RESPI PT 3

Atelectasis

- refers to closure or collapse of alveoli

- most commonly encountered abnormalities seen on a chest xray

- Excess secretions or mucus plugs may also cause obstruction of airflow and result in this in an area of the lung

Acute Atelectasis

- most common form of atelectasis

- occurs most often in the postoperative setting usually following thoracic and upper abdominal procedures or in people who are immobilized and have a shallow, monotonous breathing pattern

Common Causes of Atelectasis

- Hypoventilation

- Airway Obstruction

- Compression

- Adhesions

Types of Atelectasis

- Non-obstructive

- Obstructive

Non-obstructive atelectasis

- reduced ventilation

- monotonous low tidal breathing pattern

- compressive atelectasis

Compressive atelectasis

- restricts normal lung expansion

- ex.: pleural effusion, pneumothorax, hemothorax

Causes of non-obstructive atelectasis

- analgesia or anesthetic agents

- prolonged supine position

- splinting of chest

Obstructive Atelectasis

- common type

- blockage (foreign body, tumor, retained secretions, increased abdominal pressure, musculoskeletal and neurologic disorders, surgical procedures)

Reabsorption of gas

- cause of obstructive atelectasis

- trapped alveolar air is absorbed into the bloodstream → no additional air can enter into the alveoli because of the blockage → the affected portion of the lung becomes airless and the alveoli collapse

Signs and Symptoms of Atelectasis

- SOB

- Cough

- Sputum Production

- Tachycardia

- Tachypnea

- Pleural pain

- Central Cyanosis

Central Cyanosis

late sign of hypoxemia

Chest Xray

- diagnostic test for atelectasis

- may reveal patchy infiltrates or consolidated areas

Management of Atelectasis

- turning schedule

- early mobilization

- DBE (at least every 2 hours)

- Incentive Spirometry

Management of Atelectasis

- ICOUGH Program

- Administer prescribed opioids and sedatives judiciously

- Postural drainage and chest percussion (if indicated)

- Suctioning (if indicated)

Incentive Spirometry

- inspired air helps inflate the lungs

- ball or weight in the spirometer rises in response to the intensity of the intake of air

- the higher the ball rises, the deeper the breath

semi-Fowler position/upright position

position for Incentive Spirometry

diaphragmatic breathing

breathing technique for Incentive Spirometry

ICOUGH Program

- Incentive Spirometry

- Coughing and deep breathing

- Oral Care (brushing teeth and using mouthwash 2x a day)

- Understanding (patient and staff education)

- Getting out of bed at least 3x a day

- Head-of-bed elevation

coughing or suctioning, CPT, and postural drainage

management of atelectasis if the cause is bronchial obstruction from secretions

Thoracentesis

done if If the cause of atelectasis is compression of lung tissue and the goal is to decrease the compression

Acute Tracheobronchitis

acute inflammation of the mucous membranes of the trachea and the bronchial tree

Aspergillus

virus responsible for acute viral tracheobronchitis

Streptococcus pneumoniae

bacteria responsible for acute bacterial tranchebronchitis

Signs and Symptoms of Acute Tracheobronchitis

- dry irritating cough with scanty amount of sputum

- sternal soreness from coughing and have fever or chills, night sweats, headache, and general malaise

Inspiratory stridor and expiratory wheeze

lung sounds heard for acute trachebronchitis

Management of Acute Tracheobronchitis

- Bacterial: Antibiotics

- NO to antihistamines

- EOF

- Steam inhalation

- Moist heat application to chest

Antihistamines

avoided in acute tracheobronchitis because it can cause excessive drying and make secretions more difficult to expectorate

Steam inhalation

management of acute tracheobronchitis that help relieve laryngeal and tracheal irritation

Moist heat application to chest

management of acute tracheobronchitis that help relieve soreness

Pneumonia

inflammation of the lung parenchyma caused by various microorganisms

Microorganisms that causes Pneumonia

- bacteria

- mycobacteria

- fungi

- viruses

Classifications of Pneumonia

- Community-acquired pneumonia (CAP)

- Health care-associated pneumonia (HCAP)

- Hospital-acquired pneumonia (HAP)

- Ventilator-associated pneumonia (VAP)

Community-acquired pneumonia (CAP)

pneumonia occurring in the community or less than or equal to 48 hours after hospital admission or institutionalization of patients who do not meet the criteria for HCAP

Health-care associated pneumonia (HCAP)

pneumonia occurring in a nonhospitalized patient with extensive health care contact

Criteria for HCAP

one or more of the following:

- hospitalization for more than or equal to 2 days in an acute care facility within 90 days of infection

- residence in a nursing home or long-term care facility

- antibiotic therapy, chemotherapy, or wound care within 30 days of current infection

- hemodialysis treatment at a hospital or clinic

- home infusion therapy or home wound care

- family member with infection due to multidrug-resistant bacteria

Hospital-acquired pneumonia (HAP)

pneumonia occurring more than or equal to 48 hours after hospital admission that did not appear to be incubating at the time of admission

