respiratory conditions

what is gas exchange

- o2 is taken from air into lungs and transported to blood, CO2 taken from blood as a waste back to lungs to be exhaled

- airway and ventilation

what is perfusion

oxygenation transported to vital organs

SAO2

• comes off of ABG

• oxygen transport bonded to hemoglobin

SPO2

• comes off of pulse ox

• oxygen transport bonded to hemoglobin

PAO2

• measures oxygen in plasma

• <60 is critical

• norm is 80-100

ABG’s: uncompensated

• pH is outside norm range and respiratory/metabolic systems have not compensated to correct balance

• Ex: pH - 7.13, CO2 - 42, CO3 - 26

ABG's: partial compensation

• see changes to try and get pH back into norm range

• pH is still not within norm range

• Ex: pH - 7.48, CO2 - 31, CO3 - 21

ABG’s: complete compensation

• pH is back in norm range

• see changes to try and get pH back to norm; can see CO2 or CO3 be abnormal

• Ex: pH - 7.37, CO2.- 32, CO3 - 20

what is asthma

• chronic lung disease that inflames and narrows the airways

• airway hyperresponsiveness leads to bronchoconstriction

• worsened by mucus production

• occurs in acute periods

s/s asthma

- recurring periods of wheezing chest tightness, sob, coughing (trying to clear mucus)

- accessory muscle use

- cyanosis/hypoxemia

- increased ap diameter - chronic asthma pts w/ multiple exacerbations; not early sign

- initially low pco2 (hyperventilation), then later high (if cant intervene, hypoventilation; respiratory fatigue at this point; worse bc there is no longer any compensation)

- silent chest - worse than wheezing; indicates no air is moving; prepare to intubate

control level box for asthma - symptoms

• Daytime symptoms of wheezing, dyspnea, coughing present more than twice weekly

• Waking from night sleep with symptoms of wheezing, dyspnea, coughing

• Reliever (rescue) drug needed more than twice weekly

• Activity limited or stopped by symptoms

control level box for asthma: controlled or not?

Controlled: None of above symptoms

Partially Controlled: 1 or 2 symptoms in a week

Uncontrolled: 3 or 4 symptoms in a week or every day problems

is hypoventilation or hyperventilation worse with asthma

- hypoventilation bc rr is not compensating anymore

education of self-management for asthma

• daily = prescribed control drugs; assessment questions/peak flow monitoring (pulm fx test, green (good), yellow (keep watching), red (stop and get help)), reliever drugs as needed

• need directions for adjusting the daily controller drug schedule and when to call pcp

• emergency actions to take when asthma is not responding to controller and reliever drugs; can progress to severe or deadly w/out proper help

• routine exercise; oxygen as needed

• have to give something to dilate to open airway for oxygen

drug therapy plan for asthma

- control therapy (preventative/maintenance) vs. reliever (rescue; albuterol most comm)

- bronchodilators: saba, laba, cholinergic agonists

- antiinflam: corticosteroids, cromolyn, leukotriene modifier, monoclonal antibodies

step 1 asthma control

- as needed saba (relief)

- alternative for adults and adolescents: low dose ICS formoterol as reliever

step 2 asthma control

- saba

- ltra

- sublingual allergen immunotherapy (slit)

- adults and adolescents: low dose ics in combo or seperate w saba and regular daily laba

step 3 asthma control

- saba

- maintenece and reliever (ics)

- daily ltra or low dose sustained release theophylline

- slit

- alternative tx: maintenance ics-laba plus as needed saba

step 4 asthma control

- saba

- maintenance ics

- add lama and slit

- alternative: maintenence medium dose ics, laba with as needed saba

step 5 asthma control

- saba

- refer for assessment, phenotyping, and add on therapy

complications of asthma

status asthmaticus

status asthmaticus

- severe asthma attack, not responsive to standard tx

- can lead to pneumothorax and resp/cardiac arrest, and increased AP diameter

how to reverse status asthmaticus

- administer iv fluid, potent systemic bronchodilator, steroids, epinephrine, o2

- if pt is awake and alert, the dose of epi is going to be smaller compared to if pt is unconscious

- watch v/s bc some meds can increase HR

- assess for any rhythm changes bc some meds can decrease potassium levels

- be prepared for trach or intubation

what is copd

- chronic obstructive pulmonary disease

- emphysema & chronic bronchitis - can have one or both together

- each have different patho as to why it contributes to COPD

- the patho behind the COPD is vital in tx

- examine CXR, PFTs = FEV

risk fx for copd

- smoking

- alpha-antitrypsin deficiency (aat): genetic issue, absence of protein that prevents breakdown of lung tissue by enzymes; feeds into destruction of alveoli with emphysema

