lower respiratory problems

Overview of Lower Respiratory Problems

Lower respiratory disorders affect oxygenation, ventilation, and gas exchange.

The nurse's responsibility is to assess respiratory function, recognize complications early, and implement interventions that improve oxygenation and ventilation.

Major Categories

1. Infectious disorders

2. Restrictive respiratory disorders

3. Traumatic chest injuries

4. Vascular lung disorders

5. Environmental lung diseases

6. Lung transplantation

7. Lung cancer

Important distinction:

• Oxygenation = getting oxygen into the bloodstream.

• Ventilation = moving air in and out of the lungs.

• Gas exchange = oxygen and carbon dioxide moving between the alveoli and pulmonary capillaries.

Lower Respiratory Tract Infections

Common lower respiratory infections include:

• Acute bronchitis

• Pertussis

• Pneumonia

• Tuberculosis (TB)

These infections can impair gas exchange and lead to respiratory failure, especially in older adults and patients with chronic conditions.

Acute Bronchitis

Definition: Self-limiting inflammation of the bronchi.

Most common cause: Viral infection.

Other triggers:

• Air pollution

• Dust

• Chemical inhalation

• Smoking

• Chronic sinusitis

• Asthma

Clinical manifestations:

• Persistent cough (MOST common symptom).

• Cough often worse at night.

• Usually normal chest X-ray.

Treatment:

• Supportive care.

• Symptom relief.

• Prevent complications such as pneumonia.

• Antibiotics are generally NOT indicated because most cases are viral.

NCLEX PEARL: A patient with acute bronchitis usually needs supportive care, not antibiotics.

Pertussis (Whooping Cough)

Definition: Highly contagious bacterial respiratory infection caused by Bordetella pertussis.

Key characteristics:

• Severe, prolonged coughing episodes.

• Characteristic "whooping" sound may occur.

• Symptoms progress over time.

• Vaccination with Tdap provides protection, but immunity can decrease.

Treatment:

• Macrolide antibiotics.

• Consider prophylactic antibiotics for close contacts.

• Infectious until five days after starting appropriate antibiotic therapy, according to the lecture.

Nursing considerations:

• Droplet precautions.

• Monitor respiratory status.

• Provide supportive care.

Important: Cough suppressants, bronchodilators, and antihistamines are generally ineffective and may worsen coughing.

Memory trick: Pertussis = prolonged, progressive, paroxysmal coughing.

Acute Bronchitis vs. Pertussis

Acute Bronchitis	Pertussis
Usually viral	Bacterial
Self-limiting	Prolonged illness
Cough is common	Severe coughing episodes
Supportive treatment	Macrolide antibiotics
Normal CXR typically	Characteristic whooping cough

Pneumonia

Definition: Acute infection of the lung parenchyma, the tissue involved in gas exchange.

Pathogens reach the lungs through:

• Aspiration.

• Inhalation.

• Hematogenous spread (through the bloodstream).

Risk Factors

• Weak cough reflex.

• Older age.

• Smoking.

• Chronic diseases.

• Immobility.

• Immunosuppression.

• Aspiration risk.

Classification of Pneumonia

Type	Definition
Community-acquired (CAP)	Develops outside the hospital or in a patient without recent qualifying healthcare exposure
Hospital-acquired (HAP)	Develops 48 hours or more after hospital admission and was not present on admission
Ventilator-associated (VAP)	Develops in a patient receiving mechanical ventilation

Remember:

• CAP = community.

• HAP = hospital.

• VAP = ventilator.

Types of Pneumonia

Viral Pneumonia

• Most common type according to the lecture.

• Can range from mild to life-threatening.

Bacterial Pneumonia

• Can cause severe illness.

• May require hospitalization and antibiotic therapy.

Mycoplasma Pneumonia

• Also called atypical pneumonia.

• Has characteristics of both viral and bacterial infections.

Aspiration Pneumonia

• Caused by abnormal entry of material from the mouth or stomach into the lungs.

• Risk increases with impaired swallowing, decreased LOC, and aspiration risk.

Necrotizing Pneumonia

• Complication of bacterial pneumonia.

• Causes destruction of lung tissue.

• Tissue becomes a thick, liquid mass.

Opportunistic Pneumonia

• Occurs in immunocompromised patients.

• Examples include patients with malnutrition or immunodeficiencies.

patho and clinical manifestations

Pathophysiology of Pneumonia

Understand this sequence:

1. A pathogen enters the lungs.

2. The immune system triggers an inflammatory response.

3. Alveoli fill with fluid and debris (consolidation).

4. Some alveoli may become airless (atelectasis).

5. Mucus production may increase and obstruct airways.

6. Gas exchange decreases.

7. Hypoxemia may develop.

The BIG problem: The alveoli cannot exchange oxygen and carbon dioxide effectively when they are filled with fluid or debris.

