2. Learning Objectives
1. 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.
3. Respiratory System
Components
Lungs
Airways leading to the lungs
Blood vessels serving the lungs
Chest wall
5. Normal Aging Changes
Differentiatingnormal aging changes
from disease-related changes is difficult.
Lung structure and function with normal
aging include
Stiffeningof 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
6. Thoracic cage
The
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
7. Respiratory muscles
Respiratory 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
8. 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
9. Lung Parenchyma
Progressiveloss of elastic recoil of the
lung parenchyma and conducting
airways => respiratory system
compliance decreases
Lungbecomes less elastic as
collagenic substances surrounding
the alveoli and alveolar ducts stiffen
and form cross linkages
10. Lung Capacity
Total lung capacity (TLC) changes
little with age
Vital capacity (VC) is decreased
Rate of reduction of VC is greater in
older men than in older women
Decreased compliance of the thorax
accounts for the increase in residual
volume (RV) and expiratory reserve
volume (ERV).
11. Lung Capacity
Inspiratorycapacity of older adults
is affected by the decreased ability
to take a deep breath
Functionaldead space ventilation
in increased from one third to as
much as one half of each breath
12. Airway
Affected 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
13. Alveoli
Alveoli decrease in number
Progressive loss of the intraalveolar
septum
Alveolienlarge because of dilation
of the proximal bronchioles
14. Immune system
Decrease 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
15. 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.
16. 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
17. 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
18. Neurological Changes of
Aging and the Respiratory
System
Neuronloss 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
19. Changes That Affect
Pulmonary Function
Loss of muscle tone
Exacerbated by deconditioning +
sedentary lifestyle
Increased thoracic rigidity
Osteoporotic changes to the spine
(kyphosis)
20. Changes That Affect
Pulmonary Function
Medication use
Fatigue
Depressed cough reflex
Insomnia
Dehydration
Bronchospasm
21. Changes Affect Pulmonary
Function
Diagnosis
of neurological disease or
impairment
Dementia
Parkinson’s disease
Stroke or CVA
Increasedanteroposterior diameter of
thorax barrel chest appearance
23. Exercise and Immobility
Exercisehas a positive effect on the
respiratory and cardiovascular
systems
24. 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
25. 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
26. 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
27. Obesity
Obesityresults in a decrease in chest wall
compliance.
Inolder clients with already decreased chest
wall mobility and stiffening of the
chest, added weight greatly reduces
pulmonary functions and increases
breathlessness.
Ventilationat the bases of the lungs may be
diminished because of the clients inability to
take a deep breath
28. Sleep
Increased sleep time of older adults
increases the risk of aspiration and
oxygen desaturation during sleep
29. 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.
30. 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
31. Common Respiratory Symptoms
elevated 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
32. 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)
33. 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.
35. 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
36. 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.
37. COPD
Symptoms:
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.
38. 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.
40. Nursing Management
ASSESSMENT
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.
41. 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
42. Nursing Management
DIAGNOSIS
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.
43. Nursing Management
Planning
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.
44. Nursing Management
Intervention
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
