Ch 19: Lower Resp Disorders #2

Pleurisy (Pleuritis)

• what is it

• what kind of pain

• pain exacerbates when? diminishes when ?

• ascultation

• often after ? 4

• Inflammation of both layers of the pleura (parietal and visceral),
  which then rub together during breathing

• Classic findings: sharp, 'knife-like' pain that intensifies with inspiration, coughing, or sneezing — pain diminishes when the patient holds their breath

• Auscultation may reveal a pleural friction rub

• Often secondary to pneumonia, viral URI, tuberculosis, or chest
  trauma

managing pleurisy

• treat ?

• meds

• positioning

• application of

• if severe

• if untreated?

• Management: treat the underlying cause:

• NSAIDs,

• positioning on affected side (acts as splinting), splinting to reduce pain during
  breathing/coughing,

• application of heat or cold,

• if severe – intercostal nerve block

• if untreated or progressive, fluid can accumulate between the
  pleural layers = effusion

Pleural Effusion

• what is it

• usually secondary to ? 5

• what can cause reoccurring plueral effusion

• Abnormal collection of fluid in the pleural space
• Usually secondary to another disease process:
• Heart Failure - increased pressure = leaky capillaries
• Pneumonia - irritates pleura
• Tuberculosis
• Connective tissue disorders
• Malignancy - blocks blood flow → increases pressure (causes reoccurring plueral effusion)

s/s of plueral effusion

• progressive ?

• type of cough

• what lessens as fluid accumulates

• percussion ?

• assessment findings?

Severity of symptom is determined by the size of effusion, the
spread of its formation and the underlying lung disease
• Progressive dyspnea
• Dry cough
• Pleuritic chest pain (may lessen as fluid accumulates)
• Dullness to percussion
• Diminished/absent breath sounds and ↓ fremitus over the effusion

dx for pleural effusion

• Chest X-R & Lateral decubitus X-R (pt lies on affected side)
• Thoracentesis - diagnostic & therapeutic
• Chest CT scan

transudate vs exudate fluid

• transudate - thin, not a lot of proteins

• exudate - thicker

• guides underlying workup

tx of plueral effusion

• major goal ?

• what can we give

• procedures ?

• Major goals: Discovering and treating underlying cause, Prevent
re-accumulation of fluid & Relieve discomfort
• Supplemental O2
• Thoracentesis
• Chest tube insertion - educate pt on drain management
• Pleurodesis - powder used to keep plueral space together

Empyema

• complication of ?

• Accumulation of thick, purulent fluid (pus) in the pleural space
• Complication of pneumonia, thoracic surgery, or chest trauma

s/s of empyema

• fever

• night sweats

• pleuritic chest pain

• dyspnea

• cough

• anorexia, weight loss - cough uses a lot of ATP and lowers appetite

tx of empyema

• goal?

• medical tx?

• nursing: what is required? monitor for? support ?

• after discharge ?

• Goal of treatment is to drain the pleural cavity and fully re-
  expand the lung

• Medical: antibiotic therapy (4-6 weeks),

• chest tube drainage required

• monitor for sepsis

• nutrition support

• frequently discharged with chest tube & PICC line in place for IV antibiotics
  fluid — chest tube drainage is frequently require

Blunt Chest Trauma

• sudden compression or positive pressure into the chest wall

• MVA, falls, bicycle crashes, hit in chest, compressed

penetrating Chest trauma

• foreign object penetrates the chest wall

• knife wound, gun shot

chest trauma results in

• hypoxemia

• lung tissue damage,

• bleeding (hemorrhage),

• collapsed lung (pneumothorax)

• hypovolemia from fluid loss and cardiac failure

Primary vs Secondary survey

• ABCDE

• AMPLE

• Primary - Emergency Assessment:
  • find and fix what will kill the patient first, then look for everything else

• ABCDE: Assess airway, breathing, circulation, Disability (neurologic status), and expose pt for hidden injuries