Clinical Manifestations

• Cough (productive or nonproductive).

• Fever.

• Chills.

• Dyspnea.

• Tachypnea.

• Pleuritic chest pain.

• Abnormal lung sounds.

• Possible hypoxemia.

Pneumonia older adult considerations, complications

Older adult consideration:

Older adults may present with:

• Confusion.

• Stupor.

• Altered mental status.

They may not have the classic fever and cough presentation.

NCLEX PEARL: New confusion in an older adult can be an early sign of infection or hypoxemia.

Complications of Pneumonia

• Drug resistance.

• Pleurisy.

• Pleural effusion.

• Bacteremia.

• Pneumothorax.

• Respiratory failure.

• Sepsis.

• Lung abscess.

• Empyema.

Diagnostic Studies Pneumonia

Test	Purpose
Chest X-ray	Identifies infiltrates or consolidation
Sputum Gram stain	Identifies possible organisms
Sputum culture and sensitivity	Identifies organism and effective antibiotics
Pulse oximetry	Evaluates oxygen saturation
ABGs	Evaluates oxygenation and ventilation
CBC	Evaluates WBC count and infection response
Blood cultures	Identifies bloodstream infection when indicated

management of pneumonia

Interprofessional Management

Respiratory support:

• Oxygen therapy.

• Mechanical ventilation if necessary.

Hydration:

• IV fluids or increased oral fluids as appropriate.

• Helps maintain hydration and mobilize secretions.

Prevent complications:

• VTE prophylaxis.

• Early mobility.

• Respiratory physiotherapy.

• Balance activity with rest.

Medications:

• Antibiotics when bacterial infection is suspected or confirmed.

• Antipyretics for fever.

• Analgesics for pain.

• Pneumococcal vaccination when indicated.

Important antibiotic information:

For CAP, the lecture notes a minimum antibiotic course of five days, with discontinuation based on clinical stability and being afebrile for 48–72 hours. Actual duration depends on the organism, severity, and current guidelines.

Nursing Management of Pneumonia

1. Monitor respiratory rate, effort, and lung sounds.

2. Assess for hypoxemia.

3. Administer prescribed antibiotics and other medications.

4. Administer oxygen as prescribed.

5. Elevate HOB approximately 30° or higher as tolerated.

6. Reposition frequently.

7. Encourage coughing and deep breathing.

8. Monitor intake and output.

9. Encourage mobility as tolerated.

10. Collaborate with respiratory therapy, dietitians, and PT/OT.

Memory trick: Pneumonia = infected, inflamed, fluid-filled alveoli → impaired gas exchange.

Tuberculosis (TB)

Definition: Infectious disease caused by Mycobacterium tuberculosis.

TB primarily affects the lungs but can spread to other body systems.

Transmission

• Spread through airborne particles.

• Requires exposure to infected airborne particles.

• Risk depends on the number of droplets, concentration, length of exposure, and immune status of the exposed person.

• Can spread through the lymphatic system to other organs.

• Drug-resistant TB is possible.

Classification of TB

Type	Description	Contagious?
Primary	Initial inhalation of bacteria; immune system may contain infection	Not necessarily
Active	Bacteria replicate and cause active disease	YES
Reactivation	Previously contained TB becomes active again	YES
Latent	Bacteria are present, but patient has no active symptoms	NO

Important distinction:

Latent TB:

• Positive TB screening test.

• No active symptoms.

• Cannot spread TB to others.

• Can develop active TB later.

• Requires evaluation and treatment.

Active TB:

• Symptoms are present.

• Can spread infection.

• Requires airborne isolation and multidrug therapy.

manifestations and diagnostics TB

Clinical Manifestations

Symptoms may take 2–3 weeks to develop after infection or reactivation, according to the lecture.

Common findings:

• Persistent cough (initially dry, then productive).

• Fatigue.

• Malaise.

• Unexplained weight loss.

• Night sweats.

Late findings:

• Dyspnea.

• Hemoptysis (coughing up blood).

Memory trick: TB = Tired, Body weight loss, Blood in sputum, night sweats.

Diagnostics

Test	Purpose
Tuberculin skin test (TST)	Screens for TB exposure
QuantiFERON	Blood screening test for TB infection
Chest X-ray	Evaluates for lung involvement
Sputum smear	Looks for acid-fast bacilli
Sputum culture	Confirms organism; culture is the gold standard

treatment TB

Drug Therapy

TB requires long-term multidrug antibiotic treatment.

