n325 oxygenation conditions

acute bronchitis (infectious)

• inflammation of bronchi

• most common cause: viral infection

• primarily affect bronchi, NOT alveoli

acute bronchitis manifestations

• cough

• clear sputum - can become purulent

• fever

• dyspnea

• HA & malaise

• paroxysmal (sudden violent) coughing

• hoarseness, myalgia, chest pain

acute bronchitis diagnosis

• H&P

  • crackles (mucus buildup) and wheezes on exhalation with exertion

• chest x-ray

  • to r/o pneumonia

acute bronchitis treatment goals

• symptoms relief

  • tea, honey, cough drops, menthol

• prevent pneumonia

acute bronchitis interventions

• droplet precautions

• vital signs

• TCDB Q2H (turn, cough, deep breathe)

• PO fluids (loosen secretions)

• prevent spread

  • wash hands

  • avoid sharing articles

  • cover mouth when sneezing or coughing

  • discard soiled tissues in a plastic bag

• if secondary bacterial infection occurs:

  • persistent cough & thick purulent sputum

  • obtain a sputum culture followed by antibiotic therapy

• see HCP: fever, dyspnea, or duration greater than 4 weeks

• antitussives:

  • dextromethophran (OTC)

  • benzonatate (Rx)

  • codeine (Rx)

• expectorants:

  • guaifenesin (OTC)

• bronchodilators:

  • albuterol (Rx)

  • levalbuterol (Rx)

  • adrenergic agonists - dilate the bronchioles - cause SE of tachycardia, anxiety, incr HR/RR

pneumonia

• infection spread from bronchioles to alveoli → more dangerous

• bacterial infection → more serious/painful and needs to treat w antibiotics

• organisms reach lung by:

  • aspiration: impaired swallowing go into the lungs, food/liquid in lungs cause bacterial growth

  • inhalation

  • hematogenous spread

• community acquired

  • 6th leading cause of death for > 65 yrs old

• nosocomial

  • hospital-associated

  • ventilator-associated

  • healthcare-associated

• opportunistic and d/t aspiration

pneumonia risk factors

• smoking

• age (v young and v old)

• ETOH

• chronic disease

• immunosuppression

• recent respiratory infection

• recent hospitalization

• difficulty swallowing

• bed rest

• prolonged immobility

pneumonia pathophysiology

• infection and fluids in lung tissue

• infection → inflammatory process (swelling) in alveoli

• consolidation of debris, fibrin, fluids in affected area of lung = impaired gas exchange

pneumonia assessment

• subjective

  • fever

  • chills

  • cough

  • productive sputum

  • chest pain

• objective

  • crackles

  • rhonchi → very hoarse lung sounds → caused by thick mucus

  • decreased SaO2

• elderly considerations

  • dehydration

  • change in LOC

• diagnostics

  • CXR

  • C&S

  • CBC

  • pulse ox

  • blood cultures if increased fever

pneumonia interventions

• pulmonary toilet (TCDB, IS)

• O2 to treat hypoxemia

• hydration

• I&O

• administer medications as Rx’d

  • analgesics for pain

  • antipyretics for fever

  • antibiotics for infection

  • comfort: cough suppressants, mucolytics, bronchodilators, corticosteroids

pertussis (infectious) - AKA whooping cough

• highly contagious bacterial disease with uncontrolled, violent cough

• gram-negative bacteria attach to cilia, release toxins results in inflammation

• inspiratory gasp after cough → “whooping” sound

pertussis symptoms

• initial: similar to acute bronchitis

• severe coughing, worse at night

• vomiting may occur with coughing

• runny nose

• fever (102 F or lower)

pertussis clinical manifestations

• stage 1: 1-2 weeks

  • low-grade fever, runny nose, watery eyes, general malaise, and mild nonproductive cough

• stage 2: 2-10 weeks

  • paroxysms of cough

• stage 3: 2-3 weeks

  • less severe cough, weak

pertussis diagnosis

• initially based on symptoms

• sputum culture

• CBC

pertussis Rx’s

• airborne precautions

• antibiotics

  • macrolides (erythromycin, zithromax)