• Secondary Assessment
  • Perform a systematic head-to-toe examination after stabilization
  • Obtain AMPLE history: allergy, medications, past Hx, last meal, event that led to situation

sternal fractures

• sings

• common in motor vehicle crashes-direct blow

• anterior chest pain, tenderness, ecchymosis, Bony
  crepitus (bones rubbing together), swelling, possible chest wall deformity

rib fractures

• what ribs are most frequently involved

• if first 3 ribs are injured

• if lower ribs are injured

• if an older adult has broken ribs

• most common chest trauma with blunt injury

• Ribs 4–10 most frequently involved

• First three ribs: high mortality due to subclavian artery/vein laceration

• Lower ribs: spleen/liver injury

• Older adults with three or more rib fractures:
  • Fivefold increased mortality, fourfold increased pneumonia

s/s of rib fractures

• severe pain,

• point tenderness,

• muscle spasm,

• bruising,

• Pain aggravated by coughing, deep breathing & movement,

• Crepitus and swelling

consequences of rib and sternum fractures

• diminished ventilation due to shorter breaths

• atelectasis

• pneumonia

• hypoxia

• respiratory insufficiency and failure

managing sternum and rib fractures

• when do most rib fractures heal

• control the pain

• breathing exercises with mild sedation & Abdominal binder.

• Most rib fracture heal in 3 to 6 weeks

flail chest

• causes ?

• occurs when ?

• results in ?

• consequences?

• Complication of blunt chest trauma
• Causes: steering wheel injury, motor vehicle crash, fall, assault
• Occurs when three or more adjacent ribs fractured at two or more
sites
• Results in free-floating rib segments
• Chest wall loses stability → causes respiratory impairment, severe distress

managing a flail Chest

• what may be needed

• what can control pain

• procedure ?

• tests?

• encourage ? what do we not want to develop

  • WATCH FLAIL CHEST VIDEO IN PPT

• ventilator at times and suctioning/oral care as needed

• Pain control! - intercostal nerve blocks, splinting, binder

• Chest wall stabilization (CWS) -plating system

• Chest x-rays, ABGs , pulse oximetry, and bedside
  pulmonary function monitoring

• encoruage deep breathing, cough and lung
  expansion and secretion management - Don’t want pneumonia to develop

Penetrating Trauma

• what organs can be injured

• what are the main complications

• chest wall, lung, pleura, tracheobronchial system, esophagus, diaphragm,
  major thoracic blood vessels, heart, mediastinal structures

• pneumothorax and cardiac tamponade

pneumothorax

• how does it happen

• what is it

• 4 types

• Air enters the pleural space, destroying the negative pressure thatkeeps the lung inflated

• the lung partially or completely collapses

• • Simple /spontaneous
  • Traumatic
  • Tension

• open

Spontaneous/Simple pneumothorax

• how does it happen

• often in?

• occurs after ?

• Occurs without trauma
• Often in tall thin young apparently healthy males or in patients with underlying lung disease/ heavy smokers
• Occurs after a ruptured bleb (air bubble) or a bronchopleural fistula

Traumatic Pneumothorax

• occurs when ?

• often seen with?

• how can this happen

• Occurs when air escapes from a laceration in the lung and enters the pleural space or when air enters the pleural space through a wound in the chest wall
  • Often accompanied with hemothorax(blood pooling in pleural space)
  • Results from: Penetrating and/or Blunt chest trauma
  • Pressure related trauma or Complication of procedure

Tension Pneumothorax

• how does it happen

• what are the signs

• emergent tx?

• s/s?

• Air enters the pleural space but cannot escape → Progressively increasing pressure as pt takes each breath

• Pushes the mediastinum toward the unaffected side

• Compressing the heart and great vessels & tracheal deviation towards the
  unaffected side

• Life threatening! - in the field EMT will perform needle decompression to relive pressure

• severe respiratory distress, hypotension, distended neck veins
  • Life-threatening emergency

Open Pneumothorax

• how does it happen

• aka ?

• what is the sign?

• what does is effect ? vitals?

• An opening in the chest wall allows air to move freely in and out of the pleural space with breathing

• aka ‘Sucking chest wound’

• Lung collapses and heart and great vessels shifting or swinging to
  the unaffected side with each inspiration and back with expiration

• Affects cardiac output and circulation (BP and CO drops, HR goes up)

• life threatening emergency

general s/s of pneumothorax

• sudden ?

• breathing ?

