RESTRICTIVE LUNG DISORDERS

Pneumonia

• An inflammatory process affecting the bronchioles & alveoli

• Most common cause of death from an infection in the US

• Droplet infection

• No. 1 cause of death

• Bacterial infection

Droplet

Transmission of pneumonia

Typical Pneumonia

• Type of pneumonia

• Causes:

  • S. pneumoniae, P. canag rinii, S. aureus, K. pneumoniae, P. aeruginosa, H. influenza

• Bacterial cause

Atypical Pneumonia

• “Walking pneumonia"

  • Px does not know that they are already infected because the s/sx are not that evident

• Mycoplasma pneumonia, Chlamydia pneumoniae, pneumophila, Mycobacterium tuberculosis, viruses, parasites, fungi

Radiation pneumonia

• Type of pneumonia

• Damage to the normal lung mucosa during radiation therapy for Breast CA, Lung CA

Chemical pneumonia

• Type of pneumonia

• Ingestion of kerosene, gasoline or other chemical

  Inhalation of volatile hydrocarbons

Aspiration pneumonia

• Type of pneumonia

• Inhalation of foreign object or gastric contents during vomiting or regurgitation

• Caused by inhaling foreign substances like food, liquid, or stomach contents into the lungs, which can lead to inflammation and infection

BRONCHOPENUMONIA

Pneumonia infection is patchy diffuse and scattered throughout both lungs

LOBAR PNEUMONIA

• Inflammation is confined to one or more lobes in the lung (pneumonia)

• Consolidation of a whole lobe

Community-acquired Pneumonia

Pneumonia is contracted in a community setting or within 48 hrs of admission to a healthcare facility

Hospital-acquired Pneumonia / Nosocomial

• Pneumonia that occurs in healthcare setting > 48 hrs after admission

• X-ray and increase WBC

Opportunistic Pneumonia

• P. carinii pneumonia (Pneumocystis jirovecii)

• Fungal pneumonia

• Pneumonia related to TB

• Patients who are immunocompromised

CONGESTION

• Day 1 & 2 of pneumonia

• Stage of lung engorgement

• Blood vessels and alveoli fill with excess fluid

• Lung is heavy

• Dark red in color

• Lung pits in pressure with fingers

  • Chest percussion and you feel pain

• Exudes a bubbly, blood-tinged froth

• Back pains and fevers

RED HEPATIZATION

• Day 3 & 4 of pneumonia

• Exudate (RBCs, neutrophils, & fibrin) fill airspaces, making them more solid

• Lung is still heavy,

• Sinks in water and looks like a red piece of granite

• DOB

GRAY HEPATIZATION

• Day 5-7 of pneumonia

• Still firm

• Color change: RBCs in exudate break down

• Changes color to ?

• Looks like ordinary granite

• Softens and tears more easily

• When pressed, it exudates a purulent fluid

RESOLUTION

• Day 8 to Week 3 of pneumonia

• Exudate is digested, ingested, or coughed up

• Inflammatory exudate is either absorbed by bloodstream or expectorated

Pneumonia

ASSESSMENT FINDINGS:

• Fever 

  • Starts with low grade then high grade (38-40)

• Chills 

• Productive cough, sputum (rust colored) 

• Discomfort in the chest wall muscles 

• General malaise 

• Pain during breathing (patient exhibits shallow breathing) 

• Rusty or prune juice sputum

  • Pathognomonic sign

  • No presence of blood like hemoptysis 

Pneumonia

DIAGNOSTIC FINDINGS:

• Wheezing, crackles, decreased breath sounds

• Cyanosis (nail beds, lips, oral mucosa)

• Sputum culture reveals infectious microorganism

  • Best in the morning no toothbrushing just gargle water. Look at sputum not saliva 

• CXR shows areas of infiltrates & consolidation

Cotrimoxazole

DOC for HIV/AIDS and pedia px with pneumonia

2nd / 3rd Generation Cephalosporin

DOC for pneumonia in the hospital setting

hyperoxygenate, < 10 sec, auscultating

SUCTIONING

• Auscultate → ? → suction for ? → hyperoxygenate → check by ?