• fluids

• expectorants & suppressants are NOT helpful and are not recommended

pertussis prevention

• DPT vaccination for children; but all adults > 18 should have TDAP

• children under 2 months cannot be vaccinated

tuberculosis

• caused by Mycobacterium tuberculosis

• lungs are most commonly infected

• ¼ of world’s population has TB

• US prevalence is decreased

TB risk factors

• international travel

• live in group settings

• work in hospitals, jails, shelters, etc

tuberculosis classifications

• exposure to TB

  • inhalation of bacteria

  • inflammation

  • usually contained by immune response

• active TB

  • if initial immune response fails, bacteria replicate and disease emerges within 2 years

• latent TB infection (LTBI)

  • positive skin test but asymptomatic and non-transmissible

  • 5-10% risk of developing active TB

  • tx of LTBI is as critical as managing active TB

tuberculosis manifestations

• LTBI

  • no S/S

  • does not feel sick

  • + skin/blood test

  • normal CXR

  • (-) sputum smear

• active TB

  • cough > 3 weeks

  • chest pain

  • hemoptysis

  • weakness/fatigue

  • weight loss/anorexia

  • chills

  • fever

  • night sweats

• feels sick

• + skin/blood test

• + sputum smear

• abnormal CXR

tuberculosis diagnostics

• H&P examination

• tuberculin skin test (TST, aka mantoux test)

• quantiFERON-TB gold test

• CXR

• bacteriologic studies

• sputum smear for acid-fast bacilli (AFB)

• sputum culture

TB interventions

• active TB

  • most patients treated as outpatients

  • infectious for first 2 weeks after starting treatment if sputum (+) → airborne precautions

  • restrict visitors and limit public exposure

  • hand hygiene and oral hygiene

  • aggressive antibiotic therapy (4-9 months) → monitor adherence

    • directly observed therapy preferred, but it is controversial

• latent TB

  • antibiotic therapy (4-9 months)

atelectasis

• restrictive

• alveolar collapse

• caused by shallow breathing, sedation, decreased mobility, post-op

• easier to anticipate than to treat

• lungs don’t fully expand and secretions occlude alveoli → decreased surfactant and alveolar collapse

atelectasis assessment

• physical

  • RR and rhythm

  • SOB

  • dyspnea

  • cough

  • breath sounds decreased or absent

• diagnostic tests

  • O2 sat

  • CXR

  • ABGs

• interventions

  • re-expand alveoli

    • cough

    • suctioning

    • CPT

  • monitor for complications

ARDS (acute respiratory distress syndrome)

• restrictive

• caused by: pneumonia, sepsis, trauma, inhalation injury

• risk factors: smoking, alcohol abuse, recent high-risk surgeries

• process:

  • damage to alveoli and pulmonary capillaries

  • increased permeability of alveolar blood vessels

  • fluid accumulates in alveolar spaces

  • alveoli become airless, decreased surfactant, decreased lung compliance, decreased ventilation, hypoxia occurs

  • respiratory failure

ARDS assessment

• early:

  • may be subtle

  • increased RR, dyspnea, restlessness, cough

  • progresses quickly

• later:

  • diaphoresis

  • increased SOB

  • cyanosis

ARDS diagnostics

• imaging (CXR, CT)

• ABGs

• SaO2

ARDS interventions

• mechanical ventilation (PEEP)

• positioning → flip around, mobilize lung fields and move where fluid is settling

• pursed lip breathing

• strict I&Os

• keep patient euvolemic

• serial ABG monitoring

pulmonary fibrosis

• lung condition characterized by progressive scarring or thickening of the lung tissue surrounding the alveoli

• no good expansion of lungs or alveoli

pulmonary fibrosis causes

• environmental → long exposure to certain toxins/pollutants

• medical treatments → radiation for thoracic CA, some chemo

• chronic inflammatory processes → RA or sarcoidosis

• genetic factors → familial pulmonary fibrosis

• unknown cause: idiopathic pulmonary fibrosis

pulmonary fibrosis assessment

• SOB

• DOE (dyspnea on exertion)