• on affected side ? (2)

• percussion ?

• HR? O2?

• Sudden sharp chest pain
• Dyspnea
• Decreased/absent breath sounds on the affected side
• Hyperresonance to percussion (trapped air)
• Decreased chest expansion on affected side
• Tachycardia
• Low oxygen saturation (hypoxemia)

Management - Pneumothorax

• main goal

• small and simple?

• large symptomatic?

• tension?

• open ?

• Goal: evacuate blood or air from pleural space, restores the negative
  intrathoracic pressure

• Small, stable spontaneous - observation and supplemental oxygen

• Larger/symptomatic pneumothorax: chest tube insertion - need to restore negative pressure!

• Tension pneumothorax: needle decompression & chest tube placement

• Open pneumothorax: cover open wound with sterile gauze & tape on three sides (not 4 b/c you can cause tension pneumothorax by trapping air)

chest tubes

• purpose

• indications

• placement for what reasons?

• Purpose: remove air and/or fluid from the pleural space and restore
  negative intrapleural pressure, allowing the lung to re-expand

• Indications: pneumothorax, hemothorax, pleural effusion, empyema, and
  after thoracic surgery to restore pressure

• high placement if air in the lungs

• low placement if fluid/blood is in the lungs

nursing management of chest tubes

• what do we want in the water seal chamber? what are we looking for

• where is the drainage system

• never ?

• what doe we monitor

• @ bedside ?

• Monitor for tidaling - we want in water seal chamber - shows inhalation and exhalation

• Monitor for continuous bubbling in the water-seal chamber - indicates leak

• Keep the drainage system below the level of the chest at all times

• Never clamp a chest tube without a specific order - may cause hemothorax

• Monitor and document drainage amount, color, and consistency & look at dressing

• Keep two enclosed hemostats, a sterile occlusive dressing at the bedside
  at all times

Subcutaneous Emphysema

• how does it happen

• often occurs when

• can occur with?

• manifestations

• Air trapped under the skin, usually in the chest or neck
• Often occurs when air leaks from the lung or pleural space
• Can occur with pneumothorax or chest tube complications
• Manifestation: Swelling and a crackling/crunchy sensation (crepitus)

managing Subcutaneous Emphysema

• emergent ?

• otherwise ?

• if emergent (threatens airway patency) - tracheostomy STAT - can happen when its in the neck

• otherwise: Treat the underlying air leak, maintain chest-tube patency,
  supplemental o2 prn, monitor respiratory status and swelling

• usually dissipates on its own

Acute Respiratory Failure

• occurs when ?

• results in?

• can result from ? 5

• Occurs when the respiratory system can no longer maintain adequate gas exchange

• results in inadequate oxygenation, inadequate ventilation (CO2 removal) or both

• Hypoxemia, hypercapnia (too much CO2)

• Can result from severe pneumonia, massive atelectasis,
  pneumothorax, Pulmonary embolism or neuromuscular failure

who is at risk for ARF

• cant drive breathing

• cant move air

• cant exchange gas

• cant drive breathing - Neuromuscular/CNS

• cant move air - Chest Wall / Mechanical

• cant exchange gas - Airway/Lung Disease

what includes cant drive breathing - Neuromuscular/CNS

• Opioid/sedative overdose, anesthesia
• Stroke (esp. brainstem), High cervical spinal cord injury
• Myasthenia gravis, GBS, ALS, TBI, increased ICP

what includes cant move air - Chest Wall / Mechanical

• Flail chest, rib fractures, Kyphoscoliosis, morbid obesity
• Post-op abdominal/thoracic surgery (not breathing deep enough , pain)

what includes cant exchange gas - Airway/Lung Disease

• Sepsis / SIRS, Aspiration risk (↓LOC, dysphagia)
• Advanced age, smoking history
• Immunocompromised, immobility, Chest trauma, anaphylaxis

Early manifestations of ARF

restlessness, anxiety, tachypnea, and mild confusion — before dramatic
vital sign changes appear

late manifestations of ARF

severe hypoxemia, hypercapnia (high CO2), use of accessory muscles, cyanosis,
altered level of consciousness

Management of ARF

• nursing priority

• supplemental oxygen, noninvasive positive pressure ventilation
(BiPAP/CPAP), or invasive mechanical ventilation for severe cases
• Nursing priority:
• recognize early, subtle changes before the patient reaches
crisis

Acute Respiratory Distress Syndrome
(ARDS)

• what is it? causes?