Ventilator-associated pneumonia (VAP)

a type of HAP that develops more than or equal to 48 hours after ET tube intubation

S. pneumoniae (pneumococcus)

- most common bacterial cause of CAP

- acquired through inhalation of this organism

H. influenzae

causes a type of CAP that frequently affects older adults and those with comorbid illnesses

Common organisms responsible for HAP

- E. coli

- H. influenzae

- Klebsiella pneumoniae

- Pseudomonas aeruginosa

- S. Pneumoniae

- MRSA

Pseudomonas aeruginosa

organism responsible for HAP - prolonged intubation or tracheostomy

Methicillin-resistant staphylococcus aureus

- acquired through direct skin to skin contact: CONTACT PRECAUTION

- private room: no cohorting

- gown, gloves, antibacterial soap, alcohol-based handrub

5 key elements of the VAP bundle

- Elevation of the HOB (30-45°)

- Daily "sedation vacations" and assessment of readiness to extubate

- Peptic ulcer disease prophylaxis

- DVT prophylaxis

- Daily oral care with chlorhexidine (0.12% oral rinses)

sedation vacation

sedative doses are purposely decreased at a time of the day when it is possible to assess the patient's neurologic readiness for extubation

Pneumonia in the Immunocompromised Host

can occur with prolonged use of steroids, chemotherapy, use of broad spectrum abx, AIDS, long term mech vent

Causative agents of Pneumonia in the Immunocompromised Host

- Pneumocystis jiroveci

- Fungi

- Mycobacterium tuberculosis

Pneumocystis pneumonia (PCP)

pneumonia in the immunocompromised host caused by Pneumocystis jiroveci

Aspiration Pneumonia

resulting from entry of endogenous or exogenous substances into the lower airway

Common form of Aspiration Pneumonia

aspiration of bacteria that normally reside in the upper airways

Causes of Aspiration Pneumonia

- gastric contents

- chemical contents

- irritating gases

Pathophysiology of Aspiration Pneumonia

Entry of substances into the lower airway

↓

Neutrophils migrating into the alveoli

↓

Fill the air spaces

↓

Accumulation of secretion and edema

↓

Inadequate ventilation

↓

Occlusion of bronchi/alveoli

↓

Hypoventilation

↓

Ventilation-Perfusion (V/Q) Mismatch

Ventilation-Perfusion

refers to the ratio between ventilation (breathing) and perfusion (circulation) in the lungs

4 to 5 or 0.8

Normal V./Q. ratio

>0.8

value of VQ that would indicate ventilation exceeds perfusion

Causes of ventilation exceeds perfusion

- Blood clots

- Heart Failure

- Emphysema

- Damage to pulmonary capillaries

value of VQ that would indicate perfusion exceeds ventilation

Causes of perfusion exceeds ventilation

- Aspiration

- Blockage of bronchi by foreign object

- Pneumonia

- Severe asthma

- Pulmonary edema

- COPD

Bronchopneumonia

lung involvement: patchy areas of consolidation

Lobar pneumonia

lung involvement: consolidation of an entire lobe

Prevention of pneumonia

- Pneumococcal conjugate vaccine (PCV13)

- Pneumococcal polysaccharide vaccine (PPSV23)

Pneumococcal conjugate vaccine (PCV13)

- protects against 13 types of pneumococcal bacteria

- recommended for all adults 65 years of age or older as well as adults 19 years or older with conditions that weaken the immune system (HIV, organ transplant, leukemia)

Pneumococcal polysaccharide vaccine (PPSV23)

- newer vaccine and protects against 23 types of pneumococcal bacteria.

- recommended for all adults 65 years of age or older and for those adults 19 through 64 years of age who smoke cigarettes or who have chronic heart, lung, or liver disease, or alcoholism

Management of Pneumonia

- no known multidrug resistance: monotherapy

- With known multidrug resistance: a three-drug combination therapy

- Bacterial pneumonia: antibiotic

- Antibiotics: indicated with a viral respiratory infection only if a secondary bacterial pneumonia, bronchitis, or rhinosinusitis is present

- Viral pneumonia: supportive regimen

Monotherapy drugs for pneumonia

- Ceftriaxone

- Ampicillin/Sulbactam

- Levofloxacin

- Ertapenem

drugs for 3-drug combination therapy for pneumonia

Cephalosporin or Ceftazidime, Carbapenem or Piperacillin-Tazobactam

+

fluoroquinolone or aminoglycoside

+

linezolid or vancomycin

Supportive regimen for viral pneumonia

- Hydration: due to fever, tachypnea (insensible loss)

- Antipyretic agents (fever)

- Antitussive agents (cough suppresants)

- Antihistamines (reduce sneezing and rhinorhea)

- Nasal decongestants

- Hypoxemia (O2 therapy)