- asthma

what is emphysema

• loss of lung elasticity; lungs can't recoil back; leads to permanent damage

• when alveoli become destroyed, you lose the site and fx for gas exchange

• hyperinflation, air trapping, destruction of alveoli (permanent)

s/s emphysema

- accessory muscle use

- air hunger (gasping for air)

- uncoordinated breathing - excursion (change in pattern of breathing)

- increased rr and ap diameter (classic sign)

- wheezing, diminished breath sounds

- co2 retention (can’t get breath out), pallor/ash gray skin (advanced)

what is chronic bronchitis

- inflammation of bronchi, bronchi get thick

- increased goblet cells=increased mucus

- impaired ciliary fx (cant clear mucus)

- can't move air through mucus; feeds into gas exchange prob

s/s chronic bronchitis

- productive cough

- rhonchi (mucus), wheezing

- cyanotic, dusky appearance in exacerbation

- abg changes: can be co2 retainers, spo2 and sao2 changes

s/s both copd and emphysema

- cyanosis

- delayed capillary refill

- clubbing

- cor pulmonale

- co2 retention

- low pa02

- compensatory bicarb retention

- acidic ph (adv disease): most comm w/ emphysema

what drives you to breathe

- co2

- copd and co2 retainer: need for o2 is what stimulates them to breathe, don't over oxygenate but if showing distress dont hesitate

normal o2 for copd

- 88-92%

- but look at pt and watch s/s

- If new dx, then pt might not tolerate low oxygen levels as well

taking action for copd

• oxygen therapy - always assess pt and what they respond to and how well they tolerate it; not every pt is CO2 retainer, so have to draw ABGs to determine

• pulmonary toileting - good pulmonary hygiene; using incentive spirometry, deep breathing, turning and coughing, acapella; drying to do what we can to open alveoli

• always have suction set up next to bedside to prevent aspiration and clear mucus

• bronchodilators, steroids

• expectorant and hydration

• education and self management

• surgical management: lung transplant, lung vol reduction (removing hyperinflated dead area for emphysema pts)

education on self-management for COPD

• good breathing technqies

• diaphragmatic breathing

• pursed-lip breathing - helps blow out CO2

• good nutrition

• exercise

• coping mechanisms for anxiety

comp of copd

- hypoxemia and acidosis

- resp infection

- cor pulmonale: right-sided HF bc they had lung prob first

- dysrythmias: bc of stress on heart

- pneumothorax: from air trapping that causes rupture of alveoli that leaks into the space

- polycythemia: increased rbc; pt that lives in hypoxic state constantly, so body tries to compensate by producing more cells to carry oxygen

what is cystic fibrosis

• formation of thick mucus → impaired ability to clear secretions

• affects all secretions throughout body: gi (abd pain, steatorrhea, decreased vitamin absorption), pancreas (insulin def), testes (infertile), poor bone health

• resp failure main cause of death, high infection risk (pneumonia)

• autosomal recessive, most common among whites; always check prior to conception

• average life expectancy is late 40s

how to dx cf

• > 60 mEq/L of chloride in sweat

• can also do genetic testing to see exact mutation

s/s of cystic fibrosis

- recurrent resp infections (pneumonia) → resp distress & failure

- chest congestion

- cough

- decreased functional vital capacity/forced exp vol

- increased ap diameter (inability to breathe out well)

- clubbing (chronic)

- abdominal distention

- gerd

- steatorrhea

- vitamin deficiencies

- dm

taking action w cystic fibrosis

• complex, lifelong management - high calorie diet (fats, vitamins)

• daily chest physiotherapy w postural drainage (have to cough it up)

• protective hygiene: avoid handshaking in social settings, 6 ft apart, no cf pts interacting w each other

• gene therapy

• bilateral lung transplant - only solves respiratory infection; CF still exists, but lungs do not have CF; just damage to GI, heart, etc.

what is pulmonary arterial htn

- most common in women 20-40yrs, 50% have genetic mutation

- same underlying rx fx that cause HTN

- asymptomatic until progressed

- leads to cor pulmonale (lung prob that backed up and caused right-sided HF)

s/s pulmonary arterial HTN

- dyspnea and fatigue

- leads to cor pulmonale

how to dx pulmonary arterial HTN

- right sided heart cath

- pulm artery pressure >25

taking action pulmonary arterial hypertension

• prevent vasoconstriction/promote vasodilation

• prevent clotting

• o2 therapy

• lung transplant may be needed (pulmonary artery)

meds to prevent vasoconstriction for pulmonary arterial hypertension

• calcium channel blockers

• endothelia-receptor agonists

• phosphodiesterase inhibitors

meds to prevent clotting for pulmonary arterial HTN

warfarin

meds that prevent vasoconstriction AND clotting in combo for pulmonary arterial HTN

