ch 19: lower resp disorders (part 1)

conducting zone

• what structures doe is it include

• function?

• trachea, bronchi, bronchioles, & terminal bronchioles

• Transports, warms, humidifies, and filters air

• NO gas exchange

transitional ands respiratory zone

• structures & function

• alveolar ducts and sacs & respiratory bronchioles

• Performs the actual exchange of oxygen and carbon dioxide between the air and the blood

steps of pulmonary circulation

• 1. Right ventricle → pumps deoxygenated blood to pulmonary artery.

• 2. Pulmonary arteries → carry deoxygenated blood to the lungs.

• 3. Lungs → blood releases CO₂ and picks up O₂.

• 4. Pulmonary veins → carry oxygenated blood back to the heart to left atrium.

• 5. Left atrium → receives the oxygenated blood, which then moves into the left ventricle for systemic circulation

Atelectasis

• what is it?

• most common after ?

• how does anesthesia and pain affect ?

• other factors

• what V/Q imbalance?

• Collapse or incomplete expansion of alveoli, reducing the surface area available for gas exchange

• Most common postoperative pulmonary complication, especially after thoracic or upper abdominal surgery

• anesthesia - slows breathing

• pain after surgery - limits deep breathing and ambulation

• pts also have mucus blocking airways and surfactant impairment

• perfusion w/o ventilation

s/s of atelectasis

• dyspnea + respiratory distress w/o lobar involvement

• cough with or without sputum

• tachypnea , tachycardia & anxiety

• pleural pain

• subtle AMS - due to lack of oxygen (early sign)

• decreased chest expansion on affected side

• cyanois (late sign)

• increased WOB

• fever r/t inflammation or infectious processes

when we listen to lungs on a pt w/ atelectatsis

• when we percuss ?

• we can hear crackles on inspiration when alveoli tries to open

• diminished or absent breath sound

• dullness to percussion

risks factorsof atelectasis

• general anesthesia,

• immobility,

• pain limiting deep breathing/coughing,

• obesity,

• smoking history,

• pre-existing lung disease

what diagnostic tests confirm atelectasis

• Pulse ox Low

• Chest xray

• Ct scan

• ABG (low PO2 and high CO2)

prevention & managing (ICOUGH) +3 more

• Incentive spirometry

  •Coughing (controlled with splinting) and deep breathing

  •Oral care (brushing teeth and using mouthwash twice a day)

  •Understanding (patient and staff education)

  •Getting out of bed at least three times daily do AROM & q2hr turns

  •Head-of-bed elevation + hydration (thins secretions)

• manage pain

• give bronchodilators & mucolytics as ordered

• chest physiotherapy

how to use incentive spirometer and how often

• 10 breaths every hour they are awake

• sit up

• exhale, create seal around mouthpiece

• Breathe in as slowly and deeply as you can through your mouth to raise the piston

• When you reach your highest possible breath, hold it for 3 to 5 seconds while the piston slowly falls.

• breathe out normally

for more severe atelectasis

• 2 procedures

• 3 devices

• may require bronchoscopy to remove obstructive mucus plugs

• thoracentesis for removing plueral fluid

• CPAP

• endotracheal intubation & mechanical vent

• PEEP(positive end expiratory pressure ) - holds the alveoli open during exhalation, stopping them from collapsing

thoracentesis

• what is it

• purpose

• N/C (needs what before? monitor ? document ? before any exercise?)

• Removal of fluid in the pleural space via needle aspiration

• can be therapeutic or diagnostic

• needs consent/ educate and prep

• monitor for any bleeding at the site and BP

• document drainage & look at dressing

• pre-medicate before exercises

Acute Tracheobronchitis

• what is it

• often after 2

• Acute inflammation of the mucous membranes of the trachea and bronchial tree

• often follows URI or inhalation of chemical irritants (smoke, pollen, asbestos, dust, fiber glass)

s/s of Acute Tracheobronchitis

• how does cough change as disease progresses

• other s/s

• initially dry/ irritating / hacking cough

• as disease progresses - increased sputum

• chest pain form dry cough

• dyspnea from inflammation (narrowing airway)

• fever, chills, headache , night sweats, fatigue

medical management of Acute Tracheobronchitis

• what Is not recommended

• antibiotic if bacterial

• analgesics + antipyretics

• fluid to thin secretions

• cool vapor or steam

• DO not use antihistamines - dries secretions , harder to clear

Nursing care of tracheobronchitis

• encourage ? 2

• allow?