Traditional six- to nine-month treatment option:

Intensive phase:

• Ethambutol.

• Isoniazid (INH).

• Pyrazinamide.

• Rifampin.

Continuation phase:

• Isoniazid.

• Rifampin.

Four-month treatment option for eligible patients, as listed in the lecture:

Intensive phase (8 weeks):

• Isoniazid.

• Moxifloxacin.

• Pyrazinamide.

• Rifapentine.

Continuation phase (9 weeks):

• Isoniazid.

• Moxifloxacin.

• Rifapentine.

Important medication teaching:

• Monitor liver function.

• Avoid alcohol.

• Report symptoms of liver toxicity.

• Complete the entire prescribed treatment.

• Attend follow-up appointments and sputum testing.

Signs of possible liver toxicity:

• Yellow skin or eyes.

• Dark urine.

• Abdominal pain.

• Nausea or vomiting.

• Unusual fatigue.

management of TB

Nursing Management of TB

⭐️ AIRBORNE ISOLATION ⭐️

• Place patient in a private negative-pressure room.

• Healthcare workers wear a fit-tested N95 or higher-level respirator.

• Patient wears a surgical mask when leaving the room.

• Limit time outside the room.

• The lecture specifies 6–12 air exchanges per hour.

• Report diagnosis to public health authorities.

• Teach ways to prevent transmission at home.

Directly Observed Therapy (DOT):

A healthcare worker observes the patient taking each medication dose.

Video Directly Observed Therapy (VDOT):

Digital technology is used to observe medication adherence remotely.

Why is DOT important?

TB requires multiple medications over an extended period. Incomplete treatment increases the risk of treatment failure and drug resistance.

Pulmonary Fungal Infections

Key characteristics:

• Acquired by inhaling fungal spores.

• Can be life-threatening.

• Not transmitted person-to-person.

• Treated with antifungal medications.

Nursing considerations:

• Assess respiratory status.

• Monitor oxygenation.

• Administer prescribed antifungals.

• Monitor for treatment complications.

Lung Abscess

Definition: Necrosis and destruction of lung tissue, usually caused by aspirated bacteria.

Pathophysiology

1. Bacteria enter the lungs, often through aspiration.

2. Infection develops.

3. Lung tissue becomes necrotic.

4. A cavity forms and fills with purulent fluid.

Clinical Manifestations

• Foul-smelling sputum.

• Dark brown sputum.

• Foul taste.

• Persistent respiratory symptoms.

Diagnosis and Treatment

• Imaging.

• Antibiotic therapy.

• Promote coughing and deep breathing.

• Bronchoscopy may be used for further assessment.

Memory trick: Lung abscess = pocket of pus in the lung.

Restrictive Respiratory Disorders

Definition: Conditions that impair the ability of the lungs, chest wall, or diaphragm to expand during respiration.

This limits lung expansion and can reduce ventilation.

Two Classifications

Intrapulmonary Restrictive Disorders

The lung tissue itself is affected.

Examples:

• ARDS.

• Atelectasis.

• Chronic empyema.

• Interstitial lung disease.

• Pneumonia.

• Pleural effusion.

• Pleurisy.

• Pneumothorax.

Extrapulmonary Restrictive Disorders

The lung tissue may be normal, but something outside the lungs interferes with breathing.

Examples:

• Head injury.

• CNS lesions.

• Drug overdose.

• Kyphoscoliosis.

• Obesity.

• ALS.

• Guillain-Barré syndrome.

• Muscular dystrophy.

• Myasthenia gravis.

Memory trick:

• Intrapulmonary = inside the lungs.

• Extrapulmonary = outside the lungs.

Atelectasis

Definition: Collapse of alveoli, resulting in airless areas of the lung.

What happens?

Collapsed alveoli cannot participate effectively in gas exchange.

Risk Factors

• Postoperative patients.

• Prolonged bed rest.

• Shallow breathing.

• Poor coughing effort.

• Retained secretions.

Prevention and Nursing Management

• Encourage deep breathing.

• Encourage coughing.

• Use incentive spirometry.

• Promote early mobility.

• Reposition frequently.

• Manage pain so the patient can breathe deeply.

NCLEX PEARL: A postoperative patient who is taking shallow breaths and refusing to cough is at risk for atelectasis.

Memory trick: Atelectasis = alveoli collapse.