• prostacyclin agonists - inhibit platelet aggregation and dilate to keep good blood flow

• if IV, drip, or oral - therapy must not be interrupted; can have rebound HTN and clotting, which can cause cardiac arrest

• need to be proactive about getting prescriptions on time to prevent any interruptions

idopathic pulm fibrosis

• restrictive lung disease - decreased compliance; scarring in lungs that causes stiffness; can’t expand lungs well; can’t take deep breath

• poor prognosis

• risk fx: smoking, inhalation exposure (black lung disease, coal mining), meds

taking action for idiopathic pulm fibrosis

- corticosteroids

- immunosuppressants - put on if they think its caused by inflammatory response

- lung transplant is curative (if optional): pt should be okay after this

- supportive: psychosocial, support abcs, pulm toileting, incentive spirometer

lung cancer

• small cell lung cancer (most aggressive & likely to metastasize) v. non-small cell lung cancer

• cause reduced gas exchange

• paraneoplastic syndromes: cancer causes a secretion of hormones, start w lung cancer and end w endocrine probs (secretions of cortisol, ADH, etc)

paraneoplastic syndromes w/ lung cancer

• adrenocorticotropic hormone: cushings

• antidiuretic hormone: SIADH, weight gain, general edema, dilution of serum electrolytes

• follicle stimulating hormone: gynecomastia

• parathyroid: hypercalcemia

• ectopic insulin: hypoglycemia

warning signals of lung cancer

• Hoarseness

• Change in respiratory pattern

• Persistent cough or change in cough

• Blood-streaked sputum

• Rust-colored or purulent sputum

• Frank hemoptysis

• Chest pain or chest tightness

• Shoulder, arm, or chest wall pain

• Recurring episodes of pleural effusion, pneumonia, or bronchitis

• Dyspnea

• Fever associated with one or two other signs

• Wheezing

• Weight loss

• Clubbing of the fingers

prevention of lung cancer

• smoking cessation

• do not smoke prior to holding infants

taking action lung cancer

• chemo, targeted therapy, radiation, photodynamic therapy

• thoracentesis for pleural effusion

• oxygen/dyspnea management, pain management, hospice if terminal

• surgery: thoracotomy (cut into thorax) → lobectomy (removing lobe of lung), pneumonectomy (removing entire lung); vats (video assisted thorascopic surgery through small incision), wedge resection

• all surgery required post op placement of chest tube

difference in hospice and palliative care

- hospice: terminal <6mo to live

- palliative care: for chronic conditions, increases qol

what is a chest tube (ct)

• long, semi flexible plastic tube inserted into the pleural space and connected to a drainage system

• aka thoracostomy tube

• chest drainage system (cds)

• overall purpose of ct and cds is to restore normal vaccum (negative) pressure (allow lungs to behave like normal with expansion) in thoracic cavity by means of removing abnormal air or fluid

indications for chest tube

• post surgery (thoracostomy or vats)

• pneumothorax: too much air in pleural space

• tension pneumothorax: continuously feeding pleural space air; ex: gunshot; emergency

• hemothorax: blood

• hemopneumothorax: blood and air

• empyema: pus, infected fluid; important to drain all of it out

• pleural effusion: excess of normal fluid

dry suction cds

• most common

• ct connected to cds for 3 purposes:

  • collect fluid (d)

  • provide water seal (c): most important; seals so there isnt continuous air put into pleural space (chest cavity, NOT lung) during inhalation, it only permits air to exit; works like straw in water; doesn't back flow into ct

  • provide suction option (a, e): standard suction; have an order; not necessary bc of water seal; makes more efficient; encourages removal of air instead of waiting for natural evaporation of water; can control suction amt (standard is -20)

• gentle movement of water/bubbling

assessing chest tube and cds

• FOCA

  • fluctuation - tidaling seen during respirations; gentle movement and is normal

  • output - amount over a period of time

  • color - serous, serosanginous, sanguinous, pus

  • air leak - expected finding if it does w/ dx; normal with pneumothorax bc air is leaving pleural space; air leak is indicative of their still being air in space and having to keep chest tube in; would see air leak in water seal chamber; intermittent bubbling seen during coughing or exhalation is norm w/ pneumothorax; continuous bubbling suggests persistent air leak

maintenance of chest tube and cds

• monitor for subcutaneous emphysema- air in subq tissue; can cause face to appear edematous; not necessarily harmful, but can be if it gets into airway; indicates that air in pleural space is so bad that it exits out of space and expands to other places; norm starts around site and then makes way up; w/ this, they place pts on suction if they aren’t on it or increase suction; might have to place another chest tube w/ suction

