessory muscles of respiration, nasal flaring, and positional changes and other manifestations of respiratory distress.

Fremitus, chest wall movement, and diaphargmatic excursion

Nursing ManagementDIAGNOSIS Nursing diagnoses common for an older client with

COPD include: Ineffective airway clearance related to retained

secretions. Impaired gas exchange related to altered oxygen

supply. Risk for infection related to inadequate primary and

secondary defenses and chronic disease. Knowledge deficit: COPD related to lack of previous

exposure. Inadequate nutrition related to inability to digest or

ingest food or to absorb nutrients. Ineffective breathing pattern related to

musculoskeletal impairement and decreased energy or fatigue.

Nursing ManagementPlanning Client will maintain patent airway. Client will maintain stable weight. Client will maintain ABG values at baseline. Client will maintain a balanced intake and output. Client will be able to effectively clear secretions. Client will be able to demonstrate diaphragmatic

and pursed-lip breathing. Client will be able to demonstrate relaxation

techniques to control breathing. Client will maintain a respiratory rate between 16

and 25 breaths/min. Client will be able to list significant and reportable

signs and symptoms.

Nursing ManagementIntervention Pulmonary Rehabilitation pulmonary rehabilitation

includes 20 to 30 minutes of exercise 3 to 5 times a week

Smoking Cessation Nutrition reduce carbohydrates to only 50% of the

diet (the breakdown of carbohydrates has been shown to increase the CO₂ load

Breathing Retraining diaphragmatic breathing and pursed-lip breathing

Chest Physiotherapy Pulmonary Hygiene oral fluids of 4 t 6 quarts a day Medication Inhaled medications are only as effective

as the delivery Exercise Home Oxygen therapy

Thank you!