Bronchodilators

• drug for nebulization

• ex:

  • Salbutamol + Ipratropium

  • Duavent

  • Combivent

Mucolytic

• drug for productive cough

• ex:

  • Acetylcysteine (Fluimocil)

  • Carbocysteine 

  • Erdosteine

  • Ambroxol

OBSTRUCTIVE LUNG DISORDERS

• Conditions that make it hard to exhale all the air in the lungs

• Nothing wrong with inhalation

• More CO₂ is being retained in the lungs

• Alveoli is expanding but it is unable to deflate or slowly.

• ↑ Lung volumes

• Shortness of breath due to difficulty exhaling all the air in the lungs

• Because of damage to the lungs or narrowing of the airways inside the lungs, exhaled air comes out more slowly than normal

• Reduction in the air flow, shortness of breath and has a hard time exhaling the air

RESTRICTIVE LUNG DISORDERS

• The patient has difficulty fully expanding their lungs with air.

• Alveoli deflates but is unable to inflate properly due to either lung scarring, fibrosis, or extraparenchymal problems

• ↓ Lung volumes 

• Most often results from a condition causing stiffness in the lungs themselves

• In other cases, stiffness of the chest wall, weak muscles, or damaged nerves may cause the restriction in lung expansion.

• Reduction in lung volume due to stiffness inside the lung tissue or chest wall cavity making it difficult to take in O2

PLEURAL EFFUSION

• Abnormal collection of fluid between the visceral & parietal pleurae as a complication of:

  • Pneumonia

  • Lung CA

  • TB

  • Pulmonary embolism

  • CHF

• Normal fluid: 5-15 ml

  • Pleural effusion exceeds the normal amount which results to less expansion 

  • Higher fluid = less expansion 

• A complication of one respiratory disorder, not a stabndalone disorder

  • Pneumonia if untreated

Exudative Pleural Effusion

• Type of pleural effusion

• Thicker 

• High in protein 

• Caused by infection 

• Breast cancer 

• Antibiotics - infection

Transudative Pleural Effusion

• Type of pleural effusion

• Increase in hydrostatic pressure 

• Low plasma oncotic pressure

  • Fluid goes outside 

• Congestive HF 

• Liver cirrhosis 

• Kidney 

• Hypoalbumin = low oncotic pressure 

Transudative Pleural Effusion

• Fluid created as a result of changes in hydrostatic pressure and decreased oncotic pressure (Cirrhosis, Heart Failure, Nephrotic Syndrome)

• Fluid moves from intravascular space into extravascular space.

• There is no inflammation of the vessels and so proteins don't move out.

• Fluid buildup is caused by systemic conditions that alter the pressure in blood vessels, causing fluid to leave the vascular system.

  • Hydrothorax = accumulation of water/serous fluid

• Difficulty of breathing, bigger abdominal girth

Hydrothorax

accumulation of water/serous fluid in the pleural space

Exudative Pleural Effusion

• Caused by infections such as pneumonia, malignancy, granulomatous diseases such as tuberculosis or coccidioidomycosis, collagen vascular diseases, and other inflammatory states.

• Protein-rich fluid

• Pyothorax or Empyema = accumulation of pus

• Hemothorax = accumulation of blood

• Chylothorax = accumulation of lymph and lipoprotein

• Large proteins 

• Darker in color 

Pyothorax / Empyema

accumulation of pus in the pleural space

Hemothorax

accumulation of blood in the pleural space

Chylothorax

accumulation of lymph and lipoprotein in the pleural space

Pleural Effusion

ASSESSMENT FINDINGS:

• Fever (high grade) 

• Pain

• Dyspnea 

  • Expected sign = more fluid retained 

  • Bigger abdominal girth = DOB

• Dullness over the involved area during chest percussion

• Diminished or absent breath sounds

  • Etelectasis 

• Friction rub

• CXR & CT Scan - shows fluid accumulation

THORACENTESIS

• Invasive procedure to treat pleural effusion

• Remove the fluid in the pleural space 

• Expose the affected part 

• sitting, arms, head

• side-lying, unaffected, 1

POSITION FOR THORACENTESIS:

• ? with ? and ? on padded table

• ? position on the ? side for at least ? hour(s)

PLEURODESIS

• Irritating chemicals (talc, doxycycline, tetracycline) to make parietal and visceral pleura adhere

• To adhere the lung to the chest wall

Flail Chest

Complication of chest trauma occurring when 2 or more adjacent ribs are fractured at two or more sites, resulting in free-floating rib segments