• support oxygenation, pain management (not immediate prob; but shouldn't be ignored)

• troubleshooting

• removal performed by hcp w nurse assistance

troubleshooting chest tube and cds

• DOPE

  • Displacement (chest tube on floor) or Disconnection (chest tube still in, but disconnected from drainage system)

  • obstruction - kinked tube, mucus blockage, etc

  • pneumothorax - issue w drainage system

  • equipment failure - take down dressing and run entire line to ensure everything patent; check if eyelets are visible (shouldn’t be)

immediately notify surgeon or rapid response with chest tubes

• Tracheal deviation from midline (tension pneumo)

• Sudden onset or increased intensity of dyspnea

• Oxygen saturation less than 90%

• Drainage greater than 70 mL/hr

• Visible eyelets on chest tube - lost integrity of chest tube; have to remove and place another

• Chest tube falls out of the patient's chest → first, cover the area with dry, sterile gauze; secure dressing on 3 sides, leave 4th side open to allow air/fluid to escape

• Chest tube disconnects from the drainage system → put end of tube in a container of sterile water and keep below the level of the patient's chest

• Drainage in tube stops (in the first 24 hours)

flu key concepts

- multiple strains (a, b, c)

- rapid onset of s/s: fatigue may persist 1-2 wks after episode resolves

- contagious 24hrs before s/s and up to 5 days after

- vaccination is key: can be deadly for older pts

taking action for flu

- antiviral therapy (improves s/s)

- rest

- fluids

- older adults get hospitalized, > 65 higher dose flu vaccine

s/s covid

• norm symptoms - flu-like, SOB, headache, malaise, cough, sore throat

• New loss of taste (ageusia) or smell (anosmia)

• GI - n/v, diarrhea, abdominal pain

• Conjunctivitis

key features covid

• virus binds to ace2, which impacts vascular endothelial cells

• inflammation, vasoconstriction, hypercoagulability, endothelial dysfx, edema; NOT just resp

• risk for viral pneumonia and ards

• prevention - vaccines, handwashing, distancing/quarantine, face masks

taking action covid

• supportive care: oral antivirals for outpt high risk pts, iv antivirals and monoclonal antibodies for hospitalized pts

• wear n95, gowns, shoe covers, gloves, face shield, or goggles

pneumonia key features

• excess fluid in the lungs from inflammatory process (often infection)

• widespread is worse

• community vs. health care acquired

• patterns → lobar or bronchopneumonia

risk fx for community acquired pneumonia

• older adult

• never received the pneumococcal vaccination or received it >5 years ago

• Did not receive the influenza vaccine in the previous year

• Did not receive the COVID-19 vaccine series of boosters as recommended

• Has a chronic health problem or other coexisting condition that reduces immunity

• Has recently been exposed to respiratory viral or influenza infection

• Uses tobacco or alcohol or is exposed to high amounts of secondhand smoke

risk fx for health care acquired pneumonia

• older adult

• Has a chronic lung disease

• Has presence of gram-negative colonization of the mouth, throat, and stomach

• Has an altered level of consciousness

• Has had a recent aspiration event

• Has an endotracheal or nasogastric tube or has a tracheostomy

• Has poor nutritional status

• Has reduced immunity (from disease or drug therapy)

• Uses drugs that increase gastric pH (histamine [H2] blockers, antacids) or alkaline tube feedings

• Is currently receiving mechanical ventilation (ventilator-associated pneumonia [VAP])

box 25.2 community acquired pneumonia

• An acute infection acquired within the community

• Most common bacterial agent: Streptococcus pneumoniae

• Most common viral agents: influenza, COVID-19

• ntibiotics are often empirical based on multiple patient and environmental factors

• Treatment length: minimum of 5 days

• Prompt initiation of antibiotics required; in ED setting, first dose should be given within 4 hours

box 25.2 hospital acquired pneumonia

• Onset/diagnosis of pneumonia ≥48 hours after admission to hospital

• Encourage pulmonary hygiene and progressive ambulation

• Provide adequate hydration

• Assess risk for aspiration using an evidence-based tool

• Monitor for early signs of sepsis

• Hand hygiene is critical

• Provide vigorous oral care

pneumonia patterns

- lobar: one lobe

- bronchopneumonia: effects lungs diffusely, widespread

s/s pneumonia

• Increased respiratory rate/dyspnea

• Hypoxemia

• Cough

• Purulent, blood-tinged, or rust-colored sputum

• Fever

• Pleuritic chest discomfort

comp of pneumonia

- sepsis

- resp distress/failure

- empyema

taking action pneumonia

- implement care bundles

- vaccinate if at risk

- timely testing: culture w/in one hour of dx and prior to first antibiotic - do FIRST