• results in ? 3

• usually will have to?

• mortality ?

• A clinical syndrome characterized by Severe inflammatory process causing diffuse alveolar damage

• not a primary lung disease

• results in:
  • sudden and progressive pulmonary edema
  • Bilateral infiltrates on chest x-ray.
  • Hypoxemia unresponsive to supplemental oxygen - usually will have to intubate

• • Mortality remains significant despite treatment advances —
  prevention and early recognition of at-risk patients matters
  greatly

common triggers of ARDS

• risk rises with?

sepsis, severe pneumonia, aspiration, trauma,
massive transfusion, pancreatitis

• Risk rises with smoking, obesity, diabetes

Pathophysiology of ARDS

• Inflammation = Increased capillary permeability leads to fluid leaking
  into the alveoli (noncardiogenic pulmonary edema - does not evolve cardiac issue or high BP)

• severely impaired gas exchange and lung compliance

Manifestations ARDS

• Rapid onset of severe dyspnea and hypoxemia that does not
  respond well to supplemental oxygen alone

• SOB, irritability, cyanosis, lethargy, diaphoresis, intercostal retractions

Management of ARDS

• vent ?

• position ?

• extra treatments?

• meds ?

• tests?

• Mechanical ventilation with low tidal volumes, PEEP,

• prone position - monitor skin integrity and turn frequently

• Extracorporeal Membrane Oxygenation (ECMO)for patients with severe ARDS

• Medications – Hemodynamic support- Inotropic (digoxin) and vasopressor to maintain circulation

• CXR, ABG’s
  

ARF and ARDS in peds

• airways ?

• alveoli?

• causes ?

• early signs of distress?

• Higher risk, faster decompensation

• Small airways — minor edema = major obstruction

• Fewer alveoli, less reserve

• Causes: RSV/bronchiolitis, croup, sepsis

• Early distress signs (flaring, grunting, retractions)

ARF and ARDS in older adults

• mortality ?

• less of ? weaker ?

• recovery?

• what complicates tx?

• atypical presentation

• Highest mortality
•↓ reserve, weaker cough/immune response
•Atypical presentation — confusion over dyspnea
•Frailty drives outcomes & goals-of-care
•Slower recovery, more long-term decline
•Polypharmacy complicates treatment

• may have atypical presentation; LOC , confusion

pulmonary edema

• what is it

• cardiogenic

• non cardiogneic - common causes ?

• Abnormal accumulation of fluid in the lung tissue, the alveolar
  space or both

• Cardiogenic: Results from Left sided heart failure (pressure problem)

• Non-cardiogenic: damage to pulmonary capillary lining.
  • pneumonectomy(removal of 1 lung), as pulmonary vascular system is adjusting to one lung with same amount of blood flow
  • Chest trauma
  • Aspiration and smoke inhalation, pancreatitis, sepsis. etc

Clinical Manifestations of Pulmonary Edema

• pink frothy sputum

• gasping for air

• dyspnea

• anxious

• cyanotic

• confusion as CO2 is retained

Assessment findings Pulmonary Edema

• Rales (crackles) upon auscultation – especially posterior bases (movement of air through the alveolar fluid)
• Tachycardia
• Pulse Oximetry dropping
• Chest X-Ray – increased interstitial fluid
• ABGs worsening

Medical Management-Pulmonary Edema

• meds

• extra support

• what may be restricted

• Discover and treat underlying condition

• May require:
  • diuretics
  • vasodilators and
  • inotropic meds ---to improve left sided cardiac function

• Oxygen therapy or temporary intubation/ventilator support

• Fluid and sodium restriction when indicated to lessen fluid

Nursing Management - Pulmonary Edema

• Position upright, provide oxygen/ventilatory support as needed

• Monitor SpO , respiratory rate, lung sounds, HR, and BP

• Assess for fluid overload and peripheral edema
  • Monitor I&O, daily weigh, electrolytes and renal function
  • Monitor for crackles, worsening dyspnea, cyanosis, frothy/pink sputum