FRACTURED RIBS / STERNUM

•  Paradoxic movement of the chest: “Pendelluft”

  • The chest is pulled INWARD during inspiration, reducing the amount of air that can be drawn into the lungs

    • Instead of going out it is pulled inward causes so much pain 

  • The chest bulges OUTWARD during expiration because the intra-thoracic pressure exceeds atmospheric pressure. The patient has impaired exhalation

  • Leads to:

    • Reduced gas exchange

    • Decreased lung compliance, retained airway secretions

    • Atelectasis, Hypoxemia

FRACTURED RIBS / STERNUM

ASSESSMENT FINDINGS:

• Severe PAIN on inspiration & expiration & obvious trauma

• Shortness of breath

• Hypotension & inadequate tissue perfusion

• Respiratory acidosis

  • Less O2 in and more CO2

• CXR – confirms the diagnosis

NURSING DIAGNOSIS:

• Ineffective breathing pattern related to decreased lung expansion secondary to pain

• rib belt, elastic bandage

• mechanical ventilator 

MEDICAL MANAGEMENT FOR FRACTURED RIBS:

• Immobilize the fractured ribs

  • ? or ? is used especially in multiple rib fractures

    • Clean towel/blanket alternatives

  • it can lead to decreased lung expansion followed by pulmonary complications (pneumonia & atelectasis)

    • Oxygen source connected to a ?

codeine

analgesic for fractured ribs

1-2 hours

For fractured ribs, it is important to take deep breaths every ? to ? even though breathing is painful

PNEUMOTHORAX

• Accumulation of air in the pleural spacec

• Can lead to partial or complete collapse of the lung

Spontaneous pneumothorax

• Most common type of closed pneumothorax

• Air accumulates within the pleural space without an obvious cause (no antecedent trauma to thorax)

• Rupture of a small bleb on the visceral pleura most frequently produces this type of pneumothorax

Open pneumothorax

• usually caused by stabbing or gunshot wound

  • When you try to remove the air will go inside 

  • Inhale - + air going inside and less air going inside the lungs causes atelectasis 

  • Exhale - + Air goes out and partial reexpansion of the lungs

Tension pneumothorax

• pressure in the pleural space is POSITIVE throughout the respiratory cycle

• occurs in mechanical ventilation or resuscitation

• air enters the pleural space with each inspiration but cannot escape

• causes ⭡ intrathoracic pressure & shifting of the mediastinal contents to the unaffected side   (mediastinal shift)

• If there is fluid inside the lungs and then you clamp there will be accumulation in your pleural space and push lungs to the other side

Lobectomy

• removal of one lobe of a lung

• treatment for bronchiectasis, bronchogenic carcinoma, emphysematous blebs, lung abscesses

Pneumonectomy

• removal of an entire lung

• most commonly done as treatment for bronchogenic CA

  • Only one lung affected

Segmentectomy/ Segmental resection

• segment of lung removed

• most often done as treatment for bronchiectasis

Wedge resection

• removal of lesions that occupy only part of a segment of lung tissue

• for excision of small nodules or to obtain a biopsy

PULMONARY EMBOLISM

• Obstruction of a pulmonary artery (oxygenated blood) or one of its branches by a thrombus that originated from venous system

• Risk Factors:

  • DVT

  • Trauma, surgery, ortho,

  • Prolonged immobility

  • Hypercoagulable state

  • Asymptomatic

PULMONARY EMBOLISM

ASSESSMENT FINDINGS:

• Sudden chest pain (PLEURITIC OR SUBSTERNAL MIMICKING LIKE MI) 

• PRONOUNCED DOB

• RAPID AND WEAK PULSE

• SYNCOPE 

• DEATH WILL OCCUR WITHIN ONE HOUR AFTER ONSET OF SYMPTOMS

  • Sudden severe chest pain but was okay hours before the patient is bed bound don’t wait for monitoring call the doc immediately

heparin

• drug for pulmonary embolism

• LMWH (injection)

• Given straightaway once PE is confirmed

• WOF: Bleeding

Fibrinolytic therapy

• drug for pulmonary embolism

• recombinant tissue plasminogen activator

• ex:

  • U - urokinase

  • S - Streptokinase 

  • A - Altaplase (R TPA)

• WOF: bleeding

1 to less than 3 hrs

Golden time to receive fibrinolytic therapy

5-15 ml

Normal fluid volume in the pleural cavity