Pleurisy (Pleuritis)

Definition: Inflammation of the pleura, the membrane surrounding the lungs.

Causes

• Infection.

• Cancer.

• Autoimmune disorders.

• Trauma.

• Gastrointestinal disease.

• Certain medications.

Clinical Manifestations

• Sharp, abrupt chest pain.

• Pain worsens with inspiration.

• Possible pleural friction rub.

Why does it hurt?

Inflamed pleural surfaces rub against each other during breathing.

Treatment and Nursing Management

• Treat the underlying cause.

• Provide pain relief.

• Teach the patient to splint the rib cage when coughing.

• Intercostal nerve blocks may be considered for severe, uncontrolled pain.

Memory trick: Pleurisy = pleuritic pain that worsens when breathing in

Pleural Effusion

Definition: Abnormal accumulation of fluid in the pleural space.

IMPORTANT

Pleural effusion is a sign of another underlying condition, not necessarily a disease by itself.

Types of Pleural Effusion

Type	Fluid Characteristics	Common Causes
Transudative	Protein-poor, cell-poor fluid	Heart failure, liver disease, renal disease
Exudative	Protein-rich fluid from inflammation	Infection, cancer
Empyema	Purulent (pus-filled) fluid	Pneumonia, TB, lung abscess, infected surgical wound

Memory trick:

• Transudate = pressure/fluid imbalance.

• Exudate = inflammation.

• Empyema = pus.

Nursing Considerations

• Assess respiratory effort.

• Monitor oxygenation.

• Assess lung sounds.

• Monitor for worsening dyspnea.

• Prepare for diagnostic or therapeutic procedures as prescribed.

Interstitial Lung Diseases (ILD)

Definition: Disorders that cause inflammation or fibrosis (scarring) of the interstitium, the tissue between the air sacs of the lungs.

Causes

Many cases have an unknown cause, but possible causes include:

• Toxins.

• Medications.

• Radiation.

• Connective tissue disorders.

• Infection.

• Cancer.

Two examples:

1. Idiopathic pulmonary fibrosis.

2. Sarcoidosis.

Idiopathic Pulmonary Fibrosis (IPF)

ILD

Definition: Progressive disease characterized by chronic inflammation and scar tissue formation in the lung connective tissue.

Risk factors:

• Smoking.

• Exposure to wood dust.

• Exposure to metal dust.

• More common in males.

• Often develops between ages 50 and 70.

What happens?

Fibrosis causes the lungs to become stiff and less compliant, making it harder to expand and exchange oxygen.

Diagnostics

• Pulmonary function testing shows restrictive abnormalities.

• Impaired gas exchange.

• VATS open-lung biopsy may help confirm diagnosis.

Treatment

There is no known cure, and prognosis is poor.

Treatment may include:

• Antifibrotic medications: nintedanib and pirfenidone.

• Corticosteroids or other immunosuppressants in selected patients.

• Oxygen therapy.

• Pulmonary rehabilitation.

• Lung transplantation for eligible patients.

Memory trick: Pulmonary fibrosis = scarred, stiff lungs.

Sarcoidosis

definition: Chronic multisystem granulomatous disease that primarily affects the lungs.

Can also affect:

• Skin.

• Eyes.

• Liver.

• Kidneys.

• Heart.

• Lymph nodes.

Clinical manifestations: Vary depending on which organs are affected.

Treatment: Aims to suppress the inflammatory response.

Memory trick: Sarcoidosis = granulomas that can affect multiple organs.

Chest Trauma

Chest trauma can range from simple rib fractures to life-threatening cardiopulmonary arrest.

Two Mechanisms of Injury

Blunt Trauma

• Chest is struck by an object or strikes an object.

• Causes compression and shearing forces.

• Example: motor vehicle collision.

Penetrating Trauma

• Foreign object enters or passes through body tissues.

• Creates an open wound.

• Example: stab wound or gunshot wound.

Fractured Ribs

Definition: Fracture of one or more ribs.

• Most common type of blunt chest injury.

• Ribs 5–9 are most frequently fractured, according to the lecture.

• Can damage the pleura, lungs, heart, or other internal organs.

Nursing Priority

Control pain so the patient can breathe adequately.

Why?

Pain causes shallow breathing, which increases the risk of:

• Atelectasis.

• Retained secretions.

• Pneumonia.

• Hypoxemia.

Nursing Management

• Assess respiratory status.

• Provide prescribed analgesics.

• Encourage coughing and deep breathing.

• Teach splinting.

• Monitor for respiratory complications.