• dry cough that doesn’t go away

• fatigue

• weakness

• chest discomfort

• clubbing in fingers/toes

  • caused by chronic hypoxia to tissues

pulmonary fibrosis diagnostics

• imaging

• pulmonary function tests (PFTs) → measure lung volume and capacity

• biopsy

pulmonary fibrosis interventions

• monitoring respiratory status

• administering meds

• educating abt energy conservation

• promote adequate nutrition

• assisting with breathing exercises

• encouraging smoking cessation

• facilitating emotional support

chronic obstructive pulmonary disease

• a group of pulmonary disorders with S/S of chronic cough and expectoration, dyspnea, and impaired expiratory airflow

• combo of 3 diff diseases: chronic airflow limitation that isn’t fully reversible

  • emphysema

  • chronic bronchitis

  • asthma

COPD defining features

• irreversible airflow limitations during forced exhalation due to loss of elastic recoil

• airflow obstruction r/t

  • mucous hypersecretion (bronchitis)

  • mucosal edema (emphysema)

  • bronchospasm (asthma)

• air goes in easily but remains in the lungs

• bronchioles tend to collapse

• can cause barrel-chest look

COPD initiation

• inhalation of noxious particles

• mediators released cause damage to lung tissue

• airways inflamed

• parenchyma destroyed

COPD risk factors

• cigarette smoking

• environmental exposures

• hx of respiratory infections

• hereditary/genetics

• age

• occupational hazards

• socioeconomic status

• asthma

COPD complications

• oxygenation: hypoxemia, hypoxia, hypercapnia, respiratory acidosis

  • inflammation of airways → destruction of alveoli → restricted flow of O2 → hypercapnia → respiratory acidosis

  • hypercapnia looks like lethargy/decreased LOC

  • use BiPAP → help push air in/out of lungs

• respiratory tract infections

  • more likely to catch colds, pneumonia, or the flu

  • infection increases the damage to the lung tissue

• cardiac dysrhythmias

  • r/t respiratory and heart failure, HTN, coronary disease

• pulmonary hypertension: cor pulmonale, cardiac failure

  • constriction of pulmonary blood vessels d/t alveolar hypoxia, increased erythropoiesis → polycythemia → increased blood viscosity

  • air trapping, airway collapse, inelastic alveolar walls

  • decreased SA for capillaries to exchange gas → increased pressure in pulmonary arteries → RV has to work harder to push blood in to get oxygenated → overtime, RV begins to fail

  • hypoxia and increased CO2 → pulmonary HTN

  • cor pulmonale → RV hypertrophy → RV begins to enlarge

  • R-sided cardiac failure

    • chest discomfort, dependent edema (feet/ankles), distended neck veins (JVD)

COPD recap

• chronic inflammation (chronic bronchitis)

• limited exhalation with force (asthma)

• air trapping (emphysema)

• dyspnea

• mucus

• fatigue, weight loss, anorexia → body doesn’t have enough O2 to have appetite

• pulmonary HTN

• right-sided heart failure (cor pulmonale)

• respiratory acidosis → resp failure

• exacerbations with bacterial infections

emphysema

• chronic disease

• abnormal distention of the alveoli

  • alveoli lose elasticity, trapping air that should be expired/exhaled

• walls of alveoli break down & form one large sac

emphysema causes

• smoking/2nd hand smoke

• pollution

• chronic infection

• allergens

emphysema assessment

• dyspnea with activity

• breathlessness at rest

• barrel chest → lungs don’t fully deflate → chronic change

• chronic productive cough

• inspiration is difficult d/t barrel chest

• use accessory muscles to breathe

• difficult prolonged expiration (I:E > 1:3)

• wheezing

• rhonchi → thick mucus in bronchioles → coarse sounding

  • vs crackles in thin fluid in alveoli

• “pink puffers”

advanced emphysema

• appears drawn, anxious, pale

• speaks in short jerky sentences

• leans forward and dyspneic

• neck veins distend during inspiration

• pursed lip breathing

  • improves O2 flow by slowing rate of exhalation

emphysema interventions

• if CO2 is chronically high → resp center insensitive to CO2

• O2 needs to be kept slightly lower than “normal” to maintain drive to breathe → or else body thinks don’t need O2 and don’t need to breathe

• KEEP SAO2 BETWEEN 88-92%

• if color improves but LOC decreases, stop O2

• teach diaphragmatic/abdominal and pursed-lip breathing

• bronchodilators to open airways (SABA), corticosteroids to reduce inflammation (budesonide)