• monitor for

• bronchial hygiene - coughing + deep breathing

• encourage fluids + proper nutrition

• allow rest

• monitor for complications in high risk patients

Respiratory Syncytial Virus (RSV)

• what is it? cause ?

• occurs when ?

• most common cause of

• transmitted ? precautions ?

• reportable?

• Acute lower respiratory tract infection, usually caused by a virus

• Occurs in annual epidemics: October–March

• most common cause of bronchiolitis.

• transmitted through direct contact with respiratory secretions and contaminated surfaces

• Contact + Droplet Precaution (mask, gown, gloves & goggles)

• Outbreaks or unusual clusters – reportable to DOH

what increases the risk of severe RSV/bronchiolitis, hospitalization, and respiratory complications

• immunosuppression,

• low birth weight,

• lung disease,

• severe neuromuscular disease

• congenital heart defects

s/s of RSV/ bronchitis mild

• rhinitis

• coughing

• low grade fever

• wheezing

• tachycardia

• vomiting & diarrhea

s/s of RSV/ bronchitis severe

• tachypnea >70 (peds)

• grunting - severe distress

• wheezing

• retractions

• cyanosis

• nasal flaring

• lethargy - poor feeding + exhaustion (late sign)

diagnostic tests of RSV/ bronchitis

• nasal/nasopharyngeal swab - confirmed with Enzyme linked immunosorbent assay (ELISA) or immunofluorescent assay (IFA)

managing RSV/ bronchitis

• 5 resp

• symptom management ?

• never use

• Oxygen – humidified with or without heat

• Nebulized saline

• May need mechanical ventilation

• Suctioning

• ABG monitoring

• Fluids, antipyretics, Rest - symptom management

• never use aspirin in children ! - reyes syndrome

RSV vaccine

• only given to

• what kind of immunity

• palivizumab –Synagis

• only given to high risk infants

• provides passive immunity

Ribavirin

• what is needed with it

• aerosolized/inhaled via nebulizer - rarely used, reserved for severe RSV

• Small-Particle Aerosol Generator (SPAG) needed if administering Ribavirin. Keeps it out of the air!

what is pneumonia

• lobar vs bronchopneumonia

• which is more common

• aspiration pneumonia

• Inflammation/infection of the lung parenchyma/alveoli caused by bacteria, viruses or fungi

• reportable to DOH

• Lobar pneumonia refers to the involvement of part or entire lobe

• Bronchopneumonia refers to spots of alveoli affected throughout the bronchial tree (more common)

• aspiration pneumonia -
  Inhalation of oropharyngeal or gastric contents into the lower airway

pathophysiology of pneumonia

• what kind of V/Q

• Pathogens infiltrate the normally sterile lower respiratory tract via inhalation, aspiration, or bloodstream

• Spreads and triggers an inflammatory response

• Alveoli fill with fluid and exudate (consolidation), impairing gas exchange

• Results in perfusion-without-adequate-ventilation problem

LOOK at Table 19-2 for risk factors and preventative measures

Community-acquired pneumonia (CAP)

• Develops outside the healthcare setting or within 48 hours of admission

Hospital-acquired pneumonia (HAP)

Develops 48+ hours after admission, in a patient not on mechanical ventilation

Ventilator-associated pneumonia (VAP)

• could be from

Develops 48+ hours after endotracheal intubation

• from lack of oral care or suctioning, not being turned and positioned frequently enough

• not in semi fowlers, could be lying flat - not promoting lung expansion

Health care–associated pneumonia (HCAP)

• Occurs in non-hospitalized patients with extensive health care contact

• LTC / nursing home pts

• Dialysis pts

• Chemo pts

• Home infusion therapy pts

• antibiotic/ wound care pts

• Hospitalization for ≥2 days in an acute care facility within 90 days of infection
  

N/C of Immunompromised pts (HIV, transplant, cancer pts) with pneumonia

• Higher risk for opportunistic infections

• May have a more severe or atypical presentation

• Requires a high index of suspicion & closer monitoring

• Early diagnosis and treatment are important
  • Treatment depends on the suspected organism and severity

common risk factors of pneumonia (look at table 19-2) SALAMI

• smoking

• advanced age + altered level of consciousness

• lung disease

• alcohol use

• malnutrition + mechanical vent

• Immunocompromised + immobility

prevention of pnuemonia

• smoking cessation,

• hand hygiene,

• early mobilization,

• aspiration precautions (1:1 supervised feeding, no fluids with food, soft foods & thickened liquid)

• oral care

who is required to take the pneumococcal vaccine

• adults 65 years of age or older

• 19 years old & older with weak immune system, smoke cigarettes or have chronic heart, lung or liver disease or alcoholism

assessment findings when pt has pneumonia

• auscultation ?