NCLEX PEARL: Do not allow pain management to be overlooked. A patient who cannot breathe deeply because of rib pain is at risk for pulmonary complications.

flail chest

LIFE-THREATENING CHEST INJURY

Definition: Fracture of three or more consecutive ribs in two or more places.

This creates a free-floating segment of the chest wall.

⭐️Hallmark Finding: Paradoxical Chest Movement

• During inspiration, the unstable chest segment moves INWARD.

• During expiration, the unstable segment moves OUTWARD.

This is opposite of normal chest movement.

Why Is It Dangerous?

The unstable chest wall interferes with ventilation and can lead to respiratory distress and impaired oxygenation.

Treatment:

• Oxygen and respiratory support.

• Pain management.

• Mechanical ventilation when necessary.

• Surgical fixation may be required.

Important: Flail chest may not be immediately obvious after injury.

Memory trick: Flail chest = chest moves the WRONG way.

Pneumothorax

Definition: Air enters the pleural cavity, disrupting the normal negative-pressure environment and causing partial or complete lung collapse.

Types of Pneumothorax

Spontaneous Pneumothorax

• Occurs without an obvious traumatic injury.

• Often caused by rupture of small blebs on the lung surface.

• More common in tall, thin males.

Iatrogenic Pneumothorax

• Caused by a medical procedure or intervention.

• Examples: central line insertion or excessive ventilation.

Open Pneumothorax

- Air enters the pleural cavity through an open chest wound.

Closed Pneumothorax

- Air enters the pleural space without an open chest wall wound.

Tension Pneumothorax

⭐ ️MEDICAL EMERGENCY

• Air enters the pleural space and becomes trapped.

• Pressure increases with each breath.

• The affected lung collapses.

• The mediastinum may shift.

• Pressure on major vessels decreases venous return.

• Cardiac output can decrease, leading to obstructive shock.

Signs and Symptoms

• Sudden dyspnea.

• Chest pain.

• Decreased or absent breath sounds on the affected side.

• Tachycardia.

• Hypotension.

• Respiratory distress.

• Possible tracheal deviation in tension pneumothorax (a late finding).

Treatment

• Oxygen.

• Chest tube insertion when indicated.

• Emergency needle decompression for tension pneumothorax, followed by chest tube placement.

NCLEX PRIORITY: Sudden respiratory distress, hypotension, and absent breath sounds on one side after chest trauma should make you suspect tension pneumothorax.

Memory trick: Pneumothorax = AIR in the pleural space.

Hemothorax

Definition: Accumulation of blood in the pleural space.

Causes

• Chest wall injury.

• Diaphragm injury.

• Lung injury.

• Blood vessel injury.

• Mediastinal injury.

Treatment

• Chest tube insertion.

• Possible autotransfusion (reinfusion of the patient's own blood when appropriate).

Possible complication: Hemopneumothorax, which means BOTH air and blood are present in the pleural space.

Memory trick:

• Pneumothorax = air.

• Hemothorax = blood.

• Hemopneumothorax = air + blood.

Chylothorax

Definition: Accumulation of lymphatic fluid in the pleural space.

Cause:

• Disruption of the thoracic duct.

• May occur due to trauma or cancer.

Memory trick: Chylothorax = lymphatic fluid in the chest.

Chest Injury Comparison

Disorder	What Enters the Pleural Space?	Key Finding
Pneumothorax	Air	Lung collapse
Hemothorax	Blood	Blood accumulation
Hemopneumothorax	Air + blood	Both present
Chylothorax	Lymphatic fluid	Thoracic duct disruption
Pleural effusion	Fluid	Abnormal fluid accumulation

Pulmonary Edema

POTENTIAL EMERGENCY

Definition: Accumulation of fluid in the alveoli and interstitial spaces of the lungs.

Most common cause from the lecture: Left-sided heart failure.

Pathophysiology

1. Left ventricle cannot pump effectively.

2. Blood backs up into the pulmonary circulation.

3. Pulmonary pressure increases.

4. Fluid moves into the interstitial spaces and alveoli.

5. Gas exchange becomes impaired.

6. Hypoxemia and respiratory distress develop.

Clinical Manifestations

• Dyspnea.

• Crackles.

• Tachypnea.

• Hypoxemia.

• Anxiety and restlessness.

• Possible pink, frothy, blood-tinged sputum.

Flash pulmonary edema is a sudden, severe onset of pulmonary edema and is a medical emergency.