- organism specific antibiotics w in 24 hrs - ensure antibiotic prescribed is actually going to fight it

- smoking cessation

- SIRS monitoring: helps monitor for sepsis; increased hr, rr, wbcs, temp (widespread inflammation in body)

taking action pneumonia tx

- improve hypoxemia: o2 therapy, IS

- prevent airway obstruction: tcdb (turn, cough, deep breathe), hydrate, drugs as needed

- prevent sepsis: antibiotics if bacterial

- nutrition

what is tuberculosis

- caused by mycobacterium → slow growing, acid fast rod

- airborne spread through resp droplets - can spread quick if symptomatic

- if not symptomatic, can't spread

- primary/intitial/active or secondary/reactivation (10%) (had prev and reactivates) vs latent dormant (90%) (not infectious unless symptomatic; occurs often bc you are healthy)

- always report to CDC so can trace back to help prevent transmission

tb screening questions

- fatigue

- anorexia/weight loss

- fever

- night sweats

- cough

- hemoptysis

- recent travel to at risk area

how to dx tb

• ppd mantoux skin test: positive is >10mm induration (raised); unless immunocompromised, then >5mm; positive means you have exposure to TB or presence of inactive, NOT active

• exposure/infection=chest x ray; helps identify if active or latent

• active disease can be dx by blood analysis, sputum culture

• once test positive once, will always test positive; doesn’t mean actively sick w/ it

taking action against tb

• maintain airway and oxygenation

• combo drug therapy: inh, rifampin, pza, emb

  • strict adherance to suppress disease

  • potential for liver damage, prolonged qt

  • extensively drug resistant TB = DOT (directly observed therapy; can be RN) recommended bc absolute adherence to tx is critical for survival

• diet rich in iron, protein, vit a, b, c, e, avoid alcohol (bc drugs hard on liver)

• manage fatigue

isoniazid (INH)

• pt take drug on empty stomach to prevent slowing of drug absorption in GI tract

• take daily multiple vitamin while on drug bc drug can deplete body of b-complex

• avoid alcohol bc of liver damage

• report dark urine, jaundice, increased bruising

rifampin

• warn pt to expect reddish-orange staining of skin, urine, secretions

• females use additional contraception when taking and for 1 mth after stopping bc reduces effectiveness of oral contraceptives

• avoid alcohol bc of liver damage

• report liver damage symptoms

pyrazinaimide

• ask if pt ever had gout bc drug increases uric acid formation

• drink at least 8 ounces of water when taking and increase fluid

• wear protection from sun bc of increased photosensitivity

• avoid alcohol bc of liver damage

• report liver damage s/s

ethambutol

• pt needs to report any changes in vision bc drug can cause optic neuritis

• avoid alcohol bc drug induces severe n/v

• ever had gout?

• drink at least 8 ounces of water w/ drug and increase fluid intake

rhinosinusitis key features

- inflammation of mucus membranes of sinuses r/t drainage interference

- usually due to common cold

- can lead to cellulitis, abscess, meningitis

s/s rhinosinusitis

- pain over sinuses

- cold s/s

taking action rhinosinusitis

- symptom relief w meds, rest, hydration

- antibiotics if bacterial cause

- may require sinus surgery (deviated septum)

key features inhalation anthrax

- bacterial infection

- if caught early its fine

- fatal if untx → hemorrhage, lung cell destruction, sepsis, meningitis

- must be reported as an act of bioterrorism

- vaccine available for high risk individuals (government workers)

two stages of inhalation anthrax

- prodromal (incubation)

- fulminant (active)

- good prognosis if tx w antibiotics in prodromal stage

s/s inhalation anthrax prodromal stage

• Fever

• Fatigue

• Mild chest pain

• Dry cough

• No indications of upper respiratory infection

• Mediastinal "widening" on chest x-ray

s/s inhalation anthrax fulminant stage

• Diaphoresis

• Stridor on inhalation and exhalation

• Hypoxia

• High fever

• Mediastinitis

• Pleural effusion

• Hypotension

• Septic shock

peritonsillar abscess

- comp of acute bacterial tonsillitis

- treat with antibiotics & drain if needed

endemic/geographic resp infection

- usually spore forming fungi

- occurs w low immunity, intense exposure

- mimics flu or pneumonia

- not spread person to person

- usually supportive care w antifungals