Pulmonary Hypertension (PH)

• what is it

• normal pulmonary artery pressure is

• what happens to blood vessels in the lungs , how does it effect pressure & heart

• Sustained elevation in pulmonary artery pressure (mPAP >25mmHg at rest) due to increased resistance in the pulmonary vasculature

• Normal pulmonary artery pressure is 11-20 mm Hg at rest

• Blood vessels in the lungs narrow, stiffen, or get blocked:

• This increases resistance to blood flow leading to ↑ pulmonary artery
  pressure and the right ventricle of the heart working harder to pump blood

what are the 5 groups of pulmonary hypertension

Group 1: Toxins/drug exposure, Infections (e.g., HIV), Connective tissue
disease (e.g., scleroderma, lupus)
• Group 2: Heart disease
• Group 3: COPD, Sleep apnea/chronic hypoxia, Interstitial lung disease
• Group 4: Chronic thromboembolic disease- PE
• Group 5: unknown: Hematologic disorders (Sickle cell disease, Chronic myeloid leukemia (CML), Systemic disorders (e.g., sarcoidosis) and Metabolic disorders

Manifestations - Pulmonary hypertension

• classic sign

• where is the pain 2

• 5 more

• signs of

• Classic sign is ‘Dyspnea on exertion’ - from congestion and lack of O2
  • Substernal chest pain, weakness, fatigue, syncope,
  hemoptysis
  • Anorexia and abdominal pain in right upper quadrant
  • Signs of right-sided heart failure (peripheral edema, ascites, distended neck veins, liver engorgement, crackles, heart murmur)

how can we diagnose pulmonary HTN

• what tests

• what does an echocardiography do

• what can we do to the heart to confirm dx? and what else

• chest x-ray, pulmonary function studies, ECG, echocardiogram

• Echocardiography: estimates pulmonary artery pressure,
  assesses right ventricular size and function

• Right heart catheterization: confirms PH diagnosis, assesses
  hemodynamic abnormalities

medical management of pulmonary HTN

• primary goal

• 6 meds

• last resort

• Primary goal: manage underlying condition
  • Oxygen

• diuretics - removes fluid

• anticoagulation - improves circulation and prevents clotting

• digoxin - helps the heart pump stronger

• Calcium channel blockers (nifedipine, diltiazem/Cardizem)
  • effective only in a small group of patients

• Prostanoids (epoprostenol) - relaxes pulmonary smooth muscle
  • requires continuous IV infusion; effective in selected patients with PAH

• Lung transplant - option - if refractory to medical therapy

Nursing Management -Pulmonary HTN

• identify ?

• monitor ?

• how can we Monitor pulmonary artery pressure

• educate ?

• Identify patients who are high risk such as COPD, PE, Mitral Valve Disease and congenital abnormalities

• Monitor VS – watch for dyspnea and increased pressures- (invasive
  pressure monitoring): A-line, CVP, PA catheter, wedge

• Educate patients and families on home oxygen therapy

Cor Pulmonale

• happens from chronically elevated pulmonary artery pressure

• overworks the right ventricle → causing hypertrophy and R sided heart failure

manifestations of cor pulmonale

• Headache, sleepiness,

• hypercapnia,

• exertional dyspnea,

• wheezing, cough,

• JVD, peripheral edema, ascites, weight gain, fatigue, hepatomegaly (R sided S/S)

Management-Cor Pulmonale

• goal?

• may include

• treat both ?

• restrict ?

• monitor ?

• administer ?

• Goal improve ventilation - 24 hour/day oxygen therapy (may include assisting with intubation)

• Treat both the underlying lung disease and cardiac symptoms

• Monitor pulse ox, ABGs, V/S and EKG

• chest PT,

• turn and position, bedrest

• suctioning

• administration of bronchodilators and diuretics

• sodium / fluid restrictions + monitor I and O and daily weight

Occupational Lung Diseases (Pneumoconioses)

• what is It

• how does it cause lung damage

• may be ? once developed ?