Pulmonary Edema management

Treatment Priorities

1. Identify and treat the underlying cause.

2. Place patient in semi-Fowler's or high-Fowler's position.

3. Administer oxygen to maintain prescribed oxygenation goals.

4. Use CPAP/BiPAP or mechanical ventilation as needed.

5. Administer IV diuretics as prescribed.

6. Administer nitroglycerin when indicated to reduce preload.

7. Administer IV dobutamine if cardiac output support is required.

8. Monitor respiratory status, urine output, electrolytes, and treatment response.

Medication connections:

• Furosemide (Lasix) = diuretic; removes excess fluid.

• Nitroglycerin = venodilation; reduces preload.

• Dobutamine = increases cardiac contractility and supports cardiac output.

Nursing Priorities

• Sit the patient upright.

• Assess lung sounds.

• Monitor SpO₂ and respiratory effort.

• Administer oxygen.

• Monitor hemodynamics.

• Monitor urine output after diuretics.

• Reassess response to treatment.

NCLEX PEARL: A patient with sudden severe dyspnea, crackles, and pink frothy sputum may be experiencing flash pulmonary edema.

Memory trick: Pulmonary edema = fluid in the lungs.

Pulmonary Embolism (PE) overview

LIFE-THREATENING EMERGENCY

Definition: Blockage of one or more pulmonary arteries by an embolus.

Possible causes:

• Blood clot (thrombus).

• Fat embolus.

• Air embolus.

• Tumor.

Most PE cases originate from a DVT.

Pathophysiology

1. A clot forms, usually in a deep vein of the leg.

2. The clot breaks loose.

3. It travels through the venous circulation.

4. It enters the right side of the heart.

5. It travels into the pulmonary arteries.

6. It blocks pulmonary blood flow.

7. Gas exchange is impaired.

8. The right ventricle may become strained.

Saddle Embolus

A large thrombus lodged at the bifurcation of the pulmonary artery.

This can cause severe hemodynamic compromise.

PE risk factors and manifestations

Risk Factors

• Immobility.

• Recent surgery.

• Trauma.

• Cancer.

• Previous DVT or PE.

• Hypercoagulable conditions.

• Pregnancy and postpartum status.

• Estrogen-containing medications.

Clinical Manifestations

Symptoms may be nonspecific.

Common findings:

• Sudden shortness of breath.

• Chest pain, often pleuritic.

• Tachycardia.

• Tachypnea.

• Hypoxemia.

• Anxiety or restlessness.

• Possible hemoptysis.

• Hypotension in a massive PE.

Important: A patient can have a PE without obvious signs of DVT.

PE diagnostics

Test	Purpose
CT pulmonary angiography	Common diagnostic imaging test
V/Q scan	Alternative when contrast cannot be used
ABGs	Evaluates oxygenation and ventilation
D-dimer	Helps evaluate possible clot formation in appropriate patients
ECG	Evaluates cardiac effects and alternative causes

V/Q scan:

• V = ventilation (air movement).

• Q = perfusion (blood flow).

It compares ventilation with blood flow in the lungs.

PE treatment

Anticoagulants:

• IV unfractionated heparin.

• Subcutaneous low-molecular-weight heparin—>aPTT monitor

• Factor Xa inhibitors.

• Direct thrombin inhibitors.

• Warfarin for selected long-term therapy—> INR monitor

Thrombolytic therapy:

• May be used for life-threatening PE when appropriate.

• Breaks down existing clots.

Pulmonary embolectomy:

- May be required for massive PE when the patient is hemodynamically unstable and thrombolytic therapy is contraindicated or unsuccessful.

Nursing Management

PREVENTION IS KEY!

• Early ambulation.

• Intermittent pneumatic compression devices.

• Prescribed anticoagulant prophylaxis.

For a patient with an acute PE:

1. Initially maintain bed rest as prescribed.

2. Position in semi-Fowler's.

3. Assess respiratory and cardiovascular status frequently.

4. Administer oxygen as prescribed.

5. Maintain IV access.

6. Monitor anticoagulation labs.

7. Assess for bleeding.

8. Monitor platelet count for heparin-induced thrombocytopenia (HIT).

9. Implement fall precautions.

10. Teach long-term anticoagulant safety.

PE vs. Pneumothorax

Pulmonary Embolism	Pneumothorax
Blood clot blocks pulmonary artery	Air enters pleural space
Sudden dyspnea	Sudden dyspnea
May have pleuritic chest pain	May have pleuritic chest pain
Lung may have relatively normal breath sounds	Decreased or absent breath sounds on affected side
Treat with anticoagulation when indicated	May require chest tube

Pulmonary Arterial Hypertension (PAH) overview

Definition: Elevated pulmonary artery pressure due to increased resistance to blood flow through the pulmonary circulation.