• palpation?

• percussion ?

• LOC?

• crackles or diminished/ absent lung sounds over affected area or wheezing

• Increased tactile fremitus

• Dullness to percussion

• Older adults may present with confusion/delerium/falls or functional decline instead of classic fever and cough

other s/s of pnuemonia

• varies with the type of pneumonia causal agent and presence of underlying disease, but generally:

• Cough - (dry/productive, sputum: purulent, rust colored)

• Headache, fever, chills, fatigue

• pleuritic chest pain

• tachypnea

• Use of accessory muscles,

• ↓ appetite

diagnostic tests for pneumonia

• 4 tests

• what are invasive ways can we get sputum

• who would we use bronchoscopy on

• CXR,

• blood culture

• sputum examination - (first thing in morning )
  • Invasive procedures may be used for specimen collection
  • Nasotracheal/orotracheal suctioning, fiberoptic bronchoscopy

• Bronchoscopy: for severe chronic, reoccurring infections, compromised immune systems, and mechanically ventilated patient

risk facts for pneumonia for pediatric pts (0-12)

• RSV/viruses & Strep pneumoniae (younger)

• Mycoplasma ("walking pneumonia" - child still functioning) more common school-age

• Prematurity/low birth weight,

• incomplete vaccinations

• aspiration,

• recent viral URI,

• smoke exposure,

• daycare/crowded settings,

• malnutrition

• underlying heart, lung, or immune disorders

risk facts for pneumonia for adolescent/ adult pts

• Strep pneumoniae (most common CAP)

• Mycoplasma, Chlamydophila

• Smoking, vaping

• alcohol use - suppresses immune system and interferes with gag reflex

• close-contact living

• COPD

• immunosuppression

risk facts for pneumonia for older adult pts

• Strep pneumoniae, H. influenzae, gram-negatives,

• aspiration pneumonia

• dysphagia,

• immobility,

• ↓ cough reflex,

• comorbidities,

• institutional living

how can we prevent VAP

• position

• routine ?

• based on assessment

• spontaneously ?

• monitor ?

• semi fowlers

• routine oral care with chlorhexidine at least 1x a day or whenever you see secretions

• suctioning when you assess adventitious lung sounds or see secretions

• wake your pt spontaneously daily

• spontaneous breathing trial - see if pt can breathe on their own and be extubated

• monitor cuff presssure on ETT

complications of pneumonia

• atelectasis

• plural effusion - excess fluid in plural space

• empyema - pus in plural space

• lung abcess

• sepsis

• shock

• respiratory failure

covid

• precautions?

• similar to ? unique symptoms

• tx? meds? position?

• can lead to

• airborne, droplet and contact

• similar to pneumonia with symptoms like ageusia (loss of taste) & anosmia (loss of smell)

• tx with antivirals, steroids, o2, vent, prone position

• may lead to shock and resp. failure

SARS - severe acute respiratory syndrome

• type of ?

• spread via?

• symptoms?

clinical manifestations?

• protocol ?

• type of corona virus

• spread via droplet and contact

• contagious when symptomatic

• high fever, headache , myalgia, diarrhea, cough

• progressive hypoxia → pneumonia

• same protocol as pneumonia

transmission of TB

• what PPE

• what kind of room

• if pat has to leave room

• what kind of care

• airborne and droplet

• need N95 mask

• pt needs negative pressure room with 6 air exchanges per hour

• if pt has to leave room they need surgical mask

• clustered care is important - limit exposure to the disease

risk factors of TB - TB RISK +2

• tight living quarters / institutional living (LTC, prison, psych facility)

• below or at poverty line (homeless, lack of healthcare)

• Refugee/ immigrant

• immune system suppression (HIV, transplant, cancer, corticosteroids use)

• Substance abuse (IV drug use, alcohol abuse)

• Kids under 5 - immune system under developed

• comorbidities - diabetes, chronic kidney disease, malnourishment

• health care workers

s/s pf active TB

• early vs late ?

• may have ?

• insidious - slow and subtle but deadly

• early - low grade fever, cough, night sweats, fatigue and weight loss

• may have hemoptysis - coughing up blood

• late - high fever, chest pain , diminished bronchial sounds from consolidation, crackles

Mantoux skin test

• what is it

• read after ?