Pulmonary tuberculosis

leading cause of death from infectious disease in the world

airborne

- mode of transmission for pulmonary tuberculosis

- an infected person releases droplet nuclei (usually particles 1 to 5 mcm in diameter) through talking, coughing, sneezing, laughing, or singing

- smaller droplets remain suspended in the air and are inhaled by a susceptible person

Pathophysiology of Pulmonary Tuberculosis

Susceptible person (inhales mycobacteria) and become infected

↓

Deposited in alveoli and begin to multiply

↓

Inflammatory reaction

↓

Phagocytes engulfs the bacteria and TB-specific lymphocytes lyse (destroy) the bacilli and normal tissue

↓

Accumulation of exudates in alveoli (bronchopneumonia)

↓

2-10 weeks after exposure: Ghon tubercle formation

↓

Ghon tubercle becomes necrotic, forming a cheesy mass

↓

Calcified and form a collagenous scar

↓

Bacteria becomes dormant- no further progression

Activation of Pulmonary Tuberculosis

immunocompromised

↓

May also occur in reinfection and activation of dormant bacteria

↓

Ghon tubercle ulcerates (releasing cheesy material in the bronchi)

↓

Bacteria become airborne

↓

Ghon tubercle heals and forms scar tissue

↓

Bronchopneumonia and further tubercle formation

Signs and Symptoms of Pulmonary Tuberculosis

- usually insidious

- low grade fever

- cough (may be productive or nonproductive)

- night sweats

- fatigue

- weight loss

- hemoptysis

Tuberculin skin test/Mantoux test

diagnostic test for Pulmonary Tuberculosis that involves injection a PPD ID

Purified protein derivative

substance injected ID for Mantoux test

48-72 hours

test result for Mantoux test is read after this much time has passed after injection

induration and erythema

both of these indicators will be present if a patient will test positive for pulmonary TB

induration

raised hard area or swelling

0-4 mm

size of wheal for Mantoux test that would indicate test results are not significant

5 mm and above

size of wheal for Mantoux test indicating patient is

- considered to be at risk

- positive for pts with HIV

- Positive for who are close contacts with active TB

- Chest xray results consitent with TB

10 mm and above

size of wheal indicating

- Mildly impaired immunity

- Past exposure to TB or vaccinated with BCG

positive reaction for Mantoux test

- does not necessarily mean that active disease is present in the body

- More than 90% of people who are tuberculin significant reactors do not develop clinical TB

- all significant reactors are candidates for active TB

- the more intense the reaction, the greater the likelihood of an active infection

QuantiFERON-TB Gold Plus and T-SPOT

- diagnostic tests for TB

- available only in US (blood test)

- results are available 24-36 hours

Sputum Culture

presence of AFB on a sputum smear may indicate disease but does not confirm the diagnosis of TB because some AFB are not M. tuberculosis

anti-TB agents for 6-12 months

management of pulmonary TB

multidrug resistant TB

- resistant to isoniazid and rifampin

- At risk: HIV +, homeless, institutionalized

Extensively drug resistant TB

- Resistance to isoniazid and rifampin, in addition to any fluroquinolone, and at least one of three injectable second-line agents (i.e., amikacin, kanamycin, or capreomycin)

- At risk: HIV+ and other immunocompromised conditions

initial and continuation

2 phases of treatment guidelines of pulmonary TB

initial treatment

RIPE + Vit B6 50 mg- all taken once a daily for 8 weeks

Continuation phase

RI or Isoniazid and Rifapentine for the next 4-7 months

2-3 weeks

after this time has passed of continuous medication therapy, Patients are considered noninfectious

1 hour before meals

when to take TB medications?

tyramine rich foods/processed foods

- type of food to avoid during isoniazid therapy

- to avoid having headache, flushing, hypotension, lightheadedness, palpitations, diaphoresis

hepatotoxic

reason why alcohol is avoided during intake of TB meds

Miliary TB

- dissemination of TB infection to nonpulmonary sites of the body

- invasion of the bloodstream by the tubercle bacillus.

Lung Abscess

- localized collection of pus caused by microbial infection

- found in areas of the lung that may be affected by aspiration

aspiration of anaerobic bacteria

general cause of lung abscess

signs and symptoms of lung abscess

- fever

- prod cough

- moderate to copious amounts of foul-smelling, sometimes bloody, sputum

Diagnostic tests for Lung Abscess

- Chest X-ray

- Sputum culture

- Bronchoscopy

Prevention of Lung Abscess

- adequate oral and dental hygiene

- antibiotic therapy before dental procedures in patients who must have teeth extracted while their gums and teeth are infected

Management of Lung Abscess

- clindamycin, ampicillin-sulbactam, or carbapenem (standard for anaerobic infection)

- offer emotional support: abscess may take a long time to resolve

Pleural Disorders

- Pleurisy

- Pleural effusion

- Empyema