The lecture identifies pulmonary hypertension as a mean pulmonary artery pressure greater than 20 mmHg.

Types

Primary (Idiopathic)

- Unknown cause.

Secondary

- Develops as a complication of another disease.

Pathophysiology

Understand this progression:

1. Injury occurs to the pulmonary vascular endothelium.

2. Pulmonary vascular resistance increases.

3. Pulmonary artery pressure rises.

4. The right ventricle must work harder.

5. Right ventricular hypertrophy develops.

6. The right ventricle may enlarge (cor pulmonale).

7. Right-sided heart failure may develop.

Important connection: PAH places extra workload on the RIGHT side of the heart.

treatment PAH

1. Endothelin Receptor Antagonists

Decrease endothelin-mediated pulmonary vasoconstriction and vascular remodeling.

Examples:

• Ambrisentan.

• Bosentan.

• Macitentan.

2. Pulmonary Vasodilator Pathway Medications

Enhance nitric oxide–cGMP signaling to relax pulmonary vascular smooth muscle.

Examples:

• Sildenafil.

• Tadalafil.

• Riociguat.

MEDICATION SAFETY

Riociguat must NOT be combined with nitroglycerin because of the risk of severe hypotension.

3. Prostacyclin Therapies

Promote pulmonary vasodilation and reduce platelet aggregation.

Examples:

• Iloprost.

• Treprostinil.

• Epoprostenol.

CRITICAL: Continuous epoprostenol must NEVER be abruptly interrupted because rapid clinical deterioration can occur.

Memory trick: PAH = high pulmonary pressure → right ventricle works harder → right-sided heart failure.

Occupational and Environmental Lung Diseases

These disorders develop from inhaling dust, chemicals, or other harmful substances.

The extent of lung damage depends on:

• Toxicity of the substance.

• Amount inhaled.

• Duration of exposure.

Major Types

Pneumoconiosis

• Inhalation and retention of mineral or metal dust.

• Literally means "dust in the lungs."

• Examples include black lung disease and asbestos-related disease.

Chemical Pneumonitis

- Acute or chronic inflammation from exposure to toxic chemical fumes.

Hypersensitivity Pneumonitis

• Inflammatory reaction after inhaling an allergen.

• Example: Farmer's lung.

Memory trick:

• Pneumoconiosis = dust.

• Chemical pneumonitis = chemicals.

• Hypersensitivity pneumonitis = allergen.

Lung Transplantation

Lung transplantation may be considered for patients with progressive lung disease and a high risk of death without transplantation.

Common Indications

• COPD.

• Cystic fibrosis.

• Emphysema.

• Idiopathic pulmonary fibrosis.

• Interstitial lung disease.

• Pulmonary arterial hypertension.

Organ Allocation

• United Network for Organ Sharing (UNOS) coordinates organ allocation.

• Lung allocation score helps prioritize candidates based on urgency and expected post-transplant outcomes.

• Candidates must be prepared to travel to their transplant center when an organ becomes available.

• Travel may need to be limited.

Types of Lung Transplants

Type	Description
Single lung	One lung is removed and replaced
Bilateral lung	Both lungs are transplanted separately
Heart-lung	Heart and lungs are transplanted together
Lobar	Lung lobe from a living donor, often a relative

post transplant

Post-Transplant Nursing Care

• Close ventilation monitoring.

• Hemodynamic monitoring.

• Monitor for complications.

• Administer immunosuppressive medications.

• Support completion of self-care activities before discharge.

• Coordinate close follow-up with the transplant team.

Major Complication: Acute Rejection

HIGH-YIELD

• Acute rejection is common.

• The lecture notes it typically occurs within 5–10 days after transplantation.

• Requires close monitoring and immunosuppressive therapy.

Nursing priority: Watch for changes in respiratory status and signs of rejection or infection.

Memory trick: Transplant patient = immunosuppression + infection risk + rejection monitoring.

Lung Cancer

Lung cancer is a major cause of cancer-related deaths.

Risk Factors

The biggest risk factor is tobacco smoke exposure.

Other risk factors:

• Secondhand smoke.

• Air pollution.

• Radiation.

• Industrial chemicals.

• Asbestos exposure.

Important: Secondhand smoke contains many of the same carcinogens as mainstream tobacco smoke.

Pathophysiology

• Lung cancer arises from mutated epithelial cells.

• Cells grow abnormally and can form tumors.

• A tumor may reach approximately 1 cm before becoming detectable on chest X-ray, according to the lecture.