• what is key

• 3 types

• Lung disease caused by inhalation and accumulation of occupational dust particles in the lungs

• Inhaled dust particles → inflammation → lung tissue damage

• may be asymptomatic until late ? once developed, not reversible

• prevention is key - wear PPE at work sites

• • Asbestosis
  • Silicosis
  • Coal workers pneumoconiosis (black lung disease)

Silicosis

• what is it

• patho?

• chronic fibrotic pulmonary disease from inhaling silica dust (glass, miners, quarries and tunnels, sandblasting, stone cutters)

• Lung nodules grow larger and join together.

• Dense masses form in the upper lungs, reducing lung volume.

• Scar tissue damages the lung tissue and makes breathing harder.

• This can lead to restrictive lung disease, emphysema, high blood pressure in the lungs, and right-sided heart failure

asbestos pathophysiology

• inhaled ? causes ?

• what thickens ?

• what happens to the lungs

• as a result ?

• what damage ?

• increases the risk of

• inhaled asbestos fibers become trapped in the alveoli and cause scar tissue to form.

• The pleura thickens and develops plaques.

• Scarring makes the lungs stiff, reducing lung volume and making breathing difficult.

• Less oxygen enters the blood, causing hypoxemia

• Severe damage can lead to pulmonary hypertension, right-sided heart failure (cor pulmonale), and respiratory failure.

• Increases the risk of lung cancer, mesothelioma (cancer of the lung lining), and pleural effusion (fluid around the lungs)

Coal Worker’s Pneumoconiosis “black lung disease” pathophysiology

• inhaled?

• deposited ?

• what builds up?

• what forms

• what is the result

• inhaled dusts that are a mixture of several particles to include coal

• deposited in the alveoli and respiratory bronchioles

• Macrophages absorb coal dust but cannot clear it from the lungs.

• Dust, dead macrophages, and fibroblasts build up and clog the bronchioles and alveoli.

• Coal macules (small areas of damaged tissue) and scar tissue form.

• Lung damage can lead to localized emphysema.

• Severe cases can cause right-sided heart failure (cor pulmonale) and respiratory failure

lung cancer

• classifications and risk factors

• small lung cell

• non-small lung cell (majority)

• most common cause is inhaled carcinogen from cigarette smoke

• • Tobacco smoke & Second-hand smoke
  • Electronic nicotine delivery systems (ENDS) e.g., e-cigarettes
  • Environmental and occupational hazards, Genetic mutations

Manifestations of lung cancer

• change in?

• any cough that lasts ?

• 3 other

• may have ?

• Cough or change in a chronic cough which is often ignored and
  attributed to smoking or some other respiratory infection

• any cough that lasts more than 2 weeks needs further assessment

• Dyspnea, Hemoptysis, pleural pain

• May have Mets to brain, liver, adrenals and bone

dx tests for lung cancer

• Chest x-ray, CT Scan
• Biopsy, Bronchoscopy, VQ Scans, PFTs

Management- Lung Cancer

• therapies

• surgeries ?

• Radiation therapy
• Chemotherapy
• Surgery (• Pneumonectomy - entire lung
• Lobectomy - lobe removed , mast common
• Segmentectomy - segment of the lung
• Wedge Resection - removal of the tumor and a small wedge-shaped
portion of surrounding lung tissue

advantages of Video-Assisted Thoracoscopic Surgery (VATS)

minimally invasive, small incisions, less pain, faster recovery

• less pain = more coughing and deep breathing, less chance of atelectasis

• less pain = earlier ambulation, less r/o DVT, constipation, pressure sores

pist op nursing management

• Chest tube management
• Pain control, splinting, CDB
• Incentive spirometry, early ambulation
• Monitor respiratory status, work of breathing
• Monitor for pneumothorax, subcutaneous emphysema, hemorrhage

• Smoking cessation counseling

complications to monitor for post op

• Post-pneumonectomy pulmonary edema (PPE)
  • A rare but serious late complication. usually occurs within 72 hours after
  surgery and affects the remaining lung (same amount of blood flow with less lung to manage ) - fluid restriction, diuretics, digoxin

• • Tension pneumothorax
  • Bronchopleural fistula
  • Cardiac dysrhythmias
  • Infection
  • Pneumonia / atelectasis