• what are we looking for ?

• positive result ? for immunocompromised?

• considerations?

• 0.1 mL intradermal injection under skin

• read after 48-72 hours

• interpret induration & erythema (both are needed for a positive result)

• for immunocompromised pt - 5mm or more = positive ACTIVE TB

• 10mm or more = positive ACTIVE TB result

• BCG (Bacillus Calmette Guerin) vaccine - Will always have a positive PPD - people born in foreign countries

what other dx tests are used to determine TB infection

• Sputum analysis - first thing in morning, before brushing teeth and mouthwash or breakfast

• Chest X-Ray - will show white lung tissue if positive

• Blood test- Interferon Gamma Release Assay - QuantiFERON TB Gold & T-
  SPOT

how do we treat TB

• how long is the tx?

• meds ?

• vitamin ?

• initial vs continuation phase ?

• when is the pt non-infectious

• instruct?

• ensuring med compliance ?

• anti-TB agents for 6-12 months

• 4 or more of the following meds

• • R = Rifampin and Rifamate (rifampin & isoniazid)

  • I = Isoniazid

  • P = Pyrazinamide

  • E = Ethambutol

• vitamin B6 for neuropathy

• initial phase - 1x a day for 8 weeks

• continuation phase - lasts for 4-7 months depending on sputum tests

• non-infectous after 2-3 weeks of consistent treatment (must be complaint to meds)

• instruct pt to take meds on empty stomach

• DOT - direct observed therapy to ensure med compliance

• multidrug resistant TB

• extensive drug resistant TB

• what adds to it

• multi-resistant : resistant to at least isoniazid and rifampin

• extensive- resistant: resistant to isoniazid, rifampin, plus a fluoroquinolone and at least one injectable second-line drug

• non compliance adds to drug resistance

Lung Abcess

• what is it?

• most are ?

• what is usually the cause

• Lesion of the lung parenchyma containing pus that collapses and forms a cavity of about 2 cm.

• Most are a complication of bacterial pneumonia

• Aspiration of bacterium is usually the cause

who is at risk for lung abscess

• Immobilized patients - feed pts sitting up, to decrease r/o aspiration

• CNS disorders - ensure oral care

• Elderly - dental issues, inadequate clearing of bacteria

• Tube fed patients -

• Post-op

s/s of lung abscess

Productive cough with foul sputum

• Pleurisy with dull chest pain

Anorexia and weight loss

• Empyema

• Leukocytosis (increased WBC)/ fever/ fatigue

• Bronchopleural fistula

Lung Abscess- Diagnostics & Assessment Findings

• lung sounds ?

• what scans? what test?

• what procedure

• culture ?

• Decreased or absent breath sounds

• Pleural Friction Rub – grating sound, crackles

• Chest X-Ray shows a cavity with an air-fluid level/ ct scan

• Sputum culture identifies source

• May require bronchoscopy to dx or to treat

Management of Lung Abscess'

• positioning?

• meds

• what do we encourage

• support?

• Postural drainage and positioning – chest physiotherapy

• IV antimicrobial therapy, followed by PO

• Deep breathing and coughing exercises

• Nutritional support - weight loss common

Prevention of Lung Abscess

Turning and positioning-chest PT

• Deep breathing and coughing exercises

• Pre-dental antibiotic therapy for those with infected teeth/gums

• Appropriate antibiotic therapy for resp illnesses (based on culture)

Sarcoidosis

• Interstitial Lung disease of unknown cause

• Can involve any tissue or organ but mostly seen in the lung (pumlomary sarcoidosis) - also effects lymph nodes

pathophysiology of sarcodosis

• Hypersensitive response to bacteria, fungus, viruses or chemicals

• Hypersensitivity leads to Inflammation

• inflammation leads to granuloma (collection of macrophages) formation on the walls of alveoli

• over time leads to to fibrosis(scar tissue ), which decreases lung compliance

Granulomatous Disease

• what it it

• leads to ?

• Granulomas can appear on the walls of the alveoli or on the walls of the bronchioles

• Results in: Low lung compliance, impaired diffusion and decrease lung volume

s/s of sarcoidosis

Dyspnea, Cough, Hemoptysis, Congestion

Diagnostics - Sarcoidosis

• Chest X-Ray and CT scans show nodules in the lungs

• Transbronchial biopsy confirms diagnosis

• Pulmonary function test

• Arterial blood gases

meds for sarcoidosis

• Oral corticosteroids: tapered – can be up to 12 months

• Immune modulator: methotrexate