Two Major Types of Primary Lung Cancer

1. Non-Small Cell Lung Cancer (NSCLC)

• Most common broad category of lung cancer.

• Includes several subtypes.

• Treatment depends on the specific subtype and stage.

2. Small Cell Lung Cancer (SCLC)

• A separate major category of lung cancer.

• Often associated with tobacco exposure.

• Treatment depends on extent of disease.

Common Sites of Metastasis

• Lymph nodes.

• Liver.

• Brain.

• Bones.

• Adrenal glands.

NCLEX PEARL: New neurological symptoms in a patient with lung cancer may indicate brain metastasis.

diagnostics and treatment lung cancer

Diagnostics

• Chest X-ray.

• Bronchoscopy.

• Cytologic studies.

• Needle aspiration.

• Advanced imaging.

Accurate staging is essential to determine treatment.

Treatment Options

• Surgery.

• Radiation.

• Chemotherapy.

• Immunotherapy.

• Laser therapy.

• Other treatments depending on cancer type and stage.

Nursing Management

• Promote smoking cessation and health education.

• Provide emotional support and reassurance.

• Treat symptoms.

• Promote comfort.

• Monitor for treatment-related complications.

• Implement precautions based on chemotherapy, radiation, and immunotherapy.

Memory trick: Lung cancer = assess exposure history, identify type, determine stage, and manage treatment effects.

key review points

Condition	What Is Happening?	Hallmark Finding
Bronchitis	Inflamed bronchi	Persistent cough
Pertussis	Bacterial respiratory infection	Prolonged whooping cough
Pneumonia	Infection of lung parenchyma	Fever, cough, crackles
TB	Mycobacterial infection	Night sweats, weight loss, chronic cough
Atelectasis	Collapsed alveoli	Reduced gas exchange
Pleurisy	Inflamed pleura	Sharp pain with inspiration
Pleural effusion	Fluid in pleural space	Dyspnea, decreased breath sounds
IPF	Lung fibrosis	Stiff lungs, impaired gas exchange
Flail chest	Multiple rib fractures	Paradoxical movement
Pneumothorax	Air in pleural space	Decreased/absent breath sounds
Hemothorax	Blood in pleural space	Blood accumulation
Pulmonary edema	Fluid in alveoli	Crackles, pink frothy sputum
Pulmonary embolism	Clot in pulmonary artery	Sudden dyspnea and chest pain
PAH	Increased pulmonary vascular resistance	Right-sided heart strain

Critical Nursing Priorities

1. Active TB: Airborne isolation and negative-pressure room.

2. Pneumonia: Oxygenation, antibiotics when indicated, hydration, mobility, and airway clearance.

3. Atelectasis: Deep breathing, coughing, incentive spirometry, and early mobility.

4. Flail chest: Support ventilation and manage pain.

5. Tension pneumothorax: Emergency decompression.

6. Hemothorax: Prepare for chest tube insertion and monitor blood loss.

7. Pulmonary edema: High-Fowler's, oxygen, and prescribed diuretics/vasodilators.

8. Pulmonary embolism: Support oxygenation, anticoagulation as prescribed, and assess for hemodynamic instability.

9. PAH: Monitor right-sided heart function and medication safety.

10. Lung transplant: Monitor for rejection and infection.

Medication Safety Reminders

• TB medications: Monitor liver function and avoid alcohol.

• PE: Monitor for bleeding with anticoagulants.

• Heparin: Monitor aPTT or anti-Xa according to protocol and platelet count.

• Warfarin: Monitor INR.

• PAH medications: Never abruptly stop continuous epoprostenol.

• Riociguat: Do NOT combine with nitroglycerin due to severe hypotension risk.

• Pneumonia: Antibiotics depend on the suspected or confirmed cause.

Important Clinical Connections to Remember

• Older adult + confusion = consider pneumonia or hypoxemia.

• Vomiting or aspiration risk + respiratory symptoms = consider aspiration pneumonia.

• Postoperative + shallow breathing = risk for atelectasis.

• Sharp chest pain that worsens with inspiration = consider pleurisy.

• Chest trauma + paradoxical movement = flail chest.

• Sudden dyspnea + absent breath sounds on one side = suspect pneumothorax.

• Sudden dyspnea + hypotension + chest trauma = suspect tension pneumothorax.

• Sudden dyspnea + chest pain + tachycardia = suspect PE.

• Crackles + pink frothy sputum = pulmonary edema.

• Long-term smoking history + persistent respiratory symptoms = evaluate for lung cancer.

• Progressive lung disease + right ventricular strain = consider pulmonary hypertension.