• pulmonary rehab to improve activity tolerance

• meet nutritional needs

• monitor & manage exacerbations and complications

• barrel chest and tripod position → ribs flare and inhalation/exhalation is difficult

chronic bronchitis

• chronic cough

• increased mucus for over 3 months/year for 2+ years

• bronchial glands hyper-secrete mucus → plugs form in small bronchi → necrosis and fibrosis → trapped air

chronic bronchitis early symptoms

• productive cough of thick white mucus esp in morning and evening

• bronchospasms during severe coughing

chronic bronchitis late symptoms

• as condition worsens, sputum → yellow, purulent, copious and after coughing, blood streaked

chronic bronchitis assessment

• cyanosis

• dyspnea upon exertion - dyspnea at rest

• “blue bloater”

• dusky and cyanotic d/t

  • hypoxemia → cyanosis

  • hypercapnia → too much CO2

• respiratory acidosis

chronic bronchitis interventions

• monitor respiratory status

• manage risks for infection → flu, pneumonia, RSV, immunizations

• O2 therapy (keep O2 above 90%)

• bronchodilators to open airways

• steroids to reduce inflammation

• antibiotics if infection present

• balanced diet/increased fluid intake

• postural drainage

• patient education → avoid environmental irritants, stop smoking, avoid wind/cold, avoi others with resp. infections, breathing exercises (pursed-lip, diaphragmatic)

asthma

• exposure to allergens or irritants → inflammation

• mast cells release inflammatory mediators (leukotrienes, histamine, cytokines, prostaglandins, nitric oxide)

• eosinophils, neutrophils, lymphocytes

• result: persistent airway inflammation

• limited airflow → bronchoconstriction, hyper-reactive airway, airway edema

asthma triggers

• allergens → IgE response

• irritants

• respiratory infections

• exercise-induced asthma

• environmental temp (too cold/warm)

• drugs and food additives

  • ASA, NSAIDs, salicylates, beta blockers

• emotional stress can worsen symptoms

asthma classifications

• mild intermittent

  • 1-2 mild/week, no limitation of activity

• mild persistent

  • 2 times/week, activity is affected during episodes

• moderate persistent

  • some sx on most days, mild to moderate reduction in physical activity

• severe persistent

  • can cause rib fractures, pneumothorax, atelectasis, and pneumonia

asthma assessment

• RESPIRATORY DISTRESS

• anxiety, increased pulse and RR, diaphoresis

• hypoxemia

• WHEEZING/cough/dyspnea

• chest tightness esp night/early AM

• every breath is effort

• thick, tenacious sputum

• exhalation may be prolonged

• classic position: body leans forward, arms to at shoulder height

• decreased breath sounds with increased RR is ominous findings

• may lead to status asthmaticus

status asthmaticus

• severe, life-threatening complication of asthma

• causes:

  • abrupt discontinuation of meds

  • abuse of aerosol meds

  • hx of poorly controlled asthma over days/weeks

• S&S:

  • more severe and prolonged asthma symptoms

  • airway obstruction intensifies

  • hypotention, bradycardia, resp/cardiac arrest

  • does not respond to common therapy

  • can cause cor pulmonale, pneumothorax, death

• Rx:

  • IV fluids, bronchodilators, steroids, IV, O2, intubation w/mechanical ventilation

asthma diagnostics

• pulmonary function tests

• measure lung volumes/airflow

• uses spirometer, computer, peak flow meter

• interventions:

  • do not eat a heavy meal prior to the test

  • no smoking 4-6 hours prior

  • hold bronchodilators 4-6 hours prior

  • remind patients these are low-risk, non-invasive, painless tests

asthma medication

• goal: treatment of acute exacerbations and control chronic symptoms

• control agents:

  • inhaled corticosteroids → BLACK BOX WARNING → shouldn’t be used as a relief bed.. SABAs first

  • long-acting bronchodilators (beta-agonists and anticholinergics)

  • leukotriene modifiers

  • monoclonal antibiotics for eosinophilic asthma (benralizumab)

  • anti-IgE therapy (omalizumab)

• relief agents:

  • short-acting bronchodilators (albuterol)

  • systemic corticosteroids (prednisone)

  • ipratropium (anticholinergic, reduced mucus production)